Tubal ligation (sterilization) Questions

Is it normal to miss your menstrual cycle after you have your tubes tied?

Having your tubes tied does not affect your periods.

There is a small chance of getting pregnant after a tubal ligation (about 7 women out of 1000 who have their tubes tied will get pregnant in the first 10 years after surgery). So you need to see your Ob/Gyn for a blood pregnancy test to be 100% sure – if you are pregnant, it might be a tubal (ectopic) pregnancy which can be dangerous.

If you’re not pregnant your OB can find out why you are not regular, such as a hormone-producing ovarian cyst. If you continue to be irregular you will need more testing to find out why, but not if it’s a one-off”” episode and you go back to being regular every month.

Is a tubal reversal an option for conception if my tubes were clipped, tied, and burned?

The choices are In Vitro Fertilization (IVF) or surgical tubal reversal.

IVF involves taking fertility shots for about 8-10 days to make multiple eggs, doing a short ultrasound-guided in office procedure to remove around 10-15 eggs from your ovaries (an egg retrieval). The eggs can then be fertilized by your partner’s sperm, either by mixing the eggs and sperm and letting them fertilize ‘naturally’ in the lab (conventional IVF) or injecting each egg with a single sperm, a procedure called ICSI. The fertilized eggs grow into embryos, and we can put the best 1-3 embryos back inside your uterus (embryo transfer, a simple in-office procedure) and freeze any extra embryos. Success rates can be as high as 60% if you are 35 with good egg supply (ovarian reserve). The frozen embryos can be used to have another child, or if you don’t get pregnant the first time, or if you have a miscarriage. Not everyone has extra embryos to freeze.

Surgical tubal reversal is an outpatient surgery, done either through a surgical telescope (laparoscopy) with small incisions on your lower abdomen, or through a small bikini-line incision (mini-laparotomy). Success rates vary and depend on how much tube was destroyed, with up to 70% of women having at least one open tube after reversal with good surgical technique. There are two ways to burn the tube (unipolar and bipolar electricity) with unipolar cautery doing more damage. Tubal reversal surgery is less successful if the tubes were burned either way. There is a higher chance of tubal pregnancy than with IVF, and this is a much more delicate surgery than tying the tubes in the first place. It needs to be done by a Reproductive Endocrinology specialist, ideally using microsurgery or robotic surgery. If the surgery is successful, you will need birth control again.

It is hard to say what’s the best option without knowing more about you – it can be helpful to get the operation report and pathology report from your sterilization to see how much tube was removed and what exactly was done. If the far ends of the tubes were removed (fimbriectomy) IVF is the best choice.

It is worth doing a sperm count for your partner upfront, as if he has low sperm numbers or quality then IVF with ICSI is the best choice. It is also worth testing your fertility including your ovarian reserve (egg supply) – even with 3 kids and six pregnancies, this could be low at age 35.

We recommend seeing a Reproductive Endocrinologist at PSFC who does both tubal reversals and IVF, who can look at your individual case.

If my tubes are tied, what are my chances of getting pregnant naturally?

Your chance of getting pregnant is about 2% over the first 10 years after your tubes are tied. After you have had a tubal ligation it is totally possible to attempt to initiate a pregnancy again. You can undergo a reversal of the tubal ligation in some circumstances depending on how the original surgery was carried out. The other option is to undergo an IVF cycle, which totally bypasses the tubes altogether by taking the eggs from the ovary, making embryos in the laboratory and then transferring them directly into the uterus. A consultation with one of our doctors will allow us to determine the best possible treatment for you and help you on your way.

Is there a chance for me to donate my eggs after having tubal ligation (female sterilisation)?

Yes, you can do it. Your fallopian tubes are clipped or removed when you are sterilised, but your ovaries continue to function correctly, and the eggs produced can be retrieved.

Is a HSG test effective for infertility treatment?

