Tubal reversal: Difference between revisions

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{{Short description|Surgical reconnection of tubal ligation}}

'''Tubal reversal''' - short for '''tubal sterilization reversal''' or '''tubal ligation reversal''' - is a surgical procedure that restores [[fertility]] to women after a [[tubal ligation]]. By rejoining the separated segments of [[fallopian tube]], tubal reversal gives women the chance to become [[pregnant]] again naturally. This delicate [[surgery]] is best performed by a reproductive surgeon with specialized training and experience in the techniques of tubal ligation reversal.

{{more citations needed|date=November 2018}}

{{Infobox interventions |

Name = Tubal reversal |

Image = |

Caption = |

ICD10 = |

ICD9 = {{ICD9proc|66.7}} |

MeshID = |

OPS301 = |

OtherCodes = |

HCPCSlevel2 =

}}

'''Tubal reversal''', also called '''tubal sterilization reversal''', '''tubal ligation reversal''', or '''microsurgical tubal reanastomosis''', is a surgical procedure that can restore [[fertility]] to women after a [[tubal ligation]]. By rejoining the separated segments of the [[fallopian tube]], tubal reversal can give women the chance to become [[pregnant]] again. In some cases, however, the separated segments cannot actually be reattached to each other. In some cases the remaining segment of tube needs to be re-implanted into the uterus (a 'tubal reimplantation'). In other cases, when the end of the tube (the 'fimbria') has been removed, a procedure called a neofimbrioplasty must be performed to recreate a functional end of the tube which can then act like the missing fimbria and retrieve the egg that has been released during ovulation.

== Tubal Anatomyanatomy ==

{{unreferenced section|date=November 2018}}

The [[fallopian tube]] is a muscular tube extending from the [[uterus]] and ending with attached fimbria next to the [[ovary]]. The tube is attached to the ovary by a thin tissue called the mesosalpinx. The inner tubal lining is lined with [[cilia]]. These are microscopic hair-like projections that beat in waves that push fluid down the tube towards the uterus thereby helping move the egg or [[ovum]] to the uterus in conjunction with muscular contractions of the tube.<!-- Deleted image removed: [[File:Fallopian tube anatomy.jpg|thumb|right|Fallopian Tube Anatomy]] --> The fallopian tube is normally about 10&nbsp;cm (4&nbsp;inches) long and consists of several regions that become wider as the tube gets farther away from the uterus. Starting from the uterus and proceeding outward, these are the:

* Interstitial region – extends from the [[uterine cavity]] through the uterine muscle

* Isthmic region – narrow muscular portion adjacent to the uterus

* Ampullary region – wider and longer middle part of the tube

* Infundibular region – funnel shaped segment next to the fimbrial end

* Fimbrial region – wide opening at the end of the tube that is responsible for 'catching' the egg after it is released from the ovary during ovulation

==Tubal reversal surgeries==

To understand the techniques of tubal reversal surgery, it is helpful to visualize the [[anatomy]] of the normal [[fallopian tube]]. The fallopian tube is a muscular organ extending from the [[uterus]] and ending next to the [[ovary]]. The tube is attached to the ovary by a small ligament. The inner tubal lining is rich in [[cilia]]. These are microscopic hair-like projections that beat in waves that help move the egg or [[ovum]] to the uterus in conjunction with muscular contractions of the tube. [[Image:Fallopian_tube_anatomy.jpg|thumb|right|Fallopian Tube Anatomy]]The fallopian tube is normally about 10 cm (4 inches) long and consists of several segments. Starting from the uterus and proceeding outward, these are the:

Tubal reversal surgeries require the techniques of [[microsurgery]] to open and reconnect the fallopian tube segments that remain after a tubal sterilization, reimplant remaining segments, or create new fimbria.<ref name=zarei/><ref name=deffieux/>

===Tubotubal anastomosis===

• Interstitial segment - extends from the [[uterine cavity]] through the uterine muscle<br />

