Fallopian Tube Reconstruction 

Updated: Nov 30, 2016
Author: Krystene B DiPaola, MD; Chief Editor: Richard Scott Lucidi, MD, FACOG 

Overview

Background

The fallopian tubes are symmetrical paired tubular organs that connect the peritoneal cavity to the endometrium in the uterine cavity. The fallopian tubes are more than simple conduits or "open pipes." The fallopian tubes capture the ovum after ovulation and serve as a conduit for its travel toward the uterus. Fertilization of the egg by the sperm occurs in the fallopian tube. Following fertilization, the zygote develops into an embryo and continues to travel through the fallopian tube into the uterine cavity, where it implants in the endometrium. The fallopian tubes provide the environment and conditions for conception and for the early development of the conceptus.

Furthermore, the ovum, zygote, and embryo have no intrinsic motility. The fallopian tube is both the conduit and the transporter of the ovum and the early conceptus. Tubal function also aids transport of sperm to the site of fertilization. The fallopian tubes are thus essential and necessary in normal, natural, unassisted reproduction in women.

The multiple and complex functions of the fallopian tubes can be affected by disease, resulting in infertility and, in extreme cases, sterility. Fallopian tube reconstruction has been the traditional method of restoring reproductive function to women with tubal infertility. Today, in vitro fertilization (IVF) and embryo transfer (ET) bypass the fallopian tubes in the reproductive process and are additional options in the treatment of these patients.

For more information, see Medscape's Pregnancy Resource Center.

History of the Procedure

Fallopian tube reconstruction for tubal disease was first documented in 1896. The procedure reimplanted the fallopian tubes into the uterus. The results were dismal.

Early tubal reconstructive surgeries were performed using what is today described as macrosurgical technique. The purpose of these surgeries was to provide an open conduit from the peritoneal cavity into the uterus. Knowledge of the other multiple functions of the fallopian tubes was scanty, thus little attention was given to protecting or restoring these functions, and the results were relatively poor.

Over time, a better understanding of fallopian tube physiology, advances in perioperative care, and improvements in surgical techniques have resulted in better outcomes. Advances in macrosurgical techniques in fallopian tube reconstruction were made throughout the early 20th century. Microsurgical approaches to tubal reconstruction began to be developed during the 1960s-1970s.

Microsurgical technique is a delicate surgical style that emphasizes the use of magnification, fine atraumatic instrumentation, microsuturing, continuous irrigation to prevent desiccation, and pinpoint hemostasis. The goals are to remove pathology, restore normal anatomy, and regain function with minimal damage to adjacent normal tissue. This is achieved by minimizing inflammation and preventing adhesion formation. The microsurgical approach is more likely to preserve the function of the uterotubal junction, maintain the blood supply, and preserve the integrity of the tubal musculature.

The use of microsurgical technique in tubal reconstructive procedures has been shown to dramatically improve clinical results and has become the standard in these procedures. It requires specialized training and practice prior to its clinical application in order to achieve optimal results.

Problem

The fallopian tubes have critical functions in the reproductive process, including providing a conduit from the peritoneal cavity to the uterine cavity. The uterine cavity is the site of implantation and pregnancy. Fertilization and early embryonic growth occur in the fallopian tubes. The secretory cells of the tubal mucosa must provide the nutrients and growth factors necessary at the time of conception and for successful early embryonic development.

The fallopian tubes are involved in the transport of the ovum and sperm to the site of fertilization and in the movement of the early embryo to the uterine cavity. The ciliary motion of cells lining the tubal mucosa and the coordinated muscular activity of the uterus/fallopian tubes result in the successful transport of the gametes and early embryo through the fallopian tubes. These functions are partly regulated by the cyclical hormones of the reproductive cycle. Tubal secretory and muscular functions require normal circulation and neuronal input. Tubal blockage, damage to the tubal mucosa and muscularis, and disruption of circulatory and neuronal inputs to the fallopian tube can result in infertility and increase the risk of tubal ectopic pregnancy.

The image below depicts the sites and frequencies of ectopic pregnancy.

