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Reproductive Surgeries

Treatment of Tubal Infertility
Peter F. McComb MB, BS, FRCSC

In vitro fertilization and fertility tubal surgery
There are two treatment options for women to achieve pregnancies who have damaged fallopian tubes: fertility tubal surgery and IVF. Surgery and IVF do not compete as treatments but rather are complementary ways to achieve pregnancy.

In vitro fertilization is the only treatment option for women with inoperable fallopian tubes and for couples with tubal disease combined with other causes of infertility, such as male infertility. In general, tubal surgery should be the first treatment, with resort to IVF if tubal surgery proves unsuccessful.

The overall risks of reconstructive tubal surgery are rare and include the recognized complications of anesthesia and surgery. Surgery, if successful, offers multiple cycles in which to achieve conception and the opportunity to have more than one pregnancy. The miscarriage rate subsequent to reconstructive tubal surgery is not increased over that of the normal population.

The live birth and ectopic pregnancy rates after surgery are dependent upon the nature of the tubal disease and the extent of tubal damage.

The results are also dependent on the proper selection of patients and the technical expertise of the team and the surgeon.

Other factors include age, cost, and the wishes of the couple. Female fertility is adversely affected by age; fertility begins to decline at about 30 years of age. This trend has been observed both in "normal" couples and in those with unexplained infertility. This decline becomes much more evident after 37 years of age .

The younger woman may consider surgery first and IVF afterwards (if this becomes necessary), whereas those between 37 and 40 years of age may be advised to consider IVF first, or even both therapies at once.

Another, often underestimated, issue is the impact of a multiple pregnancy, which occurs much more frequently with IVF as a consequence of the number of embryos transferred to the uterus.

The perceptions and wishes that lead to the selection of treatment depend on many personal influences, including cultural and ethical values and views.

Tubal Surgery

Background

Human life originates within the fallopian tube. Fertilization of the egg by the sperm occurs where the tube narrows, about half way along the fallopian tube towards the uterus.

In women, egg transport through the tube (from ovary to uterus) is due to fluid currents that are caused by very rapid beating of the cilia (hair cells) that line the tube. Sperm, on the other hand, seem to be able to reach the egg mostly by tail flagellation. It is interesting that those women whose cilia do not beat (Kartaganer’s syndrome) due to a genetic defect are infertile. Fortunately, this condition is rare. Fertilization takes place in this watery environment. The tubal lining also supplies nutrition to the embryo. Clearly the fallopian tube is a unique transport system and a special place for nurture of the sperm, egg and embryo.

In the 1970’s microsurgery was adapted to fertility surgery. The delicate handling of the tissues and infinitesimally tiny sutures used in microsurgery avoid causing scar tissue due to the surgery itself (this scarring had previously led to failure of fertility operations). Many of these microsurgical techniques were devised in Vancouver, often at Vancouver General Hospital. Fertility surgeons within our own gynaecology department at the University of British Columbia are therefore able to provide success rates better, or equal to, anywhere in the world.

The success rates from different types of fertility operations vary. There is a high rate of pregnancy after sterilization reversal surgery. There is also good success after surgery to remove a portion of diseased tube found at the junction of the tube and uterus. On the other hand, laparoscopic surgery to open the end of the tube near the ovary (a ‘salpingostomy’ to treat a ‘hydrosalpinx’) yields a much more modest ‘baby’ rate. Salpingostomy improves embryo implantation should IVF be required. If the tube is blocked at the ovarian end, the fluid produced from the lining of the tube leaks into the uterus and interferes with embryo implantation.

These delicate surgical procedures offer prospects for fertility that will avoid the need for IVF for many women.

Types of Fertility Operations

There are 3 types of fertility operations on the fallopian tube that help women conceive

1. Tubal joining (tubo-tubal anastomosis) by microsurgery for reversal of sterilization.

2. Tubal joining to remove disease at the uterine end of the tube (tubo-cornual anastomosis) by microsurgery.

3. Laparoscopic * surgery to remove tubal and ovarian scarring (lysis of adhesions) and open blockages (salpingostomy) at the ovarian end of the fallopian tube.

We will also discuss how tubal surgery to open tubes can help IVF work better.

* a laparoscopy is a brief day-care operation – under anaesthesia, a telescope is inserted into the abdominal cavity to view the organs.

STERILIZATION REVERSAL: TUBAL JOINING (TUBO-TUBAL ANASTOMOSIS) BY MICROSURGERY

A join is made in each fallopian tube for sterilization reversal with technically precise microsurgery. It is exquisitely accurate surgery. Careful stitching of the tubal tissues with sutures that are as thin as hair, leads to seamless healing of the fallopian tube.

