eMedicine Specialties > Obstetrics and Gynecology > Reproductive Endocrinology and Infertility
Fallopian Tube Reconstruction: Treatment
Updated: Sep 5, 2008
Treatment
Surgical Therapy
The surgical approach to fallopian tube reconstruction is discussed in 3 parts according to the anatomic location of the obstruction: (1) the proximal portion of the tube, (2) the distal portion of the tube, and (3) the mid portion of the tube.
Occlusion of the proximal portion of the fallopian tube
Proximal occlusion of the fallopian tube can be of 2 types: intramural/interstitial and isthmic.
Intramural/interstitial obstruction
In the past, intramural/interstitial obstruction was surgically treated with tubal reimplantation through the uterine wall. This procedure is mentioned for historical interest because, in terms of achieving lasting tubal patency and subsequent pregnancy, the results are so poor that the procedure should be abandoned. Today, other more successful therapeutic options, such as IVF, are indicated.
However, intramural obstruction can be approached via hysteroscopic cannulation. The patient undergoes concurrent laparoscopy and hysteroscopy. The procedure may require 2 surgeons. The laparoscopy is performed to exclude disease in the distal portion of the fallopian tube(s). If the distal fallopian tube(s) is healthy, the surgeon can proceed to hysteroscopic cannulation.
A number of commercial cannulation kits are available for this procedure (eg, the Novy Cornual Cannulation Sets, Cook Ob/Gyn; Spencer, Ind). The tubal ostia are visualized in the endometrial cavity with the hysteroscope. A small wire is inserted through the os into the intramural portion of the tube, and a small catheter is threaded over the wire. Patency can be confirmed when dye introduced through the small catheter in the intramural portion of the tube is visualized extruding through the fimbria via laparoscopy.
Proximal tubal disease is commonly caused by salpingitis isthmica nodosa. It is commonly diagnosed when firm nodules are found on the fallopian tubes. The diagnosis is confirmed by histopathology. The hallmark of salpingitis isthmica nodosa is the presence of diverticula or outpouchings of the tubal epithelium, which are surrounded by hypertrophied smooth muscle. The diagnosis can only be confirmed by histology. It can be suspected by hysterosalpingography if proximal obstruction is present or by a stippled appearance indicating contrast medium in the diverticular projections. It is commonly bilateral and often found in fertile women. The cause of salpingitis isthmica nodosa is not known. Salpingitis isthmica nodosa is found in 0.6–11% of healthy fertile women and is almost always bilateral. There have been moderate success rates with microsurgical excision of affected areas and anastomosis of tubal segments.
Isthmic occlusion
Isthmic occlusion can be repaired by performing an isthmic-cornual or an isthmic-isthmic anastomosis as appropriate. The damaged portion of the tube is transected perpendicular to the axis of the tube. The occluded portion of the tube is resected 2 mm at a time, initially proximally and subsequently distally, until the tubal lumen is visualized.
Proximal patency is confirmed using retrograde chromopertubation through a cannula in the uterine cavity. Distal patency is confirmed by threading a piece of thin suture material from the fimbrial end toward the area of anastomosis.
An anchoring suture is placed in the proximal and distal mesosalpinx (isthmic-isthmic repair) or from the cornu proximally to the mesosalpinx distally (cornual-isthmic repair) to bring the 2 portions of the tube being anastomosed in proximity. Four interrupted sutures are placed at the 12-, 3-, 6-, and 9-o'clock positions, parallel to the axis of the tube, first within the muscularis and subsequently on the serosa, to bring together the proximal and distal portions of the tube.
Occlusion of the distal portion of the fallopian tube
Distal tubal occlusion can be surgically repaired by laparotomy or laparoscopy. Both surgical approaches achieve similar results.
Proximal patency of the tube must be confirmed with a preoperative hysterosalpingogram. Filling the fallopian tube with dilute dye at the time of surgery (via a cannula in the uterine cavity) facilitates identification of the entrance point in the distal, peritoneal surface of the tube that opens into the tubal lumen.
