- Email: [email protected]
Effective Method and Successful Pregnancy in Microsurgical Tubal Reanastomosis: A Report of 715 Cases
infertility only in 22 (40.1%), abnormal ultrasound in 2 (3.7%), and previous PID in 1 (1.8%). THL was equivalent to laparoscopy (pelvis normal or pathology found) in 50 pt. (92.5%), inconclusive in 2 (3.7%), and failed access occurred in 2 (3.7%). In 23 pt. with a normal tubal HSG, THL diagnosed a normal pelvis in 11 (47.8%), pathology in 11 (47.8%), and 1 (1.8%) was a THL failure. Tubal defects were found in 7 of 16 abnormal HSG. THL was normal in 3 (42.9%), abnormal in 3 (42.9%), and 1 (1.8%) was a THL failure. Laparoscopy was not performed subsequent to THL in 19 (33.3%) pt. Therapy performed prior to THL was considered less effective in 13 of 22 (59.1%) pt. THL was performed in-office in 30(55.5%) cases. Two pt. (3.7%) had failed entry without complication. No rectal perforation or other complication was reported. Conclusions: THL was adequate for pelvic endoscopic evaluation in 92.5% of charts reviewed, and more accurate than HSG (47.8% false negative, 42.9% false positive) in diagnosing pelvic pathology. THL appears to have a role in the anatomic investigation of the infertile woman.
P-338 The Success of Neosalpingostomy Following Bilateral Fimbriectomy Sterilization: A 10-Year Retrospective Analysis. D. E. Tourgeman, J. K. Jain, M. Bhaumik, G. C. Cook, S. Najmabadi, R. J. Paulson. Department of Obstetrics and Gynecology, University of Southern California-Keck School of Medicine, Los Angeles, CA. Objective: Reversal of sterilization by fimbriectomy is less successful than tubal reanastomsis, and the outcome of such reversal is poorly documented. The objective of this study was to review the experience of fimbriectomy reversal at our medical center and to determine which factors play a role in its success. Design: Retrospective series review. Materials and Methods: Between 11/89 and 10/99, 41 patients underwent fimbriectomy reversal with either unilateral or bilateral neosalpingostomies. All patients had at least 3 months of post-operative follow-up, for a total of 619 person-months of follow up. Using clinical charts, radiologic records and patient interviews the following endpoints were determined: time from fimbriectomy sterilization to reversal; laparoscopy vs. laparotomy for fimbriectomy reversal; uni- or bilateral neosalpingostomies; Bruhat vs. suture technique for neosalpingostomy; intra-operative tubal length; post-operative hysterosalpingogram (HSG) results if performed; whether ovulation induction agents were used post-operatively; the period of follow-up; and pregnancy outcome. Life-table analysis was used to determine pregnancy rates. Results: The mean time from sterilization to reversal was 11.5 years. Of the 41 women, 6 (14.6%) conceived at least once (all intrauterine). There was no significant difference in the age, gravity, parity, or time from sterilization in the pregnant or non-pregnant groups. There was no difference in pregnancy rates whether the procedure was achieved by laparotomy (4/16, 25%) or laparoscopy (2/25, 8%, p.0.05), whether a unilateral (0/9) or bilateral (6/32, 18.8%, p.0.05) neosalpingostomy was performed, or whether the neosalpingostomy was performed using the Bruhat technique (1/11, 9%) or suturing (5/30, 16.7%, p.0.05). Post-operative tubal length in the conception group was 8.0 6 0.6 cm versus 6.7 6 1.9 cm in the nonconception group (p,0.05). Only 1 of the 26 women (3.8%) who required clomiphene citrate for ovulation induction conceived versus 5/15 (33.3%) of those who ovulated spontaneously (p,0.05). 17 women (41%) had an HSG 3– 6 months after surgery. Complete occlusion was observed in 2/4 (50%) women after unilateral neosalpingostomy and in 7/13 (53.8%) of those who had bilateral (p.0.05). The monthly fecundability rate was 0.01. The pregnancy rate was 12.4% during the first year, 5.6% during the second, and 0% during the third year with a cumulative pregnancy probability of 17.3% at the end of the third post-operative year. Among spontaneously ovulatory women with at least 1 tube measuring $7 cm, the raw pregnancy rate was 6/24 (25%). Conclusions: Based on these data, we conclude: 1) fimbriectomy reversal is associated with a fecundability rate of 1%, 2) the probability of pregnancy appears to be highest during the first post-operative year although 1 patient conceived 4 years after the procedure, 3) pregnancy success is associated with tubal lengths $7cm and spontaneous ovulatory cycles, and 4) fimbriectomy reversal may be a viable option for selected patients.