Sites and frequencies of ectopic pregnancy. By Don Sites and frequencies of ectopic pregnancy. By Donna M. Peretin, RN. (A) Ampullary, 80%; (B) Isthmic, 12%; (C) Fimbrial, 5%; (D) Cornual/Interstitial, 2%; (E) Abdominal, 1.4%; (F) Ovarian, 0.2%; (G) Cervical, 0.2%.

Surgical techniques to reconstruct the fallopian tubes must achieve patency while minimally disrupting the tubal and pelvic anatomy in order to preserve subsequent function. Microsurgical technique in tubal reconstructive surgery best accomplishes these goals.

Epidemiology

Frequency

Infertility is defined as the inability to achieve pregnancy after 1 year of unprotected intercourse. An estimated 15% of couples of reproductive age meet this criterion and are considered infertile. A female factor is responsible in up to 50-60% of all cases. Tubal dysfunction is the cause in approximately 40% of infertile women.

Etiology

The major contributor to fallopian tube infertility is pelvic inflammatory disease (PID). The most common causes of PID are sexually transmitted diseases such as those caused by Chlamydia trachomatis and Neisseria gonorrhea. Symptoms of PID can include adnexal tenderness, strawberry cervix, and cervical motion tenderness; however, women can contract sexually transmitted diseases that can lead to tubal blockage without their knowledge because of lack of symptoms.

The long-term consequences of PID include tubal occlusion, adnexal and pelvic adhesions, recurrent PID, chronic pelvic/abdominal pain, tubo-ovarian abscess, dyspareunia, and menstrual pain. The risk of subsequent infertility is approximately 12% after 1 episode of PID, 35% after 2 episodes, and 75% after 3 or more episodes.

PID is not the only cause of tubal dysfunction amenable to reconstructive surgery. Other offenders include endometriosis, tubal sterilization, salpingitis isthmica nodosa, tuberculosis, abdominal or pelvic adhesions (resulting from surgery or other inflammatory processes), ectopic pregnancy, and, less commonly, congenital tubal anomalies, polyps, and neoplasms. Most often, the dysfunction of the fallopian tubes is a consequence of a disease process that involves inflammation, infection, adhesions, fibrosis, scarring, and obstruction. The resulting tubal dysfunction frequently has no overt clinical symptoms and remains undiagnosed until the woman discovers she is unable to conceive and seeks reproductive medical advice.

Pathophysiology

The many processes that result in tubal dysfunction involve different pathophysiologies. PID commonly causes tubal blockage, either proximally at the site of insertion into the uterus or distally at the fimbrial end. Less commonly, a midtubal segment may become occluded. Blockage at the fimbrial end results in a hydrosalpinx because the continued secretions of the tubal mucosa have no drainage into the peritoneal cavity (see the image below). As the hydrosalpinx enlarges, the tubal muscularis thins. The secretory and ciliary properties of the endosalpinx are eventually disrupted. The probability of pregnancy after repair of hydrosalpinges with a diameter of more than 3 cm is very poor. Evacuation of the fluid within a large hydrosalpinx does not restore function to the tube. Other possible sequelae of PID include pyosalpinx, tubal or tubo-ovarian abscess, and peritubal adhesions.

Hydrosalpinx. Image courtesy of Jairo E. Garcia, M Hydrosalpinx. Image courtesy of Jairo E. Garcia, MD.

The pathophysiology after tubal sterilization depends on the method used. Electrocautery of a segment or segments of the fallopian tube occludes the lumen and causes more damage to the surrounding tissues than placement of a ring or a clip over the mid portion of the tube or surgical interruption of the tube (eg, Pomeroy technique, Irving technique). Increasing the amount of damage to the fallopian tube may increase the success of the sterilization procedure, but it decreases the chance of achieving subsequent successful reconstruction. The length of a tube after a reconstructive procedure correlates with success in terms of achieving pregnancy. Patients with tubes longer than 5 cm after reconstruction have better outcomes than patients whose tubes measure 3 cm or less.

Any inflammatory condition in the pelvis, such as endometriosis or the sequelae of pelvic or abdominal surgery, may cause adhesions, tubal blockage, or injury to the tubal mucosa and/or muscularis, resulting in tubal damage and dysfunction.

