INTRODUCTION

 

The fallopian tubes are symmetrical paired tubular organs that connect the peritoneal cavity to the endometrium in the uterine cavity. The fallopian tubes are more than simple conduits or "open pipes." The fallopian tubes capture the ovum after ovulation and serve as a conduit for its travel toward the uterus. Fertilization of the egg by the sperm occurs in the fallopian tube. Following fertilization, the zygote develops into an embryo and continues to travel through the fallopian tube into the uterine cavity, where it implants in the endometrium. The fallopian tubes provide the environment and conditions for conception and for the early development of the conceptus.

Furthermore, the ovum, zygote, and embryo have no intrinsic motility. The fallopian tube is both the conduit and the transporter of the ovum and the early conceptus. Tubal function also aids transport of sperm to the site of fertilization. The fallopian tubes are thus essential and necessary in normal, natural, unassisted reproduction in women.

The multiple and complex functions of the fallopian tubes can be affected by disease, resulting in infertility and, in extreme cases, sterility. Fallopian tube reconstruction has been the traditional method of restoring reproductive function to women with tubal infertility. Today, in vitro fertilization (IVF) and embryo transfer (ET) bypass the fallopian tubes in the reproductive process and are additional options in the treatment of these patients.

History of the Procedure:

Fallopian tube reconstruction for tubal disease was first documented in 1896. The procedure reimplanted the fallopian tubes into the uterus. The results were dismal.

Early tubal reconstructive surgeries were performed using what is today described as macrosurgical technique. The purpose of these surgeries was to provide an open conduit from the peritoneal cavity into the uterus. Knowledge of the other multiple functions of the fallopian tubes was scanty, thus little attention was given to protecting or restoring these functions, and the results were relatively poor.

Over time, a better understanding of fallopian tube physiology, advances in perioperative care, and improvements in surgical techniques have resulted in better outcomes. Advances in macrosurgical techniques in fallopian tube reconstruction were made throughout the early 20th century. Microsurgical approaches to tubal reconstruction began to be developed during the 1960s-1970s.

Microsurgical technique is a delicate surgical style that emphasizes the use of magnification, fine atraumatic instrumentation, microsuturing, continuous irrigation to prevent desiccation, and pinpoint hemostasis. The goals are to remove pathology, restore normal anatomy, and regain function with minimal damage to adjacent normal tissue. This is achieved by minimizing inflammation and preventing adhesion formation. The microsurgical approach is more likely to preserve the function of the uterotubal junction, maintain the blood supply, and preserve the integrity of the tubal musculature.

The use of microsurgical technique in tubal reconstructive procedures has been shown to dramatically improve clinical results and has become the standard in these procedures. It requires specialized training and practice prior to its clinical application in order to achieve optimal results.

Problem:

The fallopian tubes have critical functions in the reproductive process, including providing a conduit from the peritoneal cavity to the uterine cavity. The uterine cavity is the site of implantation and pregnancy. Fertilization and early embryonic growth occur in the fallopian tubes. The secretory cells of the tubal mucosa must provide the nutrients and growth factors necessary at the time of conception and for successful early embryonic development.

The fallopian tubes are involved in the transport of the ovum and sperm to the site of fertilization and in the movement of the early embryo to the uterine cavity. The ciliary motion of cells lining the tubal mucosa and the coordinated muscular activity of the uterus/fallopian tubes result in the successful transport of the gametes and early embryo through the fallopian tubes. These functions are partly regulated by the cyclical hormones of the reproductive cycle. Tubal secretory and muscular functions require normal circulation and neuronal input. Tubal blockage, damage to the tubal mucosa and muscularis, and disruption of circulatory and neuronal inputs to the fallopian tube can result in infertility and increase the risk of tubal ectopic pregnancy.

Surgical techniques to reconstruct the fallopian tubes must achieve patency while minimally disrupting the tubal and pelvic anatomy in order to preserve subsequent function. Microsurgical technique in tubal reconstructive surgery best accomplishes these goals.

Frequency:

Infertility is defined as the inability to achieve pregnancy after 1 year of unprotected intercourse. An estimated 15% of couples of reproductive age meet this criterion and are considered infertile. A female factor is responsible in up to 50-60% of all cases. Tubal dysfunction is the cause in approximately 40% of infertile women.

Etiology:

The major contributor to fallopian tube infertility is pelvic inflammatory disease (PID). The most common causes of PID are sexually transmitted diseases such as those caused by Chlamydia trachomatis and Neisseria gonorrhea. Symptoms of PID can include adnexal tenderness, strawberry cervix, and cervical motion tenderness; however, women can contract sexually transmitted diseases that can lead to tubal blockage without their knowledge because of lack of symptoms.

