Reversal of Sterilization - Tubal Reversal
TUBAL REVERSAL GUARANTEE
Arizona Center for Fertility Studies is extremely confident in Dr. Nemiro's and Dr. Lipskind's experience and expertise in performing Microsurgical Reversals of Sterilization and is so committed to the success of our patients that, if a patient is not pregnant after 6 months of attempting pregnancy, and the HSG shows both tubes to be blocked, the clinic will do a cycle of standard In Vitro Fertilization (IVF) at no charge.
This guarantee does not include any work-up that is needed, the cost of anesthesia to do transvaginal egg recovery, medications, ICSI and freezing of embryos. The cost of a follow-up HSG is $200.
Also, the guarantee only applies if both tubes were put back together (which is the majority of the time) and both are closed on follow-up HSG (tubal x-ray). If at least one tube is patent or open, then the guarantee does not apply because you can still get pregnant with one open tube, it just takes twice as long.
INFORMATION ABOUT PHOENIX AND SCOTTSDALE TUBAL REVERSAL PROCEDURES
Dr. Jay S. Nemiro and Dr. Shane Lipskind, M.D. have been doing microsurgical reversals of tubal ligations since first being trained as reproductive endocrinology and infertility (REI) fellows. Since then, they have done thousands of microsurgical reversals of tubal sterilization with very high success rates of resulting tubal patency, pregnancy rates and a very low incidence of ectopic or tubal pregnancies. Where some reproductive surgeons will use magnifying glasses or loops to improve visualization, Dr. Nemiro and Dr. Lipskind were trained and have always used the operating microscope for their procedures. The operating microscope can magnify the operative field many more times than the surgical loops and thus provide better visualization of the ends of the fallopian tubes so extremely small sutures can be used to reunite the fallopian tubes. By using extremely small permanent sutures, there is very little to no reaction of the surrounding tubal tissues to the surgery, thus reducing, and most times, completely eliminating the risk of scar tissue or adhesions which can result in the surgery being unsuccessful or increasing the risk of a tubal pregnancy. As a result of these microsurgical techniques, tubal patency or the fallopian tubes remaining open following surgery, should approach 100% and the risks of a pregnancy developing in the tube (ectopic pregnancy) should be very low. Although the possibility of an ectopic pregnancy is always discussed with the patient as a potential risk, it only occurs about 2% of the time following Dr. Nemiro's and Dr. Lipskind’s microsurgical techniques.
Many times patients are worried that their tubal sterilization cannot be reversed if they have had their tubes cut, tied or burned (cauterized) or any combination of the three. Although there are some tubal sterilizations that are easier to reverse than others (Falope rings, Hulka clips or Filshie clips), it actually does not matter how your sterilization was done. The most important factor is the amount of remaining tubal segments that are left. The fallopian tube is about 10-11centimeters in length and the more tubal segments remaining, the greater the pregnancy success will be. Therefore, sterilization can be done that either cuts the tube, ties the tube or burns the tube, as long as the procedure was not too aggressive and destroyed a large segment of the fallopian tube; there usually is plenty of tubal segments remaining to do a successful reversal. As a matter of fact, 98-99% of the time, there is enough tubal segments left to proceed with the reversal. Prior to scheduling the reversal surgery, we always try to get the operative report from the sterilization, so we are able to see exactly what kind of sterilization was done and how much tube was destroyed. Sometimes the patient is not able to get a copy of her operative report. That is okay and does not mean that the surgery cannot be done. Sometimes the operative report is even wrong and does not accurately reflect either what surgical procedure was done and/or how much fallopian tube was damaged. In order to never to do a surgery that will not result in a reversal, Dr. Nemiro and Dr. Lipskind always do a diagnostic laparoscopy first to confirm that there is enough tubal length to do a successful reversal. Prior to the actual surgery, but in the operating room, a tiny incision is made in the belly button and a small telescope or laparoscope is inserted into the abdomen to look directly at the fallopian tubes to determine if there is enough tubal segments available to proceed with the reversal. If there is (98-99% of the time), the laparoscope is removed and a small bikini incision (approximately 2-3 inches) is made right above the pubic bone. At that time, the operating microscope is wheeled into position and the rest of the surgery is done by microsurgical technique under the operating microscope.
