Surgery

Conditions

Surgery may be needed for the following conditions

Endometriosis

Endometriosis is common, affecting 5-10% of women and can cause pelvic pain, severe cramping during periods, painful urination, painful and possibly bloody bowel movements, pain during intercourse, and infertility. It is estimated that endometriosis is present in 38-50% of all infertile women, and in 70-80% of women with chronic pelvic pain.

Every month the lining of the uterus thickens and becomes more vascular in order to support the implantation of an embryo and fetal development. The cells lining the uterus (endometrial cells) have the capacity to grow and divide rapidly to cause this thickening. Endometriosis occurs when endometrial cells enter the pelvic cavity and attach to the reproductive and other organs and continue to grow. Damage and blockage of the fallopian tubes can also occur. Endometriosis is “foreign” to the pelvic cavity so the body mounts an immunologic attack to destroy it, thus creating an inflammatory environment in the pelvis.

There are different theories on the cause of endometriosis. The incidence of endometriosis is higher in daughters of mothers who had endometriosis suggesting a genetic link. The most commonly accepted theory is that menstrual blood “back flows” into the pelvic cavity at the end of the ovulatory cycle. This blood is very rich in endometrial cells.Endometriosis needs estrogen to support its growth and survival. Therefore, the most common medical treatment is using medication (Lupron) which lowers estrogen levels.

Endometrial implants are sometimes removed surgically by laparoscopy. RCC’s reproductive surgeons are board certified in reproductive endocrinology and infertility and have extensive laparoscopic surgical experience. One advantage of selecting an infertility specialist to perform the diagnostic laparoscopy is that oftentimes endometriosis can be treated during this procedure.

Uterine Abnormalities

The uterus must be free of large obstructions, such as endometrial polyps and fibroids for successful implantation and pregnancy to result. These conditions are often observed on the hysterosalpinogram (HSG) during hysteroscopy or at the time of 3D saline sonogram. Sometimes, obstructions can be removed laproscopically or by using the hysteroscope during outpatient surgery.

The uterus must also be normally shaped (triangular) and free of congenital defects such as the “double uterus” (uterus didelphys) which has two horns, unicornuate uterus (only one half of the normal uterus), uterine septum (muscle growth from the top of the inside of the uterus that protrudes into the cavity) and bicornuate uterus (heart shaped). Some of these defects such as a uterine septum can be corrected by a skilled reproductive surgeon.

The lining of the uterus is known as the endometrium and consists of cells that can rapidly divide and develop under the influence of estrogen and progesterone. This development is necessary to provide an environment for optimal embryonic/fetal development. Unfortunately, some of these endometrial cells may enter the bloodstream during menses resulting in endometriosis. Sometimes the entire endometrium (lining) is not sloughed off during menses and the retained tissues form an endometrial polyp. Large endometrial polyps can almost act like an IUD and should usually be surgically removed prior to further attempts at pregnancy.

Tubal Reversal

Factors such as type of tubal ligation, patient age, and whether there are male infertility issues must be considered when deciding whether tubal reversal or IVF are the best choice. The best candidates for tubal reversal are younger women with good egg quality (ovarian reserve). These women have time to complete numerous natural intercourse cycles thus increasing the chances of success. Per cycle success rates with IVF are much higher then tubal reversal, however, some women require more than one cycle.

Women with reduced ovarian reserve (OR) may have very limited time to conceive using their own eggs as egg quality can decrease with age. IVF is usually the best choice when OR is very low making donor egg IVF the best treatment option.

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