from
the book How to Have a Baby: Overcoming Infertility
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani,
MD.
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-- Normal and Abnormal
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How
is tubal microsurgery performed ?
What
are the risks of tubal surgery ?
Once the doctor has assessed the damage and pinpointed
the location of the blockages he will decide on treatment
alternatives and how to proceed. The first choice in
the past used to be an attempt at surgery to repair
the tubal damage. However, because results with tubal
surgery were not very encouraging, many patients with
tubal damage are now advised to undergo IVF (in vitro
fertilization) as their first treatment option.
In order to select between IVF and tubal
surgery, we need to differentiate between intrinsic
tubal damage and peritubal damage. If the tubes have
been damaged because of a problem outside the fallopian
tubes, such as peritubal adhesions or endometriosis,
which have caused the tubes to get kinked, then surgery
may be useful. However, surgery is not advisable for
patients if the tubes have been blocked because of TB;
the tubes are very badly damaged; if the tubes are blocked
at multiple places; or if the tubes have been blocked
because of intrinsic tubal disease.
The likelihood of surgical success (in
terms of pregnancy), depends on the severity of the
tubal damage. If a previous infectious process has caused
scarring of the fallopian tube, the inner delicate lining
may have become irreversibly damaged. All operations
can result in re-establishing patency in some cases
- but the main aim of the surgery is not to just open
the tubes, but to achieve pregnancy - and the tubes
have to become capable of capturing the egg and transporting
it to the uterus for this to happen. Unfortunately,
surgery cannot reverse tubal damage once this has occurred.
What if only one tube is blocked? One
normal tube is sufficient to allow a pregnancy - and
most surgeons would not advise tubal surgery for these
patients. Obviously, the chances of pregnancy for such
patients is half that of normal women and therefore
establishing a pregnancy may take twice as long. The
danger of trying to surgically repair a single blocked
tube is that adhesions because of the surgery may cause
both the tubes to become blocked !
How is tubal microsurgery
performed ?
Microsurgery entails the use of the following surgical
techniques:
- Using a microscope (for adequate
magnification)
- Avoiding unnecessary trauma to the
tissues
- Employing delicate surgical instruments
- Employing fine suture (stitching)
material and ensuring precise suturing
- Handling tissues with great care
and respect, to minimize tissue damage
- Ensuring that no bleeding is left
unattended and no clots are left behind (because this
can lead to the formation of adhesions or scar tissue
after the surgery)
The microsurgery operation may take
from 1 to 4 hours. Depending on the extent of pelvic
damage and is usually done under spinal or general anesthesia.
The incision used is usually a "bikini cut" (Pfannensteil
incision) The length of stay in hospital is usually
3 to 7 days. Tubal microsurgery can be expensive and
may cost up to Rs.40,000. Sometimes a "check or second-look
laparoscopy " is performed about one week after surgery
to ensure that tubal patency is maintained and to remove
any small adhesions that may have started to re-form.
The tubal obstruction could be at the uterotubal junction
and this is called a cornual block. The conventional
surgical repair of cornual blocks involved reimplanting
the tube into the uterus - and had dismal success rates.
However, with microsurgery, it is possible to see the
very fine ends of the tubes under high magnification
and to join them together. This has a pregnancy rate
of about 50%, since the function of the rest of the
tube is basically intact.
Recently, doctors have realized that
a number of patients have cornual blocks because of
the presence of mucus plugs and debris in the very fine
cornual segment of the tubes. Newer nonsurgical methods
have now been devised to treat this. These involve the
passage of a fine guide wire or a fine balloon into
the cornual end of the tube through the uterus. This
is called a "balloon tuboplasty" or "cornual recanalisation,"
and can be done under ultrasound guidance; hysteroscopic
guidance; or fluoroscopic (X-ray) guidance. This is
a significant advance, since it saves patients the need
for major surgery; and also has excellent pregnancy
rates.
This procedure entails division of adhesions surrounding
the tubes. When no other damage is apparent, success
rates may be as high as 65%.
These include a variety of procedures which involve
removing the damaged portion of the tubes and rejoining
the healthy ends of the tube together . Success rates
vary according to the area of damage but are usually
within the range of 20 - 50%.The chances of success
are higher when the defect occurs in the middle section
of the tube.
