Cirugía tubárica frente a reproducción asistida

Jaime Saavedra Saavedra

Resumen


Toda pareja infértil con factor tubo peritoneal comprometido debe ser estudiada en forma completa; esto incluye espermograma, niveles basales de FSH el día tres del ciclo, histerosalpingografía y laparoscopia diagnóstica.

Estos estudios son decisivos para determinar si la pareja se refiere al programa de cirugía tubárica reconstructiva o al programa de técnicas de reproducción asistida.

Las tasas acumulativas de embarazo en adhesiolisis de adherencias laxas (avasculares) están entre un 50 y un 60%; en adherencias extensas (densas y vasculares) es de 0%, por tanto estas pacientes deben ir a técnicas de reproducción asistida (FIV).

En el caso de fimosis tubárica, la fimbrioplastia por microcirugía presenta una tasa de embarazo del 60% frente a un 30% por laparoscopia, por tanto para el manejo de esta patología se recomienda la microcirugía.

Las tasas de embarazo en caso de hidrosalpinx con daño tubárico mínimo y limitado (presencia de pliegues mucosos en la histerosalpingografía y menos de dos centímetros de diámetro) están entre un 28% por microcirugía y un 24% por laparoscopia; en caso de daño tubárico severo se debe realizar FIV.

Las tasas de embarazo clínico después de FIV-TE en pacientes con factor tubárico varían entre un 30.8 y un 12.8%, dependiendo de la edad de la paciente, estas tasas son mejores en mujeres menores de 35 años y bajas en mujeres de 40 años y más.

Cuando se consideran las tasas acumulativas de embarazo después de cuatro ciclos de reproducción asistida frente a salpingoovariolisis, fimbrioplastia y salpingoneostomía, la primera da mejores resultados en todos los frentes. Sin embargo, podría ser un error pronosticar que la cirugía reconstructiva vaya a ser historia pronto. Si la cirugía es exitosa ésta ofrece la posibilidad de concebir en múltiples ciclos y lograr más embarazos en forma consecutiva.

El riesgo de embarazo múltiple es bajo después del tratamiento quirúrgico.

El factor económico también puede pesar en el momento de tomar una decisión.

Los resultados anteriores sugieren que las mujeres jóvenes, con factor tubo peritoneal leve o moderado, son candidatas primarias para la cirugía tubárica reconstructiva, mientras que mujeres mayores de 35 años o aquéllas con enfermedad severa o pelvis congelada se deben dirigir al programa de reproducción asistida.


Palabras clave


cirugía tubárica; adhesiolisis; fimbrioplastia; hidrosalpinx; reproducción asistida

Texto completo:

PDF

Referencias


Lilford RJ, Watson AJ. Has in vitro fertilization made salpingostomy obsolete? Br J Obstet Gynecol 1990;97:557-60.

Benadiva CA, Kligman I, Davis O, Rosenwaks Z. In vitro fertilization versus tubal surgery: is pelvic reconstructive surgery obsolete? Fertil Steril 1995;64:1051-61.

Speroff L, Glass RM, Kase NG. Female infertility. In: Clinical gynaecologic endocrinology and infertility, 5th Ed. Baltimore: Williams and Wilkins; 1994. p. 809-39.

Trimbos-Kemper T, Trimbos B, Van Hall E. Etiological factors in tubal infertility. Fertil Steril 1982;37:384-8.

Westron L. Incidence, prevalence and trends of acute pelvic inflammatory disease and its consequences in industrialized countries. Am J Obstet Gynecol 1980;138:880-92.

Urman B, Gomel V, McComb P, Lee N. Midtubal occlusion: aetiology, management and outcome. Fertil Steril 1992;57: 747-50.

Sulak PJ, Letterie GS, Coddington CC, Hayslip CC, Woodward JE, Klein TA. Histology of proximal tubal occlusion. Fertil Steril 1987;48:437-40.

Gomel V. Salpingoovariolisis by laparoscopy in infertility. Fertil Steril 1983;40:607-11.