The Hysterosalpingogram (HSG) test is a diagnostic test, and is the best non-surgical way to check that the Fallopian tubes are open, and that they are normal-appearing. It’s also a good screening test that can pick up polyps or fibroids inside the uterus. Sometimes we see evidence of scarring around the tubes. It’s an important fertility test to do before treatment. Some women get pregnant after the HSG test, and it’s safe to try to conceive in the month you do the test, but it’s not really a fertility treatment by itself.

What causes uterine fibroids, and is there a less-invasive treatment then a hysterectomy?

Fibroids are tumors that each grow from a single cell, but are usually non-cancerous. We don’t know exactly what causes them but there may be genetic and environmental factors – race and maybe diet play a part. Up to 50% of African-American women have them, up to 25% of other ethnicities. Not all fibroids need treatment – only if they are causing symptoms like heavy or painful periods or pelvic pressure symptoms including pushing on the bladder causing frequent urination, or if they are affecting fertility.

Treatment should be individualized, not ‘one-size-fits-all’. Other than hysterectomy these are the options:

  1. Myomectomy – surgical removal of fibroids. This can be done through the hysteroscope (a small telescope that goes through the cervix) for fibroids that are totally or partly inside the cavity of the uterus. Open myomectomy goes through a bikini-line or vertical incision in the abdomen and can remove large fibroids or fibroids deep inside the muscle of the uterus. Laparoscopic myomectomy uses a telescope through the belly button, and small incisions, to remove fibroids on the outside of the uterus. These procedures are most appropriate for women who want to have children in the future, but can be done if a woman just wants to keep her uterus. With the open myomectomy, we can do an ultrasound scan during the surgery to find smaller fibroids that could be missed and cause problems in the future. It is safe to get pregnant after a myomectomy but you may need a C/Section for delivery, depending on where the fibroid or fibroids were located.
  2. Uterine artery embolization / uterine fibroid embolization (UAE / UFE) – an interventional radiologist can insert material into the blood vessels ‘feeding’ a fibroid to reduce its blood supply. This can shrink a fibroid but may not make it disappear altogether. This procedure is non-surgical but has complications, including post-procedure pain, infection or blood clots. It is not appropriate for women who want to have kids in the future – it may not be safe to get pregnant, and the procedure can reduce the blood supply to the ovaries, which get part of their blood flow from the uterus, causing diminished ovarian reserve (low egg supply).
  3. MRI-guided focused ultrasound (MRgFUS) – this non-surgical procedure uses Magnetic Resonance Imaging (MRI) to direct a powerful ultrasound beam to damage fibroids and cause them to shrink. This can be performed by a specially trained Ob/Gyn or an interventional radiologist. Again, it may shrink a fibroid but may not make it disappear altogether. It is also not an appropriate choice for a woman who wants to have children in the future.

We don’t have good medications to shrink fibroids other than Depo-Lupron shots (a monthly or 3-monthly injection given in a Dr’s office) which may be used short-term – their best use is to shrink and soften fibroids before hysteroscopic surgery. They are not a long-term treatment for fibroids due to side-effects. This may change in the future as a new class of medicines comes out (oral GnRH antagonists).

What are the treatment options for endometriosis?

Options depend on whether or not pelvic pain is an issue, and if you’re trying to conceive now, want kids in the future, or are done with childbearing. Medical treatment options are available -Depo Lupron shots work best, and we can also use letrozole tablets or birth control pills. Surgical options consist of laparoscopy with excision or ablation of the endometriosis, versus definitive surgery for women who have completed their families – removal of both ovaries with/without hysterectomy. Fertility patients may need IVF after Depo Lupron treatment or medications and IUI.

What kind of tests are done to diagnose endometriosis?

The diagnosis and treatment of endometriosis depends very much on whether or not you are trying to conceive as well. Some women with early-stage endometriosis have little or zero pelvic pain or fertility issues. We used to diagnose these women when they had a laparoscopy to tie their tubes (there are now less invasive ways to block the tubes in women who are done with childbearing).

