Acta Obstet Gynecol Scand 56: 419426, 1977
ADVANCES IN TUBOPLASTY Maxwell Roland and David Leisten From the Department of Obstetrics & Gynecology, Booth Memorial Medical Center, Queens, New York, USA
Abstract. Reconstructive oviductal surgery was performed on 205 private patients with primary and secondary infertility, who were selected from 1075 endoscopic examinations. Each patient underwent an infertility survey which included gamete formation, reception and deposition of gametes, nidation, post-coital, and semen analysis. Only those with tubal abnormalities, not responding to conservative therapy after a minimum period of six months following laparoscopic examination, were selected for tuboplasty. Spiral stents for fimbrioplasty and straight teflon tubing for mid-portion and cornua obstruction were employed. These stents were removed eight weeks post-surgery, under local anesthesia at the office. Of the 205 tuboplasties, 193 patients had sustained patency; 75 conceived; 7 aborted; and l had an ectopic pregnancy. Pregnancy occurred between 1 and 26 months after removal of the stents. Complications were very few. The use of Roland spiral teflon stents has resulted in a greater percentage in patency and pregnancy rates, as compared to those without use of stents.
ADVANCES IN TUBOPLASTY Experience accumulated in the field of infertility demonstrates abnormal tubal factors play a role in at least one third of all cases and are second only to the male factor in incidence. Oviductal reconstructive surgery for the restoration of fertility meets with increasing success as experience has been gained. Current improvements are based on more discriminating selection of patients by endoscopy and modifications of established techniques. Critical evaluation of certain aspects of technique designed to improve ovum pick-up, facilitate gamete transportation, and expedite zygote passage through the tube, is the subject of this report. Systems for properly selecting candidates for tuboplasty and for reporting the surgery and its results are also included in this study.
MATERIAL AND METHODS This presentation is based on the results in reconstructive oviductal surgery in 205 patients from our private practice. These cases were selected from 1075 endoscopic examinations (48 culdoscopies and 1 027 laparoscopies) in patients with primary or secondary infertility. Prior to endoscopic examination, all patients were evaluated by either our staff or their own gynecologists. Before we subjected any patient to endoscopic examination, each couple underwent the following ofice procedures: Gamete Formation: Determined by endometrial biopsy, serum progesterone and basal body temperature charts. If any of these factors was negative, it was repeated in order to establish the positive results. Reception and Deposition of Gametes: By means of semen analysis, post-coital, degree of fern phenomenon and semen penetration tests, combination of hydrotubation followed by carbon dioxide insufflation (I) and, when indicated, hysterosalpingogram. Preparation for Nidation: By means of endometrial biopsy, serum progesterone (RIA) and basal body temperature charts. This is done premenstrually. Upon the completion of the above procedures and if there existed either the tubal factor or possible ovarian pathology such as Steinoid ovaries, and if the latter failed to respond to several months of Clomid therapy, these patients, should they fail to conceive within a period of six months following the infertility survey and therapy, would be subjected to endoscopy. Some of these couples had been worked up by other qualified gynecologists and, if the survey included all the above-mentioned tests, and proper therapy used as stated above, certified by the abstract received, these patients would be admitted to the hospital for endoscopy. Most of these patients had laparoscopy and some, if indicated, also had hysteroscopy at the same sitting. It must be pointed out that almost all patients had tried to conceive for periods over two years. The only exception would be the elderly nulliparous patient (over 30 years of age) who would be subjected to endoscopy at an earlier date, for obvious reasons. Prior to use of endoscopy or stents, in a group of 32 patients, the postoperative patency result of tubal surgery Acro Ohstet Gvnecoi Scand 56 (1977)
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Table I. Distribution of results in patients subjected to endoscopy and found to have tubal pathology Total number of endoscopies Patients with no visible tubal disorders Patients with disorders amenable to correction Patients with contra-indications to tuboplasty
1075 699
Patients who refused tubal surgery Patients who conceived after laparoscopy but without tubal surgery (within 6 months) Patients in whom tuboplasty was performed
14
337 39
118 205
was only 56%, and only 12% achieved pregnancies following tuboplasty without stents. Only 6% resulted in live births. Table I illustrates the subsequent course of 376 of the 1 075 patients subjected to endoscopy, with presumptive diagnosis of tubal pathology established by the basic evaluation and confirmed by this procedure. It is interesting to note that 699 patients of the total endoscopies performed did not reveal tubal pathology to warrant surgery. Table I1 demonstrates the results of tuboplasty after we adopted the routine use of endoscopy and splinting techniques. Table Ill lists the time interval between tuboplasty and resulting pregnancy.
TUBAL RECONSTRUCTIVE TECHNIQUE The re-anastomosis of previously ligated tubes or midportion obstruction was performed over a straight teflon splint of narrow calibre with the simple approximation of the freshly transected, debrided ends by 5-0 chromic interrupted sutures through the seromuscular coat (2, 3) (Fig. 1). Cornual implantation of proximally occluded tubes is carried out by a significant modification of the standard procedure which has proven advantageous. The conventional technique creates a large opening with a corkborer and employs a “fishtail” incision at the cornual end of the oviduct. This implantation which is fixed by sutures in the endometrial cavity, is followed by healing with the endosalpingeal tissue growing in the cavity of the uterus. The large cornual opening in the myometrium and the tubal tissue in the endometrial cavity have proven unphysiological and, in some cases, have met with disastrous cornual nidation and alarming bleeding at tubal abortion, with tubal rupture. In contrast, we employ a narrow trocar and cannula to establish a uniformly narrow cornual interstitial tract to the endometrial cavity. The management of the diseased portion of the tube is also critical. It is our concept that the maximum length of the tube must be preserved for physiologic transport of the zygote. Therefore, to avoid sacrificing an undesirable length of tube, we employ a wire probe and simply establish a channel in the proximal portion of the oviduct (2), Acta Obstet Gynecol Scand 56 (1977)
creating a new lumen. In addition, we denude one centimeter of the serosa of the proximal portion of the oviduct. The straight teflon splint is then introduced through the fimbrial end of the oviduct and, on exiting the cornual end, is fixed within the endometrial cavity with two 4-0 chromic sutures on a large curved or straight Keith needle passed obliquely through the cavity and out the serosa of the fundus. The serosa of the oviduct is then approximated to the serosa of the fundus, at the cornual insertion, with interrupted 5-0 chromic sutures (Fig. 2 4 ) . We believe the endosalpingeal epithelium grows over the splint from the tubal side but does not reach the endometrial cavity, whose epithelium comes to line a part of the interstitial portion of the splint. We believe this to establish a more physiological union of the two epithelia, at a more appropriate junction, thus eliminating the impairment of the progression of the blastocyst through the contractile interstitial portion of the tube, and permits timely nidation. Fimbrioplasty, which is most commonly called for, has been accomplished with dramatic improvement in our results by the introduction of the Roland spiral teflon stent, as has been previously reported (4, 6). The spiral portion of the stent has a cone-shaped flare from the straight portion of the tubing so that it conforms to the shape of the ampullary and fimbriated portion of the oviduct. The teflon tubing is strengthened by a matrix of straight, fine copper wiring which is malleable, and assumes as well, the shape of the spiral cone. The critical features of successful fimbrioplasty include lysis of all adhesions and adequate dilatation of the constricted or occluded abdominal ostium of the oviduct with graduated teflon cones, at all times maintaining moistness of the fimbria with saline irrigation. The spiral cone is then inserted in the ampulla with a grooved metal cone-shaped guide and is fixed within the ampulla for the duration of healing by placing three or four 4-0 chromic sutures in the seromuscular coat of the oviduct just proximal to and parallel with the abdominal ostium and tying these over the distal loop of the spiral cone, seated deeply in the ampulla (Fig. 5 ) .
