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

Surgery for tubal infertility

BACKGROUND

Tubal surgery is a widely accepted treatment for tubal infertility. Estimated livebirth rates after surgery range from 9% for women with severe tubal disease to 69% for those with mild disease, however, its effectiveness has not been rigorously evaluated in comparison with other treatments such as in vitro fertilisation (IVF) and expectant management (no treatment). Livebirth rates have not been adequately assessed in relation to the severity of tubal damage. It is important to determine the effectiveness of surgery against other treatment options in women with tubal infertility because of concerns about adverse outcomes, intra-operative complications and the costs associated with tubal surgery.

OBJECTIVES

The aim of this review was to determine whether surgery improves the probability of livebirth compared with expectant management or IVF in the context of tubal infertility (regardless of grade of severity).

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group's trials register (searched August 2007), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue, 2007), MEDLINE (1970 to August 2007), EMBASE (1985 to August 2007) and reference lists of articles. We also handsearched relevant conference proceedings and contacted researchers in the field.

SELECTION CRITERIA

Only randomised controlled trials were considered eligible, with livebirth rate per woman as the primary outcome of interest.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed eligibility and quality of trials.

MAIN RESULTS

No suitable randomised controlled trials were identified.

AUTHORS' CONCLUSIONS

Any effect of tubal surgery relative to expectant management and IVF in terms of livebirth rates for women with tubal infertility remains unknown. Large trials with adequate power are warranted to establish the effectiveness of surgery in these women. Future trials should not only report livebirth rates per woman, but also compare adverse effects and costs of the treatments as outcomes. Factors that have a major effect on these outcomes, such as fertility treatment, female partner's age, duration of infertility, and previous pregnancy history should be considered. Livebirth rates in relation to the severity of tubal damage, and different techniques used for tubal repair including microsurgery and laparoscopic methods should also be reported.

Tubal disease: towards a classification

Tubal disease is a major cause of infertility. The amount of damage can vary greatly in extent, anatomical location and nature. For women with infertility due to tubal disease, prognostication for pregnancy often remains unclear and there is no universally accepted classification. A classification system that reliably distinguishes infertile patients with tubal disease into favourable and unfavourable groups would be useful if subsequent management could depend on this assessment, especially if the classification is able to define which group of patients would benefit most from interventions such as surgery. The progress of IVF questions the contribution of the Fallopian tube to the successful achievement of pregnancy in infertile women. Nonetheless, several studies reveal that severity is the key factor in the determining outcome, and the classifications reviewed in this paper imply that women with tubal disease could be categorized into prognostic groups using a simple classification system based on severity. However, prospective trials are needed to validate and assert the usefulness of any particular classification.

Pharmacological adjuvants during infertility surgery: a systematic review of evidence derived from randomized controlled trials

The aim of this study was to evaluate systematically the role of pharmacological agents used as adjuvants during infertility surgery to prevent or reduce postoperative adhesion formation and improve pregnancy rates. Meta-analyses were performed of the ten randomized controlled trials identified that evaluated the use of pharmacological adjuvants at infertility surgery. The administration of steroids, dextran 70, noxytioline, heparin, or promethazine have all been investigated for their adjuvant role in preventing adhesion formation during pelvic surgery for infertility. Outcome measures were taken as: pregnancy rates after infertility surgery; number of patients with absent, improved or deteriorated adhesions at second look laparoscopy (dichotomous outcomes); and changes in adhesion score from initial surgery to second look laparoscopy (ordinal outcome). None of the pharmacological adjuncts investigated in a randomized controlled fashion was shown to improve postoperative pregnancy rates. There was some evidence that steroids reduced the incidence or severity of postoperative adhesion formation; there was little evidence to support the use of dextran. The routine use of pharmacological adjuncts during infertility surgery cannot be recommended on the basis of the available evidence derived from randomized controlled trials. Dextran appears to offer no advantage. The evidence with regard to steroids is far from conclusive but tentatively indicates that they may be beneficial.

