Tubal Ligation Reversal Blog

Anesthesia for Tubal Ligation Reversal

Submitted by Pam Mills, CRNA

Being part of the anesthesia care team at Chapel Hill Tubal Reversal Center has given me the opportunity to work one on one with tubal reversal patients in an outpatient setting and to assure they receive the best medical care they have ever experienced.

For anesthesia purposes, we record pain scores and the incidence of postoperative nausea for all of our patients. We conduct comprehensive reviews of our data and implement changes to our anesthesia protocol, if necessary. This performance improvement activity is the beauty of working in a small private setting.

All of our patients receive individual attention and care. We have had patients tell us, “This is the first time in my life I have not been sick after anesthesia!” and “This was the easiest anesthesia I have ever had!”

I can’t think of anything more rewarding than to have helped our patients have a safe and pleasant experience while they are here for their tubal ligation reversal procedures.

Personalized Anesthesia Plan

If a patient tells me that she experienced nausea after an anesthetic in the past, I sit down with her and discuss our anesthesia plan and how it is designed to optimize her comfort and well being during her postoperative recovery. I want her to be confident that she will be well taken care of and that we will do everything in our power to make this anesthetic different from what she experienced previously. Our patients receive two medications through their IV to prevent nausea, and for patients with special needs I give what is is fondly referred to as my “special cocktail”. This cocktail has a combination of two additional anti-nausea medications, also given through the IV before the patient wakes up. This covers all the possible trigger centers in the body that can cause nausea.

Power of Positive Thinking

I usually end our discussion of postoperative nausea by telling the patient and family member that this will be the last we will mention of this subject, as I am a firm believer in planting the seed of positive thought. So from then on I want them to focus on positive thinking, knowing that she will be well taken care of and anticipating that she will wake up feeling well and free of pain or nausea.

Patient Care at Chapel Hill Tubal Reversal Center

Our dedication to patient care and outcome is evident in our patient follow up care. Every patient is entered into our computerized database. This database includes information from the day of surgery, their postoperative recovery, follow upcontacts by our nurses, as well as every pregnancy following the tubal reversal procedure through to its outcome. There is no better place for women to have tubal reversal surgery than at Chapel Hill Tubal Reversal Center. Our anesthesia staff goes to extra lengths to ensure the patient’s safety, comfort, and sense of well-being during and after the tubal reversal procedure.

PTLS Diagnosis and Tests

An email message received today about Post Tubal Ligation Syndrome (PTLS) from a patient who is scheduled for tubal reversal next month prompted this blog topic. I thought it would provide helpful information to others with similar concerns.

“My problem is horrible PTLS. I had my tubes tied in 05 at the time of my 3rd C-section. I understand that PTLS is not widely accepted or recognized in the medical community as a true syndrome or diagnosis, but could I expect to see something supporting that diagnosis in any blood work or hormone tests? Would it be normal to see abnormal hormone levels to some degree in support of this diagnosis or is it possible that all my levels would be ok but that the disruption in the flow of blood between ovaries and uterus could cause all of my symptoms and simply not show changes in hormone levels? Also, are there specific hormone tests I can have my ob/gyn check?

I only came across all this info on the net while desperately searching for answers to my growing list of symptoms that I never thought were related. This is very nerve wracking and exhausting. Three years is a long time and I look forward to this journey coming to an end and new one beginning, but I have so many questions and I was hoping you could steer me in the right direction so I can have any other diagnostics tests that may be helpful to my cause.”

Dr. Berger’s Response

One of the reasons that PTLS is not recognized as a true syndrome by most physicians is that there is no specific diagnostic test that is correlated with symptoms. If you search through the medical literature, you will find many studies with conflicting results. For example, you can do a search using Google Scholar for “hormones post tubal ligation syndrome” to review results from some recent medical studies.

