Introduction

In 270 infertility patients seen between 1990 and 1991 in a private gynaecological practice, two-thirds had pelvic disease requiring surgery (personal series). Sixty percent of the patients became pregnant subsequent to surgery for pelvic adhesions, endometriosis, tubal blockage, fibroids, adenomyosis, and uterine intracavity polyps, fibroids or adhesions. In contrast, only 12% of male infertility can be treated by surgery (Hudson, Baker and de Kretser, 1980).

Infertility surgery rarely requires laparotomy, most procedures being performed by laparoscopy, hysteroscopy and, more recently, falloposcopy. The last three techniques are used both to diagnose and treat the cause of infertility. Diagnostic laparoscopy is being simplified by the development of finer laparoscopes, the new 2-mm-diameter micro laparoscope requiring much smaller incisions and less anaesthesia and allowing quicker patient recovery (Downing and Wood, 1995).

Tubal surgery

A variety of procedures may be performed to overcome tubal infertility. These include fimbrioplasty, salpingostomy, salpingo-ovariolysis, tubotubal anastomosis, uterotubal anastomosis, and tubal cannulation.

The principles of tubal surgery include the following.

1. Reduction of tissue trauma by atraumatic techniques using fine instruments and keeping tissue surfaces moist.

2. Complete haemostasis reduces the risk of adhesions.

3. Abnormal tissue such as thick adhesions should be excised.

4. Tissue planes must be realigned in the normal anatomical position.

5. Magnification enables the surgeon to define the anatomy and pathology more precisely and facilitates the application of the above principles. It also enables the surgeon to use fine instruments and fine sutures.