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Evidence-based diagnosis and management of tubal factor

infertility
Pinar H. Kodaman, Aydin Arici and Emre Seli

Purpose of review Abbreviations


The investigation for potential tubal disease is an essential step CAT chlamydia antibody testing
in the work-up of infertility. This review article provides an chsp60 chlamydia heat shock protein 60
HSG hysterosalpingography
evidence-based overview of the diagnosis and management of IVF in-vitro fertilization
tubal factor infertility. IVF-ET in-vitro fertilization and embryo transfer
MIF microimmuno-fluorescence
Recent findings PID pelvic inflammatory disease
While laparoscopic chromopertubation remains the gold RCT randomized clinical trial
SIN salpingitis isthmica nodosa
standard in the diagnosis of tubal disease and SHG sonohysterography
hysterosalpingography is still widely used, newer modalities TCA tubocornual anastomosis

offer some advantages. Sonohysterography with the use of


# 2004 Lippincott Williams & Wilkins
contrast medium is superior to hysterosalpingography and
1040-872X
comparable to laparoscopic chromotubation in diagnosing tubal
blockage. Chlamydia serology is the most cost-effective and
least invasive diagnostic test for tubal disease, and it is Introduction
comparable to, if not better than, hysterosalpingography. Tubal disease is responsible for 25–35% of female
Depending on the nature and degree of tubal dysfunction as infertility [1]. It may involve the proximal, distal, or the
well as the age and ovarian reserve of the patient, various entire tube, and may be transient (obstruction), or
treatments for tubal infertility are available. For proximal tubal permanent (occlusion) [2]. Pelvic inflammatory disease
obstruction, transcervical tubal cannulation with tubal flushing is (PID) is the most common cause of tubal disease,
a reasonable first approach. Surgical techniques for tubal representing greater than 50% of cases [3,4] and may
repair, such as salpingostomy or fimbrioplasty for distal tubal affect the fallopian tube at multiple sites. After one
obstruction, can provide good results. Still, tubal factor remains episode of PID, the rate of infertility has been estimated
a major indication for in-vitro fertilization and embryo transfer, at 11%, which increases to 23% and 54% after two and
which bypasses the tubal problem altogether. In certain three episodes, respectively [5].
situations, such as the presence of hydrosalpinx, prophylactic
surgery can be used in conjunction with in-vitro fertilization and Proximal tubal disease
embryo transfer. In addition to PID, causes of proximal tubal disease
Summary include intratubal debris, congenital malformations,
As with infertility in general, the diagnosis and management of endometriosis, and salpingitis isthmica nodosa (SIN).
tubal infertility should be tailored to the individual patient. Future With SIN, diverticulae of the intramural or proximal
studies should help to further clarify the role of the various isthmic endosalpinx enlarge and eventually obliterate
diagnostic tests and therapeutic approaches for tubal infertility. the tubal lumen [6]. SIN is bilateral in most affected
patients and is associated with both infertility and
Keywords ectopic pregnancy [7]. Tubal polyps, found in approxi-
tubal infertility, hydrosalpinx, diagnosis, treatment mately 11% of hysterectomy specimens [8], also can
cause transient proximal tubal blockage. Similarly,
Curr Opin Obstet Gynecol 16:221–229. # 2004 Lippincott Williams & Wilkins. endometriosis may affect the intramural portion of the
tube, and is present at this site in 7–14% of patients with
Department of Obstetrics and Gynecology, Yale University School of Medicine, New tubal factor infertility [9,10].
Haven, Connecticut, USA

