Jurnal

Cochrane Database of Systematic Reviews
Surgery for tubal infertility (Review)
Chua SJ, Akande VA, Mol BWJ
Chua SJ, Akande VA, Mol BWJ.

Surgery for tubal infertility.
Cochrane Database of Systematic Reviews 2017, Issue 1. Art. No.: CD006415.
DOI: 10.1002/14651858.CD006415.pub3.
www.cochranelibrary.com
Surgery for tubal infertility (Review)

Copyright © 2017 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Figure 1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
WHAT’S NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
DIFFERENCES BETWEEN PROTOCOL AND REVIEW . . . . . . . . . . . . . . . . . . . . . 34
INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Surgery for tubal infertility (Review) i

[Intervention Review]
Surgery for tubal infertility
Su Jen Chua1 , Valentine A Akande2 , Ben Willem J Mol3

1
The University of Adelaide, Adelaide, Australia. 2 Obstetrics & Gynaecology, Directorate of Women’s Health, Southmead Hospital,
Bristol, UK. 3 Discipline of Obstetrics and Gynaecology, School of Medicine, Robinson Research Institute, The University of Adelaide,
Adelaide, Australia
Contact address: Ben Willem J Mol, Discipline of Obstetrics and Gynaecology, School of Medicine, Robinson Research Institute,
The University of Adelaide, Level 3, Medical School South Building, Frome Road, Adelaide, South Australia, SA 5005, Australia.
ben.mol@adelaide.edu.au.
Editorial group: Cochrane Gynaecology and Fertility Group.

Publication status and date: New search for studies and content updated (no change to conclusions), published in Issue 1, 2017.
Citation: Chua SJ, Akande VA, Mol BWJ. Surgery for tubal infertility. Cochrane Database of Systematic Reviews 2017, Issue 1. Art.
No.: CD006415. DOI: 10.1002/14651858.CD006415.pub3.
ABSTRACT
Background
Surgery remains an acceptable treatment modality for tubal infertility despite the rise in usage of in vitro fertilisation (IVF). Estimated
livebirth rates after surgery range from 9% for women with severe tubal disease to 69% for those with mild disease; however, the
effectiveness of surgery has not been rigorously evaluated in comparison with other treatments such as IVF and expectant management
(no treatment). Livebirth rates have not been adequately assessed in relation to the severity of tubal damage. It is important to determine
the effectiveness of surgery against other treatment options in women with tubal infertility because of concerns about adverse outcomes,
intraoperative complications and costs associated with tubal surgery, as well as alternative treatments, mainly IVF.
Objectives
The aim of this review was to determine the effectiveness and safety of surgery compared with expectant management or IVF in
improving the probability of livebirth in the context of tubal infertility (regardless of grade of severity).
Search methods
We searched the following databases in October 2016: the Cochrane Gynaecology and Fertility (CGF) Group trials register, the
Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health
Literature (CINAHL) and PsycINFO; as well as clinical trials registries, sources of unpublished literature and reference lists of included
trials and related systematic reviews.
Selection criteria
We considered only randomised controlled trials to be eligible for inclusion, with livebirth rate per participant as the primary outcome
of interest.
Data collection and analysis
We planned that two review authors would independently assess trial eligibility and risk of bias and would extract study data. The
primary review outcome was cumulative livebirth rate. Pregnancy rate and adverse outcomes, including miscarriage rate, rate of ectopic
pregnancy and rate of procedure-related complications, were secondary outcomes. We planned to combine data to calculate pooled
odds ratios (ORs) and 95% confidence intervals (CIs). We planned to assess statistical heterogeneity using the I2 statistic and to assess
the overall quality of evidence for the main comparisons using GRADE methods.
Surgery for tubal infertility (Review) 1
Main results
We identified no suitable randomised controlled trials.
Authors’ conclusions
The effectiveness of tubal surgery relative to expectant management and IVF in terms of livebirth rates for women with tubal infertility
remains unknown. Large trials with adequate power are warranted to establish the effectiveness of surgery in these women. Future
trials should not only report livebirth rates per patient but should compare adverse effects and costs of treatment over a longer time.
Factors that have a major effect on these outcomes, such as fertility treatment, female partner’s age, duration of infertility and previous
pregnancy history, should be considered. Researchers should report livebirth rates in relation to severity of tubal damage and different
techniques used for tubal repair, including microsurgery and laparoscopic methods.
PLAIN LANGUAGE SUMMARY
Surgery versus IVF or expectant management for women with tubal infertility
Review question
Cochrane review authors investigated the effectiveness of fallopian tube surgery compared with in vitro fertilisation (IVF) or expectant
management in overcoming infertility caused by tubal disease.
Background
Tubal surgery to overcome infertility caused by tubal disease is becoming popular, in part because of risks and costs related to IVF,
which offers another option for overcoming tubal infertility. Benefits obtained from tubal surgery would potentially be sustained over
multiple cycles and many years, even resulting in multiple livebirths. However, tubal surgery is expensive, as it requires additional
specialist training and experience among gynaecologists who perform the procedure, and it can involve adverse effects (including ectopic
pregnancies) and operative risks. The effectiveness of tubal surgery in comparison with no treatment (expectant management) or IVF
in women with tubal infertility is unknown.
Study characteristics
This review identified no suitable trials. Our literature searches are current to October 2016.
Key results
No randomised evidence is currently available. Research is needed to obtain information about adverse outcomes and costs.
BACKGROUND classification (2002) is a simple classification system that separates

infertile women into three categories according to severity of tubal
damage, namely, mild/grade I, moderate/grade II and severe/grade
III (Akande 2004). This system is defined in the section on in-
Description of the condition clusion criteria. Diagnosis is confirmed by hysterosalpingography
Tubal disease of the fallopian tubes is responsible for 25% to 35% (HSG) or laparoscopy.
of cases of female infertility (Serafini 1989). Tubal disease can in-
volve the proximal, distal or entire tube and varies in severity. Pelvic
inflammatory disease is the most common cause of tubal disease,
representing more than 50% of cases, and may affect the fallop-
Description of the intervention
ian tube at multiple sites (Honore 1999). The Hull & Rutherford Treatment options include surgical tubal repair, expectant man-
agement (i.e. waiting/no specific intervention) and in vitro fertil- Tubal infertility remains a major indication for IVF, which com-
isation (IVF). The effectiveness of these treatments has not been pletely bypasses tubal blockage and offers an 18% to 29% live-
tested rigorously in the context of randomised controlled trials birth rate per cycle (AIHW 2012; SART 2014). As IVF involves
(RCTs). manual fertilisation outside the normal reproductive system, it is
expensive, invasive and not available to all infertile patients. IVF
is associated with several potential complications, including mul-
Surgery tiple births and foetal anomalies (ASRM 2015; El-Chaar 2009).
Despite operative risks (general anaesthetic, intraoperative and Ovarian hyperstimulation syndrome (OHSS) is a potentially life-
postoperative) and a high postoperative incidence of ectopic preg- threatening adverse effect of ovulation induction. The intravascu-
nancy, surgery for tubal infertility is considered an effective treat- lar depletion associated with OHSS can lead to dehydration, hy-
ment option. Procedures such as salpingostomy (formation of an povolaemia (low volume of fluid in veins), electrolyte disturbances
opening into a uterine tube for the purpose of drainage) or fim- and thrombosis due to haemoconcentration. In IVF cycles, the
brioplasty (breaking of scar tissue around the distal end of the rate of severe OHSS requiring hospitalisation is less than 0.01%
tube) are widely performed for distal tubal obstruction. Surgery is (AIHW 2012; HFEA 2015). This figure increases with the num-
considered a viable treatment option for women with mild tubal ber of oocytes retrieved at each cycle, reaching 4.0% when more
disease, and for severe disease, laparoscopic salpingectomy before than 20 oocytes have been retrieved (AIHW 2012; HFEA 2015).
IVF has a role in improving livebirth rates among women with Older women have been shown to have poor success rates, and
hydrosalpinges (ASRM 2015; Johnson 2010; NICE 2004). increased recognition of factors such as parity (number of children
Tubal ectopic pregnancy - pregnancy in the fallopian tubes - is to whom a patient has given birth), duration of infertility, coex-
a potential adverse effect of tubal surgery. A large retrospective isting infertility factors and local IVF success rates can influence
regional study from Denmark of 236 women who underwent outcomes (AIHW 2012; SART 2014).
tubal surgery or adhesiolysis (a procedure performed to remove
scar tissue around the tube) reported an ectopic pregnancy rate of
16% (Mosgaard 1996). Higher ectopic pregnancy rates have been
How the intervention might work
associated with increasing severity of tubal damage (Akande 2004).
Compared with the 2% incidence of ectopic pregnancy reported
in the general population, rates of ectopic pregnancy after surgical
correction of tubal abnormalities are reported to be 1% to 10% Surgery
in mild tubal disease, up to 40% in severe pathology and 2.1% The largest case series to date reported an impressive intrauter-
to 11% when IVF is performed in patients with tubal infertility ine pregnancy rate of 72.8% (2369/3254) for terminal salpingo-
(Schippert 2012). neostomy and salpingo-ovariolysis performed in patients with
tubo-peritoneal infertility (Ponomarev 2009). However, the time
period over which the pregnancy rate was measured was not men-
Expectant management
tioned in the study publication, which was provided in the form of
Pregnancies do occur without treatment in women with a diag- a conference abstract. A recent meta-analysis combining 22 obser-
nosis of tubal blockage (Collins 1983; Evers 1998; NICE 2004; vational studies of women (N = 2810) undergoing salpingostomy
Wiedemann 1996). It has been suggested that this could be the for hydrosalpinges revealed a cumulative pregnancy rate of 20.0%
result of beneficial effects of diagnostic tests required to establish (95% confidence interval (CI) 17.5% to 22.8%) at one year and
infertility and the therapeutic value of counselling provided dur- 25.5% (95% CI 22.2% to 29.4%) at two years (Chu 2015). Al-
ing outpatient visits (Collins 1983). In addition, chance inclusion though surgical techniques, participant characteristics and dura-
of normal couples (i.e. those at the boundaries of normal refer- tion of follow-up were heterogeneous, study authors cited these as
ence ranges of fertility) with infertile couples during clinical stud- reasons for generalisability.
ies may be contributory. It is likely that “post hoc ergo propter The second largest case series to date (N = 1669), which strati-
hoc” (i.e. the temporal association between event A and event B fied participants according to severity of tubal disease, reported
immediately implies causation of event B by event A) does not favourable pregnancy outcomes of 55% to 80% for those with
apply for some types of infertility, as the widely held assumption mild tubal disease, including prior tubal ligation (n = 1517), and
that infertile women serve as their own controls and hence any poor pregnancy outcomes of 10% for participants with severe dis-
pregnancy after treatment can be attributed to said treatment may ease (e.g. concurrent proximal and distal lesions, extended dense
not hold true. adhesions, sclerohypertrophic tube, intra-ampullary adhesions) (n
= 152) at a minimum of two years of follow-up (Tran 2010). How-
ever, the significance of these positive results is limited by the risk
IVF of bias inherent to retrospective case series.

