Committee opinion: role of tubal surgery in the era of assisted reproductive technology

Where Microsurgical Tubal Reanastomosis Stands in the In vitro Fertilization Era

Among various options of contraception, bilateral tubal ligation (BTL) remains the most frequently used method for women worldwide even at present. However, up to 30% of those who undergo BTL eventually change their minds and wish to conceive again for a variety of reasons, such as a change in marital status or simply wanting more children. In this case, we can either approach it surgically with tubal re-anastomosis (TA) or by in vitro fertilization (IVF)-embryo transfer. Despite the many advantages of TA which lead the American Society of Reproductive Medicine Committee Opinion to recommend it as the primary choice of treatment in posttubal ligation infertility in 2012, IVF is widely being chosen as the first-line treatment nowadays. This study will review the efficacy of TA in various aspects, including pregnancy rate, cost-effectiveness, feasibility, and accessibility, based on review of the literature and our experience. Through this study, we intend to provide a basis for gynecologists to consider TA as the first option in women who wish to conceive again after BTL in this day and age of IVF.

Ethical and Legal Considerations for Sterilization Refusal in Nulliparous Women

We address the ethical and legal considerations for elective tubal sterilization in young, nulliparous women in Canada, with comparison with the United States and the United Kingdom. Professional guidelines recommend that age and parity should not be obstacles for receiving elective permanent contraception; however, many physicians hesitate to provide this procedure to young women because of the permanence of the procedure and the speculative possibility of regret. At the practice level, this means that there are barriers for young women to access elective sterilization; they are questioned or not taken seriously, or their desire for sterilization is more generally belittled by health care professionals. This article argues for further consideration of these requests and considers the ethical and legal issues that arise when preventing regret is prioritized over autonomy in medical practice. In Canada, there is a paucity of professional guidelines and articles offering practical considerations for handling such requests. Compared with the U.S. and U.K. policy contexts, we propose a patient-centered approach for practice to address requests for tubal sterilization that prioritizes informed consent and respect for patient autonomy. We ultimately aim to assure physicians that when the conditions of informed consent are met and documented, they practice within the limits of the law and in line with best ethical practice by respecting their patients' choice of contraceptive interventions and by ensuring their access to care.

Hysteroscopic versus laparoscopic management in patients with communicating hydrosalpinx and planning for IVF: a randomized controlled trial

Background

Hydrosalpinx is considered one of the obstacles that could hinder the success of IVF techniques due to the toxic effect of the hydrosalpinx fluid pouring into the uterine cavity. Tubal disconnection by either hysteroscopic or laparoscopic approaches is considered the standard in the operative management of hydrosalpinx prior to IVF cycles. The aim of the current study was to compare the success rate of hysteroscopic tubal occlusion using electro-coagulation with laparoscopic tubal disconnection in cases of hydrosalpinx prior to in vitro fertilization (IVF).

Methods

A total of 108 women with unilateral or bilateral hydrosalpinx, who were candidates for tubal occlusion before IVF, were equally randomized into two groups. Group A (n = 54) underwent hysteroscopic tubal occlusion using the roller-ball electro-coagulation of the interstitial part of the tube and the uterine cornual area, and group B (n = 54) underwent laparoscopic tubal disconnection using bipolar coagulation and a proximal tubal cut. Operative time, complications, postoperative pain measured by the visual analogue score (VAS score), and postoperative hospital stay were recorded for both groups. The success rate of tubal occlusion was assessed 1 month later using a post-menstrual hysterosalpingogram (HSG).

Results

Laparoscopic tubal disconnection was more successful than the hysteroscopic approach regarding tubal occlusion rate (96.15% vs. 86.67% respectively, p = 0.044). The operative time and postoperative pain VAS scores in the hysteroscopy group (3.65 ± 1.03 min and 1.81 ± 1.35, respectively) were significantly lower than that in the laparoscopy group (17.48 ± 4.70 min and 4.06 ± 1.65, respectively) with p < 0.001.

Conclusion

Although laparoscopic tubal disconnection is more successful, the hysteroscopic approach is an alternative which has its own limitations that can be assessed by hysterosalpingogram, especially when laparoscopy is contraindicated, technically difficult, or refused by the patient.

