In vitro fertilisation (IVF) should be considered to be the first-line treatment for moderate, severe and bilateral tubal disease. However, a systematic review has concluded that laparoscopic salpingectomy should be considered in all women with hydrosalpinges prior to IVF (evidence level 1b).
IVF or surgery?
Three economic studies suggest that patient selection and number of IVF cycles are the most important factors. By reserving tubal surgery for women with low-grade disease and reversal of clip sterilisation, the number of operations can be reduced, repeated attempts at conception are allowed and good livebirth rates can be achieved.
Life table analysis shows a significant increase in the rate of deliveries (72%) after three-to-five cycles of IVF compared with 24% overall, following tubal surgery. This must be balanced against the risks of ovarian hyperstimulation, multiple pregnancy, and the fact that, at present, the majority of British women have only one cycle of IVF.
Both surgery and IVF should be discussed without bias, bearing in mind that no randomised controlled comparison of the two exists. Prognosis should be individualised, taking into account local experience and outcomes.