Expectant management The aim of this review was to determine the effectiveness and
A retrospective analysis of 109 women with proximal tubal occlu- safety of surgery compared with expectant management or IVF
sion reported a spontaneous pregnancy rate of 10% per patient in improving the probability of livebirth in the context of tubal
and 1.6% per month (Wiedemann 1996). This study showed that infertility (regardless of grade of severity).
when assisted reproductive technology - in particular, gamete in-
trafallopian transfer (GIFT) - was used as a subsequent treatment,
the pregnancy rate was increased to 50%. A retrospective cohort METHODS
study of 562 couples with tubal factor infertility who were on the
waiting list for IVF found that the 12-month cumulative spon-
taneous pregnancy rate was only 2.4% (95% CI 1.2% to 3.9%).
More than 75% of these pregnancies occurred during the first Criteria for considering studies for this review
three months on the waiting list (Evers 1998). Another study fol-
lowed 1145 couples with infertility and noted that 61% (26/43)
of conceptions among patients with infertility of tubal origin were Types of studies
treatment independent, defined as pregnancies that occur after no
treatment, three months after medical management or 12 months We included published and unpublished randomised controlled
after surgical management, respectively. Of note, a significant per- trials (RCTs) comparing the clinical effectiveness of tubal surgery
centage of non-treated infertile couples also conceived - 35% (191/ versus expectant management or IVF. We included cross-over trials
548). However, subgroup analysis revealed that pregnancies unre- if pre-cross-over data were available.
lated to treatment were less likely to occur in women with bilat-
eral tubal occlusion (0%; 0/5) than in women with other less se-
vere tubal lesions (68%; 26/38), further emphasising the need for Types of participants
comparative studies stratifying participants according to severity
of disease (Collins 1983).
Inclusion criteria
IVF Participants were required to meet all the criteria listed below.
1. Subfertile couples with infertility of at least one year’s
Analysis of cumulative data showed that women with tubal factor,
duration.
both with and without other coexisting infertility factors, had a
2. Women younger than 40 years of age.
pregnancy rate in excess of 70% after four cycles of IVF and em-
3. Women with minor/grade I, moderate/grade II or severe/
bryo transfer (Benadiva 1995). A meta-analysis of 14 retrospective
grade III tubal damage confirmed before tubal surgery by
studies compared pregnancy rates in women with tubal infertility
hysterosalpingography (HSG) or laparoscopy.
with and without hydrosalpinx (accumulation of watery fluid in
4. Women who had undergone tubal surgery for minor/grade
the tube as a consequence of distal obstruction) and revealed the
I, moderate/grade II or severe/grade III tubal damage after
pregnancy rate to be 31.2% for the 4588 women without hydros-
investigation.
alpinx who underwent IVF (Camus 1999). Most of the studies
According to the Hull & Rutherford 2002 classification of tubal
included in this meta-analysis did not specify the number of IVF
damage (Akande 2004), minor/grade I tubal damage is defined as:
cycles completed.
1. tubal fibrosis absent even if tube occluded (proximally);
2. tubal distension absent even if tube occluded (distally);
3. mucosal appearances favourable; and
Why it is important to do this review
4. flimsy adhesions (peritubal-ovarian).
Considerable uncertainty remains about whether surgical treat- Moderate/grade II tubal damage is defined as:
ment is superior to expectant management and IVF in women 1. unilateral severe tubal damage;
with tubal factor infertility. Surgery is still commonly performed, 2. contralateral minor disease present or absent; and
especially in areas where reimbursement for IVF is not available. 3. ’limited’ dense adhesions of tubes and/or ovaries.
This systematic review evaluated the effectiveness and safety of Severe/grade III tubal damage is defined as:
surgery in comparison with other available treatments for women 1. bilateral tubal damage;
with tubal infertility. 2. extensive tubal fibrosis;
3. tubal distension greater than 1.5 cm;
4. abnormal mucosal appearance;
5. bipolar occlusion; and
OBJECTIVES 6. ’extensive’ dense adhesions.

Exclusion criteria 4. Ectopic pregnancy rate per participant.
1. Women 40 years of age or older. 5. Multiple pregnancy rate per participant (demonstration of
2. Women with multiple or other causes of infertility such as more than one sac with foetal pole on ultrasonographic scan
ovulatory or sperm dysfunction. defines multiple pregnancy).
3. Women who had undergone tubal sterilisation. 6. Incidence of OHSS per participant.
When trials included couples with infertility of various categories,
we included only couples with tubal infertility. We excluded par-
ticipants with other causes of infertility because their inclusion
Search methods for identification of studies
could have confounded outcomes. When we had doubt about the
definitions of various grades of tubal infertility, we requested more We searched for all published and unpublished RCTs comparing
information from study authors. If extraction of data is not possi- tubal surgery versus expectant management or IVF, without lan-
ble for any reason, we will exclude that trial and will state the rea- guage restriction, and in consultation with the Gynaecology and
son for exclusion. We will include in the review trials that cannot Fertility Group (CGF) Information Specialist.
be included in the meta-analysis owing to insufficient data.
Electronic searches
Types of interventions
We searched the following databases.
Included studies performed one or more comparisons of effective- 1. Gynaecology and Fertility Group (CGFG) Specialised
ness of tubal surgery versus expectant management, or of tubal Register of Controlled Trials Procite (searched 19 October 2016)
surgery versus IVF. We considered a variety of techniques for tubal (Appendix 1).
surgery to be eligible, including microsurgery or macrosurgery, la- 2. Central Register of Controlled Trials (CENTRAL) Ovid
paroscopy and minilaparotomy or laparotomy. No treatment for (searched 19 October 2016) (Appendix 2).
infertility was administered to couples undergoing expectant man- 3. MEDLINE Ovid (1946 to 19 October 2016) (Appendix 3).
agement. For women undergoing IVF, a standard IVF procedure 4. Embase Ovid (1974 to 19 October 2016) (Appendix 4).
was carried out according to standard protocols for controlled 5. PsycINFO Ovid (1806 to 19 October 2016) (Appendix 5).
ovarian stimulation, oocyte retrieval under ultrasound guidance, 6. Cumulative Index to Nursing and Allied Health Literature
insemination, embryo culture and transcervical replacement of (CINAHL) EBSCO (1982 to 19 October 2016) (Appendix 6).
embryos, most often between pro-nucleate and eight-cell stages. 7. Database of Abstracts of Reviews of Effects (DARE) in the
Embryo transfer up to the blastocyst stage and frozen replacement Cochrane Library (for reference lists from relevant non-
cycles were eligible for inclusion. Cochrane reviews) (searched 17 August 2015) (Appendix 7).
8. Trial registries for ongoing and registered trials.
i) http://www.clinicaltrials.gov (a service of the US
Types of outcome measures
National Institutes of Health) (searched 24 November 2016)
(Appendix 8).
ii) http://www.who.int/trialsearch/Default.aspx (World
Primary outcomes Health Organization International Trials Registry Platform
1. Cumulative livebirth rate per couple, where cumulative search portal) (searched 24 November 2016) (Appendix 9).
refers to time-specific or cycle-specific rates over a given time or 9. Web of Science (searched 24 November 2016) (Appendix
number of cycles, and livebirth is defined as the delivery of one or 10).
more living infants after 20 completed weeks of gestational age. 10. OpenGrey (unpublished literature from Europe) (searched
24 November 2016) (Appendix 11).
11. Latin American Caribbean Health Sciences Literature
Secondary outcomes (LILACS, trials from the Portuguese and Spanish speaking
1. Cumulative pregnancy rate per participant/couple world) (searched 24 November 2016) (Appendix 12).
(evidence of a gestational sac, confirmed on ultrasonography, 12. PubMed and Google Scholar (for recent trials not yet
defines clinical pregnancy). indexed in MEDLINE) (searched 24 November 2016)
2. Pregnancy rate per participant/couple (evidence of clinical (Appendix 13; Appendix 14).
pregnancy - evidence of a gestational sac, confirmed on 13. ProQuest Dissertations & Theses Global (searched 17
ultrasonography), including ectopic pregnancy, although August to 24 November 2016) (Appendix 15).
multiple gestational sacs in one individual count as one clinical We combined the MEDLINE search with the Cochrane highly
pregnancy). sensitive search strategy, which appears in the Cochrane Handbook
3. Livebirth rate per cycle commenced. of Systematic Reviews of Interventions (Version 5.0.2, Chapter 6,

6.4.11) (Higgins 2011), to identify randomised trials. We com- Data collection and analysis
bined the Embase, PsycINFO and CINAHL searches with trial
filters developed by the Scottish Intercollegiate Guidelines Net-
work (SIGN).
We designed a new search strategy that differed from the strategy
used in the previous version of this review, necessitating database Selection of studies
searches covering inception up to October 2015. All searches were
current to 19 October 2016. We planned that two review authors (SC and BM) would inde-
pendently undertake selection of studies after an initial screen of
titles and abstracts retrieved (by SC), employing the search strat-
Searching other resources egy outlined above. We planned that study investigators would
We searched reference lists of articles retrieved by the search, along be contacted, as required, to clarify study eligibility. We resolved
with conference abstracts not covered in the CGFG register, in discrepancies by discussion. Review authors identified no RCTs
liaison with the Information Specialist (Appendix 16). We com- via the search strategy. We documented the selection process on a
municated with trial authors and experts in the field regarding PRISMA (Preferred Reporting Items for Systematic Reviews and
additional trials. Meta-Analyses) flow chart (see Figure 1).

Figure 1. PRISMA study flow diagram.

Unit of analysis issues
Data extraction and management
We planned that the primary analysis would be randomised per
We planned that two review authors (SC and BM) would inde- woman, and we planned to include per pregnancy data for some
pendently extract data from eligible studies and would resolve dis- outcomes (e.g. miscarriage). We would briefly summarise in an
agreements by discussion or by consultation with the third review additional table data that did not allow valid analysis (e.g. “per cy-
author. Data extracted would include study characteristics and cle” data) and would not perform meta-analysis. We would count
outcome data (see data extraction form for details; Appendix 18). multiple livebirths (e.g. twins, triplets) as one livebirth event and
We would collate studies involving multiple publications in such a would include only first-phase data obtained from cross-over tri-
way that each study, with its unique study identifier and multiple als.
references, rather than each report, would be considered a single
unit of interest in the review.
We planned to extract the following data from studies selected for
Dealing with missing data
inclusion in the review.
1. Trial characteristics. We planned to analyse the data on an intention-to-treat basis as far
2. Characteristics of study participants. as possible, and to attempt to obtain missing data from the origi-
3. Outcomes. nal trialists. When these data could not be obtained, we planned
4. Analysis. to undertake imputation of individual values for the primary out-
come only. We planned to assume that livebirths did not occur in
participants without a reported outcome. For other outcomes, we
planned to analyse only available data. We would perform sensi-
Assessment of risk of bias in included studies tivity analysis of any imputation undertaken (see below).
We planned that two review authors (SC and BM) would indepen-
dently assess included studies for risk of bias using the Cochrane
risk of bias assessment tool (www.cochrane-handbook.org) to as- Assessment of heterogeneity
sess selection (random sequence generation and allocation con- We planned to consider whether clinical and methodological char-
cealment), performance (blinding of participants and personnel), acteristics of the included studies were sufficiently similar for
detection (blinding of outcome assessors), attrition (incomplete meta-analysis to provide a clinically meaningful summary. We
outcome data), reporting (selective reporting) and other bias. We would have assessed statistical heterogeneity by using the I2 statis-
planned to resolve disagreements by discussion with the third re- tic (I2 greater than 50% would indicate substantial heterogeneity)
view author. We described all judgements fully and presented our (Higgins 2003; Higgins 2011).
conclusions in the risk of bias table.
We planned to search for within-trial selective reporting when ob-
vious outcomes were not reported or were not reported in insuffi- Assessment of reporting biases
cient detail to allow inclusion and to seek published protocols for
comparison with the final published study. In view of the difficulty of detecting and correcting for publication
bias and other reporting biases, review authors planned to min-
imise their potential impact by ensuring a comprehensive search
for eligible studies and by staying alert for duplication of data.
Measures of treatment effect If we included 10 or more studies in an analysis, we planned to
use a funnel plot to explore the possibility of small study effects
For dichotomous data (e.g. livebirth rates), we planned to use
(the tendency for estimates of the intervention effect to be more
numbers of events in the control and intervention groups of each
beneficial in smaller studies).
study to calculate Peto odds ratios (ORs). We planned to present
95% confidence intervals for all outcomes. When data needed to
calculate ORs were not available, we planned to utilise the most
detailed numerical data available that might facilitate similar anal- Data synthesis
yses of included studies (e.g. test statistics, P values). We planned If studies were sufficiently similar, we planned to combine the data
to assess whether estimates calculated in the review for individual using a fixed-effect model for the following comparisons.
studies were compatible in each case with estimates reported in 1. Tubal surgery versus expectant management.
study publications. 2. Tubal surgery versus IVF.

