Tuboplasty vs. Tuboplasty vs. IVF - ET IVF - ET Seok Hyun Kim, M.D. Seok Hyun Kim, M.D. Department of Obstetrics and Department of Obstetrics and Gynecology Gynecology College of Medicine, Seoul National College of Medicine, Seoul National University University Seoul, Korea Seoul, Korea
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Tuboplasty vs. IVF - ET Tuboplasty vs. IVF - ET Seok Hyun Kim, M.D. Department of Obstetrics and Gynecology College of Medicine, Seoul National University.
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Tuboplasty vs. IVF - ETTuboplasty vs. IVF - ET
Seok Hyun Kim, M.D.Seok Hyun Kim, M.D.
Department of Obstetrics and GynecologyDepartment of Obstetrics and GynecologyCollege of Medicine, Seoul National UniversityCollege of Medicine, Seoul National University
Seoul, KoreaSeoul, Korea
Tubal Factor InfertilityTubal Factor Infertility
# Etiology# Etiology
InfectionInfection
History of laparotomyHistory of laparotomy
Congenital anomalyCongenital anomaly
PIDPID
STDSTD
Treatment of Tubal Factor InfertilityTreatment of Tubal Factor Infertility
Choice of Treatment OptionsChoice of Treatment Options
Age of patientAge of patient Etiology of tubal diseaseEtiology of tubal disease Extent of tubal diseaseExtent of tubal disease History of laparotomyHistory of laparotomy Other causes of infertilityOther causes of infertility Cost : medical / surgicalCost : medical / surgical
Tubal Surgery / TuboplastyTubal Surgery / Tuboplasty
- Success : degree of tubal or peritubal disease.- Success : degree of tubal or peritubal disease.
- Poor prognostic factors- Poor prognostic factors of neosalpingostomy of neosalpingostomy Hydrosalpinx with diameter of 3 cm or largerHydrosalpinx with diameter of 3 cm or larger No visible fimbriaeNo visible fimbriae Dense pelvic adhesionDense pelvic adhesion
Salpingostomy by Microsurgery
Values in parentheses are percentages.
Author Patients Duration of Intrauterine Ectopic Term follow-up preg. preg. preg.
Posaci, Posaci, 19991999 Presence of dense adhesion, thick tubal wall, andPresence of dense adhesion, thick tubal wall, and abnormal tubal mucosa abnormal tubal mucosa : : Term PR 3%Term PR 3% Absence of these factors : Term PR 59%Absence of these factors : Term PR 59%
Both proximal and distal injuryBoth proximal and distal injury IVF-ET indicatedIVF-ET indicated
Distal Tubal ObstructionDistal Tubal Obstruction
Pelviscopic surgeryPelviscopic surgery Lower PR, compared with microsurgeryLower PR, compared with microsurgery
Success rates related to extent of diseaseSuccess rates related to extent of disease
Audebert, Audebert, 19981998
PR : 51%PR : 51%
Ectopic PR : 23%Ectopic PR : 23%
Author Patients Type of Duration of Intrauterine Ectopic Term operation follow-up preg. preg. preg.
Kim et al, 1997 (n=Kim et al, 1997 (n=1,118)1,118) Anatomic patency rate : 88.2%Anatomic patency rate : 88.2% PR : 54.8%, DR :PR : 54.8%, DR : 72.5% 72.5% The longer the postop. residual tubal length,The longer the postop. residual tubal length, the shorter the interval to pregnancy. the shorter the interval to pregnancy.
