Tuboplasty vs. IVF - ET
Seok Hyun Kim, M.D.
Department of Obstetrics and Gynecology
College of Medicine, Seoul National University
Seoul, Korea
Tubal Factor Infertility
# Etiology
Infection
History of laparotomy
Congenital anomaly
PID
STD
Treatment of Tubal Factor Infertility
1. Surgical Approach
Laparotomy : Microsurgical technique
Laparoscopy / Pelviscopy
Transcervical : Tubal recanalization
2. Assisted Reproductive Technology (ART)
IVF - ET
Choice of Treatment Options

Age of patient

Etiology of tubal disease

Extent of tubal disease

History of laparotomy

Other causes of infertility

Cost : medical / surgical
Tubal Surgery / Tuboplasty
1. Adhesiolysis
Salpingoovariolysis
2. Proximal Tubal Occlusion
Tubocornual reanastomosis
Fluoroscopic recanalization
Transcervical balloon tuboplasty
3. Distal Tubal Occlusion
Fimbrioplasty
Neosalpingostomy
4. Tubal sterilization (T/L)
Tubal reanastomosis (TR)
Tubal Surgery
# Prevention of adhesions
Anti-inflammatory agent
Fibrinolytic agent
Barrier agent
Meticulous bleeding control
Pelviscopic operation
Pelviscopic Tubal Surgery

Lower cost

Shorter hospitalization

Faster recovery

Better compliance
Prognostic Variables of Tubal Surgery
Author
Variables in classification
Distal ampullary diameter
AFS, 1988
Tubal wall thickness
Mucosal folds at neostomy site
Type and extent of adhesions
Degree of mucosal damage
Winston & Margara, 1991 Degree of tubal fibrosis
Presence of isthmic disease
Quality of tubal / ovarian adhesions
Peritubal Adhesion
Microsurgery
PR 21~62%
Filmy adhesion
PR 39% (Hulka, 1982)
CPR 68% (Oelsner, 1994)
Dense adhesion
PR 21% (Hulka, 1982)
CPR 34% (Oelsner, 1994)
cf. IVF-ET : CPR 49~51% (Guzik, 1986; Tan, 1992)
Peritubal Adhesion

Kelly & Roberts, 1983
1 year follow-up
PR 24%
Interval to pregnancy 5.2 months

Donnez & Casanas-Roux, 1986
Term PR 64%
Ectopic PR 2%
Adhesiolysis by Microsurgery
Author
Patients
Duration of
follow-up
Diamond (1979)
Hulka (1982)
140
23 filmy
24 dense
49
> 1 year
6 months-4 years
Frantzen & Schlosser
(1982)
Kelly & Roberts
(1983)
Donnez & CasanasRoux (1986)
Luber et al. (1986)
Jacobs et al. (1988)
Singhal et al. (1991)
Oelsner et al. (1994)
1 year
Intrauterine
preg.
Ectopic
preg.
Term
preg.
86 (61)
9 (39)
5 (21)
20 (41)
8 (6)
0 (0)
1 (4)
2 (4)
80 (57)
8 (35)
4 (17)
19 (39)
21
28 months
5 (24)
0 (0)
4 (19)
42
12-86 months
-
1 (2)
27 (64)
1 (8)
0 (0)
4 (5)
3 (16)
1 (3)
7 (54)
6 (40)
29 (37)
8 (42)
6 (19)
13
15
78
19 filmy
32 dense
Values in parentheses are percentages.
3 years
50 months
55 months
101 months
8 (62)
7 (47)
32 (41)
13 (68)
11 (34)
Pelviscopic Adhesiolysis

Gomel, 1989
PR 57~62%
Half of pregnancy : < 6 months

Dense type adhesion
Laparotomy more effective
due to technical problems
Adhesiolysis by Laparoscopy
Author
Patients
Duration of
follow-up
Bruhat et al. (1982) 66 moderate > 18 months
27 severe
Donnez (1987)
32 avascular 18 months
22 vascular
Fayez (1988)
49
2 years
Gomel (1989)
92
> 9 months
Values in parentheses are percentages.
Intrauterine
preg.
Ectopic
preg.
36 (55)
12 (44)
-
5 (8)
2 (7)
-
28 (57)
57 (62)
2 (4)
5 (5)
Term
preg.
20 (62)
11 (50)
23 (47)
54 (59)
Proximal Tubal Obstruction

