Cameroon-Geneva Health Foundation

The management of tubal obstruction

Nkele Ndeki Ngoh

ABSTRACT

Tubal disease constitutes 30% of infertility problems world wide, and has persistently been the bugbear of surgeons.

Surgical attempts to solve the problem have been many and results have varied according to the technique as well as the surgeon. Earlier reports were frustrating and led to almost abandonment. The birth of new techniques accompanied with technological advancement did not only improve upon the knowledge of tubal pathology but brought along with it more than ever before, more controversies, concerning the management. Newer techniques appear to yield better results but their cost precludes many from their advantages. Simplified techniques may prove to be of much value to some communities. However, a more global approach as to the classification of pathology, patient selection, operative technique and result reporting is necessary to evaluate the real benefits of each procedure.    Key words: Tube; Obstruction; Treatment.

INTRODUCTION

Fallopian tube disease is responsible for over 20 to 30% (1) of female infertility world wide. The lesions range from intrinsic intraluminal malformation of cilia, mucosa, or muscularis to gross occlusion of the lumen. Tubal obstruction has preoccupied many gynaecologists for several years. Its importance as a major cause of infertility was recognised by Burns in 1809 (2).

Whereas tubal surgery has been criticised for lack of convincing evidence, untreated complete bilateral tubal obstruction offers no hope of pregnancy (3).

Earlier attempts on the surgical repair of the fallopian tube were met with very poor pregnancy out come. Greenhill quoted success rates of 1 in 20 in 1957 and 1 in 6  28 years later (1). Until recently many authors believed that low pregnancy rates were due to major invasive surgery, being the main treatment at that time(4). However, traditional microsurgery had an almost 20% pregnancy rate (PR) (5).

Despite the development of endoscopy during the 1960-1970s, the idea that large problems require large incisions so deeply dominated surgical thinking that there was little room to appreciate the advances of ‘ Key hole’ surgery. Effective surgical correction of diseased fallopian tube is a relatively new aspect of gynaecological surgery that came up with the ‘laparoscopic evolution’ in 1989-1990. Its sweeping success marked the end of the traditional open surgery and encouraged surgeons to consider new perspectives (6).

Currently, a 50% overall success rate in surgery on the fallopian tube has been claimed (1). This improvement may be due to the recent development of tubal endoscopic and carbon dioxide laser, techniques that have lead to better assessment of tubal disease and less invasive tuboplasty or tubal recanalisation procedures. However, despite these innovations, the absence of a universally accepted classification of the location, type and severity of tubal disease(1), combined with conflicting views of management distorts the appreciation of the true pregnancy outcome rates.

In this article we attempt to review all the pertinent articles on MEDLINE, about the management of the three main sites of obstruction which are, proximal, mid and distal.

PATHOGENESIS

Pelvic inflammatory disease, including salpingitis, is mostly caused by ascending gonorrhoeal, chlamydial and non-specific infections. Tuberculosis, probably through haematogenous spread, is also a major cause of salpingitis. These germs have been discovered in many cases of acute salpingitis and are associated with tubal obstruction (7,8,9).

The acute phase of salpingitis is characterised by oedema of the plicae. In severe cases there is leukocyte infiltration of the inner muscularis and necrosis of the tubal epithelium. This may extend to the serosa and to the ovary –causing acute oophoritis and perisalpingitis. With recurrent infection the tubal plicae adhere and form typical adenomatous spaces. Eventually the entire tubal wall becomes involved, with subsequent occlusion of the fimbriated end. Partial or complete sealing of the isthmus leads to subsequent retention of inflammatory fluid (hydrosalpinx) or pus (pyosalpinx) within the tubal lumen (10).

In tuberculous salpingitis small elevated tubercles may be identified on the serosal surface. When the disease is more advanced the tube is markedly thickened and firm and there are numerous adhesions to adjacent bowel and ovary. The lumen contains caseous material and the peritoneum of the pelvis is usually involved with small white tubercles varying in size from 0.1 to 0.2 cm. The fimbriated part is usually patent and everted. Microscopically the tubal mucosa presents with characteristic tubercles. In addition, when the disease is extensive, areas of caseous necrosis are common. In chronic cases the fallopian tubes are straight, rigid and have the appearance of a pipe stem(10). Tubal obstruction may occur from the occasional exuberant growth pattern of the epithelium.

Salpingitis isthmica nodosa is also a major cause of tubal obstruction. Wang, 1989 (7) in his series, observed that salpingitis isthmica nodosa  was the cause in 33% of tubal obstruction. Gonorrhoea and non specific infections were the 1st and 2nd most common causes in the same series. Salpingitis isthmica nodosa is a disease process of unknown aetiology, characterised by nodular thickening in the intramural and isthmic portions of the fallopian tube. It is thought to be a sequelae of inflammation either of gonorrhoeal or tuberculous type (10).

