Microsurgical Reversal of Tubal Ligations

Tubal ligation, either for the wife or husband, is frequently chosen as a means of contraception when a couple feels that they have completed their family. Unfortunately, occasionally divorce or another tragedy intercedes and the wife, if she had the tubal ligation, would like to reestablish her fertility potential and conceive more children.

Many couples feel that In Vitro Fertilization (IVF) is the best alternative in this situation. In many cases, nothing could be further from the truth.

IVF is expensive ($10,000-$20,000 per try), is not covered by insurance (in cases where a tubal ligation has been performed) and gives only a 40% per cycle at best chance of conception. Also, the chance of multi-fetal pregnancies and ectopic pregnancies are significant.

The traditional answer to restoring a woman’s fertility following a tubal ligation has been a microsurgical resection of the damaged fallopian tube with a microsurgical reanastamosis. This is a procedure that should only be performed by a fellowship trained reproductive endocrinologist who trained extensively in microsurgery (something that REI fellowship programs have gotten away from since the mid-90’s with the much greater emphasis being placed on IVF).

Success rates with microsurgical reversal of tubal ligations run as high as 80–85% in couples where the final tube length is 5 cm or more on the best side, the wife still ovulates well, and the husband is fertile. Essentially, in my hands, the couple is put back into the normal, pre-tubal ligation, fertile population.

Success does diminish with shortening length of fallopian tube. A couple can expect a 40–50% chance of a full term pregnancy if the final tube length is 4–5 cm. If the tube length is 3–4 cm, then their pregnancy success rate is 30–40%. 20–30% is the expected pregnancy rate if the final tube length is 2–3 cm. When the final tube length on the best side is less than 2 cm, the success rate is less than 5%.

When I work with a couple who wants a microsurgical reversal of a tubal ligation, we first check the fertility of the husband with a semen analysis and evaluate the quality of the wife’s current ovulatory function with basal body temperature charting. Assuming these factors are adequate, I then discuss with the couple what pregnancy percentages they feel are acceptable for them to proceed with the microsurgical tubal re-anastomosis. The couple’s acceptable success rate is determined prior to surgery.

On the day of surgery, under general anesthesia, I perform a laparoscopy and measure the length of fallopian tube remaining on both the left and right sides. The pregnancy success rate is determined by the best side (as is the pregnancy success rate with any infertility surgery). If the laparoscopic findings appear to meet the couple’s desires, I then proceed with a laparotomy (small bikini incision, usually about 6 inches long) and perform the microsurgical tubal re-anastomosis. If there is not sufficient Fallopian tube length to meet the couple’s desires, then I stop at the laparoscopy and the surgery is ended. In this case, approximately 20–30 minutes of surgical time elapsed.

Microsurgery permits me to adequately evaluate how healthy the tissue is in the lumens of the proximal and distal segments of the fallopian tubes once I open them. I then, micro-surgically, using absorbable sutures that are much finer than a strand of hair, approximate the very small proximal and distal fallopian tube lumens. Further fine sutures are then placed microsurgically around the circumference of the fallopian tube at the anastomosis site to strengthen this union while the tissues heal. Using this microsurgical approach, with the advantage of marked magnification, a patency rate well in excess of 90% is achieved.

I also anastomose both the left and right fallopian tubes. Once the operative field is “set up” it only takes another 20 to 30 minutes to do the second tube. I have always been baffled by my colleagues who do one tube and leave the other blocked, an unfortunately common practice.

Most patients are back to their normal, moderate activities, including work, in 3–4 weeks. However, full abdominal wall healing is not achieved for 3 months. Therefore, I caution ladies not to do heavy lifting or directly strain the abdominal incision until full healing has been achieved. I also ask couples to refrain from attempting to conceive for 3 months following the surgery to permit the tubes to heal (though I have had couples successfully conceive children the first month after the surgery).

A patient can expect to spend approximately $8000 overall for this surgical procedure. If only a laparoscopy is done, then a significant portion of my fee for the surgery is refunded to the patient. Included in this $8000 estimate are hospital, operating room, and anesthesia expenses.

Recently, an infrequent colleague is attempting to offer this reversal of tubal ligations non-microscopically through the laparoscope. Unfortunately, their pregnancy rates in the best of cases are only 45–50%. This is compared to the 80 – 85% pregnancy rates my patients achieve when I perform microsurgery.

If you have questions regarding this procedure, please feel free to contact me at 609–678–6147. I would be happy to discuss it with you.