Laparoscopic Tube Repair

Tube-related diseases

Laparoscopic laser surgery in tubal infertility

Among the reasons for infertility in women, tube-related problems make up 25-35%. In 1977, the operations of opening blocked or ligated by means of microsurgery were firstly performed in England and Canada successfully. These operations have been applied more successfully and commonly thanks to development of microsurgery tools and microscopes during the following years. Before laparoscopic surgical methods, microsurgery operations were performed as open operations in gynecologic diseases. Especially in the recent 15 years, it has been enabled to perform laparoscopic operations instead of open ones thanks to experienced doctors in laparoscopic surgery and development of laparoscopic tools and cameras.

With this technique called laparoscopic microsurgery, all operations that can be performed in open microsurgery can be performed as successfully as open microsurgery if the team of operation is experienced and skillful sufficiently. In that way, we can benefit from features and advantages of both microsurgery and laparoscopic surgery.

As in many countries, this method is unfortunately not recommended to the patients who can benefit from microsurgery in our country, and instead, IVF treatment is immediately applied to the patients with problems in tubes. In the countries where microsurgery and laparoscopy is advanced, tubal microsurgery is recommended to the patients with tubal factor as a first option instead of IVF treatment, and the patient is given the chance to become pregnant naturally after the tubal problems are recovered with microsurgery. In IVF implementations, chance of pregnancy does only exist within the month it is applied. If conception doesn’t occur in that trial, the patients are applied IVF treatment again until conception is achieved. Nevertheless, the patients are given the chance of pregnancy for long period if the tubal problems are eliminated successfully. Within the first 1-2 years after microsurgery, rates of pregnancy up to 60% can be obtained. If the patient doesn’t become pregnant within 1-2 years after this operation, IVF treatment is implemented. If it is considered that clinic rates of pregnancy are nearly between 20-45% per trial in IVF implementations, it will be understood why microsurgery will be convenient as a first choice in case of proper patient selection.

In spite of all developments in microsurgery and laparoscopy, these operations should not be applied to all patients with problematic or blocked tubes (tubal factor). Implementing these operations in the patients whose tubes are seriously damaged, swollen or blistered (hydrosalphenx) or most of whose tubes are resected, doesn’t bring about any positive contribution. In the patients with severely damaged tubes, opening the tubes or eliminating the adhesions isn’t sufficient for functioning of tubes. In these patients, conception doesn’t occur or the risk of ectopic pregnancy is very high. Moreover, in some cases, it is recommended to extract severely damaged and blistered tubes laparoscopically (salpenjectomy) before any IVF implementation. If the doctor doesn’t have enough experience in microsurgery and laparoscopy, these operations should not be performed or the patients should be directed to the centers experienced in these fields. Furthermore, microsurgery should be applied to the pairs to whom IVF or microinjection has been recommended due to number, motility or structural problems in sperms of the husband, and the patient should immediately be directed to a IVF center.

I. Eliminating adhesions around tubes and ovaries (Laparoscopic adhesiolysis)

As known, an oocyte cyst called follicle develops in ovary of a woman every month and this follicle breaks and the oocyte or egg cell within it falls into abdominal cavity approximately between 12-14. days after menstruation. At this stage, the egg cell should be absorbed by the extensions at the end of tubes which have a fimbria or sucker effect and it should pass through the tube. The cilia on the surface of cells covering inner cavity of tubes in the form of a very thin pipe creates a movement wave towards uterine cavity. The egg cell coming from abdominal into the tube reaches uterine cavity at the end of a 5-6-day travel with this movement wave.

The adhesions around tubes and ovaries prevent normal functions.

Better results are achieved when deformed anatomy of ovaries and tubes is normalized again by means of ‘laparoscopic adhesiolysis’. In this way, pregnancy at the rates of around 40-60% and ectopic pregnancy around 6% have been informed. There is a distinctive decrease in pregnancy rates in cases of common adhesions, tubal damages and peritoneal defects. Most of the pregnancies occur within the first 1 year.

