Reversal of Tubal Ligation
An overwhelmingly large number of women who have previously had children will make an early decision to have a tubal ligation as a method of contraception. After their tubes are ligated ("tied"), the tubes are closed so that an egg and a sperm are thereby prevented from moving into the uterus for implantation and growth. Many women, however, regret this decision later in life as they desire to have more children. Some will decide to have their Tubal Ligation reversed. Certain gynecologists who have been specially trained to put these delicate tubes back together can perform a reversal through a Microsurgical Tubal Reanastomosis (MTR).
What is Microsurgical Tubal Reanastomosis (MTR)?
MTR is a very safe and very effective operation that has been performed successfully for more than 30 years. While there are many ways to perform this operation, it is essential that an experienced physician, who is trained in the use of microsurgical instruments and techniques, performs this very delicate operation. The area of the tubes which was occluded is removed, leaving only open, healthy tube. These open, healthy, tubal segments are then connected. A multilayer, microsurgical technique is used to suture these segments together. After the tubes are repaired, a chromopertubation is performed wherein dye is injected into the uterus. This dye is passed through the repaired tubes to ensure that the tubes are open. The entire surgery is performed through a small incision of about 3 to 4 inches just at the uppermost part of the hair line. It is very important to note that either failing to properly align the tubal segments, or damaging these delicate structures, can make the difference between a successful and an unsuccessful operation.
Where does Dr. Morice perform Tubal Reversals?
Dr. Morice is on staff at Thibodaux Regional Medical Center in Thibodaux, Louisiana, Teche Regional Medical Center in Morgan City, Louisiana, and the Gulf Coast Surgical Center in Houma, Louisiana. He performs Tubal Reversals at all three facilities.
Do I have to stay in the hospital overnight?
Not anymore. Today, MTR is an outpatient surgery that typically takes about 2 hours to perform. You will be allowed to leave the hospital after eating lunch. If you are traveling from an area more than a few hours away, hotel reservations should be made so that you can spend the night nearby and avoid a long journey the same day as your procedure (please read the questions below). While some patients elect to travel back the same day to their homes out of town or out of state, a long trip should be avoided until the day following your surgery. This is strictly a precaution. Please note that while special discounted prices have been arranged at local hotels for Dr. Morice's patients, this expense is not included in the cost of the tubal reversal.
Can I have my tubes put back together even if I had them tied 15 years ago?
Yes :-)... However, in rare cases, much of the tube may have been removed (which could result in a decreased success rate), or perhaps scar tissue or other abnormalities may have formed (which could prevent the successful completion of the reversal). Dr. Morice requests a copy of the pathology report and the operative report prior to surgery. This information helps to ensure that there will be enough tube remaining to be put back together. If unavailable, these findings may not be known until the actual procedure is performed.
How successful is the procedure?
The success rate of the operation is defined as a subsequent intrauterine pregnancy. This approaches 80%. Other factors such as ovarian function and age also influence the success rate. Dr. Morice will request a recent semen analysis from the couple to rule out male-factor infertility when appropriate. While the specific type of tubal ligation will influence the success rate of the procedure, most forms of surgical sterilization can be reversed. The amount of tube which has been removed or destroyed will also influence the success rate. While we like to have 5 or more centimeters of tubal length after reanastomosis, at least 3 cm of tube are desired to achieve pregnancy for most patients.
Is the surgery dangerous?
It is surgery, and there are standard risks of surgery such as bleeding, infection, anesthesia, and injury to other structures in the pelvis and abdomen. These complications are rare with this procedure, and Dr. Morice has never had any complication with a MTR procedure. This is considered a very safe operation.
How about the risk of an ectopic pregnancy?
There is an increased risk of tubal (ectopic) pregnancy following any tubal surgery. As a precaution, as soon as a pregnancy is achieved, Dr. Morice recommends a very early evaluation to rule out a tubal pregnancy.
How much does it cost?
Few, but not most, insurance policies cover surgery for reversal of sterilization. Outpatient fees for this operation elsewhere range between $5,000 and $14,000 for all fees associated with the procedure (hospital, anesthesia, and surgeon fees). The total cost for a Microsurgical Tubal Reversal by Dr. Morice is $5,250. This price is the sum of the reduced hospital fee that Dr. Morice has arranged ($2,800), the reduced anesthesia fee that Dr. Morice has arranged ($700), and the reduced surgeon fee charged by Dr. Morice for self-pay procedures ($1,750). These fees are paid separately to each entitiy, or can be financed through Care Credit (www.CareCredit.com) and paid to Dr. Morice in full for an additional 5% fee. (As most patients travel from outside of town, please be aware that this does not include the cost of travel and local accommodation).