Subgroup analysis and investigation of heterogeneity Ongoing studies
We planned no subgroup analyses. We found no currently ongoing studies undertaken to compare
the effectiveness of tubal surgery versus expectant management or
IVF.
Sensitivity analysis
We planned to conduct sensitivity analyses for the primary out-
come to determine whether conclusions were robust to arbitrary Risk of bias in included studies
decisions made regarding eligibility and analysis. These analyses
We identified no RCTs for inclusion in the review, so we could
were to include consideration of whether review conclusions would
perform no assessment of methodological quality.
have differed if:
• eligibility were restricted to studies without high risk of bias;
• a random-effects model had been adopted;
• alternative imputation strategies had been implemented; or Effects of interventions
• the summary effect measure was relative risk rather than We found no RCTs that compared surgery versus expectant man-
odds ratio. agement or IVF in women with tubal infertility; therefore, we
cannot report study data.
Overall quality of the body of evidence - ’Summary of

findings’ table
We planned to prepare a ’Summary of findings’ table using DISCUSSION
GRADEpro software (GRADEpro GDT 2014). This table would
have evaluated the overall quality of the body of evidence for the
main review outcomes (livebirth rate and pregnancy rate) accord-
Summary of main results
ing to GRADE criteria (study limitations (i.e. risk of bias), con-
sistency of effect, imprecision, indirectness and publication bias). This review shows that evidence on this topic has not been pro-
We would have justified judgements about evidence quality (high, vided by randomised controlled trials (RCTs).
moderate or low) and would have documented and incorporated
these into reporting of results for each outcome. Two review au-
thors (SC and BM) would have made judgements independently Overall completeness and applicability of
as needed. evidence
No evidence was available. Despite potential risks of surgery,
such as possibly increased risk of ectopic pregnancy, and despite
widespread availability of in vitro fertilisation (IVF), surgical treat-
RESULTS ment remains a popular option. This is reflected by recent epi-
demiological data on fertility services indicating that although the
Description of studies ratio of IVF services to tubal surgery favours IVF, actual prevalence
of tubal surgeries performed has remained static. In the United
We identified no eligible trials for inclusion.
States, 3.2% of women 25 to 44 years of age with fertility prob-
lems have ever used reproductive surgery, and 3.1% have used IVF
Results of the search (Chandra 2014).
We included no RCTs.
Potential biases in the review process

Excluded studies As this systematic review applied a newly designed search strategy
We found one related single-centre RCT that was performed that encompassed an extensive number of databases from concep-
at a university tertiary care centre in Iran from March 2002 to tion, it is not likely that we missed relevant studies. However, we
September 2004 (2.5-year period). This study included 13 par- could not adequately assess publication bias by using a funnel plot
ticipants with unilateral hydrosalpinx and recurrent abortion, de- owing to the scarcity of RCTs on this topic. We may have au-
tected on ultrasonography and hysterosalpingography, and thus tomatically excluded good quality observational studies that may
did not meet our inclusion criteria, which required that couples adequately answer the study question owing to the nature of the
would be subfertile. protocol of this systematic review. Consideration must be given to

incorporating such studies in future reviews because well-powered advantage of surgery over IVF is the theoretically permanent
RCTs continue to be few. restoration of the ability to naturally conceive for every ovula-
tion cycle over a sustained period. This is compared with the high
chance afforded by IVF over the few cycles performed and associ-
Agreements and disagreements with other ated complications of multiple births, foetal anomalies and ovar-
studies or reviews ian hyperstimulation syndrome (OHSS) (AIHW 2012; ASRM
2015; El-Chaar 2009; HFEA 2015). Tubal surgery may be the
As a result of the limited nature of available data, it has repeatedly
only treatment option for couples who object to IVF for religious,
been difficult to draw reliable conclusions on the effectiveness of
moral or emotional reasons. Finally, when effective, tubal surgery
surgery for tubal infertility. Until data from large RCTs with ad-
leads to sustainable improvement in fertility prospects, whereas
equate power become available, clinical practice must be guided
IVF (apart from frozen embryos) provides only one chance.
on the basis of available observational studies, many of which are
Specific problems have been noted with RCTs that involve surgical
confounded by bias due to the traditional method of using each
procedures. It is difficult to standardise the surgical procedures
couple as its own internal control, hence assuming that any fer-
being tested, as procedures evolve continuously and complications
tility outcome could be totally attributed to the intervention per-
decrease as surgeons gain experience. The success rate of a specific
formed. Moreover, very few observational studies have incorpo-
procedure depends on the experience and skill of the surgeon. It
rated direct concurrent comparison of two or more cohorts un-
is important that all participating surgeons undergo appropriate
dergoing different interventions, respectively.
training before the start of an RCT to reach a certain minimal
A previous version of this review (Pandian 2008) evaluated this
level of standardisation, but this is not always possible. Blinding
topic, and a related review examined use of pelvic surgery for sub-
of participants and surgeons in surgical trials is a potential source
fertility (Ahmad 2006). Neither these reviews nor any of the nu-
of bias, particularly as it is not always possible to do this when one
merous non-Cochrane systematic reviews on this topic have pro-
of the interventions being tested is surgical. Financial support for
duced solid answers over the past three decades. Reasons for the
surgical clinical trials is limited, and this is an ongoing problem.
lack of well-designed RCTs in this area are manifold. The validity
Despite the problems described above, serious consideration
of the classification systems used to assess severity of tubal dam-
should be given to conducting RCTs to determine the effectiveness
age is questionable. Extent of tubal disease and the presence of
of surgery in comparison with expectant management and IVF
pelvic pathology are important factors in the prognosis for success
for tubal infertility. Inclusion of women with mild and moderate
after surgical repair. The pregnancy outcome has been found to
tubal disease and exclusion of women with severe tubal disease
be uniformly poor after surgical treatment in patients with severe
may provide a reasonable way forward.
tubal disease (less than 15% pregnancy rate) (Akande 2004; Wu
1988). Selection of appropriate patients is an important determi-
nant of outcomes after surgery and is not possible in the absence
of a reliable classification system. The group of patients thought
to be eligible for participation in such an RCT may, therefore,
comprise a misrepresentation of the typical patient population re- AUTHORS’ CONCLUSIONS
quired. Recruitment for such trials is impaired by the provision
of insufficient patient information; an accepted, reliable method Implications for practice
that can provide precise prognostic information for women with The effectiveness of tubal surgery relative to expectant manage-
tubal damage is needed. ment and IVF in terms of livebirth rates for women with tubal
infertility remains unknown.
The advent of IVF has diminished the role of tubal surgery, and
tubal infertility remains one of the major indications for IVF. Al-
though it is expensive and invasive, IVF is the preferred choice for
Implications for research
older women with severe tubal damage. With the reported live- Randomised studies are needed to evaluate clinical outcomes and
birth rate per IVF cycle in most centres as high as 30% (SART cost-effectiveness of tubal surgery compared with no treatment and
2014), and in light of uncertainties surrounding the outcomes of IVF. Large RCTs with sufficient power are warranted. These trials
tubal surgery, a preference for IVF may contribute to poor recruit- should include a prolonged period of follow-up (possibly lasting
ment for surgical RCTs. Furthermore, women with tubal damage several years). Treatment protocols, methods of sperm preparation
find the spontaneous pregnancy rate unacceptably low (12-month (for IVF), numbers of embryos transferred (for IVF) and inclu-
cumulative pregnancy rate (PR) of 2.4%); consequently, expectant sion and exclusion criteria should be clearly stated. Participant
management is an unattractive option for them (Evers 1998). characteristics should be clear (age, duration of infertility, infertil-
Funding constraints in some clinical situations mean that many ity investigations and previous therapy). In addition, participants
women and clinicians continue to favour surgery. An additional should be stratified according to severity of tubal lesions.

With regard to surgical interventions, researchers should describe cumulative LBRs by means of Cox proportional hazard analysis,
the techniques used and the experience of the surgeon(s). Future which is a form of survival analysis (Cohlen 2002). It is important
trials should use adequate methods of randomisation and should that they include all cycles in the denominator. If cycles with poor
clearly state numbers and reasons for drop-out and withdrawal. Al- outcomes are excluded, effectiveness can be exaggerated. In trials
location concealment should be adequate, and intention-to-treat that include tubal surgery, researchers should state the number of
analysis performed. Investigators should perform a power calcula- ectopic pregnancies.
tion and should provide a clear description of the improvement in
treatment outcome that is considered clinically significant. Use of
parallel rather than cross-over study design is also favourable for Trialists should report pregnancy outcomes in relation to differ-
continued study of these events because the latter may exaggerate ent grades of tubal damage and must describe significant adverse
treatment effectiveness. outcomes such as ectopic pregnancy (this information is crucial).
Outcome measures should include pregnancy rate (PR) and live- ACKNOWLEDGEMENTS
birth rate (LBR) per participant/couple. Although rates per cycle
Thanks to the Cochrane Gynaecology and Fertility Group for
are commonly reported, they constitute a ’unit of analysis’ error
support provided.
and do not generate valid estimates or confidence intervals. Esti-
mation of cumulative LBRs is also important. So results can be The authors of the 2016 update acknowledge the contributions of
expressed as cumulative LBR after ’n’ cycles, researchers should Professor Bhattacharya, Dr Pandian and Dr Harrild to previous
provide results after each cycle separately. They should evaluate versions of this review.
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14651858.CD002125.pub3 ∗
Indicates the major publication for the study

CHARACTERISTICS OF STUDIES
Characteristics of excluded studies [ordered by study ID]
Study Reason for exclusion
Zolghadri 2006 Did not satisfy inclusion criteria. Participants were not subfertile

DATA AND ANALYSES
This review has no analyses.
APPENDICES
Appendix 1. Gynaecology and Fertility Group Specialised Register

