A hysterotomy is completed by closing the uterus either by using a stapler or by suture, no significant differences have been noted to show one technique takes precedent over another. [ 5 ]   The muscular outer layer of the uterus in all samples of closures showed some inflammation and thickening/scarring of the tissue. [ 26 ]  In the event a midline incision is used, three layers of sutures are performed to repair the uterine wall. An interrupted suture is used to close the first and second layer and a continuous locking suture or figure-of-eight suture is used to close the third layer. [ 2 ]  Since in practice the low transverse incision is typically made, the incision is also typically closed with two layers of sutures. Though, there is a debate on whether the suture should be close with a single layer or a double layer of sutures. Double layer of sutures can promote improved healing, hemostasis and less risk of uterine rupture in the next pregnancy, whereas single layer of sutures allows for less operation time, less tissue disruption and decreased exposure to foreign suture material. [ 3 ]


Intersex medical interventions  ( IMI ), sometimes known as  intersex genital mutilations  ( IGM ), [ 1 ]  are  surgical , hormonal and other medical interventions performed to modify atypical or  ambiguous genitalia  and other  sex characteristics , primarily for the purposes of making a person's appearance more typical and to reduce the likelihood of future problems. The  history of intersex surgery  has been characterized by controversy due to reports that surgery can compromise sexual function and sensation, and create lifelong health issues. [ 2 ] [ 3 ]  The medical interventions can be for a variety of reasons, due to the enormous variety of the  disorders of sex development . Some disorders, such as salt-wasting disorder, can be life-threatening if left untreated.  [ 4 ]


Interventions on intersex infants and children are increasingly recognized as  human rights  issues. Intersex organizations, and human rights institutions increasingly question the basis and necessity of such interventions. [ 5 ] [ 6 ]  In 2011,  Christiane Völling  won the first successful case brought against a surgeon for non-consensual surgical intervention. [ 7 ]  In 2015, the  Council of Europe  recognized, for the first time, a right for intersex persons not to undergo sex-assignment treatment [ 8 ]  and Malta became the first country to prohibit involuntary or coerced modifications to sex characteristics. [ 9 ] [ 10 ] [ 11 ]


The goals of surgery vary with the type of intersex condition but usually include one or more of the following:


Physical health rationales:


Psychosocial rationales:


Both sets of rationales may be the subject of debate, particularly as the consequences of surgical interventions are lifelong and irreversible. Questions regarding physical health include accurately assessing risk levels, necessity and timing. Psychosocial rationales are particularly susceptible to questions of necessity as they reflect parental, social, and cultural concerns. There remains no clinical consensus or clear evidence regarding surgical timing, necessity, type of surgical intervention, degree of difference warranting intervention and evaluation method. [ 12 ] [ 13 ] [ 14 ]  Such surgeries are the subject of significant contention, including community activism, [ 15 ]  and multiple reports by international human rights [ 8 ] [ 16 ] [ 17 ] [ 18 ]  and health [ 2 ]  institutions and national ethics bodies. [ 5 ] [ 19 ]


Interventions include:


Surgical interventions can broadly be divided into   masculinizing surgical procedures  intended to make genitalia more like those of typical XY-males, and  feminizing surgical procedures  intended to make genitalia more like those of typical XX-females. There are multiple techniques or approaches for each procedure. Some of these are needed for variations in degrees of physical difference. Techniques and procedure have evolved over the last 60 years. Some of the different techniques have been devised to reduce complications associated with earlier techniques. There remains a lack of consensus on surgeries, and some clinicians still regard them as experimental. [ 20 ]


Some children receive a combination of procedures. For example, a child regarded as a severely undervirilized boy with a  pseudovaginal perineoscrotal hypospadias  may have midline urogenital closure, third degree hypospadias repair, chordee release and  phalloplasty , and  orchiopexy  performed. A child regarded as a severely virilized girl with  congenital adrenal hyperplasia  (CAH) may undergo both a partial clitoral recession and a  vaginoplasty . [ 21 ] [ 22 ] [ 23 ]


Orchiopexy and hypospadias repair are the most common types of genital corrective surgery performed in infant boys. In a few parts of the world  5-alpha-reductase deficiency  or defects of  testosterone  synthesis, or even rarer forms of  intersex  account for a significant portion of cases but these are rare in North America and Europe. Masculinizing surgery for completely virilized individuals with XX sex chromosomes and  CAH  is even rarer. [ medical citation needed ]  An early procedure was performed by London surgeon Thomas Brand in 1779. [ 24 ]


Orchiopexy  for repair of undescended  testes  ( cryptorchidism ) is the second most common surgery performed on infant male genitalia (after  circumcision ). The surgeon moves one or both testes, with blood vessels, from an  abdominal  or  inguinal  position to the  scrotum . If the inguinal canal is open it must be closed to prevent  hernia . Potential surgical problems include maintaining the blood supply. If vessels cannot be stretched into the scrotum, or are separated and cannot be reconnected, a testis will die and atrophy.


Hypospadias  repair  may be a single-stage procedure if the hypospadias is of the first or second degree ( urethral  opening on glans or shaft respectively) and the  penis  is otherwise normal. Surgery for third-degree hypospadias (urethral opening on  perineum  or in urogenital opening) is more challenging, may be done in stages, and has a significant rate of complications and unsatisfactory outcomes. [ 25 ]  Potential surgical problems: For severe hypospadias (3rd degree, on perineum) constructing a urethral tube the length of the phallus is not always successful, leaving an opening (a "fistula") proximal to the intended urethral opening. Sometimes a second operation is successful, but some boys and men have been left with chronic problems with fistulas, scarring and contractures that make urination or erections uncomfortable, and loss of sensation. It is increasingly recognized that long-term outcomes are poor. [ 26 ] [ 27 ]


Epispadias  repair  may involve comprehensive surgical repair of the genito-urinary area, usually during the first seven years of life, including reconstruction of the urethra, closure of the penile shaft and mobilisation of the corpora.


Urogenital closure  closure of any midline opening at the base of the penis. In severe  undervirilization  a boy may have a "pseudovaginal pouch" or a single urogenital opening in the midline of the  perineum . Potential surgical problems: The most complicated aspect of closure involves moving the urethra to the phallus if it is not already there (i.e., repairing a perineal hypospadias). Fistulas, scarring, and loss of sensation are the main risks.


Gonadectomy  (also referred to as "orchiectomy") removal of the gonads. This is done in three circumstances. (1) If the  gonads  are  dysgenetic  testes or streak gonads and at least some of the boy's cells have a  Y chromosome , the gonads or streaks must be removed because they are nonfunctional but have a relatively high risk of developing  gonadoblastoma . (2) In rare instances when an XX child has completely virilizing  congenital adrenal hyperplasia  (Prader stage 5), the  ovaries  can be removed before puberty to stop  breast  development and/or  menstruation . (3) Gonadectomy can be performed in the equally rare instance of a child with  true hermaphroditism  virilized enough to raise as male, in which ovaries or  ovotestes  can be removed. A lifetime of hormone replacement will be required, to avoid  osteoporosis  and enable sexual functioning.


Chordee  release  is the cutting of ventral penile skin and connective tissue to free and straighten the penis. A mild chordee, manifest as a well-formed penis "bent" downward by subcutaneous connective tissue, may be an isolated birth defect easily repaired by releasing some of the inelastic connective tissue on the ventral side of the shaft. In a complete chordee the phallus is "tethered" downward to the perineum by skin. A more severe chordee is often accompanied by a hypospadias and sometimes by severe undervirilization: a perineal "pseudovaginal pouch" and bifid ("split") scrotum with an undersized penis. This combination, referred to as  pseudovaginal perineoscrotal hypospadias , is in the spectrum of ambiguous genitalia due to a number of conditions.  Scarring and contracture are occasional complications, but most unsatisfactory outcomes occur when a severe hypospadias needs to be repaired as well. Long-term complications can include fistulas between  colon  or upper  rectum  and skin or other cavities, or between urethra and perineum. Loss of sensation.


Cloacal  repair  is among the most complex of the surgeries described here.  Bladder exstrophy  or more severe  cloacal exstrophy  is a major birth defect involving inadequate closure and incomplete midline fusion of multiple pelvic and perineal organs as well as the front of the  pelvis  and lower abdominal wall. The penis and scrotum are often widely  bifid  (the two embryonic parts unjoined). The penis often cannot be salvaged, although the testes can be retained. Repair may involve closure of the bladder, closure of the anterior abdominal wall,  colostomy  (temporary or permanent) with reconstruction of the rectum. If the halves of the phallus cannot be joined, they may be removed. The smallest defect in this spectrum is an  epispadias . Surgical repair for this is primarily a phalloplasty. [ 28 ]  Potential surgical problems: Surgery for the more severe degrees of cloacal exstrophy is extensive and usually multistage. A variety of potential problems and complications can occur, including need for long-term colostomy or  vesicostomy . In many cases a functional penis cannot be created. Scarring is often extensive and the lower torso severely disfigured even with fairly good outcomes.


Phalloplasty  is a general term for any reconstruction of the penis itself, especially for more unusual types of injuries, deformities, or birth defects. The principal difficulty is that erectile tissue is not easily constructed and this limits the surgeon's ability to make more than minor size changes. Construction of a narrow tube lined with mucosa (a urethra) is a similar challenge.  Minor revisions of the skin are rarely followed by problems. More complicated reconstruction may result in scarring and contracture, which can distort the shape or curvature of the penis, or interfere with erections or make them painful.


Hysterectomy  is removal of a  uterus . It is rare that a uterus or  Müllerian duct  derivatives would need to be removed from a child being raised as a boy: see  persistent Müllerian duct syndrome . The most common scenario is accidental discovery of persistent Müllerian derivatives or a small uterus during abdominal surgery of a normal boy for  cryptorchidism ,  appendectomy , or bowel disease. Removal would not involve genital surgery. A rarer indication would be that of a completely virilized XX child with  congenital adrenal hyperplasia  (Prader stage 5) being raised as a male;  ovaries  and uterus must be removed to prevent  breast  development and  menstruation  by early adolescence. Risks are simply those of abdominal surgery.


Testicular prostheses  are saline-filled plastic ovoids implanted in the scrotum. They have no function except to provide the appearance and feel of testes. Several sizes are available, but most are implanted in adolescence to avoid repeated procedures to implant larger sizes at puberty. Prostheses made of  silastic  are no longer available due to safety and perception-of-safety concerns. Potential surgical problems: Foreign body reactions, rarely with infection or erosion of scrotal skin, are minimal but constitute the most significant complication.


