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Thursday, May 20, 2010

The Tie That Binds – Should I Have My Tubes Tied? Part 3

For this women’s health series, we’ve been talking about your FAQs regarding getting your “tubes tied,” or having a bilateral tubal ligation (BTL). Today, we’ll answer a very important question that you should consider before undergoing the procedure.

What are my chances of having a baby if my tubal is reversed?
Nationwide, the cost of bilateral tubal ligation (BTL) ranges from $1,500 to $6,000. The cost of a reversal can run between $3,000 (internet quote from tubal reversal clinic) to $7,000-$15,000. The cost of a cycle of in vitro fertilization (IVF) runs about the same as tubal reversal. Most insurance plans do not cover tubal reversal or IVF after voluntary tubal ligation. So before you spend your money, you may want to know what your chances for a “take home baby”are likely to be.

The results of micro-surgical reversal of BTL was studied in 1,100 Korean woman (Kim, 1997). The majority of women had been sterilized by cautery/burning of their tubes. The average time between BTL and request for reversal was 4.25 years. The estimated success in restoring more normal anatomy was 88% with a pregnancy rate of 55%. Of those that did conceive, about 72% delivered a child. Surprisingly, there was no difference in pregnancy rates between the different types of BTL, nor between women whose reversal was much later and those that tried reversal close to sterilization. The best pregnancy rates occurred in the younger women, and among those who had longer sections of healthy tube to sew together.

Women trying for a surgical reversal of their BTL were compared to women opting to use IVF instead (Boeckxstaens, 2007). After 72 months, the delivery rates were 59.5% for the reversal group and 52% for the IVF group. One again, younger women fared better as those aged less than 37 years had a delivery rate of 72.2% after reversal surgery, whilst the older women had a 36.6% delivery rate. For those women choosing IVF, delivery rates were very similar for younger and older women (52% vs 51%).

A French study (Sitko, 2001) compared women with failed reversal of BTL with women who had blocked tubes for other reasons. Both groups were trying to become pregnant using in vitro fertilization techniques. The pregnancy rates were similar between the two groups. The probability of a term pregnancy depended more upon the age of the woman than other factors (there’s that darn age thing again!).

From the scientific point of view, the few studies which have been done are flawed because numbers are small, and women have not been randomly assigned to receive either reversal surgery or IVF (Pandian, 2008). Based upon what is known, surgical reversal of a tubal ligation seems to be more successful if the woman is in her mid-30s or younger, she is healthy and has a partner with known fertility. In terms of her tubal surgery, the better reversals occur when there is less extensive damage to the tubes (e.g., clips or rings). Many GYNs also believe that total length of the tube, once the damaged part is removed, influences pregnancy rates. This would make sense given the movement of Fallopian tubes to help catch the egg as it is released.

What about wishing one hadn’t had a BTL? A group from the World Health Organization (Curtis, 2006) reviewed the studies about regret after tubal ligation. Women having BTL before age 30 were twice as likely to want a reversal, with those younger women being eight times more likely to seek a surgical reversal or IVF. Only 4% of women regretted having a tubal ligation with the Filshie clip between 5-15 years after the procedure (MacKinzie, 2009), but this was a mixed age group. For Korean women, the most common reason cited for wanting a tubal reversal was loss of existing children (Kim, 1997). Other reasons mentioned in the literature included new relationship or new partner without children.

Overall, one should consider a tubal ligation a permanent form of birth control. While expensive reversal surgeries or IVFs are possible, the success rates are not 100%. Successful pregnancy rates decline as a woman ages. If the highest rate of regrets occurs in women under age 30, perhaps one should consider a BTL done with rings or clips to improve the odds of a reversal. A BTL is a convenient form of reliable birth control, but some of the more recent hormonal methods (e.g., Implanon) are as reliable as permanent sterilization.

Like getting married, one should assume at the outset that having a tubal ligation is forever.

Read more from the series:

Comment on this post and ask Jane your questions on the Gynecology Exchange.

Posted by: Jane Harrison-Hohner, RN, RNP at 10:15 am

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Thursday, May 13, 2010

The Tie That Binds – Should I Have My Tubes Tied? Part 2

If you’ve thought about getting your “tubes tied,” you probably have some questions on your mind about the procedure and results. Last week we talked about whether having a bilateral tubal ligation (BTL) will bring on more menstrual or mood problems. Today, we’ll look at another pressing question.

What is the failure rate for a tubal ligation?

A number of factors have been identified which influence the failure rate for BTLs. These include age of woman (older women get pregnant less frequently), the type of procedure used, and whether clips or rings were done while the tubes were more dilated (during immediate postpartum). There have been numerous studies of the failure rates of different techniques. The following represents a summary of those studies.

