Experience with 143 cases of tubal surgery

Is There Still a Place for Reconstructive Surgery in Distal Tubal Disease?

Tubal diseases account for 25–40% of female factor infertility. Mainly, they involve the distal part of the fallopian tube, and hydrosalpinx is the most severe manifestation. Usually, the management decision is made between reconstructive surgery and ART, depending on the severity of the tubal damage, patient age, ovarian reserve, and seminogram, as well as financial, religious, ethical, and psychological factors. Estimated live-birth rates after corrective surgery range from 9% to 69%. The success rate of IVF is about 30% live-birth rate per cycle initiated in women across all ages with tubal factor infertility. Surgery offers a long-term cure and patients may attempt conception many times but are burdened with perioperative adverse events. IVF bypasses potential complications of operative treatment; however, this has its own unique risks. The effectiveness of reconstructive surgery versus ART has not been adequately evaluated. The success of fertility management depends on a thorough interpretation of existing data and careful patient selection. The presented review provides updates on the most recent progress in this area.

Pregnancy outcome after laparoscopic fimbrioplasty in nonocclusive distal tubal disease

OBJECTIVE

To determine pregnancy rates (PR) after fimbrioplasty and salpingostomy in nonocclusive distal tubal disease. To evaluate the relative impact of various factors using contemporary statistical analysis.

DESIGN

Prospective cohort.

SETTING

Tertiary institutional infertility clinic.

PATIENTS(S)

Infertility patients.

INTERVENTION(S)

Fimbrioplasty and salpingostomy.

MAIN OUTCOME MEASURE(S)

Cumulative PR, monthly fecundity rates, monthly probability of pregnancy, crude PR, and cure rates.

RESULTS(S)

Thirty-five percent of patients conceived with a cure rate of 72.2%, monthly probability of pregnancy of 3.9%, and monthly fecundity rate of 3.9%. Cumulative PRs were 22%, 35%, and 58% at 6, 12, and 24 months, respectively. Pairwise comparisons (unilateral, bilateral, or either) failed to detect any statistical difference between the salpingostomy and fimbrioplasty groups. Salpingostomy patients initially may have a higher tendency to become pregnant but appear to lose that advantage after the first few months. When patients with tubo-ovarian adhesions are excluded from the analysis, patients who underwent a bilateral salpingostomy as their sole procedure had better outcome compared with those who only underwent bilateral fimbrioplasty. There was no significant association between pregnancy outcome and the presence of endometriosis, other infertility factors, or tubo-ovarian adhesions. The staging of adnexal adhesions and endometriosis did not predict pregnancy outcome.

CONCLUSION(S)

Laparoscopic fimbrioplasty and salpingostomy are clinically efficacious for the treatment of nonocclusive distal tubal disease. After accounting for statistical interactions of various factors among them, no particular association with pregnancy outcome could be identified. This illustrates the need for a revision of the classification of patients with distal tubal disease.

Microsurgical salpingostomy is not an obsolete procedure

OBJECTIVE

A review of the results of microsurgery for bilateral distal tubal blockage.

DESIGN

A retrospective review.

SETTING

Hammersmith Hospital London and local private hospitals.

SUBJECTS

388 patients with bilateral ampullary occlusion treated between 1971 and 1988 by microsurgery.

INTERVENTIONS

Full investigation for other causes of infertility followed by abdominal microsurgical salpingostomy. Repeated meticulous follow-up was essential with check laparoscopy one year after surgery.

MAIN OUTCOME MEASURE

Successful pregnancy in relation to tubal damage.

RESULTS

In 65 women microsurgery followed tubal reocclusion after failed conventionally performed salpingostomy. 74 women (23%) had one term pregnancy after primary salpingostomy and 12 women (18%) after repeat salpingostomy. Over half the women having a term pregnancy subsequently had a second infant. The tubal damage was classified in four stages according to the degree of mucosal damage and tubal fibrosis, the presence of isthmic disease and the quality of tubal and ovarian adhesions. Approximately one quarter of patients had stage I disease and amongst these 39% had babies after primary salpingostomy and 25% after repeat salpingostomy.

CONCLUSION

Microsurgical salpingostomy is a specialized procedure. Proper selection of patients, competent microsurgical technique and adequate follow-up appear crucial to success. In selected patients treatment by salpingostomy gives better results than multiple cycles of in vitro fertilization.

