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From November 1988 to December 1991, 45 infertile patients underwent salpingo-ovariolysis and/or salpingoneostomy during laparotomy or laparoscopy. Findings at surgery were scored according to the AFS classification. Salpingoscopy was performed to evaluate the status of the ampullary mucosa. The mean age of the patients was 29.5 years and the mean length of infertility prior to surgery was 4.4 years. All patients were contacted by phone to obtain information on reproductive outcome with a minimum period of 18 months of follow-up. Statistical analysis of data was performed using the Fisher's exact test. AFS scores were not correlated with reproductive outcome, while the status of the tubal mucosa at salpingoscopy was significantly correlated with reproductive outcome.
Tubal catheterization procedures have become standard of care as a primary treatment of proximal tubal occlusions. They successfully utilize a variety of catheter techniques, though all usually include a wire guide. This raises the question whether guide wire catheterizations alone can be used to treat proximal tubal occlusions. We therefore investigated consecutively 25 women with at least one proximally occluded oviduct by attempting wire guide cannulations bilaterally in 10 and unilaterally in 12 women with two tubes and in three women with a single tube. Among the 10 patients with bilateral occlusion, seven were recanalized bilaterally (70%), one unilaterally (10%) and two not at all (20%). Among the 15 patients with unilateral tubal occlusion, 12 (80%) were recanalized. In total, 27 out of 35 (77%) obstructed oviducts were recanalized. In a follow-up period of 5-17 months only one pregnancy was, however, recorded and this was a tubal pregnancy. We conclude that wire guide cannulation of proximally obstructed tubes achieves tubal patency in a large percentage of cases, comparable to other catheter techniques reported in the literature. In contrast to those, however, wire guide cannulations alone result in much lower pregnancy rates. This observation strongly suggests that wire guides, used with co-axial and balloon catheter systems, are not responsible for the pregnancy success reported for these procedures. Wire guide cannulation alone does not therefore represent adequate treatment for patients with proximally occluded Fallopian tubes.
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Exicised tubal segments (including interstial and isthmic portions) from 33 women with proximal tubal occlusive infertility were examined pathologically. We found that pathologic entities included chronic tubal inflammation (70.59%), tubal endometriosis (9.80%), obliterative fibrosis (7.84%), salpingitis isthmica nodosa (5.88%), tubal tuberculosis (3.92%). Only one of the tubes (1.96%) showed no obvious pathological change. These observations on proximal tubal occlusion in combination with clinical features and pelvic changes indicate that: (1) These are multiple distinct pathologic patterns, and pelvic findings do not predict the pathologic changes of the tubes. (2) Induced abortion and uterine curetage is an important factor for the proximal tubal occlusive infertility. Pelvic inflammatory disease and intrauterine device are other factors.
A 28-year-old infertile patient with a diagnosis of bilateral distal tubal occlusion made at hysterosalpingography and laparoscopy was found at a second laparoscopy to have bilateral single diverticula in patient tubes. The patient conceived an intrauterine pregnancy 5 months after discharge. This report casts doubt on the suggested association between tubal diverticula and infertility.
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OBJECTIVE: To compare the prognostic value of salpingoscopy with a current classification system of adnexal adhesions and distal tubal occlusion in patients with tubal infertility undergoing reconstructive tubal surgery. DESIGN: Prospective clinical study. SETTING: Department of Obstetrics and Gynecology of the Catholic University, a tertiary care University Center in Rome, Italy. PATIENTS: Fifty-five infertile patients with either adnexal adhesions (29 patients) or hydrosalpinx (26 patients) undergoing reconstructive tubal surgery. INTERVENTIONS: Salpingoscopy performed concomitantly to salpingo-ovariolysis or salpingoneostomy at the time of either operative laparoscopy or laparotomy using microsurgical techniques. MAIN OUTCOME MEASURES: Salpingoscopic findings were compared with a current classification system of adnexal adhesions and distal tubal occlusion. The patients were followed for a mean follow-up of 49 months; the pregnancy rates achieved were correlated with the salpingoscopic findings and the classification system used. RESULTS: There was a significant correlation between the salpingoscopic grade and the occurrence of a term pregnancy for both the salpingo-ovariolysis and salpingoneostomy groups of patients. There was no significant correlation between the classification system used and the occurrence of a term pregnancy for both groups of patients. CONCLUSION: Salpingoscopy plays an important role in selecting the patients who may benefit the most from reconstructive tubal surgery.
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To date, the therapy of first choice in case of proximal tubal pathology is resection of the occluded segment and microsurgical reconstruction. Essential disadvantage of this rather successful method consists in the need of a laparotomy. According to the concept of minimal invasiveness a pilot study has been undertaken to evaluate hysteroscopic proximal tube catheterization (HPTC) and balloon dilatation for recanalization. This attempt has proven intraoperatively successful in more than 80% of the cases and the first pregnancy and birth following HPTC can yet be reported.
