Among infertility reasons in women, tube related problems constitute 25-35 %. In 1977 in England and Canada, opening of the obstructed or ligated tubes with microsurgery has been conducted successfully for the first time. In the coming years, with the development of microsurgery tools and microscopes, these operations have been conducted more successfully and commonly. Before the application of laparoscopic surgery method, microsurgery operations in gynecology has been performed as open surgery. Especially during the last 15 years, with the training of experienced doctors, development of laparoscopic tools and cameras, these operations which can only be performed with open suergery in the past can now be performed laparoscopically. With this technique called laparoscopic microsurgery, all operations that can be performed in open microsurgery, if the team is experienced and skilled enough, can be perfomed successfully as open microsurgery. If performed like this, both microsurgeries and also laparoscopic surgery’s properties and advantages are benefited from.

In many countries, and unfortunately also in our country, this method is not offered to the patients who can benefit from microsurgery, but instead, test tube baby is immediately applied to the patients having tubal problems. In countries where microsurgery and laparoscopy are developed, tubal microsurgery is offered as the first option to the patients applying due to tubal problems instead of test tube baby, after the tubal problems of the patients are corrected with microsurgery, they are offered a chance to conceive via natural ways. In test tube baby applications, the chance to conceive is only present during the month that it is applied. If pregnancy does not develop during that trial, then test tube baby application is applied to the patient until pregnancy develops. But, if the problems in the tubes are abolished successfully, then the patients have a chance to conceive for a long time. Pregnancy rates up to 60 % are obtained within 1-2 years following pregnancy. After this operation, if the patient can not conceive within 1-2 years, then test tube baby is applied. When you consider that if clinical pregnancy rates per trial is approximately 20-45%, then it is easily understood why microsurgery is the first option on the condition that appropriate patients are selected.

Despite all developments in microsurgery and laparoscopy, each patient having tubal problems or having obstructed tubes (tubal factor), these operations should not be applied. For patients who have extreme damage in their tubes, having extremely inflated or swelled tubes (hydosalpinx) or having a part of their tubes removed; application of these operations does not provide a positive contribution. For patients having advanced damage in their tubes, opening of the tubes or abolishing the adhesions is not enough for the tubes to function. These patients can not conceive or ectopic pregnancy risk is too high. Even in some situations, extremely damaged and swelled tubes are recommended to be removed laparoscopically before any test tube baby application (salpinjectomy). If the doctor is not experienced enough in microsurgery and laparoscopy, then these operations should not be performed again and patients should be directed to experienced centres. In addition, for couples that test tube baby or microinjection is recommended due to the problems in the sperm count, sperm motility or structural problems, microsurgery should not be conducted, the patient should be directed to a test tube centre immediately.

I. Abolishing the adhesions around the tubes and the ovaries (Laparoscopic adhesiolysis):

As you know, every month an egg cyst called folicule develops in an ovary of a woman and this folicule cracks between the 12th-14th days of menstruation and the oocyte or egg cell inside falls down to the abdominal cavity. At this stage, the egg cell has to be sucked by fimbria or extentions providing the effect of rubber suction cup at the tip of the tubes, and passes through the tubes. Cilia covering the surfaces of the cells coating the inner space of these tubes that are in the shape of capillary pipes, provides a movement wave towards the uterine cavity. By this way, the egg cell taken inside the tube from the abdominal cavity, reaches to the uterine cavity, the womb, after a journey of 5-6 days.

Adhesions around the tubes and ovaries prevent normal functioning.

In the cases in which the deteriorating anatomy of the ovaries and the tubes are restored by an operation called 'laparoscopic adhesiolysis', successful results are obtained. By this way, pregnancy rates of 40-60% and ectopic pregnancy rates of 6% are reported. In the presence of common adhesion, tubal damage and peritoneal defects, pregnancy rates decrease significantly. Most of the pregnancies occur within the first year.

