Tubal Reversal Blog ‘tubal reversal’

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 Reversal Procedures

There are 3 types of tubal reversal procedures:

• anastomosis
• implantation
• salpingostomy - (this blog topic)

Salpingostomy Definitions

Salpingostomy is creating an opening in the fallopian tube. It is also called neosalpingostomy, which more clearly indicates the creation of a new opening in the tube.

Salpingostomy is the appropriate tubal reversal procedure when the end closest to the ovary is closed and the fallopian tube has not been divided into separate segments. This is what results from a fimbriectomy tubal ligation. It can be seen also when a fallopian tube has become closed as a result of infection (salpingitis).

How I Perform Ampullary Salpingostomy

Salpingostomy involves creating an opening in the end of the fallopian tube with a microsurgical needle electrode. The opening is enlarged and gently folded back so that the internal lining extends over the opened end of the tube. The internal lining is covered with cilia, the hairline projections that beat in coordinated waves. They help capture an egg as it is released from the ovary just as the fimbrial end of the tube does normally.

Sutures are placed around the end of the tube that has been folded back. The sutures are hidden underneath the folded-back tubal end. When ampullary salpingostomy is completed, the tubal end looks similar to a normal fallopian tube, provided there is a sufficient ampullary length of tube remaining to fold back.

Types of Salpingostomy

The type of salpingostomy is specified according to the tubal segment that has been opened. This will depend on how much of the fallopian tube was removed during a fimbriectomy. The illustration above shows an ampullary salpingostomy. Salpingostomy at the ampullary, infudibular, or fimbrial tubal segments can result in good success rates. If a large amount of tube has been removed and only the isthmic segment remains, salpingostomy is unlikely to result in pregnancy.

Comment About Salpingostomy

The success of salpingostomy for fimbriectomy tubal reversal depends upon having an adequate length of ampullary segment of the fallopian tube. The length of the remaining ampullary tubal segment can be determined from a hysterosalpingogram (HSG) or from diagnostic laparoscopy.

I recommend having an HSG or choosing the screening laparoscopy option when tubal ligation has been performed by fimbriectomy. An HSG can be ordered by the patient’s local doctor and the x-ray films sent to me for examination prior to scheduling tubal reversal surgery. Alternatively, patients can omit having an HSG and schedule their reversal surgery to start with screening laparoscopy. This will show if ampullary salpingostomy will be effective. If so, the tubal reversal procedure will be performed at the same time while the patient is under anesthesia.

Tubal Reversal Procedures

There are 3 types of tubal reversal procedures:

• anastomosis - (today’s blog topic)
• implantation
• salpingostomy

Anastomosis of Fallopian Tubes

Anastomosis connects two body parts. Tubotubal anastomosis is connecting two segments of the fallopian tube. Tubotubal anastomosis is correct medical terminology, but it is also called tubal anastomosis for short. Bilateral tubal anastomosis means that both tubes are repaired by the anastomosis technique. The anastomosis sites can be specified for each fallopian tube. They may be different for the two sides. For example, a patient may have a right isthmic-ampullary tubotubal anastomosis and a left ampullary-ampullary tubal anastomosis. Sometimes, only one fallopian tube is repairable with the anastomosis technique. This is called unilateral tubotubal anastomosis.

Bilateral Tubal Anastomosis

Most tubal ligation operations separate the fallopian tube into two segments. Bilateral tubotubal anastomosis, therefore, is the most common tubal reversal procedure. Bilateral tubal anastomosis accounts for 90% of the tubal reversal procedures at Chapel Hill Tubal Reversal Center.

How I Perform Tubal Anastomosis

After opening the blocked ends of the two tubal segments, I pass a flexible stent or thread through the tubal lumen or opening of the two segments until it reaches the uterine cavity. This ensures that the fallopian tube is open from the uterine cavity to its fimbrial end and that the tubal segments align properly. A suture placed in the connective tissue, just beneath the fallopian tube segments, draws the tubal segments together.

The muscular and outer layers of the tubal segments are connected with microsurgical sutures. Care is taken to avoid suturing the inner layer of the fallopian tube. Suture material is a foreign body. Stitches placed in the inner tubal lining can cause scarring inside the tubal lumen. When the two tubal segments are joined together, the stent is withdrawn from the fimbrial end of the tube.

Watch The Operation

The images above illustrate the principles of tubotubal anastomosis. For more details, you can watch the operation as it is being performed. A short video clip online gives an overview. If you want to watch the entire tubal anastomosis procedure, you can order a videotape or dvd of Tubal Ligation Reversal by Dr. Berger as shown on TV by the Discovery and Learning Channels. Watching the full length video will help you better understand how I perform tubotubal anastomosis as outpatient tubal reversal surgery.

Tubal Ligation by Fimbriectomy

Fimbriectomy is an infrequent type of tubal ligation in the United States. This female sterilization method is performed by removing the fimbrial end of the fallopian tube. At the fimbrial end of the tube, the inner tubal lining faces outward towards the ovary. The tubal lining is rich in cilia that beat in coordinated waves to pull the egg into the tubal opening.

Many doctors think that tubal reversal cannot be successful following a fimbriectomy because of the loss of the egg-capturing fimbria. This is a mistaken notion. Cilia are abundant in the ampullary segment of the fallopian tube. The inner lining of the remaining ampullary tubal segment can be folded outward after opening the tube and can function as a new fimbrial end. The tubal reversal procedure for fimbriectomy reversal is called ampullary salpingostomy.

