Tubal disease and tubal ligation surgery prevent women from being able to conceive.
Reproductive Care Center specialists are able to diagnose and treat conditions preventing eggs from traveling through the fallopian tubes to the uterus.
Overview
Eggs are released from the ovary and travel down the fallopian tube where fertilization occurs. The embryo remains in the tube for several days prior to reaching the uterus. Any condition that prevents the passage of the egg, such as a blockage or other tubal disease, can cause infertility.
To determine if tubal disease is causing infertility, the tubes are evaluated using a hysterosalpingogram (HSG). During an HSG test, dye is injected into the uterus while an x-ray examination is completed to monitor whether the dye flows back through the uterus into the fallopian tubes. If tubes are blocked, there are surgical options as well as IVF to consider for treatment.
Causes of Fallopian Tube Issues
Tubal blockage, or damage, can be caused by endometriosis, which can attach to, and even penetrate, the fallopian tubes. Severe pelvic infections (pelvic inflammatory disease or PID) can cause serious tubal damage as can scar tissue from previous surgeries. Rarely, a woman will be born without one, or both, of her tubes. Salpingitis Isthmica Nodosa (SIN) also known as diverticulosis of the Fallopian tube, is nodular thickening of the narrow part of the uterine tube, due to inflammation and can also be a cause of blockage of the fallopian tubes. Tubal ligation (surgical procedure to cut, tie or block the fallopian tubes) will also cause infertility.
Treatment Options
In vitro fertilization (IVF)
In vitro fertilization (IVF) is often the ‘treatment of first choice” for tubal disease. IVF is also used for women who have completed sterilization instead of tubal reversal surgery. Using IVF, the eggs are retrieved directly from the ovaries and combined with sperm in the lab, thus eliminating the need for fallopian tube transport.
Tubal Reversal Surgery
Tubal reversal surgery is often effective, however, IVF success rates are better than natural intercourse success rates after tubal reversal surgery. Women must be strongly cautioned that tubal ligation is considered a permanent means of birth control. Whether or not the tubes can be reconnected via tubal reversal surgery depends upon several factors, including where they were tied, how much tube remains, how they were tied and other factors. The risk of ectopic pregnancy is 10%, or greater, if pregnancy occurs after tubal reversal. The risk of ectopic pregnancy after IVF is usually less than 2%.
In general, studies indicate pregnancy success per cycle is higher using IVF than tubal reversal surgery. In some women, especially younger women, there may be a reasonable argument for surgery. The number of times a younger patient can have intercourse to attempt pregnancy is virtually unlimited. For example, if they are having regular intercourse, they are attempting a “natural cycle pregnancy” each month. IVF cycles are relatively expensive and the total number is often limited by cost. Some patients may only be able to attempt one of two IVF cycles with the pregnancy rate varying according to many patient specific variables. Their overall cumulative chance for pregnancy may be similar after surgery and 2-3 years of intercourse compared to one IVF cycle. This is highly dependent upon several variables.
Women in their mid to late thirties should seek care from a reproductive endocrinologist/ fertility specialist early in their care as fertility can decline very rapidly in this age group. The pregnancy success rates are usually significantly higher when IVF is used.
Tubal Reversal FAQs:
How does age affect tubal reversal success?
Younger women have a higher pregnancy rate per cycle and thus more time to attempt natural conception after a tubal reversal than older women. As women age, the quality and quantity of their eggs decline and older women (>34) have lower pregnancy rates per cycle with less time to attempt natural conception after tubal reversal. As egg quality and quantity declines, the chances that IVF will be successful are decreased. If tubal reversal is not successful within the first 1-2 years, IVF may not be a future option for older women due to decreasing egg quality, unless an egg donor is used. Per cycle success rates for IVF are significantly higher than per cycle success rates for tubal reversal surgery.
What is the preferred surgical method? Laparoscopic or mini laparotomy.
Laparoscopic tubal reversal is the preferred method as it requires a much shorter recovery time (less than one week), reduces postoperative pain, may result in less scarring, and is usually done in an outpatient setting which saves the patient money. Tubal reversal using mini-laparotomy requires a 4-5 inch incision in the abdomen at the pubic hair line which leads to more post-surgical pain with a 2-4 week recovery. Mini laparotomy may be done either in an inpatient or, in select patients, in an outpatient setting.
How do success rates compare to IVF?
Tubal reversal and IVF success rates are affected by many patient specific factors. In best conditions with women under the age of 35, pregnancy rates can be up to 65-70% within 2 years of tubal reversal. IVF success rates can exceed 50% per cycle with cumulative rates over 90% after 4 IVF attempts for appropriate candidates.
How long after the tubal reversal before I can become pregnant?
Most patients can begin to attempt pregnancy the next cycle after the surgery.
What are my chances of having a baby?
Success rates vary widely dependent upon numerous factors such as patient age, how the tubes were tied, coexisting fertility issues, male partner’s fertility, and others. In general, good candidates under 35 years of age can expect tubal reversal pregnancy rates between 65-70% within two years of the tubal reversal surgery.
Am I more likely to have a “tubal pregnancy” after a reversal?
The incidence of tubal pregnancy after reversal is reported to be between 3% and 10%. Once pregnancy has been confirmed by an hCG blood test, a vaginal ultrasound should be conducted within 2.5 weeks from the missed menses to confirm the pregnancy is in the uterus and not the tube.
What if my tubes cannot be repaired?
