Laparoscopic Tubal Re-anastomosis or In Vitro Fertilisation in Previously Ligated Patients: A Comparison of Fertility Outcomes and Survey of Patient Attitudes

INTRODUCTION: We aim to compare live birth rates, cost analysis and a survey of patient attitudes between laparosopic tubal re-anastomosis and in vitro fertilisation (IVF). MATERIALS AND METHODS: A retrospective study was done in a single reproductive medicine and IVF unit in Singapore from January 2011 to December 2016. Previously ligated patients underwent either laparoscopic tubal re-anastomosis or IVF. The primary outcome was first live birth after treatment. Interval to first pregnancy, miscarriage and ectopic pregnancies were also reported. Patients attending the subfertility clinic completed a questionnaire on IVF and tubal re-anastomosis on preferred choice of treatment, before and after reading an information sheet. RESULTS: Twelve patients underwent tubal re-anastomosis while 31 patients underwent IVF treatment. Pregnancy (75.0% vs 35.5%) and live birth (58.3% vs 25.8%) were significantly higher in the tubal surgery group (P <0.05%) after transferring all available embryos in one stimulated IVF cycle. Cost per live birth was lower in the tubal surgery group (SGD27,109 vs SGD52,438). One hundred patients participated in the survey. A majority of patients preferred tubal surgery to IVF (68.2% vs 31.8%) before given information on the procedures, but indicated a preference for IVF (54.6%) to surgery (45.4%) after receiving information on the procedures. CONCLUSIONS: For women less than 40 years of age, desiring fertility after tubal ligation, laparoscopic tubal re-anastomosis offers better live birth rates and cost-effectiveness. Patients in Singapore are equivocal as to their preference after education regarding the choices. Thus, laparoscopic tubal re-anastomosis remains a viable alternative to IVF treatment.

Laparoscopic tubal reanastomosis versus in vitro fertilization: cost-based decision analysis.

OBJECTIVE: Regret after tubal ligation continues to be a problem. After tubal ligation, couples have the option of tubal surgery or in vitro fertilization (IVF). STUDY DESIGN: Using decision analysis techniques, we compared cost-effectiveness of tubal reanastomosis by tubal type vs tubal surgery or in vitro fertilization (IVF) for 3 separate age groups of women: <35 years of age, 35 to 40 years of age and >40 years of age. Tubal techniques was divided into type A, those with more favorable prognosis because of the likelihood of having a more significant length tube at time of reanastomosis and type B, those with a worse prognosis of success. We incorporated delivery costs to address the impact of high order multiples in IVF. Data were extracted by studies available in the literature. All costs were adjusted to 2012 US dollars. One-way and 2-way sensitivity analyses were performed. RESULTS: The laparoscopic reanastomosis of type A dominated the other groups, because it was more effective and less costly then type B and IVF. However, when women were >40 years old with a history of type B, IVF was favored when its costs were at the lower limit. CONCLUSION: The most cost-effective choice for a woman desiring pregnancy after tubal ligation is laparoscopic reanastomosis after a prior clip or ring tubal ligation for women ≤40 years old. It is also the most cost-effective for the oldest cohort, assuming IVF costs are greater than $4500.

Live birth following day surgery reversal of female sterilisation in women older than 40 years: a realistic option in Australia?

OBJECTIVE: To determine the live birth rate following surgical reversal of sterilisation in women aged 40 years and older. DESIGN: Retrospective cohort study of pregnancy outcome following day surgery microsurgical reversal of sterilisation performed by two reproductive microsurgeons in the private sector. SETTING AND PATIENTS: 47 patients (aged 40 years or older) who had reversal of sterilisation performed between 1997 and 2005 in Adelaide, South Australia (n=35), or the Infertility Centre of St Louis, Missouri, USA (n=12). MAIN OUTCOME MEASURES: Independently audited live birth surviving the neonatal period. RESULTS: Of the 47 patients on whom follow-up was obtainable from the two centres, 19 (40%) had a live birth, 7 had had only a first trimester miscarriage at the time of follow-up, and 21 (44%) had failed to conceive. Age at conception ranged between 40 and 47 years. Two women had two live births following surgery. The total direct costs (Australian dollars, adjusted to 2005) in Australia were $4850 per treatment, and $11,317 per live birth. The corresponding direct cost of a single cycle of in-vitro fertilisation (IVF) in Australia has been estimated at $6940, with a cost per live birth of $97 884 for women aged 40-42 years and $182,794 for older women. CONCLUSION: Previously sterilised women wanting further pregnancy should be offered tubal surgery as an alternative to IVF, as it offers them the opportunity to have an entirely natural pregnancy. In settings where IVF is financially supported by government agencies or insurance, tubal reversal is a highly cost-effective strategy for the previously fertile woman.

