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

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.

Tubal reversal information is plentiful on the internet, but not everything that you read is accurate or factual. Of the websites that provide information about tubal ligation reversal, the one from Chapel Hill Tubal Reversal Center is most complete and accurate. It describes the various types of tubal ligation procedures and the different tubal reversal procedures that can be used. If you are interested in learning about tubal reversal, spend some time looking at the different pages on this extensive site. There is a search box at the top of every page that can direct you to specific information about any issues relating to tubal ligation reversal. Take a look also through the many topics of information on the Tubal Reversal Blog.

Tubal Reversal Surgery

Tubal ligation reversal is usually considered to be a major operation, taking several hours and requiring a hospital stay of 1 to 5 days. Complete recovery is often described as taking 4 to 6 weeks. However, the tubal reversal procedure that Dr. Berger has developed is performed as outpatient surgery with no hospital stay required and with complete recovery generally within 5 to 10 days. Since hospitalization is not required, the cost of the tubal reversal procedure is reduced by half or two-thirds of the cost when performed in a hospital. Patients are more comfortable during their post operative recovery and are able to return to work and other normal activities much faster. A free video or DVD of Dr. Berger’s tubal reversal procedure is available on the Chapel Hill Tubal Reversal Center website.

Risks of Tubal Reversal

As with any surgery, complications are always a possibility. Although rare, these may include bleeding, infection, damage to other organs, or complications of anesthesia. The most significant risk associated with tubal ligation reversal is the long term risk of having an ectopic pregnancy. This risk is increased from approximately 2% of pregnancies in the general population to approximately 10% after tubal reversal. Fortunately, the medical problem of a ruptured tubal pregnancy can be prevented by following an early pregnancy monitoring protocol that has been described by Dr. Berger and is recommended to all women after a tubal reversal procedure.

Alternative Treatment

Rather than “untying” their tubes, some women are advised to be treated by in vitro fertilization (IVF). However, IVF is more complicated and expensive, the pregnancy rate after IVF is not as high as after tubal reversal, and there is a very high incidence of multiple births (approximately 30%) after IVF. Further, there is concern about the possible long term effect of the use of potent hormones to stimulate the ovaries to produce many eggs (called “super-ovulation”) and the suspicion that it might increase the risk of ovarian cancer later in life.

Am I a Candidate for Tubal Reversal?

Although most women have been told that tubal ligation is permanent, in fact, the vast majority of tubal ligation procedures are reversible. The operative report from your tubal ligation will give a good indication if the procedure can be reversed. When there is any doubt about this, diagnostic laparoscopy can be performed to examine the fallopian tubes and then decide whether to proceed with the reversal operation.

Pregnancy Rates After Tubal Reversal

Pregnancy and birth rates after a tubal reversal are significantly better than after IVF. Neither procedure, however, can guarantee that pregnancy leading to birth will occur. Even when the fallopian tubes have been repaired, other factors – such as age, menstrual cycle regularity, ovulation or other hormonal disorders, and the fertility of the male partner - may determine when, or whether, conception will occur.

Women under the age of 30 who have a tubal reversal have an 82% pregnancy success rate; between 30-34 the pregnancy rate is 76% and for women ages 35-39, the pregnancy rate is 67%. The pregnancy rate declines for women 40 and older in accordance with the natural decline in fertility with age. However, pregnancy rates are higher for women of any age following tubal reversal than after IVF.

More Tubal Reversal Information

If you would like to discuss your individual situation with a Tubal Reversal Nurse, call (919) 968-4656. The experienced nurses at Chapel Hill Tubal Reversal Center are always happy to provide information about tubal ligation reversal. You can also exchange information with other women on the Tubal Reversal Message Board.

Surgical Technologists at Chapel Hill Tubal Reversal Center

Surgical technologists, also called surgical technicians, are the unsung heros of the surgical team at Chapel Hill Tubal Reversal Center. Patients have little interaction with them except when they are in the operating room. The surgical techs are not easily recognizable behind their surgical masks and during most of the time patients are in the operating room they are asleep! The surgical technicians, however, are responsible for making sure that all equipment is in perfect working order, the operating rooms are meticulous, and that all equipment and instruments are sterile. Their training and working every day with Dr. Berger ensures that tubal reversal procedures go smoothly, safely, and that patients are under anesthesia for the minimal length of time necessary. They must think and act quickly, safely, and accurately to assist the surgeon to achieve the optimal surgical technique throughout the entire operation, from the time a patient goes to sleep until she awakes.