Tubocornual implantation
Standard Tx. until 1970’s

Tubocornual reanastomosis
Recent improvement in results : PR ~45%
Donnez & Casanas-Roux, 1986
Damaged isthmic length < 1 cm : PR 45%
 1 cm : PR 22%
Proximal Tubal Obstruction

Tubocornual reanastomosis
McComb & Gomel, 1980
PR 58%, Term PR 53%, Ectopic PR 12%
Jacob, 1988
PR 65%, Ectopic PR 6%
Dubuisson, 1997
Interval to pregnancy 10.1 months
Term PR 57%, Ectopic PR 11%
cf. Comparable to IVF-ET : CPR 49% (Guzik, 1986)
Proximal Tubal Obstruction
# Avoidance of peritoneal entry
Prevention of adhesion formation
Use of USG, hysteroscopy, fluoroscopy,
and recanalization fallopioscopy
Fluoroscopic recanalization : PR 31%
Transcervical balloon tuboplasty : PR 34%
Transvaginal Bougie Dilatation
and Selective Salpingography
Lang & Dunaway, 1996
Case
Recanalization
Pregnancy
PR / Case
Major complication
Indications >
Salpingitis isthmica nodosa
Salpingitis and perisalpingitis
Endometriosis
Failed surgical anastomosis
187
145 (77.5%)
24
12.8%
1
62
71
8
43
Proximal Tubal Operation by Microsurgery
Author
Patients
Rock et al. (1979)**
McComb & Gomel
(1980)*
Winston (1980)*
Frantzen & Chlosser
(1982) *
Gomel (1983)*
McComb (1986)*
Jacobs et al. (1988)*
Donnez & CasanasRoux (1986)*
Singhal et al. (1991)*
Singhal et al. (1991)**
Dubuisson et al. (1997)*
Duration of
follow-up
Intrauterine
preg.
Ectopic
preg.
Term
preg.
52
38
50 months
-
13 (25)
23 (61)
2 (4)
2 (5)
8 (15)
20 (53)
43
28
> 1 year
12 (43)
1 (2)
2 (7)
16 (37)
12 (43)
48
26
17
82
> 1 year
50 months
3 years
-
30 (63)
15 (58)
11 (65)
-
3 (6)
3 (12)
1 (6)
6 (7)
27 (56)
14 (54)
8 (50)
36 (44)
27
9
120
50 months
50 months
3 years
9 (33)
2 (22)
89 (74)
2 (8)
0 (0)
13 (11)
6 (22)
1 (11)
68 (57)
*Tuboconual anastomosis ** tubocornual implantation
Values in parentheses are percentages.
Fallopioscopic Tuboplasty
Sueoka, 1998
50 patients with occluded tubes
HSG, Rubin test, Hysteroscopic hydrotubation
102 tubes treated during 53 attempts
Overall patency rate 79.4% after 1-3 months
11 pregnancies over 3-year follow-up
Distal Tubal Obstruction

Reconstructive surgery
Fimbrioplasty
Neosalpingostomy
- Success : degree of tubal or peritubal disease.
- Poor prognostic factors of neosalpingostomy
Hydrosalpinx with diameter of 3 cm or larger
No visible fimbriae
Dense pelvic adhesion
Salpingostomy by Microsurgery
Author
Swolin (1975)
Gomel (1978)
DeCherney & Kase
(1981)
Mage & Bruhat (1983)
Tulandi & Vilos (1985)
Russel et al. (1986)
Jacobs et al. (1988)
Donnez & CasanasRoux (1986)
Luber et al. (1986)
Schlaff et al. (1990)
Winston & Margara
(1991)
Singhal et al. (1991)
Audebert et al. (1991)
Patients
33
41
54
Duration of
follow-up
8 - 13 years
> 1 year
> 2 years
Intrauterine
preg.
13 (39)
12 (29)
20 (37)
Ectopic
preg.
8 (24)
5 (12)
4 (7)
Term
preg.
12 (36)
11 (27)
14 (26)
68
67
68
71
83
>18 months
2 years
6 years
3 years
42 months
19 (28)
15 (22)
28 (42)
29 (41)
-
6 (9)
3 (4)
12 (18)
8 (11)
6 (7)
14 (21)
28 (42)
23 (32)
26 (31)
17
95
323
12 - 86 months
4 years
1-10 years
2 (12)
19 (20)
106 (33)
2 (12)
7 (7)
32 (10)
2 (12)
72 (23)
97
135
50 months
2 years
33 (34)
38 (28)
6 (6)
16 (12)
28 (29)
-
Values in parentheses are percentages.
Fimbrioplasty by Microsurgery
Author
Patton (1982)
Patients
35
Jacobs et al. (1988)
29
Donnez & Casanas- 132
Roux (1986)
Luber et al. (1986)
20
Audebert et al.
76
(1991)
Values in parentheses are percentages.
Duration of
follow-up
Intrauterine
preg.
Ectopic
preg.
Term
preg.
2 years
21 (60)
1 (3)
-
3 years
36 months
20 (69)
-
2 (7)
2 (2)
17 (59)
79 (60)
12-86 months
2 years
6 (30)
27 (36)
3 (15)
5 (7)
3 (15)
-
Distal Tubal Obstruction
Superior results with Fimbrioplasty than Neosalpingostomy

