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

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

Correspondence to Emre Seli, MD, Department of Obstetrics and Gynecology, Yale
University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8063, USA
Tel: +1 203 785 4018; fax: +1 203 785 7134; e-mail: emre.seli@yale.edu
Current Opinion in Obstetrics and Gynecology 2004, 16:221–229
DOI: 10.1097/01.gco.0000129421.98370.0d
Distal tubal disease
Distal tubal disease is also caused by a multitude of
factors, including salpingitis, antecedent elective ster-
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
221
222 Fertility
implications with respect to pregnancy and ectopic rates
both before and after tubal reconstructive surgery.
Diagnosis of tubal infertility
There are multiple approaches to the diagnosis of tubal
infertility, including laparoscopy with chromopertuba-
tion, hysterosalpingography, sonohysterosalpingography,
salpingoscopy, and chlamydial serology. As will be
discussed below, each diagnostic test has certain benefits
and limitations; thus, the selection of a particular test or a
combination of tests should be individualized to the
patient.
Laparoscopic chromopertubation and
hysterosalpingography
Traditionally, laparoscopy with chromopertubation has
been the gold standard for investigating tubal patency
[12]. HSG is also widely used and has some advantages,
including the lack of need for anesthesia, relative speed
with which the procedure is completed, and a potential
therapeutic effect with oil soluble contrast media [13,14].
The therapeutic impact of HSG is, in part, due to the
flushing of tubal debris [14]. In addition, in-vitro studies
have shown that oil-based flushing media prevents
peritoneal mast cell phagocytosis of spermatozoa and
increases fecundity in subfertile mice [14].
A pathognomonic finding on HSG is seen with SIN, in
which the contrast filled diverticular projections result
in a radiographically honeycombed appearance [7,15].
Hydrosalpinx also has a characteristic appearance;
however, transvaginal ultrasound better evaluates the
volume of the dilated tubes [16]. HSG findings can be
used to stage tubal disease [17], and the appearance of
the intraluminal mucosal architecture as a rugal pattern
is a good prognostic factor for subsequent pregnancy
[11,18].
A potential limitation of HSG is tubal spasm, especially
with elevated contrast injection pressure. Based on
hysteroscopic tubal cannulation, it has been estimated
that HSG may give a false positive diagnosis of proximal
tubal obstruction 50% of the time [19]. Lower pressure,
the use of spasmolytic agents, such as glucagon,
diazepam and terbutaline [20,21], and follow-up imaging
to assess contrast spillage following resolution of spasm
have been proposed [3]. However, intermittent tubal
obstruction during HSG may suggest underlying tubal
pathology, especially in the setting of low injection
pressures, and thus the value of spasmolytic agents may
be limited [3]. Furthermore, the efficacy of these agents
with respect to reversal of tubal spasm remains to be
established [22,23]. A recent study [24 .] suggested that
unilateral corneal obstruction may be resolved in more
than 50% of patients by rotating the patient so that the
obstructed tube is in a more inferior position.
A meta-analysis comparing the accuracy of HSG to
diagnostic laparascopy with chromopertubation in the
diagnosis of tubal pathology found point estimates of
65% and 83% for sensitivity and specificity, respectively,
for HSG [12]. This analysis was limited by the inclusion
of only retrospective studies in which patients under-
went both HSG and diagnostic laparoscopy, thus
excluding those patients who conceived after HSG
[12]. However, in another study in which laparoscopy
was performed on all subjects on the day after HSG, the
latter had a similar sensitivity and specificity of 54% and
83%, respectively [25]. The inability of HSG to detect
peritubal adhesions limits its sensitivity as a diagnostic
test [12]. Still, laparoscopic chromopertubation is not a
perfect gold standard as presumed tubal obstruction may
be due to differences in resistance between the tubes,
spasm, or technical failure [12].
Sonography
Sonohysterosalpingography with the use of contrast
medium is an alternative to HSG for assessing tubal
patency [26–29]. Although the sonographic images are
inferior to those obtained fluoroscopically, abdominal
ultrasound has a sensitivity and specificity of 100% and
96%, respectively [30], while transvaginal ultrasound is
89% sensitive, yet 100% specific in the detection of tubal
blockage [31]. A meta-analysis of the latter, which
included three studies consisting of over 1000 patients,
concluded that this method is superior to HSG and
comparable to laparascopic chromopertubation [32].