Penile augmentation surgery  is surgery intended to enlarge a small penis. Early attempts in the 1950s and 1960s involved constructing a tube of non-erectile flesh extending a small penis but the penis did not function. In recent years a small number of urologists have been offering an augmentation [ clarification needed ]  procedure that involves moving outward some of the buried components of the corpora so that the penis protrudes more. The girth is augmented with transplantation of the patient's fat. This procedure is designed to preserve erectile and sexual function without surgically altering the urethra. This type of surgery is not performed on children and primarily produces a small increase in the size of a normal penis, but would be less likely to produce a major functional change in a severe  micropenis . Potential surgical problems include reabsorption of the fat, scarring resulting in interference with erectile function, and issues with physical sensation.


Concealed penis  where a normal penis is buried in suprapubic fat. In most cases, when the fat is depressed with the fingers, the penis is seen to be of normal size. This is common in overweight boys before the penile growth of puberty. Surgical techniques have been devised to improve it. [ 29 ]  The most common problems post-surgery are recurrence with continued weight gain and scarring.


In the last 50 years, the following procedures were most commonly performed to make the genitalia more typically female: virilization due to  congenital adrenal hyperplasia ; genital variations due, for example, to  cloacal exstrophy ; genital variations in infants with XY or mixed chromosomes to be raised as girls, such as  gonadal dysgenesis , partial and complete  androgen insensitivity syndrome ,  micropenis , cloacal and  bladder exstrophy . In the 21st century, feminizing surgery to support reassignment of XY infants with non-ambiguous micropenis has been largely discontinued, and surgical reassignment of XY infants with exstrophy or other significant variations or injuries is diminishing. See  history of intersex surgery .


Clitorectomy  amputation or removal of most of the  clitoris , including  glans , erectile tissue, and  nerves . This procedure was the most common clitoral surgery performed prior to 1970, but was largely abandoned by 1980 because it usually resulted in loss of clitoral sensation. Potential surgical problems: The primary effect of this surgery is a drastic reduction in ability to experience  orgasm . The appearance is not very normal. Regrowth of unwanted erectile tissue has sometimes presented problems.


Clitoroplasty , like phalloplasty, is a term that encompasses any surgical reconstruction of the clitoris, such as removal of the corpora. Clitoral recession and reduction can both be referred to as clitoroplasty. Potential surgical problems: Major complications can include scarring, contractures, loss of sensation, loss of capacity for orgasm, and unsatisfactory appearance.


Clitoral recession  involves the repositioning of the erectile body and glans of the clitoris farther back under the symphysis pubis and/or skin of the preputium and mons. This was commonly done from the 1970s through the 1980s to reduce protrusion without sacrificing sensation. Outcomes were often unsatisfactory, and it fell into disfavor in the last 15 years. [ 31 ]  Potential surgical problems: Unfortunately the subsequent sensations were not always pleasant, and erection could be painful. Adults who had a clitoral recession in early childhood often report reduced capacity for enjoyment of sexual intercourse, though similar women who had not had surgery also report a high rate of sexual dysfunction. [ 32 ]


Clitoral reduction  was developed in the 1980s to reduce size without reducing function. Lateral wedges of the erectile tissue of the clitoris are removed to reduce the size and protrusion. The neurovascular tissue is carefully spared to preserve function and sensation. Nerve stimulation and sensory responses are now often performed during the surgery to confirm function of the sensory nerves. [ 31 ] [ 33 ]  Clitoral reduction is rarely done except in combination with vaginoplasty when substantial virilization is present. Potential problems: The degree to which the goal of preserving sexual sensations is attained is a subject of controversy regarding the necessity of such treatments, and lack of firm evidence of good outcomes. [ 3 ] [ 6 ]  The success of more contemporary approaches was challenged by Thomas in 2004: "confidence in the superiority of modern surgery is almost certainly misplaced as the crucial components of current clitoral reduction surgery are not fundamentally different from those used in specialist centres 20 years ago". [ 34 ]


Vaginoplasty , the construction or reconstruction of a  vagina , can be fairly simple or quite complex, depending on the initial anatomy. If a normal internal uterus, cervix and upper vagina (the  Müllerian derivatives ) exist, and the outer virilization is modest, surgery involves separating the fused labia and widening the vaginal introitus. With greater degrees of virilization, the major challenge of the procedure is to provide a passage connecting the outer vaginal opening to the cervix which will stay wide enough to allow coitus. XY girls or women with partial  androgen insensitivity syndrome  will have a blind vaginal pouch of varying degrees of depth. Sometimes this can be dilated to a usable depth. Sometimes surgery is performed to deepen it.


The most challenging surgery with the highest complication rate is construction of an entirely new vagina (a "neovagina"). The most common instance of this is when a child will be assigned and raised as a female despite complete virilization, as with Prader 5  CAH , or (in the past) when a genetic male infant with a severely defective penis was  reassigned  as a female. One method is to use a segment of colon, which provides a lubricated mucosal surface as a substitute for the vaginal mucosa. Another is to line the new vagina with a skin graft. [ 35 ] [ 36 ] [ 37 ]  Potential surgical problems: Stenosis (narrowing) of the constructed vagina is the most common long-term complication and the chief reason that a revision may be required when a girl is older. When a neovagina is made from a segment of bowel, it tends to leak mucus; when made with a skin graft, lubrication is necessary. Less common complications include fistulas, uncomfortable scarring, and problems with urinary continence. [ 32 ] [ 38 ] [ 39 ]


Gonadectomy  is removal of the gonads. If the  gonads  are  dysgenetic  testes or streak gonads and at least some of the cells have a  Y chromosome , the gonads or streaks must be removed because they are nonfunctional but have a relatively high risk of developing  gonadoblastoma . If the gonads are relatively "normal" testes, but the child is to be assigned and raised as female, (e.g., for intersex conditions with severe undervirilization, or major malformations involving an absent or unsalvageable penis) they must be removed before puberty to prevent virilization from rising testosterone.


Testes in  androgen insensitivity  are a special case: if there is any degree of responsiveness to testosterone, they should be removed before puberty. On the other hand, if androgen insensitivity is complete, the testes may be left to produce estradiol (via testosterone) to induce breast development, but there is a slowly increasing risk of cancer in adult life. Streak gonads without a Y chromosome cell line need not be removed but will not function. Finally, the gonads in  true hermaphroditism  must be directly examined; atypical gonads with Y line or potential testicular function should be removed but in rare instances a surgeon may try to preserve the ovarian part of an ovotestis. [ 40 ]  Potential surgical problems: A lifetime of hormone replacement will be required, to avoid  osteoporosis  and enable sexual functioning.


Cloacal exstrophy  and  bladder exstrophy repair  is needed regardless of the  sex of assignment  or  rearing . Simple bladder exstrophy in a genetic female does not usually involve the  vagina . Cloacal exstrophy in a genetic female usually requires major surgical reconstruction of the entire  perineum , including  bladder ,  clitoris , symphysis pubis, and both the vaginal introitus and  urethra . However, the  uterus  and  ovaries  are normally formed. Severe bladder exstrophy or cloacal exstrophy in genetic males often renders the phallus widely split, small, and unsalvageable. The scrotum is also widely split, though testes themselves are usually normal. From the 1960s until the 1990s, many of these infants were assigned and raised as females, with fashioning of a vagina and gonadectomy as part of the perineal reconstruction. [ 28 ]


Potential surgical problems: Surgery for the more severe degrees of cloacal exstrophy is extensive and usually multistage. A variety of potential problems and complications can occur, including need for long-term  colostomy  or  vesicostomy . Creating a functional urethra is difficult and poor healing, with scarring, stricture, or fistula can require a vesicostomy to prevent urinary incontinence. Construction of a functional  internal  and  external anal sphincter  can be equally difficult when this has been disrupted as well. Functional problems can warrant a temporary or long-term colostomy. The added challenge for the most severely affected genetic females, and for genetic males who are being raised as females, is construction of a neovagina. Scarring is extensive and the lower torso disfigured even with the best outcomes. Finally, it has become apparent that some XY males (without intersex conditions) who are  reassigned  and raised as females have not developed a female gender identity and have sought reassignment back to male. [ 41 ]


There is widespread evidence of  prenatal testing and hormone treatment  to prevent intersex traits. [ 42 ] [ 43 ]  In 1990, a paper by Heino Meyer-Bahlburg titled  Will Prenatal Hormone Treatment Prevent Homosexuality?  was published in the Journal of Child and Adolescent Psychopharmacology. It examined the use of "prenatal hormone screening or treatment for the prevention of homosexuality" using research conducted on foetuses with  congenital adrenal hyperplasia  (CAH). Dreger, Feder, and  Tamar-Mattis  describe how later research constructs "low interest in babies and men – and even interest in what they consider to be men's occupations and games – as "abnormal", and potentially preventable with prenatal dex [amethasone]". [ 42 ]


The ethics of  preimplantation genetic diagnosis  to select against intersex traits was the subject of 11 papers in the October 2013 issue of the  American Journal of Bioethics . [ 44 ]  There is widespread evidence of  pregnancy terminations  arising from prenatal testing, as well prenatal hormone treatment to prevent intersex traits. [ 45 ] [ 46 ] [ 47 ] [ 48 ] [ 49 ]


In April 2014,  Organisation Intersex International Australia  made a submission on genetic selection via  preimplantation genetic diagnosis  to the  National Health and Medical Research Council  recommending that deselection of embryos and foetuses on grounds of intersex status should not be permitted. It quoted research by Professors  Morgan Holmes , Jeff Nisker, associate professor  Georgiann Davis , and by Jason Behrmann and Vardit Ravitsky. [ 50 ]  It quotes research showing  pregnancy termination  rates of up to 88% in  47,XXY  even while the  World Health Organization  describes the trait as "compatible with normal life expectancy", and "often undiagnosed". [ 51 ] [ 52 ]   Behrmann and Ravitsky find social concepts of sex, gender and sexual orientation to be "intertwined on many levels. Parental choice against intersex may thus conceal biases against same-sex attractedness and gender nonconformity." [ 53 ]


The  DSM-5  included a change from using gender identity disorder to  gender dysphoria . This revised code now specifically includes intersex people who do not identify with their sex assigned at birth and experience clinically significant distress or impairment, using the language of  disorders of sex development . [ 54 ]  This move was criticised by intersex advocacy groups in Australia and  New Zealand . [ 55 ]


A 2006 clinician "Consensus Statement on Intersex Disorders and Their Management" attempted to prioritise psychosocial support for children and families, but it also supports surgical intervention with psychosocial rationales such as "minimizing family concern and distress" and "mitigating the risks of stigmatization and gender-identity confusion". [ 56 ]


In 2012, the Swiss National Advisory Commission on Biomedical Ethics argued strongly in favour of improved psychosocial support, saying: [ 5 ]


The initial aim of counselling and support is therefore to create a protected space for parents and the newborn, so as to facilitate a close bond. In addition, the parents need to be enabled to take the necessary decisions on the child's behalf calmly and after due reflection. In this process, they should not be subjected to time or social pressures. Parents' rapid requests for medical advice or for corrective surgery are often a result of initial feelings of helplessness, which need to be overcome so as to permit carefully considered decision-making.