The two ends of the fallopian tube are opened and an end to end micro-anastomosis is done, joining the two open tubal segments with very small micro-sutures. Many times the diagnostic laparoscopy is not needed because there is an operative report and a pathology report stating the amount of fallopian tube that was removed, but Dr. Nemiro and Dr. Lipskind feel strongly that it is still important to document the procedure can be done. ACFS has worked out a relationship with the surgery center and they only charge $100 for this "assurance that the reversal can be done". It is included in the total price of the procedure and by not doing it, it would only save a patient $100 and increase the possibility that the abdomen would be opened and the reversal could not be done.
Some clinics will do an x-ray or hysterosalpingogram (HSG) first, in lieu of the diagnostic laparoscopy, to see if there is enough tubal segments left. The problem with the HSG is that it only will tell you how much tubal segment there is up to the point where the tube was "tied" but you do not know how much tubal segment is on the other side of the "tie". Therefore, Dr. Nemiro and Dr. Lipskind feel the HSG (x-ray) is of little value and do not do them.
If, at the laparoscopy, it is found that there is plenty of tube distal to the ligation but no proximal tube (tube near the uterus), then a re-implantation can be done. This is common with tubal ligations done near the uterus or with the ESSURE procedure. This is a procedure where a micro-insert is inserted into the fallopian tube and causes the fallopian tube to become blocked by the growth of tissue around the insert.
Re-implantation tubal reversal surgery is where a new opening is made in the uterus and the distal fallopian tube is inserted into that opening. The fallopian tubes are held in place by a stent that is removed in three months in the office. Although tubal re-implantation surgery still is an effective means of doing a reversal of sterilization, pregnancy rates are a bit lower than the more common end to end anastomosis, and because the uterus needs to be opened to do the procedure, patients will have to deliver by caesarean section and wait three months to attempt pregnancy to give the uterus time to heal. The good news is, tubal re-implantation surgery, only happens about 5% of the cases or less and nobody will do a C/S on you unless you are having a baby. Dr. Nemiro and Dr. Lipskind have some of the most extensive experience in the country with this procedure.
The reversal surgery is done as an outpatient in a freestanding surgical facility with an overnight stay on the second floor. The actual procedure takes about an hour or so and you can go home the following morning. Patients have a choice between going to sleep with general anesthesia or staying awake with regional or spinal anesthesia. The advantages of regional or spinal anesthesia is that there is no general anesthesia hangover, you can watch the surgery or at least know if there is enough tubal segments to reverse; and what Dr. Nemiro and Dr. Lipskind think is the best advantage of spinal anesthesia, is that at the same time the spinal medicine is inserted, spinal morphine medication is also inserted. Spinal morphine is a preservative-free morphine that travels up the spinal fluid to the pain centers of the brain. The advantage is that as the spinal wears off in about 3 to 3 1/2 hours, the spinal morphine starts working in about 3 hours, and gives you approximately 12-18 plus hours of pain relief. Many times you will not need pain medication after the surgery and when the spinal morphine completely wears off, it is early the following morning and oral pain medication will work fine and you are ready to go home in several hours. If you like the idea of the spinal morphine but do not necessarily want to stay awake, you can still do the spinal and just ask anesthesia for more sedation medication, which will cause you to gently fall asleep for an hour or so. By the time the sedation wears off, the surgery is over and you are wide-awake and with no general anesthesia hangover and are pain free.
