How Are Babies Made?
What Are My Chances?
Information About Your Tubal Sterilization
What are the Alternatives?
Who's the Best Candidate?
Preparing for Pregnancy?
How is the Reversal Performed?
Who Should do the Reversal?
What Are the Risks?
When Can I Try?
I'm Pregnant - Now What?
What if I Am Not Pregnant?

How are babies made?

Most people know this answer, but a good understanding of the reproductive process helps provide a better understanding of the reversal procedure and what can hamper its success. There are basically four different components that must be working together to make a baby. These components are:

• A sperm. Yes, it takes two, and a reversal should not be undertaken without a semen analysis.
  
• An egg. You must be ovulating (releasing the egg from the ovary) in a timely manner. Women who have menstrual cycles under 26 or over 32 days are more likely not to be releasing an egg. In women with regular cycles, information can be gained by charting pain and mucus changes. More precise information is gained by one or more of the following tests: ovulation predictor kits available in pharmacies, basal body temperature tracking, or blood testing/ultrasound through a physician’s office. Ovulation problems can often be easily fixed, but advanced warning is important.
  
• A uterus. Sometimes there can be fibroids or polyps that can decrease the chance of pregnancy or increase the risk of pregnancy loss. These are usually easily seen on ultrasound scans or during the HSG (see below).
  
• The tubes. We know the tubes are blocked, but the fallopian tube is more than just a hollow pipe. It is a complex organ with different parts performing different roles. The finger-like projections (called fimbriae) located at the end of the tube pick up the egg as it is ovulated from the ovary. The tubes have millions of tiny hairs called cilia that propel the sperm along toward the site of fertilization in the last 1/3 of the tube. The tube also makes nutrients to nurture the developing embryo for several days as it is transported into the uterus. For this reason, it is critical to know just where along the tube the sterilization was done and how much healthy tube remains.

WHAT ARE MY CHANCES THAT I WILL GET PREGNANT AFTER A STERILIZATION REVERSAL?

If the sterilization is reversed, the chances should be 100%, right? We wish it were so for everyone, but it is just not the case. There are many factors that determine success. Some of these are the type and location of the sterilization, other pelvic pathology such as endometriosis, fibroids, your age, whether or not ovulation is regularly occurring, sperm numbers and quality, lifestyle factors such as weight and smoking, and who does the procedure.

Under favorable conditions, the chance of a successful pregnancy should be about 70%. This is the rate that is published in the scientific literature. These rates should apply to women under 35 with regular ovulation who have a partner with normal semen parameters, and whose tube length in both tubes is adequate for the reversal procedure to be successfully performed. In select cases, the success may be slightly higher. Many are not this "perfect candidate" and the success rate may be lower. The rate may drop to 50% or less for some. The factors that determine success are discussed separately below

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Where on the tube was the sterilization performed?

Most sterilization procedures are performed in the middle of the tube (isthmus). At this site, the wall of the tube is relatively muscular. It is in this muscle that the stitches are placed to rejoin the tube. Sterilization near where the tube joins the uterus (the cornua) is less successful for reversal. Sterilization more toward the end of the tube where the tube is larger and more delicate (ampulla) is also less successful. Sterilization performed by removal of the end of the tube, called a fimbriectomy, is sometimes performed and is not reversible. If too much of the tube has been removed, the ends of the tubes are of different size and this makes the reversal more difficult and less successful.

What type of sterilization procedure was performed?

Many sterilizations are performed shortly after delivery, thus called "postpartum sterilization." With postpartum sterilization, the tube is usually tied and a portion removed ("cut and tied"). The tube in pregnancy may be slightly swollen and it is often difficult to know how much of the tube was removed. Since a portion of the tube was removed and sent for evaluation, an idea of how much of the tube was removed can be obtained from a pathology report. In the operation, there is usually a scar around the umbilicus (belly button). A similar procedure for removal of a portion of the tube is sometimes performed at times other than after a pregnancy. Here, a several inch incision is made just above the pubic bone. Once again, it depends on how much of the tube and which part was removed.

Most sterilizations are performed during laparoscopy in a same day surgery procedure. There are a variety of ways that have been utilized.

Electrocautery (burning). A "small" portion of the tube is cauterized (destroyed) using an electric current to burn the tube. This is one of the more frequent techniques used and can be difficult or impossible to reverse in some cases. Some physicians have used the laser to destroy a portion of the tube but the effect should be the same as cautery.

Falope Rings (sometimes called bands). A "knuckle" of the tube is picked up and a small tight plastic ring is placed over it so that the middle portion is obstructed. While the sterilization effect is immediate, with time there will be slow degeneration of the obstructed section of tube, leaving a gap much like the above post partum procedure. Since there is a precise application of the ring, the procedure is usually considered superior to the above techniques for later reversal.

Hulka Clips. There are several types of clips that may be used, but the Hulka clip is the most common in the United States. Some have claimed a higher failure rate of sterilization with clips and this may have limited their universal use. Clips clearly represent the least destructive of all techniques, with excellent pregnancy rates after reversal of sterilization.

The above represent the banding or falope ring technique. Other techniques are performed in the isthmic segment of the tube and involve either removal of a small piece of tube, cautery, banding, or placement of a "clip." Figure B represents the appearance of the tube after healing and is similar regardless of the technique of sterlization employed.

