IVF-ET VERSUS TUBAL SURGERY
Tuboplasty is less successful when the mate partner is subfertile or when there is an endocrine problem such as polycystic ovaries or, possibly, cervical scarring after conization. These patients do better with IVF. The supposed conflict between tubal microsurgeons and IVF experts is spurious. Each treatment has important merits and each will continue to have a major role in a well-run infertility unit. What must be ensured is that women who may benefit from IVF do not have effective treatment delayed by inappropriate surgery and that IVF is not offered to all comers simply because their doctor has poor expertise in good microsurgical techniques.
REFERENCES 1. Lilford RJ, Watson A J: Has in-vitro fertilisation made salpingostomy obsolete? Br J Obstet Gynaecol 1990;97:55756O 2. Boer-Meisel ME, te Velde ER, Habbema JD, Kardaun JW: Predicting the pregnancy outcome in patients treated for hydrosalpinx: A prospective study. Fertil Steril 1986;45:2329 3. Winston RML, Margara RA: Salpingostomy is not an obsolete operation. Br J Obstet Gynaecot 1991;98:637-642
311
4. Donnez J, Casanas-Roux F: Prognostic factors of fimbrial microsurgery. Fertil Steril 1986;46:200-204 5. Donnez J, Casanas-Roux F, Nisolle-Pochet M, Waeyenberg M, Karaman Y: Surgical management of tubal obstruction at the uterotubal junction. Acta Eur Fertil 1987;18:5-9 6. McComb P: Microsurgical tubocornual anastomosis for occlusive comual disease: Reproducible results without the need for tuboutedne implantation. Fertil Sterit 1986;46:571577 7. Winston RML, Margara RA: The role of tubal surgery. In Infertility Practice, Proceedings of 25th Royal College of Obstetricians and Gynaecologists Workshop, JO Drife, A Templeton (eds). London, RCOG (in press), 1992 8. Beral V, Doyle P, Tan SL, Mason BA, Campbell S: Outcome of pregnancies resulting from assisted conception. Br Med Bull 1990;46:753-768 9. The Fifth Report of the Interim Licensing Authority for Human in Vitro Fertilisation and Embryology. London, Medical Research Council and Royal College of Obstetricians and Gynaecologists, 1990 10. Winston RML: Resources for infertility treatment. Baillere's Clin Obstet Gynaecol 1991 ;5:551-573 11. Romeu A, Muasher Sj, Acosta AA, Veeck LL, eta/.: Results of in vitro fertilisation attempts in women 40 years of age and older: The Norfolk experience. Fertil Steri11987;47:130-136
R. M. L. Winston Institute of Obstetrics and Gynaecology Royal Postgraduate Medical School London, United Kingdom
In Vitro Fertilization-Embryo Transfer (IVF-ET) Versus Tubal Surgery
In making the decision as to which procedure is correct for the patient, IVF/ET versus tubal surgery, one has to evaluate the situation on two levels. The first level is general statistical information with regard to the success rates of these procedures. But, on the other hand, each case must be individualized. Factors such as a male factor and sperm antibodies should be taken into account with regard to IVF/ET, in addition to whether the patients is a low or high responder with ovulation induction. This should be compared with the pathology in the fallopian tube as far as prognosticating results is concerned. Journal of Assisted Reproduction and Genetics, Vol. 9, No. 4, 1992
There are numerous ways to assess the probability of pregnancy after repair of distal occlusion. 1. Actually open up the fallopian tube and inspect the fimbria. The problem with this, of course, is that it requires an operative procedure. 2. Another approach is to use indirect evidence as to the status of the fallopian tube. This involves hysterosalpingogram. If the hysterosalpingogram shows that there are good rugations in the fallopian tube by variegation in color (shades of gray), then success rates are
312
quite good with neosalingostomy. Qn the other hand, if the tube shows a homogeneous color on the hysterosalpingogram, this indicates pressure necrosis and destruction of the normal rugal folds, or ciliary mechanism indicating that tubal surgery will not be successful to a great degree in this group of patients. 3. The last is tuboscopy. Much work has recently been done utilizing this approach by either passing a pediatric urethroscope into the fallopian tubes through a small incision and observing the pathology, for ampullary problems, or using the hyperscope, for cornual or isthmic problems. A number of conclusions have been drawn with regard to tuboscopy. a. There can be various degrees of pathology in the fallopian tube, some severe and some not severe, all in one tube. b. It is difficult to interpret what these findings mean without correlating them with clinical outcome (it is too early for this); but tuboscopy does have a future, and as more and more of an atlas is developed, it will become a helpful procedure. The major problem with assessing the fallopian tube, though, is that the real mechanism of action is located at the cellular level, i.e., integrity of cilia and ciliary motion. This, of course, cannot be assessed with the current technology. There is a series of other modalities that have been introduced into tubal surgery in the past two decades that perhaps impact on success rates; these include the use of magnification, the use of the laser as a power source, and antiadhesive adjuncts. The key, though, as far as surgery on the fallopian tube is concerned, with regard to enhancing fertility, is the recent explosion of interest in endoscopic surgery. The reason that this takes on particular significance with regard to comparing IVFET to tubal surgery is that many of the disadvantages of laparotomy are circumvented. These include the long recuperative periods and the long time in the hospital. Yet there are no good studies comparing these two means of treatment (laparotomy versus laparoscopy), therefore results are dif-
