This common type of tubal ligation is also called the post-partum tubal ligation. It is usually done at the time of a Cesarean Section or the day after a normal vaginal delivery. The surgeon usually holds a loop of fallopian tube with special tubal forceps and then makes about a two- to four-centimeter loop of tube that he or she ties with suture. After the loop is tied tightly, the surgeon cuts out the intervening segment of tube. Some surgeons burn the cut ends.

Fortunately, this type of ligation is also quite reversible if the surgeon did not make too large a loop or did not remove the entire ampulla in the process. Most gynecologists will place the loop at the isthmic-ampullary junction and therefore remove a little bit of each portion. This leaves the microsurgeon with the task of anastomosing the isthmic portion of the tube with the ampullary portion of the tube. These parts of the fallopian tube have different diameters and different amounts of supporting muscle wall. The ampulla can at times be paper-thin, requiring the most delicate handling and techniques.

This is sometimes a complex decision with many variables including cost, success rates, age and so forth. Let us address it in parts.

Cost – This is oftentimes the great motivator toward tubal reversal in our practice. In vitro fertilization and embryo transfer procedures are more costly than tubal reversal.

Success Rates – More than 90% of the time, at least one tube is open after the microsurgical tubal reversal by Dr. Pabon. The chance of pregnancy success after a Tubal Reversal depends on three chief factors: the age of the mother, the type of ligation reversed, and the sperm count of the male partner.

Age – Just because a person had few complications with pregnancy or fertility in their twenties, does not mean that they will be as fortunate in their thirties or forties. The chance of success depends on the quality of the eggs being produced. The eggs of women as young as 33 are known to have more abnormalities that result in decreased pregnancy rates and increased miscarriages as compared to younger women. The trend continues and worsens much more quickly after the age of 36. This is why older women have fewer pregnancies and more miscarriages. This is why almost all egg donation centers limit the age of egg donors to 32 or less. Our center’s cut-off is 30.

An older woman with a prior “unfavorable type” of tubal ligation may choose to go through the IVF program because she desires the highest chance of pregnancy in a short interval of time. A younger woman with the same “unfavorable type” of tubal ligation may choose to try the tubal ligation reversal because she has more time to conceive than the more mature woman. The younger woman has the luxury of being able to wait on IVF without a significant drop in her chance of a pregnancy. The best results after tubal reversal are those of the particular age of the patient. The monthly chance of pregnancy for a normal couple in their mid-twenties is 20-25%. This decreases with age.

In the 1950s a group of immigrants from Switzerland called the Hutterites who live in the Northwest states was studied. They are a religious sect who live in a communal fashion and do not practice contraception. Only 5 of 209 women were infertile (a low infertility rate of only 2.4%). The average age at the time of the last pregnancy was 40.9 years. Eleven percent of women had no more children after the age of 34. 33% of the women were infertile by age 40. 87% were infertile by age 45.

Age of the female partner has been shown in many studies to be the most important factor for pregnancy success. A patient can have the most perfectly repaired tubes but fail to conceive because of age. Older patients don’t have as much time to conceive. Age is sometimes an incentive to proceed with IVF because several months of trying to conceive can be “compressed” into one treatment due to the recruitment of multiple eggs that is routine in IVF.

Type of Ligation – This is simple: the shorter the tube, the lower the pregnancy rates. Tubal ligations that involve extensive damage or burning of large segments of the tube leave less tube to work with. The human fallopian tube is about seven to eight centimeters in length. After a microsurgical tubal ligation reversal, the final tubal length is noted. The chance of pregnancy is lower with shorter final tubal lengths. Pregnancy rates are very low if the final tubal length is less than 2.5 centimeters. The post partum ligations (Pomeroy or Modified Pomeroy), the clips, and rubber bands are among the best to reverse. Patients who have had removal of large portions of their tubes or extensive damage will usually choose to enter the IVF program. There are cases where the patient and her partner have had children and simply want “the possibility of pregnancy” even if the tubal length is very short. In these cases a reversal can be performed after thorough counseling and discussion of the limitations.

The Sperm Count – The World Health Organization has determined that the lowest “normal” count is 20 million per milliliter or cc of ejaculate. 20 million represents the lowest possible number to be considered normal. Most men have counts in the range of 80 to 150 million sperm per milliliter of ejaculate. A more important assessment is the “total normal motile count.” This takes into account the number of sperm that are alive and appear normal. A very good recent study determined that patients with total normal motile counts of less than 10-12 million per cc are best treated with IVF. If a male partner has a suboptimal sperm count, the chance of pregnancy even after the world’s best tubal reversal will be close to zero. Please note that sometimes low sperm counts can signify a medical problem. A qualified urologist must examine the patient. One percent of the time a testicular tumor is discovered.