The long-term consequences of PID include tubal occlusion, adnexal and pelvic adhesions, recurrent PID, chronic pelvic/abdominal pain, tubo-ovarian abscess, dyspareunia, and menstrual pain. The risk of subsequent infertility is approximately 12% after 1 episode of PID, 35% after 2 episodes, and 75% after 3 or more episodes.

PID is not the only cause of tubal dysfunction amenable to reconstructive surgery. Other offenders include endometriosis, tubal sterilization, salpingitis isthmica nodosa, tuberculosis, abdominal or pelvic adhesions (resulting from surgery or other inflammatory processes), ectopic pregnancy, and, less commonly, congenital tubal anomalies, polyps, and neoplasms. Most often, the dysfunction of the fallopian tubes is a consequence of a disease process that involves inflammation, infection, adhesions, fibrosis, scarring, and obstruction. The resulting tubal dysfunction frequently has no overt clinical symptoms and remains undiagnosed until the woman discovers she is unable to conceive and seeks reproductive medical advice.

Pathophysiology:

The many processes that result in tubal dysfunction involve different pathophysiologies. PID commonly causes tubal blockage, either proximally at the site of insertion into the uterus or distally at the fimbrial end. Less commonly, a midtubal segment may become occluded. Blockage at 2 points results in a hydrosalpinx because the continued secretions of the tubal mucosa have no drainage into the peritoneal or uterine cavities. As the hydrosalpinx enlarges, the tubal muscularis thins. The secretory and ciliary properties of the endosalpinx are eventually disrupted. The probability of pregnancy after repair of hydrosalpinges with a diameter of more than 3 cm is very poor. Evacuation of the fluid within a large hydrosalpinx does not restore function to the tube. Other possible sequelae of PID include pyosalpinx, tubal or tubo-ovarian abscess, and peritubal adhesions.

The pathophysiology after tubal sterilization depends on the method used. Electrocautery of a segment or segments of the fallopian tube occludes the lumen and causes more damage to the surrounding tissues than placement of a ring or a clip over the mid portion of the tube or surgical interruption of the tube (eg, Pomeroy technique, Irving technique). Increasing the amount of damage to the fallopian tube may increase the success of the sterilization procedure, but it decreases the chance of achieving subsequent successful reconstruction. The length of a tube after a reconstructive procedure correlates with success in terms of achieving pregnancy. Patients with tubes longer than 5 cm after reconstruction have better outcomes than patients whose tubes measure 3 cm or less.

Any inflammatory condition in the pelvis, such as endometriosis or the sequelae of pelvic or abdominal surgery, may cause adhesions, tubal blockage, or injury to the tubal mucosa and/or muscularis, resulting in tubal damage and dysfunction.

Clinical Presentation:

Women with tubal infertility usually present to their obstetrician/gynecologist for evaluation and treatment after trying to achieve pregnancy with unprotected intercourse over an extended period. Eighty-five percent of couples of reproductive age achieve conception within 1 year of having unprotected sex (unless an obvious problem such as a previous tubal sterilization exists); therefore, couples should allow plenty of time to conceive prior to submitting themselves to costly, somewhat risky, and possibly unnecessary fertility evaluations and treatments.

Once tubal infertility has been established, a basic fertility evaluation must assess (1) the ability of the woman to ovulate, (2) whether the woman has a healthy reproductive tract, and (3) the availability of viable sperm. These components are the essentials necessary to have a possibility of pregnancy; therefore, if a tubal factor is identified early during the evaluation of a couple, a woman should not undergo tubal reconstruction unless it has been established that she can ovulate, that her uterus is otherwise normal, and that her male partner has adequate sperm. Proceeding otherwise risks subjecting a patient to tubal reconstructive surgery without a realistic possibility of success, defined as subsequent pregnancy and delivery of a live infant.

The initial history, physical examination, and laboratory evaluation should focus on uncovering risk factors that cause a predisposition to infertility.

Age is very important in the evaluation of female fertility. Fertility in women decreases with increasing age, reflecting decreased ovarian function. The decrease in female fertility starts at approximately age 35 years. Whereas fertility decreases with advancing age, the risk of miscarriage, congenital malformations, and complications during pregnancy increases. In one study, only 14.3% of women older than 40 years who had a tubal sterilization reversal procedure delivered live children.