DeCHERNEY
ficult to evaluate. Nevertheless, laparoscopy does represent an easier approach for the patient. In addition, some have suggested that the surgical procedures be augmented by an IVF-ET cycle, although personally I do not agree with this approach. Another tubal disease that can be successfully treated in a minimally invasive way is proximal obstruction of the fallopian tube. This can be treated with balloon or transcervical tubalplasty, which is truly an outpatient procedure yielding good results. So in answer to the quandary posed, IVF-VT versus tubal surgery, certainly a modicum of individualization is important. Some would profess that tubal surgery is dead, and only IVF/ET should be done for all patients; others would say that IVF/ET is so "unsuccessful" that is should not be performed at all and that tubal surgery is the way to go. This only reinforces to me the importance of pointing out individual differences. These include individual differences between groups--some centers are better at tubal surgery, some have better results with IVF-ET---and of course the paramount issue here is individualizing to the individual couple as far as where their success rates are likely to be greater. As an example, let us take the patient with 3-year history of bilateral/clubbed tubes, who, on hysterosalpingogram and tubosocopy, shows good rugations underneath the occluded scarred investiture of the distal end of the fallopian tube. Her chance of conceiving after neosalpingogram is approximately 35%. On the other hand, the patient in most IVF-ET centers has a t5% chance per cycle, and if she undergoes four cycles, she has a 50% chance of achieving a pregnancy. How should this case be managed? The overall success rate is better with four cycles of IVF/ET. Yet if the patient happens to be one of the fortunate one-third to conceive after tubal surgery, she has avoided the arduous task of IVF-ET. This is a complex issue in which honesty and individualization should prevail.
Alan H. DeCherney Department of Obstetrics and Gynecology Tufts University School of Medicine Boston, Massachusetts 02111
Journal of Assisted Reproduction and Genetics, Vol. 9, No. 4, 1992
Tuboplasty is less successful when the mate partner is subfertile or when there is an endocrine problem such as polycystic ovaries or, possibly, cervical scarring after conization. These patients do better with IVF. The supposed conflict between tubal microsurgeons and IVF experts is spurious. Each treatment has important merits and each will continue to have a major role in a well-run infertility unit. What must be ensured is that women who may benefit from IVF do not have effective treatment delayed by inappropriate surgery and that IVF is not offered to all comers simply because their doctor has poor expertise in good microsurgical techniques.
REFERENCES 1. Lilford RJ, Watson A J: Has in-vitro fertilisation made salpingostomy obsolete? Br J Obstet Gynaecol 1990;97:55756O 2. Boer-Meisel ME, te Velde ER, Habbema JD, Kardaun JW: Predicting the pregnancy outcome in patients treated for hydrosalpinx: A prospective study. Fertil Steril 1986;45:2329 3. Winston RML, Margara RA: Salpingostomy is not an obsolete operation. Br J Obstet Gynaecot 1991;98:637-642
311
4. Donnez J, Casanas-Roux F: Prognostic factors of fimbrial microsurgery. Fertil Steril 1986;46:200-204 5. Donnez J, Casanas-Roux F, Nisolle-Pochet M, Waeyenberg M, Karaman Y: Surgical management of tubal obstruction at the uterotubal junction. Acta Eur Fertil 1987;18:5-9 6. McComb P: Microsurgical tubocornual anastomosis for occlusive comual disease: Reproducible results without the need for tuboutedne implantation. Fertil Sterit 1986;46:571577 7. Winston RML, Margara RA: The role of tubal surgery. In Infertility Practice, Proceedings of 25th Royal College of Obstetricians and Gynaecologists Workshop, JO Drife, A Templeton (eds). London, RCOG (in press), 1992 8. Beral V, Doyle P, Tan SL, Mason BA, Campbell S: Outcome of pregnancies resulting from assisted conception. Br Med Bull 1990;46:753-768 9. The Fifth Report of the Interim Licensing Authority for Human in Vitro Fertilisation and Embryology. London, Medical Research Council and Royal College of Obstetricians and Gynaecologists, 1990 10. Winston RML: Resources for infertility treatment. Baillere's Clin Obstet Gynaecol 1991 ;5:551-573 11. Romeu A, Muasher Sj, Acosta AA, Veeck LL, eta/.: Results of in vitro fertilisation attempts in women 40 years of age and older: The Norfolk experience. Fertil Steri11987;47:130-136
R. M. L. Winston Institute of Obstetrics and Gynaecology Royal Postgraduate Medical School London, United Kingdom
In Vitro Fertilization-Embryo Transfer (IVF-ET) Versus Tubal Surgery
