REVIEW: Reconstruction, destruction and IVF: dilemmas in the art of tubal surgery

The ‘IVF revolution’ in the last quarter of a century has been astounding for both patients and their doctors. Over a million babies have been born worldwide as a result of assisted reproduction technologies, and they now constitute 1–2% of all births in the United Kingdom. The demand for this treatment seems unlikely to diminish given the high rates of chlamydial infection causing tubal disease, and the increasing number of women who wish to delay childbearing until their fourth decade. IVF was invented for tubal disease. But while tubal disease accounts for only 25–35% of infertility in women, IVF is now used to treat a wide variety of fertility problems including male factor, endometriosis, unexplained infertility and even recurrent miscarriage. The publication of league tables of assisted reproduction technologies clinic ‘success rates’ is likely to increase public perception of the success of assisted reproduction technologies. Moreover, recent guidelines from the National Institute for Clinical Excellence (NICE) confirm that assisted reproduction technologies is indeed effective, and therefore should be more widely available in the NHS. Against this background, it is perhaps easy to dismiss alternatives to IVF, particularly when they predate IVF itself. But it is also notable that, although IVF was invented for tubal disease, IVF success rates are worst for that indication (particularly in the presence of hydrosalpinges), suggesting a more complex approach to tubal factor infertility might be necessary. Practitioners of tubal surgery have certainly faced a substantial challenge to define their role, if any, in the management of tubal infertility. Data from the 1980s showed that, as a whole, the population with tubal infertility benefits little from surgery with intrauterine pregnancy rates of only 25%. This compares with rates of over 30% after one cycle of IVF and, in a study of 771 couples with tubal factor infertility, more than 70% had a live birth within four cycles of IVF. Unfortunately, no randomised controlled trial comparing IVF and tubal surgery has ever been done and there are few randomised trials even within the field of tubal surgery. In the modern era of evidence-based medicine, the continuing practice of tubal surgery may be judged by some to be ‘unscientific’. But that does not mean that it is not worth doing. On the contrary, there is a wealth of evidence that it can be highly effective. However, it does mean that the experience of the surgeon is critical. The ‘art’ of tubal surgery is accurate diagnosis, careful case selection and meticulous surgical technique. The RCOG has recognised the highly specialised nature of tubal surgery and recommended that it should only be done in a few tertiary centres. The RCOG guidelines state that tubal surgery is appropriate for mild distal disease and proximal tube obstruction. However, the choice of tubal surgery depends not only on the prognosis of surgical treatment but, crucially, on the accurate diagnosis of tubal disease. Unfortunately, there is no guidance whatsoever on how to make a definitive diagnosis, and moreover, many investigations (including laparoscopy) are performed before referral to a tertiary centre. This inevitably means that the difficult decision over whether to refer for surgery or not is almost always taken by gynaecologists who may not be trained to perform tubal microsurgery. They may not always appreciate the subtleties of proximal tubal disease, or the poor pregnancy rates achieved (11%) after treatment of disease affecting both proximal and distal tubal segments, or the very high rates (up to 85%) achieved for microsurgical reversal of sterilisation. This review aims to increase awareness of tubal disease diagnosis and surgery. It is not aimed to aggressively promote an alternative to IVF, but rather to show that tubal surgery and IVF should be complementary approaches to optimising a woman’s reproductive potential.