Tubal Ligation and Reanastomosis with Michael Epps MD

What is a tubal ligation?
A tubal ligation is a division of the fallopian tubes so that a person is no longer fertile.

What are the side effects and possible complications involved with a tubal ligation?
A tubal ligation involves a major surgery in the sense that we’re in the abdomen. It requires general anesthesia, and that, in itself, is a small risk but, nonetheless, a risk. The chance of infection or perforation in the bowel, major blood vessels, or bladder is always possible. So, it shouldn’t be gone into lightly because of these possible complications.

What are the benefits of a tubal ligation?
Well, the primary benefit of a tubal ligation is obviously the cessation of fertility. This should never be gone into with the thought, “I might change my mine in a year, two years, or five years.” This should always be gone into with the thought of not wanting anymore children.

Which women would be candidates for a tubal ligation?
The primary consideration for a tubal ligation is the completion of a family. A woman or couple who wants no further children should consider this carefully because it is a permanent process. Technically, it can be reversed but a woman who has completed her family is the ideal candidate for this procedure.

What is a tubal reanastomosis (tubal ligation reversal)?
A tubal reanastomosis is where you actually cut away the scarring created by whatever method of tubal ligation you used. It’s placing the open ends of the tube back together so that it makes it open again, therefore enabling a sperm to reach the egg, therefore making fertility possible. This procedure is possible for those tubal ligations where a coagulation has been done or a Pomeroy technique, which is often done after delivery and involves a suture being placed around the tube, was used. These particular kinds of tubal ligations can be reversed.

What are the success rates of a tubal reanastomosis?
The success rate of a tubal reanastomosis can’t be entirely predicted because it depends on multiple factors. When you’ve completed removing the scarred part of the tube and put the ends of the tube back together, you need to have at least approximately two inches left or at least four centimeters for it to function properly; that’s one factor. A woman who’s had multiple miscarriages may have some genetic problem that tends to make her miscarry; that’s another sort of problem. Of course, her husband or partner should be fertile, and that’s a factor. Sometimes, despite the best efforts, the tube will be shown as patent by what’s called a hysterosalpingogram; this means the tube just doesn’t function properly. A fertilized egg takes about five to seven days to get from the end of the tube to the uterus; if it gets there too soon, before the endometrium is ready to accept it, then a miscarriage might occur, and a woman might not even know it and just think it to be a normal period.  

How does a tubal ligation work?
The cessation of fertility by a tubal ligation involves coagulopathy, meaning that you take an electrical current and pass it through an instrument as you wrest the tube. The very interesting thing about this technique is that it can be done laparoscopically. And, it does not only heat damage, which is obvious at the time that you do it, but it can do electrical damage and spread beyond the point of the actual application or the device. That’s why, when you have this procedure, you're really not sure until you look again, prior to doing your reanastomosis, whether or not there is enough tube to put back together. Probably one of the most common types of tubal ligation is the Pomeroy tubal ligation. That involves taking a loop of the tube and tying a suture around that, and that suture then dissolves the ends of the tube so that they separate and seal over. This is often done the day after a delivery or during a cesarean section, and it often is the easiest to correct. However, where the loop of tube was taken, more towards the end of the tube or fimbria, can negatively affect the success rates when the pieces are put back together.

How does a tubal reanastomosis work?
The tubal reanastomosis that most gynecologists do at this point involves an open procedure, which means you’ll have a laparotomy— the technical term for opening the abdomen. It will be a small incision transversally across the lower abdomen, in order to get to the tubes, cut out the scarred portions, and then put back together the fresh, open tubes. Some people are beginning to do them with a robotic technique, and that allows the tubes to be taken, dissected, and corrected, possibly allowing the patient to go home the same day as the procedure. This is, to my knowledge, not done in this area at this time, but it may be. This is not a technique that I use; I actually do the open procedure.

Why are you interested in tubal ligation reversals?
My interest comes from years ago when many a young woman, ages 21 to 25, would have their second or third baby and think there would be no way ever that they would have another child. Then, lo and behold, they get divorced or separate from their partner, and prince charming, who has never fathered a child, comes along. Now, she wants to have a child again. So, it can be a tragic situation, depending on what technique was used, because it may not be able to be reversed. But, I got interested because I realized when you are that young, while still being a legal adult, you're still young and things can happen. Being able to reverse a tubal ligation is really a great joy, especially when it succeeds, of course.