Meet Our Surgical Technologists

Below is a brief history about our outstanding team of surgical techs introducing them from the left to the right in the photo. Here is a link to the web site page about our four surgical technologists at Chapel Hill Tubal Reversal Center.

Matt Murphy, ST underwent his training as a surgical technician at Chapel Hill Tubal Reversal Center where he has worked since 2005. During this time, Matt took a break to work abroad. He describes his time away as an enlightening, growth experience. Matt says that Dr. Berger is always encouraging him to research topics about surgical technique and to continue his education. Matt’s favorite subjects are science and medicine and he is in the process of getting his associates degree in science. Matt’s fluency in Spanish permits him to communicate easily with Spanish speaking patients.

Brandon Martin-Williams, ST also was trained at Chapel Hill Tubal Reversal Center as a surgical techician where he has worked since 2006. During his time at Chapel Hill Surgical Center Brandon has become interested in furthering his career in medicine. Even while working full-time, Brandon has been taking classes to finish his bachelor’s degree in Biology. Brandon hopes to go to medical school in the near future. With his demonstrated skills in the operating room, Dr. Berger believes that Brandon would be an excellent doctor.

Donna Sisson, ST has worked as a first assistant to Dr. Berger in surgery since 1990. Prior to coming to Chapel Hill Surgical Center, she worked as a surgical technologist at St. Francis Hospital in Greenville, SC and at Durham Ambulatory Care in Durham, NC where she specialized in gynecological and plastic surgery procedures. Donna says that working with Dr. Berger is particularly rewarding because Dr. Berger always strives to be on the leading edge of his profession. Donna was Dr. Berger’s first assistant in the Learning Channel’s documentary “The Operation” that features Dr. Berger performing Outpatient Tubal Ligation Reversal.

Kathy Scronce, ST has been a surgical technician at Chapel Hill Tubal Reversal Center since 2005. She previously worked as a surgical technologist at Durham Regional Hospital in Durham, NC. Kathy appreciates the fact that Dr. Berger and all of the staff at the Chapel Hill Tubal Reversal Center are extremely devoted to their patients. Kathy is an integral member of this caring team who work so well together and who concentrate on optimal surgical technique to ensure a successful experience for tubal reversal patients.

Dr. Berger’s Comment

Over the many years I have been performing tubal reversal surgery, I can truly say that I have never worked with a more professional, well trained, and competent surgical team than the one that currently exists at Chapel Hill Tubal Reversal Center. Not only are these individuals professionals in every sense, but also they are exceptional people who are truly dedicated to providing the best and safest care to patients that is possible. Although the patients who come to Chapel Hill Tubal Reversal Center are often unaware of the importance of these essential team members, our patients benefit everyday from the extraordinary way that our surgical technologists do their jobs. It is one of the many factors that makes Chapel Hill Tubal Reversal Center stand out for its excellence in patient care.

There have been many milestones in outpatient anesthesia since its inception. Imagine what the first patient was thinking when told he or she would be going home the same day after the administration of a general anesthetic! These milestones include vast improvements in patient monitoring, shorter acting anesthetics, and improved surgical techniques.

Anesthesia at Chapel Hill Tubal Reversal Center

All patients at Chapel Hill Tubal Reversal Center receive “general” anesthesia. General anesthesia for any day surgery center, but specifically for tubal reversal surgery, begins with our first phone call to prospective patients, weeks and sometime months before the actual surgical procedure. As an anesthesia provider this offers me a unique opportunity to care for patients in an outpatient, day surgery setting.

Our patients travel from all over the world to have their tubal ligation reversal performed by Dr Gary Berger. Some patients have just the basic preoperative lab work, while others have medical problems that require additional preoperative lab tests. In either case, these are done in the patient’s hometown and then faxed to our office for review.

