I recently received an email from a patient who had an ectopic pregnancy subsequent to her tubal reversal. Unfortunately, the pregnancy continued to the point of tubal rupture with the loss of the fallopian tube.

Patient’s History

I was hoping you could help me understand why my ectopic pregnancy was not detected early enough to prevent the loss of my right tube. I need to know this for the future as after my surgery I have only my left tube remaining.

I went to my doctor at approximately 3 weeks pregnant and made sure that they understood the importance of checking for ectopic pregnancy. I gave them a copy of your instructions and told them my goal is to prevent losing my tube if it is ectopic, so I told them to please check and make sure it is not ectopic. They did blood work 3 times and did a vaginal ultrasound at approximately 4 weeks and said everything was normal and the sac was in the uterus, not the tube. They did not check anything again until I spotted Tuesday of this week. I went in Wednesday and they did a vaginal ultrasound and said it was ectopic with a heartbeat and I needed surgery and my tube would have to be removed.

My tube was removed because it was starting to rupture. I never expected that to happen because I took the precautions necessary.

Can you please tell me what normal pregnancy hormone levels are for each week of pregnancy versus ectopic hormone levels?

When is an ectopic visible on ultrasound? Could this have been prevented? Was there anything else that could have been done?

Role of Serum HCG in Early Pregnancy Monitoring

HCG levels alone do not differentiate between uterine and ectopic pregnancy. The HCG levels provide the earliest evidence of whether implantation has occurred successfully (but not where it has occurred) and indicate when ultrasound examination should be able to find a gestation sac if the pregnancy is in the uterine cavity. This occurs when serum HCG reaches 1500-2000 mIU/dL. If serum HCG levels are rising too slowly, or if ultrasound does not find a gestation sac in the uterus when HCG is at the level of 1500-2000, then the pregnancy is not a normal one. It could be outside of the uterus (ectopic) or it could be an abnormal pregnancy in the uterus (blighted ovum).

Role of Transvaginal Ultrasound

A careful transvaginal ultrasound exam can detect a normally developing pregnancy in the uterus very early. It is apparent in this case that the initial ultrasound findings were not interpreted correctly. How could this occur?

An intrauterine gestation sac is a dark oval shaped area of fluid surrounded by a bright white ring or halo (the trophoblastic tissue). Probably in this case there was a small amount of fluid in the uterine cavity that was mistakenly thought to be a gestation sac. This has been described as a “pseudo-sac”. A pseudo-sac does not have the distinct white halo or ring of a true gestation sac.

In a normally developing uterine pregnancy, a follow-up ultrasound exam will show the presence of a yolk sac (the small circle within the gestation sac) within a week of the appearance of the gestation sac. If the initial ultrasound exam had been followed-up with another ultrasound scan, it would have shown that this was not a normal uterine pregnancy.

Comment

There is an increased risk of ectopic pregnancy following tubal reversal surgery. Our follow-up pregnancy statistics show that the risk of ectopic pregnancy remains constant with each pregnancy. In other words, it is the same for a first, second, third, or subsequent pregnancy after tubal reversal surgery. It is important, therefore, to monitor any pregnancy after tubal reversal early and closely.

Recommendations for early pregnancy monitoring are given on our website page entitled I’m Pregnant. Although the recomended tests were performed, the most critical one - the ultrasound exam to document the location of the gestation sac - was interpreted erroneously.

An experienced ultrasonographer should be able to differentiate between a true gestation sac and a pseudo-sac by the presence or absence of the bright halo surrounding the fluid filled sac. If there is any doubt, a repeat ultrasound exam looking for the appearance of a yolk sac should be performed.

Although ectopic pregnancy is not preventable, the complication of tubal rupture always should be. In the absence of clear ultrasound evidence of an intrauterine pregnancy, early treatment with Methotrexate is recommended. It is important to monitor serum HCG levels until the HCG level returns to less than 10 mIU/dL. This will prevent a possible ectopic pregnancy from advancing to the complication of tubal rupture.

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.

Tubal ligation was intended to be permanent. Circumstances can change and women with tied tubes may want more children. When this happens, they often are told that treatment by in vitro fertilization (IVF) is their only option. In reality, tubal reversal is the best choice.