It is important to bear in mind and also to point out to the parents that a diagnosis does not in itself entail any treatment or other medical measures, but serves initially to provide an overview of the situation and a basis for subsequent decisions, which may also take the form of watchful waiting.


...interventions have lasting effects on the development of identity, fertility, sexual functioning and the parent-child relationship. The parents' decisions should therefore be marked by authenticity, clarity and full awareness, and based on love for the child, so that they can subsequently be openly justified vis-à-vis the child or young adult.


A joint international statement by  intersex community organizations  published in 2013 sought, amongst other demands:


Recognition that medicalization and stigmatisation of intersex people result in significant trauma and mental health concerns.
In view of ensuring the bodily integrity and well-being of intersex people, autonomous non-pathologising psycho-social and peer support be available to intersex people throughout their life (as self-required), as well as to parents and/or care providers.


Specialists at the Intersex Clinic at University College London began to publish evidence in 2001 that indicated the harm that can arise as a result of inappropriate interventions, and advised minimising the use of childhood surgical procedures. [ 57 ] [ 58 ] [ 59 ] [ 60 ] [ 61 ] [ 62 ] [ 63 ] [ 64 ] [ 65 ]


A 2004 paper by  Heino Meyer-Bahlburg  and others examined outcomes from early surgeries in individuals with XY variations, at one patient centre. [ 66 ]  The study has been used to support claims that "the majority of women... have clearly favored genital surgery at an earlier age" but the study was criticized by Baratz and Feder in a 2015 paper for neglecting to inform respondents that:


(1) not having surgery at all might be an option; (2) they might have had lower rates of reoperation for  stenosis  if surgery were performed later, or (3) that significant technical improvements that were expected to improve outcomes had occurred in the 13 or 14 years between when they underwent early childhood surgery and when it might have been deferred until after puberty. [ 67 ]


In 2006, an invited group of clinicians met in Chicago and reviewed clinical evidence and protocols, and adopted a new term for intersex conditions:  Disorders of sex development  (DSD) in the journal article  Consensus Statement on Intersex Disorders and their Management . [ 56 ]  The new term refers to "congenital conditions in which development of chromosomal, gonadal, or  anatomical sex  is atypical." [ 56 ]  The term has been controversial and not widely adopted outside clinical settings: the World Health Organization and many medical journals still refer to  intersex  traits or conditions. [ 68 ]  Academics like  Georgiann Davis  and  Morgan Holmes , and clinical psychologists like  Tiger Devore  argue that the term DSD was designed to "reinstitutionalise" medical authority over intersex bodies. [ 6 ] [ 69 ] [ 70 ] [ 71 ]  On surgical rationales and outcomes, the article stated that:


It is generally felt that surgery that is carried out for cosmetic reasons in the first year of life relieves parental distress and improves attachment between the child and the parents. The systematic evidence for this belief is lacking. ... information across a range of assessments is insufficient ... outcomes from clitoroplasty identify problems related to decreased sexual sensitivity, loss of clitoral tissue, and cosmetic issues ... Feminising as opposed to masculinising genitoplasty requires less surgery to achieve an acceptable outcome and results in fewer urological difficulties... Long term data on sexual function and quality of life among those assigned female as well as male show great variability. There are no controlled clinical trials of the efficacy of early (less than 12 months of age) versus late surgery (in adolescence and adulthood), or of the efficacy of different techniques" [ 56 ]


Data presented in recent years suggests that little has changed in practice. [ 72 ]  Creighton and others in the UK have found that there have been few audits of the implementation of the 2006 statement, clitoral surgeries on under-14s have increased since 2006, and "recent publications in the medical literature tend to focus on surgical techniques with no reports on patient experiences". [ 14 ]


A 2014 civil society submission to the  World Health Organization  cited data from a large German  Netzwerk DSD/Intersexualität  study:


In a study in Lübeck conducted between 2005 and 2007 ...  81% of 439 individuals had been subjected to surgeries due to their intersex diagnoses. Almost 50% of participants reported psychological problems. Two thirds of the adult participants drew a connection between sexual problems and their history of surgical treatment. Participating children reported significant disturbances, especially within family life and physical well-being – these are areas that the medical and surgical treatment was supposed to stabilize. [ 15 ]


A 2016 Australian study of persons born with atypical sex characteristics found that "strong evidence suggesting a pattern of institutionalised shaming and coercive treatment of people". Large majorities of respondents opposed standard clinical protocols. [ 73 ]


A 2016 follow-up to the 2006 Consensus Statement, termed a  Global Disorders of Sex Development Update  stated,


There is still no consensual attitude regarding indications, timing, procedure and evaluation of outcome of DSD surgery. The levels of evidence of responses given by the experts are low (B and C), while most are supported by team expertise... Timing, choice of the individual and irreversibility of surgical procedures are sources of concerns. There is no evidence regarding the effect of surgically treated or non-treated DSDs during childhood for the individual, the parents, society or the risk of stigmatization... Physicians working with these families should be aware that the trend in recent years has been for legal and human rights bodies to increasingly emphasize preserving patient autonomy. [ 12 ]


A 2016 paper on "Surgery in disorders of sex development (DSD) with a gender issue" repeated many of the same claims, but without reference to human rights norms. [ 13 ]  A commentary to that article by  Alice Dreger  and Ellen Feder criticized that omission, stating that issues have barely changed in two decades, with "lack of novel developments", while "lack of evidence appears not to have had much impact on physicians' confidence in a standard of care that has remained largely unchanged." [ 74 ]  Another 2016 commentary stated that the purpose of the 2006 Consensus Statement was to validate existing practices, "The authoritativeness and "consensus" in the Chicago statement lies not in comprehensive clinician input or meaningful community input, but in its utility to justify any and all forms of clinical intervention." [ 75 ]


Management practices for intersex conditions have evolved over the last 60 years. In recent decades surgical practices have become the subject of public and professional controversy, and evidence remains lacking. [ 12 ] [ 13 ]


Argued or putative advantages of infant surgery:


Argued or putative advantages of surgery in adolescence or later:


Others argue that the key questions are not ones of early or late surgery, but questions of consent and autonomy. [ 75 ] [ 76 ]


Parents are frequently considered able to consent to feminizing or masculinizing interventions on their child, and this may be considered standard for the treatment of physical disorders. However this is contested, particularly where interventions seek to address psychosocial concerns. A  BMJ  editorial in 2015 stated that parents are unduly influenced by medicalized information, may not realize that they are consenting to experimental treatments, and regret may be high. [ 20 ]  Research has suggested that parents are willing to consent to appearance-altering surgeries even at the cost of later adult sexual sensation. [ 77 ]  Child rights expert  Kirsten Sandberg  states that parents have no right to consent to such treatments. [ 78 ]


Reports published in the early 1990s state that 20-50% of surgical cases result in a loss of sexual sensation. [ 79 ] [ 80 ]


A 2007 paper by Yang, Felsen and Poppas provided what the authors believe is the first study of clitoral sensitivity after clitoris reduction surgery, but the research was itself the subject of ethical debate. Postoperative patients aged older than five years were "considered candidates" for clitoral sensitivity testing, and 10 of 51 patients were tested, with 9 undergoing extended vibratory sensory testing. The initial tests were performed on the inner thigh,  labia majora ,  labia minora ,  vaginal introitus  and clitoris, with a "cotton tip applicator" and extended tests with a biothesiometer, a medical device used to measure sensitivity thresholds. Values were recorded. The authors note that there are no control data "for assessment of the viability and function of the clitoris in unaffected women." [ 81 ]  The ethics of these tests have been criticized by bioethicists, [ 82 ]  and subsequently defended by the  Office for Human Research Protections . [ 83 ]


Loss of sexual function and sensation remains a concern in a submission by the Australasian Paediatric Endocrine Group to the Australian Senate in 2013. [ 3 ]  Clinical decision-making has prioritized perceived advantages from infant clitoral reduction surgery over the potential disadvantages of reduced or distorted sexual sensation. Human rights institutions stress the informed consent of the individual concerned.


In the cases where nonfunctional testes are present, or with partial androgen insensitivity syndrome, there is a risk that these develop cancer. They are removed by  orchidectomy  or monitored carefully. [ 84 ]  In a major Parliamentary report in Australia, published in October 2013, the Senate Community Affairs References committee was "disturbed" by the possible implications of current practices in the treatment of cancer risk. The committee stated: "clinical intervention pathways stated to be based on probabilities of cancer risk may be encapsulating treatment decisions based on other factors, such as the desire to conduct normalising surgery… Treating cancer may be regarded as unambiguously therapeutic treatment, while normalising surgery may not. Thus basing a decision on cancer risk might avoid the need for court oversight in a way that a decision based on other factors might not. The committee is disturbed by the possible implications of this..." [ 6 ]


Gender identity and sexuality in intersex children have been problematized, and subjective judgements are made about the acceptability of risk of future gender dysphoria. [ 13 ] [ 85 ]  Medical professionals have traditionally considered the worst outcomes after genital reconstruction in infancy to occur when the person develops a gender identity discordant with the sex assigned as an infant. Most of the cases in which a child or adult has voluntarily changed sex and rejected  sex of assignment  and  rearing  have occurred in partially or completely virilized genetic males who were reassigned and raised as females. This is the management practice that has been most thoroughly undermined in recent decades, as a result of a small number of spontaneous self-reassignments to male. Reducing the likelihood of a gender "mismatch" is also a claimed advantage of deferring reconstructive surgery until the patient is old enough to assess gender identity with confidence.


Human rights institutions question such approaches as being "informed by redundant social constructs around gender and biology". [ 86 ]


Parents may be advised that without surgery, their child will be  stigmatized , [ 87 ]  but they may make different choices with non-medicalized information. [ 88 ]  However, there is no evidence that surgeries help children grow up psychologically healthy. [ 12 ] [ 89 ]


Unlike other aesthetic surgical procedures performed on infants, such as corrective surgery for a  cleft lip  (as opposed to a  cleft palate ), genital surgery may lead to negative consequences for sexual functioning in later life (such as loss of sensation in the genitals, for example, when a  clitoris  deemed too large or penis is reduced/removed), or feelings of freakishness and unacceptability, which may have been avoided without the surgery. Studies have revealed how surgical intervention has had psychological effects, affecting well-being and quality of life. Genital surgeries do not ensure a successful psychological outcome for the patient and might require psychological support when the patient is trying to distinguish a gender identity. [ 90 ]  The Swiss National Advisory Commission on Biomedical Ethics states that, where "interventions are performed solely with a view to integration of the child into a family and social environment, then they run counter to the child's welfare. In addition, there is no guarantee that the intended purpose (integration) will be achieved." [ 5 ]


Opponents of all "corrective surgery" on atypical sex characteristics suggest to change social opinion regarding the desirability of having genitalia that look more average, rather than perform surgery to try to make them more like those of other people.


