Female infertility: Reproductive surgery

INTRODUCTION — The availability of assisted reproductive technology has reduced the need for reproductive surgery as a primary surgical treatment of infertility. When fertility surgery is indicated, operative laparoscopy results in outcomes as good as those from similar procedures performed via open laparotomy and is associated with a shorter hospital stay, lower incidence of ileus, and faster recovery. In addition, there is less contamination of the surgical field with glove powder, bleeding is reduced due to tamponade of small vessels by the pneumoperitoneum, and drying of tissues is minimal because surgery occurs in a closed environment. All of these factors contribute to reduce postoperative adhesion formation and its associated morbidity (eg, pain, impaired fertility, bowel obstruction). Today, reproductive surgery can be divided into three categories: surgery as a primary conventional surgical treatment of infertility, surgery to enhance the pregnancy outcome of in vitro fertilization, and surgery for fertility preservation [1].

Laparoscopic surgery for the treatment of female infertility is reviewed here. The evaluation and nonsurgical treatment of female infertility are discussed separately. (See "Female infertility: Evaluation" and "Female infertility: Treatments".)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive individuals.

DIAGNOSTIC LAPAROSCOPY — The role of diagnostic laparoscopy in the management of infertility is limited. However, it can be useful in the infertility evaluation of young women with a history of pelvic inflammatory disease, ectopic pregnancy, pelvic surgery, or chronic pelvic pain. In our practice, we usually perform diagnostic laparoscopy or in vitro fertilization (IVF) treatment if three cycles of ovulation induction with intrauterine inseminations are unsuccessful. If adhesions or endometriosis are found during diagnostic laparoscopy and the patient has been appropriately consented, then an operative laparoscopic procedure for improving fertility can be undertaken at the same time.

Diagnostic laparoscopy can be avoided in older women and those with multiple infertility factors. These women are better served by IVF, instead of a surgical approach to treatment. The presence of endometriosis and adhesions does not markedly influence the effectiveness of IVF. Today, we rarely perform diagnostic laparoscopy in infertile women. (See "In vitro fertilization: Overview of clinical issues and questions".)

Chromopertubation — When laparoscopy is performed for diagnostic or therapeutic purposes in women with infertility, chromopertubation (instillation of dye through the fallopian tubes) is often performed to assess tubal patency. To perform this procedure, a dilute solution of methylene blue dye is instilled through a transcervical cannula (typically through a patent cannula used for uterine manipulation (picture 1)). Spillage of the dye from each tube is noted as a confirmation of tubal patency. If a repair procedure for tubal occlusion is performed, chromopertubation is repeated at the end of the procedure. An emerging technique is evaluation of tubal patency with the use of office hysteroscopy. Entry of air bubble or methylene blue dye into the tubal ostia suggests the absence of tubal occlusion. This technique appears to be accurate with sensitivity and specificity of 88 and 85 percent, respectively [2].

SURGICAL ROUTE — Most surgical treatments for women with infertility are performed laparoscopically. The exception to this is hysteroscopic removal of intrauterine lesions (eg, fibroid, polyp, adhesions).

Combined laparoscopy and hysteroscopy — Some women who undergo diagnostic or therapeutic procedures for infertility may require both hysteroscopy and laparoscopy. As an example, a woman with ultrasound findings of an intrauterine lesion undergoing surgical treatment of endometriosis requires evaluation of the uterine cavity.

When laparoscopic and hysteroscopic procedures are combined, the order of procedures should be based upon the indication for each procedure. If intrauterine pathology is suspected, it may be prudent to perform hysteroscopy first so that placement of the uterine cannula during laparoscopy does not cause tissue trauma that interferes with assessment of the uterine cavity. Another advantage to performing hysteroscopy followed by laparoscopy is that the peritoneal surface of the uterus can be inspected for possible uterine perforation that occurred during hysteroscopy. On the other hand, a potential disadvantage of performing hysteroscopy first is that tissue fragments may block the tubes and give the false impression of tubal occlusion during chromopertubation.

ADHESIOLYSIS — Pregnancy can occur in women with periadnexal adhesions, but the pregnancy rate appears to be higher in those who undergo adhesiolysis. The severity of adhesions can only be evaluated at the time of surgery. For women with dense pelvic adhesions ("frozen pelvis"), optimal adhesiolysis is unlikely.

