Female infertility: Reproductive surgery

INTRODUCTION — 

The availability of assisted reproductive technology has reduced the need for reproductive surgery as a primary surgical treatment of infertility. When fertility surgery is indicated, operative laparoscopy results in outcomes as good as those from similar procedures performed via open laparotomy and is associated with a shorter hospital stay, lower incidence of ileus, and faster recovery. In addition, there is less contamination of the surgical field with glove powder, bleeding is reduced due to tamponade of small vessels by the pneumoperitoneum, and drying of tissues is minimal because surgery occurs in a closed environment. All of these factors contribute to reduce postoperative adhesion formation and its associated morbidity (eg, pain, impaired fertility, bowel obstruction). Today, reproductive surgery can be divided into three categories: surgery as a primary conventional surgical treatment of infertility, surgery to enhance the pregnancy outcome of in vitro fertilization, and surgery for fertility preservation [1].

Reproductive surgery is a distinct form of gynecologic surgery [2]. If the objective of gynecologic surgery is to excise all diseases, reproductive surgery is to maintain or increase fertility. Attention not to decrease ovarian reserve and to preserve a functioning uterus and ovaries are paramount. The main objective of reproductive surgery is to assist the patient in having a family. A more extensive surgery could be performed after completion of the family if needed. It could be done by laparoscopy or hysteroscopy. Laparoscopic surgery for the treatment of female infertility is reviewed here. The evaluation and nonsurgical treatment of female infertility are discussed separately. (See "Female infertility: Evaluation" and "Female infertility: Treatments".)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. We encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive individuals.

LAPAROSCOPY

Diagnosis and treatment — Diagnostic laparoscopy is useful when combined with simultaneous surgical treatment of identified pathology, such as adhesions or endometriosis. Purely diagnostic surgery without surgical treatment is generally avoided.

Chromopertubation — When laparoscopy is performed for diagnostic or therapeutic purposes in women with infertility, chromopertubation (instillation of dye through the fallopian tubes) is performed to assess tubal patency. To perform this procedure, a dilute solution of methylene blue dye is instilled through a transcervical cannula (typically through a patent cannula used for uterine manipulation (picture 1)). Spillage of the dye from each tube is noted as a confirmation of tubal patency. If a repair procedure for tubal occlusion is performed, chromopertubation is repeated at the end of the procedure. An emerging technique is evaluation of tubal patency with the use of office hysteroscopy. Entry of air bubble or methylene blue dye into the tubal ostia suggests the absence of tubal occlusion. This technique appears to be accurate with sensitivity and specificity of 88 and 85 percent, respectively [3].

Combined laparoscopy and hysteroscopy — Some women who undergo diagnostic or therapeutic procedures for infertility may require both hysteroscopy and laparoscopy. As an example, a woman with ultrasound findings of an intrauterine lesion undergoing surgical treatment of endometriosis requires evaluation of the uterine cavity.

When laparoscopic and hysteroscopic procedures are combined, the order of procedures should be based upon the indication for each procedure. If intrauterine pathology is suspected, it may be prudent to perform hysteroscopy first so that placement of the uterine cannula during laparoscopy does not cause tissue trauma that interferes with assessment of the uterine cavity. Another advantage to performing hysteroscopy followed by laparoscopy is that the peritoneal surface of the uterus can be inspected for possible uterine perforation that occurred during hysteroscopy. On the other hand, a potential disadvantage of performing hysteroscopy first is that tissue fragments may block the tubes and give the false impression of tubal occlusion during chromopertubation.

Adhesiolysis — Pregnancy can occur in women with periadnexal adhesions, but the pregnancy rate appears to be higher in those who undergo adhesiolysis. The severity of adhesions can only be evaluated at the time of surgery. For women with dense pelvic adhesions ("frozen pelvis"), optimal adhesiolysis is unlikely.

In the only controlled study examining this issue, salpingo-ovariolysis was performed in 69 infertile women with pelvic adhesions, while 78 women with a similar degree of adhesions were not treated [4]. The cumulative pregnancy rate at 24 months follow-up was significantly higher in treated women, 45 versus 16 percent in the untreated group. Although adhesiolysis was done at laparotomy, equivalent results can be expected with laparoscopic adhesiolysis. (See "Postoperative peritoneal adhesions in adults and their prevention".)

Intrauterine adhesions are another cause of infertility. Surgical treatment is discussed in detail separately. (See "Intrauterine adhesions: Clinical manifestation and diagnosis".)

