Laparoscopic laser surgery in tubal infertility
Tubal disorders constitute 25 to 35% of the causes of infertility in women. Microsurgical operations to open blocked or tied tubes were successfully performed for the first time in 1977 in England and Canada. In the following years, thanks to the development of microsurgical instruments and microscopes, these operations began to be applied more successfully and widely. Before the application of the laparoscopic surgery method, microsurgery operations in gynecological diseases were performed via open surgery. Especially in the last 15 years, thanks to the training of experienced doctors in laparoscopic surgery and the development of laparoscopic instruments and cameras, these operations, which were only performed as open in the past, have now been allowed to be performed laparoscopically. All operations that can be performed in open microsurgery can be performed as successfully as open microsurgery with this technique named laparoscopic microsurgery, if the team that will perform the operation has sufficient experience and skills. If done in this way, the characteristics and benefits of both microsurgery and laparoscopic surgery are utilized.
As in many countries, unfortunately, this method is not recommended for patients who can potentially benefit from microsurgery in our country, instead, in vitro fertilization is applied at once to patients who have problems in their tubes. In countries where microsurgery and laparoscopy are advanced, tubal microsurgery is recommended instead of in vitro fertilization as the first option for patients who apply for tubal factor, and the chance to conceive naturally is given to the patient, after the disorders in their tubes are corrected with microsurgery. In IVF applications, the chance of pregnancy is only available within the month of application. If pregnancy does not occur in that attempt, in vitro fertilization is applied to the patients again until pregnancy occurs. However, if the disorders in the tubes are successfully resolved, the patients are given a long-term chance of getting pregnant. Pregnancy rates of up to 60% are achieved within the first 1 to 2 years following microsurgery. After this operation, if the patient cannot get pregnant within 1 to 2 years, in vitro fertilization is then applied. Considering that the clinical pregnancy rates per attempt in IVF applications are approximately between 20 to 45%, it will be understood why microsurgery would be appropriate as the first choice if appropriate patient selection is made.
Despite all the developments in microsurgery and laparoscopy, these operations should not be performed on every patient who has disorders with their tubes or whose tubes are blocked (tubal factor). The application of these operations does not make any positive contribution in patients with severe damage in their tubes, severely swollen or blistered tubes (hydrosalpinx), or in patients whose tubes were largely removed. In patients with severe damage to their tubes, opening the tubes or removing adhesions is not enough for the tubes to function. In these patients, either pregnancy does not occur or the risk of ectopic pregnancy is very high. Even in some cases, it is recommended to remove severely damaged and swollen tubes laparoscopically (salpingectomy) before any IVF application. If the physician does not have enough experience in microsurgery and laparoscopy, these operations should not be performed or the patients should be referred to experienced centers. In addition, microsurgery should not be performed for couples who have been offered IVF or microinjection due to sperm count, motility or structural problems of the husbands, and the patient should be referred to an IVF center without wasting time.
I. Removal of adhesions around the tubes and ovaries (Laparoscopic adhesiolysis)
As is known, an egg cyst, named a follicle, develops in the woman's ovary every month, and this follicle cracks and the oocyte or egg cell falls into the abdominal cavity, approximately between the 12th and 14th days of the menstrual cycle. At this stage, the egg cell must be sucked by the fimbriae located at the end of the tubes or its extensions acting as suction cups, and pass into the tube. The hairs (cilia) on the surface of the cells lining the inner cavity of the tubes, which are in the form of a very thin tube, form a wave of movement towards the uterine cavity. In this way, the egg cell taken sucked from the abdominal cavity into the tube reaches the uterine cavity, in other words the uterus, after a journey of 5 to 6 days with this movement wave.
Adhesions around the tubes and ovaries prevent the fulfillment of normal functions.
Very good outcomes are obtained in cases where the deteriorated anatomy of the ovaries and tubes is restored with the operation named 'laparoscopic adhesiolysis'. In this way, pregnancy rates of around 40-60% and ectopic pregnancy rates of around 6% have been reported. There is a significant decrease in pregnancy rates in the presence of extensive adhesion, tubal damage and peritoneal defects. Most of the pregnancies occur in the first year.