Fig. 1. Steps in reconstruction of midportion occlusion.
421
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Table 11. Tuboplasty results in patients in whom pre-operative endoscopy and stents were used Total no. of patients
Type of lesion ~~~
~~~
~~
Post-operative patency
Pregnancy
No.
%
No.
3
75
3
loo
20 129 41 193
91 96 93 94
12 45 15 75
60 35 37 39
~~
Bilaterally homogeneous Midportion A. For reanastomosis B. Midportion occlusion Comual Fimb ria 1 Bilaterally mixed Totals and %
%
Abortion* No.
Live birthsb
No.
%
~~~~
4 2 2 22 135 44 205
3
loo
1
11
4 2 7
41 13 68
92 91 87 91
a % pregnancies of patent tubes. * % of pregnancies.
In all of these procedures employing teflon splints, the distal limbs are each individually passed 2 cm apart, through the layers of the abdomen, to exit just beneath the skin. The two free ends are tied together in three combined, easily palpable knots and fixed between the Scarpa’s fascia and the skin closure (Fig. 6). Eight weeks, post-operatively, is the appropriate time for removal, which is readily accomplished with minimum discomfort by observing the following rules. With local anesthetic infiltration, a one centimeter incision is made just above the primary Pfannenstiel skin incision, the knot grasped, and each limb individually tracted until recovered from the abdominal cavity. This gentle, steady traction, on one limb at a time, straightens out the spiral cone and permits withdrawal of the tubing. This simple office technique for the removal of the stents replaces the formidable burden of a second operation to remove devices.
DISCUSSION The proper work-up of the infertile couple has been reported previously (7). An essential feature of the basic study is fiberoptic laparoscopy after gamete Table 111. Time interval between tuboplasty and pregnancy Time interval in month
NO. 1-2 3-6 7-10 11-18 19-26 Midportion Reanastomosis of previous ligation Anastomosis of occlusion Comual implantation Firnbria Bilaterally homogenous Bilaterally mixed 27-772864
3
1 2
12 45
15
1
2
6
3
1
5 1
12 4
18 8
9 2
formation in male and female, reception, deposition of gamete, nidation and transport factors have been evaluated. So valuable is the information provided at laparoscopy that only in the most unusual circumstance is one justified in attempting tuboplasty without prior laparoscopy. In the primary infertility survey for a couple, more simple techniques for estimating tubal patency and tubal configuration may be employed initially. These include hydrotubation, followed by carbon dioxide insufflation ( l ) , which must be carried out several times if an obstructive pattern is to be entertained. Also, the volume of fluid introduced must exceed the routine ten ml if the presence of a hydrosalpinx with distal occlusion is to be discovered. Hysterosalpingography, if an entirely physiologic configuration of the oviduct is demonstrated and accompanied by a good “peritoneal smear”, bilaterally, may be accepted in the initial survey and management of a couple. Since the incidence of adverse tubal factors is at least thirty-five to forty per cent, and since hysterosalpingography is deficient or in error at least twenty-five to thirty percent of the time (6), and laparoscopy has proven therapeutic in at least twenty percent of cases with partial tubal fimbrial occlusion, its use is warranted. In the large number of couples referred to the infertility specialist’s office, who have had previous infertility studies performed and have failed to conceive despite active supervision over six months, laparoscopy is mandated an essential feature of the basic study and management. A specific finding at laparoscopy, not achieved by any other mode of investigation, is the demonstration of narrowed abdominal ostia of the oviducts, referred to as phimosis. On tubal perfusion, Acta Obstet Gynecol Scnnd 56 (1977)
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Fig. 2. Opening at cornua made with a narrow trocar and cannula.
under direct laparoscopic observation, sacculation of the isthmic portion of the oviduct occurs, and the perfused blue dye is prominently visualized through the serosal coat. This observation persists after the introductory pressure of the syringe for more than thirty seconds, as one drop of dye escapes from the oviduct at a time. Another feature of laparoscopic observation, in which hysterosalpingography frequently fails, is the presence of pen-tubal adhesions, at points along the length of the oviduct, which may impede tubal motility and alter transport of the zygote. Also, the presence of fimbrial
anchored to fundus. Acta Obstet Gynecul Scund 56 (1977)
Fig. 4 . Interrupted sutures (4-0 chromic) used to approximate the serosa between the cornua and proximal portion of tube.
adhesions, which may impair ovum pick-up, readily fails to alter the “peritoneal smear” of hysterosalpingography (Fig. 6). To define the role of laparoscopy completely, it must be insisted upon that tuboplasty must not be accompanied by endoscopy at the same “sitting”, especially with partial tubal occlusion. First, the therapeutic benefit of laparoscopy is significantly high, as shown in Table 11. The judgment of the role and prognosis of surgery is made hastily and under stress, and not shared with the patient. Finally, the combined surgical procedure imposes too long an operating time, which carries the burden of added morbidity in infection and anesthetic complications. In our estimation, only a previous inadequately described adverse laparoscopy report warrants, under unusual circumstances, combined laparoscopy-tuboplasty procedure. The universal experience of a small but significant number of patients conceiving following hydrotubation and/or hysterosalpingography , is wellestablished. Nevertheless, our experience demonstrates an additional approximately twenty per cent of patients with tubal abnormalities who conceive after laparoscopy, with no other definitive therapy (Table 11). This is understandable on the basis that in the anesthetized patient, under direct observa-
grumous material and fine synechiae may be evacu-
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423
Fig. 5. (A) Spiral stent (reproduced from Roland by courtesy of Obstet Gynecol). @) Spiral stents placed into each ampulla, anchored there with 4-0 chromic sutures and brought out through comer of Pfannenstiel incision and knotted immediately below dermis.
