Women who have had tubal ligations may at some point come to regret their decision and desire fertility in the future. Pregnancy rates are influenced by both age and tubal ligation method. The highest pregnancy rate (87%) was reported by women age 29 or less who underwent reversal of a previous ring or clip method of sterilization.
The physicians at the Reproductive Science Center of New Jersey have all had extensive training in tubal reanastamosis. Listen in as Dr. William Ziegler, specialist in Reproductive Endocrinology and Infertility and the Medical Director of the Reproductive Science Center of New Jersey, shares his expertise when a couple decide to try to have a baby after Tubal ligation procedure.
Tubal Reversal and Fertility Treatments
From the Show: RSC NJ - Fertility Talk
Summary:
Air Date: 9/25/16
Duration: 10 Minutes
Transcription:
Melanie Cole (Host): Women who have had tubal ligations, may at some point in their lives come to regret that decision and desire fertility in the future. My guest today is Dr. William Ziegler. He’s a board certified specialist in reproductive endocrinology and infertility, and the Medical Director of the Reproductive Science Center of New Jersey. Welcome to the show, Dr. Ziegler. So, first tell us: what’s a tubal ligation?
Dr. William Ziegler (Guest): A tubal ligation is, basically, another form of contraception. Instead of using the birth control pill or using the IUD or using condoms, they will have their fallopian tubes basically ligated. There are different ways of doing it. One of them is cutting them; there’s another way in which they can just put a clip on them; and there’s one where you can actually put a ring on the fallopian tube itself. There is another procedure out there at this time. It’s called the “Essure process” which is basically a spring that they put in the fallopian tube and that, again, will stop the fallopian tube from picking up an egg and creating an embryo. Therefore, it is a form of contraception.
Melanie: And, this is what some women refer to as having their tubes tied?
Dr. Ziegler: That is correct.
Melanie: Is this a permanent solution to contraception or is it reversible?
Dr. Ziegler: In some cases, it is reversible. Depending on the type of tubal ligation that a woman has will determine whether or not we are able to reverse the fallopian tubes. For example, with the Essure process, which is the spring that goes through the fallopian tube, I cannot remove that spring. We cannot reverse that process. If a patient has had their entire tube removed, which is another option that some obstetricians do prefer doing. They remove the entire fallopian tube. Then, we cannot reverse that either. The ones that we can reverse are the ones in which a small segment of fallopian tube was removed from the midsection of the tube itself or those that have had what’s called a clip put on or Hulka clip or a ring put on the fallopian tube which is called a Falope ring. Those fallopian tubes, in most cases, we can remove that. We can remove the clip or remove the loop, and we can put the tube back together again.
Melanie: Very commonly, do you see women who have had this difficult decision, I would think, because it is a procedure, then change their mind and decide that they would like to continue with fertility?
Dr. Ziegler: We see it more often in those that have had their fallopian tubes ligated or tubes tied at a young age--in women who are less than the age of 35 or even less than the age of 30, that we’re seeing they are regretting having that done. Also, in cases in where a marriage has dissolved, and now they’re with a new partner, and they want to have children with the new partner. Then, we see that and then they come to our practice.
Melanie: Okay. So, then, what is the procedure? What do you counsel women or couples about when they want to reverse this procedure and are looking toward fertility?
Dr. Ziegler: What we first do is we want to make sure that the patient has a reasonable success rate once the procedure is performed. So, we would recommend getting a semen analysis on their partner if they have one, to make sure that there’s not a male factor issue that would prevent us from doing this procedure. The next is, a lot of these women are coming to us in which they’re older. So, we do want to assess their ovarian function or their ovarian reserve. So, we do blood work to make sure that their ovaries are working reasonably well. If they are not, then we do counsel them accordingly. So, after we get the preliminary workup completed, we will then proceed with surgery which is doing a laparoscopy. The procedure that we do is we do a laparoscopic tubal reversal. There are other options out there where you can use the robot--the da Vinci robot--to do this procedure or even do a bikini cut incision like a C-section incision to go inside and you can reverse the fallopian tubes. The issue that a lot of patients face is that the insurance companies that paid for you to have your tubes tied, they don’t have coverage to have them reversed. So, by doing it laparoscopically as an outpatient procedure, success rates are very similar to the other two procedures that I mentioned. It’s an outpatient procedure, and it actually saves them money.
Melanie: Then, what are some of the parameters for in vitro fertilization following tubal reversal.
