Comparison of tubal reanastomosis and in vitro fertilisation for restoring fertility in women with a history of tubal ligation.

Between January 2020 and December 2023, 306 patients who wanted to conceive again after tubal ligation sought consultation at our institution. After applying the inclusion criteria, 258 patients were included. Of the 166 patients eligible for inclusion in the TR group, seven were lost to follow-up and two experienced unsuccessful tubal recanalisation because of severe adhesions. Bilateral proximal tubal obstruction was identified during recanalisation surgery in four patients. One patient underwent intrauterine device placement because of endometrial lesions during follow-up. Ultimately, 152 patients were included in the TR group (Supplemental Fig. 1, available online). In all patients, tubal patency was confirmed both intraoperatively and postoperatively. Regrettably, intraoperative findings, including residual tubal length and ligation technique, were unavailable. Tables  1 and 2 present the baseline characteristics, key clinical outcomes and results of the multivariate logistic regression analysis. The mean age was higher in the IVF group than in the TR group (37.52 ± 3.87 years vs. 36.48 ± 3.66 years; p  = 0.036). The AMH levels, BMI and clinical pregnancy rates were similar between the two groups. The live birth rate was significantly higher in the IVF group than in the TR group (48.9% [44/90] vs. 35.5% [54/152]; aOR = 2.937; 95% CI, 1.572, 5.486; p  = 0.001). The ectopic pregnancy rate was significantly lower in the IVF group than in the TR group (2.0% [1/51] vs. 16.3% [14/86]; aOR = 0.086; 95% CI, 0.011, 0.698; p  = 0.022) (Tables  1 and 2 ). The interval to delivery after treatment was significantly shorter in the IVF group than in the TR group ( p  = 0.001) (Table  1 ). The cost of achieving a clinical pregnancy in patients with live births was significantly higher in the IVF group than in the TR group ( p  < 0.001) (Table  1 ). Table 1 Comparison of baseline characteristics and pregnancy outcomes between the TR and IVF groups TR group (n = 152) IVF group (n = 92) P -value Parity 2.05 ± 0.43 1.98 ± 0.36 0.165 Age (years) 36.48 ± 3.66 37.52 ± 3.87 0.036 AMH (ng/ml) 2.78 (1.49–4.07) 2.15 (1.21–3.81) 0.104 BMI (kg/m 2 ) 23.22 ± 3.78 22.67 ± 3.20 0.249 CCPR 49.3% (75/152) 52.2% (48/92) 0.668 CLBR 35.5% (54/152) 48.9% (44/90)* 0.041 Miscarriage rate & 20.9% (18/86) 11.8% (6/51) 0.172 Ectopic pregnancy rate & 16.3% (14/86) 2.0% (1/51) 0.021 Interval to delivery (months) 15.5 (12.0–19.3) 12.0 (11.0–16.0) 0.001 Costs # 14804 (13740–16548) 48727 (42484–55834) <0.001 *Two cases were excluded due to remaining embryos. & Miscarriage rates and ectopic pregnancy rates were calculated per pregnancy. # Costs associated with attaining a clinical pregnancy in patients who achieved live birth AMH antimüllerian hormone, BMI body mass index, CCPR cumulative clinical pregnancy rate, CLBR cumulative live birth rate, TR tubal reanastomosis, IVF in vitro fertilisation Comparison of baseline characteristics and pregnancy outcomes between the TR and IVF groups *Two cases were excluded due to remaining embryos. & Miscarriage rates and ectopic pregnancy rates were calculated per pregnancy. # Costs associated with attaining a clinical pregnancy in patients who achieved live birth AMH antimüllerian hormone, BMI body mass index, CCPR cumulative clinical pregnancy rate, CLBR cumulative live birth rate, TR tubal reanastomosis, IVF in vitro fertilisation Table 2 Multivariate logistic regression analysis of the pregnancy outcomes Pregnancy outcomes IVF group TR group aOR # (95% CI) P -value CCPR 52.2% (48/92) 49.3% (75/152) 1.526 (0.857–2.72) 0.151 CLBR 48.9% (44/90)* 35.5% (54/152) 2.937 (1.572–5.486) 0.001 Miscarriage rate & 11.8% (6/51) 20.9% (18/86) 0.462 (0.165–1.296) 0.462 Ectopic pregnancy rate & 2.0% (1/51) 16.3% (14/86) 0.086 (0.011–0.698) 0.022 *Two cases were excluded due to remaining embryos. & Miscarriage rates and ectopic pregnancy rates were calculated per pregnancy. # The odds ratio (95% CI) of cumulative clinical pregnancy rate, cumulative live birth