ated. This has been observed by us on numerous occasions at laparotomy for tubal plasty. We usually perfuse the oviducts through either the cannula at the cervical level or through the fundal area. In the latter, we have observed the extrusion of this thick type grumous material. This can be further confirmed by the microscopic examination of the expelled material. Current reports in the literature describe old and new techniques for lysis of tubo-ovarian adhesions and salpingostomy without the use of splinting devices and this, in our opinion, can only be deplored on physiologic grounds. Any manipulation that calls forth a peritoneal reaction, such as in dissection of adhesions or electrocoagulation of adhesions, will result in the establishment of new fibrinous exudate as an essential step in healing. This must represent a defeat for the surgical technique. The subcutaneous fixation of the terminal knotted portion of the stents permits intestinal motion to move the splinted oviducts and inhibit formation of new fibrinous adhesions, and thus prevent adhesions between the distal portion of the oviduct to adjacent structures. After laparoscopy, those patients who were found to have partial tubal occlusion, including those with hydrosalpinx, partially occluded, as demonstrated by persistent sacculations which do not disappear after thirty seconds, were all followed with pre-ovulatory hydrotubation and carbon dioxide tubal insufflation, described above, for at
least six months- Most of them were followed for longer periods of time before they were recommended for tubal reconstruction. As stated elsewhere, only those patients who were above 30 years of age, and had a history of trying to conceive for a minimum of two years without success, did we, in cases of complete tubal occlusion as demonstrated at laparoscopy, perform tubal surgery before the trial period of six months. In cases of hydrosalpinx with distal occlusion,
Fig. 6 . Adhesions between the fimbria and lateral wall of pelvis. Acta Obstet Gynecol Scand 56 (1977)
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we would simply incise the serosal covering and, in most cases, could observe a good amount of fimbria behind (as seen with 36 times magnification of ophthalmological lenses). In this case, we would suture the serosal portion backward and still insert the spiral stent, and anchor it there for eight weeks. Our rationale has been that by incising the serosal covering and handling the fine fimbria, there usually exists the possibility to reform adhesions. When left alone the opposing walls usually collapse and are in approximation with each other. The insertion of the stent, therefore, is found to be very helpful in preventing re-adhesions between its walls. Prevention of the distal repaired tube from lying free, and next to the abdominal contents, might cause adhesions to the adjacent tissue. One must remember that by suturing the serosal area backward, we are exposing raw surfaces to be subjected to re-adhesions. The stent in place and the distal portion of the teflon anchored keeps the abdominal wall distal portion from staying in one area and thereby kept moving by the intestine. Our criteria for the spiral stent are two-fold: ( I ) to keep the reconstructed fimbria separated and thus prevent reocclusion; (2) in patients with phimosis and partial tubal occlusion, after dilatation with graduated cone-shaped probes, the spiral stent prevents re-shrinking to its original position. The same holds true for the hydrosalpinx with occlusion, by preventing the raw surfaces resulting from lyses of adhesions of the opposing walls to readhere. Our motto is-once adhesions have been lysed, a stent must be placed. Adjuvants to tuboplasty require evaluation at the same time. The role of corticoids and promethazine (Phenergan, Wyeth Lab.) in inhibiting the formation of adhesions is not yet established (7). In pursuit of this information, we are employing corticoids and promethazine in alternate cases. We are convinced that the prophylactic use of antibiotics is warranted in all cases of tuboplasty, since an infectious factor in the etiology of tubo-ovarian adhesions can never be ruled out with certainty at the time of surgery. We therefore culture the distal portion of the tube at laparotomy. A further measure to eliminate the introduction of infection is the prohibition of sexual activity during the eight weeks period the stents remain in situ. We have recently added 200 cc of 6 % Dextran in 5 % Dextrose before closing the peritoneal cavity as additional aid to prevent post-operative adhesion. So far it has served Arta Obstet Gvnecol ScundJ6 (1977)
a purpose. Oral contraceptives, for eight weeks, are provided to prohibit the contamination of the healing epithelial surfaces by the menstruum and to block cilia formation in the presence of semi-rigid splinting material, which might damage these functionally vital cellular elements. Additional observations gathered from our years of experience with tuboplasty permit other pertinent conclusions to be drawn. And careful analysis of individual cases imparts to us a sense of awe and humility toward the work we do. In our series there were three cases that met with major complications, characterized by intestinal obstruction, peritonitis, and severe infection. Study demonstrated there were features common to these three cases. All had severe pelvic endometriosis as the primary diagnosis. Two of these had previous surgery for pelvic endometriosis and had postoperative courses characterized by febrile episodes of clinical significance. The third, an early case, presented marked pelvic endometriosis requiring extensive dissection, following which tuboplasty was performed, with spiral teflon stents to protect the fimbria from re-involvement with adhesions. All three cases required laparotomy for intestinal obstruction and bowel re-section. Most remarkable was the conclusion to the third case, operated for tuboplasty for the first time. She conceived within a year and delivered a full-term baby. Two caveats may be drawn from these cases. The presence of severe pelvic endometriosis presents a formidable problem, the surgical management of which predisposes the patient to a stormy post-operative course, frequently with super-imposed infection. This combination of complications should preclude successful reconstructive tubal surgery. That even these complications may be overcome in the future, as we acquire more experience and knowledge, is indicated by the third case, which terminated in a successful pregnancy. An additional caveat derives from experience with micro-surgical techniques. We employ ophthalmological lenses, providing three and one half times magnification, and affording adequate visualization of all anatomic features, especially if the fimbriae are kept moist with saline. Unlike neurosurgery, the employment of microsurgical techniques unnecessarily prolongs the surgical procedure and anesthesia time, which may predispose to increased morbidity. We did not find more advantage in the rise to higher magnification
Advances in tuboplasty
Table IV. Proposed classification f o r reporting work-up and management of reconstructive tubal surgety Cases to be accepted for classification 1. All other factors in reproduction have been demonstrated normal in both members of a couple 2. The identical operation is performed in both tubes or the status and management of the separately
handled tubes are individually documented and described All of the following data are reported I . Patient’s prior obstetrical history and report
of all infertility studies 2. Tuba1 deficit defined at endoscopy and peak pressures applied on tubal perfusion Operation performed 1. Site: Fimbria, mid-portion, comual procedure,
sutures used
2. Findings at tubal perfusion 3. Type of stents used; duration of placement
4. Operative diagnosis; pathological diagnosis of any
resected tissue Post-operative management 1.