In the only controlled study examining this issue, salpingo-ovariolysis was performed in 69 infertile women with pelvic adhesions, while 78 women with a similar degree of adhesions were not treated [3]. The cumulative pregnancy rate at 24 months follow-up was significantly higher in treated women, 45 versus 16 percent in the untreated group. Although adhesiolysis was done at laparotomy, equivalent results can be expected with laparoscopic adhesiolysis. (See "Postoperative peritoneal adhesions in adults and their prevention".)

Intrauterine adhesions are another cause of infertility. Surgical treatment is discussed in detail separately. (See "Intrauterine adhesions: Clinical manifestation and diagnosis".)

ENDOMETRIOSIS

Excision and ablation — Whether there is an association between minimal/mild endometriosis and infertility has been debated for many years. This controversy was somewhat resolved following a Canadian study in which 341 infertile women with minimal/mild endometriosis were randomly assigned to undergo laparoscopic ablation or excision of endometriotic lesions or laparoscopy without further surgical intervention [4]. The 36-week cumulative probability of pregnancy was significantly higher in women who received surgical treatment (31 versus 18 percent in the no treatment group) [4]. By contrast, the only other randomized trial in this area did not find any difference in the pregnancy rate between the treated and no treatment groups (24 and 29 percent, respectively, at one year follow-up) [5]. These findings may have been due to the small sample size (n = 101) of the latter study as a subsequent meta-analysis of these two trials found laparoscopic surgical treatment was associated with a significant increase in the ongoing pregnancy/live birth rate (OR 1.64, 95 percent CI 1.05 to 2.57) [6]. The number needed to treat (NNT) was 61; in other words, 61 patients would have to undergo laparoscopic ablation of endometriosis to achieve one pregnancy. (See "Endometriosis: Treatment of infertility in females".)

Endometriosis can be ablated or excised laparoscopically using scissors, electrocoagulation, laser, or ultrasonic cutting and coagulation device (eg, Harmonic Scalpel, PlasmaJet) [7]. It is not known whether one modality is more effective than another. However, in our experience, excision leads to more complete removal of endometriosis than electrocoagulation, which is especially important for women with pelvic pain.

Excision of endometriomas — The most effective treatment of endometriomas is excision. Medical therapy of an endometrioma larger than 1 cm is not effective [8], nor is aspiration, which is associated with a recurrence rate of 88 percent at six months of follow-up [9]. Fenestration and ablation (ie, removal of part of the cyst wall followed by the coagulation of the inner side of the wall) are also less effective than excision, both in terms of improving fertility and for reducing pain [8,10]. However, excision of endometrioma might be associated with decreased ovarian reserve, especially when the endometrioma cyst wall is severely adhered to the remaining ovarian tissue. In this case, the fenestration technique should be used. We usually start by attempting to perform excision. However, if the endometrioma is severely adhered to the ovarian tissue, the adhered tissue is coagulated. The presence of small endometrioma of less than 4 cm in diameter does not impair in vitro fertilization (IVF) outcome. On the other hand, excision of ovarian endometrioma ≥4 cm is associated with increased ovarian damage [11]. (See "Endometriosis: Management of ovarian endometriomas".)

A promising technique to treat ovarian endometrioma without surgery is ultrasound-guided sclerotherapy. The most commonly used sclerosing substance is absolute alcohol. It is associated with a low recurrence rate compared with surgery and does not decrease ovarian reserve. In a meta-analysis of 18 studies, the clinical pregnancy rates after IVF were similar for women treated with sclerotherapy and surgery [12].

TREATMENT OF DISTAL TUBAL OCCLUSION — Distal tubal obstruction is usually a sequela of salpingitis. Other causes are previous ectopic pregnancy, previous abdominal or pelvic surgery, and peritonitis.

Diagnosis — Distal tubal occlusion is usually diagnosed by hysterosalpingogram that shows dilated distal tube (hydrosalpinx). The diagnosis is established at the time of laparoscopy; chromopertubation leads to dilated distal tube with no passage of the dye.

Fimbrioplasty — Fimbrioplasty is performed for treatment of fimbrial phimosis, which is a partial obstruction of the distal end of the fallopian tube. The tube is patent, but there are adhesive bands that surround the terminal end. The longitudinal folds of the tube are usually preserved. Fimbrioplasty involves dividing the peritoneal adhesive bands that surround the fimbria. Gentle introduction of an alligator laparoscopic forceps into the tubal ostium followed by opening and withdrawal of the forceps helps to stretch the tube and release minor degrees of fimbrial agglutination [13].

