Infertility Treatment- Surgical Options
Tubal Reanastamosis- "Reconnecting" the Fallopian Tubes
One of the main causes of infertility is pelvic disease, which can be grouped into tubal damage, scar tissue, or endometriosis. For fertilization to occur, the sperm and egg must combine in the distal (far end from the ovary) end of the fallopian tube. Furthermore, the pelvis must have an environment that is 
“friendly” towards both the sperm and eggs. Blocked or damaged fallopian tubes impede the eggs process. After tubal sterilization, the eggs cannot make their passage.
Tubal Damage or Tubal Reanastamosis- Surgical Options
Fallopian tube damage is often the result of undiagnosed infection, caused by organisms such as Chlamydia. Chlamydia enters the fallopian tubes by way of the cervix and causes either subtle damage inside the tube, or overt tubal blockage. A true “tubal blockage” can usually be seen on the hysterosalpingogram (HSG). However, subtle tubal disease, or scar tissue around the fallopian tube, is often missed. Severe tubal disease should be treated by a fertility specialist.
If the fallopian tube has a blockage at the uterus (proximal tubal occlusion), then it is often possible to repeat the hysterosalpingogram and pass a small wire into the fallopian tube to open it. This is done in the radiology department under light sedation. If the proximal fallopian tube is opened, then the HSG dye can examine the distal end of the tube. In cases of distal fallopian tubal occlusion, a hydrosalpinx has often formed.
The fallopian tube may have a "sac of fluid" in the distal end of the tube known as a hydrosalpinx, which inhibits combining of the sperm and egg. Studies have shown that the presence of a significant hydrosalpinx (i.e. seen on ultrasound) can lower the IVF success rate by as much as 50%. Therefore, if you are considering IVF, and have a significant hydrosalpinx, consult with Dr. Deaton.
Most women with distal fallopian tube disease choose IVF over surgery due to its higher success rate. However, if the couple is unable to proceed with IVF, then it is sometimes possible to open the fallopian tube using laparoscopy.
The laparoscopy is an outpatient surgery and is often referred to as “belly button surgery.” Most women return to normal activities in 2-4 days. The success rates, resulting from opening the fallopian tubes by laparoscopy are low, often less than 20%. Furthermore, the ectopic or tubal pregnancy rate is high, often in the 30% range. Couples often choose IVF since it does not involve surgery, greatly decreases the chance of an ectopic pregnancy, and has a much higher success rate.
Women with a prior fallopian tubal ligation (cut or tied tubes for sterilization) have the option of either IVF or a tubal anastomosis (TA, reconnecting the fallopian tubes). This technique reconnects the blocked ends of the fallopian tubes and involves a major surgical procedure and a 4-6 week recovery time. The success rate depends on the type of ligation and how much fallopian tube is present to reconnect. For example, if there are less than 5 centimeters (roughly 2 inches) of fallopian tube, then the success rates are extremely low.
There are many different ways to perform a tubal ligation, including burning, tying, clips, and removal of part of the fallopian tube. In cases where burning, tying or removal was used, there is often not enough tube for reconnection and IVF is the only option. The operative notes from a previous tubal ligation can be important to determine if tubal anastomosis is an option.
Success rates are often low and women run the risk of an ectopic pregnancy after this type of fallopian tube surgery. Furthermore, it is rare for an insurance company to pay for a tubal anastomosis. Due to these factors, most couples choose IVF.
For those few women with clips on their fallopian tubes, surgery becomes a more viable option. A consultation with Dr. Deaton can help sort out these issues and decide on the best approach.
Scar Tissue and Infertility
Pelvic scar tissue can be a barrier to pregnancy. Scar tissue, or adhesions, can be due to prior surgery, pelvic infections, a ruptured appendix, or endometriosis. Success rates from laparoscopy vary widely depending on the severity of the scar tissue and the appearance of the fallopian tubes. Oftentimes, a trained infertility specialist can remove the endometrial implants during the diagnostic laparoscopy.
If the fallopian tubes are not too involved, and the scar tissue is not too severe, laser laparoscopy can be used to cut/remove the adhesions. However, if the scar tissue is severe, or if the tubes are significantly involved, IVF becomes the best option.
Couples without insurance coverage for infertility treatment often skip the laparoscopy and go straight to IVF because of the higher success rates and the lower risk of an ectopic pregnancy. IVF also avoids surgery.
Endometriosis and Infertility
Couples with a normal infertility evaluation (semen analysis, day 3 lab work, luteal phase progesterone, and HSG) often come to a difficult decision regarding whether to proceed with treatment, or consider a laparoscopy to determine the status of the pelvis.
This decision can often be complicated by confusing insurance information, especially if there is limited treatment coverage. Many times the laparoscopy can be denied by the insurance company if it is done for infertility. A good evaluation of fertility treatment costs, insurance coverage and other options is important before a decision about surgery is made.
Pelvic endometriosis can be severe and involve significant scar tissue around the fallopian tubes and ovaries, thus inhibiting fertilization. However, in the majority of cases the endometriosis is minimal and does not affect the tubes or ovaries. In these situations, a laser can be used to destroy the endometrial implants.
Unfortunately, only 25-35% of the women who undergo laser therapy of endometriosis are able to conceive in the 6-12 months following surgery. For all these reasons, women often choose infertility treatment, such as IVF, over a surgical procedure.
Uterine Cavity Abnormalities and Infertility
In addition to the pelvic cavity, the uterine cavity is also very important to a successful pregnancy. Once the sperm and egg unite in the fallopian tube, the resultant embryo must travel down the tube into the uterus, where it hopefully implants.
Conditions involving the uterine cavity can inhibit this implantation, lead to early miscarriages, or cause difficulty later in the pregnancy. The common conditions that cause infertility are polyps (greater than 1 centimeter), fibroids (those involving the uterine cavity), and adhesions inside the cavity.
These conditions can often be diagnosed with either a saline infusion sonohysterography, which is done with ultrasound in our Greensboro NC fertility clinic, or a hysterosalpingogram done in the radiology suite of the hospital. If an abnormality is found, a trained reproductive endocrinologist can perform a hysteroscopy and correct the majority of conditions.
Uterine Anomalies and Infertility
Finally, a few words about uterine anomalies that can lead to pregnancy complications. Women who suffer either, recurrent early pregnancy loss or premature labor can have an anomaly of the uterus, namely a uterine septum, a bicornuate uterus, or a double uterus.
When a septum is suspected on SIS or HSG, an MRI is performed to confirm the diagnosis. Since a septum can cause early miscarriage, it can be surgically repaired by a trained reproductive endocrinologist, fertility specialist using hysteroscopy, thus avoiding major surgery. The other forms of uterine anomaly listed above tend not to cause infertility but may lead to either premature labor or a breech presentation during pregnancy. Dr. Deaton can counsel you regarding the type of uterine abnormality you have and recommend a treatment approach.
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