Tubal Reversal Blog ‘ligation reversal specialists’

The ligation reversal specialists at Chapel Hill Tubal Reversal Center are experts in tubal ligation reversal. We evaluate and treat a large number of women who request sterilization reversal. While most women seek ligation reversal to have more children,  some seek relief from worsening physical and psychological symptoms experienced after they had their sterilization procedures. Many of these women report symptoms of Post Tubal Ligation Syndrome (PTLS). Previously, we described medical conditions that can mimic PTLS. This article describes common psychological conditions that can have symptoms similar to PTLS. These conditions can exist independently of a sterilization procedure or could be associated with the profound guilt and regret some women experience after sterilization.

Depression

Depression is a common condition affecting many people. Depression can be categorized into several types; however, for simplicity we will focus on major depression.

Major Depression

Symptoms of major depression last for a minimum of six months and may include:

• Loss of interest in normal daily activities
• Feeling sad or down
• Feeling hopeless
• Crying spells for no apparent reason
• Problems sleeping
• Trouble focusing or concentrating
• Difficulty making decisions
• Unintentional weight gain or loss
• Irritability
• Restlessness
• Being easily annoyed
• Feeling fatigued or weak
• Feeling worthless
• Loss of interest in sex
• Thoughts of suicide or suicidal behavior
• Unexplained physical problems, such as headaches

There are many overlapping symptoms between major depression and Post Tubal Ligation Syndrome. Identifying the symptoms of depression can be easy, but identifying the cause of depression can be difficult.

Anxiety

Generalized anxiety disorder can be a common condition. Anxiety is characterized by excessive or exaggerated worry about life events. People with symptoms of generalized anxiety disorder tend to expect disaster and can’t stop worrying about health, money, family, work or school. The degree of worry is often unrealistic or out of proportion for the situation. Daily life becomes a constant state of worry, fear and dread. Eventually, the anxiety so dominates thinking that it begins to interfere with daily functioning, including work, school, social activities and relationships.

Generalized Anxiety Disorder

The symptoms of generalized anxiety disorder may include:

• Excessive, constant worry and tension
• An unrealistic view of problems
• Restlessness or a feeling of being “edgy”
• Irritability
• Muscle tension
• Headaches
• Sweating
• Difficulty concentrating
• Nausea
• The need to go to the bathroom frequently
• Tiredness
• Trouble falling or staying asleep
• Trembling
• Being easily startled

People with anxiety disorders have an extreme sense of nervousness, panic, and inability to concentrate or focus. They may have depression as well. Anxiety can be generalized (happens during most of the day without any apparent cause) or can be situational (triggered by a specific event).

Post Traumatic Stress Disorder

Post traumatic stress disorder (PTSD) can develop after a person has experienced a traumatic or terrifying event in which serious physical harm occurred or was threatened. PTSD is a lasting consequence of traumatic ordeals that cause intense fear, helplessness, or horror, such as a sexual or physical assault, the unexpected death of a loved one, an accident, or a natural disaster. Most people who experience a traumatic event will have reactions that may include shock, anger, nervousness, fear or guilt. For a person with PTSD, however, these feelings continue and even increase, becoming so strong that they prevent the person from living a normal life. Symptoms of PTSD often are grouped into three main categories:

• Reliving - This involves reliving the event through thoughts, memories, and dreams of the trauma. These may include flash backs, hallucinations, and nightmares. People with this form of PTSD may also feel great distress when events occur that remind them of the trauma they suffered.
• Avoiding - This involves avoiding people, places, thoughts or situations that are reminders of the trauma. This may lead to detachment from family, friends, and loss in interest in things that were once enjoyed.
• Increased arousal - This includes excessive emotions and problems relating to others, including difficulty feeling or showing emotion, difficulty sleeping, irritability, outbursts of anger, and difficulty concentrating. Physical symptoms may also occur.

Self Evaluation

Women seeking tubal ligation reversal may be at higher risk for the above conditions for various reasons, such as sterilization performed while in an abusive relationship, sterilizations done under pressure, or death of a child or spouse after a tubal ligation. It is helpful to discuss with yourself and your partner whether you may be experiencing symptoms of depression, anxiety, or Post Traumatic Stress Syndrome. The insights of a trusted friend or loved one help in this self evaluation. In some cases the advice and intervention of an experienced mental health provider may be helpful.