What does Dr. Morice need to know to determine if my reversal will have a good chance of working... If I am a "good candidate?"
A copy of your Operative Report from your tubal ligation surgery, as well as any pathology report, should be faxed (985-702-8282) to Dr. Morice's office before you make an appointment. Fax this to Dr. Morice's attention. On the fax, please include the following: your age, weight, height, number of prior pregnancies (including any miscarriages), menstrual cycle pattern (regular or irregular cycles), prior infertility and/or medical problems, cigarette/alcohol/drug use by either yourself or partner, and date of most recent pregnancy for both yourself and your partner. He will review the reports and you will be informed of the likelihood of a successful reversal. Additionally, if you have any laboratory reports, x-rays, or hormone studies, please send these. Referrals from your gynecologist are helpful as they often include more pertinent data regarding your history.
My doctor burned my tubes but her operative report does not say how much of the tubes she burned. Can you still fix my tubes?
If you had your tubes burned, it is important to know just how and how much of the tubes were burned. Even if you had your tubes burned in two or three places, if the operative report does not specify the distance between the outer areas that were burned, it is impossible to know for sure how much healthy tube is left to be put back together. Your best chance for a successful pregnancy is if you have at least 5 centimeters of healthy tube on each side... However, pregnancies can occur with less tubal length. If your doctor burned 3 spots each 1 centimeter apart (a relatively usual practice) then you would have 'lost' 5 centimeters directly, plus a centimeter on each side... so about 7 centimeters of destroyed tube would have to be removed to put back the rest of the healthy tube. This would leave you with 3 cm on each side (on average assuming that the original tubal lengths were 10 centimeters each). With 3 centimeter tubes (after reanastomosis) you would have a less than average chance of a successful pregnancy... However, if you are young and fertile, you will have about a 50% to 60% chance of a successful pregnancy. If your doctor simply burned each tube in two spots 1 centimeter apart, you would have 'lost' 3 centimeters, plus 1 on each side... so about 5 centimeters of destroyed tube would have to be removed to put back the rest of the healthy tube. This would leave you with about 5 centimeters of healthy tube on each side (again assuming that the original tubal lengths were 10 centimeters each). If you are young and fertile, you should have a greater than 80% chance of a successful pregnancy - Please understand that these estimates are based on several presumptions (you and your partner's fertility, the average tubal length, the amount of burned tube, and any scar tissue present).
I live out of town. Can I go back to my regular doctor after the surgery?
Most patients who get their tubes reversed by Dr. Morice have traveled from outside of the Morgan City / Houma / Thibodaux area. After your surgery, Dr. Morice will be happy to see you and to take care of you for as long as you desire... But if you live more than an hour away it is just much more convenient and safe for you to have a local obstetrician managing your pregnancy. Therefore, once you get pregnant you will be expected, but certainly not required, to continue care with your regular obstetrician. Dr. Morice is happy to discuss your MTR and subsequent care with your obstetrician at any time.
How 'YOUNG' do I have to be? I'm 44... Am I too old??
As the ability of the ovary to produce an egg declines with age, patients who are 40 years old or above are generally required to have blood work done to evaluate the quality of their ovaries. In fact, any patient may have this testing done. Dr. Morice is focused on the success of your tubal reversal. If your ovaries are not producing good eggs, your likelihood of a successful tubal reversal will be diminished. If your ovarian function is diminished, IVF, instead of a tubal reversal, may be the best option for you. The most common blood work ordered to evaluate the ability of your ovaries to produce good eggs may include testing for FSH, LH, estradiol, inhibin B, and progesterone on specific days during your normal menstrual cycle. A high estradiol level may also indicate that an ovarian corpus luteum cyst left over from the previous menstrual cycle is still hormonally active. The corpus luteum is what remains of a follicle after an egg is released. For a short time after ovulation, this cyst will continue to produce the hormones needed in the event of a pregnancy. Inappropriately timed hormone production can interfere with normal growth of the uterine lining and inhibit follicle selection and growth during your cycle (ovarian function). So, when the estradiol test is too high on the third day of the cycle and a cyst is still present in the ovary, these labs can either be repeated at the beginning of the next cycle, or the ovarian cyst can be suppressed with birth control pills. If a cyst is not seen, additional checking for age-related fertility problems will be performed.
In some cases a special test called a clomiphene citrate challenge test (CCCT) is performed. FSH and estradiol levels are measured on the third day of your cycle. On your cycle days 5 through day 9, 100 milligrams of clomiphene citrate (Clomid) is taken. Two days later, your FSH level is measured again. A high FSH value (above 10) is a poor predictor of fertility.