In a series including 434 patients with distal tubal occlusion who underwent laparoscopic fimbrioplasty (enlargement of the ostium) or neosalpingostomy (creation of a new ostium) by a single surgeon, five-year actuarial delivery rates decreased as the severity of tubal occlusion increased: 53, 43, 24, and 23 percent, respectively; the ectopic rate was stable at approximately 15 percent [14]. These results are inferior to those of in vitro fertilization (IVF; 29 percent of IVF cycles result in a live birth and 0.7 percent result in ectopic pregnancy [15]). The authors concluded that fimbrioplasty/neosalpingostomy was an appropriate alternative to IVF for women with less severe tubal occlusion (stage 1 or 2), but IVF was the better option for women with more severe disease (stage 3 or 4) [14]. Time is also a consideration: half of the pregnancies occurred in the first 11 months after surgery and 75 percent occurred in the first 21 months.

Terminal salpingostomy — Terminal salpingostomy is performed to relieve tubal obstruction associated with hydrosalpinx. Efficacy for improving fertility is generally poor, but depends upon tubal wall thickness, ampullary dilation, presence of mucosal folds, percentage of ciliated cells in the fimbrial end, and peritubal adhesions [16]. The average pregnancy rate following salpingostomy is nearly 30 percent, with an ectopic pregnancy rate of 10 percent [17]. However, the pregnancy rate can be as low as zero if the tube is rigid and thick without rugae, and as high as 80 percent when tubal damage is absent or minimal by hysterosalpingogram, salpingoscopy, or inspection at surgery [16].

Summary — Surgery may be considered for young women with mild distal tubal disease because, if successful, one surgical procedure can lead to several pregnancies whereas IVF must be attempted each time pregnancy is desired. IVF is more likely than surgery to be successful in women with bilateral hydrosalpinx, older women (due to the rapid decline in fertility with advancing age), and women with severe disease (eg, severe hydrosalpinx, extensive and dense adhesions, both proximal and distal tubal occlusion). The pregnancy rate after reconstructive surgery in women with combined tubal occlusion (bipolar tubal blockage) is only 12 percent at 2.5 years follow-up [18].

SALPINGECTOMY BEFORE IN VITRO FERTILIZATION — Several reports have described a detrimental effect of hydrosalpinx on implantation and pregnancy rates [19]. The leakage of hydrosalpingeal fluid from the tube into the uterine cavity may impede implantation either by flushing the embryos out of the cavity or disrupting the endometrium at the implantation site. Furthermore, hydrosalpinx fluid contains microorganisms, debris, toxins, cytokines, and prostaglandins that may impair endometrial receptivity and possibly reduce the percentage of motile spermatozoa [19].

On a molecular level, one group demonstrated decreased endometrial HOXA10 expression in response to hydrosalpinx fluid, with restoration of HOXA10 expression after salpingectomy [20]. Since HOXA10 is an important transcription factor for implantation of the embryo, impaired expression of this gene may be a mechanism for the deleterious effect of hydrosalpinges on implantation during in vitro fertilization (IVF).

The deleterious effects of hydrosalpinx on achieving pregnancy in women undergoing IVF was demonstrated by a meta-analysis that reported decreased clinical pregnancy rates for individuals with hydrosalpinx (per subject pregnancy odds ratio [OR] 0.54, 0.32-0.89 and per transfer OR 0.44, 0.27-0.73, respectively, 19 studies) compared with patients without hydrosalpinx [21]. Hydrosalpinx was associated with increase rates of ectopic pregnancy (OR 3.48, 1.60-7.60) and miscarriage (OR 1.68, 1.17-2.40).

Pregnancy rates can be improved by removal of unilateral or bilateral hydrosalpinges prior to IVF:

●A trial that randomly assigned women with hydrosalpinges to salpingectomy or no salpingectomy before their IVF procedure reported implantation and pregnancy rates per transfer in the salpingectomy group were 10 and 34 percent, respectively, but were only 5 and 19 percent in those without salpingectomy [22].

●A meta-analysis of five randomized trials including 646 women confirmed an increase in the rate of ongoing pregnancy in women with hydrosalpinges who were treated prior to IVF with laparoscopic salpingectomy (OR 2.14, 95% CI 1.23-3.73) compared with no treatment [23]. Trials of laparoscopic tubal occlusion versus no treatment had insufficient power to detect a significant difference in the rate of ongoing pregnancy (OR 7.24, 95% CI 0.87-59.57), but did find a significant increase in the rate of clinical pregnancy (OR 4.66, 95% CI 2.47-10.01). Throughout the different comparisons, no significant differences were seen in adverse effects of surgical treatments. A nonsurgical approach, ultrasound guided aspiration of hydrosalpinges did not have a significant increase in the rate of clinical pregnancy (OR 1.97, 95% CI 0.62 to 6.29).