rate, miscarriage rate and ectopic pregnancy rate per pregnancy were adjusted for the following confounders: age, body mass index and antimüllerian hormone aOR adjusted odds ratio, CI confidence interval, CCPR cumulative clinical pregnancy rate, CLBR cumulative live birth rate, TR tubal reanastomosis, IVF in vitro fertilisation Multivariate logistic regression analysis of the pregnancy outcomes *Two cases were excluded due to remaining embryos. & Miscarriage rates and ectopic pregnancy rates were calculated per pregnancy. # The odds ratio (95% CI) of cumulative clinical pregnancy rate, cumulative live birth rate, miscarriage rate and ectopic pregnancy rate per pregnancy were adjusted for the following confounders: age, body mass index and antimüllerian hormone aOR adjusted odds ratio, CI confidence interval, CCPR cumulative clinical pregnancy rate, CLBR cumulative live birth rate, TR tubal reanastomosis, IVF in vitro fertilisation Since maternal age significantly impacts pregnancy outcomes, patients were stratified into three age groups: <35 years, 35–38 years and ≥ 38 years. Pregnancy outcomes were compared between the TR and IVF groups across these age strata (Table  3 ). No significant differences were observed in the mean age or AMH levels between the two groups within any age stratum. In the < 35 years subgroup, the IVF group exhibited a trend toward higher cumulative clinical pregnancy and live birth rates—86.7% (13/15) vs. 65.2% (30/46) ( p  = 0.209) and 84.6% (11/13) vs. 58.7% (27/46) ( p  = 0.163), respectively—along with a lower ectopic pregnancy rate—0% (0/13) vs. 13.5% (5/37) ( p  = 0.309); however, these differences lacked statistical significance. Miscarriage rates were comparable. In the 35–38 years subgroup, the IVF group demonstrated significantly higher live birth rates and lower ectopic pregnancy rates than the TR group—65.6% (21/32) vs. 36.5% (19/52) ( p  = 0.010) and 0% (0/23) vs. 20% (6/30) ( p  = 0.030), respectively—whereas clinical pregnancy and miscarriage rates showed no significant intergroup differences. In the ≥ 38 years subgroup, clinical pregnancy rates were similar between the two groups. The IVF group exhibited a trend toward lower miscarriage and ectopic pregnancy rates—13.3% (2/15) vs. 42.1% (8/19) ( p  = 0.128), 6.7% (1/15) vs. 15.8% (3/19) ( p  = 0.613), respectively—and a higher live birth rate—26.7% (12/45) vs. 14.8% (8/54) ( p  = 0.144). However, these trends were not statistically significant. Table 3 Comparison of baseline characteristics and pregnancy outcomes between the TR and IVF groups in different age categories < 35 TR group IVF group P -value n  = 46 n  = 15 Age (years) 32.39 ± 1.81 31.67 ± 2.29 0.212 AMH (ng/ml) 3.17 (2.53–4.30) 3.65 (2.41–4.50) 0.847 CCPR 65.2% (30/46) 86.7% (13/15) 0.209 CLBR 58.7% (27/46) 84.6% (11/13)* 0.163 Miscarriage rate & 13.5% (5/37) 15.4% (2/13) 1.000 Ectopic pregnancy rate & 13.5% (5/37) 0.0% (0/13) 0.309 35–38 n  = 52 n  = 32 Age (years) 35.96 ± 0.84 35.88 ± 0.87 0.652 AMH (ng/ml) 2.87 (1.79–4.34) 2.60 (1.94–4.35) 0.974 CCPR 55.8% (29/52) 65.6% (21/32) 0.371 CLBR 36.5% (19/52) 65.6% (21/32) 0.010 Miscarriage rate & 16.7% (5/30) 8.7% (2/23) 0.685 Ectopic pregnancy rate & 20% (6/30) 0.0% (0/23) 0.030 ≥ 38 n  = 54 n  = 45 Age (years) 40.46 ± 1.94 40.64 ± 2.27 0.669 AMH (ng/ml) 1.62(1.04–3.03) 1.40 (0.89–2.32) 0.354 CCPR 29.6% (16/54) 31.1% (14/45) 0.873 CLBR 14.8% (8/54) 26.7% (12/45) 0.144 Miscarriage rate & 42.1% (8/19) 13.3% (2/15) 0.128 Ectopic pregnancy rate & 15.8% (3/19) 6.7% (1/15) 0.613 * Two cases were excluded due to remaining embryos. & The miscarriage and ectopic pregnancy rates were calculated per pregnancy. AMH antimüllerian hormone, CCPR cumulative clinical pregnancy rate, CLBR cumulative live birth rate, TR tubal reanastomosis, IVF in vitro fertilisation Comparison of baseline characteristics and pregnancy outcomes between the TR and IVF groups in different age categories * Two cases were excluded due to remaining embryos. & The miscarriage and ectopic pregnancy rates were calculated per pregnancy. AMH antimüllerian hormone, CCPR cumulative clinical pregnancy rate, CLBR cumulative