Hydrotubation
2. Insufflation 3. Adjunctive medication Removal technique Post-operative performance 1. Patency 2. Obstetrical performance
a. Abortions b. Live births 3. Ectopic and location
than three and one half times with opthalmological lenses.
SUMMARY We believe these results reflect a statistically significant improvement in the results of tubal reconstructive surgery. The more judicious selection of patients for tuboplasty by laparoscopy has significantly improved the prognosis for patients to whom we offer surgical tubal reconstruction. It is important to observe in Table I the 39 patients in whom complex pathological findings demonstrated tuboplasty was contraindicated. It must also be recognized that some of the conditions that interdicted surgery might not have been recognized on hysterosalpingography. Also, it is reported that hysterosalpingography missed pathology in 30% of the cases. Therefore, it may be said laparoscopy has permitted us to find additional cases to benefit
425
from tuboplasty, over that number suggested by hysterosalpingography. These observations support our view that hysterosalpingography must not interdict early laparoscopic examination, regardless of the findings. Further, the therapeutic benefit of laparoscopy in a significant number of patients precludes the combining of the two procedures, laparoscopy and tuboplasty , in most instances. Table I reveals 118 patients conceived, following laparoscopy. Table I1 reports the improved results afforded by the critical features of our technique, particularly the employment of the Roland spiral stent in fimbrioplasty, and splinting all anastornotic sites. These tables reflect an improvement in oviductal patency rate from 56 % to 90 % when patients were more discriminately selected by laparoscopy and splinting with stents was employed routinely. The improved patency rate was accompanied by a concomitant rise in the pregnancy incidence to 39 % of patients with sustained tubal patency. The abortion rate is 3.4 %. In groups the size of those reported here, these figures fail to demonstrate a predilection by site of tubal repair. Table V. Classification of tubal disease Right
I . Endometriosis A. Ovary B. Fimbria
..................... ..................... .....................
11. Malformation (occlusion) A. Fimbnal 1. Complete 2. Partial 3. With serosa only B. Ampulla 1. Hydrosalpinx 2. Sacculation with dye only C. Mid-tube Complete occlusion D. Cornual 1. Complete occlusion 2. Partial occlusion
B. Tube-lateral wall C. Ovary-tube
Bilateral
..................... ..................... .....................
C. Ampulla D. Mid-portion E. Comual F. Cul-de-sac
111. Adhesions A. Pen-tuba1
Left
.............. ....... .............. ....... .............. .......
.......
..............
.......
..............
.......
..............
....... .............. ....... .............. ..................... .....................
.....................
Actu Obstet Gynetol Scund56 (1977)
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M . Roland and D . Leisten
Table VI. Classification of tubal surgery Previous surgery: Salpingectomy ... Oophorectomy Salp. Ooph ...
I. Peritoneal Excision of endometriosis A. Ovary B. Fimbria C. Ampulla D. Mid-portion
11. Malformntion Cfimbrial): A. Fimbrioplasty B. Incision of serosa C. Dilatation of phimosis D. Insertion of stents, type of stent, hood, spiral, none 111. Mid-portion occlusion: A. Excision of occluded portion B. Anastomosis (end-teend) C. Stent used (teflon, poly)
Right
Left
....... ....... ....... .......
.......
.......
.......
.......
.......
....... ....... .......
....... .......
....... ....... ....... ....... ....... ....... ....... ....... ....... .......
IV. Peritubal adhesions: Lysis (sharp or cauter) Kinks removed .......
.......
V. A. B. C.
.......
Cornual implantation: Excision of occluded portion Implantation (method) Stent used (teflon, poly)
VI. Adnexal adhesions: Lysis A. Between: ovary-tube B. Tube-lateral wall C. Ovary-omentum D. Omentum-tube E. Cul-de-sac (type-omentum, endometriosis) F. Endometnosis
.......
....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... .......
....... ....... ....... .......
We have only one ectopic pregnancy to report, so that no conclusions may be drawn in this regard. Finally, of the 1075 laparoscopies, 376 were found to have tubal pathology. The findings in 39 cases interdicted corrective surgery; 337 were amenable to reconstructive surgery. However, 118 conceived after laparoscopy ; 14 refused surgery. Therefore, 205 patients had tuboplasty. 90% of these had sustained tubal patency; 68 had full-term pregnancies; 7 had early abortions, and may yet conceive and carry to term. The implementation of finding tubal pathology with laparoscopy and the guidance it has provided in selecting cases for tuboplasty properly has been accompanied by additional improvement in our success with tuboplasty by the employment of rouActu Obstet Gynecol Scand 56 (1977)
tine splints, in particular, the introduction of the
... spiral teflon stent.
Further improvement, we believe, rests upon the adoption of uniform, simple classification of tubal operations so that statistically significant data can be accumulated. This will permit recognition of the differences in the success rate met by the various techniques employed for tuboplasty. A meaningful system of classification should include a very limited number of subsets of procedures, so that sufficient data for analysis will quickly accumulate. We would like to suggest the following criteria for such classification (Tables IV, V and VI). Beyond the benefits to accrue from our analysis of our current techniques for oviductal reconstructive surgery, further progress will be achieved when our knowledge of tubal function on a molecular level is increased. The role of hormonal activity in oviductal function in transport of gametes and zygotes is information which is being accrued. Functional sphincters and their hormonal control may be altered or restored by tubal plastic surgery. Tuboplasty and its adjuvants must preserve epithelial nutrition, the ciliary elements, and the contractile motility of the oviduct, so that sperm capacitation and timely ovum transport are insured. These molecular events must be better understood. REFERENCES 1. Roland, M.: Modified hydrotubation for tubal obstruction. Int J FertilZ3: 71, 1968. 2. Roland, M. & Leisten, D.: Tuboplasty in 130 patients. Improved results due to stents & pre-operative endoscopy. Obstet Gynecol39: 1972. 3. McCormick, W. G. & Torres, J.: A method fo Pomeroy tubal ligation reanastomosis. Obstet Gynecol 47: 623, 1976. 4. Roland, M.: Spiral teflon stent for tuboplasty involving fimbria. Obstet Gynecol36: no. 3, 1970. 5 . Roland, M.: Management of the Infertile Couple. Charles C. Thomas, Springfield, Ill., 1968. 6. Behrman, J. & Kistner, R.: Progress in Infertility, 2nd ed. Little, Brown, Boston, 1975. 7. Home, W., jr et al.: Prevention of post-operative adhesions following conservative operation. Treatment for human infertility. Int J Fertil18: 109, 1973. Submitted f o r Festschrift
Maxwell Roland Department of Obstetrics and Gynecology Booth Memorial Medical Center, Main St. & Booth Ave. Queens New York USA
ADVANCES IN TUBOPLASTY Maxwell Roland and David Leisten From the Department of Obstetrics & Gynecology, Booth Memorial Medical Center, Queens, New York, USA
Abstract. Reconstructive oviductal surgery was performed on 205 private patients with primary and secondary infertility, who were selected from 1075 endoscopic examinations. Each patient underwent an infertility survey which included gamete formation, reception and deposition of gametes, nidation, post-coital, and semen analysis. Only those with tubal abnormalities, not responding to conservative therapy after a minimum period of six months following laparoscopic examination, were selected for tuboplasty. Spiral stents for fimbrioplasty and straight teflon tubing for mid-portion and cornua obstruction were employed. These stents were removed eight weeks post-surgery, under local anesthesia at the office. Of the 205 tuboplasties, 193 patients had sustained patency; 75 conceived; 7 aborted; and l had an ectopic pregnancy. Pregnancy occurred between 1 and 26 months after removal of the stents. Complications were very few. The use of Roland spiral teflon stents has resulted in a greater percentage in patency and pregnancy rates, as compared to those without use of stents.