{{unreferenced section|date=November 2018}}

• Isthmic segment - narrow muscular portion adjacent to the uterus<br />

Following a [[tubal ligation]], there are usually two remaining fallopian tube segments – the proximal (close) tubal segment that emerges from the [[uterus]] and the distal (far) tubal segment that ends with the [[fimbriae of uterine tube|fimbria]] next to the [[ovary]]. After opening the blocked ends of the remaining tubal segments, a variety of microsurgical techniques are utilized to recreate a functional tube. The newly created tubal openings are drawn next to each other by placing sutures in the connective tissue that lies beneath the fallopian tubes ([[mesosalpinx]]). The retention suture prevents the tubal segments from pulling apart while the tube heals. Microsurgical sutures are used to precisely align the tubal lumens (inside canal of tube), the muscular portion ([[muscularis externa]]), and the outer layer ([[serosa]]) of the tube. Most surgeons try to avoid the use of stents which can damage the delicate cilia that line the tube and create the flow of fluid that is needed to push the egg and embryo into the uterus. Other surgeons use a narrow flexible [[stent]] to gently thread through the tubal segments or into the uterine cavity in order to line up the tubes in order to reconnect them. In either case, once the microsurgical repair is completed dye is injected through the cervix into the uterus and out through the tubes to ensure that the fallopian tube is open from the uterine cavity to its fimbrial end. The surgeons who use stents then gently withdraw them from the fimbrial end of the tube after the repair is completed.

• Ampullary segment - wider and longer middle part of the tube<br />

• Infundibular segment - funnel shaped segment next to the fimbrial end<br />

• Fimbrial segment - wide opening at the end of the tube facing the ovary

===Tubal Reimplantation===

== Microsurgery ==

Tubal ligation reversal utilizes the techniques of [[microsurgery]] to open and reconnect the fallopian tube segments that remain after a tubal sterilization procedure. Microsurgery minimizes tissue damage and [[bleeding]] during surgery. Essential elements of microsurgical technique include gentle tissue handling, magnifying the operating field, keeping body tissues in their normal state with warmed irrigation fluids, and using the smallest [[sutures]] with the thinnest needles capable of holding the tubal ends together to promote proper healing of the rejoined tubal segments.

In a small percentage of cases, a tubal ligation procedure leaves only the distal (far) portion of the fallopian tube and no proximal (close) tubal segment. This can occur when any method of tubal ligation has been applied to the isthmic segment of the fallopian tube as it emerges from the uterus. In this situation, a new opening can be created through the uterine muscle and the remaining tubal segment inserted into the uterine cavity. This microsurgical procedure is called tubal reimplantation.

==Tubal Reversal Procedures==

===Tubotubal Anastomosis===

===Neofimbrioplasty===

Following a tubal ligation, there are usually two remaining fallopian tube segments - the proximal tubal segment that emerges from the [[uterus]] and the distal tubal segment that ends with the [[fimbria]] next to the [[ovary]]. After opening the blocked ends of the remaining tubal segments, a narrow flexible [[stent]] is gently threaded through their inner cavities or lumens and into the uterine cavity. This ensures that the fallopian tube is open from the uterine cavity to its fimbrial end. The newly created tubal openings are then drawn next to each other by placing a retention suture in the connective tissue that lies beneath the fallopian tubes ([[mesosalpinx]]). The retention suture avoids the likelihood of the tubal segments subsequently pulling apart. Microsurgical sutures are used to precisely align the muscular portion ([[muscularis externa]]) and outer layer ([[serosa]]), while avoiding the inner layer ([[mucosa]]) of the fallopian tube. The tubal stent is then gently withdrawn from the fimbrial end of the tube.

Fimbriectomy is a very uncommon type of tubal ligation that is performed by removing the end (fimbria) of the fallopian tube leaving only the tubal segment attached to the uterus. After fimbriectomy, if the remaining tubal segment is long enough, the end of the tube can be opened and 'new' fimbria can be created by a procedure called a neofimbrioplasty. These "new" fimbria are not actually fimbria, but they are the cilia from the inside of the fallopian tube that have been exposed by everting the tubal lumen much like the petals of a rose are exposed once the rose blooms. These 'new' fimbria are much less effective at collecting (catching) an egg that has been released from the ovary than the real fimbria that had been removed during the fimbriectomy performed by the surgeon who did the original tubal ligation. During a neofimbrioplasty the tubal end is opened and folded back ([[marsupialized]]) so that the tubal end remains open and exposing the internal lining of the tube.