The menstrual history is essential to evaluate a possible ovulatory factor. The obstetrical history establishes whether the woman has ever been able to conceive and whether she has had any pregnancy complications, such as an ectopic pregnancy or postpartum endometritis, that may have compromised her reproductive tract.

The gynecological history reveals possible problems with the reproductive organs that may affect fertility or the possibility of pregnancy. For example, a history of Asherman syndrome with extensive destruction of the endometrial surface may preclude the possibility of embryonic implantation. The presence of fibroids or other malformations of the reproductive tract (eg, unicornuate/bicornuate uterus, uterine septum, malformations secondary to intrauterine diethylstilbestrol exposure) may affect the uterine cavity in a way that prevents a fetus from developing to viability at birth.

The medical history uncovers possible causes of ovulatory dysfunction secondary to hypothalamic/pituitary disorders or intrinsic ovarian malfunction. A history of PID, endometritis, and other causes of pelvic inflammation, such as endometriosis or appendicitis, should be elicited. Correctible medical contraindications to pregnancy (and surgery), such as uncontrolled diabetes, hypertension, or cardiac or renal disease, should be excluded or corrected.

The surgical history should focus on the pelvis because any surgery on the reproductive organs, bowel, or bladder can cause pelvic inflammation, adhesions, and tubal damage.

The physical examination should confirm normal pubertal development with the presence of normal secondary sexual characteristics. Manifestations of hormonal disorders that can affect ovulation, such as hirsutism or galactorrhea, should be sought. Examination of the abdomen may reveal scars from previous surgeries that may have affected the reproductive organs. A pelvic examination may reveal gross abnormalities of the reproductive tract. Pregnancy after a tubal sterilization reversal procedure is mostly likely to occur within the first year. Most pregnancies occur within 6 months after surgery.

INDICATIONS

Tubal reconstructive surgery is indicated in women younger than 39 years who are trying to achieve pregnancy. These women must have proven tubal infertility amenable to tubal reconstruction with an otherwise normal uterine cavity, the capacity to ovulate, and a male partner who produces enough sperm for conception through intercourse or artificial insemination.

RELEVANT ANATOMY AND CONTRAINDICATIONS

Relevant Anatomy: The fallopian tubes are seromuscular paired tubular organs that run medially from the ovaries to the cornua of the uterus. The fallopian tubes are situated toward the upper margins of the broad ligament. The tubes connect the endometrial cavity in the uterus with the peritoneal cavity toward the ovaries on each side. The tubes average 10 cm in length (range, 7-14 cm).

The tubes can be divided into 4 parts (proximally at the endometrial cavity to their distal portion near the ovary):

  • The intramural or interstitial portion (from the endometrial cavity, through the uterine wall, and to the uterine cornua)

·         The isthmus (the proximal third of the fallopian tubes outside the uterine wall)

·         The ampulla (the distal two thirds of the fallopian tubes outside the uterine wall)

·         The infundibulum, the funnel-shaped opening to the peritoneal cavity

The fimbriae are fingerlike extensions from the margins of the infundibulum toward the ovaries on each side. The intraluminal diameter varies and increases from 0.1 mm in the intramural portion to 1 cm in the ampullary portion of the tubes. The fallopian tubes receive their blood supply from the tubal branches of the uterine arteries and from small branches of the ovarian arteries. The fallopian tubes receive sensory, autonomic, and vasomotor nerve fibers from the ovarian and inferior hypogastric plexi.

Contraindications:

  • Absolute contraindications
    • Aged 40 years or older

o        Decreased ovarian reserve or ovarian failure

o        Tubal infertility not amenable to tubal reconstruction

o        Extensive tubal damage

o        Hydrosalpinx with a diameter of more than 3 cm

o        Inadequate proximal or distal tubal segment for reanastomosis

o        Projected tubal length of less than 3 cm after the reconstruction procedure

o        Extensive pelvic/peritubal adhesions

o        Abnormal uterine cavity

o        Any contraindication to pregnancy or surgery

o        Severe male factor infertility or male sterility

·         Relative contraindications

    • Age 35-39 years

o        Mild male factor infertility

 

 

  • Male factors
    • Men account for 30-40% of infertility in couples.
    • Problems typically include low semen volume, decreased sperm concentration and/or motility, and abnormal sperm morphology.
    • Semen analysis is necessary.
  • Female factors
    • In some women, ovulatory problems are a cause of infertility. Ovulatory function tests can help determine ovulatory function. Adequate ovulatory function can be confirmed with the following:
      • Normal regular menstrual cycles

§         Day 3 follicle-stimulating hormone level within the reference range

§         Midluteal-phase serum progesterone measurement confirmatory of ovulation

o        Papanicolaou test (Pap smear) results must be normal.

o        Cervical culture results (eg, C trachomatis, N gonorrhea) must be negative.