Fayez JA. An assessment of the role of operative laparoscopy in tuboplastia. Fertil Steril 1983;39:476-9.

Bowman MC, Cook ID. Comparison of fallopian tube intraluminal pathology as assessed by salpingoscopy with pelvic adhesions. Fertil Steril 1994;61:464-9.

Tulandi T, Collins JA, Burrows E, Jarrel JF, Mc Innes RA, Wrixon W, Simpson CW. Treatment dependent and treatment independent pregnancy among women with periadnexal adhesions. Am J Obstet Gynecol 1990;162:354-7.

Frantzen C, Schlosser HW. Microsurgery and post infectious tubal infertility. Fertil Steril 1982;38:397-402.

Fayez JA, Suliman SO. Infertility surgery of the oviduct: comparison between macrosurgery and microsurgery. Fertil Steril 1982;37:73-8.

Donnez J, Casanas-Roux F. Prognostic factors of fimbrial microsurgery. Fertil Steril 1986;46:200-4.

Tulandi T. Salpingoovarilysis: a comparison between laser surgery and electrosurgery. Fertil Steril 1986;45:489-91.

Watson AJS, Gupta JK, O' Donovan P, Dalton ME, Lilford RJ. The results of tubal surgery in the treatment of infertility in two non-specialist hospital. Br J Obstet Gynecol 1990;97:561-8.

Marama R, Rizzi M, Muzii L, Catalano GF, Carvana P, Mancuso S. Correlation between the American Fertility Society Classifications of adhnexal adhesions and distal tubal occlusion, salpingoscopy and reproductive outcome in tubal surgery. Fertil Steril 1995;64:924-9.

Donnez J, Nisolle M, Casanas-Roux F. CO2 laser laparoscopy in infertility women with tubal occlusion. J Gynecol Surg 1989;5:47-53.

Siegler AM, Kontopoulos V. An analysis of macrosurgical and microsurgical techniques in the management of the tuboperitoneal factor in infertility 1979;32:377-82.

Caspi E, Halperin Y. Surgical management of periadnexal adhesions. Int J Fertil 1981;26:49-54.

Hulka JF. Adnexal adhesions: a prognostic staging and classification system based of five year survey of fertility surgery results at Chapel Hill, North Carolina. Am J Obstet Gynecol 1982;144:141-8.

Lavy G, Diamond MP, De Cherney AH. Ectopic pregnancy: its relationship to tubal reconstructive surgery. Fertil Steril 1987;47:543-56.

Dubuisson JB, Bouquet de Jolienere J, Aubriot FX, Darai E, Foulot H, Mandelbrot L. Terminal tuboplasties by laparoscopy: 65 consecutives cases. Fertil Steril 1990;54:401-3.

Gomel V. Salpingostomy by microsurgery. Fertil Steril 1978; 29:380-7.

Tulandi T, Farag R, Mcinnes RA. Reconstructive surgery for hidrosalpinx and without the carbon dioxide laser. Fertil Steril 1984;42:839-45.

Mage G, Bruhat MA. Pregnancy following salpingostomy: comparison between CO2 laser and electrosurgery procedures. Fertil Steril 1983;40:472-8.

Tulandi T, Bugnah M. Operative laparoscopy: surgical modalities. Fertil Steril 1995;63:237-45.

Rock JA, Katayana KP, Martin EJ. Factors influencing the success of salpingostomy techniques for distal fimbrial obstruction. Obstet Gynecol 1978;52:591-6.

Young PE, Egan JE, Barlow J. Reconstructive surgery for infertility at the Boston Hospital for women. Am J Obstet Gynecol 1970;108:1092-8.

Debruyne F, Puttemans P, Boeckx W. The clinical value of salpingoscopy in tubal infertility. Fertil Steril 1989;51:339-46.

Audibert F, Hedon B, Arnal F. Therapeutic strategies in tubal infertility with distal pathology. Hum Reprod 1991;6:1439-45.