●A prospective study reported that the relative increase in the pregnancy rate after salpingectomy was greatest in women with a large hydrosalpinx visible on ultrasound (hazard ratio 3.8, 95% CI 1.5-9.2) [24].

Salpingostomy can eliminate the accumulation of hydrosalpinx fluid without removing the tube. The tube becomes patent and the fluid will not reaccumulate because drainage is maintained. In one small study, pregnancy rates were similar to those after salpingectomy [25]. Further research is required to determine whether laparoscopic salpingostomy is as effective as salpingectomy. In addition, reocclusion can occur in over three-quarters of cases [21].

Drainage of the hydrosalpinx at the time of oocyte collection is not effective as the tubes will refill rapidly (as little as two days) and the primary pathology (blocked tube) remains [26].

The use of antibiotics to treat hydrosalpinx prior to IVF has also been advocated. In one study, doxycycline was administered to women with documented hydrosalpinx before and after oocyte retrieval [27]. In patients with hydrosalpinx, tubal occlusion or adhesion, and endometriosis or unexplained infertility who received the antibiotic, the implantation rates were 30, 27, and 24 percent, respectively. The authors concluded that antibiotic administration in patients with hydrosalpinx achieved IVF success rates similar to those in controls, and was less costly than surgery.

A small randomized trial reported that proximal tubal occlusion using bipolar diathermy prior to IVF also improved implantation and pregnancy rates [28]. Proximal tubal occlusion was not more effective than salpingectomy. We perform laparoscopic tubal occlusion if the distal tube is completely buried in dense adhesions. However, blockage at the proximal and distal tube may lead to further dilatation of the hydrosalpinx.

Hydrosalpinx sclerotherapy — In order to minimize entry of hydrosalpinx fluid into the uterine cavity, a sclerosing agent can be instilled into the hydrosalpinx. There is no difference in the clinical pregnancy rate between hydrosalpinx sclerotherapy and salpingectomy [29].

Summary — Laparoscopic salpingectomy for hydrosalpinges (unilateral or bilateral) is the preferred procedure for improving pregnancy rates from IVF. Alternatives such as salpingostomy, antibiotic therapy, proximal tubal occlusion, and sclerotherapy were effective in small studies, but there are insufficient data to recommend them as a first line therapeutic intervention. Due the possible risks of decreased ovarian reserve secondary to interruption of ovarian blood supply, salpingectomy should be done with minimal thermal injury and very close to the fallopian tube.

TREATMENT OF PROXIMAL TUBAL OCCLUSION — The incidence of true cornual occlusion is low and surgical treatment (ie, resection and anastomosis) is not highly successful.

Diagnosis — Hysterosalpingographic findings suggestive of cornual or proximal tubal occlusion must be interpreted with caution as sensitivity and specificity are only 65 and 83 percent, respectively [30]. In one study of resected tubes thought to be proximally occluded by hysterosalpingography and/or laparoscopy but later found to have normal histology, the etiologies of the false positive diagnosis were presumed to be amorphous debris or minimal adhesions (40 percent), extensive fibrosis or salpingitis isthmica nodosa (approximately 40 percent), and tubal spasm (20 percent) [31]. In addition, we reported that repeat hysterosalpingogram in 98 women with hysterosalpingographic findings of bilateral proximal tubal occlusion revealed bilateral tubal patency in 14 women and patency of one of the tubes in 12 others; true occlusion was encountered in 72 patients (74 percent) [32].

If the fallopian tubes are not visualized on hysterosalpingogram, a repeat procedure should be done to exclude the possibility of a random technical problem or tubal spasm. If the test remains abnormal, then selective tubal catheterization under fluoroscopic or hysteroscopic control is indicated to confirm the diagnosis and potentially open the tube (see below) [33].

Nonsurgical therapy — Selective tubal catheterization alone is successful in obtaining tubal patency in 60 to 80 percent of patients, with pregnancy rates of 20 to 60 percent [34,35]; however, most studies did not have a control group of nontreated patients. Approximately one-half of the pregnancies occur in the first 12 months after the procedure. Women with good tubal perfusion pressures had significantly higher pregnancy rates than those with medium or poor perfusion pressure [35].