II. Laparoscopic tubal re-anastomosis (reconnection of ligated tubes)
Some women voluntarily want to have their tubes tied after giving birth to as many children as they want. However, they apply to the doctor with the desire to have a child again for various reasons (new marriage, losing a child, etc.). In such cases, still IVF is recommended for these patients in many centers since their tubes are blocked. In our center, tubal re-anastomosis with laparoscopic microsurgery is recommended as the first option for these patients, if the conditions are suitable. This operation gives a pregnancy chance of up to 60%, especially in cases where ring or clips are used during the tube ligation procedures. These pregnancy rates are reported by highly experienced teams. In our series, the pregnancy rate is 57%.
However, in patients who have their tubes tied, this procedure is sometimes performed by cutting a large part of the tubes. In such cases, these women's chances of conceiving after surgery are very low since there is very little intact tube tissue left behind. These patients should be directed to IVF applications.
III. Opening tube blockages
As mentioned above, the tubes are in the form of a thin tube. While the part of the tubes opening to the uterus is narrow, the end opening to the abdominal cavity is expanded in the form of a funnel. If the tubes are blocked at any point, the egg cell does not meet and fertilize with the sperm. If both tubes are blocked, there is no chance of pregnancy. In order for the tubes to function, they must be open and their epithelial lining must not be damaged. Sometimes, although there is no obstruction in the tube, the chance of pregnancy decreases in cases where there is partial stenosis (phimosis) at the tip of the tube. In this case, the stenosis is removed by performing a fimbrioplasty operation.
If there is an obstruction in the part of the tubes close to the uterus (tubo-corneal region), the first treatment option is cannulation with falloposcopy. With this procedure, the obstruction in the tubo-corneal region is tried to be opened by accessing from inside the uterus. If this procedure is not successful, an operation called 'tubo-corneal anastomosis' is performed with microsurgery. The success of this operation is reported as 50-60% by experienced teams.
The ends of the tubes opening into the abdominal cavity can often become blocked due to previous inflammations or operations. Sometimes, fluid collects behind the obstruction and the tubes are severely damaged and swollen. The success of the operation in these patients depends entirely on the condition of the tubes. If only the ends of the tubes are blocked, but the rest is normal or slightly damaged, the occluded ends are opened by laparoscopic salpingoneostomy operation, and this allows the tubes to function normally. On the other hand, in some cases, if there is severe damage to the tubes, then even if the blocked ends are opened, the chance of pregnancy is low and the risk of ectopic pregnancy increases. In selected patients, this operation gives a pregnancy chance of 30 to 45%.
IV. Removal of tubes with laparoscopic surgery (Salpingectomy) before IVF
In cases where the ends of the tubes are blocked and severely swollen (hydrosalpinx), operations to restore the integrity of the tubes are not recommended since the chance of pregnancy is very low. When these patients undergo IVF, a higher chance of pregnancy is achieved. However, in cases where there is a fluid collection in this way, it is recommended to remove the tubes before in order to increase the chance of pregnancy. It is claimed as the reason for removing the tubes before that the fluid in the tubes makes it difficult or prevents the embryos from attaching to the uterus during IVF applications. Studies have demonstrated that pregnancy outcomes after in vitro fertilization increase positively following removal of the tubes.
V. Laparoscopic ectopic pregnancy operations
A normal pregnancy develops in the uterus. In the case of ectopic pregnancy, it usually occurs in the tubes. In ectopic pregnancy, the tube can be completely removed (salpingectomy) or in appropriate cases, a salpingotomy can be performed by preserving the tube.
VI. Laparoscopic microsurgery or IVF directly?
Since there are no studies comparing the results of tubal microsurgery and those of in vitro fertilization, it is very controversial to conclude which technique is more successful in patients who are infertile due to tubal factor. In addition, although pregnancy rates are valid in the month of in vitro fertilization, pregnancy rates after tubal surgery are definite within 1-2 years. Although the live birth rates per cycle are variable, it is about 20 to 35% in vitro fertilization applications due to tubal factor. Pregnancy rates reach up to 40 to 60% if 3 to 4 attempts are made in IVF applications. If appropriate patient selection is made and performed by experienced teams, more successful results are obtained with tubal microsurgery.
There is a waiting period after tubal surgery, thus, IVF is more suitable as the first option for patients who do not want to wait, or are advanced age and unsuitable for tubal surgery. Contrary to this, tubal microsurgery can be offered as the first choice or a successful alternative in young patients who are suitable for tubal surgery, who do not want to have in vitro fertilization or who cannot achieve pregnancy with IVF.