Diagnostic Codes

There is no diagnostic code for Post Tubal Ligation Syndrome in the International Classification of Diseases (ICD). Without a specific diagnostic code, insurance companies do not provide reimbursement for testing or treatment. The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) does have other diagnostic codes that can be used, depending upon the symptoms being experienced:

• ICD-9-CM #625.0  Dyspareunia - Painful sexual intercourse.
• ICD-9-CM #625.3  Dysmenorrhea - Painful menstruation.
• ICD-9-CM #625.4  Premenstrual tension syndromes -
  Distressing physical, psychologic, or behavioral changes that occur during the luteal phase of the menstrual cycle. Symptoms of PMS are diverse (such as pain, water-retention, anxiety, cravings, and depression) and they diminish markedly 2 or 3 days after the initiation of menses.
• ICD-9-CM #626.2  Menorrhagia  - Excessive menstruation.
• ICD-9-CM #626.6  Metrorrhagia - Irregular uterine bleeding.
• ICD-9-CM #627.0  Premenopausal menorrhagia
• ICD-9-CM #626.8  Disorders of menstruation, other

Insurance Coverage

Insurance companies do not recognize PTLS as a medical entity. Depending upon the symptoms you have, your doctor could use one or more of these diagnostic codes. The specific tests that may be appropriate will depend on your symptoms. For example, if you have pelvic pain, then ultrasound examination would be appropriate as part of an evaluation for pain. Abnormal menstrual bleeding would appropriately involve hormonal assays (FSH, LH, estradiol, progesterone). Based on the results of any preoperative testing, a diagnostic code could be listed on your operative report as a preoperative and postoperative diagnosis. This might influence the insurance company regarding possible reimbursement for tubal reversal surgery. Read your insurance policy carefully. If it specifically states that tubal reversal is not a covered benefit, no matter what information is sent to the insurance company, there will be no reimbursement. If the policy does not specify that tubal reversal is excluded, then there may be a possibility of getting reimbursement from your insurance carrier.

More Information about Post Tubal Ligation Syndrome

Post Tubal Ligation Syndrome is written about on many pages of the Chapel Hill Tubal Reversal Center website. There are also many discussions about PTLS on the Tubal Reversal Message Board. Another excellent source of information is Post Tubal Ligation Syndrome News.

Tying Tubes

Many people seem to imagine the fallopian tube is like a shoe lace that is tied in a bow to prevent pregnancy. As a tubal ligation reversal specialist, I wish it were that simple- then reversing tied tubes would be a whole lot easier!

Perhaps a well meaning doctor may have told a patient one day, “I am going to tie your tubes so you don’t get pregnant.” Maybe the doctor wrote a letter to a medical journal explaining the procedure and then the terminology stuck. More likely, a reporter may have simplified the terminology for the surgical procedure of tubal ligation to make a catchy title for an article. Others may then have started using the term “tying tubes” to quickly explain a complex procedure. These explanations often have a long life span and make their way into common language.

The more accurate terminology is bilateral tubal occlusion (closure of both fallopian tubes) which results in sterilization (not being able to conceive). There are many ways to perform bilateral tubal occlusion. The most common tubal sterilization procedure is performed at the time of cesearean delivery (c-section) or immediately after having a baby. It does involve tying the tubes with a suture - but then also cutting out a segment of healthy tube, resulting in closure of the tube as it heals. The suture then dissolves. The intial suture tying is most likely where the phrase ‘tying tubes’ came from.

Another common method is to burn the tubes with electrical energy (electrocoagulation). This is usually done by laparoscopic surgery and is usually done remote from pregnancy. Lastly, there are many devices- clips and bands - which can close off the tubes and cause a portion of the tube to be destroyed.

No matter how the procedure is done, the end result is obstruction of the fallopian tube that prevents pregnancy.

Many people believe that tubal sterilization is irreversible. Although bilateral tubal occlusion is intended to be permanent, the procedure can be reversed. Chapel Hill Tubal Reversal Center is the one medical facility that specializes exclusively in reversal of tubal ligation. We have become tubal ligation reversal experts………experts at untying tied tubes!

Submitted by Dr. Charles Monteith

Dr. Montieth’s Diary on Becoming a Tubal Reversal Specialist

Today we had another successful day of untying tubes. We began the day at 7AM. Four patients were scheduled for tubal ligation reversal surgery.

I was able to first assist Dr. Berger in the first three surgeries of the day, but had to leave prior to the fourth surgery. I am becoming proficient at identifying tubal anatomy and repairing tubes that have been tied.

The first patient had her tubes tied several years ago and she was now in a new relationship. Both she and her partner desired more children. They made the decision that they would undergo tubal ligation reversal and try to pursue their dream of having children together. Her surgery went well and we were able to successfully reverse her tubal ligation.

The second patient was similar to the first and desired more children. Her surgery also went well.

