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

Abstract

Assisted reproductive techniques yield high rates of success for women with tubal factor infertility. Because they are potentially effective for all categories of infertility, for two decades, clinical and basic research in infertility has been focused on IVF techniques and outcomes, rather than developing surgical techniques or training infertility subspecialists in tubal microsurgery. Nonetheless, in comparison with IVF, reconstructive tubal surgery is inexpensive and offers multiple opportunities to attempt conception. Performing laparoscopic salpingostomy prior to IVF in women with good prognosis tubal disease may improve the outcome of subsequent IVF, while offering the potential for spontaneous conception. Tubo-tubal anastomosis for reversal of tubal ligation, performed either by a microsurgical technique through a mini-laparotomy or by laparoscopy, is preferable to IVF in younger women with no other fertility factors, because it offers potentially higher cumulative pregnancy rates. Surgery is the only alternative for women with tubal factor infertility who for personal or other reasons are unable to undergo assisted reproductive techniques. Tubal reconstructive surgery and assisted reproductive techniques must be considered complementary forms of treatment for women with tubal factor infertility, and training in tubal reconstructive surgery should be an integral part of subspecialty training in reproductive endocrinology and infertility.

From laparotomy to laparoscopy to in vitro fertilization

“…Experience with laparoscopy and microsurgery, as early as the mid-1980s, demonstrated that many complex fertility-enhancing procedures can be performed by means of minilaparotomy with a microsurgical approach (57, 58). In addition, use of special measures allowed many these procedures to be performed as day surgery, and for the patients to have a postoperative course not dissimilar from those who had a laparoscopic surgery (59,60). In the absence of comparative evidence and reported successful experience, it may be advisable to approach suitable cases with the use of minilaparotomy, minilaparotomy assisted by laparoscopy, or vice versa.…”

“…Despite our significant progress in gynecology in general and reproductive surgery, in particular, in concert with the improvements in ART outcomes, we have experienced a significant decline in the use and teaching of reconstructive surgery. In vitro fertilization began increasingly to be offered as the primary treatment option in cases of tubal and peritoneal factor infertility (60). Surprisingly, this change occurred despite the acceptance of laparoscopic access to perform many reconstructive tubal operations and the use of access by minilaparotomy for more complex procedures, both of which have become day procedures.…”

Competing Endoscopic Surgeries in the Era of Assisted Reproductive Technologies: Evidence and Practice

“…7 Honoré et al 8 in a meta-analysis examined the value of tubal microsurgery and macrosurgery, and hysteroscopic management of proximal tubal occlusion. They found that the average pregnancy rate was higher in women managed by hysteroscopic tubal recanalization compared with those managed with tubal microsurgery and open surgery or selective salpingography (48.9% vs. 38% vs. 28.8%, respectively).…”

Reconstructive tubal microsurgery and assisted reproductive technology

“…This represents a live birth rate of 32.4% among the patients followed, and a rate of 25.6% if we include all lost to follow-up as failures. Based on the American Fertility Society classification, 73 of these cases had severe tubal damage and 13 (17.8%) of these had live births, whereas in the 17 whose damage was classified as mild, 10 (58.8%) had one or more births (3,4).…”

“…Therefore, the outcome depends on the degree of rigor in the microsurgical technique and in patient selection criteria. With a precise microsurgical technique, the tubal pregnancy rate is low, 2% (3,4).…”