Trial registration

It was first registered at ClinicalTrials.gov on 30/07/2019 with registration number NCT04037813.

Outcomes after successful fallopian tube recanalization: A single institution experience: Observational Retrospective study

PURPOSE

To determine outcomes after successful fallopian tube recanalization (FTR) in women who suffer infertility with documented tubal occlusion on hysterosalpingogram.

METHODS

A retrospective review of consecutive successful FTR procedures from January 2010 to December 2016 was performed. 53 women who had hysterosalpingogram confirmed unilateral or bilateral tubal occlusion from a single tertiary academic medical center and successful FTR were eligible for inclusion. 35 (66.0%) patients had follow up at 12 months after FTR, with 13 conceiving within 1 year of the procedure. Data was collected from the medical record. Complication, conception, and take-home-baby (THB) rates were recorded. The average age of patients was 32.3 years (range 26-42 years). All patients received peri- and post-procedure antibiotics. The study was conducted with institutional IRB approval.

RESULTS

Average follow-up after FTR was 1335 days. All patients tolerated the procedure well with no immediate complications. One patient had a urinary tract infection a week after FTR. 13 (37.1%) became pregnant after FTR. Of these women, 2 had ectopic pregnancies and 2 patients had spontaneous abortions. The THB rate after FTR for all patients was 25.7%. The THB rate in women who became pregnant after FTR was 69.2%. Of those women who did not become pregnant after FTR, 19 (84.6%) went to assisted reproductive techniques, and of those, 8 (42.1%) became pregnant.

CONCLUSION

Infertility affects 8.4% of U.S. women, with tubal disease a major causative factor. In our study, successful FTR led to pregnancy in over a third of the patients with the majority giving birth to healthy babies. Given the success of obtaining pregnancy in combination with a low complication rate, FTR is a viable option in women who suffer from tubal infertility.

Robotic-assisted laparoscopic tubal anastomosis: Single institution analysis

BACKGROUND

Tubal anastomosis has similar pregnancy rates regardless of approach. Historically, robotic anastomosis has been associated with increased cost and operative time. We sought to perform a contemporary study of these metrics.

METHODS

One hundred and nine patients were identified who underwent robotic-assisted laparoscopic tubal anastomosis. Retrospective analysis of medical records was performed. Phone survey was conducted.

RESULTS

The mean operative time decreased from 140.7 ± 27.0 min in 2013 to 60.0 ± 9.1 min in 2018, with significant downward trend (p < 0.001). The mean cost was $7153.46 ± $1484.41. The pregnancy rate was 59% (35/59), and tubal patency rate was 81% (42/52). Seventy-two percent of patients under 37 years became pregnant.

CONCLUSIONS

There is significant improvement in operative time of robotic-assisted tubal anastomosis with surgical experience. Robotic tubal anastomosis outperformed historical metrics of laparoscopy and laparotomy with regard to operative time and cost in this series.

Salpingectomy may decrease antral follicle count but not live birth rate for IVF-ET patients aged 35-39 years: a retrospective study

Purpose

Problems with fallopian tubes are one of the main reasons for women to undergo in vitro fertilization-embryo transfer (IVF-ET). A large proportion of women with ectopic pregnancy, fallopian tube obstruction and hydrosalpinx have had one or both fallopian tubes removed by salpingectomy. With increasing age, ovarian reserve deteriorates, the numbers of retrieved oocytes, available embryos and high-quality embryos are reduced, and the live birth rate for women treated with IVF treatment is affected. Thus, it is important to understand how salpingectomy affects live birth rates for IVF patients of different ages. This study analyzed how patients’ age and salpingectomy influenced ovarian reserve, ovarian response and pregnancy outcomes for infertile women undergoing IVF-ET.

