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Why Don’t Doctors Do Their Tubals in the Most Reversible Way?

Syndicated from Tubal Reversal Northwest

 

Nicholas Fogelson, MD

As physicians that spend time helping women to restore fertility after a previous sterilization surgery, one is often left to ponder why some physicians who perform sterilizations do it in a way that makes it very difficult to reverse, when the don’t have to do that.  Specifically, there are techniques to very effectively cause permanent tubal sterilization while still preserving most of the Fallopian tube and making a reversal highly likely to succeed.  There are also ways of causing tubal sterility that will leave so little healthy tube that a reversal is much more difficult.  So wouldn’t it make sense to do the former?  It would seem so, but many surgeons don’t do this.

It really comes down to how obstetricians are trained.  We are trained that a sterilization surgery is permanent, and as such any sort of effort to make it more “reversible” would be a betrayal of the very reason we are doing the procedure.  That is, is the woman wanted a reversible method of birth control, she could get an IUD or use oral contraceptives instead of having a permanent sterilization surgery.  There is also the thought that somehow doing a more reversible tubal sterilization would decrease the effectiveness of that surgery, and further be a betrayal of the original purpose of the surgery.

The reality though, is that all of this is wrong.  First of all, it is a fact that many women who have sterilization surgery decide later in their life that they would like their fertility restored and to have another child.  This is particularly true when women have their children when they are still quite young.  In many cases a woman who has had two or three children by her early twenties feels certain she never wants another child, and has a sterilization.  At the time it makes sense and she feels sure about her decision.  Fast forward ten years, she is a different person than she was when she made the decision, perhaps married to a new partner, and feels like she would like another child.  This just happens so frequently that we have to realize that while a tubal sterilization is “permanent”, its possible that reversal will be desired one day.  As such, wouldn’t it make sense to do it in a way that is reversible as possible?

Second, some may be concerned that by doing a more reversible tubal sterilization, it would be less effective.   This is just wrong, and the data doesn’t bear this out.  In fact, many physicians use a technique that is both the least reversible AND the most likely to fail.  That makes no sense, but its true.

There are two techniques that are optimal for creating the most successful sterilization that is ALSO the most reversible.  The key thing is the amount of tube that is destroyed in the sterilization, as success rates in reversal are high related to how much tube is left to bring back together in the reversal surgery.

The most effective and reversible techniques are 1) a partial salpingectomy that removes a minimal piece of tube from each side (i.e. 1-1.5 cm of tube) or 2) the use of a Filschie clip, which destroys less than centimeter of fallopian tube. Both of these are associated with less than 1% failure rate over 10 years, and as long as minimal tube is removed has a high likelihood of being reversible if such a procedure is required.  A third option is a Falope ring, which can be used to remove a small amount of tube, though it can also remove more tube and is technique dependent.

The alternate technique of using bipolar cautery to dessicate and destroy a segment of tube is less reversible because it inevitably destroys more tube, sometimes dramatically more if the surgeon is zealous with the use of the cautery in a desire to guarantee sterility.  That said, the rate of failure with this technique is 2-3% over 10 years.  So why do surgeons ever do this, with its higher failure rates and less reversibility?  Hard to say.  Makes no sense.

In our opinion, the easiest tubal to reverse is one done with a Filschie clip, which destroys very little of the tube, as seen here (Courtesy of Dr. Modi / Youtube).  It is also the most effective, with a less than 1% failure rate at 10 years.

Another good technique that doesn’t damage very much of the tube is a Falope Ring, seen here (Courtesy of Dr Sakon / Youtube):

Other techniques are far less reversible.  The Essure technique is a permanent device that is placed via a hysteroscope and is quite difficult to reverse, with reversal success is around 30% with the best techniques available.  Sterilization via cautery to the tubes can be difficult to reverse if a significant portion of the tube is injured.  Salpingectomy (complete removal of the tubes) or fimriectomy (removal of the end of the tube) are both techniques that are either difficult or impossible to reverse.

So if you are a woman that is planning to do a permanent sterilization, be sure you don’t want further children, because reversal may not be possible.  But at the same time, realize that sometimes people change their minds, and your doctor has different options on how the sterilization can be performed.  A small partial salpingectomy, Filshie Clip, or Falope Ring will lead to the minimum tubal destruction required for infertility, while leaving the most possible tube in case a reversal is ever required.

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Drs Fogelson and Rosenfield of Tubal Reversal Northwest (dba Pearl Women’s Center) are available for clinical consultation for women seeking reversal of previous sterilization surgery.   Call 503-771-1883 of an appointment for consultation.

 

 

Categories: Gynecology
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