The distal occluded tube is opened using laser energy, a needlepoint unipolar electrode, or microscissors. The mucosa is everted without tension and is sutured to the serosa of the tube with a few interrupted sutures.
Occlusion of the mid portion of the fallopian tube
Midtubal occlusion is the most frequent cause of tubal sterility. In appropriate cases, anastomosis of the mid portion of the fallopian tube holds the greatest promise of success. The anastomosis can be isthmic-ampullary or ampullary-ampullary. The success of the procedure is directly correlated to the length of the tube following anastomosis.
Midtubal anastomosis can be performed via laparotomy or laparoscopy with equivalent rates of success. The procedure is similar to that described for isthmic-isthmic anastomosis. The occluded portion of the tube is resected. Portions of occluded tube (in 2-mm sections) are repeatedly resected, first proximally and then distally, until the tubal lumen is identified in the proximal and distal stumps. Patency of the stumps is confirmed with retrograde chromotubation (proximal stump) and by threading a piece of thin suture from the fimbrial end toward the area of anastomosis (distal stump).
An anchoring suture is placed in the proximal and distal mesosalpinx to bring the 2 portions of the tube being anastomosed in proximity. Four interrupted sutures are placed at the 12-, 3-, 6-, and 9-o'clock positions, parallel to the axis of the tube, first within the muscularis and subsequently on the serosa, to bring together the proximal and distal portions of the tube.
Preoperative Details
Candidates for tubal reconstruction are young women of reproductive age. In most cases, these women are healthy, and a preoperative CBC count and a serum pregnancy test are all that is required. Other preoperative evaluation is dictated by the patient's medical history and needs. The use of perioperative prophylactic antibiotics to prevent infection and corticosteroids or antiprostaglandin agents to decrease adhesion formation is controversial
Intraoperative Details
The approach for this surgery can be via laparotomy or laparoscopy with or without robotic assistance.
Strict adherence to the principles of microsurgery improves the results of tubal reconstruction.
Magnification of the operative field with an operative microscope or with surgical loupes allows for visualization of fine detail and increased accuracy of movement, both of which contribute to the delicate, gentle handling of tissues.
Meticulous, precise hemostasis that limits surrounding tissue injury is critical to maintain visualization in the magnified field. The use of crushing instruments, such as clamps and traumatic graspers, should be minimized to prevent tissue ischemia. All instruments must be fine and atraumatic, and only fine microsutures (eg, 8-0, 10-0) with tapered needles should be used on the fallopian tubes.
The drying of peritoneal and serosal surfaces is prevented with the use of continuous irrigation with warm isotonic fluid (eg, Ringer lactate solution). Minimal handling of the tissues decreases inflammation and adhesion formation. Postoperative adhesions can be decreased with the use of adhesion prevention barriers, such as oxidized regenerated cellulose (Interceed [TC7] Absorbable Adhesion Barrier, Ethicon; Somerville, NJ), or sodium hyaluronate/carboxymethylcellulose (Seprafilm Bioresorbable Membrane, Genzyme Corporation; Cambridge, Mass). These barriers maintain the healing surfaces away from each other, thus preventing adhesion formation.
Postoperative Details
Any suggestion of pelvic infection in the postoperative period requires aggressive antibiotic treatment because infection can result in adhesion formation and reocclusion of the fallopian tubes. Traditionally, pelvic rest (ie, no intercourse, nothing intravaginally) has been recommended during the first postoperative month in an effort to protect the reproductive organs during the healing period.
Follow-up
Perform a hysterosalpingogram, preferably with an oil-based contrast medium, 3 months after tubal reconstruction. If the tube(s) is patent, the patient is allowed 1 year to achieve pregnancy before further evaluation and treatment is warranted.
When indicated, manage other correctible infertility factors during the first year following surgery. For example, treat oligo-ovulatory women with ovulation induction to improve the chance of pregnancy. Perform intrauterine insemination in women with cervical infertility and to treat mild-to-moderate oligospermia.
