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Tubal Reversal, Tubal Anastomosis, and Tubal Ligation reversal refer to the same thing. It is the surgical repair of previously obstructed fallopian tubes.
A brief review of biology:
Conception in humans occurs after ovulation. A mature egg is released from the ovary. The egg then enters the fallopian tube through the end called the fimbriated end. The opening of a healthy tube leads to a very important part of the tube called the ampulla. Sperm reach the tube after passing the cervix and the uterus (womb). The sperm continue their journey through the part of the tube that is within the wall of the womb. This part is called the interstitial part of the tube. The sperm continue to travel toward the ampulla by traveling through the longest part of the tube called the isthmic segment. At its end, the isthmic segment begins to dilate and becomes the ampulla. It is there where fertilization occurs.
The fertilized egg or zygote begins to divide as it travels down the fallopian tube toward the womb. Implantation occurs about the 5th or 6th day after fertilization.
After reviewing this it becomes apparent that the process can be interrupted by a low sperm count, by abnormal or blocked tubes, and also by poor egg quality. This is why it is recommended to have a sperm count on your partner prior to going through a tubal reversal. In addition, the chance of success can be affected by other variables that have to do with the length of the tube available for repair, the part of the tube that had been previously blocked, and the age of the woman having the reversal. Read more about this below.
Gynecologic surgeons have many different ways of interrupting fallopian tubes. Different techniques are used based on the training of the surgeon. Higher success after tubal ligation reversal is expected when there is more length of tube available for repair and when the previous ligation has interrupted the mid-isthmic portion of the tube.
Hulka or Clip Tubal Ligation:
This type of tubal ligation is the most easily reversed. By their design, the clips fit best in the mid-isthmic portion of the tube. This eliminates error in placement. After the microsurgeon removes the clips, the ends of the tubes to be sewn together are of equal diameter. This makes the anastomosis easier. In addition, the isthmic portion of the fallopian tube has a relatively thicker muscular wall than the ampulla. This thicker muscular wall allows a stronger repair.
Fallope Ring (Rubber Band) Ligation
The fallope ring tubal ligation is also easily reversible if the surgeon only placed one ring per side. These very strong rubber bands are usually applied in the mid-isthmic portion of the fallopian tube. Since a loop of tube must be brought into the band, this damages more of the isthmic portion of the tube than the clips. Nonetheless, by their design, they are almost always placed in the mid-isthmic portion of the tube. Therefore, when the bands are removed by the microsurgeon, the open ends of the tube available for repair are of the same diameter and have a substantial muscular wall.
Pomeroy or Modified Pomeroy Ligation
This common type of tubal ligation is also called the post-partum tubal ligation. It is usually done at the time of a Cesarean Section or the day after a normal vaginal delivery. The surgeon usually holds a loop of fallopian tube with special tubal forceps and then makes about a two- to four-centimeter loop of tube that he or she ties with suture. After the loop is tied tightly, the surgeon cuts out the intervening segment of tube. Some surgeons burn the cut ends.
This type of ligation is also quite reversible if the surgeon did not make too large a loop or did not remove the entire ampulla in the process. Most gynecologists will place the loop at the isthmic-ampullary junction and therefore remove a little bit of each portion. This leaves the microsurgeon with the task of anastomosing the isthmic portion of the tube with the ampullary portion of the tube. These parts of the fallopian tube have different diameters and different amounts of supporting muscle wall. The ampulla can at times be paper-thin, requiring the most delicate handling and techniques.
Bipolar Cauterization of the Tubes
This procedure is usually done through the laparoscope as are the clips and bands. The technique involves holding the fallopian tube between the electrical conducting paddles of a bipolar forceps and turning on the current until enough heat is generated in the tissue (tube) so that all the water evaporates and no more current flows from one paddle through the desiccated tube and into the other paddle.
