IVF following impossible or failed surgical reversal of tubal sterilization

Dorotha Sitko1, Monique Commenges-Ducos1,4, Patrick Roland2, Aline Papaxanthos-Roche3, Jacques Horovitz1 and Dominique Dallay1

1 Département d'Obstétrique et de Gynécologie, Hôpital Pellegrin, Bordeaux, 2 Institut National pour la Santé et la Recherche Médicale, U 330 (Epidémiologie, Santé Publique et Développement), Bordeaux and 3 Laboratoire de Biologie de la Reproduction Génétique Biologique, Hôpital Pellegrin, Bordeaux, France


    Abstract
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
Microsurgical re-anastomosis or IVF offer ways of reversing previous tubal sterilization. This retrospective study analysed 56 attempts of IVF in 37 couples after impossible or failed surgical sterilization reversal. Efficacy of IVF in this group (TL) was compared with that of a tubal pathology control group (TP) at all stages of IVF (stimulation, fertilization and implantation). Depending on patient age, significantly fewer oocytes were produced after ovarian stimulation in the TL group than in the control (TP) group (P = 0.023 for all TL patients; P = 0.02 when patients aged >38 years were excluded). The total number of embryos available for transfer was significantly lower in the TL group (P = 0.0042), but this was age-related, since when women aged >38 years were excluded there was no significant difference between the two groups. The ongoing pregnancy rate was similar in both groups, the probability of ongoing pregnancy appearing to depend on patient age rather than on previous fertility.

Key words: IVF/sterilization reversal


    Introduction
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
For many women, the acceptance of permanent sterilization as a method of fertility control has been based not only on the ease and safety of the surgical procedures involved, but also on the potential complications and contraindications of other methods, such as oral contraceptives and intrauterine devices (IUD), or permanent contraindication of subsequent pregnancy. However, some women eventually regret such a decision if they subsequently experience a change in their personal, social or financial situation, or in their medical condition.

In these situations, two medical options are possible: (i) microsurgical tubal anastomosis; and (ii) IVF–embryo transfer. A number of investigators have reported various pregnancy success rates after tubal reversal, ranging from 54.8% (Kim et al., 1997Go) to 83% (Dubuisson et al., 1995Go), and 60–87% with bilateral or unilateral anastomosis (Yoon et al., 1999Go) using a microsurgical technique for the tubal re-anastomosis. In some cases, however, tubal anastomosis is impossible because of the type of sterilization that has been performed, and because of peritoneal factors and the patient's general condition. In recent years, IVF has represented a new treatment alternative for women who have undergone surgical sterilization.

In this retrospective study, the request for IVF–embryo transfer was analysed in the light of two factors: (i) the clinical conditions of any prior sterilization; and (ii) the efficacy of IVF compared with that of tubal pathologies over the same period, and in the same hands.


    Materials and methods
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
Study sample
Two groups of IVF–embryo transfer attempts performed between March 1990 and October 1998 at the University Teaching Hospital, Bordeaux Pellegrin, France were considered in this retrospective study. The first group consisted of 37 couples who had undergone 56 attempts at IVF–embryo transfer after tubal ligation (TL group). The control group of 237 couples representing 404 attempts had tubal pathologies causing their sterility (TP group). In both groups, only couples with sperm characteristics fulfilling the following criteria were included: number of spermatozoa >20x106/ml (of which at least 20% were motile), or with donor spermatozoa. For women aged >=40 years, only those with a normal ovarian reserve test were treated. Only cycles with at least one embryo obtained and transferred were retained.

Ovarian stimulation
All patients were stimulated using a combination of gonadotrophin-releasing hormone (GnRH) agonist (Buserelin®; Hoechst, Paris, France or Triporelin®; Ipsen-Biotech, Paris, Boulogne, France). All patients treated at given times received the same GnRH protocol, independently of their indication. Three protocols for ovulation induction were utilized: (i) a short protocol with flare-up (injection of GnRH agonist on day 1); (ii) a luteal protocol with down-regulation for 7 days (GnRH agonist in luteal phase); and (iii) a long protocol with down-regulation for 15 days (GnRH agonist on day 1 of the cycle by either s.c. or delayed i.m. injection). HCG was administered when the largest follicles reached a diameter of 18 mm; 10 000 IU were administered and ovocyte retrieval was performed 36 h later, using vaginal ultrasonography. The luteal phase was supported by using three 1500 UI doses of human chorionic gonadotrophin (HCG) and progesterone supplementation (intravaginal retroprogesterone) from the day of retrieval and thereafter until pregnancy status was known.

IVF
Each cumulus–oocyte complex recovered was inseminated in B2 Ménézo medium (CDD-France, Paris, France) with 5x104 spermatozoa selected by either a swim-up or the Percoll gradient centrifugation technique. At 16–20 h after insemination, fertilization was assessed by confirming the presence of two pronuclei. Before replacement, embryo quality was assessed under an inverted light microscope equipped with Nomarski optics (Nikon Diaphot, Tokyo, Japan) at x200 magnification. Embryos were classified according to two characteristics of their morphology, the form of the blastomeres (C criterion) and the percentage of fragments (D criterion): C1 for equally sized blastomeres, C0 for unequal-sized blastomeres, D1 for <10% fragments, D2 for >10 to 50% fragmentation, and D3 >50% fragmentation. Embryos with the best morphology and the most advanced stage of development were selected for transfer.

