Organ-Preserving and Reconstructive Microsurgery of the Fallopian Tubes in Tubal Infertility: Still an Alternative to In Vitro Fertilization (IVF)

Abstract

Tubal infertility mostly results from infections. Conception only is possible through complex treatments (in vitro fertilization or surgery). Success cannot be guaranteed, even after repeated treatments. Unfortunately, many couples are not informed about the prospect for success of tubal reconstruction. Problems of in vitro fertilization are low pregnancy and birth rates of 28.4% and <20% respectively (Germany) and the high number of multiple pregnancies (21%). In this retrospective study 462 women with acquired tubal infertility and further 127 women after previous sterilization underwent microsurgical treatment (microsurgical adhesiolysis, anastomosis, fimbrioplasty, salpingostomy, and refertilization due to former sterilization). The main outcome measures are the pregnancy and birth rates following the microsurgical procedure. Pregnancy and birth rates of 43.4% and 29.2%, respectively, were higher than the outcomes post-single in vitro fertilization (abortion: 6.4%, extrauterine pregnancy: 7.9%). When reversal of sterilization was performed, pregnancy and birth rates were higher at 73% and 50.6%, respectively (abortion: 15.7%, extrauterine pregnancy: 6.7%). The advantages of reconstructive microsurgery over in vitro fertilization include the ideally permanent restoration of woman's ability to conceive naturally (repeated pregnancies are possible without further therapy), a high postoperative birth rate overall, and avoidance of multiple births. It is advisable to inform the patient about the objective possibility of reconstructive tubal surgery.

Ectopic Pregnancy Following Reconstructive, Organ-Preserving Microsurgery in Tubal Infertility

“…The ectopic rate for mild aquired tubal disease is reported to be 1%-10% (Boer-Meisel et al, 1986;Winston & Margara, 1991;Nackley& Muasher, 1998) and for reversal of sterilization less than 10% (Practice Committee of American Society for Reproductive Medicine, 2008), but in contrast, EP rates increase up to 40% in the presence of intrinsic tubal damage, salpingitis isthmica nodosa and severe tubal pathology (Taylor et al, 2001;Posaci et al, 1999;Pandian et al, 2008;Marana & Quagliarello, 1988a, 1988bAkande et al, 2004, Mosgaard et al, 1996. For this reason, patients with dense adhesions like frozen pelvis and a severe tubal pathology are best referred to IVF (Schippert et al, 2010). In our own patient's collective, the EP rate following reversal of sterilization was 6.7%.…”

“…When compared with the macrosurgical approach, the use of a microsurgical technique has significantly improved the outcome of tubal anastomosis with reduced EP rates (Lavy et al, 1987). The reconstructive microsurgical techniques should include the following elements (Gauwerky, 1999, Schippert et al, 2010: Atraumatic surgical technique, complete removal of diseased tissue, careful hemostasis, preparation layer by layer and exact adaptation of the tissue structures, complete peritonealization, and continuous irrigation of exposed peritoneal tissue surfaces.…”

The place of reconstructive tubal surgery in the era of assisted reproductive techniques

“…This may be associated with technique and/or patient selection. There are several recent publications from Hanover (Germany) on retrospective studies of reconstructive tubal microsurgery, by mini-laparotomy for infertility (Schippert et al, 2010a(Schippert et al, , 2010b(Schippert et al, , 2012. Of 127 women submitted to tubal anastomosis for reversal of sterilization 38 were lost to follow-up; the outcomes were reported on the remaining 89 women, whose mean age was 35.5 years (age range 26-42).…”

“…Most of these studies were published before 1990; there is a paucity of recent publications, which implies decreased utilization of this procedure. Recent reports from Schippert et al, referred to under reversal of sterilization, also included a series on tubo-cornual anastomosis performed between 1990 and 2001 (Schippert et al, 2010a(Schippert et al, , 2010b(Schippert et al, , 2012. Of the patients contacted for the review, only 63% responded (loss to follow up rate 37%).…”

Y a-t-il une réelle place à la robotique pour la chirurgie tubaire proximale ?

“…En effet, il est clairement dé terminé (comme dans d'autres indications) qu'il s'agit d'une chirurgie pour laquelle l'entraînement et l'appartenance à un centre d'expertise permet d'obtenir de bien meilleurs ré sultats que dans le cas contraire [8].…”