Fallopian Tube Reconstruction Treatment & Management
- Author: Krystene B DiPaola, MD; Chief Editor: Richard Scott Lucidi, MD, FACOG more...
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.
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 (see the image below). 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 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.
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.
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.
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.
Perform a hysterosalpingogram 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, see eMedicineHealth's patient education articles Infertility, In Vitro Fertilization, Ectopic Pregnancy, Tubal Sterilization, Menstrual Pain, and Painful Ovulation (Mittelschmerz).
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.
Outcome and Prognosis
Most pregnancies following tubal reconstructive surgery occur within a year of the procedure. The length of the tube following reconstructive surgery is directly correlated to success in terms of subsequent pregnancy. The prognosis of the surgical repair of hydrosalpinx with a diameter greater than 3 cm is very poor. The amount of pelvic adhesions and damage at the time of surgery is inversely correlated to the success of tubal reconstruction.
Reports of pregnancy rates following fallopian tube reconstructive surgery
The success rates following tubal reconstructive surgery (reported as pregnancy or live birth) vary from author to author, thus making a comparison of results difficult because a number of important variables may differ among reports. For example, the patient populations may not be comparable in terms of the age of the patients, ovarian function, amount of preoperative tubal damage, and length of the tube following reconstruction, among others. Differences in the experience of the surgeons and in the surgical techniques used may also explain the variable results obtained. Some of the best published results are as follows:
Repair of the proximal fallopian tube
- Hysteroscopic tubal cannulation to repair intramural or interstitial obstruction can result in a patency rate of up to 90% in at least 1 tube and a pregnancy rate in the range of 50-60%.
- Similar pregnancy rates have been reported following isthmic-cornual anastomosis. The pregnancy rate following isthmic-isthmic anastomosis is highly dependent on the length of the tube following surgery and has been reported to be as high as 75% if the anastomosed tube is longer than 4 cm.
Repair of the distal fallopian tube: Pregnancy rates ranging from 10-80% have been reported, depending on the amount of tubal damage at surgery.
Repair of the mid portion of the fallopian tube
- Pregnancy rates vary according to the length of the tube following surgery.
- Pregnancy rates of up to 75% have been reported with tubes longer than 4 cm after surgical repair. The pregnancy rate drops to less than 20% in women with shorter tubes.
Future and Controversies
In the past, tubal reconstruction surgery was the mainstay treatment of tubal disease. In its early years, tubal reconstruction provided treatment when the dismal alternative was sterility. As surgical management and microsurgical techniques improved, the success rate of tubal reconstructive surgery steadily increased over time.
The birth of Louise Brown in 1978 following IVF initiated a new era in the management of tubal infertility. Pregnancy could be achieved even in the complete absence of the fallopian tubes. The early experience with IVF was relatively poor, especially compared with the success obtained with surgical reconstruction in well-selected cases of tubal infertility.
There has never been a randomized control trial to compare fallopian tube(s) surgical repair to assisted reproductive technology (ART). The US National IVF/ET Registry reported the clinical pregnancy rate following IVF in the United States in the 2005 Assisted Reproductive Technology Report. However, no such repository of data exist for patients trying to conceive on their own after microsurgical tubal repair.
In the ART report, generated by the Centers for Disease Control and Prevention (CDC), 483 fertility clinics were in operation in 2006 that provided and verified data on the outcomes of all ART cycles started at their clinics. The 138,198 ART cycles performed at these reporting clinics in 2006 resulted in 41,343 live births (deliveries of one or more living infants) and 54,656 infants. In the published medical literature, microsurgical tubal repair yields cumulative pregnancy rates ranging from 40-80%, with a monthly fecundability of 8-10%.
Tubal reconstructive surgery has been questioned as a first-line therapy for tubal disease when success with in vitro fertilization (IVF) can be achieved. Tubal reconstructive surgery has a place for well-selected patients. The factors that must be evaluated include patient's age, number of pregnancies desired after treatment, financial concerns, and overall fallopian tube health. Tubal reconstructive surgery has the potential of curing or correcting the tubal factor underlying the inability to conceive. Assisted reproduction simply bypasses the fallopian tubes during a cycle of IVF.
In general, ART offers a shorter time to pregnancy in comparison to tubal reconstructive surgery. Patients with advancing age and/or extensive tubal disease should proceed to in vitro fertilization. Younger patients with tubal disease amenable to surgical repair can benefit greatly from tubal reconstruction. It offers couples ample opportunity to achieve conception naturally. This affords couples the ability to have more than one pregnancy from a single operative procedure.
Tubal reconstructive surgery requires time to determine its success. Typically, successful patients will conceive within 1 year after the procedure. However, tubal surgery increases a patient’s risk of ectopic pregnancy. The rates of ectopic pregnancy have been reported between 4% and 10% in patients who had tubal reconstruction. In comparison, patients who undergo ART have a 2-11% risk of ectopic pregnancy. The Practice Committee for the American Society of Reproductive Medicine considers the risk significant and comparable.
Health insurance coverage and the financial resources of the couple may play an important role in the decision tree between ART and microsurgical fallopian tube repair. In 2003, both procedures generally cost approximately $10,000. Some insurance plans cover tubal reconstruction but will not cover IVF. Patients who cannot afford to pay for IVF may benefit from tubal reconstruction.
The risk of multiple gestations may influence management decisions. An epidemic of multiple gestations has been experienced over the past 25-30 years. Multiple gestations, especially triplets or more, place the mother and babies at greater risk of health problems and increase the cost of health care enormously. The natural rate of multiple gestations is on the order of 2% of pregnancies. This rate is not affected after correction of tubal infertility with tubal reconstructive surgery. However, assisted reproduction has been blamed for a large proportion of the multiple gestations observed today.
The 2003 Centers for Disease Control and Prevention Assisted Reproductive Technology report stated that, of the resulting live births, only 65.8% were singleton, 31% were twins, and 3.2% were triplet or higher-order multiples. Maternal and prenatal morbidity and mortality are higher in multiple gestation pregnancies. In addition, medical literature supports that pregnancies resulting from IVF have higher risk of perinatal morbidity.
In 2009, The American Society of Reproductive Medicine released newly revised guidelines regarding the number of embryos to transfer during in vitro fertilization (IVF) procedures. These guidelines clearly state that a high-order multiple pregnancy is considered an undesirable outcome of assisted reproductive technology (ART). The goal of these new embryo transfer guidelines is to provide a framework by which a reproductive endocrinologist can provide their patients with the best and safest care possible, encouraging a reduction in the number of high-order multiple births. The goal of ART is a singleton healthy pregnancy.
The Practice Committee of the American Society for Reproductive medicine released a statement on tubal reconstructive surgery in 2006. They concluded that maternal age, number of children desired, coexisting infertility factors, risks for ectopic and multiple pregnancy, and treatment cost as the key variables to consider between physician and couples when deciding between ART and tubal reconstructive surgery. In addition, they advise older women to proceed with IVF. In conclusion, the treatment decision should be individualized between the provider and the couple to best suit the couples' needs and optimize their chance of pregnancy and live birth.
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.
ART 2006: Assisted Reproductive Technology (ART) Report: Home. Available at http://www.cdc.gov/ART/ART2006/index.htm.
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