IVF,Infertility,Fallopian tubes,micro surgery,ART

1. TUBOTUBAL ANASTOMOSIS V/S IVF
INTHIS ERA
DR SANJAY MAKWANA
MS.,FICOG,FIAGES
Vasundhara Hospital Ltd. Jodhpur
www.vasundharafertility.com

2. • Tubal damage – 25-35% cases of infertility

3. • Fallopian tube interruption is a common form
of contraception worldwide. For a variety of
reasons (e.g. change in marital status, wish
for additional children, psychological factors),
many of these women seek restoration of
fertility.
• (Fertil-steril 2000,2008, Obst Gynecol survey 94)

4. Point to check…
• Age, ovarian reserve, prior fertility, no. of
children desired , site & extent of tubal damage,
presence of other infertility factors.
• Experience of the surgeon
• Success rates of the IVF program
• Patient preference, religious beliefs, cost, and
insurance reimbursement

5. PATIENT SCREENING AND SELECTION
Basic infetility work up
Exclude other factors
Semen analysis
IVF better choice with other co- existing factors

6. Treatment ofTubal Factor Infertility
1. Surgical Approach
Laparotomy : Microsurgical technique
Laparoscopy / Pelviscopy
Transcervical : Tubal recanalization
2. Assisted ReproductiveTechnology (ART)
IVF - ET

7. Tubal Surgery /Tuboplasty
1. Adhesiolysis
Salpingoovariolysis
2. Proximal Tubal Occlusion
Tubocornual reanastomosis
Fluoroscopic recanalization
Transcervical balloon tuboplasty
3. DistalTubal Occlusion
Fimbrioplasty
Neosalpingostomy
4.Tubal sterilization (T/L)
Tubal reanastomosis (TR)

8. Tubal Reanastomosis
Prognosis ofTR depends on
Method of ligation
Repair site of tube
Residual tubal length
Other causes of infertility
Bipolar coagulation : PR 49%
Ring, clip : PR 67%
PomeroyT/L : PR 75%
(S. Gordts Fertil steril 2009., Kim jd 1997)

9. Tubal Reanastomosis
• Better prognosis with small difference in diameter
of reconstructed tubal locations
Isthmus – isthmus
Ampulla – isthmus
Ampulla - Ampulla
( Laparoscopic micro surgery - Koh and Janik, 1996).

10. Tubal Reanastomosis
Method and location of ligation
The time interval between tubal ligation and its reversal
Potential postop. tubal length
Coexistent pelvic disease
• Gomel & Swolin, 1980
Low PR : < 4 cm of postop. tubal length
Inverse correlation between postop. tubal length
and interval to pregnancy
• In older women > 40 yrs
TR (Trimpos & Kemper, 1980)
PR : 45%, Interval to pregnancy 5.5 months
IVF-ET (Tan, 1992)
CPR : 10%
 TR indicated after 3 cycles of IVF-ET

11. Reversal ofTubal Ligation by Microsurgery
Author Patients T/L Type of Duration of Intrauterine Ectopic Term
techniques TR follow-up preg. preg. preg.
Winston (1977) 16 Partial resection, Tubocornual - 11 (69) 1 (6) -
diathermy
Gomel (1980) 118 Mostly Pomeroy Tubotubal < 40 months 76 (64) 1 (1) 69 (58)
Silber & Cohen 25 Mostly Tubocornual > 1 year 14 (56) 1 (4) -
(1980) Coagulation Tubotubal
Winston (1980) 62 - Tubotubal - 37 (60) 2 (3) -
43 - Tubocornual 26 (60) 1 (2)
Rock et al. 22 Fallopian ring Tubotubal 40 months 20 (91) 2 (9) 19 (86)
(1987) 58 Unipolar cautery Tubotubal 40 months 38 (66) 8 (14) 30 (52)
Trimbos-Kemper 45 Coagulation 15 (33) 3 (7)
(1990) 9 Pomeroy - 12-29 months 5 (56) 0 (0) 26 (33)*
24 Rings and clips 15 (63) 0 (0)

12. Tubal Reanastomosis
• Gomel, 1980
PR : 64%, Ectopic PR : 1%
Interval to pregnancy : 10.2 months
• Kim et al, 1997 (n=1,118)
Anatomic patency rate : 88.2%
PR : 54.8%, DR : 72.5%
• K.jayakrishnan, 2011 journal of Hu.Reprod. sc.
The pregnancy rate was better for laparoscopic sterilization
by Falope ring (85.7%), as compared with those with
Pomeroy's procedure (40%).

13. Tubal Reanastomosis
• Procedure - End to end tubal anastomosis was performed by
single / two -layer closure using no 6–0 prolene. First four sutures
at 6, 3, 9, and 12 o’clock were taken in the muscularis layer and
then the serosal stitches.
• Hemostasis was achieved by precise electrocoagulation by bipolar
cautery at low current setting and injection of diluted vasopressin
to mesosalpinx.The patency was assured
intraoperatively by methylene blue
injection

14. IVF - ET
 Alternative of choice to surgical approach
 Dominant role in treatment of tubal factor infertility
 Growing number of qualified IVF centers
Nearly equal to availability of tubal surgery
 Requirement of expertise and credentialing
Tubal surgery can be performed, although perhaps less
successfully, by those without speciality training.

