Tubal Ligation Operations Vary

Tubal ligation operations vary in the amount of damage they cause to the fallopian tubes. Tubal coagulation (cauterization) tends to damage more of the tube than tubal ligation and resection or tubal clips/rings. Burning or cauterizing the fallopian tubes with a monopolar coagulator is more destructive than with a bipolar coagulator. With either type of coagulator, the more times the tube is burned, the greater the amount of damage that occurs.

How Much Fallopian Tube Remains After a Tubal Ligation?

The remaining amount and condition of the fallopian tubes after tubal ligation procedures varies a great deal. A patient’s tubal ligation operative report will give an indication about the remaining tubal segments that can be repaired by a tubal reversal procedure. When available, Dr. Berger always reviews the operative reports that are sent by patients to estimate the likely outcome from a tubal reversal operation.

In most cases, the tubal ligation operative report (and a pathology report if available) will help to determine if tubal reversal is possible. Until the time of surgery, the actual condition of the fallopian tubes remains unknown. This is partly because doctors differ in how they perform tubal ligation operations. With tubal coagulation procedures, for example, the coagulator can be used at different power settings and applied for varying lengths of time to the fallopian tubes. These details usually are not specified in an operative report.

Examining the Fallopian Tubes by Laparoscopy

Laparoscopy is a surgical procedure that permits viewing the fallopian tubes through a narrow telescope placed through a small incision below the belly button into the abdominal cavity. Laparoscopy can be performed for patients who want to be assured that tubal reversal is possible.

Laparoscopy is recommended in cases where the amount of tube remaining is questionable, such as after monopolar coagulation of multiple sites along the fallopian tube.

Dr. Berger performs laparoscopy under anesthesia and proceeds directly to tubal reversal, if examination shows the tubes are repairable. The patient is under anesthesia only one time. For safety reasons, screening laparoscopy is offered only to patients with a body mass index (BMI) of less than 30.

Screening Laparoscopy Cost

The additional charge for laparoscopy is $1000. If tubal reversal is not possible, the operation will end and you will receive a refund of close to 50% of the total surgery fee. The screening laparoscopy option is similar to an insurance policy. You purchase it and hope you never need it, but it is certainly nice if you do. Most patients do not elect to have the laparoscopic examination because of its additional cost and the knowledge that Dr. Berger can repair the fallopian tubes in 98% of cases, regardless of the method of tubal ligation.

People like knowing what to expect when they come to Chapel Hill Tubal Reversal Center for their tubal reversal procedure by reproductive surgeon Dr. Gary Berger, our Medical Director.

We provide a great deal of information about this on our website, in emails and letters, and by telephone.

Learn From Others on the Tubal Reversal Message Board

Another useful source of information about what to expect is the Tubal Reversal Message Board. Through the message board, women can ask questions and get responses from Dr. Berger’s staff and from others who have had their tubal reversal procedure. A message board member recently asked this question about what to expect in the Preparing for Tubal Reversal forum with the subject heading Need Details About Consultation:

“Can someone who has already had their consultation give me details about what happens at the consultation? I’m nervous ):”

She received this detailed reply from another board member:

“My wife had her tubal reversal just this week, so it is still pretty fresh for us. We went there on Monday, so the schedule of things may be different on other days.

She was very nervous; we drove down - an eleven hour drive - not sure what to expect. While there are countless messages on the board detailing great experiences, the fear of showing up and discovering either a second-rate facility or a scam were still in the back of our minds. She was also nervous about “making weight”, even though she was not even close to the BMI cutoff; my dear wife likes to fret over everything.

We met the shuttle van at the lobby of the Sheraton at 6:45; Doctor Berger’s facility is only 5 minutes down the road. When we pulled in, the courtyard gate was unlocked and open. We made our way up the stairs to the second floor, and the receptionist was ready and waiting; the waiting room up there looks like a very cozy, large, well appointed living room.

My wife got the luck of the draw and was first, so it was a very efficient, streamlined process. First up was blood pressure, height and weight. All went well, and we immediately met with Doctor Berger. He is professional, courteous, and yes, asked why we chose this. He didn’t seem judgmental about age or weight; he seemed genuinely committed to giving my wife back her reproductive rights to the best of his ability.

After that was the vaginal ultrasound. My wife preferred for me to be present; it was about 10 minutes total, minimally invasive, and yes, the nurse fine tuned the hair line for surgery.

We were immediately escorted downstairs to the surgery reception, and we were quickly greeted by one of the surgical nurses. I believe we had some very brief paperwork at that point, but we moved so efficiently, I could be wrong. We were escorted to the surgical waiting area, where she changed into a johnny and a robe, and answered some of the standard surgical questions.

My wife is no fan of needles, and we let the nurse know that previous IV experiences weren’t very good. When the nurse had trouble with the IV, she immediately called in one of the OR nurses who took over and inserted a new IV in one quick, painless hit.

They talked us through every single step, and soon, my wife was walking in to surgery. She says she climbed onto the table and doesn’t remember a darned thing until waking up! As she was waking up, the nurse went over post-op care with me in painstaking detail. What the meds are for, when to give them, what existing meds can be taken with them, etc. It was thorough, and I felt quite capable of caring for my wife when we returned to the hotel. When she was awake and lucid, and had successfully emptied her bladder, they allowed her to dress, and called for the Hotel Shuttle. 5 minutes later, it arrived, and we were back in our hotel room before 11am!