Correspondence to Emre Seli, MD, Department of Obstetrics and Gynecology, Yale Distal tubal disease
University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8063, USA Distal tubal disease is also caused by a multitude of
Tel: +1 203 785 4018; fax: +1 203 785 7134; e-mail: emre.seli@yale.edu
factors, including salpingitis, antecedent elective ster-
Current Opinion in Obstetrics and Gynecology 2004, 16:221–229 ilization, adhesions from previous surgery, and endome-
triosis. Rock et al. [11] classified distal tubal disease into
mild, moderate, or severe categories based on the size of
hydrosalpinx, extent of adhesions, degree of fimbrial
preservation, and the appearance of the endosalpinx on
hysterosalpingography (HSG). This classification has
DOI: 10.1097/01.gco.0000129421.98370.0d 221
222 Fertility

implications with respect to pregnancy and ectopic rates A meta-analysis comparing the accuracy of HSG to
both before and after tubal reconstructive surgery. diagnostic laparascopy with chromopertubation in the
diagnosis of tubal pathology found point estimates of
Diagnosis of tubal infertility 65% and 83% for sensitivity and specificity, respectively,
There are multiple approaches to the diagnosis of tubal for HSG [12]. This analysis was limited by the inclusion
infertility, including laparoscopy with chromopertuba- of only retrospective studies in which patients under-
tion, hysterosalpingography, sonohysterosalpingography, went both HSG and diagnostic laparoscopy, thus
salpingoscopy, and chlamydial serology. As will be excluding those patients who conceived after HSG
discussed below, each diagnostic test has certain benefits [12]. However, in another study in which laparoscopy
and limitations; thus, the selection of a particular test or a was performed on all subjects on the day after HSG, the
combination of tests should be individualized to the latter had a similar sensitivity and specificity of 54% and
patient. 83%, respectively [25]. The inability of HSG to detect
peritubal adhesions limits its sensitivity as a diagnostic
Laparoscopic chromopertubation and test [12]. Still, laparoscopic chromopertubation is not a
hysterosalpingography perfect gold standard as presumed tubal obstruction may
Traditionally, laparoscopy with chromopertubation has be due to differences in resistance between the tubes,
been the gold standard for investigating tubal patency spasm, or technical failure [12].
[12]. HSG is also widely used and has some advantages,
including the lack of need for anesthesia, relative speed Sonography
with which the procedure is completed, and a potential Sonohysterosalpingography with the use of contrast
therapeutic effect with oil soluble contrast media [13,14]. medium is an alternative to HSG for assessing tubal
The therapeutic impact of HSG is, in part, due to the patency [26–29]. Although the sonographic images are
flushing of tubal debris [14]. In addition, in-vitro studies inferior to those obtained fluoroscopically, abdominal
have shown that oil-based flushing media prevents ultrasound has a sensitivity and specificity of 100% and
peritoneal mast cell phagocytosis of spermatozoa and 96%, respectively [30], while transvaginal ultrasound is
increases fecundity in subfertile mice [14]. 89% sensitive, yet 100% specific in the detection of tubal
blockage [31]. A meta-analysis of the latter, which
A pathognomonic finding on HSG is seen with SIN, in included three studies consisting of over 1000 patients,
which the contrast filled diverticular projections result concluded that this method is superior to HSG and
in a radiographically honeycombed appearance [7,15]. comparable to laparascopic chromopertubation [32].
Hydrosalpinx also has a characteristic appearance;
however, transvaginal ultrasound better evaluates the In air-contrast sonohysterography (SHG), a small amount
volume of the dilated tubes [16]. HSG findings can be of air is injected into the uterine cavity, and the passage
used to stage tubal disease [17], and the appearance of of bubbles through the tubes is assessed [33]. Jeanty et
the intraluminal mucosal architecture as a rugal pattern al. [33] found that air-contrast SHG was in agreement
is a good prognostic factor for subsequent pregnancy with laparoscopic chromopertubation 79.4% of the time.
[11,18]. A sensitivity and specificity of 85% and 87%, respec-
tively, were calculated. This study was also limited by
A potential limitation of HSG is tubal spasm, especially the fact that only those patients who did not conceive
with elevated contrast injection pressure. Based on were further investigated with diagnostic laparoscopy,
hysteroscopic tubal cannulation, it has been estimated thus, disproportionately over-representing the patients
that HSG may give a false positive diagnosis of proximal with abnormal air-contrast SHGs [33].
tubal obstruction 50% of the time [19]. Lower pressure,
the use of spasmolytic agents, such as glucagon, The main advantage of sonohysterographic methods is
diazepam and terbutaline [20,21], and follow-up imaging their ability to detect uterine abnormalities, such as
to assess contrast spillage following resolution of spasm fibroids and polyps, which may also impair fertility.
have been proposed [3]. However, intermittent tubal While air contrast SHG was able to detect 85% of
obstruction during HSG may suggest underlying tubal anomalies, HSG detected only 6% [34]. Furthermore,
pathology, especially in the setting of low injection air-contrast SHG is inexpensive, quick, and better
pressures, and thus the value of spasmolytic agents may tolerated by patients than HSG [35,36 .].
be limited [3]. Furthermore, the efficacy of these agents
with respect to reversal of tubal spasm remains to be Salpingoscopy
established [22,23]. A recent study [24 .] suggested that Salpingoscopy is an endoscopic approach for the
unilateral corneal obstruction may be resolved in more diagnosis of intraluminal tubal damage. During laparo-
than 50% of patients by rotating the patient so that the scopy, a rigid salpingoscope is inserted into the distal
obstructed tube is in a more inferior position. tubes, allowing for visualization of the ampullary tubal
Tubal factor infertility Kodaman et al. 223

