Journal of Assisted Reproduction and Genetics, Vol. 9, No. 4, 1992
CONTROVERSIES IN ASSISTED REPRODUCTION
In Vitro Fertilization Versus Reconstructive Tubal Surgery
INTRODUCTION
be advised to consider surgery followed by IVF (if this becomes necessary), those between 38 and 40 may be advised to consider IVF first, reserving surgery as a last-ditch attempt should IVF fail. The effect of cost, depending on the jurisdiction and the means of the couple, cannot be underestimated. The final decision will rest with the couple and will be influenced by their perception of the facts and their own internal value system. While the physician must at all times respect the patient's final decision, this does not mean that the physician's own value system is not worthy of respect. It is our opinion that the responsible physician will not accede to requests to perform treatment with essentially no likelihood of success.
The goals for any infertile couple should be either a live birth or the ability to feel that they have exhausted all reasonable attempts to achieve a pregnancy. If the latter is to be the outcome, the couple are more likely to resolve the conflict if they have been actively involved in the decision-making process. For the infertile woman with tubal damage there are only two realistic options to achieve pregnancy: reconstructive surgery or in vitro fertilization and embryo transfer (IVF). We have never regarded tubal surgery and IVF as competitive but rather as complementary options toward achieving the desired goal. It is the purpose of this article to suggest how nontechnical and purely technical considerations will influence the choice of treatment.
TECHNICAL CONSIDERATIONS NONTECHNICAL CONSIDERATIONS IVF clearly represents the only therapeutic option for those with inoperable tubes (absent tubes, prior tuberculous salpingitis) and tubal disease coincident with another important infertility factor (3). For others, reconstructive tubal surgery will offer a greater chance of success. For them, a logical sequence of treatment would be tubal surgery followed by IVF if the former proves unsuccessful. The decision-making process for couples who wish to pursue a therapeutic option requires the provision of accurate information with respect to both IVF and tubal surgery. This requires proper investigation. The "take-home baby" rate per cycle of IVF and the cumulative rate after multiple cycles must be provided. As the optimum number of repeated cycles of IVF is unknown, it would seem reasonable to consider the cumulative pregnancy rate after four cycles. In addition, the potential complications of the procedure, multiple pregnancy, abortion, and ectopic pregnancy rates must be considered. Finally, the effect of frozen embryo replacement upon the cumulative pregnancy rate
The nontechnical considerations include age, cost, and the wishes of the couple. The age of the female partner exerts a demonstrably detrimental effect upon conception and successful outcome. This becomes most marked after the 40th birthday. A "take-home baby" rate of 45% has been reported following reversal of sterilization in women 40 years of age or more. The anastomosed oviduct(s) had a minimum length of 4 cm and the follow-up period was at least 1 year (1). The comparable figures for IVF (per oocyte recovery cycle), in contrast, are 8.3% at the ages of 40 and 41 and 2.4% thereafter (2). In the reproductively older woman, the rapid decay in the success per single cycle of IVF must be weighed against the fact that reconstructive surgery will offer multiple cycles during which conception may occur, Whereas the younger woman may The opinions presented in this column are those of its author(s) and do not necessarily reflect those of the journal and its editors, publisher, and advertisers.