Endometriosis may affect the fallopian tube in severe cases and lead to distal obstruction with hydrosalpinx formation. Tubal obstruction is more often caused by compression or stricture than by mucosal adhesions(2) .  Tubal obstruction also results from voluntary tubal ligation and may also be a complication of pelvic surgery.

DIAGNOSIS

CLINICAL PRESENTATION

The fallopian tube is the most sensitive pelvic organ to pain (10). Patients with acute or chronic salpingitis may present with either a present or a past history of pelvic pain or dysmenorrhoea. Some who had undergone treatment may be asymptomatic but complain of either primary or unexplained secondary infertility. Others may or have had an abortion, a puerperal infection or had either undergone a voluntary surgical sterilisation or pelvic surgery for a gynaecological problem.

INVESTIGATION

BACTERIOLOGICAL :

It is generally accepted that before any assessment of tubal patency and structure the first line of investigation should be bacteriological investigation followed by treatment with appropriate antibiotics.

ASSESSMENT OF EXTENT OF TUBAL PATENCY

Hysterosalpingography (HSG). Hysterosalpingography is commonly accepted as the initial test of tubal function in the investigation of infertility (2). However it may give rise to false diagnosis of proximal obstruction because of tubal spasm. Tubal diverticulum too may be wrongly diagnosed as distal obstruction (11).

The combined use of HSG with laparoscopy increases the diagnostic possibilities to include endometriosis (12 ). However, if investigation is limited to HSG and to laparoscopy, proximal tubal obstruction (PTO) may be over diagnosed and consequently  overtreated (2).

Swart et al, 1995 (13) did a metanalysis of 20 studies comparing HSG and laparoscopy for tubal patency and peritubal adhesions. They observed that HSG was of limited use in tubal diagnosis because of its low sensitivity. However, its high specificity makes it a useful test for ruling out tubal obstruction. For the evaluation of peritubal adhesions, HSG is not reliable.

In order to circumvent the problem of tubal spasms and to distinguish organic tubal obstruction from functional obstructions, some authors have suggested the use of muscle relaxants such as terbutaline (14).

Contrast sonography, has the advantage over HSG of not using radiation (2,15) and the site of obstruction can be ascertained more accurately with colour Doppler depending on the contrast medium used. The proponents of this technique claim that, its high concordance of about 86% in diagnosing blocked tubes gives it an edge over laparoscopic chromopertubation (16).

Laparoscopic chromopertubation. With the use of intrauterine dye injection, tubal patency can be checked during laparoscopy. Under local anaesthesia, laparoscopic chromopertubation can be an office procedure (17). Laparoscopy has the added advantage of diagnosing fibroids, ovarian abnormalities, endometriosis and/or other congenital abnormalities (18).

Patency of the fallopian 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 (2).

Fallopian tube endoscopy. Tubal endoscopy either by the transvaginal (Falloscopy) or transabdominal approach (Salpingoscopy) permits the direct visualisation of the tubal epithelium. Falloscopy is used in the investigation of the status of the proximal tube. Two types exits: The coaxial (guide wire) falloscope, introduced by Kerin, requires hysteroscopy for its introduction. The linear everting catheter (LEC) falloscope has a terminal everting balloon sheath which facilitates its introduction without hysteroscopy. Falloscopy may be employed with or without general anaesthesia. They are suitable for office use. Many authors have used falloscopes for both diagnostic and therapeutic purposes. In case of proximal tubal obstruction, the only alternative for assessing the state of the tubal mucosa is by performing transabdominal salpingoscopy during laparoscopy. It is most convenient in the evaluation of the distal segment of the tube (2,20,19).

TREATMENT OF TUBAL OBSTRUCTION

In the literature, there have been many techniques and technique combinations used in the treatment of tubal disease. These range from the old laparotomy, gaseous insuflation, hydrotubation, microsurgery to the more recent laparoscopic surgery, modern microsurgery using the CO2 laser and the micro endoscopic procedures. Irrespective of the type of surgical procedure, the general principles of infertility surgery include gentle manipulation, meticulous haemostasis, prevention of post operative infection and adhesion formation (2). These could be met  by the use of good magnification instruments, continuous saline cleansing and pinpoint haemostasis.

