Surgical management of tubal disease and infertility

With the advances in assisted reproductive technology (ART), the role of reproductive surgery as the primary treatment of infertility has been questioned. Tubo-peritoneal factor infertility is common, and accounts for 30–40% of female infertility. The pathology of tubal disease ranges from peritubal adhesions, proximal and/or distal tubal blockage, hydrosalpinx to previous sterilisation. In tubo-peritoneal factor infertility, reproductive surgery remains an important option and is complementary to ART. It should be considered as the first-line treatment if a good result is expected, when the pathology is amendable or if left untreated will adversely affect the results of ART. The success of reproductive surgery depends on careful patient selection using proper investigative tools, performed in units with expertise following microsurgical principles.     

Surgical management of tubal disease and infertility

Reproductive surgery remains an important treatment option for some women with subfertility secondary to tubal disease. This review offers a comprehensive update on current evidence and guidance. Accurate investigation of the cause, site, extent is first paramount, with fertility-preserving surgical procedures reserved for women with mild tubal disease and no confounding subfertility factors. For severe tubal disease, including hydrosalpinx, a shift towards assisted reproductive technology (ART) is more often recommended, with tubal surgery instead offering a valuable adjunct to enhance reproductive success. Decisions regarding management of tubal disease are complex and require a patient-specific approach. Only surgeons with appropriate laparoscopic surgical expertize should perform tubal surgery; training the next generation of reproductive surgeons remains imperative.     

An update on surgical management of tubal disease and infertility

Reproductive surgery remains an important option and is complementary to assisted reproductive technologies. A spectrum of tubal disease of varying severity is recognized at laparoscopy. Pathology may vary from peritubal adhesions, damaged fimbriae or distorted tubal anatomy to tubal blockage or hydrosalpinx (a fluid-filled distension of the fallopian tube in the presence of distal tubal occlusion).Reproductive surgery should be considered as first-line treatment: when the correction of infertility pathology is achievable and a good result is expected; when the pathology is causing the patient pain or discomfort; and when if left uncorrected infertility pathology will compromise the results or increase the risks of assisted reproductive technology. The success of surgical infertility treatment depends on the careful selection of cases using appropriate investigative techniques, with procedures performed in centres with sufficient expertise. For both specialized reproductive and general gynaecological surgery, it is paramount to follow strict microsurgical principles to avoid adhesion formation and conserve normal tubal and ovarian tissues.     

Economic evaluation of infertility treatment for tubal disease

Purpose : The number of published studies comparing cost-effectiveness of tubal surgery and IVF treatment is limited, in part because of the difficulties of conducting randomized trials, given that IVF is now a clinically accepted treatment and the decision to offer surgery or IVF is often dictated by the severity of the tubal disease and by the availability of the methods. The aim of this study was to compare the costs of our policy of offering tubal surgery to patients with mild or moderate tubal disease with the cost of offering IVF to these and severe tubal disease. Methods : In this retrospective cohort study patients with tubal pathology as the sole reason for their infertility were included: 61 patients in the tubal surgery group and 464 patients in the IVF group. The delivery rates and costs per delivery were compared. Results : Delivery rates were 28% in the tubal surgery group within 2 years of follow-up and 52% in the IVF group that involved up to three cycles of treatment. This economic evaluation demonstrated only small differences in the average cost when considering the cost per delivery. Conclusions : With a policy involving strict selection of patients, tubal surgery will continue to have a role in the treatment of infertility.     

Surgical management of tubal disease and infertility

A spectrum of tubal disease of varying severity is recognised at laparoscopy. Pathology may vary from peritubal adhesions, damaged fimbriae or distorted tubal anatomy to tubal blockage or hydrosalpinx (a fluid-filled distension of the fallopian tube in the presence of distal tubal occlusion). Reproductive surgery remains an important option and complement to assisted reproductive technologies. Reproductive surgery should be considered as first-line treatment: when the correction of infertility pathology is achievable and a good result is expected; when the pathology is causing the patient pain or discomfort; and when if left uncorrected infertility pathology will compromise the results or increase the risks of assisted reproductive technology. The success of surgical infertility treatment depends on the careful selection of cases using appropriate investigative techniques, with procedures performed in centres with sufficient expertise. For both specialised reproductive and general gynaecological surgery, it is paramount to carefully follow the microsurgical principles to avoid adhesion formation and conserve normal tubal and ovarian tissues.     

