Tubal Reversal Blog November, 2007

Tubal Ligation by Coagulation or Cauterization

Bipolar tubal coagulation is a popular method of female sterilization in the United States. This tubal ligation method is usually performed through laparoscopy. With the bipolar (two-poles) coagulator, the fallopian tube is grasped between two poles of electrical conducting forceps and electrical current is passed through the tube between the two ends of the forceps. Damage to the tube is limited mainly to the small segment between the forceps. Burning two or three adjacent sites is common and generally results in the loss of a few centimeters of the fallopian tube. Bipolar tubal cauterization can be successfully reversed in almost all cases.

Monopolar tubal coagulation is less common than bipolar coagulation tubal ligation. With monopolar forceps, electrical current spreads further along the length of the fallopian tube. Consequently, monopolar cautery tends to damage more of the fallopian tube than bipolar cautery. In many cases, the tube is also cut after it has been coagulated.

When monopolar coagulation is applied to a single site of the tube, tubal reversal can be performed without the need for further diagnostic tests. If multiple sites of the fallopian tube have been burned with the monopolar technique, we offer a screening diagnostic laparoscopy to evaluate the tubal lengths before proceeding to reparative surgery. The screening laparoscopy option is discussed further on our website.

Tubal Coagulation Reversal Success

Each year Chapel Hill Tubal Reversal Center publishes updated statistics about pregnancy rates and pregnancy outcomes among all of the women who have had tubal reversal procedures performed by Dr. Berger. The data for women who had tubal coagulation sterilizations, presented in the table below, are from our Tubal Reversal Pregnancy Study Report 2007.

Pregnancy Rates of Our Tubal Reversal Patients

The overall pregnancy rate after tubal reversal for women with tubal coagulation procedures is 68% for patients at Chapel Hill Tubal Reversal Center. To calculate the pregnancy rate, the number of women who have become pregnant is divided by the total number who underwent a tubal reversal procedure. The following table shows the numbers and pregnancy rates according to womens’ ages at the time of their tubal reversal surgery.

Pregnancy Rates After Tubal Coagulation Reversal

Conclusion

Tubal coagulation methods of tubal ligation can be successfully reversed in most cases. The pregnancy rate after tubal reversal varies with a woman’s age at the time she has her tubal reversal procedure. The pregnancy rate is 85% for women in their twenties, 74% for those ages 30-34, 64% for women in the 35-39 year age group, and 35% for women 40 years of age or older.

What is Essure?

Essure is a permanent birth control device that has recently become available as an alternative to traditional tubal ligation methods. The spring-like device is inserted through the uterine cavity into the tubal openings using a hysteroscope. This can be done as an in-office procedure. The device expands to fill the tubal opening and then becomes scarred into place, forming a barrier so that sperm cannot reach the egg. Because of the scar formation, it cannot be pulled out of the tube. It is advertised by the manufacturer as a permanent method of birth control. In this respect, it is similar to other tubal ligation methods that are considered by most doctors to be permanent.

Here is a link to an online video animation of the placement of the Essure device into the fallopian tubes.

Is Tubal Reversal Possible For The Essure Device?

I perform 4 tubal reversal procedures each day at Chapel Hill Tubal Reversal Center. The women who come here have all varieties of tubal ligation methods. Today, one of the patients had the Essure sterilization method. When she chose this form of tubal sterilization, she was unaware that she would become remarried and want to be able to try to have a child with her new husband.

Although I could not find any previous references regarding attempts to reverse the Essure procedure, I agreed to attempt to perform a reversal for her. The way I did this was to cut the device out of the uterine muscle and then implant the remaining fallopian tube into the uterine cavity through a new opening in the uterus. This procedure is called tubouterine implantation.

The reason I removed the device was that part of the metal spring projects into the uterine cavity. If a pregnancy were to occur with the device in place, this could be harmful to the pregnancy. To my knowledge, this is the first time that the Essure sterilization procedure has been reversed.

