TUBO TUBAL ANASTOMOSIS VS IVF IN THIS ERA

DR SANJAY MAKWANA

MSFICOGFIAGES

Vasundhara Hospital Ltd Jodhpur

wwwvasundharafertilitycom

bull Tubal damage ndash 25-35 cases of infertility

bull Fallopian tube interruption is a common form

of contraception worldwide For a variety of

reasons (eg change in marital status wish

for additional children psychological factors)

many of these women seek restoration of

fertility

bull (Fertil-steril 20002008 Obst Gynecol survey 94)

Point to checkhellip

bull Age ovarian reserve prior fertility no of

children desired site amp extent of tubal damage

presence of other infertility factors

bull Experience of the surgeon

bull Success rates of the IVF program

bull Patient preference religious beliefs cost and

insurance reimbursement

PATIENT SCREENING AND SELECTION

Basic infetility work up

Exclude other factors

Semen analysis

IVF better choice with other co- existing factors

Treatment of Tubal Factor Infertility

1 Surgical Approach

Laparotomy Microsurgical technique

Laparoscopy Pelviscopy

Transcervical Tubal recanalization

2 Assisted Reproductive Technology (ART)

IVF - ET

Tubal Surgery Tuboplasty

1 Adhesiolysis

Salpingoovariolysis2 Proximal Tubal Occlusion

Tubocornual reanastomosisFluoroscopic recanalizationTranscervical balloon tuboplasty

3 Distal Tubal OcclusionFimbrioplastyNeosalpingostomy

4 Tubal sterilization (TL)Tubal reanastomosis (TR)

Tubal Reanastomosis

Prognosis of TR depends on

Method of ligation

Repair site of tube

Residual tubal length

Other causes of infertility

Bipolar coagulation PR 49

Ring clip PR 67

Pomeroy TL PR 75

(S Gordts Fertil steril 2009 Kim jd 1997)

Tubal Reanastomosis

bull Better prognosis with small difference in diameter

of reconstructed tubal locations

Isthmus ndash isthmus

Ampulla ndash isthmus

Ampulla - Ampulla

( Laparoscopic micro surgery - Koh and Janik 1996)

Tubal ReanastomosisMethod and location of ligation

The time interval between tubal ligation and its reversalPotential postop tubal lengthCoexistent pelvic disease

bull Gomel amp Swolin 1980

Low PR lt 4 cm of postop tubal length Inverse correlation between postop tubal lengthand interval to pregnancy

bull In older women gt 40 yrs

TR (Trimpos amp Kemper 1980)PR 45 Interval to pregnancy 55 months

IVF-ET (Tan 1992)CPR 10 TR indicated after 3 cycles of IVF-ET

Reversal of Tubal Ligation by Microsurgery

Author Patients TL 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 lt 40 months 76 (64) 1 (1) 69 (58)

Silber amp Cohen 25 Mostly Tubocornual gt 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)

Tubal Reanastomosis

bull Gomel 1980

PR 64 Ectopic PR 1 Interval to pregnancy 102 months

bull Kim et al 1997 (n=1118)

Anatomic patency rate 882PR 548 DR 725

bull Kjayakrishnan 2011 journal of HuReprod sc The pregnancy rate was better for laparoscopic sterilization by Falope ring (857) as compared with those with Pomeroys procedure (40)

Tubal Reanastomosis

bull Procedure - End to end tubal anastomosis was performed by

single two -layer closure using no 6ndash0 prolene First four sutures

at 6 3 9 and 12 orsquoclock were taken in the muscularis layer and

then the serosal stitches

bull 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

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

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

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)

SARTASRM IVF registry (2010)

SARTASRM IVF registry (2012)

Pregnancy Rate

49 - 75

34

31

30 - 60

30 - 70

62 - 67

27

40

84

324

352

Standard IVF-ET by Maternal Age

SART amp ASRM 2010

lt 35 yrs male factor (-)

35 - 37 yrs male factor (-)

38 - 40 yrs male factor (-)

gt 40 yrs male factor (-)

Cancellation

rate ()

102

148

193

244

Delivery

retrieval ()

339

294

212

94

Tuboplasty or IVF

bull TuboplastyMild or moderate tubal diseaseYoung female

bull IVF-ETExtensive pelvic adhesionOld age Impossible tubal reconstruction due to absenceof tubes or history of tuberculous salpingitis

Failed tubal surgeryExistence of other infertility factors

Considerations for Tuboplasty or IVF

bull Technical view Invasiveness

Infertility factors involved

bull Nontechnical view Cost

Wishes of patients

bull Surgery Specialty training

bull (surgeon considering laparoscopic tubal microsurgery

should be competent with both the traditional techniques

of microsurgery and intra corporeal micro suturing )

bull IVF-ET Expertise and credentialing of the program

Advantages and Disadvantages IVF bull per-cycle success rates and the fact that it is less surgically invasive

bull Its disadvantages are generalizable to surgeons with less skill and

experience and include cost (especially if more than one cycle is

required)

bull the frequent injections monitoring most significantly risks of

multiple pregnancy and OHSS

bull 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

bull (Human Reproduction 05 Fertil Steril 2009 2010)

bull 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

bull They also avoid the risks associated with IVF

bull 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

bull Tubal anastomosis had a higher cumulative

pregnancy rate for women less than 37 years

of age no significant difference above 37

years of age

bull Human reproduction 2007 P Devroey

Comparison of Cost per Delivery

Patient Counselling

bull The most recent national assisted reproductive

technology (ART) registry data from 2012 noted a

324 live-birth rate per cycle initiated in patients with

tubal infertility similar to the 341 rate overall(SART)

bull 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

bull 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

bull ( 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

Ann Acad Med Singapore 2010 Jan39(1)22-6Microsurgical reversal of sterilisation - is this still clinically relevant

todayTan HHLoh SF

bull Pregnancy (778 vs 700) and live birth rates (667 vs 600)

were similar between laparoscopy and open surgery The mean

interval to pregnancy was marginally lower via laparoscopy (113 vs

136 months) Hospitalisation stay was significantly halved (143 vs

300 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

Hum Reprod 2012 Jun27(6)1657-62 doi 101093humrepdes078 Epub 2012 Mar 27

High pregnancy rate after microsurgical tubal reanastomosis bytemporary loose parallel 4-quadrant sutures technique a long

long-term follow-up report on 961 casesMoon HS1 Joo BS Park GS Moon SE Kim SG Koo JS

bull The overall pregnancy rate was 851 826 being

intrauterine and 25 ectopic

bull Tubal damage ndash 25-35 cases of infertility

bull Fallopian tube interruption is a common form

of contraception worldwide For a variety of

reasons (eg change in marital status wish

for additional children psychological factors)

many of these women seek restoration of

fertility

bull (Fertil-steril 20002008 Obst Gynecol survey 94)

Point to checkhellip

bull Age ovarian reserve prior fertility no of

children desired site amp extent of tubal damage

presence of other infertility factors

bull Experience of the surgeon

bull Success rates of the IVF program

bull Patient preference religious beliefs cost and

insurance reimbursement

PATIENT SCREENING AND SELECTION

Basic infetility work up

Exclude other factors

Semen analysis

IVF better choice with other co- existing factors

Treatment of Tubal Factor Infertility

1 Surgical Approach

Laparotomy Microsurgical technique

Laparoscopy Pelviscopy

Transcervical Tubal recanalization

2 Assisted Reproductive Technology (ART)

IVF - ET

Tubal Surgery Tuboplasty

1 Adhesiolysis

Salpingoovariolysis2 Proximal Tubal Occlusion

Tubocornual reanastomosisFluoroscopic recanalizationTranscervical balloon tuboplasty

3 Distal Tubal OcclusionFimbrioplastyNeosalpingostomy

4 Tubal sterilization (TL)Tubal reanastomosis (TR)

Tubal Reanastomosis

Prognosis of TR depends on

Method of ligation

Repair site of tube

Residual tubal length

Other causes of infertility

Bipolar coagulation PR 49

Ring clip PR 67

Pomeroy TL PR 75

(S Gordts Fertil steril 2009 Kim jd 1997)

Tubal Reanastomosis

bull Better prognosis with small difference in diameter

of reconstructed tubal locations

Isthmus ndash isthmus

Ampulla ndash isthmus

Ampulla - Ampulla

( Laparoscopic micro surgery - Koh and Janik 1996)

Tubal ReanastomosisMethod and location of ligation

The time interval between tubal ligation and its reversalPotential postop tubal lengthCoexistent pelvic disease

bull Gomel amp Swolin 1980

Low PR lt 4 cm of postop tubal length Inverse correlation between postop tubal lengthand interval to pregnancy

bull In older women gt 40 yrs

TR (Trimpos amp Kemper 1980)PR 45 Interval to pregnancy 55 months

IVF-ET (Tan 1992)CPR 10 TR indicated after 3 cycles of IVF-ET

Reversal of Tubal Ligation by Microsurgery

Author Patients TL 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 lt 40 months 76 (64) 1 (1) 69 (58)

Silber amp Cohen 25 Mostly Tubocornual gt 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)

Tubal Reanastomosis

bull Gomel 1980

PR 64 Ectopic PR 1 Interval to pregnancy 102 months

bull Kim et al 1997 (n=1118)

Anatomic patency rate 882PR 548 DR 725

bull Kjayakrishnan 2011 journal of HuReprod sc The pregnancy rate was better for laparoscopic sterilization by Falope ring (857) as compared with those with Pomeroys procedure (40)

Tubal Reanastomosis

bull Procedure - End to end tubal anastomosis was performed by

single two -layer closure using no 6ndash0 prolene First four sutures

at 6 3 9 and 12 orsquoclock were taken in the muscularis layer and

then the serosal stitches

bull 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

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

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

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)

SARTASRM IVF registry (2010)

SARTASRM IVF registry (2012)

Pregnancy Rate

49 - 75

34

31

30 - 60

30 - 70

62 - 67

27

40

84

324

352

Standard IVF-ET by Maternal Age

SART amp ASRM 2010

lt 35 yrs male factor (-)

35 - 37 yrs male factor (-)

38 - 40 yrs male factor (-)

gt 40 yrs male factor (-)

Cancellation

rate ()

102

148

193

244

Delivery

retrieval ()

339

294

212

94

Tuboplasty or IVF

bull TuboplastyMild or moderate tubal diseaseYoung female

bull IVF-ETExtensive pelvic adhesionOld age Impossible tubal reconstruction due to absenceof tubes or history of tuberculous salpingitis