live birth rate, TR tubal reanastomosis, IVF in vitro fertilisation In the ≥ 38 years age group, we further stratified patients into two subgroups: 38–42 years and ≥ 42 years (Table  4 ). In the 38–42 years subgroup, the IVF group showed a trend toward higher clinical pregnancy and live birth rates and lower miscarriage and ectopic pregnancy rates compared with the TR group—40% (12/30) vs. 30.8% (12/39) ( p  = 0.425), 33.3% (10/30) vs. 15.4% (6/39) ( p  = 0.08), 15.4% (2/13) vs. 42.9% (6/14) ( p  = 0.209), 7.7% (1/13) vs. 14.3% (2/14) ( p  = 1.0) respectively; however, these differences were not statistically significant. In the ≥ 42 years subgroup, where the sample size was small ( n  = 15 per group), the TR group demonstrated a trend toward higher clinical pregnancy, miscarriage and ectopic pregnancy rates than the IVF group—26.7% (4/15) vs. 13.3% (2/15) ( p  = 0.651), 40% (2/5) vs. 0% (0/2) ( p  = 1.0) and 20% (1/5) vs. 0% (0/2) ( p  = 1.0) respectively. The live birth rates were numerically comparable between the two groups in the oldest age group. However, the limited number of participants in this age stratum precluded definitive statistical comparisons. Table 4 Comparison of baseline characteristics and pregnancy outcomes between group TR and IVF in the 38–42 years group and the ≥ 42 years group 38–42 TR group IVF group P -value n  = 39 n  = 30 Age (years) 39.46 ± 0.94 39.30 ± 1.02 0.498 AMH (ng/ml) 2.24 (1.13–3.40) 1.99 (0.97–3.31) 0.442 CCPR 30.8% (12/39) 40.0% (12/30) 0.425 CLBR 15.4% (6/39) 33.3% (10/30) 0.080 Miscarriage rate & 42.9% (6/14) 15.4% (2/13) 0.209 Ectopic pregnancy rate & 14.3% (2/14) 7.7% (1/13) 1.000 ≥ 42 n  = 15 n  = 15 Age (years) 43.07 ± 1.34 43.33 ± 1.54 0.617 AMH (ng/ml) 1.33 (0.88–1.60) 1.20 (0.87–1.47) 0.772 CCPR 26.7% (4/15) 13.3% (2/15) 0.651 CLBR 13.3% (2/15) 13.3% (2/15) 1.000 Miscarriage rate & 40.0% (2/5) 0.0% (0/2) 1.000 Ectopic pregnancy rate & 20.0% (1/5) 0.0% (0/2) 1.000 & The miscarriage and ectopic pregnancy rates were calculated per pregnancy. AMH antimüllerian hormone, CCPR cumulative clinical pregnancy rate, CLBR cumulative live birth rate, TR tubal reanastomosis, IVF in vitro fertilisation Comparison of baseline characteristics and pregnancy outcomes between group TR and IVF in the 38–42 years group and the ≥ 42 years group & The miscarriage and ectopic pregnancy rates were calculated per pregnancy. AMH antimüllerian hormone, CCPR cumulative clinical pregnancy rate, CLBR cumulative live birth rate, TR tubal reanastomosis, IVF in vitro fertilisation To compare the live birth rates and the interval to delivery post-treatment between the two groups more intuitively, we constructed Kaplan–Meier curves to assess cumulative delivery rates at sequential post-treatment intervals. Notably, the IVF group exhibited a shorter time to live birth and higher cumulative live birth rates than the TR group ( p  = 0.013; Fig.  1 ). All patients who achieved a live birth delivered at term. Fig. 1 Cumulative delivery rate for the two groups. All patients who achieved a live birth delivered at term. TR, tubal reanastomosis; IVF, in vitro fertilisation Cumulative delivery rate for the two groups. All patients who achieved a live birth delivered at term. TR, tubal reanastomosis; IVF, in vitro fertilisation

This retrospective study was conducted at the Boai Hospital of Zhongshan, affiliated with Southern Medical University. Personal information of all participants was anonymised. We included patients with a history of BTL who visited our hospital between January 2020 and December 2023 and wished to have children. Couples with other infertility factors such as oligoasthenospermia in the male partner, severe endometriosis, hydrosalpinx or severe pelvic adhesions were not included in this study. Patients selected either TR or IVF based on personal preference after receiving information regarding procedures, timelines, risks and costs associated with both options. Patients were considered lost to follow-up if they missed their appointments and could not be contacted by telephone at the time of review. All surgeries were performed by an experienced team