Tubal Reversal Blog ‘sterilization’

It is difficult to identify the first reported instance of a patient with Post Tubal Ligation syndrome (PTLS). The early literature from the 1950 – 1970’s has sporadic reports of patients who underwent tubal ligation and, subsequently, developed menstrual irregularities. In the mid – twentieth century, PTLS seems to have been discussed more that it was studied by the medical community.

Several medical studies from the 1980’s and 1990’s suggested there was no association with tubal ligation and menstral irregularities. These studies have been criticized because they involved a small number of patients, had methodological problems, and were not designed to critically evaluate for the existence of PTLS.

U.S. Collaborative Review of Sterilization Study

The most conclusive medical study to evaluate female sterilization and the effects upon American women was the U.S. Collaborative Review of Sterilization study. This study is commonly referred to as the CREST study.

The CREST study conducted by the Center for Disease Control and Preventions (CDC) and was published in the New England Journal of Medicine in 1996. To date, the CREST study has been the largest and most comprehensive evaluation of women who have undergone surgical sterilization in the United States. The study was primarily designed to evaluate the types of sterilization methods that were commonly being performed by U.S. doctors and the failure rates associated with each of the different methods of sterilization.

The study examined over 14,000 women who had tubal sterilizations (tubal ligation) from 1978 to 1986. Women were examined for up to 14 years after their sterilization procedures. The investigators specifically looked at the method of tubal ligation and failure rates (pregnancies) based on each method. They also examined the number of women who regretted their decision to undergo sterilization.

CREST  Findings

The main findings of the CREST study were that pregnancies after tubal ligation and sterilization regret were both more frequent than had been previously thought.

Women were also asked questions about changes in their menstral patterns after tubal ligation. The study compared 9514 women who underwent tubal ligation to 573 women whose partners underwent vasectomy. The women were asked about changes in their menstral patterns for up to five years after sterilization. The women who underwent sterilization were found to have fewer irregularities with their menstral patterns. The authors’ conclusion was there were no significant differences in menstral patterns in women who had tubal sterilization. A commentary by the study investigators regarding these findings can be found at the National Institute of Health.

The existence of Post Tubal Ligation syndrome has been widely speculated by many but never substantiated in a rigorous fashion by medical investigators. Many poorly done small studies have suggested PTLS does exist; however, the largest study to date, the CREST study seems to suggest otherwise.

Limitations of the CREST Study

Although the CREST study has been the largest study with the longest follow-up of women who have undergone sterilization, some investigators have criticized the study.

The CREST study has limitations evaluating PTLS because of three reasons:

1. The study population is mostly from academic centers and is made up of a large number of African American women. This has led some cautious medical investigators to suggest the study has population bias and the findings of the study may not be applicable to the general population of United States women who undergo sterilization.

2. The study did not address the question whether women may develop menstral irregularities beyond five years after their tubal ligaiton. Most of the questions regarding menstrual irregularities were not asked after five years of follow-up.

3. The study was not designed to investigate the diverse symptoms of PTLS. The primary goal was to identify what the most popular methods of tubal ligation were and what the failure rates of each method were.

If PTLS does not exist then what is going on?

Many patients come to Chapel Hill Tubal Reversal Center requesting sterilization reversal for the sole purpose of treating symptoms they identify as PTLS. Many of these patients report substantial improvement in their symptoms after tubal ligation reversal. We are not certain why patients report improvement, but it is hard to ignore their reports of improvement in symptoms after ligation reversal surgery.

Most women who have tubal ligations will not have any problems. Some women will have difficulty after a tubal ligation. Many, or perhaps the majority of them will not have PTLS. Instead, they may have an underlying medical or gynecologic illness. To aid our patients in the evaluation of difficulties they may be having after a tubal ligation, our next article will have information for patients about abnormal bleeding, painful menstruation, and possible underlying causes.

This is the second article in a fourteen part series. Our third article in this series is Diagnosing Menstrual Problems After Tubal Ligation.

