Salpingostomy and Salpingectomy

Updated: Nov 15, 2022
  • Author: Molina B Dayal, MD, MPH; Chief Editor: Michel E Rivlin, MD  more...
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Tubal disease accounts for approximately one-third of female-associated infertility, with the majority of cases being due to a history of salpingitis. [1]  While in vitro fertilization (IVF) tends to be the common treatment option for those women with tubal factor infertility, reparative surgical intervention remains an option.

Assessment of tubes

Reconstructive surgery should not be performed until a complete infertility evaluation of the couple has been made. A prior history of pelvic inflammatory disease (PID), endometriosis, or ectopic pregnancy increases the likelihood of having tubal factor infertility. 

The gold standard for evaluating the patency of tubes is diagnostic laparoscopy. However, given the invasive nature of a laparoscopy, a hysterosalpingogram (HSG) often serves as the nonsurgical test commonly used for identifying tubal pathology. [2]

Compared to laparoscopy, the HSG has moderate sensitivity (ability to detect patency when the tubes are open) but relatively high specificity. The sensitivity of the HSG for the determination of tubal patency ranges from 76-96%, with its specificity ranging from 67-100%. [2]  In other words, when an HSG suggests that both tubes are proximally occluded, there is a small likelihood that the tubes actually are open. [3]  However, if the HSG demonstrates patency, there is little chance that the tubes are blocked. The diagnosis of distal tubal occlusion is generally accurate, but proximal tubal occlusion may be the result of uterine contractions or catheter placement as opposed to true pathologic obstruction.

A review estimated the sensitivity and specificity of HSG in detecting any tubal pathology to be 53% and 87%, respectively. For bilateral tubal disease, the sensitivity and specificity were noted to be 46% and 95%, respectively. [4]

Hysterosalpingo-contrast-sonography is another method of assessing tubal status using saline-air bubble instillation with transvaginal sonography. This method is reliable if tubes are patent; however, this method is limited when identifying abnormal tubes, with sensitivity being reported as 89% and specificity as 46%. [5]


Patient selection for surgical treatment of infertility must be individualized and carefully considered. Several variables need to be considered and discussed with patients prior to recommending tubal surgery versus IVF. Patient age, their ovarian reserve (an indirect quantification of number of remaining eggs), presence of other infertility factors (including sperm factors), extent of tubal damage, number of desired children, experience of the surgeon, and success rates of their IVF program are some factors that need to be considered prior to making a decision.

The advantages of IVF include a higher per-cycle success rate, limited invasiveness, likely having multiple children from one egg retrieval (using frozen embryos), and a lower likelihood of having an ectopic pregnancy. The advantages of tubal surgery include being typically less expensive with couples attempting pregnancy every month without intervention and possibly conceiving more than once over the course of time. 

In general, IVF is most often used to treat infertility caused by tubal disease. IVF is the only treatment available for severely damaged, inoperable fallopian tubes and for situations in which tubal disease is concurrent with another fertility factor. However, reconstructive tubal surgery, such as salpingostomy and salpingectomy, should be considered in select individuals.

Salpingectomy is the surgical removal of a fallopian tube. Salpingostomy (also called neosalpingostomy) is the creation of an opening into the fallopian tube, but the tube itself is not removed in this procedure. Another term, fimbrioplasty, is often used instead of salpingostomy because salpingostomy does not specifically address the fimbriae. Reconstruction that preserves the delicate fimbriae is important for fertility outcomes. The purpose of fimbrioplasty is to open the obstructed fallopian tube and salvage enough function of the fimbriae to allow successful entrapment and transportation of the oocyte.

Distal tubal obstruction is found to be the culprit of tubal disease in the majority of cases. Various techniques of treating or bypassing tubal disease include either open or laparoscopic surgery, namely salpingectomy or salpingostomy, or assisted reproductive techniques. Fimbrioplasty is performed for patients who have patent fallopian tubes, whereas salpingostomy is performed with occluded tubes. Many times, patients have pelvic adhesions and phimosis of the fimbriated end of the fallopian tube.

Surgical treatment should be considered for all women with hydrosalpinges prior to IVF treatment. In cases of sonographically apparent hydrosalpinges, a salpingectomy, rather than a salpingostomy, is the preferred route of treatment. Some couples, however, may prefer a salpingostomy, which offers some potential of a spontaneous pregnancy; however, leaving a hydrosalpinx in place can decrease the likelihood of success with IVF. [6]  

The decision to remove or repair the fallopian tube(s) is often made intraoperatively. Distal tubal disease, such as distal hydrosalpinges, peritubal adhesions, and fimbrial phimosis (narrowing of the tubal opening) can be amenable to neosalpingostomy or fimbrioplasty. 

