Laparoscopy or laparotomy for distal tubal surgery? A meta-analysis

Of couples with subfertility, 25% have complete or partial blockage of the fallopian tube. Since the advent of in vitro fertilization (IVF), the role of tubal surgery has diminished. However, this type of surgery continues to be undertaken on selected patients with mild tubal disease, and in those with severe tubal disease, in centres where IVF is not available. This systematic review was undertaken to compare pregnancy outcomes after laparoscopic surgery with that of open microsurgical technique. Studies comparing laparoscopic techniques with conventional microsurgery requiring laparotomy for treatment of distal tubal disease were included. The relevant trials were identified from Cochrane Menstrual Disorders and Subfertility Groups of Specialised Register of Controlled Trials (searched up to July 2005). The following strategies were adapted using the OVID platform, MEDLINE (1966 to July 2005), Cochrane Central Register of Control Trials, CENTRAL, and EMBASE (1980 to July 2005). Outcomes analysed were: 'take home baby' rate, intrauterine pregnancy rate and ectopic pregnancy rate per pregnancy. Subgroup analysis was carried out to compare intrauterine pregnancy rate in the laparoscopy and conventional microsurgery groups according to the extent of tubal damage. Six relevant studies were identified. Overall, no significant difference was observed in the intrauterine pregnancy rate between the two groups, combined OR 1.32 (95% confidence interval [CI], 0.58 - 3.02). For patients with mild tubal disease, there was no significant difference in the intrauterine pregnancy rate between treatment and control group, OR 1.06 (95% CI, 0.42 - 2.70). For patients with severe tubal disease, there was a significantly increased intrauterine pregnancy rate in the laparotomy group, OR 0.34 (95% CI, 0.14 - 0.86). Appropriate patient selection is the main factor affecting outcome in terms of fertility. These data do not indicate a significant difference in pregnancy rates between open and laparoscopic techniques for lesser degrees of tubal damage. Other factors, such as costs and hospital stay, will come into the decision making, and are likely to favour laparoscopic techniques. If a decision is made to open the badly damaged tubes of a patient, then an open microsurgical technique should be employed.