Before Your Tubal Reversal Procedure

We conduct our anesthesia interview over the telephone at least a month before the scheduled procedure. This is the first step to providing good, comprehensive outpatient anesthesia care. Our next step is to send each patient written instructions of what to expect when they arrive in Chapel Hill.

Once our patients arrive at Chapel Hill Tubal Reversal Center we meet them personally and go over their history again. This ensures that both the patient and the anesthesiologist understand each other completely. We also review their instructions for that evening, making sure they understand completely about diet and other restrictions they will have to follow. The morning of surgery is less stressful for our patients because they have met our staff and have a full understanding of what to expect.

During And After Your Tubal Reversal Procedure

The tubal reversal procedure is short, only about an hour. We work closely with Dr. Berger to assure optimal pain control. During the surgery he injects local anesthesia into the muscles and surrounding tissues, thus decreasing the amount of general anesthesia necessary. In addition, our patients need less postoperative narcotics.

Our postoperative focus is then on nausea and pain control. Since each person is different, we monitor pain scores, and when our patients are comfortable they are discharged from our step down recovery room to their own hotel rooms.

We follow up with each patient and have an on going data base so that we may continue to improve our patient care in the area of tubal reversal anesthesia.

Anesthesia Team At Chapel Hill Tubal Reversal Center

Pam Mills CRNA Caryn Hertz MD James Split MD Chapel Hill Tubal Reversal Center Anesthesia Staff

We Will Ensure Your Comfort

Our experienced anesthesia team will ensure your comfort before, during, and after your tubal reversal surgery. Our two board certified anesthesiologists and registered nurse anesthetist (CRNA) specialize in outpatient anesthesia and have a total of more than 50 years of combined experience. We are an essential part of the medical and nursing team who will assess your medical status prior to surgery and will care for you during and after surgery. Our experience working every day with Dr. Gary Berger in the operating room and the recovery nurses in the post-anesthesia care unit results in the most effective care for each patient.

Submitted by Pam Mills, CRNA

Tubal Anastomosis at the Uterine Cornua

Tubouterine anastomosis is a tubal reversal procedure that is intermediate between tubotubal anastomosis and tubouterine implantation. It is also called cornual anastomosis because the tube is joined to the cornual area of the uterus with this operation. The cornu is the area where the fallopian tube normally emerges from the the uterus.

When Is Tubouterine Anastomosis Performed?

Tubouterine anastomosis is performed when there is a healthy tubal segment near the ovary, but no segment remains attached to the uterus, following a tubal ligation procedure. It is also performed when a tubal segment attached to the uterus is scarred and has no open lumen.

An incision is made into the uterus at the cornu to find the opening of the fallopian tube tube as it passes through the uterine muscle. If an opening is found, the tubal segment that remains is rejoined to the uterus at this site.

Case Histories

The topic of tubouterine anastomosis is a timely one. During the past week, 2 patients undergoing tubal reversal surgery at Chapel Hill Tubal Reversal Center required this operative procedure. In one case, each fallopian tube had been coagulated or burned next to the uterine cornu, leaving no segment attached to the uterus. The other patient had developed the condition known as salpingitis isthmica nodosa in the portion of the fallopian tube between the uterus and the a Falope ring. In both cases, tubal reversal was able to performed with the technique of tubouterine anastomosis.

Dr. Berger’s Comment

Frequently, patients have been informed by doctors who are not specialists in tubal ligation reversal that their fallopian tubes cannot be repaired after a tubal ligation. This is especially true when the proximal segments of the fallopian tubes are missing or diseased. But there are a variety of surgical techniques that can be used during tubal reversal surgery by a doctor who is an experienced tubal reversal surgeon. This is one of the advantages patients have when they come to Chapel Hill Tubal Reversal Center for their tubal reversal procedures.

Chapel Hill Tubal Reversal Center Anesthesia Team

The Anesthesia Team at Chapel Hill Tubal Reversal Center ensures your comfort before, during, and after your tubal reversal procedure. We are Caryn Hertz, MD, Pamella Mills, CRNA, and Ann Pflugrath, MD. Our team consists of two board certified anesthesiologists and a registered nurse anesthetist specializing in outpatient anesthesia. Our experience working every day with Dr. Berger results in the best care for each tubal reversal patient.