Our research at UBC provides the following advice for women who wish to undergo reversal of sterilization. The age of the woman at the time of reversal the most important factor. Those who are less than 35 years of age at the time of reversal can anticipate a baby rate of 70%, with most pregnancies occurring within 18 months after surgery. Those over 35 years of age will have a 55% baby rate. The only other predictor of fertility is the length of the joined-up tube (it needs to be at least 4 centimetres). The ectopic pregnancy rate is only 2-3% (about the same rate as for women generally).

Those specific factors that do not alter the baby rate are:

- the type of sterilization

- the length of time interval from date sterilization to date of reversal

- the number of tubes anastomosed (one or both)

Some surgeons have tried doing reversal by laparoscopy. We have experience with both approaches. Our department developed the technology to perform the first tubal anastomosis by laparoscopy in North America. However, we have concluded that the long instruments we use at laparoscopy are less precise than the short pen-like microsurgical instruments that we use at minilaparotomy (bikini incision). This precision is essential for joining tubes that are as narrow as a millimeter, but is not essential for opening the blocked ovarian end of the tube that is usually at least a centimeter wide.

Because the hospital stay for either laparoscopy or minilaparotomy is only one day, we continue to advise microsurgery through a short ‘bikini’ incision for reversal surgery.

TUBAL JOINING AT THE UTERINE END OF THE TUBE (TUBO-CORNUAL RESECTION AND ANASTOMOSIS) BY MICROSURGERY

Inflammation reaches the tube by ascending through the cervix, uterus and fallopian tubes. As it spreads, it often blocks the tube where at the junction of the tube with the uterus. This block prevents the further spread of the inflammation and therefore spares the rest of the tube from disease. This is why many women conceive after we perform microsurgery to remove this blockage and join the healthy tube to the uterus.

The blockage usually first discovered at a tubal X-ray (hysterosalpingogram – HSG). We can insert fine guidewires through the cervix and uterus to diagnose and test the blockage to make sure that it is not simply a spasm or ‘cramp’ of the tubal muscle that is masquerading as a blockage. This is best done at a laparoscopy.

After the diseased tube is removed, 56% of women will have a baby. The conceptions occur mostly within the 20 months after surgery. There is some risk of ectopic pregnancy.

LAPAROSCOPIC SURGERY TO OPEN BLOCKAGE AT THE OVARIAN END OF THE FALLOPIAN TUBE (SALPINGOSTOMY)

If there is scarring around the fimbria (ovarian end of tube) and the tube is open, then trimming off the scar tissue at a laparoscopy will give a 55% baby rate and a 6% ectopic pregnancy rate.

If the tube is completely blocked at the ovarian end (hydrosalpinx) it means that the inflammation has spread from the uterus along the length of the tube to damage the ciliated hair cells (the transport system for the oocyte). Because of this ciliary damage, the pregnancy rate is much less after surgery.

Most of the principles of microsurgery can be applied by laparoscopic surgery; in particular it provides a superb environment for healing. In the case of blockage of the ovarian end of the tube, it is the condition of the tube, once opened, that determines subsequent fertility. Laparoscopic surgery has a unique niche for removing this blockage.

We have shown that certain factors in a woman’s history predict those who will conceive after salpingostomy by laparoscopy. Baby rates of 24% are achieved with laparoscopic salpingostomy. However, it is important to avoid salpingostomy procedures in women who are susceptible to an ectopic pregnancy after surgery. As we will see, those women are better served by having the tubes clipped near the uterus, or even completely removed, so as to improve embryo implantation and the success rate of IVF.

The benefit of salpingostomy and/or removal of the tubes for embryo implantation

There is evidence that the presence of hydrosalpinges (fluid-filled tubes blocked at the ovarian end) will lead to a significant reduction in the rate of embryo implantation at IVF. This seems to be a physical effect of the tubal fluid within the uterus. We therefore recommend laparoscopically directed salpingostomy for hydrosalpinx to help those women conceive a baby who have little risk of subsequent ectopic pregnancy. For those who have a high ectopic pregnancy risk, then removal of the tube or clipping of the tube are recommended in preparation for IVF. Clearly, full pre-laparoscopy discussion is essential.

TO SUMMARIZE………….

Tubal surgery has a unique complementary role with IVF for restoration of fertility. Surgery to join tubes for sterilization reversal, and to remove diseased tube at the junction with the uterus, is front-line therapy that can exceed the success rates of even multiple attempts at IVF. Furthermore, surgery can lead to several successive pregnancies from a single intervention. This is especially important since recent studies show conclusively that the majority of couples undergoing IVF do not wish to complete 3 cycles of IVF, largely for psychological reasons.

