Tubal Reversal or IVF: Which One Is Better?

As IVF technology has become more advanced and practitioners more skilled in their techniques, some other forms of fertility treatment -- for example, ovarian drilling for PCOS -- have become less requested by patients and recommended less often by physicians. Certain corrective surgeries may be seen as no longer warranted if the only goal of treatment is pregnancy.

One such surgery, however, remains appealing to fertility patients and specialists alike: reversal of surgical tubal ligation.

Tubal ligation is a commonly performed female contraceptive surgery. Women choose to "have their tubes tied" when they believe their child-bearing days are done. With today's rates of remarriage, however, many people later change their mind and desire pregnancy again. Some fertility specialists see a high percentage of new patients who are eager to restore their fertility by reversing their tubal ligations.

Fortunately, just as IVF has become increasingly successful in helping people achieve pregnancy, so the techniques for reversing tubal ligation have become finer-tuned. Both procedures can be used to treat tubal factor infertility; in fact, IVF was first invented for that specific purpose.

So what should a woman with a previous tubal ligation consider in making her choice of fertility treatment? Some practitioners more readily recommend one treatment over another, but all agree that there are certain conditions that can be weighed and compared.

Will it work?

The first, most obvious question to consider is which procedure will work for your individual situation.

Dr. Donald Galen, Surgical Director at Reproductive Science Center of the San Francisco Bay Area and Associate Clinical Professor at University of California-Davis' Department of Ob/Gyn, says he's actually seen an increase in requests from women for information on microsurgical tubal reversal (MTR) over the past 25 years. He believes the growing interest mirrors the increasing awareness about the strong success rates for MTR.

Galen says, "The literature demonstrates that in experienced hands, most fallopian tubes can be successfully reopened. The cumulative pregnancy rate for the first year following MTR in women younger than 38 averages 70 percent or higher."

In comparison, IVF success rates (specifically, percentage of cycles resulting in pregnancy) range from 36 percent for women ages 35 to 37 to 43 percent for women younger than 35 (from 2004 Clinic Summary Report, Society for Assisted Reproductive Technology.)

For more details on the MTR procedure and the different types of tubal ligation that respond best to reversal surgery, read Tubal Ligation Reversal, a previous interview with Dr. Galen.

How much is the cost?

Typically, the next thing to come to a patient's mind when looking at treatment pros and cons is the cost factor. As with all medical treatments, patients should explore not only applicable fees and insurance benefits, but time and lifestyle costs as well.

Dr. George Koulianos, Director of The Center for Reproductive Medicine, remarks that one possible reason for his south Alabama clinic's strong demand for tubal reversals is related to insurance coverage. "Some of the carriers here cover reversal, and those same plans often do not cover IVF," he explains.

From Cincinnati's Center for Reproductive Health, Dr. Daniel Williams, Medical Director and Professor at University of Cincinnati College of Medicine's Division of Reproductive Endocrinology and Infertility, adds that the cost for reversing tubal ligation is less than for IVF because of a special arrangement his clinic has with the hospital. Such situations will vary with locations, but in general, tubal reversal can be less expensive than IVF.

The amount of interest initially expressed by patients who are exploring options does not always correlate to the types and amount of procedures actually performed. As Dr. Galen described, patients may indeed be more aware of the fertile possibilities of tubal reversal, but some will instead eventually choose IVF.

Dr. Williams explains that even with their available package pricing, "many patients don't follow through because it requires they pay up front."

On the other hand, clinics that conduct most MTRs in-office, such as RSC of the San Francisco Bay Area, are able to significantly reduce fees.

The same-day, out-patient aspect of MTR is also one that many women find superior. Dr. Galen details that the procedure is performed with either a small abdominal incision or by laparoscopic technique. Most women are able to resume normal activity within two weeks or less.

In South Carolina, Southeastern Fertility Center's Dr. John Schnorr, Division Director of Reproductive Endocrinology in the Department of Obstetrics and Gynecology at the Medical University of South Carolina, describes how patients' knowledge about IVF outcome rates plays a role in their choice. "Our experience has been that the number of people interested in tubal reversal has been stable; however, with increased IVF success rates, the number that choose tubal anastomoses (reversal) has been decreasing."

Exploring other reasons?

One of the commonly stated factors for some patients who choose tubal reversal is a desire to defer to nature more than assisted reproductive technology. As Dr. Williams puts it, "These are patients who want to maintain the possibility of conceiving 'naturally'."

Dr. Galen adds that a patient's age may play a role in her choice, "because many women are quite young when they undergo tubal sterilization, and a change of heart or remarriage will then kindle interest in having another child."

Dr. Koulianos has seen similarly in his practice, pointing out that younger women may feel more wary of reported emotional and physical stress of IVF. Also, he say, "Older patients are more receptive to IVF because they tend to want to move the process along." As do all the specialists interviewed, Koulianos and his staff inform inquiring patients that not everyone conceives as a result of tubal reversal, and getting pregnant after surgery can take several months.

Although IVF is an option for virtually all women who want to reverse a tubal ligation, Dr. Galen, who has specialized in MTR for nearly three decades, says, "Not all women are comfortable using fertility injections or with the increased risk of multiple pregnancy that is seen with IVF."

From another viewpoint, because single embryo transfer (SET) is becoming more successful in producing babies, physicians say that IVF with SET is sometimes a safer safer bet. One, Dr. Schnorr, says that there are a few female structural conditions that might actually warrant such a recommendation. "I would say anyone in which a multiple pregnancy is contraindicated would have a benefit with a single embryo transer." He cites examples such as mullerian anomaly and cervical incompetence.

The causes of infertility are numerous and complex. Women who know that at least part of their infertility is due to a previous contraceptive choice are a step ahead in the journey to pregnancy. Because other factors may be at work, such as age-related ovarian reserve issues or a new partner's male factor infertility, specialists encourage women to thoroughly consider all the nuances of the various treatment options.

Regardless of their choice, the good news is that both tubal reversal surgery and IVF are increasingly successful at helping women achieve pregnancy.