Tubal Reversal

OB/GYN's

What is Tubal Reversal?

“Tubal reversal” refers to reversing or undoing a tubal ligation procedure. Tubal reversal might better be termed “tubal reanastomosis (TR),” meaning microscopic reattachment or rejoining of separated ends of the fallopian tubes. It doesn’t mean “untying” a suture, although that would certainly make it easier.

Who is a candidate for the procedure?

The first thing to realize is that not everyone is a great candidate for this procedure. First, there are health considerations. If you have significant health factors that make future pregnancies unadvisable (such as uncontrolled diabetes or heart disease), you probably should not be thinking about TR.

The second thing to consider is that TR is not a guarantee for having a baby, or even getting pregnant. It is certainly a woman’s prerogative to change her mind and give “nature” a chance for further pregnancies, but “nature” after TR might not be as cooperative as it once was. In general, fertility decreases with age, related to many non-tubal factors, most particularly ovarian function, which declines significantly in one’s forties. In general about 2/3 to 3/4 women achieve intrauterine pregnancy with TR, but those who are younger with proven fertile partners are most likely to conceive. Your doctor can further advise you about your chances for conception as a couple with some preoperative testing such as a serum FSH (giving information about ovarian reserve) and semenalysis (sperm count.) Other factors which might impact chances for successful conception are prior history of infertility, menstrual irregularity implying ovulation dysfunction, prior surgeries, endometriosis, and the type of tubal sterilization procedure performed. Traditionally, when tubal ligation (TL) procedures are performed, part of the fallopian tube is destroyed - by burning, or cutting, or banding, or clipping, or excision, or tying. Some segment of the tube is destroyed or removed, from a few millimeters to a few centimeters. Sometimes (rarely) the whole tube is removed. Remember, the goal of the surgeon who performed TL was to make SURE that you didn’t get pregnant against your wishes. Basically, the more destructive a procedure, the less likely a TL procedure is to fail and the less likely TR is to succeed. The good news for the patient considering tubal reversal is that most of the time there is plenty of tube remaining to give an excellent chance for pregnancy after tubal reanastomosis.

As noted above, the more tube undamaged, the better the chances for conception. It also makes a difference what part of the tube was damaged during the TL procedure. It is very helpful (but not imperative) to have an operative procedure note (photos if possible) to assist with preoperative counseling. Some TR procedures are more difficult and less reliable than others, such as when the tubal (or uterine) openings are different diameters, or when tubal segments are very short. Newer sterilization procedures (Essure and Adiana) involve blocking the proximal tube at or near the junction with the uterus through the cervix using a hysteroscope. These procedures are certainly potentially reversible, but I have not yet performed TR after Essure or Adiana. This would essentially be a utero-tubal anastomosis, which is a technically more difficult procedure, but quite successful.

What are the risks?

Well the primary risk is that you spend a bunch of money and don’t get pregnant. As you probably already know, this procedure is generally not covered by insurance. We have to be honest and realistic. If our goal is a take-home pregnancy, and at least 25% of patients don’t achieve that goal, that’s a pretty big “failure rate.” For comparison, IVF (in vitro fertilization) is generally stated to have about a 30% SUCCESS rate PER TRY; and the cost of IVF is likely more than double the cost of TR for just one try. In terms of successfully opening your tubes, we can assure you that your tubes will be patent (open) at the end of the procedure. We use a stent to maintain small lumen openings during the anastomosis and perform a “dye test” to verify patency prior to closing during anesthesia. we cannot, however, guarantee that your tubes will stay open. Everyone heals differently, and some people are more prone to abnormal scarring than others. If both tubes are reanastomosed, odds are excellent that at least one will remain patent; and one patent tube is all you need to conceive.

Another very important consideration and risk factor related to tubal reanastomosis is the possibility that pregnancy can occur in the fallopian tube (ectopic pregnancy) rather than in the uterus. When this occurs, the pregnancy cannot progress to term because the tube cannot support its growth. Ectopic pregnancy risk is greatly increased after any sort of tubal surgery or tubal disease such as infection. Ectopic pregnancy occurs on average about 1-2% of all pregnancies, with that risk more like 10% after TR. Patients who conceive after TR need to see their physician as soon as they know they are pregnant. If ectopic pregnancy is confirmed, the pregnancy must be interrupted either medically or surgically, because the risk of tubal rupture carries potentially great danger.

Other risks of TR surgery are similar to most surgeries. TR is performed under general anesthesia, which, while very safe, does carry its own risks. Risk of damage to internal organs such as bowel or bladder is very low, but might be increased in patients who have severe adhesions from previous infection or surgery. Normally to keep the cost of the procedure down, TR is performed in a surgery center (St. Thomas Plaza Surgicare) on an outpatient basis. This means that you go home after the procedure and complete your recovery there. Occasionally patients having outpatient surgery (of any sort) experience postoperative problems such as nausea or inadequate pain relief which require that they be admitted overnight to the hospital (St. Thomas Mid-town Hospital). Charges for such an admission are not included in your surgical fee or facility fee, and would have to be addressed separately with the hospital. The good news on that score is that patients with insurance might be covered for such a complication.