In air-contrast sonohysterography (SHG), a small amount
of air is injected into the uterine cavity, and the passage
of bubbles through the tubes is assessed [33]. Jeanty et
al. [33] found that air-contrast SHG was in agreement
with laparoscopic chromopertubation 79.4% of the time.
A sensitivity and specificity of 85% and 87%, respec-
tively, were calculated. This study was also limited by
the fact that only those patients who did not conceive
were further investigated with diagnostic laparoscopy,
thus, disproportionately over-representing the patients
with abnormal air-contrast SHGs [33].
The main advantage of sonohysterographic methods is
their ability to detect uterine abnormalities, such as
fibroids and polyps, which may also impair fertility.
While air contrast SHG was able to detect 85% of
anomalies, HSG detected only 6% [34]. Furthermore,
air-contrast SHG is inexpensive, quick, and better
tolerated by patients than HSG [35,36 .].
Salpingoscopy
Salpingoscopy is an endoscopic approach for the
diagnosis of intraluminal tubal damage. During laparo-
scopy, a rigid salpingoscope is inserted into the distal
tubes, allowing for visualization of the ampullary tubal

mucosa. Although the degree of tubal mucosal damage,
defined as the extent of adhesions between mucosal
folds or the flattening of mucosal folds, does not
necessarily correlate with that of periadnexal adhesions
[37,38], it does directly correlate with poor pregnancy
outcome [39]. Thus, while laparascopic adhesiolysis can
restore external tubal anatomy to facilitate oocyte pick-
up, tubal function may still be compromised if the
endosalpinx is damaged [40]. This was clearly demon-
strated in a study of 51 patients with periadnexal
adhesions or hydrosalpinx, who underwent adhesiolysis
or salpingostomy, respectively, in addition to salpingo-
scopy [37]. Patients with normal tubal mucosa at the
time of laparoscopic surgery had 71% and 64% cumula-
tive pregnancy rates in the adhesiolysis and salpingost-
omy groups, respectively, while those with intraluminal
tubal damage had no intrauterine pregnancies [37].
Chlamydia serology
Chlamydia antibody testing (CAT) to assess previous
infection with Chlamydia trachomatis is a cost effective
and non-invasive approach to evaluate fallopian tubes
[41]. There are four different serological techniques for
C. trachomatis assessment: microimmuno-fluorescence
(MIF), immunofluorescence, immunoperoxidase assay,
and enzyme-linked immunosorbent assay. MIF detects
type-specific immunoglobulin G antibodies, while the
other methods detect antibodies against a much broader
antigen found after both C. trachomatis and C. pneumonia
exposure; thus, sensitivity is increased at the expense of
specificity [41].
Mol et al. [41] performed a meta-analysis comparing
CAT with HSG for the diagnosis of tubal occlusion,
using laparoscopic chromopertubation as the gold
standard. They found that MIF had a sensitivity and
specificity of 75%, while the other tests were less
specific. As the discriminative ability of CAT was
comparable to that of HSG, the authors concluded that
CAT can be used instead of HSG in the initial screening
for tubal disease [41]. Yet, CAT is limited by its inability
to provide anatomical information with respect to the
uterus or tubes and its lack of a potentially therapeutic
effect [41].
Antibody testing against chlamydia heat shock protein
60 (chsp60), a marker of chronic inflammation, has also
been proposed [42] as there is evidence that the
antibody response to chsp60 predicts subsequent risks
of tubal infertility [43] and ectopic pregnancy [44]. In a
prospective case control study using either HSG or
laparoscopic chromopertubation for comparison, Claman
et al. [42] found a 44% sensitivity and 92% specificity for
chsp60 antibody, while sensitivity and specificity of
CAT with MIF were 63% and 54%, respectively. In
another study [45], using only laparoscopic chromoper-
Tubal factor infertility Kodaman et al. 223
tubation as a reference, chsp60 had a lower sensitivity
and specificity (51% and 85%, respectively) than CAT
(54% and 92%, respectively) [45]. When both chsp60
testing and CAT were combined, the positive predictive
value with respect to the detection of true tubal disease
was increased [45].
