Dr. Montieth’s Diary on Becoming a Tubal Reversal Specialist

Today we had another successful day of untying tubes. We began the day at 7AM. Four patients were scheduled for tubal ligation reversal surgery.

I was able to first assist Dr. Berger in the first three surgeries of the day, but had to leave prior to the fourth surgery. I am becoming proficient at identifying tubal anatomy and repairing tubes that have been tied.

The first patient had her tubes tied several years ago and she was now in a new relationship. Both she and her partner desired more children. They made the decision that they would undergo tubal ligation reversal and try to pursue their dream of having children together. Her surgery went well and we were able to successfully reverse her tubal ligation.

The second patient was similar to the first and desired more children. Her surgery also went well.

The third patient had her tubes tied, but after her surgery she lost a child to Sudden Infant Death Syndrome (SIDS). We often hear stories like this from many patients who come to Chapel Hill Tubal Reversal Center. It is extremely sad to hear the stories these patients tell. My heart aches for them as they try to replace their children and add to their family. Every time I hear these stories I think of my own children and what it would be like to experience such a loss. I can not fully imagine the pain from such loss but I can understand the strong desire to replace a cherished soul. I am happy to report that her surgery went extremely well and she had an excellent operative result. I take enjoyment out of every reversal surgery I have participated in, and feel an extra sense of accomplishment when assisting in untying tubes for patients who have lost children unexpectedly.

I had to leave before the fourth patient had surgery. Fortunately, I will be back in the morning for four more reversal surgeries and to meet four more interesting people and learn about their stories.

My First Day at Nourishing Hopes and Dreams

My first day as a tubal ligation reversal specialist will always be remembered. I began my training with Dr. Berger during the first week of January 2008. We started the day off by meeting the patients who would be undergoing tubal ligation reversal at Chapel Hill Tubal Reversal Center.

I met four patients of different ages, backgrounds, and ethnicities . They were all very different people who all desired the same thing: reversal of their tubal ligation.

• The first patient was in her forties, she had emigrated from Ethiopia, her last child was more than twelve years ago, and she desired a chance to have another child.
• The second patient was in her thirties and her previous husband had died unexpectedly. She had children but her fiancé did not have any children. Together, they desired a child.
• The third patient,in her late twenties, had two children and a tubal ligation. Several years later she subsequently found a new partner and he desired a child with her. So while he was deployed overseas, she came for a tubal ligation and a chance for a new future when he returned from his military deployment.
• The fourth patient was in her late twenties and had several children. When she and her partner were in their early twenties they were financially maxed out and she had her tubes tied as an act of desperation. Several years later, she and her husband subsequently became financially stable and they wanted another child. They considered IVF but decided that a reversal was a better option for them. We also learned of an extremely sad story from this patient. She had a friend who had a tubal ligation. This friend had all of her four children die overnight in a house fire. This friend desperately has hope for a future reversal of her tubal ligation and was hoping to obtain a tubal reversal in the future.

All of the tubal reversal surgeries went well that day. The patients all did well and had technically excellent tubotubal reanastamosis (tubal ligation reversal) procedures. They all recovered well and went home to pursue their quest to add to their families.

For as long as a live, I will never be able to forget these women, their partners and the stories they told. I can never forget their quest to add children to their lives. For them I hope they attain what they desire.

My first lesson as a Tubal Reversal Specialist was that no one can predict the future, but if you always look hard enough you can always find a way - and someone to help- to correct prior mistakes.

Women who are seeking the best tubal ligation reversal physicians come to Chapel Hill Tubal Reversal Center. It is the only medical practice or facility dedicated exclusively to repairing fallopian tubes after tubal ligations. Chapel Hill Tubal Reversal Center is widely recognized as the tubal reversal facility that has the best patient care and the highest documented pregnancy and birth rates, while offering low cost outpatient tubal reversals.

Tubal Reversal Physicians at Chapel Hill Tubal Reversal Center

Our Medical Director, Dr. Gary Berger, has specialized in tubal reversals for 30 years. He is now in the process of training Dr. Charles Monteith as a tubal reversal physician. Dr. Monteith will join the practice in July 2008, at which time he will offer low cost tubal reversals of tubal ligation. During July and August 2008, a special discounted fee of $4900 will be available to patients who schedule their tubal reversal procedures with Dr. Monteith.

Dr. Charles Monteith graduated Summa Cum Laude from Xavier University and received his Medical Degree from the University of California at San Francisco. Following a Howard Hughes Research Fellowship in molecular biology, he completed his residency in obstetrics and gynecology at the University of North Carolina at Chapel Hill in 2001. Since then he has been a Clinical Assistant Professor of Obstetrics and Gynecology at the University of North Carolina Medical School. Dr. Monteith is board certified in obstetrics and gynecology and has extensive experience in laparoscopic surgery and high risk obstetrics.