Comparing Tubal Reversal and IVF

Once the fallopian tubes are repaired by tubal reversal surgery, there is a chance every month for pregnancy to occur naturally. This is why tubal reversal is more successful than IVF.

IVF requires a woman to have weeks of hormone injections to produce many eggs each time pregnancy is attempted.  The pregnancy rate with IVF is approximately 25% per treatment cycle. Most women require multiple IVF treatments to become pregnant. At a cost of $12,000 per cycle, this treatment becomes expensive very quickly!

The overall pregnancy rate  among Dr. Berger’s tubal reversal patients is 70%, and the cost of a tubal reversal procedure is less than half that of a single IVF treatment cycle.  This graph shows that pregnancy rates are higher after tubal reversal performed by Dr. Berger than after IVF. This is true regardless of a woman’s age.

Pregnancy Rates by Age After Tubal Reversal vs IVF

Tubal Reversal IVF

Conclusion About Tubal Reversal vs IVF

Tubal reversal has a higher pregnancy rate then in vitro fertilization and is much less expensive when performed at Chapel Hill Tubal Reversal Center.

Are There Hidden Costs of Tubal Reversal?

The discounted fee when paying in full at the time you schedule tubal reversal at Chapel Hill Tubal Reversal Center is $5900. This is an all-inclusive fee. There are no hidden charges! The fee covers the following:

Preoperative record review and consultation
Dr. Berger’s surgical fee
Anesthesiologist’s and nurse anesthetist’s fees
Surgical supplies
Operating facility fees
Postoperative pain medication and antibiotics
Follow-up care

What To Expect at Chapel Hill Tubal Reversal Center

Most of our patients come to Chapel Hill from other states and from other countries. To minimize the time you spend here, your preoperative consultation will be scheduled for the day preceding your tubal reversal. On the day of your reversal procedure, you will spend the morning at Chapel Hill Tubal Reversal Center and the rest of the day at your hotel room at the Sheraton-Chapel Hill. The following morning, one of our nurses will visit you at your hotel for a postoperative check prior to your returning home. You will be here for two nights, on the day prior to surgery for your preoperative consultation and on the day of your tubal reversal procedure.

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

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

Information About Tubal Reversal

The Tubal Reversal Message Board is a public service offered by Chapel Hill Tubal Reversal Center. This message board allows prospective, current, and past patients of Dr. Berger to share information with each other and Dr. Berger’s staff regarding any issue related to tubal ligation reversal.

Tubal Reversal Message Board Forums

The message board is organized into 7 separate forums:

New Message Board Members
Questions about Tubal Reversal
Preparing for Tubal Reversal
After Tubal Reversal
Weekly Pregnancy Reports
Tubal Reversal Cost and Financing
Age and Tubal Reversal

The Tubal Reversal Message Board also has a page called Today’s Active Topics. Many message board members set this as a bookmark or favorite page and enter the board through this page. It shows all of the topics under discussion for the past 24 hours regardless of the forum in which the message thread appears.

Policies and Rules of the Tubal Reversal Message Board

The Tubal Reversal Message Board is a place for women to get support, information, and share opinions with other women and our staff about tubal reversal surgery. New members agree to adhere to certain rules and policies when they join the message board and receive the privilege to post messages. These are mostly common sense rules of etiquette. On occasion, a member will lose posting privileges if the rules or policies of the board are ignored. This can occur, for example, if a person is argumentative or insulting to others, or repeatedly posts on topics unrelated to the subject of tubal ligation reversal.

Most Popular Message Board About Tubal Reversal

The Tubal Reversal Message Board has been online since January 2002 and has a total of over 11,000 registered members from all over the US and the world. They have posted over 337,000 messages. This volume of membership and posting indicates how widespread interest is about tubal reversal surgery. Anyone who has had a tubal reversal procedure performed by Dr. Berger, or who is planning on having a reversal procedure in the future, will find the Tubal Reversal Message Board to be an excellent resource.

What Is Informed Consent?

Informed consent means that a person has access to and understands all relevant information about a medical or surgical treatment necessary to make an informed decision about it. In the case of tubal ligation reversal, informed consent means that a person understands how it the surgery is performed, the alternative treatment of in vitro fertilization, and the potential benefits, risks, and likelihood of success from these treatments.