Ensuring Patient Safety

We assess the patient’s medical history even before they come to Chapel Hill Tubal Reversal Center. We speak with each patient by phone several weeks before their scheduled tubal reversal procedure. Most patients have just the basic preoperative lab tests. Some patients with medical conditions require additional tests. All of the preoperative lab work is done in the patient’s hometown, with the results being faxed to us for review. Each patient is sent written instructions of what to expect when they arrive at Chapel Hill Tubal Reversal Center.

On the day of your preoperative consultation with Dr. Berger, we will meet with you to review your medical history again. We will discuss instructions for the evening before surgery, such as about diet or other restrictions to follow to make sure you understand them. The day of surgery is less stressful for our patients because they have met our staff and have a full understanding of what to expect.

Ensuring Patient Comfort

Tubal reversal surgery by Dr. Berger is short. You will be asleep with “general” anesthesia during the 60-90 minute procedure. We work closely with Dr. Berger to assure excellent pain control after you awake from the operation. Dr. Berger injects local anesthesia into the muscles and surrounding tissues during tubal reversal surgery. This reduces the amount of anesthesia during surgery and the need for postoperative pain medication. Our postoperative focus is on nausea and pain control. Patients are discharged from the recovery room when they are comfortable, usually within one or two hours, and they are taken to their room at the Sheraton Hotel.

We Want You To Have The Best Medical Care Ever

We are fortunate at our day surgery center to have state of the art equipment with which we carefully monitor over 15 parameters during and after the tubal reversal procedure. We follow-up with all of our patients and review the evaluation forms that they complete when they have recovered. We pay special attention to any comments patients offer. Our goal is to keep tubal reversal surgery at Chapel Hill Tubal Reversal Center safe, comfortable, and the best medical experience our patients have ever had!

Tubal Reversal Procedures

There are 3 types of tubal reversal procedures:

• anastomosis
• implantation
• salpingostomy - (this blog topic)

Salpingostomy Definitions

Salpingostomy is creating an opening in the fallopian tube. It is also called neosalpingostomy, which more clearly indicates the creation of a new opening in the tube.

Salpingostomy is the appropriate tubal reversal procedure when the end closest to the ovary is closed and the fallopian tube has not been divided into separate segments. This is what results from a fimbriectomy tubal ligation. It can be seen also when a fallopian tube has become closed as a result of infection (salpingitis).

How I Perform Ampullary Salpingostomy

Salpingostomy involves creating an opening in the end of the fallopian tube with a microsurgical needle electrode. The opening is enlarged and gently folded back so that the internal lining extends over the opened end of the tube. The internal lining is covered with cilia, the hairline projections that beat in coordinated waves. They help capture an egg as it is released from the ovary just as the fimbrial end of the tube does normally.

Sutures are placed around the end of the tube that has been folded back. The sutures are hidden underneath the folded-back tubal end. When ampullary salpingostomy is completed, the tubal end looks similar to a normal fallopian tube, provided there is a sufficient ampullary length of tube remaining to fold back.

Types of Salpingostomy

The type of salpingostomy is specified according to the tubal segment that has been opened. This will depend on how much of the fallopian tube was removed during a fimbriectomy. The illustration above shows an ampullary salpingostomy. Salpingostomy at the ampullary, infudibular, or fimbrial tubal segments can result in good success rates. If a large amount of tube has been removed and only the isthmic segment remains, salpingostomy is unlikely to result in pregnancy.

Comment About Salpingostomy

The success of salpingostomy for fimbriectomy tubal reversal depends upon having an adequate length of ampullary segment of the fallopian tube. The length of the remaining ampullary tubal segment can be determined from a hysterosalpingogram (HSG) or from diagnostic laparoscopy.