Explaining his decision to join Dr. Berger in practice, Dr. Monteith says, “My interest in tubal ligation reversal comes from my love of outpatient surgery and the desire to learn skills which are becoming a dying art. My hope is to be able to continue to practice tubal reversal surgery and to keep it as an option for patients who have had prior tubal ligation and desire to become pregnant.”

Low Cost Reversals of Tubal Ligation

A special discounted fee of $4900 will be available to patients who schedule their tubal reversal procedures with Dr. Monteith for July and August 2008. If you have questions or would like further information about scheduling your tubal reversal procedure with Dr. Monteith, please contact Julia Smith, RN at (919) 656-8204.

Dr. Berger’s Comment

It is truly a pleasure to be working with Dr. Monteith, who has already established a reputation as an outstanding ob/gyn physician. By the time he completes his 6 month fellowship in tubal reversal surgery with me, he will be well qualified and certified as a Tubal Reversal Physician.

I received an email message today from a patient that prompted me to write about informed consent for tubal ligation. (See my previous blog about informed consent for tubal reversal.) Here is the message that was sent to me.

Hello, Dr. Berger,

You performed tubal reversal surgery on me on 10/29/07, and I just found out that I’m pregnant. Thank you so much! This is such a blessing. I filled out the report and have heard back from Sarah Meacham. I’ll make sure to follow her instructions.

I’m writing because I have a friend named Samantha who wants to get reversal surgery, but she would like to make sure she’s a candidate based on the information in her operative report. I told her that I would send it to you so you can look it over, so it’s attached. She and her husband have two cute little girls, but she agreed to the tubal ligation on the operating table after she gave birth to her youngest at the prodding of her doctor. She said that she made a terrible mistake and wants more children. And like me, no one she’s asked in south Florida will even consider the procedure that you do. When I told her about you, she was ecstatic. And now that I’m pregnant, she knows that it works!

Thank you again for the miracles you work for so many women. God bless you and your staff!

Sincerely,
Amy P.

I was glad to hear that Amy was pregnant and had recommended to Samantha that she come here for her tubal reversal procedure, but this part of the message caught my attention:

“…she agreed to the tubal ligation on the operating table after she gave birth to her youngest at the prodding of her doctor. She said that she made a terrible mistake…”

What Is Informed Consent?

Before performing a tubal ligation - an elective operation - a doctor should always obtain the patient’s informed consent. Informed consent is the process through which the patient becomes educated about the procedure - including its benefits, risks and alternatives - and makes the decision to have the procedure performed. Informed consent implies that the patient fully understands the issues, has asked any questions she has, had her questions answered, and makes her decision under no duress. Adequate time should be allowed for a patient to think about all of the issues before consenting to the operation.

Should Consent For Tubal Ligation be Made During Childbirth?

Many tubal reversal patients have told me that the first time they discussed a tubal ligation with their doctor while they were on their way to the operating room for a C-section. Some regretted their decision while they were on the operating table or when they awoke in the recovery room. Other patients have said they had a tubal ligation in response to pressure from their spouse, parents, or their doctor. Labor and delivery is not the best time to think about an issue with such profound and lasting results as surgical sterilization. This should be discussed and thought about at leisure, not during the stress of childbirth.

Dr. Berger’s Comment

Besides the doctor’s responsibilities in obtaining informed consent, the patient also has a responsibility when giving it. A tubal ligation is not an emergency operation. Having a tubal ligation is a decision that should be carefully considered and not made in haste. There is adequate time during the pregnancy for a doctor and patient to discuss the issue of sterilization. Bringing this up for the first time on the way to the delivery room is a mistake, in my opinion. A more deliberate approach to the process of informed consent by both doctor and patient would help avoid mistaken decisions, such as in Samantha’s case.

Why Some Patients Choose To Have Screening Laparoscopy

Tubal ligation procedures vary in the severity of injury occurring to the fallopian tubes. Although most tubal ligations are reversible, there are some cases where tubal reversal is not possible. If the operative report from your tubal ligation indicates there may be a problem in repairing the remaining tubal segments, or if you cannot get a copy of your operative report, you may be interested in the screening laparoscopy option offered at Chapel Hill Tubal Reversal Center.

With this option, your surgery begins with diagnostic laparoscopy to examine your fallopian tubes. If tubal repair is possible, tubal reversal is performed immediately while you are under anesthesia. That way you do not have to undergo anesthesia and surgery on two separate occasions.

If tubal reversal is not possible, the operation is concluded with just the diagnostic laparoscopy. There is an additional charge of $1000 to add the screening laparoscopy, but with this option you will receive almost half of the total surgery fee in refund should tubal repair not be performed. The “laparoscopy package” is excellent insurance in situations when the method of tubal ligation is unknown.

