Post Tubal Ligation Tubal Reanastomosis Versus In Vitro Fertilization
Approximately 10% of women who undergo tubal ligation subsequently wish to have another child – the most common reason being a new male partner who has never fathered children. Tubal ligation involves the interruption of the tube, typically in the mid portion or rarely resection of the distal end of the tube. All tubal ligation patients have the option of in vitro fertilization (IVF), assuming they have good ovarian reserve, i.e. a reasonable number of good quality eggs left in their ovaries. Ovarian reserve can be checked by a variety of means, the most accurate being an ultrasound count of follicles in the ovary along with a blood test known as antimullerian hormone level.
To be a candidate for tubal reconstructive surgery it must be ascertained that the patient has sufficient healthy remaining tube and that the distal working end of the tube has not been removed or damaged. If a tubal ligation has been performed using cautery often extensive tube damage has occurred. These individuals in general are not good candidates for surgery. Prior to considering tubal surgery a semen analysis to rule out a severe male factor should be performed. If a severe male factor is found, IVF using intracytoplasmic sperm injection (ICSI) is likely to be the best option.
If the female partner is older than 35, despite good ovarian reserve she is likely to have an increased proportion of poor quality eggs, often resulting in a significant delay to conception. For the older patient IVF is likely to be the preferable option. If ovarian reserve is poor, donor egg in vitro fertilization is the most realistic option. If the female partner is 35 years or less with good ovarian reserve pregnancy rates of approximately 70% can be expected with surgery, comparable to cumulative pregnancy rates with IVF.
At the Florida Institute for Reproductive Medicine tubal reanastomosis is being performed on an outpatient basis with the use of the da Vinci robot allowing individuals to return to work typically within one to three days. Surgery is associated with a significant increase in the risk of an ectopic pregnancy, i.e. a pregnancy getting “stuck” in the tube. This condition can be serious requiring emergent surgery. If a couple decides they only want a single pregnancy the issue of future contraception must be addressed. At the Florida Institute for Reproductive Medicine, using the robotic laparoscopic approach we are able to offer this surgery at a cost of $6,750 (cost for an average IVF cycle is $11,000). The primary disadvantage of IVF is a high multiple pregnancy rate. For individuals less than 38 years of age multiple pregnancy rates range from 20-40%, 98% of these being twins. While the great majority of twins do very well there is an increased risk of morbidity and mortality. Almost all multiple pregnancies are delivered by cesarean section. The issue of a multiple pregnancy can be avoided by electing to transfer a single embryo. For couples who are ethically opposed to IVF because of the issue of freezing (pre)embryos, this can be avoided through egg freezing. Because of the disadvantages associated with surgery approximately 9 out of 10 couples at our center are electing IVF as opposed to surgery. With the advent of the low cost outpatient robotic approach, we believe this ratio will decrease.