Tuboplasty vs. IVF - ET Tuboplasty vs. IVF - ET Seok Hyun Kim, M.D. Department of Obstetrics and Gynecology College of Medicine, Seoul National University

Tuboplasty vs. IVF - ETTuboplasty vs. IVF - ET

Seok Hyun Kim, M.D.Seok Hyun Kim, M.D.

Department of Obstetrics and GynecologyDepartment of Obstetrics and GynecologyCollege of Medicine, Seoul National UniversityCollege of Medicine, Seoul National University

Seoul, KoreaSeoul, Korea

Tubal Factor InfertilityTubal Factor Infertility

# Etiology# Etiology

InfectionInfection

History of laparotomyHistory of laparotomy

Congenital anomalyCongenital anomaly

PIDPID

STDSTD

Treatment of Tubal Factor InfertilityTreatment of Tubal Factor Infertility

1. 1. Surgical ApproachSurgical Approach

Laparotomy : Microsurgical techniqueLaparotomy : Microsurgical technique

Laparoscopy / Pelviscopy Laparoscopy / Pelviscopy

Transcervical : Tubal recanalization Transcervical : Tubal recanalization

2. Assisted Reproductive Technology (ART)2. Assisted Reproductive Technology (ART) IVF - ETIVF - ET

Choice of Treatment OptionsChoice of Treatment Options

Age of patientAge of patient Etiology of tubal diseaseEtiology of tubal disease Extent of tubal diseaseExtent of tubal disease History of laparotomyHistory of laparotomy Other causes of infertilityOther causes of infertility Cost : medical / surgicalCost : medical / surgical

Tubal Surgery / TuboplastyTubal Surgery / Tuboplasty

1. 1. AdhesiolysisAdhesiolysis

SalpingoovariolysisSalpingoovariolysis 2. 2. Proximal Tubal OcclusionProximal Tubal Occlusion Tubocornual reanastomosisTubocornual reanastomosis Fluoroscopic recanalizationFluoroscopic recanalization Transcervical balloon tuboplastyTranscervical balloon tuboplasty 3. Distal Tubal Occlusion3. Distal Tubal Occlusion FimbrioplastyFimbrioplasty NeosalpingostomyNeosalpingostomy 4. Tubal sterilization (T/L)4. Tubal sterilization (T/L) Tubal reanastomosis (TR)Tubal reanastomosis (TR)

Tubal SurgeryTubal Surgery

# # Prevention of adhesionsPrevention of adhesions

Anti-inflammatory agentAnti-inflammatory agent

Fibrinolytic agentFibrinolytic agent

Barrier agentBarrier agent

Meticulous bleeding controlMeticulous bleeding control

Pelviscopic operationPelviscopic operation

Pelviscopic Tubal SurgeryPelviscopic Tubal Surgery

Lower costLower cost

Shorter hospitalizationShorter hospitalization

Faster recoveryFaster recovery

Better complianceBetter compliance

Prognostic Variables of Tubal SurgeryPrognostic Variables of Tubal Surgery

Author

AFS, 1988

Winston & Margara, 1991

Variables in classification

Distal ampullary diameter

Tubal wall thickness

Mucosal folds at neostomy site

Type and extent of adhesions

Degree of mucosal damage

Degree of tubal fibrosis

Presence of isthmic disease

Quality of tubal / ovarian adhesions

Peritubal AdhesionPeritubal Adhesion

Microsurgery Microsurgery PR 21~62%PR 21~62% Filmy adhesionFilmy adhesion PR 39% (Hulka, 1982)PR 39% (Hulka, 1982) CPR 68% CPR 68% ((Oelsner, 1994) Oelsner, 1994) Dense adhesionDense adhesion PR 21% (Hulka, 1982)PR 21% (Hulka, 1982) CPR 34% CPR 34% ((Oelsner, 1994) Oelsner, 1994)

cfcf. IVF-ET : CPR 49~51% . IVF-ET : CPR 49~51% ((Guzik, 1986; Tan, 1992)Guzik, 1986; Tan, 1992)

Peritubal AdhesionPeritubal Adhesion

Kelly & Roberts, 1983Kelly & Roberts, 1983

1 year follow-up1 year follow-up

PR 24%PR 24%

Interval to pregnancy 5.2 monthsInterval to pregnancy 5.2 months

Donnez & Casanas-Roux, 1986Donnez & Casanas-Roux, 1986

Term PR 64%Term PR 64%

Ectopic PR 2%Ectopic PR 2%

Adhesiolysis by Microsurgery Author Patients Duration of Intrauterine Ectopic Term follow-up preg. preg. preg.

