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Systematic Salpingoscopy and Microsalpingoscopy during Fertiloscopy
November 2002, Vol. 9, No. 4
The Journal of the American Association of Gynecologic Laparoscopists
Systematic Salpingoscopy and Microsalpingoscopy during Fertiloscopy A. Watrelot, M.D., J. M. Dreyfus, M.D., and M. Cohen, M.D.
Abstract Study Objective. To assess the feasibility of routine salpingoscopy and microsalpingoscopy by the vaginal route during fertiloscopy. Design. Retrospective continuous series (Canadian Task Force classification II-2). Setting. Private reproductive center. Patients. Five hundred infertile women with no obvious pathology. Interventions. Fertiloscopy with salpingoscopy followed by microsalpingoscopy. Measurements and Main Results. Salpingoscopy was possible in 85% of women. In those with no pathology, only 8.2% had abnormal salpingoscopy but 37% had abnormal microsalpingoscopy. Conclusion. Fertiloscopy allows salpingoscopy and microsalpingoscopy to be performed in a reproducible and simple manner. Thus intratubal exploration should be integral to infertility assessment. (J Am Assoc Gynecol Laparosc 9(4):453–459, 2002)
Materials and Methods
Salpingoscopy was described first by two groups in France1,2 and another in Belgium.3 The last authors emphasized the importance of salpingoscopy and proposed a scoring system to aid therapeutic decisions. Lack of concordance between the outer aspect of the tubes and inner findings was reported.4 More recently, microsalpingoscopy was introduced, with the number of nuclear nuclei stained by methylene blue as a predictor of chance to conceive in women with tubal infertility.5 As all these studies were carried out during laparoscopy or even laparotomy,1 it was rather complicated to perform salpingoscopy. The need for an additional telescope with irrigation and cold light supply also make the procedure complicated. Moreover a risk of trauma exists when tubes are grasped and mobilized in order to enter them with the scope. It is probably for all these reasons that salpingoscopy is rarely performed on a routine basis.
The aims of this work were to see if salpingoscopy could be performed easily during fertiloscopy, and to try to corroborate earlier work on microsalpingoscopy5 and especially the value of nuclear dye staining in evaluating the healthiness of the tubes. We performed 500 fertiloscopies in women with no obvious tuboperitoneal pathology, and in particular with hysterosalpingogram (HSG) considered normal or doubtful. When adnexal pathology was evident, laparoscopy was the preferred method of investigation. We excluded patients with evident adnexal pathology on HSG. In addition, in cases of severe male factor infertility leading to recommendation for intracytoplasmic sperm injection (ICSI), it was not necessary to examine the tubes, and these women did not undergo fertiloscopy. Women with suspicion of tubal disease based on positive Chlamydia serology or history were
From the Centre de Recherche et d’Etude de la Stérilité, Lyon, France (all authors). Address reprint requests to A. Watrelot, M.D., Centre de Recherche et d’Etude de la Stérilité, “Le Britannia” 20 Boulevard Eugene Deruelle, 69003 Lyon, France; fax 334 77 360 773. Presented at the 29th annual meeting of American Association of Gynecologic Laparoscopsits, Orlando, Florida, November 15–19, 2000. First place winner, Golden Minisite award. Dr. Watrelot is a consultant for Soprane SA, France. Accepted for publication April 12, 2002. Revised May 1, 2003
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Salpingostomy and Microsalpingoscopy during Fertiloscopy Watrelot et al
included if HSG appeared normal or doubtful. Fertiloscopy was proposed routinely before referring the patient to in vitro fertilization (IVF). We tried to perform salpingoscopy at that time, as it was considered an integral part of the procedure. Microsalpingoscopy was added later.
tubal patency with dye. Salpingoscopy consisted of introducing the same scope into the tube through fimbriae normally located in front of the lens (Figures 3, 4, and 5). It was sometimes necessary to stabilize but not mobilize the fimbriae thanks to a micrograsping forceps introduced through the operative channel of the fertiloscope. In this case it was necessary to grasp a fimbrial fold at 12 o’clock and to push the scope gently. When tubes were fixed with adhesions it was sometimes possible to perform salpingoscopy after adhesiolysis. A bipolar probe, either VersaPoint (Gynecare, Somerville, NJ) or Ovadrill (Erbe-Soprane, France), was passed trough the operative channel to perform adhesiolysis.
