Treatment of tubal factor infertility

The majority of women with moderate to severe tubal damage are unlikely to conceive spontaneously and IVF is generally accepted as the treatment of choice in these cases. In the absence of randomized trials, evidence to support this strategy is mainly derived from observational studies.

A number of techniques for surgical reconstruction of damaged or occluded tubes have been described. Higher pregnancy rates have been reported in women who underwent tubal surgery than in those who did not (29 versus 12%) over a period of 3 years (Wu and Gocial, 1988). The success of surgical treatment depends on the extent of tubal damage, age of the woman, experience and training of the operator and availability of suitable equipment. Surgery has been shown to be effective in minor or moderate tubal damage, but of no benefit to women with severe tubal disease (Akande et al. 2004). Data from a case series have suggested that pregnancy rates following surgical treatment of proximal occlusion, mild distal block and flimsy adhesions are comparable to those after IVF. However, greater access to assisted reproduction in recent years has significantly reduced the role of tubal surgery in these cases.

Uncontrolled data indicate that approximately 50% of women with proximal tubal block can achieve a term pregnancy after microsurgical tubocornual anastomosis (Maranna and Quagliarello, 1988). Proximal tubal obstruction can be treated by tubal catheterization or cannu-lation under radiological or hysteroscopic guidance. In the absence of any direct comparisons between the two approaches, data from observational studies suggest a higher pregnancy rate (49 versus 21%) with the latter. Tubal cannulation can lead to tubal perforation in 2-5% of cases and ectopic pregnancy is 3-9% (Honore et al. 1999).

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