Indications to tubal reconstructive surgery in the era of IVF

In recent years, the treatment of tubal infertility has witnessed a shift from reconstructive surgery to in vitro fertilization. However, tubal surgery retains specific advantages, and appropriate preoperative evaluation allows improved selection of patients who are candidates for tubal reconstructive surgery by identifying the patients with good reproductive prognosis. Of pivotal importance in the selection of patients is the intratubal direct evaluation performed at salpingoscopy. Term pregnancy rates of approximately 70% and 65% may be obtained in patients with periadnexal adhesions and bilateral distal tubal occlusion, respectively, when a normal tubal mucosa is observed at salpingoscopy.     

Prediction of laparoscopic surgery outcomes in tubal infertility

This study aimed to elucidate the predictive value of hysterosalpingography (HSG) and laparoscopy (LS) scores for spontaneous pregnancy after laparoscopic surgery in 50 patients with tubal infertility. During a 1-year follow-up period, 28% of these patients became pregnant. Both scores were informative in prediction of pregnancy with the area under the ROC curve being 0.80 (95% CI 0.67-0.93) and 0.74 (95% CI 0.58-0.89) for LS and HSG scores, respectively.     

Surgical adhesives and tubal sterilization: an experimental study

AIM: Our aim was to assess the application of three currently used surgical adhesives in the tubal lumen of rabbits, to promote sterilization, using a transvaginal approach. METHODS: Fifty-seven female albino New Zealand rabbits (114 uterine tubes), which became pregnant and delivered before the experiment, were divided into four groups: GS (sham-24 tubes), GEFIBRI (0.25 mL of fibrin adhesive in 30 tubes), GE-GRF (0.25 mL of resorcin adhesive in 30 tubes) and GEBUTYL (0.25 mL of n-butyl-2-cyanoacrylate adhesive in 30 tubes). The animals were mated with proven fertile males after the experiment and observed over 30, 90 and 180 days. Pregnancy and patency were macroscopically evaluated. The tubal diameter, tubal mucosa, myosalpinx, total optical density and inflammatory process were microscopically evaluated. The statistical analysis was performed by McNemar and Wilcoxon tests for the subgroups, and Fisher's exact test and Kruskal-Wallis test for the groups, the differences identified by Dunn's multiple comparisons test (P=5%). RESULTS: GS showed patency and pregnancies in all subgroups. GEFIBRI showed patency and pregnancies in all subgroups. GE-GRF did not show patency or pregnancies, but was associated with severe inflammatory process and tubal morphology alterations. GEBUTYL did not show patency, pregnancies or morphological tubal mucosa alterations. CONCLUSIONS: The n-butyl-2-cyanoacrylate adhesive effectively promoted tubal obstruction, did not cause tubal morphological alterations, nor did it impair the rabbit pregnancy. The fibrin adhesive failed to cause the occlusion. The GRF adhesive, in spite of producing tubal occlusion, caused severe uterine tubes damage.     

A comparative analysis of arterial blood flow in unexplained infertility,tubal infertility and fertile groups

We aimed to compare ovarian (O), uterine (U) and spiral (S) artery (A) resistance of patients diagnosed as fertile, unexplained infertility (UI) and tubal factor infertility (TFI) in the peri-implantation period and independent from the impact of the treatment. UI (n?=?70), TFI (n?=?75) and fertile (n?=?72) patients’ ovarian, uterine and spiral artery pulsatility index (PI), resistance index (RI) and the endometrial thickness, serum estradiol and progesterone levels were compared. The specificity and sensitivity values were calculated according to determined cutoff values. Both TFI and control groups’ UA PI values were significantly lower than the UI group’s PI values. The highest UA RI values were found in UI group and the lowest values were in the control group. UI and TFI groups’ OA PI/RI values were significantly higher than the control group. Both the control and TFI groups’ SA PI/RI values were significantly lower than UI group’s PI/RI values. UI patients’ uterine and spiral arteries PI values >1.86 and >0.85, RI values >0.80 and >0.53 can be used as a valuable test showing reduced uterine perfusion. Ovarian artery PI values >0.96 and RI values >0.58 can be used as tests showing decreased ovarian perfusion in patients with TFI. In these patients, embryo cryopreservation can be considered.     

