Practical Training and Research in Gynecologic Endoscopy

 Tubal endoscopy

A.G. Gordon
Honorary Consultant Gynaecologist, Princess Royal Hospital, Saltshouse Road,
Hull HU8 9HE
Consultant Gynaecologist, BUPA Hospital Hull and East Riding, Lowfield Road, Anlaby,
Hull HU10 7AZ

I.W. Scudamore
Lecturer, Sheffield University & Department of Obstetrics & Gynaecology,
Jessop Hospital for Women,
Sheffield S3 7RE United Kingdom

INTRODUCTION

The importance of tubal obstruction as a major cause of infertility was recognised by Burns in 1809 (1). Since that time a number of methods of demonstrating tubal blockage have been described (2). These include transcervical insufflation with gas, radiopaque or echogenic contrast media, hydrotubation with dye controlled by laparoscopy or ultrasound and demonstrating migration of micro-spheres of albumin along the oviduct. Patency may also be confirmed by cannulation which can be performed blindly or under hysteroscopic, ultrasonic or fluoroscopic guidance.

It is generally accepted that hysterosalpingography (HSG) should be the initial test of tubal function in the investigation of infertility. However, if investigation is limited to HSG and laparoscopy, proximal tubal obstruction (PTO) may be overdiagnosed and consequently overtreated (3,4). The importance of accurate assessment of the proximal tube cannot be overstated.

There may be discrepancies between the findings at HSG, laparoscopy and intraluminal endoscopy in the presence of peritubal adhesions or endometriosis (5). Patency of the distal tube does not necessarily equate with normality of the mucosa and pathological lesions may be missed if more accurate methods of tubal assessment are not employed.

Contrast sonosalpingography using Dextran or iso-tonic saline has the advantage over HSG of not using radiation (6). The site of blockage can be ascertained more accurately with colour Doppler and SH U 454 as the contrast medium (7).

The first attempts at transvaginal endoscopic examination of the fallopian tube were made by Mohri in Japan in 1970 (8). Technical limitations and the thickness of the endoscope (2.4mm) prevented cannulation beyond 3cm in most of his cases. Using modern fibroptic systems falloposcopy allows assessment of the mucosa of the proximal and usually also the distal segments of the fallopian tube. The condition of the mucosa may yield information that relates to the prospect of successful pregnancy.

Transabdominal salpingoscopy allows a detailed assessment of the ampullary tubal mucosa. The first description by Henry-Suchet (9) was of "tuboscopy" performed at laparotomy during tubal reconstructive surgery. Cornier (10,11) utilised a 3.4mm flexible bronchoscope and Brosens (12,13) used a rigid salpingoscope which were introduced through an operating laparoscope to examine the ampullary mucosa.

The gross appearance of the tubal mucosa has been correlated with light and electron microscopy (14) and appears to be of value in the assessment of patients with (15) and without (16) other evidence of tubal disease.

INDICATIONS FOR TUBAL ENDOSCOPY

Tubal endoscopy either by the transvaginal or laparoscopic approach is indicated in the following conditions:

1. Proximal tubal disease.

Falloposcopy may be used in the investigation of the status of the proximal tubal segments. It is usually performed as an out-patient procedure avoiding the need for anaesthesia. In patients in whom HSG suggests the presence of obstructive (PTO) or non-obstructive proximal tubal disease falloposcopy may accurately define the site and nature of the lesion.

In addition to its value in assessing the proximal tubal segment it also has a potential for effecting recanalisation and tuboplasty in cases of (PTO).

In untreated PTO, transabdominal salpingoscopy is the only technique which allows examination of the distal tubal segment prior to reconstructive tubal surgery. Lesions of the ampullary mucosa have been seen in 50% of cases of PTO and restoration of patency in these cases results in a 60% pregnancy rate (17).

2. Pelvic Inflammatory Disease (PID) affecting the distal tubal segments.

In cases of suspected PID the mucosa of the distal segments may also be assessed by falloposcopy but salpingoscopy allows better visualisation and also allows assessment of the peritubal structures.

Pelvic inflammatory disease is frequently associated with lesions in the ampullary tubal mucosa. Peritubal and periovarian adhesive disease cause distal tubal blockage. The damage to the tubal mucosa may be a secondary feature (18). While the presence of peritubal adhesive disease may suggest intratubal damage, the correlation between the external and internal appearances of the tube is poor. The degree of damage to the tubal mucosa may be used to predict the possibility of intrauterine or ectopic pregnancy prior to performing neosalpingostomy. Mild adhesive disease may be associated with severe mucosal damage and there may be marked differences between the degree of involvement of the two tubes (13). It is essential, therefore, to examine the full length of the ampulla of both tubes to ascertain the degree of mucosal damage.