Screening laparoscopy is available to patients with a Body Mass Index (BMI) under 30 who are interested in more assurance regarding the outcome of the reversal surgery. It is recommended - but not required - in cases where the amount of tube remaining is questionable, such as after monopolar tubal coagulation at multiple sites along the tube.

If you have questions about the laparoscopy option, you can discuss them with Dr. Berger and the Tubal Reversal nurses during your preoperative consultation.

Patient’s History

Ana G. was one of the 4 patients I operated on today at Chapel Hill Tubal Reversal Center. She is a 28 year old woman from Angola, the mother of 3 children - ages 9, 8, and 6. She married when she was 15 and was in an abusive marriage. To keep from becoming pregnant again, she had a tubal ligation. When she had this done, all she could think about was not becoming pregnant again.

Ana eventually ran away and divorced her husband. Several years later she met a man who she fell in love with and who has treated her very well. He has no children. Now remarried, Ana feels that her second husband will want children in the future, so she decided to have a tubal ligation reversal. Although she doesn’t intend to become pregnant soon, she says that if it happens that would be fine.

Ana’s Tubal Reversal Procedure

Ana’s tubal reversal was performed by the technique of tubotubal anastomosis. Her fallopian tubes were in excellent health, with no fibrosis and with normal fimbriae and tubal endothelium. The anastomoses were isthmic-ampullary on the right and isthmic-isthmic anastomosis on the left. The tubal lengths after repair were 6.5 cm on the right and 8 cm on the left side.

Dr. Berger’s Comments

Every patient who comes to Chapel Hill Tubal Reversal Center has a unique story to tell that led up to the decision for a tubal reversal procedure. Divorce and remarriage is a common theme, and a history of abuse in the prior marriage is often one of the reasons given for the divorce.

Ana’s story is unusual in that she married at age 15 and had her tubal ligation by age 21. This may be due to the cultural differences in some African countries from the US. Although most of our patients come from the United States, couples come from many other countries to have me perform their tubal reversal surgery.

Although Ana’s operative report stated that Filshie clips had been applied to her tubes, no clips were found during surgery. It is not clear whether the operative report was incorrect, or whether the clips migrated to other locations in the abdominal cavity. This can occur if the pressure from the closed clips causes necrosis or death of the tissue within the clip. I have seen this occasionally in other patients.

Predicted Outcome After Ana’s Tubal Reversal

Based on her age and tubal lengths, Ana’s probability of becoming pregnant is 90% as documented in the post tubal reversal pregnancy statistics among patients at Chapel Hill Tubal Reversal Center.

At Chapel Hill Tubal Reversal Center, we receive requests 7 days a week, 365 days a year, for information about tubal ligation reversal. These requests come from women who regret having a tubal ligation. A staff member recently asked me how big a problem this is throughout the country. The following is in response to this question.

How Many Women Have Had A Tubal Ligation?

There is no single data source reporting the number of surgical sterilizations performed in the United States. Based on multiple sources of information, it is likely that 650,000 to 700,000 tubal sterilizations are performed each year, and more than 11 million American women have had a sterilization operation. The latest study, conducted in 2002 by the US Department of Health and Human Services, indicates that between one in four to one in five of adult, sexually active women have had a tubal ligation.⁽¹⁾

How Common Is Tubal Ligation Regret?

Many factors can affect a woman’s likelihood to regret sterilization. Among women who had a tubal ligation, risk factors for regret include young age, less education, and a husband or partner who wanted the woman to have a tubal ligation.

In 1999, a study called the Collaborative Review of Sterilization (CREST) found that 20% of women who were sterilized before the age of 30 regretted their decision. Women who were sterilized at a young age had a higher chance of requesting information about reversal, regardless of their number of living children. Also, women who reported conflict with their husbands or partners before tubal sterilization were more than three times as likely to regret their decision and more than five times as likely to request a reversal than women who did not report such conflict. ⁽²⁾

Dr. Berger’s Comment

This statistical information helps give a broader picture to the significance of the issues and comments raised in the previous blog topic - Ethics of Tubal Ligation. Additional comments on this issue are welcome from all readers.

References

1. MMWR Surveillance Summary, “Contraceptive Use — United States and Territories, Behavioral Risk Factor Surveillance System, 2002.
2. Mosher WD, Martinez GM, Chandra A, Abma JC, Wilson SJ. Use of contraception and use of family planning services in the United States: 1982–2002. Hyattsville, MD: US Department of Health and Human Services, National Center for Health Statistics, 2004. Advance Data from Vital and Health: no. 350.

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.

Tubal Ligation Operations Vary

Tubal ligation operations vary in the amount of damage they cause to the fallopian tubes. Tubal coagulation (cauterization) tends to damage more of the tube than tubal ligation and resection or tubal clips/rings. Burning or cauterizing the fallopian tubes with a monopolar coagulator is more destructive than with a bipolar coagulator. With either type of coagulator, the more times the tube is burned, the greater the amount of damage that occurs.

