 |
Tubal Reversal |
|
Tubal Reversal |
INTRODUCTION
Many women and/or men seek "permanent" sterilization as a method of birth control when they believe they wish not to have children in the future. This can take the form of a fallopian tube ligation (tubal) in the female or a vas deferens ligation in the male. Some of these men and women subsequently change their minds and wish to have the "permanent" sterilization reversed. Fortunately, the surgical blockage can be removed in most cases of ligation in either the male or female. If no other factor has occurred that would prevent conception, then this "reversal" will usually result in conception. In women this is usually the case and pregnancy can be achieved in up to 90% of reversals depending on the type of ligation that was originally performed. In men, unfortunately, this is not always the case.
BILATERAL TUBAL LIGATION
There are many types and methods of performing bilateral tubal ligation. The determining factors in the potential for anastomosis (putting the tube back together) are the part of the tube that has been destroyed and the amount of the tube destroyed (Figure 1
— shows a normal fallopian tube and defines each part of the tube}. Each type and method of ligation has a different impact on the tube and, therefore, has its own prognosis for anastomosis. Dr. Daly will review the operative note of the tubal ligation and give you an approximation of the potential for pregnancy after anastomosis. The following is intended to give you a guide to the types of ligations and the prognosis after anastomosis for each type (refer to Figure 1 for the anatomic landmarks mentioned).
85%, it may also be less than 50% if a large portion of the tube has been destroyed. In this case, IVF should be considered as an option.1) Post partum tubal ligation is usually done within 48 hours after delivery through an incision just below the umbilicus (belly button). The ligation is usually performed at or near the isthmic ampullary junction of the tube and removes 2-3 cm. of tube. The prognosis for pregnancy with anastomosis is 75-85%. Ligation at Cesarean Section is much like the post partum tubal ligation and has a similar prognosis.
2) Laparoscopic tubal ligation can be performed by several methods. Each of these techniques has its own prognosis for pregnancy:
a) Hulka Clips are usually applied in the isthmic portion of the tube or at the isthmic ampullary junction. Very little tube is destroyed and the prognosis is very good: 85-90%.
b) Fallopian Rings are applied in the same region but destroy more of the tube and frequently involve the isthmic ampullary junction. Therefore, the prognosis is not quite as good: 80-85%.
c) Unipolar cautery was very common in the 1970’s and early 1980’s but is now less commonly used. The fallopian tube is actually burned and destroyed in the areas in contact with the unipolar cautery. Often the burn is more extensive than the gynecologist appreciated at the time of the procedure. Since some gynecologists thought that burning more of the tube would make the ligation less likely to fail, there may be very limited tube remaining for anastomosis. Reversal of this type of ligation has the highest risk for subsequent ectopic pregnancy of all tubal anastomosis procedures. This is particularly true if the damaged portion of the tubes are not completely removed at the anastomosis site. Since completing his fellowship, Dr. Daly has had ten years experience in performing anastomosis and takes special care to avoid placing patients at significant risk for an ectopic pregnancy in this situation. The prognosis for pregnancy may be as high as 80%. However, if much of the tube has been destroyed, the prognosis may be less than 50%. In this case, in vitro fertilization (IVF) may be a better option for the couple.
d) Bipolar cautery is more selective in tissue destruction and usually has a better prognosis than unipolar cautery with less risk of ectopic. Again, some gynecologists believed that using the bipolar cautery at multiple sites on the fallopian tube was more effective in preventing ligation failures, so much of the tube may be damaged. Therefore, while the prognosis can be as high as
3) Fimbriectomy (complete removal of the ovarian end of the fallopian tube) procedures are generally not correctable. Fortunately, these are also relatively uncommon. In some situations, enough of the ampullary portion of the tube is left so that a new opening (neosalpingostomy) can be made. This can be done through the laparoscope (without a big incision) but at best has a prognosis of 40-50%. Therefore, IVF is usually a better choice for the couple than attempting a reversal of a fimbriectomy.
Other factors can affect prognosis as well. Any history of tubal disease or ectopic pregnancy is a strong contra-indication to the procedure. The husband should have a normal semen analysis. This is particularly important when he is not the father of pre-ligation pregnancies. The woman should have a normal ovulatory pattern as demonstrated by temperature charting and no evidence of damage to the uterus or the opening of the tubes into the uterus. All of the these factors can and will be checked at Grand Rapids Fertility prior to planning for the anastomosis surgery.
