Female fertility is controlled by reproductive hormones. An imbalance in these may cause an inability to ovulate (release an egg) called anovulation.  Anovulation may lead to symptoms of a hormonal imbalance, or possibly a woman may not ovulate due to a hormonal imbalance.  This cyclic balance between hormones is needed for fertility in women.

After menopause, imbalance is normal due to the aging process. For some younger women, even in their thirties or younger, symptoms of early onset of these hormonal imbalances and the associated disorders has become more and more of a problem.

What factors may present in young female patients?

Hormonal imbalance may be dependent on some continuing factors in a woman’s life, such as:

Nutrition or lack of it,

Basic diet imbalance,

Environmental reasons, including pollution,

Stress,

Contraceptive and birth control medication,

Exercise or lack of it,

Above average consumption of non-organic foods,

Animal products that have disproportionate amounts of estrogen,

Anovulation.

Anovulation may lead to the significant problem of disturbing hormones.  When a woman is not ovulating it means she may be producing too little of one hormone, and/or too much of another.  The production of progesterone from the ovaries does not take place during an anovulatory cycle.  The direct cyclic result is that the normal value or level of progesterone starts to decline. Also, the estrogen level starts to rise.

Note:  The amount of these hormones produced in a woman’s body can fluctuate from one month to the next even in healthy women, but is that there is an incorrect relationship between progesterone and estrogen levels which may lead to infertility.

Some surgical procedures may affect one’s ability to ovulate for a short period of time. For example, after a tubal reversal some women may undergo a temporary phase of hormonal imbalance between progesterone and estrogen levels. This will resolve as the body recovers from the tubal reversal.

Accurate functioning of fallopian tubes

Accurate tubal function involves:

1.  The fimbria of the Fallopian tube picking up the egg

2.   Transportation of the egg through the Fallopian tube by the cells that line the inside of the tube

3.  Fertilization of the egg by a healthy sperm which can penetrate the egg’s protective covering

4.  Transfer from the fallopian tube into the uterus where the embryo implants

If implantation occurs in the tube, this results in a tubal pregnancy.

For the above processes to occur, the tube must be open. Many patients have undergone a tubal ligation procedure which has closed the tube. Tubal reversal is a challenging surgery that can be done by an experienced surgeon that allows one to regain the previous anatomy and physiology of the healthy tube.  After a tubal reversal, fertility prognosis is based on accurate functioning of the tubes. Other infertility factors may also be present which may hinder conception.

What types of tests are available in the work-up of tubal disease?

Most fertility physicians will examine the history of the patient and may suggest any of the following tests according to the degree and nature of the disease history:

1.  Hysterosalpingography (HSG) is the most commonly used method

2.  Laparoscopic chromopertubation is a more invasive technique standard in the diagnosis of tubal disease

3.  Sonohysterography with the use of contrast medium is not as accurate as HSG in diagnosing tubal blockage

4.  Chlamydia serology is the most cost-effective and least invasive diagnostic test

Various available treatments according to the degree and nature of tubal disease

Treatment depends on degree and nature of the tubal dysfunction, while the age and ovarian reserve of the patient determine what options are available for the patient.

1.  With the existence of a hydrosalpinx, prophylactic surgery can remove the hydrosalpinx

2.  For proximal tubal obstruction, a possible first treatment is transcervical tubal cannulation with tubal flushing

3.  For tubal repair in tubal obstruction, some surgical techniques include salpingostomy and fimbrioplasty

Many patents now prefer in-vitro fertilization and embryo transfer by bypassing the tubal problems altogether.  In certain situations, in combination with in-vitro fertilization and embryo transfer, any above type of treatment may be used in dealing with tubal dysfunction. If the tubal disease is secondary to a history of a tubal ligation, then a tubal reversal may be the best option for restoring fertility. Tubal reversal has a better rate of subsequent pregnancy for those patients with a history of tubal ligation.

About 20-25% of all cases of infertility are related to tubal factor infertility. Tubal factor infertility may be due to one or more of the following reasons:

1. Completely blocked fallopian tubes, either one or both, by scar tissue inside the tube or by prior surgery such as tubal ligation
2. Tubal scarring without blockage of the tube but with damage to the cells that line the inside of the fallopian tube
3. A disturbance in the architecture of the tube such as with a hydrosalpinx (water-filled tube) or scar tissue outside of the tube which distorts the tube

Medical reasons include:

1. Pelvic endometriosis
2. Pelvic infection, such as pelvic inflammatory disease (PID)
3. Scar tissue that forms after pelvic surgery.  Some times after tubal ligation, scar tissue may occur over the blockage site. This can be removed easily during a tubal reversal.  Tubal reversal is an option in such a case to regain fertility.