Tubocornual anastomosis — Tubocornual anastomosis can be performed in women with true cornual obstruction. The cornual portion of the tube is resected followed by anastomosis [36]. Depending upon the extent and severity of tubal damage, intrauterine pregnancy rates range from 16 to 55 percent and ectopic pregnancy rates are 7 to 30 percent. Since this procedure is traditionally performed by laparotomy, rather than laparoscopically, and the intrauterine pregnancy rate is relatively low, in vitro fertilization (IVF) is often a better alternative. Tubocornual anastomosis can be performed by laparoscopy; however, the number of reported cases is small [37].

Summary — Selective tubal catheterization may achieve tubal patency and improve short-term pregnancy rates in women who appear to have proximal tubal occlusion by hysterosalpingography. In women with true cornual occlusion, IVF is likely to be more successful than tubocornual anastomosis.

TUBAL REANASTOMOSIS

Overview — Indications for tubal anastomosis include reversal of sterilization, midtubal block secondary to pathology, tubal occlusion from ectopic pregnancy, and salpingitis isthmica nodosa. The goal is to remove abnormal tissue and reapproximate the healthy tubal segments with as little adhesion formation as possible. The technique involves microsuturing using 6-0 to 10-0 sutures. Tubal patency is confirmed with subsequent hysterosalpingogram (image 1).

Sterilization reversal, although not always successful, is the most successful surgical reconstructive procedure for improving fertility. Factors that may influence the success rate of tubal reanastomosis include the age of the patient, time from sterilization, and sterilization technique. (See "Female interval permanent contraception: Procedures".)

In one large series, pregnancy rates after sterilization reversal among women aged 15 to 30 years, 30 to 33 years, and 34 to 49 years were 73, 64, and 46 percent, respectively [38]. Most pregnancies occurred within two years after reversal. Of interest, 23 percent of patients subsequently underwent another sterilization. In another series, tubal anastomosis resulted in live births in 41 percent of women with a previous electrocautery procedure, 50 percent of those who had a Pomeroy tubal ligation, 75 percent of women with rings, and 84 percent of those with clips [39].

In a retrospective cohort study of 163 patients, the cumulative delivery rate over 72 months was comparable in women who had undergone in vitro fertilization (IVF) versus those who had surgical sterilization reversal (52 versus 60 percent). The only significant difference in delivery rates was found in a subset of patients aged <37 years (52 percent after IVF and 72 percent after reversal). Surgery is associated with lower cost than IVF. Based on their findings, we could consider laparoscopic sterilization reversal in women younger than 37 years who have ≥4 cm of residual tube. For others, IVF is a better option [40].

Indeed, tubal length is another important factor in successful reversal. The pregnancy rate after tubal anastomosis is 75 percent in women with tubal length of 4 cm or more, but only 19 percent in those with shorter tubes [41].

Pregnancy rates after laparoscopic tubal anastomosis and conventional microsurgical anastomosis are equivalent, 80 to 81 percent 12 months after surgery [42]. Ectopic pregnancy rates are also similar at 2.5 to 2.8 percent. However, the laparoscopic approach is more economical: at our institution USD $861 for laparoscopic reconstruction versus $1348 with laparotomy [43]. The disadvantage of laparoscopic tubal anastomosis is that it is more demanding technically than an open microsurgical procedure.

Tubal reanastomosis can also be performed using robot-assisted laparoscopy. In preliminary studies, tubal reanastomosis using robot-assisted laparoscopy compared with conventional laparoscopy and minilaparotomy appears to have a similar success rate and a short recovery time, but longer operative times and higher costs [44,45]. Comparisons of conventional laparoscopy with minilaparotomy have found that the laparoscopic approach is effective and cost-efficient. Further study is needed to evaluate whether robotics facilitate a minimally invasive approach. (See 'Tubal reanastomosis' above.)

There are few comparative studies of robotic tubal reanastomosis. Existing studies are limited by a lack of data regarding the surgeon's level of experience with robotics, which may impact operative time.

Observational studies have compared robotic-assisted laparoscopy with minilaparotomy tubal reanastomosis and found that the two procedures were associated with similar intrauterine pregnancy rates at 9- to 10-month follow-up (27 to 74 percent) [44,45]; there was no consistent effect on the rate of ectopic pregnancy. Robotic procedures had significantly longer operative times (3.4 to 3.8 versus 2.6 to 3.0 hours); no differences in complication rates were reported. Women in the robotic group had a faster return to normal activities (11 versus 20 to 28 days).

