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Microsurgery and postinfectious tubal infertility
VoL 38, No.4, October 1982 Printed in UBA.
FERTILITY AND STERILITY Copyright c 1982 The American Fertility Society
Microsurgery and postinfectious tubal infertility
Christiane Frantzen, M.D.* Hans-Walter Schlosser, M.D. Department of Obstetrics and Gynecology, University of Dusseldorf, Federal Republic of Germany
Because of the excellent results achieved by microsurgical approaches for reversal of sterilization, microsurgical techniques were considered promising for improving the outcome of the repair of postinfectious tubal disease as well. Unfortunately, these hopes did not materialize. Only a small percentage of infertile patients suffering from tubal damage subsequent to pelvic inflammatory disease were helped by tubal surgery. While anatomic reconstruction frequently was successful, these techniques failed to reverse postinfectious infertility in most cases. It is likely that alterations of the tubal wall and occasionally other not yet fully recognized functional disorders of the oviduct fail to respond to surgery. The value of microsurgery as opposed to conventional techniques in the therapy of postinfectious tubal infertility can be judged only by critically analyzing what has been achieved to date. We must then ask ourselves whether further improvement in microsurgical techniques would necessarily help us achieve a better rate of success in these cases, or whether it might not be preferable to concentrate on drug adjuvants or on a better selection of patients. TUBAL PATHOLOGY
In postinfectious tubal disease one usually can observe three possible morphologic characteristics: (1) perisalpingeal and peri ovarian adhesions; (2) damage to the distal tubal segments; and (3) occlusion of the proximal tubal segments. It is likely that perisalpingeal adhesions impair fertility only when the mobility of the fimbriated end and consequently ovum pickup are disturbed. By contrast, adhesions along the isthmic portion of the proximal ampullary segment seem to have Vol. 38, No.4, October 1982
no influence on fertility as long as they do not kink or compress the tubal lumen. Adhesions that completely encase the ovary and consequently prevent ovum pickup require surgical treatment. Agglutination of the fimbriae, varying from minor phimosis to complete occlusion of the ampullary end, is the most common outcome after tubal inflammation. Ovum capture frequently is impaired when the ampullary end of the tube is adherent to the ovarian surface. Approximately 30% of all patients suffering from involuntarily acquired tubal infertility demonstrate unilateral or bilateral cornual blockage, combined with other morphologic findings. In the majority of these cases salpingitis isthrnica nodosa, postinfectious fibrous stenosis, or fibrous obliteration of the tubal lumen can be diagnosed. It is striking that most of these patients are older than 30 years of age and have a history of secondary infertility. A history of induced abortion or ectopic pregnancy often is elicited. Pathologic intramural and isthmic blockage may be secondary to a variety of factors. Apart from infectious diseases, including salpingitis isthmica nodosa, gross intraluminal adhesions, and tuberculosis, numerous noninfectious factors can be recognized; for example, intramural polyps, endometriosis, calcified ectopic pregnancy, restrictive or kinking adhesions, and intramural myomata. In most cases a preoperative identification of the causes of the cornual occlusion is impossible. CLASSIFICATION AND EVALUATION OF TUBAL DISEASE
The question of whether or not improved Burgical techniques have achieved progress in infertility surgery can be answered in part by a compariFrantzen and Schlosser Postinfectious tubal infertility
397
son of success rates of microsurgical and conventional procedures. However, a mere comparison of statistics can be misleading. Inflammation of the fallopian tubes leads to multicentric disease and presumably to numerous functional alterations as well. For this reason, attempts to classifY these alterations have been less than ideal. The only point of agreement has been the classification of tubal disease according to the surgical procedure required in each case. This concurrence was established at the meeting of the International Fertility Society in Miami Beach in 1977. 1 However, such a system of classification does not permit a uniform evaluation because it fails to take into consideration the extent of tubal damage. Several authors confuse the terms fimbriolysis, fimbrioplasty, and salpingostomy. For practical purposes, we choose to use the term "salpingostomy" only when it is necessary to reestablish patency in a completely occluded ampullary segment. The term "fimbrioplasty" has been applied to the situation in which transfundally injected dye traverses a phimotic ostium. 2 Similar terminology has been adopted by several authors. 3 In many cases oviductal inflammation leads to different pathologic conditions in the right and left fallopian tubes, thus creating problems in statistical evaluation. How are we to interpret results if salpingolysis has been performed on one side and salpingostomy on the contralateral side? We consider that patients with disparate findings in both fallopian tubes must be included in the group that has less serious conditions. 2 If pregnancy occurred, it is logical to assume that the embryo most probably was transported by the less damaged oviduct. Using the previously mentioned example for statistical purposes, we would have to regard the case as salpingolysis, because a salpingostomy by itself is the more difficult procedure and carries with it a poorer prognosis for restoration of fertility. It is still indispensable that we include some patients in a miscellaneous group. For example, this principle might apply if repair of a cornual block was necessary on one side and a fimbrial occlusion was necessary on the contralateral side. Although it is generally accepted that different surgical techniques have different effects on the rates of success,4-6 there is uncertainty about the . influence of preoperative and postoperative mechanical and medicinal expediency (application of corticosteroids, antibiotic therapy, hydropertubation, early postoperative laparoscopy, etc.).7.8 Undoubtedly, optimal postoperative medical care 398
Frantzen and Schlosser Postinfectious tubal infertility
