Tubal Ligation Reversal Surgery

Understanding modern tubal surgery The history of tubal ligation reversal

Microsurgical tubotubal anastomosis (tubal ligation reversal) is successful at restoring natural fertility. The main advantage of microsurgical tubotubal anastomosis is the procedure allows women the ability to become naturally pregnant without having to rely on cycle dependent treatment for conception.

Although the perception among health care providers is tubal ligation reversal is neither successful nor effective for treatment of secondary infertility, the reality is tubal reversal surgery can be very successful at allowing natural conception and pregnancy.

Most health care providers are unaware the American Society for Reproductive Medicine (ASRM) has consistently recommended and supported tubotubal anastomosis as an effective treatment for tubal sterilization¹. ASRM has consistently supported sterilization reversal as an alternative to in-vitro fertilization (IVF). In committee opinion they have consistently concluded:

• Tubal anastomosis for reversal of tubal sterilization has a significantly higher cumulative pregnancy rate than IVF, and it is more cost efficient, even in women 40 years of age or older.
•  Tubal anastomosis for reversal of tubal sterilization has a significantly higher cumulative pregnancy rate than IVF, and it is more cost efficient, even in women 40 years of age or older.

To better understand the current status of tubal ligation reversal surgery as an infertility treatment and as a successful alternative to in-vitro fertilization (IVF), it is important to understand the history and evolution of these treatments. When one understands the evolution of the two infertility treatments then it is easier to understand how tubal ligation reversal has become undervalued in the eyes of most health care providers.

History of Tubal Ligation Reversal

Reconstructive tubal surgery was performed with limited success as early as the late 1800’s². The first initial reports appeared in European medical journals. As was customary at the time, these reports were limited to minimal descriptive paragraphs, were sporadic, and the success of the treatment was always in question.  A search of PubMed reveals the first indexed published articles about tubal surgery begin to appear in British medical journals in the mid 1950’s³. The first articles on tubal repair surgery reported on the success of ‘tubal plastic operations’ and tubouterine implantation⁴. The majority of initial published studies on tubal surgery were from Europe. The first description of tubal repair using a microscope was published in Germany in 1959⁵.

American studies on surgical reversal of sterilization began to appear in medical journals in the early 1970’s. Shortly thereafter case reports and small cohort studies on microsurgical tubotubal anastomosis involving human patients began to be published within peer reviewed medical journals in the United States⁶. A significant amount of research attention was focused on clinical microsurgical tubotubal anastomosis in the late 1970’s and early 1980’s. Most of this research centered on the reversibility of different methods of sterilization, surgical and clinical factors that predicted pregnancy success, and which factors influenced patient’s decisions to have sterilization reversal.

Success of tubal ligation reversal

Tubotubal anastomosis has historically been and currently is an acceptable treatment for tubal sterilization. The success of tubotubal anastomosis at our center ranges from 60% to 80%. The main benefit of tubal reversal for our patients is the treatment is effective, patients can become pregnant more than once, and multiple medical interventions are usually not required.

Although tubal reversal is effective and safe, the main risk of tubotubal anastomosis is ectopic pregnancy.

Assisted Reproduction

A brief history of in-vitro fertilization

Research in assisted reproduction did not begin until after the 1840’s when it was first learned that sperm were required for fertilization of eggs. Early clinical experiments and success with assisted reproduction centered on intra-uterine sperm injection for the treatment of ‘female infertility’, which ironically was mostly ‘male factor’ in origin.  In the 1930’s, in-vitro fertilization experiments on rabbit models developed the foundation of future research into IVF and demonstrated assisted reproduction was possible and could be applied to humans. Although, the first successful in-vitro fertilization of human eggs occurred in the 1940’s the first successful IVF pregnancy would not occur until 1978. A major impediment to IVF research was societal resistance to this new technology because of ethical and religious concerns regarding the creation, manipulation, and destruction of life.

The first successful IVF pregnancy resulting in birth was reported in Great Britain in 1978 and the first successful IVF pregnancy resulting in birth in the United States occurred in 1981. After proving IVF could result in successful pregnancy and birth, IVF research since the early 1980s focused on improving the success of assisted reproduction and studying IVF birth outcomes.⁷

Success of in-vitro fertilization

In-vitro fertilization is an acceptable treatment for most forms of infertility and currently the success of a single treatment cycle of in-vitro fertilization ranges from 35% to 40%. The main benefit of IVF is that it can treat most forms of infertility.

The main risks are multiple gestation pregnancy, exposure to high dose hormonal medications, and the potential for ethical/religious.

Tubal ligation reversal

A historical perspective

Understanding the history of tubal sterilization reversal and in-vitro fertilization is important to understanding today’s attitudes and perceptions towards the two treatments. Both treatments were complex undertakings but the risks of both treatments are entirely different. If one understands the risks of each treatment, the time at which certain medical discoveries and improvements were being made, and the influences of health care costs and availability or lack of availability of training then the divergence in popularity and perceptions of these two treatments are more easily understood.

