MANAGEMENT OF TUBAL INFERTILITY
G. de Candolle and *J. Bouquet de Jolinière
The aim of this paper is to review the available methods of evaluation and management of tubal infertility. The different diagnostic tools will be described together with discussion of the different surgical approaches. Finally a clinical approach is suggested, which of course should be adapted to the possibilities of each centre.
Tubal infertility includes the changes due to inflammation which affect the fallopian tube and its relation towards the ovary in a way that will affect ovulation, the transport of the egg, sperm, or embryo, or alter the function of the tube as the site of fertilization. Tuboperitoneal disease may result from genital tract infection (e. g. chlamydia) and less frequently from extratubal inflammation (e. g. appendicitis, peritonitis), previous surgery, or from endometriosis. Another special group with tubal infertility consists of those patients who desire reversal of their tubal sterilization.
The diagnosis of tubal patency based on X-ray or laparoscopic findings is not considered a complete or an absolute diagnosis.
X-ray gives an idea about the size and shape of the uterine cavity, the isthmus and the cervical canal when viewing anteroposterior or profile films. In some cases it may be necessary to obtain an oblique view in order to analyze the uterine wall. Starting with the intramural portion and ending with the ampulla, the tubal morphology should be analyzed for the calibre of its lumen, presence of any mucosal folds or any sign of thickening or rigidity of the tubal wall. Finally the tubal patency can be evaluated and the radio-opaque dye spills may suggest adhesion or the presence of an adnexal mass.
Laparoscopy provides useful information on the external aspect of the uterus, its size, shape and the appearance of the serosa suggesting the presence of a former inflammatory process. The cornua should be inspected very carefully, looking for signs of rigidity, abnormal surface vessels, thickening of the cornua or isthmic part of the tube due either to endometriosis or post infectious changes. The extreme pathology is described as salpingitis isthmica nodosa. Adhesions should be looked at, described and classified; from gross adhesions fixing the adnexa in the pouch of Douglas to filmy ones including those limited to the end of the ampulla. When injecting the blue dye, particular attention should be given at the pressure which has to be applied to obtain a passage, as it gives information about the resistance exerted by the intramural and the isthmic portions of the tube. Damage at this level is often missed by the inexperienced laparoscopist. Any dilatation or stricture of the tubal lumen should be recorded. Ovaries should be inspected for the presence of cysts or endometriotic implants. Finally the peritoneal surface is assessed by looking for any evidence of endometriosis, especially subtle and atypical lesions which have been shown to be particularly active.
Tuboscopy by anterograde or retrograde route is under evaluation in several centres. Its usefulness in the evaluation and even treatment of tubal disease has been evident even if technical problems remain to be solved before introducing it as a routine tool.
A useful tool in the assessment of tubal and adnexal damage is provided by scoring systems described by several authors. These scores usually take into account not only the anatomic changes, but also the age of the patient. Special attention should be given to associated infertility factors such as ovulatory disturbances or male infertility. The final aim is not only to restore tubal function, but also to get the patient pregnant.
Endometriosis is usually scored by the revised American Fertility Society score (1) even if this system was claimed to be imperfect or has raised major controversies, especially in Europe. The major advantage of all these scores is the possibility to describe lesions in the same way in different centres and consequently to evaluate the results of different treatment schemes.
The evaluation of the infertile couple will often need X-ray and laparoscopy, especially if no other major cause of infertility has been diagnosed. This very careful assessment of the female internal genitalia would minimize the number of couples being classified as having unexplained infertility and moreover it would overcome the problem of underestimating the mechanical factor when combined with other infertility factors, thus leading to better treatment results.
The modern microsurgical approach to tubal reconstruction has nearly doubled pregnancy rates over conventional macrosurgical techniques (2,13).
Site of the disease.
The tubal surgeon can distinguish between the pathological findings according to the site which is affected; thus they can be described as:
The principles of microsurgery are based on good tissue exposure by a large incision, magnification through the operating microscope, and gentle tissue handling. To minimize tissue trauma, glass rods are used for example, thus avoiding any peritoneal and tissue damage which may lead to adhesion formation. Tissues should not be grasped if possible, even with the hand, as latex gloves can provoke peritoneal surface damage and consequently adhesions. Finally, and apart from equipment and principles, the tubal surgeon should have had special training.
Indications for microsurgery.
Results of microsurgical treatment.
Table 1 shows the results of microsurgical treatment according to the different techniques.
These numbers vary considerably in the literature, depending mostly on the selection of cases, but also on the time which is left after the operation and the evaluation of the results (12)!
Choice of the appropriate treatment.
Substantial controversies have been raised regarding whether to operate on patients or to offer them medically assisted conception such as in vitro fertilization. If an operation is chosen, it should be performed through the laparoscope or by conventional open microsurgical technique. Many questions are still not answered and prospective randomized studies are not available to compare the results of distal tubal obstruction treated by either laparoscopy or open microsurgery. However, there is substantial evidence that endoscopic treatment is as good as open microsurgery (5) and even has the advantage of minimizing postoperative morbidity.
We report here on series of 65 consecutive laparoscopic distal tuboplasties, performed during the period between May 1986 and May 1988.
Materials and methods.
