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  » Infertility  »  Uterine Fibroids, Myoma or Leiomyoma

Pelvic endometriosis or any scar tissue in the area of the tubes or ovaries would be expected to reduce the chances for success after tubal reversal surgery. However, IVF pregnancy rates are generally not affected by these conditions. Therefore, IVF is probably a better option in women with significant endometriosis or pelvic scar tissue.

Female age

Chances for pregnancy with either tubal reversal or IVF decline in the mid to late 30's and more dramatically starting at about age 38. By age 43-44, very few women will be able to have a baby using either approach. This issue makes careful and honest counseling very important for women between about 35 to 43 years of age. I would discourage women 43 and older from pursuing either option because of the dismal success rates at that age and beyond. Egg donation is a more viable option in that scenario.

Egg quantity and quality

Some women have a decline in either egg quantity or quality earlier in life than expected. Therefore, the woman's " ovarian reserve" should be tested before a decision is made regarding whether to proceed with either tubal reversal or IVF.

Tubal reversal surgery

The biggest advantage of tubal reversal surgery over IVF is that once the women has gone through the surgery she hopefully will not need any intervention through a physician such as drugs, medications or procedures in order to get pregnancy. Obviously, the idea is that good old fashion sex will then give them the baby that they want. There is also very low risk for multiple pregnancy - twins occur naturally in only 1 in 90 pregnancies. The biggest disadvantage is the fact that the women has to go through a big surgery and if pregnancy does not result after the tubal reversal her only option remaining is IVF. A small disadvantage is that after she has her additional children, she will need to use contraception or have her tubes (or her husband’s) tied again.

In vitro fertilization - IVF

In vitro fertilization involves stimulating the woman with medications, taking a number of eggs from her ovaries, fertilizing them with her husbands sperm and transferring some of the resulting embryos back into her uterus with the hope that one will implant. There is detailed information elsewhere on this site about in vitro fertilization.

The biggest advantage of IVF is that the woman avoids the tubal reversal surgery. Another advantage is that the outcome is known 10 days after the procedure when we do the first pregnancy test rather then waiting for a year or more to find out whether the procedure is successful. Success rates with IVF vary greatly according to the program. Some IVF programs have pregnancy rates with tubal factor infertility of over 50% per attempt in women under 40 years old. Other programs with the same type of patients report pregnancy rates of only 20 to 30% (or sometimes less). The reason for this is that some IVF programs are better than others. This is why the couple should do some careful comparisons before choosing an IVF program.

The biggest disadvantages of IVF are that the woman has to take medications to stimulate development of multiple eggs and that there is always some risk for multiple pregnancy - although this can be controlled by limiting the numbers of embryos transferred to 2 (or 3). Another disadvantage is that if the first attempt does not work the couple must try again and unless there were left over embryos that were frozen the cost for the repeat cycle would be the same as the initial cycle.

 

What's involved

Expected pregnancy rate

Tubal pregnancy rate

Reconnect tubes after tubal ligation

Major surgery, large incision, hospitalization, 2-6 weeks recovery time

Up to 75% over 1-2 years

4-15% of pregnancies

IVF after tubal ligation

Shots for 2-3 weeks
Egg retrieval
Embryo transfer

60-70% for one cycle
(at our center, age under 35)

Our IVF Rates

1% of pregnancies
(or less)

Women that have had tubal ligations often ask me: "What is the best way for me to have another baby, should I do IVF or should I have the tubal reversal surgery?"

I do not believe that there is a best way. The best way to try to have another baby for an individual woman is up to her. She needs to be counseled regarding the pros and cons of both of these approaches and then consider the risks and benefits and costs of each.

If we had a crystal ball that would tell us what, if anything,  would get the couple a baby it would be easy to decide. If anyone has  such a crystal ball for sale, please call me immediately...

For more information about details regarding tubal reversal surgery and IVF, there are many other pages on this website related to both tubal surgery and in vitro fertilization.

Vasectomy reversal vs. sperm aspiration from the vas deferens or testicle

Many men have had a vasectomy for contraception and then later have gotten remarried and regretted the decision to become surgically sterilized. There are 3 general options for attempts at further child bearing in such a situation.

