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Term pregnancy after fallopian tube transposition
FERTILITY AND STERILITY
Vol. 56, No.6, December 1991
Copyright c 1991 The American Fertility Society
Printed on acid-free paper in U.S.A.
Term pregnancy after fallopian tube transposition
Matthias Yolk, M.D.* Winfried Obermeier, M.D. Burkhard Stang, M.D. Friedrich Berndt, M.D. Department of Gynecology and Obstetrics, St. Vincenz-Hospital, Limburg, Germany
In treating tubal sterility, the microsurgeon must be aware that in some cases it may be necessary to contact organs (tube-tube or tube-ovary) from different sides to deal with congenital malformations or with the different anatomic remnants after tubal sterilization. 1-6 CASE REPORT
The patient was a 23-year-old married woman with primary sterility who presented herself to the department of Gynecology and Obstetrics at St. Vincenz Hospital, Limburg, Germany, in October 1989. In July 1988, she had undergone laparoscopy, and congenital malformation of the genital organs was diagnosed with the result that she should be submitted to in vitro fertilization and embryo transfer. She came to us with the question as to whether microsurgical correction may be possible. After laparoscopy and hysterosalpingography, we became aware of the following situation (Fig. 1). She had a left unicornuate uterus and a patent left fallopian tube of normal length. At the place where the left ovary normally is situated only a thin white cord could be seen. Biopsy was performed and no follicles were found. On the right side was a rudimentary uterine horn without cavity. The right ovary was of normal size and in the normal position. From the right fallopian tube, Received May 16, 1991; revised and accepted August 20, 1991.
* Reprint requests: Priv.-Doz. Dr. Med. Matthias Volk, Frauenklinik, St. Vincenz-Krankenhaus, Auf dem Schafsberg, D-6250 Limburg Germany.
1194
Volk et aI.
Communications-in-brief
only a 2-cm-Iong fimbrial end was found from which a thin atretic cord ran to the right rudimentary uterine horn. We discussed the situation with the patient and reconstructive microsurgery was carried out in December 1989. Inspection ofthe pelvis confirmed the diagnosis, so we decided to perform a transposition of the left tube. First, the fimbrial end of the right tube was removed. Then we mobilized the left tube by severing the mesosalpinx with the unipolar microelectrode without damaging the longitudinal vessels. By doing this we noticed that the bends of the tube disappeared and that the length increased almost doublefold. After meticulous hemostasis, the left tube was laid to the right side in such a way that the fimbrial end reached the right ovary without the slightest tension. We were anxious that the uterine origin of the left tube was not bent by this maneuver. Then the tube was fixed in this position in such a way that the fimbrial end was in contact with the right ovary and was mobile enough to lay onto the ovary during ovulation. We further fixed the tube to the dorsal side of the uterine fundus to prevent complications with the small bowel (i.e., ileus) by using 6 X 0 prolene (Fig. 2). There were no complications after surgery and she was discharged after 12 days. She conceived spontaneously 6 months later and intrauterine pregnancy was confirmed by ultrasonography. Because of breech presentation, primary cesarean section was performed on February 12, 1991. The anatomic situation after the cesarean section was as follows: the left tube was running over the fundus uteri and was fixed there by a thin membrane like a mesosalpinx without blood vessels. Distance of fimbrial end to the right ovary was 5
Fertility and Sterility
cm. This was due to enlargement of uterus during pregnancy. DISCUSSION
The case presented here was complicated by the fact that only one tube was available. It was therefore impossible to lengthen the tube by performing an anastomosis of contralateral tubal parts. We only had the possibility to mobilize the tube to such an extent that the fimbrial end could be moved to the contralateral ovary. Various methods of tubal transposition have been proposed. Shapiro and Hanint reported in 1979 about a successful anastomosis of a fimbrial segment pedicle graft. Transposition of the tube and intramural-ampullary anastomosis was performed by Gomel and McComb. 1 The retrouterine isthmic-isthmic tuba] anastomosis of contralateral tubal segments was reported by Pittaway.4 He rotated the uterus by 160 degrees. Okamura et al. 3 reported a case very similar to our case: right rudimentary uterine horn but two fallopian tubes of which the left was closed. They performed intraisthmic anastomosis of contralateral tubes and rotated the uterus by 20 degrees. A case of endometriosis was reported by Haney.2 He carried out retrouterine intraisthmic anastomosis using relaxing incisions of lateral peritoneum to afford approximation of both ovaries without tension.
