Tubal Reversal vs. IVF

2. Male Factor

One of the first things we need to assess before deciding whether a tubal reversal or IVF is your best option, is your partner’s sperm count, even if he has had children with another woman (or with you). If there is a significant decrease in normal sperm number, function or quality, the recommended and necessary treatment would likely be IVF with ICSI (intracytoplasmic sperm injection). In couples where the woman has open tubes and the male partner has a significant issue, IVF is the treatment of choice and very successful.It is not prudent medical practice to have the woman undergo tubal reversal, a potentially risky and expensive surgery, since it will not fix the male issue contributing to the infertility.

3. Age and Reproductive Status of the Woman

With advancing age, there is a significant decrease in pregnancy success rate with either IVF or tubal reversal treatment, and an increase in both the infertility and miscarriage rates due to factors such as decreased egg quality and decreased stimulation ability of the ovaries (commonly known as “ovarian reserve”). In general, some of these changes can occur as early as 5-10 years prior to menopause and in less common cases, beginning as early as the late 20’s or early 30’s. A very important part of the initial evaluation will be to assess your ovarian reserve with blood tests and an ultrasound, both of which will need to be done while you are on your period (cycle days 2, 3, or 4). If we find that your ovarian reserve is declining (indicating a decreased chance of successful pregnancy), we usually would recommend that you undergo more aggressive treatment with IVF since it has been shown to give you the shortest time to pregnancy and best chance for success.

Since natural conception can take some time, even with a very successful tubal reversal, we also would usually recommend that women over age 38 undergo IVF as the treatment of choice and discourage any woman over age 40 from considering tubal reversal surgery. At this age, the longer 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. Occasionally, when we do ovarian reserve testing we discover results that would suggest that regardless of the treatment choice, the chances for successful pregnancy would be less than 5%. In those circumstances we would recommend against either treatment and recommend donor egg IVF versus adoption as having the most realistic chances of conception.

4. Medical Factors

With our years of experience, we have found that women who are overweight have lower success rates with any types of fertility treatment including attempts at tubal reversal. The procedure itself is microsurgical and very delicate in nature. Women who are more than 25% over their ideal body weight often have weight distribution that makes a traditional tubal reversal very difficult. Weight issues may also significantly impact IVF success and increase risks as well. As a result, IVF is only offered to women with a body mass index (BMI) of 32 or less. Therefore, in some cases, we may recommend significant weight loss prior to offering any fertility treatment. Additionally, there are certain gynecologic and/or medical conditions that would make tubal reversal surgery less advisable. As a result, prior to offering either treatment, you will be required to undergo a medical screening process in an effort to identify any issues that may complicate pregnancy or make it more dangerous to get pregnant. If we identify such issues, you may also be required to consult with a high risk OB specialist for preconceptual counseling to ensure that all steps are taken to optimize pregnancy outcome. Rarely, we will recommend against either treatment because of medical issues that make pregnancy or surgery inadvisable.

5. Surgical and Anesthesia Risks

Several risks are associated with any surgical procedure, whether it be tubal reversal surgery or the IVF retrieval.

For tubal reversal surgery, one of the main risks 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. In most circumstances, the surgery usually takes 2-4 hours and involves an open procedure where a 4-6 inch incision is made near the pubic hairline. In some cases, this surgery can be performed through a telescope through the belly button which reduces the time of surgical recovery. In general, the recommended recovery time after surgery ranges from 3 days to 2 weeks. In addition, the waiting time prior to trying to conceive averages 2 to 3 weeks. If pregnancy is not achieved within 6 months after the reversal, it is then recommended that you undergo an X-ray test (Hysterosalpingogram) to confirm that the tubes have remained open. Potential, risks from either open or laparoscopic 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).

During the IVF procedure, the woman undergoes an IVF egg harvesting, 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 anesthesia complication risks.

6. Family Planning

We have to consider your current and future plans in our recommendation for the optimal treatment for you. The ideal candidate for a tubal reversal would be a younger woman who wants more than one additional child, as a tubal reversal will allow you to retain your fertility after the delivery of your next child. Once your childbearing is completed however, you will be again forced to decide whether you want yet another surgery to perform a tubal sterilization procedure, or whether another form of contraception is preferable. In contrast, when undergoing IVF, the tubes remain blocked, so there is no additional contraception needed.

Another consideration for couples that may already have children is a potential desire to have another child of a particular gender in order to create a balance of genders within the family. This process is called family balancing or gender selection and can be successfully accomplished through the use ofIVF with additional testing termed Pre-implantation Genetic Screening. Utilizing this process, one can virtually guarantee having a child of the preferred gender assuming they are successful with the IVF process.

8.  Success Rates

One of the most critical factors affecting success rates with tubal reversals is the method of tubal sterilization used, as mentioned above. 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 / electrocautery (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.

The success of reversal surgery also depends on the length of remaining tube after tubal sterilization procedure and where the tubal interruption was originally performed (at the beginning versus the end of the tubes). Much of the medical literature supports that a minimum remaining tubal length after the reversal greater than 3.5 cm is necessary in order to achieve and sustain a pregnancy. For reference, the tube is ordinarily about 8-10 cm in length. Longer tubes after reversal 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. This is why more destructive tubal ligations are associated with lower chances of success with the tubal reversal options in comparison to undergoing IVF.

We 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 our own internal IVF pregnancy success rates between 2007 and 2010 range between 60% to as high as 77%. (Please see Success Rates section of website for detailed information). Therefore, if you choose to undergo IVF instead of a tubal reversal with us, know that you will be receiving world class care and will have as good a chance of conceiving there is.

Summary Overview

As with any medical procedure, IVF and tubal reversals both have pros and cons, or risks and benefits that need to be considered (this is not an exhaustive discussion of the risks and benefits of each, just an overview).

Tubal Reversal

Pros: Tubal reversals afford couples multiple opportunities to get pregnant. There are no increased risks of having a multiple pregnancy (twins or more). For many couples, this feels like a more “natural” approach to conception.

Cons: The risk of having a tubal or ectopic pregnancy after tubal surgery is as high as 15-20%. This will likely result in the need for yet another surgery and can be a potentially life-threatening situation. The tubal reversal itself is longer and associated with a higher incidence of complications than IVF. Occasionally, you will undergo the surgery only to have us find at the time of surgery that it is not possible to reverse one or both tubes. In addition, you may end up needing to do IVF anyway if tubes re-occlude after surgery or if you experience infertility even if your tubes remain open.

In Vitro Fertilization

Pros: IVF is the best treatment available for couples who are infertile, and the time to successful pregnancy is often faster. The surgical procedure to harvest the eggs is done under IV sedation instead of general anesthesia. There is no need for contraception decisions once childbearing is completed.

Cons: IVF is an involved procedure that takes several weeks from start to finish. Depending on the number of embryos transferred, the risk of having multiples ranges from 3-4% to as high as 35% for twins. Multiple pregnancies have higher risks such as preterm labor and delivery, pregnancy complications, cesarean section, pregnancy loss, etc.