Specializing in tubal surgery and the treatment of infertility in women who have had tubal ligations (tubes tied), we meet many patients who share many different stories with us. In the fall of 2008, I was conducting a preoperative evaluation with a patient for a tubal ligation reversal after she had an unsuccessful IVF treatment cycle. Here is her story.
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Chapel Hill Tubal Reversal Center offers an excellent alternative to in vitro fertilization (IVF) – namely, tubal surgery to untie tubes and correct tubal blockage. If you have had your fallopian tubes tied (tubal ligation) or have blocked tubes and want to become pregnant, then tubal surgery may be the best treatment for you.
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.
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).
Tubal ligation reversal at Chapel Hill Tubal Reversal Center is a simple and safe outpatient operation for reversing tubal sterilization through a small incision that results in minimal discomfort and recovery time.
Dr. Gary Berger and Dr. Charles Monteith specialize in untying tubes. Women travel to Chapel Hill, NC from all over the United States and other parts of the world to have their tubes repaired after a previous tubal ligation. Over 7000 women have chosen to come here for their reversal procedures because we specialize exclusively in tubal ligation reversal, have perfected the outpatient approach to reversal surgery, and have the best success in terms of pregnancies after tubal reversal surgery.
This article profiles a patient who came to Chapel Hill Tubal Reversal Center for reversing tubal ligation at which time she was found to have ovarian endometriosis.
The patient and her husband traveled from Monterrey, California for tubal ligation reversal. She is 44 years old and is a banker. She has two children from previous marriage, ages 12 and 15. Her husband is a meteorologist. He has two children from a previous marriage, ages 16 and 18. They moved from Texas to California and have been married together for 1 year and 3 months. Together, they desire a child of their own.
Prior to traveling to visit us, they had a consultation with a reproductive endocrinologist near where they live. They expressed dissatisfaction with their consultation because they felt the doctor only wanted to offer them in-vitro fertilization (IVF). They did consider IVF but decided the procedure was not for them. During the preoperative consultation they specifically stated:
“We wanted to have a baby as God intended it.”
They did their own search for tubal reversal doctors and chose to come to Chapel Hill Tubal Reversal Center because we specialize exclusively in reversing tubal ligation. They felt their chance for a successful reversal procedure would be best at our center.
She was a healthy person and denied any known preexisting problems or menstrual abnormalities. We reviewed her tubal ligation operative and pathology reports that described at least 3 cm removed from each fallopian tube. We discussed their expectations and the risks and benefits of tubal reparative surgery.
During her surgical procedure and upon entering the abdominal cavity, we discovered brown fluid suggesting the presence of endometriosis. Close inspection of the right ovary revealed endometriosis inside of it and partially involving the right tube.
We removed the endometriosis and repaired the right tube. The left tube and ovary were normal. The left tube was repaired without difficulty.
She did well during the surgery. In the recovery room, we informed her and her husband of the unexpected endometriosis and the successful repair of both fallopian tubes.
Endometriosis can be suspected in most patients based on a careful evaluation of a menstrual history. Many women with endometriosis will have extremely painful menstrual periods. Menstruation can be so painful patients may require large amounts of pain medications, miss time from work, or will have pelvic pain which drastically affects their personal lives. Many women give a history of severe pelvic pain, especially with intercourse and will plan their sexual activity based on their menstrual cycles. Many patients, like this one, can have minimal or no symptoms of endometriosis.
We could not have predicted this patient’s endometriosis in advance because of her absence of preexisting symptoms. Fortunately, we were able to successfully reverse her tubal ligation and remove the endometriosis at the same time.
We wish her well on her trip back to Monterrey California and hope a healthy pregnancy will be in her near future.
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.
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.
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.
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.
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.
We periodically write case reports on patients who undergo tubal ligation reversal at Chapel Hill Tubal Reversal Center. The patient we will profile today had a ligation reversal procedure at our center last month.
She and her husband traveled to Chapel Hill from West Virginia. She is 34 years old and previously was an in-vitro fertilization (IVF) nurse. She is the mother of two children (ages 5 and 2). Her husband works as an engineer and is the father of both of their children. She had a tubal ligation after her second child because of two difficult, high-risk pregnancies.
Her first pregnancy was a vaginal birth complicated by heavy post-partum bleeding. Her heavy bleeding required a dilation and curettage (D and C) and emergency abdominal surgery to control the blood loss. She was diagnosed as having a placenta accreta. This is a condition where the placenta has invaded into the uterus too deeply and does not separate normally from the uterus at the time of delivery. She recovered from this surgery and eventually had a second pregnancy. This child was delivered by C-section and she had a Pomeroy tubal ligation done during the C-section. The operative report described tying and cutting the tubes as well as burning the ends. The pathology report described 1.5 cm tubal segments as being removed.
