Untying the Tubes: Reversal Rate Is Rising

When Cathy and Craig Gurney of Ontario got married in 1981, they knew they would not be having any children. After all, during her previous marriage, Gurney had undergone a tubal ligation seven months after the birth of her son, Gerrit.

Gurney, 35, said she decided to have the operation in 1977, “mainly because my first husband didn’t want any children; he had been married before and had a son.” She was unable to use an IUD or take birth control pills for health reasons, she said, and that left only two options--a vasectomy for her husband or tubal ligation for her.

‘Him or Me’

“So,” Gurney recalled, “the choice was him or me, and somehow we decided on me.”

At the time, having her tubes tied seemed like the right thing to do, Gurney said, but “I didn’t count on my husband leaving and remarrying.”

Nor did she anticipate the emotional repercussions of the procedure. “Seeing other women who had children and knowing I could never do it again, I took it really hard,” Gurney said. And after getting remarried, she said, the idea of not having any children with her new husband was even harder to take.

“It made it like an obsession that I would want to give him his own child,” she said. “There’s just something about being able to share that.”

Gurney is not alone.

A small but statistically significant number of women who have tubal ligations--a procedure in which the Fallopian tubes are cut or blocked so the egg cannot meet sperm and be fertilized--have serious second thoughts about having chosen what is designed to be a permanent form of sterilization.

As Gurney discovered, however, there is a surgical technique to reverse a tubal ligation. The procedure is called tubal reanastomosis, better known as the reversal of tubal ligations.

Although reversals have been performed for years with conventional surgery, the chance of success--as measured by the delivery of a healthy baby--was only 20% to 30% before the advent of microsurgery a decade ago. Since then, the chance of success has increased dramatically--to as high as 80%.

Of the estimated 650,000 American women who undergo tubal ligations each year, about 5% have the procedure reversed, according to Dr. Jordan M. Phillips of Santa Fe Springs, chairman of the board of the American Assn. of Gynecological Laparoscopists.

‘Regret Level’

“We call it the regret level,” Phillips said, noting that there is no way of knowing the exact number of women who have reversals. “Some doctors do a large number of cases; others do not, and there is no way of knowing.” But, he added: “The number is increasing. Now there are doctors spending their whole time doing this.”

Not all women who have undergone tubal ligations are aware that the procedure can be reversed, said Dr. Ari Babaknia, founder and director of the California Infertility Institute in Santa Ana who performed about 40 reversals last year. Based on his experience, Babaknia said, “maybe 80% of women don’t know this can be reversed.” And, he added, “some doctors don’t even know it’s possible.”

Dr. Sergio Stone, director of the division of infertility at UC Irvine Medical Center, acknowledged that some of his reversal patients have been told by doctors that their tubal ligations cannot be reversed. But, said Stone, who performs about four reversals a month (the same number he’s been doing for the past 10 years), “even in the worst cases we can give a patient a 30% chance, unless there has been total destruction of the tube.”

Phillips said most women give a lot of thought to having their tubes tied, “but their lives change and as their life situation changes, their fertility requirements may change.” As a result, he said, these women are highly motivated to have a baby.

In a survey Babaknia conducted last year to find out why his patients wanted a reversal, he discovered that the majority--about 62%--had remarried and wanted a child with their new husband.

Suffered Tragedies

“The rest of them had some tragedies in their lives in which they lost their children; we had five patients who had crib deaths,” he said. “We also had a very interesting group of patients who had some kind of emotional or psychological problem after tying their tubes; they felt kind of guilty that they did it, that they terminated the function of their body.”

Seven patients, Babaknia added, “were with the same husband, but they simply wanted more children.”

Unlike a tubal ligation--usually a 20- to 30-minute operation that can be performed on an outpatient basis--a reversal is major abdominal surgery, requiring a two- to three-hour operation and about three or four days of hospitalization in addition to a couple of weeks recovery at home, according to Babaknia. A reversal is also more expensive, he said, costing $5,000 to $6,000 (for surgical fees and hospitalization) compared to about $1,500 for a tubal ligation done on an outpatient basis.

Undergoing the reversal procedure, however, is no guarantee the woman will become pregnant. Babaknia said about 60% of his patients end up giving birth.

“It’s not really known why the other 40% doesn’t get pregnant,” he said, “but there are several factors that will tell you even before surgery whether this patient has a better chance than another patient.

“Obviously, a younger woman has a better chance. If somebody has her tubes reversed at age 32, it’s better than at age 40: Fertility is normally higher at age 32.”

