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 When the two tubal segments are joined together, the stent is withdrawn from the fimbrial end of the tube.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.

Tubal Ligation by Fimbriectomy

Fimbriectomy is an infrequent type of tubal ligation in the United States. This female sterilization method is performed by removing the fimbrial end of the fallopian tube. At the fimbrial end of the tube, the inner tubal lining faces outward towards the ovary. The tubal lining is rich in cilia that beat in coordinated waves to pull the egg into the tubal opening.

Many doctors think that tubal reversal cannot be successful following a fimbriectomy because of the loss of the egg-capturing fimbria. This is a mistaken notion. Cilia are abundant in the ampullary segment of the fallopian tube. The inner lining of the remaining ampullary tubal segment can be folded outward after opening the tube and can function as a new fimbrial end. The tubal reversal procedure for fimbriectomy reversal is called ampullary salpingostomy.

Fimbriectomy Reversal Pregnancy Rates

Chapel Hill Tubal Reversal Center publishes statistics updated annually regarding pregnancy rates and pregnancy outcomes for all of the women who have had tubal reversal procedures performed by Dr. Berger. The data for women who had tubal ligation procedures by fimbriectomy are from our Tubal Reversal Pregnancy Study Report 2007.

The overall pregnancy rate after fimbriectomy tubal reversal is 56% for patients at Chapel Hill Tubal Reversal Center. The following table shows the numbers and pregnancy rates according to womens’ ages at the time of their tubal reversal procedure.

Pregnancy Rates After Fimbriectomy Reversal

Recommendations for Fimbriectomy Reversal

The success of fimbriectomy 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 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.

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.

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.

Almost every article one reads about tubal ligation stresses that it is permanent. Most doctors and the lay public believe this to be true. In my experience, however, tubal ligation is reversible in over 95% cases!

Doctors stress that tubal ligation is a permanent method birth control because it cannot be discontinued easily such as stopping the use of birth control pills or the patch, removing an IUD, or avoiding the use of barriers contraceptives (condom or diaphragm). In the past, reversing a tubal ligation procedure involved complicated surgery with its attendant high cost (up to $35,000). The outpatient tubal ligation procedure that I have developed is uncomplicated surgery and avoids the expense of hospital charges. This has reduced the cost of tubal reversal surgery to under $6000. This is less than the cost of a single treatment cycle with in vitro fertilization (averaging $10,000 - $12,000). My effort over the past 3 decades has been to make tubal reversal surgery easy to undergo and affordable for couples.

There are some methods of female sterilization that are not reversible. These include complete removal of the fallopian tubes (total salpingectomy) and extremely destructive methods of partial salpingectomy that do not leave two segments to repair. An example of the latter is when only a short portion of the tube is attached to the uterus and the remaining segment contains only fimbrial tissue with no tubal muscle or opening. In this case, the fimbrial tissue alone cannot be rejoined successfully to the uterine segment of tube. Fortunately, this is an unusual occurrence. In cases where there is a sufficient length of tube attached to the uterus, it can be opened and be able function normally even without the fimbrial end. This is called ampullary salpingostomy. This technique is useful in reversing a fimbriectomy (removal of the fimbrial or ovarian end of the fallopian tube).

Reviewing the operative report from a tubal ligation procedure usually will indicate how destructive the procedure was. When there is a question about this, diagnostic laparoscopy can be performed to examine what remains of the fallopian tubes. If there are sufficient segments to repair, tubal reversal can be done right then while the patient is under anesthesia.

The best method of tubal ligation to reverse is the clip procedure. The Hulka Clip was developed in the 1970s by Dr. Jaroslav Hulka, a professor of obstetrics and gynecology at the University of North Carolina at Chapel Hill. (Dr. Hulka was one of my most influential teachers during my residency in ob-gyn at UNC.) The tubal ring also is an excellent method for reversing. The clip and ring procedures tend to damage the least amount of the fallopian tube and leave behind long segments to repair.

The most common tubal ligation procedures involves tying and cutting the tubes (ligation/resection) or burning the tubes (coagulation). Experience shows that 98% of these procedures are reversible.

Summary: Tubal ligation is not really permanent in the sense that it can be reversed in almost all cases. This is fortunate for those women who want another chance to have a baby after having their tubes tied. Tubal reversal is more successful, less complicated, and less expensive than the alternative treatment of in vitro fertilization.