Embryo transfer
Uterine transfer of embryos was performed 2 or 3 days after oocyte retrieval, with a maximum of three embryos. Previous findings have established that there is no significant difference whether transfer is performed on either on day 2 or day 3 (Van Os et al., 1989Go). Any excess embryos were cryopreserved.

Statistical analysis
Data were expressed as mean (± SD) and as percentages. Student's t-test and the {chi}2 were used to discriminate between groups. Significance was asessed by using the Stata program (University Drive East, College Station USA; version 5.0). Variables considered were age, anterior parity, stimulation protocol, total number of human menopausal gonadotrophin (HMG) ampoules, number of oocytes obtained, number of embryos and their quality (C and D criteria), and ongoing pregnancy (defined as a pregnancy which continued >12 weeks after transfer).


    Results
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
Prior sterilization conditions
The mean age of TL patients when tubal sterilization was performed was 28 (range 20–37) years; only one woman from this group was sterilized after the age of 35 years. Some 89.2% of women already had children at the time of sterilization (mean number of children = 2.8). In 28 cases sterilization had been `voluntary' (in 24 cases after three children had been born), and nine cases were considered as medical sterilization (five for three or more Caesarean sections, and four for general diseases in which maternity was contraindicated). Tubal sterilization had been carried out using various methods, by different teams in various regions (laparostomy using the Promeroy technique or variant laparoscopy with Fallopian rings, electrocoagulation or clips). In 16 of these cases, the procedure had been carried out during a Caesarean section. The most common reasons for requests were: change in marital status (n = 26), change in couple's attitudes after their children had grown up (n = 6), and accidental death of a child (n = 5). In three cases, women had been unable to conceive following medical sterilization performed on account of an obstetric accident.

In 11 cases IVF was requested because of failure of tubal microsurgical anastomosis. In 18 cases the sterilization procedure report or laparoscopy performed before repermeabilization ruled out this possibility because of the type of sterilization procedure or peritoneal factors. In eight cases IVF was the first procedure proposed, albeit for different reasons.

IVF conditions
Patient data relating to the IVF in the two groups are listed in Table IGo. The anterior parity level was 89.2% in the TL group, and 23% in the TP group. There was no difference in embryo quality between the groups. In the TL group, the 56 IVF–embryo transfer cycles resulted in seven ongoing pregnancies (12.5%), while in the TP group 404 IVF–embryo transfer attempts resulted in 66 ongoing pregnancies (16.3%).


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Table I. Comparison of stages of IVF in the tubal ligation (TL) and tubal pathology (TP) groups
 

    Discussion
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
Sterilization conditions
A woman may regret prior sterilization for a number of reasons. Age is a major reason, and many women who request reversal are known to have been young at the time of sterilization [mean 28 (range 20–37) years]. In the present study, only one woman had been sterilized after the age of 35 years, while 25 women (67%) requested reversal due to a change in their marital status. In 43% of cases sterilization was carried out during Caesarean section. Our results are similar to those of previous studies, and especially to those in the French survey carried out in 60 centres (Antoine et al., 1993Go). According to that study, there are three main situations in France which give rise to requests for sterilization reversal: (i) if tubal sterilization is performed when the patient is young; (ii) if it is carried out during Caesarean section or immediately after childbirth; and (iii) if the couple's relationship is at risk. It has been noted (Langer et al., 1993Go) that sterilization performed for `any reason other than already having enough children' may lead a woman to regret her decision. The `baby wish'—especially for the patient with new partner—remains in the foreground, irrespective of the patient's existing number of children (mean 2.8 children, range 0–5). The number of women with contraindications to pregnancy at the time of sterilization was not high in our group (24%), and some contraindications were of only relative importance at the time of IVF (three prior Caesarean sections, diabetes) because of medical progress. In other cases, the `baby wish' is so strong that women do not take heed of the medical contraindication.

The request for surgical tubal re-anastomosis preceded IVF–embryo transfer in 29 cases (78%), and 62% of those patients could not be operated on, usually because the techniques used for sterilization had been too mutilating. Even if the sterilization were to be considered as final, these techniques should not be used. Indeed, it has been found (Langer et al., 1993Go) that patients considered surgical reversal to be preferable to IVF because of the `restoration of the mutilation'. Sometimes, this satisfaction with reversal is independent of the pregnancy achieved.