The once commonly used gaseous insufflation became obsolete when its usefulness was questioned in1986 (2). On the contrary hydrotubation is used by some authors to maintain tubal patency while some feel it may predispose to infection. Grant (1971), (21) used hydrotubation and had a PR of 37% as against 16%pregnancies in treated controls. Recent reports especially from China reveal the importance of hydrotubation in the treatment of tubal disease (22). Those who use hydrotubation as an adjuvant to the post surgical management of tubal obstruction do it on day 3,6 and 14 (1).

Since 1987, following the approval of tubal endoscopic techniques on humans in the USA , there have been many reports of several techniques and technique combinations on the treatment of tubal obstruction (20). Hereby we review some of the common techniques and technique combinations relative to the site of obstruction.

A: TREATMENT OF PROXIMAL TUBAL OBSTRUCTION

I) ENDOTUBOPLASTY TECHNIQUES

The first known attempt to pass instruments through the vagina and enter the tubal lumen by the uterotubal ostium (UTO), was attributed to Tyler Smith in 1849. In 1856, Gardner described a method for transvaginal passage of graduated probes. In 1970, a fibroscope 1mm in diameter was used to examine the tubal lumen but poor illumination and technical problems made it difficult to explore this adequately (20). Intra-luminal tubal endoscopy may be performed by the transvaginal (falloscopy) or transabdominal (salpingoscopy) approach (2).

FALLOSCOPY

The coaxial technique of falloscope described by Kerin,1990 (20) required hysteroscopically directed tubal cannulation with a flexible guide-wire having an outer diameter (OD) of 0.3-0.8 mm followed by serial passage of a Teflon cannula (OD up to 1,3) over the guide wire. The guide-wire was then removed and the falloscope passed down the lumen of the Teflon cannula (2). The falloscope has balloon catheters with a shaft OD of 1,0 mm and inflated balloon diameters ranging from 2 to 5 mm over lengths of 2 cm that were used for dilating tubal strictures breaking down intraluminal adhesions and mobilising intaluminal debris. This coaxial balloon catheter had its balloon mounted outside the catheter shaft (20).

The second (more recent) type of falloscope is the Linear Eversion Catheter (LEC) system (Imagyn Medical Inc,San Clemente, California, USA). It utilises a pressurised tubular polyethylene balloon which can be unrolled from within a plastic polymer cannula after having the falloscope preloaded into its lumen. The balloon caries the endoscope into and along the tube, protecting the tube and endoscope from damaging one another and negotiating the curves and strictures without exerting sharing forces on the tubal wall (2). The LEC system may be used without hysteroscopic control (2,20).

Falloscopic descriptions of endotubal lesions, secondary to endotubal infection, tubal surgery, ectopic pregnancy, salpingitis isthmica nodosa (SIN), endotubal polyps and non-specific areas of devascularisation, epithelial flattening, atrophy and fibrosis, have been published (23). From these falloscopic findings Kerin, (1992) (23) developed  a scoring system for tubal disease as shown in table I.

 Table I: Falloscopic classification and localisation of tubal lumen disease (23)

 A cumulative score for each tube of: 20 = Normal Tubal lumen; > 20 but < 30= Moderate Endotubal disease;  > 30= Severe Endotubal disease. Mucus Plugs or Tubal Debri, Endotubal Polyps, Salpingitis Isthmica Nodosa, Inflammatory, Infective; Neoplastic conditions and absent tubal segments are each assigned a score of 2 to 3 depending on the significance of the lesion.

 Falloscopy may be combined with other procedures such as :

(1)Laparoscopy.

(2)Ultrasound.

(3)Fluoroscopy.

(4)Hysteroscopy and laparoscopy.

(5)Lavage under pressure.

The coaxial technique may be used to canalise the tubal lumen, and/or the balloon catheter may be used to dilate the lumen (Balloon tuboplasty) (14). Tables II to IX are summarise the various techniques described in the literature. Pregnancy rates (PR) are mentioned when possible.

Table II:Fluroscopic guided transcervical catheter salpingoplasty with catheter and guide wire.

 Table III: Fluroscopic guided transcervical balloon tuboplasty.

 Table IV: Laparoscopic guided transvaginal catheterisation followed by ultrasonographic guided hydrotubation to ascertain patency.

 Table V: Hysteroscopic, laparoscopic and fluroscopic guide wire cannulation and direct balloon tuboplasty (DBT)

  Table VI: Laparoscopic guided falloscopy with LEC.

 Table VII: Non hysteroscopic falloscopy.

 Table VIII: Ultrasound guided transcervical tuboplasty.

 Table IX: Ultrasound and fluroscopic guided transcervical balloon tuboplasty:

NB: N°= Number. Pat = Patency.  IUP= Intrauterine pregnancy. EP= Ectopic pregnancy.