If the postoperative hysterosalpingogram demonstrates bilateral tubal occlusion, refer the patient for IVF. The fallopian tubes are so delicate that repeated surgeries generally worsen the chances of success.
For excellent patient education resources, visit eMedicine's Pregnancy and Reproduction Center and Women's Health Center. Also, see eMedicine's patient education articles Infertility, In Vitro Fertilization, Ectopic Pregnancy, Tubal Sterilization, Menstrual Pain, and Mittelschmerz.
Complications
Women who have undergone tubal reconstruction are at a higher risk of ectopic pregnancy. Early evaluation of a pregnancy is critical to determine the site of implantation. Ectopic pregnancies identified early are small and can be managed more safely and easily. Women should be advised to contact their doctor within the first 2 weeks of a missed period. A vaginal ultrasound at the sixth week of gestation should identify an intrauterine sac, if present. If not present, the ectopic pregnancy should be managed medically or surgically as indicated.
More on Fallopian Tube Reconstruction |
| Overview: Fallopian Tube Reconstruction |
| Workup: Fallopian Tube Reconstruction |
 Treatment: Fallopian Tube Reconstruction |
| Follow-up: Fallopian Tube Reconstruction |
| References |
| « Previous Page | Next Page » |
References
Centers for Disease Control and Prevention. 2005 Assisted Reproductive Technology (ART) Report. Available at http://www.cdc.gov/ART/ART2005/index.htm. Accessed September 5, 2008.
Practice Committee of the American Society for Reproductive Medicine. The role of tubal reconstructive surgery in the era of assisted reproductive technologies. Fertil Steril. Nov 2006;86(5 Suppl):S31-4. [Medline].
Apodaca CC, Gililland JL. Successful repeat microsurgical fallopian tube anastomosis. A case report. J Reprod Med. May 1995;40(5):407-8. [Medline].
Degueldre M, Vandromme J, Huong PT, Cadière GB. Robotically assisted laparoscopic microsurgical tubal reanastomosis: a feasibility study. Fertil Steril. Nov 2000;74(5):1020-3. [Medline].
Detweiler MB, Detweiler JG, Fenton J. Sutureless and reduced suture anastomosis of hollow vessels with fibrin glue: a review. J Invest Surg. Sep-Oct 1999;12(5):245-62. [Medline].
Dubuisson JB, Aubriot FX, Henrion R. [Microsurgical desterilizations. Reflections on 65 cases]. J Gynecol Obstet Biol Reprod (Paris). 1986;15(2):223-9. [Medline].
Dubuisson JB, Chapron C, Nos C, et al. Sterilization reversal: fertility results. Hum Reprod. May 1995;10(5):1145-51. [Medline].
Eytan O, Azem F, Gull I, Wolman I, Elad D, Jaffa AJ. The mechanism of hydrosalpinx in embryo implantation. Hum Reprod. Dec 2001;16(12):2662-7. [Medline].
Falcone T, Goldberg JM, Margossian H, Stevens L. Robotic-assisted laparoscopic microsurgical tubal anastomosis: a human pilot study. Fertil Steril. May 2000;73(5):1040-2. [Medline].
Feinberg EC, Levens ED, DeCherney AH. Infertility surgery is dead: only the obituary remains?. Fertil Steril. Jan 2008;89(1):232-6. [Medline].
Gan SX. [Pathological observations on fallopian tubes after sterilization]. Zhonghua Fu Chan Ke Za Zhi. Mar 1991;26(2):103-5, 125. [Medline].
Gauwerky JF. [Endoscopic sterilization reversal]. Zentralbl Gynakol. 1991;113(15-16):865-8. [Medline].
Glock JL, Kim AH, Hulka JF, et al. Reproductive outcome after tubal reversal in women 40 years of age or older. Fertil Steril. Apr 1996;65(4):863-5. [Medline].
Gomel V. Microsurgical reversal of female sterilization: a reappraisal. Fertil Steril. Jun 1980;33(6):587-97. [Medline].