mucosa. Although the degree of tubal mucosal damage, tubation as a reference, chsp60 had a lower sensitivity
defined as the extent of adhesions between mucosal and specificity (51% and 85%, respectively) than CAT
folds or the flattening of mucosal folds, does not (54% and 92%, respectively) [45]. When both chsp60
necessarily correlate with that of periadnexal adhesions testing and CAT were combined, the positive predictive
[37,38], it does directly correlate with poor pregnancy value with respect to the detection of true tubal disease
outcome [39]. Thus, while laparascopic adhesiolysis can was increased [45].
restore external tubal anatomy to facilitate oocyte pick-
up, tubal function may still be compromised if the Management of tubal infertility
endosalpinx is damaged [40]. This was clearly demon- Depending on the type and degree of tubal dysfunction,
strated in a study of 51 patients with periadnexal various approaches are available. The treatment of
adhesions or hydrosalpinx, who underwent adhesiolysis choice is also determined by other factors such as the
or salpingostomy, respectively, in addition to salpingo- age and the ovarian reserve of the patient, presence or
scopy [37]. Patients with normal tubal mucosa at the absence of a male factor, and socioeconomic considera-
time of laparoscopic surgery had 71% and 64% cumula- tions. In addition to less invasive techniques such as
tive pregnancy rates in the adhesiolysis and salpingost- transcervical tubal cannulation and selective salpingo-
omy groups, respectively, while those with intraluminal graphy, and various surgical approaches, in-vitro fertiliza-
tubal damage had no intrauterine pregnancies [37]. tion and embryo transfer (IVF-ET) is a viable alternative
for all types of tubal dysfunction.
Chlamydia serology
Chlamydia antibody testing (CAT) to assess previous Proximal tubal occlusion
infection with Chlamydia trachomatis is a cost effective Proximal tubal blockage, suggested by failure of contrast
and non-invasive approach to evaluate fallopian tubes medium to enter the intramural or isthmic portion of
[41]. There are four different serological techniques for either tube is diagnosed in 10–30% of HSGs performed
C. trachomatis assessment: microimmuno-fluorescence for infertility [22]. Therapeutic approaches for proximal
(MIF), immunofluorescence, immunoperoxidase assay, tubal occlusion include transcervical tubal cannulation,
and enzyme-linked immunosorbent assay. MIF detects tubocornual anastomosis, and IVF-ET.
type-specific immunoglobulin G antibodies, while the
other methods detect antibodies against a much broader Transcervical tubal cannulation and selective salpingography
antigen found after both C. trachomatis and C. pneumonia In selective salpingography, the injection of contrast
exposure; thus, sensitivity is increased at the expense of medium through a transcervical catheter passed into the
specificity [41]. proximal tubal ostium creates increased pressures that
can clear tubal debris. Transcervical tubal cannulation for
Mol et al. [41] performed a meta-analysis comparing the reversal of proximal tubal occlusion can be
CAT with HSG for the diagnosis of tubal occlusion, performed under fluoroscopic [46,47], falloposcopic
using laparoscopic chromopertubation as the gold [48], sonographic [30–32], or hysteroscopic guidance
standard. They found that MIF had a sensitivity and [3,19,49,50]. Threading of an atraumatic guidewire
specificity of 75%, while the other tests were less through the catheter (tubal cannulation) allows for direct
specific. As the discriminative ability of CAT was mechanical disruption of inspissated material [3]. While
comparable to that of HSG, the authors concluded that 85% of occlusions can be overcome in this way, there is a
CAT can be used instead of HSG in the initial screening 30% reocclusion rate [51–53], and tubal perforation
for tubal disease [41]. Yet, CAT is limited by its inability occurs in 3–11% of cases [54]. Although these perfora-
to provide anatomical information with respect to the tions are usually minor and heal spontaneously, the
uterus or tubes and its lack of a potentially therapeutic associated trauma and inflammation can lead to intratu-
effect [41]. bal adhesions and further tubal dysfunction [3].