1058-0468/92/0800-0306506.50/0 © 1992 Plenum Publishing Corporation
306
307
IVF VERSUS T U B A L S U R G E R Y
must be computed in the analysis. Armed with this information, the couple will be in a position to make logical choices when similar information with respect to tubal surgery, in their particular case, is provided. It is imperative that such figures reflect local experience, which may be better or worse than reported international data. However, for the sake of this discussion, figures derived from the world literature are used. While most registries report pregnancy and delivery rates based upon oocyte recovery cycles, the couple will wish to know the rates based on cycles initiated. Thus, although the delivery rate per oocyte pickup cycle (OPU) in the collective U.S. data for 1989 was 14%, 15.5% of cycles initiated were canceled prior to OPU (4). Therefore, the delivery rate per cycle initiated was 11.8%. French data have shown that the pregnancy rate remains relatively constant in successive cycles (5). If the U.S. figure of 11.8% is used, the cumulative delivery rate after four cycles of treatment would be 40%. While this figure may be improved by replacement of frozen embryos, the net effect would be small because not all cycles provide spare embryos, nor would all the frozen embryos withstand the thawing process. Transfer of cryopreserved embryos yields a clinical pregnancy rate of 11% and a delivery rate of 8% (4); a quarter of these pregnancies will abort. IVF is not risk-free, especially in stimulated cycles. Although uncommon, ovarian hyperstimulation, bleeding, and infection occur. Four percent of pregnancies are triplets or a higher order of multiples. The twin pregnancy rate is approximately 20%. Multiple pregnancy leads to an increased frequency of prematurity and delivery of babies of low birth weight. The perinatal mortality is just under 10%. In IVF pregnancies the abortion rate is between 20 and 25%, and the overall tubal pregnancy rate is 6% (4,5) (of clinical pregnancies). However, the rate of tubal pregnancy is 12% in patients with tubal disease, the very patients who must choose between IVF and tubal surgery (6). The second part of the technical decision-making process hinges upon understanding the success rate and complications of tubal surgery. The overall risks of reconstructive tubal surgery (using laparotomy or laparoscopy) are small and include recognized complications of anesthesia and surgery. Surgery, if successful, will offer multiple cycles in which to achieve conception and the opportunity to have more than one pregnancy. The abortion rate subsequent to reconstructive tubal surgery is not Journal of Assisted Reproduction and Genetics, Vol. 9, No. 4, 1992
increased over that of a normal population. The live birth and ectopic pregnancy rates are dependent upon the specific nature of the tubal disease and the extent of tubal damage.
INVESTIGATION Both male and female partners should be thoroughly investigated. The presence of severe semenal abnormalities would tilt the scales in favor of IVF, although the success rate in these circumstances is lower. Hysterosalpingography (HSG) and laparoscopy are complementary methods of assessing tubal and periadnexal factors. Preliminary HSG provides invaluable information. It will reveal proximal tubal occlusion, nonocclusive proximal tubal disease, distal tubal occlusion, and the nature of the intratubal architecture. These findings will greatly influence the decision whether or not to undertake reconstructive procedures at the time of the subsequent diagnostic laparoscopy (7).
SELECTION Periadnexal adhesive disease may be the sole apparent lesion or may coexist in conjunction with tubal occlusion. The tubes may be occluded proximally or distally as the end result of pathological processes or may have been interrupted by a previous sterilization. If periadnexal adhesive disease is the sole lesion, laparoscopic salpingoovariolysis should complement the diagnostic laparoscopy. The subsequent live birth rate will be approximately 50 to 60%. Ectopic pregnancies occur in 5% of patients who have undergone this procedure. If, in addition, it is necessary to perform fimbrioplasty, the live birth rate falls to between 40 and 48%, with no change in the rate of ectopics (8-13). Distal tubal occlusion may be treated surgically. A review of published reports indicates that the live birth rate following microsurgical salpingostomy varies between 19 and 35%. The ectopic pregnancy rate ranges from 5 to 18%. These results are less impressive than those attained by other microsurgical tubal procedures (14,15). Laparoscopic satpingostomy in appropriately selected cases may yield similar results (13,16-19). The factors that affect the outcome of salpingos-
308