Patients with a good prognosis have limited filmy adhesions, mildly dilated tubes (< 3 cm) with thin walls, and preservation of the mucosal folds [7]  and can have a neosalpingostomy or fimbrioplasty performed. Patients with a poor prognosis, ie, those with thick, dense peritubal adhesions, significantly dilated tubes (>3 cm) with thick walls, and limited luminal mucosa, tend to require a salpingectomy. 


Reconstructive tubal surgery is not recommended in a woman of advanced maternal age. Given the low monthly chance of pregnancy following surgery in the setting of an already reduced fecundability in a woman of advanced maternal age, IVF is the better treatment option. In contrast, reconstructive surgery for a young woman with minimal tubal disease is a reasonable option.

In general, patients who fail to conceive after primary tubal reconstructive surgery have severely limited success with repeat surgical procedures. In these cases, a second surgical procedure is not recommended and IVF is strongly indicated.

In a retrospective study of 434 infertile women who underwent laparoscopic salpingostomy, Audebert et al found evidence that the procedure should not be utilized in certain patients, based on factors such as tubal or adhesion stage and chlamydial serology. The investigators, who measured outcomes in terms of intrauterine pregnancy, delivery, and ectopic pregnancy rates (as achieved without IVF), reported poor-prognosis patterns in association with the following [8] :

  • Stage 3 or 4 endometriosis 

  • Previous ectopic pregnancy

  • Severe adhesive disease

  • Prior salpingostomy

  • Positive chlamydial serology test


Surgical Considerations


Contemporary laparoscopy equipment consists of an imaging system comprised of a endoscope (laparoscope), video camera system and display moniros, a light source, an abdominal insufflation system utilizing carbon dioxide gas, and specialized surgical instruments. Laparoscopes range in size from 1.8 mm to 12 mm in diameter with lenses available in varying viewing angles. Most gynecologic surgeons prefer the 0-degree lens, as it provides a panoramic view of the pelvis. Angled lenses (30-degree and 45-degree) help in evaluating the anterior abdominal wall or operating around masses. 

A Veress needle, direct trocar insertion, or open entry may used to gain initial access and create a pneumoperitoneum. The umbilicus is most commonly utilized, although the Palmer's Point in the left upper quadrant is a common alternative whent the umbilicus is not safe or feasible. Accessory ports allow for the insertion of operative laparoscopic instruments. Port sleeves range from 2 to 15 mm in diameter and are available as reusable, disposable, and reposable systems. A uterine manipulator (placed transvaginally) allows for movement of the uterus to optimize visualization of and access to pelvic structures.

Grasping forceps are used to manipulate tissue and come in a variety of types with different specializations. There are broad, flat forceps and finer forceps used to handle more delicate tissue. Toothed forceps apply traction on tissue such as ovarian cysts or leiomyomas that need to be removed. Forceps with pointed ends are used for tissue dissection and surgical plane development. A disposable Babcock-type atraumatic grasper with a ratcheted scissors handle is useful in handling adnexal structures. Needle drivers are also available for situations when suturing becomes necessary.

Hemostasis has traditionally been achieved with monopolar and bipolar instrumentations. Special instruments have been designed to achieve hemostasis while minimizing thermal damage. These include advanced bipolar electrosurgical  instruments and ultrasonic instruments.

Suction and irrigation are essential for all types of laparoscopic surgery. Irrigation is important to remove debris, visualize a bleeding source, and to dissect and create tissue planes (hydrodissection). Many types of suction instruments have been designed that are adequate for removal of irrigation fluid, or intraperitoneal air and smoke. A large-bore device is best for removal of blood clots when brisk bleeding is encountered (ruptured ectopic) and also for passing laser fiber.

Patient preparation


The patient is placed in a supine or dorsal lithotomy position with the patient's legs placed in Allen stirrups. The knees should be deflexed to avoid stretching of the femoral nerve. [9]   The buttocks should be a few centimeters beyond the edge of the table to allow uterine manipulation. A   bladder catheter is inserted to prevent bladder distension, thereby decreasing the risk of bladder perforation during trocar insertion and also facilitating visualization of pelvic structures.



Approach considerations

Tubal surgery uses the basic principles of microsurgery. Microsurgery entails surgery under magnification, thus minimizing peritoneal trauma and/or tissue damage; the goal of this technique is to limit or even prevent the formation of postoperative adhesions.

Tissue damage can be minimized in the following manner [10] :

  • Delicately handling tissues

  • Limiting the use of electrical/laser energy

  • Irrigating the peritoneal cavity with heparinized lactated Ringer's solution, thus providing constant moisture to the serosa and preventing tissue desiccation

  • Limiting foreign body exposure

  • Ensuring scrupulous hemostasis

  • Limiting lateral tissue damage

  • Completely removing injured tissue

  • Carefully dissecting proper tissue plane cleavage

  • Exactly reapproximating tissue planes

  • Using magnification with fine microsurgical instruments and suture material to ensure the above principles are adhered to

  • Thoroughly irrigating the peritoneal cavity with complete removal of foreign body, blood, and/or debris


Neosalpingostomy is the creation of a new opening in a tube with an occluded distal hydrosalpinx. The new stoma (opening) can be located at the terminal end of the tube or at the ampullary or isthmic portions of the tube. Ampullary and isthmic neosalpingostomies, however, have little clinical applicability because the likelihood of pregnancy with limited tubal length is extremely low.