Unfortunately, the heat generated in this process has been shown to spread along the tube for a distance of up to almost one inch (two centimeters) in either direction. In addition, most gynecologists place the paddles two or three times in adjacent portions of the isthmic segment. The damage caused by this type of ligation may be so extensive so that only one or two centimeters of tube are available for repair on either side of the previous cauterization.
This type of tubal ligation can be reversed in most cases only if the tube was cauterized only in one spot or if the paddles were applied 2-3 times in very close or adjoining portions of the tube. Oftentimes a patient's tubes are only 2-3 centimeters in final length after this type of reversal. This leads to lower pregnancy rates after reversal. For that reason, many patients decide to enter into the "in vitro" fertilization program instead. When a patient is treated with "in vitro" fertilization, the clinic actually performs all the functions of the fallopian tube; that is, collection of the egg, fertilization of the egg, culture of the fertilized egg and pre-embryos, and finally transfer into the womb.
Monopolar Cauterization of the Tubes
This type of tubal interruption is also done through the laparoscope. It involves burning one or more adjoining segments of the fallopian tube and usually interrupting them also by cutting them. The heat generated can damage adjoining segments to the tube and lead to very short tubes for anastomosis. Repair can be attempted if the surgery notes indicate that a relatively conservative procedure was performed.
Salpingectomy
Salpingectomy is the medical term for removal of the tube. Fortunately, some gynecologists use this term to describe a partial salpingectomy and not a total removal of the tube. This type of tubal ligation can be reversed as long as some tube was left near the womb and some portion of the ampulla has been left behind for repair. If there is less than 2 or 3 centimeters remaining for repair, then a reversal is not usually recommended because of a very low chance of success (less than 10%).
Dr. Pabon has been performing Microsurgery and Tubal Ligation Reversals since 1992. During his training he was exposed to the techniques of gynecologic microsurgeons that who to Houston and Louisville from all over the U.S.A. and Europe. In addition, he sought exposure to the microsurgical techniques of plastic surgeons, vascular surgeons, urologists, and brain surgeons. His broad exposure and practice has led to a very efficient and successful technique. Please refer to the About Us section.
How is Dr. Pabon different?
Dr. Pabon is a Board Certified Reproductive Endocrinologist and Infertility Specialist as well as a Board Certified Obstetrician and Gynecologist.
Dr. Pabon uses both magnifying loupes and a surgical Zeiss stereomicroscope. The loupes are useful in applying microsurgical techniques in the initial dissection (incision and exposure of the tubes) while the Zeiss stereomicroscope is used to achieve higher magnification during the actual anastomosis (reversal). The Zeiss stereomicroscope can magnify up to 20 times while giving more depth of field than loupes (at each magnification). This allows for the most accurate placement of all sutures.
Dr. Pabon has both an IVF practice and a Tubal Reversal practice. This allows him a better perspective than most in considering the options for each patient. In addition, this allows him to offer most patients who fail to conceive one year after a tubal ligation reversal a
$1,000 discount on a single IVF treatment in his center. Please refer to our fees section for the details of this great back-up.
Dr. Pabon does not have a set cut-off for the size (weight) of a patient desiring tubal ligation reversal. Patients are counseled regarding their size and the increased risk of both surgical complications and pregnancy complications with increased size. Weight loss is always advisable before any surgery or pregnancy. There are many patients who may be heavy and carry their weight in parts other than the planned surgical incision site (for example their thighs or rear) and may be turned down by other surgeons because of their "high BMI." Dr. Pabon looks at each patient individually. Patients who do have a rather large tummy are advised to lose weight prior to the reversal because the obesity in the area of the planned surgery will make the surgery more difficult and sometimes impossible due to the limited length of the available micro-surgical instruments. In addition, obese patients have a higher risk of post-surgery complications like wound problems, blood clots or lung problems.
If you are heavy and would like consideration for a tubal ligation reversal, please send a photo of your abdomen from both the front and side along with your new patient form and tubal ligation records.