With the different techniques, it is not possible to compare the various methods used. It is generally accepted that tubal endoscopic procedures provide a better assessment of the structure of the tubal mucosa thus facilitating patient selection. Falloscopic techniques are less invasive, have high patency rates (>80% in most studies) but appear to be limited to non-fibrotic tubal obstructions. Complications of perforation are possible in cases of applied force to bypass complete pathologic obstructions such as SIN (28). Their use without general anaesthesia gives it a further advantage in daily office use.

II) HSYTEROSCOPIC TUBAL CATHETERIZTION AND HYDROTUBATION

This technique has been described by Su-Chong,1994 and others in the Chinese literature and success rates of 35,9%, and 40-60% have been reported (22,18). In  Su-Chong`s (1994) (22) series 54 infertile women with previously diagnosed tubal disease underwent hysteroscopic catheterisation . Catheterisation was performed by the introduction at the utero-tubal ostium (UTO) of a plastic tube of 1.4 OD, up to 1-5 mm into the tubal lumen under hysteroscopic guidance. The procedure was followed by successive monthly selective hydrotubation over a period of 3 months. Patency was achieved in 62.5% of cases of intramural block and 38.8% of isthmic stenosis. Globally, complete patency was achieved in 54.1%. Thirteen women fell pregnant, 12 were intrauterine pregnancies and one was an ectopic pregnancy. Su-Chong (1994), however pointed out the possible complication of hydrosalpinx with this technique.

III) INTRAUTERINE INJECTION OF ‘ANGELICAE’ COMPLEX.

Lian et al, 1991 (33), after preliminary experimentation in rabbits, followed up 48 infertile women. Fallopian tubal obstruction had been previously proved by hysterosalpingography in all the women. These women were divided into two groups. Thirty patients were treated with intrauterine injection of ‘Angelicae’ complex. The control group of eighteen women were treated with transcervical intrauterine injection of gentamycin and 0,9% saline for 3 to 6 months. The effective rates were 94.6% and 56.6% (p < 0,01) and the subsequent pregnancy rates were 46.7% and 27.8% respectively in the different groups. Angelicae complex is a Chinese medication of the Kampo medicines which has an effect on the clearance of  circulating immune complexes (34). 

 IV) MICROSURGICAL ANASTOMOSIS FACILITATED BY CO2 LASER MICRODISSECTION OF INTRAMURAL SEGMENT AND RESECTION OF SCARRED TISSUE.

Vilos,1991 (5), reported the use of CO2 laser technique in the microdissection of intramural segment and resection of scarred tissue prior to microsurgical anastomosis. Within a period of 5 years, 21 fallopian tubes in 14 patients had been anastomised using this technique. After re-anastomosis, tubal length was 4 to 8 cm in all tubes. All patients were followed for at least 1 year post surgery. In this study, 7 of the included women had proximal tubal occlusion after electrocautery for sterilisation. In this group, the tubal patency rate was 100%, whereas the intrauterine pregnancy rate was 71% (5 of 7 patients). One other patient had two successive ectopic pregnancies. The seventh patient was 40 years old and did not ovulate on 150 mg of clomiphene citrate. In the other group of seven women, proximal tubal obstruction was associated with other tubal diseases. In this group one patient with salpingitis isthmica nodosa conceived twice after bilateral intramural re-anastomosis.

B: TREATMENT OF MID-SEGMENT OCCLUSION

The most common surgical treatment of the mid segment is re-anastomosis for reversal of sterilisation (1). Other causes may be localised constriction from previous tubal repair following ectopic pregnancy, endometriosis, infection and congenital constrictions (1,35). Mid segment tubal occlusion as a complication of inguinal repair is rare (35).

In the selection of patients, preoperative HSG and laparoscopy to determine the length of the proximal tube and that of the remaining tube are important (1). The PR after surgery in most studies has been associated with the length of the tube (36,37,38). The longer the tube is above the critical length of 3cm (1) the better the PR outcome. However, in a large study by Kim et al,1997 (39) there was no statistically significant difference in the lengths of tubes. However, he observed that the younger patients had longer tubes and became pregnant earlier than the older patients with shorter tubes.

The success rate also depends on the type of sterilisation that was carried out (1). It is higher with the Pomeroy and Uchida techniques as well as with the fallopian ring and the Hulka clip methods of ligation (1,40).

Re-anastomosis of the chronically ill tube is not helpful. Wang et al, 1998 (7) in a series of sixty cases of female infertility in which several operative procedures were used, re-anastomosis of the chronically ill tubes was not helpful. However neither unilateral nor bilateral re-anastomosis seems to affect the PR outcome.