She explained to us, “My decision to have a tubal ligation was not done prayerfully but was more of a medically made decision.” She and her husband now desire more children in their life, and they traveled to Chapel Hill Tubal Reversal Center to have her tubal ligation reversed.
We were concerned that her doctor described in the operative report the tubal cauterization (burning) after tying and cutting the tubes. Since the mention of the cauterization was vague (we had no idea if a small segment was burned or the entire tube was burned) we discussed starting with a screening laparoscopy. Our patient was able to talk to her doctor who performed the tubal ligation. The doctor assured her only the ends of the tubes were burned. Since this can be a common practice and seemed minimal, the decision was made to proceed with ligation reversal without starting with a screening laparoscopy.
During her operation we found the right fallopian tube was abnormal. The right tube was long and healthy appearing, but there was no fimbriated end of the tube. This area is one of the most critical areas of the tube. The fimbriated ends act like millions of small fingers, which pick up the egg and direct the egg down the tube. The repair of this tube would require a more difficult microsurgical salpingostomy and creation of a ‘neo-fimbriated’ end of tube.
A microsurgical salpingosotomy was performed on her right tube. The left side was more normal- we had two tubal segments that we repaired with the usual anastomosis procedure. The entire operation was about one hour and fifteen minutes.
The story of this patient illustrates several important concepts:
1. She was a knowledgeable medical professional. She understood what it meant to have a tubal ligation. Many patients of all walks of life will have changes of heart as their lives change. Even medical professionals will make health care decisions for themselves, which later turn out to not be right for them. None of us can predict the future.
2. She was an IVF nurse and was aware of the pros and cons of tubal ligation reversal vs IVF. She and her husband decided ligation reversal was a more appropriate path for them.
3. Operative and pathology reports provide helpful information in planning for tubal repair, but they can sometimes be misleading.
4. The right tube was very difficult to repair. Often we will question ourselves as to whether a difficult tube should be repaired or should we just focus on the ‘better’ tube. We can never predict with 100% certain what will or will not work to help get a patient pregnant, so we like to give all patients the benefit of the doubt and try at all costs to open all the tubes we operate on.
We wish her and her husband a successful outcome of her tubal reversal operation and hope their prayerful decision will be soon rewarded.
Submitted by Dr. Charles Monteith
Many women who have had a tubal ligation find themselves considering tubal ligation reversal. We have patients who come to Chapel Hill Tubal Reversal Center from all areas of the United States, Europe and Asia for ligation reversal procedures. They come to have their tubes untied for a variety of reasons. Many patients have told us about the frustration they felt when talking to their ob/gyn doctors about tubal ligation reversal or to a reproductive specialist who recommended only in-vitro fertilization (IVF). Many patients have also said their doctors minimize their concerns about symptoms they developed after having their tubes tied.
We recently published a blog about why some doctors may have negative opinions regarding ligation reversal surgery: Why your doctor may be cold to the idea of tubal ligation reversal. We also went to our message board and asked our patients and prospective patients about personal experiences with their physicians when talking about ligation reversal surgery. There we found out that many doctors were very supportive of their patient’s desire to have reversal surgery. The responses can be read under the message board topic: Share your doctors’ attitudes about tubal ligation reversal. Please feel free to leave your story about your experience when seeking reversal surgery or your doctor’s attitude toward the surgery. To leave comments on the Tubal Reversal Doctors Blog, please register and then log in (right hand column). Alternatively, you can add posts to the message board topics shown above.
At Chapel Hill Tubal Reversal Center, we are committed to providing you with the information you want to know about. That’s why the Chapel Hill Tubal Reversal team welcome your ideas, questions and comments. Whether you’re wondering about tubal reversal pregnancy rates, PTLS or how to talk to your doctor about having your tubes untied, we want to be able to address your concerns about tubal ligation reversal.
Submitted by Dr. Charles Monteith
DrMonteith@tubal-reversal.net
Women who want more children after tubal ligation must decide between two treatment options: In-vitro fertilization (IVF) and tubal ligation reversal.
This medical treatment involves controlling the woman’s natural cycle with hormone injections that stimulate the ovaries to produce a large number of eggs. The eggs are retrieved from the ovaries, combined with sperm in a laboratory and the fertilized eggs are placed inside the uterus. A single course or cycle of treatment takes three to eight weeks. The success rates are variable and depend on the reasons for infertility. In general, success rates per cycle are 10 to 30 percent.
Most IVF specialists advise patients to start the process by planning to undergo at least three cycles. The average cost of a cycle in the US is approximately $10,000 to $12,000, and can be as high as $20,000. Recently CNN and the NY Times have reported on the costs of in-vitro fertilization.