tomy include (i) distal ampullary diameter, (ii) tubal wall thickness, (iii) nature of the tubal endothelium at the neostomy site, (iv) extent of adhesions, and (v) type of adhesions. These factors have been quantified in a scoring system which permits estimation of the likely surgical outcome (20). In unfavorable cases, IVF should be the initial treatment of choice. In those deemed very favorable, live birth rates of between 50 and 70% have been achieved by microsurgical salpingostomy. If surgery appears to be the initial treatment of choice, the decision whether or not to proceed with an immediate laparoscopic salpingostomy or undertake reconstructive microsurgery must depend upon local experience and success rates with both approaches. In cases of proximal tubal occlusion, transcervical fallopian tube catheterization may be useful in elucidating false-positive results obtained by hysterosalpingography and in overcoming obstruction associated with a mucous plug or cornual synechiae (21). Microsurgical correction of pathological tubal occlusion resulting from salpingitis isthmica nodosa, endometriosis, and extensive postinflammatory fibrosis yields live birth rates between 37 and 58% and ectopic pregnancy rates between 5 and 7% (15,22-24). Based upon local experience, we offer microsurgical correction as the first line of treatment. Laparoscopic approaches to the reconstruction of previous midtubal sterilization are currently under exploration. However, these techniques, for the present, must be viewed as experimental. Tubotubal anastomosis by microsurgery produces the best success rates, which are dependent principally upon the length of the reconstructed tube. Live birth rates of 60 to 80% can be achieved provided that the reconstructed tube is longer than 4 cm and the ampullary portion more than 1 cm (15,22,25-27). The tubal pregnancy rates are usually low. These procedures are now performed on a short (24-hr)-hospital stay basis and offer the opportunity to conceive more than once. Such results would favor the choice of this approach over IVF. If a fimbriectomy has been performed, the outcome with reconstructive surgery is dependent upon the remaining ampullary length. Live birth rates of approximately 30% can be achieved provided that at least 50% of the ampulla has been preserved (15). The choice of the primary therapeutic approach must rest with the patient. If less than 50% of the ampulla has been preserved, IVF is recommended.
GOMEL AND TAYLOR
CONCLUSION The development of operative laparoscopy, microsurgery, and IVF in the last 20 years has improved the outlook of couples suffering from tubal infertility. These are complementary approaches which may be used singly or in combination. The choice of the primary and any subsequent treatment is dependent upon a careful consideration of both technical and nontechnical factors. These must be individualized to the circumstances of the patients. Factual information about success and complication rates must accurately reflect local experience. Active involvement of the couple in the decision-making process is more likely to result in resolution of the conflict of infertility if treatment should prove unsuccessful.
REFERENCES 1. Trimbos-Kemper TCM: Reveral of sterilization in women over 40 years of age: A multicenter survey in the Netherlands. Fertil Steril 1990;53:575-577 2. FIVNAT 1989 et bilan general 1986-1989. Contr Fertil Sexual 1990;18:588-600 3. Gomel V: Microsurgery in Female Infertility. Boston, Littie, Brown, 1983, pp 129-134 4. Medical Research International, Society for Assisted Reproductive Technology, The American Fertility Society: In vitro fertilization-embryo transfer (IVF-ET) in the United States: 1989 results from the IVF-ET registry. Fertil Steril 1991;55: 14-23 5. Cohen J: The efficiency and efficacy of IVF and GIFT. Hum Reprod 1991 ;6:613-618 6. Zouves C, Erenus M, Gomel V: Tubal ectopic pregnancy after in vitro fertilization and embryo transfer: A role for proximal occlusion or salpingectomy after failed distal tubal surgery? Fertil Steril 1991 ;56:691-695 7. Gomel V, Taylor PJ: Laparoscopy and Hysteroscopy in Gynaecologic Practice. Chicago, Year Book Medical, 1986, pp 77-79 8. Gomel V: Laparoscopic tubal surgery in infertility. Qbstet Gynecol 1975;46:47-48 9. Gomel V: Salpingo-ovariolysis by laparoscopy in infertility. Fertil Steril 1983;340:607-610 10. Bruhat MA, Mage G, Manhes H, Soualhat C, et al.: Laparoscopy procedures to promote fertility: Ovariolysis and salpingolysis results of 93 selected cases. Acta Eur Fertil 1983; 14:476-479 11. Fayez JA: An assessment of the role of operative laparoscopy in tuboplasty. Fertil Steril 1983;39:476-479 12. Gomel V: Microsurgery in Female Infertility. Boston, Little, Brown, 1983, pp 143-144 13. Dubuisson JB, Borquet deJoliniere J, Aubriot FX, et al.: Terminal tuboplasties by laparoscopy: 65 consecutive cases. Fertil Steril 1990;54:401-403 Journal of Assisted Reproduction and Genetics, Vol. 9, No. 4, 1992
TUBAL SURGERY OR IVF?