Answers To Common Questions About Essure Reversal

We have provided answers to common questions about Essure reversal in the following blog article,  Essure Reversal: What You Need To Know .

Tubal Ligation by Falope Ring and Hulka Clip

The Falope ring and Hulka clip are occlusive methods of tubal ligation. They block the fallopian tubes, but no tubal segments are clamped, removed, or burned. The Falope ring is also referred to as the tubal ring or tubal band. It constricts a segment of the fallopian tube very tightly, like an extra strong rubber band.

The Hulka clip is a miniature clamp placed across a very small (2-3 mm) segment of the fallopian tube. Another clip method besides the Hulka clip is the Filshie clip. The clips are similar except that the Hulka clip is made out of silastic and the Filshie clip is made out of metal. Occlusive methods of tubal ligation are predictably the best in terms of reversal since they damage such a tiny segment of the fallopian tube.

In contrast to the Pomeroy method, these occlusive devices are applied through a laparoscope. (Laparoscopy involves making a small incision below the belly button.) Many doctors prefer to apply tubal rings or clips when performing a tubal ligation on young women in recognition of the greater likelihood that a tubal reversal may be wanted in the future. Studies have shown that tubal ligation regret and the desire for tubal ligation reversal is more common when a tubal sterilization is performed among women in the twenties than among older women.

Tubal Clip and Ring Reversal Success

Each year Chapel Hill Tubal Reversal Center publishes current statistics about pregnancy rates and pregnancy outcomes among all of the women who have had tubal reversal procedures performed by Dr. Berger. The data for women who had tubal rings or clips shown in the table below is from our Tubal Reversal Pregnancy Study Report 2007.

Pregnancy Rates of Our Tubal Reversal Patients

The overall pregnancy rate after tubal reversal for women with clips or rings is 76% for patients at Chapel Hill Tubal Reversal Center. In the table below, the first column shows ages groups. The second column shows the number of women in each age group who had a tubal reversal. The third column shows the number of women in that group who became pregnant and the last column shows the percentage of women who became pregnant (the pregnancy rate) after their reversal procedures.

Pregnancy Rates After Tubal Reversal of Clips/Rings

Highest Pregnancy Rates After Tubal Reversal

The highest tubal reversal pregnancy rates are seen among women who have reversal of tubal clips or tubal rings. For women in their twenties, the pregnancy rate was 87%. The pregnancy rate ranged from 83% to 73% for women in their thirties. Among women age 40 or older, the pregnancy rate was significantly lower (47%), reflecting the decline in natural fertility with age. These pregnancy rates among our tubal reversal patients are similar to the pregnancy rates for women who have never had a tubal ligation to begin with.

Pomeroy Technique of Tubal Ligation and Resection

The most common type of tubal ligation is the Pomeroy procedure, named after Dr. Ralph Pomeroy who described it in 1930. The Pomeroy method involves picking up a segment of the fallopian tube to create a knuckle, placing a tie or ligature with absorbable suture around its base, and then cutting off the knuckle of tube above the tie. As the suture dissolves, the 2 remaining tubal segments separate from each other.

“Modified” Pomeroy Techniques

Interestingly, Dr. Pomeroy did not publish his technique in the medical literature but simply demonstrated it to other doctors. Some of them subsequently published the technique, but with modifications.

Currently, many doctors use the term modified Pomeroy procedure when they describe the tubal ligation they have performed in a patient’s operative report. Each doctor seems to have his or her own way of operating and there are many variations from the original method. Some doctors use absorbable suture, while others use permanent sutures that do not dissolve. Some doctors place more than one tie around the tube and many doctors also burn or cauterize the tubal ends.

A tubal ligation operative report is useful as a guide but does not predict exactly what the remaining tubal segments will be at the time of a reversal procedure. Fortunately, Pomeroy tubal ligation and its modifications are usually excellent in terms of reversibility.