Figure 2 Diagram of the postoperative anatomic site. The fimbrial end ofthe fallopian tube on the right side has been removed. The left fallopian tube has been mobilized so that the fimbrial end could be sutured to the right ovary.
SUMMARY
A 23-year-old woman suffered from primary sterility because of congenital malformation of the uterus and tubes. There was a left unicornuate uterus. The left ovary and the isthmic and ampullary parts of the right tube were missing. Microsurgical transposition of the left tube was performed successfully. Our technique may encourage microsurgeons to use transposition of fallopian tube in cases in which only one tube and one ovary on contralateral sides are available.
REFERENCES
Figure 1 Preoperative anatomic site. Left unicornuate uterus with right rudimentary horn and no left ovary. Note the absence of the isthmic part of the fallopian tube on the right side.
Vol. 56, No.6, December 1991
1. Gomel V, McComb P: Microsurgical transposition ofthe human fallopian tube and ovary with subsequent intrauterine pregnancy. Fertil Steril 43:804, 1985 2. Haney AF: Utilization of contralateral fallopian tube segments in tubal reanastomosis. Fertil Steril 37:701, 1982 3. Okamura H, Furuki Y, Matsuura K, Honda Y: Microsurgical transposition of the human fallopian tube: report of a successful case of pregnancy. Fertil Steril 50:980, 1988 4. Pittaway DE: Tubal reanastomosis of a contralateral fallopian tube. Fertil Steril 46:976, 1986 5. Shapiro SS, Haning RV, Jr: Tubal anastomosis of a fimbrial segment pedicle graft. Fertil Steril32:478, 1979 6. West ST, Marana R: Successful term pregnancies after tubal anastomosis utilizing contralateral tubal segments. Int J Fertil 21:403, 1987
Volk et aJ.
Communications-in-brief
1195
Vol. 56, No.6, December 1991
Copyright c 1991 The American Fertility Society
Printed on acid-free paper in U.S.A.
Term pregnancy after fallopian tube transposition
Matthias Yolk, M.D.* Winfried Obermeier, M.D. Burkhard Stang, M.D. Friedrich Berndt, M.D. Department of Gynecology and Obstetrics, St. Vincenz-Hospital, Limburg, Germany
In treating tubal sterility, the microsurgeon must be aware that in some cases it may be necessary to contact organs (tube-tube or tube-ovary) from different sides to deal with congenital malformations or with the different anatomic remnants after tubal sterilization. 1-6 CASE REPORT
The patient was a 23-year-old married woman with primary sterility who presented herself to the department of Gynecology and Obstetrics at St. Vincenz Hospital, Limburg, Germany, in October 1989. In July 1988, she had undergone laparoscopy, and congenital malformation of the genital organs was diagnosed with the result that she should be submitted to in vitro fertilization and embryo transfer. She came to us with the question as to whether microsurgical correction may be possible. After laparoscopy and hysterosalpingography, we became aware of the following situation (Fig. 1). She had a left unicornuate uterus and a patent left fallopian tube of normal length. At the place where the left ovary normally is situated only a thin white cord could be seen. Biopsy was performed and no follicles were found. On the right side was a rudimentary uterine horn without cavity. The right ovary was of normal size and in the normal position. From the right fallopian tube, Received May 16, 1991; revised and accepted August 20, 1991.
* Reprint requests: Priv.-Doz. Dr. Med. Matthias Volk, Frauenklinik, St. Vincenz-Krankenhaus, Auf dem Schafsberg, D-6250 Limburg Germany.
1194
Volk et aI.