The results of tubal surgery in the treatment of infertility in two non-specialist hospitals

The results of surgery for tubal damage, other than reversal of sterilization, were studied in two large hospitals. This is the first recent study from centres claiming no special expertise in this surgery. An unusually high follow-up rate was obtained. The term pregnancy rate for patients operated on for bilateral distal tubal occlusion was 4%. The success rate is lower than the lowest reported, overall success rates for each cycle of in vitro fertilization (IVF) and very much lower than cumulative term pregnancy rates for tubal surgery reported by most other authors. Patients with distal tubal occlusion but minimal adhesions had the best prognosis. Our results suggest that, provided in vitro fertilization is available, only those patients with good prognostic factors should undergo tubal surgery. These represent the minority of all patients with non-iatrogenic tubal blockage.

Factors influencing the success of microsurgery for distal tubal occlusion

Ninety-three infertile women with distal tubal occlusion were subjected to salpingostomy in 1982-1984. In 78 of them follow-up data were available for 2-5 years. Second look laparoscopy was performed in 47 patients at a median of 4 months postoperatively. It showed one or both tubes patent in 45 (96%). In the total series of 93 patients, 13% had live births, 7.5% spontaneous abortions, and 13% ectopic pregnancies. Severe adnexal adhesions and the extent of fimbrial damage found at operation or at second look laparoscopy were the most significant factors related to the poor outcome of microsurgery. Our experience suggests that cases with severe adhesions and poor tubal status should be primarily directed to in vitro fertilization program rather than to microsurgery.

Ectopic pregnancy: its relationship to tubal reconstructive surgery

Ectopic pregnancy is the shady companion of tubal surgery. Among patients with ectopic pregnancy, relatively few have a history of tubal surgery as their underlying etiologic factor when compared with other etiologies such as PID. Nevertheless, a history of tubal surgery should place the patient at a higher-risk group for ectopic pregnancy; 3% to 20% of these patients will encounter an ectopic pregnancy after the corrective surgery. The incidence of ectopic pregnancy after tubal surgery is extremely variable and is closely linked to the degree of restoration of normal functional and anatomic integrity after the surgical procedure. This depends, to a large extent, on the amount of previous damage to the tube and its potential reversibility. Major improvements in surgical technique can, therefore, have reduced, but not eliminated, the occurrence of tubal pregnancy. The incidence of ectopic pregnancy associated with any given tubal surgical procedure should be taken into consideration when surgery is contemplated. When the risk of ectopic pregnancy is unacceptably high, or when the patient is reluctant to be exposed to a high risk of ectopic pregnancy, IVF-ET could be offered as an alternative. Table 11 represents the incidence of ectopic pregnancy associated with the various surgical procedures. The figures demonstrate the wide variation in outcome for the same procedure.

Ectopic pregnancy

One out of every 100 to 300 pregnancies is ectopic, and the prevalence is increasing. The classic triad of symptoms; amenorrhea, abdominal pain, and abnormal bleeding, varies greatly among individuals, and ectopic pregnancies frequently are confused with other conditions, such as ovarian cyst, pelvic inflammatory disease, and spontaneous abortion. Ruptured ectopic pregnancies cause hemorrhage and shock and are the leading cause of maternal mortality in the first trimester. Although conservation surgery and tuboplasty have improved the fertility outlook of the ectopic patient, only one-third of such women will be delivered of a live baby. In this overview of ectopic pregnancy, the etiology, symptoms, physical findings, and management/treatment are presented.

Results of microsurgical treatment of tubal infertility and early second-look laparoscopy in the post-pelvic inflammatory disease patient: implications for in vitro fertilization

Sixty-nine patients with tubal infertility secondary to pelvic inflammatory disease were surgically treated by one of three infertility surgeons, who used microsurgery for repair of the tubal pathologic condition and early second-look laparoscopy 6 to 30 days postoperatively for lysis of postoperative adhesions. No patient was included in this group whose disease was thought to have originated from endometriosis or prior abdominal surgery. The average follow-up time was 43.1 months (range 12 to 85.9). Nine patients were excluded from the analysis. Pregnancy outcome by procedure, expressed as the percentage of patients conceiving, was as follows: adhesiolysis, 69% (61% term, 8% ectopic); fimbrioplasty, 35% (25% term, 10% ectopic); salpingostomy, 30% (18% term, 12% ectopic); and cornual implantation, 60% (40% term, 20% ectopic). No added therapeutic value could be attributed to the use of early second-look laparoscopy. Given the relatively poor outcome of fimbrioplasty and salpingostomy, it may be prudent to advise patients with bilateral partial and/or total tubal occlusion against tuboplasty in favor of in vitro fertilization and embryo transfer.