WOMEN- CONSIDERING A TUBAL ANASTOMOSIS
Initial Visit: The first step is an initial visit with the physician. At this time, Dr. Daly will review the medical history and records, particularly the operative note from the tubal ligation. Ideally, a semen analysis can be done on the same day to assess the man’s sperm production. If the cycle of temperature charting has been performed by the patient prior to her initial visit, a very good assessment can be made for the prospect for reversal along with a recommendation.
Second Visit: At the second visit, a review of the temperature charts and semen analysis is carried out (if not done at the initial visit). An office hysteroscopy is performed to be sure the uterus is normal and the opening of the tubes do not show any damage. If everything is normal at this time and the couple chooses to proceed with surgery, it can be scheduled at this visit.
Surgery: At surgery, a laparoscopy is first carried out to be sure that an adequate portion of tube is available for anastomosis. If this is present, Dr. Daly would continue with the procedure and perform the anastomosis at laparotomy. Generally, patients are kept overnight and discharged within 23 hours of their procedure.
The cost of pre-operative counseling and screening is between $400-600, depending on the testing that may be indicated.
The cost of the surgery for tubal anastomosis is estimated as
follows:-
Surgeon’s fee: $2400.-
Anesthesiologist physician fee: $1700, depending on the length of the surgery.-
Estimated hospital charges with discharge the next day (will vary with length of the surgery) $5600 - $7000. If a longer stay is necessary the hospital will charge the patient a daily fee for each additional day.The total estimated cost, therefore, is $9700 or more. The surgeon’s fee is pre-paid in our office prior to the surgery. The hospital now requires prepayment the day of surgery also.
MEN- CONSIDERING VAS LIGATION REVERSAL
In general, restoring patency of the vas deferens can be accomplished and sperm obtained in the ejaculate. However, the longer duration of the ligation, the poorer the prognosis for pregnancy. This is due to two factors. First and less important, the ligation may gradually decrease the number of sperm the testes can produce, perhaps as a result of a back-up caused by the ligation. Second and more important, the male may gradually produce antibodies against his own sperm that can either damage the sperm or prevent them from reaching or fertilizing the egg. Normally, there is a barrier between the male’s immunologic defenses and the sperm. This keeps his immunologic defenses from "seeing" the sperm and reacting against them. When the vas ligation is done, this barrier is broken and gradually his defenses see the sperm and respond by making antibodies. These antibodies attach to the sperm. They may damage the sperm so they lose their motility. If the sperm are motile, they still cannot get into the woman’s body to the egg because her defenses are made to keep anything with an antibody on it out of her womb. However, as long as the antibodies are not on a certain part of the head of the sperm, the sperm can fertilize the egg if they can reach one. It is, therefore, possible to help some couples with sperm antibodies to achieve pregnancy with assisted reproductive technology procedures that combine eggs and sperm in the same location. In general, men with a ligation of less than five years will not have a major antibody problem. With more than ten years, most, but not all, will have antibodies. Between five and ten years antibodies may or may not be present.
Is there any way to find out about
antibodies before doing the reversal?Yes. A blood test can be done to determine whether antibodies to sperm are present in the male. Further, if antibodies are present, this test, called an indirect immunobeads test, will tell where the antibodies are located: at the head of the sperm, at the mid-section, or at the tail. This will allow the couple to be completely counseled on the probability of the success of the vas reversal and what else may need to be done to help them conceive a child after the reversal has been performed. While this test is not infallible, it can be very useful for the couple before deciding on what course to pursue. By having this information, they will know whether the vas reversal alone is likely to be successful or whether additional assisted reproductive technology procedures such as IVF or GIFT may ultimately be necessary for conception to occur.
GRAND RAPIDS
FERTILITY& IVF, P.C.1900 Wealthy Street, SE Suite 315
695-5941
Grand Rapids, Michigan 49506
Tel: (616)774-2030 Fax: (616)774-2053
Toll Free 1 (800)Douglas C. Daly, M.D.
Board-Certified Reproductive Endocrinology/ Infertility Board-Certified Obstetrics/ Gynecology
|
||