14. Gomel V: Salpingostomy by microsurgery. Fertil Steri11978; 29:380-387 15. Gomel V: Microsurgery in female infertility. Boston, Little, Brown, 1983, pp 225-244 16. Gomel V: Salpingostomy by laparoscopy. J Reprod Med 1975; 18:265-268 17. Daniell JF, Herbert CM: Laparoscopic salpingostomy utilizing the CO2. Fertil Steril 1984;41:558-563 18. Bruhat MA, Dubuisson JB, Pouly JL, et al.: La Coeliochirurgie. In Encycl Med Chir Techn Chirurg UroI-Gynecoh Paris, Editions Techniques, 1989, Vot 6, p 38 19. McComb P, Paleoulogou A: The intussusception salpingostomy technique for the therapy of distral ovoductal occlusion at laparoscopy. ©bstet Gynecol 1991 ;78:443-447 20. Gomel V: Distal tubal occlusion. Fertil Steril 1988;49:946948 21. Kerin JF, Surrey ES, Williams DB, Daykhovsky L, Grundfest WS: Falloposcopic observations of endotubal isthmic plugs as a cause of reversible obstruction and their histological characterization. J Laparoendoscop Surg 1991 ;1:103-110 22. Gomel V: Tubal reanastomosis by microsurgery. Fertil Stedl 1977;28:59-65 23. Donnez J, Casanas-Roux F: Prognostic factors influencing the pregnancy rate after microsurgical cornual anastomosis. Fertil Steril 1986;46:1089-1092
309
24. McComb P: Microsurgical tubocornual anastomosis for occlusive cornual disease: Reproducible results without the need for tubouterine implantation. Fertil Steril 1986;46:571577 25. Gomel V: Microsurgical reversal of female sterilization: A reappraisal. Fertil Steril 1980;33:587-597 26. Winston RML: Reversal of sterilization. Clin Obstet Gynecol 1980;23:1261-1268 27. Xue P, Fa Y-Y: Microsurgical reversal of female sterilization. J Reprod Med 1989;34:45t-455
Victor Gomel 1 Department of Obstetrics and Gynaecology University of British Columbia University and Grace Hospitals Vancouver, B.C., Canada Patrick J. Taylor Department of Obstetrics and Gynaecology University of British Columbia St. Paul's Hospital Vancouver, B.C., Canada 1 To whom correspondence should be addressed.
Tubal Surgery or in Vitro Fertilization (IVF)? Some authors (1) unthinkingly state that reproductive surgery is now obsolete. A more thoughtful view is that the introduction of IVF has resulted in great improvements in surgical management by ensuring better selection of surgical cases and consequently improved results. Boer-Meisel et al. (2) were among the first to show that results following salpingostomy were related principally to the degree of tubal damage. Sadly, other reproductive surgeons have not followed their lead. Had a classification system for tubal damage been agreed upon sooner, many women could have had more logical planning of treatment. Not all tubal damage is suitable for surgery. The lead should have been taken from gynecological oncologists, who have long recognized that it is entirely inappropriate to offer Wertheim's hysterectomy for Stage IV of the cervix. The treatment of hydrosalpinges by salpingostomy illustrates the point particularly well. Although operations to open the fimbria carry the worst progJournal of Assisted Reproduction and Genetics, Vol. 9, No. 4, 1992
nosis of all fertility surgery, in properly selected cases salpingostomy gives term pregnancy rates of 35-45% (3,4). This is over twice the live delivery rate achieved after a cycle of treatment in only a very few of the best IVF programs. Against this relatively good success rate must be set the fact that results are generally not immediate; most series report that the majority of pregnancies occurs only after a year following salpingostomy, presumably because epithelial regeneration is slow. Treatment of cornual block, revolutionized by microsurgical cornual anastomosis, is more successful. It carries term pregnancy rates of 45-60% (5-7), and results are better than those after multiple IVF cycles. Moreover, most pregnancies after cornual surgery occur within 8 months. Adhesiolysis, whether by open surgery or by laser laparoscopy, also has results superior to IVF in a single cycle. Good results are obtained only in patients with limited pathology, who should be offered the most appropriate treat-
CONTROVERSIES IN ASSISTED REPRODUCTION
In Vitro Fertilization Versus Reconstructive Tubal Surgery
INTRODUCTION
be advised to consider surgery followed by IVF (if this becomes necessary), those between 38 and 40 may be advised to consider IVF first, reserving surgery as a last-ditch attempt should IVF fail. The effect of cost, depending on the jurisdiction and the means of the couple, cannot be underestimated. The final decision will rest with the couple and will be influenced by their perception of the facts and their own internal value system. While the physician must at all times respect the patient's final decision, this does not mean that the physician's own value system is not worthy of respect. It is our opinion that the responsible physician will not accede to requests to perform treatment with essentially no likelihood of success.