II. Laparoscopic tubal re-anastomosis (bringing ligated tubes end to end)

Some women who have children in desired number have their tubes ligated willingly. However, they sometimes apply to doctors to have baby again due to several reasons (new marriage, death of child, etc). In such cases, IVF is recommended to these patients in many centers as their tubes are blocked. In our center, if the conditions are proper, tubal re-anastomosis operation with laparoscopic microsurgery is recommended as the first option. Especially, if rings or clips have been used during tube ligation operation, this operation offers the chance of pregnancy at the rates up to 60%. These pregnancy rates are those notified by well experienced teams. In our series, rate of pregnancy is 57%.

However, in some patients with ligated tubes, this operation is performed by resecting a wide part of tubes. In such cases, chance of these women to become pregnant after operation is very low as very little healthy tube tissue has remained. IVF treatment should be recommended to these patients.

III. Opening tube obstructions

As stated above, tubes are like a thin pipe. While end of the tubes opening to uterus is narrow, the end opening to abdominal cavity expands like a funnel. If the tubes are blocked at any place, conception of oocyte cell and sperm doesn’t occur. If both of the tubes are blocked, there is no chance for pregnancy. In order for the tubes to function, they should be open and the inner epithelial should be undamaged. Sometimes, even if the tube isn’t blocked, the chance for pregnancy decreases in case of partial narrowness at the end of tube (fimosis). In such cases, the narrowness is eliminated by means of fimbrioplasty operation.

If there is an obstruction at a point next to the uterus (tubo-corneal region), the first treatment choice is canulation with falloposcopy. With this operation, it is tried to eliminate the obstruction in tubo-corneal region by reaching through uterus. If this operation becomes unsuccessful, the operation called ‘tubo-corneal anastomosis’ is performed with microsurgery. Success of this operation is notified as 50-60% by experienced teams.

The ends of tubes opening to abdominal cavity may be blocked frequently due to infections or operations. Sometimes, liquid accumulates behind the obstruction and the tubes get damages and swells significantly. In these patients, success of the operation is completely based on the state of tubes. If only the ends of tubes are blocked but the remaining parts are normal or a bit damaged, normal functioning of tubes is ensured by opening the blocked ends with laparoscopic salpingoneostomy operation. However, in some cases, if the tubes are damaged extensively, chance for pregnancy decreases and risk of ectopic pregnancy increases even if the blocked ends are opened. In selected patients, this operation gives chance for pregnancy at the rates between 30-45%.

IV. Extraction of tubes before IVF operation with laparoscopic surgery (Salpenjectomy)

When the ends of tubes are blocked and swell significantly (hydrosalpenx), the operations of opening the tubes are not recommended as the chance for pregnancy is very low. Higher rates of pregnancy can be achieved when IVF treatment is applied to these patients. However, when the tubes blister in that way, it is recommended to extract the tubes beforehand in order to increase the chance for pregnancy. The reason for extraction of tubes is suggested that the liquid within the tubes makes implantation of embryos difficult or prevents it during IVF treatment. In the studies, it has been shown that rates of pregnancy increase after IVF treatment after the tubes are extracted.

V. Laparoscopic ectopic pregnancy operations

A normal pregnancy develops within uterus. In case of ectopic pregnancy, it generally develops within tubes. In ectopic pregnancy, the tube can be extracted completely (salpenjectomy) or salpingotomy operation can be performed protecting the tubes in proper cases.

VI. Laparoscopic microsurgery or direct IVF treatment?

As there are no studies comparing results of tubal microsurgery and IVF, which technique is successful in infertile patients due to tubal factor is controversial. Furthermore, while rates of pregnancy are valid within the month in which IVF is applied, rates of pregnancy after tubal surgery become clear within 1-2 years. In IVF implementations performed due to tubal factor, rates of live birth per cycle are variable but around 20-35%. Rates of pregnancy reach 40-60% when 3-4 trials are performed in IVF implementations. Tubal microsurgery gives more successful results if the patients are selected properly and it is performed by experienced teams.

IVF is more convenient as the first choice in the patients who don’t want to wait due to long waiting period after tubal surgery and who are inconvenient for tubal surgery due to advanced age. In the contrast, tubal microsurgery can be the first choice or a successful alternative in young patients convenient for tubal surgery and those who don’t want IVF treatment or cannot become pregnant with IVF implementation.
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