There are several many different techniques that can be used to reconnect tubes and, in some cases, the tube can even be connected directly to the uterus (usually IVF is a better option). If the tubes were severely damaged during tubal ligation, and cannot be reconnected, the best option is in vitro fertilization. Success rates vary but in appropriate candidates achieve 50% pregnancy per cycle with cumulative pregnancy rates after 4 cycles of greater than 90%.
Can surgery be successful If my tubes were tied using the Essure or Adiana method ?
Essure and Adiana provide permanent sterilization by blocking a portion of the fallopian tube. Reversal surgery in these instances is much more difficult due to the fact that a portion of the uterine wall needs to be opened and insertion of a more distal portion of the tube into the uterine wall/cavity in order to restore passage. Tubal blockage after surgery is more common in this type of surgery. While some very experienced surgeons are offering tubal reversal as an option after Essure or Adiana, it is the predominant view of infertility specialists that IVF offers much higher pregnancy rates with less risk of uterine rupture and ectopic pregnancies. We do not recommend tubal reversal after Essure or Adiana sterilization.
What if I think I am pregnant after the procedure?
Use a home pregnancy kit to confirm a positive test. Call RCC immediately to schedule an appointment to evaluate the levels of hCG (blood pregnancy test) and a serum progesterone level (helps to determine the risk of ectopic). A vaginal ultrasound will be ordered when appropriate to insure the pregnancy is in the uterus and not the fallopian tube.
What do I do if I have not conceived after tubal reversal?
We recommend evaluation 12 months after tubal reversal if less than 35 years of age, 6 months if between age 30-39 and after 3 months if over the age of 39. We initially recommend obtaining a hysterosalpingogram (HSG) to determine if the fallopian tubes are open. If the tubes are blocked, IVF is recommended. If at least 1 tube is open, further evaluation and treatment (ovulation enhancement and/or artificial insemination) should be considered to increase the chance for conception).
Comparison of Tubal Reversal to IVF
The table below shows a detailed comparison of the advantages of IVF vs. traditional tubal reversal surgery. When tubal blockage is the only cause of infertility, IVF success rates are typically high.
Comparison of IVF and Tubal Reversal Surgery (Mini-Laparotomy)
Factors Affecting Success
| Factors | IVF | Tubal Reversal via Mini-Laparotomy |
| Age <35, adequate tubal length, normal uterus, normal egg quality testing, normal semen analysis | >50-60% delivered pregnancy rate per treatment cycle (1 month). >90% cumulative chance for delivery with 4 fresh IVF cycles. | 5-15% delivered pregnancy rate per natural cycle after tubal reversal surgery, >50-60% cumulative chance for conception within 2 years |
| Age 40, otherwise same as above | 20-30% delivered pregnancy rate per treatment cycle, >60% cumulative chance for delivery with 4 fresh IVF cycles. | 1-5% delivered pregnancy rate per natural cycle after tubal reversal surgery, >30-40% cumulative chance for conception in 2 years |
| Age 44, otherwise same as above (most women have abnormal egg quality test results at this age) | 2% delivered pregnancy rate per treatment cycle (not recommended). The use of donor egg should be considered. | <1% delivered pregnancy rate per natural cycle after surgery. Surgery is not recommended. The use of donor egg should be considered. |
| Short tubal length or fimbriectomy (distal tube removed) | Same as above | Lower pregnancy rate and higher ectopic rate. Surgery is not recommended. |
| Abnormal semen parameters (expected low fertilization rates) | Same as above | Lower pregnancy rate. Surgery is not recommended unless the use of donor sperm is planned. |
| Marginal egg quality | Lower pregnancy rate but possibly a better option given the higher monthly conception rate | Lower pregnancy rate but possibly less expensive as multiple monthly attempts can be made at no additional cost |
| Poor egg quality (low egg retrieval score, high FSH) | Not recommended. Patient should consider the use of donor egg. | Not recommended. Patient should consider the use of donor egg. |
| History of significant pelvic infection(s), pelvic adhesions, advanced endometriosis or prior ectopic pregnancy | No change in pregnancy rate. | Not recommended. |
| Days off work for treatment cycle or surgery and recovery | 2-6 office visits (30 minutes) over 10 days, 1 day for egg retrieval, 1 day for embryo transfer, feeling of pelvic bloating may last 1-3 weeks. | 1 day for tubal reversal surgery, possible 1-2 days in the hospital, 3-10 days at home for recovery, 6 weeks for “complete” recovery, preoperative and postoperative office visit |
| Time to conception | Usually within 6-12 months | Up to 1-2 years |
| Size of incision | No incisions needed, needle aspiration of eggs performed | One 5-6 cm lower abdominal incision |
| Risk for ectopic pregnancy (potentially life threatening) | 1-2% | 5-20% – dependent on tubal length, tubal opening size match, and associated adhesions |
| 2 or more children desired | 20-30% twin rate with transfer of 2 good day 5 embryos (more than 2 not recommended) | 1-2% chance for twins in a natural cycle, if pregnancy is successful, no additional costs for attempting more pregnancies |
| Need for contraception after delivery | Tubal ligation is still effective | Yes |
| Cost (prepaid cash prices) | $7,000 – $13,000 per treatment cycle | $10,000-$15,000 in Utah, <$7,000 in some tubal reversal surgery centers outside of Utah |
| Money Back Guarantee option available if no delivery | Yes, 100% of fees paid to RCC, certain restrictions apply, no refund for medication or anesthesia costs | No |
