Tubal Ligation Reversal

Fallopian tube microscopic anatomy

• Endosalpinx - the inner endothelial layer, or endothelium
  
• Myosalpinx - the middle muscular layer, or muscularis
  
• Serosa - the outer membranous layer, or epithelium
  

The endosalpinx has many folds, particularly in the ampullary and infundibular regions, that increase the surface area within the tubal lumen. The myosalpinx consists of two muscle layers, an inner circular and an outer longitudinal layer. A third muscle layer is present in the interstitial segment of the tube. The serosa is a smooth membrane that envelopes the tubal muscle and secretes a lubricating fluid to prevent friction against other internal organs. The segment shown in cross-section here is the isthmus.

Fallopian tube functions

The functions of the fallopian tube include capturing the egg upon its release from the ovary; moving the egg toward the uterus; assisting the movement of sperm toward the egg; and nourishing the egg after fertilization during its early development, until it is transferred into the uterine cavity.

The muscular layers of the tube contract in peristaltic waves, propelling the sperm and egg toward each other. Fertilization normally occurs in the ampullary region of the tube. The fertilized egg or zygote divides repeatedly as it is moved toward the uterine cavity which is the normal site of implantation. The tubal inner endothelial lining is covered with cilia. Cilia are tiny hair-like projections that beat in coordinated waves. Cilia assist in capturing the egg by the fimbria and transporting it toward the uterus. The endothelium also secretes a nutrient-rich fluid that sustains the egg after fertilization and during the earliest phase of embryo development.

Indications for tubal reversal

Tubal ligation reversal is indicated for women who want to become pregnant after a tubal sterilization. There is an alternative treatment – in vitro fertilization (IVF) – that is more appropriate for women with severely damaged tubes due to tubal infection (salpingitis), a history of multiple ectopic pregnancies or whose husbands have severe sperm disorders. For all others, tubal reversal is the better treatment in terms of success and cost.

Reasons for tubal reversal

• relieve symptoms associated with a tubal ligation
• feel whole again
• comply with religious beliefs
• feel like a normal woman
• relieve regret of a prior mistake
• correct a decision made during a bad relationship
• fill the emptiness from the loss of a child or another loved one
  

Tubal sterilization methods

There are three main types of tubal sterilization procedures:

• Tying and cutting (ligation/resection)
• Burning (coagulation, cautery)
• Blocking with occlusive devices (clips, rings, Essure)
  

Tying and cutting

The most common method of tubal sterilization involves tying (ligating) the tube and cutting out a segment. This leaves two disconnected parts of the tube. Many people refer to any method of tubal sterilization as "tubal ligation". The Pomeroy technique is the most popular ligation procedure, particularly at the time of a Caesarian section. A loop is created by picking up the fallopian tube and a ligature or tie wrapped tightly at the base of the loop. Part of the tied segment is cut out. As the suture material dissolves, the two segments separate. Their ends become covered over by the growth of the serosa. There are many variations of the tying and cutting technique.

Burning

Burning the tube with electrical current (electrocoagulation or electrocautery) is most often performed through laparoscopic surgery.  The amount of damage to the tube depends on the type of coagulation (monopolar or bipolar), the power settings on the electrical generator, the length of time the tube is burned, and the number of times and locations where it is burned.  At present, bipolar coagulation is the technique used by most doctors who burn the tube to achieve tubal blockage as a sterilization procedure. Bipolar coagulation is safer to use and less damaging than monopolar coagulation.

Blocking

Occlusive devices cause blockage from outside (tubal clips, rings or bands), or inside the tube (Essure). They avoid using electricity which carries the risk of injury to a nearby organ such as the intestine. They are more difficult to apply and tend to have a higher failure rate than other methods. The tubal clip (Hulka clip or Filshie clip) is least damaging to the tube and the best for reversing of all sterilization types.  Essure is a new device introduced into the tube through the uterus as an office procedure. It becomes scarred within the tube and  is the most difficult of tubal sterilization methods to reverse.

Tubal reversal success

The purpose of having a tubal reversal procedure is to be able to conceive again, so the issue of success is one of the most important questions people have about the procedure. Pregnancy rates after tubal reversal are related to many factor such as a woman’s age, her specific type of tubal ligation procedure, experience of the doctor performing the reversal operation and other variables. Overall, approximately 70 percent of women who have their tubes untied can expect to become pregnant again when the operation is performed by a tubal reversal specialist. Younger women have the highest pregnancy rates. This reflects the fact that fertility is naturally highest among women under 30 years of age and decreases as age increases.