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Some women have their tubes ligated willingly after having children. However, due to some reasons (new marriage, death of the child etc.), they apply to a doctor with the desire to have a baby again. In these cases, again in many centres, test tube baby is recommended to these patients since their tubes are congested. In our centre if the conditions are in favour, tubal re-anastomosis operation with laparoscopic microinjection is recommended as the first choice. Especially, if ring or clip is used for the ligation of the tubes, this operation provides a pregnancy chance up to 60%. These pregnancy rates are the ones reported by highly experienced teams. In our own series, the pregnancy rate is 57%.

However, it is understood that even though patients are informed that their tubes had been ligated, sometimes most of them are actually cut off. In these cases, since very few intact tube tissue remains, these women have a low chance to conceive after the operation. These patients should be directed to test tube baby applications.

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As mentioned above, tubes are like thin pipes. Their ends at the uterus opening are narrow and the other ends opening to the abdominal cavity widen like a funnel. If the tubes are obstructed somewhere, oocyte can not meet with the sperm and be fertilized. If both of the tubes are obstructed, then there is no chance for pregnancy. In order for the tubes to function, they should be open and the epithelium coating inside should be intact. Sometimes though not obstructed, due to partial narrowing (fimosis) at the end of the tube, pregnancy chance decreases. In this case, with fimbrioplasty operation this narrowing is removed.

If there is an obstruction within the tube near the uterus end (tubo-corneal region), then the first option is cannulation with phalloscopy. With this process, the obstruction in the tubo-corneal region is tried to be removed by reaching inside from uterus. If this fails, then an operation called 'tubo-corneal anastomosis' is performed with microsurgery. The success of this operation is reported to be 50-60% by experienced teams.

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The ends of the tubes near the abdominal cavity can frequently be obstructed due to previous infections or operations. Sometimes liquid is gathered at the back of the obstructipn and the tubea are extremely swelled. The success of the operation in these patients depends solely on the condition of the tubes. If only the ends of the tubes are obstructed and the rest is normal or slightly damaged, then the obstructed ends are opened with laparoscopic salpingoneostomy and provide normal functioning. However, in some cases if tubes are critically damaged, then even if the obstructed ends are opened, pregnancy chance is quite low and the risk of ectopic pregnancy increases. In selected patients this operation gives a pregnancy chance of 30-45%.

When the ends of the tubes are obstructed and extremely swelled (hydrosalpinx) the opening of the tubes are not recommended since the chance to conceibe isvery little. When test tube baby is applied to these patients, high rates of pregnancy are obtained. However, when tubes are swelled like this, in order to increase the risk to conceive, they are recommended to be taken out before. As the reason to remove the tubes, it is suggested that the liquid inside the tubes during the test tube baby application, makes it difficult for the embryo to attach to the uterus or prevent it completely. With the conducted studies it has been shown that after the tubes are removed in these test tube applications, the pregrancy results increase positively.

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A normal pregnancy develops inside the uterus. In ectopic pregnancy, it generally develops inside the tubes. In ectopic pregnancy, the tube can completely be removed (salpinjectomy) or in appropriate cases the tube is preserved and salpingotomy can be performed.

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Since studies comparing the results of tubal microsurgery and test tube baby are not present, which technique is proved to be successful in infertile patients due to tubal factor is very controversial. In addition, since the pregnancy rates are valid within the month of the application, pregnancy rates after tubal surgery becomes definite within 1-2 years. In test tube baby applications, performed due to tubal factor, birth rates per cycle, though variable, approximates to 20-35%. In test tube baby applications if 3-4 trials are performed, pregnancy rates reach up to 40-60%. If appropriate patients are selected and performed by experienced teams, more successful results are obtained by tubal microsurgery.

Due to the waiting period after tubal surgery, for patients who do not want to wait, patients in declining years and patients inappropriate for tubal surgery, test tube baby is more appropriate as the first option. However, in young patients, appropriate to tubal surgery, patients who do not want to have test tube baby applied or for patients who can not conceive with test tube baby, tubal microsurgery can be offered as the first option in treatment or a successful alternative.