If it does not appear that you are making good eggs, Dr. Morice will recommend that you proceed with IVF rather than a tubal reversal. You may need to consider an IVF procedure using an egg donor. Dr. Morice works with several excellent physicians around the U.S. who perform IVF procedures and who have lists of egg donors available. For the purposes of achieving pregnancy, Dr. Morice will not perform a tubal reversal on any patient with a poor chance of fertility due to poor ovarian function.
I'm a newlywed, and my partner is older and has never had children. Does he need to be tested?
Any male over 30 with a history of never fathering a child is a candidate for a semen analysis. Any man over 40 is strongly advised to get a semen analysis. Also, men who work in chemical plants, work with radiation, who have a history of Mumps, who have a history of testicular trauma, or who have a history of a varicocele need to consider having a semen analysis. Just like blood work done on you, the semen analysis can be ordered by fax at your local laboratory facility and your partner can have the test performed locally. Dr. Morice will receive a faxed copy of the semen analysis report and he will review it with you for an in-depth evaluation of your chances for a successful tubal reversal.
I live out of town. How is this going to work with me coming into town to have my surgery?
If you are coming from out of town you will have an office visit the afternoon prior to surgery. You will be sent to the hospital to register and to have your blood drawn. You will meet Dr. Morice and go over the surgery with him. Your history and physical will be performed, and you will have a pelvic ultrasound in the office. You will then be able to go to your hotel and rest for the night. The following morning you will arrive at Teche Regional Medical Center at a time depending on when your surgery is scheduled. You will meet the anesthesiologist who will review with you the General Anesthesia that is used for the surgery. The surgery takes an average of two hours. After your surgery, and after you have eaten regular food and have voided and ambulated, you will be discharged home and you can return to your hotel. Most patients are able to travel home the evening of their surgery, or the morning following their surgery, depending on how far away they live.
Will Dr. Morice be able to check my blood work before I come in from out of town to have my surgery? What if my blood work is abnormal?
Your blood work will be done at a local laboratory or hospital the week before your surgery. Dr. Morice will fax orders to your local facility and the results will be faxed back to Dr. Morice so that he can review them before you come in for your surgery. In rare cases, the blood work may show that you are not a good candidate for surgery at the time, and you may be advised to do things that would help correct any abnormal labs so that you can have the surgery performed in the future.
I would like to know if you have to be under a certain weight
More so than weight, we look at Body Mass Index (BMI). BMI, determined by your height and weight, gives us information on the amount of body fat expected to potentially complicate a surgery. For a MTR, it is best to have a BMI of less than 30 (ie. a 5'6" patient who weighs less than 185 lbs). A BMI of less than 25 is 'normal.' The bigger the patient, the bigger the incision and the more difficult the surgery. Also, heavier patients tend to have more fertility issues. We can do a reversal in anyone with a BMI of less than 35, but for safety issues, patients with BMIs above this are not the best surgical candidates. If your BMI is above 35, please make every attempt to achieve weight loss through a strict dieting and exercise program. Please realize that optimal weight will increase your fertility as well, and that we want to make sure that you are fertile so that you will be able to get pregnant after we reverse your tubes. A BMI calculator is available at www.nhlbisupport.com/bmi
There may be an additional surgical fee for patients with a BMI of 35 or greater as the procedure may take more time and require additional surgery and anesthesia.
When can we have SEX after the surgery?
Generally we ask that you refrain from any sexual activity for at least two weeks after surgery, and then just take it slow and easy. Remember, you should use birth control for the first two months after surgery, so that any sexual activity needs to be performed with caution. While your tubes will take a few weeks to a couple of months to heal, the abdominal incision may take even longer to heal. If you resume sexual activity too soon, pain at the incision site may be a problem.
If I had my tubes 'tied,' should I consider In Vitro Fertilization (IVF) or a Microsurgical Tubal Reanastomosis (MTR) procedure?
This will depend on your age, prior fertility issues, and type of tubal ligation surgery. If you are 37 years old or younger, with no prior fertility issues, you will most likely benefit more from a MTR than from IVF. If you are over 38, or if you have had prior fertility issues, IVF may be the best choice for you. This question will be best answered only by a careful review of your history and the surgery that you had to ligate your tubes.
What are the advantages and disadvantages of both MTR and IVF?
Tubal reversal surgery - MTR: The biggest advantage of MTR over IVF is that once you have completed the reversal, you may no longer need any intervention through a physician (such as expensive medications or procedures) in order to get pregnant. Regular intercourse, in time, should lead to a pregnancy. There is also a very low risk for multiple pregnancy (twins occur naturally in only 1 out of every 90 pregnancies). The biggest disadvantage is that this is a minor surgical procedure. Also, there is the possibility that the tubes may have been too damaged to be reversed, or that other infertility issues will prevent pregnancy. Also, after your additional child (or children), you will need to use contraception (or have your tubes tied again).