FERTILITY & STERILITYt
P-339 Effective Method and Successful Pregnancy in Microsurgical Tubal Reanastomosis: A Report of 715 Cases. H. S. Moon, B. S. Joo, S. J. Park, K. S. Kim, J. H. Yoon, G. W. Lee. Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Moonhwa Hospital, Pusan, Korea. Objectives: Tubal reanastomosis has been performed by various techniques such as macrosurgery, microsurgery, and laparoscopic operation. The most important aim of tubal reanastomosis is a successful pregnancy following operation. However, according to various reports one-third of the patients who underwent tubal reanastomosis have not conceived postoperatively. The purposes of this study are to report the outcome of tubal reanastomosis by microsurgical procedures and to determine the important factors affecting the fertility potential after reanastomosis. Design: Retrospective clinical study for 715 patients who have undergone microsurgical tubal reanastomosis from March 1988 to March 1999 at Moonhwa Hospital. Materials and Methods: The operation was performed by one physician, first author, in all patients who had underwent tubal sterilization. 582 patients were followed up for a minimal period of one year, and among them, 8 patients were excluded for the analysis of pregnancy outcomes because of contraception use. A two-layer closure using 9-0 nylon sutures was performed under a Topcon OMS-300 operative microscope. Dexamethason was used in pre- and post-operation, and Micro-tie using 8-0 or 9-0 nylon was used for hemostasis. Results: The overall pregnancy rate (PR) was 90.2% (518 cases), of which, intrauterine PR was 87.6% (503 cases) and ectopic PR was 2.6% (15 cases). The cumulative pregnancy rate was 78.6% (451 cases) in the first one year, 86.8% (498 cases) in two years, 89.7% (515 cases) in three years. With our method of microscopic operation, age was the most significant factor affecting the success of pregnancy and the PR was 98.4% for patients aged 21–30 years, 96.9% for patients aged 31–35 years, 89.8% for patients aged 36 – 40 years, and 55.0% for patients aged .40 years (P,0.005). When tubal length after reanastomosis was less than 2 cm, no one became pregnant. The ectopic PR was highest in the cornual-ampulla (C-A) portion compared to other sites of reanastomosis. One fourth of the pregnancies in C-A anastomosis group ended in ectopic pregnancy. However, there were no significant differences in PR considering the parameters of the sterilization method and the menstrual phase at reanastomosis. Conclusions: Our microsurgical procedure could be an excellent method considering high pregnancy rate. Age may be the most important factor to predict the fertility outcomes after tubal reanastomosis. Cornual-ampulla portion was the prevalent site of ectopic pregnancy.