Donnez & Casanas-Roux, 1986
Fimbrioplasty
: PR 60%
Neosalpingostomy : PR 31%

Posaci, 1999
Presence of dense adhesion, thick tubal wall, and
abnormal tubal mucosa : Term PR 3%
Absence of these factors : Term PR 59%
Both proximal and distal injury
IVF-ET indicated
Distal Tubal Obstruction
Pelviscopic surgery
Lower PR, compared with microsurgery
Success rates related to extent of disease

Audebert, 1998
PR
: 51%
Ectopic PR : 23%
Distal Tubal surgery by Laparoscopy
Author
Fayez (1983)
Patients
14
19
21
Daniel &
Herbert (1984)
Dubuisson et al. 31
(1990)
Canis et al.
87
(1991)
Audebert et al
24
(1991)
31
McComb &
22
Paleologou (1991)
Dubuisson et al. 81
(1994)
Audebert et al.
35
(1998)
Type of
operation
Duration of
follow-up
Intrauterine
preg.
Ectopic
preg.
Term
preg.
Fimbrioplasty
Salpingoneostomy
Salpingostomy
2 years
2 years
18 months
3 (21)
0 (0)
4 (19)
2 (14)
2 (11)
1 (5)
3 (21)
0 (0)
2 (10)
Fimbrioplasty
Salpingoneostomy
Fimbrioplasty
Salpingostomy
Fimbrioplasty
Salpingostomy
Salpingostomy
18 months
18 months
3 years
8 (26)
3 (10)
7 (23)*
1 (3)
6 (7)
1 (4)
2 (6)
1 (5)
-
> 1 year
10 (29)
29 (33)
4 (17)
4 (13)
-
5 (23)
Salpingostomy
3-60 months
26 (32)
4 (5)
26 (32)
Fimbrioplasty
2-5 years
18 (51)
8 (23)
13 (37)
* For the total group
Values in parentheses are percentages.
2 years
-
Tubal Reanastomosis
Performed in 0.2% of T/L patients

Gomel, 1980
PR : 64%, Ectopic PR : 1%
Interval to pregnancy : 10.2 months

Kim et al, 1997 (n=1,118)
Anatomic patency rate : 88.2%
PR : 54.8%, DR : 72.5%
The longer the postop. residual tubal length,
the shorter the interval to pregnancy.
Tubal Reanastomosis
Prognosis of TR depends on
Method of ligation
Repair site of tube
Residual tubal length
Other causes of infertility
# Bipolar coagulation : PR 49%
Ring, clip
: PR 67%
Pomeroy T/L
: PR 75%
Tubal Reanastomosis

Better prognosis with small difference in diameter
of reconstructed tubal locations
e.g. isthmus - isthmus (I-I)
cornua - isthmus (I-I)

Gomel & Swolin, 1980
Low PR : < 4 cm of postop. tubal length
Inverse correlation between postop. tubal length
and interval to pregnancy
Tubal Reanastomosis

Preoperative diagnostic laparoscopy
Method and location of ligation
Potential postop. tubal length
Coexistent pelvic disease