The goals for any infertile couple should be either a live birth or the ability to feel that they have exhausted all reasonable attempts to achieve a pregnancy. If the latter is to be the outcome, the couple are more likely to resolve the conflict if they have been actively involved in the decision-making process. For the infertile woman with tubal damage there are only two realistic options to achieve pregnancy: reconstructive surgery or in vitro fertilization and embryo transfer (IVF). We have never regarded tubal surgery and IVF as competitive but rather as complementary options toward achieving the desired goal. It is the purpose of this article to suggest how nontechnical and purely technical considerations will influence the choice of treatment.
TECHNICAL CONSIDERATIONS NONTECHNICAL CONSIDERATIONS IVF clearly represents the only therapeutic option for those with inoperable tubes (absent tubes, prior tuberculous salpingitis) and tubal disease coincident with another important infertility factor (3). For others, reconstructive tubal surgery will offer a greater chance of success. For them, a logical sequence of treatment would be tubal surgery followed by IVF if the former proves unsuccessful. The decision-making process for couples who wish to pursue a therapeutic option requires the provision of accurate information with respect to both IVF and tubal surgery. This requires proper investigation. The "take-home baby" rate per cycle of IVF and the cumulative rate after multiple cycles must be provided. As the optimum number of repeated cycles of IVF is unknown, it would seem reasonable to consider the cumulative pregnancy rate after four cycles. In addition, the potential complications of the procedure, multiple pregnancy, abortion, and ectopic pregnancy rates must be considered. Finally, the effect of frozen embryo replacement upon the cumulative pregnancy rate
The nontechnical considerations include age, cost, and the wishes of the couple. The age of the female partner exerts a demonstrably detrimental effect upon conception and successful outcome. This becomes most marked after the 40th birthday. A "take-home baby" rate of 45% has been reported following reversal of sterilization in women 40 years of age or more. The anastomosed oviduct(s) had a minimum length of 4 cm and the follow-up period was at least 1 year (1). The comparable figures for IVF (per oocyte recovery cycle), in contrast, are 8.3% at the ages of 40 and 41 and 2.4% thereafter (2). In the reproductively older woman, the rapid decay in the success per single cycle of IVF must be weighed against the fact that reconstructive surgery will offer multiple cycles during which conception may occur, Whereas the younger woman may The opinions presented in this column are those of its author(s) and do not necessarily reflect those of the journal and its editors, publisher, and advertisers.
