Tubal reversal

Tubal reversal - short for tubal sterilization reversal or tubal ligation reversal - is a surgical procedure that restores fertility to women after a tubal ligation. By rejoining the separated segments of fallopian tube, tubal reversal gives women the chance to become pregnant again naturally. This delicate surgery is best performed by a reproductive surgeon with specialized training and experience in the techniques of tubal ligation reversal.

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Tubal Anatomy

To understand the techniques of tubal reversal surgery, it is helpful to visualize the anatomy of the normal fallopian tube. The fallopian tube is a muscular organ extending from the uterus and ending next to the ovary. The tube is attached to the ovary by a small ligament. The inner tubal lining is rich in cilia. These are microscopic hair-like projections that beat in waves that help 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 segments. Starting from the uterus and proceeding outward, these are the:

• Interstitial segment - extends from the uterine cavity through the uterine muscle
• Isthmic segment - narrow muscular portion adjacent to the uterus
• Ampullary segment - wider and longer middle part of the tube
• Infundibular segment - funnel shaped segment next to the fimbrial end
• Fimbrial segment - wide opening at the end of the tube facing the ovary

Microsurgery

Tubal ligation reversal utilizes the techniques of microsurgery to open and reconnect the fallopian tube segments that remain after a tubal sterilization procedure. Microsurgery minimizes tissue damage and bleeding during surgery. Essential elements of microsurgical technique include gentle tissue handling, magnifying the operating field, keeping body tissues in their normal state with warmed irrigation fluids, and using the smallest sutures with the thinnest needles capable of holding the tubal ends together to promote proper healing of the rejoined tubal segments.

Tubal Reversal Procedures

Tubotubal Anastomosis

Following a tubal ligation, there are usually two remaining fallopian tube segments - the proximal tubal segment that emerges from the uterus and the distal tubal segment that ends with the fimbria next to the ovary. After opening the blocked ends of the remaining tubal segments, a narrow flexible stent is gently threaded through their inner cavities or lumens and into the uterine cavity. This ensures that the fallopian tube is open from the uterine cavity to its fimbrial end. The newly created tubal openings are then drawn next to each other by placing a retention suture in the connective tissue that lies beneath the fallopian tubes (mesosalpinx). The retention suture avoids the likelihood of the tubal segments subsequently pulling apart. Microsurgical sutures are used to precisely align the muscular portion (muscularis externa) and outer layer (serosa), while avoiding the inner layer (mucosa) of the fallopian tube. The tubal stent is then gently withdrawn from the fimbrial end of the tube.

Tubouterine Implantation

In a small percentage of cases, a tubal ligation procedure leaves only the distal portion of the fallopian tube and no proximal tubal segment. This may occur when monopolar tubal coagulation 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 tubouterine implantation, uterotubal implantation, or, simply, tubal implantation. Tubal implantation is performed when tubal anastomosis is not possible due to the absence of a proximal tubal segment and interstitial tubal lumen.

Reasons for Tubal Reversal

Women give many reasons for having a tubal ligation reversal. One of the questions that Dr. Berger asks his patients is “What made you decide to have a tubal reversal procedure at this time?” The most common responses to this question are:

• Remarriage with desire to have children with new spouse (75%)
• Same marriage with desire to have more children (20%)
• Death of a child (2%)
• Relief of symptoms of "Post Tubal Ligation Syndrome" (2%)
• Religious or spiritual concerns (1%)

Sterilization Regret

In a study called the U.S. Collaborative Review of Sterilization (CREST) , women who had tubal ligations were asked "Do you still think tubal sterilization as a permanent method of birth control was a good choice for you?" Overall, 13% of women said they did not think that the tubal ligation was a good choice. The percentage expressing regret 20% for women aged 30 years or younger at the time of sterilization, compared with 6% for women older than 30 years at the time of tubal ligation. For women under age 25, the rate 40%.

Despite the high percentage of women who subsequently regret having had a tubal ligation, only 0.2% of women in the CREST study underwent tubal reversal. Reasons for this discrepancy may include lack of information about tubal reversal, cost of the procedure, and lack of insurance coverage for this procedure. Women often receive inaccurate information about tubal reversal - such as tubal ligation cannot be reversed, or the only treatment option is in vitro fertilization (IVF), or tubal reversal is available only as a high cost operation requiring hospitalization.

Questions To Ask

Here are some questions to ask to consider to find out if tubal reversal is right for you.

Have you had your tubes tied, but would now like to conceive again?

If you have had a tubal ligation performed (commonly referred to as having your tubes tied), then you may be a candidate for tubal reversal surgery.

What type of tubal ligation did you have?

There are several different ways for a doctor to tie somebody's tubes. In order for a tubal reversal to be successful, there needs to be enough healthy tube remaining for the repair.

Women with the clip or ring (band) method of tubal ligation have the highest pregnancy rates after undergoing tubal reversal surgery, but almost any method of tubal ligation can be reversed successfully. If you aren't sure what type of tubal ligation you had, you can obtain a copy of your operative and pathology reports relating to your tubal ligation. These reports will give you specific information about your tubal ligation procedure.

How old are you?

The natural fertility rate declines with increasing age. As with any pregnancy, conceiving after reversal surgery is more likely for younger than older women. If you are older than 40, it is still possible to become pregnant if you are ovulating and having menstrual periods, but pregnancy rates will be lower than for younger women. Tubal reversal surgery restores, but does not increase, the natural level of fertility associated with age.

What should I look for in a doctor to perform my tubal reversal?

You can check online to see if the doctor is a Fellow of the American College of Obstetricians and Gynecologists and also a member of the Society of Reproductive Surgeons. Doctors with both of these credentials have the training and experience best suited for tubal reversal surgery.

Ask the doctor how many tubal reversal surgeries he or she has performed. The more experienced the doctor the less likely it is that something unexpected will happen. Some doctors perform tubal reversals on an outpatient basis. This avoids the cost and risks of hospitalization, such as hospital-acquired infection. Also ask the doctor about the pregnancy and birth rates among his patients after the surgery. A reputable doctor will offer to share this information with you including the number of patients having the procedure, the number who have become pregnant, and the outcome of the pregnancies (birth, miscarriage, or ectopic pregnancy).

• "Age and Fertility" Summary Graph.

• "Society of Reproductive Surgeons" Patient Resources.

• "Tubal Reversal Video.