Tubal Reversal FAQs
Poor Ovarian Reserve and Tubal Reversal
Young women with poor ovarian reserve do well after surgery. Though they have fewer eggs, they tend to have normal eggs.
For women 40 and above with poor ovarian reserve, IVF is usually not a reasonable option. However, tubal reversal can result in delivery. We have had deliveries after tubal reversal with FSH levels in the 20s. The reason tubal reversal works better than IVF in this situation is that you have 13 cycles and 13 tries every year after reversal. The vast majority of eggs in women 40 and above are abnormal. We need lots of eggs to get pregnancies. If we have lots of eggs, it is more likely that one or two will be normal. Additionally, eggs appear more “fragile” in the older woman. If we can leave them in the body, and keep them out of the IVF lab, we tend to get higher delivery rates.
Can I do a tubal reversal if I only have one tube?
Reproductive surgeons have known for years that a woman’s pregnancy rate is based on the best tube. This was verified with tubal reversal in women with only one tube. In this study the delivery rates were identical when comparing one tube vs two tubes. There was one surprise in that the month by month pregnancy rate was also the same. Our most extreme example was a woman with only one ovary which was on the right and only one tube which was on the left. Additionally, she was 41 years old. She conceived shortly after surgery and miscarried then conceived again and delivered a healthy baby.
Does Husband Affect Pregnancy Chances?
Yes they do! It takes two. We are a full fertility center and can usual do a basic sperm count on the day you are here. Otherwise we can have one done before your first visit.
The best predictor of pregnancy rate is number of motile sperm and quality of motility. However, there are some subtle differences also. For example, it has been shown that infertility rates are doubled when the sperm count is normal but the man is over 40. On the opposite side of this, women over 40 have higher delivery rates if there husband is under 40 and the younger the man the higher the delivery rates.
You can’t change your husband’s age so how do you make him better. First is the obvious. No smoking. It is clear that this significantly lowers delivery rates. Alcohol consumption needs to be limited to no more than the equivalent of two beers in one day. No averaging it out here. Some herbs can profoundly lower sperm counts. Since truth in advertizing is not required in herbal supplements, you never know what is really in them. Neither of you can take herbs (they can increase the risk of bleeding during surgery). Weight is becoming a significant problem in male fertility. Fat cells make estrogen. Sperm production is highly dependent on testosterone levels and the relative level of testosterone to estrogen, the T/E ratio. The T/E ratio shifts in favor of estrogen with increasing weight. Additionally, heat hurts sperm production. With higher weight there is more heat around the testes and lower sperm production. We also see more damage to the DNA in the sperm in these situations. This can result in higher miscarriage risk.
For men with high blood pressure you need good control. Otherwise you body reads the stress and decides that making sperm is more than it needs to do right now. There is one group of medications that has been questioned in male fertility. These are called calcium channel blockers. They do not change sperm counts but appear to make it difficult for the sperm to fuse with the egg. Not all fertility experts agree that this is a problem but it is enough of a concern for us that we suggest that you see if another class of drugs could control your blood pressure just as well.
Fertility Medication and Tubal Reversal
Fertility medications are usually not necessary after surgery. If you are ovulating normally they will not make you better and can in fact lower pregnancy potential. If you required fertility medications before, or if your cycles have changes and are not as predictable you may need fertility medications. If you only required Clomid pills to conceive then it is reasonable to do a tubal reversal. If you needed fertility injections then you may be better off doing IVF. It just depends on how difficult it was for you to conceive before.
Fibroids and Fertility after Reversal
Other than sperm problems, this is the most common other problem found. It is a primary reason that we include a screening ultrasound in our package. Fibroids are muscle tumor in the uterus. They are very rarely cancerous. The most common symptoms are bleeding problems and pressure like on your bladder. The can also prevent pregnancy or cause miscarriage or early delivery. There is a strong family predisposition. They are common anyway and by age 35 we can find them in about one in three women. Most are not a problem. As I like to say they are like real estate. It’s all about location, locations, and then location. If they are not distorting the inside of the uterus then they are unlikely to be a fertility or pregnancy concern. If there are fibroids that are likely to cause a problem then they should be removed before the tubal reversal. There are two reasons for this. The first is insurance and hospitals. I have done tubal reversal at the same time I have done myomectomy. The myomectomy is a much larger surgery and requires hospitalization for 2 or 3 days. In these cases we got permission to do the two surgeries together. They paid for the myomectomy costs and the hospital charges “overage” for the extra cost of the tubal reversal. Problem is their “overage” is always far greater than doing the tubal reversal by itself. Additionally, thought the insurance companies knew about the plan in advanced they sometimes get very confused afterwards and it can take years to straighten out the payment. The second issue is medical. The most common complications of removal of fibroids is adhesions were the organs in the pelvis stick together during healing. The tubes and ovaries are frequently involved in this and the tubes may be kinked by these adhesions. We may have to do another surgery to try to remove these adhesions. Therefore, it works better to do the reversal after the myomectomy so you can take down adhesions while doing the reversal.
Endometriosis and Reversal
Most women in this situation have limited disease. Most commonly we see an endometrioma (cyst of endometriosis) in a ovary at ultrasound. If we know about it in advance, then we just take the cyst out at the time of surgery. This has not caused any problems. Superficial endometriosis can be burned away with micro-cautery. Deeper endometriosis is not in a position were it can be reached by the small incision so cannot be removed.
Other Fertility Factors
In treatment of infertility we say that factors are more than additive. For example; if you have endometriosis that is expected to lower your pregnancy rate by 20% and your husband’s sperm count is slightly reduced and expected to lower by 20% that does not add up to a 40% reduction. That is a 60% reduction. The exact number is not important but you get the idea. You already have a tubal factor that will lower your chance by 20 to 35% after reversal (80 to 65% delivery rated depending on type of tubal ligation). If you are young and the other factors are minor then tubal reversal will still be best. If the other factors are severe then chance of success falls and IVF may be better.
What about laparoscopic or robotic tubal reversal?
I was very interested in this idea when it first came up about 15 years ago. In fact, I had the first commercial set of laparoscopic microsurgical instruments sold in the US. They are gathering dust in one of our storage rooms. The problem was cost. When the techniques were put in place it was immediately seen that surgery time was prolonged. Six hours of surgery was not unusual. Operating rooms usually charge in 15 minute blocks. That was a lot of blocks. Additionally, surgery centers make their money by doing lots of small case so they did not want these long cases. That put us back in the hospital with their inflated. Some surgeons tried to shorten the time by doing single stitch or no-stitch surgeries (used a type of glue). Surgery was shorter and pregnancy rates were substantially lower. Next came the robots. This can also reduce the time in the operating room. However, this is extremely expensive equipment to use. Cost of doing the surgery is estimated at around $20,000. What do you get for that extra money? You get 5 punctures instead of one small incision. It does not improve delivery rates. It probably shortens recovery by 3 or 4 days and that is it. If you are willing to spend that type of money, just do IVF and have no incisions.
I am committed to continuing to do micro-surgical tubal anastomosis using techniques proven to be superior over more that 30 years of medical experience.