The third patient had her tubes tied, but after her surgery she lost a child to Sudden Infant Death Syndrome (SIDS). We often hear stories like this from many patients who come to Chapel Hill Tubal Reversal Center. It is extremely sad to hear the stories these patients tell. My heart aches for them as they try to replace their children and add to their family. Every time I hear these stories I think of my own children and what it would be like to experience such a loss. I can not fully imagine the pain from such loss but I can understand the strong desire to replace a cherished soul. I am happy to report that her surgery went extremely well and she had an excellent operative result. I take enjoyment out of every reversal surgery I have participated in, and feel an extra sense of accomplishment when assisting in untying tubes for patients who have lost children unexpectedly.

I had to leave before the fourth patient had surgery. Fortunately, I will be back in the morning for four more reversal surgeries and to meet four more interesting people and learn about their stories.

The Doctor Who Unties Tubes

Dr. Gary Berger is a tubal reversal doctor who specializes exclusively in procedures to untie tubes. Dr. Berger created the first and only tubal reversal clinic - Chapel Hill Tubal Reversal Center. This is the best place to get tubes untied for women who want another baby after tubal ligation.

Why Untie Tubes?

One of the questions Dr. Berger asks his patients is what made them decide to have their tubes untied. In answering this question, women describe the circumstances which led them to want another child after tubal ligation. Most cases involve divorce and remarriage. Often the husband has no children, and the couple would like to have a family of their own. Some couples already have children together but realize that having a tubal ligation was a decision that they regret. Death of a child, religious considerations, and the desire to relieve symptoms of “Post Tubal Ligation Syndrome” are other reasons for wanting to get tubes untied.

Pregnancy After Tubes Tied

Although there are many websites that discuss reverse tubal ligation, information about success rates is often lacking or stated in general terms. To make a fully informed decision about tubal reversal, women should have specific and accurate statistics about pregnancies regarding a doctor’s own patients rather than a general statistic taken from some other source. Otherwise, it has little meaning.

Tubal Reversal Center Pregnancies

Chapel Hill Tubal Reversal Center provides information each week about pregnancies after tubal reversal procedures performed by Dr. Berger. Whenever one of Dr. Berger’s patients becomes pregnant, they can submit a Pregnancy Report Form to alert the Tubal Reversal Center staff of their pregnancy. This enables Dr. Berger and his nurses to monitor the results of the Early Pregnancy Protocol that is recommend by Dr. Berger. Each week, the new pregnancy reports are tabulated and listed in the Weekly Pregnancy Reports forum on the Tubal Reversal Message Board. During this past week, there were 20 new pregnancies reported by Dr. Berger’s tubal reversal patients. This is more than reported in a year by most doctors who perform tubal reversal procedures! Additional information about the new pregnancies is shown in the Pregnancy Announcements section of the Chapel Hill Tubal Reversal Center website. A complete statistical analysis of the outcome of all tubal reversals is published as the Tubal Reversal Study Report each year.

Conclusion

By establishing a medical facility exclusively for tubal reversal procedures that untie tubes, following up on all patients who have had a reverse tubal ligation, and publishing their pregnancy statistics, Chapel Hill Tubal Reversal Center has set a new standard for other doctors who provide tubal reversal services to follow.

What is Reverse Tubal Ligation?

Reverse tubal ligation - or more properly, tubal ligation reversal - is a procedure to get tubes untied for women who desire a pregnancy after tubal ligation. There are actually several procedures that can be used to untie tubes after the tubes have been tied.

Techniques of Reverse Tubal Ligation

There are 3 main techniques that can be used for reversing tubal ligation.

1. Tubal anastomosis
2. Tubal implantation
3. Salpingostomy (Fimbriectomy Reversal)

Tubal Anastomosis

Tubal Anastomosis

The most common method for untying tubes is the reverse tubal ligation procedure of tubal anastomosis. Anastomosis refers to joining two body parts, and tubotubal anastomosis is joining two tubal segments together. Most techniques that tie tubes result in two separate tubal segments, so the simplest way to get tubes untied in these cases is with the anastomosis procedure. 

For more details about untying tubes via tubal anastomosis, see the topic on Tubal Reversal by Tubal Anastomosis on the Tubal Reversal Blog and the description of Microsurgical Tubal Anastomosis on the Chapel Hill Tubal Reversal Center website.

What is the Cost of Untying Tubes?

Reverse tubal ligation is usually described as extremely expensive, ranging from $10,000 to $30,000. The tubal anastomosis procedure to untie tubes costs $5900 at Chapel Hill Tubal Reversal Center. Because it is done as outpatient surgery and performed four times a day, the cost savings is passed on to the women who want kids after tubal ligation.