Pomeroy Tubal Ligation Reversal Success

At Chapel Hill Tubal Reversal Center, we keep a record of all patients’ tubal reversal operations, including the tubal ligation method, the remaining tubal segment lengths, and other important findings at the time of surgery. Since we maintain long term follow-up with our patients, we are able to provide accurate statistics about pregnancies and their outcomes after tubal reversal surgery. Here are some of the pregnancy statistics for women who have had a Pomeroy type of tubal ligation.

Pregnancy Rates of Our Tubal Reversal Patients

The overall pregnancy rate after Pomeroy tubal ligation reversal is 70% for patients at Chapel Hill Tubal Reversal Center. The table below shows pregnancy rates according to women’s ages at the time of tubal reversal. The first column shows ages by 5 year groupings. The second column shows the number of women in each age group who had a tubal reversal. The third and fourth columns show the number and the percentage of women who became pregnant after their reversal procedure. The data shown in this table come from our Tubal Reversal Pregnancy Study Report 2007.

Here is how the pregnancy rate is calculated: The number of pregnant women (column 3) divided by all women in that age category who had reversal surgery (column 2) times 100 equals the percentage of women who became pregnant (column 4). A doctor has to know all of this information in order to be able to state what the success rate is for his patients.

Pregnancy Rate By Age After Pomeroy Tubal Reversal

Good News About Pomeroy Reversal

The good news is that for women under age 40, two-thirds to four-fifths will become pregnant following a tubal reversal procedure. Even for women age 40 and over, approximately 4 out of 10 will conceive another pregnancy. From the follow-up data that we have for our tubal reversal patients, there is good reason for optimism when reversing a Pomeroy tubal ligation.

Our Tubal Reversal Center is Unique

Dr. Berger is the only physician in the country with a practice that is specifically limited to tubal reversal surgery. That is the only procedure performed here with Dr. Berger performing four reversals each day, five days a week. We have a high staff/patient ratio with one or two nurses devoted specifically to your care while you are here. All of our nurses have advanced certification in cardiac life support (ACLS) and our anesthesiologists are MDs with board certification in anesthesiology. The anesthesiologists are employees here and not anesthesia staff from another hospital or anesthesia service. In other words, everyone at Chapel Hill Tubal Reversal Center has expertise in caring for tubal reversal patients and performing reversal surgery. While you are here, you will only be with other women and couples who are here specifically for the same purpose.

We Provide Accurate Tubal Reversal Statistics

We keep detailed data and statistics on each of our patients (such as age, tube length, medical history, tube of tubal ligation, pregnancy history). This is obtained by ongoing contact with our patients to ensure we have accurate information regarding their surgery and their outcome. Dr. Berger maintains and publishes data regarding pregnancy rates and pregnancy outcomes following tubal reversal surgery. We know of no other doctor or medical facility that does this.

On the Internet, claims about tubal reversal pregnancy rates are often made without supporting information or documentation – such as a description of the patient population, study method, and follow-up interval. Most Internet sites about tubal reversal do not provide any factual data at all. Any doctor may say that his patients have a particular success rate, but supporting the claim with actual data involves considerable effort. Performing a follow-up study such as this one requires keeping an accurate record of patients and their findings, as well as maintaining ongoing patient contact to determine the outcomes of treatment. That is the only way a doctor can actually know what the pregnancy and outcome statistics are for his patients. Without this detailed type of information, the accuracy of any claim of success rates should be questioned.

At Chapel Hill Tubal Reversal Center, nurses enter information into an electronic patient database at the patient’s registration, the surgical procedure, and from regular post-operative communications with our staff. If we have not heard from patients after their recovery from surgery, our nurses contact them at 6 and 12-month intervals. We know of no other doctor, hospital, or clinic that maintains such ongoing patient follow-up records after tubal reversal surgeries. I believe Dr. Berger’s commitment to providing accurate, up-to-date data is reflected in the fact that he requires this time-consuming but important procedure to be followed so that valid information can be obtained. Each year we publish the results of our follow-up study, reflecting surgical and pregnancy outcomes. This is the most comprehensive study done to date of tubal reversal surgery and its resulting outcomes, showing that for the majority of women who have undergone a tubal ligation procedure and decide later they would like to have more children, tubal reversal surgery is a better option than in vitro fertilization (IVF).