(searched from inception to 19 October 2016) (PROCITE platform)
Keywords CONTAINS “Fallopian tube obstruction” or “tubal factor” or “tubal flushing” or “tubal infertility” or “tubal inflation”
or “tubal occlusion” or “tubal occlusion - proximal” or “tubal patency” or “tubal reconstruction” or “tubal subfertility” or “tube
drainage” or “tuboplasty” or “Fallopian Tube Fixation” or “fallopian tubes” or “tubal anastomosis” or “tubal disorders” or “tubo-ovarian
abscess” or “salpingectomy” or “Salpingitis-Physiopathology” or “salpingo-oopherectomy” or “Salpingolysis” or “*Salpingostomy-
”or “salpingotomy” or “Hydrosalpinx” or “hydrosalpingies” or “hydrosalpinges” or “falloscopy” or “laparoscopic salpingectomy” or
“laparoscopic salpingoovolysis” or “laparoscopic salpingotomy” or “laparoscopic tubal fulguration” or “microsurgery” or “microscopic”
or “microdiathermy” or “microlaparoscopy” or “hydrotubation” (446 hits)
Appendix 2. CENTRAL CRSO search strategy

(searched from inception to 19 October 2016) (CRSO web platform)
#1 MESH DESCRIPTOR Fallopian Tube Diseases EXPLODE ALL TREES 137
#2 MESH DESCRIPTOR Pelvic Inflammatory Disease EXPLODE ALL TREES 422
#3 MESH DESCRIPTOR Salpingitis EXPLODE ALL TREES 42
#4 (tubal infertility):TI,AB,KY 52
#5 ( tubal factor):TI,AB,KY 55
#6 (disten* adj3 tub*):TI,AB,KY 5
#7 (tubal subfertility):TI,AB,KY 2
#8 (tub* adj3 occlusion*):TI,AB,KY 163
#9 (tube* adj3 damage*):TI,AB,KY 7
#10 (tubal adj3 damage*):TI,AB,KY 12
#11 (adhesion* adj3 tub*):TI,AB,KY 22
#12 fallopian:TI,AB,KY 534
#13 (peritubal adj3 adhesion*):TI,AB,KY 3
#14 (tub* adj3 block*):TI,AB,KY 78
#15 hydrosalpin*:TI,AB,KY 53
#16 (Tub* adj3 lesion*):TI,AB,KY 46
#17 (disease* adj3 tub*):TI,AB,KY 222
#18 (occlu* adj3 oviduct*):TI,AB,KY 2
#19 (adhesion* adj3 oviduct*):TI,AB,KY 2
#20 (Tub* adj3 obstruction*):TI,AB,KY 61
#21 #1 OR #2 OR #3 OR #4 OR #5 OR #6 OR #7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR
#17 OR #18 OR #19 OR #20 1531
#22 MESH DESCRIPTOR Gynecologic Surgical Procedures EXPLODE ALL TREES 3630
#23 MESH DESCRIPTOR Salpingectomy EXPLODE ALL TREES 22
#24 MESH DESCRIPTOR salpingostomy EXPLODE ALL TREES 38
#25 MESH DESCRIPTOR Hand-Assisted Laparoscopy EXPLODE ALL TREES 7
#26 MESH DESCRIPTOR Laparoscopy EXPLODE ALL TREES 4243
#27 Laparoscop*:TI,AB,KY 9365
#28 MESH DESCRIPTOR Laparotomy EXPLODE ALL TREES 622
#29 Laparotomy:TI,AB,KY 1812
#30 electrosurg*:TI,AB,KY 352
#31 MESH DESCRIPTOR Electrosurgery EXPLODE ALL TREES 204
#32 MESH DESCRIPTOR Microsurgery EXPLODE ALL TREES 518
#33 microsurg*:TI,AB,KY 732
#34 minilaparotom*:TI,AB,KY 106
#35 (tubo-cornual anastomosis):TI,AB,KY 0
#36 fimbrioplasty:TI,AB,KY 6
#37 adhesiolysis:TI,AB,KY 85
#38 reconstruction:TI,AB,KY 3866
#39 (recanalizing or recanalising):TI,AB,KY 7
#40 (recanalisation or recanalization):TI,AB,KY 872
#41 (salpingostomy or salpingectomy):TI,AB,KY 142
#42 aspiration:TI,AB,KY 3801
#43 electrocoagulation:TI,AB,KY 716
#44 MESH DESCRIPTOR Sclerotherapy EXPLODE ALL TREES 432
#45 Sclerotherap*:TI,AB,KY 1153
#46 emboli?ation:TI,AB,KY 1111
#47 excision*:TI,AB,KY 3333
#48 #22 OR #23 OR #24 OR #25 OR #26 OR #27 OR #28 OR #29 OR #30 OR #31 OR #32 OR #33 OR #34 OR #35 OR #36
OR #37 OR #38 OR #39 OR #40 OR #41 OR #42 OR #43 OR #44 OR #45 OR #46 OR #47 27783
#49 #21 AND #48 358
Appendix 3. MEDLINE search strategy

(searched form 1946 to 19 October 2016) (Ovid platform)
1 exp fallopian tube diseases/ or pelvic inflammatory disease/ or salpingitis/ (11952)
2 tubal infertility.tw. (707)
3 tubal subfertility.tw. (14)
4 tubal factor.tw. (719)
5 tubal fibrosis.tw. (6)
6 (disten$ adj3 tube).tw. (70)
7 (disten$ adj3 tubal).tw. (10)
8 tubal occlusion.tw. (912)
9 (occlusion adj3 tubes).tw. (70)
10 (occlusion adj3 tube).tw. (306)
11 ((tube adj3 damage) or (tubal adj3 damage)).tw. (426)
12 (tube adj3 damage).tw. (124)
13 (adhesion$ adj3 tubal).tw. (199)
14 (adhesion$ adj3 tube).tw. (216)
15 (adhesion$ adj3 tubes).tw. (66)
16 fallopian.tw. (9086)
17 (peritubal adj3 adhesion$).tw. (117)
18 (tube adj3 block$).tw. (530)
19 (tubal adj3 block$).tw. (160)
20 (tubes adj3 block$).tw. (206)
21 hydrosalpin$.tw. (842)
22 ((Tubal adj3 lesion$) or (Tube adj3 lesion$)).tw. (240)
23 ((disease$ adj3 tubal) or (disease$ adj3 tubes)).tw. (576)
24 (oviduct$ adj3 damage$).tw. (33)
25 (oviduct$ adj3 fibrosis).tw. (4)
26 (disten$ adj3 oviduct$).tw. (7)
27 (occlu$ adj3 oviduct$).tw. (48)
28 (adhesion$ adj3 oviduct$).tw. (24)
29 ((Tubal adj3 obstruction$) or (Tube adj3 obstruction$)).tw. (1058)
30 1 and 29 (266)
31 or/1-28,30 (21711)
32 gynecologic surgical procedures/ or salpingectomy/ or salpingostomy/ (9590)
33 (surgery or surgical).tw. (1441006)
34 32 and 33 (6300)
35 laparoscopy/ or hand-assisted laparoscopy/ (70173)
36 Laparoscop$.tw. (101252)
37 Laparotomy/ (17222)
38 Laparotomy.tw. (40722)
39 electrosurgery/ or microsurgery/ (28971)
40 microsurg$.tw. (22043)
41 minilaparotom$.tw. (994)
42 tubo-cornual anastomosis.tw. (1)
43 fimbrioplasty.tw. (71)
44 adhesiolysis.tw. (1226)
45 reconstruction.tw. (160461)
46 (recanalizing or recanalising).tw. (173)
47 (recanalisation or recanalization).tw. (9700)
48 (salpingostomy or salpingectomy).tw. (1786)
49 aspiration.tw. (68032)
50 electrocoagulation.tw. (2763)
51 Sclerotherapy/ (4766)
52 Sclerotherap$.tw. (6126)
53 emboli?ation.tw. (39239)
54 or/32,34-53 (469023)
55 31 and 54 (5028)
56 randomized controlled trial.pt. (432907)
57 controlled clinical trial.pt. (91818)
58 randomized.ab. (373391)
59 randomised.ab. (76600)
60 placebo.tw. (185046)
61 clinical trials as topic.sh. (180215)
62 randomly.ab. (265326)
63 trial.ti. (163366)
64 (crossover or cross-over or cross over).tw. (71526)
65 or/56-64 (1126803)
66 exp animals/ not humans.sh. (4325953)
67 65 not 66 (1039022)
68 55 and 67 (282)
Utilising the Cochrane Highly Sensitive Search Strategies for identifying randomised trials in MEDLINE (Higgins 2011)

Appendix 4. Embase search strategy
(searched from 1974 to 19 October 2016) (Ovid platform)
1 exp uterine tube disease/ or pelvic inflammatory disease/ or salpingitis/ (14863)
3 tubal subfertility.tw. (15)
5 tubal fibrosis.tw. (6)
7 (disten$ adj3 tubal).tw. (17)
9 (occlusion adj3 tubes).tw. (64)
10 (occlusion adj3 tube).tw. (332)
11 ((tube adj3 damage) or (tubal adj3 damage)).tw. (476)
12 (tube adj3 damage).tw. (133)
13 (adhesion$ adj3 tubal).tw. (251)
14 (adhesion$ adj3 tube).tw. (222)
15 (adhesion$ adj3 tubes).tw. (62)
17 (peritubal adj3 adhesion$).tw. (140)
18 (tube adj3 block$).tw. (617)
19 (tubal adj3 block$).tw. (221)
20 (tubes adj3 block$).tw. (242)
21 hydrosalpin$.tw. (1071)
22 ((Tubal adj3 lesion$) or (Tube adj3 lesion$)).tw. (309)
23 ((disease$ adj3 tubal) or (disease$ adj3 tubes)).tw. (649)
24 (oviduct$ adj3 damage$).tw. (26)
25 (oviduct$ adj3 fibrosis).tw. (3)
26 (disten$ adj3 oviduct$).tw. (5)
27 (occlu$ adj3 oviduct$).tw. (41)
28 (adhesion$ adj3 oviduct$).tw. (25)
30 1 and 29 (278)
31 or/1-28,30 (25812)
32 gynecologic surgical procedures/ or salpingectomy/ or salpingostomy/ (14627)
34 32 and 33 (9079)
35 laparoscopy/ or hand-assisted laparoscopy/ (56876)
37 Laparotomy/ (57049)
39 electrosurgery/ or microsurgery/ (28040)
41 minilaparotom$.tw. (1149)
42 tubo-cornual anastomosis.tw. (3)
43 fimbrioplasty.tw. (78)
46 (recanalizing or recanalising).tw. (235)
47 (recanalisation or recanalization).tw. (12911)
50 electrocoagulatioaintern.tw. (2749)

