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Thoughts on the management of infertility


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Thoughts on Achieving Pregnancy after a Tubal Ligation

Pregnancy is certainly possible after a tubal ligation. You most likely have the opportunity to choose between two options: repairing the tubes (tubal reversal surgery) or bypassing the tubes (IVF). My objective is to provide a review of the issues you may consider in making this choice.

Successful pregnancy after tubal reversal surgery depends on how much of the tube was destroyed (and where) by the tubal ligation, the competence of the surgeon in performing this procedure, and the underlying fertility of the couple.

Most of the tubal ligations that we see in this region of the country use either a post partum Pomroy-type procedure or are laparoscopic and use coagulation (electrocautery). These procedures remove or destroy a large segment of the tube. The minimal length of tube after repair necessary to achieve pregnancy is at least four centimeters. Also the fimbria (or distal end) needs to present and undamaged. The best published studies show a tubal patency rate after tubal reversal surgery in this setting of 70%. If the tubal ligation used a Hulka clip or a fallope ring, then the best published studies cite a 90% patency rate after surgery.

The pregnancy/delivery rate will be always be lower than the patency rate and will be related to fertility factors in the couple. A long interval to achieve pregnancy before the tubal ligation portends a poor prognosis after the tubal reversal surgery. It is likely that the most significant factor in achieving pregnancy quickly has also changed- namely age. For example, the pregnancy rate after any therapy decreases by 50% from age 35 to age 40.

Some patients decide between tubal reversal surgery and IVF on the basis of cost. If both procedures are self-paid, then IVF usually provides the lower cost for producing a baby. If the surgery is paid for, one still has to consider the time lost from work (about 6 weeks with surgery and days to a week with IVF).

Tubal reversal surgery is best for the younger (under thirty) patient, who wishes to benefit from the surgery by having more than one child from the procedure. Most reproductive endocrinologists would recommend against the surgery for women age 40 and above, because the chance of getting pregnant after the surgery is rather low and you are likely to be giving up your real chance of getting pregnant with IVF since that pregnancy rate rapidly decreases with age.

Between age thirty and forty, the decision to do either IVF or undertake tubal reversal surgery is less clear and depends on individual factors. For example, a 34 year old who had a laparoscopic tubal ligation by cautery should expect a pregnancy/delivery rate of about 49% in the first year after surgery (patency rate of 70% and unselected pregnancy rate in this age range after a year of 70%). Alternatively one might expect a pregnancy rate of greater than 58% after two tries at IVF (the delivery rate after one cycle of IVF for infertility patients under age 35 in many programs is about 35%).

At age thirty, a patient who had a tubal ligation using a laparoscopic Hulka clip would have an expected pregnancy/delivery rate of about 72% over the first year after surgery (90% patency rate together with an 80% pregnancy/delivery rate). The expected pregnancy/delivery rate after three cycle of IVF would be 73% (still assuming a pregnancy/delivery rate of 35%/cycle).

Another option to consider after tubal ligation is Mini-stim IVF.  If the female partner is young and has a high underlying fertility, then producing one or two fertilized embryos may be all that is necessary to achieve pregnancy.  Few drugs are used and the cost is only a third to  a half of a traditional IVF cycle.