Management of tubal infertility
Depending on the type and degree of tubal dysfunction,
various approaches are available. The treatment of
choice is also determined by other factors such as the
age and the ovarian reserve of the patient, presence or
absence of a male factor, and socioeconomic considera-
tions. In addition to less invasive techniques such as
transcervical tubal cannulation and selective salpingo-
graphy, and various surgical approaches, in-vitro fertiliza-
tion and embryo transfer (IVF-ET) is a viable alternative
for all types of tubal dysfunction.
Proximal tubal occlusion
Proximal tubal blockage, suggested by failure of contrast
medium to enter the intramural or isthmic portion of
either tube is diagnosed in 10–30% of HSGs performed
for infertility [22]. Therapeutic approaches for proximal
tubal occlusion include transcervical tubal cannulation,
tubocornual anastomosis, and IVF-ET.
Transcervical tubal cannulation and selective salpingography
In selective salpingography, the injection of contrast
medium through a transcervical catheter passed into the
proximal tubal ostium creates increased pressures that
can clear tubal debris. Transcervical tubal cannulation for
the reversal of proximal tubal occlusion can be
performed under fluoroscopic [46,47], falloposcopic
[48], sonographic [30–32], or hysteroscopic guidance
[3,19,49,50]. Threading of an atraumatic guidewire
through the catheter (tubal cannulation) allows for direct
mechanical disruption of inspissated material [3]. While
85% of occlusions can be overcome in this way, there is a
30% reocclusion rate [51–53], and tubal perforation
occurs in 3–11% of cases [54]. Although these perfora-
tions are usually minor and heal spontaneously, the
associated trauma and inflammation can lead to intratu-
bal adhesions and further tubal dysfunction [3].
Tubocornual anastomosis
For macrosurgical tubal reanastomosis in the setting of
proximal tubal occlusion, the tubal isthmus is excised,
the residual tube is axially incised along its antimesen-
teric border, and then reimplanted into a new uterotomy
posterior to the cornu [4]. With the microsurgical
technique, the patent portions of the distal tube and
the interstitial tube are reanastomosed using 10X to 20X
magnification [55]. Reported ongoing pregnancy rates
following microsurgical tubocornual anastomosis (TCA)
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].
Furthermore, macrosurgical TCA is associated with a
high incidence (up to 80%) of stenosis [3].
Honore et al. [3] performed a meta-analysis comparing
microsurgical and macrosurgical TCA with tubal
cannulation/selective salpingography. While the analy-
sis was limited by the lack of randomized clinical trials
(RCTs) and specification of coexisting tubal pathology
in many of the included studies, microsurgical TCA
was found to result in a higher ongoing pregnancy rate
(47%) than the macrosurgical technique (22%). In
addition, radiographic therapies for tubal recannulation
were not as effective as microsurgery [3]. An exception
was hysteroscopic transcervical tubal cannulation with
an average ongoing pregnancy rate of 49%. Thus, in
selected patients, namely those without coexisting
tubal pathology, hysteroscopic transcervical tubal can-
nulation with selective salpingography, may be as
effective, but less invasive and less costly than the
microsurgical approach [3].
Distal tubal occlusion
Distal tubal disease represents approximately 85% of all
cases [59] of tubal infertility. In addition to IVF, surgical
interventions, such as salpingostomy and fimbrioplasty,
are available for the treatment of distal tubal occlusion.
Salpingostomy
Salpingostomy can be performed in the setting of
adhesive disease, tubo-ovarian abscess, hydrosalpinx,
and ectopic pregnancy. The overall pregnancy rate after
salpingostomy is only 30% with one quarter of these
being ectopic in nature [59]. When patients are
classified into mild, moderate, and severe subcategories
[11], the pregnancy rates following salpingostomy are
81, 31, and 16%, respectively, [60]. As might be
predicted, ectopic rates increase with moderate to
severe disease compared with mild disease [60]; but,
paradoxically, severe disease is associated with a lower
ectopic rate than moderate disease, likely because
oocyte retrieval is completely impaired in the setting
of severe tubal dysfunction [61].