TREATMENT OF DISTAL TUBAL OCCLUSION — 

Distal tubal obstruction is usually a sequela of salpingitis. Other causes are previous ectopic pregnancy, previous abdominal or pelvic surgery, and peritonitis.

Diagnosis — Distal tubal occlusion is usually diagnosed by hysterosalpingogram that shows dilated distal tube (hydrosalpinx). The diagnosis is established at the time of laparoscopy; chromopertubation leads to dilated distal tube with no passage of the dye.

Fimbrioplasty — Fimbrioplasty is performed for treatment of fimbrial phimosis, which is a partial obstruction of the distal end of the fallopian tube. The tube is patent, but there are adhesive bands that surround the terminal end. The longitudinal folds of the tube are usually preserved. Fimbrioplasty involves dividing the peritoneal adhesive bands that surround the fimbria. Gentle introduction of an alligator laparoscopic forceps into the tubal ostium followed by opening and withdrawal of the forceps helps to stretch the tube and release minor degrees of fimbrial agglutination.

In a series including 434 patients with distal tubal occlusion who underwent laparoscopic fimbrioplasty (enlargement of the ostium) or neosalpingostomy (creation of a new ostium) by a single surgeon, five-year actuarial delivery rates decreased as the severity of tubal occlusion increased: 53, 43, 24, and 23 percent, respectively; the ectopic rate was stable at approximately 15 percent [5]. These results are inferior to those of in vitro fertilization (IVF; 29 percent of IVF cycles result in a live birth and 0.7 percent result in ectopic pregnancy [6]). The authors concluded that fimbrioplasty/neosalpingostomy was an appropriate alternative to IVF for women with less severe tubal occlusion (stage 1 or 2), but IVF was the better option for women with more severe disease (stage 3 or 4) [5]. Time is also a consideration: half of the pregnancies occurred in the first 11 months after surgery and 75 percent occurred in the first 21 months.

Terminal salpingostomy — Terminal salpingostomy is performed to relieve tubal obstruction associated with hydrosalpinx. Efficacy for improving fertility is generally poor, but depends upon tubal wall thickness, ampullary dilation, presence of mucosal folds, percentage of ciliated cells in the fimbrial end, and peritubal adhesions. The average pregnancy rate following salpingostomy is nearly 30 percent, with an ectopic pregnancy rate of 10 percent [7]. However, the pregnancy rate can be as low as zero if the tube is rigid and thick without rugae, and as high as 80 percent when tubal damage is absent or minimal by hysterosalpingogram, salpingoscopy, or inspection at surgery [8].

Candidates and pregnancy rates — Surgery may be considered for young women with mild distal tubal disease because, if successful, one surgical procedure can lead to several pregnancies whereas IVF must be attempted each time pregnancy is desired. IVF is more likely than surgery to be successful in women with bilateral hydrosalpinx, older women (due to the rapid decline in fertility with advancing age), and women with severe disease (eg, severe hydrosalpinx, extensive and dense adhesions, both proximal and distal tubal occlusion). The pregnancy rate after reconstructive surgery in women with combined tubal occlusion (bipolar tubal blockage) is only 12 percent at 2.5 years follow-up [9].

TREATMENT OF HYDROSALPINX

Pathophysiology — Several reports have described a detrimental effect of hydrosalpinx on implantation and pregnancy rates [10]. The leakage of hydrosalpingeal fluid from the tube into the uterine cavity may impede implantation either by flushing the embryos out of the cavity or disrupting the endometrium at the implantation site. Furthermore, hydrosalpinx fluid contains microorganisms, debris, toxins, cytokines, and prostaglandins that may impair endometrial receptivity and possibly reduce the percentage of motile spermatozoa [10].

On a molecular level, one group demonstrated decreased endometrial HOXA10 expression in response to hydrosalpinx fluid, with restoration of HOXA10 expression after salpingectomy [11]. Since HOXA10 is an important transcription factor for implantation of the embryo, impaired expression of this gene may be a mechanism for the deleterious effect of hydrosalpinges on implantation during in vitro fertilization (IVF).

Negative impact on in vitro fertilization (IVF) — The deleterious effects of hydrosalpinx on achieving pregnancy in women undergoing IVF was demonstrated by a meta-analysis that reported decreased clinical pregnancy rates for individuals with hydrosalpinx (per subject pregnancy odds ratio [OR] 0.54, 0.32-0.89 and per transfer OR 0.44, 0.27-0.73, respectively, 19 studies) compared with patients without hydrosalpinx [12]. Hydrosalpinx was associated with increase rates of ectopic pregnancy (OR 3.48, 1.60-7.60) and miscarriage (OR 1.68, 1.17-2.40).