ADVANCES IN TUBOPLASTY Experience accumulated in the field of infertility demonstrates abnormal tubal factors play a role in at least one third of all cases and are second only to the male factor in incidence. Oviductal reconstructive surgery for the restoration of fertility meets with increasing success as experience has been gained. Current improvements are based on more discriminating selection of patients by endoscopy and modifications of established techniques. Critical evaluation of certain aspects of technique designed to improve ovum pick-up, facilitate gamete transportation, and expedite zygote passage through the tube, is the subject of this report. Systems for properly selecting candidates for tuboplasty and for reporting the surgery and its results are also included in this study.
MATERIAL AND METHODS This presentation is based on the results in reconstructive oviductal surgery in 205 patients from our private practice. These cases were selected from 1075 endoscopic examinations (48 culdoscopies and 1 027 laparoscopies) in patients with primary or secondary infertility. Prior to endoscopic examination, all patients were evaluated by either our staff or their own gynecologists. Before we subjected any patient to endoscopic examination, each couple underwent the following ofice procedures: Gamete Formation: Determined by endometrial biopsy, serum progesterone and basal body temperature charts. If any of these factors was negative, it was repeated in order to establish the positive results. Reception and Deposition of Gametes: By means of semen analysis, post-coital, degree of fern phenomenon and semen penetration tests, combination of hydrotubation followed by carbon dioxide insufflation (I) and, when indicated, hysterosalpingogram. Preparation for Nidation: By means of endometrial biopsy, serum progesterone (RIA) and basal body temperature charts. This is done premenstrually. Upon the completion of the above procedures and if there existed either the tubal factor or possible ovarian pathology such as Steinoid ovaries, and if the latter failed to respond to several months of Clomid therapy, these patients, should they fail to conceive within a period of six months following the infertility survey and therapy, would be subjected to endoscopy. Some of these couples had been worked up by other qualified gynecologists and, if the survey included all the above-mentioned tests, and proper therapy used as stated above, certified by the abstract received, these patients would be admitted to the hospital for endoscopy. Most of these patients had laparoscopy and some, if indicated, also had hysteroscopy at the same sitting. It must be pointed out that almost all patients had tried to conceive for periods over two years. The only exception would be the elderly nulliparous patient (over 30 years of age) who would be subjected to endoscopy at an earlier date, for obvious reasons. Prior to use of endoscopy or stents, in a group of 32 patients, the postoperative patency result of tubal surgery Acro Ohstet Gvnecoi Scand 56 (1977)
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Table I. Distribution of results in patients subjected to endoscopy and found to have tubal pathology Total number of endoscopies Patients with no visible tubal disorders Patients with disorders amenable to correction Patients with contra-indications to tuboplasty
1075 699
Patients who refused tubal surgery Patients who conceived after laparoscopy but without tubal surgery (within 6 months) Patients in whom tuboplasty was performed
14
337 39
118 205
was only 56%, and only 12% achieved pregnancies following tuboplasty without stents. Only 6% resulted in live births. Table I illustrates the subsequent course of 376 of the 1 075 patients subjected to endoscopy, with presumptive diagnosis of tubal pathology established by the basic evaluation and confirmed by this procedure. It is interesting to note that 699 patients of the total endoscopies performed did not reveal tubal pathology to warrant surgery. Table I1 demonstrates the results of tuboplasty after we adopted the routine use of endoscopy and splinting techniques. Table Ill lists the time interval between tuboplasty and resulting pregnancy.
TUBAL RECONSTRUCTIVE TECHNIQUE The re-anastomosis of previously ligated tubes or midportion obstruction was performed over a straight teflon splint of narrow calibre with the simple approximation of the freshly transected, debrided ends by 5-0 chromic interrupted sutures through the seromuscular coat (2, 3) (Fig. 1). Cornual implantation of proximally occluded tubes is carried out by a significant modification of the standard procedure which has proven advantageous. The conventional technique creates a large opening with a corkborer and employs a “fishtail” incision at the cornual end of the oviduct. This implantation which is fixed by sutures in the endometrial cavity, is followed by healing with the endosalpingeal tissue growing in the cavity of the uterus. The large cornual opening in the myometrium and the tubal tissue in the endometrial cavity have proven unphysiological and, in some cases, have met with disastrous cornual nidation and alarming bleeding at tubal abortion, with tubal rupture. In contrast, we employ a narrow trocar and cannula to establish a uniformly narrow cornual interstitial tract to the endometrial cavity. The management of the diseased portion of the tube is also critical. It is our concept that the maximum length of the tube must be preserved for physiologic transport of the zygote. Therefore, to avoid sacrificing an undesirable length of tube, we employ a wire probe and simply establish a channel in the proximal portion of the oviduct (2), Acta Obstet Gynecol Scand 56 (1977)
creating a new lumen. In addition, we denude one centimeter of the serosa of the proximal portion of the oviduct. The straight teflon splint is then introduced through the fimbrial end of the oviduct and, on exiting the cornual end, is fixed within the endometrial cavity with two 4-0 chromic sutures on a large curved or straight Keith needle passed obliquely through the cavity and out the serosa of the fundus. The serosa of the oviduct is then approximated to the serosa of the fundus, at the cornual insertion, with interrupted 5-0 chromic sutures (Fig. 2 4 ) . We believe the endosalpingeal epithelium grows over the splint from the tubal side but does not reach the endometrial cavity, whose epithelium comes to line a part of the interstitial portion of the splint. We believe this to establish a more physiological union of the two epithelia, at a more appropriate junction, thus eliminating the impairment of the progression of the blastocyst through the contractile interstitial portion of the tube, and permits timely nidation. Fimbrioplasty, which is most commonly called for, has been accomplished with dramatic improvement in our results by the introduction of the Roland spiral teflon stent, as has been previously reported (4, 6). The spiral portion of the stent has a cone-shaped flare from the straight portion of the tubing so that it conforms to the shape of the ampullary and fimbriated portion of the oviduct. The teflon tubing is strengthened by a matrix of straight, fine copper wiring which is malleable, and assumes as well, the shape of the spiral cone. The critical features of successful fimbrioplasty include lysis of all adhesions and adequate dilatation of the constricted or occluded abdominal ostium of the oviduct with graduated teflon cones, at all times maintaining moistness of the fimbria with saline irrigation. The spiral cone is then inserted in the ampulla with a grooved metal cone-shaped guide and is fixed within the ampulla for the duration of healing by placing three or four 4-0 chromic sutures in the seromuscular coat of the oviduct just proximal to and parallel with the abdominal ostium and tying these over the distal loop of the spiral cone, seated deeply in the ampulla (Fig. 5 ) .