IVF–embryo transfer
IVF–embryo transfer now represents a new treatment alternative for women after tubal ligation, but so far there are insufficient data available relating to this question. In the present study a high pregnancy rate was expected in sterilized women because of their potential fertility, as proved by their prior parity (in 89% of cases). Paradoxically, it was found that the ongoing pregnancy rate was lower in the TL than in the TP group (12.5% versus 16.3%) (Table IGo). This is probably due to the fact that sterilized women were significantly older at the time of IVF, than TP women (36 versus 32 years). Age is known to be an important factor affecting the outcome of fertility treatment. In cases of tubal sterilization, the pregnancy rates after tubal anastomosis were reported to decrease with increasing patient age (Yoon et al., 1999Go), while others (Glock et al., 1996Go) have reported a high frequency of spontaneous abortion in women aged >=40 years; the pregnancy rate after IVF has been reported to reduce strongly after the age of 37 years (Templeton et al., 1996Go). In our previous study (Commenges-Ducos et al., 1998Go), it was found specifically that older women had a lower probability of having oocytes and a lower probability of embryo implantation.

Subsequently, in the present study the IVF–embryo transfer result was compared in both groups, but only women aged <38 years were included (Table IIGo). The 36 IVF cycles in the sterilized group of women aged <38 years resulted in six pregnancies (16.7%). In the control group, 60 pregnancies were obtained from 350 IVF–embryo transfer attempts (17.1%). It is possible that the difference between the crude pregnancy rates was indeed due to the difference in age distribution between the two groups. However, the lower mean age of the control group in our study, even when only women aged <38 years were included (Table IIGo), must be recognized as a limitation which restricts the interpretation of the results. The fact that TP women needed significantly more HMG for ovarian stimulation (see Table IGo) can be explained by difficulties of the diffusion of exogenous gonadotrophins into the follicular fluid in patients with peri-ovarian adhesions (Nagata et al., 1998Go).


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Table II. Comparison of stages of IVF in the tubal ligation (TL) and tubal pathology (TP) groups aged <38 years
 
In conclusion, the outcome after IVF following impossible or failed surgical reversal of tubal sterilization depends upon age of the woman at the time of treatment. Previous fecundity is not a factor of better prognosis. The choice between IVF and tubal surgery after tubal sterilization must be made after considering the severity of the tubal lesion. The two techniques are thus complementary (Posaci et al., 1999Go).


    Acknowledgements
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
The authors thank the clinical and biological teams at the IVF Center, Pellegrin Hospital, Bordeaux, France.


    Notes
 
4 To whom correspondence should be addressed at: Maternité Pellegrin, Service du Professeur Dallay, Place Amélie Raba Léon, 33076 Bordeaux Cédex, France. E-mail: monique.commenges{at}chu-bordeaux.fr Back


    References
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
Antoine, J.M., Dubuisson, J.B., Tournaire, H. et al. (1993) Les demandes de déstérilisation tubaire. J. Gynecol. Obstet. Biol. Reprod., 12, 583–591.

Commenges-Ducos, M., Tricaud, S., Papaxanthos-Roche, A. et al. (1998) Modelling of probability of success of stages of in vitro fertilisation and embryo transfer: stimulation, fertilisation and implantation. Hum. Reprod., 13, 78–83.[Abstract]

Dubuisson, J.-B., Chapron, Ch., Nos, C. et al. (1995) Sterilization reversal: fertility result. Hum. Reprod., 10, 1145–1151.[Abstract]

Glock, J.L., Kim, A.H., Hulka, J.F. et al. (1996) Reproductive outcome after tubal reversal in women 40 years of age or older. Fertil. Steril., 65, 863–865.[ISI][Medline]

Kim, S.H., Shin, C.J., Kim, J.G. et al. (1997) Microsurgical reversal of tubal sterilization: a report on 1,118 cases. Fertil. Steril., 68, 865–870.[ISI][Medline]

Langer, M., Hick, P., Nemeskeri, N. et al. (1993) Psychological sequelae of surgical reversal or of IVF after tubal ligation. Int. J. Fertil., 38, 44–49.[ISI]

Nagata, Y., Honjou, K., Sonoda, M. et al. (1998) Peri-ovarian adhesion interfere with diffusion of gonadotrophin into follicular fluid. Hum. Reprod., 13, 2072–2076.[Abstract]

Posaci, C., Camus, M., Osmanagaoglu, K. et al. (1999) Tubal surgery in the era of assisted reproductive technology: clinical options. Hum. Reprod., 14 (Suppl. 1), 120–136.[Medline]

Templeton, A., Morris, J.K. and Parslow, W. (1996) Factors that affect outcome of in vitro fertilisation treatment. Lancet, 348, 1402–1406.[ISI][Medline]

Van Os, H.C., Leerentveld, R.A., Alberda, A.Th. (1989) The influence of the interval between in vitro fertilization and embryo transfer and some others variables on treatment outcome. Fertil. Steril., 51, 360–362.[ISI][Medline]

Yoon, T.K., Sung, H.R., Kang, H.G. et al. (1999) Laparoscopic tubal anastomosis: fertility outcome in 202 cases. Fertil. Steril., 72, 1121–1126.[ISI][Medline]

Submitted on July 28, 2000; accepted on January 4, 2001.





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