The next morning promptly at 7 am, the nurse visited our hotel room, inspected the incision, and took every bit of time we needed to feel comfortable for our trip home.

A few tips:

• An important detail is that Doctor Berger’s facility is amazingly efficient; while you don’t feel rushed, you are done before you know it. They have fine tuned the process so very little time is wasted.

• Stick to the medicine schedule! Don’t be a hero and skip your pain meds or you will regret it. My wife had a few bouts of soreness that would have been difficult in the days after surgery without meds.

• The nurses are all wonderful people; we enjoyed meeting them and letting them take care of my wife. Let them take care of you, and you will do fine.”

Support Before, During, and After Tubal Reversal

At Chapel Hill Tubal Reversal Center, our relationship with patients does not begin and end on the date of surgery.  When you choose Dr. Berger as your tubal reversal doctor, you can expect to have our support before, during, and after surgery.  We are available 24 hours a day, 7 days a week to answer questions and to provide education and information about the tubal reversal process.  Our goal is to provide you with all of the tools you will need on your tubal reversal journey.

Information About Tubal Reversal

The Tubal Reversal Message Board is a public service offered by Chapel Hill Tubal Reversal Center. This message board allows prospective, current, and past patients of Dr. Berger to share information with each other and Dr. Berger’s staff regarding any issue related to tubal ligation reversal.

Tubal Reversal Message Board Forums

The message board is organized into 7 separate forums:

New Message Board Members
Questions about Tubal Reversal
Preparing for Tubal Reversal
After Tubal Reversal
Weekly Pregnancy Reports
Tubal Reversal Cost and Financing
Age and Tubal Reversal

The Tubal Reversal Message Board also has a page called Today’s Active Topics. Many message board members set this as a bookmark or favorite page and enter the board through this page. It shows all of the topics under discussion for the past 24 hours regardless of the forum in which the message thread appears.

Policies and Rules of the Tubal Reversal Message Board

The Tubal Reversal Message Board is a place for women to get support, information, and share opinions with other women and our staff about tubal reversal surgery. New members agree to adhere to certain rules and policies when they join the message board and receive the privilege to post messages. These are mostly common sense rules of etiquette. On occasion, a member will lose posting privileges if the rules or policies of the board are ignored. This can occur, for example, if a person is argumentative or insulting to others, or repeatedly posts on topics unrelated to the subject of tubal ligation reversal.

Most Popular Message Board About Tubal Reversal

The Tubal Reversal Message Board has been online since January 2002 and has a total of over 11,000 registered members from all over the US and the world. They have posted over 337,000 messages. This volume of membership and posting indicates how widespread interest is about tubal reversal surgery. Anyone who has had a tubal reversal procedure performed by Dr. Berger, or who is planning on having a reversal procedure in the future, will find the Tubal Reversal Message Board to be an excellent resource.

What Is Informed Consent?

Informed consent means that a person has access to and understands all relevant information about a medical or surgical treatment necessary to make an informed decision about it. In the case of tubal ligation reversal, informed consent means that a person understands how it the surgery is performed, the alternative treatment of in vitro fertilization, and the potential benefits, risks, and likelihood of success from these treatments.

The Informed Consent Process

When meeting with patients during their consultation, I explain the outpatient tubal reversal procedure that I perform. Even before we meet at the preoperative consultation, patients review extensive information on the Chapel Hill Tubal Reversal Center website, receive printed information about the procedure, and can watch a video or dvd showing each step in the tubal reversal operation.

We also discuss the relative advantages and disadvantages of the alternative treatment of in vitro fertilization. Most important, we provide complete and accurate statistics about pregnancy rates and birth rates after the tubal reversal procedures I have performed.

Benefits and Risks

The primary benefit from tubal reversal surgery is the opportunity to become pregnant at any time in the future. It is simpler, safer, and less expensive than the alternative treatment (in vitro fertilization or IVF). The main risk associated with IVF is multiple pregnancy (33%), compared with the risk of ectopic pregnancy after tubal reversal surgery (10-15%). The medical complication of ectopic pregnancy is tubal rupture. This can be prevented by adhering to our recommended protocol for early pregnancy monitoring.

What is the Expected Success Rate?

Pregnancy and birth rates are the most important measures of success after tubal reversal for most couples. To determine what these are, a doctor must include all tubal reversal procedures and maintain follow-up with patients to learn their subsequent pregnancy histories. Since pregnancies can occur at any time, the follow-up effort and data recording must be done on a continuing basis.

Each week we provide feedback about new pregnancies reported to us via Weekly Pregnancy Reports and Pregnancy Announcements. Information about both the pregnant women and those who have not yet become pregnant is updated annually and published in our Tubal Reversal Pregnancy Study Report. The pregnancy rates and birth rates shown in this report permit prospective patients to learn the statistical probability for success, based on the experience of previous patients for whom I have performed a tubal ligation reversal.

To my knowledge, Chapel Hill Tubal Reversal Center is the only medical facility that collects, analyzes, and publishes complete and accurate statistics about the success of tubal reversal surgery based on all patients who have had the procedure performed. With this detailed information, and only this kind of information, it becomes possible to make a fully informed decision about tubal reversal surgery.

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 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.

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.