Diamond (1979) 140 > 1 year 86 (61) 8 (6) 80 (57)Hulka (1982) 23 filmy 6 months-4 years 9 (39) 0 (0) 8 (35)

24 dense 5 (21) 1 (4) 4 (17)Frantzen & Schlosser 49 1 year 20 (41) 2 (4) 19 (39) (1982) Kelly & Roberts 21 28 months 5 (24) 0 (0) 4 (19) (1983) Donnez & Casanas- 42 12-86 months - 1 (2) 27 (64) Roux (1986) Luber et al. (1986) 13 3 years 8 (62) 1 (8) 7 (54)Jacobs et al. (1988) 15 50 months 7 (47) 0 (0) 6 (40)Singhal et al. (1991) 78 55 months 32 (41) 4 (5) 29 (37)Oelsner et al. (1994) 19 filmy 101 months 13 (68) 3 (16) 8 (42)

32 dense 11 (34) 1 (3) 6 (19)

Values in parentheses are percentages.

Pelviscopic AdhesiolysisPelviscopic Adhesiolysis

Gomel, 1989Gomel, 1989

PR 57~62%PR 57~62%

Half of pregnancy : < 6 monthsHalf of pregnancy : < 6 months

Dense type adhesionDense type adhesion

Laparotomy more effectiveLaparotomy more effective

due to technical problemsdue to technical problems

Adhesiolysis by Laparoscopy

Author Patients Duration of Intrauterine Ectopic Term

follow-up preg. preg. preg.

Bruhat et al. (1982) 66 moderate > 18 months 36 (55) 5 (8) -

27 severe 12 (44) 2 (7) -

Donnez (1987)32 avascular 18 months - - 20 (62)

22 vascular 11 (50)

Fayez (1988) 49 2 years 28 (57) 2 (4) 23 (47)

Gomel (1989) 92 > 9 months 57 (62) 5 (5) 54 (59)


Proximal Tubal ObstructionProximal Tubal Obstruction

Tubocornual implantationTubocornual implantation Standard Tx. until 1970’sStandard Tx. until 1970’s

Tubocornual reanastomosisTubocornual reanastomosis Recent improvement in results : PR ~45%Recent improvement in results : PR ~45%

Donnez & Casanas-Roux, 1986Donnez & Casanas-Roux, 1986

Damaged isthmic length < 1 cm : PR 45%Damaged isthmic length < 1 cm : PR 45%

1 cm : PR 22%1 cm : PR 22%


Tubocornual reanastomosisTubocornual reanastomosis McComb & Gomel, 1980McComb & Gomel, 1980 PR 58%, Term PR PR 58%, Term PR 53%, 53%, Ectopic PR 12% Ectopic PR 12% JacobJacob, 1988, 1988 PR 65%, Ectopic PR 6%PR 65%, Ectopic PR 6% Dubuisson, Dubuisson, 19971997 Interval to pregnancy 10.1 monthsInterval to pregnancy 10.1 months Term PR 57%, Ectopic PR 11%Term PR 57%, Ectopic PR 11%

cfcf. Comparable to IVF-ET : CPR 49% . Comparable to IVF-ET : CPR 49% ((Guzik, 1986Guzik, 1986) )


# Avoidance of peritoneal entry# Avoidance of peritoneal entry Prevention of adhesion formationPrevention of adhesion formation

Use of USG, hysteroscopy,Use of USG, hysteroscopy, fluoroscopy,fluoroscopy,

and recanalization fallopioscopy and recanalization fallopioscopy

Fluoroscopic recanalization Fluoroscopic recanalization : : PR 31%PR 31%

Transcervical balloon tuboplastyTranscervical balloon tuboplasty : : PR 34%PR 34%

Transvaginal Bougie DilatationTransvaginal Bougie Dilatationand Selective Salpingographyand Selective Salpingography

Lang & Dunaway, 1996Lang & Dunaway, 1996 Case 187Case 187

Recanalization 145 (77.5%)Recanalization 145 (77.5%)

Pregnancy 24Pregnancy 24

PR / Case 12.8%PR / Case 12.8%

Major complication 1Major complication 1

Indications >Indications >

Salpingitis isthmica nodosa 62Salpingitis isthmica nodosa 62

Salpingitis and perisalpingitis 71Salpingitis and perisalpingitis 71

Endometriosis 8Endometriosis 8

Failed surgical anastomosis 43Failed surgical anastomosis 43

Proximal Tubal Operation by Microsurgery

Author Patients Duration of Intrauterine Ectopic Term follow-up preg. preg. preg.