of surgeons using a laparotomy or laparoscopic approach. All reanastomoses were performed at the isthmic portion of the fallopian tubes using a standard four-stitch technique. Tubal patency was confirmed intraoperatively and again 1 week postoperatively via hydrotubation. For patients who underwent IVF, ovarian stimulation protocols were individualised according to patient-specific characteristics. Additionally, for patients aged ≥ 38 years, preimplantation genetic testing for aneuploidy (PGT-A) was utilised in a subset of cases based on patient preference. All baseline characteristics and pregnancy outcomes were obtained from medical records or through telephone contact with the patients. In the TR group, patients were followed up until either a live birth was achieved or a clinical pregnancy did not occur within 1 year. Patients who failed to conceive within 1 year were generally advised to transition to IVF, as the increase in pregnancy rate was slow after this period. In the IVF group, follow-up continued until all embryos from one oocyte retrieval cycle were transferred (up to 1 year) or until the first live birth occurred. We focused on the cumulative live birth rate per retrieval cycle, as patients are typically interested in this outcome, given the financial and personal constraints that may limit their willingness to undergo additional IVF cycles. The primary outcome of this retrospective cohort study was the live birth rate, defined as the delivery of a neonate who reached or surpassed 24 weeks of gestation. Clinical pregnancy was defined as the detection of a gestational sac through transvaginal ultrasound examination at an age of 6 to 7 weeks. Clinical miscarriage was defined as the termination of an intrauterine pregnancy occurring after the confirmation of a gestational period between 6 and 20 weeks. Ectopic pregnancy was defined as the detection of a gestational sac outside the endometrial cavity. Cumulative clinical pregnancy rates and live birth rates were calculated per retrieval. Miscarriage rates and ectopic pregnancy rates were calculated per pregnancy. In patients with live births, costs encompassed all related medical expenses incurred before achieving clinical pregnancy, including hospitalisation costs due to ectopic pregnancy or missed abortion. Statistical analyses were performed using SPSS (version 22.0; IBM Corp., USA). Continuous variables are expressed as mean ± standard deviation for normally distributed data or as median (interquartile range) for non-normally distributed data; intergroup comparisons were conducted using independent-samples t-tests or Mann–Whitney U tests, as appropriate. Categorical variables are presented as frequency (percentage), with group differences analysed using the chi-square test or Fisher’s exact test, as appropriate. Time to live birth was analysed using Kaplan–Meier curves, and group differences were assessed using the log-rank test. Multivariate logistic regression was performed to determine the adjusted odds ratios (aOR) of pregnancy outcomes. The odds ratios (95% confidence interval [CI]) of pregnancy outcomes were adjusted for the following confounders: age, body mass index (BMI) and antimüllerian hormone (AMH) level. A two-tailed p  < 0.05 was considered statistically significant.

In conclusion, this study elucidates the significant differences in reproductive outcomes between TR and IVF in women with a history of tubal ligation, particularly emphasising the critical role of age. Specifically, TR may be a more cost-effective option for younger patients, while IVF yields better outcomes for women of advanced maternal age; however, both methods have a poor prognosis in patients with very advanced maternal age because of decreased ovarian reserve and a high miscarriage rate. These findings may aid clinical decision-making and influence future treatment protocols. By highlighting the importance of personalised treatment strategies based on patient demographics, this study provides valuable insights into reproductive medicine, ultimately aiming to enhance patient care and optimise fertility treatment outcomes.

