Distal Tubal Occlusion (Excluding Sterilization or Hydrosalpinx) Distal tubal disease and occlusion are causal in 85% of all tubal infertility and can be secondary to a variety of inﬂammatory conditions including infection, endometriosis, or prior abdominal or pelvic surgery (211,223). Patients younger than 35 years of age with mild distal tubal disease, normal tubal mucosa, and absent or minimal pelvic adhesions are the best candidates for corrective microsurgery (223). In vitro fertilization should be considered for older patients or those with diminished ovarian reserve, combined proximal and distal tubal disease, severe pelvic adhesions, tubal damage that is not amenable to reconstruction, or additional infertility factors (223,224). Fimbrioplasty involves lysis of fimbrial adhesions or dilation of fimbrial phimosis, whereas salpingostomy (also known as salpingoneostomy) involves the creation of a new tubal opening in an occluded fallopian tube (223). In well-selected patients, pregnancy rates are reported to be 32% to 42.2%, 54.6% to 60%, 30% to 34.6%, and 55.9% for adhesiolysis, fimbrioplasty, salpingostomy, and nonsterilization-related anastamosis, respectively (211,223). As a group, these procedures are associated with a 7.9% rate of subsequent ectopic pregnancy (223).
Sterilization Reversal Twenty percent of women express regret following sterilization, and 1% to 5% of those will request reversal, often after a change in marital status. The technique for sterilization reversal involves microsurgical dissection of the occluded ends of the fallopian tube followed by a layered reapposition of the proximal and distal tubal segments. Surgical approaches include minilaparotomy, laparoscopy, and robotic-assisted laparoscopy (224,225). Pregnancy rates following microsurgical tubal reanastamosis for sterilization reversal are 55% to 81%, with most pregnancies occurring within 18 months of surgery (224). Ectopic pregnancy rates following the procedure are generally less than 10% but may approach 18% (223,226). The main predictors of success are age younger than 35 years, isthmic-isthmic or ampulo-ampullar anastamosis, final anastamosed tubal length greater than 4 cm, and less-destructive sterilization methods such as use of rings or clips (224,226). Unlike vasectomy reversal, the length of time between fallopian tubal sterilization and reversal does not seem to affect outcome. IVF should be considered in lieu of sterilization reversal for older patients or those with diminished ovarian reserve, severe pelvic adhesions, additional infertility factors, or prior unsuccessful reanastamosis (223,224).
Hydrosalpinx Distal occlusion may lead to ﬂuid buildup in the fallopian tube, causing a hydrosalpinx. Hydrosalpinx ﬂuid impedes embryo development and implantation (211). A meta-analysis of 14 studies and 1,004 patients with hydrosalpinges concluded that IVF pregnancy rates were significantly lower in the presence of hydrosalpinges (227). Salpingectomy for hydrosalpinx prior to IVF significantly improves both pregnancy and live birth rates when compared to IVF performed with the fallopian tubes in situ, although laparoscopic tubal occlusion appears to be a reasonable alternative (228–230). There are significantly less outcome data on the use of transvaginal needle drainage and salpingostomy for treatment of hydrosalpinges prior to IVF (211).