1058-0468/92/0800-0306506.50/0 © 1992 Plenum Publishing Corporation
306
307
IVF VERSUS T U B A L S U R G E R Y
must be computed in the analysis. Armed with this information, the couple will be in a position to make logical choices when similar information with respect to tubal surgery, in their particular case, is provided. It is imperative that such figures reflect local experience, which may be better or worse than reported international data. However, for the sake of this discussion, figures derived from the world literature are used. While most registries report pregnancy and delivery rates based upon oocyte recovery cycles, the couple will wish to know the rates based on cycles initiated. Thus, although the delivery rate per oocyte pickup cycle (OPU) in the collective U.S. data for 1989 was 14%, 15.5% of cycles initiated were canceled prior to OPU (4). Therefore, the delivery rate per cycle initiated was 11.8%. French data have shown that the pregnancy rate remains relatively constant in successive cycles (5). If the U.S. figure of 11.8% is used, the cumulative delivery rate after four cycles of treatment would be 40%. While this figure may be improved by replacement of frozen embryos, the net effect would be small because not all cycles provide spare embryos, nor would all the frozen embryos withstand the thawing process. Transfer of cryopreserved embryos yields a clinical pregnancy rate of 11% and a delivery rate of 8% (4); a quarter of these pregnancies will abort. IVF is not risk-free, especially in stimulated cycles. Although uncommon, ovarian hyperstimulation, bleeding, and infection occur. Four percent of pregnancies are triplets or a higher order of multiples. The twin pregnancy rate is approximately 20%. Multiple pregnancy leads to an increased frequency of prematurity and delivery of babies of low birth weight. The perinatal mortality is just under 10%. In IVF pregnancies the abortion rate is between 20 and 25%, and the overall tubal pregnancy rate is 6% (4,5) (of clinical pregnancies). However, the rate of tubal pregnancy is 12% in patients with tubal disease, the very patients who must choose between IVF and tubal surgery (6). The second part of the technical decision-making process hinges upon understanding the success rate and complications of tubal surgery. The overall risks of reconstructive tubal surgery (using laparotomy or laparoscopy) are small and include recognized complications of anesthesia and surgery. Surgery, if successful, will offer multiple cycles in which to achieve conception and the opportunity to have more than one pregnancy. The abortion rate subsequent to reconstructive tubal surgery is not Journal of Assisted Reproduction and Genetics, Vol. 9, No. 4, 1992
increased over that of a normal population. The live birth and ectopic pregnancy rates are dependent upon the specific nature of the tubal disease and the extent of tubal damage.
INVESTIGATION Both male and female partners should be thoroughly investigated. The presence of severe semenal abnormalities would tilt the scales in favor of IVF, although the success rate in these circumstances is lower. Hysterosalpingography (HSG) and laparoscopy are complementary methods of assessing tubal and periadnexal factors. Preliminary HSG provides invaluable information. It will reveal proximal tubal occlusion, nonocclusive proximal tubal disease, distal tubal occlusion, and the nature of the intratubal architecture. These findings will greatly influence the decision whether or not to undertake reconstructive procedures at the time of the subsequent diagnostic laparoscopy (7).
SELECTION Periadnexal adhesive disease may be the sole apparent lesion or may coexist in conjunction with tubal occlusion. The tubes may be occluded proximally or distally as the end result of pathological processes or may have been interrupted by a previous sterilization. If periadnexal adhesive disease is the sole lesion, laparoscopic salpingoovariolysis should complement the diagnostic laparoscopy. The subsequent live birth rate will be approximately 50 to 60%. Ectopic pregnancies occur in 5% of patients who have undergone this procedure. If, in addition, it is necessary to perform fimbrioplasty, the live birth rate falls to between 40 and 48%, with no change in the rate of ectopics (8-13). Distal tubal occlusion may be treated surgically. A review of published reports indicates that the live birth rate following microsurgical salpingostomy varies between 19 and 35%. The ectopic pregnancy rate ranges from 5 to 18%. These results are less impressive than those attained by other microsurgical tubal procedures (14,15). Laparoscopic satpingostomy in appropriately selected cases may yield similar results (13,16-19). The factors that affect the outcome of salpingos-
308