The main risks of tubal reversal surgery are the risks inherent with any surgical intervention and the risk of ectopic pregnancy. No surgery is without risk and having surgery in the 1970’s was much different than having surgery today.

In the 1970’s surgery was a major undertaking. All major gynecologic surgical procedures occurred within a hospital setting. Outpatient surgery for major gynecologic surgery did not become possible until the advent of minimally invasive surgical techniques, which began in the 1980’s. During the height of microsurgical tubotubal anastomosis, most post-operative recoveries for major surgical procedures involved long hospitalizations of up to 7 days for routine and uncomplicated surgery. Antibiotic selection to minimize the risk of surgical infection was limited. Surgery, hospitalization, costs of treatment, and recovery were and continue to be major obstacles to the widespread provision of microsurgical tubal surgery.

The main risk of tubal reversal was and currently is ectopic pregnancy. Diagnosis of ectopic pregnancy prior to the 1980’s was challenging without today’s modern diagnostic technologies which most of us currently take for granted. Without early and accurate pregnancy testing, easily accessible diagnostic ultrasound, lack of minimally invasive surgical techniques, and no highly effective medical treatment, ectopic pregnancy was a major source of morbidity and mortality before the 1980’s.

Accurate pregnancy testing and diagnosis

Today we take home urine pregnancy testing for granted. Easy to use and accurate pregnancy testing has not always been available.

In the 1970’s the first human chorionic gonadotropin (HCG) pregnancy tests were only available to clinicians, testing results were qualitative, and results were sometimes unreliable. With further improvements more reliable HCG testing was developed but quantitative HCG testing was not developed until the mid 1970’s. The first commercially available home pregnancy test was not released until 1979. Although these early home test were a major advancement in women’s health care, the first home pregnancy test were complicated, required several steps to perform and took two hours to complete. Home testing results had to be confirmed by the patient’s doctor. Home pregnancy test were gradually improved in the 1980’s and became more similar to the home pregnancy tests we are familiar with today.⁸

Diagnostic ultrasound

The history of ultrasound is quite extensive and a detailed history of ultrasound is outside of the scope of this discussion. Quite simply, modern ultrasound with ready availability to the average clinician and readily identifiable imagery did not become available until the 1980’s.

Before the 1980’s ultrasounds were large machines and the images were of poor quality and difficult to interpret. Diagnosis of pelvic pathology was challenging until ultrasound technology began to improve. Today ultrasounds can be as small as a hand-held brief case and the can provide clinicians better images with which to make better clinical diagnoses.

Ectopic treatment

Most health care providers are not cognizant of how difficult it was to diagnose ectopic pregnancy before the advent of accurate pregnancy testing, diagnostic ultrasound, and laparoscopic surgery. Before 1980, reliable diagnosis of ectopic pregnancies required major surgery. Most ectopic pregnancies presented late with signs of tubal rupture and required treatment with surgery to remove the fallopian tube. If a patient presented with abdominal pain and a history suggestive of pregnancy then the only way to diagnose an ectopic was with abdominal surgery. Before laparoscopy was perfected in the 1980’s the only surgical option was cul de centesis or laparotomy.

The first reports of methotrexate treatment for abnormal pregnancy did not appear in the literature until 1964.⁹ The majority of initial abnormal pregnancies treated with methotrexate in the 1960’s were ectopic pregnancies that were difficult to treat with surgery: cancerous gestational tissue, abdominal and interstitial ectopic pregnancies, as well as invasive placental abnormalities. Despite these initial reports of treatment success of abnormal pregnancy with methotrexate in the 1960’s, the treatment of fallopian tube ectopic pregnancies was not described until 1982.¹⁰ The treatment of ectopic pregnancy with methotrexate did not become widely accepted within the medical profession until the late 1980’s.

Currently morbidity and mortality from ectopic pregnancy is much different than in the 1970’s. Ectopic pregnancies are easier to diagnose with accurate pregnancy testing and diagnostic ultrasound. Medical treatment with methotrexate combined with serum HCG monitoring is very effective and has now become an acceptable first line treatment for early ectopic pregnancy.

When one understands the risks of tubal surgery in the 1970s, the difficulty in diagnosing ectopic pregnancy, and the lack of effective medical treatment for ectopic pregnancy it is easier to understand from a historical viewpoint how the alternative treatment of IVF was more appealing from a risk perspective. After the first successful IVF pregnancy in the 1980’s further innovations in the field of assisted reproduction made the treatment more successful and more amenable to office based treatment. Although in-vitro fertilization is expensive, IVF infertility treatment can be performed in an office based setting at a more affordable cost than can typical hospital based surgery with inpatient admission and the risk of ectopic pregnancy with IVF treatment is only minimally increased.