Watson et al.’s recent meta-analysis [62 . .] demonstrated
increased term pregnancy and decreased ectopic rates
with microscopic compared with macroscopic salpingost-
omy. They also analyzed four non-randomized studies
comparing laparascopic with open, microsurgical salpin-
gostomy [63–66] and found that the overall and
intrauterine pregnancy rates were significantly reduced
with the laparoscopic approach [62 . .]. Yet, taking into
consideration the economic and recovery time benefits
of laparoscopy [67], salpingostomy by this method is
recommended in a setting in which IVF-ET is subse-
quently available if salpingostomy fails [64].
The use of prostheses to maintain tubal patency
following salpingostomy has also been investigated
[68–70]. In two studies [69,70], the prostheses were
used for postoperative irrigation, while the control
groups received transcervical irrigation, and Decherney
et al. [68] compared microsurgery alone with macro-
surgery using a prosthesis. Meta-analysis showed no
benefit of prosthesis use with respect to subsequent
pregnancy rates [62 . .]. There is also no demonstrable
benefit for the use of the carbon dioxide laser for
salpingostomy [71–74].
Fimbrioplasty
Fimbrioplasty, the lysis of adhesions between fimbrial
fronds or dilatation of fimbrial phimosis, attempts to
restore fimbrial function [61]. As would be expected with
improved tubal ability for oocyte retrieval, fimbrioplasty
results in almost double the conception rate (approxi-
mately 60%) of cuff salpingostomy for a completely
occluded distal tube [59]. Furthermore, with the use of
microsurgical technique, the intrauterine pregnancy and
ectopic rates are improved at 59% and 6%, respectively,
when compared with macrosurgical fimbrioplasty (42%
and 14%, respectively) [75]. Laparoscopic and open
microsurgical fimbrioplasty appear to be comparable with
regard to intrauterine pregnancy rates; however, with the
former, the ectopic rate can be up to 14% [61,76,77].
Hydrosalpinges
Distal tubal occlusion from infection may lead to the
formation of hydrosalpinges [78]. While hydrosalpingeal
fluid does not appear to have direct toxic effects on
human embryos [79,80], it impedes embryo develop-
ment due to its deficiencies in essential nutrients and
energy stores [80,81]. Furthermore, the leakage of
hydrosalpinx fluid into the uterine cavity compromises
implantation not only by altering endometrial receptivity
[82–84], but also by mechanically washing the blastocyst
away from the endometrial surface [85].
Meta-analyses of large retrospective series [78,86] have
shown that compared with patients with tubal infertility
of other causes, women with hydrosalpinx have about
half the pregnancy, implantation, and delivery rates, and
up to twice the incidence of spontaneous abortion after
IVF-ET [78,86]. Treatment options for hydrosalpinx
include drainage, salpingostomy, proximal tubal ligation,
and salpingectomy [87].
Drainage of the hydrosalpinx fluid
Transvaginal needle aspiration of a hydrosalpinx under
ultrasound guidance either before an IVF-ET cycle or at
the time of oocyte retrieval is the least invasive
intervention. Non-randomized studies have conflicted
in their conclusions as to the effectiveness of this
approach as the fluid tends to reaccumulate [87].

Salpingostomy
It has been argued that approximately one-third of
women with hydrosalpinges have a good prognosis for
spontaneous pregnancy following reconstructive surgery
[88]. However, the expertise required to select this
population, including assessment with salpingoscopy, is
not always available. Currently, there are no RCTs
comparing salpingostomy with laparoscopic salpingect-
omy in the setting of hydrosalpinx.
Proximal tubal ligation
Two retrospective studies with small sample sizes
suggested improved pregnancy rates following proximal
tubal ligation compared with salpingectomy in women
with hydrosalpinges undergoing IVF-ET [89,90]. Again,
no prospective RCT is available to support this
approach.