improves the chances of pregnancy considerably. In addition, the number of patients lost to followup impairs a statistical evaluation, since these women must be listed as failures. Except for tubal reconstruction for intramural obstruction, conceptions following microsurgical oviductal repair for postinfectious disease often occur 8 to 20 months later, but cases in which conception has occurred more than 4 years later are not unusual. This situation indicates the importance of comparable postoperative follow-up interval when one is comparing various surgical techniques. Microsurgery seems to be indicated only when the fallopian tubes are in suitable condition. The more extensive the tubal damage, the less chance there is for one to establish an advantage for microsurgical techniques. The chances for success through microsurgery might be maximized if patients with limited tubal damage were referred to specialized units at the outset. The criteria applied to the selection of patients determine the rate of success-for microsurgical as well as conventional tubal surgery. General history is important. Factors such as advanced age, ovulatory insufficiency, subfertility of the husband, preceding gynecologic surgery, previous ectopic pregnancy, and repeat tuboplasty may carry a reduced prognosis for pregnancy. Selection criteria on the basis of the morphologic condition of the tubes are even more decisive (e.g., extent of pathologic-anatomic alterations, extent and distribution of adhesions, endometriosis, etc.). In the literature it is rare to find information concerning the number of patients excluded from surgery following preoperative laparoscopy. With few exceptions, surgeons fail to report on how often they have terminated a procedure because intraoperative findings differed significantly from those that were diagnosed preoperatively. CLINICAL EXPERIENCES AND RESULTS
Between February 28, 1981, and January 1, 1976, we performed microsurgery on 478 patients with postinfectious tubal infertility at the Department of Obstetrics and Gynecology, Dusseldorf University Medical School. We have analyzed data from 234 patients who underwent tuboplasty through December 31,1980. The following findings were considered to be absolute contraindications for microsurgery: diseases that are incompatible with pregnancy, ovulatory failure refractory to induction of ovulation, genital tu. berculosis, and resection of more than two-thirds Fertility and Sterility
of the ampullary segment during a previous operation. An age in excess of 40 years as well as subfertility of the husband were regarded as relative contraindications to surgery. Except for those mentioned previously, patients were not selected on the basis of morphologic findings. Our preoperative workup customarily includes laparoscopy, hysterosalpingography and, under special conditions (e.g., intramural obstruction), hysteroscopy. In spite of these diagnostic procedures, a discrepancy between preoperative and intraoperative findings occasionally was encountered. Limitations of preoperative diagnosis occasionally led to operations on patients with unilateral tubal damage, although the contralateral side seemed to be intact. Naturally, these patients were excluded from further statistical evaluation. In other cases surgical efforts had to be abandoned because laparoscopic findings had been deceptive. Such errors occurred mainly when a cornual obstruction or sactosalpinges with minimal spillage of dye were suspected. It was striking that suspected sactosalpinges often merely proved to be extremely thin-walled and hypoplastic oviducts without any aspect ofphimosis at the fimbriated end. In these usually convoluted oviducts the ampullary segment sometimes displayed hernia-like projections with a distension resembling genuine sactosalpinges during chromopertubation. Microsurgical reconstruction of the fallopian tube was found to be impossible at the time of surgery in 31 patients because of the extent of the pathologic findings (a complete obliteration of tubal lumen, a completely destroyed ampullary segment, or tuberculosis that had not been previously appreciated). Most often, however, efforts at reconstruction were abandoned because it was not possible to reconstruct the ovarian surface. Some of these patients had histories of tuboovarian abscess, ovarian wedge resection, or ovarian cyst extirpation. These patients frequently had been treated for a prolonged time for ovarian insufficiency. In the presence of dense adhesions, which occasionally prevent proper examination of fallopian tubes and ovaries by laparoscopy, or if the preoperative workup was not accomplished at our own hospital, we prefer to initiate our microsurgical procedure with an explorative minilaparotomy. Our experience shows that the explorative minilaparotomy offers the best opportunity for an exact preoperative diagnosis. In the meantime, extensive publications have appeared that deal with microsurgical techniques Vol. 38, No.4, October 1982
for salpingolysis, fimbrioplasty, salpingostomy, and anastomosis. 1 , 3-6 Undeniably subtle surgery guarantees maximal preservation of functioning tissue and minimization of the trauma that is simply caused by surgery itself. Loupes are a great help for tubal surgery but they do not seem to provide sufficient magnification for cornual anastomosis. 3 There can be no doubt that higher magnification, as provided by the operating microscope, is preferable for an exact dissection of tissue borders. In salpingolysis we consider crucial a minute dissection of the adherent fimbriated end from the ovary and the best possible restoration of the original anatomy and mobility of the tubes. While dissecting the ampullary segment from the ovary, one must take care to avoid damage to the vessels that run into the suspensory ligament of the ovary and supply the fimbriae. Experience has shown that certain surgical adjuvants can provide considerable advantage. Fixation of long mobile epiploic appendices, duplication or partial resection of the omentum majus, split peritoneal grafts on rough peritoneal areas and, occasionally, uterine suspension have helped to improve our anatomic results. One can prevent the mobilized adnexa from readhering in the pouch of Douglas by gathering up the parietal peritoneum and the posterior layer of the broad ligament and by fixing these structures to the posterior uterine wall. 2 When adhesion formations cannot be used for peritonization, we attempt to excise them completely. All our patients are treated with antibiotics postoperatively. Corticosteroids are administered routinely intraoperatively and postoperatively unless an anastomosis is performed. We avoid postoperative hydropertubation. Our results in terms of pregnancy following reconstruction of postinfectious tubal damage are disappointing. A term pregnancy rate ofless than 30% has been attained (Table 1). The voluntary abandonment of most criteria for patient selection seems to be a plausible explanation for these unsatisfactory results. We did not refuse surgery when patients desperately desired it because we did not wish to deprive our patients of an opportunity to give birth to a child. Our stand received its justification when several patients whose oviducts were considered hopelessly damaged established a pregnancy following tuboplasty. In addition, 33.8% of the patients in this series required further treatment for ovarian insufficiency. Proven subfertility of the husband impaired the Frantzen and Schlosser Postinfectious tubal infertility
399
Table 1. Microsurgical Repair of Pastinfectious Tubes: Results No.