It is important that all pelvic and periadnexal adhesions are lysed prior to undertaking an attempt of neosalpingostomy. This method ensures that the new opening will be placed at an appropriate location, at the most distal portion of the tube. Once the salpingo-ovariolysis is completed and the tube is completely free, the tube is distended with transcervical chromopertubation. An avascular area is identified at the distal-most aspect of the fallopian tube and a cruciate area is cauterized and then incised using microelectrode/microsurgical scissors. The central avascular point is then entered with the incision being extended in a cruciate fashion.

In this manner, the new opening forms a new fimbria-ovary relationship. Bleeding is controlled with careful desiccation using a microelectrode. Once a reasonable sized stoma is attained, the flaps created in the process are secured by desiccating their serosal surface, which allows them to fold back upon themselves.  The leaves may also be secured with suture.  This process is referred to as fimbrioplasty.


Fimbrioplasty is reconstruction of the tubal fimbriae or infundibulum where fimbrial agglutination or partial distal tubal occlusion exists. The fimbrioplasty procedure to open the tube more widely is essentially the same as a neosalpingostomy. The technique of fimbrioplasty is the same regardless of whether the procedure is performed via an open incision or a laparoscopic approach.

A small opening is usually present at the distal end of the tube, which can be easily visualized with transcervical chromopertubation. If the opening is covered by fibrous tissue, this tissue must be excised to gain access to the fimbriae. Agglutination can be corrected by inserting either mosquito forceps or alligator forceps, with its jaws closed followed by opening its jaws and withdrawing the forceps multiple times (see the image below). The direction in which the jaws are opened should be varied in order to optimize the de-agglutination. Bleeding is usually minimized with a gentle technique.

In some instances, the ampullary portion of the tube distends with minimal efflux of dye solution. In this situation, it is necessary to longitudinally incise the tube along its antimesosalpinx border to the fimbriated end. The incision is made electrosurgically with a microelectrode or mechanically with microsurgical scissors. The edges of the 2 flaps can be folded back with electrosurgery by desiccating the serosal margins of the flaps, causing them to fold backward, away from the fimbriae.


Although the surgeon should be as conservative as possible, the patient may be better served with a single well-functioning fallopian tube than with 2 defective tubes, which elicits an increased risk for ectopic pregnancy or recurrence of pelvic adhesions. One cause of a defective tube is presence of a hydrosalphinx, a swollen, filled tube caused by fluid buildup. Patients with untreated hydrosalphinges have proven lower fertility rates than those without a hydrosalphinx. Patients with hydrosalpinges who undergo IVF experience half the pregnancy rate of those who do not have a hydrosalpinx. [5]  If the fallopian tubes are beyond repair, or in the case of hydrosalphinges, bilateral salpingectomy is recommended in preparation for IVF.

One simple laparoscopic method includes cauterization of the tubo-ovarian ligament first with bipolar cautery, followed by sharp transection of the tube with scissors. This can be acconplished as a single step with modern advanced bipolar instruments. The mesosalpinx is also cauterized and transected in a similar manner, staying as close as possible to the length of the tube so as to not impact the vascular supply to the ovary. The proximal tube is then cauterized and transected, leaving approximately 1 cm of nondiseased interstitial tube, if possible. The specimen is then removed with an endoscopic bag. 

In instances where a bipolar cautery device may not be present, laparoscopic sutures and scissors may be used for the removal of the tube. After identifying the fallopian tube, it is seperated from the surrounding tissue taking special care to avoid bleeding and, similarly as above, damanaging vascular supply to the ovary. With laparospic suture, the tube is tied at the uterine end and subsequently cut out and removed from the abdomen.

Laparoscopic salpingectomy. Fallopian tubes are re Laparoscopic salpingectomy. Fallopian tubes are resected from the fimbrial end to the uterine cornu. Careful resection is performed at the posterior margin of the fallopian tubes, while conserving the mesosalpinx. Courtesy of Korean Society of Obstetrics and Gynecology [Kim M, Kim YH, Kim YB, Kim J, Kim JW, Park MH, et al. Bilateral salpingectomy to reduce the risk of ovarian/ fallopian/peritoneal cancer in women at average risk: a position statement of the Korean Society of Obstetrics and Gynecology (KSOG). Obstet Gynecol Sci. 2018 Sept;61(5):542-52. Online at]




In general, the main outcome measure of importance is birth of a child, or livebirth rate (LBR). Most outcomes after tubal surgery are reported as the likelihood of pregnancy over the course of a specified time, typically at yearly intervals. This is in contrast to LBR with IVF is reported per treatment cycle, not over an interval of time. For this reason, comparison of success rates between reparative tubal surgery and IVF is difficult. As a result, there are limited studies comparing these two interventions. 

