Questions and Answers
I had my tubes "tied" several years ago. Now I would like to become pregnant again. What are my options?
Generally there are two options: tubal reanastomosis, i.e., microsurgical repair of the fallopian tubes, or in vitro fertilization.
Approximately one to two percent of women eventually seek a reversal of a previous tubal ligation. Though the term "ligation"
is often used, the methods for tubal sterilization vary and success rates for microsurgical repair of the fallopian tubes
depend on the surgical approach used to achieve tubal occlusion or blockage.
What factors affect the success rate of tubal reanastomosis?
The surgical technique used to achieve sterilization is a major prognostic factor. One of the most common surgical techniques
used in tubal ligation is electrocautery or the application of electrical current to the midportion of both tubes. Because
of the extensive tubal destruction that follows this technique, reanastomosis is least likely to be technically successful
with this method.
Immediate postpartum tubal ligation, performed at the time of cesarian section or vaginal delivery, involves removing a
small section of the fallopian tube at the midportion called the isthmic region. This method generally yields enough remaining
tubal length to achieve reanastomosis.
The best results with microsurgical repair are achieved after Fallope rings, tiny silastic rings, or Hulka clips are placed
over a small segment of tube. A copy of the operative report describes the surgical method used in the original procedure.
What other factors predict success?
Many investigators have concluded that tubal length is directly related to subsequent intrauterine pregnancy. Pregnancy
is least likely to occur in women with shortened fallopian tubes of less than four centimeters. In our practice, we perform
a hysterosalpingogram to study the uterus and tubes prior to attempting surgery. This helps determine proximal tubal length
and to ensure there are no intrauterine filling defects such as fibroids or adhesions that can obstruct the cavity.
According to studies, age, number of previous pregnancies, and interval from sterilization to reversal surgery did not
affect the pregnancy rate. Of course, patients over age 40 generally have a decreased pregnancy rate compared to younger women.
The quality of the male partner's sperm is another important factor. Before planning surgery, we obtain a semen analysis.
If the male partner has an abnormal sperm analysis with either a low sperm concentration or low motility, then we may recommend
in vitro fertilization as the better option.
What is the success rate of tubal reanastomosis?
A cumulative pregnancy rate of approximately 70% has been reported from a compilation of several large series, with 55%
live births, nine percent spontaneous miscarriages, and five percent ectopic pregnancies. Fifty percent of intrauterine pregnancies
were conceived within six months of surgery.
How is tubal reanastomosis performed?
First, a small incision is made in the lower abdomen. If there is a history of pelvic adhesions or any question that tubal
length may not be sufficient for reanastomosis, then a laparoscopy may be performed to determine if microsurgery will be technically
possible. This would save the patient from conventional open surgery if the prognosis does not seem favorable.
Under the operating microscope, or under magnification from special operating lenses called microsurgical "loops," both
obstructed ends of the fallopian tubes are transected (cut transversely), then two layers of tiny nylon sutures are placed
circumferentially to approximate the inner portion, called the muscularis, of both segments of tube and then the outer layers,
called the tubal serosa. Dye is then injected through the cervix to demonstrate patency of each reapproximated tube.
The hospital stay may be as short as one or two nights. Postoperative recovery may take three to six weeks.
In summary, microsurgical repair of previous tubal sterilization may be a successful option for a couple who meet the following
criteria: tubal sterilization performed by segmental resection or the placement of Fallope rings or clips, adequate tubal
length as documented by hysterosalpingogram or laparoscopy, and normal semen parameters. For patients who do not meet these
requirements, in vitro fertilization may be a better alternative.