What are the options?
Women regretting their tubal sterilization procedure have 2 options:
- Surgical reversal of sterilization
- In Vitro Fertilization (IVF)
Am I good candidate for reversal of sterilization?
1.5% of women who have undergone tubal ligation decide to have surgery to reverse the procedure. Depending on the method of sterilization utilized, successful pregnancies following reversal of tubal ligation occur in 60-80% of cases within the first 12 months after surgery.
You are not a candidate for reversal of sterilization if:
- Your sterilization procedure involved complete removal of the fallopian tubes (salpingectomy).
- The sterilization utilized multiple point tubal coagulation (burning) technique. The length of the tube after reattachment is much shorter than normal and is less likely to result in a functioning tube or a successful pregnancy.
- The end of the tube (fimbriae) is damaged as result of your tubal ligation procedure. Surgery is contraindicated because it is highly unlikely that eggs will be successfully captured from the ovaries and transported into the tube.
- Your partner has a low sperm count (male factor). Not enough sperm reaches the egg in the fallopian tube, decreasing the likelihood of successful fertilization of the egg. In such cases, In Vitro Fertilization (IVF) is a better option.
- You are over the age of 40. You may need to consider IVF as soon as possible because the quality of your eggs is decreasing more rapidly.
- You have Diminished Ovarian Reserve (DOR). With poor quality eggs neither reversal of sterilization or IVF will solve your problem. In such cases donor egg IVF is usually advised.
How is the tubal reversal performed?
Tubal reversal is increasingly being performed by an outpatient minimally invasive robotic laparoscopic technique, involving 4 small ½ inch abdominal incisions. The segments of the tubes are precisely aligned and reattached utilizing robotic 3D imaging. The advantage of this surgery is a much shorter recovery period as compared with major abdominal reversal surgery.
The most significant factors influencing success rate with reversal procedures are the level of expertise of the surgeon and length of tube remaining after sterilization. Success rates are highest when the length of the tube is estimated to be more than 2 inches.
During surgery, the two disconnected tubal segments (fig. 1) are prepared for reattachment. The tubal segment closest to the uterus is held and the end is cut (fig. 2) to expose the tubal opening (fig. 3).
fig. 1fig. 2fig. 3
Blue dye, injected into the uterus, flows into the tube and through the cut end indicating that it is open and ready for reattachment (fig. 4). The other side of the tube is similarly prepared for reattachment. The segments are then carefully aligned and stitched together with very fine sutures (fig. 5). The tube is now tested to make sure it is open by injecting blue dye through it and observing the dye as it exits from the end of the tube (fig. 6).
fig. 4fig. 5fig. 6
IVF: an alternative to reversal surgery
Today, In Vitro Fertilization (IVF) offers an alternative to surgical reversal of tubal ligation. With IVF, the woman’s eggs are removed directly from the ovaries, fertilized in a laboratory Petri dish, and the resultant embryos placed into the uterus. Thus, the tubes are simply bypassed in the process.
What are the advantages of IVF?
- Reversal of tubal ligation until recently was a major surgical operation, with significant post-operative pain and up to four to six weeks of recuperation.
- The risk of ectopic (tubal) pregnancy following reversal of sterilization is about 5-10% as compared with 1% after IVF.
- A woman younger than 35, undergoing two IVF attempts at a clinic with good success rates has a better chance of having a baby compared with surgical reversal of sterilization.
- There is no need to repeat the tubal ligation or utilize other methods of birth control after one’s family is completed.
- IVF with Intracytoplasmic Sperm Injection (ICSI) is the treatment of choice when male factor is present, because there may not be enough sperm to fertilize the egg naturally in the tube even if the reversal procedure has been successful.
What are the advantages of surgery?
- Reversal of sterilization can now be accomplished by outpatient robotic laparoscopic surgery, a procedure comparing more favorably with IVF treatment.
- IVF treatment is costly and may need to be repeated several times before it is successful.
- IVF is time consuming and involves daily gonadotropin hormone injections, blood tests and several ultrasounds.
- Two or more attempts at IVF may be more costly than surgical reversal of sterilization.
- IVF carries a risk of multiple births.
- If the couple wants more than one child, and there are no frozen embryos available, they would need to repeat the entire IVF process.
What are the success rates with IVF and reversal of sterilization?
- With sterilization reversal procedure – cumulative pregnancy rates 1 year after surgery are 60-80% if you are young with minimal tubal damage after sterilization.
- With IVF, pregnancy rates vary with your age. The expected pregnancy rates are listed in the table below:
The choice between reversal of tubal ligation or IVF is a personal one and must take into consideration cost and risks of treatment, success rates, recuperation period and number of children desired.
Both procedures may not be appropriate for women with high FSH level (diminished ovarian reserve); donor egg IVF should be considered instead.