Acta Obstet Gynecol Scand 56: 415417, 1977
PREREQUISITES FOR TUBOPLASTY Alvin M. Siegler From the Department of Obstetrics and Gynecology (Head:J . H . Nelson Jr), State University of New York, Brooklyn, New York
Abstract. Techniques in measuring tubal patency and interpretation of findings can be misleading. Laparoscopic study of infertile women with suspected, diseased fallopian tubes is always prerequisite to tuboplasty. Observations must be accompanied by intrauterine injection of adequate amounts of dye and gentle tubal manipulations. Determined efforts should be made to eliminate reconstructive operations on nonsalvageable tubes because successful term pregnancies following tuboplasties are related more to the extent of tubal damage than to operative technique or postoperative management.
Many infertile women with diseased Fallopian tubes do not have tuboplasty because of contraindications existing such as age, a history of pelvic tuberculosis, obesity or a recent adnexal infection with residual pelvic tenderness. Infertility studies may reveal seminal inadequacy, poor sperm migration or ovular dysfunction. When the limited chances of success are described some women refuse operations. In a report by Murray (1) on 2 148 infertile women 311 (14.5%) were operated upon and of these 86 had tuboplasty. Crane & Woodruff (2) reporting their experiences with 96 tuboplasties maintained that the properly selected patient and extent of periadnexal adhesive disease greatly influenced prognosis. OBrien and colleagues (3) reviewed 173 tuboplastic operations, 61 of them on private patients, followed by a 35% pregnancy rate. Of 1 126 clinic patients seen during a 10-year period for infertility 424 (37 %) had tubal disease but only 112 came for reconstructive surgery. The incidence of tubal disease reported as a cause of sterility in any series varies with the type of patients studied. Peterson & Behrman (4) noted that 5 % of women with unexplained infertility had subsequent tubal pathology at laparoscopy. Corson & Bolognese ( 5 ) found tubal disease in 145 (58%)
of 249 patients undergoing laparoscopy for infertility. The results from conventional nonoperative tests for tubal patency, uterotubal insufflation and hysterosalpingography, may be misleading because of the inherent limitations of these procedures. The results also depend upon the physicians technique and interpretation. A presumptive diagnosis of tubal occlusion during insufflation can be made if passage of carbon dioxide does not occur below 200 mmHg, kymographic oscillations are absent, and no shoulder pain follows the test. Of 500 infertile women who eventually became pregnant, Rubin (6) noted initial pressures of 200 mmHg on one or two occasions in only 12 patients (2.4%) but none conceived after three negative tests. In a similar group of 296 infertile women, Siegler (7) found only one patient who conceived after three negative tests. These observations suggest that reported failure of carbon dioxide to pass through Fallopian tubes is indeed a poor prognostic sign. Uterotubal insufflation is not too accurate in the presence of dilated, occluded ampullae resulting occasionally in misleading or false positive tests. Salpingography can show the size of a distal, tubal obstruction but not the condition of fimbriae, the degree of tubal fixation or endosalpingeal destruction. Persistent, localized collections observed on the follow-up X-ray film suggest ampullary disease. Boyd & Holt (8) made a diagnosis of hydrosalpinx by hysterosalpingography in 130 instances and a subsequent laparotomy disclosed only four normal (3.1 %) patent tubes. Hysterosalpingographic interpretations of distal obstruction without dilatation is less accurate because at laparoscopy many tubes show patency but are restricted by peritubal adhesions. Young and colleagues (9) perArtir Ohstet Gvnecol Srand 56 (1977)
416
A . M . Siegler