In older women > 40 yrs
TR (Trimpos & Kemper, 1980)
PR : 45%, Interval to pregnancy 5.5 months
IVF-ET (Tan, 1992)
CPR : 10%
 TR indicated after 3 cycles of IVF-ET
Reversal of Tubal Ligation by Microsurgery
Author
Winston (1977)
Gomel (1980)
Silber & Cohen
(1980)
Winston (1980)
Patients
16
118
25
62
43
Rock et al.
22
(1987)
58
Trimbos-Kemper 45
(1990)
9
24
T/L
techniques
Type of
TR
Partial resection, Tubocornual
diathermy
Mostly Pomeroy
Mostly
Tubotubal
Tubocornual
Duration of
follow-up
< 40 months
> 1 year
Intrauterine
preg.
Ectopic
preg.
11 (69)
1 (6)
76 (64)
14 (56)
1 (1)
1 (4)
37 (60)
26 (60)
20 (91)
38 (66)
15 (33)
5 (56)
15 (63)
2 (3)
1 (2)
2 (9)
8 (14)
3 (7)
0 (0)
0 (0)
Term
preg.
69 (58)
-
Coagulation
Tubotubal
Tubotubal
Tubocornual
Fallopian ring
Tubotubal
Unipolar cautery Tubotubal
Coagulation
Pomeroy
Rings and clips
* For the total group
Values in parentheses are percentages.
40 months
40 months
12-29 months
19 (86)
30 (52)
26 (33)*
Fecundability of Tuboplasty




Proximal tubal obstruction
3.5% (Gillett, 1989)
Distal tubal obstruction
2~3% (Williams, 1988; Canis, 1991)
Tubal reanastomosis
8% (Henderson, 1984)
Secondary tuboplasty
1% (Lauritsen, 1982)
Expertise required : tubal surgery specialist
IVF - ET

Alternative of choice to surgical approach

Dominant role in treatment of tubal factor infertility

Growing number of qualified IVF centers
Nearly equal to availability of tubal surgery

Requirement of expertise and credentialing
Tubal surgery can be performed, although perhaps less
successfully, by those without speciality training.
Status of ART

Benadiva, 1995
Is pelvic reconstructive surgery obsolete?

Penzias, 1996
Is there ever a role for tubal surgery?

Dubuisson, 1998
Are there still indications for tubal surgery in infertility?
Tuboplasty vs. IVF-ET
Procedures
Pregnancy Rate
TR (1990)
49 - 75 %
Fimbrial recanalization (1990)
34 %
Transcervical tuboplasty (1990)
31 %
Salpingolysis (1991)
30 - 60 %
Laparoscopic fimbrioplasty (1991)
30 - 70 %
Laparoscopic salpingolysis (1992)
62 - 67 %
Laparoscopic distal tuboplasty (1993)
27 %
Tubal reconstruction (1996)
40 %
SART/ASRM IVF registry (1995)
28.4 %
SART/ASRM IVF registry (1997)
28.9 %
Comparison of Reported Outcomes
for ART Procedures
IVF
No. of cycles
IVF + ICSI GIFT
33,032
18,312
1,943
ET / retrieval (%)
92.8
94.3
98.6
No. of clinical preg.
8,975
6,072
627
Delivery /retrieval (%)
28.4
27.1
30.0
Ectopic preg. /ET (%)
0.9
0.6
1.0
SART & ASRM, 1997
Standard IVF-ET by Maternal Age
Cancellation Delivery /
rate (%)
retrieval (%)
male factor (-)
10.2
33.9
35 - 37 yrs, male factor (-)
14.8
29.4
38 - 40 yrs, male factor (-)
19.3
21.2
> 40 yrs,
24.4
9.4
< 35 yrs,
male factor (-)
SART & ASRM,1997
Tuboplasty or IVF ?

Tuboplasty
Mild or moderate tubal disease
Young female

IVF-ET
Extensive pelvic adhesion
Old age
Impossible tubal reconstruction due to absence
of tubes or history of tuberculous salpingitis
Failed tubal surgery
Existence of other infertility factors
Considerations for Tuboplasty or IVF ?

Technical view : Invasiveness
Infertility factors involved

Nontechnical view : Cost
Wishes of patients

Surgery : Specialty training

IVF-ET : Expertise and credentialing

Development of operative laparoscopy, microsurgery
Comparison of Cost per Delivery
IVF-ET
Tubal surgery
Holst, 1991 (Norway)
$ 12,000
$ 17,000
Neumann, 1994 (USA)
$ 66,000
$ 50,000
Van Voorhis, 1997 (USA)
$ 43,138
$ 76,232
Cost per delivery
Patient Counselling

Fecundability
Tuboplasty : 2-4%
IVF - ET
: 20%

Successful tuboplasty : more than one pregnancy possible

Women’s age, infertility factor

Take-home-baby rate and CPR of IVF, No. of IVF cycles

Potential complications
Multiple pregnancy, abortion, ectopic pregnancy
Tuboplasty vs. IVF-ET
Conclusions
1. The goal for infertile couples should be live birth or
at least the ability to feel that they did their best.
2. These options should be carefully considered and
individualized, regarded as complementary,
not competitive, to achieve the desired goal.