Getting pregnant after tubal sterilization: surgical reversal or IVF?

BACKGROUND: When women regret having had a tubal sterilization, is the pregnancy rate higher with surgical reversal or IVF? METHODS: This retrospective cohort study analyses the delivery rates of 163 patients undergoing IVF treatment (n = 79) or surgical reversal (n = 84). Pregnancy outcomes were obtained by reviewing medical records or contacting private physicians and patients. The life table method was used to calculate the chance of becoming pregnant and to construct cumulative pregnancy curves. Cumulative pregnancy curves are compared by log rank tests. A P-value of <0.05 is considered as statistically significant. The cost-effectiveness of the two strategies was also evaluated. RESULTS: Patient characteristics did not differ between the two groups. The cumulative delivery rate during 72 months was 52.0% in the IVF group and 59.5% in the reversal group (ns). Age was the only factor that influenced delivery rates significantly. The cumulative delivery rate for patients aged < 37 years was 52.4% after IVF and 72.2% after reversal (P = 0.012), while cumulative delivery rates for patients aged 37 years or older were, respectively, 51.4 and 36.6%, a difference that did not reach statistical significance. The average cost per delivery was 11,707 euros for IVF, compared with 6015 euros for surgical reversal. However, in patients aged 37 years or older the difference in cost was smaller. CONCLUSION: Considering the cumulative delivery rates involved, surgical reversal is recommended for patients younger than 37; older patients are advised to opt for IVF.

Tubal anastomosis by robotic compared with outpatient minilaparotomy.

OBJECTIVE: To compare tubal anastomosis by robotic system compared with outpatient minilaparotomy. METHODS: In this retrospective case-control study, women were identified by current procedural terminology code for tubal anastomosis. We included all cases of tubal anastomosis for reversal of a prior tubal ligation by either outpatient minilaparotomy or robotic system technique. Cases performed by laparoscopy without aid of the robot were excluded. Comparisons were based on Fisher's exact, chi(2), and Wilcoxon rank sum tests. RESULTS: There were 26 cases of tubal anastomosis performed with the robot and 41 cases performed by outpatient minilaparotomy. The two groups were comparable in age, body mass index, and parity. Anesthesia time for the robotic technique (median with interquartile range) was 283 (267-290) minutes compared with 205 (170-230) minutes with outpatient minilaparotomy (P<.001). Surgical times for the robot and minilaparotomy were 229 (205-252) minutes and 181 (154-202) minutes respectively (P=.001). Hospitalization times, pregnancy, and ectopic pregnancy rates were not significantly different. The robotic technique was more costly. The median difference in costs of the procedures was $1,446 (95% confidence interval $1,112-1,812) (P<.001). The time to return to work was significantly shorter in the robotic system group by approximately 1 week (P=.013). CONCLUSION: Robotic surgery for tubal anastomosis was successfully accomplished without conversion to laparotomy. The robotic technique for tubal anastomosis required significantly prolonged surgical and anesthesia times over outpatient minilaparotomy (P

Vasectomy related infertility: a major and costly medical problem.

Of a group of 860 men who attended a private infertility clinic in Western Australia, 80 (9.3%) presented with vasectomy-related infertility. Of these men, 73 (91%) requested treatment due to re-marriage. The median age of the men was 42.5 years and their present partners were approximately 10 years younger. The median vasectomy interval in the men in this study was 9 years. Treatment of vasectomy-related infertility included vasectomy reversal procedures, donor insemination and both in-vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). It is suggested that care must be taken in counselling such patients prior to a vasectomy. The cryopreservation of semen prior to vasectomy would also make much of this type of infertility treatment unnecessary.

Microsurgical tubal anastomoses performed as an outpatient procedure by minilaparotomy are less expensive and as safe as those performed as an inpatient procedure.