Imaging Studies:

  • Hysterosalpingography is used to determine the presence of proximal fallopian tubes.
  • When necessary, saline sonography further defines abnormalities of the uterine cavity.

Other Tests:

  • Basal body temperature charting can help identify female ovulatory factors.

Diagnostic Procedures:

  • Laparoscopy
    • This procedure helps to (1) evaluate the amount of pelvic adhesions and tubal damage before tubal reconstructive surgery; (2) measure the diameter of a hydrosalpinx to determine the feasibility of tubal reconstruction; and (3) identity the distal portion of the fallopian tube(s) prior to tubal reanastomosis following sterilization procedures.
    • This procedure also facilitates estimation of the length of the tube resulting from the tubal reconstructive surgery.
    • Tubal and pelvic reconstruction can be performed with the patient under the same anesthesia following diagnostic laparoscopy, via operative laparoscopy, or via laparotomy when necessary. However, patients may request a different surgical procedure on a different day if a laparotomy is required.
  • Timed endometrial biopsy can help identify female ovulatory factors.

TREATMENT

Surgical therapy:

The surgical approach to fallopian tube reconstruction is discussed in 3 parts according to the anatomic location of the obstruction: (1) the proximal portion of the tube, (2) the distal portion of the tube, and (3) the mid portion of the tube.

Occlusion of the proximal portion of the fallopian tube

Proximal occlusion of the fallopian tube can be of 2 types: intramural/interstitial and isthmic.

Intramural/interstitial obstruction

In the past, intramural/interstitial obstruction was surgically treated with tubal reimplantation through the uterine wall. This procedure is mentioned for historical interest because, in terms of achieving lasting tubal patency and subsequent pregnancy, the results are so poor that the procedure should be abandoned. Today, other more successful therapeutic options, such as IVF, are indicated.

However, intramural obstruction can be approached via hysteroscopic cannulation. The patient undergoes concurrent laparoscopy and hysteroscopy. The procedure may require 2 surgeons. The laparoscopy is performed to exclude disease in the distal portion of the fallopian tube(s). If the distal fallopian tube(s) is healthy, the surgeon proceeds to hysteroscopic cannulation.

A number of commercial cannulation kits are available for this procedure (eg, the Novy Cornual Cannulation Sets, Cook Ob/Gyn; Spencer, Ind). The tubal ostia are visualized in the endometrial cavity with the hysteroscope. A small wire is inserted through the os into the intramural portion of the tube, and a small catheter is threaded over the wire. Patency can be confirmed when dye introduced through the small catheter in the intramural portion of the tube is visualized extruding through the fimbria via laparoscopy.

Isthmic occlusion

Isthmic occlusion can be repaired by performing an isthmic-cornual or an isthmic-isthmic anastomosis as appropriate. The damaged portion of the tube is transected perpendicular to the axis of the tube. The occluded portion of the tube is resected 2 mm at a time, initially proximally and subsequently distally, until the tubal lumen is visualized.

Proximal patency is confirmed using retrograde chromopertubation through a cannula in the uterine cavity. Distal patency is confirmed by threading a piece of thin suture material from the fimbrial end toward the area of anastomosis.

An anchoring suture is placed in the proximal and distal mesosalpinx (isthmic-isthmic repair) or from the cornu proximally to the mesosalpinx distally (cornual-isthmic repair) to bring the 2 portions of the tube being reanastomosed in proximity. Four interrupted sutures are placed at the 12-, 3-, 6-, and 9-o'clock positions, parallel to the axis of the tube, first within the muscularis and subsequently on the serosa, to bring together the proximal and distal portions of the tube.

Occlusion of the distal portion of the fallopian tube

Distal tubal occlusion can be surgically repaired by laparotomy or laparoscopy. Both surgical approaches achieve similar results.

Proximal patency of the tube must be confirmed with a preoperative hysterosalpingogram. Filling the fallopian tube with dilute dye at the time of surgery (via a cannula in the uterine cavity) facilitates identification of the entrance point in the distal, peritoneal surface of the tube that opens into the tubal lumen.