Photographs of intersex children's genitalia are circulated in medical communities for documentary purposes, and individuals with intersex traits may be subjected to repeated genital examinations and display to medical teams. Problems associated with experiences of medical photography of intersex children have been discussed [ 91 ]  along with their ethics, control and usage. [ 92 ]  "The experience of being photographed has exemplified for many people with intersex conditions the powerlessness and humiliation felt during medical investigations and interventions". [ 92 ]


Additionally, parents are not often consulted on the decision-making process when choosing the sex of the child, and they may be advised to conceal information from their child. The Intersex Society of North America stated that "For decades, doctors have thought it necessary to treat intersex with a concealment-centered approach, one that features downplaying intersex as much as possible, even to the point of lying to patients about their conditions." [ 93 ]


In 2015, an editorial in the  BMJ  described current surgical interventions as experimental, stating that clinical confidence in constructing "normal" genital anatomies has not been borne out, and that medically credible pathways other than surgery do not yet exist. [ 20 ]


The  Council of Europe  highlights several areas of concern in relation to intersex surgeries and other medical treatment:


The Council of Europe argues that secrecy and shame have perpetuated human rights abuses and a lack of social understanding of the reality of intersex people. It calls for respect for "intersex persons' right not to undergo sex assignment treatment". [ 8 ]


Alice Dreger , a US professor of Clinical Medical Humanities and Bioethics, argues that little has changed in actual clinical practice in recent years. [ 72 ]  Creighton and others in the UK have found that there have been few audits of the implementation of the 2006 statement, clitoral surgeries on under-14s have increased since 2006, and "recent publications in the medical literature tend to focus on surgical techniques with no reports on patient experiences". [ 14 ]


Institutions like the Swiss National Advisory Commission on Biomedical Ethics, [ 5 ]  the  Australian Senate , [ 6 ]  the Council of Europe, [ 8 ] [ 94 ]   World Health Organization , [ 2 ] [ 95 ]  and UN  Office of the High Commissioner for Human Rights [ 96 ]  and Special Rapporteur on Torture [ 16 ]  have all published reports calling for changes to clinical practice.


In 2011,  Christiane Völling  won the first successful case brought against a surgeon for non-consensual surgical intervention. The Regional Court of Cologne, Germany, awarded her €100,000. [ 7 ]


In April 2015, Malta became the first country to recognize a right to bodily integrity and physical autonomy, and outlaw non-consensual modifications to sex characteristics. The Act was widely welcomed by civil society organizations. [ 9 ] [ 10 ] [ 11 ] [ 97 ]


In June 2017,  Joycelyn Elders ,  David Satcher , and  Richard Carmona , three former Surgeons General of the United States published a paper at the  Palm Center , [ 98 ] [ 99 ] [ 100 ]  calling for a rethink of early genital surgeries on children with intersex traits. The statement reflected on the history of such interventions, their rationales and outcomes, stating:


When an individual is born with atypical genitalia that pose no physical risk, treatment should focus not on surgical intervention but on psychosocial and educational support for the family and child. Cosmetic genitoplasty should be deferred until children are old enough to voice their own view about whether to undergo the surgery. Those whose oath or conscience says “do no harm” should heed the simple fact that, to date, research does not support the practice of cosmetic infant genitoplasty.


Irving Operation  is a gynaecological operative technique for permanent sterilization in women. It was proposed to reduce the failure rate of  Pomeroy procedure  for female sterilization. In Irving operation, the proximal part of  fallopian tube  is buried back into the myometrium, thereby obstructing its lumen. [ 1 ]


The Irving operation was proposed by Dr. Irving in 1924. [ 2 ]


A transverse incision is made on the abdomen and fallopian tube is identified. While holding the fallopian tube with an  Allis clamp , a hemostat is used to open the  mesosalpinx . Using absorbable sutures, proximal portion of fallopian tube is tied, and a segment of fallopian tube is removed. The proximal part of the fallopian tube is pulled into the defect. The distal portions of the Fallopian tube are ligated and left in place. The abdomen is closed in layers. [ citation needed ]


Irving operation can be reversed with tubal reversal microsurgery. Pregnancy rate after tubal reversal in Irving operation is around 60 percent. [ citation needed ]


The  Manchester operation ,  Manchester repair  or simply  Fothergill operation  is a technique used in  gynaecologic  surgeries. It is an operation for  uterine prolapse  by fixation of the  cardinal ligaments . Its purpose is to reduce the  cystourethrocele  and to reposition the uterus within the  pelvis . The major steps of the intervention are listed below:


High amputation of cervix during this procedure may cause cervical incompetence. [ 1 ]


Success rate of Manchester operation was re-evaluated at the Department of Obstetrics and Gynecology of Hacettepe University School of Medicine, Ankara, Turkey for clinical characteristics, complications, and satisfaction scores of patients. A high degree of acceptance/satisfaction and a low morbidity rate show the Manchester operation to be a good option for the treatment of uterine prolapse in women who wish to keep their uterus. [ 2 ]


Metroplasty  (also called  Strassman metroplasty,   uteroplasty  or  hysteroplasty ) is a  reconstructive surgery  used to repair  congenital anomalies  of the  uterus , including  septate uterus  and  bicornuate uterus . The surgery entails removing the abnormal tissue that separates the  cornua  of the uterus, then using several layers of stitches to create a normal shape. [ 1 ]


Nymphotomy  is the surgical procedure of  incision  into the  labia minora . Surgical removal of the labia minora is called  nymphectomy . In  plastic surgery , the term  labiaplasty , which describes  plastic surgery  of the  labia  (often in the form of  labia minora reduction ) is now more commonly used.


The term  nymphectomy  is also used to describe removal of parts of the labia as part of  female genital cutting .


Oophorectomy  ( / ˌ oʊ . ə f ə ˈ r ɛ k t ə m i / ; from  Greek   ᾠοφόρος ,  ōophóros , 'egg-bearing' and  ἐκτομή ,  ektomḗ , 'a cutting out of'), historically also called  ovariotomy , is the  surgical  removal of an  ovary  or ovaries. [ 1 ]  The surgery is also called  ovariectomy , but this term is mostly used in reference to non-human animals, e.g. the surgical removal of ovaries from laboratory animals.  Removal of the ovaries of females is the biological equivalent of  castration  of males; the term  castration  is only occasionally used in the medical literature to refer to oophorectomy of women. In  veterinary medicine , the removal of ovaries and uterus is called  ovariohysterectomy  ( spaying ) and is a form of  sterilization .


The first reported successful human oophorectomy was carried out by (Sir)  Sydney Jones  at  Sydney Infirmary , Australia, in 1870. [ 2 ]


Partial oophorectomy  or  ovariotomy  is a term sometimes used to describe a variety of surgeries such as ovarian cyst removal, or resection of parts of the ovaries. [ 3 ]  This kind of surgery is fertility-preserving, although ovarian failure may be relatively frequent. Most of the long-term risks and consequences of oophorectomy are not or only partially present with partial oophorectomy.


In humans, oophorectomy is most often performed because of diseases such as  ovarian cysts  or  cancer ; as  prophylaxis  to reduce the chances of developing ovarian  cancer  or breast  cancer ; or in conjunction with  hysterectomy  (removal of the uterus). In the 1890s people believed oophorectomies could cure menstrual cramps, back pain, headaches, and chronic coughing, although no evidence existed that the procedure impacted any of these ailments. [ 4 ]


The removal of an ovary together with the  fallopian tube  is called  salpingo-oophorectomy  or  unilateral salpingo-oophorectomy  ( USO ). When both ovaries and both fallopian tubes are removed, the term  bilateral salpingo-oophorectomy  ( BSO ) is used. Oophorectomy and salpingo-oophorectomy are not common forms of  birth control  in humans; more usual is  tubal ligation , in which the fallopian tubes are blocked but the ovaries remain intact. In many cases, surgical removal of the ovaries is performed concurrently with a hysterectomy. The formal medical name for removal of a woman's entire reproductive system (ovaries, fallopian tubes, uterus) is "total abdominal hysterectomy with bilateral salpingo-oophorectomy" (TAH-BSO); the more casual term for such a surgery is "ovariohysterectomy". "Hysterectomy" is removal of the uterus (from the Greek ὑστέρα hystera "womb" and εκτομία ektomia "a cutting out of") without removal of the ovaries or fallopian tubes.


Oophorectomy for benign causes is most often performed by abdominal  laparoscopy . Abdominal  laparotomy  or robotic surgery is used in complicated cases [ clarification needed ]  or when a malignancy is suspected. [ citation needed ]


According to the  Centers for Disease Control , 454,000 women in the United States underwent oophorectomy in 2004. The first successful operation of this type, account of which was published in the  Eclectic Repertory and Analytic Review  (Philadelphia) in 1817, was performed by  Ephraim McDowell  (1771–1830), a surgeon from  Danville, Kentucky . [ 5 ]  McDowell was dubbed as the "father of ovariotomy". [ 6 ] [ 7 ]  It later became known as Battey's Operation, after  Robert Battey , a surgeon from  Augusta, Georgia , who championed the procedure for a variety of conditions, most successfully for  ovarian epilepsy . [ 8 ]


Most bilateral oophorectomies (63%) are performed without any medical indication, and most (87%) are performed together with a hysterectomy. [ 9 ]  Conversely, unilateral oophorectomy is commonly performed for a medical indication (73%; cyst, endometriosis, benign tumor, inflammation, etc.) and less commonly in conjunction with hysterectomy (61%). [ 9 ]


Special indications include several groups of women with substantially increased risk of ovarian cancer, such as high-risk  BRCA mutation  carriers and women with endometriosis who also have frequent  ovarian cysts . [ citation needed ]


Bilateral oophorectomy has been traditionally done in the belief that the benefit of preventing ovarian cancer would outweigh the risks associated with removal of ovaries. However, it is now clear that prophylactic oophorectomy without a reasonable medical indication decreases long-term survival rates substantially [ 10 ]  and has deleterious long-term effects on health and well-being even in post-menopausal women. [ 11 ]  The procedure has been postulated as a possible treatment method for female sex offenders. [ 12 ]


The procedure is sometimes performed at the same time as  hysterectomy  in transgender men and  non-binary  people. The long term effects of oophorectomy in this population are not well studied. [ 13 ]


Oophorectomy can significantly improve survival for women with high-risk  BRCA mutations , for whom  prophylactic  oophorectomy around age 40 reduces the risk of ovarian and  breast cancer  and provides significant and substantial long-term survival advantage. [ 14 ]  On average, earlier intervention does not provide any additional benefit but increases risks and adverse effects.


