Tubal Reversal Blog ‘fallopian tube’

The tubal reversal doctors at  Chapel Hill Tubal Reversal Center are specialists in fallopian tube repair.  Although most of patients come to Chapel Hill Tubal Reversal Center for tubal ligation reversal, others come for fallopian tube repair after a tubal infection or pelvic inflammatory disease (PID), ectopic pregnancy, or previous surgery involving the fallopian tubes.

Fallopian Tube Anatomy

The fallopian tube begins within the muscular wall of the uterus (interstitial segment), leads away from the uterine wall (isthmic segment), becomes wider (ampulla), extends to the widest area near the end of the tube (infundibulum), and ends next to the ovary (fimbrial segment).

Read the rest of this article and comment on it. »

Tubal Reversal Experts

The tubal ligation reversal experts of Chapel Hill Tubal Reversal Center are experienced at sterilization reversal. Many women who have had their ‘tubes tied’ will come to our center to have their ‘tubes untied’. Unfortunately, a ligation reversal is not as easy as ‘untying’ the tubes- we wish the process was that simple.

We employ a microsurgical approach to repair and reattach the ends of the tubes. This process is called tubotubal anastamosis, and provides a patient with an excellent chance of becoming pregnant naturally. We specialize in ligation reversal and in reversal of difficult tubal ligation procedures.
We would like to present the story of one of our patients who had an atypical sterilization procedure.

Reversal of an Unusual Sterilization Procedure

The patient’s name is Ofralinda. She and her husband, Juan, came to us from Texas. Ofralinda is 35 and she works as an OSHA compliance officer. Her husband is in construction. Ofralinda desired a tubal ligation reversal in order to have more children. She had a rare and atypical sterilization procedure termed the Uchida procedure.

Uchida Sterilization Procedure

A Japanese physician, Dr. Uchida, first described this method of sterilization in 1961. This method involves removing a large segment of the fallopian tube and suturing (sewing) the cut end of the fallopian tube into the wall of the uterus. Dr. Uchida first published information about his method of sterilization after having performed over 50,000 procedures without any pregnancy failures. This is an effective but also  complicated method of surgical sterilization. Most modern physicians have never performed or seen a Uchida sterilization. We have seen several patients who have presented with a Uchida sterilization procedure and we have had success with reversal of this method.

Uchida Sterilization Reversal

Ofralinda had a 60-minute outpatient tubal ligation reversal. Her surgery went well. We found her tubes to be short (due to the large amount of tube removed with her initial Uchida sterilization) but otherwise healthy. We were able to successfully repair both of her fallopian tubes. She has since been discharged back to her home and we wish her well. We would like to hear a report of a successful pregnancy from her within the year.

Sterilization Reversal at Chapel Hill Tubal Reversal Center

We specialize in tubal ligation reversal. Our tubal ligation reversal specialists perform over 800 reversal procedures every year on women from across the world. We regularly have patients from as far away as Hawaii, Alaska, and the Caribbean. Occasionally, we will have patients from Australia, Asia, and Europe.

Most tubal ligation procedures are reversible. The pregnancy rates after reversal are generally higher than after in vitro fertilization (IVF) and we specialize in difficult tubal reversal procedures.

Dr. Monteith’s Diary – May 22, 2008

One of our 4 tubal reversal patients today had the following story.

She was from North Carolina and had three older children. She had her tubes tied several years ago. As time passed, she changed her mind and desired more children. She wanted a tubal ligation reversal and after searching the internet for the best tubal reversal doctor, she found out about Dr. Berger and she came to Chapel Hill Tubal Reversal Center to get her tubes untied.

Prior to her surgery, we reviewed her operative and pathology reports from her tubal ligation surgery, as we do with all patients. There was a shocking finding in her doctor’s description of her tubal ligation. Her doctor described removing 8 cm of fallopian tube on both sides! The fallopian tubes are normally about 10 cm in total length, and if 8cm of tube had been removed, there would be very little tube left to repair. Her pathology report, however, stated two separate 2 cm of tube lengths were the lengths of tubal segments sent to the pathologist for examination.

If the doctor really did remove 8cm of tube, then it might not be possible to repair her tubes successfully. If the pathology report was correct, then she should have good lengths left to reapproximate. Perhaps the pathology report was correct and the doctor did remove 2cm of fallopian tube but cauterized (burned) the rest. We were not sure. We had a dilemma.

Dr. Berger had initially recommended treatment by IVF. She did not want to do this, so the recommendation was made to start her operation with a screening laparoscopy . We were concerned if we proceeded straight to ligation reversal surgery, she may not have good fallopian tubes and she would have gone through an unnecessary operation.

