Most patients who undergo tubal ligation do so after careful consideration and remain satisfied with the decision to eliminate their future fertility. However, much like the 6 to 10 percent of men who elect to reverse a vasectomy, according to the Cleveland Clinic, a small percentage of women who have their "tubes tied" may later decide they want biological children.
So what are their options? As an OB-GYN or reproductive specialist, you have a delicate job of guiding patients through their choices and being clear about the possibility of success. Surgical reversal and IVF after tubal ligation are both potential options for pregnancy.
Tubal Ligation and Reversal Surgery
Tubal ligation is a surgical procedure in which the fallopian tubes are cut, tied, clamped, banded or sealed off. Most often, the procedure is done on an outpatient basis with laparoscopic surgery, but some people also decide to have tubal ligation in-hospital after giving birth.
Although it is considered permanent sterilization, tubal ligation may be reversed with surgery, called tubal anastomosis. Tubal ligation done with clips or rings has the highest chance of being successfully reversed. Procedures that involve scarring, such as Essure or Adiana, are not reversible.
Tubal anastomosis is major surgery, done by reconnecting the separated ends of the fallopian tubes with microsurgical techniques. Multiple studies have consistently shown tubal reanastomosis to successfully lead to pregnancy and live births for many patients.
Research in Human Reproduction Update found a pooled pregnancy rate of 42 to 69 percent for women who underwent sterilization reversal. Women younger than 40 tend to have better results with getting pregnant after reversal surgery than older women.
IVF After Tubal Ligation
Many patients wonder: Can you do IVF after a tubal ligation? For most, the answer is yes. If tubal reanastomosis fails or cannot be done, the patient may be able to undergo IVF. Many who undergo tubal ligation were previously fertile, which may increase their chances of conception with IVF.
Patients who have damage to the fallopian tubes or not enough healthy tube to reattach are candidates for IVF rather than reversal surgery. A committee opinion in Fertility & Sterility said tubal anastomosis should not be considered in patients with a final tubal length less than 4 cm, significant tubo-ovarian adhesions or stage 3 to 4 endometriosis — or if there is more than a mild male factor infertility.
A small study published in Annals of the Academy of Medicine, Singapore, found pooled pregnancy rates of 35.5 percent and live birth rates of 25.8 percent for women undergoing IVF after tubal ligation.
How to Counsel Patients
Choosing between IVF and reversal surgery may not be easy for all patients. If someone is eligible for either procedure, they should be evaluated for the quantity and quality of oocytes to determine the likelihood of a successful pregnancy with either approach. Semen analysis should also be recommended for any male partner or sperm donor.
Tubal anastomosis carries benefits for many patients. It is often less expensive than IVF, and couples can continue trying to conceive spontaneously, rather than undergoing fertility cycles with IVF. It's also very successful for many patients, especially those under age 40. One analysis in Fertility & Sterility found tubal anastomosis to be the most cost-effective option for women younger than 41, whereas IVF was more cost-effective for women age 41 and older.
However, the committee opinion in Fertility & Sterility found pregnancy rates of 41.7 percent to 70.6 percent in women age 40 to 45 with tubal anastomosis. The committee recommends microsurgical anastomosis to reverse tubal ligation, even in women over age 40 who have no contraindications.
As women age, their chances of pregnancy decline overall. The type of tubal ligation procedure, health of fallopian tubes, oocyte quality and any male partner's fertility are all factors to consider and discuss when choosing between tubal anastomosis and IVF. Patient choice is also a factor. The Singapore study found that although tubal reanastomosis led to more pregnancies and live births, patients showed a preference for IVF after learning more about each procedure.
Any discussion should include a realistic analysis of outcomes for each option, as well as discussions of the costs, risks and benefits of each procedure.
