Sperm-Egg Transport Solving Tubal Problems

The two most common surgical procedures performed with the laparoscope are the cutting and removal (lysis) of thin pelvic adhesions surrounding the ovaries, tubes, and uterus, and the surgical removal of endometriosis implants. Sometimes I will sever nerves to the uterus to relieve the pain associated with endometriosis, open a blocked fallopian tube or remove a large ovarian cyst. At present most, but not all tubal repairs can be performed with the laparoscope.

Lysis of Adhesions
In this procedure the surgeon removes adhesions (scar tissue) with a laparscopic scissors, bipolar electrocautery instruments, harmonic scalpel, or laser. Best results are obtained if the band of scar tissue is removed and not just cut. Results appear to be better after laparoscopy than laparotomy. The adhesiolysis (cutting adhesions) is more effective preventing new adhesions from forming than they are after an operation to treat existent adhesions.

Salpingostomy/Fimbrioplasty (opening the fimbria and repairing the tube)
Sometimes infection, endometriosis or surgical trauma cause the "petals" of the fimbria to close in on themselves much as a tulip might close at night. Pressure from fluid building up inside the tube causes the tube to dilate (hydrosalpinx). When this happens, it is unlikely that the ciliated inner lining will be intact and functional. I can use a laser or microscopic cautery needle to carve an X-shaped incision at the end of the tube to allow the "petals" to separate and fold back into their normal position. If the fimbria are not restored by this procedure, I can open the tube, but without fimbria the tube has little chance of retrieving the egg. Women with severely damaged or atrophied fimbria have less than a 10 percent chance of achieving pregnancy. In vitro fertilization may offer the best chance for success. (See chapter 21 for a description of in vitro fertilization.)

Salpingectomy (removal of the fallopian tube)
Occasionally a tube is in such poor condition that it must be removed or sealed to give preference to the better tube. In vitro fertilization may be more successful if a large, dilated fallopian tube is removed prior to treatment. Bleeding from a ruptured ectopic pregnancy may require that I tie off the blood supply to the tube or remove the tube. Provided the woman has one good tube, I may remove a diseased tube if it is damaged beyond repair and causing pain. If both tubes are not functional or must be removed, I turn my attention to freeing up the ovaries for in vitro egg retrieval procedures.

Removing an Ectopic Pregnancy
While most ectopic pregnancies occur in women with no risk factors, often I will suspect ectopic pregnancy in women who have had surgical treatment of tubal abnormalities, previous ectopic pregnancies or an hCG titre that demonstrates a suboptimal rise. The hCG level should rise a minimum of 60% in 48 hrs. After the level is above ~1800 miu/ml, I can usually see the pregnancy inside the uterus with transvaginal ultrasound. If the rise is repeated less than 60% or the pregnancy is not seen by a certain point, I will suspect either a miscarriage or an ectopic pregnancy. Oftentimes I will locate a gestational sac in the fallopian tube on ultrasound. If the diagnosis is made early enough when the pregnancy is small, the drug methtrexate can be used to dissolve the pregnancy and avoid surgery in up to 85% of those treated. If I have any doubt that an ectopic pregnancy exists, I may still choose to treat with methotrexate to avoid later complications and more expensive surgical treatments.

For those patients unwilling to receive methotrexate therapy, I will perform a laparoscopy to confirm the diagnosis. Sometimes the pregnancy is small enough that I can simply slit open the tube lengthwise and carefully suction out the material. It is not necessary to repair the tubal incision. The tube will heal normally without being stitched.

When a more advanced pregnancy ruptures the tube, I will snip out the distorted portion of the tube to remove the pregnancy. Because the tube has a greater tendency to bleed during pregnancy, I will not reconnect the two ends at that time. If within a year the woman does not conceive with the other tube, I may consider further surgery to reconnect the tube.

Removing the Ovary
If at all possible, I try to conserve an ovary. If an ectopic pregnancy implants on the ovary, however, destruction of the ovarian tissue and excessive bleeding may require its removal. The ovary may also have to be removed when it has been entirely replaced with endometriosis (see "Chocolate Cyst" in chapter 17), when it becomes tumorous or when it is painful. Sometimes ovarian enlargement caused by a tumor or cyst may cause the ovary to twist and cut off its blood supply. When this happens, I must remove the ovary. As long as one ovary is intact, however, fertility should not be compromised.