The different possibilities of anastomosis are isthmic-isthmic, isthmic-ampullary and ampullary-ampullary (1). Re-anastomosis of tubal segments requires adequate proximal and distal lengths of normal tube. After excision of the occluded segment, the mesosalpinx is approximated, and an end to end , layer to layer anastomosis performed. Disparity between the calibre of the residual normal tube segments is compensated by angulation incision of the smaller diameter segment or by a smaller incision made in the potentially larger segment. The anastomosis may be performed over a nylon splint (1).

Theoretically, the procedure of re-anastomosis is better achieved by way of microsurgery under magnification (1). However, Jones and Rock, 1978 (41) found no difference between macro- and microsurgery. Winston and Gomel without using magnification in microsurgery had a success rate of 70% (1). Similarly Gupta et al, 1990 reported a higher PR of 88% with macroscopic tuboplasty in 57 cases with reversal of sterilisation (42). Despite these controversies many large studies reveal very high success rates following microsurgery. Liu et al,1997 out of 1029 cases, had 960 IUPs and only 12 EPs (43). Kim et al,1997(39) out of 922 cases had a global PR of 53% (38). Kim et al,1997 (37) out of 387 cases had a PR of 91%. In a relatively smaller study of 23 patients, Fischer,1996 (44) obtained an overall PR of 78.3% and an IUP of 68.6%.

Laparoscopic microsurgery though relatively new (46) is gradually being considered an alternative to open microsurgery. The first laparoscopic microsurgical anastomosis was carried out in February 1992 and since then most cases of laparoscopic microsurgery had encouraging results. Yoon et al (1997) (40) reported a PR of 77.7% (38/49). Lee et al,1995 (47) reported a successful case in a woman of 33 years who had had a failed tubal anastomosis. Silva and Perlins,1995 (47) used a combination of laparoscopic and minilaparotomy techniques in treating 11 patients of which five (45%) had an IUP and one had two successive ectopic pregnancies. Kartz and Donesky, 1994 (48) out of 5 patients had a PR of 50%. Various stitch techniques to ease laparoscopic microsurgery have been developed. Dubuisson and Swolin, 1995 (45) used a new one- stitch technique to treat 4 cases. The stitch was placed at the ``12 o`clock`` site of the antimesenteric border. Barjot et al ,(1999) (49) used a three stitch technique in 16 patients and had a PR of 31.2% (5/16). However, Reich et al, 1993 (50) in a retrospective review of 22 laparoscopic tubal anastomosis cases, in which the Swolin two-stitch technique was used, reported a low overall fertility rate.

C: TREATMENT OF DISTAL TUBAL OBSTRUCTION

The very frustrating PR results (0-5%) of tubal surgical repair in the pre-antibiotic era of the 1930s led almost 60% of the participants of the Chicago Gynaecologist Society to be ``definitely opposed`` to salpingostomies and tubal implantations (51). From that period until 1977, the combination of a thick walled ampulla and an intramural occlusion was considered irreparable, and the tube was left in-situ (52). However, in case of thick-walled tubal end, a so called ‘cuff neostomy’ was performed. Palmer,1960 (52) described a less radical technique of neostomy which consisted of stripping the fibrotic muscular layer under the microscope so that eversion of the mucosa was easier.

In addition to conventional and traditional microsurgery, other operative techniques on the distal tube include the use of laparoscopy and CO2 laser. All of these can be used in performing salpingostomies, fimbrioplasties and salpingectomies. As of now there is no consensus about which of the methods yields the best results in terms of intrauterine pregnancy out come.

CONVENTIONAL SURGERY AND TRADITIONAL MICROSURGERY.

Earlier PR results of conventional surgery ranged from 5.6%  to 41% while those of traditional microsurgery range from 21%  to  37% (53). Term pregnancy rates in conventional surgery are quite variable and generally less than 20% whereas those of microsurgery are less variable and most are in 20% to 30% range (51).The success depends on the type of technique used. Verhoven in 1983 in a review of 167 cases reported a PR of 20.4% following microsurgery salpingostomy and 0% after cuff neostomy (52).

Fimbrioplasty and Neosalpingostomy.

