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Salpingostomy and Salpingectomy

Overview

Background

Salpingectomy is the surgical removal of a fallopian tube. Salpingectomy is different from salpingostomy (also called neosalpingostomy). Salpingostomy is the creation of an opening into the fallopian tube, but the tube itself is not removed in this procedure.

The term fimbrioplasty is often used instead of salpingostomy (ie, simply opening the fallopian tube) because salpingostomy does not address the important role of the fimbriae. Reconstruction that preserves the delicate fimbriae is important for fertility outcomes. The purpose of fimbrioplasty is to open the obstructed fallopian tube and salvage enough function of the fimbriae to allow successful entrapment and transportation of the oocyte.

Indications

In vitro fertilization (IVF) is often used to treat infertility caused by tubal disease. IVF is the only treatment available for severely damaged, inoperable fallopian tubes and for situations in which tubal disease is concurrent with another fertility factor. However, reconstructive tubal surgery, such as salpingostomy and salpingectomy, should be considered in select individuals.

Distal tubal obstruction is found to be the culprit of tubal disease in the majority of cases. Various techniques of treating or bypassing tubal disease include either open or laparoscopic surgery, namely salpingectomy or salpingostomy, or assisted reproductive techniques. Fimbrioplasty is performed for patients who have patent fallopian tubes, whereas salpingostomy is performed with occluded tubes. Many times, patients have pelvic adhesions and phimosis of the fimbriated end of the fallopian tube.

Surgical treatment should be considered for all women with hydrosalpinges prior to IVF treatment. In cases of sonographically apparent hydrosalpinges, a salpingectomy, rather than a salpingostomy, is the preferred route of treatment. Some couples, however, may prefer a salpingostomy, which offers some potential of a spontaneous pregnancy.

For many infertile couples, a several-month postoperative trial at spontaneously conceiving is undesirable and unwise. Therefore, patient selection for surgical treatment of infertility must be individualized and carefully considered.

Contraindications

The role of reconstructive tubal surgery in a woman of advanced maternal age is limited. Given the low monthly chance of pregnancy following surgery in the setting of an already reduced fecundability in a woman of advanced maternal age, IVF is the better treatment option. In contrast, reconstructive surgery for a young woman with minimal tubal disease is a reasonable option.

In general, patients who fail to conceive after primary tubal reconstructive surgery have severely limited success with repeat surgical procedures. In these cases, assisted reproductive techniques are strongly indicated.

In a retrospective study of 434 infertile women who underwent laparoscopic salpingostomy, Audebert et al found evidence that the procedure should not be utilized in certain patients, based on factors such as tubal or adhesion stage and chlamydial serology. The investigators, who measured outcomes in terms of intrauterine pregnancy, delivery, and ectopic pregnancy rates (as achieved without IVF), reported poor-prognosis patterns in association with the following
:

Tubal stage 3 or 4

Previous ectopic pregnancy

Severe adhesion stage

Repeated salpingostomy

Positive chlamydial serology test

Outcomes

The cause of tubal disease must be taken into consideration when determining the prognosis for successful surgery. Successful surgical outcomes depend on whether tubal disease is due to intrinsic (from ascending infection or salpingitis isthmica nodosa) or extrinsic (previous pelvic surgery, endometriosis) causes. The location, type, and degree of tubal injury impact the chance of surgical success. The presence of tubal rugae on HSG, the absence of or presence of small hydrosalpinges (< 15 mm in diameter), the absence of significant pelvic adhesions, and the presence of fimbriae during laparoscopy are all associated with good prognosis following tubal reconstructive surgery.

In a study of 186 women who underwent IVF, 24 women underwent salpingectomy after one or two failed IVF cycles. Salpingectomy implied a significant increase in birth rate. Within the subgroup of patients with ultrasound-visible hydrosalpinges, the birth rate was even higher. Implantation rate was significantly higher in patients who had undergone salpingectomy (27.2% versus 20.2%); in the subgroup of patients with ultrasound-visible hydrosalpinges, the difference was even larger (30.3% versus 17.1%).

For patients with mild distal tubal disease, long-term live-birth rates after surgical treatment are in the range of 39-59% (approximately 5% per month probability of pregnancy) with an associated ectopic pregnancy rate of 4-10%. The outcome for patients with severe distal tubal disease is significantly worse, with an overall pregnancy rate of less than 15%, which equates to a monthly fecundability rate of 1-2%.

Results of fimbrioplasty are difficult to distinguish from other tubal corrective surgeries because this procedure tends to be included as a method of salpingostomy. In one series of 40 patients who underwent microsurgical fimbrioplasty, 63% of patients had intrauterine pregnancies and 5% had ectopic pregnancies after 2 years of follow-up.
Other series have reported an ectopic pregnancy rate ranging between 5% and 12.9% after 18 months of follow-up.
In most cases, approximately half of patients never conceived in the interval of time studied. No randomized controlled trials for fimbrioplasty versus other methods of tubal reconstructive surgery have been done.

The major determinants of outcome from neosalpingostomy are the degree of pre-existing tubal damage and the extent and type of periadnexal adhesions. In cases of mild tubal damage, the reported live birth rates are 40-60%. Live birth rates are reported to be < 20% in cases where severely damaged tubes exist.

A retrospective, cross-sectional analysis that included 334,639 tubal ectopic pregnancies reported that the proportion of salpingostomy decreased from 17.0% in 1998 to 7.0% in 2011, while the rate of salpingectomy increased from 69.3% in 1998 to 80.9% in 2011.

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