Surgical treatment for tubal disease in women due to undergo in vitro fertilisation

Neil Johnson, Sabine van Voorst, Martin C Sowter, Annika Strandell, Ben Willem J Mol, Neil Johnson, Sabine van Voorst, Martin C Sowter, Annika Strandell, Ben Willem J Mol

Abstract

Background: Tubal disease, and particularly hydrosalpinx, has a detrimental effect on the outcome of in-vitro fertilisation (IVF). Performing a surgical intervention such as salpingectomy, tubal occlusion, aspiration of the hydrosalpinx fluid, or salpingostomy, prior to the IVF procedure in women with hydrosalpinges is thought improve the likelihood of successful outcome.

Objectives: To assess and compare the value of surgical treatments for tubal disease prior to IVF.

Search strategy: Trials were sought in the Cochrane Menstrual Disorders and Subfertility Group trials register, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, PSYCHMED and in Conference proceedings and reference lists up until Ocober 28 2009. Researchers in the field were contacted to reveal unpublished studies.

Selection criteria: All trials comparing a surgical treatment for tubal disease with a control group generated by randomisation were considered for inclusion in the review.

Data collection and analysis: Two reviewers independently assessed trial quality and extracted data. The studied outcomes were live birth, ongoing pregnancy, viable-, clinical- and biochemical pregnancy, ectopic pregnancy, miscarriage, multiple pregnancy, ovarian function and complications.

Main results: Five randomised controlled trials involving 646 women were included in this review. Four studies assessed salpingectomy versus no treatment, two of which also included a tubal occlusion arm, and one trial assessed aspiration versus no treatment. No trials reported on the primary outcome: live birth. The odds of ongoing pregnancy (Peto OR 2.14, 95%CI 1.23 to 3.73) and of clinical pregnancy (Peto OR 2.31, 95%CI 1.48 to 3.62) however were increased with laparoscopic salpingectomy for hydrosalpinges prior to IVF. Laparoscopic occlusion of the fallopian tube versus no intervention did not increase the odds of ongoing pregnancy significantly (Peto OR 7.24, 95%CI 0.87 to 59.57) but the odds of clinical pregnancy (Peto OR 4.66, 95%CI 2.47 to 10.01) had sufficient power to show a significant increase. Comparison of tubal occlusion to salpingectomy did not show a significant advantage of either surgical procedure in terms of ongoing pregnancy (Peto OR: 1.65, 95%CI 0.74, 3.71) or clinical pregnancy (Peto OR 1.28, 95%CI 0,76 to 2.14). One RCT reported efficacy of ultrasound guided aspiration, however the odds of pregnancy did not show a significant increase in the odds of clinical pregnancy (Peto OR 1.97, 95%CI 0.62 to 6.29), and confidence intervals were wide. Throughout the different comparisons no significant differences were seen in adverse effects of surgical treatments.

Authors' conclusions: Surgical treatment should be considered for all women with hydrosalpinges prior to IVF treatment. Previous evidence supported only unilateral salpingectomy for a unilateral hydrosalpinx (bilateral salpingectomy for bilateral hydrosalpinges). This review now provides evidence that laparoscopic tubal occlusion is an alternative to laparoscopic salpingectomy in improving IVF pregnancy rates in women with hydrosalpinges. Further research is required to assess the value of aspiration of hydrosalpinges prior to or during IVF procedures and also the value of tubal restorative surgery as an alternative (or as a preliminary) to IVF.

Conflict of interest statement

Two of the authors (MS and AS) have performed clinical studies assessing the interventions studied in this review (Sowter 1997;Strandell 1999), the latter being one of the included RCTs in this review.

Neil Johnson works as a gynaecologist at Auckland City Hospital (a public hospital) in the National Women's Minimal Access Surgery and Endometriosis Service. NJ is also a private gynaecologist with groups called Endometriosis Auckland and Repromed Auckland. Within the last 3 years NJ has received financial support to attend conferences or to arrange research meetings from the following companies: Organon, Serono, Schering and Device Technologies.

Sabine van Voorst at the time was a medical student of the faculty of Health, Medicine and Life Sciences of the University of Maastricht, the Netherlands. She is now a resident in Obstetrics and Gynaecology at the Reinier de Graaf Gasthuis in Delft, the Netherlands. She has no financial conflict of interest.

Annika Strandell is a gynaecologist at Kungälv Hospital, associate professor at the University of Gothenburg and employed at the regional center for Health Technology Assessment in Göteborg, Sweden. She was the principle investigator and co‐ordinator of the Scandinavian trial on salpingectomy for hydrosalpinges prior to IVF. She has no financial conflict of interest.