Salpingolysis Fimbrioplasty Salpingostomy Anastomosis Anastomosis and fimbrial repair Miscellaneous procedures
49 49 85 28 15
Total
234
8
Intrauterine pregnancies
20 (40.8%) 13 (26.5%) 16 (18.8%) 12 (42.9%) 3 7 71 (30.3%)
Term pregnancy"
19 11 12 12 3
Abortion
(38.8%) (22.4%) (14.1%) (42.9%)
1 (2.0%) 2 (4.1%) 4 (4.7%)
7
Ectopic· pregnancy
2 2 3 2
Not pregnant
(4.1%) (4.1%) (3.5%) (7.1%)
27 (55.1%) 34 (69.4%) 66 (77.7%) 14 (50.0%) 12
10 (4.3%)
153 (65.4%)
Reocclusionl recurrence Ofgr088
adhesions
1 4 8 6 4
(2.0%) (8.7%) (9.4%) (21.4%)
1
64 (27.4%)
7 (3.0%)
23 (9.8%)
"One patient had an ectopic pregnancy and later had a term pregnancy.
chances of conception in another 15.4% of the patients. However, an analysis of our data indicated that the pregnancy rate of women with additional factors contributing to infertility compared well with those of patients suffering from tubal factors alone, provided these supplementary factors were treated promptly and appropriately. Reduction in the age limit for surgical candidates also might result in better statistics. In our experience pregnancy rates are similar in patients with primary and secondary infertility. Success rates in patients who have undergone repeated tubal surgery are poor. In this group, 11 of 5B patients achieved an intrauterine pregnancy, 2 of whom, however, aborted. Most patients with previous tubal surgery required repeat salpingostomy. In cases of previous attempts at tubal reconstruction, gross pathology of the tubal wall and a distinctly shortened ampullary segment often were characteristic findings at the ultimate procedure. Laparoscopy is advised if patients fail to establish a pregnancy 1 year after surgery. Largely as a result of microsurgical techniques we have been able to observe satisfactory anatomic results, as evidenced by visualization at the follow-up laparoscopy. Recurrence of adhesions has been rare; however, reocclusion or repeat phimosis of the recreated ostium has been found in B.1 % of our patients.
In our experience the prognosis for fertility is essentially established by two parameters: (1) the extent of fibrosis of the tubal wall, and (2) the extent of deciliation of the epithelial cells lining the lumen. Despite the absence of adhesions and the reestablishment of tubal patency, reconstructive surgery usually did not leaq to pregnancy if the tubal walls were found to be extremely thickened and rigid. Unfortunately, precise histologic criteria for the extent of tubal damage are not yet available. In our experience biopsies offer little help, because different areas of the oviduct are affected by differing degrees of disease. Therefore, biopsies cannot be representative for the entire fallopian tube, and evaluation continues to be based upon subjective criteria. We find the following approach to be highly effective: two surgeons, using the highest magnification of an operating microscope, inspect and evaluate the mucosa and the tubal wall ofthe ampullary end independently. Tubal damage is considered mild when ciliation exceeds 75% ofthe surface cells and when the tubal wall measures less tl1an 1 mm in thickness. A wall 1 to 2 mm thick and preservation of 50% to 75% healthy-appearing mucosa classifies the moderate damage. Gross disease is evident when tubal wall thickness exceeds 2 mm. This condition is always accompanied by extensive reduction or complete loss of visible mucosa.
Table 2. Results According to Tubal Wall Disease: Minor Damage No.
Salpingolysis Fimbrioplasty Salpingostomy Anastomosis Anastomosis and fimbrial repair Miscellaneous procedures
400
Intrauterine pregnancy
41 30 10 24 6
19 .10 5 12 3
7
6
Frantzen and Schlosser Postinfectious tubal infertility
Ectopic pregnancy
1 1
Not pregnant
22 19 5 11 3
1
Fertility and Sterility
Table 3. Results According to Tubal Wall Disease: Moderate Damage No.