We Follow-up With Patients and Are Always Available

Another reason to choose Dr. Berger and Chapel Hill Tubal Reversal Center is the staff! We are available 24 hours a day/7 days a week to answer questions and concerns. Patients regularly express amazement at the level of care, compassion, and professionalism that they were shown before, during, and after surgery. Patients also like the fact that they receive follow-up calls on post-op day 1 and 3 and at 2 weeks, simply to see how they were doing and to have any questions answered. Our nurses follow-up with each patient again at 6 months and one year after surgery.

Submitted by Julia Smith, R.N.
Nurse Administrator

About Me

Sometimes patients ask about my background and why I became a tubal reversal doctor. (It’s a fair question, since I ask them what made them decide to have a tubal reversal.) I usually tell them about my first year after medical school when I was an intern in medicine at Duke University Hospital taking care of critically ill and dying patients. That is when I decided to devote my medical career to assisting with the beginning of life rather than its ending.

Influential Teachers

The first tubal surgery that I assisted in was during my first year of residency in obstetrics and gynecology at Johns Hopkins Hospital in 1970. At the University of North Carolina where I completed my residency, Dr. Jaroslav Hulka (the inventor of the Hulka clip) taught me the basic principles of tubal reversal surgery. In 1976, I went to Europe to learn tubal microsurgery from Dr. Robert Winston. Dr. Winston’s microsurgical method was an advancement but also a major operation of several hours duration resulting in hospitalization for 5 days or more.

My goal was to make tubal reversal easier to undergo and less costly for the patient. This was accomplished by combining the best principles of gyn surgery, microsurgery, and plastic surgery techniques. I had the great fortune of operating for many years with the renowned plastic surgeon, Dr. Erle Peacock, author of the surgical text entitled “Wound Healing”.

Outpatient Tubal Reversal

By the mid-1980s, I developed the outpatient surgical approach to tubal ligation reversal that I use – and continue to improve upon – to this day. What was a major and expensive in-hospital operation with prolonged recovery became a comfortable outpatient procedure that is affordable for most couples. It is the most gentle operation that exists for restoring tubal anatomy and has resulted in the birth of more babies in the world than any other tubal reconstructive operation.

Anyone who is interested in seeing how I perform outpatient tubal ligation reversal can watch the entire operation that was recorded on video and shown on Discovery and TLC. In this video, each step of the procedure is described as it is performed.

My Viewpoint

I have been fortunate to have had the best teachers in the world in the art of surgical technique as it applies to the fallopian tube. Specializing in tubal reversal surgery over the past 30 years has allowed me to assist more than 6000 couples in the beginning of life with the safest, most comfortable, and most successful tubal reversal operation.

The circumstances that lead people to have a tubal reversal procedure are unique to each person. Understanding them is helpful to me as a tubal reversal specialist providing their care during and after tubal reversal surgery.

Preoperative Consultation

When meeting new patients, I begin the preoperative consultation by asking about the circumstances that have them brought to me. After greeting patients and having them get settled comfortably in my office, I ask: What made you decide to have a tubal reversal at this time? Each person or couple responds in their own way to this nondirective question, often touching on their personal, social, and medical history that have brought them to this point in their lives. Their responses provide the context for the discussion that follows about their tubal reversal procedure.

Reasons for Tubal Reversal

The reasons given for having a tubal reversal vary. The most common one is that the patient is in, or about to enter, a new marriage. Often, the man has no biological children. Even when both partners have children from previous marriages, they want to establish a family of their own. Less commonly, couples who already have children together want to expand their family. For these couples, their past choice to have a tubal ligation is no longer the right decision for them. Sometimes they describe religious considerations, a change in financial stability, or tragically, the death of a child.