3. Endometriosis.

Endometriosis may be associated with adhesive disease and the tube is frequently involved in severe endometriosis. There may also be distal tubal obstruction with hydrosalpinx formation. The tubal obstruction is more often caused by compression or stricture than by mucosal adhesions. Salpingoscopy in endometriosis usually reveals a normal mucosal architecture.

4. Ectopic pregnancy.

The prevalence of recurrence of ectopic pregnancy after conservative surgery depends on the underlying disease rather than the operative technique. Scoring systems have been described to determine the choice between conservative and radical surgery (19). The appearance of the tubal mucosal folds of the contralateral tube, or the ipsilateral mucosa if there is no bleeding, should also be taken into account. Since the mucosal morphology is not always related to the extent of the external tubal disease, salpingoscopy or falloposcopy allow a more rational approach to the selection of treatment and evaluation of the prognosis. Tubal endoscopy is also recommended in the investigation of patients with a history of a previous ectopic pregnancy.

5. Unexplained infertility.

Tubal mucosal lesions may be detected in patients whose fallopian tubes appear normal and patent at laparoscopy or HSG.

6. Prior to assisted fertilisation.

Endoscopy may be used to confirm tubal normality in cases where intrauterine insemination or gamete or early embryo transfer to the tube are being considered.

TECHNIQUES OF INTRA-LUMINAL TUBAL ENDOSCOPY.

Inta-luminal tubal endoscopy may be performed by the transvaginal (falloposcopy) or transabdominal (salpingoscopy) approach.

1. FALLOPOSCOPY

Modern technological advances have enabled the development by Kerin in 1989-1990 of endoscopes with greatly improved optical properties and yet outer diameters of as little as 0.5mm (20,21).

Instruments.

The coaxial technique of falloposcopy described by Kerin (20,21) required hysteroscopically directed tubal cannulation with a flexible guide-wire (OD 0.3-0.8mm) followed by serial passage of a Teflon cannula (OD up to 1.3mm) over the guide-wire. The guide-wire was then removed and the falloposcope passed down the lumen of the Teflon cannula. Irrigation with Ringer's Lacate solution facilitated movement of the endoscope within the cannula and lifted the tubal mucosa of the lens allowing better vision. The best way to view the tubal lumen was to visualise while the endoscope and cannula during withdrawal.

The Linear Eversion Catheter (LEC) system (Imagyn Medical Inc., San Clemente, Califirnia, USA) utilises a pressurised tubular polyethylene balloon which can be unrolled from within a plastic polymer cannula after having the falloposcope preloaded into its lumen. The balloon carries the endoscope into and along the tube, protecting the tube and endoscope from damaging one another and negotiating the curves and strictures without exerting shearing forces on the tubal wall (22). Reliable atraumatic cannulation is achieved because, if the balloon is correctly placed, it will follow the path of least resistance, that is into the fallopian tube. Furthermore, the catheter design simplifies the procedure which does not require the multiple manoeuvres of the co-axial technique. The LEC system may be used without hysteroscopic control (23,24). Altering the pressure within the tubular balloon as the balloon is advanced enables it to be carried into and along the tube.

Technique.

The technique involves approximation of the catheter tip to the utero-tubal ostium, direct visualisation of the ostium and/or the "utero-tubal gutter" using the endoscope advanced to the end of the catheter and then advancement of the balloon into the tube. The endoscope is always kept within the balloon during eversion because this cushions the sharp end of the endoscope and protects the tubal mucosa and the endoscope from damage. If cannulation is successful the balloon should advance easily for 1-2cm. The endoscope can then be brought forward to the tip of the balloon to confirm its positioning within the tube. Advancement of the balloon and endoscope can then proceed in a step-wise manner. An understanding of the relationship of the tip of the balloon to the tip of the endoscope as the two are moved along the tube is fundamental to the procedure.

As the balloon has a double layered wall the endoscope moves forwards at twice the speed of the balloon tip. It is crucial to keep the endoscope tip behind the balloon during eversion. Hence it is important to move forward in a co-ordinated series of 1-2cm steps with the endoscope being withdrawn 1-2cm each time it reaches the balloon tip. This requires a good understanding of the mechanism of hydraulic pressure in the balloon. The pressure in the balloon needs to be raised in order to advance the balloon tip. This "grips" the endoscope preventing movement independent of the balloon and so the pressure needs to be reduced each time the endoscope is withdrawn within the balloon. Flushing the lumen with a crystalloid solution assists in the advancement of the endoscope by providing lubrication.