OBJECTIVE: To determine the cost-effectiveness, safety, and success of microsurgical tubal anastomoses performed by minilaparotomy as an outpatient. DESIGN: Retrospective. SETTING: Military tertiary care medical center. PATIENT(S): Seventy consecutively seen women of reproductive age who were undergoing surgical reversal of sterilization from August 1, 1993, through August 1, 1995. INTERVENTION(S): Microsurgical sterilization reversal by minilaparotomy was performed as an inpatient (group 1, 47 patients) or as an outpatient (group 2, 23 patients). MAIN OUTCOME MEASURE(S): Cost, complication rate, pregnancy rate. RESULT(S): The procedure cost more for inpatients ($3,116) than for outpatients (!,456). Pregnancy rates were similar (56% in group 1 vs. 75% in group 2). There was only one complication in the series. CONCLUSION(S): Outpatient microsurgical sterilization reversal performed by minilaparotomy is as safe and effective as the inpatient procedure and is less expensive.

PIP: A retrospective study conducted at a military tertiary care medical center in Portsmouth, Virginia (US), assessed the cost-effectiveness, safety, and success of microsurgical tubal anastomoses performed by minilaparotomy on an outpatient basis. The medical records of 70 consecutive women who underwent surgical sterilization reversal at the facility in 1993-95 were reviewed; 47 women received minilaparotomy as an inpatient procedure and 23 on an outpatient basis. All patients were seen in the clinic 2-4 weeks postoperatively and no significant complications were recorded. The total cost of the procedure was $3116 for inpatients and $1456 for outpatients. At follow-up (range, 19-43 months after surgery), the crude pregnancy rate was 56% in the inpatient group and 75% among women who underwent the procedure as outpatients. These findings indicate that minilaparotomy can be performed on an outpatient basis with significant cost savings but no adverse effect on patient safety. Appropriate preoperative counseling and postoperative follow-up are essential, however.

Fertility options after vasectomy: a cost-effectiveness analysis.

OBJECTIVE: To evaluate cost per delivery using two different initial approaches to the treatment of postvasectomy infertility. DESIGN: Model of expected costs and results in the United States in 1994. SETTING: Men with postvasectomy infertility, evaluated and treated at centers with experience in vasectomy reversal or sperm retrieval and ICSI. PATIENT(S): Men with postvasectomy infertility, with a female partner < or = 39 years of age. INTERVENTION(S): Initial microsurgical vasectomy reversal was compared with retrieved epididymal or testicular sperm. Actual treatment charges, complication rates, and pregnancy and delivery rates obtained in the United States were used for cost per delivery analysis. MAIN OUTCOME MEASURE(S): Cost per delivery, delivery rates. RESULT(S): Cost per delivery with an initial approach of vasectomy reversal was only $25,475. (95% confidence interval $19,609 to $31,339), with a delivery rate of 47%. However, the cost per delivery after sperm retrieval and ICSI was $72,521. (95% confidence interval $63,357 to $81,685), with an average of $73,146 for percutaneous or testicular sperm retrieval and $71,896 for surgical epididymal sperm retrieval. The delivery rate after one cycle of sperm retrieval and ICSI was 33%. CONCLUSION(S): The most cost-effective approach to treatment of postvasectomy infertility is microsurgical vasectomy reversal. This treatment also has the highest chance of resulting in delivery of a child for a single intervention.

PIP: Calculations of cost per delivery for vasectomy reversal versus sperm retrieval-intracytoplasmic sperm injection (ICSI) under a wide variety of initial assumptions clearly indicate that vasectomy reversal is associated with lower costs per delivery and higher delivery rates. The data for the models on average postvasectomy infertility costs were derived from 6 specialized medical centers in the US in 1994; only men with female partners 39 years or younger were included. The overall vasectomy reversal pregnancy rate was 52%, with an estimated live delivery rate of 47%; for sperm retrieval and ICSI procedures, the mean weighted delivery rate per attempt was 33%. The average cost per delivery for vasectomy reversal (including pretreatment evaluation, surgeon's fee, anesthesia, ambulatory charges, complication costs, lost work costs, and delivery costs weighted for the number of procedures performed at each center) was US $25,475 (95% confidence interval, $19,609-31,339). In contrast, the cost per delivery after sperm retrieval and ICSI was US $72,521 (95% confidence interval, $63,357-81,685), with an average of $73,146 for percutaneous or testicular sperm retrieval and $71,896 for surgical epididymal sperm retrieval. Overall inpatient charges for delivery of a singleton gestation were $9845 ($37,947 for twin gestations and $109,765 for triplet gestations). Unless microsurgical epididymal sperm aspiration results improve dramatically or ICSI procedural costs and multiple gestation rates decrease, vasectomy reversal will remain the indicated treatment for men interested in fertility restoration after vasectomy.