  • Pomeroy Procedure (section of tube surgically removed): 1.0% (Nardin, 2003), 1.0% (Robinson, 2004), 0% (Oligbo, 2009)
  • Unipolar Coagulation: 0.75% (Peterson, 1996)
  • Bipolar Coagulation: 2.48% (Peterson, 1996)
  • Filshie Clip: 0.9% (Dominik, 2000), 0.34 % (MacKenzie, 2009), 1.1% (Oligbo, 2009)
  • Hulka Spring Clip: 3.6 % (Peterson,1996), 2.8% (Dominik, 2000)
  • Silastic Rings: 1.7% (Peterson, 1996)

According to Peterson (1996) and his researchers at Centers for Disease Control and Prevention (CDC), the highest failure rates of BTL have been for women under the age of 30 receiving bipolar coagulation (5.4%), and Hulka clips (5.2%). For women who have had tubal ligations by residents (young MDs learning the specialty practice of OB/GYN), it is reassuring to know that their failure rates are similar to other, more experienced operators (Rakow, 2008).

Unfortunately, if a woman with a tubal ligation conceives there is a much higher chance of having an ectopic, commonly known as tubal, pregnancy. Napolitano (1996) identified a 36% rate of ectopics in women with a failed tubal ligation. Peterson and colleagues (1997) followed over 10,000 women for 5-14 years after BTL. The rate of ectopic pregnancy in that very large group was less than 1%. Because of the duration of follow up, Peterson was able to determine that the risk of an ectopic pregnancy was just as high 4-10 years after surgery as during the first 3 years.

To summarize, overall tubal ligations fail in 1.3% or less of procedures. If one does become pregnant, up to 33% can be ectopic pregnancies (Awonuga, 2009).

To see a good picture of methods for performing a BTL, check out this WebMD link.

Next week we’ll look at another FAQ: What are my chances of having a baby if my tubal is reversed?

Comment on this post and ask Jane your questions on the Gynecology Exchange.

Posted by: Jane Harrison-Hohner, RN, RNP at 10:44 am

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Thursday, May 6, 2010

The Tie That Binds – Should I Have My Tubes Tied? Part 1

For anyone considering having their “tubes tied” as a form of more permanent birth control, this blog series is for you. For anyone with their (Fallopian) tubes already tied and wondering about a reversal, this blog series is for you. When the OB/GYN hands you a nicely printed pamphlet, or you read the consent form for the operation, many important questions are not addressed. After reading your posts for ten years, certain questions seem to come up repeatedly about bilateral tubal ligation (BTL). By the time you’re done have read this series, you should know the answers to your most frequently asked questions.

Normal Fallopian tube, cross section

“Normal Fallopian Tube, Cross Section”
Ed Uthman / CC BY 2.0

Does having a tubal bring on more menstrual or mood problems?
The majority of publications about “post tubal syndrome” are from the 80s. Interestingly, this is also true for publications about “premenstrual syndrome/PMS.” Perhaps women’s concerns were finally the focus of research attention!

Many of the first studies seemed to find that women who had a BTL noted: changes in menstrual bleeding patterns (e.g. changes in cycle length, changes in amount of flow, increased cramps, more erratic bleeding), worsening of PMS or other mood symptoms and alterations in sexual function.

Given the frequency of BTL these purported outcomes were concerning. Since that time several hundred scientific articles have been published on “post tubal syndrome.” The problem is that many of the studies tended to lump all women with tubals together. That is, young and old, recent BTL or long after BTL, number of prior pregnancies and type of tubal surgery done.

According to Gentil and colleagues (1998), studies that did try and control for age, time since BTL, number of children, etc. did not find significant differences between women with tubals and those who used vasectomy, diaphragm, condoms or other non-hormonal methods of birth control. The one exception was younger women (aged 20-29) with previous menstrual problems. In that subgroup, there did seem to be a worsening of menstrual changes.

A very large study, 9,514 women with BTL, compared to 573 women whose partners received a vasectomy, were followed for five years after the sterilization procedures. Fortunately, the menstrual cycles of many participants were clearly charted before the sterilizations so it was easier to identify if a change really occurred. It was also documented which type of birth control method was used before sterilization. The final results found no significant differences between the two groups except an increase in cycle irregularity among women with a BTL. Of the six types of tubal ligation procedures, there were no differences in menstrual characteristics. That is, the least damaging procedure to the tube (clips) was the same as the most destructive (unipolar coagulation).

In a smaller study of 112 women with the same type of BTL procedure (Pomeroy), Shobeiri and Atashkhoii (2005) found no overall difference when compared to 288 nonsterilized women. However, once women were broken into subgroups by age, the women in their 40s (sterilized or not) had more abnormal bleeding than women in their 30s. Many women choose a tubal ligation when done with childbearing. By this age we can observe that there are starting to be “normal” menstrual problems associated with “aging ovaries.”

In summary, the overall evidence is against the existence of a post-tubal syndrome of menstrual abnormalities, sexual changes and increased mood problems. There may be a small subgroup of women aged less than 30 who had prior menstrual problems for whom the BTL worsens symptoms. It is also true that studies are composites of women. An individual can certainly have an outcome, or experience, that is different than the average of a group. But for a woman deciding about the long term outcome of tubal ligation, having a favorable menstrual history bodes well for a good post-tubal outcome.

Over the next few weeks, we’ll look at the following FAQs:

  • Part 2: What is the failure rate for a BTL?
  • Part 3: What are my chances of having a baby if my tubal is reversed?

Comment on this post and ask Jane your questions on the Gynecology Exchange.

Posted by: Jane Harrison-Hohner, RN, RNP at 12:39 pm

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