Antibody testing against chlamydia heat shock protein Tubocornual anastomosis


60 (chsp60), a marker of chronic inflammation, has also For macrosurgical tubal reanastomosis in the setting of
been proposed [42] as there is evidence that the proximal tubal occlusion, the tubal isthmus is excised,
antibody response to chsp60 predicts subsequent risks the residual tube is axially incised along its antimesen-
of tubal infertility [43] and ectopic pregnancy [44]. In a teric border, and then reimplanted into a new uterotomy
prospective case control study using either HSG or posterior to the cornu [4]. With the microsurgical
laparoscopic chromopertubation for comparison, Claman technique, the patent portions of the distal tube and
et al. [42] found a 44% sensitivity and 92% specificity for the interstitial tube are reanastomosed using 10X to 20X
chsp60 antibody, while sensitivity and specificity of magnification [55]. Reported ongoing pregnancy rates
CAT with MIF were 63% and 54%, respectively. In following microsurgical tubocornual anastomosis (TCA)
another study [45], using only laparoscopic chromoper- range from 38 to 56% [56–58], while those for macro-
224 Fertility

surgical TCA are in the range of 16 to 25% [4,56]. The use of prostheses to maintain tubal patency
Furthermore, macrosurgical TCA is associated with a following salpingostomy has also been investigated
high incidence (up to 80%) of stenosis [3]. [68–70]. In two studies [69,70], the prostheses were
used for postoperative irrigation, while the control
Honore et al. [3] performed a meta-analysis comparing groups received transcervical irrigation, and Decherney
microsurgical and macrosurgical TCA with tubal et al. [68] compared microsurgery alone with macro-
cannulation/selective salpingography. While the analy- surgery using a prosthesis. Meta-analysis showed no
sis was limited by the lack of randomized clinical trials benefit of prosthesis use with respect to subsequent
(RCTs) and specification of coexisting tubal pathology pregnancy rates [62 . .]. There is also no demonstrable
in many of the included studies, microsurgical TCA benefit for the use of the carbon dioxide laser for
was found to result in a higher ongoing pregnancy rate salpingostomy [71–74].
(47%) than the macrosurgical technique (22%). In
addition, radiographic therapies for tubal recannulation Fimbrioplasty
were not as effective as microsurgery [3]. An exception Fimbrioplasty, the lysis of adhesions between fimbrial
was hysteroscopic transcervical tubal cannulation with fronds or dilatation of fimbrial phimosis, attempts to
an average ongoing pregnancy rate of 49%. Thus, in restore fimbrial function [61]. As would be expected with
selected patients, namely those without coexisting improved tubal ability for oocyte retrieval, fimbrioplasty
tubal pathology, hysteroscopic transcervical tubal can- results in almost double the conception rate (approxi-
nulation with selective salpingography, may be as mately 60%) of cuff salpingostomy for a completely
effective, but less invasive and less costly than the occluded distal tube [59]. Furthermore, with the use of
microsurgical approach [3]. microsurgical technique, the intrauterine pregnancy and
ectopic rates are improved at 59% and 6%, respectively,
Distal tubal occlusion when compared with macrosurgical fimbrioplasty (42%
Distal tubal disease represents approximately 85% of all and 14%, respectively) [75]. Laparoscopic and open
cases [59] of tubal infertility. In addition to IVF, surgical microsurgical fimbrioplasty appear to be comparable with
interventions, such as salpingostomy and fimbrioplasty, regard to intrauterine pregnancy rates; however, with the
are available for the treatment of distal tubal occlusion. former, the ectopic rate can be up to 14% [61,76,77].