Salpingectomy before IVF — Pregnancy rates can be improved by removal of unilateral or bilateral hydrosalpinges prior to IVF. If performed, salpingectomy should be done with minimal thermal injury and very close to the fallopian tube to minimize interruption of ovarian blood supply with resultant decreased ovarian reserve. Supporting data include:

●A trial that randomly assigned women with hydrosalpinges to salpingectomy or no salpingectomy before their IVF procedure reported implantation and pregnancy rates per transfer in the salpingectomy group were 10 and 34 percent, respectively, but were only 5 and 19 percent in those without salpingectomy [13].

●In a systematic review and meta-analysis of five randomized studies and nine observational studies, the live birth (risk ratio [RR] 1.59, 95% CI 1.17-2.16) and clinical pregnancy (RR 1.27, 95% CI 1.02-1.57) rates were higher in the salpingectomy group than in the control group. Salpingectomy does not impair the ovarian response during subsequent IVF treatment [14].

●In a Cochrane review, the authors reported that salpingectomy increases clinical pregnancy rate versus no surgery (RR 2.02, 95% CI 1.44-2.82; four randomized controlled trials; n = 455; I2 = 42.5 percent; moderate-quality evidence). Proximal tubal occlusion is associated with higher IVF pregnancy rate compared with no tubal surgery (RR 3.21, 95% CI 1.72-5.99) [15].

●A prospective study reported that the relative increase in the pregnancy rate after salpingectomy was greatest in women with a large hydrosalpinx visible on ultrasound (hazard ratio 3.8, 95% CI 1.5-9.2) [16].

Salpingostomy — Salpingostomy can eliminate the accumulation of hydrosalpinx fluid without removing the tube. The tube becomes patent and the fluid will not reaccumulate because drainage is maintained. In one small study, pregnancy rates were similar to those after salpingectomy [17]. Further research is required to determine whether laparoscopic salpingostomy is as effective as salpingectomy. In addition, reocclusion can occur in over three-quarters of cases [12].

Drainage of the hydrosalpinx at the time of oocyte collection is not effective as the tubes will refill rapidly (as little as two days) and the primary pathology (blocked tube) remains [18].

A small randomized trial reported that proximal tubal occlusion using bipolar diathermy prior to IVF also improved implantation and pregnancy rates [19]. Proximal tubal occlusion was not more effective than salpingectomy. However, blockage at the proximal and distal tube may lead to further dilatation of the hydrosalpinx.

Hydrosalpinx sclerotherapy — In order to minimize entry of hydrosalpinx fluid into the uterine cavity, a sclerosing agent can be instilled into the hydrosalpinx. There is no difference in the clinical pregnancy rate between hydrosalpinx sclerotherapy and salpingectomy [20].

TREATMENT OF PROXIMAL TUBAL OCCLUSION — 

The incidence of true cornual occlusion is low and surgical treatment (ie, resection and anastomosis) is not highly successful.

Diagnosis — Hysterosalpingographic findings suggestive of cornual or proximal tubal occlusion must be interpreted with caution as sensitivity and specificity are only 65 and 83 percent, respectively [21]. In one study of resected tubes thought to be proximally occluded by hysterosalpingography and/or laparoscopy but later found to have normal histology, the etiologies of the false positive diagnosis were presumed to be amorphous debris or minimal adhesions (40 percent), extensive fibrosis or salpingitis isthmica nodosa (approximately 40 percent), and tubal spasm (20 percent) [22]. In addition, we reported that repeat hysterosalpingogram in 98 women with hysterosalpingographic findings of bilateral proximal tubal occlusion revealed bilateral tubal patency in 14 women and patency of one of the tubes in 12 others; true occlusion was encountered in 72 patients (74 percent) [23].

If the fallopian tubes are not visualized on hysterosalpingogram, a repeat procedure should be done to exclude the possibility of a random technical problem or tubal spasm. If the test remains abnormal, then selective tubal catheterization under fluoroscopic or hysteroscopic control is indicated to confirm the diagnosis and potentially open the tube (see below) [24].