Tubal pelvic damage: prediction and prognosis

Tubal pelvic damage is a common cause of infertility, and laparoscopy is the accepted gold standard for its diagnosis. However, laparoscopy is both costly and invasive. Chlamydia is now recognized as the most common cause of tubal pelvic damage. In contrast to laparoscopy, evidence of past chlamydial infection using serology is readily available, and the test is simple and quick to perform. As such, serology can be used as a screening test in infertile women. It is accepted that screening tests may have higher margins of error and may be less accurate than diagnostic tests. Screening is most valuable when detecting a disease for which the treatment is more effective when undertaken at the earliest opportunity. Because there are justified constraints to the indiscriminate use of laparoscopy, there is a need to minimize the number of patients who do not have disease (false positives) who are subjected to this diagnostic investigation. An appropriate Chlamydia antibody titre that would distinguish women at risk of tubal pelvic damage should be determined using diagnostic test analysis and clinical judgement. Identification by serology of women who are likely to have damage would enable these women to undergo a diagnostic test such as laparoscopy sooner, allowing treatment to be provided earlier. However, the severity of tubal pelvic damage varies, and the need to distinguish women with a favourable or unfavourable prognosis after treatment using a simple classification system is discussed.

Cost-effective treatment for the couple with infertility

Although the evaluation of cost-effective approaches to infertility treatment remains in its infancy, several important principles have emerged from the initial studies in this field. Currently, in treating couples with infertility without tubal disease or severe male-factor infertility, the most cost-effective approach is to start with IUI or superovulation-IUI treatments before resorting to IVF procedures. The woman's age and number of sperm present for insemination are significant factors influencing cost-effectiveness. The influence of certain diagnoses on the cost-effectiveness of infertility treatments requires further study. Even when accounting for the costs associated with multiple gestations and premature deliveries, the cost of IVF decreases within the range of other cost-effective medical procedures and decreases to less than the willingness to pay for these procedures. Indeed, for patients with severe tubal disease, IVF has been found to be more cost-effective than surgical repair. The cost-effectiveness of IVF will likely improve as success rates show continued improvements over the course of time. In addition, usefulness of embryo selection and practices to reduce the likelihood of high-order multiple pregnancies, without reductions in pregnancy rates, will significantly impact cost-effectiveness. The exclusion of infertility treatments from insurance plans is unfortunate and accentuates the importance of physicians understanding the economics of infertility treatment with costs that are often passed directly to the patient. The erroneous economic policies and judgments that have led to inequities in access to infertility health care should not be tolerated.

Cost-effective treatment of the infertile couple

OBJECTIVE

To review the published literature on the cost-effective approach to infertility treatment.

DESIGN

The literature on the economics and cost-effectiveness of infertility treatments was reviewed. Studies related to this topic were identified through MEDLINE.

RESULT(S)

Few cost-effectiveness studies about infertility treatment have been published. In the absence of tubal blockage and severe male factor, use of IUI and hMG-IUI is more cost-effective than IVF. In vitro fertilization is at least as cost-effective as tubal surgery. Although IVF costs are high, they fall well within the range of other accepted medical treatments and are below the general public's willingness to pay for these treatments.

CONCLUSION(S)

Cost-effectiveness analysis is an important means of improving quality of care while controlling costs. Further work regarding cost-effectiveness of treatments among different diagnostic groups is needed.

First and subsequent pregnancies after tubal microsurgery: evaluation of the fertility index

OBJECTIVE

To determine the number of children born after a tubal microsurgical operation and to evaluate the fertility index, a long-term measure of reproductive potential.

DESIGN

A case series involving a follow-up questionnaire.

SETTING

A tertiary care university hospital.

PATIENT(S)

Three hundred twelve women undergoing microsurgery for tubal disease.

INTERVENTIONS

A range of open microsurgical procedures including reversal of sterilizations.

MAIN OUTCOME MEASURE(S)

Cumulative pregnancy rates to the first and second normal pregnancies and calculation of the fertility index.

RESULT(S)

The 2-year cumulative pregnancy rates (probability +/- SE) for a first normal pregnancy for proximal disease, distal disease, tubal reanastomoses, and tubal adhesions were 0.51 +/- 0.05, 0.29 +/- 0.06, 0.47 +/- 0.06, and 0.30 +/- 0.07, respectively. Of the 288 (92%) women responding to the questionnaire, 142 women had at least one child. Of the 100 women who wanted a second child, 68 succeeded, the proportions being similar in each surgery category. The fertility index described restoration of normal fertility in 30%, 12%, 34%, and 23% for women with proximal disease, distal disease, anastomotic procedures, and adhesion disease, respectively.