Fig. 1. Steps in reconstruction of midportion occlusion.
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Table 11. Tuboplasty results in patients in whom pre-operative endoscopy and stents were used Total no. of patients
Type of lesion ~~~
~~~
~~
Post-operative patency
Pregnancy
No.
%
No.
3
75
3
loo
20 129 41 193
91 96 93 94
12 45 15 75
60 35 37 39
~~
Bilaterally homogeneous Midportion A. For reanastomosis B. Midportion occlusion Comual Fimb ria 1 Bilaterally mixed Totals and %
%
Abortion* No.
Live birthsb
No.
%
~~~~
4 2 2 22 135 44 205
3
loo
1
11
4 2 7
41 13 68
92 91 87 91
a % pregnancies of patent tubes. * % of pregnancies.
In all of these procedures employing teflon splints, the distal limbs are each individually passed 2 cm apart, through the layers of the abdomen, to exit just beneath the skin. The two free ends are tied together in three combined, easily palpable knots and fixed between the Scarpa’s fascia and the skin closure (Fig. 6). Eight weeks, post-operatively, is the appropriate time for removal, which is readily accomplished with minimum discomfort by observing the following rules. With local anesthetic infiltration, a one centimeter incision is made just above the primary Pfannenstiel skin incision, the knot grasped, and each limb individually tracted until recovered from the abdominal cavity. This gentle, steady traction, on one limb at a time, straightens out the spiral cone and permits withdrawal of the tubing. This simple office technique for the removal of the stents replaces the formidable burden of a second operation to remove devices.
DISCUSSION The proper work-up of the infertile couple has been reported previously (7). An essential feature of the basic study is fiberoptic laparoscopy after gamete Table 111. Time interval between tuboplasty and pregnancy Time interval in month
NO. 1-2 3-6 7-10 11-18 19-26 Midportion Reanastomosis of previous ligation Anastomosis of occlusion Comual implantation Firnbria Bilaterally homogenous Bilaterally mixed 27-772864
3
1 2
12 45
15
1
2
6
3
1
5 1
12 4
18 8
9 2
formation in male and female, reception, deposition of gamete, nidation and transport factors have been evaluated. So valuable is the information provided at laparoscopy that only in the most unusual circumstance is one justified in attempting tuboplasty without prior laparoscopy. In the primary infertility survey for a couple, more simple techniques for estimating tubal patency and tubal configuration may be employed initially. These include hydrotubation, followed by carbon dioxide insufflation ( l ) , which must be carried out several times if an obstructive pattern is to be entertained. Also, the volume of fluid introduced must exceed the routine ten ml if the presence of a hydrosalpinx with distal occlusion is to be discovered. Hysterosalpingography, if an entirely physiologic configuration of the oviduct is demonstrated and accompanied by a good “peritoneal smear”, bilaterally, may be accepted in the initial survey and management of a couple. Since the incidence of adverse tubal factors is at least thirty-five to forty per cent, and since hysterosalpingography is deficient or in error at least twenty-five to thirty percent of the time (6), and laparoscopy has proven therapeutic in at least twenty percent of cases with partial tubal fimbrial occlusion, its use is warranted. In the large number of couples referred to the infertility specialist’s office, who have had previous infertility studies performed and have failed to conceive despite active supervision over six months, laparoscopy is mandated an essential feature of the basic study and management. A specific finding at laparoscopy, not achieved by any other mode of investigation, is the demonstration of narrowed abdominal ostia of the oviducts, referred to as phimosis. On tubal perfusion, Acta Obstet Gynecol Scnnd 56 (1977)
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M . Roland and D . Leisten
Fig. 2. Opening at cornua made with a narrow trocar and cannula.
under direct laparoscopic observation, sacculation of the isthmic portion of the oviduct occurs, and the perfused blue dye is prominently visualized through the serosal coat. This observation persists after the introductory pressure of the syringe for more than thirty seconds, as one drop of dye escapes from the oviduct at a time. Another feature of laparoscopic observation, in which hysterosalpingography frequently fails, is the presence of pen-tubal adhesions, at points along the length of the oviduct, which may impede tubal motility and alter transport of the zygote. Also, the presence of fimbrial
anchored to fundus. Acta Obstet Gynecul Scund 56 (1977)
Fig. 4 . Interrupted sutures (4-0 chromic) used to approximate the serosa between the cornua and proximal portion of tube.
adhesions, which may impair ovum pick-up, readily fails to alter the “peritoneal smear” of hysterosalpingography (Fig. 6). To define the role of laparoscopy completely, it must be insisted upon that tuboplasty must not be accompanied by endoscopy at the same “sitting”, especially with partial tubal occlusion. First, the therapeutic benefit of laparoscopy is significantly high, as shown in Table 11. The judgment of the role and prognosis of surgery is made hastily and under stress, and not shared with the patient. Finally, the combined surgical procedure imposes too long an operating time, which carries the burden of added morbidity in infection and anesthetic complications. In our estimation, only a previous inadequately described adverse laparoscopy report warrants, under unusual circumstances, combined laparoscopy-tuboplasty procedure. The universal experience of a small but significant number of patients conceiving following hydrotubation and/or hysterosalpingography , is wellestablished. Nevertheless, our experience demonstrates an additional approximately twenty per cent of patients with tubal abnormalities who conceive after laparoscopy, with no other definitive therapy (Table 11). This is understandable on the basis that in the anesthetized patient, under direct observa-
grumous material and fine synechiae may be evacu-
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423
Fig. 5. (A) Spiral stent (reproduced from Roland by courtesy of Obstet Gynecol). @) Spiral stents placed into each ampulla, anchored there with 4-0 chromic sutures and brought out through comer of Pfannenstiel incision and knotted immediately below dermis.