Failed tubal surgeryExistence of other infertility factors

Considerations for Tuboplasty or IVF

bull Technical view Invasiveness

Infertility factors involved

bull Nontechnical view Cost

Wishes of patients

bull Surgery Specialty training

bull (surgeon considering laparoscopic tubal microsurgery

should be competent with both the traditional techniques

of microsurgery and intra corporeal micro suturing )

bull IVF-ET Expertise and credentialing of the program

Advantages and Disadvantages IVF bull per-cycle success rates and the fact that it is less surgically invasive

bull Its disadvantages are generalizable to surgeons with less skill and

experience and include cost (especially if more than one cycle is

required)

bull the frequent injections monitoring most significantly risks of

multiple pregnancy and OHSS

bull 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

bull (Human Reproduction 05 Fertil Steril 2009 2010)

bull 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

bull They also avoid the risks associated with IVF

bull 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

bull Tubal anastomosis had a higher cumulative

pregnancy rate for women less than 37 years

of age no significant difference above 37

years of age

bull Human reproduction 2007 P Devroey

Comparison of Cost per Delivery

Patient Counselling

bull The most recent national assisted reproductive

technology (ART) registry data from 2012 noted a

324 live-birth rate per cycle initiated in patients with

tubal infertility similar to the 341 rate overall(SART)

bull 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

bull 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

bull ( 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

Ann Acad Med Singapore 2010 Jan39(1)22-6Microsurgical reversal of sterilisation - is this still clinically relevant

todayTan HHLoh SF

bull Pregnancy (778 vs 700) and live birth rates (667 vs 600)

were similar between laparoscopy and open surgery The mean

interval to pregnancy was marginally lower via laparoscopy (113 vs

136 months) Hospitalisation stay was significantly halved (143 vs

300 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

Hum Reprod 2012 Jun27(6)1657-62 doi 101093humrepdes078 Epub 2012 Mar 27

High pregnancy rate after microsurgical tubal reanastomosis bytemporary loose parallel 4-quadrant sutures technique a long

long-term follow-up report on 961 casesMoon HS1 Joo BS Park GS Moon SE Kim SG Koo JS

bull The overall pregnancy rate was 851 826 being

intrauterine and 25 ectopic

bull Fallopian tube interruption is a common form

of contraception worldwide For a variety of

reasons (eg change in marital status wish

for additional children psychological factors)

many of these women seek restoration of

fertility

bull (Fertil-steril 20002008 Obst Gynecol survey 94)

Point to checkhellip

bull Age ovarian reserve prior fertility no of

children desired site amp extent of tubal damage

presence of other infertility factors

bull Experience of the surgeon

bull Success rates of the IVF program

bull Patient preference religious beliefs cost and

insurance reimbursement

PATIENT SCREENING AND SELECTION

Basic infetility work up

Exclude other factors

Semen analysis

IVF better choice with other co- existing factors

Treatment of Tubal Factor Infertility

1 Surgical Approach

Laparotomy Microsurgical technique

Laparoscopy Pelviscopy

Transcervical Tubal recanalization

2 Assisted Reproductive Technology (ART)

IVF - ET

Tubal Surgery Tuboplasty

1 Adhesiolysis

Salpingoovariolysis2 Proximal Tubal Occlusion

Tubocornual reanastomosisFluoroscopic recanalizationTranscervical balloon tuboplasty

3 Distal Tubal OcclusionFimbrioplastyNeosalpingostomy

4 Tubal sterilization (TL)Tubal reanastomosis (TR)

Tubal Reanastomosis

Prognosis of TR depends on

Method of ligation

Repair site of tube

Residual tubal length

Other causes of infertility

Bipolar coagulation PR 49

Ring clip PR 67

Pomeroy TL PR 75

(S Gordts Fertil steril 2009 Kim jd 1997)

Tubal Reanastomosis

bull Better prognosis with small difference in diameter

of reconstructed tubal locations

Isthmus ndash isthmus

Ampulla ndash isthmus

Ampulla - Ampulla

( Laparoscopic micro surgery - Koh and Janik 1996)

Tubal ReanastomosisMethod and location of ligation

The time interval between tubal ligation and its reversalPotential postop tubal lengthCoexistent pelvic disease

bull Gomel amp Swolin 1980

Low PR lt 4 cm of postop tubal length Inverse correlation between postop tubal lengthand interval to pregnancy

bull In older women gt 40 yrs

TR (Trimpos amp Kemper 1980)PR 45 Interval to pregnancy 55 months

IVF-ET (Tan 1992)CPR 10 TR indicated after 3 cycles of IVF-ET

Reversal of Tubal Ligation by Microsurgery

Author Patients TL 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 lt 40 months 76 (64) 1 (1) 69 (58)

Silber amp Cohen 25 Mostly Tubocornual gt 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)

Tubal Reanastomosis

bull Gomel 1980

PR 64 Ectopic PR 1 Interval to pregnancy 102 months

bull Kim et al 1997 (n=1118)

Anatomic patency rate 882PR 548 DR 725

bull Kjayakrishnan 2011 journal of HuReprod sc The pregnancy rate was better for laparoscopic sterilization by Falope ring (857) as compared with those with Pomeroys procedure (40)

Tubal Reanastomosis

bull Procedure - End to end tubal anastomosis was performed by

single two -layer closure using no 6ndash0 prolene First four sutures

at 6 3 9 and 12 orsquoclock were taken in the muscularis layer and

then the serosal stitches

bull 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

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

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

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)

SARTASRM IVF registry (2010)

SARTASRM IVF registry (2012)

Pregnancy Rate

49 - 75

34

31

30 - 60

30 - 70

62 - 67

27

40

84

324

352

Standard IVF-ET by Maternal Age

SART amp ASRM 2010

lt 35 yrs male factor (-)

35 - 37 yrs male factor (-)

38 - 40 yrs male factor (-)

gt 40 yrs male factor (-)

Cancellation

rate ()

102

148

193

244

Delivery

retrieval ()

339

294

212

94

Tuboplasty or IVF

bull TuboplastyMild or moderate tubal diseaseYoung female

bull IVF-ETExtensive pelvic adhesionOld age Impossible tubal reconstruction due to absenceof tubes or history of tuberculous salpingitis

Failed tubal surgeryExistence of other infertility factors

Considerations for Tuboplasty or IVF

bull Technical view Invasiveness

Infertility factors involved

bull Nontechnical view Cost

Wishes of patients

bull Surgery Specialty training

bull (surgeon considering laparoscopic tubal microsurgery

should be competent with both the traditional techniques

of microsurgery and intra corporeal micro suturing )

bull IVF-ET Expertise and credentialing of the program

Advantages and Disadvantages IVF bull per-cycle success rates and the fact that it is less surgically invasive

bull Its disadvantages are generalizable to surgeons with less skill and

experience and include cost (especially if more than one cycle is

required)

bull the frequent injections monitoring most significantly risks of

multiple pregnancy and OHSS

bull 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

bull (Human Reproduction 05 Fertil Steril 2009 2010)

bull 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

bull They also avoid the risks associated with IVF

bull 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

bull Tubal anastomosis had a higher cumulative

pregnancy rate for women less than 37 years

of age no significant difference above 37

years of age

bull Human reproduction 2007 P Devroey

Comparison of Cost per Delivery

Patient Counselling

bull The most recent national assisted reproductive

technology (ART) registry data from 2012 noted a

324 live-birth rate per cycle initiated in patients with

tubal infertility similar to the 341 rate overall(SART)

bull 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

bull 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

bull ( 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

Ann Acad Med Singapore 2010 Jan39(1)22-6Microsurgical reversal of sterilisation - is this still clinically relevant

todayTan HHLoh SF

bull Pregnancy (778 vs 700) and live birth rates (667 vs 600)

were similar between laparoscopy and open surgery The mean

interval to pregnancy was marginally lower via laparoscopy (113 vs

136 months) Hospitalisation stay was significantly halved (143 vs

300 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

Hum Reprod 2012 Jun27(6)1657-62 doi 101093humrepdes078 Epub 2012 Mar 27

High pregnancy rate after microsurgical tubal reanastomosis bytemporary loose parallel 4-quadrant sutures technique a long

long-term follow-up report on 961 casesMoon HS1 Joo BS Park GS Moon SE Kim SG Koo JS

bull The overall pregnancy rate was 851 826 being

intrauterine and 25 ectopic

Point to checkhellip

bull Age ovarian reserve prior fertility no of

children desired site amp extent of tubal damage

presence of other infertility factors

bull Experience of the surgeon

bull Success rates of the IVF program

bull Patient preference religious beliefs cost and

insurance reimbursement

PATIENT SCREENING AND SELECTION

Basic infetility work up

Exclude other factors

Semen analysis

IVF better choice with other co- existing factors

Treatment of Tubal Factor Infertility

1 Surgical Approach

Laparotomy Microsurgical technique

Laparoscopy Pelviscopy

Transcervical Tubal recanalization

2 Assisted Reproductive Technology (ART)

IVF - ET

Tubal Surgery Tuboplasty

1 Adhesiolysis

Salpingoovariolysis2 Proximal Tubal Occlusion

Tubocornual reanastomosisFluoroscopic recanalizationTranscervical balloon tuboplasty

3 Distal Tubal OcclusionFimbrioplastyNeosalpingostomy

4 Tubal sterilization (TL)Tubal reanastomosis (TR)

Tubal Reanastomosis

Prognosis of TR depends on

Method of ligation

Repair site of tube

Residual tubal length

Other causes of infertility

Bipolar coagulation PR 49

Ring clip PR 67

Pomeroy TL PR 75

(S Gordts Fertil steril 2009 Kim jd 1997)

Tubal Reanastomosis

bull Better prognosis with small difference in diameter

of reconstructed tubal locations

Isthmus ndash isthmus

Ampulla ndash isthmus

Ampulla - Ampulla

( Laparoscopic micro surgery - Koh and Janik 1996)

Tubal ReanastomosisMethod and location of ligation

The time interval between tubal ligation and its reversalPotential postop tubal lengthCoexistent pelvic disease

bull Gomel amp Swolin 1980

Low PR lt 4 cm of postop tubal length Inverse correlation between postop tubal lengthand interval to pregnancy

bull In older women gt 40 yrs

TR (Trimpos amp Kemper 1980)PR 45 Interval to pregnancy 55 months

IVF-ET (Tan 1992)CPR 10 TR indicated after 3 cycles of IVF-ET

Reversal of Tubal Ligation by Microsurgery

Author Patients TL 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 lt 40 months 76 (64) 1 (1) 69 (58)

Silber amp Cohen 25 Mostly Tubocornual gt 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)

Tubal Reanastomosis

bull Gomel 1980

PR 64 Ectopic PR 1 Interval to pregnancy 102 months

bull Kim et al 1997 (n=1118)

Anatomic patency rate 882PR 548 DR 725

bull Kjayakrishnan 2011 journal of HuReprod sc The pregnancy rate was better for laparoscopic sterilization by Falope ring (857) as compared with those with Pomeroys procedure (40)

Tubal Reanastomosis

bull Procedure - End to end tubal anastomosis was performed by

single two -layer closure using no 6ndash0 prolene First four sutures

at 6 3 9 and 12 orsquoclock were taken in the muscularis layer and

then the serosal stitches

bull 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

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

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

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)

SARTASRM IVF registry (2010)

SARTASRM IVF registry (2012)

Pregnancy Rate

49 - 75

34

31

30 - 60

30 - 70

62 - 67

27

40

84

324

352

Standard IVF-ET by Maternal Age

SART amp ASRM 2010

lt 35 yrs male factor (-)

35 - 37 yrs male factor (-)

38 - 40 yrs male factor (-)

gt 40 yrs male factor (-)

Cancellation

rate ()

102

148

193

244

Delivery

retrieval ()

339

294

212

94

Tuboplasty or IVF

bull TuboplastyMild or moderate tubal diseaseYoung female

bull IVF-ETExtensive pelvic adhesionOld age Impossible tubal reconstruction due to absenceof tubes or history of tuberculous salpingitis