Marana R, Quagliarello J. Distal tubal occlusion: microsurgery versus in vitro fertilization a review. Int J Fertil 1988;33: 107-14.

Novy MJ, Thurmond AS, Patton P. Diagnosis of cornual obstruction by transcervical fallopian tube cannulation. Fertil Steril 1986;46:21-7.

Kerin JF, Surrey ES, Williams DB, Daykhovsky L, Grundfest WS. Falloscopic observations of endotubal isthmic plugs as a causal of reversible obstruction and their histological characterization. J Laparoendosc Surg 1991;1:103-10.

Gomel V. Tubal reanastomosis by microsurgery. Fertil Steril 1977;28:59-65.

Lavy G, Diamond MP, DeCherney AH. Pregnancy following tubocornual anastomosis. Fertil Steril 1986;46:21-7.

Patton PE, William TJ, Coulan CB. Results of microsurgical reconstruction in patients with combined proximal and distal tubal occlusion: double obstruction. Fertil Steril 1987;48:670-7.

Henderson SR. The reversibility of female sterilization with the use of microsurgery: a report on 102 patients with more than one year of follow-up. Am J Obstet Gynecol 1984;149:57-64.

Rock JA, Bergquist CA, Zacur HA. Tubal anastomosis following unipolar cautery. Fertil Steril 1982;37:613-20.

Society For Assisted Reproductive Technology, The American Fertility Society: Assisted Reproductive Technology in the United States and Canada: 1993 results generates from The American Fertility Society /Society for Assisted Reproductive Technology Registry. Fertil Steril 1994;62:1121-31.

Olsner G, Tarlatzis BC. Radical surgery for extrauterine pregnancy. In: De Cherney AH, editorial. Ectopic Pregnancy. Rockville, MD: Aspen Publishers; 1986. p. 127-32.

Bruhat MA, Manhes H, Mage G. Treatment of ectopic pregnancy by means of laparoscopy. Fertil Steril 1980;33:411-6.

Saavedra JS, Navarro NH, Díaz C. Embarazo ectópico: manejo ambulatorio. Rev Colomb Obstet Ginecol 2001;52:79-85.

Registro Latinoamericano de Reproducción Asistida. En: Zegers F, Gadalmes V, Balmaceda J. Ciclos de tratamiento y embarazo clínico según tipo de procedimiento; 1999.

Tietze C. Reproductive span and rate reproduction among Hutterite women. Fertil Steril 1957;8:59-64.

Menken J, Trussell J, Larsen U. Age and infertility. Science 1986;233:1389-95.

Sherman BM, Korenman SG. Hormonal characteristics of human menstrual cycle throughout reproductive life. J Clin Invest 1975;55:699-705.

Lenton EA, Dekretser DM, Woodward AJ. Inhibin concentrations throughout the menstrual cycle of normal, infertile and older women compared with those during spontaneous conceptions cycles. J Clin Endocrinol Metab 1991;73:1180-6.

Sharma V, Riddle A, Mason BA. An analysis of a clinical pregnancy in an ultrasound based ambulatory in vitro fertilization program. Fertil Steril 1988;49:468-74.

Piette C, De Mouzon J, Buchelot A. In vitro fertilization: influence of women's age on pregnancy rates. Hum Reprod 1990;5:56-62.

Romeu A, Muasher SJ, Acosta AA. Results of in vitro fertilization attempts in women 40 years of age and older: The Norfolk experience. Fertil Steril 1987;47:130-7.

Navot D, Rosenwaks Z, Margalioth EJ. Prognostic assessment of female fecundity. Lancet 1987;19:645-51.

Toner JP, Philput CB, Jones GS, Muasher SJ. Basal follicle stimulating hormone levels is a better predictor of in vitro fertilization performance than age. Fertil Steril 1991;55:784-91.