Salpingolysis Fimbrioplasty Salpingostomy Anastomosis Anastomosis and fimbrial repair Miscellaneous procedures
Intrauterine pregnancy
4 10 30 2 3
2 8
1
Ectopic pregnancy
Not pregnant
1
3 8 21 2 3
1
1
At present, surgeons appreciate that in addition to morphologic abnormalities, a variety of functional tubal disorders might exist that cannot be fully detected by preoperative or intraoperative evaluation. Such disorders do not necessarily correlate with the pathologic-anatomic findings. As expected, the poorest results are obtained in patients requiring salpingostomy. Frequently the mucosal and the muscular layers of sactosalpinges have been largely destroyed. Often reconstruction and provision of a sufficiently wide neoostium require resecting a major portion of the ampulla when tubal walls are thick and rigid. Even when microsurgery is used, such cases are accompanied by a high risk of reocclusion or repeat phimosis. If sactosalpinges are loculated, giving a honeycomb appearance, the chances for success are poor. Although there are usually only a few mucosal residua in extremely dilated and thin-walled sactosalpinges, the situation is more favorable than when the oviducts are narrow and thick-walled. It is still unknown whether muscular elements and the mucosa can regenerate after salpingostomy. 3 While Winston 3 achieved a term pregnancy rate of 17.5% for salpingostomy and our results are 14.1% (Table 1), Gomel 6 and Swolin4 reported 27% and 29% term pregnancy rates, respectively. However, in contrast to other authors, we found a surprisingly low ectopic pregnancy rate. The data in Tables 2, 3, and 4 demonstrate a clear correlation between the extent of tubal damage and the pregnancy rate. Salpingolysis is considered to be the most promising. We have obtained better success rates after
salpingolysis than after salpingostomy. However, in spite of satisfactory anatomic results, the outcome still was not ideal (Tables 1 to 4). The failure to establish a pregnancy can be explained in part by the existence of additional unrecognized functional disorders. A variety of conditions involving the fimbriated end of the oviduct are treated by fimbrioplasty. A prognosis can only be given in individual cases because the repair of a phimotic but patent oviduct includes minor deagglutinations of the fimbriae as w~ll as radial incisions and eversion of a hydrosalpinx with a pinpoint-sized opening. The nature and extent of tubal wall pathology, which determines the results of surgery, differ greatly in oviducts requiring fimbrioplasty (Tables 2 to 4). The chances for success after repair of postinfectious cornual occlusion are a little more promising (Table 1). In our experience cornual anastomosis yielded a 42.9% term pregnancy rate. Complete removal of pathologic tissue is indispensable in this procedure. Occasionally extensive resection technically is extremely difficult or even impossible. Anatomic alterations such as in extensive salpingitis isthmica nodosa might extend to the uterine cavity or even occasionally involve the adjacent portions of the ampulla. 9 In our earlier experience patency with free passage of dye was of paramount importance and thus all of the scarred tissue was not resected. However, in this instance postoperative laparoscopy revealed a high incidence of tubal reocclusion. Presently we favor extensive resection of the inflamed segments of oviduct, by which patency rates are ultimately improved. It is striking that
Table 4. Results According to Tubal Wall Disease: Extensive Damage Salpingolysis Fimbrioplasty Salpingostomy Anastomosis Anastomosis and fimbrial repair Vol. 38, No.4, October 1982
No.
Intrauterine pregnancy
Ectopic pregnancy
Not pregnant
4 9
1 1 3
1
2 8 41 1 6
45
2 6
1 1
Frantzen and Schlosser Postinfectious tubal infertility
401
in patients with intramural occlusion, the fimbriae usually appear norma1. 3 It is likely that the ascending infection was arrested at an early stage by the proximal tubal occlusion. The majority of women with cornual occlusion have secondary infertility. Presumably, a progressive disease such as salpingitis isthmica nodosa, which primarily leads to stenosis of the tubal lumen and in some cases to tubal gestation, ultimately results in complete occlusion of the oviduct. We often have observed complete proximal occlusion unilaterally and delayed transport of dye into the contralateral tube. Initially we avoided operating upon the patent cornu. At present, however, we tend to scrutinize all abnormal findings because postoperative laparoscopy has shown that in several women patency was reestablished in the anastomosed tube, while proximal occlusion ultimately developed in the previously patent and untreated oviduct. We do not consider combined proximal and distal tubal occlusion as a contraindication to tubal reconstructive surgery. Often only limited damage of the fimbriated end is observed in these cases, and the outcome is better than in cases with extensive tubal disease (Table 1). Apropos of these considerations, all patients included in our miscellaneous group demonstrated less mucosal damage and fibrosis in the intramurally occluded tube than in the distally diseased oviduct.
results after repair of postinfectious tubal sterility. Microsurgery has been most successful in lysis of adhesions and achieves satisfactory anatomic results. It is likely that success rates may be improved further by use of pharmacologic adjuvants. An improvement in the selection of patients also should achieve improved statistical results. To overcome bias against a stricter selection procedure, we must develop preoperative diagnostic methods that permit a more precise evaluation of the morphologic and functional condition of the tubes. Such an improved preoperative evaluation would enable a differentiation between surgically treatable and surgically untreatable cases of postinfectious tubal infertility.
PERSPECTIVES
Further refinements of microsurgical techniques are not likely to improve the disappointing
REFERENCES 1. Siegler AM: Surgical treatments for tuboperitoneal causes of infertility since 1967. Fertil Steril 28:1019, 1977 2. Schlosser HW, Frantzen C, Beck L: Uber den Stellenwert mikrochirurgischer Techniken ~i der operativen Therapie der tubaren Sterilitat. Geburlshilfe Frauenheilkd 39:545, 1979 3. Winston RML: Microsurgery of the fallopian tube: from fantasy to reality. Fertil Steril 34:521,1980 4. Swolin K: Electromicrosurgery and salpingostomy: longterm results. Am J Obstet Gynecol 121:418, 1975 5. Garcia CR, Mastroianni L: Microsurgery for treatment of adnexal disease. Fertil Steril 34:413, 1980 6. Gomel V: Clinical results of infertility microsurgery. In Microsurgery in Female Infertility, Edited by PG Crosignani, BL Rubin. London, Academic Press, 1980, p 77 7. Wallach EE: Tubal reconstructive surgery-1980. Fertil Steril 34:531, 1980 8. Pfeffer WH: Adjuvants in tubal surgery. Fertil Steril 33: 245, 1980 9. Schenker JR, Burns EL: A study and classification of nodular lesions of the fallopian tubes "salpingitis isthmica nodosa." Am J Obstet Gynecol 45:624, 1943
Received May 7, 1982. *Reprint requests: Priv.-Doz. Dr. med Christiane Frantzen, Department of Obstetrics and Gynecology, University of Dusseldorf, D-4000 Dusseldorf, Federal Republic of Germany.