Failed tubal surgeryExistence of other infertility factors

Considerations for Tuboplasty or IVF

bull Technical view Invasiveness

Infertility factors involved

bull Nontechnical view Cost

Wishes of patients

bull Surgery Specialty training

bull (surgeon considering laparoscopic tubal microsurgery

should be competent with both the traditional techniques

of microsurgery and intra corporeal micro suturing )

bull IVF-ET Expertise and credentialing of the program

Advantages and Disadvantages IVF bull per-cycle success rates and the fact that it is less surgically invasive

bull Its disadvantages are generalizable to surgeons with less skill and

experience and include cost (especially if more than one cycle is

required)

bull the frequent injections monitoring most significantly risks of

multiple pregnancy and OHSS

bull 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

bull (Human Reproduction 05 Fertil Steril 2009 2010)

bull 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

bull They also avoid the risks associated with IVF

bull 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

bull Tubal anastomosis had a higher cumulative

pregnancy rate for women less than 37 years

of age no significant difference above 37

years of age

bull Human reproduction 2007 P Devroey

Comparison of Cost per Delivery

Patient Counselling

bull The most recent national assisted reproductive

technology (ART) registry data from 2012 noted a

324 live-birth rate per cycle initiated in patients with

tubal infertility similar to the 341 rate overall(SART)

bull 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

bull 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

bull ( 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

Ann Acad Med Singapore 2010 Jan39(1)22-6Microsurgical reversal of sterilisation - is this still clinically relevant

todayTan HHLoh SF

bull Pregnancy (778 vs 700) and live birth rates (667 vs 600)

were similar between laparoscopy and open surgery The mean

interval to pregnancy was marginally lower via laparoscopy (113 vs

136 months) Hospitalisation stay was significantly halved (143 vs

300 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

Hum Reprod 2012 Jun27(6)1657-62 doi 101093humrepdes078 Epub 2012 Mar 27

High pregnancy rate after microsurgical tubal reanastomosis bytemporary loose parallel 4-quadrant sutures technique a long

long-term follow-up report on 961 casesMoon HS1 Joo BS Park GS Moon SE Kim SG Koo JS

bull The overall pregnancy rate was 851 826 being

intrauterine and 25 ectopic

PATIENT SCREENING AND SELECTION

Basic infetility work up

Exclude other factors

Semen analysis

IVF better choice with other co- existing factors

Treatment of Tubal Factor Infertility

1 Surgical Approach

Laparotomy Microsurgical technique

Laparoscopy Pelviscopy

Transcervical Tubal recanalization

2 Assisted Reproductive Technology (ART)

IVF - ET

Tubal Surgery Tuboplasty

1 Adhesiolysis

Salpingoovariolysis2 Proximal Tubal Occlusion

Tubocornual reanastomosisFluoroscopic recanalizationTranscervical balloon tuboplasty

3 Distal Tubal OcclusionFimbrioplastyNeosalpingostomy

4 Tubal sterilization (TL)Tubal reanastomosis (TR)

Tubal Reanastomosis

Prognosis of TR depends on

Method of ligation

Repair site of tube

Residual tubal length

Other causes of infertility

Bipolar coagulation PR 49

Ring clip PR 67

Pomeroy TL PR 75

(S Gordts Fertil steril 2009 Kim jd 1997)

Tubal Reanastomosis

bull Better prognosis with small difference in diameter

of reconstructed tubal locations

Isthmus ndash isthmus

Ampulla ndash isthmus

Ampulla - Ampulla

( Laparoscopic micro surgery - Koh and Janik 1996)

Tubal ReanastomosisMethod and location of ligation

The time interval between tubal ligation and its reversalPotential postop tubal lengthCoexistent pelvic disease

bull Gomel amp Swolin 1980

Low PR lt 4 cm of postop tubal length Inverse correlation between postop tubal lengthand interval to pregnancy

bull In older women gt 40 yrs

TR (Trimpos amp Kemper 1980)PR 45 Interval to pregnancy 55 months

IVF-ET (Tan 1992)CPR 10 TR indicated after 3 cycles of IVF-ET

Reversal of Tubal Ligation by Microsurgery

Author Patients TL 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 lt 40 months 76 (64) 1 (1) 69 (58)

Silber amp Cohen 25 Mostly Tubocornual gt 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)

Tubal Reanastomosis

bull Gomel 1980

PR 64 Ectopic PR 1 Interval to pregnancy 102 months

bull Kim et al 1997 (n=1118)

Anatomic patency rate 882PR 548 DR 725

bull Kjayakrishnan 2011 journal of HuReprod sc The pregnancy rate was better for laparoscopic sterilization by Falope ring (857) as compared with those with Pomeroys procedure (40)

Tubal Reanastomosis

bull Procedure - End to end tubal anastomosis was performed by

single two -layer closure using no 6ndash0 prolene First four sutures

at 6 3 9 and 12 orsquoclock were taken in the muscularis layer and

then the serosal stitches

bull 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

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

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

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)

SARTASRM IVF registry (2010)

SARTASRM IVF registry (2012)

Pregnancy Rate

49 - 75

34

31

30 - 60

30 - 70

62 - 67

27

40

84

324

352

Standard IVF-ET by Maternal Age

SART amp ASRM 2010

lt 35 yrs male factor (-)

35 - 37 yrs male factor (-)

38 - 40 yrs male factor (-)

gt 40 yrs male factor (-)

Cancellation

rate ()

102

148

193

244

Delivery

retrieval ()

339

294

212

94

Tuboplasty or IVF

bull TuboplastyMild or moderate tubal diseaseYoung female

bull IVF-ETExtensive pelvic adhesionOld age Impossible tubal reconstruction due to absenceof tubes or history of tuberculous salpingitis

Failed tubal surgeryExistence of other infertility factors

Considerations for Tuboplasty or IVF

bull Technical view Invasiveness

Infertility factors involved

bull Nontechnical view Cost

Wishes of patients

bull Surgery Specialty training

bull (surgeon considering laparoscopic tubal microsurgery

should be competent with both the traditional techniques

of microsurgery and intra corporeal micro suturing )

bull IVF-ET Expertise and credentialing of the program

Advantages and Disadvantages IVF bull per-cycle success rates and the fact that it is less surgically invasive

bull Its disadvantages are generalizable to surgeons with less skill and

experience and include cost (especially if more than one cycle is

required)

bull the frequent injections monitoring most significantly risks of

multiple pregnancy and OHSS

bull 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

bull (Human Reproduction 05 Fertil Steril 2009 2010)

bull 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

bull They also avoid the risks associated with IVF

bull 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

bull Tubal anastomosis had a higher cumulative

pregnancy rate for women less than 37 years

of age no significant difference above 37

years of age

bull Human reproduction 2007 P Devroey

Comparison of Cost per Delivery

Patient Counselling

bull The most recent national assisted reproductive

technology (ART) registry data from 2012 noted a

324 live-birth rate per cycle initiated in patients with

tubal infertility similar to the 341 rate overall(SART)

bull 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

bull 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

bull ( 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

Ann Acad Med Singapore 2010 Jan39(1)22-6Microsurgical reversal of sterilisation - is this still clinically relevant

todayTan HHLoh SF

bull Pregnancy (778 vs 700) and live birth rates (667 vs 600)

were similar between laparoscopy and open surgery The mean

interval to pregnancy was marginally lower via laparoscopy (113 vs

136 months) Hospitalisation stay was significantly halved (143 vs

300 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

Hum Reprod 2012 Jun27(6)1657-62 doi 101093humrepdes078 Epub 2012 Mar 27

High pregnancy rate after microsurgical tubal reanastomosis bytemporary loose parallel 4-quadrant sutures technique a long

long-term follow-up report on 961 casesMoon HS1 Joo BS Park GS Moon SE Kim SG Koo JS

bull The overall pregnancy rate was 851 826 being

intrauterine and 25 ectopic

Treatment of Tubal Factor Infertility

1 Surgical Approach

Laparotomy Microsurgical technique

Laparoscopy Pelviscopy

Transcervical Tubal recanalization

2 Assisted Reproductive Technology (ART)

IVF - ET

Tubal Surgery Tuboplasty

1 Adhesiolysis

Salpingoovariolysis2 Proximal Tubal Occlusion

Tubocornual reanastomosisFluoroscopic recanalizationTranscervical balloon tuboplasty

3 Distal Tubal OcclusionFimbrioplastyNeosalpingostomy

4 Tubal sterilization (TL)Tubal reanastomosis (TR)

Tubal Reanastomosis

Prognosis of TR depends on

Method of ligation

Repair site of tube

Residual tubal length

Other causes of infertility

Bipolar coagulation PR 49

Ring clip PR 67

Pomeroy TL PR 75

(S Gordts Fertil steril 2009 Kim jd 1997)

Tubal Reanastomosis

bull Better prognosis with small difference in diameter

of reconstructed tubal locations

Isthmus ndash isthmus

Ampulla ndash isthmus

Ampulla - Ampulla

( Laparoscopic micro surgery - Koh and Janik 1996)

Tubal ReanastomosisMethod and location of ligation

The time interval between tubal ligation and its reversalPotential postop tubal lengthCoexistent pelvic disease

bull Gomel amp Swolin 1980

Low PR lt 4 cm of postop tubal length Inverse correlation between postop tubal lengthand interval to pregnancy

bull In older women gt 40 yrs

TR (Trimpos amp Kemper 1980)PR 45 Interval to pregnancy 55 months

IVF-ET (Tan 1992)CPR 10 TR indicated after 3 cycles of IVF-ET

Reversal of Tubal Ligation by Microsurgery

Author Patients TL 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 lt 40 months 76 (64) 1 (1) 69 (58)

Silber amp Cohen 25 Mostly Tubocornual gt 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)

Tubal Reanastomosis

bull Gomel 1980

PR 64 Ectopic PR 1 Interval to pregnancy 102 months

bull Kim et al 1997 (n=1118)

Anatomic patency rate 882PR 548 DR 725

bull Kjayakrishnan 2011 journal of HuReprod sc The pregnancy rate was better for laparoscopic sterilization by Falope ring (857) as compared with those with Pomeroys procedure (40)

Tubal Reanastomosis

bull Procedure - End to end tubal anastomosis was performed by

single two -layer closure using no 6ndash0 prolene First four sutures

at 6 3 9 and 12 orsquoclock were taken in the muscularis layer and

then the serosal stitches

bull 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

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

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

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)

SARTASRM IVF registry (2010)

SARTASRM IVF registry (2012)

Pregnancy Rate

49 - 75

34

31

30 - 60

30 - 70

62 - 67

27

40

84

324

352

Standard IVF-ET by Maternal Age

SART amp ASRM 2010

lt 35 yrs male factor (-)

35 - 37 yrs male factor (-)

38 - 40 yrs male factor (-)

gt 40 yrs male factor (-)

Cancellation

rate ()

102

148

193

244

Delivery

retrieval ()

339

294

212

94

Tuboplasty or IVF

bull TuboplastyMild or moderate tubal diseaseYoung female

bull IVF-ETExtensive pelvic adhesionOld age Impossible tubal reconstruction due to absenceof tubes or history of tuberculous salpingitis

