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IVF Should Supplant Tubal Fertility Surgery

by Dr. Geoffrey Sher on September 21, 2016

A progressive increase in success rates with IVF versus tubal fertility surgery has over the last 25 years brought about a shift away from the latter to the former. And so it should be, because even in young women, attempted surgical restoration of compromised Fallopian tubes is by and large associated with at best a 30-50% chance of a viable pregnancy within 2-3 years of undergoing attempted surgical restoration. This translates into a 2-3% chance of a baby per month of trying to conceive following such surgery. Conversely, when IVF performed in comparable cases, the likelihood of success following a single attempt (where fresh and frozen embryo transfers are included) is > 50%, i.e. approximately 20 times higher. Moreover, as compared to surgery, IVF is associated with far lower morbidity and besides, when the surgical approach fails to yield a baby, IVF will ultimately become the final option, anyway.

This having been said, the fact is that surgery and is still being performed to address tubal infertility throughout this country. Sadly, one reason for this (however illogical it might seem), is that presently many insurance companies selectively cover the cost of surgery while denying reimbursement for IVF. Accordingly many patients, feel compelled for financial reasons to first try tubal surgery before committing to out-of-pocket costs associated with IVF. As I see it, this policy by many insurance providers makes no fiscal sense because it would undoubtedly be in their own self-interest to support that which is most likely to be successful in the shortest period of time and which satisfies their clients’ needs. Fortunately, this is changing such that in the foreseeable future most tubal fertility surgery will hopefully be relegated to the history books.

Therapeutic reproductive surgery used to be performed through an open incision in the abdominal wall (laparotomy), allowing the surgeon to have direct (hands-on) access to the pelvic structures. However, today it is largely conducted via laparoscopy, either manually or robotically. Here, a thin telescope –like instrument is introduced through a small incision made below the belly button and other surgical instruments are introduced into the pelvis via several puncture sites in the lower abdomen. The laparoscope permits high resolution images of the pelvic structures to be transmitted onto a screen so that the surgeon can perform the required surgery while monitoring virtual progress there. The laparoscopic approach is far less painful, can be performed on in ambulatory (out-patient) surgical centers. In fact, with the exception of some cases where tubal reconnection (re-anastomosis) is undertaken to reconnect previously ligated Fallopian tubes, and in some cases, for the removal of relatively inaccessible uterine fibroids (myomectomy) almost all tubal fertility surgery is currently being performed laparscopically.

For the record, the factors that influence the likelihood of tubal Fertility surgery being successful include:

A. Whether or Not the Woman Has Undergone Previous End-Tubal Surgery

The first attempt at corrective tubal surgery offers by far the best chance of success.  Should the first attempt fail to result in pregnancy, then subsequent attempts are less likely to results in a healthy pregnancy.  In other words, women who have undergone a previous failed attempt at tubal surgery have a very much-reduced chance of success following a second or third attempt at surgical correction.

B. The Type of Surgery Performed

  • Salpingostomy (surgery to unblock Fallopian tubes that are blocked at their ends): Here the end(s) of the tube(s) must be stitched back or folded back through the use of laser surgery, have the poorest chance of achieving a pregnancy (<20% within 3 years) and a high risk (>10%) that the embryo will implant in the Fallopian tube (Ectopic/Tubal pregnancy) with an incumbent risk of tubal rupture, and potentially catastrophic internal bleeding. In my opinion Salpingostomy should no longer be performed.
  • Salpingolysis (freeing of adhesions surrounding otherwise patent fallopian tubes). Here ,  microsurgery is conducted to free such adhesions so as to mobilize the tubes so as to restore the normal anatomical relationship between the end(s) of the fallopian tube(s) and ovary (ies), the average clinical pregnancy rate following the performance of this procedure is about 30%-40%) within three years.
  • Tubal reanastamosis (to reverse a prior tubal ligation). Here, provided that such surgery is performed by an expert microsurgeon (see below) the baby rate is about around 50% within 3 years.
  • Tubal reimplantation [to transect and then re-implant fallopian tubes blocked at the point that they emerge from the uterus (proximal occlusion, into the uterus]. This procedure should also be relegated to history books.
  • Tubal recanalization.  This involves direct visualization of the interior of the uterus using a hysteroscope. This allows access to the internal openings of the Fallopian tubes, providing an opportunity to introduce a thin cannula, in the hope of re-opening proximally occluded tubes. It is successful in establishing a subsequent pregnancy within 3 years, in about 20%-30% of cases so treated.
  • Salpingectomy: When fallopian tubes are distended with fluid, blood or purulent material, and in situations where the tube is totally destroyed, it should be removed or proximally transected/clipped as a prelude to IVF

The commonest cause (by far) of tubal damage, is prior sexually transmitted  pelvic inflammation Pelvic inflammatory disease (PID)  most often attacks the inner lining of the fallopian tube(s), and involves both tubes. Even when one tube is found to be open (patent) and HSG or laparoscopic visualization suggests that only one tube is damaged, in almost all cases both fallopian tubes will be affected and the fact that one appears uninvolved, merely means that the degree of involvement is less than the other, more severely damaged tube. The sophisticated anatomy of the inner tube and the wall make it impossible to correct the inevitable internal tubal damage surgically. That is why IVF is needed to by-pass the tubal damage. It also serves to explain why women who conceive following pelvic reconstructive surgery where the cause of the infertility relates to chronic pelvic inflammatory disease have a relatively high incidence of ectopic/tubal pregnancy.  The reported incidence of subsequent tubal pregnancy ranges between eight (8%) and seventeen percent (17%) in such cases.  Diseases such as endometriosis are less likely to damage the inner lining of the fallopian tube(s) and this is the reason that ectopic pregnancy following surgery in cases of endometriosis is much lower.

Based upon the above, it is my policy to recommend IVF to all my patients with tubal disease or as a prelude to IVF, where hydrosalpinx (fluid collection in one or both tubes) is encountered. In the latter cases, I usually recommend salpingectomy and if that is not anatomically feasible, I recommend proximal ligation or ligation or clipping of the tube(s) where it exits the uterine wall), so as to avoid the tubal fluid from tracking into the uterus and damaging the embryo(s). For older women and those with diminished ovarian reserve ((DOR), the imperative to go directly to IVF is even more pressing because they face the onslaught of the “biological clock” and do not have the time to take the chance that surgery might work for them. They need to “make hay while the sun still shines”!

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