402
Frantzen and Schlosser Postinfectious tubal infertility
Fertility and Sterility
FERTILITY AND STERILITY Copyright c 1982 The American Fertility Society
Microsurgery and postinfectious tubal infertility
Christiane Frantzen, M.D.* Hans-Walter Schlosser, M.D. Department of Obstetrics and Gynecology, University of Dusseldorf, Federal Republic of Germany
Because of the excellent results achieved by microsurgical approaches for reversal of sterilization, microsurgical techniques were considered promising for improving the outcome of the repair of postinfectious tubal disease as well. Unfortunately, these hopes did not materialize. Only a small percentage of infertile patients suffering from tubal damage subsequent to pelvic inflammatory disease were helped by tubal surgery. While anatomic reconstruction frequently was successful, these techniques failed to reverse postinfectious infertility in most cases. It is likely that alterations of the tubal wall and occasionally other not yet fully recognized functional disorders of the oviduct fail to respond to surgery. The value of microsurgery as opposed to conventional techniques in the therapy of postinfectious tubal infertility can be judged only by critically analyzing what has been achieved to date. We must then ask ourselves whether further improvement in microsurgical techniques would necessarily help us achieve a better rate of success in these cases, or whether it might not be preferable to concentrate on drug adjuvants or on a better selection of patients. TUBAL PATHOLOGY
In postinfectious tubal disease one usually can observe three possible morphologic characteristics: (1) perisalpingeal and peri ovarian adhesions; (2) damage to the distal tubal segments; and (3) occlusion of the proximal tubal segments. It is likely that perisalpingeal adhesions impair fertility only when the mobility of the fimbriated end and consequently ovum pickup are disturbed. By contrast, adhesions along the isthmic portion of the proximal ampullary segment seem to have Vol. 38, No.4, October 1982
no influence on fertility as long as they do not kink or compress the tubal lumen. Adhesions that completely encase the ovary and consequently prevent ovum pickup require surgical treatment. Agglutination of the fimbriae, varying from minor phimosis to complete occlusion of the ampullary end, is the most common outcome after tubal inflammation. Ovum capture frequently is impaired when the ampullary end of the tube is adherent to the ovarian surface. Approximately 30% of all patients suffering from involuntarily acquired tubal infertility demonstrate unilateral or bilateral cornual blockage, combined with other morphologic findings. In the majority of these cases salpingitis isthrnica nodosa, postinfectious fibrous stenosis, or fibrous obliteration of the tubal lumen can be diagnosed. It is striking that most of these patients are older than 30 years of age and have a history of secondary infertility. A history of induced abortion or ectopic pregnancy often is elicited. Pathologic intramural and isthmic blockage may be secondary to a variety of factors. Apart from infectious diseases, including salpingitis isthmica nodosa, gross intraluminal adhesions, and tuberculosis, numerous noninfectious factors can be recognized; for example, intramural polyps, endometriosis, calcified ectopic pregnancy, restrictive or kinking adhesions, and intramural myomata. In most cases a preoperative identification of the causes of the cornual occlusion is impossible. CLASSIFICATION AND EVALUATION OF TUBAL DISEASE
The question of whether or not improved Burgical techniques have achieved progress in infertility surgery can be answered in part by a compariFrantzen and Schlosser Postinfectious tubal infertility
397
son of success rates of microsurgical and conventional procedures. However, a mere comparison of statistics can be misleading. Inflammation of the fallopian tubes leads to multicentric disease and presumably to numerous functional alterations as well. For this reason, attempts to classifY these alterations have been less than ideal. The only point of agreement has been the classification of tubal disease according to the surgical procedure required in each case. This concurrence was established at the meeting of the International Fertility Society in Miami Beach in 1977. 1 However, such a system of classification does not permit a uniform evaluation because it fails to take into consideration the extent of tubal damage. Several authors confuse the terms fimbriolysis, fimbrioplasty, and salpingostomy. For practical purposes, we choose to use the term "salpingostomy" only when it is necessary to reestablish patency in a completely occluded ampullary segment. The term "fimbrioplasty" has been applied to the situation in which transfundally injected dye traverses a phimotic ostium. 2 Similar terminology has been adopted by several authors. 3 In many cases oviductal inflammation leads to different pathologic conditions in the right and left fallopian tubes, thus creating problems in statistical evaluation. How are we to interpret results if salpingolysis has been performed on one side and salpingostomy on the contralateral side? We consider that patients with disparate findings in both fallopian tubes must be included in the group that has less serious conditions. 2 If pregnancy occurred, it is logical to assume that the embryo most probably was transported by the less damaged oviduct. Using the previously mentioned example for statistical purposes, we would have to regard the case as salpingolysis, because a salpingostomy by itself is the more difficult procedure and carries with it a poorer prognosis for restoration of fertility. It is still indispensable that we include some patients in a miscellaneous group. For example, this principle might apply if repair of a cornual block was necessary on one side and a fimbrial occlusion was necessary on the contralateral side. Although it is generally accepted that different surgical techniques have different effects on the rates of success,4-6 there is uncertainty about the . influence of preoperative and postoperative mechanical and medicinal expediency (application of corticosteroids, antibiotic therapy, hydropertubation, early postoperative laparoscopy, etc.).7.8 Undoubtedly, optimal postoperative medical care 398
Frantzen and Schlosser Postinfectious tubal infertility