In vitro fertilization - IVF: In vitro fertilization involves stimulating your ovaries with medications and taking a number of eggs from your ovaries during a minor surgical procedure. These removed eggs are then individually fertilized with sperm and then transferred back into the uterus with the hope that one will implant. The biggest advantage of IVF is that you can avoid the minor surgery involved with MTR, but you will still need a minor surgical procedure for egg retrieval. Also, the outcome of IVF is known 10 days after the procedure (with the first pregnancy test) vs. waiting 6 months to a year or more to find out whether MTR was successful. Success rates with IVF will vary greatly according to the IVF program, with the average pregnancy rates less than 50% per attempt in women under 40 years old. Some IVF programs report pregnancy rates of only 20 to 30% (or sometimes less). The biggest disadvantages of IVF are that you have to take medications to stimulate the development of multiple eggs. Risks of over-stimulating the ovaries can be life-threatening (Ovarian Hyperstimulation Syndrome - OHSS). Also, the risk for multiple pregnancy is greatly increased.
Another disadvantage is that if the first attempt does not work, you must do IVF again. Often there would be embryos left over that were frozen from the first cycle so that it is much less expensive and easier for a second attempt using the frozen embryos. However, if no frozen embryos are left from the first cycle, the cost for the second attempt is usually the same as for the first one.
Discussion
Many women desire to have another baby after a prior tubal ligation for many reasons, such as a second marriage, a change in financial status, or the loss of a child. Unfortunately, most people are not aware that tubal ligation is so highly successful. Most gynecologists consider a patient who has had a tubal reversal to be an 'infertility' patient and they simply send them to a physician who specializes in IVF, rather than a physician skilled in tubal reversal. Yet a tubal reversal can be reversed through a low cost, short outpatient surgery! Information is widely available about IVF results in the United States from the Centers for Disease Control (CDC). This can be compared to the higher rates of successful pregnancy outcome following a tubal reversal.
Tubal reversal surgery allows couples the option of natural conception, or if desired, ovulation induction and Intra-Uterine Insemination. Unlike IVF, reversal can give a couple opportunities to have more than just one child without having to undergo any further procedures. For most women, tubal reversal has a higher pregnancy rate and a higher birth rate than IVF and is therefore considered the best treatment.
The type of tubal ligation will determine whether your chance of pregnancy is closer to 85% or less than 60%. Of the major tubal sterilization methods, the most common is tying and cutting out a segment of the tube (ligation / resection). The second and third most common procedures are mechanical occlusion by tubal clips / rings, or coagulation (burning) of the tubes. The least likely is removing the end of the tube (a fimbriectomy). The likelihood of a successful pregnancy following these procedures varies. The greatest success rate occurs in patients who had a mechanical occlusion using Filshie clips. The least successful is in patients who had a fimbriectomy. The reason for this relates to the amount of tube that will be left after the tubal reversal is performed. Greater length relates to a higher success rate, therefore, if more tube was removed or damaged during the tubal ligation, then less tube will be left after the tubal reversal. A normal fallopian tube before ligation is approximately 10 cm (4 inches). Women with longer tubal lengths have significantly higher pregnancy rates than women with shorter tubal lengths.
It is especially important to understand that your expected fertility is based on your age, your medical history, your ovulatory function, and your partner's semen analysis. These factors will play a large role in the rate of successful pregnancy after tubal reversal. Younger women have higher pregnancy rates than older women, as do patients who are in good health without any history or risk factors for infertility.
After your reversal, you may not need a follow-up office visit. Most patients have absolutely no problems and are feeling completely 'back to normal' just a few weeks after their procedure. If there are any concerns or unanswered questions, patients can either call the office at any time, or schedule a visit after their surgery is performed.
While it takes a month or two for the tubes to heal, we ask that patients wait two months before trying to get pregnant. Any couple may choose infertility assistance such as induction of ovulation and / or monitoring of new follicles. Dr. Morice also performs super-ovulation (stimulation of the ovaries with medication to force them to make better eggs), Intra-Uterine Insemination (IUI: injection of prepared sperm into the uterine cavity at the time of ovulation), trigger shot administration (an injection of medicine that will force ovulation), and sperm preparation (separation and selection of the most motile and active sperm from the semen sample) when indicated. This more aggressive approach for the infertile couple has been beneficial in accelerating pregnancy rates among older or poorly ovulating patients.
