Infertility Tubal Surgery vs. IVF: How to Decide!
A progressive increase in success rates with IVF versus tubal fertility surgery has over the last 15 years brought about a shift away from the latter to the former. And so it should be, because attempted surgical restoration of compromised Fallopian tubes is by and large associated with at best a 30-40% chance of a baby within 2-3 years. The one exception is when surgery is done to restore the patency of Fallopian tubes that were previously, deliberately surgically ligated for contraception, where the post-surgery success rate is slightly higher (i.e., 50% within 2-3 years).
On the other hand, with IVF performed on comparable cases, there is often a better chance of success following a single completed cycle of IVF treatment (with all fresh and frozen embryo transfers included) and within 2 such comprehensive cycles of treatment, a higher birth rate. Moreover, as compared to surgery, IVF is associated with far lower morbidity and in many cases, when the surgical approach fails to yield a baby, IVF will ultimately become the final option.
This having been said, the fact is that tubal fertility surgery remains popular and is still being performed throughout this country. The reason for this (however illogical it might seem), is that presently many insurance companies will cover the cost of surgery while denying reimbursement for IVF. Accordingly, many women choose (for financial reasons) to first try tubal surgery before committing to the out-of-pocket costs associated with IVF. Frankly this makes no sense to me because it would be in the insurance provider’s own enlightened (financial and image-related) self interest to support that which is most likely to be successful in the shortest period of time, and which satisfies their clients’ needs.
I am still hopeful that one day the light will go on and they will come to their senses. At the present time, since tubal fertility surgery is still widely performed, it is very appropriate that women/couples contemplating undergoing such surgery be made aware of those factors that will affect outcome.
Therapeutic reproductive surgery can be performed through an open incision in the abdominal wall (laparotomy), allowing the surgeon to have direct (hands-on) access to the pelvic structures. It can also be performed through laparoscopy, where a thin telescope–like instrument is introduced through a small incision made below the belly button and other surgical instruments are introduced into the pelvis via several puncture sites in the lower abdomen. The laparoscope permits high resolution images of the pelvic structures to be transmitted onto a screen so that the surgeon can perform the required surgery while monitoring virtual progress there. The laparoscopic approach is far less painful, can be performed on an ambulatory (out-patient) basis and, as such, is rapidly replacing laparotomy. In fact, with the exception of some cases where tubal reconnection (re-anastomosis) is undertaken to reconnect previously ligated Fallopian tubes, and sometimes for the removal of uterine fibroids (myomectomy), almost all tubal fertility surgery is currently being performed laparscopically.
Factors that influence the likelihood of tubal Fertility surgery being successful are:
- Whether or Not The Woman Has Undergone Previous Tubal Surgery
The first attempt at corrective tubal surgery offers by far the best chance of success. Should the first attempt fail to result in pregnancy, then subsequent attempts are less likely to result in a healthy pregnancy. In other words, women who have undergone a previous failed attempt at tubal surgery have a very much-reduced chance of success following a second or third attempt at surgical correction.
- The Type of Surgery Performed
Women undergoing salpingostomy (surgery to unblock Fallopian tubes that are blocked at their ends) where the end(s) of the tube(s) must be stitched back or folded back through the use of laser surgery, can expect relatively low success rates (15-20% baby rate within 3 years). In cases where the tubes are open but surrounded by adhesions, and microsurgery is conducted to free such adhesions to mobilize the tubes (salpingolysis) so as to restore the normal anatomical relationship between the end(s) of the fallopian tube(s) and ovary (ies), the average clinical pregnancy rate is about 30% within three years. When surgery is performed (on the appropriate candidate) to reverse a prior tubal ligation (see below) the baby rate is about around 50% within 2-3 years. All this of course, is provided that the surgery is performed by an microsugical expert.It should be realized, however, that pelvic inflammatory disease most often attacks the inner lining of the fallopian tube(s). Regardless of outside appearances, which might suggest that only one tube is affected, both fallopian tubes are usually involved to some degree. Diseases such as endometriosis are less likely to damage the inner lining of the fallopian tube(s). Accordingly, women who conceive following pelvic microlaser reconstructive surgery where the cause of the infertility relates to chronic pelvic inflammatory disease, have a relatively high incidence of a tubal (ectopic) pregnancy. The reported incidence of subsequent tubal pregnancy ranges between eight and seventeen percent (8-17%) in such cases. The incidence of tubal pregnancy following surgery in cases of endometriosis is significantly lower.
Based upon the above statistics, it is our policy at SIRM to confine the performance of tubal surgery for two sets of circumstances:
- Women who are candidates for salpingolysis (have at least one patent Fallopian tube and require freeing of adhesions) and are under age 35, have never undergone tubal fertility surgery in the past, have normal ovarian reserve, and where there is no additional factor contributing towards the infertility (e.g. male infertility)
- As a prelude to IVF, where, because of fluid collection in one or both tubes (hydrosalpinx), the patient requires removal (salpingectomy) or tubal ligation to avoid the fluid tracking into the uterus and damaging the embryo(s). Older women face the onslaught of the “biological clock” and do not have the time to rely on the chance that surgery might work for them.