improves the chances of pregnancy considerably. In addition, the number of patients lost to followup impairs a statistical evaluation, since these women must be listed as failures. Except for tubal reconstruction for intramural obstruction, conceptions following microsurgical oviductal repair for postinfectious disease often occur 8 to 20 months later, but cases in which conception has occurred more than 4 years later are not unusual. This situation indicates the importance of comparable postoperative follow-up interval when one is comparing various surgical techniques. Microsurgery seems to be indicated only when the fallopian tubes are in suitable condition. The more extensive the tubal damage, the less chance there is for one to establish an advantage for microsurgical techniques. The chances for success through microsurgery might be maximized if patients with limited tubal damage were referred to specialized units at the outset. The criteria applied to the selection of patients determine the rate of success-for microsurgical as well as conventional tubal surgery. General history is important. Factors such as advanced age, ovulatory insufficiency, subfertility of the husband, preceding gynecologic surgery, previous ectopic pregnancy, and repeat tuboplasty may carry a reduced prognosis for pregnancy. Selection criteria on the basis of the morphologic condition of the tubes are even more decisive (e.g., extent of pathologic-anatomic alterations, extent and distribution of adhesions, endometriosis, etc.). In the literature it is rare to find information concerning the number of patients excluded from surgery following preoperative laparoscopy. With few exceptions, surgeons fail to report on how often they have terminated a procedure because intraoperative findings differed significantly from those that were diagnosed preoperatively. CLINICAL EXPERIENCES AND RESULTS
Between February 28, 1981, and January 1, 1976, we performed microsurgery on 478 patients with postinfectious tubal infertility at the Department of Obstetrics and Gynecology, Dusseldorf University Medical School. We have analyzed data from 234 patients who underwent tuboplasty through December 31,1980. The following findings were considered to be absolute contraindications for microsurgery: diseases that are incompatible with pregnancy, ovulatory failure refractory to induction of ovulation, genital tu. berculosis, and resection of more than two-thirds Fertility and Sterility
of the ampullary segment during a previous operation. An age in excess of 40 years as well as subfertility of the husband were regarded as relative contraindications to surgery. Except for those mentioned previously, patients were not selected on the basis of morphologic findings. Our preoperative workup customarily includes laparoscopy, hysterosalpingography and, under special conditions (e.g., intramural obstruction), hysteroscopy. In spite of these diagnostic procedures, a discrepancy between preoperative and intraoperative findings occasionally was encountered. Limitations of preoperative diagnosis occasionally led to operations on patients with unilateral tubal damage, although the contralateral side seemed to be intact. Naturally, these patients were excluded from further statistical evaluation. In other cases surgical efforts had to be abandoned because laparoscopic findings had been deceptive. Such errors occurred mainly when a cornual obstruction or sactosalpinges with minimal spillage of dye were suspected. It was striking that suspected sactosalpinges often merely proved to be extremely thin-walled and hypoplastic oviducts without any aspect ofphimosis at the fimbriated end. In these usually convoluted oviducts the ampullary segment sometimes displayed hernia-like projections with a distension resembling genuine sactosalpinges during chromopertubation. Microsurgical reconstruction of the fallopian tube was found to be impossible at the time of surgery in 31 patients because of the extent of the pathologic findings (a complete obliteration of tubal lumen, a completely destroyed ampullary segment, or tuberculosis that had not been previously appreciated). Most often, however, efforts at reconstruction were abandoned because it was not possible to reconstruct the ovarian surface. Some of these patients had histories of tuboovarian abscess, ovarian wedge resection, or ovarian cyst extirpation. These patients frequently had been treated for a prolonged time for ovarian insufficiency. In the presence of dense adhesions, which occasionally prevent proper examination of fallopian tubes and ovaries by laparoscopy, or if the preoperative workup was not accomplished at our own hospital, we prefer to initiate our microsurgical procedure with an explorative minilaparotomy. Our experience shows that the explorative minilaparotomy offers the best opportunity for an exact preoperative diagnosis. In the meantime, extensive publications have appeared that deal with microsurgical techniques Vol. 38, No.4, October 1982
for salpingolysis, fimbrioplasty, salpingostomy, and anastomosis. 1 , 3-6 Undeniably subtle surgery guarantees maximal preservation of functioning tissue and minimization of the trauma that is simply caused by surgery itself. Loupes are a great help for tubal surgery but they do not seem to provide sufficient magnification for cornual anastomosis. 3 There can be no doubt that higher magnification, as provided by the operating microscope, is preferable for an exact dissection of tissue borders. In salpingolysis we consider crucial a minute dissection of the adherent fimbriated end from the ovary and the best possible restoration of the original anatomy and mobility of the tubes. While dissecting the ampullary segment from the ovary, one must take care to avoid damage to the vessels that run into the suspensory ligament of the ovary and supply the fimbriae. Experience has shown that certain surgical adjuvants can provide considerable advantage. Fixation of long mobile epiploic appendices, duplication or partial resection of the omentum majus, split peritoneal grafts on rough peritoneal areas and, occasionally, uterine suspension have helped to improve our anatomic results. One can prevent the mobilized adnexa from readhering in the pouch of Douglas by gathering up the parietal peritoneum and the posterior layer of the broad ligament and by fixing these structures to the posterior uterine wall. 2 When adhesion formations cannot be used for peritonization, we attempt to excise them completely. All our patients are treated with antibiotics postoperatively. Corticosteroids are administered routinely intraoperatively and postoperatively unless an anastomosis is performed. We avoid postoperative hydropertubation. Our results in terms of pregnancy following reconstruction of postinfectious tubal damage are disappointing. A term pregnancy rate ofless than 30% has been attained (Table 1). The voluntary abandonment of most criteria for patient selection seems to be a plausible explanation for these unsatisfactory results. We did not refuse surgery when patients desperately desired it because we did not wish to deprive our patients of an opportunity to give birth to a child. Our stand received its justification when several patients whose oviducts were considered hopelessly damaged established a pregnancy following tuboplasty. In addition, 33.8% of the patients in this series required further treatment for ovarian insufficiency. Proven subfertility of the husband impaired the Frantzen and Schlosser Postinfectious tubal infertility
399
Table 1. Microsurgical Repair of Pastinfectious Tubes: Results No.