The patient had a different plan. She declined both IVF and screening laparoscopy. Her desire was to have a tubal reversal no matter what. She reasoned if it was not meant to be – then it would not be. She was well informed regarding the possibility of us not being able to repair either fallopian tube. She wanted us to try to work with what she had. Her thinking was that any chance is better than no chance.

As tubal ligation reversal experts we were well aware of the possibility that this approach might lead to disappointment and unnecessary surgery and cost to the patient. We always want to maximize everyone’s chance of success. We never want a patient to undergo an unsuccessful operation. On the other hand, we recognize each patient is a unique person – a person with dreams and desires.

Our patients are well informed and understand the risks and potentially benefits of their treatment options. We do one thing very, very well at Chapel Hill Tubal Reversal Center: reversal of tubal ligation. The second thing we do well is allowing patients to make their own decisions regarding their health care. We do this by giving them the most complete and accurate information about tubal reversal surgery. We rarely say ‘No’ to patients who want to have their tubes untied.

There are some occasions where we may decline to perform surgery – if we believe that operating might be harmful or not have a possibility of being able to repair the fallopian tubes. We do realize a successful ligation reversal is important; however, equally as important, is a patient’s desire to try. For many of our patients the only thing worse than not having a successful ligaton reversal is not ever having tried.

This patient was the first patient of the day. We started the surgery with some fear that we might not see any fallopian tubes. Upon entry into the abdomen we did see good tube lengths and her repair went extremely well! She had a good surgical result and her total tubal lengths were about 4-5 cms on both sides.

We ended the surgery happy and content. As it turned out, this patient knew what she wanted and had confidence that it would work out. In the end, we were glad we did her reversal, allowing her make the decision that seemed right to her, and we were very glad that she was right!

Submitted by Dr. Charles Monteith

Tubal Sterilization Methods

‘Tying tubes’ is a phrase that is commonly used to refer to surgical procedures that result in tubal sterilization.

There are many different ways to block the fallopian tubes for tubal sterilization: ligation and resection (tying and cutting), tubal clips or rings, and electrocoagulation (burning). No matter how the procedure is done, the end result is closure or occlusion of the fallopian tube. This prevents sperm from reaching an egg.

Tubal Ligation and Resection

The most common female sterilization procedure is the ligation and resection method. This was the earliest reported method of sterilization, and it is still a very common and effective procedure. According to the method described by Dr. Ralph Pomeroy, an absorbable suture is tied around a “knuckle” of the fallopian tube that has been elevated and a segment is resected (cut out). The cut ends close as the tube heals. As the suture dissolves, the two tubal segments pull apart. Ligation and resection is currently the most popular form of sterilization for women. It is often performed during a cesarean delivery (C-section) or following a normal delivery.

Untying ‘Tied’ Tubes

A common misconception is that fertility can be restored by simply ‘untying’ the tubes. Tubal ligation reversal is not that simple. Tubal ligation and resection is reversed by opening the closed ends of the tubes and joining the tubal segments back together in perfect alignment using microsurgical techniques. Approximately 70% of patients at Chapel Hill Tubal Reversal Center become pregnant after a reversal of a ligation and resection procedure.

Tubal Ligation and Resection Can Be Reversed

Many people believe tubal sterilization is permanent and irreversible. Although tubal ligation and resection sterilization is intended to be permanent, this procedure can be reversed. Chapel Hill Tubal Reversal Center is the medical facility that specializes in tubal ligation reversal. We are experts in reversing tubal ligations- or ‘untying’ tubes that have been ‘tied’!

Submitted by Dr. Charles Monteith

History of Tubal Sterilization

The first tubal sterilization method was tubal ligation and resection, reported in 1881! Ligation and resection- or ‘tying tubes’ was the most common surgery for sterilization until the advent of laparoscopic surgery in the mid 1900’s. As laparoscopic surgery became more popular, electrocoagulation (electrical burning) of the fallopian tubes became a popular method of female sterilization.

Tubal Electrocoagulation Results in Burned Tubes

The first description of laparoscopic electrocoagulation, in 1962, used a type of electrical current termed monopolar current – hence the term monopolar tubal coagulation. This sterilization procedure uses electric current to destroy part of the fallopian tube. The burned part of the tube turns into scar tissue and the remaining tubal segments are separated and blocked. This was a very popular form of laparoscopic sterilization from 1970 until the early 1980’s.

Although monopolar electrocautery is a very effective form of tubal sterilization, studies showed that it had a higher complication rate than for electrocoagulation using bipolar current, where the damage to the fallopian tube (or other structures) is more easily restricted. Sterilization procedures done by monopolar current are gradually decreasing and being replaced with bipolar current. Monopolar cautery, however, is still used for tubal sterilization by some doctors.

