NY Tubal Reversal

The women’s Fallopian must be open to provide access of the sperm to the egg; the tube is where they travel to meet one another, merge together (”fertilize”) to form the beginning of the babys ’growth(=the “embryo”) which will continue to develop as it travels though the tube and is eventually deposited into the uterus (the “womb”) where it takes root ("implantation”) and grow into a baby.

Your tubes weren’t really “tied”; this is only the slang term for having a tubal ligation or sterilization.

A part of your tube has either been removed or destroyed by cutting and suturing(e.g. Pomeroy procedure), laparoscopic burning or cautery, or by crushing using a clip, band, or ring applied to the tube. The newer Essure and Adrianna procedures permanently damage and block the beginning of the tube as it exits the uterus by hysteroscopically inserting(though the uterine cavity) a destructive permanent metal device into the tube.
 

Rarely the end of the tube is sutured or burned and the fingerlike projections needed to sweep the ovulated egg into the tubal opening(= the “fimbriae”) excised, this procedure being called a “fimbriectomy”.

Anatomically,the degree of success depends on how long the tube is post repair and if the the fimbriae have been left in good condition.

Although I have successfully repaired tubes as short as 1.5 cm post surgery and those that have had their fimbriae removed, success is progressively less and less the shorter the resulting tube and the with reduction in the amount of healthy fimbrial tissue. IVF may be recommended as having greater potential for success in some cases and can be arranged at our affiliate IVF center.

Clip sterilization often yields the least tubal damage and high reversal success; extensive tubal cauterizations and fimbriectomy cause more extensive damage that in general may give lesser success on reversal. However each individual case differs and any sterilization technique which has caused minimal damage can lead to excellent success rates.

Therefore, before your consultation, we need to know the details of your tubal sterilization surgery; you should request in writing by letter, email or fax from either the doctor who did your sterilization or the medical records department of the center where it was done a copy of the “dictated” or handwritten operative report of your tubal sterilization and the accompanying pathology report. Photocopies of any videoprints if taken at the time of surgery should be obtained.

Often this will be enough for us to determine the condition and length of the remaining tube, the key to us knowing what procedure is best for you tubal reversal and approximately what the success rates should be.

If this information is unavailable or unclear, we recommend doing a laparoscopic/hysteroscopic surgical visual evaluation of your tubes on the day of your scheduled tubal reversal; based on what we find, we will then proceed with or cancel your tubal reversal based an whatever criteria we have agreed on presurgery. Although far less accurate, a tubal-uterine xray (HSG= hysterosalpingogram ) or sonohysterogram may be done instead of laparoscopy since it is less invasive and expensive; these can be done by a competent radiologist before your NY Tubal Reversal Consultation or by Dr. Wenof; copies of the films should be sent to us for review. Sonohysterogram can be done however on the day of your scheduled surgery preceding the procedure at an additional cost, as is the laparoscopy /hysteroscopy. These xrays however only give information of the uterine cavity and the part of the tube still attached to the uterus. The condition and length of the disconnected distal end of the tubal remains unknown, somewhat compromising our ability to optimally counsel you.

Yes! The major additional factors include your “ovarian reserve” and the “quality of the sperm”.
 

Ovarian reserve means both the quality and quantity of fertilizable eggs readily available in your ovaries. Age is the most important determining factor, however past ovarian surgery, radiation, or chemotherapy may damage the ovary and reduce egg reserve prematurely. Unfortunately, some women are born with less egg reserve or have medical conditions that reduce their reserve.

We recommend checking your ovarian reserve before your procedure with a series of tests.Serum FSH(=Follicle Stimulating Hormone) and E2(estradiol) must be done on day 2,3,or 4 of your menses; serum AMH(Antimullerian Hormone) as well as a transvaginal ovarian ultrasound to count the number of follicle sizes 2-10 mm.(=”antral follicles”), called an AFC or Antral Follicle Count can be done anytime of your menstrual cycle and are done to measure egg reserve.

An accurate sperm count (Semenanalysis) is strongly recommended; it should be done in a bona fide “fertility lab”, not in a general commercial lab! Most commercial labs don’t use optimal techniques to assess sperm counts, yielding to questionable accuracy of their results. Improper fertility therapeutic choices might be recommended based on an inaccurate semenanalysis which could sabotage your potential for success!

NO! There are 3 distinct types of repair depending on the the type of sterilization done: Tubal Reanastomosis, Tubal Reimplantation (Tubal Implantation), and Terminal Neosalpingostomy.

Tubal Reanastomosis reconnects the 2 cut portions of the tube when a part of the midportion has been excised or destroyed by open ligation (e.g.”Pomeroy procedure”), by laparoscopic cauterization (“burning”), or by a clip or ring application.
 

