Surgery versus IVF or expectant management for women with tubal infertility

Review question

Cochrane review authors investigated the effectiveness of fallopian tube surgery compared with in vitro fertilisation (IVF) or expectant management in overcoming infertility caused by tubal disease.


Tubal surgery to overcome infertility caused by tubal disease is becoming popular, in part because of risks and costs related to IVF, which offers another option for overcoming tubal infertility. Benefits obtained from tubal surgery would potentially be sustained over multiple cycles and many years, even resulting in multiple livebirths. However, tubal surgery is expensive, as it requires additional specialist training and experience among gynaecologists who perform the procedure, and it can involve adverse effects (including ectopic pregnancies) and operative risks. The effectiveness of tubal surgery in comparison with no treatment (expectant management) or IVF in women with tubal infertility is unknown.

Study characteristics

This review identified no suitable trials. Our literature searches are current to October 2016.

Key results

No randomised evidence is currently available. Research is needed to obtain information about adverse outcomes and costs.

Authors' conclusions: 

The effectiveness of tubal surgery relative to expectant management and IVF in terms of livebirth rates for women with tubal infertility remains unknown. Large trials with adequate power are warranted to establish the effectiveness of surgery in these women. Future trials should not only report livebirth rates per patient but should compare adverse effects and costs of treatment over a longer time. Factors that have a major effect on these outcomes, such as fertility treatment, female partner's age, duration of infertility and previous pregnancy history, should be considered. Researchers should report livebirth rates in relation to severity of tubal damage and different techniques used for tubal repair, including microsurgery and laparoscopic methods.

Read the full abstract...

Surgery remains an acceptable treatment modality for tubal infertility despite the rise in usage of in vitro fertilisation (IVF). Estimated livebirth rates after surgery range from 9% for women with severe tubal disease to 69% for those with mild disease; however, the effectiveness of surgery has not been rigorously evaluated in comparison with other treatments such as IVF and expectant management (no treatment). Livebirth rates have not been adequately assessed in relation to the severity of tubal damage. It is important to determine the effectiveness of surgery against other treatment options in women with tubal infertility because of concerns about adverse outcomes, intraoperative complications and costs associated with tubal surgery, as well as alternative treatments, mainly IVF.


The aim of this review was to determine the effectiveness and safety of surgery compared with expectant management or IVF in improving the probability of livebirth in the context of tubal infertility (regardless of grade of severity).

Search strategy: 

We searched the following databases in October 2016: the Cochrane Gynaecology and Fertility (CGF) Group trials register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO; as well as clinical trials registries, sources of unpublished literature and reference lists of included trials and related systematic reviews.

Selection criteria: 

We considered only randomised controlled trials to be eligible for inclusion, with livebirth rate per participant as the primary outcome of interest.

Data collection and analysis: 

We planned that two review authors would independently assess trial eligibility and risk of bias and would extract study data. The primary review outcome was cumulative livebirth rate. Pregnancy rate and adverse outcomes, including miscarriage rate, rate of ectopic pregnancy and rate of procedure-related complications, were secondary outcomes. We planned to combine data to calculate pooled odds ratios (ORs) and 95% confidence intervals (CIs). We planned to assess statistical heterogeneity using the I2 statistic and to assess the overall quality of evidence for the main comparisons using GRADE methods.

Main results: 

We identified no suitable randomised controlled trials.