Methods

A total of 1922 patients that underwent IVF-ET treatment from January 1, 2012, to December 31, 2018, were included in this retrospective study. The patients were divided into two groups according to whether or not they had a previous history of salpingectomy. The salpingectomy (group A, 534 patients) and control groups (group B, 1388 patients) were then further divided into two subgroups according to patient age (age<35 years, and age 35–39 years). Ovarian reserve, ovarian response, and IVF outcomes were investigated for each subgroup. Logistic regression model was used to estimate the relationship between clinical pregnancy and live births and patients’ baseline characteristics.

Results

In the salpingectomy group, antral follicle counts (AFC) were significantly lower for the subgroup aged 35 to 39 years compared with the control group. But this difference did not appear in women younger than 35 years. In addition, there were no significant differences in levels of basal follicle stimulation hormone (FSH), basal luteinizing hormone (LH), basal estradiol (E₂), total gonadotropins (Gn) dose, duration of Gn, numbers of retrieved oocytes, fertilization rates, numbers of available embryos, live birth rates, clinical pregnancy rates, miscarriage rates, ectopic pregnancy rates, or multiple pregnancy rates between the salpingectomy group and the control group (P > 0.05). Age is a risk factor for the clinical pregnancy and live birth.

Conclusion

Salpingectomy may decrease antral follicle count but not live birth rate for IVF-ET patients aged 35–39 years. The increased female age was negative related with clinical pregnancy and live birth.

From laparotomy to laparoscopy to in vitro fertilization

Before the modern era of in vitro fertilization, reproductive surgery to deal with pelvic disease was the key intervention in the management of infertility. A series of clinical observations and animal experiments led to the development of microsurgical principles, which were applicable to all forms of gynecologic surgery. The evolution of endoscopy permitted minimally invasive approaches to most pelvic pathology. Assisted reproductive techniques now have primacy in the management of infertility, but women deserve to have fertility-enhancing or fertility-sparing surgery performed by a surgeon with relevant training. Thus, we have an obligation to maintain formal training programs in reproductive surgery.

Declining rates of sterilisation reversal procedures in western Australian women from 1990 to 2008: the relationship with age, hospital type and government policy changes

BACKGROUND

Female sterilisation is usually performed on an elective basis at perceived family completion, however, around 1-3% of women who have undergone sterilisation elect to undergo sterilisation reversal (SR) at a later stage. The trends in SR rates in Western Australia (WA), proportions of SR procedures between hospital types (public and private), and the effects of Federal Government policies on these trends are unknown.

METHODS

Using records from statutory state-wide data collections of hospital separations and births, we conducted a retrospective descriptive study of all women aged 15-49 years who underwent a SR procedure during the period 1st January 1990 to 31st December 2008 (n = 1868 procedures).

RESULTS

From 1991 to 2007 the annual incidence rate of SR procedures per 10,000 women declined from 47.0 to 3.6. Logistic regression modelling showed that from 1997 to 2001 the odds of women undergoing SR in a private hospital as opposed to all other hospitals were 1.39 times higher (95% CI 1.07-1.81) and 7.51 times higher (95% CI 5.46-10.31) from 2002 to 2008. There were significant decreases in SR rates overall and among different age groups after the Federal Government interventions.

CONCLUSION

Rates of SR procedures in WA have declined from 1990 to 2008, particularly following policy changes such as the introduction of private health insurance (PHI) policies. This suggests decisions to undergo SR may be influenced by Federal Government interventions.

Hydrosalpinx: Tubal surgery or in vitro fertilisation? An everlasting dilemma nowadays; a narrative review

The decision on how to treat tubal diseases, specifically hydrosalpinx, is a difficult one. Ιt involves surgical, medical, social, emotional and economic factors. This narrative review aims to increase awareness of tubal disease diagnosis and treatment, to compare between tubal surgery and in vitro fertilisation (IVF) for tubal factor infertility, and to investigate the effect of the combination of both. This way, we can be more effective, safe and provide our patients with better treatment results. The review analysed randomised studies, trials and meta-analysis, which give new aspects on the treatment methods for tubal pathology before IVF. Recent papers published in English have been studied, alongside guidelines and committee opinions from previous years. Tubal surgery and IVF aim to exploit a woman's reproductive potential. IVF and endoscopic tubal surgery must be thought of as complementary, rather than competing techniques in tubal disease cases, in order to improve fertility outcome. The first-line treatment for young women less than 35 years old with minor tubal pathology, is tubal surgery. IVF should be offered if there are other factors in a couple's subfertility, if the patient is >38 years old, if moderate to severe tubal disease is present, and if it has been more than 12 months post-surgery.