===Tubouterine Implantation===

In a small percentage of cases, a tubal ligation procedure leaves only the distal portion of the fallopian tube and no proximal tubal segment. This may occur when monopolar tubal coagulation has been applied to the isthmic segment of the fallopian tube as it emerges from the uterus. In this situation, a new opening can be created through the uterine muscle and the remaining tubal segment inserted into the uterine cavity. This microsurgical procedure is called tubouterine implantation, uterotubal implantation, or, simply, tubal implantation. Tubal implantation is performed when tubal anastomosis is not possible due to the absence of a proximal tubal segment and interstitial tubal lumen.

===Mini-laparotomy tubal reversal===

== Reasons for Tubal Reversal ==

Mini-laparotomy for tubal reversal surgery involves making a small, 2 to 3 inch incision in the abdominal wall just above the pubic bone after shaving the hair with a sterile hair clipper. The size and ___location of the incision as well as the plastic surgery techniques used to close it make the thin scar nearly invisible after it has healed. Atraumatic surgical techniques involve the use of local anesthesia at the incision site and other tissues operated upon. This makes the surgery comfortable and minimizes post-operative pain. As opposed to standard operative methods, avoiding the use of surgical retractors and packs, constantly irrigating tissues to keep them moist and at body temperature, and operating under magnification throughout the procedure results in very rapid patient recovery. Operating with microsurgical instruments allows precision in suturing of the tubal segments.

Women give many reasons for having a tubal ligation reversal. One of the questions that Dr. Berger asks his patients is “What made you decide to have a tubal reversal procedure at this time?” The most common responses to this question are:

===Microsurgical Tubal Reanastomosis (MTR)===

• Remarriage with desire to have children with new spouse (75%)<br />

• Same marriage with desire to have more children (20%)<br />

• Death of a child (2%)<br />

• Relief of symptoms of "Post Tubal Ligation Syndrome" (2%)<br />

• Religious or spiritual concerns (1%)

In this Process, The area of the tubes which was occluded is removed, leaving only open, healthy tube. These open, healthy, tubal segments are then connected. A multi layer, micro surgical technique is used to suture these segments together. After the tubes are repaired, a [[chromopertubation]] is performed wherein dye is injected into the uterus. This dye is passed through the repaired tubes to ensure that the tubes are open. The entire surgery is performed through a small incision of about 3 to 4 inches just at the uppermost part of the hair line. Failing to properly align the tubal segments, or damaging these delicate structures, can make the difference between a successful and an unsuccessful operation.<ref>{{Cite web|url=http://www.thibodauxgynob.com/tubal-reversal-surgery|title = Tubal Ligation Reversal &#124; Dr. Morice - Low Cost Tubal Reversal Doctors &#124; Thibodaux, Louisiana, USA &#124; &#124; Thibodaux Gynecology & Obstetrics| date=28 June 2012 }}</ref>

== Sterilization Regret ==

===Laparoscopic tubal reversal===

In a study called the U.S. Collaborative Review of Sterilization (CREST) , women who had tubal ligations were asked "Do you still think tubal sterilization as a permanent method of [[birth control]] was a good choice for you?" Overall, 13% of women said they did not think that the tubal ligation was a good choice. The percentage expressing regret 20% for women aged 30 years or younger at the time of sterilization, compared with 6% for women older than 30 years at the time of tubal ligation. For women under age 25, the rate 40%.

Laparoscopic Tubal Reversal is a minimally-invasive surgical procedure ([[laparoscopy]]), using small, specially designed instruments to repair and reconnect the fallopian tubes.

Despite the high percentage of women who subsequently regret having had a tubal ligation, only 0.2% of women in the CREST study underwent tubal reversal. Reasons for this discrepancy may include lack of information about tubal reversal, cost of the procedure, and lack of insurance coverage for this procedure. Women often receive inaccurate information about tubal reversal - such as tubal ligation cannot be reversed, or the only treatment option is in vitro fertilization ([[IVF]]), or tubal reversal is available only as a high cost operation requiring [[hospitalization]].