Complication rates from the surgery are rare, and everyone has been able to go home the following morning. Nobody has ever needed a blood transfusion and nobody has had to be re-admitted to the surgical recovery center. In all of the thousands of procedures that Dr. Nemiro and Dr. Lipskind have done, they have never had a serious complication and nobody had to stay more than overnight after the surgery. They are confident enough in their surgical techniques that patients do not have to worry about banking their blood weeks prior to the procedure. They have never had to do a blood transfusion. The infection rate after surgery is around 3%. It is always in the incision, and not in the abdomen where the tubal reversal was done, and can be treated with oral antibiotics and does not affect the outcome of the procedure.
Recovery time at home is usually 5-10 days, depending on the patient. At the end of 2 weeks you can drive, make love and attempt pregnancy, take long walks and return to work as long as you do not have a physical job. At the end of 6 weeks there are absolutely no physical restrictions. Average time to pregnancy after the surgery is about 6-7 months and twice as long if Dr. Nemiro and Dr. Lipskind were only able to put one tube back together. Pregnancy rates are not half with one tube, it just takes twice as long to conceive, because most women ovulate, or release an egg, by alternating side to side. Sometimes, the doctors will suggest adding low dose fertility medication causing ovulation to occur out of both sides; therefore, reducing the time it takes to get pregnant.
As soon as you are late on your period, even by a few days, Dr. Nemiro, Dr. Lipskind, or their staff will do a urine pregnancy test at no charge, and if positive, an early ultrasound, also at no charge, to document that the pregnancy is in the uterus. Once the pregnancy is seen in the uterus, you are generally home free. Although, there is always the risk of a miscarriage, it is no higher as a result of the reversal surgery. Success rates for pregnancy are around 50-70+% and generally related to the age of the patient. The younger you are, the more successful you will be. Even women in their early forties, still have a chance of a successful pregnancy.
Prior to surgery, a sperm count is done on the partner at no charge, and the couple is given the option to do a complete work-up prior to the surgery to look for any factors that may interfere with a successful pregnancy after the surgery. Unless something is obvious, most couples will decline the work-up and understand that there is a small risk that something might be overlooked that will interfere with them being successful. If the couple is not successful by about 6 months after the surgery, the first thing that will be recommended is to do a x-ray or HSG to document tubal patency. Once tubal patency is documented, the couple can continue to attempt pregnancy a bit longer or can start a work-up and consider additional treatment options to help them conceive.
DIAGRAM OF TUBAL REVERSALS
When a woman decides to have a tubal sterilization and thus end her natural ability to have any more children; thousands of women will change their minds sometime during their lifetime. Although, told at the time that the sterilization is not reversible, 98-99% of tubal ligations are reversible.
Falope rings and/or Hulka and Filshie clips are the easiest to reverse because they are generally placed at the isthmic or beginning and thin part of the tube closest to the uterus, which is not where fertilization occurs (it occurs more distally in the lower third of the tube).The rings or clips also cause very little damage to the fallopian tube because they are less than one centimeter in size. More commonly, however, tubes are either tied, cut or burned in the middle of the fallopian tube; making the tubes easier to put back together because the size of the tube in that location is bigger than in the isthmic part. However, pregnancy rates could be slightly less because gynecologic surgeons tend to be a bit more aggressive in that area destroying, statistically, a greater percentage of the tube. A reversal can still be done 98-99% of the time even if the tubal ligation was done in that area and pregnancy rates are still very good.
REVERSAL OF STERILIZATION VS. IN VITRO FERTILIZATION
Mostly, if not all the time, fertility clinics will try to talk a patient out of a reversal of sterilization, trying to convince them that In-Vitro Fertilization (In-Vitro Fertilization (IVF)) is their better choice. This is usually done by "scaring" them about the risks of surgery and anesthesia and "how safe" In-Vitro Fertilization (IVF) is. True, there are risks to any surgical procedure; but the truth is, that the risks and complications of surgery and anesthesia from a reversal of sterilization are rare. Think about it, where could you be safer than in a major medical center out-patient facility with board certified anesthesiologists. Frankly, the two biggest risks are not surgery and anesthesia, but driving from your house to the doctor's office on major highways and pregnancy, itself. Don't kid yourself, pregnancy is risky business for women and, as you know, there can be many different complications during and at birth. Highway fatalities are far greater than any risks associated with elective surgery in a young healthy woman. Women are willing to take these two risks every day.