Salpingolysis Fimbrioplasty Salpingostomy Anastomosis Anastomosis and fimbrial repair Miscellaneous procedures
49 49 85 28 15
Total
234
8
Intrauterine pregnancies
20 (40.8%) 13 (26.5%) 16 (18.8%) 12 (42.9%) 3 7 71 (30.3%)
Term pregnancy"
19 11 12 12 3
Abortion
(38.8%) (22.4%) (14.1%) (42.9%)
1 (2.0%) 2 (4.1%) 4 (4.7%)
7
Ectopic· pregnancy
2 2 3 2
Not pregnant
(4.1%) (4.1%) (3.5%) (7.1%)
27 (55.1%) 34 (69.4%) 66 (77.7%) 14 (50.0%) 12
10 (4.3%)
153 (65.4%)
Reocclusionl recurrence Ofgr088
adhesions
1 4 8 6 4
(2.0%) (8.7%) (9.4%) (21.4%)
1
64 (27.4%)
7 (3.0%)
23 (9.8%)
"One patient had an ectopic pregnancy and later had a term pregnancy.
chances of conception in another 15.4% of the patients. However, an analysis of our data indicated that the pregnancy rate of women with additional factors contributing to infertility compared well with those of patients suffering from tubal factors alone, provided these supplementary factors were treated promptly and appropriately. Reduction in the age limit for surgical candidates also might result in better statistics. In our experience pregnancy rates are similar in patients with primary and secondary infertility. Success rates in patients who have undergone repeated tubal surgery are poor. In this group, 11 of 5B patients achieved an intrauterine pregnancy, 2 of whom, however, aborted. Most patients with previous tubal surgery required repeat salpingostomy. In cases of previous attempts at tubal reconstruction, gross pathology of the tubal wall and a distinctly shortened ampullary segment often were characteristic findings at the ultimate procedure. Laparoscopy is advised if patients fail to establish a pregnancy 1 year after surgery. Largely as a result of microsurgical techniques we have been able to observe satisfactory anatomic results, as evidenced by visualization at the follow-up laparoscopy. Recurrence of adhesions has been rare; however, reocclusion or repeat phimosis of the recreated ostium has been found in B.1 % of our patients.
In our experience the prognosis for fertility is essentially established by two parameters: (1) the extent of fibrosis of the tubal wall, and (2) the extent of deciliation of the epithelial cells lining the lumen. Despite the absence of adhesions and the reestablishment of tubal patency, reconstructive surgery usually did not leaq to pregnancy if the tubal walls were found to be extremely thickened and rigid. Unfortunately, precise histologic criteria for the extent of tubal damage are not yet available. In our experience biopsies offer little help, because different areas of the oviduct are affected by differing degrees of disease. Therefore, biopsies cannot be representative for the entire fallopian tube, and evaluation continues to be based upon subjective criteria. We find the following approach to be highly effective: two surgeons, using the highest magnification of an operating microscope, inspect and evaluate the mucosa and the tubal wall ofthe ampullary end independently. Tubal damage is considered mild when ciliation exceeds 75% ofthe surface cells and when the tubal wall measures less tl1an 1 mm in thickness. A wall 1 to 2 mm thick and preservation of 50% to 75% healthy-appearing mucosa classifies the moderate damage. Gross disease is evident when tubal wall thickness exceeds 2 mm. This condition is always accompanied by extensive reduction or complete loss of visible mucosa.
Table 2. Results According to Tubal Wall Disease: Minor Damage No.
Salpingolysis Fimbrioplasty Salpingostomy Anastomosis Anastomosis and fimbrial repair Miscellaneous procedures
400
Intrauterine pregnancy
41 30 10 24 6
19 .10 5 12 3
7
6
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Ectopic pregnancy
1 1
Not pregnant
22 19 5 11 3
1
Fertility and Sterility
Table 3. Results According to Tubal Wall Disease: Moderate Damage No.