formed tuboplasties on 112 infertile clinic patients, confirming the observations of Ozaras (10) who correlated postoperative pregnancy rates following salpingoneostomy with preoperative radiologic rugal markings. Their presence indicated minimal endosalpingeal disease, 60% of the patients conceiving after tuboplasty while in their absence only 7 % became pregnant. Swolin & Rozencrantz (1 1) compared findings of laparoscopy and hysterosalpingography in 143 patients, both methods being in agreement in the diagnosis of partial or complete tubal obstruction and tubal adhesions in 90 women (63%). Significant tubal abnormalities differing in degree were seen with both techniques in 24 other patients (17%). Normal laparoscopic findings were found in 14 women whose hysterosalpingograms were interpreted as abnormal. Bilateral tubal patency was detected in a previous hysterosalpingogram in 12 patients although partial obstruction was noted on laparoscopy. Radiologic studies were performed before ovulation with water soluble media followed the next day by laparoscopy using methylene blue or indigo carmine with saline. Maathius and colleagues (12) and Coltart (13) found in comparing the results of hysterosalpingography and laparoscopy, that most errors occurred because detection of significant peritubal adhesions cannot be made by radiologic techniques. Results from insufflation and salpingography should be carefully interpreted but it is sometimes difficult to evaluate the extent of tubal abnormalities without endoscopy. Although Frangenheim (14) who no longer advocates hysterosalpingography in infertile women he does advise laparoscopy to evaluate the pelvis and has recommended tuboplasty in almost one-third of his patients. In bilateral cornual blockage contrast fluid does not fill the tubes and none is seen in the peritoneal cavity on the delayed film. In these patients it is important to record the amount of fluid used, the degree of leakage at the cervic, the force and resistance to the instillation and the patients’ complaint of pain. Careful search for intramural and isthmic filling is important because their demonstration can influence the selection of the type of tubal reconstruction. With laparoscopy the tubal isthmus can be palpated to search for the characteristic nodularity of salpingitis isthmica nodosa, fimbriae can be manipulated and observed, ostia can be probed and tubal patency can be tested by injecting dilute soluActu Obstet Gynecol Scand56 (1977)
tions of dye through the cervix. Steptoe (15) advises laparoscopy in infertile patients to verify tubal patency with hydrotubation, to assess tubal obstruction and fimbrial involvement, to evaluate tubes for possible tuboplasty, and to lyse peritubal adhesions. Operative descriptions are dictated immediately following the procedure according to an organized plan so that important information is not forgotten. Rarely endoscopic observations are misleading or difficult to interpret and an occasional unnecessary laparotomy is done. Congenital or inflammatory luminal fibrosis and salpingitis isthmica nodosa are the most common causes for organic proximal obstruction. The condition is suspected if 1) nonpatency to COz insufflation occurs at 200 mmHg for 2 min at a flow rate of 30 ml per minute with increasing suprapubic midline pain but no subsequent shoulder pain; 2) opacification of no more than 2 to 3 cm of the fallopian tubes is seen after adequate amounts of contrast media have been injected without subsequent dispersion; 3) at laparoscopy occasional blanching of the isthmic segment is seen with resistance to the injection of dye through the cervical cannula and some vaginal reflux. Tuboplasty is feasible if distal segments including fimbriae are normal. Isthmic filling of indigo carmine in grossly normal tubes without spill usually indicates insufficient dye rather than intratubal blockage. The exact site of occlusion in this area may be difficult to locate but occasionally isthmic distention and blanching are seen proximal to the obstruction. Salpingitis isthmica nodosa can be missed on hysterosalpingography and laparoscopy unless careful observations are made. Palpation and manipulation of the tubal isthmus with a tactile proble are essential. Laparoscopy is prerequisite to tuboplasty in patients who have cornual or midtubal blockage on radiologic studies because the condition of the distal tubal segments is unknown. At laparotomy intrauterine fundal injections of dye are attempted to prove obstruction before tubal transection and anastomosis, or implantation. Occasionally this maneuver causes tubal filling despite previous studies indicating cornual obstruction. Even with final corroboration showing bilateral occlusion, subsequent examinations of excised segments may not reveal any abnormality. Boyd & Holt (8) reported 34% of tubal specimens from such patients examined histologically proved normal. In a patient desirous of reversing a tubal steriliza-