Surgery does not bear the same profound risk of multiple pregnancy as does IVF.

Salpingostomy has a special niche role in selected women with hydrosalpinx. Tubal removal and/or clipping are otherwise important for those who are best treated by IVF, so as to improve embryo implantation.

The condition of the fallopian tubes ultimately determines whether pregnancies will result from tubal surgery. Conversely, the condition of the fallopian tubes does not determine whether pregnancies ensue from IVF (unless a large hydrosalpinx is visible on pelvic ultrasound). Therefore, the prospects of pregnancy after IVF are complementary to prospects of pregnancy after tubal surgery and provide additional benefit. For this reason, infertile couples may wish to avail themselves of either or both options.

Costs:

Fortunately, all tubal surgery, except for reversal of sterilization, is covered by the medical services plan. The cost of reversal of sterilization totals about $5,500. This amount includes payment for operating room services, anaesthesia and microsurgery.

References:

1. McComb, P., Halbert, S.A., Gomel, V. Pregnancy, ciliary transport and the reversed ampullary segment of the fallopian tube, Fertil. Steril. 34:386-390 (1980)

2. Halbert, S.A., McComb, P., Patton, D.L. Function and structure of the rabbit oviduct following fimbriectomy: Part I: Distal ampullary salpingostomy, Fertil. Steril. 35:349-354 (1981)

3. McComb, P., Halbert, S.A. Reproduction in rabbits after excision of the oviductal isthmus, ampullary-isthmic junction and utero-isthmic junction, Fertil. Steril.

4. McComb, P., Verdugo, P., Langley, L. The oviductal cilia and Kartagener's syndrome, Fertil. Steril. 46:412-416 (1986)

5. Gomel V. Microsurgical reversal of sterilization: a reappraisal. Fertil Steril 1980; 33:587.

6. Rouzi, A.A., Mackinnon, M., McComb, P.F. Predictors of success of reversal of sterilization. Fertil. Steril., 64:29-36 (1995)

7. McComb P, Gomel V. Cornual occlusion and its microsurgical reconstruction. Clin Obstet Gynecol 1980;23:1229.

8. McComb P. Microsurgical tubocornual anastomosis for occlusive cornual disease: reproducible results without the need for tubouterine implantation. Fertil Steril 1986;46:571

9. Thurmond AS. Selective salpingography and fallopian tube recanalization. AJR Am J Roentgenol 1991;156:33.

10. Awartani K, McComb PF Microsurgical resection of nonocclusive salpingitis isthmica nodosa is beneficial. Fertil. Steril. 2003 May; 79(5):1199-203.

11. Gomel V. Salpingo‑ovariolysis by laparoscopy in infertility. Fertil Steril 1983; 34: 607.

12. Gomel V. Laparoscopic tubal surgery in infertility. Obstet Gynecol 1975; 46: 47.

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14. Gomel V. Salpingostomy by laparoscopy. J Reprod Med 1977; 18: 265.

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16. Taylor RC, Berkowitz J, McComb PF. Role of salpingostomy in the treatment of hydrosalpinx. Fertil. Steril. 2001 March; 75:594-600.

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18. Zouves C, Erenus M, Gomel V. Tubal ectopic pregnancy after in vitro fertilization and embryo transfer: a role for proximal occlusion or salpingectomy after failed distal tubal surgery? Fertil Steril 1991;56:691.

19. Strandell A, Waldenstrom U, Nilsson L, et al. Hydrosalpinx reduces in-vitro fertilization/embryo transfer pregnancy rates. Hum Reprod 1994; 9: 863

20. Strandell A, Lindhard A, Waldenstrom U et al. Hydrosalpinx and IVF outcome: a prospective, randomized, multicentre trial in Scandinavia on salpingectomy before IVF. Hum Reprod 1999; 14: 2762

21. Strandell A, Lindhard A, Waldenstrom U et al. Hydrosalpinx and IVF outcome: cumulative results after salpingectomy in a randomized, controlled trial. Hum Reprod 2001; 16: 2403

22. McComb PF, Taylor RC. Pregnancy outcome after unilateral salpingostomy with a contralateral patent oviduct. Fertil. Steril. 2001 Dec; 76(6):1278-9.

23. Land JA, Courtar DA, Evers JL. Patient dropout in an assisted reproductive technology program: implications for pregnancy rates. Fertil Steril 1997;68:278-81.

24 Olivius K, Friden B, Lundin K, Bergh C. Cumulative probability of live birth after three in vitro fertilization/intracytoplasmic sperm injection cycles. Fertil Steril 2002; 77:505-510.