After general anesthesia has been administered, a 5mm (less than 3/8-inch) tube ([[trocar]]) is inserted inside the navel, and a special gas is pumped into the abdomen to create enough space to perform the operation safely and precisely. The [[laparoscope]] (a telescope), attached to a camera, is brought into the abdomen through the same tube, and the pelvis and abdomen are thoroughly inspected. The fallopian tubes are evaluated and the obstruction (ligation, burn, ring, or clip) is examined. Three small instruments (5mm each, less than {{frac|1|4}}-inch) are used to remove the occlusion and prepare the two segments of the tube to be reconnected.

== Questions To Ask ==

Once the connection ([[anastomosis]]) is completed, a blue dye is injected through the cervix, traveling through the uterus and tubes, all the way to the abdomen. This is to make sure the tubes have been aligned properly and that the connection is working well.

Here are some questions to ask to consider to find out if tubal reversal is right for you.

Patients are sent home the same day of surgery. The few stitches that are placed will be under the skin and will be absorbed by the body, without need for removal.

'''Have you had your tubes tied, but would now like to conceive again?'''

Patients should wait two months prior to attempting pregnancy in order to give the tubes a chance to heal completely. Trying to conceive before could result in an increased risk of [[ectopic pregnancy]] (pregnancy inside the fallopian tube instead of in the uterus).

If you have had a tubal ligation performed (commonly referred to as having your tubes tied), then you may be a candidate for tubal reversal surgery.

When performed by a trained laparoscopic tubal reversal surgeon, laparoscopic tubal reversal combines the success rates of micro-surgical techniques with the advantages of minimally-invasive surgery – namely faster recovery, better healing, less pain, fewer complications, and no large disfiguring scars.<ref name=rotman/> Laparoscopic surgery can be more expensive than an open surgery using a 2 to 3 inch incision because it requires additional surgical equipment.

'''What type of tubal ligation did you have?'''

===Robotic assisted tubal reversal===

There are several different ways for a doctor to tie somebody's tubes. In order for a tubal reversal to be successful, there needs to be enough healthy tube remaining for the repair.

Robotic assisted tubal reversal surgery is a surgical procedure in which the fallopian tubes are repaired by a surgeon using a remotely controlled, robotic surgical system.

Women with the clip or ring (band) method of tubal ligation have the highest [[pregnancy]] rates after undergoing tubal reversal surgery, but almost any method of tubal ligation can be reversed successfully. If you aren't sure what type of tubal ligation you had, you can obtain a copy of your operative and pathology reports relating to your tubal ligation. These reports will give you specific information about your tubal ligation procedure.

The robotic system involves two components: a patient side-cart (also referred to as the robot) and a surgeon's console. The robot is placed adjacent to the patient and has several attached arms. Each arm has a unique surgical instrument and performs a specialized surgical function. The surgeon sits near the patient at the surgeon's console and visualizes the surgery through a monitor. The surgeon performs the entire reversal surgery using controllers located inside the surgeon's console.

'''How old are you?'''

Robotic tubal ligation reversal uses the same small incisions as a traditional laparotomy tubal reversal surgery. Smaller incisions generally result in less pain and quicker return to work when compared to traditional tubal ligation reversal using larger abdominal incisions. The robotic system offers a greater range of motion and more surgical dexterity than a surgeon can obtain during laparoscopic tubal ligation reversal, but not as much dexterity as with an open procedure using a 2 to 3 inch incision. The disadvantages to robotic surgery are longer operating times and much higher costs than even traditional laparoscopic surgery.

The natural fertility rate declines with increasing age. As with any pregnancy, conceiving after reversal surgery is more likely for younger than older women. If you are older than 40, it is still possible to become [[pregnant]] if you are ovulating and having menstrual periods, but pregnancy rates will be lower than for younger women. Tubal reversal surgery restores, but does not increase, the natural level of fertility associated with age.

'''What should I look for in a doctor to perform my tubal reversal?'''

