Tubal Reversal verus in vitro fertilization (IVF)

The Burning Question

One of the most common questions I get asked both by physicians and by patients around the Southeast is about tubal reversal surgery compared to in vitro fertilization (IVF).


It's easy to understand why there is so much interest. Millions of women have had their tubes tied. Inevitably, if millions of women are opting for "permanent" sterilization, many of them will later regret it.

I could spend a lot of time talking about who is likely to regret this decision. There is good data on that. But I'm not writing this blog entry for women who are trying to decide among different contraceptive options. I'm writing this for the women who find themselves in the unfortunate situation of wanting another child, but their tubes have been surgically blocked, cut, burned, clipped, tied, fried (and/or all of the above).


The bottom line is there are many people who regret their decision and they always ask me the same question: which is better, tubal reversal surgery (reanastamosis) or IVF?


The Universal Answer
One of my mentors drove a lot of residents and fellows crazy when they approached him looking for a quick answer to what they thought was an easy question.


To almost every question, his answer was, "It depends."

Then he'd launch into a 5-10 minute lecture on the pro's and con's and nuances, caveats, hard and fast rules, exceptions to those rules and so on.


I'll try not to do that to you.


If you want the short answer to this question, I'll give it to you and I'll tell you why. Just scroll to the bottom of this blog and read: "The Short Answer." But be warned, you'll miss some good stuff in between.


Critical Questions I Must Know to Answer the Question for You...
For me to know to best advise a patient, there are some absolutely critical questions I need answered.


1) How were her tubes sterilized?
2) How old is she?
3) How many more children does she wish to have?
4) Does her partner have adequate sperm?
5) Does she or her partner have a history of previous infertility?
6) Does she or her partner have any religious barriers to IVF?


Tackling these questions one at a time:

1) How were her tubes sterilized?

In general, the less damage to the tube, the easier the repair. Some methods,
such as the Filshie Clip, or the Fallope Ring create very little damage and
reconnecting these is a lot easier than if the tubes were burned in multiple
locations, or if large segments of the tube were resected. It can be
important for a physician to see the operative report from the tubal
ligation. If a lot of damaged tube has to be removed and there is not much
to put back together, the chances of success are much lower. In general, a
minimum of 4 cm of tube is required at the conclusion of the reanastomosis
to have a legitimate shot at getting pregnant.

2) How old is she?

Older women, especially in their forties, have less time to conceive and
their monthly pregnancy rates are much lower than younger women. After age 37, monthly fertility rates begin to drop rapidly. There are women at age 37 who get their tubes reversed, but if they have not had a baby in one year, then their chances of conceiving at age 38 are significantly lower. Each 6 months to a year, fertility wanes. For good prognosis patients, a single cycle of IVF is generally as successful as trying to conceive for one year on your own. In other words, you can pack a year's worth of treatment into two months.

Even for young women, ovarian reserve testing should be considered. This testing can tell you if your eggs are behaving their age, or
like a much older woman.

3) How many more children does she wish to have?

A young woman who wants to have several more children spaced out over several years may be the best candidate for tubal ligation reversal. When she's not trying to get pregnant, she'll need to use some kind of birth control, but this can stop when she's ready to try again.

On the other hand, a woman who wants only one child, or the older woman who wants more than one child may be a better candidate for IVF. If she only want one child, we can limit the number of embryos we place in the uterus. In some cases, we only place one embryo in the uterus. Once she delivers her baby, she still has her sterilization in place.

Finally, the older woman who wants more than one child may do best with IVF. In her case, we can be a little more aggressive about the number of embryos we place in the uterus, assuming she is willing chance the pregnancy will be twins. Also, if she gets pregnant and
delivers a single child, she may have embryos that we were able to
freeze. Months later, after birth, after she finishes breast feeding and
gets through the sleep deprivation of having a newborn, she can return
to clinic and use the embryos that are in storage. She will have
virtually the same chance of conceiving as she did when she was a
younger age.

4) Does her partner have adequate sperm?

A lot of centers which specialize in tubal ligation reversals do not require a
semen analysis of the male partner. I will acknowledge that in most cases, the male partner will have adequate sperm, but on numerous occasions, shortly before tubal surgery, I have found that the male partner's sample was wholly inadequate. Surgery would have put those women at unnecessary risk, with little hope of achieving pregnancy. If a physician does not offer or recommend a semen analysis be performed, I would be suspicious that he or she was not acting in my best interest.

5) Does either partner have a prior history of infertility?

If so, I would carefully consider your choice. In these cases spontaneous
pregnancy is much less likely and IVF would be favored.

6) Does she have religious barriers to IVF?

If so, tubal ligation should be preferred.

So who should you seek for advice?

The best people to talk to are physicians who perform both procedures. They are less likely to sway you toward one over the other. They will also try to put the statistics into real clinical context to help you understand what you're getting for your time, effort and money.