For women with high-risk  BRCA2  mutations, oophorectomy around age 40 has a relatively modest benefit for survival; the positive effect of reduced breast and ovarian cancer risk is nearly balanced by adverse effects. The survival advantage is more substantial when oophorectomy is performed together with prophylactic  mastectomy . [ 15 ] [ 16 ]


The risks and benefits associated with oophorectomy in the BRCA1/2 mutation carrier population are different than those for the general population. Prophylactic risk-reducing salpingo-oophorectomy (RRSO) is an important option for the high-risk population to consider. Women with BRCA1/2 mutations who undergo salpingo-oophorectomy have lower all-cause mortality rates than women in the same population who do not undergo this procedure. In addition, RRSO has been shown to decrease mortality specific to breast cancer and ovarian cancer. Women who undergo RRSO are also at a lower risk for developing ovarian cancer and first occurrence breast cancer. Specifically, RRSO provides BRCA1 mutation carriers with no prior breast cancer a 70% reduction of ovarian cancer risk. BRCA1 mutation carriers with prior breast cancer can benefit from an 85% reduction. High-risk women who have not had prior breast cancer can benefit from a 37% (BRCA1 mutation) and 64% (BRCA2 mutation) reduction of breast cancer risk. These benefits are important to highlight, as they are unique to this BRCA1/2 mutation carrier population. [ 17 ]


In rare cases, oophorectomy can be used to treat  endometriosis  by eliminating the menstrual cycle, which will reduce or eliminate the spread of existing endometriosis as well as reducing pain. Since endometriosis results from an overgrowth of the uterine lining, removal of the ovaries as a treatment for endometriosis is often done in conjunction with a hysterectomy to further reduce or eliminate recurrence. [ citation needed ]


Oophorectomy for endometriosis is used only as last resort, often in conjunction with a hysterectomy, as it has severe side effects for women of reproductive age. However, it has a higher success rate than retaining the ovaries. [ 18 ]


Partial oophorectomy (i.e., ovarian cyst removal not involving total oophorectomy) is often used to treat milder cases of endometriosis when non-surgical hormonal treatments fail to stop cyst formation. Removal of ovarian cysts through partial oophorectomy is also used to treat extreme pelvic pain from chronic hormonal-related pelvic problems.


Oophorectomy is an intra-abdominal surgery and serious complications stemming directly from the surgery are rare. When performed together with hysterectomy, it has influence on choice of surgical technique as the combined surgery is much less likely to be performed by vaginal hysterectomy. [ citation needed ]


Laparotomic  adnexal  surgeries are associated with a high rate of adhesive small bowel obstructions (24%). [ 19 ]


An infrequent complication is injuring of the  ureter  at the level of the  suspensory ligament of the ovary . [ 20 ]


Oophorectomy has serious long-term consequences stemming mostly from the hormonal effects of the surgery and extending well beyond menopause. The reported risks and adverse effects include premature death, [ 21 ] [ 22 ]  cardiovascular disease, cognitive impairment or dementia, [ 23 ]   parkinsonism , [ 24 ]   osteoporosis  and bone fractures, decline in psychological well-being, [ 25 ]  and decline in sexual function.  Hormone replacement therapy  does not always reduce the adverse effects. [ 10 ]


Oophorectomy is associated with significantly increased all-cause long-term mortality except when performed for cancer prevention in carriers of high-risk BRCA mutations. This effect is particularly pronounced for women who undergo oophorectomy before age 45. [ 22 ]


The effect is not limited to women who have oophorectomy performed before menopause; an impact on survival is expected even for surgeries performed up to the age of 65. [ 26 ]  Surgery at age 50-54 reduces the probability of survival until age 80 by 8% (from 62% to 54% survival), surgery at age 55-59 by 4%. Most of this effect is due to excess cardiovascular risk and hip fractures. [ 26 ]


Removal of ovaries causes hormonal changes and symptoms similar to, but generally more severe than,  menopause . Women who have had an oophorectomy are usually encouraged to take hormone replacement drugs to prevent other conditions often associated with menopause. Women younger than 45 who have had their ovaries removed with prophylactic bilateral oophorectomy face a mortality risk 170% higher than women who have retained their ovaries. [ 22 ]  Retaining the ovaries when a hysterectomy is performed is associated with better long-term survival. [ 21 ]  Hormone therapy for women with oophorectomies performed before age 45 improves the long-term outcome and all-cause mortality rates. [ 22 ] [ 27 ]


Women who have had bilateral oophorectomy surgeries lose most of their ability to produce the hormones  estrogen  and  progesterone , and lose about half of their ability to produce  testosterone , and subsequently enter what is known as "surgical  menopause " (as opposed to normal menopause, which occurs naturally in women as part of the aging process). In natural menopause the ovaries generally continue to produce low levels of hormones, especially androgens, long after menopause, which may explain why surgical menopause is generally accompanied by a more sudden and severe onset of symptoms than natural menopause, symptoms that may continue until the natural age of menopause. [ 28 ]  These symptoms are commonly addressed through hormone therapy, utilizing various forms of estrogen, testosterone,  progesterone , or a combination. [ citation needed ]


When the ovaries are removed, a woman is at a seven times greater risk of cardiovascular disease, [ 29 ] [ 30 ] [ 31 ]  but the mechanisms are not precisely known. The hormone production of the ovaries currently cannot be sufficiently mimicked by drug therapy. The ovaries produce hormones a woman needs throughout her entire life, in the quantity they are needed, at the time they are needed, in response to and as part of the complex  endocrine system .


Oophorectomy is associated with an increased risk of  osteoporosis  and bone fractures. [ 32 ] [ 33 ] [ 34 ] [ 35 ] [ 36 ]   A potential risk for oophorectomy performed after menopause is not fully elucidated. [ 37 ] [ 38 ]   Reduced levels of testosterone in women is predictive of height loss, which may occur as a result of reduced  bone density . [ 39 ]   In women under the age of 50 who have undergone oophorectomy,  hormone replacement therapy  (HRT) is often used to offset the negative effects of sudden hormonal loss such as  early-onset osteoporosis  as well as menopausal problems like  hot flashes  that are usually more severe than those experienced by women undergoing natural menopause.


Oophorectomy substantially impairs sexuality. [ 40 ]  Substantially more women who had both an oophorectomy and a hysterectomy reported  libido  loss, difficulty with sexual arousal, and vaginal dryness than those who had a less invasive procedure (either hysterectomy alone or an alternative procedure), and hormone replacement therapy was not found to improve these symptoms. [ 41 ]   In addition, oophorectomy greatly reduces testosterone levels, which are associated with a greater sense of sexual desire in women. [ 42 ]  However, at least one study has shown that psychological factors, such as relationship satisfaction, are still the best predictor of sexual activity following oophorectomy. [ 43 ]  Sexual intercourse remains possible after oophorectomy and coitus can continue.  Reconstructive surgery remains an option for women who have experienced benign and malignant conditions. [ 44 ]   : 1020–1348


The side effects of oophorectomy may be alleviated by medicines other than hormonal replacement. Non-hormonal biphosphonates (such as  Fosamax  and  Actonel ) increase bone strength and are available as once-a-week pills. Low-dose  selective serotonin reuptake inhibitors  such as  Paxil  and  Prozac  alleviate vasomotor menopausal symptoms, i.e., "hot flashes". [ 45 ]


In general, hormone replacement therapy is somewhat controversial due to the known  carcinogenic  and  thrombogenic  properties of  estrogen ; however, many physicians and patients feel the benefits outweigh the risks in women who may face serious health and quality-of-life issues as a consequence of early surgical menopause. The ovarian hormones estrogen, progesterone, and testosterone are involved in the regulation of hundreds of bodily functions; it is believed by some doctors that hormone therapy programs mitigate surgical menopause side effects such as increased risk of cardiovascular disease, [ 46 ]  and female sexual dysfunction. [ 47 ]


Short-term hormone replacement with estrogen has negligible effect on overall mortality for high-risk BRCA mutation carriers. Based on computer simulations, overall mortality appears to be marginally higher for short-term HRT after oophorectomy or marginally lower for short-term HRT after oophorectomy in combination with mastectomy. [ 48 ]  This result can probably be generalized to other women at high risk in whom short-term (i.e., one- or two-year) treatment with estrogen for hot flashes may be acceptable.


Ovarian drilling , also known as multiperforation or  laparoscopic  ovarian diathermy, is a surgical technique of puncturing the membranes surrounding the ovary with a laser beam or a surgical needle using minimally invasive laparoscopic procedures. [ 1 ]  It differs from ovarian wedge resection, which involves the cutting of tissue. Minimally invasive ovarian drilling procedures have replaced wedge resections. [ 2 ]  Ovarian drilling is favored over wedge resection because cutting into the ovary might result in adhesions, potentially complicating postoperative outcomes. [ 3 ]  Ovarian drilling and ovarian wedge resection are treatment options to reduce the amount of  androgen  producing tissue in women with  polycystic ovarian syndrome  (PCOS). [ 4 ]  PCOS is the primary cause of anovulation, which results in female infertility. [ 5 ]  The induction of mono-ovulatory cycles can restore fertility. [ 6 ]


The oral drug  clomiphene citrate  (CC) is the first-line treatment for PCOS-related infertility, yet one-fifth of women are resistant to the drug and fail to ovulate. [ 7 ]  Patients are considered resistant if the treatment fails for six months at the appropriate dosage. [ 1 ]   Women who are resistant to the medication clomiphene citrate are commonly treated with medications that induce ovulation such as gonadotrophins. [ 8 ]  Medications that induce ovulation such as CC can also be associated with multiple pregnancies and problems with the women's cycle and this therapy is very expensive due to the route of administration (daily by injection) and the requirement for regular ultrasounds,  laparoscopic  ovarian drilling is sometimes considered by medical professionals for treating anovulation. [ 8 ]  Known side effects and risks include the need for  anesthesia , the risk of infection, and a risk of adhesions forming. [ 8 ]  There may sometimes be a smaller risk of the person losing ovarian function. [ 8 ]


Ovarian drilling is a surgical alternative to CC treatment or recommended for women with  WHO Group II ovulation disorders . [ 6 ]  Other non-surgical medical options in the treatment of PCOS include the oestrogen receptor modulator  tamoxifen ,  aromatase inhibitors , insulin sensitising drugs, and hormonal ovarian stimulation. [ 9 ]  The effectiveness of the surgical procedure is similar to CC or gonadotropin treatment for induced ovulation for PCOS patients, but results in fewer multiple pregnancies per ongoing pregnancy regardless if the technique is unilaterally or bilaterally performed. [ 10 ]