Salpingostomy Hydrosalpinges
Salpingostomy can be performed in the setting of Distal tubal occlusion from infection may lead to the
adhesive disease, tubo-ovarian abscess, hydrosalpinx, formation of hydrosalpinges [78]. While hydrosalpingeal
and ectopic pregnancy. The overall pregnancy rate after fluid does not appear to have direct toxic effects on
salpingostomy is only 30% with one quarter of these human embryos [79,80], it impedes embryo develop-
being ectopic in nature [59]. When patients are ment due to its deficiencies in essential nutrients and
classified into mild, moderate, and severe subcategories energy stores [80,81]. Furthermore, the leakage of
[11], the pregnancy rates following salpingostomy are hydrosalpinx fluid into the uterine cavity compromises
81, 31, and 16%, respectively, [60]. As might be implantation not only by altering endometrial receptivity
predicted, ectopic rates increase with moderate to [82–84], but also by mechanically washing the blastocyst
severe disease compared with mild disease [60]; but, away from the endometrial surface [85].
paradoxically, severe disease is associated with a lower
ectopic rate than moderate disease, likely because Meta-analyses of large retrospective series [78,86] have
oocyte retrieval is completely impaired in the setting shown that compared with patients with tubal infertility
of severe tubal dysfunction [61]. of other causes, women with hydrosalpinx have about
half the pregnancy, implantation, and delivery rates, and
Watson et al.’s recent meta-analysis [62 . .] demonstrated up to twice the incidence of spontaneous abortion after
increased term pregnancy and decreased ectopic rates IVF-ET [78,86]. Treatment options for hydrosalpinx
with microscopic compared with macroscopic salpingost- include drainage, salpingostomy, proximal tubal ligation,
omy. They also analyzed four non-randomized studies and salpingectomy [87].
comparing laparascopic with open, microsurgical salpin-
gostomy [63–66] and found that the overall and Drainage of the hydrosalpinx fluid
intrauterine pregnancy rates were significantly reduced Transvaginal needle aspiration of a hydrosalpinx under
with the laparoscopic approach [62 . .]. Yet, taking into ultrasound guidance either before an IVF-ET cycle or at
consideration the economic and recovery time benefits the time of oocyte retrieval is the least invasive
of laparoscopy [67], salpingostomy by this method is intervention. Non-randomized studies have conflicted
recommended in a setting in which IVF-ET is subse- in their conclusions as to the effectiveness of this
quently available if salpingostomy fails [64]. approach as the fluid tends to reaccumulate [87].
Tubal factor infertility Kodaman et al. 225

Salpingostomy (32% versus 11%) and at 2 years (45% versus 16%)


