TUBAL REVERSAL BY MICROSURGERY AND ROBOTIC TUBAL ANASTAMOSIS

Tubal ligation is used very commonly as a form of contraception in the United States. When life circumstances change often the question of whether this procedure is reversible comes up. Fortunately with modern microsurgical techniques, the answer most often is that it can be reversed.

Tubal ligation can be performed by a variety of techniques Some of the more common methods include the Pomeroy technique, frequently employed on the first day after delivering a baby, or interval sterilization, frequently performed through the laparoscope remote from child bearing. Several different laparoscopic techniques may be used for laparoscopic sterilization. These include cautery (burning of the tubes), rings or clips to occlude the tubes, or cutting or removing portions of the tubes. All of these methods are intended to provide permanent methods of contraception.

However, life circumstances change for many of our patients, and many women desire to regain their fertility after having a previous tubal sterilization performed. Fortunately, the new technique of microscopic tubal reansatamosis (sterilization reversal) is a highly successful surgical procedure available to many patients from specialized infertility surgeons. The newest technique is a robotic tubal ligation reversal.  The first technique uses and open bikini type incision.  Robotic procedures are done using small laparoscopic incisions and the assistance of a robotic controller.  Other alternatives to surgical reanastamosis include in vitro fertilization, a process in which the fallopian tubes are bypassed all together and fertilization is achieved outside the body. Both of these techniques have distinct advantages and disadvantages with overall relatively similar success rates.

Cumulative pregnancy rates over 1-2 years following sterilization reversal often approximate 60%-70%. However, the range of pregnancy rates may vary from 20%-95%. There are multiple factors influencing the outcome of the procedure. Of these, the length of healthy fallopian tube left to be repaired following sterilization reversal is the single most important factor. Success rates are very acceptable when 4-6cms of tube are left When less than 4cms of undamaged tube remain at the end of microsurgery, success rates fall dramatically. Patients at risk for short tubal length are primarily those in which either large segments of tube were removed or in which "multiple burn" cautery technique was utilized for sterilization. Those with the best prognosis are usually women who have clips or rings placed on their tubes or postpartum tubal ligations performed.

Another factor in tubal reversal success is the use of microsurgical technique. Controlled studies examining the differences between surgeons using a microscope and those utilizing other methods of sterilization reversal have clearly identified the superiority of the microscopic approach. Not all hospital operating rooms are equipped with appropriate microscopic instrumentation, and only a surgeon trained in microscopic technique should perform microscopic tubal reanastamosis. Most surgeons performing microsurgical tubal reanastamosis will do so through a mini-laparotomy incision. This is a "bikini cut" skin incision usually approximately 2/3 the size of a cesarean section scar. Most patients require a 1 to 2 night hospital stay following tubal anastamosis:



During the course of a microsurgical tubal reanastamosis, the fallopian tubes are brought into the incision. The damaged or scarred portions of the fallopian tubes are removed. Then, using suture that is too fine to be seen by the naked eye, the healthy segments of tube are stitched back together under the microscope. This is usually accomplished in two layers. At the completion of the operation, patency of the fallopian tubes is confirmed by injecting dye through the uterus out the fallopian tubes. Patency rates are greater than 80% in most instances. Unfortunately, due to previous scar tissue from the sterilization procedure or due to scar tissue which may result from the reanastamosis procedure, open tubes do not always function normally.



In the example above the tubes have been microsurgically reconstructed. The suture line is barely visible on the left tube.

Robotic Tubal ligation Reversal

The newest technique for reconstructing the tubes involves the use of robotic arms which are introduced through small laparoscopic incisions.  The Davinci Robot is a $1.5 million surgical computerized assistant which allows the surgeon to work at a remote console in the operating room and perform the same surgery which was once done by an open incision laparoscopically.  Operating time with the robot is slightly longer.  The recovery time for the patient is measured in days rather than weeks after standard microsurgical anastamosis.

Below is an image of the robotic set up.  Once the robotic arms are introduced, the surgeon works at a computerized console to perform the procedure.   The robotic arms obey the commands of the surgeon at the console.

Below are images of the robotic arms suturing the tubal segments back together:

The following image is of a completed robotic reversal.  Both tubes are reattached with dye flowing freely through them.  Blue dye is commonly used during tubal surgery to show that the tubes are reconnected:

Other significant factors, which may effect the outcome of tubal reanastamosis, include the age of the female partner, the ovulatory status of the female partner, as well as the reproductive history and sperm function of the male partner. Prior to having tubal anastamosis performed, your surgeon may perform laboratory testing to confirm the "ovarian reserve" or ovulatory status of the female partner. In addition most surgeons will require a semen analysis on the male partner to confirm that live sperm are present prior to putting the female partner through a relatively lengthy operation. Many couples will conceive quickly after tubal anastamosis, but the full benefit of the surgery may not be recognized for 1-2 years of attempted conception. In the event that tubal anastamosis fails to achieve pregnancy, in vitro fertilization may still be an option for many couples.

The physician members of the Institute for Reproductive Health have all had extensive training in tubal anastamosis. If you think you may be interested in a consult regarding microscopic tubal reversal, please contact our office staff at (513) 924-5550. We will help you to request your operative records in order to determine if the particular procedure used is reversible. We will also estimate your chances of success with this procedure.