If the tubes have been severely damaged and have formed
a hydrosalpinx (in which the fimbriae stick to one another
and the tube is closed off) the surgery required is
called neosalpingostomy, in which the surgeon opens
the hydrosalpinx and creates a new opening for the repaired
tube. While this is technically easy, success rates
are very poor (about 20%) because the physiologic functioning
of the fimbriae rarely returns to normal.
If the damage is less severe (fimbrial
agglutination, in which the fimbriae are stuck to one
another; or phimosis, in which the tube is narrowed,
but open), then surgical repair is more successful,
with pregnancy rates being about 50%.
What are the risks of tubal
surgery ?
The risk of having an ectopic (tubal)
pregnancy is increased following tubal surgery. Fallopian
tubes which have been operated on may have a damaged
inner lining, and this can impair the movement of the
embryo down the tube. This is why, in patients who have
had tubal surgery, the diagnosis of a pregnancy should
be made as soon as possible (preferably within a few
days of missing a menstrual period), to rule out the
possibility of an ectopic pregnancy.
The best chance of success is with the
first surgical operation; therefore, you need to go
to a specialized centre. The chances of success will
depend upon the extent of tubal damage and also on the
skill of the surgeon. The best chance of achieving a
pregnancy is in the surgeon. The best chance of achieving
a pregnancy is in the first few months after surgery,
and most women who are going to get pregnant after tubal
surgery will conceive within this time. Some doctors
believe that using ovulation induction and / or intrauterine
insemination after tubal surgery helps to maximize the
chances of a pregnancy.
If the patient has not conceived within
one year after the surgery, then follow-up testing in
the form of an HSG and / or laparoscopy is advisable,
to determine whether the fallopian tubes are still open.
If the first surgery has been unsuccessful,
the chance of success as a result of reoperation is
very low, and IVF is the only treatment choice for such
patients.
In the future, it is possible that tubal
transplants may become a reality and that scientists
may also develop artificial synthetic tubes to replace
damaged ones.
With operative laparoscopy, it is now
possible to open damaged tubes through the laparoscope,
thus saving the patient major surgery. A hydrosalpinx
can be repaired by opening it with a laser or cautery
and then keeping it open with sutures: and even the
complicated operation of tubal reanastomosis has been
performed by experienced surgeons through the laparoscope
(using sutures or special adhesive glue). However, the
results with this surgery are often poor, because
these damaged tubes often do not function properly even
after the surgery.
Fig 4. Schematic showing damaged fallopian tubes because
of pelvic inflammatory disease ( PID). The left tube
has formed a hydrosalpinx; and the right is engulfed
in peritubal adhesions.
Fig 5. Operative laparoscopy, during which an adhesion
is being divided (adhesiolysis)
In women, sterilization for family planning is usually
done through an operation called tubal ligation, which
is usually carried out through the laparoscope. The
aim of the operation is to block the tubes and prevent
the sperm and egg from meeting each other.
The vast majority of people are very happy with sterilization.
Nevertheless, there are a few women who are very distressed
afterwards and would do almost anything to get things
undone. The commonest reason why such women regret sterilization
is because their child dies or because they have remarried
and wish to bear their new husband’s child.
If there is a reasonable amount of tube remaining, even
if only on one side, then it may be possible to perform
tubal microsurgery to rejoin the tubes. On the whole,
the more tube which has been left undamaged, the better
the chances of success. Thus, patients who have had
a tubal ligation done through the laparoscope, using
Falope rings (silastic bands) or clips, have an excellent
chance of achieving a pregnancy after microsurgical
reversal of the ligation, because these methods cause
minimal tubal damage.
After reviewing the operative notes,
a laparoscopy may be advised, so that the exact state
of the fallopian tubes can be assessed. If the patient
has enough normal tube, tubal microsurgery may be attempted
and pregnancy rates can be as high as 75% in favorable
cases. Some skilled surgeons can even perform this type
of tubal reanastomosis through the laparoscope (using
sutures or special adhesive glue). If, unfortunately,
the patient has had both tubes completely removed or
if the tubes are very badly damaged, then the only chance
of success will be with IVF.
Most patients who will conceive after
tubal reanastomosis will do so within 1 year. If they
do not, then the next step for them would be IVF.
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-- Normal and Abnormal
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