If there is difficulty in everting and advancing the balloon, the balloon tip should be identified visually with the endoscope which is then withdrawn a little and used to support the pressurised balloon thus aiding its advancement. Attempting to force the advancement of the balloon and endoscope may damage the balloon, the endoscope or the wall of the fallopian tube. If performed properly, the technique allows cannulation to a distance of 10cm. Tubal damage is unlikely unless the endoscope is allowed to project beyond the balloon during eversion because the balloon exerts no shear force on the tubal wall.

Imaging of the tube is easiest during withdrawal of the endoscope. As the balloon and endoscope are withdrawn along the tube the tip of the endoscope is kept approximated to the tip of the balloon. Once again the balloon tip will move at twice the rate of the endoscope. Less pressure is needed within the balloon during withdrawal and so, by flushing with a saline solution simultaneously, it is possible to constantly wind forward the endoscope during withdrawal at a rate which keeps the tips of the balloon and endoscope approximated to one another. The flush also lifts the tubal mucosa off the endoscope lens allowing better vision. Imaging can be carried out in this way until the endoscope and balloon re-enter the catheter within the uterine cornu.

Findings and classification.

Kerin and his co-workers devised a classification of tubal disease from their experience of using the co-axial technique in 112 tubes from 75 women (25). All were suspected of having endotubal disease following HSG and laparoscopic dye assessment. They devised an objective scoring of the tubal condition based on the appearance of the tubal folds, vascularity, dilatation, adhesions and pallor, correlating these scores inversely with the subsequent pregnancy rates (Table 1). This method of scoring the tubal status was based on methods of assessment which were considered as having prognostic significance in the treatment of distal tubal disease by a number of authors (15,21,26,27).

Table 1 : Relationship of tubal score and subsequent pregnancy rates

After Kerin (25)

They found that in 66 patients with evidence of endotubal disease on conventional assessment there was evidence of falloposcopic abnormality in 54% of tubes examined. If the tubal score was used to quantify the degree of disease present, 29% showed evidence of mild/moderate disease and 25% were severely damaged.

Results.

In an unpublished personal series (IWS) of 222 fallopian tubes mostly examined in an out-patient setting in patients with suspected tubal disease, successful cannulation of at least the proximal segment was achieved in 217 (97.7%). In 54 (24.9%) only the proximal segment could be assessed either due to severe proximal disease (68.7%) or factors such as poor patient tolerance or difficulty with balloon and endoscope eversion. Of the 163 (75.1%) tubes in which both the proximal and distal segments were examined, 84 (51.5%) showed of no or mild damage while 79 (48.5%) showed evidence of moderate or severe damage. The tubes considered to have minimal damage are those which might retain their function. These data are consistent with the data previously reported by Kerin (25) of 52/112 (46%) tubes assessed in their series as having "normal" appearances and being considered to have a good prognosis for tubal function. In patients with "unexplained infertility" and "normal" tubes by HSG and laparoscopy, Kerin reported a 20% prevalence of tubal disease (21). In 25 such cases examined personally (IWS) 7 (28%) appeared damaged.

2. SALPINGOSCOPY

Detailed examination of the mucosa of the distal segment of the fallopian tube has an important role in the investigation of infertility. The intact fold structure of the mucosa with its secretory and ciliated cells is essential for normal gamete transport and fertilisation. Pathological lesions in the distal tube are associated with infertility and ectopic pregnancy. The mucosa may show changes such as flattening of the folds, deciliation, fine or dense adhesions, fibrosis and occlusion of the lumen. Flattening of the folds and deciliation occurring in thin-walled hydrosalpinx may be reversible when tubal patency has been restored. Pregnancy can occur after the flattened mucosal folds and stretched myosalpinx have recovered.

Scanning electron microscopy studies have shown that pregnancy can occur in the presence of deciliation and adhesions but the prevalence of tubal pregnancy is 50%. Pregnancy does not occur when there is fibrosis of the ampullary segment (28).

Intruments.