I recommend having an HSG or choosing the screening laparoscopy option when tubal ligation has been performed by fimbriectomy. An HSG can be ordered by the patient’s local doctor and the x-ray films sent to me for examination prior to scheduling tubal reversal surgery. Alternatively, patients can omit having an HSG and schedule their reversal surgery to start with screening laparoscopy. This will show if ampullary salpingostomy will be effective. If so, the tubal reversal procedure will be performed at the same time while the patient is under anesthesia.

Tubal Reversal Procedures

There are 3 types of tubal reversal procedures:

• anastomosis
• implantation - (this blog topic)
• salpingostomy

Implantation of Fallopian Tubes

Implantation of the fallopian tube is inserting the tube through a new opening into the uterus. Tubouterine implantation is correct medical terminology, but it is also called tubal implantation, uterotubal implantation, or uterine implantation.

Most tubal ligation operations leave two fallopian tube segments that can be reconnected. In some cases, only one tubal segment remains that is separated from the uterus and the portion of the tube within the uterine muscle is blocked as well. This is most likely to occur when a tubal ligation has been performed by monopolar tubal coagulation applied to the tubal segment next to the uterus. In this situation, tubal implantation is required as the tubal reversal procedure.

How I Perform Tubal Implantation

Tubal implantation is performed by making an incision through the uterine muscle. The incision is carried down into the uterine cavity. The tubal segment that has been separated from the uterus is opened and passed down until its proximal end is inside the uterine cavity. Before implanting the tube in the uterus, a suture is placed through the open end that goes inside the uterus. This suture is used to anchor the fallopian tube within the uterine cavity.

When the tube has been anchored inside the uterine cavity, sutures are placed in the uterine muscle around the implanted tube. Care must be taken to close the uterine incision sufficiently to allow healing, but not so tightly that it compresses or constricts the implanted tube. Tubal implantation is a more difficult operation to perform than tubal anastomosis. Tubal implantation accounts for 1% of tubal reversal procedures at Chapel Hill Tubal Reversal Center.

Tubal Reversal Procedures

There are 3 types of tubal reversal procedures:

• anastomosis - (today’s blog topic)
• implantation
• salpingostomy

Anastomosis of Fallopian Tubes

Anastomosis connects two body parts. Tubotubal anastomosis is connecting two segments of the fallopian tube. Tubotubal anastomosis is correct medical terminology, but it is also called tubal anastomosis for short. Bilateral tubal anastomosis means that both tubes are repaired by the anastomosis technique. The anastomosis sites can be specified for each fallopian tube. They may be different for the two sides. For example, a patient may have a right isthmic-ampullary tubotubal anastomosis and a left ampullary-ampullary tubal anastomosis. Sometimes, only one fallopian tube is repairable with the anastomosis technique. This is called unilateral tubotubal anastomosis.

Bilateral Tubal Anastomosis

Most tubal ligation operations separate the fallopian tube into two segments. Bilateral tubotubal anastomosis, therefore, is the most common tubal reversal procedure. Bilateral tubal anastomosis accounts for 90% of the tubal reversal procedures at Chapel Hill Tubal Reversal Center.

How I Perform Tubal Anastomosis

After opening the blocked ends of the two tubal segments, I pass a flexible stent or thread through the tubal lumen or opening of the two segments until it reaches the uterine cavity. This ensures that the fallopian tube is open from the uterine cavity to its fimbrial end and that the tubal segments align properly. A suture placed in the connective tissue, just beneath the fallopian tube segments, draws the tubal segments together.

The muscular and outer layers of the tubal segments are connected with microsurgical sutures. Care is taken to avoid suturing the inner layer of the fallopian tube. Suture material is a foreign body. Stitches placed in the inner tubal lining can cause scarring inside the tubal lumen. When the two tubal segments are joined together, the stent is withdrawn from the fimbrial end of the tube.

Watch The Operation

The images above illustrate the principles of tubotubal anastomosis. For more details, you can watch the operation as it is being performed. A short video clip online gives an overview. If you want to watch the entire tubal anastomosis procedure, you can order a videotape or dvd of Tubal Ligation Reversal by Dr. Berger as shown on TV by the Discovery and Learning Channels. Watching the full length video will help you better understand how I perform tubotubal anastomosis as outpatient tubal reversal surgery.