Failed tubal surgeryExistence of other infertility factors

Considerations for Tuboplasty or IVF

bull Technical view Invasiveness

Infertility factors involved

bull Nontechnical view Cost

Wishes of patients

bull Surgery Specialty training

bull (surgeon considering laparoscopic tubal microsurgery

should be competent with both the traditional techniques

of microsurgery and intra corporeal micro suturing )

bull IVF-ET Expertise and credentialing of the program

Advantages and Disadvantages IVF bull per-cycle success rates and the fact that it is less surgically invasive

bull Its disadvantages are generalizable to surgeons with less skill and

experience and include cost (especially if more than one cycle is

required)

bull the frequent injections monitoring most significantly risks of

multiple pregnancy and OHSS

bull 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

bull (Human Reproduction 05 Fertil Steril 2009 2010)

bull 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

bull They also avoid the risks associated with IVF

bull 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

bull Tubal anastomosis had a higher cumulative

pregnancy rate for women less than 37 years

of age no significant difference above 37

years of age

bull Human reproduction 2007 P Devroey

Comparison of Cost per Delivery

Patient Counselling

bull The most recent national assisted reproductive

technology (ART) registry data from 2012 noted a

324 live-birth rate per cycle initiated in patients with

tubal infertility similar to the 341 rate overall(SART)

bull 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

bull 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

bull ( 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

Ann Acad Med Singapore 2010 Jan39(1)22-6Microsurgical reversal of sterilisation - is this still clinically relevant

todayTan HHLoh SF

bull Pregnancy (778 vs 700) and live birth rates (667 vs 600)

were similar between laparoscopy and open surgery The mean

interval to pregnancy was marginally lower via laparoscopy (113 vs

136 months) Hospitalisation stay was significantly halved (143 vs

300 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

Hum Reprod 2012 Jun27(6)1657-62 doi 101093humrepdes078 Epub 2012 Mar 27

High pregnancy rate after microsurgical tubal reanastomosis bytemporary loose parallel 4-quadrant sutures technique a long

long-term follow-up report on 961 casesMoon HS1 Joo BS Park GS Moon SE Kim SG Koo JS

bull The overall pregnancy rate was 851 826 being

intrauterine and 25 ectopic

Tubal Surgery Tuboplasty

1 Adhesiolysis

Salpingoovariolysis2 Proximal Tubal Occlusion

Tubocornual reanastomosisFluoroscopic recanalizationTranscervical balloon tuboplasty

3 Distal Tubal OcclusionFimbrioplastyNeosalpingostomy

4 Tubal sterilization (TL)Tubal reanastomosis (TR)

Tubal Reanastomosis

Prognosis of TR depends on

Method of ligation

Repair site of tube

Residual tubal length

Other causes of infertility

Bipolar coagulation PR 49

Ring clip PR 67

Pomeroy TL PR 75

(S Gordts Fertil steril 2009 Kim jd 1997)

Tubal Reanastomosis

bull Better prognosis with small difference in diameter

of reconstructed tubal locations

Isthmus ndash isthmus

Ampulla ndash isthmus

Ampulla - Ampulla

( Laparoscopic micro surgery - Koh and Janik 1996)

Tubal ReanastomosisMethod and location of ligation

The time interval between tubal ligation and its reversalPotential postop tubal lengthCoexistent pelvic disease

bull Gomel amp Swolin 1980

Low PR lt 4 cm of postop tubal length Inverse correlation between postop tubal lengthand interval to pregnancy

bull In older women gt 40 yrs

TR (Trimpos amp Kemper 1980)PR 45 Interval to pregnancy 55 months

IVF-ET (Tan 1992)CPR 10 TR indicated after 3 cycles of IVF-ET

Reversal of Tubal Ligation by Microsurgery

Author Patients TL 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 lt 40 months 76 (64) 1 (1) 69 (58)

Silber amp Cohen 25 Mostly Tubocornual gt 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)

Tubal Reanastomosis

bull Gomel 1980

PR 64 Ectopic PR 1 Interval to pregnancy 102 months

bull Kim et al 1997 (n=1118)

Anatomic patency rate 882PR 548 DR 725

bull Kjayakrishnan 2011 journal of HuReprod sc The pregnancy rate was better for laparoscopic sterilization by Falope ring (857) as compared with those with Pomeroys procedure (40)

Tubal Reanastomosis

bull Procedure - End to end tubal anastomosis was performed by

single two -layer closure using no 6ndash0 prolene First four sutures

at 6 3 9 and 12 orsquoclock were taken in the muscularis layer and

then the serosal stitches

bull 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

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

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

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)

SARTASRM IVF registry (2010)

SARTASRM IVF registry (2012)

Pregnancy Rate

49 - 75

34

31

30 - 60

30 - 70

62 - 67

27

40

84

324

352

Standard IVF-ET by Maternal Age

SART amp ASRM 2010

lt 35 yrs male factor (-)

35 - 37 yrs male factor (-)

38 - 40 yrs male factor (-)

gt 40 yrs male factor (-)

Cancellation

rate ()

102

148

193

244

Delivery

retrieval ()

339

294

212

94

Tuboplasty or IVF

bull TuboplastyMild or moderate tubal diseaseYoung female

bull IVF-ETExtensive pelvic adhesionOld age Impossible tubal reconstruction due to absenceof tubes or history of tuberculous salpingitis

Failed tubal surgeryExistence of other infertility factors

Considerations for Tuboplasty or IVF

bull Technical view Invasiveness

Infertility factors involved

bull Nontechnical view Cost

Wishes of patients

bull Surgery Specialty training

bull (surgeon considering laparoscopic tubal microsurgery

should be competent with both the traditional techniques

of microsurgery and intra corporeal micro suturing )

bull IVF-ET Expertise and credentialing of the program

Advantages and Disadvantages IVF bull per-cycle success rates and the fact that it is less surgically invasive

bull Its disadvantages are generalizable to surgeons with less skill and

experience and include cost (especially if more than one cycle is

required)

bull the frequent injections monitoring most significantly risks of

multiple pregnancy and OHSS

bull 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

bull (Human Reproduction 05 Fertil Steril 2009 2010)

bull 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

bull They also avoid the risks associated with IVF

bull 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

bull Tubal anastomosis had a higher cumulative

pregnancy rate for women less than 37 years

of age no significant difference above 37

years of age

bull Human reproduction 2007 P Devroey

Comparison of Cost per Delivery

Patient Counselling

bull The most recent national assisted reproductive

technology (ART) registry data from 2012 noted a

324 live-birth rate per cycle initiated in patients with

tubal infertility similar to the 341 rate overall(SART)

bull 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

bull 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

bull ( 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

Ann Acad Med Singapore 2010 Jan39(1)22-6Microsurgical reversal of sterilisation - is this still clinically relevant

todayTan HHLoh SF

bull Pregnancy (778 vs 700) and live birth rates (667 vs 600)

were similar between laparoscopy and open surgery The mean

interval to pregnancy was marginally lower via laparoscopy (113 vs

136 months) Hospitalisation stay was significantly halved (143 vs

300 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

Hum Reprod 2012 Jun27(6)1657-62 doi 101093humrepdes078 Epub 2012 Mar 27

High pregnancy rate after microsurgical tubal reanastomosis bytemporary loose parallel 4-quadrant sutures technique a long

long-term follow-up report on 961 casesMoon HS1 Joo BS Park GS Moon SE Kim SG Koo JS

bull The overall pregnancy rate was 851 826 being

intrauterine and 25 ectopic

Tubal Reanastomosis

Prognosis of TR depends on

Method of ligation

Repair site of tube

Residual tubal length

Other causes of infertility

Bipolar coagulation PR 49

Ring clip PR 67

Pomeroy TL PR 75

(S Gordts Fertil steril 2009 Kim jd 1997)

Tubal Reanastomosis

bull Better prognosis with small difference in diameter

of reconstructed tubal locations

Isthmus ndash isthmus

Ampulla ndash isthmus

Ampulla - Ampulla

( Laparoscopic micro surgery - Koh and Janik 1996)

Tubal ReanastomosisMethod and location of ligation

The time interval between tubal ligation and its reversalPotential postop tubal lengthCoexistent pelvic disease

bull Gomel amp Swolin 1980

Low PR lt 4 cm of postop tubal length Inverse correlation between postop tubal lengthand interval to pregnancy

bull In older women gt 40 yrs

TR (Trimpos amp Kemper 1980)PR 45 Interval to pregnancy 55 months

IVF-ET (Tan 1992)CPR 10 TR indicated after 3 cycles of IVF-ET

Reversal of Tubal Ligation by Microsurgery

Author Patients TL 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 lt 40 months 76 (64) 1 (1) 69 (58)

Silber amp Cohen 25 Mostly Tubocornual gt 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)

Tubal Reanastomosis

bull Gomel 1980

PR 64 Ectopic PR 1 Interval to pregnancy 102 months

bull Kim et al 1997 (n=1118)

Anatomic patency rate 882PR 548 DR 725

bull Kjayakrishnan 2011 journal of HuReprod sc The pregnancy rate was better for laparoscopic sterilization by Falope ring (857) as compared with those with Pomeroys procedure (40)

Tubal Reanastomosis

bull Procedure - End to end tubal anastomosis was performed by

single two -layer closure using no 6ndash0 prolene First four sutures

at 6 3 9 and 12 orsquoclock were taken in the muscularis layer and

then the serosal stitches

bull 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

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

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

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)

SARTASRM IVF registry (2010)

SARTASRM IVF registry (2012)

Pregnancy Rate

49 - 75

34

31

30 - 60

30 - 70

62 - 67

27

40

84

324

352

Standard IVF-ET by Maternal Age

SART amp ASRM 2010

lt 35 yrs male factor (-)

35 - 37 yrs male factor (-)

38 - 40 yrs male factor (-)

gt 40 yrs male factor (-)

Cancellation

rate ()

102

148

193

244

Delivery

retrieval ()

339

294

212

94

Tuboplasty or IVF

bull TuboplastyMild or moderate tubal diseaseYoung female

bull IVF-ETExtensive pelvic adhesionOld age Impossible tubal reconstruction due to absenceof tubes or history of tuberculous salpingitis

Failed tubal surgeryExistence of other infertility factors

Considerations for Tuboplasty or IVF

bull Technical view Invasiveness

Infertility factors involved

bull Nontechnical view Cost

Wishes of patients

bull Surgery Specialty training

bull (surgeon considering laparoscopic tubal microsurgery

should be competent with both the traditional techniques

of microsurgery and intra corporeal micro suturing )

bull IVF-ET Expertise and credentialing of the program

Advantages and Disadvantages IVF bull per-cycle success rates and the fact that it is less surgically invasive

bull Its disadvantages are generalizable to surgeons with less skill and

experience and include cost (especially if more than one cycle is

required)

bull the frequent injections monitoring most significantly risks of

multiple pregnancy and OHSS

bull 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

bull (Human Reproduction 05 Fertil Steril 2009 2010)

bull 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

bull They also avoid the risks associated with IVF

bull 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

bull Tubal anastomosis had a higher cumulative

pregnancy rate for women less than 37 years

of age no significant difference above 37

years of age

bull Human reproduction 2007 P Devroey

Comparison of Cost per Delivery

Patient Counselling

bull The most recent national assisted reproductive

technology (ART) registry data from 2012 noted a

324 live-birth rate per cycle initiated in patients with

tubal infertility similar to the 341 rate overall(SART)

bull 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

bull 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

bull ( 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

Ann Acad Med Singapore 2010 Jan39(1)22-6Microsurgical reversal of sterilisation - is this still clinically relevant

todayTan HHLoh SF

bull Pregnancy (778 vs 700) and live birth rates (667 vs 600)

were similar between laparoscopy and open surgery The mean

interval to pregnancy was marginally lower via laparoscopy (113 vs

136 months) Hospitalisation stay was significantly halved (143 vs

300 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

Hum Reprod 2012 Jun27(6)1657-62 doi 101093humrepdes078 Epub 2012 Mar 27

High pregnancy rate after microsurgical tubal reanastomosis bytemporary loose parallel 4-quadrant sutures technique a long

long-term follow-up report on 961 casesMoon HS1 Joo BS Park GS Moon SE Kim SG Koo JS

bull The overall pregnancy rate was 851 826 being

intrauterine and 25 ectopic

Tubal Reanastomosis

bull Better prognosis with small difference in diameter

of reconstructed tubal locations

Isthmus ndash isthmus

Ampulla ndash isthmus

Ampulla - Ampulla

( Laparoscopic micro surgery - Koh and Janik 1996)