Therapeutic Results from the Laparoscopy
About half of the time no evidence of a fertility problem is found. (Oddly enough, of those with no abnormal findings, one-third will get pregnant following the procedure.) Where a problem is identified, about three-fourths of the time it is endometriosis and one-fourth of the time adhesions. If repairs must be made to the fallopian tubes and/or if microsurgery is needed, I will usually perform abdominal surgery. (See the discussion of laparotomy below.)

Once a problem has been corrected (during the laparoscopy or during subsequent abdominal surgery), you will have a 50-65 percent chance of getting pregnant. Repeat attempts to correct fallopian tube abnormalities are less successful.

When pregnancy is achieved an ultrasound examination is recommended soon after the pregnancy is confirmed to determination its location. After tubal surgery, the pregnancy can implant in the fallopian tube in 10-15% of patients.

Potential Complications from the Laparoscopy
Although complications are rare, the risks of the procedure include injury to abdominal structures, infection in the bladder or incisions, bleeding, allergies to medications, complications from general anesthesia, and pelvic infections. Should damage occur to other organs during the procedure, abdominal surgery may be required to correct it.

Falloposcopy is an experimental technique that allows us to place a scope directly inside the fallopian tube to examine the quality of the mucosal lining. If I find bare patches, I know that the woman is at increased risk for ectopic pregnancy and that reconstructive tubal surgery will be less likely to restore her fertility.

Unfortunately, at present the procedure requires laparoscopy to gain access to the fimbriated end of the tube. New equipment will soon allow this procedure to be performed by passing tiny catheters through the cervix and uterus into the fallopian tube. While falloposcopy promises to be a valuable tool for predicting the success of tubal repairs, it has not yet been proven cost effective in the management of tubal infertility.

When to Perform a Laparotomy
I will recommend abdominal surgery (laparotomy) to restore fertility if with the HSG and laparoscopy I discover:

Removal of large uterine leimyoma (fibroids) deep within the uterine muscle
Fallopian tube reanastomosis after tubal sterilization
Extensive and/or large endometrial implants of the bowel that cannot be treated laparoscopically

Purpose of the Laparotomy
Abdominal surgery affords me the access I need to perform delicate microscopic surgical procedures such as tubal reanastomosis with greater success. While many cases of endometriosis of the bowel may be handled by endoscopic resection, laparotomy may be necessary to handle the difficult case. Laparoscopic suturing techniques have been developed that allow us to sew without opening the abdomen. Yet, I believe that for the those patients with multiple fibroid tumors or those with fibroid deep within the wall of the uterus, a laparotomy will provide a better repair.

Procedures Used During Laparotomy
After you're anesthetized (either by going to sleep or with an epidural block), the surgeon will usually make a small bikini cut (side to side above your pubic bone) through your abdominal wall to expose your pelvic organs for inspection and repair. Depending on your fertility problem, a number of corrective procedures may be performed:

Tubocornual Anastomosis (removing tubal blockage and reconnecting the tube to the uterus)
When the tubal blockage occurs near the uterus, I can cut out the bad portion of the tube and reconnect the good end to the uterus, with the aid of an operating microscope. I shave away the layers of the uterus over the tubal opening, align the opening with the tube, and suture the end of the tube to the uterus. At present, in vitro fertilization would appear to provide better pregnancy rates at lower cost in most cases.

Tubotubal Anastomosis (removing a diseased portion of the tube and reconnecting the ends; sterilization reversal)
Sometimes repeated infection will block the fluid-filled tube. Removing the blocked portion may restore function to the tube. If it hasn't been stretched too far out of shape, I can remove a section of the tube and reconnect the ends to form a functional passage. The best results occur when the two ends of the tube are similar in size and when the remaining portion exceeds three inches in length. This procedure will restore fertility to half of the women treated.

Sterilization reversals are far more successful than corrective surgery for damage from infection: 60 percent or more will become pregnant after the surgery. This indicates to me that infection often impairs the tubal lining to the point that restoring patency does not restore tubal function. The best success with this procedure has been achieved by skilled microsurgeons using operating microscopes. While laparoscopic techniques are being tested to replace this procedure, as yet they have not duplicated the results of laparotomy tubal reanastomosis.