A retrospective, Cleveland Clinic study compared 26 patients who underwent robotic assisted tubal reversal to 41 patients who underwent outpatient mini-laparotomy (abdominal incision) tubal reversal. Robotic tubal reversal patients, when compared to abdominal tubal reversal surgery patients, had longer times under anesthesia (283 minutes vs 205 minutes) and longer times in surgery (229 minutes vs 181 minutes). On average, robotic tubal reversal patients returned to work one week sooner than abdominal tubal reversal patients and the robotic tubal reversal surgeries were also more expensive than abdominal tubal reversal surgeries.<ref name=rodgers/>

You can check online to see if the doctor is a Fellow of the American College of Obstetricians and Gynecologists and also a member of the Society of Reproductive Surgeons. Doctors with both of these credentials have the training and experience best suited for tubal reversal surgery.

An Ohio State University study evaluating robotic tubal reversal vs abdominal tubal reversal discovered similar findings but also evaluated pregnancy outcomes. Robotic tubal reversal surgery, when compared to abdominal tubal reversal surgery, had longer operative times (201 minutes vs 155 minutes), shorter hospital stays (4 hours compared to 34 hours), and quicker return to activities of daily living. Pregnancy outcomes of robotic tubal reversal surgery patients were also compared to pregnancy outcome of abdominal incision tubal reversal patients. Approximately 65% of the robotic tubal reversal surgery patients became pregnant compared with 50% of the abdominal incision patients. Of the pregnancies, 6 abnormal pregnancies were in the robotic tubal reversal patients (4 ectopic and 2 miscarriage) and 2 were in the abdominal incision patients (1 ectopic and 1 miscarriage). Both surgeries were expensive and were found to cost in excess of $92,000. Robotic tubal reversal surgery was slightly more costly than the abdominal incision tubal reversal.<ref name=patel/>

Ask the doctor how many tubal reversal surgeries he or she has performed. The more experienced the doctor the less likely it is that something unexpected will happen. Some doctors perform tubal reversals on an outpatient basis. This avoids the cost and risks of hospitalization, such as [[hospital-acquired infection]]. Also ask the doctor about the pregnancy and birth rates among his patients after the surgery. A reputable doctor will offer to share this information with you including the number of patients having the procedure, the number who have become pregnant, and the outcome of the pregnancies ([[birth]], [[miscarriage]], or [[ectopic pregnancy]]).

==Am= IEssure a candidate for tubalsterilization reversal surgery?===

{{unreferenced section|date=November 2018}}

[[Essure|Essure sterilization]] was a tubal occlusion procedure that was approved by the FDA in 2002. The Essure procedure involves inserting a small camera ([[hysteroscope]]) through the [[cervix]] and into the uterine cavity. Two small, metallic coils are then inserted into each tubal [[ostium of the fallopian tube|ostia]] and into the isthmic portion of the fallopian tube. The coils cause the isthmic portion of the fallopian tube to be blocked with scar tissue. To confirm tubal closure, a [[hysterosalpingogram]] should be performed three months after the Essure procedure. If either fallopian tube is open after the Essure procedure, then the Essure procedure can be repeated or another type of tubal occlusion method can be performed. Essure was discontinued in 2018 due to a large number of reported [[serious adverse event]]s.<ref>{{Cite web|url=https://www.fda.gov/news-events/press-announcements/statement-fda-commissioner-scott-gottlieb-md-manufacturer-announcement-halt-essure-sales-us-agencys|archive-url=https://web.archive.org/web/20190724220729/https://www.fda.gov/news-events/press-announcements/statement-fda-commissioner-scott-gottlieb-md-manufacturer-announcement-halt-essure-sales-us-agencys|url-status=dead|archive-date=July 24, 2019|title = Statement from FDA Commissioner Scott Gottlieb, M.D., on manufacturer announcement to halt Essure sales in the U.S.; agency's continued commitment to postmarket review of Essure and keeping women informed|website = [[Food and Drug Administration]]|date = 24 March 2020}}</ref>

Reversal of Essure sterilization requires the blocked isthmic portion of the tube be bypassed by tubouterine implantation. During a tubouterine implantation procedure, the blocked portion of the fallopian tube containing the Essure sterilization device is surgically resected. The remaining portion of each healthy fallopian tube is then reintroduced into the newly created openings. This procedure can restore the natural function of the fallopian tube and allow for natural conception. The first case of successful outpatient tubouterine implantation to reverse Essure sterilization was published in 2012.<ref name="pubmed.ncbi.nlm.nih.gov">{{Cite journal|pmid = 22270442|year = 2012|last1 = Monteith|first1 = C. W.|last2 = Berger|first2 = G. S.|title = Successful pregnancies after removal of intratubal microinserts|journal = Obstetrics and Gynecology|volume = 119|issue = 2 Pt 2|pages = 470–2|doi = 10.1097/AOG.0b013e3182383959|s2cid = 22116497}}</ref>