Tubal ReanastomosisMethod and location of ligation

The time interval between tubal ligation and its reversalPotential postop tubal lengthCoexistent pelvic disease

bull Gomel amp Swolin 1980

Low PR lt 4 cm of postop tubal length Inverse correlation between postop tubal lengthand interval to pregnancy

bull In older women gt 40 yrs

TR (Trimpos amp Kemper 1980)PR 45 Interval to pregnancy 55 months

IVF-ET (Tan 1992)CPR 10 TR indicated after 3 cycles of IVF-ET

Reversal of Tubal Ligation by Microsurgery

Author Patients TL 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 lt 40 months 76 (64) 1 (1) 69 (58)

Silber amp Cohen 25 Mostly Tubocornual gt 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)

Tubal Reanastomosis

bull Gomel 1980

PR 64 Ectopic PR 1 Interval to pregnancy 102 months

bull Kim et al 1997 (n=1118)

Anatomic patency rate 882PR 548 DR 725

bull Kjayakrishnan 2011 journal of HuReprod sc The pregnancy rate was better for laparoscopic sterilization by Falope ring (857) as compared with those with Pomeroys procedure (40)

Tubal Reanastomosis

bull Procedure - End to end tubal anastomosis was performed by

single two -layer closure using no 6ndash0 prolene First four sutures

at 6 3 9 and 12 orsquoclock were taken in the muscularis layer and

then the serosal stitches

bull 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

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

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

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)

SARTASRM IVF registry (2010)

SARTASRM IVF registry (2012)

Pregnancy Rate

49 - 75

34

31

30 - 60

30 - 70

62 - 67

27

40

84

324

352

Standard IVF-ET by Maternal Age

SART amp ASRM 2010

lt 35 yrs male factor (-)

35 - 37 yrs male factor (-)

38 - 40 yrs male factor (-)

gt 40 yrs male factor (-)

Cancellation

rate ()

102

148

193

244

Delivery

retrieval ()

339

294

212

94

Tuboplasty or IVF

bull TuboplastyMild or moderate tubal diseaseYoung female

bull IVF-ETExtensive pelvic adhesionOld age Impossible tubal reconstruction due to absenceof tubes or history of tuberculous salpingitis

Failed tubal surgeryExistence of other infertility factors

Considerations for Tuboplasty or IVF

bull Technical view Invasiveness

Infertility factors involved

bull Nontechnical view Cost

Wishes of patients

bull Surgery Specialty training

bull (surgeon considering laparoscopic tubal microsurgery

should be competent with both the traditional techniques

of microsurgery and intra corporeal micro suturing )

bull IVF-ET Expertise and credentialing of the program

Advantages and Disadvantages IVF bull per-cycle success rates and the fact that it is less surgically invasive

bull Its disadvantages are generalizable to surgeons with less skill and

experience and include cost (especially if more than one cycle is

required)

bull the frequent injections monitoring most significantly risks of

multiple pregnancy and OHSS

bull 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

bull (Human Reproduction 05 Fertil Steril 2009 2010)

bull 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

bull They also avoid the risks associated with IVF

bull 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

bull Tubal anastomosis had a higher cumulative

pregnancy rate for women less than 37 years

of age no significant difference above 37

years of age

bull Human reproduction 2007 P Devroey

Comparison of Cost per Delivery

Patient Counselling

bull The most recent national assisted reproductive

technology (ART) registry data from 2012 noted a

324 live-birth rate per cycle initiated in patients with

tubal infertility similar to the 341 rate overall(SART)

bull 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

bull 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

bull ( 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

Ann Acad Med Singapore 2010 Jan39(1)22-6Microsurgical reversal of sterilisation - is this still clinically relevant

todayTan HHLoh SF

bull Pregnancy (778 vs 700) and live birth rates (667 vs 600)

were similar between laparoscopy and open surgery The mean

interval to pregnancy was marginally lower via laparoscopy (113 vs

136 months) Hospitalisation stay was significantly halved (143 vs

300 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

Hum Reprod 2012 Jun27(6)1657-62 doi 101093humrepdes078 Epub 2012 Mar 27

High pregnancy rate after microsurgical tubal reanastomosis bytemporary loose parallel 4-quadrant sutures technique a long

long-term follow-up report on 961 casesMoon HS1 Joo BS Park GS Moon SE Kim SG Koo JS

bull The overall pregnancy rate was 851 826 being

intrauterine and 25 ectopic

Tubal ReanastomosisMethod and location of ligation

The time interval between tubal ligation and its reversalPotential postop tubal lengthCoexistent pelvic disease

bull Gomel amp Swolin 1980

Low PR lt 4 cm of postop tubal length Inverse correlation between postop tubal lengthand interval to pregnancy

bull In older women gt 40 yrs

TR (Trimpos amp Kemper 1980)PR 45 Interval to pregnancy 55 months

IVF-ET (Tan 1992)CPR 10 TR indicated after 3 cycles of IVF-ET

Reversal of Tubal Ligation by Microsurgery

Author Patients TL 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 lt 40 months 76 (64) 1 (1) 69 (58)

Silber amp Cohen 25 Mostly Tubocornual gt 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)

Tubal Reanastomosis

bull Gomel 1980

PR 64 Ectopic PR 1 Interval to pregnancy 102 months

bull Kim et al 1997 (n=1118)

Anatomic patency rate 882PR 548 DR 725

bull Kjayakrishnan 2011 journal of HuReprod sc The pregnancy rate was better for laparoscopic sterilization by Falope ring (857) as compared with those with Pomeroys procedure (40)

Tubal Reanastomosis

bull Procedure - End to end tubal anastomosis was performed by

single two -layer closure using no 6ndash0 prolene First four sutures

at 6 3 9 and 12 orsquoclock were taken in the muscularis layer and

then the serosal stitches

bull 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

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

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

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)

SARTASRM IVF registry (2010)

SARTASRM IVF registry (2012)

Pregnancy Rate

49 - 75

34

31

30 - 60

30 - 70

62 - 67

27

40

84

324

352

Standard IVF-ET by Maternal Age

SART amp ASRM 2010

lt 35 yrs male factor (-)

35 - 37 yrs male factor (-)

38 - 40 yrs male factor (-)

gt 40 yrs male factor (-)

Cancellation

rate ()

102

148

193

244

Delivery

retrieval ()

339

294

212

94

Tuboplasty or IVF

bull TuboplastyMild or moderate tubal diseaseYoung female

bull IVF-ETExtensive pelvic adhesionOld age Impossible tubal reconstruction due to absenceof tubes or history of tuberculous salpingitis

Failed tubal surgeryExistence of other infertility factors

Considerations for Tuboplasty or IVF

bull Technical view Invasiveness

Infertility factors involved

bull Nontechnical view Cost

Wishes of patients

bull Surgery Specialty training

bull (surgeon considering laparoscopic tubal microsurgery

should be competent with both the traditional techniques

of microsurgery and intra corporeal micro suturing )

bull IVF-ET Expertise and credentialing of the program

Advantages and Disadvantages IVF bull per-cycle success rates and the fact that it is less surgically invasive

bull Its disadvantages are generalizable to surgeons with less skill and

experience and include cost (especially if more than one cycle is

required)

bull the frequent injections monitoring most significantly risks of

multiple pregnancy and OHSS

bull 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

bull (Human Reproduction 05 Fertil Steril 2009 2010)

bull 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

bull They also avoid the risks associated with IVF

bull 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

bull Tubal anastomosis had a higher cumulative

pregnancy rate for women less than 37 years

of age no significant difference above 37

years of age

bull Human reproduction 2007 P Devroey

Comparison of Cost per Delivery

Patient Counselling

bull The most recent national assisted reproductive

technology (ART) registry data from 2012 noted a

324 live-birth rate per cycle initiated in patients with

tubal infertility similar to the 341 rate overall(SART)

bull 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

bull 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

bull ( 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

Ann Acad Med Singapore 2010 Jan39(1)22-6Microsurgical reversal of sterilisation - is this still clinically relevant

todayTan HHLoh SF

bull Pregnancy (778 vs 700) and live birth rates (667 vs 600)

were similar between laparoscopy and open surgery The mean

interval to pregnancy was marginally lower via laparoscopy (113 vs

136 months) Hospitalisation stay was significantly halved (143 vs

300 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

Hum Reprod 2012 Jun27(6)1657-62 doi 101093humrepdes078 Epub 2012 Mar 27

High pregnancy rate after microsurgical tubal reanastomosis bytemporary loose parallel 4-quadrant sutures technique a long

long-term follow-up report on 961 casesMoon HS1 Joo BS Park GS Moon SE Kim SG Koo JS

bull The overall pregnancy rate was 851 826 being

intrauterine and 25 ectopic

Reversal of Tubal Ligation by Microsurgery

Author Patients TL 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 lt 40 months 76 (64) 1 (1) 69 (58)

Silber amp Cohen 25 Mostly Tubocornual gt 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)

Tubal Reanastomosis

bull Gomel 1980

PR 64 Ectopic PR 1 Interval to pregnancy 102 months

bull Kim et al 1997 (n=1118)

Anatomic patency rate 882PR 548 DR 725

bull Kjayakrishnan 2011 journal of HuReprod sc The pregnancy rate was better for laparoscopic sterilization by Falope ring (857) as compared with those with Pomeroys procedure (40)

Tubal Reanastomosis

bull Procedure - End to end tubal anastomosis was performed by

single two -layer closure using no 6ndash0 prolene First four sutures

at 6 3 9 and 12 orsquoclock were taken in the muscularis layer and

then the serosal stitches

bull 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

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

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

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)

SARTASRM IVF registry (2010)

SARTASRM IVF registry (2012)

Pregnancy Rate

49 - 75

34

31

30 - 60

30 - 70

62 - 67

27

40

84

324

352

Standard IVF-ET by Maternal Age

SART amp ASRM 2010

lt 35 yrs male factor (-)

35 - 37 yrs male factor (-)

38 - 40 yrs male factor (-)

gt 40 yrs male factor (-)

Cancellation

rate ()

102

148

193

244

Delivery

retrieval ()

339

294

212

94

Tuboplasty or IVF

bull TuboplastyMild or moderate tubal diseaseYoung female

bull IVF-ETExtensive pelvic adhesionOld age Impossible tubal reconstruction due to absenceof tubes or history of tuberculous salpingitis