Use of ICSI in IVF cycles in women with tubal ligation does not improve pregnancy or live birth rates

STUDY QUESTION

Does ICSI improve outcomes in ART cycles without male factor, specifically in couples with a history of tubal ligation as their infertility diagnosis?

SUMMARY ANSWER

The use of ICSI showed no significant improvement in fertilization rate and resulted in lower pregnancy and live birth (LB) rates for women with the diagnosis of tubal ligation and no male factor.

WHAT IS KNOWN ALREADY

Prior studies have suggested that ICSI use does not improve fertilization, pregnancy or LB rates in couples with non-male factor infertility. However, it is unknown whether couples with tubal ligation only diagnosis and therefore iatrogenic infertility could benefit from the use of ICSI during their ART cycles.

STUDY DESIGN, SIZE, DURATION

Longitudinal cohort of nationally reported cycles in the Society for Assisted Reproductive Technology Clinic Outcomes Reporting System (SART CORS) of ART cycles performed in the USA between 2004 and 2012.

PARTICIPANTS/MATERIALS, SETTING, METHODS

There was a total of 8102 first autologous fresh ART cycles from women with the diagnosis of tubal ligation only and no reported male factor in the SART database. Of these, 957 were canceled cycles and were excluded from the final analysis. The remaining cycles were categorized by the use of conventional IVF (IVF, n = 3956 cycles) or ICSI (n = 3189 cycles). The odds of fertilization, clinical intrauterine gestation (CIG) and LB were calculated by logistic regression modeling, and the adjusted odds ratios (AORs) with 95% confidence intervals were calculated by adjusting for the confounders of year of treatment, maternal age, race and ethnicity, gravidity, number of oocytes retrieved, day of embryo transfer and number of embryos transferred.

MAIN RESULTS AND THE ROLE OF CHANCE

The main outcome measures of the study were odds of fertilization (2PN/total oocytes), clinical intrauterine gestation (CIG/cycle) and live birth (LB/cycle). The fertilization rate was higher in the ICSI versus IVF group (57.5% vs 49.1%); however, after adjustment this trend was no longer significant (AOR 1.14, 0.97-1.35). Interestingly, both odds of CIG (AOR 0.78, 0.70-0.86), and odds of LB were lower (AOR 0.77, 0.69-0.85) in the ICSI group. Plurality at birth, mean length of gestation and birth weight did not differ between the two groups.

LIMITATIONS, REASONS FOR CAUTION

This was a retrospective study, therefore only the available parameters could be included, with parameters of interest such as smoking status not available for inclusion. Smoking status may have led practitioners to use ICSI to improve pregnancy and LB outcomes.

WIDER IMPLICATIONS OF THE FINDINGS

Studies have shown that in the USA there is an increasing usage of ICSI for non-male factor infertility despite a lack of evidence-based benefit. Our study corroborates this increasing use over the last 8 years, specifically in the tubal ligation only patient population. Even after adjusting for multiple confounders, the patients who underwent ICSI had no statistically significant improvement in fertilization rate and actually had a lower likelihood of achieving a clinical pregnancy and LB. Therefore, our data suggest that the use of ICSI in tubal ligation patients has no overall benefit. This study contributes to the body of evidence that the use of ICSI for non-male factor diagnosis does not improve ART outcomes over conventional IVF.

STUDY FUNDING/COMPETING INTERESTS

None.