How is the TR procedure performed?

Dr. Macey learned to perform microscopic tubal reanastomosis during residency in North Carolina in 1990 and has been successfully performing it ever since. Little has changed in terms of the procedure and success rates. The procedure takes me about three hours. While some doctors have performed the procedure laparoscopically, most experts continue to perform a mini-laparotomy. This involves a medium-small incision over the pubic bone (a bikini-cut) and use of retractors (if necessary) to hold tissues back for the surgery. The thinner your tummy, the smaller the incision necessary. A device is placed into the uterus from the vagina to manipulate and elevate the uterus out of the pelvis into the incision. This helps to minimize the amount of retraction necessary, thus decreasing the amount of postoperative pain encountered. Another technique which decreases postoperative pain is the injection of local anesthetics into the tissue prior to your awakening from anesthesia.

Once the uterus and tubes are exposed, a powerful operating microscope is utilized to precisely visualize the very delicate layers of the fallopian tubes. The distal closed-off stump of the proximal portion of tube is carefully cut layer by layer until a healthy lumen (opening) is identified and healthy (undamaged / unscarred) surrounding tissue is reached. Through the uterine manipulator, blue dye is injected into the uterine cavity and through the tubal stumps. A fine flexible stent is placed through the proximal opening to assist with continuous identification of the lumen. The proximal stump of the distal tubal segment is then dissected in a similar fashion, until healthy lumen and muscular wall are reached. Several medium support sutures are placed through nearby connective tissue to bring the distal portion of tube close to the proximal portion. This relieves tension and allows for use of very fine sutures for the actual joining of the ends (anastomosis) of two portions of fallopian tube. The absorbable (dissolving) sutures and tiny needles that are used are almost too small to see without magnification. These are the same types of sutures used on the eye. Two distinct rows of sutures are placed taking care to minimize the amount of suture material exposed to the lumen. Very fine surgical instrumentation meticulous hemostasis, constant irrigation, and non–adhesion producing packing is necessary to reduce the risk of postoperative scarring and adhesion formation. Once both tubes have been reanastomosed, patency is verified by injecting blue dye through the uterus and out the distal tubes. All the layers of the abdominal wall are the closed and the uterine manipulator is removed. The skin is closed with sutures under the skin that dissolve.

Will you be able to complete the procedure for sure?

Only if you have fallopian tubes. If you have fallopian tubes, I can improve your fertility chances. If the most distal fallopian tube segment, called the fimbriated portion of the infundibulum, has been excised as part of the TL procedure, then a TR procedure per se cannot be performed, because there are no tubal segments to rejoin. What could be performed to improve fertility is a microscopic neosalpingostomy and fimbrioplasty. This is just a fancy way to say “build you a new funnel shaped opening on the end of your tube” and “try to flower out the remaining cilia” (hair-like structures which move the egg up the tube) so that they might better grasp the egg when ovulation occurs. This procedure certainly has potential for success, but likely less than the 2/3 chance. This procedure can sometimes be performed laparoscopically.

Traditionally, it has been stated that 4 centimeters (about 2 inches) of tube needs to remain for a good chance of success. That number is somewhat arbitrary, and TR can be performed with shorter segments of remaining tube with variable success. Remember, there is likely a continuum of prognosis from excellent chance to poor chance, depending on the many factors mentioned above outside of the tubal factor.

Diagnostic laparoscopy can be performed prior to the mini-laparotomy if you wish for me to evaluate the tubal segments prior to proceeding with TR. This would be an appropriate consideration if there were no operative report, or if there were suspicion that removal of the distal tube had been performed. There is an extra cost for performing laparoscopy prior to TR, but if TR is not performed, most of the surgical fee would be refunded.

What are the logistics of having the procedure?

The first step is to try to figure out what sort of TL procedure you had. Try to get the operative dictation from the hospital or the doctor who performed the procedure. If not available, then perhaps you can find out from the doctor what type of procedure he usually performed. The next step is to find out whether your partner is fertile, although this is not a requirement. We can point you to how/where to obtain a semenalysis if you like. The next step is an office consultation. We will decide if any further testing is advisable. Sometimes we obtain an ultrasound and/or HSG (hysterosalpingogram) which is an XRay test involving the injection of XRay contrast material into your uterus. The HSG will show us how much of your tube is remaining at the proximal portion and whether there are any polyps or fibroids that might interfere with pregnancy. Ultrasound will alert us to any ovarian abnormalities and some fibroids. Both of these tests might be covered by insurance. A surgery date can be set after that visit pending the results of any tests we decide upon.