Watch Dr. Berger Untie Tubes

The tubal reversal operation by Dr. Berger has been featured on television - this video clip on YouTube is 3 minutes long. To watch the entire operation, you can order a free video or DVD of tubes untied.

Other Methods to Untie Tubes

Tubal implantation and salpingostomy are less frequent techniques to untie the tubes after a tubal ligation. For descriptions of these techniques, see the topic on Tubal Reversal by Tubal Implantation and Tubal Reversal by Salpingostomy on the Tubal Reversal Blog or Read the section on Reversal Illustrations on the Chapel Hill Tubal Reversal Center website.

Is There a Simple Procedure to Untie Tubes?

Women who have had their tubes tied and then want to get tubes untied often ask if there is a simple procedure that permits pregnancy after tubes tied. Often they envision a tubal ligation as if there is a bow tied around the tubes that can be simply untied, like one unties a shoelace. This is actually not the case. The common term “tying tubes” simplifies what is a tubal ligation - or tubal sterilization - is.

How Tubes are “Tied”

Pomeroy Tubal Ligation

Tied and Cut

Final Result

The most common type of tubal ligation involves putting a surgical ligature (or tie) around a loop of the fallopian tube and then cutting off the segment that has been ligated. The two tubal segments separate from each other. This is the Pomeroy technique, first describe by Dr. Ralph Pomery. Some doctors burn the ends of the tubes that have been cut and may use the term “modified” Pomeroy procedure in their operative report.

Another common type of ligation/resection procedure is the Parkland tubal ligation. With this techniqe, two ligatures are placed around the tube at a distance from each other and the portion of the fallopian tube in between the ligatures is resected (cut out). There are many other variations of the ligation and resection method of tubal ligation.

Tubal sterilization can also be performed by burning the tubes. This may be done with electocoagulation (coagulation, cautery, or cauterization) or with thermal coagulation. There are also variations with the coagulation methods of tubal ligation, such as the use of monopolar or bipolar coagulators, and the number of sites burned and for how long they are burned. The greater the number and the longer coagulator is applied to the tube, the greater the amount of damage.

A third method of female sterilization involves simply blocking or obstructing the tube with clips or rings. In general, these tend to cause the least amount of damage to the tube. Of all tubal ligation techniques, the tubal clip (Filshie clip or Hulka clip) is the least damaging and the one that consistenly gives the best results when the tubes are “untied” or repaired.

Essure is another new tubal sterilization procedure. This does not require surgery, but it is the least reversible method for women wanting kids after tubal ligation.

Dr. Berger’s Comment

This summary is to help women who want to get their tubes untied. The first thing to know is what tying tubes actually means. It is not as simple as placing a string around the tube that can later be untied. Contrary to what some people think, tubes don’t become untied by themselves after a certain length of time. With this basic information about the fallopian tube and tubal ligation methods in mind, I will explain how reversal of tubal ligation is done in the next topic Tubal Reversal Blog - How to Get Tubes Untied: Reverse Tubal Ligation.

Dr. Caryn M. Hertz - Director of Anesthesia

Caryn M. Hertz, MD is a Board Certified Anesthesiologist and has worked in the field for over 20 years. She has devoted her professional career to the subspecialty of ambulatory (outpatient) anesthesia. She has been working with Dr. Gary Berger at Chapel Hill Tubal Reversal Center since 1995.

Originally from Queens, New York, Dr. Hertz attended college at The Cooper Union for the Advancement of Science and Art, graduate school at The University of Pennsylvania, and medical school at the University of Rochester. She completed her residency in anesthesiology at Beth Israel Hospital in Boston (a Harvard affiliate) and at the University of North Carolina at Chapel Hill. After finishing her residency, she was employed at Duke University Medical Center for 5 years, specializing in preoperative assessment and ambulatory surgery. Dr Hertz has worked at Chapel Hill Surgical Center ever since.

Dr. Hertz says, “I am dedicated to making each patient’s surgery comfortable and safe. Working regularly with Dr. Berger has enabled me to truly optimize and continually improve the Tubal Ligation Reversal experience for our patients.”

Dr. Hertz and her family have lived in Chapel Hill since 1989. Having relocated from the Northeast, they very much enjoyed the mild weather, beautiful environment, and remarkable community here in Chapel Hill.