Recovery From the Laparotomy
When an epidural anesthetic and IV sedation are used along with local anesthesia at the incision sites, post operative discomfort can be minimized. While most women choose to remain in the hospital overnight or two to three days, many patients have returned home on the day of surgery. Recovery should require three to five days of rest at home or in the hospital and three to four weeks of restricted activity:

• No driving for two weeks
• No intercourse for two to four weeks
• No heavy activity or lifting for four to six weeks
• Absence from work for two to four weeks

Potential Complications from the Laparotomy
As with any surgical procedure there is always a slight chance for adverse reactions to the anesthesia and medications; and for postoperative infection.

The Key to Successful Fertility Surgery: Preventing Adhesions from Re-forming
The key to successful fertility surgery is minimizing the damage from infection, from the organs drying out, and from bleeding. Microsurgical techniques cause the least amount of damage, since the specially coated instruments are small and delicate. By using microsurgery we can control bleeding and blood clotting, which may start the formation of new adhesions. We can also use fine bipolarcautery needles to selectively excise small areas of tissue-endometrial implants, for example-and to stop the bleeding from very tiny blood vessels. Special solutions are used during surgery to keep the organs from drying out. Before completing the surgical procedure, the raw surfaces are often covered with a adhesion barrier membrane to prevent the reformation of adhesions (Interceed, Goretex). Alternatively, some physicians will place fluid inside the abdomen to float the internal organs and prevent raw surfaces from sticking together.

Second-Look Laparoscopy
Some physicians will perform a second-look procedure one to six weeks after the surgery. If filmy adhesions are re-formed, the physician can clean them out at that time. As microlaparoscopy under local anesthesia is far less costly than standard laparoscopy, second-look procedures may be more frequently performed as equipment becomes available.

I often perform an HSG six weeks to six months after the surgery to demonstrate tubal patency. Depending on the nature of the surgery and the woman's age, I may recommend in vitro fertilization if pregnancy has not occurred within six months to one year.

Repeat Tubal Surgery
Tubal surgery costs between $7,000 and $13,000, exposes you to the pain and risks of major abdominal surgery, and may cause you to miss up to six weeks of work. In addition, it may be up to two years before you know if tubal surgery is a success or failure. Experience shows that success rates for repeat tubal surgery are fairly poor. A repeat salpingostomy, for example, has a poorer success rate (less than 10 percent) than in vitro fertilization. The primary difficulty you may have with choosing between tubal surgery and in vitro is that your insurance will pay for tubal surgery, whereas it often won't pay for in vitro procedures, which cost up to $8-10,000 per cycle.

Although in vitro procedures may require traveling to distant clinics and more doctor visits, they expose you to fewer risks than repeat surgery and have a greater chance of success. In addition, within a short time you will know if in vitro will work, whereas with surgery it may take up to two years to find out. While the risk of ectopic pregnancy is higher after tubal surgery, multiple pregnancies are higher after in vitro fertilization.

Margaret B.'s Story
Margaret B. suffered a ruptured appendix when she was eighteen years old. She was in the hospital for three weeks and nearly died. At twenty-four she had a PID infection which did not require hospitalization. She'd always been concerned that these infections (peritonitis) could have affected her fertility, but her doctors would never confirm her suspicion.

"At thirty I went off the Pill, and my periods resumed in three months. After six months of trying to get pregnant we became concerned and consulted Dr. Perloe" Margaret said.

"When he did my laparoscopy, he found I had adhesions so thick that he could barely see anything else. During my surgery he found that my right tube was blocked and the fimbria had deteriorated. Although he attempted to repair the tube, he was doubtful that it would work. My left tube, however, was in good shape once he removed the pelvic adhesions from around it. After the surgery he told me I had a fifty-fifty chance of getting pregnant.

"I returned home within hours of my surgery. Dr. Perloe told me to stay home; and not to vacuum, pick up grocery sacks, or do any heavy work. After a week or two, he said, I could return to work."

"Three months after my surgery Dr. Perloe repeated my tubal X ray. That's when we got the bad news: both of my tubes had blocked up with adhesions. My husband and I didn't want to go through another laparotomy, so we decided to try in vitro."

"I'm happy to report that our second in vitro try was successful! Jon was born last month."

For more information on your initial visit to your physician read the
INCIID Routine Fertility Workup or IVF.com Homepage.

Miracle Babies and Other Happy Endings
for Couples with Fertility Problems
Copyright © 1986 Mark Perloe M.D., and Linda Gail Christie.