Infertility surgery: microsurgery.

Tubal and peritoneal factors continue to be a leading cause of infertility. In vitro fertilization, operative laparoscopy, and microsurgery are alternatives, but they are frequently complimentary therapeutic approaches. Proper investigation is the key to select the primary treatment modality. A well-performed hysterosalpingography is most valuable in the initial assessment of the tubes and uterus. Hysterosalpingosonography, radionuclide hysterosalpingography, and falloposcopy are experimental investigative tools that may be useful in selected circumstances. Effective adjuvants to reduce postoperative adhesions continue to elude the surgeon and new substances are being experimented with. In proximal tubal obstruction, selective salpingography and tubal catheterization may differentiate cornual spasm from pathologic tubal occlusion and may be therapeutic when viscous material or endotubal synechia are the cause of obstruction. Microsurgery remains the effective approach for significant lesions such as salpingitis isthmica nodosa, endometriosis, obliterative fibrosis, and chronic follicular salpingitis. Distal tubal occlusion is amenable to treatment via either laparoscopy or microsurgery. The functional status of the oviduct appears to be the most important prognostic factor in subsequent pregnancy outcome.