tomy include (i) distal ampullary diameter, (ii) tubal wall thickness, (iii) nature of the tubal endothelium at the neostomy site, (iv) extent of adhesions, and (v) type of adhesions. These factors have been quantified in a scoring system which permits estimation of the likely surgical outcome (20). In unfavorable cases, IVF should be the initial treatment of choice. In those deemed very favorable, live birth rates of between 50 and 70% have been achieved by microsurgical salpingostomy. If surgery appears to be the initial treatment of choice, the decision whether or not to proceed with an immediate laparoscopic salpingostomy or undertake reconstructive microsurgery must depend upon local experience and success rates with both approaches. In cases of proximal tubal occlusion, transcervical fallopian tube catheterization may be useful in elucidating false-positive results obtained by hysterosalpingography and in overcoming obstruction associated with a mucous plug or cornual synechiae (21). Microsurgical correction of pathological tubal occlusion resulting from salpingitis isthmica nodosa, endometriosis, and extensive postinflammatory fibrosis yields live birth rates between 37 and 58% and ectopic pregnancy rates between 5 and 7% (15,22-24). Based upon local experience, we offer microsurgical correction as the first line of treatment. Laparoscopic approaches to the reconstruction of previous midtubal sterilization are currently under exploration. However, these techniques, for the present, must be viewed as experimental. Tubotubal anastomosis by microsurgery produces the best success rates, which are dependent principally upon the length of the reconstructed tube. Live birth rates of 60 to 80% can be achieved provided that the reconstructed tube is longer than 4 cm and the ampullary portion more than 1 cm (15,22,25-27). The tubal pregnancy rates are usually low. These procedures are now performed on a short (24-hr)-hospital stay basis and offer the opportunity to conceive more than once. Such results would favor the choice of this approach over IVF. If a fimbriectomy has been performed, the outcome with reconstructive surgery is dependent upon the remaining ampullary length. Live birth rates of approximately 30% can be achieved provided that at least 50% of the ampulla has been preserved (15). The choice of the primary therapeutic approach must rest with the patient. If less than 50% of the ampulla has been preserved, IVF is recommended.
GOMEL AND TAYLOR
CONCLUSION The development of operative laparoscopy, microsurgery, and IVF in the last 20 years has improved the outlook of couples suffering from tubal infertility. These are complementary approaches which may be used singly or in combination. The choice of the primary and any subsequent treatment is dependent upon a careful consideration of both technical and nontechnical factors. These must be individualized to the circumstances of the patients. Factual information about success and complication rates must accurately reflect local experience. Active involvement of the couple in the decision-making process is more likely to result in resolution of the conflict of infertility if treatment should prove unsuccessful.
REFERENCES 1. Trimbos-Kemper TCM: Reveral of sterilization in women over 40 years of age: A multicenter survey in the Netherlands. Fertil Steril 1990;53:575-577 2. FIVNAT 1989 et bilan general 1986-1989. Contr Fertil Sexual 1990;18:588-600 3. Gomel V: Microsurgery in Female Infertility. Boston, Littie, Brown, 1983, pp 129-134 4. Medical Research International, Society for Assisted Reproductive Technology, The American Fertility Society: In vitro fertilization-embryo transfer (IVF-ET) in the United States: 1989 results from the IVF-ET registry. Fertil Steril 1991;55: 14-23 5. Cohen J: The efficiency and efficacy of IVF and GIFT. Hum Reprod 1991 ;6:613-618 6. Zouves C, Erenus M, Gomel V: Tubal ectopic pregnancy after in vitro fertilization and embryo transfer: A role for proximal occlusion or salpingectomy after failed distal tubal surgery? Fertil Steril 1991 ;56:691-695 7. Gomel V, Taylor PJ: Laparoscopy and Hysteroscopy in Gynaecologic Practice. Chicago, Year Book Medical, 1986, pp 77-79 8. Gomel V: Laparoscopic tubal surgery in infertility. Qbstet Gynecol 1975;46:47-48 9. Gomel V: Salpingo-ovariolysis by laparoscopy in infertility. Fertil Steril 1983;340:607-610 10. Bruhat MA, Mage G, Manhes H, Soualhat C, et al.: Laparoscopy procedures to promote fertility: Ovariolysis and salpingolysis results of 93 selected cases. Acta Eur Fertil 1983; 14:476-479 11. Fayez JA: An assessment of the role of operative laparoscopy in tuboplasty. Fertil Steril 1983;39:476-479 12. Gomel V: Microsurgery in Female Infertility. Boston, Little, Brown, 1983, pp 143-144 13. Dubuisson JB, Borquet deJoliniere J, Aubriot FX, et al.: Terminal tuboplasties by laparoscopy: 65 consecutive cases. Fertil Steril 1990;54:401-403 Journal of Assisted Reproduction and Genetics, Vol. 9, No. 4, 1992
TUBAL SURGERY OR IVF?