Salpingectomy
Following many retrospective reports and two small
RCTs [91,92] suggesting the benefit of salpingectomy,
Strandell et al. [93] performed a multicenter prospective
RCT addressing the role of laparoscopic salpingectomy
versus no treatment for hydrosalpinx prior to IVF. They
found significantly increased pregnancy and delivery
rates of 37% and 29%, respectively, in the salpingectomy
group compared with rates of 24% and 16%, respec-
tively, in the non-intervention group. Furthermore, they
confirmed a worse baseline prognosis for patients with
bilateral and ultrasound-visible hydrosalpinges and
demonstrated improved outcome following salpingect-
omy [93]. A meta-analysis by Johnson et al. [94] analyzed
data from the three RCTs and concluded that laparo-
scopic salpingectomy should be considered for all
women with hydrosalpinges due to undergo IVF-ET.
Adhesions
It has been well-established that laparoscopy results in
fewer and less dense adhesions postoperatively than
does laparotomy [67,95]. Adhesions can be ablated using
a cold knife, electrocautery, or the laser. The latter has
been advocated not only due to its precision, but also
because of its ability to minimize surrounding tissue
damage and bleeding, both of which should theoretically
reduce subsequent adhesion formation [61]. However,
two RCTs [96,97] have shown no significant benefit of
the carbon dioxide laser over conventional techniques.
There are no RCTs assessing the role of lysis of
periadnexal adhesions as compared with no treatment
[62 . .]. While it might be predicted that the role of
adhesiolysis is limited given the propensity of adhesions
to recur, one non-randomized, but controlled study of
open adhesiolysis [98] found a significant increase in
pregnancy rates with treatment. The pregnancy rate was
three times higher in the treatment group both at 1 year
Tubal factor infertility Kodaman et al. 225
(32% versus 11%) and at 2 years (45% versus 16%)
compared with the control group [98].
While there are also no RCTs comparing laparoscopic
with laparoscopy [62 . .], a retrospective study comparing
laparoscopic with open microsurgical adhesiolysis found
no difference in the subsequent pregnancy rates [63];
however, there was a trend towards increased intrauter-
ine and reduced ectopic pregnancies with the former.
Despite the inconclusive findings of this study, given
that infertility is directly correlated with adhesions [99]
and that laparoscopic adhesiolysis can be done at the
time of diagnostic laparoscopy and offers the additional
benefits of decreased cost and postoperative recovery
time, it is recommended that routine laparotomy for
adhesiolysis be avoided.
Patients with adnexal adhesions that are extensive,
thick, or vascular are less likely to benefit from surgery
than women with mild to moderate disease [99,100].
The limited evidence suggests that laparoscopic lysis of
adhesions is a reasonable first line of treatment for the
latter group, while patients with severe disease should
instead undergo IVF-ET [61]. Furthermore, based on
Audibert et al.’s study [64] of almost 300 patients with
distal tubal disease, who underwent reconstructive
surgery, if spontaneous pregnancy is to occur, it will do
so in the first 6–12 months following surgery. Thus,
those patients who fail to conceive 1 year after
adhesiolysis should also proceed with IVF-ET [61].
Sterilization
Female sterilization is the most commonly used method
of contraception worldwide. Due to its permanent
nature, sterilization is associated with a risk of regret
and many women request conception following this
procedure. Evaluation of data obtained from 2253
women who had undergone tubal sterilization showed
a strong correlation between regrets and youthful age
and changes in marital situation [101]. Possible options
are surgical reanastomosis and IVF-ET.
Tubal reanastomosis
Tubal reanastomosis for reversal of sterilization is
feasible if adequate residual tube length remains; in
fact, following the procedure, the length of the longest
tube in centimeters multiplied by 10 provides an
approximation of the subsequent term delivery rate
[102]. The degree of tubal damage from prior steriliza-
tion also affects outcome; thus, tubal reanastomosis after
Silastic ring or clip placement has a better prognosis than
that after electrocauterization [103]. The latter, and
unipolar cautery in particular, is associated with in-
creased ectopic pregnancy rates [104]. Other factors that
predict successful sterilization reversal include the
location of the anastomosis, with isthmus–isthmus
226 Fertility
anastomoses having the highest subsequent pregnancy
rate of 81% [102], the age of the patient, and the
presence of other coexisting tubal pathology [61].