Gomel V. Reversal of tubal sterilization versus IVF in the era of assisted reproductive technology: a clinical dilemma. Reprod Biomed Online. Oct 2007;15(4):403-7. [Medline].
Gomel V. Tubal reanastomosis by microsurgery. Fertil Steril. Jan 1977;28(1):59-65. [Medline].
Henry A, Rinehart W, Piotrow PT. Reversing female sterilization. Popul Rep C. Sep 1980;C97-123. [Medline].
Honore GM, Holden AE, Schenken RS. Pathophysiology and management of proximal tubal blockage. Fertil Steril. May 1999;71(5):785-95. [Medline].
Hurst BS, Thomsen S, Lawes K, Ryan T. Controlled radiofrequency endotubal sterilization. Adv Contracept. Jun 1998;14(2):147-52. [Medline].
Jenkins CS, Williams SR, Schmidt GE. Salpingitis isthmica nodosa: a review of the literature, discussion of clinical significance, and consideration of patient management. Fertil Steril. Oct 1993;60(4):599-607. [Medline].
Jiang ZM, Luo TX, Zheng HG, et al. [Ultrastructural study of fallopian tubes after occlusive sterilization with phenol-mucilage]. Shengzhi Yu Biyun. Nov 1991;11(4):35-8. [Medline].
Kim JD, Kim KS, Doo JK, Rhyeu CH. A report on 387 cases of microsurgical tubal reversals. Fertil Steril. Nov 1997;68(5):875-80. [Medline].
Kim SH, Shin CJ, Kim JG, Moon SY, Lee JY, Chang YS. Microsurgical reversal of tubal sterilization: a report on 1,118 cases. Fertil Steril. Nov 1997;68(5):865-70. [Medline].
Koh CH, Janik GM. Laparoscopic microsurgical tubal anastomosis. In: Adamson GD, ed. Endoscopic Management of Gynecological Disease. Philadelphia, Pa: Lippincott-Raven; 1996:119-45.
Koh CH, Janik GM. Laparoscopic microsurgical tubal anastomosis. Obstet Gynecol Clin North Am. Mar 1999;26(1):189-200, viii. [Medline].
Lang EK. The efficacy of transcervical recanalization of obstructed postoperative fallopian tubes. Eur Radiol. 1998;8(3):461-5. [Medline].
Li MS. [A clinical analysis of 317 cases of salpingo-anastomoses]. Zhonghua Fu Chan Ke Za Zhi. May 1991;26(3):166-8, 188-9. [Medline].
Margolis MT, Thoen LD, Wheeless CR Jr, Mercer LJ. Rabbit fallopian tube reanastomosis using a microvascular stapling device. J Gynecol Surg. 1995;11(2):79-83. [Medline].
Mettler L, Ibrahim M, Lehmann-Willenbrock E, Schmutzler A. Pelviscopic reversal of tubal sterilization with the one- to two-stitch technique. J Am Assoc Gynecol Laparosc. Aug 2001;8(3):353-8. [Medline].
Owen ER, Pickett-Heaps AA. The microsurgical basis of Fallopian tube reconstruction. Aust N Z J Surg. Jun 1977;47(3):300-5. [Medline].
Posaci C, Camus M, Osmanagaoglu K, Devroey P. Tubal surgery in the era of assisted reproductive technology: clinical options. Hum Reprod. Sep 1999;14 Suppl 1:120-36. [Medline].
Putman JM, Holden AE, Olive DL. Pregnancy rates following tubal anastomosis: Pomeroy partial salpingectomy versus electrocautery. J Gynecol Surg. Fall 1990;6(3):173-8. [Medline].
Reich H, McGlynn F, Parente C, et al. Laparoscopic tubal anastomosis. J Am Assoc Gynecol Laparosc. Nov 1993;1(1):16-9. [Medline].
Rouzi AA, Mackinnon M, McComb PF. Predictors of success of reversal of sterilization. Fertil Steril. Jul 1995;64(1):29-36. [Medline].