Laparoscopically directed salpingoscopy allows evaluation of the distal tubal segment to become a standard part of the investigation of infertility. The rigid salpingoscope (Karl Storz GmBH & Co., Tuttlingen, Germany) is introduced through the operating channel of the laparoscope (11,12)

The component parts of the salpingoscope are:

1. A 10 or 11mm operating laparoscope.
2. The salpingoscope sheath which is 5mm in diameter and has a Luer connector at the proximal end for a saline infusion. The sheath fits into the operating channel of the laparoscope and protrudes 8cm from the distal end.
3. An obturator with a conical distal end which facilitates introduction of the sheath into the tubal ostium.
4. The salpingoscope which is a 2.8mm diameter telescope, is 5cm longer than the sheath and has a 0o distal lens. The salpingoscope may have a variable proximal lens similar to the Hamou microcolpohysteroscope (Storz) which allows the tubal mucosa to be examined under x60 magnification. The telescope moves freely within its sheath. This allows it to be advanced 5cm beyond the tip of the sheath to visualise the full length of the ampulla.
5. A 500ml bag of normal saline and connecting tubing with which to instill fluid through the sheath and distend the tube.
6. Atraumatic tube-holding forceps which are used to align the tube with the salpingoscope and to grasp it over the salpingoscope to form a water-tight seal.
7. The normal accessory instruments for laparoscopy including light source, fibroptic cables and camera, automatic laparoflator, electrosurgical generator and laser.

Technique.

Standard diagnostic laparoscopy is performed which should include a full, systematic examination of the upper and lower abdomen and the pelvic organs. The uterus should be cannulated with a Spackman cannula to allow it to be manipulated and to perform chromopertubation. At least one secondary trocar and cannula should be inserted to carry ancillary forceps. If there is pelvic adhesive disease, the adhesions should be divided and the adnexa fully mobilised by scissor, electrosurgical or laser dissection. Salpingoscopy can be performed if the distal tube is patent. If the distal tube is blocked, the surgeon has a choice of two techniques which may be performed.

Salpingoscopy without fully opening the distal tube may be performed if the plan is to investigate the status of the tubal mucosa and, if it is suitable for reconstructive surgery, to perform elective laparotomy and microsurgical neosalpingostomy at a later date. The distal tube should be grasped with atraumatic forceps and a small incision made at the star-shaped scar which marks the site of occlusion. The incision may be made with scissors, monopolar microneedle or laser. The salpingoscope may then be introduced through the small opening and the tubal mucosa examined.

If the plan is to proceed to laparoscopic neosalpingostomy if the mucosa is suitable, the initial radial incisions for salpingostomy should be made with a microneedle or laser, the tube opened and examined either at that stage or after completing the formation of the cuff by eversion and coagulating or suturing the serosa.

The technique of salpingoscopy is now the same whether the tube was originally patent or has been opened. It is usually easier to examine the right tube first because the left adnexa are often hidden behind the sigmoid colon. Examination of the left side should always follow. The bowel can be mobilised if necessary to permit access to the tube.

First the instruments must be assembled. The salpingoscope sheath with its obturator is inserted into the operating channel and the saline bag connected to its Luer fitting port. The bag of saline is suspended one metre above the level of the patient's body. Fluid is run through the system to prime it.

The procedure to examine the right tube is as follows:

1. The uterus is anteverted by the assistant using the Spackman cannula. No dye should be introduced at this stage because it would obscure the mucosal folds and make full examination impossible.
2. The surgeon should now lift the right tube and ovary out of the pelvis using the atraumatic forceps.
3. When the right adnexa have been lifted and are lying above the level of the uterine body the assistant should retrovert the uterus, rotate it through 90 degrees and displace the fundus into the right ovarian fossa. The adnexa should now lie on the anterior surface of the uterus. The tube should be lateral to the ovary and the fimbriae ovaricae can be clearly seen.
4. The surgeon gently manipulates the right tube until it is aligned with the laparoscope. The fimbrial opening may be found by following the fimbriae ovaricae from the ovary towards the tube. The ostium is close to the antimesenteric border. The tip of the laparoscope is now brought close to the tube and the salpingoscope sheath slowly advanced out of the operating channel towards the fibriae.
5. When the tip of the sheath is seen to enter the fimbrial opening, the atraumatic tube-holding forceps are used to gently draw the tube over the sheath. When the sheath is securely in the tube the forceps are closed over the full circumference of the tube and sheath to form a water-tight seal. The position of the sheath within the tube can be confirmed by opening the stop-cock and allowing saline to flow into the tube which may be seen to distend. This must be closed again before the next step.
6. The obturator should be withdrawn and the salpingoscope inserted into the sheath. The light cable and camera are transferred from the laparoscope to the salpingoscope and the saline infusion commenced. An image of the distal end of the sheath and the tubal mucosa should appear on the screen.
7. Under direct visual control the salpingoscope is advanced out of its sheath into the tubal infundibulum and along the ampulla. The ampulla normally has one or two bends in its lumen but with care these can be negotiated and the full length of the segment examined as far as the isthmo-ampullary junction.
8. Proximal tubal patency can be confirmed by chromopertubation with dilute methylene blue dye. The dye can be seen to pass along the tube and stain the mucosa.