Muasher SJ, Oehninger S, Simonetti S. The value of basal and/or stimulated serum gonadotropin levels in the prediction of stimulation response and in vitro fertilization outcome. Fertil Steril 1988;50:298-307.

Fanchin R. De Ziegler D, Olivennes. Exogenous follicle stimulant hormone ovarian reserve test (Efort): a simple a reliable screening test for detecting poor responders in vitro fertilization. Hum Reprod 1994;9:1607-11.

Scott RT Jr. Evaluation and treatment of low responders. Semin Reprod Endocrinol 1996;14:317-37.

Scott RT, Leonardi MR, Hoffman GE. Prospective evaluation of clomiphene citrate challenge test screening in the general infertility population. Obstet Gynecol 1993;82:539-45.

Seifer DB, Lambert-Messerlian G, Hogan JW, Gardiner AC, Blazar AS, Berk CA. Day 3 serum inhibin-B is predictive of assisted reproductive technologies outcome. Fertil Steril 1997;67:110-4.

Balash J, Creus M, Fabregues F, Carmona F. Inhibin, follicle stimulant hormone, and age as predictors of ovarian response in invitro fertilization cycles stimulated with gonadotropin- realizing hormone agonist-gonadotropin treatment. Am J Obstet Gynecol 1996;175:1226-30.

Loumaye E, Billion JM, Mine JM. Prediction of individual response to controlled ovarian hyperestimulation by means of clomiphene citrate challenge test. Fertil Steril 1990;53:295-301.

Levy T, Limor R, Villa Y, Eshel A, Eckstein N, Vagman I, Lidor A, Ayalon D. Another look at co-treatment with growth hormone and human menopausal gonadotropins in poor ovarian responders. Hum Reprod 1993;6:834-49.

Battaglia DE, Goodwing P, Klein NA, Soules MR. Influence of maternal age on meiotic spindle assembly in oocytes from naturally cycling women. Hum Reprod 1996;11:2217-22.

Benadiva AC, Kleigman I, Rosenwaks Z. Assisted reproductive technology versus tubal surgery. In: Sanfilipo JS, Levine RL, editor. Operative gynaecology endoscopy; 1989. p. 278-305.

Navot D, Bergh PA, Williams MA. Poor oocyte quality rather than implantation failure is a cause of age related decline in female infertility. Lancet 1991;337:1375-81.

Munne S, Alikani M, Tomkin G. Embryo morphology, developmental rates and maternal age are correlated with chromosome abnormalities. Fertil Steril 1995;64:382-9.

Padilla SL, García JE. Effect of maternal age and number of in vitro fertilization procedures on pregnancy outcome. Fertil Steril 1989;52:270-6.

Mage G, Pouly JL, Bouquet de Joliniere J, Chabrand J, Riouallon A, Bruhat MA. A preoperative classification to predict the intrauterine and ectopic pregnancy rates after distal tubal microsurgery. Fertil Steril 1986;46:807-10.

Dubuisson JB, Chapron C, Morice P, Aubriot FX, Foulot H, Bouquet de Joliniere J. Laparoscopic salpinguectomy fertility results according to the tubal mucosal appearance. Hum Reprod 1994;9:334-9.

Singhal V, Li TC, Cooke ID. An analysis of factors that influencing the outcome of 232 consecutives tubal microsurgery cases. Br J Obstet Gynaecol 1991;98:628-36.

Meyer WR, Beyler SA. Deleterious effects of hidrosalpingues on in vitro fertilization and endometrial integrin expression. Assist Reprod Rev 1995;5:201-3.


comments powered by Disqus

Métricas de artículo

Cargando métricas ...

Metrics powered by PLOS ALM




Copyright (c) 2016 Revista Colombiana de Obstetricia y Ginecología

Licencia de Creative Commons
Este obra está bajo una licencia de Creative Commons Reconocimiento-NoComercial-SinObraDerivada 4.0 Internacional.

ISSN Impreso       0034-7434 

ISSN Electrónico   2463-0225

https://doi.org/10.18597/issn.0034-7434