Has in-vitro fertilization made salpingostomy obsolete?

Article Abstract:

One type of infertility involves the blockage of one or both of the fallopian tubes leading from the ovaries to the uterus. Tubal surgery (salpingostomy) will not be able to restore fertility in cases where the tubes have multiple blockages or where the pelvis is frozen with fiber-like tissue. In other cases, practitioners must decide whether or not to perform surgery or to proceed with in vitro fertilization (IVF), a technique where the egg and sperm are united outside the body and the fertilized embryo is then reintroduced to the uterus for implantation. For patients with extreme blockage, the choice of IVF is obvious. However, for patients having an intermediate prognosis, the decision is less clear. The role of in vitro fertilization as a first line of treatment is controversial. Treatment plans depend on the probability of success (i.e. the birth of a baby), acceptance into an in vitro fertilization program, the likelihood of encountering complications, and cost. An article in the July issue of the British Journal of Obstetrics and Gynaecology reviews the overall success of tubal surgery. The studies reviewed many have potential biases, which include the erroneous reporting of results (ie. pregnancy versus live born infant figures) and poor patient selection (using patients who previously failed surgery for IVF studies or inappropriate comparison groups). Apart from potential biases, a single cycle of IVF is more successful than surgery in patients with tubal blockages occurring nearer to the ovaries (distal blockage). Both methods are considered safe and yield the same rate of tubal pregnancy, although IVF procedures may result in a multiple-fetus pregnancy. The long-term psychological effects of each method have not been well studied. Economically speaking, since IVF is more effective than tubal surgery, it can be argued that it should be the treatment of choice. However, couples with limited finances may not have the advantage of choosing the more expensive IVF procedure. It is concluded that clinicians should reserve tubal surgery for women who have distal obstruction in both tubes with minimal openings and extensive scar tissue and who lack access to IVF programs. Insurers are encouraged to make IVF more available as a first-line treatment. (Consumer Summary produced by Reliance Medical Information, Inc.)

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The results of tubal surgery in the treatment of infertility in two non-specialist hospitals

Article Abstract:

One type of infertility involves the blockage of one or both of the fallopian tubes leading from the ovaries to the uterus. In some cases, tubal surgery, salpingostomy, can restore reproductive potential. In other cases a procedure called in vitro fertilization (IVF) unites the sperm and egg outside of the body and reintroduces the fertilized embryo into the uterus for implantation. IVF as a first-line treatment for infertile couples with tubal damage is controversial. Most of the studies examining the success of tubal surgery have been performed in specialist hospitals. However, most of the surgery in England is actually performed in nonspecialist (general) hospitals. This makes them a good environment to assess the success of tubal surgery in achieving pregnancy, because there is less rigorous patient selection, less technical expertise and more complete follow-up of patients. The results of tubal surgery performed on infertile women with tubal blockage, particularly involving both tubes blocked at the end nearer to the ovary, are reported. Of the 40 patients with distal tubal blockage alone, four conceived after surgery (10 percent) and two delivered at term (four percent). The pregnancy success rate after tubal surgery, 11 percent in this study, was lower than the overall success rate for each cycle of IVF (between 20 and 35 percent) and much lower than the cumulative success rate of all tubal surgery reports. Tubal surgery offers patients with distal tubal blockage and minimal scar tissue the best chance of success. It is concluded that tubal surgery should be reserved for women who have the most likelihood of a surgical success, while IVF should be promoted as a first line treatment for other types of tubal blockages. IVF programs, which are not widely available in all regions in England, should be made more accessible. (Consumer Summary produced by Reliance Medical Information, Inc.)

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Microsurgical salpingostomy is not an obsolete procedure

Article Abstract:

Although some researchers now believe that in vitro fertilization (IVF), in which the egg and sperm are joined under laboratory conditions and the resulting embryo implanted into the uterus, is the best treatment for female infertility due to blocked fallopian tubes. However, a role for microsurgery, a surgical method of unblocking tubes, still exists. The results of microsurgery in 388 patients with blockages in both tubes are reported. In 65 cases, the procedure was performed after a previous surgery to open the tube (salpingostomy). Eighty-six women gave birth to at least one infant, and more than half of these had a second infant later. It was possible in 291 cases to score the degree of tubal damage prior to surgery (most patients had undergone laparoscopy, a technique of viewing the reproductive organs); this was an important reason for the high success rate. Patients with hydrosalpinges (dilatation of the tube at the end farthest from the uterus due to accumulated fluid) tended to have badly damaged tubes. The rate of conception improved slightly one year after the procedure. The authors believe that open surgery (where the abdomen is opened) is more successful than laparoscopic surgery (where surgery is performed through a hollow tube inserted via a small abdominal incision) because blockage is less likely to recur. They believe, furthermore, as 'unrepentant tubal surgeons', that tubal surgery should not be stopped in favor of IVF, and that salpingostomy is the best treatment for carefully selected patients. (Consumer Summary produced by Reliance Medical Information, Inc.)

Methods, Surgery, Fallopian tubes

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