Dr. Pabon has perfected the technique for Tubal Ligation Reversal to a high level of efficiency. This has allowed our anesthesia team and our Outpatient Surgery Center of give very competitive prices. It is our belief that we have the lowest package price for Outpatient Tubal Reversals in the Continental U.S.A.
The package price of $4,500 is all-inclusive. Please refer to our fees section. Dr. Pabon has lowered the price in order to give more families the opportunity to realize a dream. Tubal Ligation Reversal is a relatively "low overhead" procedure for Dr. Pabon since he has negotiated very successfully with the Doctors Same Day Surgery Center and the Anesthesiologists that staff the center (TAGOS anesthesia). By "low overhead" we mean that Dr. Pabon chooses not to do these outpatient procedures in the office. By doing them in a fully accredited and certified outpatient surgery center, Dr. Pabon is able to have a lower personal office expense. This is because the outpatient surgery center provides all the pre-surgical, intra-surgical and post-surgical nurses and staff.
We are not a "discount bargain basement tubal reversal center."
Dr. Pabon also has a very successful IVF and infertility practice. He enjoys the higher tubal reversal volume that the lower fee has brought. He performs one or two tubal reversals oftentimes before his office opens. Dr. Pabon notes that the Tubal Ligation patients are quite nice, motivated, and driven. He enjoys seeing them, he enjoys the surgery, he is compensated well, and is still honored that many people choose to travel here for their Tubal Reversals and other treatments.
Dr. Pabon does perform tubal reversals for out of state
patients.
Dr. Pabon's technique and efficiency allow completion of the procedure in half the time usually required by others. This results in much less patient discomfort and over 90% patency rates after tubal ligation reversals. Using his microsurgical and mini-incision techniques, Dr. Pabon has been able to perform Tubal Reversals in an outpatient setting since 1993. Prior to that, he had performed them in the hospital requiring an overnight stay. During his Post-Doctoral and Post-Residency fellowship at the University of Louisville, he perfected his mini-incision techniques. Since then, he has performed thousands of tubal ligation reversal with great success and not a single complication (excluding the expected 8-10% risk of ectopic pregnancy after tubal reversal). Such complex surgery can be successfully performed in an outpatient setting because of a general surgical philosophy of minimal trauma and microsurgical technique.
The Tubal Ligation Reversal
Dr. Pabon usually begins by making a small "bikini" incision just above the pubic bone. He is very gentle during the entire surgery.
Dr. Pabon enters the inner abdominal sac within only minutes of the initial incision. Then, if the patient is not very obese, he is able to tie a suture to the top of the womb.
Dr. Pabon then uses gentle traction to elevate the womb and the fallopian tubes so they can be easily handled and repaired. Great care is taken to keep all tissues moist throughout the procedure.
Dr. Pabon identifies the fallopian tubes and determines where they are blocked. This is done with the magnification gained by surgical loupes. The scarred and blocked part of the tubes is removed. Small bleeding points are controlled using a micro-bipolar electrical instrument. The open tubes are checked using a micro-lacrimal probe. This confirms that the tube is open to the womb and to the fimbrial end.
The open ends of the tube are then brought together with a suture that is the same size as is used to repair coronary arteries in the heart (6-0). The 6-0 suture is placed using the surgical loupes. This suture is placed just under the open ends in order to bring the open ends closer together and remove tension from the anastomosis. Then the operating Zeiss stereomicroscope is brought in. All subsequent sutures are placed using the Zeiss stereomicroscope. The tube is sutured together using 9-0 nylon suture (much finer than a human hair). This type of suture is also used by eye surgeons for suturing the cornea.
Three to four 9-0 sutures are used depending on the size of the tube. The 9-0 sutures put the inner and muscle layers together. A slightly larger (8-0) suture is used to put together the outer surface of the tube in order to further support the anastomosis.
