Objective <p>To evaluate and compare the efficacy of tubal reanastomosis and in vitro fertilisation in achieving reproductive success in women who had undergone tubal ligation and desired additional children.</p> Methods <p>This study included 152 and 92 patients who underwent tubal reanastomosis and in vitro fertilisation after tubal ligation, respectively, at a university-affiliated in vitro fertilisation centre between January 2020 and December 2023. The primary endpoint was clinical outcomes, cost and time to achieve live birth.</p> Results <p>The clinical pregnancy rates were similar between the two groups. The ectopic pregnancy rate in the tubal reanastomosis group was significantly higher than that in the in vitro fertilisation group (16.3% vs. 2.0%, <i>p</i> = 0.021). The live birth rate in the in vitro fertilisation group was significantly higher than that in the tubal reanastomosis group (48.9% vs. 35.5%, <i>p</i> = 0.041). The interval to delivery after treatment in the in vitro fertilisation group was significantly shorter than that in the tubal reanastomosis group (<i>p</i> = 0.001). Among the age-stratified subgroups (&lt; 35, 35–38 and ≥ 38 years), the in vitro fertilisation group demonstrated significantly higher live birth rates than the tubal reanastomosis group in the 35–38 years subgroup (65.6% vs. 36.5%; <i>p</i> = 0.010). In the ≥ 38-year subgroup, the in vitro fertilisation group showed a non-significant trend toward a lower miscarriage rate (13.3% vs. 42.1%, <i>p</i> = 0.128) and a higher live birth rate (26.7% vs. 14.8%, <i>p</i> = 0.144) than the tubal reanastomosis group. When the age group was further stratified into 38–42 years and ≥ 42 years, live birth rates were comparable between the two groups among patients aged ≥ 42 years.</p> Conclusions <p>This study elucidated significant differences in reproductive outcomes between tubal reanastomosis and in vitro fertilisation in women with a history of tubal ligation, emphasising the critical role of age.</p>