Divergence of tubal reversal and IVF

All of us are attracted to technology and innovation.

IVF was new and innovative in the 1980s, was a more encompassing treatment for all forms of infertility, and did not have to be performed in a hospital setting. In comparison, tubal reversal had to be performed in a hospital and required overnight hospitalization with several nights stay. Surgery performed in a hospital has always been, currently is, and will always be a more expensive proposition than outpatient treatment. Although medical treatment of ectopic pregnancy was undergoing rapid improvements in the 1980’s most health care providers had knowledge of the increased morbidity experienced by many women from ectopic in the early years of their training prior to the 1980’s. This previous clinical experience could have only caused IVF to be seen more acceptable as a treatment alternative to tubal ligation reversal surgery.

As health insurance support became less common for infertility treatment and patients began to pay directly for these treatments, in-vitro fertilization began to evolve at the expense of microsurgical tubotubal anastomosis. In-vitro fertilization moved to the office whereas microsurgical tubotubal anastomosis remained stuck in the hospital setting. Since IVF is considered a more encompassing office based treatment for the larger portion of the population of infertile couples and tubotubal anastomosis focuses on a smaller segment of the infertile population, the two treatments began to diverge in favor of a more affordable office based, all-inclusive form of treatment.

The end result has been that very few microsurgical tubotubal anastomosis procedures are being performed in the hospital setting. When fewer procedures are done in traditional hospital settings, training physicians get less exposure to tubal reversal surgery and do not receive training in tubal surgery. The lack of familiarity with tubal reversal surgery has led many physicians (both primary care and even specialists) to assume tubal surgery is ineffective.

The most simplistic form of thinking is often, “Since I have not seen it in my training or in my practice then it must not be an effective or recommended treatment.”

Current recommendations on

tubal reversal surgery

We have had good experience with providing tubal reversal surgery to our patients.

We have focused our efforts on providing both affordable and safe outpatient surgery. Our ability to keep tubal reversal surgery outpatient and the availability of highly effective diagnosis and treatment protocols for ectopic pregnancy continue to make tubotubal anastomosis an effective alternative treatment to IVF for women who have had surgical sterilization. The effectiveness of tubotubal anastomosis has been continually affirmed by ASRM.¹

We perform microsurgical tubotubal anastomosis using a mini-laparotomy incision. Both laparoscopic and robotic tubal reversal surgeries significantly increase both time and cost of surgery without increasing pregnancy success. Since patients are paying directly for this treatment the more technological treatments are neither affordable nor feasible and don’t increase the success of the procedure.

Pain after surgery is directly proportional to the length of the abdominal incision. Our techniques for microsurgical tubal reversal avoids the use of self-retaining abdominal wall retractors and are performed using small abdominal incisions. Our success rates have been as high as 80% depending on the age of the patient and the type of tubal ligation reversed.

Although ectopic pregnancy is a real risk, we encourage early testing with home pregnancy test, serial HCG monitoring, early endovaginal ultrasound when the HCG is in the discrimination zone, and early treatment with methotrexate if clinically indicated.  Using this approach the risk of ectopic pregnancy can be managed and mitigated.

References

1. Committee opinion: role of tubal surgery in the era of assisted reproductive technology. American Society for Reproductive Medicine. Fertility Sterility 2012;97:539-45.
2. Ries E. Plastic operation on the fallopian tubes. Am J Surg Gynecology 1899;11:180.
3. Hellman LM. Tubal plastic operations.J Obstet Gynaecol Br Emp. 1956 Dec;63(6):852-60.
4. Green-armytage VG.Tubo-uterine implantation. J Obstet Gynaecol Br Emp. 1957 Feb;64(1):47-9.
5. Walz W. Tubal sterility operation with the aid of an operating microscope. Z Geburtshilfe Gynakol. 1959;153:49-55. German.
6. Siegler AM, Perez RJ. Reconstruction of fallopian tubes in previously sterilized patients. Fertil Steril. 1975 May;26(5):383-92.
7. Test Tube Babies.  Timeline: The History of In Vitro Fertilization. Documentary by Chana Gazit & Hilary Klotz Steinman.  PBS .
8. A Timeline of Pregnancy Testing. The Office of NIH History. http://history.nih.gov/exhibits/thinblueline/timeline.html
9. Riggs JA, Wainer AS, Hahn GA, Farell DM. Extrauterine tubal choriocarcinoma: a case report and review of recent literature. Am J Obstet Gynecol. 1964 Mar 1;88:637-41.
10. Treatment of interstitial ectopic pregnancy with methotrexate: report of a successful case. Tanaka T, Hayashi H, Kutsuzawa T, Fujimoto S, Ichinoe K. Fertil Steril. 1982.