15.  Benadiva, 1995
Is pelvic reconstructive surgery obsolete?
 Penzias, 1996
Is there ever a role for tubal surgery?
 Dubuisson, 1998
Are there still indications for tubal surgery in infertility?
Status of ART

16. Tuboplasty vs. IVF-ET
Procedures
TR (1990)
Fimbrial recanalization (1990)
Transcervical tuboplasty (1990)
Salpingolysis (1991)
Laparoscopic fimbrioplasty (1991)
Laparoscopic salpingolysis (1992)
Laparoscopic distal tuboplasty (1993)
Tubal reconstruction (1996)
Lap. Micro surgical anastomosis (2011)
SART/ASRM IVF registry (2010)
SART/ASRM IVF registry (2012)
Pregnancy Rate
49 - 75 %
34 %
31 %
30 - 60 %
30 - 70 %
62 - 67 %
27 %
40 %
84%
32.4 %
35.2 %

17. Standard IVF-ET by Maternal Age
SART & ASRM 2010
< 35 yrs, male factor (-)
35 - 37 yrs, male factor (-)
38 - 40 yrs, male factor (-)
> 40 yrs, male factor (-)
Cancellation
rate (%)
10.2
14.8
19.3
24.4
Delivery /
retrieval (%)
33.9
29.4
21.2
9.4

18. Tuboplasty or IVF ?
• Tuboplasty
Mild or moderate tubal disease
Young female
• IVF-ET
Extensive pelvic adhesion
Old age
Impossible tubal reconstruction due to absence
of tubes or history of tuberculous salpingitis
Failed tubal surgery
Existence of other infertility factors

19. Considerations forTuboplasty or IVF ?
• Technical view : Invasiveness
Infertility factors involved
• Nontechnical view : Cost
Wishes of patients
• Surgery : Specialty training
• (surgeon considering laparoscopic tubal microsurgery
should be competent with both the traditional techniques
of microsurgery and intra corporeal micro suturing )
• IVF-ET : Expertise and credentialing of the program

20. Advantages and Disadvantages
IVF• per-cycle success rates and the fact that it is less surgically invasive
.
• Its disadvantages are generalizable to surgeons with less skill and
experience and include cost (especially if more than one cycle is
required),
• the frequent injections / monitoring , most significantly, risks of
multiple pregnancy and OHSS
• IVF alone has been associated with a higher incidence of adverse
perinatal outcomes in singleton infants such as perinatal mortality,
preterm delivery, low and very low birth weights, intrauterine
growth retardation, and congenital malformations

22. • The advantages of Lap. tubal surgery are that it is a
one-time, usually minimally invasive outpatient
procedure, and patients may attempt conception
every month without further intervention and may
conceive more than once
• They also avoid the risks associated with IVF.
• The disadvantages are the risks for surgical
complications, While the risk of ectopic pregnancy is
increased in patients having IVF for tubal disease, it is
higher after tubal surgery.

23. • Tubal anastomosis had a higher cumulative
pregnancy rate for women less than 37 years
of age, no significant difference above 37
years of age.
• Human reproduction 2007: P Devroey

24. Comparison of Cost per Delivery

25. Patient Counselling

26. • The most recent national assisted reproductive
technology (ART) registry data from 2012 noted a
32.4% live-birth rate per cycle initiated in patients with
tubal infertility, similar to the 34.1% rate overall(SART).
• Meaningful success rates with the various tubal
surgical procedures are largely lacking. Most of the
published literature is from surgeons with the greatest
expertise.Their results may not be generalizable to less
skilled or experienced surgeons.

28. • The results of tubal surgery and IVF are not directly
comparable because surgical success is reported as
pregnancy rate per patient, whereas IVF success
rates are per cycle. As a result, there are no
adequate trials comparing pregnancy rates with tubal
surgery versus IVF .
• ( Cochrane Database syst rev. 2008 )
However IVF has a higher per cycle pregnancy rate
whereas tubal anastomoses has higher cumulative
pregnancy rate and is more cost effective

29. Ann Acad Med Singapore. 2010 Jan;39(1):22-6.
Microsurgical reversal of sterilisation - is this still clinically relevant
today?
Tan HH,Loh SF.
• Pregnancy (77.8% vs 70.0%) and live birth rates (66.7% vs 60.0%)
were similar between laparoscopy and open surgery.The mean
interval to pregnancy was marginally lower via laparoscopy (11.3 vs
13.6 months). Hospitalisation stay was significantly halved (1.43 vs
3.00 days) but ectopic pregnancies were increased 3-fold (3 vs 1) with
laparoscopy. Compared with IVF, the estimated average cost per
delivery for laparoscopic reversal was reduced for laparoscopic
reversal with no multiple pregnancies.

30. Hum Reprod. 2012 Jun;27(6):1657-62. doi: 10.1093/humrep/des078.
Epub 2012 Mar 27.
High pregnancy rate after microsurgical tubal reanastomosis by
temporary loose parallel 4-quadrant sutures technique: a long
long-term follow-up report on 961 cases.
Moon HS1, Joo BS, Park GS, Moon SE, Kim SG, Koo JS.
• The overall pregnancy rate was 85.1, 82.6 being
intrauterine and 2.5% ectopic.

31. Tuboplasty vs. IVF-ET
Conclusions
1.The goal for infertile couples should be live birth or
at least the ability to feel that they did their best.
2.These options should be carefully considered and
individualized, regarded as complementary,
not competitive, to achieve the desired goal.