Presentation

Women with tubal infertility usually present to their obstetrician/gynecologist for evaluation and treatment after trying to achieve pregnancy with unprotected intercourse over an extended period. Eighty-five percent of couples of reproductive age achieve conception within 1 year of having unprotected sex (unless an obvious problem such as a previous tubal sterilization exists); therefore, couples should allow plenty of time to conceive prior to submitting themselves to costly, somewhat risky, and possibly unnecessary fertility evaluations and treatments.

A basic fertility evaluation must assess (1) the ability of the woman to ovulate, (2) whether the woman has a healthy reproductive tract, and (3) the availability of viable sperm. These components are the essentials necessary to have a possibility of pregnancy; therefore, if a tubal factor is identified early during the evaluation of a couple, a woman should not undergo tubal reconstruction unless it has been established that she can ovulate, that her uterus is otherwise normal, and that her male partner has adequate sperm. Proceeding otherwise risks subjecting a patient to tubal reconstructive surgery without a realistic possibility of success, defined as subsequent pregnancy and delivery of a live infant.

The initial history, physical examination, and laboratory evaluation should focus on uncovering risk factors for infertility.

Age is very important in the evaluation of female fertility. Fertility in women decreases with increasing age, reflecting decreased ovarian function. The decrease in female fertility starts at approximately age 35 years. Fertility decreases with advancing age and there is increased risk of miscarriage, congenital malformations, and complications during pregnancy. In one study, only 14.3% of women older than 40 years who had a tubal sterilization reversal procedure delivered live children.

The menstrual history is essential to evaluate a possible ovulatory factor. The obstetrical history establishes whether the woman has ever been able to conceive and whether she has had any pregnancy complications, such as an ectopic pregnancy or postpartum endometritis, that may have compromised her reproductive tract.

The gynecological history reveals possible problems with the reproductive organs that may affect fertility or the possibility of pregnancy. For example, a history of Asherman syndrome with extensive destruction of the endometrial surface may preclude the possibility of embryonic implantation. The presence of fibroids or other malformations of the reproductive tract (eg, unicornuate/bicornuate uterus, uterine septum, malformations secondary to intrauterine diethylstilbestrol exposure) may affect the uterine cavity in a way that prevents a fetus from developing to viability at birth.

The medical history uncovers possible causes of ovulatory dysfunction secondary to hypothalamic/pituitary disorders or intrinsic ovarian malfunction. A history of PID, endometritis, and other causes of pelvic inflammation, such as endometriosis or appendicitis, should be elicited. Correctible medical contraindications to pregnancy (and surgery), such as uncontrolled diabetes, hypertension, or cardiac or renal disease, should be excluded or corrected.

The surgical history should focus on the pelvis because any surgery on the reproductive organs, bowel, or bladder can cause pelvic inflammation, adhesions, and tubal damage.

The physical examination should confirm normal pubertal development with the presence of normal secondary sexual characteristics. Manifestations of hormonal disorders that can affect ovulation, such as hirsutism or galactorrhea, should be sought. Examination of the abdomen may reveal scars from previous surgeries that may have affected the reproductive organs. A pelvic examination may reveal gross abnormalities of the reproductive tract. Pregnancy after a tubal sterilization reversal procedure is mostly likely to occur within the first year. Most pregnancies occur within 6 months after surgery.

Indications

Tubal reconstructive surgery is indicated in women younger than 39 years who are trying to achieve pregnancy. These women must have proven tubal infertility amenable to tubal reconstruction with an otherwise normal uterine cavity, the capacity to ovulate, and a male partner who produces enough sperm for conception through intercourse or artificial insemination.

Relevant Anatomy

The fallopian tubes are seromuscular paired tubular organs that run medially from the ovaries to the cornua of the uterus. The fallopian tubes are situated toward the upper margins of the broad ligament. The tubes connect the endometrial cavity in the uterus with the peritoneal cavity toward the ovaries on each side. The tubes average 10 cm in length (range, 7-14 cm).