Dr. Ziegler: After we reverse the fallopian tubes, we usually recommend waiting two menstrual cycles before they try to conceive. If they fail to conceive within six to eight months after a tubal reversal, we do recommend them coming back in and we do either an HSG test or a dye test to determine whether or not the fallopian tubes are still patent, whether they’re still open. Because even though we make sure the tubes are open, at the end of our procedure, there is a healing process that occurs, and you could get some narrowing or even occluding of the fallopian tube. If you do get seem narrowing on an HSG test or on a dye test, that’s not always apparent. So, if a couple, after having their tubes reversed, if the tubes are blocked, then we talk about going for in vitro fertilization. If the tubes are open, then we talk about fertility treatment as I would with any other couple that have had a workup and everything s normal. That’s when we talk about doing possibly super ovulation with inseminations or even going directly to IVF, depending on what their insurance plan covers. I mentioned before how it doesn’t cover for the tubal reversal, but if a tubal reversal is successful, in many insurance companies, the couples still have infertility coverage because the tubes are open. And, therefore, it is as if they never had a tubal ligation at all.
Melanie: Does tubal ligation affect the egg quantity and quality of the woman even after its reversed?
Dr. Ziegler: It can. There has been some studies out that have shown that there is an artery that travels underneath the fallopian tube, and if that artery is compromised, then it could decrease some blood flow going to the ovary. The ovary is fed by two arteries. One is called the “ovarian artery” which is a very large one, that comes off a very large blood vessel, and the other one is a smaller artery, but it is significant, and that’s the tubal artery. If that artery is compromised, again, the ovary may show additional aging compared to the patient’s chronological age.
Melanie: So, then, wrap it up for us, when you’re counseling couples and, as you said, there are many different reasons why they might want a reversal of this tubal ligation. What do you tell them every day about making this decision and what they can expect in fertility?
Dr. Ziegler: Usually, we sit down with the patient, we talk about it after we get everything--all the information back with regard to semen analysis and a woman’s ovarian reserve testing. We talk about success rates. I also talk about the length of the fallopian tube which I need to reverse. The shorter the tube, the lower the pregnancy rate, and the higher ectopic rate. Even if we do reverse the tube and there’s a decent amount of fallopian tube there, they still have anywhere between a 15-20% ectopic rate or tubal pregnancy rates. So, when they do get pregnant, they do need to be monitored very closely. We also talk about the age effect that, even though I reverse her fallopian tubes, that she is still of a certain chronological age, and that has some sequelae with it.
Melanie: Tell us about your team at the Reproductive Science Center of New Jersey.
Dr. Ziegler: We are a team of professionals which have a goal to provide the highest quality of medical care in a very comfortable environment. We do not want to cause a couple additional stress in going through the infertility process or going through a tubal reversal process. A lot of times, women regret having their tubes tied and, therefore, they do have some depression, they do have some mood issues, and we do intervene with psychologists and psychiatrists to help them through this emotional time of their life.
Melanie: Thank you so much for being with us today, Dr. Ziegler. It’s great information. You’re listening to Fertility Talk with RSCNJ. For more information, you can go to www.fertilitynj.com. That’s www.fertilitynj.com. This is Melanie Cole. Thanks so much for listening.
Melanie Cole (Host): Women who have had tubal ligations, may at some point in their lives come to regret that decision and desire fertility in the future. My guest today is Dr. William Ziegler. He’s a board certified specialist in reproductive endocrinology and infertility, and the Medical Director of the Reproductive Science Center of New Jersey. Welcome to the show, Dr. Ziegler. So, first tell us: what’s a tubal ligation?
Dr. William Ziegler (Guest): A tubal ligation is, basically, another form of contraception. Instead of using the birth control pill or using the IUD or using condoms, they will have their fallopian tubes basically ligated. There are different ways of doing it. One of them is cutting them; there’s another way in which they can just put a clip on them; and there’s one where you can actually put a ring on the fallopian tube itself. There is another procedure out there at this time. It’s called the “Essure process” which is basically a spring that they put in the fallopian tube and that, again, will stop the fallopian tube from picking up an egg and creating an embryo. Therefore, it is a form of contraception.
Melanie: And, this is what some women refer to as having their tubes tied?
Dr. Ziegler: That is correct.
Melanie: Is this a permanent solution to contraception or is it reversible?
Dr. Ziegler: In some cases, it is reversible. Depending on the type of tubal ligation that a woman has will determine whether or not we are able to reverse the fallopian tubes. For example, with the Essure process, which is the spring that goes through the fallopian tube, I cannot remove that spring. We cannot reverse that process. If a patient has had their entire tube removed, which is another option that some obstetricians do prefer doing. They remove the entire fallopian tube. Then, we cannot reverse that either. The ones that we can reverse are the ones in which a small segment of fallopian tube was removed from the midsection of the tube itself or those that have had what’s called a clip put on or Hulka clip or a ring put on the fallopian tube which is called a Falope ring. Those fallopian tubes, in most cases, we can remove that. We can remove the clip or remove the loop, and we can put the tube back together again.
Melanie: Very commonly, do you see women who have had this difficult decision, I would think, because it is a procedure, then change their mind and decide that they would like to continue with fertility?