To determine the likelihood of success from a tubal reversal procedure, it is useful to review the operative report from your tubal ligation. If a portion of the tubes have been removed, the pathology report will also be helpful to review as well. The pathology report will give measurements of the removed portions. Despite the common belief that tubal ligation is permanent, tubal repair is possible in most cases through the technique of bilateral tubotubal anastomosis. There are some situations, however, that fall outside of the usual circumstances and therefore require different approaches for successful tubal repair.

Surgeons who published the first case report of successful Essure reversal subsequently published a larger cohort study of 70 patients who underwent outpatient tubouterine implantation to reverse Essure sterilization and 36% of patients reported pregnancy through natural conception.<ref name="pubmed.ncbi.nlm.nih.gov"/>

'''Special Circumstances'''

Dr. Charles Monteith, Medical Director of A Personal Choice Tubal Reversal Center, has collected non-published data on the risks of outpatient Essure reversal surgery.{{cn|date=July 2022}} Between 2009 and 2018, Monteith performed 469 outpatient tubouterine implantation procedures to reverse Essure sterilization. He documented intraoperative, postoperative, and pregnancy risks associated with his procedures.

• No tubal segment remains at the uterus (the proximal tubal segment). In this case, tubouterine implantation needs to be performed. This involves creating a new opening into the uterus into which the remaining segment of fallopian tube is implanted.

Intraoperative risks observed were failure to complete the planned procedure (either Essure removal and tubal occlusion or Essure removal and bilateral tubouterine implantation) <1%, fracture of Essure devices during removal (approximately 10% risk with manual traction and < 1% with en bloc dissection), transfer to hospital <1%, referral to Emergency room or hospital within 24 hours of surgery <1%, bleeding requiring blood transfusion or hospitalization for operative complication 0%, anesthesia complication 0%, and death 0%.

• A proximal tubal segment is on one side and a distal tubal segment is on the other side. In this case the contralateral tubal segments are connected to create one fallopian tube. In this situation, the egg is retrieved from the ovary by the distal tubal segment on one side and delivered to the uterus through the proximal tubal segment on the other side.

Postoperative risks observed were major surgical site infection 0%, minor surgical site infection <1%, need for a second operation/procedure within 30 days <1%, and persistent symptoms requiring additional surgery < 10%.

• A fimbriectomy has been performed. Tubal ligation by fimbriectomy involves removing a portion (usually up to one-third) of the fallopian tube closest to the ovary. To reverse this procedure, ampullary salpingostomy is performed.

Pregnancy related risks were failure to become pregnant and possible tubal closure (estimated to be <60%) and ectopic pregnancy 5%.

• The fimbrial end of the tube is closed or "clubbed" as a result of prior infection or [[salpingitis]]. This condition is sometimes referred to as [[pelvic inflammatory disease]] or [[PID]]. In this case, the fimbrial end of the tube must be opened by the technique of fimbrial salpingostomy. Often, pelvic [[adhesions]] are present that must also be removed (lysis of adhesions). These procedures are required in addition to tubal reversal to completely open the fallopian tube and allow it to capture eggs from the ovaries.

All patients were advised to have a planned cesarean delivery before the onset of labor and the risk of uterine rupture was observed to be 4%. The majority of uterine ruptures occurred at 36/37 weeks gestation.

Factors associated with more difficult surgical procedures were patient obesity (BMI ≥ 30), presence of uterine leiomyomas, and uterine adhesive disease primarily from prior cesarean delivery.<ref>A Personal Choice website Essure Reversal Risks https://www.tubal-reversal.net/essure-reversal/essure-reversal-risks/</ref>

• At the time of [[surgery]], disease of the proximal or isthmic segment of the fallopian tube is discovered due to tubal [[endometriosis]] or salpingitis isthmica nodosa. These abnormal areas of the fallopian tube require removal prior to the tubal repair.