If patients do not become pregnant six months after ovulation has been reestablished from ovarian drilling treatment, drug treatments may be reintroduced or  in vitro fertilisation  (IVF) may be considered. [ 1 ]


Part of the criteria of PCOS diagnosis includes elevated levels of androgens in the bloodstream or other signs of androgen excess ( hyperandrogenism ). [ 1 ]  The procedure causes a drop in serum  androgen  levels and possibly in  estrogen  levels. [ 5 ]  After ovarian follicles and stroma are destroyed, there is a reduction in these hormone levels. [ 11 ]  The procedure results in a decrease in plasma  luteinizing hormone  (LH) and in pulsations as well as a periodic drop in  inhibin B  levels. [ 1 ]  The most plausible theory states that the reduction of these hormone concentrations leads to an increase in the secretion of  follicle-stimulating hormone  (FSH) and sex hormone-binding  globulin , leading to effective follicular maturation and ovulation. [ 5 ] [ 1 ]  Low serum  oestradiol  concentrations are associated with decreased  aromatase  activity. [ 1 ]  Inflammatory growth factors such as  insulin-like growth factor-1  are produced due to injury and aid the effects of FSH through greater blood flow and gonadotropin delivery. [ 11 ]  Circulating and intrafollicular levels of  anti-Müllerian hormone  (AMH), which can help quantify recruitable ovarian follicle activity, are reduced after laparoscopic ovarian drilling in women with PCOS. [ 12 ]


When the clinician determines that ovarian drilling is appropriate and the woman decides to undergo this treatment, consent is obtained. The risks are communicated to the woman. [ 13 ]


The most commonly performed method is with a monopolar needle or hook because of the equipment's availability and simple installation. [ 6 ]  Other common instrumentation consists of the use of a bipolar electrical surgical electrodes or a CO 2 , argon, or ND-YAG  laser . [ 14 ]  This instrumentation has the ability to produce the intended results with a very focal approach. Typically, a 100 W electrical cautery dissector is first used to cross the ovarian cortex, then electrocoagulation is performed at 40 W, however rates range from 30 to 400 W. [ 1 ]  The surgical punctures are performed on the ovarian cortex and are usually 4–10 mm deep and 3 mm wide. [ 10 ] [ 11 ]  The number of punctures is related to subsequent ability to conceive—it has been found that five to ten punctures are more likely to produce the intended conception. [ 13 ]  Ovarian drilling is performed laparoscopically and either transumbilical ( culdoscopy ) or transvaginal ( fertiloscopy ). [ 1 ]


Though preferable to creating incisions on the ovary, ovarian drilling does have some risks. These are: pelvic adhesion formation,  hemorrhage ,  gas embolism ,  pneumothorax ,  premature ovarian failure , long-term ovarian function, developing  hyperstimulation syndrome , adhesion formation,  infertility  and  multiple births . [ 2 ] [ 13 ] [ 6 ] [ 15 ]  Transvaginal hydrolaparoscopy (THL) ovarian drilling may minimize the risk of iatrogenic adhesion formation and decreased ovarian reserve (DOR), which can impinge upon fertility. [ 16 ]  LOD does not contribute to the risk of decreased ovarian reserve. [ 12 ]  There is risk of electrical accidents with monopoly current. [ 1 ]  A rare complication of LOD is major vascular injury, mostly on the small vessels in the anterior abdominal wall when the Veress needle and trocar are inserted at the beginning of the procedure. [ 15 ]


Ovarian drilling has lower rates of  ovarian hyperstimulation syndrome  and of  multi-fetal gestation . [ 17 ] [ 8 ]  The advantages of the procedure also include its singular treatment, as opposed to several trials of ovulation inductions. [ 2 ]  Other benefits of this technique include cost-effectiveness and that it can be performed as an  outpatient procedure . [ 6 ]


Ovarian drilling was first used in the treatment of PCOS in 1984 and has evolved as a safe and effective surgery. [ 11 ]  After performing laparoscopic electrosurgical ovarian drilling in CC-resistant patients in 1984, Gjönnaess found that this technique increased ovulation rates to 45 percent and pregnancy rates to 42 percent. [ 18 ]  In 1988, laparoscopic multiple punch resection of ovaries on the hypothalamo-pituitary axis, slightly modified from Gjönnaess's operation, caused a reduction in LH pulsation and pituitary responsiveness in the treatment of PCOS. [ 19 ]  In 1989, ovarian drilling was conducted with argon, carbon dioxide (CO 2 ) or  potassium-titanyl-phosphate  (KTP) laser vaporization causing spontaneous ovulation in 71 percent of those treated. [ 14 ]  The procedure has been modified and popularized in the treatment of patients with CC-resistance. [ 11 ]


Presacral neurectomy  is one of the treatments for chronic pelvic pain and  dysmenorrhea . Lapraroscopic presacral neurectomy is an initial surgical intervention for chronic pelvic pain when medical therapy fails. [ 1 ]


The sensory pathways from the pelvic viscera pass through the  superior hypogastric plexus   and  inferior hypogastric plexus  to the spinal columns. The excision of presacral nerve trunk results in the obstruction of the pain pathway from the hypogastric plexi to the spinal cord. Presacral neurectomy denervates the uterus and causes loss of some bladder sensation. [ 2 ]


Presacral neurectomy is offered to patients for whom medical therapy for chronic pain relief has failed. The efficacy of the procedure is around 75-80%. Less than 1% of all patients have major complications following the surgery. [ 3 ]


A  resuscitative hysterotomy , also referred to as a  perimortem Caesarean section  ( PMCS ) or  perimortem Caesarean delivery  ( PMCD ), is a  hysterotomy  performed to  resuscitate  a woman in middle to late  pregnancy  who has entered  cardiac arrest . [ 1 ]  Combined with a  laparotomy , the procedure results in a  Caesarean section  that removes the  fetus , thereby abolishing the  aortocaval compression  caused by the pregnant uterus. [ 1 ]  This improves the mother's chances of  return of spontaneous circulation , and may potentially also deliver a viable  neonate . [ 1 ]  The procedure may be performed by  obstetricians ,  emergency physicians  or  surgeons  depending on the situation. [ 2 ] [ 3 ]


Where cardiac arrest occurs in a pregnant woman, irrespective of the condition of the  fetus , the procedure should be performed immediately if  basic  and  advanced life support  attempts are proving unsuccessful at achieving return of spontaneous circulation, and the woman's uterus is deemed capable of causing aortocaval compression. [ 1 ] [ 3 ] [ 4 ]  The threshold for this is passed when the uterus is so large that the  fundus  may be  palpated  at the level of the woman's  umbilicus ; for a  singleton  pregnancy, this occurs at around 20 weeks of  gestational age [ 3 ] [ 4 ]  (but may be earlier in  multiple pregnancy ). Although hysterotomy is crucial for resuscitation of the mother in such situations, if the gestational age is less than approximately 24 to 25 weeks the procedure will necessarily lead to the death of the fetus (or fetuses), as this is estimated to be the lower limit for  fetal viability . [ 4 ]  If the fetus is over 24 weeks' gestation, Caesarean delivery also offers the best chance of rescue for the neonate. [ 4 ]


If the mother's medical condition is such that there is no reasonable prospect of maternal resuscitation or viability (for example, after a nonsurvivable injury, or an unwitnessed arrest with prolonged pulselessness), then the procedure may be attempted immediately as a means of saving the unborn fetus primarily. [ 3 ]


The procedure should not be performed if the uterus is not judged to be large enough to cause maternal haemodynamic changes through aortocaval compression, as there is no potential benefit to the mother and the fetus or fetuses will not be viable in such an early stage of pregnancy. [ 3 ]


Potential structures that may be damaged during the procedure are as for Caesarean section, including the fetus itself and the maternal bowel, bladder, uterus and uterine blood vessels. [ 5 ]


Once the decision to operate has been made, the procedure should be performed immediately at the site where cardiac arrest has taken place and standard basic and advanced life support resuscitation methods should continue throughout. [ 3 ]  These should include manual displacement of the uterus towards the patient's left side, to reduce aortocaval compression. [ 2 ]  If the arrest occurs in a healthcare facility that has staff on site who are capable of performing a resuscitative hysterotomy (such as at a hospital), the patient should not be moved to an  operating theatre  as this will delay the procedure. [ 3 ]  Out-of-hospital cardiac arrests may need to be transported to a healthcare facility first if qualified staff are not immediately available. [ 4 ]


Other than a  scalpel , no specialised surgical equipment is needed for a resuscitative hysterotomy. [ 3 ]  The  American Heart Association  recommends that healthcare facilities that may be required to treat a case of maternal cardiac arrest should keep in stock an emergency equipment tray for the purpose, including a scalpel with a No. 10 blade, a Balfour  retractor , surgical  sponges ,  Kelly  and Russian  forceps , a  needle driver ,  sutures  and suture scissors - but the procedure should commence regardless of whether the tray is available. [ 3 ]


Basic  aseptic  measures, such as pouring  antiseptic  solution over the woman's  abdomen  prior to incision, may be considered as long as this adds no delay. [ 3 ]  An assistant should manually displace the gravid uterus to the woman's left throughout the procedure until the fetus has been delivered, to assist the simultaneous efforts of those resuscitating the woman. [ 3 ]  Either a classical midine  incision  or a  Pfannenstiel incision  may be used depending on operator preference; the former may theoretically give better exposure, but practising obstetricians or surgeons may be more comfortable with a Pfannenstiel approach as this is more commonly used for Caesarean sections. [ 3 ]  Once the uterus is opened, the fetus is delivered and should be resuscitated by a separate team. [ 3 ]  It may be possible to then use the abdominal incision to deliver direct cardiac massage through the (intact) diaphragm. [ 2 ] [ 4 ]


After the placenta is delivered, the uterus is massaged to stimulate contraction and is closed with a running locking absorbable suture and the abdomen is then closed; alternatively, the wound may be temporarily packed with sterile gauze, with definitive closure delayed until specialist obstetric help arrives or until the patient is fit for transport to a formal operating theatre. [ 2 ] [ 3 ]   Uterotonic  agents like  oxytocin  may be considered, balancing potential reduction of  haemorrhage  with the tendency of oxytocin to cause  hypotension . [ 3 ]   Antibiotics  should be administered to reduce infection risk if maternal survival is thought feasible at this stage of the resuscitation. [ 3 ]  If there is return of spontaneous circulation, additional uterotonic agents will likely be needed due to bleeding from uterine atony. [ 2 ]


The American Heart Association first added resuscitative hysterotomy to its recommended guidelines for  cardiopulmonary resuscitation  and emergency cardiac care in 1992, based on limited  case report  evidence. [ 4 ]  Many case reports have since been published reporting that, in maternal cardiac arrest, evacuation of the uterus is often associated with abrupt return of spontaneous circulation or other improvement in the mother's condition. [ 4 ]