Dr. Berger’s Comment

One of the many things that makes tubal reversal surgery safe and comfortable at Chapel Hill Tubal Reversal Center is the close coordination among the professional staff who work together every day. This makes the tubal reversal procedure go smoothly and without any unnecessary waste of time for the patient who is under anesthesia. It is like a finely tuned orchestra, with each player knowing exactly what the other is doing. This coordinated team work comes only with constant repetition. The surgical and anesthesia staff at Chapel Hill Tubal Reversal Center practice together each day, and doing four procedures a day allows us to work toward the goal of perfection in patient care. It is the goal that we all strive for each day, with each patient, and each tubal ligation reversal. Other doctors and nurses who have visited our facility are amazed at how quickly patients recover from their operations.

Introducing James Split MD

It is a happy occasion to introduce another new member of the staff of Chapel Hill Surgical Center. Dr. James Split is a Board Certified Anesthesiologist. He has worked at Chapel Hill Surgical Center since December 2007. He previously lived and worked in Greensboro, North Carolina for the last 18 months. Before moving to North Carolina, Dr. Split practiced medicine in Michigan for 25 years. He obtained his medical degree at the University of Michigan in 1979 and practiced Emergency Medicine for the first 11 years of his career. He both practiced and taught Emergency medicine in an Emergency Medicine Residency and held a clinical faculty position at Michigan State University. In 1990, he returned to the University of Michigan to train in anesthesiology. He completed his anesthesiology residency in 1993 and has been in the full time practice of anesthesiology since then. Dr. Split is a member of the American Society of Anesthesiologists and The Society for Ambulatory Anesthesia.

Dr. Split will be speaking with many of you as part of your pre-operative evaluation. If you have any general questions about anesthesia, you can add comments to this blog or post them on the Tubal Reversal Message Board and he will to answer them. If you have specific questions that require privacy, or that may not be of interest to others, please send Dr. Split an e-mail to DrSplit@tubal-reversal.net and he will respond.

Dr. Berger’s Comment

The highest priority for patients who come to me for tubal reversal surgery to untie tubes is patient safety during and after surgery. This is ensured by the involvement of medical professionals who are the most highly trained and qualified specialists. Our two anesthesiologists are certified by the American Board of Anesthesiology. The anesthesiologist is the physician responsible for the monitoring and care of patients while they are asleep during their tubal reversal procedure and for their safe and comfortable recovery in the post anesthesia care unit (PACU). Dr. Split’s background in Emergency Medicine gives him an added dimension of knowledge and experience. On behalf of all of our staff, I am very pleased to welcome Dr. Split to Chapel Hill Surgical Center and Chapel Hill Tubal Reversal Center.

My First Day at Nourishing Hopes and Dreams

My first day as a tubal ligation reversal specialist will always be remembered. I began my training with Dr. Berger during the first week of January 2008. We started the day off by meeting the patients who would be undergoing tubal ligation reversal at Chapel Hill Tubal Reversal Center.

I met four patients of different ages, backgrounds, and ethnicities . They were all very different people who all desired the same thing: reversal of their tubal ligation.

• The first patient was in her forties, she had emigrated from Ethiopia, her last child was more than twelve years ago, and she desired a chance to have another child.
• The second patient was in her thirties and her previous husband had died unexpectedly. She had children but her fiancé did not have any children. Together, they desired a child.
• The third patient,in her late twenties, had two children and a tubal ligation. Several years later she subsequently found a new partner and he desired a child with her. So while he was deployed overseas, she came for a tubal ligation and a chance for a new future when he returned from his military deployment.
• The fourth patient was in her late twenties and had several children. When she and her partner were in their early twenties they were financially maxed out and she had her tubes tied as an act of desperation. Several years later, she and her husband subsequently became financially stable and they wanted another child. They considered IVF but decided that a reversal was a better option for them. We also learned of an extremely sad story from this patient. She had a friend who had a tubal ligation. This friend had all of her four children die overnight in a house fire. This friend desperately has hope for a future reversal of her tubal ligation and was hoping to obtain a tubal reversal in the future.

All of the tubal reversal surgeries went well that day. The patients all did well and had technically excellent tubotubal reanastamosis (tubal ligation reversal) procedures. They all recovered well and went home to pursue their quest to add to their families.

For as long as a live, I will never be able to forget these women, their partners and the stories they told. I can never forget their quest to add children to their lives. For them I hope they attain what they desire.

My first lesson as a Tubal Reversal Specialist was that no one can predict the future, but if you always look hard enough you can always find a way - and someone to help- to correct prior mistakes.