The most serious risk of IVF is ovarian hyperstimulation syndrome (OHSS). Ovarian hyperstimulation syndrome may be classified as mild, moderate or severe. The worst cases are associated with pregnancy since HCG (the pregnancy hormone) continues to stimulate the ovaries. Severe OHSS is a life threatening complication. Despite careful monitoring, up to 33 percent of IVF treatments has been reported to be associated with mild forms of OHSS. Severe OHSS has been reported in three to eight percent of IVF cycles. Other risks of IVF are multiple gestations (30-50 percent) and ectopic pregnancy (three percent).
This surgical treatment involves reattaching fallopian tubes that have previously undergone surgical separation (tubal occlusion or tubal ligation). The surgery time can range from one to five hours, and the average costs in the US can be $8,000 to $9,000, but can be as high as $25,000. Approximately 70 percent of patients who undergo tubal ligation reversal will become pregnant. Pregnancy rates for reversal depend on the patient’s age and the method of tubal ligation, and can range from 20 to 80 percent. The main risk of tubal ligation reversal is an increased risk of ectopic pregnancy (10 percent).
IVF is a good treatment for couples who have unexplained infertility, severe sperm disorders and for women with severely damaged fallopian tubes from pelvic inflammatory disease (PID).
Tubal ligation reversal is a better treatment for women who have previously had a tubal ligation and who do not have any of the above indications for IVF.
Misinformation regarding tubal ligation reversal exists on the Internet. Most of this misinformation centers on the success of ligation reversal when compared to IVF, the cost and the risks of the surgical procedure.
The success rates of ligation reversal are related to the type of sterilization procedure a patient has undergone. At Chapel Hill Tubal Reversal Center, 69 percent of patients become pregnant after reversal of ligation and resection sterilizations. Clip and band sterilization procedures have excellent reversal results with 76 percent of patients becoming pregnant.
For IVF the success rates depend on the reason for infertility and can range from 10 to 50 percent. The average success of a single cycle is approximately 30 percent. The success rates of IVF decrease with maternal age over 35 years of age. After 40 to 42 years of age, IVF specialists will advise the use of donor eggs (eggs from another woman) to increase the chances of success. Many IVF specialists will attempt to increase the pregnancy rate of IVF by transferring several embryos into the uterus. This increases the chance of multiple gestations. Sometimes high order multiple gestations (triplets or more) will occur and these pregnancies can be very high-risk pregnancies.
Tubal ligation reversal has a higher chance of success when compared to a cycle of IVF by providing the couple with multiple opportunities to become pregnant and the ability to have more than one pregnancy without the need for hormonal control of the cycle.
Chapel Hill Tubal Reversal Center has success rates that are better than the 30 percent average success rates associated with an individual cycle of IVF.
Many sources quote tubal ligation reversal as high as $25,000. This is true if reversal ligation surgery is done in a hospital-based ambulatory care center or a hospital with an overnight stay. If a patient has a laparoscopic tubal ligation reversal or robotic assisted tubal ligation reversal, then they will pay much higher costs for surgery.
When performed as an outpatient procedure through a small abdominal incision and using microsurgical technique, ligation reversal surgery can be very affordable. Many patients are mislead to believe modern technology results in better success of ligation reversal; however, current medical literature does not support increased success rates for tubal ligation reversal when these surgeries are done laparoscopically or with robotic assistance. Success rates are similar with the use of these modern technologies when compared with abdominal incisions and microsurgical operative techniques. What is very clear is the use of these modern technologies dramatically increase the cost of reversal surgery.
The medical director of Chapel Hill Tubal Reversal Center, Dr. Gary Berger, has perfected a mini-laparotomy approach (mini-abdominal incision). He has continually refined this technique over the last twenty years. It allows easy access to the fallopian tubes and a quick operation. This minimizes the amount of time a patient spends under anesthesia. The decreased anesthetic time results in faster postoperative recovery and reduces the cost and risk of being under an anesthetic. Many hospitals charge patients for anesthesia by the minute and the longer a surgery, the higher the cost. This is true even if the surgery is done in a hospital ambulatory care center. The longer a patient is exposed to anesthesia, the more difficult and longer it takes to recover from the medication effects.
Chapel Hill Tubal Reversal Center is a free standing health care facility that is licensed by the State of North Carolina as a surgical center and has been accredited by the Joint Commission on Hospital Accreditation. Our free standing center is dedicated only to ligation reversal. We do not have to charge for anesthesia by the minute to help subsidize the services of other patients. To help patients who have ligation reversal at our center have a good postoperative period, patients stay at a local hotel and are seen the day after surgery by one of our tubal reversal nurses. Mini-laparotomy surgery is extremely safe with minimal postoperative discomfort and therefore, does not require an unnecessary, overnight hospital stay. A hotel stay is far cheaper than a hospital admission. As a result, we are able to offer ligation reversal for $5,900.