The pregnancy rate in our study was consistent with the results of a systematic review, which reported that the pregnancy rate following sterilisation reversal ranged from 42% to 69% [ 5 ]. Surgical reversal can be accomplished using three different approaches: laparotomy, conventional laparoscopy and robot-assisted surgery. Additionally, Korucu et al. reported comparable fertility outcomes following macroscopic TR via mini-laparotomy [ 11 ]. Madison et al. conducted a literature review and concluded that conventional laparoscopy was the most favourable approach compared with other surgical reversal methods, considering both pregnancy outcomes and cost. The authors noted that TR was preferable for women aged < 40 years, given its pregnancy outcomes and cost-effectiveness [ 5 , 6 , 10 ]. However, some authors have suggested that TR is more cost-effective than IVF across all age groups, and the authors found no differences in outcomes when comparing various surgical approaches [ 12 ]. The different approaches did not significantly influence pregnancy outcomes in our study (Supplemental Table 1, available online). Studies have shown that factors affecting pregnancy outcomes after TR include age, anastomosis site, tubal length, time of ligation, and ligature type [ 13 – 15 ]. Reversal of sterilisation procedures performed with rings or clips results in higher pregnancy rates than procedures performed via resection or coagulation [ 16 ]. However, a meta-analysis suggested that factors such as postoperative tubal length, duration since ligation, and anastomosis site had no significant impact on pregnancy outcomes, apart from age [ 5 ]. Similarly, in the present study, age was identified as the primary factor affecting pregnancy outcomes. However, the available data from patients who underwent tubal anastomosis lacked documentation of tubal ligation methods and fallopian tube length, which precluded evaluation of these potential influencing factors. In the era of IVF, many researchers have confirmed the importance of sterilisation reversal in restoring fertility [ 17 , 18 ]. However, they noted that a direct comparison between these two options was challenging because of inherent differences in reporting fertility outcomes [ 17 ]. Many studies have compared pregnancy outcomes following tubal reversal with those following IVF for tubal pathology, rather than specifically examining IVF outcomes in women with a history of tubal ligation. However, data on pregnancy rates after IVF in women who have undergone sterilisation are lacking. These patients are generally fertile and have better postoperative success rates than those with tubal pathologies. When compared with national IVF success rates by age, women with prior tubal ligation may also have a better prognosis for IVF [ 19 ]. To our knowledge, direct comparative studies are scarce, and those available are either limited by small sample sizes or inconsistent follow-up periods [ 8 , 9 ]. In our study, we directly compared patients who underwent tubal ligation followed by tubal reversal with those who chose IVF. Additionally, the follow-up duration was standardised. Age is an independent prognostic factor affecting pregnancy outcomes [ 20 – 22 ]; therefore, we performed subgroup analyses stratified by age to compare outcomes across different age groups. We believe that, when counselling patients about both options, clinicians should provide the cumulative pregnancy rate within 1 year after TR and the cumulative pregnancy rate per oocyte retrieval cycle during IVF treatment. Patients with strong pregnancy intentions typically proceed with IVF if conception fails within 1 year post-surgery, and most patients undergoing IVF complete the transfer of all embryos from their first retrieval cycle within 1 year. Therefore, our study compared the 1-year postoperative pregnancy outcomes after TR with the pregnancy outcomes from the first IVF oocyte retrieval cycle. Our study revealed that IVF was superior in women aged 35–38 years, which differs from the findings of previous studies [ 6 , 8 ]. This may have been due to the higher reported IVF pregnancy outcomes in our study, likely reflecting the rapid development of this technology. However, costs should also be considered when making decisions. Our data revealed a trend toward a higher spontaneous abortion rate and a lower live birth rate in patients aged ≥ 38 years in the TR group than in the IVF group, possibly due to the use of PGT-A. Therefore, for patients of advanced maternal age (≥ 38 years), IVF may be prioritised to achieve a faster time to live birth. Furthermore, age-stratified subgroup analysis suggested a trend toward converging outcomes in patients aged ≥ 42 years; however, the small sample size in this subgroup precluded definitive statistical conclusions. Notably, both methods have a poor prognosis at this age, underscoring the predominant impact of age-related ovarian decline on reproductive success. Many studies have reported an increased rate of ectopic pregnancy after surgical TR compared with IVF [ 23 , 24 ]. The rate of ectopic pregnancy after TR in our study was approximately 16.3%, which is higher than the rate observed in the general population (2%) [ 25 ]. The elevated ectopic pregnancy rate observed in our study may be attributable to factors such as prior tubal ligation methods and residual tubal length. However, the absence of detailed surgical records in our data constitutes a study limitation and a potential source of bias. Many experts have expressed concern that reconstructive tubal microsurgery is being taught and practised less frequently [ 26 , 27 ]. In the United States, the number of surgeons with