The Informed Consent Process

When meeting with patients during their consultation, I explain the outpatient tubal reversal procedure that I perform. Even before we meet at the preoperative consultation, patients review extensive information on the Chapel Hill Tubal Reversal Center website, receive printed information about the procedure, and can watch a video or dvd showing each step in the tubal reversal operation.

We also discuss the relative advantages and disadvantages of the alternative treatment of in vitro fertilization. Most important, we provide complete and accurate statistics about pregnancy rates and birth rates after the tubal reversal procedures I have performed.

Benefits and Risks

The primary benefit from tubal reversal surgery is the opportunity to become pregnant at any time in the future. It is simpler, safer, and less expensive than the alternative treatment (in vitro fertilization or IVF). The main risk associated with IVF is multiple pregnancy (33%), compared with the risk of ectopic pregnancy after tubal reversal surgery (10-15%). The medical complication of ectopic pregnancy is tubal rupture. This can be prevented by adhering to our recommended protocol for early pregnancy monitoring.

What is the Expected Success Rate?

Pregnancy and birth rates are the most important measures of success after tubal reversal for most couples. To determine what these are, a doctor must include all tubal reversal procedures and maintain follow-up with patients to learn their subsequent pregnancy histories. Since pregnancies can occur at any time, the follow-up effort and data recording must be done on a continuing basis.

Each week we provide feedback about new pregnancies reported to us via Weekly Pregnancy Reports and Pregnancy Announcements. Information about both the pregnant women and those who have not yet become pregnant is updated annually and published in our Tubal Reversal Pregnancy Study Report. The pregnancy rates and birth rates shown in this report permit prospective patients to learn the statistical probability for success, based on the experience of previous patients for whom I have performed a tubal ligation reversal.

To my knowledge, Chapel Hill Tubal Reversal Center is the only medical facility that collects, analyzes, and publishes complete and accurate statistics about the success of tubal reversal surgery based on all patients who have had the procedure performed. With this detailed information, and only this kind of information, it becomes possible to make a fully informed decision about tubal reversal surgery.

Tubal Ligation by Coagulation or Cauterization

Bipolar tubal coagulation is a popular method of female sterilization in the United States. This tubal ligation method is usually performed through laparoscopy. With the bipolar (two-poles) coagulator, the fallopian tube is grasped between two poles of electrical conducting forceps and electrical current is passed through the tube between the two ends of the forceps. Damage to the tube is limited mainly to the small segment between the forceps. Burning two or three adjacent sites is common and generally results in the loss of a few centimeters of the fallopian tube. Bipolar tubal cauterization can be successfully reversed in almost all cases.

Monopolar tubal coagulation is less common than bipolar coagulation tubal ligation. With monopolar forceps, electrical current spreads further along the length of the fallopian tube. Consequently, monopolar cautery tends to damage more of the fallopian tube than bipolar cautery. In many cases, the tube is also cut after it has been coagulated.

When monopolar coagulation is applied to a single site of the tube, tubal reversal can be performed without the need for further diagnostic tests. If multiple sites of the fallopian tube have been burned with the monopolar technique, we offer a screening diagnostic laparoscopy to evaluate the tubal lengths before proceeding to reparative surgery. The screening laparoscopy option is discussed further on our website.

Tubal Coagulation Reversal Success

Each year Chapel Hill Tubal Reversal Center publishes updated statistics about pregnancy rates and pregnancy outcomes among all of the women who have had tubal reversal procedures performed by Dr. Berger. The data for women who had tubal coagulation sterilizations, presented in the table below, are from our Tubal Reversal Pregnancy Study Report 2007.

Pregnancy Rates of Our Tubal Reversal Patients

The overall pregnancy rate after tubal reversal for women with tubal coagulation procedures is 68% for patients at Chapel Hill Tubal Reversal Center. To calculate the pregnancy rate, the number of women who have become pregnant is divided by the total number who underwent a tubal reversal procedure. The following table shows the numbers and pregnancy rates according to womens’ ages at the time of their tubal reversal surgery.

Pregnancy Rates After Tubal Coagulation Reversal

Conclusion

Tubal coagulation methods of tubal ligation can be successfully reversed in most cases. The pregnancy rate after tubal reversal varies with a woman’s age at the time she has her tubal reversal procedure. The pregnancy rate is 85% for women in their twenties, 74% for those ages 30-34, 64% for women in the 35-39 year age group, and 35% for women 40 years of age or older.