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National Collaborating Centre for Women's and Children's Health (UK). Fertility: Assessment and Treatment for People with Fertility Problems. London (UK): RCOG Press; 2004 Feb. (NICE Clinical Guidelines, No. 11.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

8Tubal and uterine surgery

Proximal tubal occlusion is a common cause of tubal infertility. However, proximal tubal obstruction is probably overdiagnosed, as intrauterine pregnancies do occur spontaneously in women with proximal tubal blockage diagnosed by HSG and/or laparoscopy and dye.626 [Evidence level 3]

If tubal surgery is effective it may enable couples to conceive naturally without further intervention.627

8.1. Tubal microsurgery and laparoscopic tubal surgery

Microsurgical tubocornual anastomosis has been regarded as the standard treatment for proximal tubal blockage. However, we did not find any RCTs or controlled observational studies comparing microsurgery with no treatment or with IVF. A case series study reported that 27%, 47% and 53% of women with proximal tubal blockage who had microsurgical tubocornual anastomosis achieved a live birth within one, two and 3.5 years of surgery, respectively.628 [Evidence level 3] A review of nine other case series studies reported that about 50% of women with proximal tubal blockage who had microsurgical tubocornual anastomosis achieved a term pregnancy but it did not specify the time period upon which this figure was based.629 [Evidence level 3]

A cohort study with a follow-up period of three years reported higher pregnancy rates in women who underwent tubal surgery compared with those who did not (29% with surgery versus 12% without surgery; p < 0.05).630 [Evidence level 2b] The surgery was more effective in women with milder pelvic disease (stage I, 67% with surgery versus 24% without surgery, p < 0.05; stage II, 41% with surgery versus 10% without surgery, p < 0.05; stage III, 12% with surgery versus 3% without surgery, not significant; and stage IV, 0% with surgery, pelvic disease so severe that surgery not offered). Several case series reported that pregnancy rates after tubal surgery were comparable with those resulting from IVF in women with filmy adhesions, mild distal occlusion or proximal tubal blockage.631–635 [Evidence level 2b–3]

Case series following up women after surgery for distal tubal occlusion reported live birth rates of 20–30%.631,636,637 [Evidence level 3] The success of tubal microsurgery assessed in case series was reported to range from 5% term pregnancy rate at 36 months284 to 25% cumulative pregnancy rates at 12 months and 40% at 50 months.637 [Evidence level 3] This included a heterogeneous group of women with proximal or distal tubal disease. The severity of tubal damage was linked closely to outcome, with better results in those with filmy adhesions and limited damage, compared with those with more extensive pathology. Success rates with tubal surgery are also thought to depend upon the severity of the tubal damage as well as the age of the woman, duration of infertility and other associated infertility factors.637 [Evidence level 3] It has also been suggested that specialised training, experience and availability of equipment have a major effect on the outcome of tubal surgery.2,284,637 [Evidence level 4]

A narrative review of ten case series (n = 1128) reported a cumulative ectopic pregnancy rate per pregnancy of 23% in women who underwent salpingoneostomy for distal tubal occlusion.636 [Evidence level 3] Another narrative review of five case series studies (n = 118) reported a cumulative ectopic pregnancy rate per pregnancy of 8% in women who underwent tubocornual anastomosis for proximal tubal occlusion.629 [Evidence level 3]

A number of trials have evaluated different surgical techniques for tubal surgery. One systematic review of eight RCTs and 14 observational studies evaluating various surgical techniques for treating tubal infertility found no difference in pregnancy rates between the different techniques used such as CO2 laser adhesiolysis versus diathermy adhesiolysis (53% with laser versus 52% with diathermy; OR 1.04; 95% CI 0.65 to 1.67), with laser salpingostomy versus diathermy salpingostomy (35% with laser versus 27% with diathermy; OR 1.30; 95% CI 0.77 to 2.19) or the use of an operating microscope versus magnifying lenses (loupes) (72% with microscope versus 78% with loupes; OR 0.75; 95% CI 0.26 to 2.15).638 [Evidence level 1a] Women with proximal and distal tubal disease and reversal of sterilisation were included in this review. [Evidence level 1a] The review of the 14 observational studies did not detect a difference between laparoscopic adhesiolysis and microsurgical adhesiolysis in improving outcome. [Evidence level 2b]

A systematic review of five RCTs (n = 588) found no improvement in pregnancy rates with the use of postoperative hydrotubation (OR 1.12; 95% CI 0.57 to 2.21) or hydrotubation with steroids (OR 1.10; 95% CI 0.74 to 1.64) or hydrotubation with antibiotics (OR 0.67; 95% CI 0.30 to 1.47) or second-ook laparoscopy with adhesiolysis (OR 0.96; 95% CI 0.44 to 2.07). The comparison groups received no treatment but the trials were small and of poor quality.639 [Evidence level 1a]

The appropriate therapeutic approach to tubal infertility will depend upon careful patient selection according to the individual’s clinical circumstances and involving the couple in the decision-making process.640–643

Retrospective case series suggest that most pregnancies occur between 12 and 14 months after tubal surgery, although conception have occurred sooner in those with minimal disease.627,631,631,637,644–646 [Evidence level 3] It may be reasonable to discuss IVF with women who have not conceived 12 to 18 months after tubal surgery.

RECOMMENDATION

For women with mild tubal disease tubal surgery may be more effective than no treatment. In centres where appropriate expertise is available it may be considered as a treatment option. [D]

RESEARCH RECOMMENDATION

Further research is needed to evaluate the clinical and cost effectiveness of tubal surgery compared with no treatment and other treatment options, particularly in vitro fertilisation. This research should include consideration of any adverse consequences of treatment, such as ectopic pregnancy. [D]

8.2. Tubal catheterisation or cannulation

Tubal catheterisation/cannulation can be performed using either a radiographic approach (selective salpingography combined with tubal cannulation) or a hysteroscopic approach (hysteroscopic tubal cannulation).