ated. This has been observed by us on numerous occasions at laparotomy for tubal plasty. We usually perfuse the oviducts through either the cannula at the cervical level or through the fundal area. In the latter, we have observed the extrusion of this thick type grumous material. This can be further confirmed by the microscopic examination of the expelled material. Current reports in the literature describe old and new techniques for lysis of tubo-ovarian adhesions and salpingostomy without the use of splinting devices and this, in our opinion, can only be deplored on physiologic grounds. Any manipulation that calls forth a peritoneal reaction, such as in dissection of adhesions or electrocoagulation of adhesions, will result in the establishment of new fibrinous exudate as an essential step in healing. This must represent a defeat for the surgical technique. The subcutaneous fixation of the terminal knotted portion of the stents permits intestinal motion to move the splinted oviducts and inhibit formation of new fibrinous adhesions, and thus prevent adhesions between the distal portion of the oviduct to adjacent structures. After laparoscopy, those patients who were found to have partial tubal occlusion, including those with hydrosalpinx, partially occluded, as demonstrated by persistent sacculations which do not disappear after thirty seconds, were all followed with pre-ovulatory hydrotubation and carbon dioxide tubal insufflation, described above, for at
least six months- Most of them were followed for longer periods of time before they were recommended for tubal reconstruction. As stated elsewhere, only those patients who were above 30 years of age, and had a history of trying to conceive for a minimum of two years without success, did we, in cases of complete tubal occlusion as demonstrated at laparoscopy, perform tubal surgery before the trial period of six months. In cases of hydrosalpinx with distal occlusion,
Fig. 6 . Adhesions between the fimbria and lateral wall of pelvis. Acta Obstet Gynecol Scand 56 (1977)
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M. Roland and D.Leisten
we would simply incise the serosal covering and, in most cases, could observe a good amount of fimbria behind (as seen with 36 times magnification of ophthalmological lenses). In this case, we would suture the serosal portion backward and still insert the spiral stent, and anchor it there for eight weeks. Our rationale has been that by incising the serosal covering and handling the fine fimbria, there usually exists the possibility to reform adhesions. When left alone the opposing walls usually collapse and are in approximation with each other. The insertion of the stent, therefore, is found to be very helpful in preventing re-adhesions between its walls. Prevention of the distal repaired tube from lying free, and next to the abdominal contents, might cause adhesions to the adjacent tissue. One must remember that by suturing the serosal area backward, we are exposing raw surfaces to be subjected to re-adhesions. The stent in place and the distal portion of the teflon anchored keeps the abdominal wall distal portion from staying in one area and thereby kept moving by the intestine. Our criteria for the spiral stent are two-fold: ( I ) to keep the reconstructed fimbria separated and thus prevent reocclusion; (2) in patients with phimosis and partial tubal occlusion, after dilatation with graduated cone-shaped probes, the spiral stent prevents re-shrinking to its original position. The same holds true for the hydrosalpinx with occlusion, by preventing the raw surfaces resulting from lyses of adhesions of the opposing walls to readhere. Our motto is-once adhesions have been lysed, a stent must be placed. Adjuvants to tuboplasty require evaluation at the same time. The role of corticoids and promethazine (Phenergan, Wyeth Lab.) in inhibiting the formation of adhesions is not yet established (7). In pursuit of this information, we are employing corticoids and promethazine in alternate cases. We are convinced that the prophylactic use of antibiotics is warranted in all cases of tuboplasty, since an infectious factor in the etiology of tubo-ovarian adhesions can never be ruled out with certainty at the time of surgery. We therefore culture the distal portion of the tube at laparotomy. A further measure to eliminate the introduction of infection is the prohibition of sexual activity during the eight weeks period the stents remain in situ. We have recently added 200 cc of 6 % Dextran in 5 % Dextrose before closing the peritoneal cavity as additional aid to prevent post-operative adhesion. So far it has served Arta Obstet Gvnecol ScundJ6 (1977)
a purpose. Oral contraceptives, for eight weeks, are provided to prohibit the contamination of the healing epithelial surfaces by the menstruum and to block cilia formation in the presence of semi-rigid splinting material, which might damage these functionally vital cellular elements. Additional observations gathered from our years of experience with tuboplasty permit other pertinent conclusions to be drawn. And careful analysis of individual cases imparts to us a sense of awe and humility toward the work we do. In our series there were three cases that met with major complications, characterized by intestinal obstruction, peritonitis, and severe infection. Study demonstrated there were features common to these three cases. All had severe pelvic endometriosis as the primary diagnosis. Two of these had previous surgery for pelvic endometriosis and had postoperative courses characterized by febrile episodes of clinical significance. The third, an early case, presented marked pelvic endometriosis requiring extensive dissection, following which tuboplasty was performed, with spiral teflon stents to protect the fimbria from re-involvement with adhesions. All three cases required laparotomy for intestinal obstruction and bowel re-section. Most remarkable was the conclusion to the third case, operated for tuboplasty for the first time. She conceived within a year and delivered a full-term baby. Two caveats may be drawn from these cases. The presence of severe pelvic endometriosis presents a formidable problem, the surgical management of which predisposes the patient to a stormy post-operative course, frequently with super-imposed infection. This combination of complications should preclude successful reconstructive tubal surgery. That even these complications may be overcome in the future, as we acquire more experience and knowledge, is indicated by the third case, which terminated in a successful pregnancy. An additional caveat derives from experience with micro-surgical techniques. We employ ophthalmological lenses, providing three and one half times magnification, and affording adequate visualization of all anatomic features, especially if the fimbriae are kept moist with saline. Unlike neurosurgery, the employment of microsurgical techniques unnecessarily prolongs the surgical procedure and anesthesia time, which may predispose to increased morbidity. We did not find more advantage in the rise to higher magnification
Advances in tuboplasty
Table IV. Proposed classification f o r reporting work-up and management of reconstructive tubal surgety Cases to be accepted for classification 1. All other factors in reproduction have been demonstrated normal in both members of a couple 2. The identical operation is performed in both tubes or the status and management of the separately
handled tubes are individually documented and described All of the following data are reported I . Patient’s prior obstetrical history and report
of all infertility studies 2. Tuba1 deficit defined at endoscopy and peak pressures applied on tubal perfusion Operation performed 1. Site: Fimbria, mid-portion, comual procedure,
sutures used
2. Findings at tubal perfusion 3. Type of stents used; duration of placement
4. Operative diagnosis; pathological diagnosis of any
resected tissue Post-operative management 1.