Rock et al. (1979)** 52 50 months 13 (25) 2 (4) 8 (15)McComb & Gomel 38 - 23 (61) 2 (5) 20 (53) (1980)*Winston (1980)* 43 - - 1 (2) 16 (37)Frantzen & Chlosser 28 > 1 year 12 (43) 2 (7) 12 (43) (1982) *Gomel (1983)* 48 > 1 year 30 (63) 3 (6) 27 (56)McComb (1986)* 26 50 months 15 (58) 3 (12) 14 (54)Jacobs et al. (1988)* 17 3 years 11 (65) 1 (6) 8 (50)Donnez & Casanas- 82 - - 6 (7) 36 (44) Roux (1986)*Singhal et al. (1991)* 27 50 months 9 (33) 2 (8) 6 (22)Singhal et al. (1991)** 9 50 months 2 (22) 0 (0) 1 (11)Dubuisson et al. (1997)* 120 3 years 89 (74) 13 (11) 68 (57)

*Tuboconual anastomosis ** tubocornual implantation Values in parentheses are percentages.

Fallopioscopic TuboplastyFallopioscopic Tuboplasty

Sueoka, 1998Sueoka, 1998

50 patients with occluded tubes 50 patients with occluded tubes

HSG, Rubin test, Hysteroscopic hydrotubationHSG, Rubin test, Hysteroscopic hydrotubation

102 tubes treated during 53 attempts102 tubes treated during 53 attempts

Overall patency rate 79.4% after 1-3 monthsOverall patency rate 79.4% after 1-3 months

11 pregnancies over 3-year follow-up11 pregnancies over 3-year follow-up

Distal Tubal ObstructionDistal Tubal Obstruction

Reconstructive surgeryReconstructive surgery

FimbrioplastyFimbrioplasty NeosalpingostomyNeosalpingostomy

- Success : degree of tubal or peritubal disease.- Success : degree of tubal or peritubal disease.

- Poor prognostic factors- Poor prognostic factors of neosalpingostomy of neosalpingostomy Hydrosalpinx with diameter of 3 cm or largerHydrosalpinx with diameter of 3 cm or larger No visible fimbriaeNo visible fimbriae Dense pelvic adhesionDense pelvic adhesion

Salpingostomy by Microsurgery


Author Patients Duration of Intrauterine Ectopic Term follow-up preg. preg. preg.

Swolin (1975) 33 8 - 13 years 13 (39) 8 (24) 12 (36)Gomel (1978) 41 > 1 year 12 (29) 5 (12) 11 (27)DeCherney & Kase 54 > 2 years 20 (37) 4 (7) 14 (26) (1981)Mage & Bruhat (1983) 68 >18 months 19 (28) 6 (9) 14 (21)Tulandi & Vilos (1985) 67 2 years 15 (22) 3 (4) - Russel et al. (1986) 68 6 years 28 (42) 12 (18) 28 (42)Jacobs et al. (1988) 71 3 years 29 (41) 8 (11) 23 (32)Donnez & Casanas- 83 42 months - 6 (7) 26 (31) Roux (1986)Luber et al. (1986) 17 12 - 86 months 2 (12) 2 (12) 2 (12)Schlaff et al. (1990) 95 4 years 19 (20) 7 (7) -Winston & Margara 323 1-10 years 106 (33) 32 (10) 72 (23) (1991) Singhal et al. (1991) 97 50 months 33 (34) 6 (6) 28 (29)Audebert et al. (1991) 135 2 years 38 (28) 16 (12) -

Fimbrioplasty by Microsurgery

Author Patients Duration of Intrauterine Ectopic Term

follow-up preg. preg. preg.

Patton (1982) 35 2 years 21 (60) 1 (3) -

Jacobs et al. (1988) 29 3 years 20 (69) 2 (7) 17 (59)

Donnez & Casanas- 132 36 months - 2 (2) 79 (60)

Roux (1986)

Luber et al. (1986) 20 12-86 months 6 (30) 3 (15) 3 (15)

Audebert et al. 76 2 years 27 (36) 5 (7) -

(1991)



Superior results with Fimbrioplasty than NeosalpingostomySuperior results with Fimbrioplasty than Neosalpingostomy

Donnez & Casanas-Roux, 1986Donnez & Casanas-Roux, 1986 Fimbrioplasty : PR Fimbrioplasty : PR 60%60% Neosalpingostomy : PRNeosalpingostomy : PR 31% 31%