Does minor tubal damage cause infertility?

In most cases, any minor damage to the tubes does not account for infertility.  It has to be carefully diagnosed whether the infertility problem is only due to tubal damage, or if some other secondary infertility factor also exists.

What standard tests are available for the diagnosis of tubal infertility?

Hysterosalpingogram (HSG) can be performed to investigate the problem.  This is an x-ray exam done in a radiology department.  The dye is injected through the cervix into the uterine cavity.  If the fallopian tubes are open, the dye flows through the tubes and into the abdominal cavity. Sometimes after a tubal reversal, the dye can be seen changing diameters as it passes across the specific site of the tubal reversal.

Does a negative HSG rule out the diagnosis of tubal infertility factor?

Even if the HSG is good (meaning that there is good flow of dye through the tubes), this does not mean that the tubal function is normal.  The inside layer of the fallopian tube can be brutally damaged even if the tube is open.  Tubes that have damage to the inside cell layer may be the factor of the tubal infertility problem even though the tube is ‘open.’ This is particularly important when considering a tubal reversal as the surgeon chosen must be skilled at performing a tubal reversal without damaging the inside of the fallopian tube.

Management of tubal factor infertility

The management of tubal factor infertility is generally done either by a tubal reversal or by in-vitro fertilization (IVF).

What will be different with periods after a tubal reversal?

It all depends. Every patient has a different experience after a tubal reversal.

The very first menstrual cycle after tubal reversal could come early, or more probably, late.  It is not unusual for the first menstruation after your tubal reversal to be heavy and painful.

Management of the pain;

• A normal pain reliever such as Motrin may provide some relief
• Prescription pain medications will be prescribed after a tubal reversal
• Feelings of weakness and fainting may be experienced

Some standard risks of the tubal reversal surgery may include bleeding, infection, anesthesia problems, and injury to other structures in the pelvis and abdomen.  These complications are extremely rare and the tubal reversal procedure is considered a very safe operation.

Patients must continue care with their regular obstetrician / gynecologist after their tubal reversal. Patients are instructed to wait at least two months before attempting pregnancy. Normal signs and symptoms and prior menstrual cycle patterns appear only if you are not having any other secondary medical problems. Regular follow-up is necessary.

An alternative to tubal reversal center” href=”http://www.mybabydoc.com/”>tubal reversal is in-vitro fertilization (IVF).

Which method is better for regaining fertility?

Whether or not IVF or tubal reversal is better must be based on individual factors and workup.

IVF is a nonconventional method and involves the daily administration of fertility injections.  The patient’s response is checked over a 2-4 week period, together with frequent visits for further management.  At the appropriate time, the eggs are harvested from the woman by placing a needle through the vagina and into the ovary.  This procedure drains follicular fluid from the ovaries.  On the day of egg salvage, the husband’s sperm is combined with the patient’s eggs and the embryos are produced.  The succession of the fertilized eggs (now an embryo) is monitored over a phase of several days.  The embryos are transferred back into the patient’s uterine cavity by insertion of a small tube through the cervix and into the uterus.

Some reasons making IVF a less desirable choice than Tubal Reversal include:

• In general, one to four embryos are transferred, depending on the patient’s age.  The success rate of pregnancy is quite variable and may lead to multiple attempts. When couples are unproductive, they must want the process again, which is costly
• IVF has a much greater risk for multiple gestations than Tubal Reversal
• Some couples may not have the time nor wish to make multiple visits to the clinic, which are obligatory for IVF, and nt for Tubal Reversal
• Many of the steps for IVF are uncomfortable. Many people must convince themselves that the procedure may work ‘this time,’ unlike Tubal Reversal which involves just one procedure
• Risks of over-stimulating the ovaries are much greater than for Tubal Reversal, and can be very serious (Ovarian Hyperstimulation Syndrome – OHSS).

Tubal reversal is preferable for people who want to conceive naturally with a conventional procedure.

What are the disadvantages of having a Tubal Reversal rather than IVF?

• Tubal Reversal allows the possibility to conceive more pregnancies. This is a disadvantage for those who just want to have single child . This requires future contraception.
• Any pregnancy after Tubal Reversal needs to be monitored early due to an increased risk for ectopic pregnancy

Success rate comparison between IVF and Tubal Reversal:

• It is found 20-35% success rate via IVF.
• It is found 66% pregnancy rate over time via tubal reversal.

