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  » Infertility  »  Problems of the uterus and uterine lining that can cause or contribute to reproductive problems such as infertility or recurrent miscarriage:

Tubal reversal surgery and in vitro fertilization IVF after tubal ligation

Women who have had tubal ligations sometimes regret their decision and want to have children in the future. There are 2 options, tubal reversal surgery and in vitro fertilization - IVF. Both of these are reasonable options and how the woman chooses to proceed should be based on an educated consideration of the pros and cons of each.

Most women have their tubes tied before they leave the hospital after they deliver, or they come in for tubal ligation by laparoscopy which is an outpatient surgical procedure done through a scope that goes through the belly button.

Tubal reversal surgery requires a laparotomy which is a much larger incision on the abdomen usually approximately 4 to 6 inches in length. Since the skin and all the muscles and other tissues of the abdominal wall must be cut through there is considerably more discomfort and a much longer recovery time following the surgery as compared to a laparoscopic surgery such as tubal ligation.

Some surgeons are now performing tubal reversal surgeries through the laparoscope. However, this is a relatively difficult technique and there is not yet sufficient published data to support that pregnancy rates will be equal to those following the traditional laparotomy. Most women will need to be in the hospital for approximately 3 days following tubal reversal surgery and will need to be off work for a minimum of 2 to 3 weeks.

There are 5 important issues regarding tubal reversal surgery that need to be considered and discussed. The sperm quality of the male partner, tubal status, status of other possible pelvic conditions, female age, and egg quantity and quality.

Sperm quality

The male partner needs a sperm test prior to decision making about tubal reversal vs. IVF after tubal ligation. If the sperm quality is good, then the couple could possibly consider both options. If the sperm quality is poor, IVF is the better option. This is because pregnancy rates are low without using IVF if there is poor sperm quality (low sperm count or motility). With IVF with ICSI, poor sperm quality is easily overcome.

Tubal status

The length of the remaining tubal stumps after tubal ligation (or cauterization if the tubes were burned instead of tied or clipped)

Delicate fimbria (F) at end of tube (T), is close to ovary so it can pick up the egg

is very important. The longer the 2 remaining stumps are on each side the better the chances for successful reversal and pregnancy. The shorter the stumps the lower are the chances for pregnancy. Unfortunately, it can not be known how much tube is remaining for certain without surgery. A hysterosalpingogram (dye test in radiology) can tell us how long the proximal stump is (the piece of tube attached to the uterus) but the dye test will not tell us anything about the length of the distal stump (the far end of the tube that has been separated from the uterus). Some women go through tubal reversal surgery with very short tubes. This results in low chances for subsequent pregnancy.

The fimbria are delicate, fluffy structures at the end of the tube that "pick up" the egg when it is released from the ovary at the time of ovulation. If the fimbriated end of the tube is damaged or has been removed, chances for success with reversal are low.

If both portions of fallopian tube are significant long (sometimes they are quite short) , the fimbria are in good condition, and the surgery is done expertly, the expected pregnancy rate in young women (under 35) without other fertility problems (husband also has good sperm quality) should be about 75%. This means that after 1 year of trying 75% of women should be able to get pregnant if the tubal anatomy was good and these other factors are all normal. If any of these factors are abnormal, expected pregnancy rates after tubal reversal would be significantly lower.