Failed tubal surgeryExistence of other infertility factors

Considerations for Tuboplasty or IVF

bull Technical view Invasiveness

Infertility factors involved

bull Nontechnical view Cost

Wishes of patients

bull Surgery Specialty training

bull (surgeon considering laparoscopic tubal microsurgery

should be competent with both the traditional techniques

of microsurgery and intra corporeal micro suturing )

bull IVF-ET Expertise and credentialing of the program

Advantages and Disadvantages IVF bull per-cycle success rates and the fact that it is less surgically invasive

bull Its disadvantages are generalizable to surgeons with less skill and

experience and include cost (especially if more than one cycle is

required)

bull the frequent injections monitoring most significantly risks of

multiple pregnancy and OHSS

bull 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

bull (Human Reproduction 05 Fertil Steril 2009 2010)

bull 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

bull They also avoid the risks associated with IVF

bull 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

bull Tubal anastomosis had a higher cumulative

pregnancy rate for women less than 37 years

of age no significant difference above 37

years of age

bull Human reproduction 2007 P Devroey

Comparison of Cost per Delivery

Patient Counselling

bull The most recent national assisted reproductive

technology (ART) registry data from 2012 noted a

324 live-birth rate per cycle initiated in patients with

tubal infertility similar to the 341 rate overall(SART)

bull 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

bull 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

bull ( 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

Ann Acad Med Singapore 2010 Jan39(1)22-6Microsurgical reversal of sterilisation - is this still clinically relevant

todayTan HHLoh SF

bull Pregnancy (778 vs 700) and live birth rates (667 vs 600)

were similar between laparoscopy and open surgery The mean

interval to pregnancy was marginally lower via laparoscopy (113 vs

136 months) Hospitalisation stay was significantly halved (143 vs

300 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

Hum Reprod 2012 Jun27(6)1657-62 doi 101093humrepdes078 Epub 2012 Mar 27

High pregnancy rate after microsurgical tubal reanastomosis bytemporary loose parallel 4-quadrant sutures technique a long

long-term follow-up report on 961 casesMoon HS1 Joo BS Park GS Moon SE Kim SG Koo JS

bull The overall pregnancy rate was 851 826 being

intrauterine and 25 ectopic

Tubal Reanastomosis

bull Gomel 1980

PR 64 Ectopic PR 1 Interval to pregnancy 102 months

bull Kim et al 1997 (n=1118)

Anatomic patency rate 882PR 548 DR 725

bull Kjayakrishnan 2011 journal of HuReprod sc The pregnancy rate was better for laparoscopic sterilization by Falope ring (857) as compared with those with Pomeroys procedure (40)

Tubal Reanastomosis

bull Procedure - End to end tubal anastomosis was performed by

single two -layer closure using no 6ndash0 prolene First four sutures

at 6 3 9 and 12 orsquoclock were taken in the muscularis layer and

then the serosal stitches

bull 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

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

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

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)

SARTASRM IVF registry (2010)

SARTASRM IVF registry (2012)

Pregnancy Rate

49 - 75

34

31

30 - 60

30 - 70

62 - 67

27

40

84

324

352

Standard IVF-ET by Maternal Age

SART amp ASRM 2010

lt 35 yrs male factor (-)

35 - 37 yrs male factor (-)

38 - 40 yrs male factor (-)

gt 40 yrs male factor (-)

Cancellation

rate ()

102

148

193

244

Delivery

retrieval ()

339

294

212

94

Tuboplasty or IVF

bull TuboplastyMild or moderate tubal diseaseYoung female

bull IVF-ETExtensive pelvic adhesionOld age Impossible tubal reconstruction due to absenceof tubes or history of tuberculous salpingitis

Failed tubal surgeryExistence of other infertility factors

Considerations for Tuboplasty or IVF

bull Technical view Invasiveness

Infertility factors involved

bull Nontechnical view Cost

Wishes of patients

bull Surgery Specialty training

bull (surgeon considering laparoscopic tubal microsurgery

should be competent with both the traditional techniques

of microsurgery and intra corporeal micro suturing )

bull IVF-ET Expertise and credentialing of the program

Advantages and Disadvantages IVF bull per-cycle success rates and the fact that it is less surgically invasive

bull Its disadvantages are generalizable to surgeons with less skill and

experience and include cost (especially if more than one cycle is

required)

bull the frequent injections monitoring most significantly risks of

multiple pregnancy and OHSS

bull 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

bull (Human Reproduction 05 Fertil Steril 2009 2010)

bull 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

bull They also avoid the risks associated with IVF

bull 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

bull Tubal anastomosis had a higher cumulative

pregnancy rate for women less than 37 years

of age no significant difference above 37

years of age

bull Human reproduction 2007 P Devroey

Comparison of Cost per Delivery

Patient Counselling

bull The most recent national assisted reproductive

technology (ART) registry data from 2012 noted a

324 live-birth rate per cycle initiated in patients with

tubal infertility similar to the 341 rate overall(SART)

bull 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

bull 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

bull ( 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

Ann Acad Med Singapore 2010 Jan39(1)22-6Microsurgical reversal of sterilisation - is this still clinically relevant

todayTan HHLoh SF

bull Pregnancy (778 vs 700) and live birth rates (667 vs 600)

were similar between laparoscopy and open surgery The mean

interval to pregnancy was marginally lower via laparoscopy (113 vs

136 months) Hospitalisation stay was significantly halved (143 vs

300 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

Hum Reprod 2012 Jun27(6)1657-62 doi 101093humrepdes078 Epub 2012 Mar 27

High pregnancy rate after microsurgical tubal reanastomosis bytemporary loose parallel 4-quadrant sutures technique a long

long-term follow-up report on 961 casesMoon HS1 Joo BS Park GS Moon SE Kim SG Koo JS

bull The overall pregnancy rate was 851 826 being

intrauterine and 25 ectopic

Tubal Reanastomosis

bull Procedure - End to end tubal anastomosis was performed by

single two -layer closure using no 6ndash0 prolene First four sutures

at 6 3 9 and 12 orsquoclock were taken in the muscularis layer and

then the serosal stitches

bull 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

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

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

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)

SARTASRM IVF registry (2010)

SARTASRM IVF registry (2012)

Pregnancy Rate

49 - 75

34

31

30 - 60

30 - 70

62 - 67

27

40

84

324

352

Standard IVF-ET by Maternal Age

SART amp ASRM 2010

lt 35 yrs male factor (-)

35 - 37 yrs male factor (-)

38 - 40 yrs male factor (-)

gt 40 yrs male factor (-)

Cancellation

rate ()

102

148

193

244

Delivery

retrieval ()

339

294

212

94

Tuboplasty or IVF

bull TuboplastyMild or moderate tubal diseaseYoung female

bull IVF-ETExtensive pelvic adhesionOld age Impossible tubal reconstruction due to absenceof tubes or history of tuberculous salpingitis

Failed tubal surgeryExistence of other infertility factors

Considerations for Tuboplasty or IVF

bull Technical view Invasiveness

Infertility factors involved

bull Nontechnical view Cost

Wishes of patients

bull Surgery Specialty training

bull (surgeon considering laparoscopic tubal microsurgery

should be competent with both the traditional techniques

of microsurgery and intra corporeal micro suturing )

bull IVF-ET Expertise and credentialing of the program

Advantages and Disadvantages IVF bull per-cycle success rates and the fact that it is less surgically invasive

bull Its disadvantages are generalizable to surgeons with less skill and

experience and include cost (especially if more than one cycle is

required)

bull the frequent injections monitoring most significantly risks of

multiple pregnancy and OHSS

bull 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

bull (Human Reproduction 05 Fertil Steril 2009 2010)

bull 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

bull They also avoid the risks associated with IVF

bull 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

bull Tubal anastomosis had a higher cumulative

pregnancy rate for women less than 37 years

of age no significant difference above 37

years of age

bull Human reproduction 2007 P Devroey

Comparison of Cost per Delivery

Patient Counselling

bull The most recent national assisted reproductive

technology (ART) registry data from 2012 noted a

324 live-birth rate per cycle initiated in patients with

tubal infertility similar to the 341 rate overall(SART)

bull 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

bull 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

bull ( 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

Ann Acad Med Singapore 2010 Jan39(1)22-6Microsurgical reversal of sterilisation - is this still clinically relevant

todayTan HHLoh SF

bull Pregnancy (778 vs 700) and live birth rates (667 vs 600)

were similar between laparoscopy and open surgery The mean

interval to pregnancy was marginally lower via laparoscopy (113 vs

136 months) Hospitalisation stay was significantly halved (143 vs

300 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

Hum Reprod 2012 Jun27(6)1657-62 doi 101093humrepdes078 Epub 2012 Mar 27

High pregnancy rate after microsurgical tubal reanastomosis bytemporary loose parallel 4-quadrant sutures technique a long

long-term follow-up report on 961 casesMoon HS1 Joo BS Park GS Moon SE Kim SG Koo JS

bull The overall pregnancy rate was 851 826 being

intrauterine and 25 ectopic

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

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

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)

SARTASRM IVF registry (2010)

SARTASRM IVF registry (2012)

Pregnancy Rate

49 - 75

34

31

30 - 60

30 - 70

62 - 67

27

40

84

324

352

Standard IVF-ET by Maternal Age

SART amp ASRM 2010

lt 35 yrs male factor (-)

35 - 37 yrs male factor (-)

38 - 40 yrs male factor (-)

gt 40 yrs male factor (-)

Cancellation

rate ()

102

148

193

244

Delivery

retrieval ()

339

294

212

94

Tuboplasty or IVF

bull TuboplastyMild or moderate tubal diseaseYoung female

bull IVF-ETExtensive pelvic adhesionOld age Impossible tubal reconstruction due to absenceof tubes or history of tuberculous salpingitis

Failed tubal surgeryExistence of other infertility factors

Considerations for Tuboplasty or IVF

bull Technical view Invasiveness

Infertility factors involved

bull Nontechnical view Cost

Wishes of patients

bull Surgery Specialty training

bull (surgeon considering laparoscopic tubal microsurgery

should be competent with both the traditional techniques

of microsurgery and intra corporeal micro suturing )

bull IVF-ET Expertise and credentialing of the program

Advantages and Disadvantages IVF bull per-cycle success rates and the fact that it is less surgically invasive

bull Its disadvantages are generalizable to surgeons with less skill and

experience and include cost (especially if more than one cycle is

required)

bull the frequent injections monitoring most significantly risks of

multiple pregnancy and OHSS

bull 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

bull (Human Reproduction 05 Fertil Steril 2009 2010)

bull 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

bull They also avoid the risks associated with IVF

bull 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

bull Tubal anastomosis had a higher cumulative

pregnancy rate for women less than 37 years

of age no significant difference above 37

years of age

bull Human reproduction 2007 P Devroey

Comparison of Cost per Delivery

Patient Counselling

bull The most recent national assisted reproductive

technology (ART) registry data from 2012 noted a

324 live-birth rate per cycle initiated in patients with

tubal infertility similar to the 341 rate overall(SART)

bull 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

bull 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

bull ( 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

Ann Acad Med Singapore 2010 Jan39(1)22-6Microsurgical reversal of sterilisation - is this still clinically relevant

todayTan HHLoh SF

bull Pregnancy (778 vs 700) and live birth rates (667 vs 600)

were similar between laparoscopy and open surgery The mean

interval to pregnancy was marginally lower via laparoscopy (113 vs

136 months) Hospitalisation stay was significantly halved (143 vs

300 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

Hum Reprod 2012 Jun27(6)1657-62 doi 101093humrepdes078 Epub 2012 Mar 27

High pregnancy rate after microsurgical tubal reanastomosis bytemporary loose parallel 4-quadrant sutures technique a long

long-term follow-up report on 961 casesMoon HS1 Joo BS Park GS Moon SE Kim SG Koo JS

bull The overall pregnancy rate was 851 826 being

intrauterine and 25 ectopic

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

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)

SARTASRM IVF registry (2010)

SARTASRM IVF registry (2012)