Local anesthesia is placed on the tubes and in all the layers of the abdomen. The anesthesia team is also focused and highly trained in outpatient surgery. This allows for discharge of patients usually within two hours of their surgery. If patients reside near our office, they are given a routine post-surgery appointment 3-5 days later. If patients live far away and plan to travel home in one to two days, then Dr. Pabon or one of our nurses will check on them by coming by the hotel the day after surgery if there are any concerns. This "house call" can only be done if patients stay at the Hampton Inn near our office.
What are the risks of the Tubal Reversal Surgery?
Like any medical or surgical procedure, there are potential risks. The reversals are done through a small but standard lower abdominal incision. This carries all the routine risks of that type of incision such as infections, future hernias, chronic incision numbness, or injury to other structures. Dr. Pabon is a surgeon with an extensive record without surgical complications. Through the application of his delicate and precise surgical technique, he has avoided serious complications.
There is an occasional superficial incision infection that can be treated with antibiotics and cleaning. This occurs in fewer than 5% of cases. This is remarkable given that many of our patients are larger than the usual weight cut-off for most surgeons. Obesity is a risk factor for incision problems after surgery.
The more common complication of Tubal Reversal surgery is the future risk of ectopic pregnancy. All patients who have undergone a tubal repair of any type are forever at increased risk of ectopic pregnancy. An ectopic pregnancy is a pregnancy that implants in an abnormal location. After tubal reversal microsurgery, there is an 8-10% chance that a subsequent pregnancy may implant in the fallopian tube instead of implanting in the womb. A pregnancy that implants in the fallopian tube is not a normal pregnancy. It can result in swelling of the tube, and in some cases the tube can rupture. This can lead to internal bleeding and a possible surgical emergency. A ruptured tubal pregnancy is considered a dire emergency. Patients can have severe pain and significant internal bleeding. This can result in the need to have emergency surgery and even a blood transfusion.
Our patients are instructed to avoid pregnancy for 6 weeks following the reversal. Then they are to keep track of their ovulations by using an over-the-counter ovulation predictor kit. They should have relations once each day for two days following the positive ovulation surge result. If a menstrual cycle does not begin within two weeks of ovulation, then a blood pregnancy test (quantitative Beta hCG) should be done immediately. The positive result should be followed closely by a qualified gynecologist who is aware that the patient had a prior tubal reversal. This is important in order to determine as early as possible whether a patient has a normal pregnancy or an ectopic pregnancy.
If an ectopic pregnancy is detected early, it can usually be treated with medication with up to an 85% chance of success in clearing the pregnancy without surgery. The medication used for this is called Methotrexate. It is injected intramuscularly at a dose of 50 milligrams per meter squared. Methotrexate inhibits the use of Folic acid by rapidly growing cells. Patients must be counseled not to consume Folic acid during the treatment because it can lead to a treatment failure. This is difficult to do since many foods (breads, juices, fruit, and vegetables) contain natural and added Folic acid. Once the initial injection of Methotrexate is given, the patient will feel some pain in the area of the degenerating ectopic pregnancy. This warrants close observation by the attending physician. The quantitative Beta hCG is measured one week after the initial injection. If the value of the Beta hCG has dropped more than 15%, a second injection is not necessary. In this fashion, a patient with an ectopic pregnancy can avoid surgery and removal a potentially functional tube.
Please understand that not all early ectopic pregnancies can and should be treated with Methotrexate. The criteria for this decision are beyond the scope of this document and certainly are within the scope of the abilities of a Board Eligible or Certified Ob/Gyn or Reproductive Endocrinologist.
In summary, the most common complication of a Tubal Ligation Reversal is a subsequent ectopic pregnancy. Patients can try to avoid serious consequences by not ignoring a delayed menstrual cycle or a menstrual cycle that appears different in any way. Many ectopic pregnancies are associated with vaginal spotting or bleeding. When in doubt, please contact Dr. Pabon or your qualified Ob/Gyn. so that an early blood test can be ordered. No emergency contacts should come through the web site or e-mail. Please call the office.