Dr. Ziegler: We see it more often in those that have had their fallopian tubes ligated or tubes tied at a young age--in women who are less than the age of 35 or even less than the age of 30, that we’re seeing they are regretting having that done. Also, in cases in where a marriage has dissolved, and now they’re with a new partner, and they want to have children with the new partner. Then, we see that and then they come to our practice.
Melanie: Okay. So, then, what is the procedure? What do you counsel women or couples about when they want to reverse this procedure and are looking toward fertility?
Dr. Ziegler: What we first do is we want to make sure that the patient has a reasonable success rate once the procedure is performed. So, we would recommend getting a semen analysis on their partner if they have one, to make sure that there’s not a male factor issue that would prevent us from doing this procedure. The next is, a lot of these women are coming to us in which they’re older. So, we do want to assess their ovarian function or their ovarian reserve. So, we do blood work to make sure that their ovaries are working reasonably well. If they are not, then we do counsel them accordingly. So, after we get the preliminary workup completed, we will then proceed with surgery which is doing a laparoscopy. The procedure that we do is we do a laparoscopic tubal reversal. There are other options out there where you can use the robot--the da Vinci robot--to do this procedure or even do a bikini cut incision like a C-section incision to go inside and you can reverse the fallopian tubes. The issue that a lot of patients face is that the insurance companies that paid for you to have your tubes tied, they don’t have coverage to have them reversed. So, by doing it laparoscopically as an outpatient procedure, success rates are very similar to the other two procedures that I mentioned. It’s an outpatient procedure, and it actually saves them money.
Melanie: Then, what are some of the parameters for in vitro fertilization following tubal reversal.
Dr. Ziegler: After we reverse the fallopian tubes, we usually recommend waiting two menstrual cycles before they try to conceive. If they fail to conceive within six to eight months after a tubal reversal, we do recommend them coming back in and we do either an HSG test or a dye test to determine whether or not the fallopian tubes are still patent, whether they’re still open. Because even though we make sure the tubes are open, at the end of our procedure, there is a healing process that occurs, and you could get some narrowing or even occluding of the fallopian tube. If you do get seem narrowing on an HSG test or on a dye test, that’s not always apparent. So, if a couple, after having their tubes reversed, if the tubes are blocked, then we talk about going for in vitro fertilization. If the tubes are open, then we talk about fertility treatment as I would with any other couple that have had a workup and everything s normal. That’s when we talk about doing possibly super ovulation with inseminations or even going directly to IVF, depending on what their insurance plan covers. I mentioned before how it doesn’t cover for the tubal reversal, but if a tubal reversal is successful, in many insurance companies, the couples still have infertility coverage because the tubes are open. And, therefore, it is as if they never had a tubal ligation at all.
Melanie: Does tubal ligation affect the egg quantity and quality of the woman even after its reversed?
Dr. Ziegler: It can. There has been some studies out that have shown that there is an artery that travels underneath the fallopian tube, and if that artery is compromised, then it could decrease some blood flow going to the ovary. The ovary is fed by two arteries. One is called the “ovarian artery” which is a very large one, that comes off a very large blood vessel, and the other one is a smaller artery, but it is significant, and that’s the tubal artery. If that artery is compromised, again, the ovary may show additional aging compared to the patient’s chronological age.
Melanie: So, then, wrap it up for us, when you’re counseling couples and, as you said, there are many different reasons why they might want a reversal of this tubal ligation. What do you tell them every day about making this decision and what they can expect in fertility?
Dr. Ziegler: Usually, we sit down with the patient, we talk about it after we get everything--all the information back with regard to semen analysis and a woman’s ovarian reserve testing. We talk about success rates. I also talk about the length of the fallopian tube which I need to reverse. The shorter the tube, the lower the pregnancy rate, and the higher ectopic rate. Even if we do reverse the tube and there’s a decent amount of fallopian tube there, they still have anywhere between a 15-20% ectopic rate or tubal pregnancy rates. So, when they do get pregnant, they do need to be monitored very closely. We also talk about the age effect that, even though I reverse her fallopian tubes, that she is still of a certain chronological age, and that has some sequelae with it.
Melanie: Tell us about your team at the Reproductive Science Center of New Jersey.
Dr. Ziegler: We are a team of professionals which have a goal to provide the highest quality of medical care in a very comfortable environment. We do not want to cause a couple additional stress in going through the infertility process or going through a tubal reversal process. A lot of times, women regret having their tubes tied and, therefore, they do have some depression, they do have some mood issues, and we do intervene with psychologists and psychiatrists to help them through this emotional time of their life.
Melanie: Thank you so much for being with us today, Dr. Ziegler. It’s great information. You’re listening to Fertility Talk with RSCNJ. For more information, you can go to www.fertilitynj.com. That’s www.fertilitynj.com. This is Melanie Cole. Thanks so much for listening.