Tubal Ligation Regret

Many women have told me that they had a tubal ligation as a way out of a bad situation. Some did not want to have any more children while in a failing or abusive marriage. Others felt pressured into having their tubes tied by a parent, other family members, spouse, or even their doctor. Women who had their tubes tied while undergoing a C-section often report they made a hasty decision while in labor and almost immediately felt that it was a mistake.

Post Tubal Ligation Syndrome

An increasing number of women describe a variety of symptoms that started when they had their tubes tied. Most often these include heavy or painful periods, headaches, irritability, or other emotional reactions that were not present before their tubal sterilization. Many of these patients have been treated by their doctors with hormones, anti-depressants, or other medications to no avail and usually have been told that Post Tubal Ligation Syndrome does not exist. But they are convinced from their own histories that it does. A study that we are currently conducting finds that over 90% of these women report improvement or complete relief of their symptoms after tubal reversal surgery. Clearly, more research about this controversial subject is warranted.

Informed Consent and Patient Follow-up

Whatever the reasons for having a tubal reversal, it is important for patients to be fully informed about the potential benefits and risks of the operation. Equally important is the long term follow-up that we maintain with patients after surgery. This has enabled us to document and report the outcomes of tubal reversal surgery to a much greater extent than has ever been done before.

Chapel Hill Tubal Reversal Center

Chapel Hill Tubal Reversal Center is the only medical center exclusively for tubal ligation reversal. Patients travel from all over to have their tubal reversal procedures performed here. After surgery, each patient puts a pin in the map indicating where she is from. The map below shows that people come from all over the country. In fact, patients come here from all over the world.

Why Patients Come Here

Why are people willing to travel so far for a surgical procedure? They tell me it is to get the best outcome that is possible. Most patients have found out about us while doing research about tubal reversal surgery and doctors on the internet. Many have seen “The Operation“ on TV or the free video or dvd that we send out on request. This video gives a real couple’s perspective of the outpatient procedure and how well it works. When it comes to having a very much wanted baby, most people are willing to travel to get the best outcome.

What They Say About Us

To have an idea of what it is like to be one of our patients, read what previous patients have said about their experiences here. There are thousands of comments on various website pages such as About Us and Pregnancy Testimonials. Or visit an independent website such as RateMDs.com. Here are a few of the comments patients have made on this doctors rating site:

“Dr. Berger and his staff were awesome!!!! They were extremely kind and patient, very approachable, and every detail of my surgery and recovery were explained. I only needed pain medication the first night following my surgery and I was able to resume my normal activities the next day. I would highly recommend Dr. Berger to everyone considering tubal reversal surgery. God has granted him the power to make miracles happen.” Shelia TR 06/08/07

“The care I received from Dr. Berger was phenomenal. It was the most professional and compassionate medical experience I have ever had. The follow up care has been just as impressive even now, over a year and a half later. Dr. Berger is the best choice a couple could possibly make.” Julia and Kevin Disorda – Vermont

“Dr. Berger and his staff are just amazing, not only as people but at the work they do. I traveled from California to see Dr. Berger and could not be happier with my decision. I was so pleased with how fast my recovery was and that I had no pain after the surgery. Dr. Berger and staff are there for you whenever you need them, and will make you feel as if you are family.” Sharon Lincoln – California

The fallopian tube is an amazing and versatile reproductive organ. Its functions include capturing an egg from the ovary at the time of ovulation; nourishing the fertilized egg or zygote during its early cell divisions; and delivering the blastocyst into the uterine cavity when it is time for implantation. The different parts of the fallopian tube correspond to these various functions.

Tubal Anatomy

The end of the tube furthest from the uterus is the fimbria. The fimbrial segment is lush with cilia that beat vigorously and sweep the egg into the tube where it is fertilized. The egg is quickly moved by the bell-shaped infundibular segment into the ampullary region of the tube. Over the next several days, the combination of muscular contractions and ciliary movement move the egg toward the uterus. The ampulla provides nourishing fluid that allows repeated cell divisions. When the dividing egg (zygote) reaches the stage where the outer membrane dissolves (blastocyst), it is time to be delivered into the uterine cavity. This is the function of the muscular isthmic segment of tube closest to the uterus.