Findings.

1. Normal structure
   The infundibulum has a concentric structure of folds. In the normal tube the folds are well formed and move freely in the distending fluid. In the ampulla there are 4-6 major folds each about 4mm in height. Accessory folds arise from their sides giving a complex appearance. On high power examination the accessory folds are seen to be well vascularised but neither the cellular pattern nor the cilia can be visualised. Several minor folds each about 1mm in height lie between the major folds.
   When the junction of ampulla and isthmus is reached the major folds give way to three or four rounded folds each about 0.2-0.4mm in height which continue into the isthmic segment. The fluid in the ampulla may be turbid with flocculent material particularly when salpingoscopy is performed around the time of menstruation.
2. Tortuous tube.
   Occasionally a convoluted or tortuous tube may be seen. The folds are flattened and the tubal wall appears very thin. Cannulation may be difficult when the infundibular folds are complex and the tortuous lumen may prevent progress through the ampulla. This abnormality is probably due to herniation of the tubal mucosa through areas where the myosalpinx is deficient. The abnormality may involve part of or the whole ampulla. It may be erroneously interpreted as hydrosalpinx at HSG. It is not believed to be a cause of infertility as it is found in parous women.
3. Accessory ostia.
   Occasionally an accessory ostium is seen on the antimesenteric border of the tube. More rarely the accessory ostium is not patent in which case an oocyte could be trapped in it and unable to reach the tubal lumen.
4. Vascular abnormalities.
   Vascular abnormalities of the small vessels in the folds have been described but their significance is uncertain (29). Marked vascularisation with haemorrhagic spots are suggestive of chronic inflammation.
5. Adhesions and fibrosis.
   The most significant abnormal findings are adhesions and fibrosis of the tubal walls. Filmy adhesions may be found between otherwise normal folds. They are avascular and may be focal or diffuse. Thick fibrous vascularised adhesions may produce distortion of the fold structure. They are usually extensive and involve the whole ampulla. Fibrosis is the end result of a chronic severe infectious process and results in a rigid tubal wall with complete loss of the normal fold pattern. These changes have been classified as follows (12):

• Grade 1Normal fold pattern
• Grade 2Separation and flattening of major folds
• Grade 3Peripheral filmy and focal adhesions
• Grade 4Fibrous adhesions across more than 50% of the lumen
• Grade 5Fibrosis of the tubal walls with loss of the fold system

Results.

In a series of 227 laparoscopic salpingoscopies performed by one of the authors (AGG), the tubes were recorded as externally normal in 160 patients. At salpingoscopy, three of these were noted to have minor abnormalities (1.8%). One of these patients had had a previous ectopic pregnancy so may have been suspected to have a mucosal abnormality. When salpingoscopy was performed on the 67 patients with adhesive disease, which included both distal tubal obstruction and peritubal adhesions, 30 had a normal tubal mucosa and 37 (55%) had mucosal abnormalities.

In a series described by Heylen (28), 232 salpingoscopies were performed on 158 patients at the time of diagnostic laparoscopy for infertility. The cumulative pregnancy rates are shown in Table 2.

Table 2 :

DISCUSSION

Using the LEC system falloposcopy allows direct visualisation of the proximal segment and provides an atraumatic approach to tubal recanalisation in the presence of apparent proximal tubal disease. This results in a high rate of tubal cannulation in these patients (30,31). The proximal segments of both tubes can be examined and compared (32) as can the distal segments in most patients. In addition to providing a technique of proximal tubal assessment, the falloposcope has a role to play in tuboplasty in cases of PTO (23,30,33). Intratubal lesions may be identified by falloposcopy when the HSG appearances are normal as well as a healthy appearance where damage is suspected (34).

Salpingoscopy enables a more specific assessment of the distal tubal mucosa, further refining the prediction of successful tubal function (9,12,26). The salpingoscopic appearances appear to be of value in the assessment of patients with (15) or without (16) other evidence of tubal disease. Blinded comparitive studies of falloposcopy and salpingoscopy show good correlation between the two techniques in the assessment of tubal damage and consequently in the prognosis of tubal function (35).

Tubal endoscopy has a role to play in the fine assessment of tubal disease and should be part of the protocol for investigating patients with PTO, PID, ectopic pregnancy, unexplained infertility and prior to tubal surgery and some forms of assisted conception, thus avoiding unnecessary surgery in these cases.

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