Prerequisites f o r tuboplasty
tion operation, laparoscopy can verify the presence of a distal tubal segment, evaluate the gross appearance of the fimbriated end, and enable the gynecologist to ascertain the feasibility of tubal reconstruction. Referred increasing lower quadrant pains during CO, insufflation suggest ampullary obstruction. The degree of distension and character of mucosal folds can be seen on hysterosalpingography, large terminal dilatations without luminal markings being a poor prognostic sign. Ozaras (10) found that only the 8 patients who had slight dilatation and linear mucosal markings conceived after ampullary salpingoneostomy . If ampullary disease is associated with salpingitis isthmica nodosa, tuboplasty is contraindicated. Rigid luminal contours indicate chronic advanced salpingitis with fibrosis possibly suggestive of tuberculous salpingitis. At laparoscopy in prefimbrial phimosis caused by endosalpingeal ampullary adhesions, free fimbriae are noted with tubal filling, some dilatation but minimal spill of dye. In the absence of peritubal adhesions, these problems can be treated by hydrotubation. In some patients, in whom pregnancy still does not occur following ovarian wedge resection, despite successful correction of anovulation laparoscopic examination is indicated to search for the extent of postoperative peritubal adhesions. Relatively normal fimbriae can be obscured by adhesions covering the adnexa and posterior leaf of the broad ligament. Gentle manipulation, probing and cervical instillation of dilute indigo carmine can show tubal patency with adhesions or distal tubal filling without spill. At laparoscopy chromotubation is indispensable especially if terminal tubal segments are fixed firmly in the cul-de-sac. Tubal filling with only moderate distention but some spilling of dye in the culde-sac or behind occlusive adhesions is a favorable sign. A dilated tube with pale thin walls, distended with fluid before instillation of any dye, is discerned readily. Additional pathology such as myomas or ovarian endometriosis indicates a poor prognosis. Less diseased, club-shaped, distally occluded tubes have a more natural pink color, feel less tense during probing and fill but do not spill fluid under laparoscopic control. An occasional hydrosalpinx can fill with dye during chromotubation, rupture
417
and extravasate material into the mesosalpinx, thus explaining abnormal patency to CO, or contrast medium in some of these patients.
REFERENCES I . Murray, E. G.: The peritoneal factor in female sterility. Fertil Sterill: 371, 1953. 2. Crane, M. &Woodruff, J. D.: Factors influencing the success of tuboplastic procedures. Fertil Steril 19: 810, 1968. 3. OBrien, J . R., Arronet, G. H. & Eduljee, S. Y.: Operative treatment of Fallopian tube pathology in human fertility. Am J Obstet 6ynecol 103: 520, 1969. 4. Peterson, E. P. & Behrman, S. J.: Laparoscopy of the infertile patient. Obstet Gynecol36: 363, 1970. 5. Corson, L. & Bolognese, R. J.: Laparoscopy: An overview and results of a large series. J Reprod Med 9: 148, 1972. 6 . Rubin, I. C.: Uterotubal Insufflation. C. V. Mosby, St. Louis, 1947. 7. Siegler, A. M.: Hysterosalpingography. Medcom Press., New York, 1974. 8. Boyd, I. E. & Holt, E. M.: Tubal sterility: patency tests and results of operation. J Obstet Gynecol Br Comm80: 142, 1973. 9. Young, P. E., Egan, J. E., Barlow, J. J. & Mulligan, W.: Reconstruction surgery at the Boston Hospital for Women. Am J Obstet GynecollO8: 1093, 1970. 10. Ozaras, H.: The value of plastic operations on the fallopian tubes in the treatment of female infertility. A clinical and radiologic study. Acta Obstet Gynecol Scand47: 489, 1968. 11. Swolin, K. & Rosencrantz, M.: Laparoscopy vs. hysterosalpingography in sterility investigations. A comparative study. Fertil Steril23: 270, 1972. 12. Maathius, J. B., Horbach, J. G. M. & Hall, E. V . : A comparison of the results of hysterosalpingography and laparoscopy in the diagnosis of Fallopian tube dysfunction. Fertil Steri123: 428, 1972. 13. Coltart, T. M.: Laparoscopy in the diagnosis of tubal patency. J Obstet Gynecol Br Comm 77: 69, 1970. 14. Frangenheim, H.: Vergleichende Untersuchungen zwischen dem Wert der Hysterosalpingographie und der Coelioskopie bei der Sterilitatsdiagnostik. Arch Gynaekol204: 167, 1967. 15. Steptoe, P.: Gynecological laparoscopy. J Reprod Med10:211, 1973.