Can Burned Tubes Be Repaired?

Patients often ask whether burned tubes can be repaired. In most cases, monopolar electrocoagulation sterilization procedures can be reversed. The success of reversal is dependent on the amount of fallopian tube that has been damaged by the electrocautery. This information is usually available in the tubal ligation operative report. When in doubt, a screening laparoscopy can be performed. Approximately 50% of patients at Chapel Hill Tubal Reversal Center will become pregnant after a reversal of a monopolar coagulation sterilization procedure.

Many people, including doctors, have been told that tubal sterilization is permanent and irreversible. Although monopolar tubal coagulation is intended to be permanent, this procedure is usually revesible. The best place for women to have their tubes ‘untied’ when they have been burned is Chapel Hill Tubal Reversal Center – the only medical facility that specializes in reversal of tubal ligation.

Submitted by Dr. Charles Monteith

Falope Ring Sterilization

The Yoon Falope rings were developed in the 1960’s as a safer alternative to laparoscopic monopolar cautery tubal sterilization. This procedure is performed by inserting a laparoscope just under the belly button. The fallopian tube is then identified and a device holds the tube while the silastic ring is slid over a 2-3 cm ’knuckle’ of tube that is kinked off by the ring. This is done once for each side.

The common misperception is that the Falope ring is what prevents pregnancy and that reversal of the procedure simply requires removal of the ring. The Falope ring causes the squeezed ’knuckle’ of tube to undergo avascular necrosis (to die and become absorbed by the body). After this happens the ends of the tubal segments outside the ring close up, thereby preventing sperm from reaching the egg.

Falope Ring Sterilization Reversal

Reversing Falope ring sterilization is not as easy as just removing the ring. The closed ends of the tubes must be opened and the tubal segments must be rejoined.

Falope rings cause destruction of a minimal length of fallopian tube and reversal of this type of tubal ligation gives excellent results. Approximately 75% of patients at Chapel Hill Tubal Reversal Center become pregnant after a reversal of a Falope ring sterilization procedure.

Many people believe tubal sterilization is permanent and irreversible. Although tubal sterilization with Falope rings is intended to be permanent, this procedure can be reversed. Chapel Hill Tubal Reversal Center is the only medical facility that specializes exclusively in reversal of tubal ligation.

Tying Tubes is Not Like Tying a Shoe Lace

Many patients seem to imagine the fallopian tube is like a shoe lace which is tied up like a bow to prevent pregnancy. As tubal ligation reversal specialists, we wish it were that easy- then untying tied tubes would be easier!

‘Tying fallopian tubes’ is a common language phrase used to describe several different surgical procedures that result in tubal sterilization (a procedure intended to permanently prevent pregnancy). The more correct medical term is bilateral (both sides) tubal occlusion (closure of the fallopian tube).

Tubal Ligation Methods

There are many different ways to occlude (close) the fallopian tubes: ligation and resection (tying and cutting), clips and rings, and coagulation (burning). No matter how the procedure is done the end result causes the tube to close, heal shut, and prevent sperm from fertilizing an egg.

Filshie Clip Tubal Ligation

One common form of laparoscopic (camera) sterilization is the use of Filshie clips to occlude both fallopian tubes. The Filshie clip was approved for use in the United States in the mid 1990’s. The Filshie clip is a small titanium clip which is lined with a thin silicone cushion. The clip was an improvement over the Yoon Falope Ring and the Hulka Clip because it was as easy to apply with less risk of operative complications. The clip also has the advantage of destroying only a very small portion of the fallopian tube- approximately 4mm (approximately the thickness of two quarters stacked on each other). The adjacent tube is not affected. The majority of Filshie clips placed in the United States are done by laparoscopic surgery; however, there is a growing trend to use them for tubal occlusion at the time of cesarean delivery (c-section).

The Filshie clip causes bilateral tubal occlusion by squeezing a very small portion of the tube. The squeezed portion is deprived of its blood supply and eventually undergoes avascular necrosis (dies and is absorbed by the body). This causes the fallopian tube to be divided in half and the two ends to close up. The Filshie clip is held in place (in between the two divided ends) by a small amount of scar tissue which forms over the clip.

A common misconception is that the Filshie clips can simply be removed to reverse the sterilization process- that the tubes can be unclipped. Unfortunately, tubal ligation reversal for Filshie clips is not as simple as just opening the clips. Filshie clip tubal occlusion is reversed by removing the clips and using microsurgical techniques to open the closed ends and join the tubal segments back together in perfect alignment.