In making the decision as to which procedure is correct for the patient, IVF/ET versus tubal surgery, one has to evaluate the situation on two levels. The first level is general statistical information with regard to the success rates of these procedures. But, on the other hand, each case must be individualized. Factors such as a male factor and sperm antibodies should be taken into account with regard to IVF/ET, in addition to whether the patients is a low or high responder with ovulation induction. This should be compared with the pathology in the fallopian tube as far as prognosticating results is concerned. Journal of Assisted Reproduction and Genetics, Vol. 9, No. 4, 1992
There are numerous ways to assess the probability of pregnancy after repair of distal occlusion. 1. Actually open up the fallopian tube and inspect the fimbria. The problem with this, of course, is that it requires an operative procedure. 2. Another approach is to use indirect evidence as to the status of the fallopian tube. This involves hysterosalpingogram. If the hysterosalpingogram shows that there are good rugations in the fallopian tube by variegation in color (shades of gray), then success rates are
312
quite good with neosalingostomy. Qn the other hand, if the tube shows a homogeneous color on the hysterosalpingogram, this indicates pressure necrosis and destruction of the normal rugal folds, or ciliary mechanism indicating that tubal surgery will not be successful to a great degree in this group of patients. 3. The last is tuboscopy. Much work has recently been done utilizing this approach by either passing a pediatric urethroscope into the fallopian tubes through a small incision and observing the pathology, for ampullary problems, or using the hyperscope, for cornual or isthmic problems. A number of conclusions have been drawn with regard to tuboscopy. a. There can be various degrees of pathology in the fallopian tube, some severe and some not severe, all in one tube. b. It is difficult to interpret what these findings mean without correlating them with clinical outcome (it is too early for this); but tuboscopy does have a future, and as more and more of an atlas is developed, it will become a helpful procedure. The major problem with assessing the fallopian tube, though, is that the real mechanism of action is located at the cellular level, i.e., integrity of cilia and ciliary motion. This, of course, cannot be assessed with the current technology. There is a series of other modalities that have been introduced into tubal surgery in the past two decades that perhaps impact on success rates; these include the use of magnification, the use of the laser as a power source, and antiadhesive adjuncts. The key, though, as far as surgery on the fallopian tube is concerned, with regard to enhancing fertility, is the recent explosion of interest in endoscopic surgery. The reason that this takes on particular significance with regard to comparing IVFET to tubal surgery is that many of the disadvantages of laparotomy are circumvented. These include the long recuperative periods and the long time in the hospital. Yet there are no good studies comparing these two means of treatment (laparotomy versus laparoscopy), therefore results are dif-
DeCHERNEY
ficult to evaluate. Nevertheless, laparoscopy does represent an easier approach for the patient. In addition, some have suggested that the surgical procedures be augmented by an IVF-ET cycle, although personally I do not agree with this approach. Another tubal disease that can be successfully treated in a minimally invasive way is proximal obstruction of the fallopian tube. This can be treated with balloon or transcervical tubalplasty, which is truly an outpatient procedure yielding good results. So in answer to the quandary posed, IVF-VT versus tubal surgery, certainly a modicum of individualization is important. Some would profess that tubal surgery is dead, and only IVF/ET should be done for all patients; others would say that IVF/ET is so "unsuccessful" that is should not be performed at all and that tubal surgery is the way to go. This only reinforces to me the importance of pointing out individual differences. These include individual differences between groups--some centers are better at tubal surgery, some have better results with IVF-ET---and of course the paramount issue here is individualizing to the individual couple as far as where their success rates are likely to be greater. As an example, let us take the patient with 3-year history of bilateral/clubbed tubes, who, on hysterosalpingogram and tubosocopy, shows good rugations underneath the occluded scarred investiture of the distal end of the fallopian tube. Her chance of conceiving after neosalpingogram is approximately 35%. On the other hand, the patient in most IVF-ET centers has a t5% chance per cycle, and if she undergoes four cycles, she has a 50% chance of achieving a pregnancy. How should this case be managed? The overall success rate is better with four cycles of IVF/ET. Yet if the patient happens to be one of the fortunate one-third to conceive after tubal surgery, she has avoided the arduous task of IVF-ET. This is a complex issue in which honesty and individualization should prevail.
Alan H. DeCherney Department of Obstetrics and Gynecology Tufts University School of Medicine Boston, Massachusetts 02111
Journal of Assisted Reproduction and Genetics, Vol. 9, No. 4, 1992