51 Sclerotherapy/ (8628)
52 Sclerotherap$.tw. (7813)
54 or/32,34-53 (552917)
55 31 and 54 (6793)
56 Clinical Trial/ (848860)
57 Randomized Controlled Trial/ (380154)
58 exp randomization/ (67586)
59 Single Blind Procedure/ (20772)
60 Double Blind Procedure/ (122634)
61 Crossover Procedure/ (43961)
62 Placebo/ (261129)
63 Randomi?ed controlled trial$.tw. (121529)
64 Rct.tw. (17856)
65 random allocation.tw. (1441)
66 randomly.tw. (296704)
67 randomly allocated.tw. (22974)
68 allocated randomly.tw. (2045)
69 (allocated adj2 random).tw. (734)
70 Single blind$.tw. (16181)
71 Double blind$.tw. (153400)
72 ((treble or triple) adj blind$).tw. (471)
73 placebo$.tw. (218534)
74 prospective study/ (302585)
75 or/56-74 (1662347)
76 case study/ (33245)
77 case report.tw. (287952)
78 abstract report/ or letter/ (933800)
79 or/76-78 (1248567)
80 75 not 79 (1622351)
81 (exp animal/ or animal.hw. or nonhuman/) not (exp human/ or human cell/ or (human or humans).ti.) (5341103)
82 80 not 81 (1508716)
83 55 and 82 (661)
Appendix 5. PsycINFO search strategy

(searched from 1806 to 19 October 2016) (Ovid platform)
1 exp Gynecological Disorders/ (1613)
8 2 or 3 or 4 or 5 or 6 or 7 (63)
9 1 and 8 (4)
10 8 or 9 (63)
11 exp Gynecology/ or exp Surgery/ (50237)
19 electrocoagulation.tw. (67)
22 or/11-21 (82130)
23 10 and 22 (20)
24 random*.ti,ab,hw,id. (159256)
25 trial*.ti,ab,hw,id. (148083)
26 controlled stud*.ti,ab,hw,id. (10491)
27 placebo*.ti,ab,hw,id. (35395)
28 ((singl* or doubl* or trebl* or tripl*) and (blind* or mask*)).ti,ab,hw,id. (25155)
29 (cross over or crossover or factorial* or latin square).ti,ab,hw,id. (25065)
30 (assign* or allocat* or volunteer*).ti,ab,hw,id. (137432)
31 treatment effectiveness evaluation/ (20480)
32 mental health program evaluation/ (1970)
33 exp experimental design/ (52046)
34 “2000”.md. (0)
35 or/24-34 (434710)
36 23 and 35 (1)
Appendix 6. CINAHL search strategy

(searched from 1982 to 19 October 2016) (EBSCO platform)
# Query Results
S57 S44 AND S56 200
S56 S45 OR S46 OR S47 OR S48 OR S49 OR S50 OR S51 OR 1,081,306

S52 OR S53 OR S54 OR S55
S55 TX allocat* random* 5,281
S54 (MH “Quantitative Studies”) 14,919
S53 (MH “Placebos”) 9,827
S52 TX placebo* 39,650
S51 TX random* allocat* 5,281
S50 (MH “Random Assignment”) 41,699
S49 TX randomi* control* trial* 110,746
S48 TX ( (singl* n1 blind*) or (singl* n1 mask*) ) or TX ( (doubl* 857,082

n1 blind*) or (doubl* n1 mask*) ) or TX ( (tripl* n1 blind*)
or (tripl* n1 mask*) ) or TX ( (trebl* n1 blind*) or (trebl* n1

(Continued)
mask*) )
S47 TX clinic* n1 trial* 190,012
S46 PT Clinical trial 79,719
S45 (MH “Clinical Trials+”) 203,397
S44 S22 AND S43 1,006
S43 S23 OR S24 OR S25 OR S26 OR S27 OR S28 OR S29 OR 539,009

S30 OR S31 OR S32 OR S33 OR S34 OR S35 OR S36 OR
S37 OR S38 OR S39 OR S40 OR S41
S42 TX salpingo neostom* 0
S41 TX recanalisation or TX recanalization 1,140
S40 TX salpingostomy or salpingectomy 231
S39 TX recanalizing or TX recanalising 17
S38 TX lysis N2 adhesion* 67
S37 TX reconstruction 19,742
S36 TX adhesiolysis 129
S35 TX fimbrioplasty 5
S34 TX tubo-cornual anastomosis 0
S33 TX excision 9,388
S32 TX minilaparotom* 65
S31 (MM “Microsurgery+”) 1,269
S30 TX Laparotomy 4,259
S29 (MM “Laparotomy”) 839
S28 TX microsurg* 2,853
S27 TX Laparoscop* 20,801
S26 (MH “Surgery, Laparoscopic+”) 4,692

(Continued)
S25 TX surgical 160,422
S24 TX surgery 467,855
S23 (MM “Surgery, Gynecologic+”) 6,174
S22 S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7 OR S8 OR 2,773
S9 OR S10 OR S11 OR S12 OR S13 OR S14 OR S15 OR
S16 OR S17 OR S18 OR S19 OR S20 OR S21
S21 TX disease* N3 tubal 27
S20 TX disease* N3 tubes 322
S19 TX Tube N3 lesion* 8
S18 TX tubes N3 lesion* 8
S17 TX Tubal N3 lesion* 6
S16 TX hydrosalpin* 61
S15 TX tubal N3 block* 13
S14 TX tube* N3 block* 115
S13 TX pelvic inflammatory 1,041
S12 TX peritubal N3 adhesion* 1
S11 TX fallopian 1,155
S10 TX adhesion* N3 tub* 30
S9 TX tubal occlusion 71
S8 TX disten* N3 tube* 10
S7 TX tubal fibrosis 2
S6 TX tub* N3 damage 271
S5 (MM “Pelvic Inflammatory Disease”) 416
S4 TX tubal factor 113
S3 TX tubal subfertility 10

(Continued)
S2 TX tubal infertility 112
S1 (MM “Fallopian Tube Diseases+”) 268
Appendix 7. DARE search strategy

Cochrane Library (searched 24 November 2016)
All fields: “Fallopian tube obstruction” or “tubal factor” or “tubal flushing” or “tubal infertility” or “tubal inflation” or “tubal occlusion”
or “tubal occlusion - proximal” or “tubal patency” or “tubal reconstruction” or “tubal subfertility” or “tube drainage” or “tuboplasty” or
“Fallopian Tube Fixation” or “fallopian tubes” or “tubal anastomosis” or “tubal disorders” or “tubo-ovarian abcess” or “salpingectomy”
or “Salpingitis-Physiopathology” or “salpingo-oopherectomy” or “Salpingolysis” or “*Salpingostomy” or “salpingotomy” or “Hydros-
alpinx” or “hydrosalpingies” or “hydrosalpinges” or “falloscopy” or “laparoscopic salpingectomy” or “laparoscopic salpingoovolysis” or
“laparoscopic salpingotomy” or “laparoscopic tubal fulguration” or “microsurgery” or “microscopic” or “microdiathermy” or “microla-
paroscopy” or “hydrotubation”
(142 hits)
Appendix 8. http://www.clinicaltrials.gov search strategy
PATIENT INTERVENTION COMPARATOR OUTCOME
(Infertile Surgery
OR infertility OR surgical
OR subfertile OR surgically
OR subfertility) AND
(Tubal OR
tube
OR tubes
OR oviduct
OR oviducts)
(Infertile OR infertility OR subfertile OR subfertility) AND (Tubal OR tube OR tubes OR oviduct OR oviducts) AND (Surgery OR
surgical OR surgically)
(searched 24 November 2016)
45 hits
Appendix 9. World Health Organization International Trials Registry Portal search strategy

(Subfertility
OR subfertile
OR infertility
OR infertile)
AND
(“Fallopian tube” OR “Fallop-
ian tubes”
OR oviduct
OR oviducts
OR tubal)
NOT male
Subfertility AND tubal NOT male (0 trials)

Infertility AND tubal NOT male (11 trials)
Infertile AND tubal NOT male (11 duplicates)
Subfertile AND tubal NOT male (0 trials)
Subfertility AND oviduct* NOT male (0 trials)
Infertility AND oviduct* NOT male (1 trials)
Infertile AND oviduct* NOT male (1 duplicate)
Subfertile AND oviduct* NOT male (0 trials)
Subfertility AND Fallopian tube* NOT male (0 trials)
Infertility AND Fallopian tube* NOT male (2 trials)
Infertile AND Fallopian tube* NOT male (2 duplicate)
Subfertile AND Fallopian tube* NOT male (0)
28 hits (13 hits minus duplicates)
Appendix 10. Web of Science search strategy

Version 5.18, limited to Web of Science Core Collection database
Basic Search option
search tag:TOPIC search tag: TOPIC search tag: TOPIC

“fallopian tube disease*” or ((“gynecologic surgical proce- ((randomi* NEAR/1 “con-
“pelvic inflammatory disease” dures” or salpingectomy or trolled trial*”) OR “controlled
or “salpingitis” OR salpingostomy) AND (surgery clinical trial” OR “random al-
“tubal infertil*” OR “tubal sub- or surgical)) OR (“gynecologic location*” OR “double-blind”
fertil*” OR surgical procedures” or salp- OR “single-blind” OR (clin*
tubal factor OR “tubal fibrosis” ingectomy or salpingostomy) NEAR/25 trial*) OR ((singl*
OR (disten* NEAR/3 tube) OR or “hand-assisted laparoscopy“ or doubl* or tripl* or trebl*)
(disten* NEAR/3 tubal) OR OR Laparoscop* OR Laparo- NEAR/25 (blind* or mask*))
“tubal occlusion” OR (occlu- tomy OR electrosurgery or mi- OR
sion NEAR/3 tubes) OR (oc- crosurg* OR minilaparotom* placebo* OR “Research de-
clusion NEAR/3 tube) OR OR tubo-cornual anastomo- sign”) NOT (animal* not hu-
((tube NEAR/3 damage) or

(Continued)
(tubal NEAR/3 damage)) OR sis OR fimbrioplasty OR ad- man*)

(tube NEAR/3 damage) OR hesiolysis OR reconstruction
(adhesion* NEAR/3 tubal) OR OR (recanalizing or recanal-
(adhesion* NEAR/3 tube) OR ising) OR (recanalisation or
(adhesion* NEAR/3 tubes) OR recanalization) OR (salpingos-
fallopian OR (peritubal NEAR/ tomy or salpingectomy) OR as-
3 adhesion*) OR (tube NEAR/ piration OR electrocoagulation
3 block*) OR (tubal NEAR/ OR Sclerotherapy OR Scle-
3 block*) OR (tubes NEAR/3 rotherap* OR emboli?ation
block*) OR hydrosalpin* OR
((Tubal NEAR/3 lesion*) or
(Tube NEAR/3 lesion*)) OR
((disease* NEAR/3 tubal) or
(disease* NEAR/3 tubes)) OR
(oviduct* NEAR/3 damage*)
OR
(oviduct* NEAR/3 fibrosis) OR
(disten* NEAR/3 oviduct*) OR
(occlu* NEAR/3 oviduct*) OR
(adhesion* NEAR/3 oviduct*)
OR (((Tubal NEAR/3 obstruc-
tion*) or (Tube NEAR/3 ob-
struction*)) AND (“fallopian
tube disease*” or “pelvic inflam-
matory disease” or salpingitis))
The RCT filter was adapted from the Medline RCT filter provided by Cochrane (Higgins 2005)
(193 hits)
Appendix 11. OpenGrey search strategy

“fallopian tube disease*” or ((“gynecologic surgical proce- ((randomi* NEAR/1 “con-