The distal occluded tube is opened using laser energy, a needlepoint unipolar electrode, or microscissors. The mucosa is everted without tension and is sutured to the serosa of the tube with a few interrupted sutures.

Occlusion of the mid portion of the fallopian tube

Midtubal occlusion is the most frequent cause of tubal sterility. In appropriate cases, reanastomosis of the mid portion of the fallopian tube holds the greatest promise of success. The reanastomosis can be isthmic-ampullary or ampullary-ampullary. The success of the procedure is directly correlated to the length of the tube following reanastomosis.

Midtubal reanastomosis can be performed via laparotomy or laparoscopy with equivalent rates of success. The procedure is similar to that described for isthmic-isthmic reanastomosis. The occluded portion of the tube is resected. Portions of occluded tube (in 2-mm sections) are repeatedly resected, first proximally and then distally, until the tubal lumen is identified in the proximal and distal stumps. Patency of the stumps is confirmed with retrograde chromotubation (proximal stump) and by threading a piece of thin suture from the fimbrial end toward the area of reanastomosis (distal stump).

An anchoring suture is placed in the proximal and distal mesosalpinx to bring the 2 portions of the tube being reanastomosed in proximity. Four interrupted sutures are placed at the 12-, 3-, 6-, and 9-o'clock positions, parallel to the axis of the tube, first within the muscularis and subsequently on the serosa, to bring together the proximal and distal portions of the tube.

Preoperative details: Candidates for tubal reconstruction are young women of reproductive age. In most cases, these women are healthy, and a preoperative CBC count and a serum pregnancy test are all that is required. Other preoperative evaluation is dictated by the patient's medical history and needs. The use of perioperative prophylactic antibiotics to prevent infection and corticosteroids or antiprostaglandin agents to decrease adhesion formation is controversial

Intraoperative details: Strict adherence to the principles of microsurgery improves the results of tubal reconstruction.

Magnification of the operative field with an operative microscope or with surgical loupes allows for visualization of fine detail and increased accuracy of movement, both of which contribute to the delicate, gentle handling of tissues.

Meticulous, precise hemostasis that limits surrounding tissue injury is critical to maintain visualization in the magnified field. The use of crushing instruments, such as clamps and traumatic graspers, should be minimized to prevent tissue ischemia. All instruments must be fine and atraumatic, and only fine microsutures (eg, 8-0, 10-0) with tapered needles should be used on the fallopian tubes.

The drying of peritoneal and serosal surfaces is prevented with the use of continuous irrigation with warm isotonic fluid (eg, Ringer lactate solution). Minimal handling of the tissues decreases inflammation and adhesion formation. Postoperative adhesions can be decreased with the use of adhesion prevention barriers, such as oxidized regenerated cellulose (Interceed [TC7] Absorbable Adhesion Barrier, Ethicon; Somerville, NJ), or sodium hyaluronate/carboxymethylcellulose (Seprafilm Bioresorbable Membrane, Genzyme Corporation; Cambridge, Mass). These barriers maintain the healing surfaces away from each other, thus preventing adhesion formation.

Postoperative details: Any suggestion of pelvic infection in the postoperative period requires aggressive antibiotic treatment because infection can result in adhesion formation and reocclusion of the fallopian tubes. Traditionally, pelvic rest (ie, no intercourse, nothing intravaginally) has been recommended during the first postoperative month in an effort to protect the reproductive organs during the healing period.

Follow-up care: Perform a hysterosalpingogram, preferably with an oil-based contrast medium, 3 months after tubal reconstruction. If the tube(s) is patent, the patient is allowed 1 year to achieve pregnancy before further evaluation and treatment is warranted.

When indicated, manage other correctible infertility factors during the first year following surgery. For example, treat oligo-ovulatory women with ovulation induction to improve the chance of pregnancy. Perform intrauterine insemination in women with cervical infertility and to treat mild-to-moderate oligospermia.

If the postoperative hysterosalpingogram demonstrates bilateral tubal occlusion, refer the patient for IVF. The fallopian tubes are so delicate that repeated surgeries generally worsen the chances of success.

COMPLICATIONS

Women who have undergone tubal reconstruction are at a higher risk of ectopic pregnancy. Early evaluation of a pregnancy is critical to determine the site of implantation. Ectopic pregnancies identified early are small and can be managed more safely and easily. Women should be advised to contact their doctor within the first 2 weeks of a missed period. A vaginal ultrasound at the sixth week of gestation should identify an intrauterine sac, if present. If not present, the ectopic pregnancy should be managed medically or surgically as indicated.