experience in TR is decreasing at an alarming rate [ 17 ]. This option is often overshadowed by the widespread use of expensive IVF techniques. Our study concluded that TR remains a cost-effective option for women wishing to conceive after tubal ligation, especially for younger women aged < 35 years. Extensive training in microsurgical principles is the key to achieving successful outcomes. Compared with IVF, TR can result in spontaneous conception and provide recurrent opportunities to conceive without the need for additional treatment. However, embryos frozen at a younger age can reduce the risk of age-associated birth defects and genetic abnormalities if subsequent pregnancies are desired. Thus, recommendations should be tailored based on the age of the patient. TR and IVF should not be regarded as competing treatments but rather as complementary options necessary to achieve the desired goal. In our reproductive centre, among patients who failed to achieve pregnancy after TR, subsequent IVF yielded a 40% live birth rate per cycle. To our knowledge, this is the first study with the largest sample size to directly compare pregnancy outcomes between the TR and IVF groups. Additionally, this is the first study to report on BTL in China, which has the largest population of BTL cases in the world. While our current findings showed a higher live birth rate and a lower ectopic pregnancy rate for IVF, larger sample sizes may reveal additional statistically significant differences, particularly in advanced maternal age subgroups, where our study was underpowered. The limitations of this study stem primarily from its retrospective design, which inherently introduces potential biases and confounding variables. Patients’ choice of pregnancy method may be influenced by various socioeconomic factors, leading to selection bias. Moreover, a lack of standardisation in the original ligation procedure and the unavailability of intraoperative data may have introduced confounding factors that affected pregnancy outcomes in the TR group, thereby impacting the analytical results. Additionally, variations in patient selection criteria and follow-up protocols (1 year after surgery, with some patients achieving live birth after 2 years) may influence the generalisability of the findings. These limitations necessitate caution when interpreting the results, as they may not fully reflect the complexities of clinical practice in diverse populations. Future randomised controlled trials are warranted to validate these findings and strengthen the evidence regarding the efficacy of TR versus IVF.

Among the various options for contraception, bilateral tubal ligation (BTL) remains the most frequently used method for women worldwide, particularly after they have given birth to two or more children. The global prevalence of female sterilisation is approximately 26.6% [ 1 ], with a higher percentage observed in China (approximately 30.5%) [ 1 ]. However, women who have undergone tubal ligation may desire to conceive again for various reasons, such as the loss of a child or divorce. In China, within the context of family planning policies, tubal sterilisation is one of the most common methods of birth control. However, following the full relaxation of the second- and third-child policies, more women are seeking to have additional children. Women who want to restore their fertility after tubal ligation may undergo tubal reanastomosis (TR) or in vitro fertilisation (IVF). The American Society for Reproductive Medicine Committee Opinion supports TR as an option for achieving post-tubal ligation fertility and recommends microsurgical TR as the technique of choice for tubal ligation reversal, as stated in 2021 and previously in 2012 [ 2 , 3 ]. Age is the most important prognostic factor when considering treatment options [ 2 ]. TR is the only method that allows patients to conceive naturally and has been proven effective in many studies, especially among younger women [ 4 , 5 ]. However, with the increasing success rate of IVF, many couples choose IVF directly due to concerns about advanced age, decreased ovarian reserve, operative failure, or the risk of ectopic pregnancy after TR. In some countries, surgical reversal has become a lost art [ 6 ]. We believe that it is important to provide counselling to help women determine the most suitable method for achieving fertility after BTL. To the best of our knowledge, direct comparative data between TR and IVF in women after tubal ligation are lacking. The number of cases in Tan et al.’s study was small, and the authors compared pregnancy outcomes after TR with those after IVF in patients with tubal factor infertility [ 7 ]. In a 2020 study, the authors compared pregnancy outcomes between TR and IVF [ 8 ]; however, the sample size was small, and participants were not stratified by age. Additionally, the follow-up period in the study by Boeckxstaens et al. varied substantially across patients [ 9 ]. Messinger et al. developed a model to compare the cost of TR with that of IVF and found that TR was the most cost-effective approach for most women aged < 41 years. Nevertheless, they used data from published literature and did not consider the time to achieve live birth [ 10 ]. Therefore, the lack of robust, large-scale studies addressing the specific reproductive outcomes associated with these two treatment approaches necessitates further investigation. Our retrospective cohort study aimed to fill this gap by examining the reproductive outcomes of women who underwent TR compared with those who chose IVF after BTL.

Supplementary Material 1. Supplementary Material 1. Supplementary Material 2. Supplementary Material 2.