Tubal Reversal Blog ‘ligation reversal’

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.

Lack of Familiarity or Training

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.

Other Mistaken Ideas Doctors May Have

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.

Why I Came to Chapel Hill Tubal Reversal Center

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.

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

As my training as a Tubal Reversal Specialist continues, I would like to share the story of one of our recent patients.

This patient lives in Pennsylvania. She came to Chapel Hill Tubal Reversal Center for a ligation reversal and her story is similar to many of the women who come here to have their tubes untied.

She is 32 and had two older teenage children. She had her tubes tied after her second child. Unfortunately, her husband died after her tubal ligation, but she eventually found a new partner who did not have any children. She and her partner eventually decided they wanted a child together. They had researched the possibility of having another child and made an appointment with an infertility specialist in Pennsylvania. She considered in-vitro fertilization (IVF); however, she and her infertility specialist decided the better option for her would be tubal ligation reversal. Her infertility specialist recommended Dr. Berger as the tubal reversal expert who could give her the best tubal reversal procedure so she and her partner could pursue their desire of having more children.

When the patient came to Chapel Hill Tubal Reversal Center for her pre-operative visit, her partner was unable to travel with her for the reversal surgery; however, she did bring a close friend. We reviewed her medical history. Her tubal ligation surgery was performed many years ago and there were no operative or pathology reports available. She was able to get some information from her ob/gyn doctor who told her she had the ’standard type of tubal ligation’. She told us about her history and her dreams of having more children.

I was happy that she had excellent operative results and a successful bilateral ligation reversal. She stayed overnight at the local Sheraton Hotel where she was seen in the morning by one of the Chapel Hill Tubal Reversal Nurses. Following the postoperative check-up, she returned to her home in Pennsylvania to pursue her quest for adding more children to her family. We are eager to hear from her as soon as she has a positive pregnancy test!

Submitted by Dr. Charles Monteith
Chapel Hill Tubal Reversal Center