OUTCOME AND PROGNOSIS

Most pregnancies following tubal reconstructive surgery occur within a year of the procedure. The length of the tube following reconstructive surgery is directly correlated to success in terms of subsequent pregnancy. The prognosis of the surgical repair of hydrosalpinx with a diameter greater than 3 cm is very poor. The amount of pelvic adhesions and damage at the time of surgery is inversely correlated to the success of tubal reconstruction.

Reports of pregnancy rates following fallopian tube reconstructive surgery

The success rates following tubal reconstructive surgery (reported as pregnancy or live birth) vary from author to author, thus making a comparison of results difficult because a number of important variables may differ among reports. For example, the patient populations may not be comparable in terms of the age of the patients, ovarian function, amount of preoperative tubal damage, and length of the tube following reconstruction, among others. Differences in the experience of the surgeons and in the surgical techniques used may also explain the variable results obtained. Some of the best published results are as follows:

  • Repair of the proximal fallopian tube
    • Hysteroscopic tubal cannulation to repair intramural or interstitial obstruction can result in a patency rate of up to 90% in at least 1 tube and a pregnancy rate in the range of 50-60%.

o        Similar pregnancy rates have been reported following isthmic-cornual anastomosis. The pregnancy rate following isthmic-isthmic anastomosis is highly dependent on the length of the tube following surgery and has been reported to be as high as 75% if the anastomosed tube is longer than 4 cm.

·         Repair of the distal fallopian tube: Pregnancy rates ranging from 10-80% have been reported, depending on the amount of tubal damage at surgery.

·         Repair of the mid portion of the fallopian tube

    • Pregnancy rates vary according to the length of the tube following surgery.

o        Pregnancy rates of up to 75% have been reported with tubes longer than 4 cm after surgical repair. The pregnancy rate drops to less than 20% in women with shorter tubes.

FUTURE AND CONTROVERSIES

In the past, tubal reconstruction surgery was the mainstay treatment of tubal disease. In its early years, tubal reconstruction provided treatment when the dismal alternative was sterility. As surgical management and techniques improved, and with the implementation of the concepts of microsurgery, the success rate of tubal reconstructive surgery steadily increased over time.

The birth of Louise Brown in 1978 following IVF initiated a new era in the management of tubal infertility. Pregnancy could be achieved even in the complete absence of the fallopian tubes. The early experience with IVF was relatively poor, especially compared with the success obtained with surgical reconstruction in well-selected cases of tubal infertility.

Individual clinics can achieve rates of more than 50% live births per ET, including women with irreparable tubal damage or with absent fallopian tubes. Overall, in 2000, more than 26% of initiated cycles of assisted reproduction, specifically for the diagnosis of tubal infertility, resulted in a live birth. In general, couples diagnosed with tubal factor infertility who undergo assisted reproduction have above-average success rates.

The place of tubal reconstructive surgery in the present management of tubal infertility has been questioned in view of the success rates that can be achieved with IVF. A number of factors must be considered in such a discussion. In well-selected cases, tubal reconstructive surgery has the potential of curing or correcting the tubal factor underlying the inability to conceive. Assisted reproduction simply bypasses the fallopian tubes during a cycle of IVF.

Given that no treatment guarantees success today, a young woman who wants more than one child and who is considered a good candidate for tubal reconstruction may benefit from corrective surgery rather than from multiple cycles of IVF. On the other hand, because tubal reconstruction may require as much as 1 year of trial to test its success, an older woman with tubal infertility may benefit more from a cycle, or multiple cycles, of assisted reproduction. Age is critical in terms of ovarian function. A woman in her early 40s may not have the luxury of waiting a year after tubal reconstruction to then proceed to IVF if she does not achieve pregnancy.

The risk of ectopic pregnancy and of multiple gestations may influence management decisions. Ectopic pregnancy rates following tubal reconstruction have been reported to be as high as 5-10%. IVF can result in a tubal pregnancy if the embryos end up in the fallopian tube rather than in the uterine cavity following ET. The ectopic pregnancy rate following IVF is in the range of 2-3%.

Tubal reconstructive surgery has a definite place in the management of tubal infertility today. Choosing the best candidates for the procedure is critical and must involve, among other considerations, existing pathology, age, and the financial options of the patients. The use of microsurgical technique is the standard of surgical care to achieve the best results to protect and maintain the patient's reproductive potential. As better methods and materials to decrease and prevent postoperative intrapelvic adhesions become available, the success of fallopian tube reconstruction in well-selected cases should continue to improve.