=== Adiana sterilization reversal ===

Most doctors would be unable to perform a tubal reversal in these special situations. This is why having tubal reversal surgery performed by the most experienced tubal surgeon is the best advice when choosing a doctor for the surgery.

Adiana sterilization was approved by the FDA in 2009. Adiana sterilization is a hysteroscopic tubal occlusion procedure, which is very similar to [[Essure]] sterilization. The Adiana procedure involves inserting a small camera (hysteroscope) through the cervix and into the uterine cavity. A smaller catheter is inserted into the tubal ostia. The catheter emits radiowaves (microwaves). The radiowaves cause injury to the tubal lining and will result in the tube gradually closing. Prior to removal of the catheter a small silicone stent is left inside the isthmic portion of the tube and this promotes tubal closure by the acceleration of the tubal scarring.

Adiana sterilization is similar to Essure sterilization and the Adiana procedure causes blockage of the proximal isthmic portion. Adiana sterilization can surgical reversed with tubouterine implantation. The first case of successful outpatient tubouterine implantation to reverse Adiana sterilization was published in 2011.<ref>{{Cite journal|pmid = 21601195|year = 2011|last1 = Monteith|first1 = C. W.|last2 = Berger|first2 = G. S.|title = Normal pregnancy after outpatient tubouterine implantation in patient with Adiana sterilization|journal = Fertility and Sterility|volume = 96|issue = 1|pages = e45-6|doi = 10.1016/j.fertnstert.2011.04.082|doi-access = free}}</ref>

Hologic Corporation discontinued the procedure in March 2012, resolving ongoing litigation with Conceptus concerning patent infringement claims.<ref>{{Cite web |url=http://investors.hologic.com/index.php?s=43&item=447 |title=Hologic Announces Second Quarter Fiscal 2012 Operating Results - Apr 30, 2012 |access-date=2012-05-15 |archive-date=2012-05-09 |archive-url=https://web.archive.org/web/20120509194500/http://investors.hologic.com/index.php?s=43&item=447 |url-status=dead }}</ref>

==Tubal Reversal Surgery versus IVF==

'''Comparing Success Rates and Costs'''

== Tubal reversal success rates ==

Most women who have had a tubal ligation in the past and are now seriously considering becoming pregnant again will have spoken with their doctor and may have been told [[in vitro fertilization]] (or [[IVF]]) is the best or only treatment option.

Tubal reversal success rates vary widely depending upon many factors.<ref name=gomel/> These include the women's ages, methods of tubal ligation that they had performed, experience of the surgeon and techniques for repairing the tubes, length of follow-up after reversal surgery among other factors. Overall, for those who are less than 35 years of age at the time of reversal, more than 70% achieve intrauterine pregnancy, with most pregnancies occurring within 18 months after surgery.<ref name=gomel/> Overall, for those who are 35 years of age or more, approximately 55% will achieve an intrauterine pregnancy.<ref name=gomel/>

== References ==

For most women tubal reversal surgery is actually the better option. Once the fallopian tubes are repaired, there is the chance to become pregnant naturally each and every month.

{{Reflist| refs =

IVF requires injections with hormonal medications and having a minor surgical procedure performed with each attempt to become pregnant. Based on current national statistics, the pregnancy rate for IVF is approximately 27% and each treatment cycle costs between $6,000 to $15,000.

<ref name=zarei>{{Cite journal|pmid = 19661750|year = 2009|last1 = Zarei|first1 = A.|last2 = Al-Ghafri|first2 = W.|last3 = Tulandi|first3 = T.|title = Tubal surgery|journal = Clinical Obstetrics and Gynecology|volume = 52|issue = 3|pages = 344–50|doi = 10.1097/GRF.0b013e3181b08b5f|s2cid = 32827043}}</ref>

In most cases, tubal reversal is the more successful and cost-effective alternative for pregnancy in women who have been previously sterilized and now desire to have another baby.