“pelvic inflammatory disease” dures” or salpingectomy or trolled trial*”) OR “controlled
or “salpingitis” OR salpingostomy) AND (surgery clinical trial” OR “random al-
“tubal infertil*” OR “tubal sub- or surgical)) OR (“gynecologic location*” OR “double-blind”
fertil*” OR surgical procedures” or salp- OR “single-blind” OR (clin*
tubal factor OR “tubal fibrosis” ingectomy or salpingostomy) NEAR/25 trial*) OR ((singl*
OR (disten* NEAR/3 tube) OR or “hand-assisted laparoscopy“ or doubl* or tripl* or trebl*)
(disten* NEAR/3 tubal) OR OR Laparoscop* OR Laparo- NEAR/25 (blind* or mask*))
“tubal occlusion” OR (occlu- tomy OR electrosurgery or mi- OR
sion NEAR/3 tubes) OR (oc- crosurg* OR minilaparotom* placebo* OR “Research de-
clusion NEAR/3 tube) OR OR tubo-cornual anastomo- sign”) NOT (animal* not hu-
((tube NEAR/3 damage) or sis OR fimbrioplasty OR ad- man*)
(tubal NEAR/3 damage)) OR hesiolysis OR reconstruction

(Continued)
(tube NEAR/3 damage) OR OR (recanalizing or recanal-

(adhesion* NEAR/3 tubal) OR ising) OR (recanalisation or
(adhesion* NEAR/3 tube) OR recanalization) OR (salpingos-
(adhesion* NEAR/3 tubes) OR tomy or salpingectomy) OR as-
fallopian OR (peritubal NEAR/ piration OR electrocoagulation
3 adhesion*) OR (tube NEAR/ OR Sclerotherapy OR Scle-
3 block*) OR (tubal NEAR/ rotherap* OR embolization OR
3 block*) OR (tubes NEAR/3 embolization
OR
struction*)) AND (“fallopian
tube disease*” or “pelvic inflam-
matory disease” or salpingitis))
(“fallopian tube disease*” or “pelvic inflammatory disease” or “salpingitis” OR “tubal infertil*” OR “tubal subfertil*” OR tubal factor
OR “tubal fibrosis” OR (disten* NEAR/3 tube) OR (disten* NEAR/3 tubal) OR “tubal occlusion” OR (occlusion NEAR/3 tubes)
OR (occlusion NEAR/3 tube) OR ((tube NEAR/3 damage) or (tubal NEAR/3 damage)) OR (tube NEAR/3 damage) OR (adhesion*
NEAR/3 tubal) OR (adhesion* NEAR/3 tube) OR (adhesion* NEAR/3 tubes) OR fallopian OR (peritubal NEAR/3 adhesion*) OR
(tube NEAR/3 block*) OR (tubal NEAR/3 block*) OR (tubes NEAR/3 block*) OR hydrosalpin* OR ((Tubal NEAR/3 lesion*) or (Tube
NEAR/3 lesion*)) OR ((disease* NEAR/3 tubal) or (disease* NEAR/3 tubes)) OR (oviduct* NEAR/3 damage*) OR (oviduct* NEAR/
3 fibrosis) OR (disten* NEAR/3 oviduct*) OR (occlu* NEAR/3 oviduct*) OR (adhesion* NEAR/3 oviduct*) OR (((Tubal NEAR/
3 obstruction*) or (Tube NEAR/3 obstruction*)) AND (“fallopian tube disease*” or “pelvic inflammatory disease” or salpingitis)))
AND (((“gynecologic surgical procedures” or salpingectomy or salpingostomy) AND (surgery or surgical)) OR (“gynecologic surgical
procedures” or salpingectomy or salpingostomy) or “hand-assisted laparoscopy“ OR Laparoscop* OR Laparotomy OR electrosurgery or
microsurg* OR minilaparotom* OR tubo-cornual anastomosis OR fimbrioplasty OR adhesiolysis OR reconstruction OR (recanalizing
or recanalising) OR (recanalisation or recanalization) OR (salpingostomy or salpingectomy) OR aspiration OR electrocoagulation OR
Sclerotherapy OR Sclerotherap* OR embolization OR embolization ) AND (((randomi* NEAR/1 “controlled trial*”) OR “controlled
clinical trial” OR “random allocation*” OR “double-blind” OR “single-blind” OR (clin* NEAR/25 trial*) OR ((singl* or doubl* or
tripl* or trebl*) NEAR/25 (blind* or mask*)) OR placebo* OR “Research design”) NOT (animal* not human*))
0 hits

Appendix 12. LILACS search strategy
Limited to the LILACs database using the “Controlled Clinical Trial” tag as provided by the search portal
(TW:Fallopian Tube Disease*) (TW:Laparo-

or (TW:tubal infertility) scop*) or (TW:Microsurg*) or
OR (TW:tubal subfertility) (TW:tubal surgery) OR
OR (TW:tubal factor*) or (TW:
(TW:Pelvic Inflammatory Dis- surgery oviduct*) OR (TW:sur-
ease) OR (TW:tubal factor in- gical* oviduct*) OR (TW:infer-
fertil*) OR (TW:tubal factor tility surgery) OR
subfertil*) OR (TW:tubal dam- (TW:surgery infertil*) OR
age) OR (TW:tubal fibrosis) (TW:surgery subfertil*) OR
OR (TW:tube damage*) OR (TW:surgical* infertil*) OR
(TW:tube fibrosis) (TW:surgical* subfertil*)
OR (TW:oviduct* damage*)
OR (TW:oviduct* fibrosis) OR
(TW:tubal distension*)
OR (TW:tube distension*) OR
(TW:distended tube) OR (TW:
distended tubes) OR (TW:dis-
tended oviduct*) OR (TW:
oviduct distension*) OR (TW:
tubal occlusion) OR
(TW:occluded tube) OR (TW:
occluded tubes) OR (TW:tube
occlu*)
OR (TW:occluded
oviduct*) OR (TW:oviduct oc-
clu*) OR (TW:tubal adhesion*)
OR (TW:tube adhesion*) OR
(TW:oviduct adhesion*)
((TW:Fallopian Tube Disease*) or (TW:tubal infertility) OR (TW:tubal subfertility) OR (TW:tubal factor*) or (TW:Pelvic Inflamma-
tory Disease) OR (TW:tubal factor infertil*) OR (TW:tubal factor subfertil*) OR (TW:tubal damage) OR (TW:tubal fibrosis) OR (TW:
tube damage*) OR (TW:tube fibrosis) OR (TW:oviduct* damage*) OR (TW:oviduct* fibrosis) OR (TW:tubal distension*) OR (TW:
tube distension*) OR (TW:distended tube) OR (TW:distended tubes) OR (TW:distended oviduct*) OR (TW:oviduct distension*)
OR (TW:tubal occlusion) OR (TW:occluded tube) OR (TW:occluded tubes) OR (TW:tube occlu*) OR (TW:occluded oviduct*) OR
(TW:oviduct occlu*) OR (TW:tubal adhesion*) OR (TW:tube adhesion*) OR (TW:oviduct adhesion*)) AND ((TW:Laparoscop*)
or (TW:Microsurg*) or (TW:tubal surgery) OR (TW:surgery oviduct*) OR (TW:surgical* oviduct*) OR (TW:infertility surgery) OR
(TW:surgery infertil*) OR (TW:surgery subfertil*) OR (TW:surgical* infertil*) OR (TW:surgical* subfertil*))
5 hits

Appendix 13. PubMed search strategy
(From 2012 to 24 November 2016) (limit to last 5 years)
Fallopian Tube Disease*[tw] or Laparo- (randomized controlled

tubal infertility[all] OR tubal scop*[tw] or Microsurg*[tw] or trial[pt] OR controlled clinical
subfertility[all] OR tubal fac- laparotomy*[tw] or aspiration trial[pt] OR randomized[tiab]
tor*[all] or Pelvic Inflamma- [tw] or tubal surgery[all] OR OR placebo[tw] OR drug
tory Disease[tw] OR tubal fac- surgery oviduct*[all] OR sur- therapy[sh] OR randomly[tiab]
tor infertil*[all] OR tubal factor gical* oviduct*[all] OR infer- OR trial[tiab] OR groups[tiab])
subfertil*[all] OR tubal dam- tility surgery[all] OR surgery NOT (animals[mh] NOT hu-
age[all] OR tubal fibrosis[all] infertil*[all] OR surgery sub- mans[mh])
OR tube damage*[all] OR tube fertil*[all] OR surgical* infer-
fibrosis[all] OR oviduct* dam- til*[all] OR surgical* subfer-
age*[all] OR oviduct* fibro- til*[all] OR adhesiolysis [all]
sis[all] OR salpingostomy [all] OR
OR tubal distension*[all] OR salpingectomy [all] OR em-
tube distension*[all] OR dis- bolisation[all] OR emboliza-
tended tube[all] OR distended tion[all] OR reconstruction[all]
tubes[all] OR surgical
OR distended oviduct*[all] OR OR surgically
oviduct distension* [all] OR
tubal occlusion[all] OR oc-
cluded tube[all] OR occluded
tubes[all] OR tube occlu* [all]
OR occluded oviduct*[all] OR
oviduct occlu* [all] OR tubal
adhesion*[all] OR tube adhe-
sion*[all] OR oviduct adhe-
sion*[all] OR hydrosalpin* [all]
OR fallopian [all]
OR oviducts)Fallopian Tube
Disease*[tw] or tubal infer-
tility[all] OR tubal subfertil-
ity[all] OR tubal factor*[all]
or Pelvic Inflammatory Dis-
ease[tw] OR tubal factor in-
fertil*[all] OR tubal factor
subfertil*[all] OR tubal dam-
age[all] OR tubal fibrosis[all]
OR tube damage*[all] OR tube
fibrosis[all] OR oviduct* dam-
age*[all] OR oviduct* fibro-
sis[all]
OR tubal distension*[all] OR
tube distension*[all] OR dis-
tended tube[all] OR distended
tubes[all]
OR distended oviduct*[all] OR

(Continued)
oviduct distension* [all] OR

tubal occlusion[all] OR oc-
cluded tube[all] OR occluded
tubes[all] OR tube occlu* [all]
OR occluded oviduct*[all] OR
oviduct occlu* [all] OR tubal
adhesion*[all] OR tube adhe-
sion*[all] OR oviduct adhe-
sion*[all] OR hydrosalpin* [all]
OR fallopian [all]
(Fallopian Tube Disease*[tw] or tubal infertility[all] OR tubal subfertility[all] OR tubal factor*[all] or Pelvic Inflammatory Disease[tw]
OR tubal factor infertil*[all] OR tubal factor subfertil*[all] OR tubal damage[all] OR tubal fibrosis[all] OR tube damage*[all] OR
tube fibrosis[all] OR oviduct* damage*[all] OR oviduct* fibrosis[all] OR tubal distension*[all] OR tube distension*[all] OR distended
tube[all] OR distended tubes[all] OR distended oviduct*[all] OR oviduct distension* [all] OR tubal occlusion[all] OR occluded
tube[all] OR occluded tubes[all] OR tube occlu* [all] OR occluded oviduct*[all] OR oviduct occlu* [all] OR tubal adhesion*[all] OR
tube adhesion*[all] OR oviduct adhesion*[all] OR hydrosalpin* [all] OR fallopian [all]) AND (Laparoscop*[tw] or Microsurg*[tw] or
laparotomy*[tw] or aspiration [tw] or tubal surgery[all] OR surgery oviduct*[all] OR surgical* oviduct*[all] OR infertility surgery[all]
OR surgery infertil*[all] OR surgery subfertil*[all] OR surgical* infertil*[all] OR surgical* subfertil*[all] OR adhesiolysis [all] OR
salpingostomy [all] OR salpingectomy [all] OR embolisation[all] OR embolization[all] OR reconstruction[all]) AND ((randomized
controlled trial[pt] OR controlled clinical trial[pt] OR randomized[tiab] OR placebo[tw] OR drug therapy[sh] OR randomly[tiab]
OR trial[tiab] OR groups[tiab]) NOT (animals[mh] NOT humans[mh]))
This search utilised the Cochrane Highly Sensitive Search Strategy for identifying randomized trials in MEDLINE: sensitivity-maxi-
mizing version (2008 revision) (Higgins 2011)
(76 hits)
Appendix 14. Google Scholar search strategy

