Tubal sterilization is the most common method of contraception among married women in the United States. The risk of failure of tubal ligation is 1-2% over a 10 year period. When failure occurs, approximately 30% of pregnancies are ectopic pregnancies (pregnancy in the fallopian tube). Overall 1-2% of women may regret tubal ligation and it’s more common in women who are younger than age 30 at the time of tubal sterilization. Factors that impact the decision to have reversal of tubal sterilization (tubal reversal) include a change in marital status, death of a child, having only boys or girls prior to sterilization and the desire to expand the family.
Tubal reversal is generally done under microscopic approach through a lower horizontal abdominal incision measuring 6 cm (minilaparotomy). The surgery may take 2-3 hours depending on the difficulty of the case. General anesthesia is required, but most patients can be discharged home the same day (outpatient surgery) because of the small abdominal incision. Recovery is relatively fast and patients may return to work fairly quickly.
The success rate of tubal reversal can be as high as 70% in patients less than 35 and 50% in patients above age 35. In patients above the age of 40 the live birth rate is approximately 15%. Success rates after tubal reversal are not dependent on the length of the remaining tube (as long as the final length is ≥ 4 cm), site of tubal ligation and length of time from ligation to reversal. On the other hand success rates are significantly dependent on the age of the patient and other factors that may affect fertility such as ovulatory disorders and male factor.
Patients who are candidates for tubal reversal need an evaluation of ovarian reserve by a day 3 FSH and estradiol level, a hysterosalpingogram (dye test to visualize endometrial cavity and fallopian tubes), semen analysis and documentation of ovulation. Patients who have abnormalities in one of these tests should be counseled on the possibility of decreased success rates after tubal reversal. These patients may be better served by undergoing in-vitro fertilization (IVF).
The risk factors of tubal reversal are low and associated with general anesthesia and surgery, ectopic pregnancy (2-8%) and the need to use contraception following pregnancy. The benefits of tubal reversal are natural conception, achievement of a singleton pregnancy, onetime fee for surgery and the avoidance of using fertility drugs.
The alternative approach is to undergo IVF. The advantages of IVF include timing of the cycle and pregnancy, high success rates per cycle (comparable to the overall success rates with tubal reversal), avoidance of surgery and general anesthesia, and treatment of other factors such as male factor and ovulatory dysfunction. The disadvantages are the possibility of increased cost if multiple attempts are necessary, increased rate of multiple gestation (30-40%) and the risk of prematurity, using fertility drugs, the risk of ectopic pregnancy (2-4%), ovarian hyperstimulation syndrome and the need to repeat IVF if future pregnancy is desired.
Dr. Bayrak recommends a detailed consultation and a thorough evaluation of the couple to determine which approach is most appropriate for candidates considering tubal reversal.