P-340 Conventional Operative Laparoscopy Versus CO2 Laseroscopy in the Management of Pelvic Adhesions, Distal Tubal Diseases, and Polycystic Ovarian Syndrome: A Comparative Study. S. Y. El-Sahwi, M. A. Kamel, A. H. Warda, M. M. El-Faham. University of Alexandria, Shatby Maternity Hospital, Alexandria, Egypt. Objectives: To compare the effectiveness of conventional operative laparoscopy and CO2 laseroscopy in the management of pelvic adhesion, distal tubal diseases and polycystic ovarian syndrome (PCOS). Design: Retrospective comparative study. Materials and Methods: 565 patients complaining of infertility divided into three groups: Group I: 250 patients with pelvic adhesion. Group II: 174 patients with distal tubal diseases. Group III: 141 patients with PCOS. All patients were subjected either to conventional or CO2 Laser three puncture operative laparoscopy. Conventional laparoscopy results were compared to CO2 laseroscopy in each group. Live birth rates were assessed within 2 years of the intervention. Results: Group I: Pelvic adhesions with patent tubes (250 patients). The total live birth rate in the conventional group (165 patients) was 46% (75/165). This was subdivided into 64% (41/64), 49% (30/61) and 10% (4/40) in mild, moderate and severe cases of pelvic adhesions, respectively. The corresponding figures in CO2 laseroscopy group (85 patients) were 42% (36/85), 49% (26/53), 38% (9/24) and 13% (1/8) respectively. The differences between the two interventions are not statistically significant. Group II: Distal tubal diseases, the total live birth rate in the conventional lapa-
S201
P-338 The Success of Neosalpingostomy Following Bilateral Fimbriectomy Sterilization: A 10-Year Retrospective Analysis. D. E. Tourgeman, J. K. Jain, M. Bhaumik, G. C. Cook, S. Najmabadi, R. J. Paulson. Department of Obstetrics and Gynecology, University of Southern California-Keck School of Medicine, Los Angeles, CA. Objective: Reversal of sterilization by fimbriectomy is less successful than tubal reanastomsis, and the outcome of such reversal is poorly documented. The objective of this study was to review the experience of fimbriectomy reversal at our medical center and to determine which factors play a role in its success. Design: Retrospective series review. Materials and Methods: Between 11/89 and 10/99, 41 patients underwent fimbriectomy reversal with either unilateral or bilateral neosalpingostomies. All patients had at least 3 months of post-operative follow-up, for a total of 619 person-months of follow up. Using clinical charts, radiologic records and patient interviews the following endpoints were determined: time from fimbriectomy sterilization to reversal; laparoscopy vs. laparotomy for fimbriectomy reversal; uni- or bilateral neosalpingostomies; Bruhat vs. suture technique for neosalpingostomy; intra-operative tubal length; post-operative hysterosalpingogram (HSG) results if performed; whether ovulation induction agents were used post-operatively; the period of follow-up; and pregnancy outcome. Life-table analysis was used to determine pregnancy rates. Results: The mean time from sterilization to reversal was 11.5 years. Of the 41 women, 6 (14.6%) conceived at least once (all intrauterine). There was no significant difference in the age, gravity, parity, or time from sterilization in the pregnant or non-pregnant groups. There was no difference in pregnancy rates whether the procedure was achieved by laparotomy (4/16, 25%) or laparoscopy (2/25, 8%, p.0.05), whether a unilateral (0/9) or bilateral (6/32, 18.8%, p.0.05) neosalpingostomy was performed, or whether the neosalpingostomy was performed using the Bruhat technique (1/11, 9%) or suturing (5/30, 16.7%, p.0.05). Post-operative tubal length in the conception group was 8.0 6 0.6 cm versus 6.7 6 1.9 cm in the nonconception group (p,0.05). Only 1 of the 26 women (3.8%) who required clomiphene citrate for ovulation induction conceived versus 5/15 (33.3%) of those who ovulated spontaneously (p,0.05). 17 women (41%) had an HSG 3– 6 months after surgery. Complete occlusion was observed in 2/4 (50%) women after unilateral neosalpingostomy and in 7/13 (53.8%) of those who had bilateral (p.0.05). The monthly fecundability rate was 0.01. The pregnancy rate was 12.4% during the first year, 5.6% during the second, and 0% during the third year with a cumulative pregnancy probability of 17.3% at the end of the third post-operative year. Among spontaneously ovulatory women with at least 1 tube measuring $7 cm, the raw pregnancy rate was 6/24 (25%). Conclusions: Based on these data, we conclude: 1) fimbriectomy reversal is associated with a fecundability rate of 1%, 2) the probability of pregnancy appears to be highest during the first post-operative year although 1 patient conceived 4 years after the procedure, 3) pregnancy success is associated with tubal lengths $7cm and spontaneous ovulatory cycles, and 4) fimbriectomy reversal may be a viable option for selected patients.