Female sterilisation using tubal occlusive methods are reviewed. The various techniques, failure rates, mortality, short and long-term morbidity, psychosexual effects and reversibility are discussed. Tubal occlusion is an effective method of female sterilisation but if failure should occur ectopic pregnancies are more likely if tubal diathermy, and less likely if Fallope rings or Filshie clips have been used for the original sterilisation procedure. Mortality rates are low and occur as a once-only risk when compared to ongoing contraception. Short-term morbidity rates are low when sterilisation is performed via the laparoscope, with single portal entry being more likely to result in complications. Mini-laparotomy and laparotomy also have low morbidity levels but complication rates are much higher when a transvaginal approach is used. There is no increase in morbidity when tubal sterilisation is performed at the time of pregnancy termination, providing uterine evacuation is not performed by hysterotomy. In the majority of cases no menstrual disturbance is noted; however, a small increase in menstrual disorders as a direct result of tubal sterilisation cannot be excluded absolutely. Sterilisation does not affect sexual satisfaction. Regret is more likely if the sterilisation is performed (i) post-termination or in the puerperium, (ii) when there is marital disharmony and (iii) for medical rather than social reasons. Low parity is not associated with regret except in cultures where high parity is prized. Microsurgical methods of reversal have higher pregnancy and lower ectopic rates than macrosurgical techniques. Successful reversal is inversely related to the degree of tubal destruction at the initial operation.
Background: The optimal treatment of infertility due to tubal occlusion has not been established. Many practitioners feel that the success of tubal repair exceeds that of in vitro fertilization (IVF); however, previous studies of pregnancy after tubal surgery have been limited by bias in patient selection, follow-up, or surgical expertise. The purpose of the present study was to determine the outcome after repair of distal tubal occlusion performed by experienced surgeons in an unselected patient population with consistent follow-up.Design: Chart review with telephone contact of patients lost to follow-up.Methods: The records of all tubal surgery performed between 1989 and 1996 at the University of Alabama Hospital and The Kirklin Clinic outpatient surgery facility were reviewed. All women with infertility due to distal tubal occlusion, with or without pelvic adhesions, who had no other significant infertility factors were included for study. Details of the infertility history, operative procedure, and postoperative course were recorded. Patients lost to follow-up within 1 year after surgery were contacted by telephone for information regarding subsequent testing and treatment and pregnancy outcome.Results: Eighty-three women aged 19-39 years met the entry criteria for this study. Follow-up of at least 1 year was obtained in all but 11 patients. Tubal surgery was accomplished by laparotomy in 19 women; 64 women underwent tubal repair by laparoscopy. Within 1 year of surgery, 9 hysterosalpingograms, 51 clomiphene cycles, and 20 gonadotropin cycles were performed on the study group. Pregnancy was achieved within 1 year in 13 women; of these, there were 6 live births (9.6% birth rate per surgery), 2 spontaneous abortions, and 3 ectopic pregnancies. There were no live births among women who underwent tubal repair by laparotomy. None of the postoperative gonadotropin cycles resulted in pregnancy. Seven women underwent IVF within 1 year after surgery because of extensive tubal damage noted at surgery. Based on current charges for the infertility treatments performed, the cost of a live birth with tubal surgery exceeded $120,000, versus less than $50,000 per live birth with IVF using results obtained nationally or at UAB.Conclusions: The cost-effectiveness of reconstructive surgery in unselected patients with distal tubal occlusion is less than that of IVF. Empiric use of gonadotropins for ovarian stimulation does not improve pregnancy rates after tubal surgery. In our series, laparoscopic tubal repair seemed to give results superior to that of laparotomy.