IVF is the best option for patients for whom tubal reversal is not possible, or in patients who are poor candidates for a tubal reversal. Many patients will have additional infertility factors presence, such as diminished ovarian reserve (can be evidenced by a rising follicle stimulating hormone (FSH) value), blocked fallopian tubes, advanced age, other medical conditions, or severe sperm abnormalities that make tubal reversal a less optimal procedure that IVF. Additionally, some tubal ligations remove too much of the fallopian tube to reanastomosis, and therefore a tubal reversal is less likely to be successful.

The chances of conceiving after having a tubal reversal are considerably better than with IVF, with a 70 to 80% safe success rate for those women who are under 40 years of age.  Most women are able to conceive naturally within a year of their surgery.

When does the ectopic rate after tubal reversal enter in critical risk zone?

There is no set age limit for the risk of an ectopic pregnancy after tubal reversal, but some empirical data suggests that women above 40 have a higher risk in general with tubal reversal, and likewise with ectopic pregnancy after a reanastomosis. The risk of an ectopic pregnancy among the general population is about 1 in 100 and this risk increases to about 5 in 100 after undergoing a tubal reversal.

There is some optimistic analysis of the fertility results observed as well. Although it was demonstrated that age is the most significant predictive factor, for women who had undergone a microsurgical tubal anastomosis procedure (tubal reversal) at age 40 years or older, the reproductive outcomes of the microsurgical tubal anastomosis patients demonstrated a tubal reversal was a justifiable alternative to IVF, even when considering an ectopic pregnancy rate of 2.4 percent.

Managing ectopic pregnancy after tubal reversal

It is important that women are aware about the risk of ectopic pregnancy prior the tubal reversal.  Early diagnosis is needed once a positive pregnancy test is obtained.  If the blood pregnancy test (HCG level) is 1,500 or greater, the contents of the uterus should be seen with a vaginal ultrasound exam. Early diagnosis at this stage is important.  If it is diagnosed that you have an ectopic pregnancy, one or two doses of a prescribed medicine will absorb the ectopic.  Note that time is most important thing, and there are limits to the use of medicine in treating ectopic pregnancy. If the ectopic pregnancy is too far along, the only option may be surgery, and in this case it is extremely important to have a skilled minimally invasive surgeon such as Dr. Morice perform the procedure so that when removing the ectopic pregnancy the fallopian tube suffers minimal damage.

What makes you fit for having a tubal reversal?

Patients need to be more aware of the fertile possibilities of tubal reversal before going for a tubal reversal.  The factors that go into whether a tubal reversal is right for you are:

1. Age:  Better if you are less than 40.  Analysis of the fertility results demonstrated that age was the most significant predictive factor.  This directly links to ovulation. Decide about a tubal reversal at the right time.  There is a sharp turn down in fertility that starts to occur approximately at the age of 36 in women.  Even so, the chances of pregnancy stay good until women reaches 40.  If a woman is beyond the age of 43, the chances of producing eggs in good health can be much lower.

1. Type of ligation: As there are many types and methods of performing bilateral tubal ligation (ie by rings, clips, fulguration, Parkland, Pomeroy, Falope ring, coagulation, and Irving), the damage to the tubes may differ from one patient to another. If the tubal ligation is performed without excessive damage to the tubes, nearly all types of tubal ligations can be reversed with a tubal reversal procedure. To ensure patency, after tubal reversal a colored dye is used to examine the patency of the fallopian tubes.

1. Blockage site on the tube.  HysteroSalpigoGram (HSG) is the test that allows Dr. Morice to better evaluate the blockage site on the tubes in the prospective patient for tubal reversal, and to get a better idea of how much proximal tubal length is available for a tubal reversal or reanastomosis.   If the ligation method caused excessive scar tissue on the blockage site, this could minimize the potential of fertility later.  The amount of healthy tube remaining is extremely important when considering a tubal reversal to regain fertility.

1. Hormone levels:  Checking the hormone levels is an excellent indicator of fertility and must be considered for all patients over the age of 30 before a tubal reversal.  This includes a day 2-4 FSH level and estradiol level.

1. Normal uterus: All patients undergoing a tubal reversal should have an ultrasound report prior to the procedure. Dr. Morice performs this as part of the routine work-up and this is included in the price of the tubal reversal procedure.

1. Some other factors:  There are other factors that provide good predictive value for success with tubal reversal. These include your general health, obstetrical history, partner’s health, social habits such as smoking and drinking, and frequency of intercourse.