CONCLUSION(S)

The fertility index is a useful measure of long-term reproductive potential. The high recurrent pregnancy rate emphasizes the value of microsurgery in restoring normal fertility to some women.

The management of female infertility by tubal microsurgical reconstruction: a ten year review

The outcome of 368 consecutive tubal microsurgical operations excluding reversal of sterilizations, over a ten year period at the Rotunda Hospital, is presented. One hundred and ten conceptions resulted giving a pregnancy rate of 29.9% per procedure. The 'take home baby rate' was 24.2%, with miscarriage and ectopic pregnancy rates of 2.7% and 3% respectively.

Transport in vitro fertilization--a novel scheme for community-based treatment

OBJECTIVE

To provide an inexpensive and extensive in vitro fertilization (IVF) service for the Mersey Region, United Kingdom.

DESIGN

Twenty-four transport IVF patients treated in two district general hospitals using the central university laboratory as co-ordination point for treatment schedule and embryology. Outcomes were compared with 26 control patients treated in the central unit.

SETTING

Royal Liverpool University Hospital, a central IVF unit, and two district general hospitals in the Mersey Region.

PATIENTS

Fifty patients under 35 years of age with irreversible tubal damage selected and treated by IVF, half in the central unit and the other half in two district general hospitals.

MAIN OUTCOME MEASURES

Pregnancy rate (PR) in the different centers.

RESULTS

A PR of 42.3% per cycle in the peripheral hospitals compared with 30.7% per cycle in the central unit.

CONCLUSION

Transport IVF is an inexpensive and feasible alternative to standard IVF in a central unit for patients without access to central units.

Resources for infertility treatment

Infertility is common, a serious medical problem in both advanced and underdeveloped countries. At present, medical resources are often used very haphazardly and frequently extravagantly to combat fertility problems. Whilst it seems very unlikely that society will be able to prevent infertility effectively, there is no doubt that the resources available could be better organized for greater benefit. There is evidence of poor co-ordination of services, of inadequate financial planning by health managers, and squandering of limited resources by professionals. Better organization of in vitro fertilization (IVF), with the promotion of larger regional services, would be an effective use of finances. IVF is too often only available to the wealthy and the selection of patients for treatment is frequently arbitrary; many fertility treatments are of unproved value and are wasteful. It is argued, for example, that many patients receiving gamete intrafallopian transfer (GIFT) for so-called 'unexplained infertility' would be better treated by other, less expensive, methods which are often more effective. Many useful treatments, such as tubal surgery, are being disregarded or misused and there is need for better education of specialists who treat infertile patients. Better primary care of infertile patients should include non-medical counselling, and investigation and firm diagnosis before treatment is commenced. The heavy accent on high technology in the treatment of infertility is often misplaced, and we need to strike a careful balance if resources are to be properly allocated.

An analysis of factors influencing the outcome of 232 consecutive tubal microsurgery cases

A consecutive series of 232 tubal microsurgical operations performed at the Jessop Hospital for Women, Sheffield, between 1983 and 1989, was analysed. The various contributory factors to tuboperitoneal damage were reviewed. Eighty patients (35%) conceived, resulting in 66 (29%) live births and 14 (6%) miscarriages. A further 12 (5%) had ectopic pregnancies. The overall cumulative conception rate (CCR) was 40% at the end of 50 months. Microsurgery has been most successful in the adhesiolysis group (n = 78) with a CCR of 46% at the end of 50 months. The terminal salpingostomy group (n = 97) had a CCR of 40% at the end of 36 months. There was a significant reduction in the live birth rate for the group with hydrosalpinx greater than 20 mm in diameter compared with the group with less than 20 mm (P = 0.05). The proximal anastomosis group (n = 27) had a CCR of 33%. No pregnancy was reported following reconstructive surgery for multiple occlusion sites. Overall, the extent of pelvic adhesions had a significant influence on the outcome (P = 0.02). The likelihood of conception was significantly influenced by the duration of infertility (P = 0.02) but not affected by the aetiology of tuboperitoneal damage, parity or age of the patient. In our hands, tubomicrosurgery is more cost-effective than in-vitro-fertilization as a primary treatment of infertility due to tubal diseases.