The Role of Tubal Reconstructive Surgery in the Era of IVF
Over the last few years, the ease, accessibility and efficacy of IVF has increased dramatically. The success of tubal reconstructive surgery has remained relatively stable although the invasiveness of the surgery decreases. Such divergence between IVF success and need for surgical involvement calls for a reassessment of a cost/risk to benefit ratio whether it may be more efficacious to repair the fallopian tubes or to pursue IVF.
Regardless of age, prior to making the commitment to moving forward, one should undergo a complete infertility evaluation to eliminate the possibility of coexistent infertility factors. Laparascopy is the gold standard to asses the candidacy for tubal repair. Although hysterosalpingogram (HSG) is relatively simple, it does not afford the same information as surgical assessment.
Furthermore, it is difficult to compare success rates achieved comparing IVF to tubal repair. IVF success rates are measured and evaluated according to embryo transfer per cycle. In contrast, after surgical repair, there is no time-dependent modicum to assess pregnancy rates and often are tabulated on a yearly basis.
In general, repair for damage within the structure of the fallopian tubes affords modest pregnancy rates (10-60%) with ectopic rates as high at 20%. However, in more favorable instances, such as reversal of elective sterilization procedures (tubal ligation), cumulative pregnancy rates can be as high as 80%.
Whether IVF is more cost-effective or not remains uncertain. Because there are no randomized controlled trials, the best therapy is both difficult and individualized. Factors to be discussed with patients contemplating reversal include maternal age, risk of multiple pregnancy, procedure and risk of ectopic pregnancy. Micosurgical tubal anastomosis and IVF remain viable options.
Tubal anastomosis is appealing to those who desire reversal or are not comfortable with IVF. The need for major surgery, potential complications and resultant, eventual need for contraception are distinct disadvantages. In women under the age of 35, this reconstructive procedure is a legitimate choice. However, and predictably, a lower success rate occurs in aging women and those women may glean a distinct advantage from assisted reproductive technologies.