Can I have a child after a tubal ligation?

Sterility caused by tubal ligation

It is not unusual that a woman who has undergone a tubal ligation wants to become pregnant again some years later. There are many reasons (personal, family, relationship…) to want to have another child as the circumstances around us vary with time, and a decision which before seemed definitive now has to be reconsidered.

The tubal ligation technique involves surgically blocking the sperm reaching the ampulla of the Fallopian tube and with it the fertilisation of the egg which naturally takes place in this area. Normally a segment of the tube is tied with an absorbable ligature and cut out. As a result of this procedure the cut ends of the tube separate, thereby increasing the contraception effectiveness of the technique. The drawback of the treatment arises when the original function of the tubes has to be restored.

Even if the repermeability is technically possible, there are many disadvantages to carry it out such as the distance between the cut out segments and adhesion among others. Even a perfect surgical technique cannot guarantee the effectiveness of the repair as it depends on many factors (both the permeability and the motility of the tube have to be restored). However, in some cases this technique is specially recommended, for example when very young women consider more than one pregnancy in the future.

That is why nowadays women who have undergone the tube ligation choose IVF technique as it allows the patient to become pregnant sooner without having to wait for the results of a surgical procedure. However, the woman’s age is a decisive factor for the successful outcome of this treatment because the chances of a pregnancy decrease with age. Therefore, once the decision has been taken it is not wise to delay it.

Study of tubal ligation infertility

Tubal ligation is a definitive contraception method, and that is why women normally have had children before (therefore they are initially fertile) which simplifies the necessary study. In this case the basic sterility study involves a short series of additional tests that are carried out in order to confirm the fertility of the couple who wishes to have a child.

- Although not absolutely necessary, it is very helpful to obtain the register of the basal temperature from the last few months in order to find out if ovulation takes place and, if so, on which day of the menstrual cycle.

- It is important to have a blood test to see if there are any hormonal alterations. The hormone basal test (FSH, LH and Estradiol) verifies the ability of the ovaries to produce eggs.

- The male partner has a spermogram, especially if he previously has not had children. It is a simple analysis which checks the fertilising capacity of the sperm.

- When the results of the tests are ready, the diagnosis is made and the most suitable treatment is recommended.

If no additional infertility factor is present

When it is confirmed that the ability of the ovaries to produce eggs is conserved and there is neither male nor endometrium pathology, In Vitro fertilisation (IVF) will be recommended as Artificial Insemination cannot be undertaken due to the dysfunction of the Fallopian tubes. IVF can be carried out in conjunction with intracytoplasmic sperm injection (ICSI) or without it. This technique is suggested when the male sperm count is low or is of poor quality.

If an additional infertility factor is present

If an endometrial polyp or myoma has been diagnosed, a hysteroscopy can be performed to confirm it. Hysteroscopy is an exploration of the inside of the uterine cavity which normally happens without the need of an anaesthetic. Sometimes certain pathologies can be diagnosed and even treated (for example, polyps and myomas can be removed). In this case the recommended technique is also IVF.

In Vitro Fertilisation

It is a very precise technique which requires a strict procedure as well as sophisticated equipment and that in the right hands can prove to be very satisfactory. The fertilisation does not take place in its natural environment but in the laboratory. It allows for a strict control on behalf of the team of biologists.

- The first step in this technique is to gain control of the woman’s cycle pharmacologically. To do so, specific fertility drugs have to be administered over consecutive days. Moreover, with a pharmacological ovarian stimulation it is possible to obtain several eggs in one cycle which increases the possibilities of a successful outcome as only the best ones are chosen.

- The ovulation screening is done via an ultrasound scan and a series of tests. When there are enough follicles of the sufficient size, the egg collection is carried out by means of an ultrasound. This is an ambulatory procedure which takes place in the operation theatre under regional anaesthetic or sedation.

- The eggs that meet the required conditions are placed into a glass dish together with the sperm to be fertilised (In Vitro). From this stage of the procedure comes the commonly-used name In Vitro. Around 50.000 spermatozoa are needed to fertilise each egg, both sperm and eggs have to be incubated for several hours.

- The sperm has to be prepared before being used for the fertilisation. The preparation takes place at the same time as the egg selection in the laboratory.

- Two or three days later the embryos obtained after the egg fertilisation are identified. Two or three of them will be transferred to the woman’s uterus with a technique similar to Artificial Insemination. Normally only one of these embryos implants but it has to be taken into account that sometimes more than one might do so.

The unused embryos are frozen in liquid nitrogen (cryopreservation) and can be used in future cycles if a pregnancy does not occur at the first attempt. Obviously, it simplifies the process and makes it cheaper, although the pregnancy rates decrease.

Intracytoplasmic sperm injection (ICSI)

This technique is known by its English initials (ICSI) and consists of injecting a single sperm inside the egg. For this procedure the number of spermatozoa to fertilise the egg is far lower. ICSI came about to treat sterility cases in which apart from a tubal ligation problem, there is also the problem of the male partner’s sperm (low sperm count, immotile sperm or another alteration which decreases its fertilising ability).

- A rather high number of spermatozoa is necessary for Artificial Insemination or In Vitro fertilisation. However, in some cases only a few are available and in such a case ICSI proves invaluable to bring about a pregnancy, which otherwise would be impossible.

- The sperm injection is performed individually: a single sperm in injected inside the egg which is obtained via the classical IVF treatment and by means of a micromanipulator attached to a microscope. This technique is called microinjection.

- The same procedure is carried out with all the available eggs, therefore In Vitro fertilisation is possible even with very few spermatozoa.

- The remaining steps are the same as for the classical IVF. The obtained embryos are transferred to the uterus after two or three days when they have reached the necessary level of maturity. There are also procedures called co-culture which allow for the transfer of more mature embryos that have a greater chance of developing.