Does Anatomy Predict Function After Tubal Reversal?

Given the complexity of the functions of the fallopian tube, one might wonder if any portion is essential for pregnancy to occur. Years ago, based on the information available in medical texts, I assumed that there would be essential parts or a minimum length of tube needed to result in a normal pregnancy. However, there was little information available to answer this question. Therefore, I began recording the portions of tube removed, tubal segment lengths remaining, and other details about each patient’s reversal operation in an electronic database. Since the staff members at Chapel Hill Tubal Reversal Center follow-up with patients regarding pregnancy after tubal reversal, it has become possible to study the interaction of tubal anatomy and the tube’s ability to function normally.

A Surprising Discovery

Over the 30 years that I have been performing tubal reversal procedures, I have seen every variation of tubal ligation imaginable regarding the sections of tubes removed and lengths of tube remaining to repair. It was surprising to learn that no specific part of the fallopian tube is absolutely required for pregnancy to occur. Somehow, the fallopian is able to compensate for the loss of specific parts and still function normally! Based on this knowledge, I am optimistic in being able to repair any kind of tubal sterilization procedure with the expectation that it will allow the possibility of having more children.

Risk of Ectopic Pregnancy

Tubal surgery is associated with an increased risk of ectopic pregnancy (a pregnancy outside of the uterine cavity). The risk of ectopic pregnancy is 2-3% in the general population. After tubal ligation and tubal ligation reversal, the risk is approximately 10%. Therefore, every woman who is pregnant following tubal reversal should be considered at risk for ectopic pregnancy until proven otherwise. This is the rationale for the early pregnancy monitoring protocol that I recommend to all of my patients.

Early pregnancy monitoring

Early pregnancy monitoring begins when a woman has a positive home pregnancy test confirming that she is pregnant. Following this, serum quantitative HCG assays should be performed twice a week. These measure the blood levels of the pregnancy hormone, human chorionic gonadotropin. The HCG doubling time in early pregnancy is normally 2-3 days. In a healthy pregnancy, the HCG level will double with each successive blood test.

When the HCG level reaches 1500 mIU/dL, a vaginal ultrasound exam should be performed to identify an intrauterine gestation sac. The gestation sac appears as a black circle or oval surrounded by a bright white “halo”.

If no gestation sac is seen, the HCG assay and ultrasound should be repeated 1 or 2 days later. If the HCG is rising and still no gestation sac is seen, the pregnancy is progressing – but not normally – and is either an intrauterine pregnancy that will miscarry (a “blighted ovum”) or is outside of the uterus. In either case, we recommend ending such a pregnancy with an injection of methotrexate in order to prevent the possible complication of tubal rupture.

Tubal rupture occurs when an ectopic pregnancy grows through and tears the fallopian tube. When this happens, intra-abdominal bleeding is likely to occur. A ruptured ectopic pregnancy is considered a surgical emergency and often results in removal of the ruptured tube. Fortunately, tubal rupture can be prevented by adhering to our early pregnancy monitoring protocol.

What To Do When You Become Pregnant

When you have a positive pregnancy test, please alert us and complete the Pregnancy Report Form that is shown as a link at the bottom of the I’m Pregnant page. We will follow your testing with you to be sure you are having the proper tests done at the right time and that they are being interpreted correctly. We follow-up on all pregnancies with each of our tubal reversal patients.

An easy way to remember the early pregnancy monitoring testing protocol is to read the I’m Pregnant page on the Chapel Hill Tubal Reversal Center website when you become pregnant. This page can be printed and taken to your local doctor. If your doctor has any questions about my recommendations, please give the doctor my pager number. I am available at all times by pager for urgent medical concerns and/or communication with your doctor.