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In Vitro Fertilization versus tubal reversal (tubaric reanastomosis) for subfertility after tubal ligation

Tubal ligation is the most popular birth control method in the world since it has proven to be a safe and effective method for the control of fertility. It also avoids the adverse effects and potential complications associated with other methods. Worldwide there are approximately 138 million women of reproductive age that have undergone the procedure of tubal ligation. Results of research shows that sterilization is becoming more frequent among younger women. Given the increase in the proportion of women who use the method, an increase of women who request its reversal, is expected (1-13%).

Among the most important reasons to request the recovery of fertility after a tubal sterilization, are: young age at the time of the procedure (less than or equal to 30 years), new partner, death of a child, changes in economic situation and wish for a child of the opposite sex.

Once arrived at the point to recover the fertility, there are two main treatment routes:

1) Tubal recanalization: it consists of a tubal microsurgical anastomosis, it is a major surgical process that is performed under anesthesia by the performance of an abdominal incision.

2) The realization of in vitro fertilization (IVF): this is a technique of assisted reproduction which replaces the function of the uterine tubes.

Very different rates of success have been observed in the literature regarding tubal reconstruction surgery. This is the side effect of the use of various techniques, the lack of strict criteria for the inclusion of patients in the studies and the managed definition of “success”. The technology of assisted reproduction is shown as an alternative for surgery for the treatment of infertility. Thanks to the good results of IVF, the short time needed to achieve the goal and thanks to its safety.

Considerations:

1) Age is the most important predictor for result in fertility. The best approach for patients over 35 years of age who wish to regain fertility after surgical sterilization, is assisted reproduction. This because of the short waiting time to achieve pregnancy.

2) The pregnancy rate decreases as times passes by since performing the surgical sterilization. It is considered a good prognosis for pregnancy when the tubal recanalization is performed within a period of less than 5 years.

3) To decide the best approach for a patient, it is necessary to take into account the age of the patient, the type of sterilization, previous surgeries and associated pathologies such as endometriosis.

4) Before considering the recanalization of a patient, it should be studied if there are concomitant factors that affect fertility. For example the presence of male factor or ovarian factor (ovarian dysfunction, decreased ovarian reserve, requiring an IVF procedure or ICSI).

5) The success rate for tubal recanalization surgery increases if at the end of the procedure the tubal length is at least 4 cm long.

6) The types of tubal occlusion with better prognosis for the reversion, are occlusions made with the technique of Hulka clips or Yoon rings (In Colombia the sterilization technique is called Pomeroy, which consists of cutting and cauterizing the tubal ends.This technique is the one with the worst prognosis for the reversal).

7) For patients with bilateral tubal occlusion and with concomitant hydrosalpinx, surgical reversion is not recommended due to the embryotoxic effect of the mentioned fluid.

8) The success of a tubal recanalization depends on the experience and skills of the surgeon and on the adequate selection of the patient.

9) Most subfertile patients only want one more pregnancy. Thanks to in vitro fertilization the surgical sterilization is maintained after achieving pregnancy.

Not recommended to recanalize if: Less than 2 cm of distal length of the tube, great pelvic damage, absence of proximal segment demonstrable by hysterosalpingography (HSG) or laparoscopy. Women older than 37 years, tubes less than 4 cm, severe adherent syndrome, moderate or severe male factor.