Tubal ligation is meant to be a permanent procedure to achieve sterilization in a woman but certain circumstances may cause a person to regret their decision and ask for a reversal of the procedure. While in many cases it may be possible to perform a tubal ligation reversal procedure, it has to be kept in mind that this involves undergoing major surgery. It is a much more complicated and fairly expensive compared to a tubal ligation procedure.
What is Tubal Ligation Reversal?
Tubal ligation reversal is a procedure by which the separated segments of the fallopian tubes are reattached or realigned again. This procedure is also called tubal reanastomosis or recanalization. By reestablishing continuity of the fallopian tubes it makes fertilization and subsequent pregnancy possible. However, it is a lengthy procedure, needing special skills of the surgeon and is a costly affair, with no absolute guarantee of pregnancy.
Reasons for a Tubal Ligation Reversal
Regret following tubal sterilization may occur due to a number of reasons, prompting a woman to seek advice regarding reversal procedures.
- A change in circumstances, such as death of a child, divorce, death of her spouse or remarriage, may make a woman regret her decision.
- The decision for tubal sterilization may have been made in haste, without really considering the implications. This is one of the common reasons for the request for a reversal by young women, and sometimes if is done too soon after delivery.
- The decision may have been taken under pressure, either from the husband, partner or other family members.
- Chances of regret are there if tubal sterilization was done as a means of tackling certain situations such as marital problems, financial difficulties, being out of work, or some short-term physical or mental problem.
Tubal Ligation Reversal Procedure
- Tubal ligation reversal is a major surgery and is a more complicated procedure than tubal ligation.
- It may take from 1 to 3 hours to perform this surgery.
- Usually has to be done under general anesthesia.
- The incision may be larger than the one given for the tubal sterilization procedure resulting in long term concerns about scarring.
- The patient may need a longer hospital stay and a longer time to recuperate.
Newer methods of reversal using microsurgery techniques may be performed under local anesthesia on an outpatient basis. Shorter operation time (may be less than an hour), only a few hours of hospital stay and quicker recovery makes this method more attractive. However, doctors performing such operations need to be specially trained in the procedure. Tiny sutures, using the thinnest of needles, are used to join the two separated portions of the tubes. The operating field, including the tubes, is visualized in a magnified manner and microsurgery also ensures less tissue damage and bleeding during the procedure.
- Minilaparotomy Tubal Reversal
- Surgery may be done under general anesthesia with a small incision on the abdomen just above the pubic bone.
- Laparoscopic Tubal Reversal
- Tiny incisions on the abdomen allow the passage of a laparoscope (a long, thin, telescope-type instrument with a camera at the end) and other microsurgical instruments for performing the operation.
- Robotic Assisted Tubal Reversal
- A remote controlled robotic system is used by the surgeon to perform this procedure.
- Tubotubal Anastomosis
- The blocked ends of the two tubal stumps are opened.
- A stent is passed through the tube and the two ends are brought close together over it.
- Sutures are placed on the muscular layer and outer serosal layer so that the tubes are aligned properly but the inner mucosal layer is left untouched.
- The stent is withdrawn and the abdomen closed in layers.
- Tubouterine Implantation
- Essure or Adiana methods of sterilization need a different type of reversal surgery than what is normally done for reversal of other sterilization methods.
- The device (coil or matrix) that is inserted in the tube to achieve sterilization impacts in the uterine end of the fallopian tube and produces scar tissue here as well as in a small part of the overlying uterus.
- To bypass the area of scarring, the intrauterine part of the tube together with the scarred portion of the uterus must be removed.
- The healthy portion of the tube is then implanted into a newly created opening in the uterus.
- This method of reversal is known as tubouterine implantation and is also done in other cases where only the farthest (distal) part of the tube is present.
- Ampullary Salpingostomy
- This is necessary when the fimbrial portion of the tube has been removed to perform tubal sterilization.
- Reversal involves opening the tubal end and folding the inner lining outwards and fixing it with sutures so that it does not close back again.
Risks of Tubal Ligation Reversal
- The main risk following a tubal ligation reversal procedure is the possibility of an ectopic pregnancy, which seems to occur quite frequently in subsequent pregnancies. After a reversal procedure a woman should be educated about this possibility and as soon as a positive pregnancy test is obtained, the first objective should be to rule out an ectopic pregnancy.
- Tubal ligation reversal procedure is a major surgery and as such, risks associated with all other surgeries are also possible here, such as :
- Anesthetic complications.
- Hemorrhage – during or after surgery.
- Injury to the surrounding organs such as the bladder and bowel.
Chances of Pregnancy after Tubal Ligation Reversal
Pregnancy rates following tubal ligation reversal are usually quite good. However, the success of ligation reversal or chances of pregnancy afterwards will depend upon certain factors, such as :
- Tubal Length
- Following tubal ligation where a part of the fallopian tube has been cut, there will be two stumps left – one attached to the uterus and the other lying separately.
- During a reversal operation, the two ends of the stumps are joined together again.
- The shorter the stumps, lesser is the chance of pregnancy following re-anastomosis.
- However, while the length of the proximal stump (attached to the uterus) can be determined by a dye test, it may not always be possible to determine the length of the separated end of the tube, so the success of the operation cannot always be predicted definitely.
- Type of Tubal Ligation
- Tubes that have been blocked with a clip or ring cause less damage and women who have undergone this method of tubal ligation have better chances of pregnancy after reversal than tubes that have been cut or burned.
- It may not be advisable to go for reversal in those women where a ligation procedure has removed a large part of the tube.
- Successful pregnancies have been achieved following reversal after newer techniques such as Essure or Adiana implant, but more data is required regarding long-term statistics.
- Tubal Diameter
- The remaining ends of the two portions of the tube that are to be reanastomosed should ideally be of the same diameter so that they can be joined together smoothly.
- This will ensure better chances of pregnancy and possibly lesser chances of ectopic pregnancy.
- Younger women have better chances of pregnancy following tubal reversal.
- Women over the age of 38 may not be suitable candidates for this procedure.
- Semen Analysis
- It is advisable to get the male partner’s semen analysis done to be sure that the sperm count, motility and sperm quality is viable for fertilization.
- This ensures that the pregnancy will not be hindered due to some problem with the male partner.
- Pelvic Pathology
Any pelvic pathology or abnormal ovarian function that may make pregnancy difficult even after tubal reversal procedure has to be ruled out.
- Other Considerations
Sometimes, even after all conditions seem favorable, pregnancy may not occur following a tubal ligation reversal procedure. In case pregnancy does not occur after a reversal procedure the only other option remaining – other than adoption – is IVF (in vitro fertilization).