Click here for more information on Tubal Reversal
In Vitro Fertilization versus Tubal Reversal
This is sometimes a complex decision. Let us address it in parts.
Cost
This is oftentimes the great motivator toward tubal reversal in our practice. In vitro fertilization and embryo transfer procedures are more costly than tubal reversal. Please refer to our fees section.
Success Rates
As mentioned elsewhere, more than 90% of the time, at least one tube is open after the microsurgical tubal reversal by Dr. Pabon. The chance of pregnancy success after a Tubal Reversal depends on three chief factors: the age of the mother, the type of ligation that was reversed, and the sperm count of the male partner.
Age
Just because someone had three or more kids easily in their twenties does not mean that they will do so with ease in their forties or even their thirties. The chance of success depends on the quality of the eggs being produced. The eggs of women as young as 33 are known to have more abnormalities that result in decreased pregnancy rates and increased miscarriages as compared to younger women. The trend continues and worsens much more quickly after the age of 36. This is why older women have fewer pregnancies and more miscarriages. This is why almost all egg donation centers limit the age of egg donors to 32 or less. Our center's cut-off is 30.
An older woman with a prior "unfavorable type" of tubal ligation may choose to go through the IVF program because she desires the highest chance of pregnancy in a short interval of time. A younger woman with the same "unfavorable type" of tubal ligation may choose to try the tubal ligation reversal because she has more time to conceive than the more mature woman. The younger woman has the luxury of being able to wait on IVF without a significant drop in her chance of a pregnancy. The best results after tubal reversal are those of the particular age of the patient. Recall that the monthly chance of pregnancy for a normal couple in their mid-twenties is 20-25%. This decreases with age.
In the 1950s a group of immigrants from Switzerland called the Hutterites who live in the Northwest states was studied. They are a religious sect who live in a communal fashion and do not practice contraception. Only 5 of 209 women were infertile (a low infertility rate of only 2.4%). The average age at the time of the last pregnancy was 40.9 years. Eleven percent of women had no more children after the age of 34. 33% of the women were infertile by age 40. 87% were infertile by age 45.
Age of the female partner has been shown in many studies to be the most important factor for pregnancy success. A patient can have the most perfectly repaired tubes but fail to conceive because of age. Older patients don't have as much time to conceive. That is sometimes an incentive to proceed with IVF. IVF can "compress" several months of trying to conceive into one treatment due to the recruitment of multiple eggs that is routine in IVF.
Type of Ligation
This is simple: the shorter the tube, the lower the pregnancy rates. Tubal ligations that involve extensive damage or burning of large segments of the tube leave less tube to work with. The human fallopian tube is about seven to eight centimeters in length. After a microsurgical tubal ligation reversal, the final tubal length is noted. The chance of pregnancy is lower with shorter final tubal lengths. Pregnancy rates are very low if the final tubal length is less than 2.5 centimeters. The post partum ligations (Pomeroy or Modified Pomeroy), the clips, and rubber bands are among the best to reverse. Patients who have had removal of large portions of their tubes or extensive damage will usually choose to enter the IVF program. There are cases where the patient and her partner have had children and simply want "the possibility of pregnancy" even if the tubal length is very short. In these cases a reversal can be performed after thorough counseling and discussion of the limitations.
The Sperm Count
The World Health Organization has determined that the lowest "normal" count is 20 million per milliliter or cc of ejaculate. 20 million represents the lowest possible number to be considered normal. Most men have counts in the range of 80 to 150 million sperm per milliliter of ejaculate. A more important assessment is the "total normal motile count." This takes into account the number of sperm that are alive and appear normal. A very good recent study determined that patients with total normal motile counts of less than 10-12 million per cc are best treated with IVF. If a male partner has a suboptimal sperm count, the chance of pregnancy even after the world's best tubal reversal will be close to zero. Please note that sometimes low sperm counts can signify a medical problem. A qualified urologist must examine the patient. One percent of the time a testicular tumor is discovered.
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