Pregnancy Rate

49 - 75

34

31

30 - 60

30 - 70

62 - 67

27

40

84

324

352

Standard IVF-ET by Maternal Age

SART amp ASRM 2010

lt 35 yrs male factor (-)

35 - 37 yrs male factor (-)

38 - 40 yrs male factor (-)

gt 40 yrs male factor (-)

Cancellation

rate ()

102

148

193

244

Delivery

retrieval ()

339

294

212

94

Tuboplasty or IVF

bull TuboplastyMild or moderate tubal diseaseYoung female

bull IVF-ETExtensive pelvic adhesionOld age Impossible tubal reconstruction due to absenceof tubes or history of tuberculous salpingitis

Failed tubal surgeryExistence of other infertility factors

Considerations for Tuboplasty or IVF

bull Technical view Invasiveness

Infertility factors involved

bull Nontechnical view Cost

Wishes of patients

bull Surgery Specialty training

bull (surgeon considering laparoscopic tubal microsurgery

should be competent with both the traditional techniques

of microsurgery and intra corporeal micro suturing )

bull IVF-ET Expertise and credentialing of the program

Advantages and Disadvantages IVF bull per-cycle success rates and the fact that it is less surgically invasive

bull Its disadvantages are generalizable to surgeons with less skill and

experience and include cost (especially if more than one cycle is

required)

bull the frequent injections monitoring most significantly risks of

multiple pregnancy and OHSS

bull 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

bull (Human Reproduction 05 Fertil Steril 2009 2010)

bull 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

bull They also avoid the risks associated with IVF

bull 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

bull Tubal anastomosis had a higher cumulative

pregnancy rate for women less than 37 years

of age no significant difference above 37

years of age

bull Human reproduction 2007 P Devroey

Comparison of Cost per Delivery

Patient Counselling

bull The most recent national assisted reproductive

technology (ART) registry data from 2012 noted a

324 live-birth rate per cycle initiated in patients with

tubal infertility similar to the 341 rate overall(SART)

bull 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

bull 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

bull ( 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

Ann Acad Med Singapore 2010 Jan39(1)22-6Microsurgical reversal of sterilisation - is this still clinically relevant

todayTan HHLoh SF

bull Pregnancy (778 vs 700) and live birth rates (667 vs 600)

were similar between laparoscopy and open surgery The mean

interval to pregnancy was marginally lower via laparoscopy (113 vs

136 months) Hospitalisation stay was significantly halved (143 vs

300 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

Hum Reprod 2012 Jun27(6)1657-62 doi 101093humrepdes078 Epub 2012 Mar 27

High pregnancy rate after microsurgical tubal reanastomosis bytemporary loose parallel 4-quadrant sutures technique a long

long-term follow-up report on 961 casesMoon HS1 Joo BS Park GS Moon SE Kim SG Koo JS

bull The overall pregnancy rate was 851 826 being

intrauterine and 25 ectopic

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)

SARTASRM IVF registry (2010)

SARTASRM IVF registry (2012)

Pregnancy Rate

49 - 75

34

31

30 - 60

30 - 70

62 - 67

27

40

84

324

352

Standard IVF-ET by Maternal Age

SART amp ASRM 2010

lt 35 yrs male factor (-)

35 - 37 yrs male factor (-)

38 - 40 yrs male factor (-)

gt 40 yrs male factor (-)

Cancellation

rate ()

102

148

193

244

Delivery

retrieval ()

339

294

212

94

Tuboplasty or IVF

bull TuboplastyMild or moderate tubal diseaseYoung female

bull IVF-ETExtensive pelvic adhesionOld age Impossible tubal reconstruction due to absenceof tubes or history of tuberculous salpingitis

Failed tubal surgeryExistence of other infertility factors

Considerations for Tuboplasty or IVF

bull Technical view Invasiveness

Infertility factors involved

bull Nontechnical view Cost

Wishes of patients

bull Surgery Specialty training

bull (surgeon considering laparoscopic tubal microsurgery

should be competent with both the traditional techniques

of microsurgery and intra corporeal micro suturing )

bull IVF-ET Expertise and credentialing of the program

Advantages and Disadvantages IVF bull per-cycle success rates and the fact that it is less surgically invasive

bull Its disadvantages are generalizable to surgeons with less skill and

experience and include cost (especially if more than one cycle is

required)

bull the frequent injections monitoring most significantly risks of

multiple pregnancy and OHSS

bull 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

bull (Human Reproduction 05 Fertil Steril 2009 2010)

bull 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

bull They also avoid the risks associated with IVF

bull 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

bull Tubal anastomosis had a higher cumulative

pregnancy rate for women less than 37 years

of age no significant difference above 37

years of age

bull Human reproduction 2007 P Devroey

Comparison of Cost per Delivery

Patient Counselling

bull The most recent national assisted reproductive

technology (ART) registry data from 2012 noted a

324 live-birth rate per cycle initiated in patients with

tubal infertility similar to the 341 rate overall(SART)

bull 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

bull 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

bull ( 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

Ann Acad Med Singapore 2010 Jan39(1)22-6Microsurgical reversal of sterilisation - is this still clinically relevant

todayTan HHLoh SF

bull Pregnancy (778 vs 700) and live birth rates (667 vs 600)

were similar between laparoscopy and open surgery The mean

interval to pregnancy was marginally lower via laparoscopy (113 vs

136 months) Hospitalisation stay was significantly halved (143 vs

300 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

Hum Reprod 2012 Jun27(6)1657-62 doi 101093humrepdes078 Epub 2012 Mar 27

High pregnancy rate after microsurgical tubal reanastomosis bytemporary loose parallel 4-quadrant sutures technique a long

long-term follow-up report on 961 casesMoon HS1 Joo BS Park GS Moon SE Kim SG Koo JS

bull The overall pregnancy rate was 851 826 being

intrauterine and 25 ectopic

Standard IVF-ET by Maternal Age

SART amp ASRM 2010

lt 35 yrs male factor (-)

35 - 37 yrs male factor (-)

38 - 40 yrs male factor (-)

gt 40 yrs male factor (-)

Cancellation

rate ()

102

148

193

244

Delivery

retrieval ()

339

294

212

94

Tuboplasty or IVF

bull TuboplastyMild or moderate tubal diseaseYoung female

bull IVF-ETExtensive pelvic adhesionOld age Impossible tubal reconstruction due to absenceof tubes or history of tuberculous salpingitis

Failed tubal surgeryExistence of other infertility factors

Considerations for Tuboplasty or IVF

bull Technical view Invasiveness

Infertility factors involved

bull Nontechnical view Cost

Wishes of patients

bull Surgery Specialty training

bull (surgeon considering laparoscopic tubal microsurgery

should be competent with both the traditional techniques

of microsurgery and intra corporeal micro suturing )

bull IVF-ET Expertise and credentialing of the program

Advantages and Disadvantages IVF bull per-cycle success rates and the fact that it is less surgically invasive

bull Its disadvantages are generalizable to surgeons with less skill and

experience and include cost (especially if more than one cycle is

required)

bull the frequent injections monitoring most significantly risks of

multiple pregnancy and OHSS

bull 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

bull (Human Reproduction 05 Fertil Steril 2009 2010)

bull 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

bull They also avoid the risks associated with IVF

bull 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

bull Tubal anastomosis had a higher cumulative

pregnancy rate for women less than 37 years

of age no significant difference above 37

years of age

bull Human reproduction 2007 P Devroey

Comparison of Cost per Delivery

Patient Counselling

bull The most recent national assisted reproductive

technology (ART) registry data from 2012 noted a

324 live-birth rate per cycle initiated in patients with

tubal infertility similar to the 341 rate overall(SART)

bull 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

bull 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

bull ( 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

Ann Acad Med Singapore 2010 Jan39(1)22-6Microsurgical reversal of sterilisation - is this still clinically relevant

todayTan HHLoh SF

bull Pregnancy (778 vs 700) and live birth rates (667 vs 600)

were similar between laparoscopy and open surgery The mean

interval to pregnancy was marginally lower via laparoscopy (113 vs

136 months) Hospitalisation stay was significantly halved (143 vs

300 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

Hum Reprod 2012 Jun27(6)1657-62 doi 101093humrepdes078 Epub 2012 Mar 27

High pregnancy rate after microsurgical tubal reanastomosis bytemporary loose parallel 4-quadrant sutures technique a long

long-term follow-up report on 961 casesMoon HS1 Joo BS Park GS Moon SE Kim SG Koo JS

bull The overall pregnancy rate was 851 826 being

intrauterine and 25 ectopic

Tuboplasty or IVF

bull TuboplastyMild or moderate tubal diseaseYoung female

bull IVF-ETExtensive pelvic adhesionOld age Impossible tubal reconstruction due to absenceof tubes or history of tuberculous salpingitis

Failed tubal surgeryExistence of other infertility factors

Considerations for Tuboplasty or IVF

bull Technical view Invasiveness

Infertility factors involved

bull Nontechnical view Cost

Wishes of patients

bull Surgery Specialty training

bull (surgeon considering laparoscopic tubal microsurgery

should be competent with both the traditional techniques

of microsurgery and intra corporeal micro suturing )

bull IVF-ET Expertise and credentialing of the program

Advantages and Disadvantages IVF bull per-cycle success rates and the fact that it is less surgically invasive

bull Its disadvantages are generalizable to surgeons with less skill and

experience and include cost (especially if more than one cycle is

required)

bull the frequent injections monitoring most significantly risks of

multiple pregnancy and OHSS

bull 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

bull (Human Reproduction 05 Fertil Steril 2009 2010)

bull 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

bull They also avoid the risks associated with IVF

bull 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

bull Tubal anastomosis had a higher cumulative

pregnancy rate for women less than 37 years

of age no significant difference above 37

years of age

bull Human reproduction 2007 P Devroey

Comparison of Cost per Delivery

Patient Counselling

bull The most recent national assisted reproductive

technology (ART) registry data from 2012 noted a

324 live-birth rate per cycle initiated in patients with

tubal infertility similar to the 341 rate overall(SART)

bull 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

bull 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

bull ( 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

Ann Acad Med Singapore 2010 Jan39(1)22-6Microsurgical reversal of sterilisation - is this still clinically relevant

todayTan HHLoh SF

bull Pregnancy (778 vs 700) and live birth rates (667 vs 600)

were similar between laparoscopy and open surgery The mean

interval to pregnancy was marginally lower via laparoscopy (113 vs

136 months) Hospitalisation stay was significantly halved (143 vs

300 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

Hum Reprod 2012 Jun27(6)1657-62 doi 101093humrepdes078 Epub 2012 Mar 27

High pregnancy rate after microsurgical tubal reanastomosis bytemporary loose parallel 4-quadrant sutures technique a long

long-term follow-up report on 961 casesMoon HS1 Joo BS Park GS Moon SE Kim SG Koo JS

bull The overall pregnancy rate was 851 826 being

intrauterine and 25 ectopic

Considerations for Tuboplasty or IVF

bull Technical view Invasiveness

Infertility factors involved

bull Nontechnical view Cost

Wishes of patients

bull Surgery Specialty training

bull (surgeon considering laparoscopic tubal microsurgery

should be competent with both the traditional techniques

of microsurgery and intra corporeal micro suturing )

bull IVF-ET Expertise and credentialing of the program

Advantages and Disadvantages IVF bull per-cycle success rates and the fact that it is less surgically invasive

bull Its disadvantages are generalizable to surgeons with less skill and

experience and include cost (especially if more than one cycle is

required)