How Much Fallopian Tube Remains After a Tubal Ligation?

The remaining amount and condition of the fallopian tubes after tubal ligation procedures varies a great deal. A patient’s tubal ligation operative report will give an indication about the remaining tubal segments that can be repaired by a tubal reversal procedure. When available, Dr. Berger always reviews the operative reports that are sent by patients to estimate the likely outcome from a tubal reversal operation.

In most cases, the tubal ligation operative report (and a pathology report if available) will help to determine if tubal reversal is possible. Until the time of surgery, the actual condition of the fallopian tubes remains unknown. This is partly because doctors differ in how they perform tubal ligation operations. With tubal coagulation procedures, for example, the coagulator can be used at different power settings and applied for varying lengths of time to the fallopian tubes. These details usually are not specified in an operative report.

Examining the Fallopian Tubes by Laparoscopy

Laparoscopy is a surgical procedure that permits viewing the fallopian tubes through a narrow telescope placed through a small incision below the belly button into the abdominal cavity. Laparoscopy can be performed for patients who want to be assured that tubal reversal is possible.

Laparoscopy is recommended in cases where the amount of tube remaining is questionable, such as after monopolar coagulation of multiple sites along the fallopian tube.

Dr. Berger performs laparoscopy under anesthesia and proceeds directly to tubal reversal, if examination shows the tubes are repairable. The patient is under anesthesia only one time. For safety reasons, screening laparoscopy is offered only to patients with a body mass index (BMI) of less than 30.

Screening Laparoscopy Cost

The additional charge for laparoscopy is $1000. If tubal reversal is not possible, the operation will end and you will receive a refund of close to 50% of the total surgery fee. The screening laparoscopy option is similar to an insurance policy. You purchase it and hope you never need it, but it is certainly nice if you do. Most patients do not elect to have the laparoscopic examination because of its additional cost and the knowledge that Dr. Berger can repair the fallopian tubes in 98% of cases, regardless of the method of tubal ligation.

If you have had your tubes tied and would like to become pregnant again, tubal reversal surgery is probably the best option for you. Tubal ligation reversal is the most successful and cost-effective way to become pregnant for 98% of women who have had a tubal ligation and now want to have another baby.

What Is Your Age?

The natural fertility rate declines with age. Pregnancy rates after tubal reversal, therefore, are highest for younger women.  Although pregnancy rates are lower for older women, you can still become pregnant after age 40 if you are ovulating and have periods.

Dr. Berger has kept detailed records of his patients and has compiled a comprehensive follow-up study on pregnancy after tubal reversal for all of his patients. His patients under 30 have a 77% pregnancy rate after having a tubal reversal procedure. The pregnancy rate is 72% for women ages 30-34 , 62% for women 35-39, and 34% for those 40 years of age and older after tubal reversal surgery performed by Dr. Berger.

What Type of Tubal Ligation Did You Have?

There are several ways that a doctor can tie a woman’s fallopian tubes. Women with the ring or clip method of tubal ligation have a 74% pregnancy rate after undergoing tubal reversal surgery. Women with the tubal coagulation technique have a 65% pregnancy rate, while women with tubal ligation and resection methods have a 62% probability for pregnancy after reversal surgery.

If you aren’t sure what type of tubal ligation you had, don’t worry! You can get a copy of your operative and pathology reports relating to your tubal ligation, and fax them to Chapel Hill Tubal Reversal Center at (919) 967-8637. Please attach the Fax Cover Sheet so we can reach you when your records arrive. Dr. Berger will review the operative report at no charge and we will contact you regarding possible outcomes for you following reversal surgery.

How To Choose The Best Tubal Reversal Doctor?

The most important question to ask is how many tubal reversal surgeries the doctor has performed. The more experience the doctor has, the better your outcome will be. Dr. Berger has the most experience with this operative procedure of any reproductive surgeon in the world and has performed more than 6,000 tubal reversals! He is considered by other medical professionals in the US and abroad to be the best tubal reversal doctor.

Also ask if the doctor performs tubal reversals on an outpatient basis. Outpatient tubal reversal reduces cost and avoids the risks of hospitalization, such as infection with hospital-acquired bacteria. Chapel Hill Tubal Reversal Center is the only center worldwide that is dedicated exclusively to outpatient tubal ligation reversal, and Dr. Berger is the only doctor who specializes in and limits his practice to outpatient tubal reversal surgery.

I Will Be Happy To Assist You

If you would like additional information or would like to schedule your tubal reversal procedure, please feel free to contact me. You can reach me from 8 am to 8 pm Eastern Time at (919) 656-8204 or by e-mail at JuliaS@tubal-reversal.net. I will be glad to answer any questions you might have!

Submitted by Julia Smith, RN
Nurse Administrator