Readers can also view patient submitted stories about their menstrual symptoms, reasons for reversing tubal ligation, and outcomes after reversal reversal surgery. Each patient’s story is listed below:

Meet Momzilla
Meet Andrea
Meet Rebecca
Meet Praybelieving
Meet Katherine

We invite readers to join the  Tubal Reversal Message Board where they can discuss and share personal experiences with tubal ligation. We also would like patients to join our PTLS Forum and share personal experiences regarding physical or mental symptoms noticed after tubal ligation.

In the spring of 2007, I had a chance encounter with an individual, which started me along a new career path. This path has led me to a specialization in tubal ligation reversal. In the summer of 2008, I joined Dr. Gary Berger at Chapel Hill Tubal Reversal Center as a ligation reversal specialist.

Many people have asked me why I decided to leave my practice of obstetrics and gynecology. To understand my reasons for leaving, one has to understand my reasons for entering the practice of medicine.

I entered the field of medicine with the very simple ideals of sacrifice, hard work, and self-determination to improve the human condition. These ideals were based on observations I had of my grandfather, who was a general medical practitioner.

My grandfather graduated from Meharry Medical School in 1932. He had two black bags, an office, and a red Studebaker sedan for house calls and visits to the hospital. He worked long hours and helped many people in the African-American community. His patients were his patients and he was their doctor. And, there simply were very few doctors who would see them during the times of racial segregation. They needed and depended on him and he needed them as well. He needed them to carry out his vision of what medicine was truly about – caring for those in need and significantly improving the human condition. He and two other independent physicians personally took care of patients for a five county area around Columbia, South Carolina. His patients loved and respected him. These three doctors worked hard for their community. If they were not there, then no one else would have been. My grandfather was a critical component of wellness for his patients.

As a young boy, I would go to work with my grandfather every Saturday. I would observe him working in his black and white checkerboard tiled office. I would sit behind his desk as he examined patients. I vividly remember the smell of alcohol, moldy penicillin- the sight of cotton balls in glass jars, scary metal syringes clanking inside metal trays, and the sounds of coughing coming from the waiting room. For the most part, I did not comprehend any of what occurred there, but I always remembered a good warm feeling. These Saturdays created many, many memories for me.

My grandfather shared many stories with me from his early days of being a healer. The practice of medicine for him was more of an art and less of a science. The only science at the time was anatomy and surgery. Penicillin had not yet been invented! My grandfather worked during the Great Depression, made house calls, and performed home births. There was no such thing as health insurance for any his patients. Many times he was paid in produce, livestock, and quite often nothing was paid to him. He did his job as a service to the people of South Carolina who would otherwise have no one else to turn to. He worked extremely hard because he was needed. And, because he saw the patients others doctors would not even touch, he was irreplaceable. As I grew older, I realized I admired his position as an irreplaceable caretaker who made a significant impact upon the lives of those he touched. To some extent, I chose this aspect of him as the most important quality I wanted to emulate.

As young man, I entered medicine with some of the romantic ideals I observed as a child. More specifically, I chose obstetrics and gynecology because it was one of the last remaining areas of medicine where you could be a complete physician. It was a discipline of medicine where you can treat illness, perform surgery and have long-standing relationships with patients and family members. Since finishing medical school, I have come to realize many things have changed since my grandfather practiced medicine. Many things have occurred which have made the field of medicine a very different entity from the vision I observed through my grandfather as a child.

The practice of modern medicine

Several aspects of modern medicine disturb me.

Patients no longer have their doctor. Instead, they go to a doctor who is allowed by their medical insurance. We live in a mobile society. Many patients change jobs, move and are never seen again. The same is true of mobile physicians.

Many doctors are controlled by either insurance companies, hospital administration, or by malpractice insurance companies. Medicine has become less of an art between two people and more of a business interaction. Medical practice decisions are not always made with patient’s best interest, but instead based on market share and the activities of the competition and capitalism.

Malpractice lawsuits and the threat of legal action are at the top of physicians’ concerns. Many treatment or diagnostic recommendations are not made for medical reasons, but more because of liability concerns. Often we order tests not to detect physical ailments, but rather to avoid liability problems.

Declining reimbursements and rising malpractice insurance costs have also created situations where doctors have to see larger number of patients in shorter periods of time. Seeing larger numbers of patients leads to quicker and less fulfilling relationships.