It has been argued that approximately one-third of compared with the control group [98].
women with hydrosalpinges have a good prognosis for
spontaneous pregnancy following reconstructive surgery While there are also no RCTs comparing laparoscopic
[88]. However, the expertise required to select this with laparoscopy [62 . .], a retrospective study comparing
population, including assessment with salpingoscopy, is laparoscopic with open microsurgical adhesiolysis found
not always available. Currently, there are no RCTs no difference in the subsequent pregnancy rates [63];
comparing salpingostomy with laparoscopic salpingect- however, there was a trend towards increased intrauter-
omy in the setting of hydrosalpinx. ine and reduced ectopic pregnancies with the former.
Despite the inconclusive findings of this study, given
Proximal tubal ligation that infertility is directly correlated with adhesions [99]
Two retrospective studies with small sample sizes and that laparoscopic adhesiolysis can be done at the
suggested improved pregnancy rates following proximal time of diagnostic laparoscopy and offers the additional
tubal ligation compared with salpingectomy in women benefits of decreased cost and postoperative recovery
with hydrosalpinges undergoing IVF-ET [89,90]. Again, time, it is recommended that routine laparotomy for
no prospective RCT is available to support this adhesiolysis be avoided.
approach.
Patients with adnexal adhesions that are extensive,
Salpingectomy thick, or vascular are less likely to benefit from surgery
Following many retrospective reports and two small than women with mild to moderate disease [99,100].
RCTs [91,92] suggesting the benefit of salpingectomy, The limited evidence suggests that laparoscopic lysis of
Strandell et al. [93] performed a multicenter prospective adhesions is a reasonable first line of treatment for the
RCT addressing the role of laparoscopic salpingectomy latter group, while patients with severe disease should
versus no treatment for hydrosalpinx prior to IVF. They instead undergo IVF-ET [61]. Furthermore, based on
found significantly increased pregnancy and delivery Audibert et al.’s study [64] of almost 300 patients with
rates of 37% and 29%, respectively, in the salpingectomy distal tubal disease, who underwent reconstructive
group compared with rates of 24% and 16%, respec- surgery, if spontaneous pregnancy is to occur, it will do
tively, in the non-intervention group. Furthermore, they so in the first 6–12 months following surgery. Thus,
confirmed a worse baseline prognosis for patients with those patients who fail to conceive 1 year after
bilateral and ultrasound-visible hydrosalpinges and adhesiolysis should also proceed with IVF-ET [61].
demonstrated improved outcome following salpingect-
omy [93]. A meta-analysis by Johnson et al. [94] analyzed Sterilization
data from the three RCTs and concluded that laparo- Female sterilization is the most commonly used method
scopic salpingectomy should be considered for all of contraception worldwide. Due to its permanent
women with hydrosalpinges due to undergo IVF-ET. nature, sterilization is associated with a risk of regret
and many women request conception following this
Adhesions procedure. Evaluation of data obtained from 2253
It has been well-established that laparoscopy results in women who had undergone tubal sterilization showed
fewer and less dense adhesions postoperatively than a strong correlation between regrets and youthful age
does laparotomy [67,95]. Adhesions can be ablated using and changes in marital situation [101]. Possible options
a cold knife, electrocautery, or the laser. The latter has are surgical reanastomosis and IVF-ET.
been advocated not only due to its precision, but also
because of its ability to minimize surrounding tissue Tubal reanastomosis
damage and bleeding, both of which should theoretically Tubal reanastomosis for reversal of sterilization is
reduce subsequent adhesion formation [61]. However, feasible if adequate residual tube length remains; in
two RCTs [96,97] have shown no significant benefit of fact, following the procedure, the length of the longest
the carbon dioxide laser over conventional techniques. tube in centimeters multiplied by 10 provides an
approximation of the subsequent term delivery rate
There are no RCTs assessing the role of lysis of [102]. The degree of tubal damage from prior steriliza-
periadnexal adhesions as compared with no treatment tion also affects outcome; thus, tubal reanastomosis after
[62 . .]. While it might be predicted that the role of Silastic ring or clip placement has a better prognosis than
adhesiolysis is limited given the propensity of adhesions that after electrocauterization [103]. The latter, and
to recur, one non-randomized, but controlled study of unipolar cautery in particular, is associated with in-
open adhesiolysis [98] found a significant increase in creased ectopic pregnancy rates [104]. Other factors that
pregnancy rates with treatment. The pregnancy rate was predict successful sterilization reversal include the
three times higher in the treatment group both at 1 year location of the anastomosis, with isthmus–isthmus
226 Fertility