A comparative analysis of arterial blood flow in unexplained infertility, tubal infertility and fertile groups

We aimed to compare ovarian (O), uterine (U) and spiral (S) artery (A) resistance of patients diagnosed as fertile, unexplained infertility (UI) and tubal factor infertility (TFI) in the peri-implantation period and independent from the impact of the treatment. UI (n = 70), TFI (n = 75) and fertile (n = 72) patients' ovarian, uterine and spiral artery pulsatility index (PI), resistance index (RI) and the endometrial thickness, serum estradiol and progesterone levels were compared. The specificity and sensitivity values were calculated according to determined cutoff values. Both TFI and control groups' UA PI values were significantly lower than the UI group's PI values. The highest UA RI values were found in UI group and the lowest values were in the control group. UI and TFI groups' OA PI/RI values were significantly higher than the control group. Both the control and TFI groups' SA PI/RI values were significantly lower than UI group's PI/RI values. UI patients' uterine and spiral arteries PI values >1.86 and >0.85, RI values >0.80 and >0.53 can be used as a valuable test showing reduced uterine perfusion. Ovarian artery PI values  >0.96 and RI values  >0.58 can be used as tests showing decreased ovarian perfusion in patients with TFI. In these patients, embryo cryopreservation can be considered.

Clinical Effectiveness of Modified Laparoscopic Fimbrioplasty for the Treatment of Minimal Endometriosis and Unexplained Infertility

Objective. To study the reproductive outcomes of modified laparoscopic fimbrioplasty (MLF), a surgical technique designed to increase the working surface area of the fimbriated end of the fallopian tube. We postulated that an improvement in fimbrial function through MLF will improve reproductive outcomes. Design. Retrospective cohort study. Setting. Academic tertiary-care medical center. Patients. Women with minimal endometriosis or unexplained infertility, who underwent MLF during diagnostic laparoscopy (n = 50) or diagnostic laparoscopy alone (n = 87). Intervention. MLF involved gentle, circumferential dilatation of the fimbria and lysis of fimbrial adhesions bridging the fimbrial folds. Main Outcome Measures. The primary outcome was pregnancy rate and the secondary outcome was time to pregnancy. Results. The pregnancy rate for the MLF group was 40.0%, compared to 28.7% for the control group. The average time to pregnancy for the MLF group was 13 weeks, compared to 18 weeks for the control group. The pregnancy rate in the MLF group was significantly higher for patients ≤35 ys (51.5% versus 28.8%), but not for those >35 ys (17.6% versus 28.6%). Conclusion. MLF was associated with a significant increase in pregnancy rate for patients ≤35 ys.

Cost and efficacy comparison of in vitro fertilization and tubal anastomosis for women after tubal ligation

OBJECTIVE

To compare cost and efficacy of tubal anastomosis to in vitro fertilization (IVF) in women who desired fertility after a tubal ligation.

DESIGN

Cost-effectiveness analysis.

SETTING

Not applicable.

PATIENT(S)

Not applicable.

INTERVENTION(S)

Not applicable.

MAIN OUTCOME MEASURE(S)

Cost per ongoing pregnancy.

RESULT(S)

Cost per ongoing pregnancy for women after tubal anastomosis ranged from $16,446 to $223,482 (2014 USD), whereas IVF ranged from $32,902 to $111,679 (2014 USD). Across maternal age groups <35 and 35-40, years tubal anastomosis was more cost effective than IVF for ongoing pregnancy. Sensitivity analyses validated these findings across a wide range of ongoing pregnancy probabilities as well as costs per procedure.

CONCLUSION(S)

Tubal anastomosis was the most cost-effective approach for most women less than 41 years of age, whereas IVF was the most cost-effective approach for women aged ≥41 years who desired fertility after tubal ligation. A model was created that can be modified based on cost and success rates in individual clinics for improved patient counseling.

Pregnancy success after hysteroscopic sterilization reversal

OBJECTIVE

To evaluate the effectiveness of hysteroscopic sterilization reversal by assessing pregnancy rates and identifying surgical complications.

METHODS

All patients at a single center undergoing elective reversal of hysteroscopic sterilization for fertility were followed from January 2009 to May 2014. Eligible patients met prespecified criteria for outpatient surgery. Patients underwent outpatient reversal using a transverse suprapubic abdominal incision with tubouterine implantation performed with either bilateral cornual or single transverse posterior-fundal uterine incisions. Patients were evaluated on postoperative day 1, called the following day, and e-mailed at 2 weeks and 12 months. Pregnancy outcomes were assessed through a 12-month questionnaire and self-reporting using an Internet-based patient portal. Univariate analysis of patient and operative characteristics was performed.

