Techniques for pelvic surgery in subfertility (Cochrane Review)

A substantive amendment to this systematic review was last made on 23 March 1998. Cochrane reviews are regularly checked and updated if necessary.

Background: Since the advent of in-vitro fertilisation (IVF) the role of infertility surgery has diminished. This type of surgery is still however widely performed.and there are many different surgical techniques that can be used to repair blocked or damaged Fallopian tubes. Most evidence in this area comes from uncontrolled series.

Objectives: To evaluate surgical techniques for the treatment of tubal infertility (adhesiolysis, salpingostomy, surgery for proximal tubal occlusion, reversal of sterilisation).

Search strategy: This review has drawn on the search strategy developed for the Subfertility Group as a whole. Relevant trials were identified from the Group's Register of Controlled Trials.

Selection criteria: All randomised controlled trials investigating an aspect of infertility surgery technique. Non-randomised data were included for the following topics 1) The role of infertility surgery versus no treatment 2) The role of infertility surgery versus alternative treatments,3) the role of magnification, 4) The role of the CO2 laser at infertility surgery, 5) the role of operative laparoscopy to perform infertility surgery. Non- RCT data were excluded if :-i) The treatment and control groups differed significantlyii) The treatment and control groups were operated by a different team or in a different instituteiii) Where pregnancy outcome data were not given.

Data collection and analysis: Data were extracted independently by the first 2 authors. Differences of opinion were registered and resolved by consensus with the senior author (RL). Two by two tables were generated for each trial for the dichotomous outcome of pregnancy and the effects on pregnancy rate of each study is expressed as an odds ratio with 95% confidence intervals.

Main results: 1) INFERTILITY SURGERY VERSUS NO TREATMENTOne non RCT compared open adhesiolysis versus no treatment and found significantly more pregnancies in the treatment group compared with the control group.2) INFERTILITY SURGERY VERSUS ALTERNATIVE TREATMENTS.No RCTs investigated the role of infertility surgery compared with In vitro fertilisation (IVF). There were no studies comparing tubal surgery for proximal tubal occlusion versus hysteroscopic or radiologically controlled recannulation.3) MAGNIFICATION FOR INFERTILITY SURGERYThere was a non significant reduction in pregnancy rate when the operating microscope (magnification x4-x16) was used rather than Loupes (magnification x2-x4.5) in the only RCT to study this. . One RCT randomised patients to microsurgery versus a macrosurgical technique involving a prosthesis. There were more pregnancies in the microsurgery group, but this was not significant, and the trial consisted of only 18 participants.All the non-RCT studies comparing microsurgery with macrosurgery had a historical control group. Meta-analysis of studies investigating the role of magnification for adhesiolysis and for salpingostomy revealed a statistically significant increase in pregnancy rates and reduction in ectopic pregnancy rates for microsurgery versus macrosurgery for both procedures.For reversal of sterilisation there was a significant improvement in term pregnancy rates, and a non significant reduction in ectopic ratesThere was no significant difference between microsurgical and macrosurgical treatment of proximal tubal occlusion for any outcome.4) THE USE OF LASER AT INFERTILITY SURGERYTwo RCTs investigated the use of the CO2 laser at infertility surgery. There was no significant difference in pregnancy outcome after adhesiolysis, or salpingostomy. Two non randomised studies also investigated the role of the laser. Overall there was no significant difference using the CO2 laser compared with standard techniques for adhesiolysis, salpingostomy or reversal of sterilisation . 5) LAPAROSCOPIC INFERTILITY SURGERYFour studies investigated the use of laparoscopic techniques for infertility surgery. There were no RCTs. One study compared laparoscopic versus open microsurgical adhesiolysis. There was no significant difference in pregnancy rates between the techniques. There was a non-significant increase in term and intrauterine pregnancy rates, and a non significant reduction in ectopic pregnancy rates. Four studies compared laparoscopic versus open microsurgical salpingostomy. There was a significantly reduced total and intrauterine pregnancy rates after laparoscopic salpingostomy versus open microsurgical salpingostomy.6) OTHER INTERVENTIONS AT INFERTILITY SURGERY INVESTIGATED BY RCT.Three randomised studies compared the results of salpingostomy with and without a prosthesis to maintain tubal patency. The use of the prosthesis was analysed as the treatment group in two studies. In both studies the prosthesis was used for post operative irrigation and the control group received transcervical hydrotubation. There was no significant difference in pregnancy rates between treatment or control groups in either study, or when the studies were added using meta-analysis. One study compared the use of microsurgery versus a macroscopic technique utilising a prosthesis . This small study showed no significant difference in outcome, but the trend was towards an increased pregnancy rate with microsurgery. One RCT investigated the role of fibrin sealant at reversal of sterilisation and found identical levels of post-operative adhesions between tubes operated upon with fibrin glue compared with conventional surgery.

Reviewers' conclusions: The following conclusions can be drawn from RCTs:-a) There is no significant advantage of using magnification with the operating microscope versus loupes. b) The use of the CO2 laser at infertility surgery offers no benefit in terms of pregnancy. The following conclusions may be inferred with caution from non-randomised data:-a) The treatment of adhesions by adhesiolysis appears to improve the possibility of conceiving. b) There appears to be an advantage in using magnification versus no magnification. c) Laparoscopic salpingostomy appears to have a reduced pregnancy outcome compared to open surgery. d) Laparoscopic adhesiolysis may be as effective as microsurgical adhesiolysis.

Citation: Watson A, Vandekerckhove P, Lilford R. Techniques for pelvic surgery in subfertility (Cochrane Review). In: The Cochrane Library, Issue 3, 2003. Oxford: Update Software.

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This is an abstract of a regularly updated, systematic review prepared and maintained by the Cochrane Collaboration. The full text of the review is available in The Cochrane Library (ISSN 1464-780X).

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