bull the frequent injections monitoring most significantly risks of

multiple pregnancy and OHSS

bull 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

bull (Human Reproduction 05 Fertil Steril 2009 2010)

bull 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

bull They also avoid the risks associated with IVF

bull 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

bull Tubal anastomosis had a higher cumulative

pregnancy rate for women less than 37 years

of age no significant difference above 37

years of age

bull Human reproduction 2007 P Devroey

Comparison of Cost per Delivery

Patient Counselling

bull The most recent national assisted reproductive

technology (ART) registry data from 2012 noted a

324 live-birth rate per cycle initiated in patients with

tubal infertility similar to the 341 rate overall(SART)

bull 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

bull 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

bull ( 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

Ann Acad Med Singapore 2010 Jan39(1)22-6Microsurgical reversal of sterilisation - is this still clinically relevant

todayTan HHLoh SF

bull Pregnancy (778 vs 700) and live birth rates (667 vs 600)

were similar between laparoscopy and open surgery The mean

interval to pregnancy was marginally lower via laparoscopy (113 vs

136 months) Hospitalisation stay was significantly halved (143 vs

300 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

Hum Reprod 2012 Jun27(6)1657-62 doi 101093humrepdes078 Epub 2012 Mar 27

High pregnancy rate after microsurgical tubal reanastomosis bytemporary loose parallel 4-quadrant sutures technique a long

long-term follow-up report on 961 casesMoon HS1 Joo BS Park GS Moon SE Kim SG Koo JS

bull The overall pregnancy rate was 851 826 being

intrauterine and 25 ectopic

Advantages and Disadvantages IVF bull per-cycle success rates and the fact that it is less surgically invasive

bull Its disadvantages are generalizable to surgeons with less skill and

experience and include cost (especially if more than one cycle is

required)

bull the frequent injections monitoring most significantly risks of

multiple pregnancy and OHSS

bull 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

bull (Human Reproduction 05 Fertil Steril 2009 2010)

bull 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

bull They also avoid the risks associated with IVF

bull 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

bull Tubal anastomosis had a higher cumulative

pregnancy rate for women less than 37 years

of age no significant difference above 37

years of age

bull Human reproduction 2007 P Devroey

Comparison of Cost per Delivery

Patient Counselling

bull The most recent national assisted reproductive

technology (ART) registry data from 2012 noted a

324 live-birth rate per cycle initiated in patients with

tubal infertility similar to the 341 rate overall(SART)

bull 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

bull 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

bull ( 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

Ann Acad Med Singapore 2010 Jan39(1)22-6Microsurgical reversal of sterilisation - is this still clinically relevant

todayTan HHLoh SF

bull Pregnancy (778 vs 700) and live birth rates (667 vs 600)

were similar between laparoscopy and open surgery The mean

interval to pregnancy was marginally lower via laparoscopy (113 vs

136 months) Hospitalisation stay was significantly halved (143 vs

300 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

Hum Reprod 2012 Jun27(6)1657-62 doi 101093humrepdes078 Epub 2012 Mar 27

High pregnancy rate after microsurgical tubal reanastomosis bytemporary loose parallel 4-quadrant sutures technique a long

long-term follow-up report on 961 casesMoon HS1 Joo BS Park GS Moon SE Kim SG Koo JS

bull The overall pregnancy rate was 851 826 being

intrauterine and 25 ectopic

bull 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

bull They also avoid the risks associated with IVF

bull 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

bull Tubal anastomosis had a higher cumulative

pregnancy rate for women less than 37 years

of age no significant difference above 37

years of age

bull Human reproduction 2007 P Devroey

Comparison of Cost per Delivery

Patient Counselling

bull The most recent national assisted reproductive

technology (ART) registry data from 2012 noted a

324 live-birth rate per cycle initiated in patients with

tubal infertility similar to the 341 rate overall(SART)

bull 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

bull 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

bull ( 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

Ann Acad Med Singapore 2010 Jan39(1)22-6Microsurgical reversal of sterilisation - is this still clinically relevant

todayTan HHLoh SF

bull Pregnancy (778 vs 700) and live birth rates (667 vs 600)

were similar between laparoscopy and open surgery The mean

interval to pregnancy was marginally lower via laparoscopy (113 vs

136 months) Hospitalisation stay was significantly halved (143 vs

300 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

Hum Reprod 2012 Jun27(6)1657-62 doi 101093humrepdes078 Epub 2012 Mar 27

High pregnancy rate after microsurgical tubal reanastomosis bytemporary loose parallel 4-quadrant sutures technique a long

long-term follow-up report on 961 casesMoon HS1 Joo BS Park GS Moon SE Kim SG Koo JS

bull The overall pregnancy rate was 851 826 being

intrauterine and 25 ectopic

bull Tubal anastomosis had a higher cumulative

pregnancy rate for women less than 37 years

of age no significant difference above 37

years of age

bull Human reproduction 2007 P Devroey

Comparison of Cost per Delivery

Patient Counselling

bull The most recent national assisted reproductive

technology (ART) registry data from 2012 noted a

324 live-birth rate per cycle initiated in patients with

tubal infertility similar to the 341 rate overall(SART)

bull 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

bull 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

bull ( 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

Ann Acad Med Singapore 2010 Jan39(1)22-6Microsurgical reversal of sterilisation - is this still clinically relevant

todayTan HHLoh SF

bull Pregnancy (778 vs 700) and live birth rates (667 vs 600)

were similar between laparoscopy and open surgery The mean

interval to pregnancy was marginally lower via laparoscopy (113 vs

136 months) Hospitalisation stay was significantly halved (143 vs

300 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

Hum Reprod 2012 Jun27(6)1657-62 doi 101093humrepdes078 Epub 2012 Mar 27

High pregnancy rate after microsurgical tubal reanastomosis bytemporary loose parallel 4-quadrant sutures technique a long

long-term follow-up report on 961 casesMoon HS1 Joo BS Park GS Moon SE Kim SG Koo JS

bull The overall pregnancy rate was 851 826 being

intrauterine and 25 ectopic

Comparison of Cost per Delivery

Patient Counselling

bull The most recent national assisted reproductive

technology (ART) registry data from 2012 noted a

324 live-birth rate per cycle initiated in patients with

tubal infertility similar to the 341 rate overall(SART)

bull 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

bull 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

bull ( 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

Ann Acad Med Singapore 2010 Jan39(1)22-6Microsurgical reversal of sterilisation - is this still clinically relevant

todayTan HHLoh SF

bull Pregnancy (778 vs 700) and live birth rates (667 vs 600)

were similar between laparoscopy and open surgery The mean

interval to pregnancy was marginally lower via laparoscopy (113 vs

136 months) Hospitalisation stay was significantly halved (143 vs

300 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

Hum Reprod 2012 Jun27(6)1657-62 doi 101093humrepdes078 Epub 2012 Mar 27

High pregnancy rate after microsurgical tubal reanastomosis bytemporary loose parallel 4-quadrant sutures technique a long

long-term follow-up report on 961 casesMoon HS1 Joo BS Park GS Moon SE Kim SG Koo JS

bull The overall pregnancy rate was 851 826 being

intrauterine and 25 ectopic

Patient Counselling

bull The most recent national assisted reproductive

technology (ART) registry data from 2012 noted a

324 live-birth rate per cycle initiated in patients with

tubal infertility similar to the 341 rate overall(SART)

bull 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

bull 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

bull ( 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

Ann Acad Med Singapore 2010 Jan39(1)22-6Microsurgical reversal of sterilisation - is this still clinically relevant

todayTan HHLoh SF

bull Pregnancy (778 vs 700) and live birth rates (667 vs 600)

were similar between laparoscopy and open surgery The mean

interval to pregnancy was marginally lower via laparoscopy (113 vs

136 months) Hospitalisation stay was significantly halved (143 vs

300 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

Hum Reprod 2012 Jun27(6)1657-62 doi 101093humrepdes078 Epub 2012 Mar 27

High pregnancy rate after microsurgical tubal reanastomosis bytemporary loose parallel 4-quadrant sutures technique a long

long-term follow-up report on 961 casesMoon HS1 Joo BS Park GS Moon SE Kim SG Koo JS

bull The overall pregnancy rate was 851 826 being

intrauterine and 25 ectopic

bull The most recent national assisted reproductive

technology (ART) registry data from 2012 noted a

324 live-birth rate per cycle initiated in patients with

tubal infertility similar to the 341 rate overall(SART)

bull 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

bull 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

bull ( 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

Ann Acad Med Singapore 2010 Jan39(1)22-6Microsurgical reversal of sterilisation - is this still clinically relevant

todayTan HHLoh SF

bull Pregnancy (778 vs 700) and live birth rates (667 vs 600)

were similar between laparoscopy and open surgery The mean

interval to pregnancy was marginally lower via laparoscopy (113 vs

136 months) Hospitalisation stay was significantly halved (143 vs

300 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

Hum Reprod 2012 Jun27(6)1657-62 doi 101093humrepdes078 Epub 2012 Mar 27

High pregnancy rate after microsurgical tubal reanastomosis bytemporary loose parallel 4-quadrant sutures technique a long

long-term follow-up report on 961 casesMoon HS1 Joo BS Park GS Moon SE Kim SG Koo JS

bull The overall pregnancy rate was 851 826 being

intrauterine and 25 ectopic

bull 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

bull ( 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

Ann Acad Med Singapore 2010 Jan39(1)22-6Microsurgical reversal of sterilisation - is this still clinically relevant

todayTan HHLoh SF

bull Pregnancy (778 vs 700) and live birth rates (667 vs 600)

were similar between laparoscopy and open surgery The mean

interval to pregnancy was marginally lower via laparoscopy (113 vs

136 months) Hospitalisation stay was significantly halved (143 vs

300 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

Hum Reprod 2012 Jun27(6)1657-62 doi 101093humrepdes078 Epub 2012 Mar 27

High pregnancy rate after microsurgical tubal reanastomosis bytemporary loose parallel 4-quadrant sutures technique a long

long-term follow-up report on 961 casesMoon HS1 Joo BS Park GS Moon SE Kim SG Koo JS

bull The overall pregnancy rate was 851 826 being

intrauterine and 25 ectopic

Ann Acad Med Singapore 2010 Jan39(1)22-6Microsurgical reversal of sterilisation - is this still clinically relevant

todayTan HHLoh SF

bull Pregnancy (778 vs 700) and live birth rates (667 vs 600)

were similar between laparoscopy and open surgery The mean

interval to pregnancy was marginally lower via laparoscopy (113 vs

136 months) Hospitalisation stay was significantly halved (143 vs

300 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

Hum Reprod 2012 Jun27(6)1657-62 doi 101093humrepdes078 Epub 2012 Mar 27

High pregnancy rate after microsurgical tubal reanastomosis bytemporary loose parallel 4-quadrant sutures technique a long

long-term follow-up report on 961 casesMoon HS1 Joo BS Park GS Moon SE Kim SG Koo JS

bull The overall pregnancy rate was 851 826 being

intrauterine and 25 ectopic

Hum Reprod 2012 Jun27(6)1657-62 doi 101093humrepdes078 Epub 2012 Mar 27

High pregnancy rate after microsurgical tubal reanastomosis bytemporary loose parallel 4-quadrant sutures technique a long

long-term follow-up report on 961 casesMoon HS1 Joo BS Park GS Moon SE Kim SG Koo JS

bull The overall pregnancy rate was 851 826 being

intrauterine and 25 ectopic

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