Characterizing the endometrium in unexplained and tubal factor infertility: a multiparametric investigation

OBJECTIVE: To characterize endometrial development in unexplained and tubal factor infertility. DESIGN: Prospective study of 20 women with unexplained infertility, 22 with tubal factor infertility, and 21 fertile controls in the midproliferative, periovulatory, and midluteal phases of the menstrual cycle. SETTING: Reproductive Medicine Department of St. Mary's Hospital, Manchester, United Kingdom. PATIENT(S): Women awaiting assisted conception. INVESTIGATION(S): Serum hormone assays, transvaginal ultrasound, Doppler, and midluteal endometrial biopsies. MAIN OUTCOME MEASURE(S): Serum levels of E2, P, and LH, endometrial ultrasound morphometry, uterine and subendometrial artery Doppler, and endometrial histology and biochemistry. RESULT(S): Women with unexplained infertility demonstrated significantly reduced uterine artery flow velocity in all phases, significantly elevated uterine and subendometrial artery impedance in the periovulatory and midluteal phases, and significantly reduced endometrial texture in the midproliferative phase. Women with tubal factor infertility demonstrated significantly reduced uterine artery flow velocity, without a concomitant increase in impedance, and significantly greater expression of endometrial glandular and luminal keratan sulphate. CONCLUSION(S): Unexplained infertility is associated with a profound impairment of endometrial perfusion that might be amenable to treatment by perfusion enhancers. Tubal factor infertility is associated with endometrial developmental defects that might be corrected by salpingectomy. Endometrial ultrasound and Doppler studies are likely to become a vital tool in the investigation of infertility.     

输卵管妊娠期待治疗与药物治疗

输卵管妊娠是最常见的异位妊娠,近年来国内外报道发病率呈上升趋势,但输卵管妊娠破裂导致的死亡率呈下降趋势,这主要得益于早期的诊断和治疗。输卵管妊娠的早期治疗方法以手术治疗及保守治疗为主,在掌握适应证的前提下,期待治疗及药物治疗也能够取得良好的疗效并保护生育功能。文章就近年来输卵管妊娠的期待治疗及药物治疗的研究进展进行阐述。     

Influence of various tubal surgeries to serum antimullerian hormone level and outcome of the subsequent IVF-ET treatment

Abstract

Objective: To compare the influence of various tubal surgeries to ovarian reserve via serum level of antimullerian hormone (AMH) and the subsequent in vitro fertilization and embryo transplantation (IVF-ET) outcome in patients with simple tubal infertility.

Study design: A prospective cohort study was conducted on 134 IVF cycles undegone by 26 and 34 cases with bilateral and unilateral salpingectomy, respectively, 23 cases with bilateral oviducts interrupted in the proximal and 51 cases with bilateral oviducts obstruction without intervention as controls.

Results: Serum AMH displayed its great superiority to traditional markers of ovarian reserve in correspondence with antral follicles count and decisive effect for the number of oocytes retrieved after stimulation in each group. No significant differences on ovarian reserve and responsiveness or IVF-ET outcome existed among four groups comparable on essential characteristics, except for numerically higher clinical pregnancy rate and live birth rate after various tubal surgeries versus no intervention for bilateral oviducts obstruction. Especially, bilateral salpingectomy precursed the statistically highest implantation rate (51.0% versus 28.0%, 39.1%, 30.4%) and numerically best IVF outcome.

Conclusion: Tubal surgical procedures have some beneficial effect for improving IVF outcome without significant impact on ovarian reserve or responsiveness. Bilateral salpingectomy appears to be an appropriate procedure before IVF treatment for bilateral salpingitis, especially hydrosalpinx.