From them, you should get truthful statistics about real results. If you looked at a graph of how many pregnancies occur after tubal ligation reversal compared to IVF, you would probably run straight to surgery and have your tubes reversed - because in every age group, far more pregnancies are achieved per reversal than per IVF cycle (according to nationwide IVF statistics).

But not so fast! If you look a little closer, you'll notice the live birth rate only barely favors tubal reversal over the average national IVF success rate.

First, what happened to all of those extra pregnancies? Many of these tubal reversal pregnancies are located in the tube.

Another reason live birth rates are similar between tubal reversal and IVF is this: the statistical deck is stacked in favor of tubal reversal. That's because many tubal reversal clinics compare their success rates to "average national IVF success rates."

This is NOT a fair comparison.

Tubal reversal patients are the best prognosis patients for conception. To compare these patients to ALL IVF patients is like comparing apples to Orangutans.

Most IVF patients do not have proven fertility and voluntary sterility like tubal reversal patients do; most have multiple other more-serious fertility problems.

If you randomised these best prognosis patients to tubal reversal versus IVF, you would almost certainly see significantly higher live birth rates from IVF, with a much lower risk of tubal pregnancy.

The Short Answer

Ok, I promised you a short answer. If you've read this far, you're probably going to think I'm just going to recommend IVF, but I'm not going to do that. See which category you are in, and this is generally what I would advise.

1) Money is scarce and you can find a cheap tubal reversal and you're willing to sacrifice some chance of success - go with tubal reversal.
2) If you have religious conflicts with IVF - go with tubal reversal.
3) If you are a young woman who wants several more children spread out over a number of years - go with tubal reversal.
4) If you want to get pregnant but don't want to have to use future contraception - go with IVF.
5) If you want just one child - go with IVF.
6) If you're older and want several more children - go with IVF.
7) If you want the highest chance of pregnancy, period - go with IVF.


Conclusion

I hope this was simple enough. There are some details, some pros and cons of each choice that I have left out of this blog post. For any individual patient, there may be additional testing I'd recommend. I didn't discuss all the risks associated with each procedure, either.

If you have questions regarding which treatment is right for you, come see us. Dr. Scotchie and I will try to help you find it.

Interpret With Caution!

It’s been a while since I’ve written anything here. Quite frankly, I’ve been a bit busy, and no topic seemed particularly inspiring. Until yesterday.

I was asked to make a comment for a local television station, WRCB TV3 Eyewitness News, which was running a story on a New York fertility doctor (Dr. Sami David) who says that too many couple use IVF to get pregnant and that many of those couples should try alternate methods first. He notes that his favorite fertility drug is antibiotics.

What I am about to write may at first sound like a preamble to denouncing this doctor’s claims, or like a build up to a defense of IVF.

It really is neither.

The "Caution" Part...

I am saying there is a lot said about fertility and infertility treatments which should be interpreted with caution. In this post I’m going to elaborate on some of the ways any news story you might encounter can be misinterpreted.

This post is also an expansion of what I would have like to have said if the news station actually had the time to air it. My response to the news story was limited to about 8 seconds and the reporter was only able to highlight a couple of sentences of my response. Such is the nature of broadcast journalism. I am very grateful to Channel 3, the NBC affiliate, that they gave me what time they could spare to my point of view. I am also very happy that they put my entire response on their website.

It appears that the story was filmed by a New York affiliate station and sent to local NBC affiliates from the network. Local affiliates could interview local physicians as time permitted. In case the link above does not work, I’ll give you the skinny on the news story:

Dr. Sami David performed the first IVF procedure in New York and he has not done one since that time. He says that IVF has a high failure rate and that many people who resort to IVF could get pregnant without it. He said doctors need to pay more attention to treating the man and looking for not-so-obvious causes of infertility and treat those causes. The story illustrates the proof of this concept by interviewing a woman who went through three IVF cycles but miscarried all three times. She then saw Dr. David, conceived and now, happily, has a child. Dr. David has now written a book explaining much of this. It is called Making Babies.

Unavoidable Bias

There are several inherent and hard to avoid biases in stories like this. For example, simply by saying Dr. David is offering an alternative, this does not mean many people in our field aren’t also incorporating some of the same treatments. Much of what Dr. David promotes and what your typical fertility would promote will be similar. The implication is that most fertility doctors push a lot of people to IVF.

As a matter of fact, fewer than 10% of our patients ever require IVF. Dr. Scotchie and I try very hard to use IVF as a last resort.

Another unavoidable bias is that simply by reporting this story, makes the information seem like its new. Just because this story is in the news, this does not make it new. The reason Dr. David is in the news is not because of remarkable success rates. The reason he is in the news is because he has written a book. He is promoting the book and he seems to be doing a good job with that. By saying this, I’m not trying to imply that Dr. David wrote this only to promote his practice and to make money. I have not read the book, but until I see proof otherwise, I’ll assume that he wrote it to get the word out that for some people, there are alternatives to IVF. Quite frankly, if I were a reporter, I’d be inclined to write a story about it, because there people who would be interested in it.

