Techniques for pelvic surgery to improve fertility

Damage to the fallopian tubes is a common cause of women having difficulty conceiving. Until assisted conception techniques such as in-vitro fertilisation (IVF) were developed the only medical treatment available to improve the chances of getting pregnant in this situation was by operating on the tubes. Such surgery has become much less common since the advent of IVF and most of the data about the results of this intervention are more than 20 years old. Women today still undergo tubal surgery if the doctor considers the prognosis is good or if IVF is not available to patients. If surgery is undertaken, various techniques have been advocated to try to enhance surgery and the pregnancy rate. These include the use of magnification including microsurgical techniques, laparoscopic surgery, laser or electrodiathermy to minimise blood loss and scarring and positioning a prosthesis around the tube. The purpose of this review is to determine the evidence to justify the use of tubal surgery, and the techniques used.

Very few good quality studies were found that could be included in this review. There were no trials which compared the results of tubal surgery to no treatment, IVF or alternative treatment. The small studies found did not give evidence of benefit or disadvantage of any of the techniques advocated to enhance results. More studies should be undertaken to investigate the role of tubal surgery and techniques to enhance the results of surgery.

Authors' conclusions: 

From these limited data there is no evidence of benefit or disadvantage of tubal surgery versus no treatment or alternative treatments. Likewise there is no evidence of advantage or disadvantage of using microsurgery over standard techniques; laparoscopic approach over laparotomy; the use of CO2 laser; or electrocoagulation over thermocoagulation.
Randomised controlled trials should be undertaken to determine the role of tubal surgery versus no treatment or alternative treatments.
Randomised controlled trials should be undertaken to determine the role at tubal surgery of magnification, laparoscopic approach, the use of lasers or electrocoagulation.

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Background: 

Since the introduction of in-vitro fertilisation (IVF) tubal surgery has been less frequently undertaken as a technique to improve fertility in women with damaged fallopian tubes. There are various surgical techniques that can be used to repair blocked or damaged fallopian tubes.

Objectives: 

To evaluate the role of tubal surgery in the management of tubal infertility and to evaluate surgical techniques for the treatment of tubal infertility.

Search strategy: 

This review has drawn on the search strategy developed for the Menstrual Disorders and Subfertility Group. We identified relevant trials from the Cochrane Menstrual Disorders and Subfertility Group Specialised Register (searched up to July 2005) and Cochrane Central Register of Controlled Trials (CENTRAL). The following databases were searched using the OVID platform:
1. MEDLINE (1966 to July 2005);
2. EMBASE (1980 to July 2005).

Selection criteria: 

All randomised controlled trials investigating the following topics on infertility surgery technique as follows were included.
1) The role of infertility surgery versus no treatment.
2) The role of infertility surgery versus alternative treatments.
3) The role of magnification.
4) The role of the CO2 laser at infertility surgery.
5) The role of operative laparoscopy to perform infertility surgery.
6) Any other intervention regarding surgical technique investigated by RCT.

Data collection and analysis: 

Data were extracted independently by the first two authors. Differences of opinion were recognised and resolved by consensus.

Two by two tables were generated for each trial for the dichotomous outcome of pregnancy and the effects on pregnancy rate of each study is expressed as an odds ratio with 95% confidence intervals.

Main results: 

Seven randomised control trials were identified. No RCTs comparing infertility surgery versus no treatment or alternative treatments were found. There was no RCT found investigating the use of magnification for tubal surgery.
There was no evidence for or against the use of a CO2 laser compared with standard techniques for adhesiolysis (OR for pregnancy 1.07, 95% CI 0.40 to 2.87) or salpingostomy (OR for pregnancy 1.38, 95% CI 0.47 to 4.05) from two RCTs.
One RCT randomised women for salpingostomatolysis by laparotomy and laparoscopy using the classic approach or the one suture technique. There was no evidence of benefit or disadvantage when laparoscopy was compared to laparotomy. The OR for bilateral tubal patency was 1.32 (95% CI 0.55 to 3.22) and unilateral tubal patency OR was 0.82 (95% CI 0.29 to 2.29). The pregnancy rate was not reported.
There was no evidence of benefit or disadvantage from two RCTs assessing the use of a prosthesis at salpingostomy compared with non-use (combined odds of pregnancy (term) in group using the prosthesis as compared to the control (OR for pregnancy at term 1.17, 95% CI 0.47 to 2.93).
There was no evidence of benefit or disadvantage difference in one RCT comparing Cuff versus Bruhat technique for salpingostomy One RCT compared two methods of salpingostomy (OR for pregnancy rate ( intrauterine) 1.02, 95% CI 0.22 to 4.61).
One RCT showed no evidence of benefit or disadvantage for the use of thermocoagulation or electrocoagulation at adhesiolysis, odds for pregnancy rate between the two groups OR 0.87 (95% CI 0.51 to 1.46).

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