<ref name=rotman>Rotman C., Rana N., Song J., Sueldo C. Chapter - Laparoscopic Tubal Anastomosis. ''Infertility and Assisted Reproduction''. Cambridge University Press. 2008.</ref>

<ref name=rodgers>{{Cite journal|pmid = 17540810|year = 2007|last1 = Rodgers|first1 = A. K.|last2 = Goldberg|first2 = J. M.|last3 = Hammel|first3 = J. P.|last4 = Falcone|first4 = T.|title = Tubal anastomosis by robotic compared with outpatient minilaparotomy|journal = Obstetrics and Gynecology|volume = 109|issue = 6|pages = 1375–80|doi = 10.1097/01.AOG.0000264591.43544.0f|s2cid = 13736474}}</ref>

<ref name=patel>{{Cite journal|pmid = 18054354|year = 2008|last1 = Dharia Patel|first1 = S. P.|last2 = Steinkampf|first2 = M. P.|last3 = Whitten|first3 = S. J.|last4 = Malizia|first4 = B. A.|title = Robotic tubal anastomosis: Surgical technique and cost effectiveness|journal = Fertility and Sterility|volume = 90|issue = 4|pages = 1175–9|doi = 10.1016/j.fertnstert.2007.07.1392|doi-access = free}}</ref>

<ref name=deffieux>{{Cite journal|pmid = 21331539|year = 2011|last1 = Deffieux|first1 = X.|last2 = Morin Surroca|first2 = M.|last3 = Faivre|first3 = E.|last4 = Pages|first4 = F.|last5 = Fernandez|first5 = H.|last6 = Gervaise|first6 = A.|title = Tubal anastomosis after tubal sterilization: A review|journal = Archives of Gynecology and Obstetrics|volume = 283|issue = 5|pages = 1149–58|doi = 10.1007/s00404-011-1858-1|s2cid = 28359350}}</ref>

<!--<ref name=berger>{{Cite journal|pmid = 26980770|year = 2016|last1 = Berger|first1 = G. S.|last2 = Thorp Jr|first2 = J. M.|last3 = Weaver|first3 = M. A.|title = Effectiveness of bilateral tubotubal anastomosis in a large outpatient population|journal = Human Reproduction (Oxford, England)|volume = 31|issue = 5|pages = 1120–5|doi = 10.1093/humrep/dew038|pmc = 4840024}}</ref>-->

<ref name=gomel>{{Cite journal|pmid = 16674012|year = 2006|last1 = Gomel|first1 = V.|last2 = McComb|first2 = P. F.|title = Microsurgery for tubal infertility|journal = The Journal of Reproductive Medicine|volume = 51|issue = 3|pages = 177–84}}</ref>

}}

{{Female genital procedures}}

Information comparing tubal reversal vs IVF, including cost and pregnancy and birth statistics, is available at http://www.tubal-reversal.net/tubal-reversal-vs-ivf.htm.

{{DEFAULTSORT:Tubal Reversal}}

== External links ==

[[Category:Gynecological surgery]]

*[http://video.google.com.au/videoplay?docid=-1862116096185180588 "Tubal Reversal" on Google Video shows the operation by reproductive surgeon Dr. Gary Berger.]

*[http://www.tubal-reversal.net/tubal_anastomosis_implantation.htm "Tubal Reversal Illustrations" showing tubotubal anastomosis and tubouterine implantation, from the Chapel Hill Tubal Reversal Center website.]

*[http://www.greenjournal.org/cgi/content/full/93/6/889 "U.S. Collaborative Review of Sterilization" reports the findings of the CREST study.]

*[http://www.babycenter.com/refcap/preconception/fertilityproblems/6155.html "Age and Fertility" Summary Graph.]

*[http://www.reprodsurgery.org/patientinfo.html "Society of Reproductive Surgeons" Patient Resources.]

*[http://www.squidoo.com/tubalreversalsurgery "Preparing For Tubal Reversal Surgery"]

*[http://www.tubal-reversal.net/tubal-reversal-vs-ivf.htm "Tubal Reversal vs. IVF" compares pregnancy and birth statistics for the two treatment options.]

[[Category:Tubal_reversal]]

[[Category:Fallopian_tubes]]

[[Category:Female_reproductive_system]]

[[Category:Gynecology]]

[[Category:List_of_surgical_procedures]]