Submitted for Festschrift A. M. Siegler Department of Obstetrics and Gynecology State University of New York Brooklyn, New York USA
Acta Obstet Gynecol Scand 56 (1977)
PREREQUISITES FOR TUBOPLASTY Alvin M. Siegler From the Department of Obstetrics and Gynecology (Head:J . H . Nelson Jr), State University of New York, Brooklyn, New York
Abstract. Techniques in measuring tubal patency and interpretation of findings can be misleading. Laparoscopic study of infertile women with suspected, diseased fallopian tubes is always prerequisite to tuboplasty. Observations must be accompanied by intrauterine injection of adequate amounts of dye and gentle tubal manipulations. Determined efforts should be made to eliminate reconstructive operations on nonsalvageable tubes because successful term pregnancies following tuboplasties are related more to the extent of tubal damage than to operative technique or postoperative management.
Many infertile women with diseased Fallopian tubes do not have tuboplasty because of contraindications existing such as age, a history of pelvic tuberculosis, obesity or a recent adnexal infection with residual pelvic tenderness. Infertility studies may reveal seminal inadequacy, poor sperm migration or ovular dysfunction. When the limited chances of success are described some women refuse operations. In a report by Murray (1) on 2 148 infertile women 311 (14.5%) were operated upon and of these 86 had tuboplasty. Crane & Woodruff (2) reporting their experiences with 96 tuboplasties maintained that the properly selected patient and extent of periadnexal adhesive disease greatly influenced prognosis. OBrien and colleagues (3) reviewed 173 tuboplastic operations, 61 of them on private patients, followed by a 35% pregnancy rate. Of 1 126 clinic patients seen during a 10-year period for infertility 424 (37 %) had tubal disease but only 112 came for reconstructive surgery. The incidence of tubal disease reported as a cause of sterility in any series varies with the type of patients studied. Peterson & Behrman (4) noted that 5 % of women with unexplained infertility had subsequent tubal pathology at laparoscopy. Corson & Bolognese ( 5 ) found tubal disease in 145 (58%)
of 249 patients undergoing laparoscopy for infertility. The results from conventional nonoperative tests for tubal patency, uterotubal insufflation and hysterosalpingography, may be misleading because of the inherent limitations of these procedures. The results also depend upon the physicians technique and interpretation. A presumptive diagnosis of tubal occlusion during insufflation can be made if passage of carbon dioxide does not occur below 200 mmHg, kymographic oscillations are absent, and no shoulder pain follows the test. Of 500 infertile women who eventually became pregnant, Rubin (6) noted initial pressures of 200 mmHg on one or two occasions in only 12 patients (2.4%) but none conceived after three negative tests. In a similar group of 296 infertile women, Siegler (7) found only one patient who conceived after three negative tests. These observations suggest that reported failure of carbon dioxide to pass through Fallopian tubes is indeed a poor prognostic sign. Uterotubal insufflation is not too accurate in the presence of dilated, occluded ampullae resulting occasionally in misleading or false positive tests. Salpingography can show the size of a distal, tubal obstruction but not the condition of fimbriae, the degree of tubal fixation or endosalpingeal destruction. Persistent, localized collections observed on the follow-up X-ray film suggest ampullary disease. Boyd & Holt (8) made a diagnosis of hydrosalpinx by hysterosalpingography in 130 instances and a subsequent laparotomy disclosed only four normal (3.1 %) patent tubes. Hysterosalpingographic interpretations of distal obstruction without dilatation is less accurate because at laparoscopy many tubes show patency but are restricted by peritubal adhesions. Young and colleagues (9) perArtir Ohstet Gvnecol Srand 56 (1977)
416
A . M . Siegler