After opening the healed blocked middle portions of the tubes , their openings are realigned with fine microsurgical sutures, and stitched back together restoring patency to the entire tube.
Tubal Reimplantation is the process of opening the blocked tube and reinserting through a new “hole in the uterus” when the original opening has been damaged beyond repair. Certain tubal cauterizations done exactly where the tube exits the uterus (the ”cornual area”), and all Essure and Adrianna sterilizations cause so much damage to the original area of tubal entry into the uterus, that new openings must be made into which the opened ends of the beginning of the tubes are placed and suture secured. The new opening is the sutured closed in such a way to prevent compression and blockage of the inserted tube, but with enough strength to reduce the chances of spontaneous uterine ruture during the enlargement of the uterus during pregnancy.

For this reason, anyone undergoing tubal reimplantation must deliver by prescheduled C-Section and never be allowed to go though labor to prevent uterine rupture!!!

Terminal Neosalpingostomy is done when sterilization has been done by removal of the fimbriae of the tube (e.g. Ichida Procedure). The poorest success rates of at best 20-40% occur; this is seldom done in the USA but is still practiced in other countries. Since the finger-like projections that sweep the egg into the tube to allow optimal fertilization are missing, we try to recreate a working tubal opening at the far (distal or ovarian) end of the tube by surgically opening it and folding back the end, much like folding back a shirt sleeve. Sometimes a “pseudofimbriae“ will form from the exposed tubal lining and pregnancies occur.

Yes, since we use only a small few- inch incision to gain access to your inner pelvic cavity, if your abdominal wall is too thick due to increased weight, the access to your tubes is compromised.

Although a larger incision could solve the problems, it might also require a more difficult prolonged recovery necessitating a formal, and far more costly, in-hospital procedure with increased postop pain, complications, and an overnight stay.

We have therefore developed methods of same day outpatient tubal reversal for heavier individuals that are either entirely laparoscopic/hysteroscopic or “hybrid” = laparoscopy/hysteroscopy combined with minilapartomy (our standard incision). However these procedures are much more difficult and time consuming, taking as long as 3x that of are regular reversal. We therefore must charge progressively higher additional costs as the weight and BMI increases. The precise cost would be determined at the time of your consultation.

If your ovarian reserve is normal and you are willing to commit to a 6-12 month program of weight loss, we would be glad to delay your procedure until the standard reversal can be technically accomplished. We will even assist you in finding the right doctor near you qualified in giving you such assistance.

Since obesity alone lowers fertility and increases miscarriages and pregnancy complications in all women, although not mandatory , we strongly recommend presurgical weight loss as the best course of action if your egg reserve is normal!

Costs are based on the difficulty and the average length of the operation needed. This, in turn, is determined by your BMI( weight vs height), and the nature and extent of the tubal damage done by your particular type of sterilization . Review of the operative and pathology reports of the tubal sterilization usually gives us this information. However, as previously discussed , additional Xray procedures, laboratory tests, or in a few individuals, a diagnostic Laparoscopy/Hysteroscopy is necessary to know which reversal technique is recommended; these tests impart additional costs.

The COMPREHENSIVE SURGICAL FEE includes the following:

• Careful review of all forms and records submitted and advise of any further testing recommended or  missing befor the intitial consultation.
• Initial comprehensive consultation with Dr. Wenof at which all information is further reviewed,clarified, and a therapeutic plan is formulated to give maximum success.  Any still missing or recommended tests or preliminary treatments are arranged.
• Scheduling of your surgery.
• Recommended  followup consultations at 1 and 4 weeks  by phone or in person are  scheduled.
• All “surgicenter” fee including the preop and postop “recovery room” fees; the surgeons operating fee, the anesthesiology fees and intraoperative and immediate postop medications.
• Late pm phone “ rounds” to check on how you are feeling.

Costs are based on the difficulty and the average length of the operation needed. This, in turn, is determined by your BMI( weight vs height), and the nature and extent of the tubal damage done by your particular type of  sterilization . Review of the  operative and pathology reports of   the  tubal sterilization usually gives us this information. However, as previously discussed , additional Xray procedures, laboratory tests, or in a few individuals, a diagnostic Laparoscopy/Hysteroscopy is  necessary to know which reversal technique is recommended; these tests impart additional costs.

The  COMPREHENSIVE  SURGICAL  FEE includes the following:

• Careful review of all forms and records submitted and advise of any further testing recommended or  missing befor the intitial consultation.
• Initial comprehensive consultation with Dr. Wenof at which all information is further reviewed,clarified, and a therapeutic plan is formulated to give maximum success.  Any still missing or recommended tests or preliminary treatments are arranged.
• Scheduling of your surgery.
• Recommended  followup consultations at 1 and 4 weeks  by phone or in person are  scheduled.
• All “surgicenter” fee including the preop and postop “recovery room” fees; the surgeons operating fee, the anesthesiology fees and intraoperative and immediate postop medications.
• Late pm phone “ rounds” to check on how you are feeling.