Patients’ concerns and questions do not always get addressed in the haste. Many times this can result in quick, impersonal physician patient interactions, which can sometimes lead to resentment and discontent.

Having to see larger numbers patients in stressful medical situations will sometimes creates interpersonal friction between nurses, staff, doctors and patients. Unfortunately, the interpersonal friction of the modern hospital environment has become commonplace and, in many instances, is considered both normal and acceptable. I always detested this last, unfortunate reality of modern medicine.

Over the last several years, I have found myself gradually growing despondent because of the realizations I have outline above. I am not saying what I did while practicing obstetrics and gynecology was insignificant, but I began to feel as if I were not making the significant difference in patients’ lives I had envisioned. I was not the vision of my grandfather.

Relationships between caregivers and patients are strained today. In my past practice, if I did not show up for work one day, then one of my eight partners would have covered for me. When I left at 5PM, then one of my partners would deliver the baby. If I did not do a patient’s surgery, then someone else would have. Many patients would leave in the middle of their prenatal care and resume care somewhere else never to be seen again. I felt as if I was a replaceable cog in the modern machine of medicine. These were not observations and feelings I had when I spent Saturdays with my grandfather.

Why did I decide to join Dr. Berger at Chapel Hill Tubal Reversal Center?

I decided to join the surgical center because it rekindled intense feelings in me about why I wanted to be a physician like my grandfather. In working at this surgical center, I am able to do very important things for patients and to significantly impact upon their lives. I am able to perform surgical techniques, which are gradually being forgotten by the medical world. I have a sense of being both critical and irreplaceable.

Most people do not realize how important a medical facility Chapel Hill Tubal Reversal Center is. The center is the only facility in the United States, which specializes in the reversal of tubal ligations. There are several reversal providers scattered around the states; however, they mostly do in-vitro fertilization (IVF) and very few reversal surgeries.

Tubal ligation reversal is becoming a dying surgical art – not because the surgery is ineffective (it is far more successful than IVF), but because current reproductive endocrinologist are not getting trained in ligation reversal. Current endocrinology fellows leave their training programs with little or no experience in tubal ligation reversal. The infertility specialist of tomorrow is not getting the ligation reversal training they need today. Why? Insurance plans will not pay for the surgery and the procedures are too costly if done in hospitals and training centers.

Many patients come to Chapel Hill Tubal Reversal Center from all over the world pursuing dreams of more children or feeling more complete through reversal of their sterilization. Many women have regret over their prior decisions and want to be made whole again. Many women undergo sterilization only to have extreme psychological distress, as events unfold in the future over which they have no control. Many women chose sterilization because they were in terrible relationships only to find a loving partner with whom they want more kids. Some patients have religious conversions and want to be as God intended them to be. Sadly, some women have had children die and they long to replace that missing face. For me, there is a greater sense of purpose in using my skills as a physician.

Dr. Berger has been the sole provider of ligation reversal at Chapel Hill Tubal Reversal Center and has done over 7,000 reversal surgeries. He has pioneered a surgical technique, which allows the surgery to be done quickly on an outpatient basis. As a result, tubal ligation reversal at the center is far less costly than hospital provided ligation reversal. Many women have benefited from his tireless work over the last twenty years. If Dr. Berger did not come to work, then many women would not have the option of sterilization reversal.

One can easily see when Dr. Berger offered to train me, I would have been a fool to decline his offer.

When I came to understand the important nature of the work, which was done at the center, I began to remember what my core values were. I felt like I could be a real doctor again. Using my talents, I could help individuals who would have nowhere else to turn. I can make a significant impact upon both my life and the lives of the patients and families I treat. These were feelings I had regarding the work of my grandfather.

As I depart….

I have had many fond memories of working as an academic generalist obstetrician and gynecologist. I have great memories of working with many bright and talented residents and medical students- many humorous stories from many late night experiences. I have had wonderful relationships with nursing and support staff and will miss them dearly. I have been privileged to bring many beautiful babies into this world. Mostly, I will miss the patients who chose me as their physician and allowed me to walk them through the problems of their lives.