Tubal Reversal
Tubal Ligation
Tubal ligation is a commonly performed sterilization procedure. There are a variety of ways in which the procedure can be performed. Laparoscopic procedure using electrocautery, clips or rings to occlude the proximal portion of the tubes is a common method to block tubes. Clips and rings cause a crush injury so that the blood supply in a small segment of the fallopian tube is cut off. Eventually, this segment of the fallopian tube will die.. What is left is a missing piece of the tube close to where the tube implants to the uterus (referred to as the proximal end). Once a small segment of tube has died, the clip or ring will remain. Another commonly used method is cautery. During cautery, a small segment of tube is grasped with a bipolar grasping forceps, and an electrical current is passed through it until the tube is literally fried. This usually results in approximately 2-3 cm of tubal destruction. This segment of the tube also dies and the end result is a missing segment of the tube.
Sometimes a tubal ligation is performed at the same time as a cesarean section. This procedure is called a Pomeroy procedure. During this procedure, a small section of the tube is actually cut out and the ends are tied off with suture material. A less commonly performed procedure is a fimbriectomy. During this procedure, the ends of the tube are completely removed. Because the fimbria is an essential part of the tube, this procedure is irreversible.
Surgical Tubal Reversal
Dr. Kaufmann is a surgeon who specializes in microsurgical techniques such as tubal reversal. If a tubal reversal is to be considered, it is important to identify how much of the initial tubal ligation was performed. With clips or rings, there is usually enough tube left for the surgeon to work with and repair the fallopian tubes. Tubal cautery tends to cause more damage to the tube. However, in many cases these tubes are also amenable to repair. The important thing is for the surgeon to identify that there is at least 4-5 cm of fallopian tube to work with (average length of fallopian tube is 6-10 cm). If there is any doubt regarding whether a tubal reversal could be considered, we will first perform a laparoscopy to evaluate the quality and length of tube remaining and if there is a sufficient length of tube, he will proceed with the tubal reversal.
Most tubal reversals are done using an open technique. This means making a 2-3 inch incision in the abdomen in a bikini-like fashion. The abdomen is opened and using a microscope the ends of the tubes are reconnected (tube-to-tube reanastomosis). The procedure normally takes 2 hours. After the procedure, you will spend a couple of hours in the recovery room and will be sent home that day. In some less common cases, you may decide to spend the night in the hospital. As the surgical procedure is not covered by your health plan, the decision to spend the night in the surgical facility will be an added expense.
Success rates for this procedure are partially dependent on the technique that was originally used to occlude your tubes and your age. Age has a significant effect on fertility.
The chance of becoming pregnant after a successful tubal reversal in a woman under age 35 is 60-80% over a two-year period. Before having a tubal reversal, it is always important to do a semen analysis, as the sperm quality can seriously affect fertility as well. Other appropriate tests may include ovulation tests and tests for ovarian reserve.
During your first visit with us, we will review the operative notes and pathology report from your tubal ligation. We will use these to assist us in determining the length of tube that was removed .
Pregnancy After Tubal Reversal
We ask patients to take a pregnancy test as soon as they have missed a period, and inform us of all positive pregnancy tests. The main risk associated with tubal ligation reversal is ectopic pregnancy, which occurs in 10% of pregnancies after tubal surgery. Detected early, an ectopic or tubal pregnancy can be treated medically to avoid damage to the fallopian tube and the need for additional surgery. When a woman has a positive pregnancy test, we repeat blood serum HCG tests twice a week and perform a vaginal ultrasound when the HCG level reaches 1500 to look for the pregnancy sac.
Success of Tubal Ligation Reversal
The success of tubal ligation reversal depends primarily on the length of the fallopian tubes after repair, patient age, and method that was used for the ligation. There must be three to four centimeters of fallopian tube for pregnancy to occur. Prior to reversal, it is helpful for the patient to supply us with a copy of the surgical note from the initial tubal ligation procedure. If portions of the tubes were actually removed, a pathology report is also helpful.