Selective salpingography can provide information about proximal and distal tubal obstruction. An RCT (n = 273) reported that selective salpingography was a better diagnostic test for proximal tubal obstruction than laparoscopy and dye.647 [Evidence level 1b] Selective salpingography combined with tubal cannulation can be adopted as a ‘see and treat’ approach for proximal tubal obstruction in appropriately selected patients.

We found no RCTs that compared the effects of selective salpingography plus tubal catheterisation or hysteroscopic cannulation with no treatment on pregnancy rates in women with proximal tubal obstruction.

A systematic review of observational studies included ten cohort and 11 other observational studies of selective salpingography and tubal catheterisation (n = 482 women), and four observational studies of hysteroscopic tubal cannulation for proximal tubal blockage (n = 133 women). Hysteroscopic tubal cannulation was associated with a higher pregnancy rate than selective salpingography plus tubal catheterisation (49% with hysteroscopy versus 21% with salpingography).648 [Evidence level 2b–3] As no untreated group was included in any of the studies reviewed, the likelihood of spontaneous pregnancy without treatment cannot be determined. Intrauterine pregnancy in women with proximal tubal blockage diagnosed by both HSG and laparoscopy/dye does occur without surgical treatment.626 [Evidence level 3]

Tubal perforation (a complication associated with tubal cannulation) has been reported to occur in 2–5% of women undergoing tubal cannulation,649,650 although the clinical significance of this was not reported. Ectopic pregnancy occurred in 3–9% of women undergoing selective salpingography plus tubal catheterisation.648 [Evidence level 2b–3]

RECOMMENDATION

For women with proximal tubal obstruction selective salpingography plus tubal catheterisation, or hysteroscopic tubal cannulation, may be treatment options because these treatments improve the chance of pregnancy. [B]

8.3. Uterine surgery

Uterine myoma (leiomyoma)

We did not find any RCTs comparing myomectomy versus expectant management for women with leiomyomas. The incidence of myoma in women with infertility without any obvious cause of infertility is estimated to be 1.0–2.4%.651,652

A systematic review of 11 cohort studies suggests that women with submucous myoma have lower pregnancy rates compared with women with other causes for their infertility (RR 0.30, 95% CI 0.13 to 0.70). Myomectomy was not associated with an increase in live birth rate (RR 0.98, 95% CI 0.45 to 2.41) but was associated with a higher pregnancy rate (RR 1.72, 95% CI 1.13 to 2.58).653 [Evidence level 2b] Another cohort study found that women with intramural uterine fibroids had a reduced chance of pregnancy when compared with women with no fibroids following assisted reproduction (OR 0.46, 95% CI 0.24 to 0.88), having adjusting for number of embryos replaced and for age of over 40 years.401 [Evidence level 2b]

A case–control study found a lower pregnancy rate in women with myoma when compared with women without myoma (11% versus 25%). The pregnancy rate in women following myomectomy was higher than that in women with untreated myoma (42% versus 25%).654 [Evidence level 3]

An RCT (n = 109) that compared different surgical methods for undertaking myomectomy (abdominal myomectomy versus laparoscopic myomectomy) found no differences in pregnancy rates (55.9% with abdominal myomectomy versus 53.6% with laparoscopic myomectomy) or miscarriage rates (12% versus 20%) in women with large myomas. There was significantly higher incidence of postoperative fever and a drop in haemoglobin and hospital stay in the group following abdominal myomectomy.655 [Evidence level 1b]

Septate uterus

Uterine septum is a congenital anomaly of the female reproductive tract. The incidence is not increased among women with infertility compared with other women (2–3%).656,657 It is more common in women who have had recurrent pregnancy loss or preterm birth.658–660 Hysteroscopic metroplasty has not been shown to increase pregnancy rates in women with infertility who have a septate uterus.661–664 [Evidence level 2b–3]

Intrauterine adhesions

Intrauterine adhesions are rare but they may result from previous uterine evacuation or surgery. They are associated with oligo/amenorrhoea. A case series (n = 40) suggests that hysteroscopic adhesiolysis restored normal menstrual pattern in 81% of women of the 16 infertile women in the series, 63% (n = 10) conceived and 37% (n = 6) delivered a viable infant.665 [Evidence level 3]

RECOMMENDATION

Women with amenorrhoea who are found to have intrauterine adhesions should be offered hysteroscopic adhesiolysis because this is likely to restore menstruation and improve the chance of pregnancy. [C]

RESEARCH RECOMMENDATIONS

Randomised controlled trials are needed to evaluate any benefits of surgical treatment of leiomyoma on improving the chance of live birth.

Further research is needed to evaluate any benefit on live birth rates of surgical resection of uterine septum in women with fertility problems.

Copyright © 2004, National Collaborating Centre for Women’s and Children’s Health.

Apart from any fair dealing for the purposes of research or private study, criticism or review, as permitted under the Copyright, Designs and Patents Act, 1988, no part of this publication may be reproduced, stored or transmitted in any form or by any means, without the prior written permission of the publisher or, in the case of reprographic reproduction, in accordance with the terms of licences issued by the Copyright Licensing Agency in the UK. Enquiries concerning reproduction outside the terms stated here should be sent to the publisher at the UK address printed on this page.

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Cover of Fertility
Fertility: Assessment and Treatment for People with Fertility Problems.
NICE Clinical Guidelines, No. 11.
National Collaborating Centre for Women's and Children's Health (UK).
London (UK): RCOG Press; 2004 Feb.

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