Posaci, Posaci, 19991999 Presence of dense adhesion, thick tubal wall, andPresence of dense adhesion, thick tubal wall, and abnormal tubal mucosa abnormal tubal mucosa : : Term PR 3%Term PR 3% Absence of these factors : Term PR 59%Absence of these factors : Term PR 59%

Both proximal and distal injuryBoth proximal and distal injury IVF-ET indicatedIVF-ET indicated


Pelviscopic surgeryPelviscopic surgery Lower PR, compared with microsurgeryLower PR, compared with microsurgery

Success rates related to extent of diseaseSuccess rates related to extent of disease

Audebert, Audebert, 19981998

PR : 51%PR : 51%

Ectopic PR : 23%Ectopic PR : 23%

Author Patients Type of Duration of Intrauterine Ectopic Term operation follow-up preg. preg. preg.

Fayez (1983) 14 Fimbrioplasty 2 years 3 (21) 2 (14) 3 (21) 19 Salpingoneostomy 2 years 0 (0) 2 (11) 0 (0)

Daniel & 21 Salpingostomy 18 months 4 (19) 1 (5) 2 (10) Herbert (1984)Dubuisson et al. 31 Fimbrioplasty 18 months 8 (26) 3 (10) 7 (23)* (1990) Salpingoneostomy 18 monthsCanis et al. 87 Fimbrioplasty 3 years 10 (29) 1 (3) - (1991) Salpingostomy 29 (33) 6 (7)Audebert et al 24 Fimbrioplasty 2 years 4 (17) 1 (4) - (1991) 31 Salpingostomy 4 (13) 2 (6)McComb & 22 Salpingostomy > 1 year - 1 (5) 5 (23) Paleologou (1991) Dubuisson et al. 81 Salpingostomy 3-60 months 26 (32) 4 (5) 26 (32) (1994)Audebert et al. 35 Fimbrioplasty 2-5 years 18 (51) 8 (23) 13 (37) (1998)* For the total group


Distal Tubal surgery by Laparoscopy

Tubal ReanastomosisTubal Reanastomosis

Performed in 0.2% of T/L patientsPerformed in 0.2% of T/L patients

Gomel, 1Gomel, 1980980 PR : 64%, Ectopic PR : PR : 64%, Ectopic PR : 1% 1% Interval to pregnancy : 10.2 monthsInterval to pregnancy : 10.2 months

Kim et al, 1997 (n=Kim et al, 1997 (n=1,118)1,118) Anatomic patency rate : 88.2%Anatomic patency rate : 88.2% PR : 54.8%, DR :PR : 54.8%, DR : 72.5% 72.5% The longer the postop. residual tubal length,The longer the postop. residual tubal length, the shorter the interval to pregnancy. the shorter the interval to pregnancy.

Prognosis of TRPrognosis of TR depends on depends on

Method of ligationMethod of ligation

Repair site of tube Repair site of tube

Residual tubal lengthResidual tubal length

Other causes of infertilityOther causes of infertility

# Bipolar coagulation : PR 49%# Bipolar coagulation : PR 49%

Ring, clip : PRRing, clip : PR 67% 67%

Pomeroy T/L : PRPomeroy T/L : PR 75% 75%


Better prognosis with small difference in diameterBetter prognosis with small difference in diameter

of reconstructed tubal locationsof reconstructed tubal locations

e.g. isthmus - isthmus (I-I)e.g. isthmus - isthmus (I-I)

cornua - isthmus (I-Icornua - isthmus (I-I))

Gomel & Swolin, 1980Gomel & Swolin, 1980 Low PR : < Low PR : < 4 4 cm of postop. tubal length cm of postop. tubal length Inverse correlation between postop. tubal lengthInverse correlation between postop. tubal length and interval to pregnancyand interval to pregnancy


Preoperative diagnostic laparoscopyPreoperative diagnostic laparoscopy Method and location of ligation Method and location of ligation Potential postop. tubal lengthPotential postop. tubal length Coexistent pelvic diseaseCoexistent pelvic disease

In In older women > 40 yrsolder women > 40 yrs TR TR (Trimpos & Kemper, 1980)(Trimpos & Kemper, 1980) PR : 45%, Interval to pregnancy 5.5 monthsPR : 45%, Interval to pregnancy 5.5 months IVF-ET IVF-ET (Tan, 1992)(Tan, 1992) CPR : 10%CPR : 10% TR indicated after 3 cycles of IVF-ETTR indicated after 3 cycles of IVF-ET


Reversal of Tubal Ligation by MicrosurgeryReversal of Tubal 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)