14. Gomel V: Salpingostomy by microsurgery. Fertil Steri11978; 29:380-387 15. Gomel V: Microsurgery in female infertility. Boston, Little, Brown, 1983, pp 225-244 16. Gomel V: Salpingostomy by laparoscopy. J Reprod Med 1975; 18:265-268 17. Daniell JF, Herbert CM: Laparoscopic salpingostomy utilizing the CO2. Fertil Steril 1984;41:558-563 18. Bruhat MA, Dubuisson JB, Pouly JL, et al.: La Coeliochirurgie. In Encycl Med Chir Techn Chirurg UroI-Gynecoh Paris, Editions Techniques, 1989, Vot 6, p 38 19. McComb P, Paleoulogou A: The intussusception salpingostomy technique for the therapy of distral ovoductal occlusion at laparoscopy. ©bstet Gynecol 1991 ;78:443-447 20. Gomel V: Distal tubal occlusion. Fertil Steril 1988;49:946948 21. Kerin JF, Surrey ES, Williams DB, Daykhovsky L, Grundfest WS: Falloposcopic observations of endotubal isthmic plugs as a cause of reversible obstruction and their histological characterization. J Laparoendoscop Surg 1991 ;1:103-110 22. Gomel V: Tubal reanastomosis by microsurgery. Fertil Stedl 1977;28:59-65 23. Donnez J, Casanas-Roux F: Prognostic factors influencing the pregnancy rate after microsurgical cornual anastomosis. Fertil Steril 1986;46:1089-1092
309
24. McComb P: Microsurgical tubocornual anastomosis for occlusive cornual disease: Reproducible results without the need for tubouterine implantation. Fertil Steril 1986;46:571577 25. Gomel V: Microsurgical reversal of female sterilization: A reappraisal. Fertil Steril 1980;33:587-597 26. Winston RML: Reversal of sterilization. Clin Obstet Gynecol 1980;23:1261-1268 27. Xue P, Fa Y-Y: Microsurgical reversal of female sterilization. J Reprod Med 1989;34:45t-455
Victor Gomel 1 Department of Obstetrics and Gynaecology University of British Columbia University and Grace Hospitals Vancouver, B.C., Canada Patrick J. Taylor Department of Obstetrics and Gynaecology University of British Columbia St. Paul's Hospital Vancouver, B.C., Canada 1 To whom correspondence should be addressed.
Tubal Surgery or in Vitro Fertilization (IVF)? Some authors (1) unthinkingly state that reproductive surgery is now obsolete. A more thoughtful view is that the introduction of IVF has resulted in great improvements in surgical management by ensuring better selection of surgical cases and consequently improved results. Boer-Meisel et al. (2) were among the first to show that results following salpingostomy were related principally to the degree of tubal damage. Sadly, other reproductive surgeons have not followed their lead. Had a classification system for tubal damage been agreed upon sooner, many women could have had more logical planning of treatment. Not all tubal damage is suitable for surgery. The lead should have been taken from gynecological oncologists, who have long recognized that it is entirely inappropriate to offer Wertheim's hysterectomy for Stage IV of the cervix. The treatment of hydrosalpinges by salpingostomy illustrates the point particularly well. Although operations to open the fimbria carry the worst progJournal of Assisted Reproduction and Genetics, Vol. 9, No. 4, 1992
nosis of all fertility surgery, in properly selected cases salpingostomy gives term pregnancy rates of 35-45% (3,4). This is over twice the live delivery rate achieved after a cycle of treatment in only a very few of the best IVF programs. Against this relatively good success rate must be set the fact that results are generally not immediate; most series report that the majority of pregnancies occurs only after a year following salpingostomy, presumably because epithelial regeneration is slow. Treatment of cornual block, revolutionized by microsurgical cornual anastomosis, is more successful. It carries term pregnancy rates of 45-60% (5-7), and results are better than those after multiple IVF cycles. Moreover, most pregnancies after cornual surgery occur within 8 months. Adhesiolysis, whether by open surgery or by laser laparoscopy, also has results superior to IVF in a single cycle. Good results are obtained only in patients with limited pathology, who should be offered the most appropriate treat-
