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.

How Does Anyone Have a Baby?

If you are having difficulty getting or staying pregnant, you are not alone. At some point, infertility affects 15% of all couples. Recurrent pregnancy loss affects another 3% of couples.

If you are one of these couples, you may feel isolated and depressed. You will get all sorts of helpful and unhelpful advice from people (including yourself) who really do care. Perhaps one of the worst things someone can tell you is to “relax” or “quit trying so hard.” This advice generally has two effects:

To make you even more tense.

To make you think it’s all your fault.

At Tennessee Reproductive Medicine, we understand the stress that infertility and pregnancy loss causes. While it is true that in extreme cases stress can cause a woman to stop ovulating, very rarely is stress a cause of infertility. If stress isn’t causing the infertility, as so many people commonly think, let’s consider what is normal and abnormal in the world of conception so you can take charge of your fertility. 

Normal Conception Rates
After one year of adequate unprotected intercourse, 85% of couples ages 20-40 will be pregnant. Of the 15% who aren’t pregnant, half of those will be pregnant within the second year. The monthly chance of conceiving among couples in which the woman is less than 32 years old is approximately 20-25%. This illustrates that human reproduction is very INEFFICIENT! It may take some couples many months to conceive and this is within the range of normal. After age 32, monthly conception rates start to decrease slightly, then more significantly after age 35 to about 10-15% chance per month.

When Should I Seek Help Conceiving?
Infertility is considered the lack of conception after 12 months of unprotected regular intercourse (timed adequately during the suspected time of ovulation). All couples who have not conceived after 12 months warrant a full evaluation. While some couples will spontaneously conceive after 12 months of attempts, most will need some form of fertility therapy and further attempts at natural conception may be wasting precious time.

Furthermore, many couples warrant a sooner evaluation if there is a history suggestive of:

-ovulation disorders
-tubal disorders
-male reproduction disorders
-female greater than 35 years old
-endometriosis
-female with prior radiation or chemotherapy treatments

Do I need a fertility specialist?
Sometimes this is an easy question to answer, sometimes it's difficult. Consider your situation and conditions by taking this TRM Quiz at http://www.trmbaby.com/welcome/do_I_need_fertility.shtml. If the total number of points equals or exceeds 15 points, and you wish to conceive, strong consideration should be given to seeing a fertility specialist, specifically a reproductive endocrinologist.

Infertility: From the Inside Out

On June 12, 1993, on a blistering hot Chattanooga day, I married Kristi Cheryl Poe. It was a big wedding. Lots of family. Even more friends.

There is a picture of my wife from our honeymoon in Bermuda. She is standing in the bedroom of an old house that has been turned into a museum. Her hands are cupped in front of her, her shoulders hunched and a guilty smile crosses her face as she looks back at the camera. She’s standing over a baby’s crib. The cradle at her feet and the guilty look speak volumes about the direction she wants our lives to go. It’s clear. She wants kids.

To be honest, I hadn’t given much thought to children at this point, but it was plain to see that this meant a lot to her. When we got back from Bermuda we placed that picture, among others, on the wall in our den. That picture reminded us of very happy times.

We thought our lives were fabulous. Like many young couples, we were not in a rush to start a family, but we also didn’t try to prevent it from happening.

So in the beginning, not getting pregnant in a given month was no big deal. We knew these things took time. So time passed.

More time passed. Months passed. Seasons passed, then years, and anniversaries and the births of friends’ children. Then birthdays of children.

Throughout all of this, month after month, the picture on the wall hung there, reminding us of what she, now we, wanted very badly. The picture on the wall had not changed. My wife still had the same smile on her face, but now instead of looking guilty, it started to look a little sad.

In fact, every time I looked at that picture of my wife, I secretly wondered if we were not meant to have a child. That made me sad. So much optimism, crushed.

I can’t say this didn’t wear on us a little. We began to lean on friends and confide in them. Most of them were absolutely wonderful. They just listened. But I have to confess, it was hard to hear advice from some people who had easily gotten pregnant.

“Relax,” they reassured.

or

“Oh, you’re just trying too hard.”

or

“I know someone who adopted, and then got pregnant!”

or

“I know someone who quit trying and then BAM, got pregnant!”

You get the gist.


If you’re reading this, you’ve probably heard these stories yourself. I was too early in my career to know anything about something called “recall bias” (more on this later in an upcoming post). I assumed that stress was a major cause of infertility. And I knew what these people were saying. It was apparent without reading too far between the lines.

They were essentially saying, “It’s all your fault. You’re causing this.”

If these people were trying to help us relax, I confess it had the opposite effect.

All of this occurred at the beginning of our nearly 10 year journey with infertility that would take us across more than 600 miles and to three fertility centers and more cycles of IVF than I can remember reliably. Over the coming months, I’d like to document that journey and use this as a touchstone to talk about infertility treatments and tests.

It is my hope that this blog will help two groups of people: those who are struggling with infertility, and those who are giving advice.

Every couple is different. Having been a patient and a doctor who treats these conditions, I’ve seen what infertility can do to people and to families. I’ve seen it from many angles and from the inside out. I’ll tell you what I’ve learned.

Our particular journey as a married couple started with a trip to Bermuda. That little picture on our wall is a reminder to us of who we were and what happened to us along the way. It is a reminder of the joy and the unspeakable sorrows, the hope and the disappointments we experienced along the way. For better or for worse, our experiences with infertility shaped us as a couple. These experiences shaped me as a doctor.

For me, that picture of my wife in Bermuda says so much. It’s a constant reminder of how cruel hope can be and of how fragile and how strong we all are. For these reasons, it is still one of my favorite pictures of my wife.