The tubes can be divided into 4 parts (proximally at the endometrial cavity to their distal portion near the ovary):

  • The intramural or interstitial portion (from the endometrial cavity, through the uterine wall, and to the uterine cornua)

  • The isthmus (the proximal third of the fallopian tubes outside the uterine wall)

  • The ampulla (the distal two thirds of the fallopian tubes outside the uterine wall)

  • The infundibulum, the funnel-shaped opening to the peritoneal cavity

The fimbriae are fingerlike extensions from the margins of the infundibulum toward the ovaries on each side. The intraluminal diameter varies and increases from 0.1 mm in the intramural portion to 1 cm in the ampullary portion of the tubes. The fallopian tubes receive their blood supply from the tubal branches of the uterine arteries and from small branches of the ovarian arteries. The fallopian tubes receive sensory, autonomic, and vasomotor nerve fibers from the ovarian and inferior hypogastric plexi.

Histologically, the uterine tubes are composed of 3 layers—the mucosa, muscularis, and serosa. The 3 different cell types within the mucosa of the uterine tubes include the columnar ciliated epithelial cells (25%), secretory cells (60%), and narrow peg cells (< 10%).

For more information about the relevant anatomy, see Uterine Tube (Fallopian Tube) Anatomy.

Contraindications

Absolute contraindications to fallopian tube reconstruction

  • Aged 40 years or older

  • Decreased ovarian reserve or ovarian failure

  • Tubal infertility not amenable to tubal reconstruction

  • Extensive tubal damage

  • Hydrosalpinx with a diameter of more than 3 cm

  • Inadequate proximal or distal tubal segment for anastomosis

  • Projected tubal length of less than 3 cm after the reconstruction procedure

  • Extensive pelvic/peritubal adhesions

  • Abnormal uterine cavity

  • Any contraindication to pregnancy or surgery

  • Severe male factor infertility or male sterility

Relative contraindications to fallopian tube reconstruction

  • Age 38-39 years

  • Mild male factor infertility

 

Workup

Laboratory Studies

Male factors

See the list below:

  • Men account for 30-40% of infertility in couples.

  • Problems typically include low semen volume, decreased sperm concentration and/or motility, and abnormal sperm morphology.

  • Semen analysis is necessary.

Female factors

In some women, ovulatory problems are a cause of infertility. Ovulatory function tests can help determine ovulatory function. Adequate ovulatory function can be confirmed with the following:

  • Normal regular menstrual cycles

  • Day 3 follicle-stimulating hormone level within the reference range

  • Anti-mullerian hormone level

  • Midluteal-phase serum progesterone measurement confirmatory of ovulation

Papanicolaou test (Pap smear) results must be normal.

Cervical culture results (eg, C trachomatis, N gonorrhea) must be negative.

Imaging Studies

Hysterosalpingography may be used to determine the presence of proximal fallopian tubes.

When necessary, saline sonography further defines abnormalities of the uterine cavity.

Other Tests

Basal body temperature charting can help identify female ovulatory factors.

Diagnostic Procedures

Laparoscopy

  • This procedure helps to (1) evaluate the amount of pelvic adhesions and tubal damage before tubal reconstructive surgery; (2) measure the diameter of a hydrosalpinx to determine the feasibility of tubal reconstruction; and (3) identity the distal portion of the fallopian tube(s) prior to tubal anastomosis following sterilization procedures.

  • This procedure also facilitates estimation of the length of the tube resulting from the tubal reconstructive surgery.

  • Tubal and pelvic reconstruction can be performed with the patient under the same anesthesia following diagnostic laparoscopy, via operative laparoscopy, or via laparotomy when necessary. However, patients may request a different surgical procedure on a different day if a laparotomy is required.

Timed endometrial biopsy can help identify female ovulatory factors.

 

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 (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.

Salpingitis isthmica nodosa. Image courtesy of Jai Salpingitis isthmica nodosa. Image courtesy of Jairo E. Garcia, MD.

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 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).

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.

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.

A prospective study by Seyam et al indicated that in patients with bilateral obstruction of the proximal fallopian tubes, fertility outcomes are not significantly different between treatment with either ultrasonographically guided tubal recanalization (UGTR) or office-based microhysteroscopic ostial dilatation (MHOD). In the study, in which a special fallopian tube catheter was used in both procedures, the cumulative pregnancy rate in women who underwent UGTR was 25.9% at 12-month follow-up, compared with 26.3% in women who underwent MHOD.[1]

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. 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.[2] 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%.[3]

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.[4]

The Practice Committee of the American Society for Reproductive medicine released a statement on tubal reconstructive surgery in 2006.[5] 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.