We classified operations according to the French tubal score (Table 2). This score is based on three factors:
Tubal score is the sum of the subscore for each of the three criteria : Grade I, 2-5; Grade II, 6-10; Grade III, 11-15; Grade IV >15. Modified from Mage et al. (10).
Of the 65 operations, 31 were fimbrioplasties and 34 were salpingostomies. Of the 34 salpingostomies, 28 were scored I or II, and 6 were scored III or IV.
Before distal tuboplasty, meticulous excision of all adhesions from the ovary and the tube was performed to re-establish mobility of the ampulla and of the fimbria ovarica. Velamentous adhesions were excised using scissors exclusively. Dense adhesions were excised using the CO2 laser, especially those gluing ampulla to ovary, or ovary to uterus. Distal tuboplasty was performed using various operative procedures. In cases of fimbrioplasty, constrictive fibrotic bands responsible for stenosis of the fimbrial ostium were incised using fine scissors, as in microsurgical procedures.
Agglutinated fimbria were dilated with atraumatic forceps introduced closed into the ostium and withdrawn opened. In cases of salpingostomy, hydrosalpinges were incised with scissors at the point where the tubal wall appeared thinnest after transcervical chromohydrotubation. The incision was then enlarged by applying careful divergent traction with atraumatic forceps and limited to scarred areas. The laser CO2 beam, set on continuous mode, was used when the tubal wall appeared thick. A small spot size (<1mm) and power densities from 5,000 to 15,000 W/cm2 were used.
Incision with scissors was sufficient for obtaining adequate eversion of the mucosa in cases of thin hydrosalpinges with inverted fimbriae. When incising the tube was insufficient for obtaining a well developed neo-ostium, eversion was obtained by provoking retraction of the serosa distal to the incision, using thermocoagulation, bipolar coagulation, or defocalized CO2 laser beam. CO2 laser was used in 20 cases (30.8%) for adhesiolysis in cases with dense adhesions, for tubal incision of thick hydrosalpinges, or to perform eversion.
At the end of the procedure, the peritoneal cavity was irrigated with Ringer’s lactate solution. Prophylactic antibiotics (cyclins) were administered systematically for 2 weeks.
The outcome was evaluated 18 months postoperatively. Women lost to follow-up were considered as failures. This time period was chosen because most pregnancies occur within the initial 18 months after surgery.
In our series of 65 cases, no patient required laparotomy for bleeding, and no bladder or bowel injury was observed. The length of the procedure was 30 to 90 minutes. All patients were discharged 2 days postoperatively.
Fertility outcome is shown in Table 3. Twenty-two patients became pregnant (33.8%) ; 18 achieved intrauterine pregnancies (27.7%), of which 15 delivered (23%). The rate of intrauterine pregnancy was 25.8% in the fimbrioplasty group and 29.4% in the neosalpingostomy group. The rate of ectopic pregnancy (EP) was 12.9% and 2.9%, respectively. The cumulative intrauterine pregnancy rate was 19.7% at 6 months and 27.7% at 12 months. No pregnancy was obtained between 12 and 18 months.
Microsurgery has been the treatment of choice for tubal infertility except in cases where the tubes are severely damaged, for which in vitro fertilization is indicated. In Gomel’s series (8), 89 microsurgical salpingostomies were followed for more than 1 year; 30 patients (33.7%) achieved one or more pregnancies, 28 (31.5%) had one or more live births and 8 (9%) had EP. In Dubuisson’s series (6) concerning 76 microsurgical salpingostomies with a follow up of >2 years, 28 patients (36.8%) achieved one or more pregnancies and 17 (22.3%) had EP.
The outcome after laparoscopic distal tuboplasty was disappointing in early reports. Fayez (7) reported 36% postoperative tubal obstruction after laparoscopic fimbrioplasty and 2 EP in a group of 19 salpingostomies. More recently, encouraging results have been reported (4,11). In a series of 62 salpingostomies, Bruhat (4) reported 17 intrauterine (IU) pregnancies (27.4%). In our present series, we have observed an IU pregnancy rate of 27.7%. In the absence of randomized clinical trials in large populations, laparoscopic and microsurgical approaches cannot be compared directly. However in skillful hands operative laparoscopy results tend to approach those of microsurgery. This improvement can be attributed to the development of atraumatic instruments adapted for laparoscopic surgery, and to the use of the CO2 laser. Over the past several months, we have used a flexible CO2 laser fiber prototype, 70 cm long and 2 mm in diameter, introduced suprapubically, which is more manageable than the conventional hand pieces (4). With the 10-mm laparoscope, the magnification was estimated to be three times the real object when the tip of the endoscope is placed 1 cm from the fimbria. Such magnification is sufficient for performing fimbrioplasty or neosalpingostomy. For eversion of salpingostomies, the laparoscopic technique using the CO2 laser or thermocoagulation achieves results anatomically comparable with those obtained by microsurgery (9).
Laparoscopic surgery offers greater comfort to patients and is more economical, with shorter operative and postoperative hospitalization than laparotomy. Laparoscopic procedures limit the risk of postoperative adhesions (3). Nevertheless, operative laparoscopy requires a laparoscopist well trained in endoscopic procedures and tubal surgery. Our results suggest that operative laparoscopy may be an alternative to microsurgery by laparotomy for management of distal tubal lesions.
Edited by Aldo Campana,