Tubal Reversal vs. IVF- Which is More Effective?
Tubal reversal surgery or IVF are often used to reverse a previous tubal ligation. Tubal ligation is one of the most popular forms of birth
control for married couples who believe that they have
completed their families. Regretfully, approximately 3-5% of
patients subsequently regret their decision to undergo permanent
sterilization. Our Utah fertility center offers both tubal reversal surgery or IVF for appropriately selected patients.
Tubal reversal surgery is sought more commonly when the tubal ligation was
performed prior to the age of 30. About 50% of the time, the
reason for the desire for more children is due to loss of the
first spouse or divorce and subsequent marriage to a new
partner. Often the new husband does not have any children or the
couple wants to have children together.
In normal physiology, once the eggs are released (ovulated) from the ovarian follicles they must be picked up by the fimbriated end of the fallopian tubes. The fimbria are fingerlike projections that assist in collection of the egg.
As the egg starts to travel down the fallopian tube, fertilization occurs. The embryo remains in the tube for several days prior to reaching the uterus. Any
method that blocks the fallopian tube inhibits this passage
and prevents pregnancy. Oftentimes, the blockage can be seen with the HSG examination.
Tubal reversal surgery success depends upon numerous factors including how the tubes were "tied". Tubal ligation or sterilization is performed using several common methods. These include laparoscopic methods to burn
(cautery), clip (Hulka or Filshie clip), cut and remove a
section of fallopian tube, band (Falope Ring - small thick
rubber band that strangulates the tissue), removal of the distal
end of the tube (Krohner fimbriectomy), or complete removal of
the fallopian tube (salpingectomy).
In addition the most common
method used during mini-laparotomy immediately after delivery or at the
time of cesarean section is a partial salpingectomy (removal of
a small portion of the tube often with associated burning of the
ends of the tube). All of these methods result in blockage of
the fallopian tube that does not allow transport of the egg.
Our Utah fertility clinic treats many women seeking tubal reversal procedures.
In the 1980's and 1990's surgical treatment to reconnect the
fallopian tubes (tubal reversal surgery) was commonly performed. Tubal reversal surgery was a covered procedure while Dr. Blauer was in the US Air Force and
patients flew from all over the world to have their surgery
performed by him at Wright Patterson Air Force Base where he was
assigned from 1989-1993. One or two tubal reversal surgeries per week were performed by Dr. Blauer during these years. Tubal reversal surgery was performed using a minilaparotomy
and microsurgical techniques. Success rates per cycle for IVF at our Utah clinic usually exceed tubal reversal surgery.
Tubal reversal success depends on several
factors including the type of surgery that was initially
performed to block the tubes, the length of remaining tube, the
age and health of the woman and the quality of the husband's
sperm. In optimal conditions, in women under 35, pregnancy rates
up to 65-70% within 2 years of the tubal reversal can be achieved.
More commonly pregnancy rates of about 50% are achieved.
Tubal reversal surgery was once primarily a procedure done as an inpatient
with a mini-laparotomy that required 3-4 hours of surgery, 2-3
days of hospitalization, and a 4-6 week recovery period prior to
returning to work. Using more modern techniques some fertility centers now
do tubal reversal as an outpatient procedure often using laparoscopy which decreases
the hospital stay and minimizes the recovery period. Tubal
reversal often costs more than $10,000 not including any lost
time from work. Performing tubal reversal procedures on an outpatient
basis reduces cost.
Tubal reversal surgery may be a reasonable option especially for younger women, although the per cycle success rates for IVF are higher. The number of times a younger couple can have intercourse to attempt pregnancy is virtually unlimited. For example, if they are having regular intercourse, they are attempting a “natural cycle pregnancy” each month. IVF cycles are relatively expensive and the total number is often limited by cost. Some couples may only be able to attempt one of two IVF cycles with the pregnancy rate varying according to many patient specific variables. Their overall cumulative chance for pregnancy may be similar after surgery and 2-3 years of intercourse compared to one IVF cycle. This is highly dependent upon several “couple specific” variables.
In the 1990's as IVF pregnancy rates improved and after appropriate counseling regarding the IVF option, fewer patients opted for surgical tubal reversal but instead utilize IVF. The advantages of IVF over tubal reversal surgery usually include:
- Higher pregnancy rate per cycle - >50% for IVF
compared to 5-10%/cycle after tubal reversal
- Lower risk of ectopic pregnancy in the fallopian tube -
1-2% risk after IVF
compared to 8-15% after tubal reversal surgery.
- Similar or lower cost for IVF compared to tubal reversal surgery.
- Less time off work with IVF
compared to the usual post operative recovery for tubal
reversal.
- Tubal sterilization is still affective after IVF
for contraception if no additional children are desired
- Quicker time to conception and delivery after IVF
which can be critical for the women who is over the age of
35 and who may have rapidly decreasing ovarian reserve
Tubal reversal is employed but in most cases, in vitro fertilization (IVF) is now the ‘treatment of first choice”
after tubal ligation. Using IVF, the eggs are retrieved directly from the ovaries and combined with sperm in the lab, thus eliminating the need for fallopian tube transport.
In general, numerous studies demonstrate that pregnancy success per cycle is higher using IVF
than tubal reversal surgery. In our opinion, women should consult with a reproductive endocrinologist/ fertility specialist
to discuss whether tubal reversal surgery or IVF is the best option in their specific cases. It it helpful
to have a copy of the operative notes regarding the tubal
ligation for review at the time of the consult.
Infertility Causes
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