The Google Scholar search was run via the Publish or Perish program. (Harzing 2007)
(tubal OR fallop- surgery Random pregnancy

ian OR oviduct) AND (infertil-
ity OR infertile OR subfertile
OR subfertility)
NOT male
NOT men
NOT animal
Year of publication between: 2016 and 2016

1. Search field (all of the words): tubal, infertility, surgery, random, pregnancy AND Search Field (none of the words): male, men,
animal (107 hits)
2. Search field (all of the words): tubal, infertile, surgery, random, pregnancy AND Search Field (none of the words): male, men, animal
(87 hits)
3. Search field (all of the words): tubal, subfertile, surgery, random, pregnancy AND Search Field (none of the words): male, men,
animal (11 hits)
4. Search field (all of the words): tubal, subfertility, surgery, random, pregnancy AND Search Field (none of the words):male, men,
animal (106 hits)
5. Search field (all of the words): fallopian, infertility, surgery, random, pregnancy AND, Search field (none of the words): male, men,
animal (77 hits)
6. Search field (all of the words): fallopian, infertile, surgery, random, pregnancy AND Search field (none of the words): male, men,
animal (61 hits)
7. Search field (all of the words): fallopian, subfertile, surgery, random, pregnancy AND Search field (none of the words): male, men,
animal (9 hits)
8. Search field (all of the words): fallopian, subfertility, surgery, random, pregnancy AND Search field (none of the words): male, men,
animal (79 hits)
9. Search field (all of the words): oviduct, infertility, surgery, random, pregnancy AND Search field (none of the words): male, men,
animal (5 hits)
10. Search field (all of the words): oviduct, infertile, surgery, random, pregnancy AND Search field (none of the words): male, men,
animal (3 hits)
11. Search field (all of the words): oviduct, subfertile, surgery, random, pregnancy AND Search field (none of the words): male, men,
animal (0 hits)
12. Search field (all of the words):oviduct, subfertility, surgery, random, pregnancy AND Search field (none of the words): male, men,
animal (5 hits)
Total: 550 hits (146 hits excluding duplicates)
Appendix 15. ProQuest Dissertations & Theses Global search strategy

Searched 24th November 2016
“fallopian tube disease*” or ((“gy- ((randomi* NEAR/1 “con- Pregnan* OR birth*

“pelvic inflammatory disease” necologic surgical procedure*” trolled trial*”) OR “controlled
or salpingitis OR or salpingectomy or salpingos- clinical trial” OR “random al-
“tubal infertil*” OR” tubal sub- tomy) AND (surgery or surgi- location*” OR “double-blind”
fertil*” OR cal)) OR (“gynecologic surgical OR “single-blind” OR (clin*
“tubal factor” OR “tubal fi- procedure*” or salpingectomy NEAR25 trial*) OR ((singl*
brosis” OR (disten* NEAR/ or salpingostomy) OR “hand- or doubl* or tripl* or trebl*)
3 tube) OR (disten* NEAR/ assisted laparoscopy” OR La- NEAR/25 (blind* or mask*))
3 tubal) OR “tubal occlusion” paroscop* OR Laparotomy OR OR
OR (occlusion NEAR/3 tubes) electrosurgery or microsurg* placebo* OR “Research de-
OR (occlusion NEAR/3 tube) OR minilaparotom* OR tubo- sign”) NOT (animal* not hu-
OR ((tube NEAR/3 damage) or cornual anastomosis OR fim- man*)
(tubal NEAR/3 damage)) OR brioplasty OR adhesiolysis OR
(tube NEAR/3 damage) OR reconstruction OR (recanaliz-
(adhesion* NEAR/3 tubal) OR ing or recanalising) OR (re-
(adhesion* NEAR/3 tube) OR canalisation or recanalization)
(adhesion* NEAR/3 tubes) OR OR (salpingostomy or salp-
fallopian OR (peritubal NEAR/ ingectomy) OR aspiration OR
3 adhesion*) OR (tube NEAR/ electrocoagulation OR Scle-
3 block*) OR (tubal NEAR/ rotherap* OR emboli?ation
3 block*) OR (tubes NEAR/3

(Continued)

OR
struction*)) AND (exp fallop-
ian tube diseases or pelvic in-
flammatory disease or salpingi-
tis)) NOT male
NOT male
(“fallopian tube disease*” or “pelvic inflammatory disease” or salpingitis OR “tubal infertil*” OR” tubal subfertil*” OR “tubal factor”
OR “tubal fibrosis” OR (disten* NEAR/3 tube) OR (disten* NEAR/3 tubal) OR “tubal occlusion” OR (occlusion NEAR/3 tubes)
OR (occlusion NEAR/3 tube) OR ((tube NEAR/3 damage) or (tubal NEAR/3 damage)) OR (tube NEAR/3 damage) OR (adhesion*
NEAR/3 tubal) OR (adhesion* NEAR/3 tube) OR (adhesion* NEAR/3 tubes) OR fallopian OR (peritubal NEAR/3 adhesion*) OR
(tube NEAR/3 block*) OR (tubal NEAR/3 block*) OR (tubes NEAR/3 block*) OR hydrosalpin* OR ((Tubal NEAR/3 lesion*) or (Tube
NEAR/3 lesion*)) OR ((disease* NEAR/3 tubal) or (disease* NEAR/3 tubes)) OR (oviduct* NEAR/3 damage*) OR (oviduct* NEAR/
3 fibrosis) OR (disten* NEAR/3 oviduct*) OR (occlu* NEAR/3 oviduct*) OR (adhesion* NEAR/3 oviduct*) OR (((Tubal NEAR/3
obstruction*) or (Tube NEAR/3 obstruction*)) AND (exp fallopian tube diseases or pelvic inflammatory disease or salpingitis)) NOT
male) AND (((“gynecologic surgical procedure*” or salpingectomy or salpingostomy) AND (surgery or surgical)) OR (“gynecologic
surgical procedure*” or salpingectomy or salpingostomy) OR “hand-assisted laparoscopy” OR Laparoscop* OR Laparotomy OR
electrosurgery or microsurg* OR minilaparotom* OR tubo-cornual anastomosis OR fimbrioplasty OR adhesiolysis OR reconstruction
OR (recanalizing or recanalising) OR (recanalisation or recanalization) OR (salpingostomy or salpingectomy) OR aspiration OR
electrocoagulation OR Sclerotherap* OR emboli?ation ) AND (Pregnan* OR birth*) AND (((controli* NEAR/1 “controlled trial*”)
OR “controlled clinical trial” OR “control allocation*” OR “double-blind” OR “single-blind” OR (clin* NEAR25 trial*) OR ((singl*
or doubl* or tripl* or trebl*) NEAR/25 (blind* or mask*)) OR placebo* OR “Research design”) NOT (animal* not human*))
132 hits
Appendix 16. ESHRE and ASRM search strategy

Handsearching of the ESHRE 2007, ESHRE 2015 and ASRM 2008 conference abstracts as these are not covered by the search of the
Gynaecology and Fertility Group specialised register.
1. ESHRE 2007 (2)
i) Gordts S, Campo R, Puttemans P, Valkenburg M, Brosens I, Gordts S. Microsurgical reversal of tubal sterilisation: to be
preferred? Hum Reprod. 2007;22(Suppl 1):i227.
ii) Hotineanu AL, Moshin VN, Hotineanu AV, Croitor ME. The effect of the proximal tubal “clamping” prior to the IVF in
patients with distal tubal occlusion. Hum Reprod. 2007;22(Suppl 1):i126.
2. ASRM 2008 (5)
i) Fukuda A, Hamada A, Sawabe M, Sonoda M, Nakaoka Y, Morimoto Y. Pregnancy rate of bilateral tubal occlusion patients
by IVF improves after recovery of tubal patency by falloposcopic tuboplasty. Fertility and sterility. 2008;90(Supplement):S155.
ii) Poncelet C, Ducarme G, Yazbeck C, Uzan M, Madelenat P, Carbonnel M. Efficacy and safety of transient ovariopexy in
severe endometriotic patients. A ten year experience. . Fertility and sterility. 2008;90(Supplement):S167-8.
iii) Sawabe M, Fukuda A, Hamada A, Sonoda M, Nakaoka Y, Morimoto Y. Experience of 1000 falloposcopic tuboplasty (FT)
cases: FT is a novel, patient friendly and effective regimen for tubal factor infertility before ART. Fertility and sterility. 2008;
90(Supplement):S40.
iv) Jindal UN, Verma YB, Sodhi S, Verma S. Comparative evaluation of laparoscopy and endometrial polymerase chain
reaction for the diagnosis of female genital tuberculosis in infertile women in India. Fertility and sterility. 2008;90(Supplement):S152.
v) Hirano Y, Shibahara H, Shimada K, Suzuki T, Takamizawa S, Suzuki M. Clinical role of transvaginal hydrolaparoscopy for
the diagnosis of early stage endometriosis. Fertility and sterility. 2008;90(Supplement):S441.
3. ESHRE 2015 (3)
i) Chu J, Harb HM, Gallos ID, Dhillon RK, Al-Rshoud FM, Robinson L, et al. Salpingostomy in the treatment of
hydrosalpinx: a systematic review and meta-analysis. Hum Reprod. 2015;30(Supp 1):i448.
ii) Wang XR, Bao HC, Hao CF. Core-pulling Salpingectomy: A Novel Surgical for Hydrosalpinx before IVF-ET. Hum
Reprod. 2015;30(Supp 1):i33-4.
iii) Lind T, Olofsson JI, Holte J, Hadziosmanovic N, Berglund L, Gudmundsson J, et al. Reduced clinical pregnancy rates by
ART in women with a history of unilateral oophorectomy. Results of a large multi-center cohort study. Hum Reprod. 2015;30(Supp
1):i33.
Total = 10 abstracts
Appendix 17. Reference lists of included trials and related reviews

