Treatment Options
Tubal Reversal vs IVF
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As a practice specializing in infertility, we receive many calls from couples in which the woman has previously undergone a tubal sterilization procedure. Many of these couples are interested in undergoing a tubal reversal procedure in which the tubes are reanastomosed or put back together in order to achieve pregnancy. We believe that after considering the risks and benefits, most women are better off both medically and financially opting for in-vitro fertilization (IVF). Based off of this belief, Advanced Fertility Care no longer offers tubal reversal services.
IVF is a fertility treatment in which a woman's ovaries are stimulated with medication to maximize the number of eggs produced per cycle; these eggs are then extracted through a minor surgical procedure, fertilized with sperm in the laboratory, and these embryos (usually no more than 2-3) are transferred into the woman's uterus. The fallopian tubes are bypassed in this process and the previous issue of the tubal sterilization is avoided.
With the improvement of skill and technology in the field of assisted reproductive technology, the success rates with IVF have soared to record highs over the last several years. These success rates differ from one fertility center to another and are dependent on multiple factors including the patient population, physician skill and diligence, expertise of the embryologist, and quality of the embryology laboratory. We at Advanced Fertility Care are proud to boast one of the highest IVF success rates in the state as well as the country. Our clinical pregnancy rates per embryo transfer vary by age group, but in 2007 ranged from 62.3% to as high as 76.9%. (Please see Success Rates section of website for detailed information).
When considering these success rates in comparison to potential success rates for tubal reversal, minimal if any differences in cost, and much higher risks with tubal reversal, it is our physician's opinion that IVF is the medical procedure of choice in almost all cases.
For those couples who have either religious or other non-medical based reasons to prefer tubal reversal over IVF, we recommend they seek care at a larger tubal reversal center of excellence that focuses solely on tubal reversals.
We recommend IVF over tubal reversal for most women for the following 7 reasons:
1. Age and Reproductive Status of the Woman
Prior to having any tubal reversal procedure, a woman's reproductive potential should be carefully scrutinized by the Ob/Gyn or reproductive surgeon planning on performing the surgery, PRIOR to undergoing the surgery. With advancing age, there is a significant decrease in pregnancy success rate, and increase in both the infertility and miscarriage rates due to factors such as decreased egg quality and stimulation ability of the ovaries (Òovarian reserveÓ). In general, some of these changes can occur as early as 5-10 years prior to menopause and in rare cases, beginning in the late 20's to early 30's. Since natural conception can take some time, even with a very successful tubal reversal, the longer the time spent waiting for surgical recovery and natural conception can cause a significant decrease in a woman's ovarian reserve and further decrease the odds of becoming pregnant.
2. Ectopic and Miscarriage Risk
In general, the chance of tubal pregnancy (ectopic pregnancy) is 5% after even a successful tubal reversal. This is 2-5 times higher than the general population risk of ectopic of 1-2.5%. Some actual data from large tubal reversal centers actually show that this life-threatening risk may even be significantly higher, with 9% of pregnancies resulting in ectopics for those with sterilization performed with clip/ring method and as high as 19% for those who initially had their tubes burned. This increased risk may likely stem from the non-visible injury occurring to the tubes which is most severe when electrical burning of the tubes is performed.
Unfortunately, one of the most common forms of tubal sterilization is fulguration (burning) which uses electrical burns to destroy the tubes. It is well described that in addition to the portion of the tube that is burned, there may be a portion of visibly normal tube adjacent to the area of the burn that may have had some damage as well. If this area is not removed at the time of the tubal reversal, this may also increase the risk of ectopic pregnancy. In contrast, the risk of ectopic pregnancy with IVF is no greater than that of normal conception.
3. Pregnancy Success Rates
To determine success rates after tubal reversal based on age, we looked at data from some of the most successful tubal reversal centers* in the country and the highest pregnancy rate reported was approximately 55% in women under age 30. That number dropped to as low as 40% in women over age 40. In addition, miscarriage rates were reported on average to be 36% across all age groups with the highest rate of miscarriage after tubal reversal occurring in the 40+ year old category which was 45%. We at Advanced Fertility Care are proud to boast one of the highest IVF success rates in the state as well as the country. Our clinical pregnancy rates per embryo transfer vary by age group, but in 2007 ranged from 62.3% to as high as 76.9%. (Please see Success Rates section of website for detailed information).
