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【medical-news】输卵管复通 vs. IVF：哪个是最佳选择
By Susan Conway M.D., M.P.H., M.M.Sc.
Sterilization is the most common contraceptive method utilized by couples in the United States. Approximately 27% of fertile women choose tubal sterilization as their method of contraception. About half of these surgeries are performed within 48 hours post-partum and the other half as interval procedures remote from a pregnancy. The procedures are meant to be permanent and most women enter into the decision with a sincere intention to prevent additional pregnancies.
But life is full of surprises. Circumstances change, relationships change and familybuilding goals may change accordingly. Despite having consented to permanent sterilization, up to 14.3% of sterilized women request information regarding fertility options within 14 years of the procedure. What are the options couples who desire pregnancy following tubal sterilization?
The answer to that question is as varied as the couples asking it. Many factors may influence the decision-making process. Generally speaking, the categorical options are either surgery to reverse the sterilization (tubal reversal) or in vitro fertilization(IVF). Which process is the least expensive? Which is the easiest and least risky?Which is the best choice based on female age? Most importantly, which is the most likely to result in a successful conception?
Tubal Reversal
In most instances the technique is an outpatient or “short-stay” procedure using a small abdominal incision and micro-surgical techniques to restore the connection between the interrupted tubal segments. As with any surgery, there are risks involved including infection, poor tissue healing, further damage to the fallopian tubes, uterus or ovaries as well as other surrounding tissues, and anesthetic complications. Furthermore, one must consider the post-operative recovery period and time off from work, usually relatively minimal but possibly prolonged. Each patient must determine these risks with her surgeon based on her individual circumstance. Keep in mind that the tubes will always be somewhat damaged following any type of surgery and the risk of ectopic (tubal) pregnancy is ever present. If a reversal is successful there is also the need to again consider postpartum contraception options.
Not all types of tubal sterilizations are reversible. If the remaining fallopian tube segments are not healthy due to previous damage or the segments are extremely short, successful reversal is not feasible. Some types of tubal sterilizations are not technically reversible such as distal fimbriectomy and trans-cervically placed proximal coils (Essure). Others, such as the Irving and Uchida techniques or those in which very large tubal segments were damaged or removed, may be technically reversible but the observed post-operative pregnancy rates are so dismally low that most surgeons do not recommend attempting it. Therefore, it is extremely important to know what sort of sterilization procedure was performed when considering surgery. Patients should obtain a copy of their sterilization operative note and pathology report (if tubal segments were removed) for review with their surgeon. A semen analysis for the male partner should always be done prior to surgery; if the findings are significantly abnormal, tubal reversal is extremely unlikely to result in a successful conception. Ruling out a significant male factor avoids unnecessary and costly surgery with its attendant risks.
The cost of tubal reversal is widely variable depending on the surgeon, hospital and region. Insurance policies very rarely cover the procedure. In some areas, the cost of tubal reversal exceeds IVF which then directly affects the procedure’s availability. In other areas, surgeons performing tubal reversals have set up high-volume outpatient surgery clinics which allow costs to be kept to a relative minimum. Keep in mind that the experience of the surgeon is critical to the likelihood of success. Microsurgery requires extensive further training beyond a general OB-GYN or surgery residency; look for a surgeon with such training and experience.
IVF
In vitro fertilization has become the dominant technique for achieving pregnancy in women with abnormal or blocked fallopian tubes. Since its introduction in the late 1970’s, the technique has been refined, success rates have improved dramatically and its use is now applied to many additional fertility problems such as severe male factor and unexplained infertility. In essence, the technique involves intentionally hyper-stimulating the ovaries, obtaining the oocytes via needle-aspiration, combining them with the sperm in the laboratory and selection among resultant embryos for transfer back to the uterus. The events which ordinarily occur in the fallopian tubes thus occur in the laboratory, providing a sort of “tubal bypass”. IVF allows selection of the healthiest embryos for transfer and often a choice among several embryos. It is less invasive than surgery and associated post-procedure down-time is minimal. Its greatest risks are ovarian hyperstimulation syndrome (occurring in 1-5% of patients) and multiple gestations.
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作者:admin@医学,生命科学 2011-06-28 05:45
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