Tubal Ligation

Fertility Following Fallopian Tube Ligation

Normal function of the fallopian tube The fallopian tube serves as a conduit for the fertilized embryo to reach the uterus. After ovulation, the oocyte (egg) is picked up by the fimbria of the tube. The fimbria are fine, finger-like projections found at the end of the tube.

The fallopian tube also provides a channel for the sperm to reach and fertilize the oocyte. After being "picked up" from the ovary, the oocyte is normally fertilized in the distal portion of the fallopian tube. The fertilized egg, now an embryo, is then transported to the uterus. Implantation into the uterine lining then follows. The entire process of ovulation, oocyte pick up, fertilization, transport of the embryo to the uterus, and implantation of the embryo into the uterine lining is thought to take about seven days.

Fallopian Tube Ligation

Obstruction of the fallopian tube (tubal ligation), prevents sperm from reaching the oocyte in the distal portion of the fallopian tube. The oocyte may still be "picked up" by the fimbrae, but transport to the uterus is blocked by the tubal ligation. The immune system will eliminate the unfertilized egg (a microscopic structure) in the same fashion as happens during a cycle in which a pregnancy does not occur.

Fertility Options Following Fallopian Tube Ligation

Following a tubal ligation, there are several options for women who wish to conceive. Patients may undergo surgery to repair the obstructed fallopian tubes. This procedure is called a tubal anastomosis.

The other option is in vitro fertilization (IVF). In the IVF procedure, oocytes are removed from the ovaries. Fertilization of the oocytes with sperm is performed in the IVF lab. The resulting embryos are then transferred into the uterus. In this clinical situation, IVF is being used to "bypass" the fallopian tubes.

Tubal Anastomosis (Reanastomosis)

Tubal anastomososis is performed by making a small incision on the abdomen to access the fallopian tubes. The procedure is performed under magnification using microsurgical techniques. All the physicians of the Fertility Specialists of Houston have undergone extensive training and are experienced in the performance of this surgery.

Tubal anastomosis usually requires patients to receive a general anesthetic. Most patients undergoing tubal anastomosis will stay in the hospital for one to two days following the procedure.

There are multiple factors that affect the success of tubal anastomosis. Two critical factors are i) the status of the fimbria, and ii) the length of the fallopian tube following the anastomosis. If the fimbria have been damaged, the success rates are significantly diminished. In some cases, the fimbria may have been removed at the time of the tubal ligation procedure. In these cases, tubal anastomosis is not possible. In contrast, the best prognosis for tubal anastomosis is found in cases in which the fallopian tubes were occluded using a clip or small band. If the fallopian tube has been occluded in multiple locations (as is performed in some cases that use electrocautery), then tubal anastomosis may not be possible.

Tubal Anastomosis or in vitro fertilization (IVF)?

There are no studies that directly compare pregnancy rates of tubal anastomosis and IVF. When deciding between these options, patients must consider various factors. Overall, pregnancy rates are similar between patients undergoing tubal anastomosis and those choosing IVF. However, pregnancy rates may be slightly higher in younger patients (i.e. < 37 years old) who choose tubal anastomosis while higher pregnancy rates may be found in older patients treated with IVF.

Depending on the hospital facility used for the tubal anastomosis, the costs of the two procedures are similar.

Advantages of tubal anastomosis include the opportunity to have multiple pregnancies over a prolonged period of time. Compared with IVF, there is also a decreased rate of multiple pregnancies (e.g. twins). Unfortunately, the time to achieve a pregnancy is longer with tubal anastomosis. The success of the procedure may not be fully appreciated until several years have passed following the surgery.

Patients choosing IVF will avoid the recovery period following surgery for tubal anastomosis. Choosing IVF allows the maintenance of permanent sterilization in the woman so that no further contraception choice by either partner will be needed after the desired pregnancy(ies) have occurred. Other advantages of IVF include a shorter period of time to achieve pregnancy. There is also a decreased rate of tubal pregnancy following IVF (< 2%) compared with tubal anastomosis.

References

• Feinberg EC, Levans ED, DeCherney AH. Infertility surgery is dead: only the obituary remains? Fertil Steril 2008;89:232-6
  
  
• Practice Committee of the American Society for Reproductive Medicine. The role of tubal reconstructive surgery in the era of assisted reproductive technologies. Fertil Steril 2006;86:s31-4
  
  
• Yossry M, Aboulghar M, D'Angelo A, Gillet W. In vitro fertilization versus tubal reanastomosis (sterilization reversal) for subfertility after tubal sterilization (Review). Chocrane Database 2008
  
  
• Boeckxstaens A, Devroey P, Collins J, Tournaye H. Getting pregnant after tubal sterilization: surgical reversal or IVF? Hum Reprod 2007;22:2660-4

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