anastomoses having the highest subsequent pregnancy setting of mild to moderate tubal disease if the patient is
rate of 81% [102], the age of the patient, and the young and has adequate ovarian reserve. These patients
presence of other coexisting tubal pathology [61]. should be offered IVF-ET if pregnancy does not occur
within 1 year following surgery [61,62 . .,64].
In their meta-analysis, Watson et al. [62 . .] examined the
role of microsurgery versus macrosurgery in the reversal Older patients and those with severe tubal disease
of sterilization. The available studies were limited by the should proceed directly to IVF-ET as this offers an
lack of RCTs and the use of historical control groups immediate chance for conception while avoiding the
[56,105–109]. However, as expected, the utilization of potential morbidity of surgery [61]. The dire outlook for
magnification during sterilization reversal as well as tubal surgery in the setting of severe disease is under-
during adhesiolysis and salpingostomy led to higher scored by a study of patients with both proximally and
pregnancy and lower ectopic rates. Although most tubal distally occluded tubes in which the conception rate was
surgery is performed with the operating microscope only 12.5% and no live births occurred within 2.5 years
[62 . .], one RCT demonstrated that there was no of the reconstructive procedure [115]. Yet, even in such
advantage of using the microscope instead of magnifying patients, surgery, such as, prophylactic salpingectomy,
spectacles (loupes) [110]. Furthermore, there is no may be the first line of treatment in the setting of
benefit of using fibrin sealant instead of suture material hydrosalpinx [93] or tubes affected by multiple ectopic
during sterilization reversal with respect to subsequent pregnancies in order to maximize the chances of
adhesion formation [111]. intrauterine pregnancy with IVF-ET.

Although IVF-ET is often performed in place of Finally, the choice to proceed with surgery, IVF-ET, or
sterilization reversal in many centers, there are no RCTs both needs to be individualized to the patient as it
comparing the two procedures [62 . .]. Sterilization depends on the presence of coexisting infertility factors,
reversal in younger patients has a high success rate and local IVF success rates, and cost [61]. With respect to the
allows for multiple subsequent pregnancies [61]. While latter, insurance companies are more likely to pay for
sterilization reversal in older patients is more controver- surgical procedures than IVF-ET, and cost also becomes
sial, a Scandinavian study [112] reported a 33% term an issue when multiple, successive pregnancies are
pregnancy rate in women over 40 years following desired [61].
sterilization reversal. The decision to perform this
surgery should be based on the age and ovarian reserve Conclusion
of the patient in addition to the length and status of the In addition to the gold standard of laparoscopic
remaining tubes [61]. chromopertubation, other diagnostic modalities, includ-
ing HSG, SHG, salpingoscopy, and chlamydia serology
In-vitro fertilization and embryo transfer versus surgery can assess tubal patency and offer some advantages.
IVF-ET completely bypasses the tubal blockage, and, Depending on the nature and degree of tubal dysfunc-
on the basis of 1999 data, offers an almost 30% delivery tion as well as the age and ovarian reserve of the patient,
rate per cycle [113]. IVF-ET success rates decrease with various approaches to the treatment of tubal infertility
advancing age from almost 50% in patients less than 30 are available. While surgical intervention is an effective
years of age to 28% in patients between age 35 and 38 treatment for most tubal problems, tubal factor remains
years, and 9% or less in patients over 41 years [61]. One one of the major indications for IVF-ET. However, in
analysis of the cumulative data showed that patients with certain situations, such as recurrent ectopic pregnancy
tubal factor, both with and without other coexisting and hydrosalpinx, prophylactic surgery can be used in
infertility factors, will have a greater than 70% pregnancy conjunction with IVF-ET to improve subsequent
rate after four IVF-ET cycles [61]. Yet, IVF-ET is pregnancy outcomes.
expensive, not available to all infertility patients, and a
recent prospective, randomized trial comparing a tradi-
tional approach to infertility with IVF-ET as first line References and recommended reading
therapy found that the former was associated with lower Papers of particular interest, published within the annual period of review, have
been highlighted as:
costs and higher pregnancy rates overall [114]. . of special interest
.. of outstanding interest

There are no RCTs addressing the role of surgery versus


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