My First Thought

My first thought upon hearing what Dr. Sami has to say is: I agree that some people get thrust into IVF too quickly. I think some doctors don’t do enough investigation to find out if there is a treatable cause. This is especially true of male factor infertility. I know this because I get to review a lot of medical records as a second opinion, and not just from Tennessee or the surrounding areas. Friends from all over the country refer their friends to me to give them my assessment.

Doctors are partly to blame, and there are various reasons for this. High tech treatments do generate more income for the practice than low tech treatments. Also, high tech treatments are generally far more likely to be successful than low tech treatments. A pregnant patient is usually a very satisfied patient. It makes the patient feel good. It makes the doctor feel good.

It can be difficult for patients to know if a doctor is pushing you too quickly into IVF. Second opinions can be valuable here. However… CAUTION must be exercised when getting a second opinion. (I promise to write about this VERY soon. But this is too big a topic to tackle here.)

Sometimes the doctors push for IVF too quickly and, truthfully, sometimes the patients push themselves into IVF before they’ve tried all other reasonable options.

My Biggest Fear

My biggest fear about this story is that there would be people who would interpret Dr. David’s message in a way that would cause them to delay seeking the advice of a fertility specialist.

I worry especially about women approaching their mid- to late-30s who spend several years trying on their own, or using herbal or homeopathic remedies. By the time they reach my office, they have significantly decreased chances of conceiving due to age, or due to the limited number of remaining reproductive years with which to attempt pregnancy.

Despite treatment, it can take some couples years to conceive. I should know. My wife and I were one of those couples.

Dangers of Interpreting Success

It is sometimes hard for doctors to know if it was treatment or time which cured a patient.

I am careful to counsel my patients that I may not know if it was our treatment which helped them conceive. In some cases, all we can say is that we increased the odds of conception in a given month.

It is a happy reality of my practice that some patients will conceive spontaneously before, between or after an infertility treatment.

In cases when patients get pregnant between treatments, patients usually understand that they did not conceive due to treatment. I will know it, too.

Some practitioners have a difficult time in knowing if a patient got pregnant because of treatment or simply because it was a patient’s time to conceive. For example: Suppose I am a doctor who gives everyone an antibiotic or an herbal remedy. A portion of my patients would have conceived anyway. But since all of my patients are “under treatment” at all times, I would be likely to think that the therapy was what made the difference. The patient would think so, too.

Under a lot of alternative regimens, patients are always technically in treatment. In these cases, it can be very difficult to know what actually caused the pregnancy. In my experience, the assumption of the practitioner and the patient is to give credit to the treatment.

In certain situations, I downplay my role to patients. Still, when they get pregnant, they give me the credit, even when it’s more likely that I was not the difference maker.

Example:

If I do surgery on 12 infertility patients and remove low-grade endometriosis and then do no other treatments, studies have shown that 3 of them will get pregnant within the next 12 months. All three who conceive say “the surgery worked” and that’s why they got pregnant. All three give me the credit.

The truth is, if I had not done surgery, 2 of the 12 would have conceived on their own.

This means, I must do 12 surgeries to get one additional pregnancy than doing nothing. This is called number needed to treat, NNT, to get 1 different outcome.

I tell patients this beforehand. Still, EVERY single patient who has gotten pregnant after surgery remarks something like, “The surgery worked!”

I usually say something like, “Maybe, there’s a 33% chance that it did.”

This example illustrates the point that doctors and patients can be very likely to give or accept credit more often than deserved.

Even when it is more probable that my intervention had something to do with the pregnancy, I am careful to counsel patients that the only thing we did was increase the chance.

For Example:

If I do an intrauterine insemination (IUI) on a patient and the patient gets pregnant, I cannot always say that the pregnancy was due to the procedure or due to intercourse that she and her partner had a few days earlier. All I know is that the IUI increased their chances of conception that month.

The news story used an example of a patient to represent Dr. David's success. In this example, the patient had failed to have a baby after three IVF attempts. She was then treated by Dr. David, and after an unspecified amount of time, she got pregnant. Did Dr. David's treatment get her pregnant? Or was it just her time to succeed? Clearly both the doctor and the patient have given him the credit. In all honesty, neither of them could possibly know.

I am wary when anecdotes are used as evidence that a treatment is successful. It does not mean I don’t try some of those same treatments myself, but both the patient and I must still be wary about interpreting the results.

My Final Thought

I’m sure there is a lot more I could write. But my wife is cleaning the house for family members of mine that are arriving from out of town, and it seems somehow wrong that she is doing all of the work, so I’ll leave it at this.

I have not read Dr. David’s book, yet. My suspicion is that I will agree much more than disagree with it. I do think it is very sensible to not turn your back on any practical ways to improve your ability to conceive.

There are many recommendations out there for stress reduction, optimal supplements, exercise, sexual positions. I’ll try to address some of these issues in future blogs.

I think I’ll write about the pitfalls of second opinions next.

But first, I have to mop.