Tubal reversal surgery is extremely safe in the appropriate patient. Patients who are not morbidly obese and who do not have severe heart, lung or vascular disease are excellent candidates for outpatient reversal surgery. There is a 10 percent risk of ectopic surgery after ligation reversal; however, with close follow-up of an early pregnancy, this risk can be appropriately managed to avoid the complication of tubal rupture.
We have had excellent operative results with few adverse outcomes in our reversal patients. We advise close follow-up care of our patients. Most suspected ectopic pregnancies are diagnosed early and treated with medical management to prevent complications.
At Chapel Hill Tubal Reversal Center, we are tubal ligation reversal experts dedicated to providing safe and low cost tubal ligation reversal. By keeping the cost low and focusing only on tubal ligation reversal, we make reversing a tubal ligation available to women who would be unable to afford the high cost of in-vitro fertilization or tubal reversal in the hospital setting.
Submitted by Dr. Monteith
Chapel Hill Tubal Reversal Center
Many doctors will give you less than a warm response when you ask about tubal ligation reversal. Ever wonder why?
I would like to use myself as an example. I started my obstetrics and gynecology (ob/gyn) residency in July 1997 and finished in June 2001. I never saw a single tubal reversal operation performed at the university where I trained. Not one. I saw many unusual and rare things, but I never saw a tubal ligation reversal. I am not alone. Many other doctors would probably tell you the same thing if you asked them.
Most doctors- especially those who have trained within the last 15 years – are unfamiliar with tubal ligation reversal. The reason is simple. Ligation reversal is considered elective surgery. As a result, these procedures are rarely done in hospitals. Therefore, doctors in training get little or no exposure to these surgical procedures. Because of this, most doctors have little knowledge about these types of operations.
Sometimes doctors in training will reason that if they never saw a particular operation, the surgery does not exist because it is not beneficial and may even be harmful. Of course, this is faulty reasoning.
I would have never thought ligation reversal is an effective surgery if it were not for a three minute experience I had when I was a second year resident doing my reproductive endocrinology rotation.
I was with a physician who was the head of our reproductive endocrinology department. We were counseling a 38-year-old patient who was married, had a tubal ligation and wanted to become pregnant again. At the conclusion of her visit, she had asked what she should do? Since I had seen every patient with fallopian tube problems treated with in-vitro fertilization (IVF), I mumbled to myself, “We are going to recommend you get IVF.” Before I could finish my mumbled response, the director said, “I recommend you get a tubal ligation reversal.” My mouth dropped open! Why did we recommend an operation that we did not perform and one I had never seen? I remember exactly what he said next, “We can do this procedure for you. The cost of tubal reversal will be $15,000 here at the hospital. I recommend you talk with Dr. Gary Berger, a tubal reversal specialist who does them for considerably less cost.”
After the conversation, I asked him why we didn’t do tubal reversal procedures at our hospital. He responded, “Charles, we have to charge patients more for this surgery in the hospital. Since patients have to pay out of pocket, most people will be unable to afford the surgery with us. This is a great procedure for her because she will have the ability to get pregnant many times.”
“But isn’t the success rate less than 50 percent?”, I asked. He dropped his glasses down, looked over the rims and told me in a very direct voice, “No! In the best of hands, the success rate is 80 percent.” Somehow he seemed offended that I thought he had recommended a bad treatment.
This conversation happened in 1998. I filed this brief exchange in my memory and mostly forgot about it for the rest of my training.
Many doctors might say a general ob/gyn resident would not see any of these surgeries while training, but a doctor in training as a reproductive endocrinologist would. Unfortunately, this is not true. I had two friends who trained to be reproductive endocrinology specialists. One did two tubal reversals over a three year period of training, the other did none.
It is unfortunate that my friends, who had little or no experience with reversal surgery, are going to be the same doctors who will counsel patients about it. No wonder they routinely recommend IVF – a treatment that they received almost exclusive training in during their fellowship programs.
I hope my personal experience can illustrate why general ob/gyn doctors may not support their patients who want to have their tubal ligations reversed, and why reproductive specialists mostly do IVF. I view tubal ligation reversal as a disappearing surgical skill that may not be available to patients in the future. This is why I asked to join Dr. Berger’s staff at Chapel Hill Tubal Reversal Center. To help women with tubal ligations who want to get pregnant is the reason why I have decided to embark on the path to become a tubal ligation reversal specialist.
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Gary S. Berger, M.D. |
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Charles Monteith, M.D. |
Tubal Ligation Reversal News
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