Hydrotubation
2. Insufflation 3. Adjunctive medication Removal technique Post-operative performance 1. Patency 2. Obstetrical performance
a. Abortions b. Live births 3. Ectopic and location
than three and one half times with opthalmological lenses.
SUMMARY We believe these results reflect a statistically significant improvement in the results of tubal reconstructive surgery. The more judicious selection of patients for tuboplasty by laparoscopy has significantly improved the prognosis for patients to whom we offer surgical tubal reconstruction. It is important to observe in Table I the 39 patients in whom complex pathological findings demonstrated tuboplasty was contraindicated. It must also be recognized that some of the conditions that interdicted surgery might not have been recognized on hysterosalpingography. Also, it is reported that hysterosalpingography missed pathology in 30% of the cases. Therefore, it may be said laparoscopy has permitted us to find additional cases to benefit
425
from tuboplasty, over that number suggested by hysterosalpingography. These observations support our view that hysterosalpingography must not interdict early laparoscopic examination, regardless of the findings. Further, the therapeutic benefit of laparoscopy in a significant number of patients precludes the combining of the two procedures, laparoscopy and tuboplasty , in most instances. Table I reveals 118 patients conceived, following laparoscopy. Table I1 reports the improved results afforded by the critical features of our technique, particularly the employment of the Roland spiral stent in fimbrioplasty, and splinting all anastornotic sites. These tables reflect an improvement in oviductal patency rate from 56 % to 90 % when patients were more discriminately selected by laparoscopy and splinting with stents was employed routinely. The improved patency rate was accompanied by a concomitant rise in the pregnancy incidence to 39 % of patients with sustained tubal patency. The abortion rate is 3.4 %. In groups the size of those reported here, these figures fail to demonstrate a predilection by site of tubal repair. Table V. Classification of tubal disease Right
I . Endometriosis A. Ovary B. Fimbria
..................... ..................... .....................
11. Malformation (occlusion) A. Fimbnal 1. Complete 2. Partial 3. With serosa only B. Ampulla 1. Hydrosalpinx 2. Sacculation with dye only C. Mid-tube Complete occlusion D. Cornual 1. Complete occlusion 2. Partial occlusion
B. Tube-lateral wall C. Ovary-tube
Bilateral
..................... ..................... .....................
C. Ampulla D. Mid-portion E. Comual F. Cul-de-sac
111. Adhesions A. Pen-tuba1
Left
.............. ....... .............. ....... .............. .......
.......
..............
.......
..............
.......
..............
....... .............. ....... .............. ..................... .....................
.....................
Actu Obstet Gynetol Scund56 (1977)
426
M . Roland and D . Leisten
Table VI. Classification of tubal surgery Previous surgery: Salpingectomy ... Oophorectomy Salp. Ooph ...
I. Peritoneal Excision of endometriosis A. Ovary B. Fimbria C. Ampulla D. Mid-portion
11. Malformntion Cfimbrial): A. Fimbrioplasty B. Incision of serosa C. Dilatation of phimosis D. Insertion of stents, type of stent, hood, spiral, none 111. Mid-portion occlusion: A. Excision of occluded portion B. Anastomosis (end-teend) C. Stent used (teflon, poly)
Right
Left
....... ....... ....... .......
.......
.......
.......
.......
.......
....... ....... .......
....... .......
....... ....... ....... ....... ....... ....... ....... ....... ....... .......
IV. Peritubal adhesions: Lysis (sharp or cauter) Kinks removed .......
.......
V. A. B. C.
.......
Cornual implantation: Excision of occluded portion Implantation (method) Stent used (teflon, poly)
VI. Adnexal adhesions: Lysis A. Between: ovary-tube B. Tube-lateral wall C. Ovary-omentum D. Omentum-tube E. Cul-de-sac (type-omentum, endometriosis) F. Endometnosis
.......
....... ....... ....... ....... ....... ....... ....... ....... ....... ....... ....... .......
....... ....... ....... .......
We have only one ectopic pregnancy to report, so that no conclusions may be drawn in this regard. Finally, of the 1075 laparoscopies, 376 were found to have tubal pathology. The findings in 39 cases interdicted corrective surgery; 337 were amenable to reconstructive surgery. However, 118 conceived after laparoscopy ; 14 refused surgery. Therefore, 205 patients had tuboplasty. 90% of these had sustained tubal patency; 68 had full-term pregnancies; 7 had early abortions, and may yet conceive and carry to term. The implementation of finding tubal pathology with laparoscopy and the guidance it has provided in selecting cases for tuboplasty properly has been accompanied by additional improvement in our success with tuboplasty by the employment of rouActu Obstet Gynecol Scand 56 (1977)
tine splints, in particular, the introduction of the
... spiral teflon stent.
Further improvement, we believe, rests upon the adoption of uniform, simple classification of tubal operations so that statistically significant data can be accumulated. This will permit recognition of the differences in the success rate met by the various techniques employed for tuboplasty. A meaningful system of classification should include a very limited number of subsets of procedures, so that sufficient data for analysis will quickly accumulate. We would like to suggest the following criteria for such classification (Tables IV, V and VI). Beyond the benefits to accrue from our analysis of our current techniques for oviductal reconstructive surgery, further progress will be achieved when our knowledge of tubal function on a molecular level is increased. The role of hormonal activity in oviductal function in transport of gametes and zygotes is information which is being accrued. Functional sphincters and their hormonal control may be altered or restored by tubal plastic surgery. Tuboplasty and its adjuvants must preserve epithelial nutrition, the ciliary elements, and the contractile motility of the oviduct, so that sperm capacitation and timely ovum transport are insured. These molecular events must be better understood. REFERENCES 1. Roland, M.: Modified hydrotubation for tubal obstruction. Int J FertilZ3: 71, 1968. 2. Roland, M. & Leisten, D.: Tuboplasty in 130 patients. Improved results due to stents & pre-operative endoscopy. Obstet Gynecol39: 1972. 3. McCormick, W. G. & Torres, J.: A method fo Pomeroy tubal ligation reanastomosis. Obstet Gynecol 47: 623, 1976. 4. Roland, M.: Spiral teflon stent for tuboplasty involving fimbria. Obstet Gynecol36: no. 3, 1970. 5 . Roland, M.: Management of the Infertile Couple. Charles C. Thomas, Springfield, Ill., 1968. 6. Behrman, J. & Kistner, R.: Progress in Infertility, 2nd ed. Little, Brown, Boston, 1975. 7. Home, W., jr et al.: Prevention of post-operative adhesions following conservative operation. Treatment for human infertility. Int J Fertil18: 109, 1973. Submitted f o r Festschrift
Maxwell Roland Department of Obstetrics and Gynecology Booth Memorial Medical Center, Main St. & Booth Ave. Queens New York USA
