Thursday, July 11, 2013

Surgery for Sterilization Reversal using the da Vinci Surgical System

Robert DeSantis, MD, FACOG – Trinity OB/GYN


Each year in the United States over 600,000 women undergo a permanent sterilization procedure.  Studies show that up to 20% of women will regret this decision within five years of their sterilization procedure.  Approximately 5-10 percent of these women will ultimately decide to have the procedure reversed to have a baby.   Currently most of the reversal procedures are done through an open incision in the belly using microsurgical techniques.  This can include from one, up to several days in the hospital and take six to eight weeks of recovery.  Pain is one of the main issues during recovery.


The procedure has also been accomplished with smaller incisions as an outpatient procedure.  Laparoscopic approaches are reported in the literature and are performed in a fashion similar to open techniques.  The American Society of Reproductive Medicine notes that “only surgeons who are very facile with laparoscopic suturing and who have extensive training in conventional tubal microsurgery should attempt this procedure.”  The procedure requires opening the occluded ends of the fallopian tubes that have been tied and anastomosing them with a fine non-reactive suture material using magnification and microsurgical techniques. 


When faced with a decision for tubal reversal, women also have other options available such as advanced reproductive technology including in vitro fertilization (IVF).  Women must evaluate their options and look at both the pros and the cons.  Women younger than 30 years of age with good tubal length have the best chance of success.  Rates have been reported around 75-80% or better in this group.  Success is also based on sperm count and other fertility factors.  Short tubal length is a con to tubal reversal and your physician should discuss this with you prior to proceeding with any fertility surgery.  IVF has been proven to be a better procedure for short tubes.  Success rates decline significantly after age 43 for various reasons and this should be discussed with your healthcare provider.   There are reports of women undergoing tubal reversal between 40-45 years of age with cumulative pregnancy rates ranging between 41-71%.  Boeckxstaens et al published a retrospective cohort study in 2007 in Human Reproduction on tubal reversal versus IVF and showed a significantly higher cumulative pregnancy rate for women younger than 37 years of age.  However, they did not see any significance in women 37 years or older.  Women undergoing IVF have a higher per cycle pregnancy rate, however, the cumulative rate allows for more opportunities to become pregnant and is more cost efficient.  In fact, studies have shown the average cost per delivery for tubal reversal to be half that of IVF pregnancies. 


As an OB/GYN and a da Vinci surgeon, I have performed over 300 cases on the da Vinci system including tubal reversal. The da Vinci technology allows me to perform sterilization reversals with all the advantages of minimally invasive procedures with far more precision than conventional laparoscopy. This translates into a shorter hospital stay, with most patients returning home the same day as surgery. It also leads to less post-operative pain and a rapid return to normal daily activities.  Most patients are discharged home within hours of surgery and return to work within days of surgery.  They are allowed to begin trying to conceive within 10-21 days after surgery.  Success rates with the da Vinci system are comparable to traditional laparotomy with rates as high as 74-80% viable live pregnancies currently reported.  Other procedures performed by using the da Vinci system include hysterectomy, oophorectomy, myomectomy, sacralcolpopexy for prolapse and excision of endometriosis. 


Rodgers AK, Goldberg JM, Hammel JP, Falcone T. Tubal Anastomosis by Robotic Compared with Outpatient Minilaparotomy. Obstet Gynecol 2007; 109:1375-1380.

Patel SPD, Steinkampf MP, Whitten SJ, Malizia BA. Robotic tubal anastomosis: surgical technique and cost effectiveness. Fertil Steril 2008; 90:1175-1179.


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