Reversing Tubal Ligation

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MAY 2010 | The Triangle Physician

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Sandy has her postoperative hotel visit with Jennifer Okun, RN.

According to Dr. Berger, the success of fallopian tube reversal is directly linked to surgical experience, and with the increased interest in IVF, the experience that he and Dr. Monteith have is unmatched.

Reversing tubal ligation

"What I've taken is a very complex, high-tech, expensive procedure and simplified it to make it accessible," says Dr. Berger. "The beauty of the reversal surgery as I developed it, is it's more effective doing it this way, requires a quarter of the time and expense, and the patients do better. It's also safer when performed in the outpatient setting and with minimal operating time."

Tubal ligation reversal involves microsurgical techniques to open and reconnect the fallopian tube segments that remain after a tubal ligation. The blocked ends of the segments are opened and a narrow flexible stent is gently threaded through their inner cavities, or lumens, into the uterine cavity. This ensures that the fallopian tube is open from the uterine cavity to its fimbrial end.

The newly created tubal openings are then drawn next to each other by placing a retention suture in the connective tissue that lies beneath the fallopian tubes. The retention suture avoids the likelihood of the tubal segments subsequently pulling apart. Microsurgical sutures are used to precisely align the muscularis and serosa, while avoiding the mucosa of the fallopian tube. The tubal stent is then gently withdrawn from the fimbrial end of the fallopian tube.

Sandy, Brian, and Dr. Berger discussing Sandy’s procedure and postoperative instructions in the 2nd stage PACU. Over the years, through constant examination of every step in the procedure, Dr. Berger has reduced operating time, tissue trauma, blood loss (5-10 ml), need for post-operative analgesics and healing time before resuming normal activities (four to six days vs. the usual four to six weeks). Minimizing operating and anesthesia time benefits the patient by reducing cost as well as post-operative complications. Working with the same operating and anesthesia team on a daily basis facilitates efficiency, safety, and patient comfort during and after surgery. "Compared with any other approach, such as using a surgical robot, laparoscopic instruments and other microsurgical techniques, our data prove the point that this is the most effective method," Dr. Berger says.

Evidence-based medicine

Chapel Hill Tubal Reversal Center also is remarkable because of its database on outcomes that help guide patient decision-making and expectations. It is the world's largest by virtue of the number of procedures performed at the center and the extensive pregnancy follow up. Today, it contains outcomes of more than 5,000 tubal reversal patients since 2000. "By having this specialized facility, the world's largest patient base, a system to maintain follow up, and accumulating and analyzing the data, we really have established for this kind of procedure what patients can expect," says Dr. Berger. "It's a significant accomplishment. No one ever had this type of data before based on a patient population numbering in the thousands."

Tammy talking with Dr. Monteith in the 2nd stage PACU. The center's database shows that on average 2 out of 3 women have become pregnant after their reversal procedures at Chapel Hill Tubal Reversal Center. It also finds that pregnancy rates vary with age and tubal ligation method. Women under age 30 with tubal clip procedures had a 90 percent pregnancy rate, which fell to 31 percent for those 40 and older who had tubal coagulations.

"They give you hope and also give you reality. The reality is there is always the chance that it won't work out," says Ms. Gove. "My biggest encouragement was the length of my fallopian tubes." Dr. Monteith gave her a 70 percent chance of pregnancy, based on her age, medical history and sterilization method.