The cause of tubal disease must be taken into consideration when determining the prognosis for successful surgery. Successful surgical outcomes depend on whether tubal disease is due to intrinsic (from ascending infection or salpingitis isthmica nodosa) or extrinsic (previous pelvic surgery, endometriosis) causes. The location, type, and degree of tubal injury impact the chance of surgical success. The presence of tubal rugae on HSG, the absence of or presence of small hydrosalpinges (< 15 mm in diameter), the absence of significant pelvic adhesions, and the presence of fimbriae during laparoscopy are all associated with good prognosis following tubal reconstructive surgery. [11]

In general, pregnancy rates after tubal surgery depend on the degree of tubal disease and are better in those women who have a good prognosis (young age, no other concurrent fertility factor, minimally diseased tubes). Clearly, those who require tubal removal will have a lower likelihood of spontaneous pregnancy than those who have reconstructive surgery performed on their tubes. 


The major determinants of outcome from neosalpingostomy are the degree of pre-existing tubal damage and the extent and type of periadnexal adhesions. In cases of mild tubal damage, the reported live birth rates are 40-60%. Live birth rates are reported to be < 20% in cases where severely damaged tubes exist. A meta-analysis of salpingostomy for the treatment of hydrosalpinx found the natural clinical pregnancy rate following salpingostomy to be 27%. [12]  Similarly, researchers in a study evaluating 402 cases of fimbrioplasty and neosalpingostomy in females with infertility found that 26.1% of women achieved a live intrauterine pregnancy with 2.6% rate of ectopic pregnancy. As previous studies have shown, this study also demonstrated that pregnancy rates were significantly associated with tubal disease stage with 63% pregnancy rate in stage 1, 15% in stage 3 and 00% in stage 4. [13]

A retrospective, cross-sectional analysis that included 334,639 tubal ectopic pregnancies reported that the proportion of salpingostomy decreased from 17.0% in 1998 to 7.0% in 2011, while the rate of salpingectomy increased from 69.3% in 1998 to 80.9% in 2011. [14]


Results of fimbrioplasty are difficult to distinguish from other tubal corrective surgeries because this procedure tends to be included as a method of salpingostomy. In one series of 40 patients who underwent microsurgical fimbrioplasty, 63% of patients had intrauterine pregnancies and 5% had ectopic pregnancies after 2 years of follow-up. [15]  Other series have reported an ectopic pregnancy rate ranging between 5% and 12.9% after 18 months of follow-up. [16, 17]  In most cases, approximately half of patients never conceived in the interval of time studied. No randomized controlled trials for fimbrioplasty versus other methods of tubal reconstructive surgery have been done.


In a study of 186 women who underwent IVF, 24 women underwent salpingectomy after one or two failed IVF cycles. Salpingectomy implied a significant increase in birth rate. Within the subgroup of patients with ultrasound-visible hydrosalpinges, the birth rate was even higher. Implantation rate was significantly higher in patients who had undergone salpingectomy (27.2% versus 20.2%); in the subgroup of patients with ultrasound-visible hydrosalpinges, the difference was even larger (30.3% versus 17.1%). [18, 19]

For patients with mild distal tubal disease, long-term live-birth rates after surgical treatment are in the range of 39-59% (approximately 5% per month probability of pregnancy) with an associated ectopic pregnancy rate of 4-10%. The outcome for patients with severe distal tubal disease is significantly worse, with an overall pregnancy rate of less than 15%, which equates to a monthly fecundability rate of 1-2%. [20]



Tubal disease is a relatively common cause of female-associated infertility. Whereas in vitro fertilization (IVF) tends to be the common treatment option for those women with tubal factor infertility, reparative surgical intevention remains an option. Maternal age and ovarian reserve, quality of sperm, extent of tubal disease, presence of other infertility factors, experience of the surgeon, IVF center success rates, and number of desired children are important factors while considering reconstructive tubal surgery. The HSG should be considered the standard first-line noninvasive test to assess tubal patency and status. Salpingectomy is reserved for surgically irreparably damaged or moderate to severe hydrosalpinges even if tubal patency is noted, whereas fimbrioplasty or neosalpingostomy is recommended for mild hydrosalpinges and for filmy adhesions in young women without any other concurrent infertility factors. There are no trials comparing pregnancy rates of tubal surgery versus IVF; however, most IVF pregnancies occur within one year of undertaking treatment compared to a longer time to conception after tubal surgery.