RESULTS

Seventy patients underwent bilateral tubouterine implantation and completed at least 12 months of follow-up. All surgeries were outpatient without any immediate operative complications. Four patients had complications between 2 and 30 days, none requiring extended hospitalization. Women who became pregnant were younger (mean age 34 years) than those who did not become pregnant (mean age 38 years). Twenty-five patients (36%, 95% confidence interval [CI] 25-47%) reported a total of 31 naturally conceived pregnancies. Twenty-seven percent (19/70, 95% CI 17-37%) of those undergoing surgery subsequently reported live births. A single pregnancy complication of postpartum hemorrhage after cesarean delivery requiring transfusion was reported; no ectopic pregnancies were reported.

CONCLUSION

Hysteroscopic sterilization can be reversed using tubouterine implantation and both pregnancy and live birth rates are promising.

Should IVF be used as first-line treatment or as a last resort? A debate presented at the 2013 Canadian Fertility and Andrology Society meeting

Infertility outcomes can be influenced by many factors. Although a number of treatments are offered, deciding which one to use first is a controversial topic. Although IVF may have superior efficacy in achieving a live birth with a reasonable safety profile, the availability of cheaper and less invasive treatments preclude its absolute use. For this reason, certain patient groups with 'good-prognosis' infertility are traditionally treated with less invasive treatments first. 'Good-prognosis' infertility may include unexplained infertility, mild male factor infertility, stage I or II endometriosis, unilateral tubal blockage and diminished ovarian reserve. Here, evidence behind the use of IVF as a first-line treatment is compared with its use as a last-resort option in women with 'good-prognosis' infertility.

State-mandated insurance coverage is associated with the approach to hydrosalpinges before IVF

The aim of this study was to determine whether practice in states with infertility insurance mandates is associated with physician-reported practice patterns regarding hydrosalpinx management in assisted reproduction clinics. A cross-sectional, internet-based survey of 442 members of Society for Reproductive Endocrinology and Infertility or Society of Reproductive Surgeons was performed. Physicians practising in states without infertility insurance mandates were more likely to report performing diagnostic surgery after an inconclusive hysterosalpingogram than physicians practising in states with mandates (RR 1.2, 95% CI 1.1-1.3, P < 0.01). Additionally, respondents in states without mandates were more likely to report that, due to lack of infertility insurance coverage, they did not perform salpingectomy (SPX) or proximal tubal occlusion (PTO) before assisted reproduction treatment (RR 1.4, 95% CI 1.1-1.8, P = 0.01). Finally, respondents in states without mandates were less likely to report that the presence of assisted reproduction treatment coverage determined the urgency with which they pursued SPX or PTO before treatment (RR 0.7, 95% CI 0.5-1.0, NS). These results persisted after controlling for physician years in practice, age and clinic volume. In conclusion, self-reported physician practice interventions for hydrosalpinges before assisted reproduction treatment may be associated with state-mandated infertility insurance. Fallopian tube dysfunction is a known cause of infertility and severe dysfunction is manifested by dilation and occlusion, known as hydrosalpinx. Outcomes with assisted reproductive techniques (ART) are lower when hydrosalpinges are present and while there are several theories for this, reproductive specialist recommend "neutralizing" the tube either by occlusion or removal in order to enhance pregnancy rates. In the United States, coverage for infertility services is not uniform with only 15 states having some legislation requiring infertility benefits. Some states where ART is covered liberally, physicians might have different practice patterns related to the neutralization of hydrosalpinges compared to those who are in non -mandated states. We utilized a survey of over 400 providers in the United States to examine their practice patterns as it relates to hydrosalpinges based on which state they practice in and whether or not that state has mandated coverage of not.