If the patient had no problems becoming pregnant prior to tubal ligation, and the reversal is successful, the patient should be able to conceive. At your consultation we will attempt to give you a better idea of what to expect regarding your chances of conception after your reversal.
In Vitro Fertilization
Another option for becoming pregnant following a tubal ligation is in vitro fertilization. In vitro fertilization is the process by which fertility drugs are used to stimulate the ovaries to produce a number of eggs. Eggs are grown in little capsules of fluid called follicles, which can be monitored by ultrasound. Usually 10 days of fertility drugs are required to stimulate the ovaries. When the eggs are mature, they are retrieved by ultrasound guidance. An ultrasound probe is inserted into the vagina with a needle along side of it to aspirate the eggs. The eggs are then fertilized in a laboratory using the partner's sperm. Fertilized eggs are called embryos. Embryos are cultured in a special incubator for 2-5 days and then the embryos of the best quality are placed back into the uterus by a procedure called an embryo transfer.
The success rates of in vitro fertilization are directly proportional to age. For healthy women under 35 with 2 embryos transferred, the chances for a successful pregnancy are 55%. As women get older, success rates start declining. By age 40, the success rate is closer to 30 or 40%. The risk of multiple pregnancies with in vitro fertilization is related to the number of embryos that are transferred back to the uterus. As women age, the competence of embryos starts to decline. Because of this, an extra 1 or 2 embryos may be transferred to compensate for this fact and improve pregnancy rate.
Tubal reversal or In Vitro Fertilization
The following factors require consideration when deciding between tubal reversal and in vitro fertilization:
- Age. As previously mentioned, the maternal age does have a significant impact on fertility. Fertility starts declining significantly after the age of 35 and then precipitously after the age of 39 to 40.
- Male factor. It is important for the semen analysis to be performed before considering which option to choose. If the semen analysis shows poor quality of sperm, then by far the better option would be in vitro fertilization.
- Social circumstances. In some situations, couples do not want to wait for pregnancy and therefore may decide to proceed with in vitro fertilization.
- Cost. The cost of in vitro fertilization is approximately $10,000 to $12,000. The cost of a tubal reversal, which includes the surgeon's, assistant, anesthesiologist and facility cost are $6,000.
- Personal preference. Also depends on the particular person's willingness to undergo a laparotomy or in vitro fertilization. A laparotomy requires a general anesthetic and of course time for recovery. In vitro fertilization involves a commitment with regards to monitoring during the cycle itself, egg retrieval, and embryo transfer.
As you can see, there are numerous considerations to process when deciding between in vitro fertilization or tubal reversal. The main advantage of having a tubal reversal is that once it has been done, there is an ongoing chance of pregnancy every month. The success rates of both tubal reversal and in vitro fertilization are higher in the younger age group.
Dr. Kaufmann and staff will be happy to provide you with information that may assist you in making a decision.
Estimated Tubal Reversal Costs:
Surgeon’s Fee $3,000 (including assistant surgeon)
Anesthesia Charge $800
Facility Fees $2,200
Total Estimated Fees $6,000
*Total Estimated Fees do not include follow-up care.
*Total estimated fees do not include the cost of yuor initial visit.
Initial Office Visit $400
This visit includes an examination and a pelvic ultrasound examination.
Fort Worth Fertility must be paid by check, money order or credit card at least 7 days prior to surgery or surgery will be cancelled
Fees may be subject to change without notice
Testimonials
"I had my tubal reversal in June 2006 and 18 months later we have our little Kourtney. Words cannot express how grateful my family and I are to Dr. Kaufmann." Joan W. and Family
"My tubal reversal baby is here! He was born 11-9-07. Please thank Dr Kaufmann." Lisa P.
"It took me only 4 months to get pregnant after my tubal reversal." Susan and Johnny H.