Sunday, April 17, 2011

Tubal Reversal Vs. IVF: Which Would Be Better? Asks 38 Yr. Old Mom Who Wants One More Child


Dear Doctor, I've just turned 38 and I have three children. Right after the birth of my third, I had my tubes tied. Somehow it made sense at the time but now I regret it. My kids are between the ages of 6 and 9 all delivered by c-section, and we would like one more. My ObGyn highly recommends IVF instead of a tubal reversal. I have a consultation with an infertility doctor in a few weeks and I am a little nervous. I would like some information or advice for a woman in my situation. I had no problems conceiving at all, have never missed a period, except during pregnancy, and I ovulate every month without fail.

My husband and I would consider adoption as well. Either way, IVF or adoption, they both are expensive and carry a risk of not working out, so we really want to make the best decision for our family. We just know that we want to expand our family. Thanks so much. K. from Maine


Hello K. from Maine,

Your question is a common one and one that I have to discuss often. Hopefully I will be able to give you the facts so that you can make your decision. I have to commend your Gyn doctor for his recommendations, as I think he/she is correct, and I am sure that your infertility doctor will concur. Here is what I tell my patients to consider.

Let's look at the pros and cons of each option:

First let's consider tubal reversal. What tubal reversal (called a tubal reanastamosis) does is it brings the previously damaged or separated tubes back together so that they are open again. There are two initial considerations when considering this procedure. One is what type of tubal ligation was done. Some tubal ligations, and the doctors that do them, are more permanent. Most doctors doing tubal ligations realize and fear that if the tubal ligation (or "BTL" bilateral tubal ligation) fails, they are at risk for a malpractice suit. For that reason, they make doubly sure that it doesn't fail by doing as much damage to the tube as possible i.e. either remove/burn a large portion of the tube or remove the end of the tube "fimbria". This is especially true when the BTL is done immediately after a delivery or during a c-section, called a postpartum tubal ligation. Because the tube is readily accessible, the Physician will usually cut, tie and burn a large segment. The more damage a tube undergoes, the less chances that it can be repaired or that the repair will work.

The second consideration is how much tube is left to repair. The Fallopian tube needs a minimal amount of length and structure for it to be a functional tube. If the fimbriated end is removed or a large portion of the tube removed or burned, there will not be sufficient tube to repair for a tube to be functional. The tube is after all, a functioning structure with muscle and cilia within. If the proper segments are not available it doesn't work. The fallopian tube is not just a tube. So based on the fact that your tubal ligation was done at the time of a c-section, I would make the assumption that there is not sufficient tube to repair.

Another disadvantage to consider, of course, is what if the surgery is not successful. Not because there is not enough tubal length, but because it does not come together properly or heal properly. Because a surgery is being done, you cannot control how it heals or repairs itself. We can only bring the tube together and hope for the best. What I mean is that the tube can become misaligned so that it is not patent. Or, you can develop scar tissue at the site of repair which can block the tube completely or partially. So even if we assume that there is sufficient length of tube, it may not work due to factors that you cannot control. If the tube heals partially so that there it is only partially open or has scar tissue, you would then be at risk for a tubal pregnancy or "ectopic", which is a surgical emergency and carries the risk of death from rupture and hemorrhage.

Next you have to consider what are your chances of pregnancy if the reversal were successful. If the repair is successful, that is that all the previous criteria is met, then it will restore your natural chances of pregnancy. However, because you have aged since your last child and are now 39 years old, your natural chance of pregnancy has decreased significantly. Your last pregnancy was at the age of 32 years old when you conceived. At that time you had a 50-60% chance of pregnancy per year or 15% per month of trying. Now you are 39 years old. Your natural fertility rate has declined due to age and is now 12% per year or approximately 1-3% per month.You will also need to consider that this is a surgery, done either by a small incision "minilaparotomy", large incision like your c-section "laparotomy" or by laparoscopy. It carries all the risks of surgery and requires general anesthesia. There is also the risk that you may have scar tissue formation around the tubes due to the prior c-sections and tubal ligation that would make the surgery difficult or not possible. It is not a simple surgery like the tubal ligation. (As someone who has done hundreds of cases and come up against mega scar tissue, believe me it is not a walk in the park.) It is actually a very difficult microsurgery that requires a Physician with the proper skills to complete properly.

Finally, there is the issue of cost. In my surgery center, it will cost $10,000 for a tubal reversal (Physician fee and Surgery center fee). That will vary according to your area so you will need to check to see what the price will be for you. I did have a patient go to North Carolina for a tubal repair, at 38 years old and it cost her about $8000. She is still not successfully pregnant. She did get pregnant but had a miscarriage (partly because of the decreased fertility rate due to age). In any case, is $8000-10,000 worth a 1-3% chance of pregnancy per month?

In your case, you also have to consider that since you want only one more child, after all this expense and surgery, will you then have another tubal ligation? Also, having had 3 c-sections, you know that you will need to have another c-section. Finally, you also need to consider that you have a genetic risk of Down's syndrome that is 1/100 births due to your age i.e. it is significantly increased and your risk of miscarriages is increased.

Now let's examine the alternative, which is IVF. In this procedure, the eggs are taken directly from the ovaries so the tubes are bypassed and not required to be repaired. First, it is not a surgery but a procedure where a needle is introduced through the vagina to retrieve the eggs, under ultrasound guidance. Sedation is used but general anesthesia is not required. There is some risk but nothing like a surgery. So, the benefit is that as long as your ovaries are still working well, so that they stimulate well and produce an adequate number of follicles that have eggs in them, you can be sure that the procedure can be completed in it's entirety. There is no risk that the treatment cannot be completed. Now, there is the risk that a pregnancy will not result, different from reversal in that there is both the risk that the surgery will fail and that a pregnancy will not result, because the last two steps your body has to go through to achieve the pregnancy are still natural steps and we don't have the technology to make it happen. But because IVF accomplishes 7 of the 9 steps required for a pregnancy to naturally occur, the chances of success are higher. Also, despite this, at 39 years old pregnancy rates are 50-60% per treatment cycle (i.e. per month of trying). As you can see, this treatment also helps to overcome the age factor as well because more eggs can be retrieved and so there is a higher chance that we will get a good egg. There is still the genetic and miscarriage risks due to age, but I think those are reduced because IVF is less of a "natural" procedure and the weaker eggs/embryos do not survive the process. But, those risks are still there.

In the 17 years that I have been doing IVF, I have only had two cases of Down's syndrome in my patients, both in patients over 40 years old.

Well I think I have written one of my longer answers :)... so I think I should stop here. As you can see, IVF is better because it has a better chance of success in consideration of your age and type of tubal ligation, and it is less risky. The cost is higher, approximately $15,000 in all, but it has a better chance of working. You should consult my blog where I have written on this subject as well.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program

Monterey, California, U.S.A

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