In their meta-analysis, Watson et al. [62 . .] examined the
role of microsurgery versus macrosurgery in the reversal
of sterilization. The available studies were limited by the
lack of RCTs and the use of historical control groups
[56,105–109]. However, as expected, the utilization of
magnification during sterilization reversal as well as
during adhesiolysis and salpingostomy led to higher
pregnancy and lower ectopic rates. Although most tubal
surgery is performed with the operating microscope
[62 . .], one RCT demonstrated that there was no
advantage of using the microscope instead of magnifying
spectacles (loupes) [110]. Furthermore, there is no
benefit of using fibrin sealant instead of suture material
during sterilization reversal with respect to subsequent
adhesion formation [111].
Although IVF-ET is often performed in place of
sterilization reversal in many centers, there are no RCTs
comparing the two procedures [62 . .]. Sterilization
reversal in younger patients has a high success rate and
allows for multiple subsequent pregnancies [61]. While
sterilization reversal in older patients is more controver-
sial, a Scandinavian study [112] reported a 33% term
pregnancy rate in women over 40 years following
sterilization reversal. The decision to perform this
surgery should be based on the age and ovarian reserve
of the patient in addition to the length and status of the
remaining tubes [61].
In-vitro fertilization and embryo transfer versus surgery
IVF-ET completely bypasses the tubal blockage, and,
on the basis of 1999 data, offers an almost 30% delivery
rate per cycle [113]. IVF-ET success rates decrease with
advancing age from almost 50% in patients less than 30
years of age to 28% in patients between age 35 and 38
years, and 9% or less in patients over 41 years [61]. One
analysis of the cumulative data showed that patients with
tubal factor, both with and without other coexisting
infertility factors, will have a greater than 70% pregnancy
rate after four IVF-ET cycles [61]. Yet, IVF-ET is
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
therapy found that the former was associated with lower
costs and higher pregnancy rates overall [114].
There are no RCTs addressing the role of surgery versus
IVF-ET in the treatment of patients with tubal factor
infertility. However, based on the available evidence,
the following recommendations can be made [61]. An
initial surgical approach, especially if performed at the
time of diagnostic laparoscopy, is appropriate in the
setting of mild to moderate tubal disease if the patient is
young and has adequate ovarian reserve. These patients
should be offered IVF-ET if pregnancy does not occur
within 1 year following surgery [61,62 . .,64].
Older patients and those with severe tubal disease
should proceed directly to IVF-ET as this offers an
immediate chance for conception while avoiding the
potential morbidity of surgery [61]. The dire outlook for
tubal surgery in the setting of severe disease is under-
scored by a study of patients with both proximally and
distally occluded tubes in which the conception rate was
only 12.5% and no live births occurred within 2.5 years
of the reconstructive procedure [115]. Yet, even in such
patients, surgery, such as, prophylactic salpingectomy,
may be the first line of treatment in the setting of
hydrosalpinx [93] or tubes affected by multiple ectopic
pregnancies in order to maximize the chances of
intrauterine pregnancy with IVF-ET.
Finally, the choice to proceed with surgery, IVF-ET, or
both needs to be individualized to the patient as it
depends on the presence of coexisting infertility factors,
local IVF success rates, and cost [61]. With respect to the
latter, insurance companies are more likely to pay for
surgical procedures than IVF-ET, and cost also becomes
an issue when multiple, successive pregnancies are
desired [61].
Conclusion
In addition to the gold standard of laparoscopic
chromopertubation, other diagnostic modalities, includ-
ing HSG, SHG, salpingoscopy, and chlamydia serology
can assess tubal patency and offer some advantages.
Depending on the nature and degree of tubal dysfunc-
tion as well as the age and ovarian reserve of the patient,
various approaches to the treatment of tubal infertility
are available. While surgical intervention is an effective
treatment for most tubal problems, tubal factor remains
one of the major indications for IVF-ET. However, in
certain situations, such as recurrent ectopic pregnancy
and hydrosalpinx, prophylactic surgery can be used in
conjunction with IVF-ET to improve subsequent
pregnancy outcomes.
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