The reversal of Filshie clip tubal occlusion is usually technically easier than some other methods of sterilization because such a minimal amount of tube is destroyed in the occlusion process.

Approximately 76% of patients at Chapel Hill Tubal Reversal Center become pregnant after a reversal of a Filshie clip sterilization procedure.

Tubal Sterilization Can Be Reversed

Many people believe tubal sterilization is permanent and irreversible. Although Filshie clip sterilization is intended to be permanent, this procedure can be reversed. Chapel Hill Tubal Reversal Center is the one medical facility that specializes in tubal ligation reversal.

We have become experts in reversing all types of tubal ligations- or ‘untying’ tubes that have been ‘tied’!

Submitted by Dr. Charles Monteith

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

I recently received an email from a patient who had an ectopic pregnancy subsequent to her tubal reversal. Unfortunately, the pregnancy continued to the point of tubal rupture with the loss of the fallopian tube.

Patient’s History

I was hoping you could help me understand why my ectopic pregnancy was not detected early enough to prevent the loss of my right tube. I need to know this for the future as after my surgery I have only my left tube remaining.

I went to my doctor at approximately 3 weeks pregnant and made sure that they understood the importance of checking for ectopic pregnancy. I gave them a copy of your instructions and told them my goal is to prevent losing my tube if it is ectopic, so I told them to please check and make sure it is not ectopic. They did blood work 3 times and did a vaginal ultrasound at approximately 4 weeks and said everything was normal and the sac was in the uterus, not the tube. They did not check anything again until I spotted Tuesday of this week. I went in Wednesday and they did a vaginal ultrasound and said it was ectopic with a heartbeat and I needed surgery and my tube would have to be removed.

My tube was removed because it was starting to rupture. I never expected that to happen because I took the precautions necessary.

Can you please tell me what normal pregnancy hormone levels are for each week of pregnancy versus ectopic hormone levels?

When is an ectopic visible on ultrasound? Could this have been prevented? Was there anything else that could have been done?

Role of Serum HCG in Early Pregnancy Monitoring

HCG levels alone do not differentiate between uterine and ectopic pregnancy. The HCG levels provide the earliest evidence of whether implantation has occurred successfully (but not where it has occurred) and indicate when ultrasound examination should be able to find a gestation sac if the pregnancy is in the uterine cavity. This occurs when serum HCG reaches 1500-2000 mIU/dL. If serum HCG levels are rising too slowly, or if ultrasound does not find a gestation sac in the uterus when HCG is at the level of 1500-2000, then the pregnancy is not a normal one. It could be outside of the uterus (ectopic) or it could be an abnormal pregnancy in the uterus (blighted ovum).

Role of Transvaginal Ultrasound

A careful transvaginal ultrasound exam can detect a normally developing pregnancy in the uterus very early. It is apparent in this case that the initial ultrasound findings were not interpreted correctly. How could this occur?

An intrauterine gestation sac is a dark oval shaped area of fluid surrounded by a bright white ring or halo (the trophoblastic tissue). Probably in this case there was a small amount of fluid in the uterine cavity that was mistakenly thought to be a gestation sac. This has been described as a “pseudo-sac”. A pseudo-sac does not have the distinct white halo or ring of a true gestation sac.

In a normally developing uterine pregnancy, a follow-up ultrasound exam will show the presence of a yolk sac (the small circle within the gestation sac) within a week of the appearance of the gestation sac. If the initial ultrasound exam had been followed-up with another ultrasound scan, it would have shown that this was not a normal uterine pregnancy.

Comment

There is an increased risk of ectopic pregnancy following tubal reversal surgery. Our follow-up pregnancy statistics show that the risk of ectopic pregnancy remains constant with each pregnancy. In other words, it is the same for a first, second, third, or subsequent pregnancy after tubal reversal surgery. It is important, therefore, to monitor any pregnancy after tubal reversal early and closely.

Recommendations for early pregnancy monitoring are given on our website page entitled I’m Pregnant. Although the recomended tests were performed, the most critical one – the ultrasound exam to document the location of the gestation sac – was interpreted erroneously.

An experienced ultrasonographer should be able to differentiate between a true gestation sac and a pseudo-sac by the presence or absence of the bright halo surrounding the fluid filled sac. If there is any doubt, a repeat ultrasound exam looking for the appearance of a yolk sac should be performed.

Although ectopic pregnancy is not preventable, the complication of tubal rupture always should be. In the absence of clear ultrasound evidence of an intrauterine pregnancy, early treatment with Methotrexate is recommended. It is important to monitor serum HCG levels until the HCG level returns to less than 10 mIU/dL. This will prevent a possible ectopic pregnancy from advancing to the complication of tubal rupture.

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.