Tubal disease affects around 30% of couples who undergo treatment for infertility. Tubal surgery remains an option for couples with financial, ethical, and/or religious concerns regarding in vitro fertilization (IVF). The fallopian tubes are necessary for conception. This is the site where the egg is released after it exits the ovarian follicle. The sperm travel up the vagina, through the cervix, and into the uterus.
Assessment of Tubal Damage
If tubal damage is suspected, a limited evaluation is required. Diagnostic tests include documentation of ovulation, which involves using basal body temperature records, luteal serum progesterone assays, and urine luteinizing hormone (LH) predictor kits. In addition, a semen analysis is performed on the male partner.
For women older than 35 years of age, follicle-stimulating hormone (FSH) testing is done to assess decreased ovarian reserve. To define the extent of tubal damage, a laparoscopy and hysterosalpingography are required.
According to the U. S. National Survey of Family Growth, around one million women have tubal ligation (sterilization) procedures each year. Of these women, one percent later have tubal reversal surgery. Tubal reanastomosis is a procedure used to open the tubes for conception. Two things that predict a poor prognosis after surgery are extensive cautery and removal of large segments of the fallopian tube.
Success rates after a tubal reanastomosis depend on maternal age, postoperative tube length, the number of tubes repaired, coexisting fertility factors, and the location of the anastomosis. Pregnancy rates range from 45% to 80%, according to studies. Compared to other surgical treatments for tubal disease, tubal reversal results in the highest pregnancy rates. This procedure is often used for couples who are not comfortable with IVF.
Fimbriolysis and Fimbrioplasty
Fimbriolysis is a procedure to treat distal tubal injury where there is no occlusion. A fimbria is a fingerlike projection at the end of the fallopian tube. Fimbriolysis is the separation of an attached fimbria. With fimbrioplasty, the surgeon repairs a partially occluded fimbria. The surgical outcomes of both fimbriolysis and fimbrioplasty are dependent on the severity of fimbria damage and tubal disease.
With minimal disease, pregnancy rates are higher than 50%, but with severe disease, pregnancy rates are lower, at around 25%. In addition, the risk for ectopic pregnancy increases to 12% following this procedure. If the couple cannot become pregnant after one year, IVF should be considered.
Neosalpingostomy is the surgical repair of a fallopian tube occlusion. A diagnosis of tubal occlusion is made using hysterosalpingography, but to define the stage and extent of tubal damage, laparoscopy is necessary. With mild occlusion, pregnancy rates are 70-80%. However, with severe disease, these rates drop to about 15%. Ectopic pregnancy risk following the procedure are around 10%, but this also depends on the degree of tubal damage.
When no pregnancy occurs after one year following the procedure, IVF is an option. For older women, IVF should be considered before the surgery, because the low probability of surgical success and the risk for ectopic pregnancy.
Proximal Tubal Recannulation
Proximal tubal cannulation employs hysteroscopic technology to repair the fallopian tubes. This surgery is used for upper tube occlusive disease. Causes of obstruction include endometriosis, infection, inflammation, and obliterative fibrosis.
Pregnancy rates following the procedure are as high as 85%, depending on the severity of damage. However, 28% of women experience reocclusion. The risk for ectopic pregnancy is around 12% with this procedure.