If you have had a tubal ligation and are experiencing any of the problems associated with Post Tubal Ligation Syndrome (PTLS), consider having an evaluation by your doctor for undiagnosed medical conditions. If  depression, anxiety or other symptoms interfere with your daily life, work, or relationships, then you may benefit by consultation with an experienced mental health provider.

PTLS Article Series

This is the fifth article in our 14 part series on PTLS and associated medical conditions. Our next article, Post Tubal Ligation Syndrome: A Long Bumpy Ride, will address our experience with Post Tubal Ligation Syndrome. We invite readers to join the Tubal Reversal Message Board and participate in the PTLS Forum to share personal experiences with physical or psychological symptoms following a tubal ligation.

Women who want more children after tubal ligation must decide between two treatment options:  In-vitro fertilization (IVF) and tubal ligation reversal.

In-Vitro Fertilization (IVF)

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).

Tubal Ligation Reversal

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).

When to Choose IVF or Tubal Reversal

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.

Ligation Reversal Misinformation

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.

Success Rates

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.

Cost

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.

Risk of Tubal Reversal Surgery

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.

Our Goal

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.

At Chapel Hill Tubal Reversal Center, we want to maximize the chances for pregnancy after tubal ligation reversal for all of our patients. One step that is helpful in planning for a tubal reversal procedure is examining the pathology report from a patient’s medical record. Pathology reports can provide critical information to a tubal reversal specialist since they convey additional information beyond what is contained in the operative report describing the tubal ligation.

What is a pathology report?

A pathology report- sometimes shortened to ‘path report’- is a typed report from a pathologist (doctor who studies healthy and diseased tissue) that describes the removed tubal segments. Usually when tissue is removed by a surgical operation, it is sent to a pathologist for examination. After this examination, a pathologist will create a typed report describing what was observed.

When a tubal ligation and resection procedure has been performed, a segment of fallopian tube was removed and most likely sent to a pathologist. Therefore, a pathology report should exist in the patient’s medical record. When a sterilization has been performed by tubal electrocautery or with tubal clips or rings, there will not be a pathology report because no tubal tissue is removed with these tubal ligation methods.

A pathology report will help our tubal reversal doctors determine exactly what was done during a ligation and resection procedure and what your chances of tubal reversal success will be.

Examples of Pathology Reports After Tubal Ligation

Here are some examples of what the pathology reports may show after a tubal ligation and resection:

Scenario 1
Operative note states, “A standard ligation and resection was done.” Pathology report states, “Two 1.5 cm isthmic sections of fallopian tube were examined.” In this case, the pathology report confirms that small amounts of isthmic tubal segments were removed and the chance of successful ligation reversal is very good.

Scenario 2

Operative note states, “A bilateral ligation was done…tubes were resected.” Pathology report states, “Two 4 cm sections of fallopian tube were examined and fimbrial ends were present on both sections.” In this case, the pathology report demonstrates that the patient has had a fimbriectomy. We would advise the patient that fimbrectomy reversal will be the appropriate procedure to reverse this type of tubal ligation.

Scenario 3
Operative note states, “A typical bilateral tubal ligation was done.” Pathology report states, “Two 7 cm section of fallopian tubes were examined.” In this case, the pathology report shows that large amounts of tubal length were removed. This is not a typical bilateral tubal ligation, and the chance of a reversing tubal ligation is remote. In this case, we would advise the patient that IVF would be a better treatment option for her than tubal reversal surgery.

Get Expert Opinion

As tubal reversal experts who specialize in ‘untying tied tubes’,  we have found that most tubal ligations are reversible. Any patient considering ligation reversal should send us a copy of their operative report and, if ligation and resection was done, a copy of the pathology report. We will review these reports, without charge, and provide the best recommendation for becoming pregnant after tubal ligation.

Submitted by Dr. Charles Monteith
Chapel Hill Tubal Reversal Center