formed tuboplasties on 112 infertile clinic patients, confirming the observations of Ozaras (10) who correlated postoperative pregnancy rates following salpingoneostomy with preoperative radiologic rugal markings. Their presence indicated minimal endosalpingeal disease, 60% of the patients conceiving after tuboplasty while in their absence only 7 % became pregnant. Swolin & Rozencrantz (1 1) compared findings of laparoscopy and hysterosalpingography in 143 patients, both methods being in agreement in the diagnosis of partial or complete tubal obstruction and tubal adhesions in 90 women (63%). Significant tubal abnormalities differing in degree were seen with both techniques in 24 other patients (17%). Normal laparoscopic findings were found in 14 women whose hysterosalpingograms were interpreted as abnormal. Bilateral tubal patency was detected in a previous hysterosalpingogram in 12 patients although partial obstruction was noted on laparoscopy. Radiologic studies were performed before ovulation with water soluble media followed the next day by laparoscopy using methylene blue or indigo carmine with saline. Maathius and colleagues (12) and Coltart (13) found in comparing the results of hysterosalpingography and laparoscopy, that most errors occurred because detection of significant peritubal adhesions cannot be made by radiologic techniques. Results from insufflation and salpingography should be carefully interpreted but it is sometimes difficult to evaluate the extent of tubal abnormalities without endoscopy. Although Frangenheim (14) who no longer advocates hysterosalpingography in infertile women he does advise laparoscopy to evaluate the pelvis and has recommended tuboplasty in almost one-third of his patients. In bilateral cornual blockage contrast fluid does not fill the tubes and none is seen in the peritoneal cavity on the delayed film. In these patients it is important to record the amount of fluid used, the degree of leakage at the cervic, the force and resistance to the instillation and the patients’ complaint of pain. Careful search for intramural and isthmic filling is important because their demonstration can influence the selection of the type of tubal reconstruction. With laparoscopy the tubal isthmus can be palpated to search for the characteristic nodularity of salpingitis isthmica nodosa, fimbriae can be manipulated and observed, ostia can be probed and tubal patency can be tested by injecting dilute soluActu Obstet Gynecol Scand56 (1977)
tions of dye through the cervix. Steptoe (15) advises laparoscopy in infertile patients to verify tubal patency with hydrotubation, to assess tubal obstruction and fimbrial involvement, to evaluate tubes for possible tuboplasty, and to lyse peritubal adhesions. Operative descriptions are dictated immediately following the procedure according to an organized plan so that important information is not forgotten. Rarely endoscopic observations are misleading or difficult to interpret and an occasional unnecessary laparotomy is done. Congenital or inflammatory luminal fibrosis and salpingitis isthmica nodosa are the most common causes for organic proximal obstruction. The condition is suspected if 1) nonpatency to COz insufflation occurs at 200 mmHg for 2 min at a flow rate of 30 ml per minute with increasing suprapubic midline pain but no subsequent shoulder pain; 2) opacification of no more than 2 to 3 cm of the fallopian tubes is seen after adequate amounts of contrast media have been injected without subsequent dispersion; 3) at laparoscopy occasional blanching of the isthmic segment is seen with resistance to the injection of dye through the cervical cannula and some vaginal reflux. Tuboplasty is feasible if distal segments including fimbriae are normal. Isthmic filling of indigo carmine in grossly normal tubes without spill usually indicates insufficient dye rather than intratubal blockage. The exact site of occlusion in this area may be difficult to locate but occasionally isthmic distention and blanching are seen proximal to the obstruction. Salpingitis isthmica nodosa can be missed on hysterosalpingography and laparoscopy unless careful observations are made. Palpation and manipulation of the tubal isthmus with a tactile proble are essential. Laparoscopy is prerequisite to tuboplasty in patients who have cornual or midtubal blockage on radiologic studies because the condition of the distal tubal segments is unknown. At laparotomy intrauterine fundal injections of dye are attempted to prove obstruction before tubal transection and anastomosis, or implantation. Occasionally this maneuver causes tubal filling despite previous studies indicating cornual obstruction. Even with final corroboration showing bilateral occlusion, subsequent examinations of excised segments may not reveal any abnormality. Boyd & Holt (8) reported 34% of tubal specimens from such patients examined histologically proved normal. In a patient desirous of reversing a tubal steriliza-
Prerequisites f o r tuboplasty