Maybe it is a good thing, because most fertility specialists are not well trained in doing reversals of sterilization. Most current REI (reproductive endocrinology and infertility) fellowships have little or no training in microsurgical reversals of sterilization and put most, if not all, their emphasis on training them to do In-Vitro Fertilization (IVF). That is not a bad thing, because In-Vitro Fertilization (IVF) can be a successful procedure, but a woman needs to know all her options and those options need to be presented to her without bias. Once the pros and cons of each procedure are discussed, including financial costs, success rates and logistics, and done unbiasedly, then the couple can make their choice as to what procedure is best for them. "Quite frankly, In-Vitro Fertilization (IVF) is much easier to do than standing for an hour or so in surgery, and the clinic makes more money".
Besides "scaring" them with the risks of surgery and anesthesia, it is argued that if you do In-Vitro Fertilization (IVF), not only will you not have to undergo surgery and time lost for recovery, but you will not have to worry about future birth control and having to deal with a future sterilization for you or your partner. Dr. Nemiro's and Dr. Lipskind's answer to that is, "if you are having to worry about birth control in the future, that is a good problem to have".
From a more practical point of view, a reversal of sterilization costs less than a single attempt at In-Vitro Fertilization (IVF), and you can continue trying to get pregnant, "at no charge"; whereas, with In-Vitro Fertilization (IVF), a single attempt is more expensive than the reversal and if you are not successful, subsequent attempts at In-Vitro Fertilization (IVF) continue to cost more money. The cost of a reversal of sterilization at ACFS is $9,109, which includes everything but the initial consultation (which can be used as a credit toward the surgery) and HIV and hepatitis B and C, which can be done by your PCP and covered by insurance. In-Vitro Fertilization (IVF) costs around DOUBLE, generally takes 1-2 attempts to be successful, and requires a work-up (costing about $1500 but can be done by your OB/GYN) to be sure not to overlook anything that could affect the success of the In-Vitro Fertilization (IVF) procedure. With the reversal of sterilization, most couples will waive the work-up, because, if something is "missed", it can always be tested for and treated later and nothing is lost financially other than a little time.
PRICES FOR A TUBAL REVERSAL
TOTAL COST OF A REVERSAL OF STERILIZATION
This fee includes everything but the initial consultation of $300, which can be applied to the cost of the procedure, and HIV and hepatitis B and C, which can be done by your primary care provider (PCP) and covered by insurance.
All follow-up visits and consultations, urine pregnancy tests and OB ultrasounds are done at no charge.
For the convenience of our patients, in-state or out-of-state, initial consultations, surgery and pre-operative visit can be scheduled all on the same day as the surgery. All you need to do is call the office, let them know you are interested in a reversal of sterilization and that you would like to schedule everything for the same day. There is always the option to initially schedule a phone or in-office consultation to review your medical history and operative/pathology report and discuss what is the best option for you - a reversal of your sterilization or In-Vitro Fertilization (IVF).
THERE SHOULD NEVER BE A NEED FOR A WOMAN LIVING IN ARIZONA TO TRAVEL OUT OF STATE. Dr. Nemiro and Dr. Lipskind have seen patients from all over the country and have done more microsurgical reversals of sterilization than most physicians, have excellent tubal patency rates, as well as pregnancy rates, and complications are rare. Our prices are comparable to other reproductive surgeons in the country (don't forget to factor in travel, hotel and eating expenses to go out of state).
Arizona Center for Fertility Studies strongly believes in the woman's right to choose which procedure is best for them - a reversal of sterilization or In-Vitro Fertilization (IVF).
Selection of a clinic, their experience and expertise with microsurgical reversals of sterilization is far more important than "shopping the cost of the surgery" (although that is important too).