FERTILITY & STERILITYt
P-339 Effective Method and Successful Pregnancy in Microsurgical Tubal Reanastomosis: A Report of 715 Cases. H. S. Moon, B. S. Joo, S. J. Park, K. S. Kim, J. H. Yoon, G. W. Lee. Center for Reproductive Medicine, Department of Obstetrics and Gynecology, Moonhwa Hospital, Pusan, Korea. Objectives: Tubal reanastomosis has been performed by various techniques such as macrosurgery, microsurgery, and laparoscopic operation. The most important aim of tubal reanastomosis is a successful pregnancy following operation. However, according to various reports one-third of the patients who underwent tubal reanastomosis have not conceived postoperatively. The purposes of this study are to report the outcome of tubal reanastomosis by microsurgical procedures and to determine the important factors affecting the fertility potential after reanastomosis. Design: Retrospective clinical study for 715 patients who have undergone microsurgical tubal reanastomosis from March 1988 to March 1999 at Moonhwa Hospital. Materials and Methods: The operation was performed by one physician, first author, in all patients who had underwent tubal sterilization. 582 patients were followed up for a minimal period of one year, and among them, 8 patients were excluded for the analysis of pregnancy outcomes because of contraception use. A two-layer closure using 9-0 nylon sutures was performed under a Topcon OMS-300 operative microscope. Dexamethason was used in pre- and post-operation, and Micro-tie using 8-0 or 9-0 nylon was used for hemostasis. Results: The overall pregnancy rate (PR) was 90.2% (518 cases), of which, intrauterine PR was 87.6% (503 cases) and ectopic PR was 2.6% (15 cases). The cumulative pregnancy rate was 78.6% (451 cases) in the first one year, 86.8% (498 cases) in two years, 89.7% (515 cases) in three years. With our method of microscopic operation, age was the most significant factor affecting the success of pregnancy and the PR was 98.4% for patients aged 21–30 years, 96.9% for patients aged 31–35 years, 89.8% for patients aged 36 – 40 years, and 55.0% for patients aged .40 years (P,0.005). When tubal length after reanastomosis was less than 2 cm, no one became pregnant. The ectopic PR was highest in the cornual-ampulla (C-A) portion compared to other sites of reanastomosis. One fourth of the pregnancies in C-A anastomosis group ended in ectopic pregnancy. However, there were no significant differences in PR considering the parameters of the sterilization method and the menstrual phase at reanastomosis. Conclusions: Our microsurgical procedure could be an excellent method considering high pregnancy rate. Age may be the most important factor to predict the fertility outcomes after tubal reanastomosis. Cornual-ampulla portion was the prevalent site of ectopic pregnancy.
P-340 Conventional Operative Laparoscopy Versus CO2 Laseroscopy in the Management of Pelvic Adhesions, Distal Tubal Diseases, and Polycystic Ovarian Syndrome: A Comparative Study. S. Y. El-Sahwi, M. A. Kamel, A. H. Warda, M. M. El-Faham. University of Alexandria, Shatby Maternity Hospital, Alexandria, Egypt. Objectives: To compare the effectiveness of conventional operative laparoscopy and CO2 laseroscopy in the management of pelvic adhesion, distal tubal diseases and polycystic ovarian syndrome (PCOS). Design: Retrospective comparative study. Materials and Methods: 565 patients complaining of infertility divided into three groups: Group I: 250 patients with pelvic adhesion. Group II: 174 patients with distal tubal diseases. Group III: 141 patients with PCOS. All patients were subjected either to conventional or CO2 Laser three puncture operative laparoscopy. Conventional laparoscopy results were compared to CO2 laseroscopy in each group. Live birth rates were assessed within 2 years of the intervention. Results: Group I: Pelvic adhesions with patent tubes (250 patients). The total live birth rate in the conventional group (165 patients) was 46% (75/165). This was subdivided into 64% (41/64), 49% (30/61) and 10% (4/40) in mild, moderate and severe cases of pelvic adhesions, respectively. The corresponding figures in CO2 laseroscopy group (85 patients) were 42% (36/85), 49% (26/53), 38% (9/24) and 13% (1/8) respectively. The differences between the two interventions are not statistically significant. Group II: Distal tubal diseases, the total live birth rate in the conventional lapa-
S201