* For the total group


Fecundability of TuboplastyFecundability of Tuboplasty

Proximal tubal obstructionProximal tubal obstruction 3.5% (Gillett, 3.5% (Gillett, 1989)1989) Distal tubal obstructionDistal tubal obstruction 2~3% (Williams, 1988; Canis, 1991)2~3% (Williams, 1988; Canis, 1991) Tubal reanastomosisTubal reanastomosis 8% (Henderson, 8% (Henderson, 1984)1984) Secondary tuboplastySecondary tuboplasty 1% (Lauritsen, 1% (Lauritsen, 1982)1982)

Expertise required : Expertise required : tubal surgery specialisttubal surgery specialist

IVF - ETIVF - ET

Alternative of choice to surgical approachAlternative of choice to surgical approach

Dominant role in treatment of tubal factor infertilityDominant role in treatment of tubal factor infertility

Growing number of qualified IVF centersGrowing number of qualified IVF centers Nearly equal to availability of tubal surgeryNearly equal to availability of tubal surgery

Requirement of expertise and credentialingRequirement of expertise and credentialing Tubal surgery can be performed, although perhaps less Tubal surgery can be performed, although perhaps less

successfully, by those without speciality training.successfully, by those without speciality training.

Benadiva, 1995Benadiva, 1995 Is pelvic reconstructive surgery obsolete?Is pelvic reconstructive surgery obsolete?

Penzias, 1996Penzias, 1996 Is there ever a role for tubal surgery?Is there ever a role for tubal surgery?

Dubuisson, 1998Dubuisson, 1998 Are there still indications for tubal surgery in infertility?Are there still indications for tubal surgery in infertility?

Status of ART

Tuboplasty vs. IVF-ETTuboplasty 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)

SART/ASRM IVF registry (1995)

SART/ASRM IVF registry (1997)

Pregnancy Rate

49 - 75 %

34 %

31 %

30 - 60 %

30 - 70 %

62 - 67 %

27 %

40 %

28.4 %

28.9 %

Comparison of Reported Outcomes Comparison of Reported Outcomes for ART Procedures for ART Procedures

No. of cycles

ET / retrieval (%)

No. of clinical preg.

Delivery /retrieval (%)

Ectopic preg. /ET (%)

SART & ASRM, 1997

IVF

33,032

92.8

8,975

28.4

0.9

IVF + ICSI

18,312

94.3

6,072

27.1

0.6

GIFT

1,943

98.6

627

30.0

1.0

Standard IVF-ET by Maternal AgeStandard IVF-ET by Maternal Age

SART & ASRM,1997

< 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

Tuboplasty or IVF ?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

Considerations for Tuboplasty or IVF ?Considerations for Tuboplasty or IVF ?

Technical view : InvasivenessTechnical view : Invasiveness

Infertility factors involvedInfertility factors involved Nontechnical view : CostNontechnical view : Cost

Wishes of patientsWishes of patients Surgery : Specialty trainingSurgery : Specialty training IVF-ET : Expertise and credentialingIVF-ET : Expertise and credentialing Development of operative laparoscopy, microsurgeryDevelopment of operative laparoscopy, microsurgery

Comparison of Cost per DeliveryComparison of Cost per Delivery

Cost per delivery

Holst, 1991 (Norway)

Neumann, 1994 (USA)

Van Voorhis, 1997 (USA)

Tubal surgery

$ 17,000

$ 50,000

$ 76,232

IVF-ET

$ 12,000

$ 66,000

$ 43,138

Patient CounsellingPatient Counselling

Fecundability Tuboplasty : 2-4% IVF - ET : 20%

Successful tuboplasty : more than one pregnancy possible

Women’s age, infertility factor

Take-home-baby rate and CPR of IVF, No. of IVF cycles

Potential complications Multiple pregnancy, abortion, ectopic pregnancy

Tuboplasty vs. IVF-ETTuboplasty vs. IVF-ET

ConclusionsConclusions

1. The goal for infertile couples should be 1. The goal for infertile couples should be live birthlive birth or or

at least the ability to feel that they at least the ability to feel that they did their bestdid their best..

2. These options should be carefully considered and2. These options should be carefully considered and

individualized, regarded as individualized, regarded as complementary,complementary,

not competitive,not competitive, to achieve the desired goal. to achieve the desired goal.

Documents

Tuboplasty vs. IVF - ET Tuboplasty vs. IVF - ET Seok Hyun Kim, M.D. Department of Obstetrics and Gynecology College of Medicine, Seoul National University