The second factor, he said, is how many years have passed since the tubal ligation. “If it’s less than five years, they have a very good chance of getting pregnant. If it’s more than five, especially more than seven years, they don’t have a good chance. It appears that when the tube stays closed for more than seven years, it might lose some of its function in propelling the egg and sperm toward each other despite the fact that the tube is open.”

The remaining length of the normally five-inch-long Fallopian tubes is also crucial to the success of a reversal, Babaknia said.

“Basically the less tissue removed, the better the results,” he said. “If the remaining tube is more than three inches, we have a very good chance. If it’s less than two inches, the chance is not as good.”

Of the three main methods of doing tubal ligations--cauterization (an electrical current burns a section of the tube), using a ring or using a clip--the ring and clip destroy the least amount of tissue. If the tubes were burned, Babaknia explained, it is more difficult to correct because there often is little tube left.

Phillips said, however, that about 70% of tubal ligations performed in the United States are still done by the cauterization method. Stone concurs, saying he seldom finds reversal patients who have had tubal ligations done with the clip or ring.

But Babaknia believes that more doctors are now using the clip and ring methods because of their higher reversal success rates. In fact, he said, about two-thirds of the tubal ligations done at Western Medical Center in Santa Ana are done with the clip or ring: “Now that a lot of women are changing their minds, you tend to do a procedure that has a better chance of reversal,” he said.

Make Sure

With such a large percentage of patients who seek a reversal doing so because of remarriage, Babaknia said, “I think the first two criteria for (women) who want to tie their tubes is to make sure this is the number of children they want, and to make sure they have a stable marriage.”

But even if they believe their relationship is secure and they have all the children they want, Babaknia advises younger women to use a less drastic form of contraception “because more than 80% of the people who come to me to have their tubes reversed have done their tubal ligation before age 30.”

Stone advises women not to have their tubes tied at the time of delivery. “It’s the worst time to make a decision,” he said, adding that he recommends selecting a doctor who will do a “conservative” tie or clip in case the woman later changes her mind about not wanting any more children.

Babaknia said the first step for someone considering the reversal procedure is an interview with an infertility specialist who has experience in tubal surgery. In the interview, the couple discuss the reasons for requesting the reversal and motivation for having another baby, and the doctor explains the surgery and success rates.

Semen Analysis

Next, a preoperative medical work-up is conducted. It includes a semen analysis to show whether the male’s sperm is adequate and an evaluation of the female cyclic hormones to show whether there is adequate ovulation and hormones for implantation of the fertilized egg. X-rays are taken of the tubes and the uterus to locate the tube ends, and a diagnostic laparoscopy--a procedure in which the surgeon views the Fallopian tubes through a scope inserted through a tiny incision below the navel--is conducted to determine the remaining length of the tubes. If the tubes are too short, Babaknia said, he advises not doing a reversal because of the slim chance of getting pregnant.

The reversal operation, which the surgeon performs while looking through an operating microscope, involves sewing the ends of the tubes together with four sutures that are thinner than a human hair.

Phillips, who is emeritus professor in the department of obstetrics and gynecology at the UC Irvine California College of Medicine, said the reversal procedure requires that the surgeon have both manual dexterity and patience. “It takes,” he said, “a special type of person.”

“The technique,” Babaknia observed, “is very delicate, tedious and meticulous, and one who does it has to not just have the expertise but has to enjoy doing it. Otherwise, you’re standing up there up to three hours just to put in four sutures.”

For Babaknia, who averages four reversals a month, it’s well worth the time and effort.

“You know you’re helping somebody to reach what they want,” he said. “And when you reverse it and they get pregnant, the feeling is just tremendous,” he said. “When you see that joy, when you see that feeling in these people, it gives you all the energy in the world.”

Although the average patient who has undergone reversal surgery becomes pregnant six to nine months after surgery, Babaknia said, some patients have conceived as soon as a month after surgery.

For Cathy Gurney, one of Babaknia’s reversal patients, it was a much longer wait. Because of ovulation problems, it took her 2 1/2 years to get pregnant.

But, as Gurney said a few days after giving birth to her daughter, Katie Elizabeth, “it was well worth everything I went through.”

Gurney, whose labor lasted four hours, said her husband, Craig, was in the delivery room when their daughter was born.

“I’ve never seen him cry so hard; he was just so touched,” she said. “It just really hit him.”

As for women who are contemplating having their tubes tied, Gurney said: “I think they should really check into it and know exactly what they’re doing and (consider) that it is permanent. Not everybody is as lucky as I’ve been.”