"Irreversible Tubal Sterilization..."

In 1996, more than two million tubal sterilizations were performed in the U.S., for an average annual rate of 1.5 per 1,000 women. The success of sterilization reversal depends on the type of procedure originally performed, the patient's age, and whether there are other infertility factors present. In ideal circumstances, 50-75 percent of the women who have sterilization reversal surgery may be able to conceive. Another option, which avoids surgery, is oocyte (egg) aspiration, in vitro fertilization and embryo transfer (IVF-ET). In this report we describe the case of a woman who had a previous tubal cauterization, a previous right oophorectomy, diminished ovarian reserve and luteal phase deficiency. Her husband had asthenozoospermia and teratozoospermia.

Twins Sarah and Clayton were born after successful in vitro fertilization at CRH. They are examples of the thousands of successful outcomes in our fertility programs including IVF.

IVF resulting in Twin Delivery Following Irreversible Tubal Sterilization

Case Report

Mrs. Peggy Schultz is a 35-year-old woman (Gravida 2, Para 2) with a six-year history of secondary infertility and a previous tubal sterilization. A previous hysterosalpingogram had shown bilateral tubal occlusion and a normal endometrial cavity. Her day 3 FSH was 5.9 miu/ml, with an E₂ level of 62 pg/ml. Her husband's semen analysis demonstrated a motility of 8% and a normal morphology of 9%. Peggy had documentation of granulosa cell programmed cell death (apoptosis) related to her chronological age and poor oocyte quality. Thus, she requested proceeding with IVF-ET rather than a tubal microanastomosis.

“Eight cell embryos were replaced into the endometrial cavity followed by hormone supplementation to correct luteal phase deficiency.”

Controlled supra-ovulation was attained with follicular phase leuprolide acetate (Lupron; TAP Pharmaceuticals, North Chicago, IL), followed by 10 days of gonadotropin administration (daily dose: 300 miu FSH; Repronex, Ferring Pharmaceuticals Inc., White Plains, NJ). With multiple follicles of 18 mm, and an E₂ level of 9,765 pg/ml, 10,000 iu HCG (Novarel™, Ferring Pharmaceuticals Inc., White Plains, NJ) then was given intramuscularly to trigger resumption of the meiotic prophase in preparation for oocyte aspiration.

Twenty oocytes were retrieved 36 hours after HCG administration, and after conventional insemination, 15 became normally fertilized. Gametes were prepared in human tubal fluid (HTF) supplemented with 10% human serum albumin (HSA; In Vitro Care, San Diego, CA), and for culture to day 3, all zygotes were placed into IVC-1 plus 10% HSA (In Vitro Care). On day 3 of development, seven of the embryos were of good quality, possessing eight cells.

On day 3 after retrieval, the patient was asymptomatic and presented for ET.  At transfer, four eight-cell pre-embryos were replaced into the endometrial cavity.

This transfer resulted in a viable dizygotic twin pregnancy that experienced no obstetrical complications. The twins were delivered vaginally at 35^1/2 weeks’ gestation. Baby Sarah Schultz weighed 5’ 1” and measured 18”. Twin Clayton Schultz weighed 5’ 10” and measured 17^1/2” at birth. Sarah and Clayton currently are developing normally at 16 months.

Discussion

The increasing success of IVF allows for alternative therapeutic options to tubal reversals. The results with IVF in terms of live births, too, have equaled and, in many cases, improved upon the results from tubal anastomosis. (Ironically, the initial indication for using IVF in humans was irreversible damage to or destruction of the fallopian tubes.)

Fewer tubal ligation reversals are being performed because of the increasing success of and access to IVF procedures. There have been no trials directly comparing these two treatments. Furthermore, no comparisons of the relative cost-effectiveness of the two approaches have been published. Anecdotally, patients who desire at most one more pregnancy opt for IVF because further birth control methods would not be needed if they successfully conceived and delivered from an IVF cycle.

“The increasing success of IVF allows for alternative therapeutic options to tubal reversals”

There are a number of factors that may help decide whether fallopian tube anastomosis or IVF is the best approach. One key question is whether the patient will need additional treatment to conceive after fertility surgery. Once the cost of this treatment is taken into consideration, the more cost-effective option may be advantageous. Thus, polycystic ovarian syndrome is likely to require ovulation induction treatment, whether the patient chooses surgery or IVF. In these cases IVF may be a more cost-effective treatment. Also, if the husband's semen analysis is dismal, IVF is usually a better option, as ICSI can provide excellent results when the man has fertility problems.

Tubal anastomosis poses a risk of ectopic pregnancy; the risk with IVF is less than 3%. IVF requires multiple office visits, but a surgical incision is avoided and recovery is in hours rather than days or weeks. The cost of each procedure varies widely from institution to institution, but is in comparable ranges.

Pregnancy rates after surgical correction depend on the patient’s age, the partner's fertility status, the type of prior tubal ligation, the site on the tube of the sterilization, the health of the tubes (free of infection or scarring), the surgeon's microsurgical skills and experience, and tubal length after correction.

Conclusions

IVF –ET is an effective and non-surgical treatment alternative for women after tubal ligation.

In spite of this couple’s irreversible tubal sterilization, poor oocyte quality, previous oophorectomy and a sperm factor, a successful outcome is demonstrated  by a twin delivery following IVF-ET.

IVF-ET  must be considered a complementary rather than a competitive procedure. Adequate patient selection is crucial to find the best therapeutic approach.

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