It is very useful to have a copy of the operative report describing the sterilization procedure. Patients often tell their doctors they want to make sure they are "never pregnant again." Some doctors may take this literally. Some doctors are more aggressive than others with the procedure. Remember, sterilization was not meant to be temporary. Again, how much of the tube remains and the location of the sterilization is all-important.

When was the procedure performed?

Success with reversal of male sterilization (vasectomy) is dependent on how long ago the procedure was performed. This seems to be less important in the reversal of female sterilization. Unfortunately, other detrimental processes may have occurred with advancing age, which may reduce fertility. One of the greatest concerns is that the egg supply is constantly dwindling. Most women will lose fertility by age forty and fertility is significantly reduced by age 35. With age also comes an increased risk of endometriosis and fibroids that not only may reduce fertility in general, but also make the reversal procedure more difficult.

What are the alternatives to Surgery?

Who's the best candidate?

It is very important for women over age 35 to have a simple blood test for FSH (follicle stimulating hormone) to measure the underlying ovarian reserve and make sure there are adequate numbers of eggs remaining in the ovaries. Prior to undergoing surgery it is also necessary to assess your partner’s sperm count.

Preparing for pregnancy

Pregnancy should be prepared for by more than a sterilization reversal. There are several interventions that can both improve fertility and increase the chances of a normal healthy child. All women considering pregnancy should start folic acid at a dose of at least 400 mcg daily. Folic acid can reduce certain types of birth defects as well as possibly improving ovarian function. Smoking has been shown to significantly decrease both male and female fertility. While dieting is not encouraged, proper nutrition and regular exercise is. You should talk with your physician about other suggestions.

How is the surgery to reverse sterilization preformed?

The concept of the operation is straightforward. There is a block in the tube or piece of tube missing in the middle portion of the tube. An incision is made on each side just past the blockage and to the place where there is normal and open (patent) tube. The two ends are then brought together using very fine stitches. The most successful procedures are performed under a microscope so that the edges of the tubes can be easily seen and the stitches properly placed. The tube is then tested in the operating room with blue dye to make sure it is open. Most often the procedure is performed through a small incision in the lower abdomen, just below the bikini line. The procedure usually takes between 1-1/2 and 3 hours.

A very small number of surgeons are performing the procedure through the laparoscope. With this approach the recovery time is shorter, but the surgery is generally longer and more expensive. The success is no better and may be less than when the procedure is performed while looking through the microscope.

Who should do the reversal operation?

Sterilization is much easier to perform than to reverse. Many gynecologists and even a few general surgeons will do an occasional procedure. Sterilization reversal however, is not an occasional operation. The key questions become: 1) What specialized training and credentials does the surgeon have in performing this type of surgery? 2) How many years has the surgeon been performing the operation? 3) How many reversals does he/she do each year and 4) What is his/her overall success rate?

What are the risks of surgery? What about recovery time?

Tubal reversal is a major surgery that is usually very safe with a very low complication rate. As with any operation, complications can occur even under the best of circumstances. A partial list of risks/complications includes problems with anesthesia, infections, and bleeding, as well as the very rare potential for damage to other structures such as the bowel, bladder and ureters. It is important that specific risks be discussed with your surgeon in advance. It takes as long as six weeks for complete healing. During the first portion of the recovery activity is usually quite limited. Each individual and each operation is different. Again, this should be discussed with your surgeon.

When can I try? How long will it take?

Usually you can resume intercourse and start trying to conceive after the second period, and in some cases, the first. For the first couple of weeks your abdomen may still be tender from the surgery. The tubes should be sufficiently healed about 4 weeks after the surgery. You may become pregnant in the first month of trying. Most pregnancies are achieved in the first year after the procedure. If only one tube is open, it may take longer.

I'm pregnant- now what?

When you undergo a tubal repair, you also increase your chances of having a tubal pregnancy or pregnancy in the tube. The ectopic pregnancy rate is not very high -- about 10%, but as a precaution, every pregnancy achieved after a sterilization reversal should be considered an ectopic pregnancy until an ultrasound scan shows the pregnancy to be in the uterus.

If you experience a missed or an abnormal period, or any of the signs and symptoms of pregnancy after a tubal repair, then you should contact your physician immediately for a sensitive blood pregnancy test called a quantitative hCG. This test may be repeated at 48 hour intervals to assess the progress of the pregnancy and it is usually necessary to perform an early ultrasound for localization of the gestational sac (the small fluid filled area where the baby is growing.) Pregnancies achieved after sterilization reversals are no different from any other pregnancy. With both, every woman will worry; that is a natural part of being a mom.

What if I am not pregnant?

If a pregnancy is not achieved in the first six months, a consideration should be given to repeating the HSG to see if the tubes are open. This is also a way of flushing the tubes and the procedure itself may improve chances of a pregnancy. The other factors that influence fertility, such as ovulation and sperm quality, should be revisited. Sometimes oral fertility drugs may help. In select cases a laparoscopy to reevaluate the tubes and remove scar tissue that may form from the surgery is recommended if the HSG is normal, but this is not routine and should be carefully considered. Repeat reversal is likely to have much poorer chances than the original procedure. Repeat procedures are highly discouraged. Most who are good candidates for reversal of sterilization are also good candidates for IVF. IVF will bypass tubes that are not properly functioning.

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