1. Boer-Meisel, ME, te Velde, ER, Habbema, JD & Kardaun, JW 1986, ’Predicting the pregnancy outcome in patients treated for
hydrosalpinx: a prospective study’, Fertil Steril, vol. 45, no. 1, Jan, pp. 23-29.
2. Vasquez, G, Boeckx, W & Brosens, I 1995, ’Prospective study of tubal mucosal lesions and fertility in hydrosalpinges’, Hum Reprod,
vol. 10, no. 5, May, pp. 1075-1078.
3. Marcoux, S, Maheux, R & Berube, S 1997, ’Laparoscopic surgery in infertile women with minimal or mild endometriosis. Canadian
Collaborative Group on Endometriosis’, N Engl J Med, vol. 337, no. 4, Jul 24, pp. 217-222.
4. Hughes, EG, Fedorkow, DM & Collins, JA 1993, ’A quantitative overview of controlled trials in endometriosis-associated infertility’,
Fertil Steril, vol. 59, no. 5, May, pp. 963-970.
5. Parazzini, F 1999, ’Ablation of lesions or no treatment in minimal-mild endometriosis in infertile women: a randomized trial.
Gruppo Italiano per lo Studio dell’Endometriosi’, Hum Reprod, vol. 14, no. 5, May, pp. 1332-1334.
6. Bontis JN, Dinas KD. Management of hydrosalpinx: reconstructive surgery or IVF? Ann NY Acad Sci 2000;900:260 -71.
7. Murray DL, Sagoskin AW, Widra EA, Levy MJ. The adverse effect of hydrosalpinges on in vitro fertilization pregnancy rates and
the benefit of surgical correction. Fertil Steril 1998;69:41-5.
8. Sagoskin AW, Lessey BA, Mottla GL, Richter KS, Chetkowski RJ, Chang AS, et al. Salpingectomy or proximal tubal occlusion of
unilateral hydrosalpinx increases the potential for spontaneous pregnancy. Hum Reprod 2003;18:2634 -7.
9. Nackley AC, Muasher SJ. The significance of hydrosalpinx in in vitro fertilization. Fertil Steril 1998;69:373-84.
10. Strandell A, Lindhard A. Why does hydrosalpinx reduce fertility? The importance of hydrosalpinx fluid. Hum Reprod 2002;17:
1141-5.
11. Eytan O, Azem F, Gull I, Wolman I, Elad D, Jaffa AJ. The mechanism of hydrosalpinx in embryo implantation. Hum Reprod
2001;16:2662-7.
12. Bildirici I, Bukulmez O, Ensari A, Yarali H, Gurgan T. A prospective evaluation of the effect of salpingectomy on endometrial
receptivity in cases of women with communicating hydrosalpinges. Hum Reprod 2001;16:2422- 6.
13. Zeyneloglu HB. Hydrosalpinx and assisted reproduction: options andrationale for treatment. Curr Opin Obstet Gynecol 2001;13:
281-6.
14. Dechaud H. Hydrosalpinx and ART: hydrosalpinges suitable for salpingectomy before IVF. Hum Reprod 2000;15:2464-5
15. Choe J, Check JH. Salpingectomy for unilateral hydrosalpinx may improve in vivo fecundity. Gynecol Obstet Invest 1999;48:285-
7.
16. Barmat LI, Rauch E, Spandorfer S, Kowalik A, Sills ES, Schattman G, et al. The effect of hydrosalpinges on IVF-ET outcome. J
Assist Reprod Genet 1999;16:350-4.
17. Camus E, Poncelet C, Goffinet F, Wainer B, Merlet F, Nisand I, et al. Pregnancy rates after in-vitro fertilization in cases of tubal
infertility with and without hydrosalpinx: a meta-analysis of published comparative studies. Hum Reprod 1999;14:1243-9.
17 articles identified

Appendix 18. Data extraction
The following information was extracted from the studies selected for the review:
Trial characteristics
1. Method of randomisation
a. Third-party randomisation: e.g. computer, telephone randomisation.
b. True randomisation by trialist: e.g. sequentially numbered, sealed, opaque envelopes, register, on-site computer system.
c. Method not stated.
2. Study design
a. Cross-over or parallel design.
b. Duration of follow up.
c. Type of follow up.
3. Size of the studies

a. Number of women recruited.
b. Number of women randomised.
c. Number of women excluded.
d. Number of women analysed.
e. Number of women lost to follow up.
f. Details of drop-outs given.
g. Duration of follow up.
4. Study setting
a. Single or multi- centred.
b. Location.
c. Timing.
5. Analysis
a. Sample size with power calculation.
b. Whether or not analysed by intention-to-treat:
b1. done;
b2. not done, but possible;
b3. not possible;
b4. uncertain.
6. The extent to which the Consolidated Standards of Reporting Trials criteria (CONSORT) are met.
Characteristics of the study participants

a. Subfertile couples with at least one year’s duration of infertility.
b. Females under forty years of age.
c. Minor/grade I, moderate/grade II, or severe/grade III tubal damage confirmed prior to tubal surgery by means of HSG or laparoscopy.
d. Women who have had tubal surgery for minor/grade I, moderate/grade II, or severe/grade III tubal damage carried out following
investigation.
1. Baseline characteristics
a. Age of the female partner.
b. Primary or secondary infertility.
c. Duration of subfertility.
d. Previous fertility treatment.
2. Interventions used
a. Tubal surgery.

b. Expectant management.
c. IVF.
Outcomes
1. Primary
Cumulative livebirth rate per couple.
2. Secondary
a. Cumulative pregnancy rate per patient/couple.
b. Pregnancy rate per patient/ couple.
c. Livebirth rate per treatment cycle commenced.
d. Ectopic pregnancy rate per patient.
e. Multiple pregnancy rate per patient.
f. Incidence of OHSS per patient.
All assessments of trial quality and data extraction will be independently performed by three review authors (SJ, VA, BM) using forms
designed according to Cochrane guidelines. Any discrepancies will be resolved by a senior review author (BM). Additional information
on trial methodology or actual original trial data will be sought from the corresponding authors of trials which appear to meet the
eligibility criteria but are unclear in aspects of methodology, or where the data are in a form unsuitable for meta-analysis.
Analysis
Should suitable trials become available in future, statistical analysis will be performed in accordance with the guidelines developed
by the Gynaecology and Fertility group. Heterogeneity between the results of different studies will be examined by inspecting the
scatter in the data points and the overlap in their confidence intervals and, more formally, using I2 tests. The possible contribution
of differences in trial design to any heterogeneity identified in this manner, will be investigated. Where possible, the outcomes will be
pooled statistically.
For cross-over trials, only the data from the first phase (i.e. before cross-over) will be used.
For dichotomous data (e.g. pregnancy rate), results for each study will be expressed as an odds ratio with 95% confidence interval and
combined for meta-analysis where appropriate, with RevMan software using the Peto-modified Mantel-Haenzel method. If possible, a
sub-group analysis will be performed to assess the clinical effectiveness of tubal surgery in women with grades I, II and III tubal damage
separately. Sensitivity analysis will be undertaken to examine the stability of the results in relation to a number of factors including
study quality and the source of the data.
Time line
The review is expected to be updated within two years of publication on the Cochrane Library or earlier should a seminal piece of
research become available. New searches for RCTs will be performed every two years thereafter, and the review updated accordingly.
WHAT’S NEW
Date Event Description
16 January 2017 New search has been performed The background and methods sections have been up-
dated to current Cochrane standards
16 January 2017 New citation required but conclusions have not changed New searches did not identify any studies eligible for
inclusion

HISTORY
Date Event Description
14 April 2008 Amended Converted to new review format
3 March 2008 New search has been performed Contact details updated
15 November 2006 New citation required and conclusions have changed Substantive amendments made
CONTRIBUTIONS OF AUTHORS
Su Jen Chua: literature search, data extraction, trial selection, quality assessment, data entry and analysis, writing of the first draft of
the review.
Valentine Akande: development of the protocol, commenting on the draft of the review.
Ben Mol: trial selection, quality assessment, revising of the final draft of the review.
DECLARATIONS OF INTEREST
BM has received payment for consultancy from biopharmaceutical company ObsEva Geneva. SC and VA have no interests to declare.
SOURCES OF SUPPORT
Internal sources
• Robinson Research Institute, Adelaide, Australia.
External sources
• None, Other.
DIFFERENCES BETWEEN PROTOCOL AND REVIEW

For the 2016 update, we ensured that the definition of clinical pregnancy was consistent across review outcomes.

INDEX TERMS
Medical Subject Headings (MeSH)

Fallopian Tube Diseases [∗ surgery]; Fallopian Tubes [∗ surgery]; Fertilization in Vitro; Infertility, Female [∗ surgery]; Watchful Waiting
MeSH check words

Female; Humans


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Cochrane Database of Systematic Reviews

Surgery for tubal infertility (Review)

Chua SJ, Akande VA, Mol BWJ

Chua SJ, Akande VA, Mol BWJ.

Surgery for tubal infertility (Review)

Surgery for tubal infertility (Review) i

Surgery for tubal infertility

Su Jen Chua1 , Valentine A Akande2 , Ben Willem J Mol3

Editorial group: Cochrane Gynaecology and Fertility Group.

We identified no suitable randomised controlled trials.

PLAIN LANGUAGE SUMMARY

BACKGROUND classification (2002) is a simple classification system that separates

Surgery for tubal infertility (Review) 3

Surgery for tubal infertility (Review) 4

Surgery for tubal infertility (Review) 5

Surgery for tubal infertility (Review) 6

Surgery for tubal infertility (Review) 7

Surgery for tubal infertility (Review) 8

Overall quality of the body of evidence - ’Summary of

Potential biases in the review process

Surgery for tubal infertility (Review) 9

Surgery for tubal infertility (Review) 10

Surgery for tubal infertility (Review) 12

Characteristics of excluded studies [ordered by study ID]

Study Reason for exclusion

Surgery for tubal infertility (Review) 13

Appendix 1. Gynaecology and Fertility Group Specialised Register

Appendix 2. CENTRAL CRSO search strategy

Appendix 3. MEDLINE search strategy

Surgery for tubal infertility (Review) 16

Surgery for tubal infertility (Review) 17

Appendix 5. PsycINFO search strategy

Appendix 6. CINAHL search strategy

S57 S44 AND S56 200

S56 S45 OR S46 OR S47 OR S48 OR S49 OR S50 OR S51 OR 1,081,306

S55 TX allocat* random* 5,281

S54 (MH “Quantitative Studies”) 14,919

S53 (MH “Placebos”) 9,827

S52 TX placebo* 39,650

S51 TX random* allocat* 5,281

S50 (MH “Random Assignment”) 41,699

S49 TX randomi* control* trial* 110,746

S48 TX ( (singl* n1 blind*) or (singl* n1 mask*) ) or TX ( (doubl* 857,082

Surgery for tubal infertility (Review) 19

S47 TX clinic* n1 trial* 190,012

S46 PT Clinical trial 79,719

S45 (MH “Clinical Trials+”) 203,397

S44 S22 AND S43 1,006

S43 S23 OR S24 OR S25 OR S26 OR S27 OR S28 OR S29 OR 539,009

S42 TX salpingo neostom* 0

S41 TX recanalisation or TX recanalization 1,140

S40 TX salpingostomy or salpingectomy 231

S39 TX recanalizing or TX recanalising 17

S38 TX lysis N2 adhesion* 67

S37 TX reconstruction 19,742

S36 TX adhesiolysis 129

S34 TX tubo-cornual anastomosis 0

S33 TX excision 9,388

S31 (MM “Microsurgery+”) 1,269

S30 TX Laparotomy 4,259

S48 TX ( (singl* n1 blind) or (singl n1 mask) ) or TX ( (doubl 857,082

“fallopian tube disease” or ((“gynecologic surgical proce- ((randomi NEAR/1 “con-

“fallopian tube disease” or ((“gy- ((randomi NEAR/1 “con- Pregnan* OR birth*