Prognosis of TRPrognosis of TR depends on depends on
Method of ligationMethod of ligation
Repair site of tube Repair site of tube
Residual tubal lengthResidual tubal length
Other causes of infertilityOther causes of infertility
Better prognosis with small difference in diameterBetter prognosis with small difference in diameter
of reconstructed tubal locationsof reconstructed tubal locations
e.g. isthmus - isthmus (I-I)e.g. isthmus - isthmus (I-I)
cornua - isthmus (I-Icornua - isthmus (I-I))
Gomel & Swolin, 1980Gomel & Swolin, 1980 Low PR : < Low PR : < 4 4 cm of postop. tubal length cm of postop. tubal length Inverse correlation between postop. tubal lengthInverse correlation between postop. tubal length and interval to pregnancyand interval to pregnancy
Tubal ReanastomosisTubal Reanastomosis
Preoperative diagnostic laparoscopyPreoperative diagnostic laparoscopy Method and location of ligation Method and location of ligation Potential postop. tubal lengthPotential postop. tubal length Coexistent pelvic diseaseCoexistent pelvic disease
In In older women > 40 yrsolder women > 40 yrs TR TR (Trimpos & Kemper, 1980)(Trimpos & Kemper, 1980) PR : 45%, Interval to pregnancy 5.5 monthsPR : 45%, Interval to pregnancy 5.5 months IVF-ET IVF-ET (Tan, 1992)(Tan, 1992) CPR : 10%CPR : 10% TR indicated after 3 cycles of IVF-ETTR indicated after 3 cycles of IVF-ET
Tubal ReanastomosisTubal Reanastomosis
Reversal of Tubal Ligation by MicrosurgeryReversal of Tubal Ligation by Microsurgery
Author Patients T/L Type of Duration of Intrauterine Ectopic Term
Expertise required : Expertise required : tubal surgery specialisttubal surgery specialist
IVF - ETIVF - ET
Alternative of choice to surgical approachAlternative of choice to surgical approach
Dominant role in treatment of tubal factor infertilityDominant role in treatment of tubal factor infertility
Growing number of qualified IVF centersGrowing number of qualified IVF centers Nearly equal to availability of tubal surgeryNearly equal to availability of tubal surgery
Requirement of expertise and credentialingRequirement of expertise and credentialing Tubal surgery can be performed, although perhaps less Tubal surgery can be performed, although perhaps less
successfully, by those without speciality training.successfully, by those without speciality training.
Benadiva, 1995Benadiva, 1995 Is pelvic reconstructive surgery obsolete?Is pelvic reconstructive surgery obsolete?
Penzias, 1996Penzias, 1996 Is there ever a role for tubal surgery?Is there ever a role for tubal surgery?
Dubuisson, 1998Dubuisson, 1998 Are there still indications for tubal surgery in infertility?Are there still indications for tubal surgery in infertility?
Status of ART
Tuboplasty vs. IVF-ETTuboplasty vs. IVF-ET
Procedures
TR (1990)
Fimbrial recanalization (1990)
Transcervical tuboplasty (1990)
Salpingolysis (1991)
Laparoscopic fimbrioplasty (1991)
Laparoscopic salpingolysis (1992)
Laparoscopic distal tuboplasty (1993)
Tubal reconstruction (1996)
SART/ASRM IVF registry (1995)
SART/ASRM IVF registry (1997)
Pregnancy Rate
49 - 75 %
34 %
31 %
30 - 60 %
30 - 70 %
62 - 67 %
27 %
40 %
28.4 %
28.9 %
Comparison of Reported Outcomes Comparison of Reported Outcomes for ART Procedures for ART Procedures
No. of cycles
ET / retrieval (%)
No. of clinical preg.
Delivery /retrieval (%)
Ectopic preg. /ET (%)
SART & ASRM, 1997
IVF
33,032
92.8
8,975
28.4
0.9
IVF + ICSI
18,312
94.3
6,072
27.1
0.6
GIFT
1,943
98.6
627
30.0
1.0
Standard IVF-ET by Maternal AgeStandard IVF-ET by Maternal Age
SART & ASRM,1997
< 35 yrs, male factor (-)
35 - 37 yrs, male factor (-)
38 - 40 yrs, male factor (-)
> 40 yrs, male factor (-)
Cancellation
rate (%)
10.2
14.8
19.3
24.4
Delivery /
retrieval (%)
33.9
29.4
21.2
9.4
Tuboplasty or IVF ?Tuboplasty or IVF ?
Tuboplasty Mild or moderate tubal disease Young female
IVF-ET Extensive pelvic adhesion Old age Impossible tubal reconstruction due to absence of tubes or history of tuberculous salpingitis Failed tubal surgery Existence of other infertility factors
Considerations for Tuboplasty or IVF ?Considerations for Tuboplasty or IVF ?
Wishes of patientsWishes of patients Surgery : Specialty trainingSurgery : Specialty training IVF-ET : Expertise and credentialingIVF-ET : Expertise and credentialing Development of operative laparoscopy, microsurgeryDevelopment of operative laparoscopy, microsurgery
Comparison of Cost per DeliveryComparison of Cost per Delivery
Cost per delivery
Holst, 1991 (Norway)
Neumann, 1994 (USA)
Van Voorhis, 1997 (USA)
Tubal surgery
$ 17,000
$ 50,000
$ 76,232
IVF-ET
$ 12,000
$ 66,000
$ 43,138
Patient CounsellingPatient Counselling
Fecundability Tuboplasty : 2-4% IVF - ET : 20%
Successful tuboplasty : more than one pregnancy possible
Women’s age, infertility factor
Take-home-baby rate and CPR of IVF, No. of IVF cycles