These terms have created a lot of controversy. In 1977 the 9th  World Congress of Fertility and Sterility defined Fimbrioplasty as : a) deagglutination and/or dilatation of the fimbriae, b) by incision of the peritoneal ring, c) by incision of the tubal wall. Salpingo-neostomy (Salpingostomy) was defined as: a) terminal, b) mid-ampullary (medial), c) isthmic (including linear salpingostomy) (51). Authorities differed whether surgery on distal tubes found to have remnants of the fimbriae after incision of the tubal wall constituted a fimbrioplasty or salpingostomy (51). The modified definition of fimbrioplasty by the 10th  World Congress (1980) of Fertility and Sterility as ``with serosal incision for completely occluded tube`` did not help (51) . In reporting cases Verhoven (1983) and Bateman (1987) used the term ``Fimbrioplasty`` in cases of partial tubal obstruction with fimbriae present and salpingostomy as complete tubal obstruction, regardless of the findings after incision. In complete tubal obstruction there is no spillage, and if pin point openings were found the repairs were not considered as salpingostomy because these tubes usually had undergone less damage and offered the possibility of better results (52). From earlier reports, fimbrioplasty has always yielded better PR than salpingostomies (52) as shown in the table Xa and Xb.

Table Xa :Results of salpingostomy.

 Table X b: :Results of fimbrioplasty.

 LAPAROSCOPY

Results of salpingoscopy and fimbrioplasty done by laparoscopic surgery also give an edge to fimbrioplasty in terms of IUPs. Lavergne (64) in 1996 out of 46 cases of laparoscopic surgery in which salpingostomy and fimbrioplasty were performed, 75% of the 18 patients who were pregnant were as a result of fimbrioplasty. Table XI is a summary of three studies comparing fimbrioplasties and salpingostomies.

Table XI: Fimbrioplasty compared with salpingostomy.

 Tubal Score.

Many authors hold that, the outcome of tubal surgery depends on the extent of tubal damage. While IUPs are higher in tubal stages I and II, and fairly low in stage III, they are hopeless in stage IV as observed in table III. Dubuisson (1994),(68) Filipini (1996),(69) Kasia (1997),(67) and many others state that patients with tubal stage IV would benefit more from IVF-ET. Table XII is a summary of the various findings.

Table XII :Variation of IUP rates with tubal score.

NB :Values in parentheses are percentages.

CO2 Laser in laparoscopic and micro surgery.

With the advent of CO2 laser the IUP outcome of laparoscopic surgery is almost equating that of modern microsurgery. CO2 laser has the advantage of performing adhesiolysis by vaporisation. For neostomy, the tube can be sectioned without any bleeding and the surgeon can work both, quickly and accurately (5,70,71). In 1991, Canis (72) operated on 87 patients. He used a combination of laparoscopic surgery and CO2 laser. The IUP outcome per tubal stage, as observed in table XIII, was better than those described earlier. However, not all results were statistically significant.

 Table XIII : CO2 laser laparoscopic surgery versus microsurgery.

SALPINGECTOMY OR CONSERVATIVE SURGERY.

Alboulgar et al,1998 (73), were the first to mention how fluid in the uterine cavity before embryo transfer could be a possible hindrance for implantation. Hydrosalpinx fluid has pH values (8.45 to 8.65), significantly higher than the physiologic range and at either the 100% or 10% concentration it has a significant embryotoxic effect (74).  Anderson et al (1994) (75) diagnosed hydrosalpinges by ultrasound and found that those patients with hydrosalpinges had decreased pregnancy rates and increased miscarriage rates. There is however a controversy as to the benefits and disadvantages of salpingectomy or conservative management. Aspiration of the hydrosalpinx fluid has been tried (76) while others have proposed salpingectomy and or referring the patient for IVF-ET (77).

Dechaud et al,1998 (78), in a pilot study of 60 women who underwent IVF-ET, reported an implantation rate of 13.4% in women with salpingectomy and only 8.6% in those without salpingectomy. Still in the same group the rate of ongoing pregnancies was higher (34%) in the salpingectomy group compared to the control group (8.7%). However, Bredjaer (1999) (79), in a case control study found no difference in the rates of implantation and ongoing pregnancies between the two groups. Table XIV is a summary of both studies.

Table XIV: salpingectomy versus no salpingectomy before IVF-ET.

Nb : N°= number  Impl R=Implantation rate.    On Pr=Ongoing pregnancy. 

VanVoorhis (76) in 1998 carried out a study in which he assessed the differences in implantation rates between women with tubal disease with or without hydrosalpinges based on ultrasound diagnosis. He observed that implantation as well as clinical pregnancy rates were reduced in women with hydrosalpinges although these differences did not quite reach statistical significance. His results as well as those of similar studies are summarised in table XV.

In the summary that follows the ongoing pregnancy has been calculated as the percentage of the difference between the total number of pregnancies and the total number of pregnancy loss over the total number of pregnancies.

Table XV : Hydrosalpinx compared with no hydrosalpinx in IVF-ET.