Communications-in-brief
only a 2-cm-Iong fimbrial end was found from which a thin atretic cord ran to the right rudimentary uterine horn. We discussed the situation with the patient and reconstructive microsurgery was carried out in December 1989. Inspection ofthe pelvis confirmed the diagnosis, so we decided to perform a transposition of the left tube. First, the fimbrial end of the right tube was removed. Then we mobilized the left tube by severing the mesosalpinx with the unipolar microelectrode without damaging the longitudinal vessels. By doing this we noticed that the bends of the tube disappeared and that the length increased almost doublefold. After meticulous hemostasis, the left tube was laid to the right side in such a way that the fimbrial end reached the right ovary without the slightest tension. We were anxious that the uterine origin of the left tube was not bent by this maneuver. Then the tube was fixed in this position in such a way that the fimbrial end was in contact with the right ovary and was mobile enough to lay onto the ovary during ovulation. We further fixed the tube to the dorsal side of the uterine fundus to prevent complications with the small bowel (i.e., ileus) by using 6 X 0 prolene (Fig. 2). There were no complications after surgery and she was discharged after 12 days. She conceived spontaneously 6 months later and intrauterine pregnancy was confirmed by ultrasonography. Because of breech presentation, primary cesarean section was performed on February 12, 1991. The anatomic situation after the cesarean section was as follows: the left tube was running over the fundus uteri and was fixed there by a thin membrane like a mesosalpinx without blood vessels. Distance of fimbrial end to the right ovary was 5
Fertility and Sterility
cm. This was due to enlargement of uterus during pregnancy. DISCUSSION
The case presented here was complicated by the fact that only one tube was available. It was therefore impossible to lengthen the tube by performing an anastomosis of contralateral tubal parts. We only had the possibility to mobilize the tube to such an extent that the fimbrial end could be moved to the contralateral ovary. Various methods of tubal transposition have been proposed. Shapiro and Hanint reported in 1979 about a successful anastomosis of a fimbrial segment pedicle graft. Transposition of the tube and intramural-ampullary anastomosis was performed by Gomel and McComb. 1 The retrouterine isthmic-isthmic tuba] anastomosis of contralateral tubal segments was reported by Pittaway.4 He rotated the uterus by 160 degrees. Okamura et al. 3 reported a case very similar to our case: right rudimentary uterine horn but two fallopian tubes of which the left was closed. They performed intraisthmic anastomosis of contralateral tubes and rotated the uterus by 20 degrees. A case of endometriosis was reported by Haney.2 He carried out retrouterine intraisthmic anastomosis using relaxing incisions of lateral peritoneum to afford approximation of both ovaries without tension.
Figure 2 Diagram of the postoperative anatomic site. The fimbrial end ofthe fallopian tube on the right side has been removed. The left fallopian tube has been mobilized so that the fimbrial end could be sutured to the right ovary.
SUMMARY
A 23-year-old woman suffered from primary sterility because of congenital malformation of the uterus and tubes. There was a left unicornuate uterus. The left ovary and the isthmic and ampullary parts of the right tube were missing. Microsurgical transposition of the left tube was performed successfully. Our technique may encourage microsurgeons to use transposition of fallopian tube in cases in which only one tube and one ovary on contralateral sides are available.
REFERENCES
Figure 1 Preoperative anatomic site. Left unicornuate uterus with right rudimentary horn and no left ovary. Note the absence of the isthmic part of the fallopian tube on the right side.
Vol. 56, No.6, December 1991
1. Gomel V, McComb P: Microsurgical transposition ofthe human fallopian tube and ovary with subsequent intrauterine pregnancy. Fertil Steril 43:804, 1985 2. Haney AF: Utilization of contralateral fallopian tube segments in tubal reanastomosis. Fertil Steril 37:701, 1982 3. Okamura H, Furuki Y, Matsuura K, Honda Y: Microsurgical transposition of the human fallopian tube: report of a successful case of pregnancy. Fertil Steril 50:980, 1988 4. Pittaway DE: Tubal reanastomosis of a contralateral fallopian tube. Fertil Steril 46:976, 1986 5. Shapiro SS, Haning RV, Jr: Tubal anastomosis of a fimbrial segment pedicle graft. Fertil Steril32:478, 1979 6. West ST, Marana R: Successful term pregnancies after tubal anastomosis utilizing contralateral tubal segments. Int J Fertil 21:403, 1987
Volk et aJ.
Communications-in-brief
1195