Summary — We consider sterilization reversal in young women with more than 4 cm of residual tube and prior ring or clip sterilization. In other women, IVF may be a better option. We recommend a laparoscopic approach (for the usual advantages of laparoscopic surgery) if a surgeon experienced in laparoscopic tubal anastomosis is available. Otherwise, laparotomy can be performed with good results.

OVARIAN WEDGE RESECTION AND DRILLING — The first line of treatment for polycystic ovary syndrome (PCOS)-related anovulatory infertility is change in lifestyle and medical treatment using drugs such as clomiphene citrate, letrozole, gonadotropins, and metformin [46,47]. Laparoscopic ovarian drilling is a second-line option for normal-weight patients who do not respond to medical therapy and have no other causes of infertility. During drilling, multiple holes are made on the surface of the ovary, which results in a decrease in circulating androgen levels and resultant resumption of cyclic ovulation. Ovulation rates of 80 percent and pregnancy rates of 54 to 82 percent have been reported, although laparoscopic drilling has also been associated with a decreased live birth rate compared with ovulation induction [48,49]. Ovarian wedge resection is generally no longer performed because of the high rate of pelvic adhesions and risk of premature ovarian insufficiency following the procedure [46].

Detailed discussions of medical therapy and laparoscopic surgery for treatment of PCOS can be found separately. With the availability of in vitro fertilization and in vitro maturation treatments, surgery is rarely performed anymore.

●(See "Treatment of polycystic ovary syndrome in adults".)

●(See "Treatment of polycystic ovary syndrome in adults", section on 'Laparoscopic surgery'.)

LEIOMYOMA — Treatment of leiomyoma to enhance fertility in subfertile women is discussed separately.

LAPAROSCOPIC PRESERVATION OF FERTILITY — We perform laparoscopic surgery for preservation of ovarian function and fertility in young women at risk of premature ovarian failure, such as those undergoing chemotherapy or radiation therapy for malignancy [50]. Options for these women are discussed in detail separately. (See "Fertility and reproductive hormone preservation: Overview of care prior to gonadotoxic therapy or surgery".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Female infertility".)

SUMMARY AND RECOMMENDATIONS

●The role of diagnostic laparoscopy in the management of infertility is limited. However, it can be useful in the infertility evaluation of young individuals with a history of pelvic inflammatory disease, ectopic pregnancy, pelvic surgery, or chronic pelvic pain. If adhesions or endometriosis is found during diagnostic laparoscopy, then an operative laparoscopic procedure for improving fertility can be undertaken at the same time. If successful, one surgical procedure can lead to several pregnancies whereas in vitro fertilization (IVF) must be attempted each time pregnancy is desired. (See 'Diagnostic laparoscopy' above and 'Endometriosis' above and 'Treatment of distal tubal occlusion' above.)

●Diagnostic laparoscopy can be avoided in older individuals and those with multiple infertility factors. These women are better served by IVF, instead of a surgical approach to treatment, because IVF is more likely than surgery to be successful in women with bilateral tubal occlusion, older patients (due to the rapid decline in fertility with advancing age), and women with severe disease (eg, severe hydrosalpinx, extensive and dense adhesions, both proximal and distal tubal occlusion, endometriosis). (See 'Diagnostic laparoscopy' above and 'Endometriosis' above and 'Treatment of distal tubal occlusion' above.)

●Laparoscopic salpingectomy for hydrosalpinges is the preferred procedure for improving pregnancy rates in patients planning to undergo IVF. Alternatives, such as proximal tubal occlusion, salpingostomy, and antibiotic therapy, have been shown to be effective in small studies, but there are insufficient data to recommend them as a first-line therapeutic intervention. (See 'Salpingectomy before in vitro fertilization' above.)

●We perform tubal catheterization selectively in patients who appear to have proximal tubal occlusion demonstrated by hysterosalpingography. In individuals with true cornual occlusion, IVF is more likely to be effective than tubocornual anastomosis. (See 'Treatment of proximal tubal occlusion' above.)

●For patients who desire sterilization reversal, we perform the procedure in young patients with more than 4 cm of residual tube. In other women, IVF appears to be a better option. We use a laparoscopic approach (for the usual advantages of laparoscopic surgery) if a surgeon experienced in laparoscopic tubal anastomosis is available. Otherwise, laparotomy can be performed with good results. (See 'Tubal reanastomosis' above.)