The negative effect of hydrosalpinges on implantation as observed in the above studies seems to be nullified when the hydrosalpinx is treated. It may be that surgical removal has an advantage over aspiration. In the summary that follows (Table XVI) van Voorhis,(1998)(76) used aspiration for treatment whereas Vandrome et al (1995) (80) used surgical treatment. When these cases were compared to a control group with untreated hydrosalpinges, the implantation rate was still higher in the treated group than in the control group. However, both the implantation rate and the ongoing pregnancy rate were higher in the surgically treated group than in the aspirated group. More studies have to be carried out to show if this difference could be due to the incomplete removal of hydrosalpinx fluid by aspiration procedures.

Table XVI :Hydrosalpinx treated versus untreated hydrosalpinges in IVF-ET.

The study carried out by Shelton et al (1996) (84) falls in line with the above studies but peculiar because it was a retrospective study in which the same patients were followed up by the same team. When fresh and frozen embryo transfers were carried out in 15 patients who had hydrosalpinges there was only one pregnancy. This pregnancy ended in a miscarriage. However, after salpingectomy fresh and frozen embryo transfers resulted in 9/15 (60%) pregnancies, of which 3 ended in miscarriages and 6 (67%) were ongoing pregnancies (84).

Discussion

Green Armytage (1959),  sited by Bateman, (1987),(51) as early as 1959 remarked that tubal disease was the still the greatest bugbear of infertility clinics. To date, Green-Amrytage`s quotation is still quite appropriate (51). Its magnitude can be objectivated from the plethora of techniques and technique combinations that are employed today to treat this disease.

In the pre-antibiotic era of the 1930s the pregnancy rates were frustrating  (0-5%) (51). It gradually climbed to 20-30% with microsurgery and lately to 50-79% with the combined use of CO2 laser techniques in both laparoscopic and laparotomy microsurgery. With the invention of falloscope a good proportion of intraluminal pathology of tubal obstructions was found not to be of tubal origin (14). The tendency since then has been shifted towards endotubal surgery which of course has its own limits.

In the mid 1980s, when Platia and Kudy (1985) and Confino et al (1986) suggested the possibility of  intraluminal interventions, DeCherney, 1987  (84) was sceptical. Today, apart from tubal spasms, transcervical tubal catheterisation has been applied in dislodging intraluminal plugs, functional sphincterotomy and polypectomy (14). Its success can be seen from the many authors who have used various methods in applying this procedure.

This suggests that a transvaginal catheter approach towards proximal tubal occlusion can be successful in achieving patency in a good number of women and will allow pregnancy  in many (19). The patency rates have reached high levels such as 90-97% (19). However the PR outcome which is the prime concern of the surgery has also climbed  (50%) (19) but not as much. The various techniques have their merits and demerits:

Fluoroscopic guided catherisation has the advantage of being both diagnostic and therapeutic. The highly detailed image of the fallopian tube remains unsurpassed by sonography even when high resolution Doppler flow equipment is used (Stern et al 1991) (31). This method, however, exposes patients to radiation, the equipment is expensive and not easily available (31).

 Sonographic guided intracervical catheterisation has the advantage over fluroscopic procedures in that it is less expensive, readily available (Lisse and Sydow,1991) (31), can be used on an out patient basis and for the deposition of spermatozoa and gametes. It is also minimally invasive, diagnostic and therapeutic. The human fallopian tube is a tortuous organ which renders ultrasonoghaphic imaging rather difficult. Frequent movements of the catheter tip call for continuos movement of the transducer. This requires a very skilful reproductive sonographer who is familiar with genital anatomy and sonographic appearance of the catheter (31). Visualisation of microbubbles through the fallopian tube and into the cul-de-sac `lighting up` is a less equivocal sign of tubal patency (31).

Balloon tuboplasty is equally minimal invasive and can be used on outpatient basis. It has the added advantage of achieving functional sphincterotomy. This is particularly useful because it delays the reformation of intraluminal plugs unlike other procedures which simply dislodge them(14).

When transcervical tubal catheterisation is performed under laparoscopic guidance the structure of the uterine cavity is seen and any abnormalities noted.

Transcervical tuboplasty combined with laparosopy has the advantage of direct visualisation of pelvic structures and other related pathologies.

Though complications with the use of tubal catheterisation procedures are few cases of perforation of the ampulla have been noted especially when force is used to bypass fibrotic occlusions and salpingitis nodosa.

In China a less expensive method of tubal catheterisation under hysteroscopic control has been developed (18,22). In the place of catheters, flexible plastic tubes of 1.4 mm OD were introduced at the UTO up to 1-5 mm into the tubal lumen. This was followed by hydrotubation over a period of 3 months.  A global patency rate of 54% and PR of 24% were achieved. These results were lower than the other more expensive methods of tubal catheterisation and almost equate with those of more invasive surgical techniques.