The ‘gold standard’ for diagnosis is still to perform a diagnostic/operative laparoscopy, an outpatient surgery performed under anesthesia where a small incision below your belly button allows us to pass a surgical telescope into your abdomen and pelvis and look for endometriosis and often destroy or cut out endometriosis if we find it. More advanced endometriosis may show up on pelvic ultrasound (a sonogram which is best performed with a transvaginal probe), bur early-stage endometriosis will not show up on ultrasound. If you are trying to conceive, a hysterosalpingogram (HSG) does not ‘see’ endometriosis but looks for blocked tubes or scar tissue around the tubes, which can occur in women who have endometriosis, as well as for other reasons like past infections.

If you’re not trying to conceive and your main problem is pelvic pain, while it’s more satisfying to have a ‘proven’ diagnosis, it is acceptable to treat the pain with medications (Depo-Lupron shots) without performing a laparoscopy first.

If you are trying to conceive, having endometriosis may change the course of your treatment in subtle or obvious ways. Having endometriosis (and surgical endometriosis treatment) may cause diminished ovarian reserve (low egg supply), scarring around the tubes or pelvic adhesions (scar tissue), or both. Some women with endometriosis need in vitro fertilization (IVF) to deal with these issues, and Depo-Lupron shots before IVF may improve success rates.

Do I need surgery to treat endometriosis?

In general, you only need endometriosis surgery if you –
1. Want to have kids and have a large endometrioma (endometriosis cyst within the ovary) or

  1. Are completely done with wanting kids and wish to have definitive surgery – removal of both ovaries (with or without hysterectomy).

Surgery rarely ‘cures’ endometriosis unless the surgery is removal of both ovaries (with or without hysterectomy). Removing both ovaries takes away most of a woman’s production of estrogen hormone which stimulates endometriosis tissue and may cause it to grow.

Any other surgery (laparoscopy with laser treatment or cautery or excision of endometriosis, and/or removal of endometriosis cysts) may not remove all the endometriosis in your pelvis – even if your surgeon destroys or excises all visible spots of endometriosis on the surface of the uterus or behind the uterus, on or in the ovaries or on the pelvic side wall, there may be deeper areas of endometriosis not visible on laparoscopy which are missed. Endometriosis may also be hidden underneath areas of scarring.

Because of the above, some women get good pain relief after surgery to treat endometriosis, and some women don’t get good pain relief after surgery. Women with significant endometriosis (more than just a few spots on the surface of the uterus or ovaries) often do better with surgery to confirm the diagnosis and to treat visible disease, followed by Depo-Lupron injections to suppress any endometriosis that’s left behind, than with surgery alone. Surgery alone may provide short term relief of endometriosis pain (a few months up to a few years) before the disease and pain symptoms recur. Women who undergo multiple laparoscopies may get diminishing returns, with less and less pain relief with each successive laparoscopy.

Depo-Lupron can be used on its own without laparoscopy too – it also (but reversibly) takes away most of a woman’s production of estrogen hormone which stimulates endometriosis tissue. If you have pelvic pain symptoms suggesting endometriosis and your pain goes away with Depo-Lupron you are at least 80% likely to have endometriosis.

If you want to try to conceive and you have only small endometriomas, or early stage endometriosis without any endometriosis cysts visible on ultrasound, the surgery may do more harm than good by damaging some normal ovary tissue, which can reduce your ovarian reserve (the number of eggs left in your ovaries).

So the answer is complex but in summary – not everyone with endometriosis needs surgery – it is only definitely needed for big endometriosis cysts or women who are done childbearing. Unless you have both ovaries removed cure is unlikely, but you may get benefit in terms of reducing your pain for a period of time. Medical treatment with Depo-Lupron after surgery often gives better pain control than just surgery. Depo-Lupron can be used on its own without surgery, too.


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