Twenty years of Cochrane reviews in menstrual disorders and subfertility

The past three decades have seen considerable change in the understanding of clinical research methods. There has been an acceptance that RCTs are the best way of establishing treatment effectiveness and a recognition that, while single studies are useful, pooling knowledge from a complete body of work is likely to provide the best evidence. Advances in methodology have been mirrored by the many advances in the field of reproductive medicine, such as assisted reproduction, assessment of male fertility, ovulation induction and laparoscopic surgery. Together, they have led to welcome improvements in the outcomes of fertility treatments. In particular, systematic reviews have become important tools enabling clinicians and patients to make health-care decisions based on evidence from all the available high-quality studies. The move towards identifying and aggregating the highest quality evidence has been led by the Cochrane Collaboration, which this year celebrates 20 years of preparing and publishing systematic reviews. This paper outlines the achievements, progress and challenges of this enterprise to date, with a particular focus on systematic reviews of reproductive medicine.

Laparoscopic tubal reanastomosis versus in vitro fertilization: cost-based decision analysis

OBJECTIVE

Regret after tubal ligation continues to be a problem. After tubal ligation, couples have the option of tubal surgery or in vitro fertilization (IVF).

STUDY DESIGN

Using decision analysis techniques, we compared cost-effectiveness of tubal reanastomosis by tubal type vs tubal surgery or in vitro fertilization (IVF) for 3 separate age groups of women: <35 years of age, 35 to 40 years of age and >40 years of age. Tubal techniques was divided into type A, those with more favorable prognosis because of the likelihood of having a more significant length tube at time of reanastomosis and type B, those with a worse prognosis of success. We incorporated delivery costs to address the impact of high order multiples in IVF. Data were extracted by studies available in the literature. All costs were adjusted to 2012 US dollars. One-way and 2-way sensitivity analyses were performed.

RESULTS

The laparoscopic reanastomosis of type A dominated the other groups, because it was more effective and less costly then type B and IVF. However, when women were >40 years old with a history of type B, IVF was favored when its costs were at the lower limit.

CONCLUSION

The most cost-effective choice for a woman desiring pregnancy after tubal ligation is laparoscopic reanastomosis after a prior clip or ring tubal ligation for women ≤40 years old. It is also the most cost-effective for the oldest cohort, assuming IVF costs are greater than $4500.

Infertility evaluation

Infertility is a common condition, affecting 15% of couples trying to conceive. The infertility evaluation includes an assessment of both the female and the male partner to discern the factors contributing to their difficulty in conceiving. The basic evaluation includes a careful history of both partners, physical examination of the female partner, investigation of ovulatory function and tubal status, and semen analysis. A more detailed investigation is performed as dictated by individual factors.

Tubal factor infertility: diagnosis and management in the era of assisted reproductive technology

Tubal factor infertility accounts for a large portion of female factor infertility. The most prevalent cause of tubal factor infertility is pelvic inflammatory disease and acute salpingitis. The diagnosis of tubal occlusion can be established by a combination of clinical suspicion based on patient history and diagnostic tests, such as hysterosalpingogram, sonohysterosalpingography, and laparoscopy with chromopertubation. Depending on several patient factors, tubal microsurgery or more commonly in vitro fertilization with its improving success rates are the recommended treatment options.

Role of female pelvic anatomy in infertility

Infertility is defined as a couple's failure to achieve pregnancy after one year of regular, unprotected intercourse. The etiology of infertility can be due to female factors, male factors, combined male and female factors, or have an unknown etiology. This review focuses on the role of female pelvic anatomy in infertility. Normal anatomy and the physiology of reproduction will be discussed, as well as the anatomic and pathophysiologic processes that cause infertility including ovulatory disorders, endometriosis, pelvic adhesions, tubal blockage, mullerian anomalies, and abnormalities affecting the uterine cavity such as leiomyomata and endometrial polyps.

Diagnostic evaluation of the infertile female: a committee opinion

Diagnostic evaluation for infertility in women should be conducted in a systematic, expeditious, and cost-effective manner to identify all relevant factors with initial emphasis on the least invasive methods for detection of the most common causes of infertility. The purpose of this Committee Opinion is to provide a critical review of the current methods and procedures for the evaluation of the infertile female, and it replaces the 2006 ASRM Practice Committee document titled "Optimal evaluation of the infertile female."