Nonsurgical therapy — Selective tubal catheterization alone is successful in obtaining tubal patency in 60 to 80 percent of patients, with pregnancy rates of 20 to 60 percent [25,26]; however, most studies did not have a control group of nontreated patients. Approximately one-half of the pregnancies occur in the first 12 months after the procedure. Women with good tubal perfusion pressures had significantly higher pregnancy rates than those with medium or poor perfusion pressure [26].

Tubocornual anastomosis — Tubocornual anastomosis can be performed in women with true cornual obstruction. The cornual portion of the tube is resected followed by anastomosis. Depending upon the extent and severity of tubal damage, intrauterine pregnancy rates range from 16 to 55 percent and ectopic pregnancy rates are 7 to 30 percent. Since this procedure is traditionally performed by laparotomy, rather than laparoscopically, and the intrauterine pregnancy rate is relatively low, in vitro fertilization (IVF) is often a better alternative.

Summary — Selective tubal catheterization may achieve tubal patency and improve short-term pregnancy rates in women who appear to have proximal tubal occlusion by hysterosalpingography. In women with true cornual occlusion, IVF is likely to be more successful than tubocornual anastomosis.

TUBAL REANASTOMOSIS

●Indications – Tubal reanastomosis provides a treatment option for patients with focal tubal disease who are unable to access IVF. Indications for tubal anastomosis include reversal of sterilization, midtubal block secondary to pathology, tubal occlusion from ectopic pregnancy, and salpingitis isthmica nodosa. The success rate of tubal reanastomosis is impacted by the age of the patient, time from prior sterilization, and the sterilization technique.

●Procedure – We perform the procedure in young patients with more than 4 cm of residual tube. The goal is to remove abnormal tissue and reapproximate the healthy tubal segments with as little adhesion formation as possible. The technique involves microsuturing the cut ends of the tube using 6-0 to 10-0 sutures. Tubal patency is confirmed with subsequent hysterosalpingogram (image 1). The procedure is generally performed laparoscopically; some centers using robot assistance.

●Supporting data – Studies of tubal reanastomosis have mainly been performed in patients with prior surgical tubal occlusion. In a meta-analysis that combined data from 22 studies using three surgical approaches (laparotomy, laparoscopy, and robot-assisted laparoscopy), the overall live birth rate was 42.6 percent (95% CI 34.9-51.4) and the ectopic pregnancy rate was 6.8 percent (95% CI 4.6-9.0) [27]. Rates were similar for the three surgical techniques. For patients ≤35 years, the birth rates after reversal of tubal occlusion are similar to those of IVF; IVF is more effective for those over 35 years old [28].

SOCIETY GUIDELINE LINKS — 

Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Female infertility".)

SUMMARY AND RECOMMENDATIONS

●Role of laparoscopy – Diagnostic laparoscopy is useful when combined with simultaneous surgical treatment of identified pathology, such as adhesions or endometriosis. Purely diagnostic surgery without surgical treatment is generally avoided. (See 'Laparoscopy' above.)

●Distal tubal occlusion – Distal tubal obstruction is most commonly a sequelae of salpingitis; other causes include previous ectopic pregnancy, previous abdominal or pelvic surgery, and peritonitis. Surgical treatment varies by the location and extent of the occlusion. Fimbrioplasty is performed for treatment of fimbrial phimosis, which is a partial obstruction of the distal end of the fallopian tube. Terminal salpingostomy is performed to relieve tubal obstruction associated with isolated distal hydrosalpinx. (See 'Treatment of distal tubal occlusion' above.)

●Hydrosalpinx – Laparoscopic salpingectomy for hydrosalpinges is the preferred procedure for improving pregnancy rates in patients planning to undergo IVF. Alternatives, such as proximal tubal occlusion, salpingostomy, and antibiotic therapy, have been shown to be effective in small studies, but there are insufficient data to recommend them as a first-line therapeutic intervention. (See 'Treatment of hydrosalpinx' above.)

●Proximal tubal occlusion – The incidence of true proximal occlusion in the cornua is low and surgical treatment (ie, resection and anastomosis) is not highly successful. As IVF is more likely to be effective than tubocornual anastomosis, we perform tubal catheterization selectively in patients who appear to have proximal tubal occlusion demonstrated by hysterosalpingography. (See 'Treatment of proximal tubal occlusion' above.)

●Tubal reanastomosis – Tubal reanastomosis provides a treatment option for patients with focal tubal disease who are unable to access IVF, including patients who desire sterilization reversal. (See 'Tubal reanastomosis' above.)