tion operation, laparoscopy can verify the presence of a distal tubal segment, evaluate the gross appearance of the fimbriated end, and enable the gynecologist to ascertain the feasibility of tubal reconstruction. Referred increasing lower quadrant pains during CO, insufflation suggest ampullary obstruction. The degree of distension and character of mucosal folds can be seen on hysterosalpingography, large terminal dilatations without luminal markings being a poor prognostic sign. Ozaras (10) found that only the 8 patients who had slight dilatation and linear mucosal markings conceived after ampullary salpingoneostomy . If ampullary disease is associated with salpingitis isthmica nodosa, tuboplasty is contraindicated. Rigid luminal contours indicate chronic advanced salpingitis with fibrosis possibly suggestive of tuberculous salpingitis. At laparoscopy in prefimbrial phimosis caused by endosalpingeal ampullary adhesions, free fimbriae are noted with tubal filling, some dilatation but minimal spill of dye. In the absence of peritubal adhesions, these problems can be treated by hydrotubation. In some patients, in whom pregnancy still does not occur following ovarian wedge resection, despite successful correction of anovulation laparoscopic examination is indicated to search for the extent of postoperative peritubal adhesions. Relatively normal fimbriae can be obscured by adhesions covering the adnexa and posterior leaf of the broad ligament. Gentle manipulation, probing and cervical instillation of dilute indigo carmine can show tubal patency with adhesions or distal tubal filling without spill. At laparoscopy chromotubation is indispensable especially if terminal tubal segments are fixed firmly in the cul-de-sac. Tubal filling with only moderate distention but some spilling of dye in the culde-sac or behind occlusive adhesions is a favorable sign. A dilated tube with pale thin walls, distended with fluid before instillation of any dye, is discerned readily. Additional pathology such as myomas or ovarian endometriosis indicates a poor prognosis. Less diseased, club-shaped, distally occluded tubes have a more natural pink color, feel less tense during probing and fill but do not spill fluid under laparoscopic control. An occasional hydrosalpinx can fill with dye during chromotubation, rupture
417
and extravasate material into the mesosalpinx, thus explaining abnormal patency to CO, or contrast medium in some of these patients.
REFERENCES I . Murray, E. G.: The peritoneal factor in female sterility. Fertil Sterill: 371, 1953. 2. Crane, M. &Woodruff, J. D.: Factors influencing the success of tuboplastic procedures. Fertil Steril 19: 810, 1968. 3. OBrien, J . R., Arronet, G. H. & Eduljee, S. Y.: Operative treatment of Fallopian tube pathology in human fertility. Am J Obstet 6ynecol 103: 520, 1969. 4. Peterson, E. P. & Behrman, S. J.: Laparoscopy of the infertile patient. Obstet Gynecol36: 363, 1970. 5. Corson, L. & Bolognese, R. J.: Laparoscopy: An overview and results of a large series. J Reprod Med 9: 148, 1972. 6 . Rubin, I. C.: Uterotubal Insufflation. C. V. Mosby, St. Louis, 1947. 7. Siegler, A. M.: Hysterosalpingography. Medcom Press., New York, 1974. 8. Boyd, I. E. & Holt, E. M.: Tubal sterility: patency tests and results of operation. J Obstet Gynecol Br Comm80: 142, 1973. 9. Young, P. E., Egan, J. E., Barlow, J. J. & Mulligan, W.: Reconstruction surgery at the Boston Hospital for Women. Am J Obstet GynecollO8: 1093, 1970. 10. Ozaras, H.: The value of plastic operations on the fallopian tubes in the treatment of female infertility. A clinical and radiologic study. Acta Obstet Gynecol Scand47: 489, 1968. 11. Swolin, K. & Rosencrantz, M.: Laparoscopy vs. hysterosalpingography in sterility investigations. A comparative study. Fertil Steril23: 270, 1972. 12. Maathius, J. B., Horbach, J. G. M. & Hall, E. V . : A comparison of the results of hysterosalpingography and laparoscopy in the diagnosis of Fallopian tube dysfunction. Fertil Steri123: 428, 1972. 13. Coltart, T. M.: Laparoscopy in the diagnosis of tubal patency. J Obstet Gynecol Br Comm 77: 69, 1970. 14. Frangenheim, H.: Vergleichende Untersuchungen zwischen dem Wert der Hysterosalpingographie und der Coelioskopie bei der Sterilitatsdiagnostik. Arch Gynaekol204: 167, 1967. 15. Steptoe, P.: Gynecological laparoscopy. J Reprod Med10:211, 1973.
Submitted for Festschrift A. M. Siegler Department of Obstetrics and Gynecology State University of New York Brooklyn, New York USA
Acta Obstet Gynecol Scand 56 (1977)
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