How to know the success rate

To know what the success rate is after tubal reversal surgery, the doctor needs to maintain ongoing contact with his patients to find out who becomes pregnant and what the outcome of the pregnancy is (birth, miscarriage, ectopic pregnancy). Since it is possible to become pregnant more than once after the tubes are repaired, which is one of the advantages of tubal reversal, each pregnancy should be recorded and followed. This is not as simple a task as it may seem. Every woman who becomes pregnant will not necessarily contact the doctor who performed the operation, so it requires a follow-up system by the doctor’s office or the hospital where the operation was performed. Then, the results of patient follow-up contacts needed to be recorded in a way that they can be analyzed. With passing time, the pregnancy rate keeps changing as new pregnancies are reported. The pregnancy rate will also depend on the characteristics of the patient population, such as the women's ages and the specific types of tubal ligation procedures that are being reversed. Doctors and hospitals do not normally maintain continuing follow-up or maintain a data collection and analysis system that required to do this, since it is expensive and time-consuming. But without such a data system, a doctor will not actually be able to know what the success rate is for his patients. Most doctors, when asked about the success of their operations, will say they have a success rate that is really just an estimate, a guess, or perhaps a figure they have read in a medical publication from a study of some other doctor's results.

Tubal reversal pregnancy study

The most accurate pregnancy data and statistics about tubal reversal come from the Tubal Reversal Pregnancy Study. This study includes the largest population of tubal reversal patients ever reported. It is based on the tubal reversal procedures performed at Chapel Hill Tubal Reversal Center, the only medical facility devoted solely to tubal ligation reversal surgery. The facility maintains a patient follow-up system that permits continuing analysis of the outcomes of the tubal reversal procedures performed there. The Tubal Reversal Pregnancy Study Report is quite detailed. The following tables summarize some of the information from the latest study report.

Pregnancy rates by age

Pregnancy rates for women of different ages are shown in the following table. The overall pregnancy rate was 69 percent, ranging from a high of 82 percent for women under 30 years old to a low of 41percent for women age 40 and over.

     Pregnancy Rates by Age

Pregnancy rates by method

Pregnancy rates by age and method

It seems from the above two tables, that a woman's age is a better predictor of tubal reversal success than the specific method of tubal sterilization being reversed. The next table is a cross-tabulation that shows pregnancy rates taking into account age and tubal ligation method simultaneously. This table shows clearly that age is the more important predictor of success. Younger women have higher pregnancy rates after tubal reversal despite how their tubes were tied, and pregnancy rates decline with increasing age regardless of the specific type of tubal sterilization.                                          

                                    Pregnancy Rates by Age and Type of Tubal Sterilization

Births, miscarriages, ectopics

The following table shows the percentages of births, miscarriages and ectopic pregnancies for women who become pregnant after tubal ligation reversal. Approximately half of the pregnancies result in birth, one-third in miscarriage and 15 percent in ectopic pregnancy. The miscarriage rate is not higher than in the general population, but the ectopic pregnancy is significantly higher than the background rate of two percent in the US population. Ectopic pregnancy is the main risk associated with tubal reversal surgery.

                                         Births, Miscarriages, and Ectopic Pregnancies by Age

Age	Pregnant	Birth	Miscarriage	Ectopic
<30	460	255 (55%)	149 (32%)	56 (12%)
30-34	1130	567 (50%)	371 (33%)	192 (17%)
35-39	978	451 (46%)	373 (38%)	154 (16%)
40+	207	83 (40%)	94 (45%)	30 (15%)

The next table shows the outcomes of pregnancies following reversal of different tubal ligation procedures. Tubal ligation reversal after tubal blockage by clips or rings results in the highest birth rate (60 percent) and a lowest ectopic pregnancy rate (9 percent). These are the best tubal ligation methods for reversing sterilization.
 

Births, Miscarriages, Ectopic Pregnancies by Tubal Ligation Method

Method	Pregnant	Birth	Miscarriage	Ectopic
Blocking	697	418 (60%)	217 (31%)	62  (9%)
Tying and cutting	1098	507 (46%)	407 (37%)	184 (17%)
Burning	805	354 (44%)	298 (37%)	153 (19%)

More Information about Tubal Reversal

Read more about Tubal Reversal Surgery - a Knol by Julia Smith, RN, Nurse Administrator of Chapel Hill Tubal Reversal Center.