A  retropubic paravaginal repair  is the surgical procedure to reattach the anterior lateral  vaginal wall  and its connective tissue to its normal position in the  pelvis  to correct  pelvic organ prolapse . It may be necessary to preserve normal function of pelvic organs after the vagina has detached from its normal position and has moved along with underlying tissues away from the pelvic sidewall. A common finding in repairing this condition is that the  arcus tendineus fasciae  has become detached. The procedure is usually performed by a  gynecological   surgeon  using pelvic surgery techniques. [ citation needed ]


Women who experience  stress incontinence  and who need a paravaginal repair often receive a Burch colposuspension to correct the problem. [ 1 ]


Sacrohysteropexy  is a surgical procedure to correct  uterine prolapse . It involves a resuspension of the prolapsed uterus using a strip of synthetic mesh to lift the uterus and hold it in place. It allows for normal  sexual function  and preserves  childbearing function . [ 1 ]


Sacrohysteropexy  can be performed as an open operation or  laparoscopically  (via keyhole incisions). The advantages of laparoscopic approach include superior visualisation of the anatomy with laparoscopic magnification, decreased hospital stay, reduced postoperative pain, more rapid recovery and smaller incisions. [ citation needed ]


The aim of laparoscopic hysteropexy is to restore and reinforce normal uterine support by suspending the  uterus  from the  sacral promontory  using  polypropylene  mesh. The mesh is strongly attached at two points: namely the uterus/ cervix  and the anterior longitudinal  ligament  over the sacral promontory. Hysteropexy restores the normal support of the  vagina , suspending the uterus back in its anatomical position by reinforcing weakened ligaments with a mesh. This procedure allows the length of the vagina to be restored without compromising its calibre, and is therefore likely to have a favourable functional outcome. [ citation needed ]


The advantages of this operation over  hysterectomy , as well as preservation of  fertility , are a stronger repair, with less risk of recurrent prolapse. Cuts to the vagina itself are also avoided so it is likely there is less risk of subsequent sexual problems. [ 2 ] [ 3 ]


Salpingectomy  refers to the surgical removal of a  fallopian tube .  This may be done to treat an ectopic pregnancy or  cancer , to prevent cancer, or as a form of  contraception .


This procedure is now sometimes preferred over its ovarian tube-sparing counterparts due to the risk of  ectopic pregnancies .  For contraceptive purposes, this procedure is irreversible and more effective than  tubal ligation .


Salpingectomy is different from and predates both  salpingostomy  and  salpingotomy . The latter two terms are often used interchangeably and refer to creating an opening into the tube (e.g. to remove an  ectopic pregnancy ), but the tube itself is not removed. [ 1 ]  Technically, the creation of a new tubal opening ( os , after the  Latin  word for 'mouth') by surgery would be a  salpingostomy , while the incision into the tube to remove an ectopic is a  salpingotomy . [ citation needed ]


Salpingectomy was performed by  Lawson Tait  in 1883 in women with a bleeding  ectopic pregnancy ; it is now established as a routine and lifesaving procedure [ clarification needed ] . Other indications for a salpingectomy include infected tubes (as in a  hydrosalpinx ) or as part of the surgical procedure for tubal cancer. [ citation needed ]


A bilateral salpingectomy will lead to  sterility , and was used for that purpose; however, less invasive, possibly reversible procedures have become available as  tubal occlusion procedures . Bilateral salpingectomies continue to be requested by some  voluntarily childfree  people over tubal ligation because it reduces the risk of developing cancer; this is called  prophylactic salpingectomy . [ 2 ]  It can be performed non-electively on women who are at a high risk of developing ovarian cancer, as a preventative measure.


Salpingectomy has traditionally been done via a  laparotomy ; more recently however,  laparoscopic  salpingectomies have become more common as part of  minimally invasive surgery . The tube is severed at the point where it enters the  uterus  and along its mesenteric edge with hemostatic control. [ citation needed ]


Salpingectomy is commonly done as part of a procedure called a  salpingo- oophorectomy , in which one or both  ovaries , as well as one or both fallopian tubes, are removed in one operation (a bilateral salpingo-oophorectomy (BSO) if both ovaries and fallopian tubes are removed).  If a BSO is combined with an abdominal  hysterectomy  (there are different methods of hysterectomy available), the procedure is commonly called a TAH-BSO: total abdominal hysterectomy with a bilateral salpingo-oophorectomy. Sexual intercourse remains possible after salpingectomy, surgical and radiological cancer treatments, and chemotherapy. Reconstructive surgery remains an option for women who have experienced benign and malignant conditions. [ 3 ]   : 1020–1348


Salpingectomies were performed in the United States in the early 20th century in accordance with  eugenics legislation . From  Buck v. Bell  (1927):


The Virginia statute providing for the sexual sterilization of inmates of institutions supported by the State who shall be found to be afflicted with an hereditary form of insanity or imbecility, is within the power of the State under the  Fourteenth Amendment . [ 4 ]


Buck v. Bell , while not expressly overturned, was implicitly overturned by  Skinner v. Oklahoma  (1942), in which the Court held that a person's choices whether to aid in the propagation of the human species was a cognizable fundamental right guaranteed under the 14th Amendment of the Constitution, a liberty retained by the people under the 9th Amendment of the Constitution.


In  medicine ,  salpingo-oophorectomy  is the removal of an  ovary  and its  fallopian tube . [ 1 ] [ 2 ]  This procedure is most frequently associated with prophylactic surgery in response to the discovery of a  BRCA mutation , particularly those of the normally  tumor suppressing   BRCA1  gene (or, with a statistically lower negative impact, those of the tumour suppressing  BRCA2  gene), which can increase the risk of a woman developing  ovarian cancer  to as high as 65% (as high as 25% for a mutated  BRCA2  gene). [ 3 ]


Transvaginal mesh , also known as  vaginal mesh implant , is a net-like surgical tool that is used to treat  pelvic organ prolapse (POP)  and  stress urinary incontinence (SUI)  among female patients. The  surgical mesh  is placed transvaginally to reconstruct weakened pelvic muscle walls and to support the urethra or bladder. [ 1 ] [ 2 ]


A number of mesh materials with varying absorbability has been explored to maximise the  biocompatibility  as well as the repair efficacy of mesh. Depending on the target vaginal space, the application of transvaginal mesh differs in terms of mesh shape, surgical incision and the position of mesh. [ 3 ]


Since 2019, transvaginal mesh has been banned by the US  Food and Drug Administration  (FDA) due to the high prevalence of complications, including mesh erosion, pain and pelvic infection. [ 3 ] [ 4 ]  Complications may arise from concomitant surgery and inappropriate surgical techniques, while they can also be prevented with uterus preservation. [ 5 ] [ 6 ]  Transvaginal mesh was once used widely for nearly 25% of prolapse interventions until the FDA ban, yet approximately 1 out of 15 patients required a mesh removal in the past decade. [ 7 ] [ 8 ] [ 9 ]


Based on how transvaginal mesh reacts inside the patient’s body, the implant is classified into 4 subtypes: [ 10 ] [ 3 ]


The selection of mesh subtype to be placed in patients requires consideration of patients' preference and risk analysis, including evaluation of recurrence risk and complication risk by surgical personnel. [ 12 ]


Transvaginal mesh is used to repair symptomatic  pelvic organ prolapse  that causes pain and discomfort among patients and to treat  stress urinary incontinence . [ 1 ]


Transvaginal mesh prevents pelvic organs, such as the  bladder ,  uterus  and  rectum  from sagging into the vagina due to weak pelvic muscles by acting as a  hammock  underneath. [ 3 ]  Depending on the organs involved, it can be placed on the anterior, posterior, or top wall of vagina transvaginally. In some special cases of  vaginal vault prolapse , the vagina may collapse after the  removal of the uterus  and a transvaginal mesh can be positioned on top of the vagina to fix it in place. [ 3 ]


Transvaginal mesh, also called bladder sling in this case, holds up the  urethra  when pelvic muscles weaken. [ 3 ]  This prevents  bladder leakage  during physical movements that increases bladder pressure. [ 3 ]


Compared to traditional native tissue repair surgery, transvaginal mesh, especially when placed in anterior vaginal area, has improved POP repair outcomes but similar SUI repair outcomes. [ 10 ]


Advantages over native tissue repair are mainly associated with improved surgical procedures, for example, simpler and less invasive procedures, higher reproducibility of techniques and durability. However, transvaginal mesh remains as a refuted method due to its adverse complications. [ 5 ]


As pelvic organ prolapse and stress urinary incontinence can be present separately or simultaneously, surgical mesh is implanted into  vesicovaginal  and  rectovaginal  region through the vaginal route in different approaches, to manage patients’ condition properly.


The goal of POP repair with transvaginal mesh is to increase longevity in patients by reconstructing organ position and preventing pelvic organs from bulging into the vagina. [ 3 ]  Generally, the position and incisions for transvaginal mesh are determined by the corresponding pelvic muscle defect, which differs from patient to patient. [ 3 ]


The implantation usually starts with anterior  colpotomy , which is an incision on the anterior vaginal wall to assess the vesicovaginal space in front of the vagina. [ 3 ] [ 5 ]  For patients who have undergone  hysterectomy  or will be preserving their  uterus , only longitudinal anterior incision can be performed. [ 5 ]  For patients who are also receiving a concomitant  hysterectomy , an anterior  colpotomy , a Cross-T-shaped incision that cuts around the cervix, or a single incision around the cervix and across the vagina will be performed. [ 5 ]


In consideration of the patient's specific conditions, the transvaginal mesh can be positioned in front of the vaginal wall ( cystocele  correction), behind the vaginal wall ( rectocele  correction), or on top of the vagina ( uterine prolapse  correction). [ 3 ]


For cystocele corrections, horizontal arms will be inserted on the lateral bladder walls through the  obturator foramen  by an  Emmet needle . [ 5 ]  Meanwhile, vertical straps will be placed onto the fibrous thickenings of  pelvic fascia  anteriorly and posteriorly in order to reposition the bladder. [ 5 ]


Alternatively, an incision on the posterior vaginal wall will be needed to place the mesh through the  perineal skin  for rectocele correction. [ 5 ]  To hold the rectum upright, the horizontal straps are inserted into space surrounding the rectum, brought out of the body and pulled below the anus. [ 13 ]  If both corrections are required, transvaginal mesh can be cut into two pieces before operation and adjusted for accurate reconstruction. [ 5 ]  After putting the prolapsed organs back to its original position and reinforcing the vaginal wall, the incision is closed with  sutures . [ 5 ]