Many agents have been used in hydrotubation with the aim of maintaining tubal patency (2). Grants,1971(21) used hydrotubation and had a PR of over 40% in his series. Lian et al (1991) used the `Angelica`complex in hydrotubating women with proximal tubal obstruction and achieved a patency rate of 94.6% as well as a PR of 46.7%. Unfortunately there are very few reports so far on the use of this complex in hydrotubation. Otherwise, if these results could be reproducible, hydrotubation, using the ہngelica`complex , as an adjuvant to transcervical tubal catheterisation may be beneficial.

Laparoscopic and laparotomy microsurgical techniques in combination with CO2 laser are used for the treatment of tubal implantations (5). However preference of this technique, except for a selected group of patients, should be reconsidered. Sulak et al,1987 demonstrated that crystallised tubal secretions can cause  obstruction of the proximal tube (14). Similarly in a multicentre study, Confino et al (1990), observed that a significant proportion of their patients with proximal tubal had obstructions form intraluminal plugs. If tubal occlusion is caused in many by intraluminal plug formation, microsurgical tubal re-anastomosis would convert an apparently normal tube into a scarred tube (14).

In mid tubal occlusions, sterilisation reversal is the main surgical procedure(1). Most of the operations used to  be carried out through laparotomy with or without magnification but presently they are also carried out by microsurgical laparoscopy (1,44). Results of surgery seem to be associated with the tubal length above the critical 3 cm (36,37,38) and the previous method of surgical intervention (1,40) than to the type of reconstructive surgery opted for. The global PR outcome is fairly high and varies between 50 to almost 90% in both laparotomy with or without magnification and  laparoscopic microsurgery (1,37,40,44). The Pomeroy, Uchida, Fallopian ring and the Hulka methods of ligation have the highest reversal success rate. The recently developed laparoscopic ٍne` (Dubuisson,1995), `two` (Barjio et al,1999), and `three`(Reich,1993) stitch techniques have facilitated laparoscopic microsurgery (46, 49,50).

In the treatment of distal occlusion almost all the studies have shown that hydrosalpinx and/or the chronically ill tube are associated with low rates of implantation and high rates of pregnancy loss. Irrespective of the tubal score the pregnancy out come is better with: i) fimbrioplasty than with neo-salpingostomy  (51, 52,67), ii) salpingectomy than with the chronically ill tube (78, 79), iii) diseased tube  without hydrosalpinx than  with a tube with hydrosalpinx (75,76,80,81,82,83), iv)  aspirated hydrosalpinx than with a non-aspirated hydrosalpinx (76),  v) surgically treated hydrosalpinx than with an aspirated hydrosalpinx (80). The above findings apply to both cases of normal pregnancy and to IVF-ET. In a prospective study carried out by Shelton et al (1996), fresh and frozen embryo transfers were carried out in 15 women who had hydrosalpinges. The only pregnancy that issued ended up in a miscarriage. However, after salpingectomy, fresh and frozen transfers resulted in 9 pregnancies (60%), of which there were 3 miscarriages and 6 (67%) ongoing pregnancies (84).

From the above observation it will be logical to go for the most profitable surgical procedures which to our opinion will be fimbrioplasty for the less damaged tubes and surgical removal of the more damaged tubes prior to IVF/ET. However, the fact that cases of intrauterine pregnancies have been reported following neo-salpingostomy in patients who have had several  failed trials of IVF/ET (78). Also the fact that surgical removal of diseased tubes may not be accompanied by positive IVF/ET result, preventive salpingectomy should not be routine. A better understanding of the actions of hydrosalpinx fluid may be the solution of this problem.

Aboulgar et al,1998 (73) observed fluid accumulation in the uterine cavity during embryo transfer, and Anderson (75) sonographic diagnosed hydrosalpinx and observed its association with low rates of implantation and high pregnancy loss. Following these findings many studies have confirmed this association. Mukeherjee (74) demonstrated its significant embryotoxic nature. The real mechanism by which the fluid affects implantation is not known. It is however speculated that the mechanism may be: i) reflux of fluid into the uterine cavity; ii) irreversible endometrial damage; iii) release of intrauterine cytokines, prostaglandins, leukotrienes and other inflammatory compounds directly into the endometrium, or via the circulatory or lymphatic system;  iv)  delayed hypersensitive response to increased production of a 57-kda heat shock protein leading to pregnancy loss or v) chronic endometritis caused by chlamydia trachomatis. All off the above mechanisms may potentially act by altering endometrial receptivity (6).

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