The relationship between a previously undetected Chlamydia trachomatis infection, tubal infertility, immunity to heat shock proteins and subsequent in-vitro fertilization (IVF) outcome was evaluated. Women with tubal occlusion, with or without hydrosalpinges, and no history of C. trachomatis infection were tested for circulating antibodies to the human 60-kDa heat shock protein (Hhsp60), the C. trachomatis 10-kDa heat shock protein (Chsp10) and C. trachomatis surface antigens prior to their initial IVF cycle. Sera were obtained from 50 women whose male partners were infertile, 58 women with tubal occlusion but no hydrosalpinx and 39 women with tubal occlusions plus hydrosalpinx. Clinical pregnancies were documented in 68% of the women with male factor infertility. This was higher than the 43.1% rate in women with tubal occlusions (P = 0.04) and the 41% rate in women with hydrosalpinx (P = 0.02). C. trachomatis antibodies were present in one (2%) women with male factor infertility as opposed to 15 (25.9%) women with tubal occlusion (P = 0.003) and 13 (33%) with hydrosalpinx (P < 0.0001). Antibodies to Chsp10 were more prevalent in women with hydrosalpinx (46.8%) than in women with male factor infertility (P < 0.0001, 6%) or tubal occlusion (P = 0.0009, 15.5%). Hhsp60 antibodies were equally more prevalent in women with tubal occlusion plus (46.8%) or minus hydrosalpinx (41.4%) than in women with male factor infertility (P < 0.0002). Hhsp60 was more prevalent in those women positive for Chsp10 (P = 0.02) or C. trachomatis (P = 0.04) antibodies than in women lacking these antibodies. There was no relationship between any of the antibodies measured in sera and IVF outcome.
OBJECTIVE: To evaluate and compare the clinical impact of proximal tubal occlusion and salpingectomy when performed before IVF in patients with hydrosalpinges. DESIGN: Prospective randomized study. SETTING: Assisted reproduction unit in an obstetrics and gynecology department in a university hospital in Greece as well as assisted reproduction unit in an urban clinic in a major city in Greece. PATIENT(S): One hundred fifteen patients with unilateral or bilateral hydrosalpinges who were candidates for IVF treatment. INTERVENTION(S): Laparoscopic proximal tubal occlusion, laparoscopic salpingectomy, controlled ovarian hyperstimulation, IVF, and embryo transfer. MAIN OUTCOME MEASURE(S): Implantation rate, clinical-pregnancy rate, ongoing-pregnancy rate, abortion rate, and ectopic-pregnancy rate. RESULT(S): Patients who underwent proximal tubal occlusion before IVF demonstrated significantly increased implantation, clinical-pregnancy, and ongoing-pregnancy rates compared with those with no surgical intervention and demonstrated implantation, clinical-pregnancy, and ongoing-pregnancy rates comparable to those who underwent salpingectomy. CONCLUSION(S): Proximal tubal occlusion, when performed in women with unilateral or bilateral hydrosalpinges before their IVF treatment, represents a potentially beneficial surgical procedure, increasing significantly the chances for successful implantation and for clinical and ongoing pregnancy. Proximal tubal occlusion may be viewed as a valid alternative when salpingectomy is technically difficult or not feasible.
During the 5-year period 1976--1980 9 430 patients underwent tubal occlusion at Groote Schuur Hospital, Cape Town. Of these patients 24, or 2.5/1 000, became pregnant after the procedure. An analysis of the pregnancy rate for each method of tubal occlusion is reported. Bilateral tubal occlusion by laparotomy or falope rings has flow failure rate; cauterization has not.
This study was undertaken to assess the effects of different tubal occlusion procedures on ovarian function. Three groups of subjects randomized to tubal occlusion by laparoscopy and Yoon ring (24 subjects), minilaparotomy and Yoon ring (19 subjects) and minilaparotomy and Pomeroy (22 subjects), and one separate control group of 26 healthy subjects not using any form of contraception were studied in a prospective design. The characteristics of the menstrual patterns were studied for one year after sterilization. Determination of the circulating progesterone levels were made on days 15, 20 and 25 of menstrual cycles initiated 1, 3, 6 and 12 months following the tubal ligation. In the analysis of the bleeding pattern there was a statistically significant difference in the mean segment length and in the longest bleeding-free interval in the subjects who had been sterilized by minilaparotomy with Yoon ring, when compared to the other two study groups and to the control group. However, the magnitude of this difference in number of days was not considered clinically significant. There was no statistically significant difference in the percentage of ovulatory cycles within the study and the control groups, or when the results of the study groups were compared with each other or to the control group.
The success of IVF has established it as a viable alternative to microsurgery in the treatment of infertility associated with certain types of tubal occlusion. The authors have recently reported on the success rates of microsurgery versus IVF in cases of distal tubal occlusion. The present study summarizes the results reported in the world literature for microsurgery in cases of proximal tubal occlusion secondary to surgical sterilization, previous infection, or endometriosis, and compares them with the results reported for IVF. Based on what has been published to date, it appears that microsurgical tubocornual anastomosis remains the procedure of choice for proximal tubal occlusion.
Intraluminal images were reliably obtained by office falloposcopy in the presence of proximal tubal occlusion. Although there were associations between data obtained at laparoscopy and intralumenal appearances, these relations were not uniform, indicating that there may be a role for falloposcopic assessment in planning the management of proximal tubal occlusion. A prospective study is advocated to assess the linear eversion catheter as a therapy for proximal tubal occlusion.