Transvaginal mesh surgery is expected to show improved pelvic support after the first few weeks, particularly for non-absorbable meshes which have a higher biocompatibility and permanent outcome. [ 9 ]  For absorbable meshes, longer recovery time and lower durability are expected as native tissues need to grow into the pores to support the weakened organs. [ 11 ] [ 9 ]


Transvaginal mesh, also known as midurethral or bladder neck sling for  SUI  repair, can be used to support the urethra or the neck of the bladder in two surgical approaches, namely the  retropubic  and  transobturator . In the retropubic approach, two incisions above the  pubic bone  and one incision in the vagina are performed. [ 14 ]  The transvaginal mesh is then placed under the urethra through the  retropubic space , which is anterior to bladder and posterior to  pubic symphysis , and brought out to the  suprapubic area . [ 15 ]  In the  transobturator  approach, two incisions in the  groin  area and one incision in the vagina are performed. [ 14 ]  The transvaginal mesh is inserted through the  obturator foramen  to avoid damage of pelvic organs, and brought out to the skin in the groin area. [ 15 ]  Since 2008, mini-slings with single vaginal incision have been introduced to reduce complications without comprising the successful rate. [ 14 ] [ 16 ]


Intraoperative complications are of low risk and include vaginal or pelvic  hematoma , bleeding, rectal injury and bladder injury. [ 5 ] [ 17 ]  In contrast, postoperative complications are most frequent among patients and are mainly related to the mesh. [ 3 ]  The high incidence of postoperative complications of transvaginal mesh has led to its ban by the FDA in 2019. [ 18 ]


Mesh erosion describes the exposure, extrusion or protrusion of the mesh exteriorly at the surgery scar. [ 3 ]  Generally, it is the most common postoperative complication and 10.3% of the patients experience mesh erosion within 12 months for pelvic organ prolapse (POP) repair. [ 3 ] [ 4 ] [ 19 ]  Mesh erosion can be classified into 2 main types according to the location of erosion: [ 4 ]


Postoperative vaginal extrusion is defined as a mesh extrusion through the  vaginal mucosa  and is the most common form of mesh erosion. [ 3 ] [ 4 ]  Patients with this complication usually present with discomfort in the vagina as a result of mucosal irritation, abnormal  vaginal discharge , or pelvic pain. [ 4 ]  For sexually active patients, their partners may even feel pain during  intercourse , causing notice of the presentation. [ 4 ]


The most common site for vaginal extrusion is usually in the midline of the surgical incision site since major causes of vaginal extrusion include suture disruption,  subclinical infection  and damage at the surrounding tissue. [ 4 ]


As vaginal extrusion worsen due to delayed healing,  conservative treatment  with oestrogen or antibiotics and recommendation for  sexual abstinence  is usually suggested to alleviate the symptoms. [ 6 ] [ 4 ]  If conservative treatment fails due to large mesh exposure (i.e. > 0.5mm), partial mesh excision is suggested with symptoms expected to resolved in 71-95% of the patients. [ 6 ] [ 4 ] [ 20 ] [ 21 ]  If partial mesh excision fails, a more invasive complete mesh excision will be considered to avoid further complications, especially for those with severe complications. [ 4 ]


Postoperative erosion into the urethra or bladder is less common and presents within 18 month after mesh surgery. [ 7 ] [ 4 ]  Patients with this complication typically show urge incontinence, stress urinary incontinence,  urinary retention ,  hematuria  or  dysuria . [ 4 ]


Complete inspection of urethra by  cystoscopy  can help diagnose this complication and the mesh must be excised. [ 4 ]


Postoperative pain is usually experienced at pelvic, groin, thigh region or during sexual intercourse. Furthermore, it can be caused by mesh erosion or  subclinical infection . [ 3 ] [ 4 ]  One hypothesised  aetiology  for mesh-related pain is that inflammatory response induces the shrinkage of mesh, leading to  vaginal tightening . [ 3 ] [ 4 ] [ 22 ] [ 23 ]


To treat postoperative pain, an examination in the pelvic region is performed to determine the cause of pain. [ 4 ]  If there are no significant examination findings, pain relief drugs, such as  nonsteroidal anti-inflammatory medicine , will be first prescribed to patients. [ 4 ]  If the pain persists for months,  local anesthetics  with  corticosteroids  can be injected at the site of pain. [ 4 ]  For more severe cases, mesh excision with targeted physical therapy can be considered as a last resort. [ 4 ] [ 24 ]


Although postoperative infection seldom occur among patients who have undergone mesh surgery, it is still an  inherent risk  for any surgical implantations and results in severe implications. [ 4 ] [ 5 ] [ 6 ]  In cases of severe infection, complete mesh excision is highly commended. [ 7 ]


Other common complications include urinary problems, abnormal bleeding,  organ perforation  while some rare complications, such as recurrent pelvic organ prolapse, neuro-muscular problems, vaginal scarring and emotional problems are also observed. [ 7 ] [ 3 ] [ 4 ]  From 2008 to 2010, three deaths were associated with transvaginal mesh surgery for  POP  repair due to  bowel perforation  and abnormal bleeding. [ 3 ]


The number and extent of concomitant surgeries increase with the complication risks. [ 5 ] [ 6 ] [ 25 ]


However, for patients who require concurrent mesh slings, concomitant  hysterectomy  is often necessary. [ 5 ] [ 6 ] [ 25 ]  Certain incision methods for  hysterectomy , such as an inverted T incision, will also increase the risk of complications significantly. [ 5 ] [ 6 ]


The size of the incision and extent of sling tension should be minimized to reduce risk of complications. [ 6 ] [ 4 ] [ 25 ]  This is often determined by the surgical skills of surgeons. [ 6 ] [ 4 ] [ 25 ]


Uterine preservation and minimal incision size should be performed as they prevent damage to the urogenital system. [ 5 ]


Initially used in the 50s to mend  abdominal hernias ,  gynecologists  started to use meshes to repair pelvic organ prolapse (POP) and stress urinary incontinence (SUI) in the 90s. [ 18 ]  Over time, manufacturers seized the demand for specific mesh with desired shapes for POP and SUI repair, resulting in the first SUI and POP-specific mesh to be cleared by the FDA as class II moderate-risk devices in 1996 and 2002. [ 26 ]  In 2006, approximately one-third of POP patients opted for mesh implantation, in which over 90% mesh surgeries were performed transvaginally, rather than traditional native tissue repair or with other devices. [ 9 ]  Due to the popular response, mesh products evolved into surgical mesh kits with the addition of new insertion tools, such as tissue fixation anchors. [ 27 ]


Starting from 2008, the FDA took escalating actions to deal with the growing adverse effects and low repair efficacy of transvaginal mesh for POP repair. In 2011, it issued an FDA Safety Communication, pointing out concerns for transvaginal mesh. [ 18 ]   In 2016, the FDA reclassified transvaginal mesh for POP repair into a class III high-risk device, requiring manufacturers to submit a premarket approval application to keep transvaginal mesh products on the market. [ 18 ]  After an advisory committee meeting, the FDA announced that the safety and effectiveness of transvaginal mesh for POP are not scientifically assured and all transvaginal mesh products, except midurethral slings, were banned to protect the health of female patients on 16 April 2019. [ 18 ]


Currently, there are several legal actions against major transvaginal mesh manufacturers like  Johnson & Johnson  and  Boston Scientific  to compensate complications. [ 9 ]  A class of 700 Australian women sued Johnson & Johnson for selling defective transvaginal meshes. [ 9 ]  Similar self-claimed victims in the United Kingdom and the United States have sparked off more than 100,000 transvaginal mesh-related lawsuits. [ 9 ]  Up until now, Johnson & Johnson and Boston Scientific have agreed for payments in total of $8 billion to resolve the claims. [ 28 ]


Tubal reversal , also called  tubal sterilization reversal ,  tubal ligation reversal , or  microsurgical tubal reanastomosis , is a surgical procedure that can restore  fertility  to women after a  tubal ligation . By rejoining the separated segments of the  fallopian tube , tubal reversal can give women the chance to become  pregnant  again. In some cases, however, the separated segments cannot actually be reattached to each other. In some cases the remaining segment of tube needs to be re-implanted into the uterus (a 'tubal reimplantation'). In other cases, when the end of the tube (the 'fimbria') has been removed, a procedure called a neofimbrioplasty must be performed to recreate a functional end of the tube which can then act like the missing fimbria and retrieve the egg that has been released during ovulation.


The  fallopian tube  is a muscular tube extending from the  uterus  and ending with attached fimbria next to the  ovary . The tube is attached to the ovary by a thin tissue called the mesosalpinx. The inner tubal lining is lined with  cilia . These are microscopic hair-like projections that beat in waves that push fluid down the tube towards the uterus thereby helping move the egg or  ovum  to the uterus in conjunction with muscular contractions of the tube. The fallopian tube is normally about 10 cm (4 inches) long and consists of several regions that become wider as the tube gets farther away from the uterus. Starting from the uterus and proceeding outward, these are the:


Tubal reversal surgeries require the techniques of  microsurgery  to open and reconnect the fallopian tube segments that remain after a tubal sterilization, reimplant remaining segments, or create new fimbria. [ 1 ] [ 2 ]


Following a  tubal ligation , there are usually two remaining fallopian tube segments - the proximal (close) tubal segment that emerges from the  uterus  and the distal (far) tubal segment that ends with the  fimbria  next to the  ovary . After opening the blocked ends of the remaining tubal segments, a variety of microsurgical techniques are utilized to recreate a functional tube. The newly created tubal openings are drawn next to each other by placing sutures in the connective tissue that lies beneath the fallopian tubes ( mesosalpinx ). The retention suture prevents the tubal segments from pulling apart while the tube heals. Microsurgical sutures are used to precisely align the tubal lumens (inside canal of tube), the muscular portion ( muscularis externa ), and the outer layer ( serosa ) of the tube. Most surgeons try to avoid the use of stents which can damage the delicate cilia that line the tube and create the flow of fluid that is needed to push the egg and embryo into the uterus. Other surgeons use a narrow flexible  stent  to gently thread through the tubal segments or into the uterine cavity in order to line up the tubes in order to reconnect them. In either case, once the microsurgical repair is completed dye is injected through the cervix into the uterus and out through the tubes to ensure that the fallopian tube is open from the uterine cavity to its fimbrial end. The surgeons who use stents then gently withdraw them from the fimbrial end of the tube after the repair is completed.


In a small percentage of cases, a tubal ligation procedure leaves only the distal (far) portion of the fallopian tube and no proximal (close) tubal segment. This can occur when any method of tubal ligation has been applied to the isthmic segment of the fallopian tube as it emerges from the uterus. In this situation, a new opening can be created through the uterine muscle and the remaining tubal segment inserted into the uterine cavity. This microsurgical procedure is called  tubal reimplantation.