The success of reversal surgery depends on factors such as the length of remaining tube after tubal sterilization procedure. Much of the medical literature supports that a minimum remaining tubal length greater than 3.5 cm is necessary in order to achieve and sustain a pregnancy, since tubes that are 3.5 cm can dramatically increase the miscarriage rate. Longer tubes were associated with better pregnancy outcomes than shorter tubes and miscarriage rates/ectopic rates increased with shorter tubal lengths. In a large study of over 2500 patients conducted by one of the larger surgical centers, tubal lengths less than 4.9 only resulted in a 32% ongoing pregnancy rate.
One of the other critical factors affecting success rates with tubal reversals is the method of tubal sterilization used. Data from institutions that perform many tubal reversals annually reveal that pregnancy outcomes after tubal ligation by clip/ring showed the highest ongoing pregnancy rate of 60%, while most of the pregnancy rates for other forms of sterilization such as fulgaration (burning), tying, or cutting only had ongoing birth rates between 44%-49% with miscarriage rates in the 31%-36% and ectopic pregnancy rates ranging between 9% for clip/ring and as high as 19% for those who had initially had their tubes burned.
4. Surgical and Anesthesia Risks
Several risks are associated with tubal reversal surgery. The first risk is that the surgery is not successful and the tubes remain blocked. This can occur immediately after surgery during the healing time or any period of time after surgery. There appears to be approximately a 2% risk for one tube and 0.5% risk for both tubes to become scarred over and closed.
A second risk is that from surgery itself. The surgery usually takes 2-4 hours and involves an open procedure where a 4-6 inch incision is made near the pubic hairline. Potential, risks from open surgery include scar formation, bleeding, bladder or bowel injury, and infection. Furthermore, general intubated (ventilator) anesthesia is used during these types of cases, increasing the risks of anesthesia related complications over lesser types of anesthetics such as those used during the course of the IVF egg harvesting (eg. intravenous sedation). In many centers, patients are required to have at least an over night stay for recovery in the hospital. In general, the recommended recovery time prior to trying to conceive can range from 4-8 weeks post surgery.
During the IVF procedure, the woman undergoes a minor surgical procedure in the office setting in which an ultrasound guided needle is passed through the vaginal wall into the ovaries in order to withdraw the eggs from the ovaries. Risks to this procedure are extremely rare and may include injury to bladder, bowel, bleeding, and infection. The procedure itself lasts approximately fifteen minutes and recovery time ranges from 30 minutes to 1 hour post procedure, after which the patient is sent home. Most women can return to normal activity the very next day. In contrast to general anesthesia used in tubal reversals, intravenous sedation is used and the woman continuously breathes on her own during the entire procedure without the assistance of a ventilator. Foregoing the use of general inhaled anesthetics greatly reduces the anesthesia complication rate.
5. Male Factor
This is another critical factor that should be investigated prior to undergoing a tubal reversal procedure. If there is a significant decrease in normal sperm number, function or quality, the recommended treatment would likely involve assisted reproductive technologies such as IVF, in which the tubes are bypassed in the process of achieving pregnancy anyway. Therefore, having the woman undergo a surgical tubal reversal would not be optimal and would increase potential risks needlessly.
6. Future contraception
Undergoing tubal reversal also raises the issue of future contraception once again after childbearing is completed. This potentially could necessitate another surgery in order to once again perform tubal sterilization if that is the preferred method of the woman. In contrast, when undergoing IVF, the tubes remain blocked, so there is no additional contraception needed.
7. Cost
Costs for tubal reversals vary nationwide between physicians and surgical centers. On average, the cost of a tubal reversal by a experienced surgeon can range between $6000-$20,000 depending on physician professional fees and facility/hospital fees. In comparison, IVF costs can range anywhere from $10,000-$25,000 and include options for multiple cycle package plans, and in some circumstances, money-back guarantees.
In many cases, after an initial fresh IVF cycle, there may be enough embryos for a woman to freeze, which would then allow for additional attempts at IVF for greatly reduced costs ($2500-$3500 per attempt) if the initial attempt is unsuccessful or if a couple wishes to have more than one child.