1. Vasectomy reversal surgery

2. Sperm aspiration from the testicle or vas deferens and then in vitro fertilization using the wife’s eggs

3. Donor sperm insemination of the wife

Vasectomy reversal surgery

Vasectomy reversal surgery is more successful if the period of time since the vasectomy has been less than 10 years. At about 10 years out there is a substantial drop in the subsequent pregnancy rates. Therefore, it is not recommended that vasectomy reversal be done when the intervening time has been 10 years or more.

Vasectomy reversal surgery is usually very expensive and is not covered by insurance. This procedure is done by a Urologist. The total cost to the couple from what we have heard from patients that have undergone the procedure is approximately $10,000 to $15,000 including the surgeon and the hospital fees. The obvious advantage to vasectomy reversal surgery is that if it is successful the couple can conceive further children without medical assistance. Disadvantages include the high cost and the fact that if the surgery is not successful the couple is faced with the other 2 options (above) without having improved their fertility at all.

Sometimes couples have a concern regarding future birth control after vasectomy reversal surgery. For example, if they want only 1 more child - once they are successful there will be a need for further birth control or further surgical sterilization. This issues applies to both vasectomy reversals and tubal reversal surgery for the women.

Sperm aspiration from the vas deferens or testicle

Sperm can be aspirated with a needle from the testicle or from the vas deferens (the tube that carries the sperm from the testicle). The man is given some drugs to sedate him and some local anesthesia is also used to numb the area. Then a small needle is inserted and sperm is aspirated. There should be no severe pain. The procedure generally takes about 30 minutes.

Usually millions of sperm are obtained which are of sufficient quantity and quality to use to fertilize the wife’s eggs in the laboratory using in vitro fertilization - IVF. Unfortunately, there is not enough sperm obtained to make is reasonable to proceed with insemination of the wife. Therefore, the woman will have to go through ovarian stimulation and in vitro fertilization in order to have a chance to get pregnant using this sperm. Usually, a special procedure is performed that involves injection of each individual egg with a single sperm using specialized tools and microscopes. This is called intracytoplasmic sperm injection, or ICSI.

ICSI in progress
ICSI needle in inside egg, sperm is being injected
Holding pipette at the far left holds the egg steady

The sperm can be used fresh if it is obtained on the same day that the eggs are obtained from the woman, or it can be frozen and then thawed and used later. Usually enough sperm is aspirated so that it can be split up into several vials and multiple attempts of IVF can be performed if that will be necessary.

The sperm aspiration procedure is performed by a urologist or a reproductive endocrinologist (infertility specialist).

The cost for the procedure depends on several factors including the surgical fees of the physician, charges for sperm freezing, facility fees and anesthesia fees. If it is performed in a hospital or surgicenter, the costs are generally higher than if it is performed in an office setting. The total cost of a sperm aspiration including freezing will generally be somewhere between $1000 and $5000 - depending on the variables mentioned above.

Donor sperm insemination

This is a fairly simple process in which the couple chooses a donor from a major sperm bank, of which there are several, and the frozen donor sperm is thawed and placed into the uterus at the time of her ovulation. This process is described in more detail on the donor insemination page .

So which option is the best?

For many couples with a relatively young female partner and a relatively shorter time since the vasectomy has been performed, vasectomy reversal surgery is probably the best initial option.

If the female partner is close to 40 years of age, it is my opinion that there should always be some evaluation of the fertility status of the female before proceeding with either reversal surgery or sperm aspiration. This female evaluation would be best done by a Reproductive Endocrinology and Infertility specialist. In this age group, the best option may be sperm aspiration and IVF.

If a vasectomy reversal has been performed and it has not been successful, a second surgery is of low yield and should be avoided. Sperm aspiration and IVF will be the best option in this scenario, unless the couple prefers donor insemination.

Couples should be fully informed of the pros and cons of these approaches prior to making their decision. In many cases it is advisable to consult with both a Reproductive Endocrinologist and an Urologist before making the final decision. Most Urologists are not well versed in discussing the options of IVF since that is not part of their training or professional skills. The reproductive endocrinologist does not perform vasectomy reversals and therefore is not the best expert to discuss the details of that option.