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Infertility Causes > Woman > Fallopian Tubes and Surrounding Structures Overview - Evaluation - Treatment Options - DiagnosisEvaluating Degrees of Tubal Damage and Assessing Treatments There are certainly different degrees of tubal damage. It can range from a few thin and easily removed adhesions around the tube and ovary, to virtually complete destruction of the fallopian tube and very extensive adhesions. The chances of a successful pregnancy following surgical correction are directly related to the extent of the damage. Minimal disease can be corrected with up to a sixty percent or higher chance of successful pregnancy. Tubes that are severely damaged, on the other hand, may have only a three to five percent chance of working properly following surgery, whether it is major surgery or surgery performed laparoscopically. Again, there is good evidence that severely damaged tubes should be removed rather than correctedCcorrection results in very poor chances of successful pregnancy while removal seems to improve the success rate of IVF, which will be the more successful alternative anyway. There are very few reasons to have major surgery for purposes of improving fertility. Removal of large fibroids and tubal reanastamosis following a tubal ligation (see below) are probably still best done via a major surgical approach. Virtually every other problem is best treated through the laparoscope. The chances of successful pregnancy following major surgery for treatment of severe tubal disease do not justify the pain and cost of the procedure. IVF is a better alternative: It costs less, is more successful, and is less invasive. Tubal Ligation One special category of tuboperitoneal factor is tubal occlusion as a result of a prior tubal ligation. There are many different reasons that individuals decide to try to have their tubes untied, including remarriage and a simple desire for more children. The fallopian tubes are, however, never actually tied. There are many different ways of doing a tubal ligation, but they all involve destroying at least a small portion of the tube. This can range from removal of a small piece of the tube to destruction or removal of the entire tube. Some tubal ligations can be reversed (the tubes put back together), and some can't. In general, the more of the tube that was destroyed at the time of the tubal ligation, the poorer the chances of successful function after tubal reanastamosis are. The use of cautery to do a tubal ligation also makes it less likely that the tubes can be repaired. If, however, only a small piece of tube is missing, surgery for putting the tubes back together (reanastamosis) is very successful, with postsurgery pregnancy rates as high as eighty percent. Office Laparoscopy There has been some interest generated lately in a procedure known as office laparoscopy. This involves the use of very small instruments (2 mm), and the procedure is done under local anesthesia in an office-type setting. The advantages of this procedure are the cost savings associated with doing the procedure in the office rather than in an operating room, and the fact that it is done under local rather than general anesthesia. However, there are some significant limitations to this procedure. In fact, at the current time, this is essentially a purely diagnostic procedure, although some simple and quick procedures such as tubal ligation or gamete intrafallopian transfer (GIFT) can be done very effectively using this technique. And office laparoscopy may have some role in helping a physician determine the cause of a woman's pelvic pain. But office laparoscopy currently does not have much of a role in evaluating the infertile woman. We have already seen that unless there is a significant index of suspicion of tubal disease, HSG is the preferred method of tubal evaluation. HSGs are still much less invasive and much less expensive than office laparoscopy. And we also know that if we are going to do a laparoscopy, we might as well be prepared to correct whatever pathology we encounter. Office laparoscopy does not allow one to do longer, more involved surgeries such as repairing fallopian tubes, removing adhesions or lasering endometriosis. If significant pathology is encountered, another surgical procedure must be scheduled at a later date to correct that problem. Doing an office laparoscopy would, in essence, be the same as doing a laparoscopy and then coming back and doing a major surgery at a later date. If there is enough of a reason to do a surgical procedure, it makes more sense to do one that allows correction of a problem, not one that may result in yet another surgery. Saline Infusion Sonohysterography Saline infusion sonohysterography is a relatively new technique. It allows one to assess the uterine cavity, and to a certain extent, the fallopian tubes in the office using ultrasound. At the time of a pelvic exam, a small catheter is placed through the cervix and into the uterus. The speculum is removed and the vaginal ultrasound probe is introduced. Saline is slowly injected through the catheter and the outlines of the uterine cavity are evaluated. This is an excellent means of evaluating the uterine cavity for abnormalities such as polyps, fibroids and congenital anomalies. Its utility, however, is somewhat limited by the compromised evaluation and visualization of the fallopian tubes, which it provides. It does not allow nearly the accuracy or detail that an HSG does in terms of the status of the tubes. As we have discussed above, we rely fairly heavily on the results of the HSG. The HSG may very well be the only form of tubal evaluation we perform. I do not feel that the reliability and accuracy of saline infusion sonohysterograpy are good enough to use it instead of the HSG for tubal evaluation. Furthermore, there is no evidence that doing saline infusion sonohysterography improves conception rates following the procedure. Therefore, I much prefer HSG for tubal evaluation. If we are simply interested in evaluating the uterine cavity for abnormalities; saline infusion sonohysterography is a perfectly appropriate means of doing so. © 2005 Jarrett Fertility Group |