Improved combined laparoscopic and minilaparotomy technique to allow for reversal of extensive tubal sterilization.

We assessed the efficacy of combined laparoscopic and minilaparotomy for outpatient microsurgical reversal of extensive tubal sterilization in 11 women undergoing the procedure and followed for a mean of 24.7 months. All patients desired reversal of extensive tubal sterilization, and had 4 cm or less of the longer oviduct remaining. The mean operating time was 110 minutes, and the mean total cost was $5067. There were no major complications. Two women were treated for uncomplicated cystitis within 1 month of surgery. Five (45%) of 11 women delivered viable infants; one patient had two ectopic pregnancies. These preliminary data suggest that outpatient combined laparoscopy and minilaparotomy may be effective in patients who desire restoration of fertility after extensive tubal sterilization.

Government-funding program on reversal of tubal sterilization.

Three hundred and sixty-one women were provided government-funded sterilization reversal services with the technique of microsurgery. A large majority of reasons (89.8%) for requesting reversal surgery was a loss of children, and the mean interval between sterilization and reversal was 28.7 months. Two hundred and seven (69.7%) of 297 follow-up cases have experienced term delivery or intra-uterine pregnancy and 5 cases were ectopic pregnancy. The largest number of reversal clients (63.3%) were sterilized by the laparoscopic unipolar coagulation technique and the next largest group (24.2%) was sterilized by the laparoscopic banding technique. The highest pregnancy rate (77.8%) was shown in clients who had undergone laparoscopic banding technique while the lowest (65.9%) was the group of laparoscopic unipolar coagulation. A more than 60% of the clients became pregnant within 6 months of their reversal surgery, with the shortest interval being 1 month, the longest 39 months, and the mean 7.6 months. A large majority of the successful cases, 81.6%, were pregnant within 1 year of their reversal surgery.

PIP: Physicians at 15 institutions in the Republic of Korea conducted microsurgery to reverse tubal sterilization in 361 22-38 year old women (mean 28.8 years) of parity 0-2 (mean 0.4) between 1980 and 1988. The government paid for the sterilization reversal services. The leading reason for regret and reversal of tubal sterilization was death of a child (89.8%). The researchers were able to follow up on 297 cases (18 months-8 years after reversal surgery). 69.7% (207) of the cases became pregnant after tubal sterilization. Most reversal clients (63.3%) had had laparoscopic unipolar coagulation followed by the laparoscopic banding technique (24.2%). The laparoscopic banding technique resulted in a more successful reversal rate (77.8%), however. Only 65.9% of clients who had had laparoscopic unipolar coagulation became pregnant. The most successful reversal by sterilization type was for clients who had had postpartum Pomeroy technique (90%). The most successful reversal by anastomosis site was isthmic-isthmic (80.9%) and the least successful was cornual-ampullary (64.9%). 61.8% became pregnant within 6 months after reversal and 81.6% within 1 year. The success rate was highest among the women who underwent their reversal 25-36 months after the sterilization (78.4%) and the lowest rate among those with an interval of 37-48 months (53.5%). The mean interval between reversal and conception was 7.6 months, the shortest interval being 1 month and the longest 39 months. As voluntary sterilization occurs more often at lower parity among younger women, Korea expects to continue to see more sterilization reversal requests.

Sterilization: Canadian choices.

Significant differences in cost and safety between vasectomy and tubal ligation have been reported. For this reason the incidence of these two procedures between 1976 and 1986 was studied to obtain information upon which future policy decisions might be based. Although tubal ligation predominated in almost every province and year its rate declined by 27.6% over the study period, whereas the rate of vasectomy increased by 39.1%. When projected to 1988 the national rates for the two procedures became nearly equal; those for Quebec had become equal by 1986. Provincial differences were most marked in eastern Canada, where neighbouring provinces had the highest and the lowest rates of sterilization in the country. Given the relative economic and surgical disadvantages of tubal ligation, policymakers may wish to consider fostering an increased acceptance of vasectomy, particularly in areas where such acceptance continues to be slow.

Analysis of the feasibility of storing human semen for future artificial insemination.

Patients about to undergo vasectomy, retroperitoneal lymph node dissection, pelvic radiotherapy or chemotherapy frequently wish to store semen for future artificial insemination. The probability that this will result in a pregnancy is approximately 33% and the logistics are complicated. These problems are discussed and a cost analysis is presented. A list of semen banks presently storing homologous human semen and registered with the American Association of Tissue Banks also is presented.