Sacks G, Trew G. Reconstruction, destruction and IVF: dilemmas in the art of tubal surgery. BJOG. Nov 2004;111(11):1174-81. [Medline].
Shen Y, Xue P. [Morphological observation of mucosal epithelium after tubal sterilization]. Shengzhi Yu Biyun. Jun 1992;12(3):23-8. [Medline].
Silber SJ, Cohen R. Microsurgical reversal of female sterilization: the role of tubal length. Fertil Steril. Jun 1980;33(6):598-601. [Medline].
Silva PD, Perkins HE. Improved combined laparoscopic and minilaparotomy technique to allow for reversal of extensive tubal sterilization. J Am Assoc Gynecol Laparosc. May 1995;2(3):327-30.
Speroff L, Glass RH, Kase NG. Female infertility. In: Speroff L, Glass RH, Kase NG, eds. Clinical Gynecologic Endocrinology and Infertility. 6th ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1999:1013-42.
Strandell A, Waldenstrom U, Nilsson L, Hamberger L. Hydrosalpinx reduces in-vitro fertilization/embryo transfer pregnancy rates. Hum Reprod. May 1994;9(5):861-3.
Swolin K. [50 fertility operations. I. Literature and methods]. Acta Obstet Gynecol Scand. 1967;46(2):234-50. [Medline].
Tortoriello DV, McGovern PG, Colon JM, et al. Critical ovarian hyperstimulation syndrome in a coasted in-vitro fertilization patient. Hum Reprod. Nov 1998;13(11):3005-8. [Medline].
Tran DK. Microsurgical tubal reanastomosis. J Gynecol Obstet Biol Reprod (Paris). 1986;15 Suppl:103-4.
Van Voorhis BJ. Comparison of tubal ligation reversal procedures. Clin Obstet Gynecol. Sep 2000;43(3):641-9. [Medline].
Vandromme J, Chasse E, Lejeune B, et al. Hydrosalpinges in in-vitro fertilization: an unfavourable prognostic feature. Hum Reprod. Mar 1995;10(3):576-9.
Wang X, Bilolo KK, Qi S, et al. Restoration of fertility in oophorectomized rats after tubo-ovarian transplantation. Microsurgery. 2002;22(1):30-3. [Medline].
Wang YH. [Microsurgical technique of tubal reconstruction after surgical sterilization: a report of 40 cases]. Shengzhi Yu Biyun. Nov 1988;8(4):19-22. [Medline].
Winston RM. Microsurgical tubocornual anastomosis for reversal of sterilisation. Lancet. Feb 5 1977;1(8006):284-5. [Medline].
Yoon TK, Sung HR, Cha SH, Lee CN, Cha KY. Fertility outcome after laparoscopic microsurgical tubal anastomosis. Fertil Steril. Jan 1997;67(1):18-22. [Medline].
Yossry M, Aboulghar M, D'Angelo A, Gillett W. In vitro fertilisation versus tubal reanastomosis (sterilisation reversal) for subfertility after tubal sterilisation. Cochrane Database Syst Rev. Jul 19 2006;3:CD004144. [Medline].
Further Reading
Keywords
fallopian tube reconstruction, ovum, ovulation, sperm, zygote, embryo, fertilization, endometrium, uterus, uterine cavity, reproduction, fertility, infertility, in vitro fertilization, IVF, embryo transfer, ET, Papanicolaou test, Pap smear, follicle-stimulating hormone, FSH, tubal disease, ectopic pregnancy, pelvic inflammatory disease, PID, sexually transmitted diseases, STDs, Chlamydia trachomatis, C trachomatis, Neisseria gonorrhea, N gonorrhea, tubal occlusion, adnexal adhesions, pelvic adhesions, chronic pelvic pain, chronic abdominal pain, tubo-ovarian abscess, tuboovarian abscess, dyspareunia, menstrual pain, endometriosis, tubal sterilization, salpingitis isthmica nodosa, hydrosalpinx, pyosalpinx, peritubal adhesions, fallopian tube infertility, tubal dysfunction, fallopian tube dysfunction