Salpingolysis Fimbrioplasty Salpingostomy Anastomosis Anastomosis and fimbrial repair Miscellaneous procedures
Intrauterine pregnancy
4 10 30 2 3
2 8
1
Ectopic pregnancy
Not pregnant
1
3 8 21 2 3
1
1
At present, surgeons appreciate that in addition to morphologic abnormalities, a variety of functional tubal disorders might exist that cannot be fully detected by preoperative or intraoperative evaluation. Such disorders do not necessarily correlate with the pathologic-anatomic findings. As expected, the poorest results are obtained in patients requiring salpingostomy. Frequently the mucosal and the muscular layers of sactosalpinges have been largely destroyed. Often reconstruction and provision of a sufficiently wide neoostium require resecting a major portion of the ampulla when tubal walls are thick and rigid. Even when microsurgery is used, such cases are accompanied by a high risk of reocclusion or repeat phimosis. If sactosalpinges are loculated, giving a honeycomb appearance, the chances for success are poor. Although there are usually only a few mucosal residua in extremely dilated and thin-walled sactosalpinges, the situation is more favorable than when the oviducts are narrow and thick-walled. It is still unknown whether muscular elements and the mucosa can regenerate after salpingostomy. 3 While Winston 3 achieved a term pregnancy rate of 17.5% for salpingostomy and our results are 14.1% (Table 1), Gomel 6 and Swolin4 reported 27% and 29% term pregnancy rates, respectively. However, in contrast to other authors, we found a surprisingly low ectopic pregnancy rate. The data in Tables 2, 3, and 4 demonstrate a clear correlation between the extent of tubal damage and the pregnancy rate. Salpingolysis is considered to be the most promising. We have obtained better success rates after
salpingolysis than after salpingostomy. However, in spite of satisfactory anatomic results, the outcome still was not ideal (Tables 1 to 4). The failure to establish a pregnancy can be explained in part by the existence of additional unrecognized functional disorders. A variety of conditions involving the fimbriated end of the oviduct are treated by fimbrioplasty. A prognosis can only be given in individual cases because the repair of a phimotic but patent oviduct includes minor deagglutinations of the fimbriae as w~ll as radial incisions and eversion of a hydrosalpinx with a pinpoint-sized opening. The nature and extent of tubal wall pathology, which determines the results of surgery, differ greatly in oviducts requiring fimbrioplasty (Tables 2 to 4). The chances for success after repair of postinfectious cornual occlusion are a little more promising (Table 1). In our experience cornual anastomosis yielded a 42.9% term pregnancy rate. Complete removal of pathologic tissue is indispensable in this procedure. Occasionally extensive resection technically is extremely difficult or even impossible. Anatomic alterations such as in extensive salpingitis isthmica nodosa might extend to the uterine cavity or even occasionally involve the adjacent portions of the ampulla. 9 In our earlier experience patency with free passage of dye was of paramount importance and thus all of the scarred tissue was not resected. However, in this instance postoperative laparoscopy revealed a high incidence of tubal reocclusion. Presently we favor extensive resection of the inflamed segments of oviduct, by which patency rates are ultimately improved. It is striking that
Table 4. Results According to Tubal Wall Disease: Extensive Damage Salpingolysis Fimbrioplasty Salpingostomy Anastomosis Anastomosis and fimbrial repair Vol. 38, No.4, October 1982
No.
Intrauterine pregnancy
Ectopic pregnancy
Not pregnant
4 9
1 1 3
1
2 8 41 1 6
45
2 6
1 1
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in patients with intramural occlusion, the fimbriae usually appear norma1. 3 It is likely that the ascending infection was arrested at an early stage by the proximal tubal occlusion. The majority of women with cornual occlusion have secondary infertility. Presumably, a progressive disease such as salpingitis isthmica nodosa, which primarily leads to stenosis of the tubal lumen and in some cases to tubal gestation, ultimately results in complete occlusion of the oviduct. We often have observed complete proximal occlusion unilaterally and delayed transport of dye into the contralateral tube. Initially we avoided operating upon the patent cornu. At present, however, we tend to scrutinize all abnormal findings because postoperative laparoscopy has shown that in several women patency was reestablished in the anastomosed tube, while proximal occlusion ultimately developed in the previously patent and untreated oviduct. We do not consider combined proximal and distal tubal occlusion as a contraindication to tubal reconstructive surgery. Often only limited damage of the fimbriated end is observed in these cases, and the outcome is better than in cases with extensive tubal disease (Table 1). Apropos of these considerations, all patients included in our miscellaneous group demonstrated less mucosal damage and fibrosis in the intramurally occluded tube than in the distally diseased oviduct.
results after repair of postinfectious tubal sterility. Microsurgery has been most successful in lysis of adhesions and achieves satisfactory anatomic results. It is likely that success rates may be improved further by use of pharmacologic adjuvants. An improvement in the selection of patients also should achieve improved statistical results. To overcome bias against a stricter selection procedure, we must develop preoperative diagnostic methods that permit a more precise evaluation of the morphologic and functional condition of the tubes. Such an improved preoperative evaluation would enable a differentiation between surgically treatable and surgically untreatable cases of postinfectious tubal infertility.
PERSPECTIVES
Further refinements of microsurgical techniques are not likely to improve the disappointing
REFERENCES 1. Siegler AM: Surgical treatments for tuboperitoneal causes of infertility since 1967. Fertil Steril 28:1019, 1977 2. Schlosser HW, Frantzen C, Beck L: Uber den Stellenwert mikrochirurgischer Techniken ~i der operativen Therapie der tubaren Sterilitat. Geburlshilfe Frauenheilkd 39:545, 1979 3. Winston RML: Microsurgery of the fallopian tube: from fantasy to reality. Fertil Steril 34:521,1980 4. Swolin K: Electromicrosurgery and salpingostomy: longterm results. Am J Obstet Gynecol 121:418, 1975 5. Garcia CR, Mastroianni L: Microsurgery for treatment of adnexal disease. Fertil Steril 34:413, 1980 6. Gomel V: Clinical results of infertility microsurgery. In Microsurgery in Female Infertility, Edited by PG Crosignani, BL Rubin. London, Academic Press, 1980, p 77 7. Wallach EE: Tubal reconstructive surgery-1980. Fertil Steril 34:531, 1980 8. Pfeffer WH: Adjuvants in tubal surgery. Fertil Steril 33: 245, 1980 9. Schenker JR, Burns EL: A study and classification of nodular lesions of the fallopian tubes "salpingitis isthmica nodosa." Am J Obstet Gynecol 45:624, 1943
Received May 7, 1982. *Reprint requests: Priv.-Doz. Dr. med Christiane Frantzen, Department of Obstetrics and Gynecology, University of Dusseldorf, D-4000 Dusseldorf, Federal Republic of Germany.
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