Fimbriectomy Reversal Pregnancy Rates

Chapel Hill Tubal Reversal Center publishes statistics updated annually regarding pregnancy rates and pregnancy outcomes for all of the women who have had tubal reversal procedures performed by Dr. Berger. The data for women who had tubal ligation procedures by fimbriectomy are from our Tubal Reversal Pregnancy Study Report 2007.

The overall pregnancy rate after fimbriectomy tubal reversal is 56% for patients at Chapel Hill Tubal Reversal Center. The following table shows the numbers and pregnancy rates according to womens’ ages at the time of their tubal reversal procedure.

Pregnancy Rates After Fimbriectomy Reversal

Recommendations for Fimbriectomy Reversal

The success of fimbriectomy reversal depends upon having an adequate length of ampullary segment of the fallopian tube. The length of the remaining ampullary tubal segment can be determined from a hysterosalpingogram (HSG) or from diagnostic laparoscopy.

I recommend having an HSG or choosing the screening laparoscopy option when tubal ligation has been performed by fimbriectomy. An HSG can be ordered by the patient’s local doctor and the x-ray films sent to me for examination prior to scheduling tubal reversal surgery. Alternatively, patients can omit having an HSG and schedule their reversal surgery to start with screening laparoscopy. This will show if ampullary salpingostomy will be effective. If so, the tubal reversal procedure will be performed at the same time while the patient is under anesthesia.

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.

What is Essure?

Essure is a permanent birth control device that has recently become available as an alternative to traditional tubal ligation methods. The spring-like device is inserted through the uterine cavity into the tubal openings using a hysteroscope. This can be done as an in-office procedure. The device expands to fill the tubal opening and then becomes scarred into place, forming a barrier so that sperm cannot reach the egg. Because of the scar formation, it cannot be pulled out of the tube. It is advertised by the manufacturer as a permanent method of birth control. In this respect, it is similar to other tubal ligation methods that are considered by most doctors to be permanent.

Here is a link to an online video animation of the placement of the Essure device into the fallopian tubes.

Is Tubal Reversal Possible For The Essure Device?

I perform 4 tubal reversal procedures each day at Chapel Hill Tubal Reversal Center. The women who come here have all varieties of tubal ligation methods. Today, one of the patients had the Essure sterilization method. When she chose this form of tubal sterilization, she was unaware that she would become remarried and want to be able to try to have a child with her new husband.

Although I could not find any previous references regarding attempts to reverse the Essure procedure, I agreed to attempt to perform a reversal for her. The way I did this was to cut the device out of the uterine muscle and then implant the remaining fallopian tube into the uterine cavity through a new opening in the uterus. This procedure is called tubouterine implantation.

The reason I removed the device was that part of the metal spring projects into the uterine cavity. If a pregnancy were to occur with the device in place, this could be harmful to the pregnancy. To my knowledge, this is the first time that the Essure sterilization procedure has been reversed.

Pomeroy Technique of Tubal Ligation and Resection

The most common type of tubal ligation is the Pomeroy procedure, named after Dr. Ralph Pomeroy who described it in 1930. The Pomeroy method involves picking up a segment of the fallopian tube to create a knuckle, placing a tie or ligature with absorbable suture around its base, and then cutting off the knuckle of tube above the tie. As the suture dissolves, the 2 remaining tubal segments separate from each other.

“Modified” Pomeroy Techniques

Interestingly, Dr. Pomeroy did not publish his technique in the medical literature but simply demonstrated it to other doctors. Some of them subsequently published the technique, but with modifications.

Currently, many doctors use the term modified Pomeroy procedure when they describe the tubal ligation they have performed in a patient’s operative report. Each doctor seems to have his or her own way of operating and there are many variations from the original method. Some doctors use absorbable suture, while others use permanent sutures that do not dissolve. Some doctors place more than one tie around the tube and many doctors also burn or cauterize the tubal ends.

A tubal ligation operative report is useful as a guide but does not predict exactly what the remaining tubal segments will be at the time of a reversal procedure. Fortunately, Pomeroy tubal ligation and its modifications are usually excellent in terms of reversibility.

Pomeroy Tubal Ligation Reversal Success

At Chapel Hill Tubal Reversal Center, we keep a record of all patients’ tubal reversal operations, including the tubal ligation method, the remaining tubal segment lengths, and other important findings at the time of surgery. Since we maintain long term follow-up with our patients, we are able to provide accurate statistics about pregnancies and their outcomes after tubal reversal surgery. Here are some of the pregnancy statistics for women who have had a Pomeroy type of tubal ligation.

Pregnancy Rates of Our Tubal Reversal Patients

The overall pregnancy rate after Pomeroy tubal ligation reversal is 70% for patients at Chapel Hill Tubal Reversal Center. The table below shows pregnancy rates according to women’s ages at the time of tubal reversal. The first column shows ages by 5 year groupings. The second column shows the number of women in each age group who had a tubal reversal. The third and fourth columns show the number and the percentage of women who became pregnant after their reversal procedure. The data shown in this table come from our Tubal Reversal Pregnancy Study Report 2007.

Here is how the pregnancy rate is calculated: The number of pregnant women (column 3) divided by all women in that age category who had reversal surgery (column 2) times 100 equals the percentage of women who became pregnant (column 4). A doctor has to know all of this information in order to be able to state what the success rate is for his patients.

Pregnancy Rate By Age After Pomeroy Tubal Reversal

Good News About Pomeroy Reversal

The good news is that for women under age 40, two-thirds to four-fifths will become pregnant following a tubal reversal procedure. Even for women age 40 and over, approximately 4 out of 10 will conceive another pregnancy. From the follow-up data that we have for our tubal reversal patients, there is good reason for optimism when reversing a Pomeroy tubal ligation.