Operative Technique Our technique is divided into five steps using the disposable fertiloscope kit (Soprane SA, France; Figures 1 and 2): hydropelviscopy, dye test, salpingoscopy, microsalpingoscopy, and hysteroscopy.6 Fertiloscopy was performed under either local or general anesthesia, based on patient’s choice. Local anesthesia was paracervical block with lidocaine; no sedation was added. Salpingoscopy was done after checking
FIGURE 2. Principles of fertiloscopic salpingoscopy. FIGURE 1. Principles of fertiliscopy.
FIGURE 3. Grasping the fimbriae.
FIGURE 4. Normal ampulla.
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FIGURE 5. Intraampullary adhesions.
FIGURE 6. Microsalpingoscopy, stage A (normal).
In rare cases of hydrosalpinx not diagnosed by HSG, it was possible to create a small hole at the apex of the hydrosalpinx in order to insert the telescope. In all cases, the telescope was gently pushed if possible until the isthmoampullary junction was reached. During the whole procedure it was necessary to irrigate the tube through the sheath of the telescope to ensure limited dilatation of the ampulla. A tap located on the sheath of the telescope allowed for in-flow adjustment to avoid too high pressure in the ampulla, even if only gravity was used to irrigate the pelvis and tubes. By rotating the telescope on its axis and due to the 30-degree lens, each portion of the ampulla was examined. For salpingoscopy, no magnification was added. All pathologic findings were carefully identified, such as intraampullary adhesions or flattened folds. We classified salpingoscopy as abnormal only in cases of intratubal adhesions, because that is the only condition always correlated with pregnancy outcome.3,4 Fertiloscopy is performed with the 2.9-mm Hamou II telescope (Karl Storz, Tuttlingen, Germany), which achieves magnification up to 180 times by rotating the wheel near the eyepiece. Given this feature, microsalpingoscopy was possible with the same scope. Microsalpingoscopy was performed after the dye test (Figures 6 and 7), thus it was possible to examine the number of dye-stained nuclei on tubal epithelium. These are either intermediary cells on epithelium or inflammatory cells in the middle of tubal folds. The number of dye-stained nuclei allows one to classify the tubes in four stages from normal (stage 1), in
FIGURE 7. Microsalpingoscopy, stage B (dye-stained nuclei).
which no nuclei are stained, to pathologic (stage 4), in which a great number of cells appear to be stained.5 As this classification is somewhat subjective, we divided our findings in two groups: A, no or very few nuclear dye-stained nuclei were observed, and B, staining was evident on several epithelial folds associated with nuclei stained between the folds. Tubal biopsy was performed at this stage through a 5F operative channel of the endoscope. Hysteroscopy was the last step and was done with the same scope. Endometrial biopsy was performed at this time if pathology was suspected, especially
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Salpingostomy and Microsalpingoscopy during Fertiloscopy Watrelot et al
Failure was mostly due to inability to enter the tube and follow its curves with the scope. It was necessary to perform adhesiolysis in 15 (31.5%) of 48 women with periadnexal adhesions before entering the tubes. In fact some fixity of the tubes was more helpful than not, except when tubes were attached behind the ovaries.
to look for correlation between tubal mucosa and endometrium. At the end of the procedure, the telescope was removed and saline ran out freely. It was not important to remove all the saline, as what remained was spontaneously reabsorbed over the next few hours. No sutures were required on the small vaginal scar. Patients were discharged immediately if fertiloscopy was done under local anesthesia, and in a few hours if it was done with general anesthesia. Due to the small vaginal scar, the only recommendations to patients were to avoid using vaginal tampons and to abstain from intercourse for 6 days.
Anesthesia Among the 500 patients, 98 (19.6%) chose local anesthesia. It was possible to enter 164 tubes (83.6%). There was no significant difference between failure and ability to enter the tube without grasping it based on type of anesthesia. A surprise, salpingoscopy, even when grasping the fimbriae, was not painful, but if the procedure took too long (>15 min), patient position was not well tolerated and the procedure had to be finished quickly. That was the cause of two failures.
Results We divided our study in two periods, from 1997 to 1999 when only salpingoscopy was performed, and after January 1999 when microsalpingoscopy was systematically added. Therefore, 289 patients were included in the first period and 211 in the second. Mean time for all steps of fertiloscopy was 13 minutes (range 9–22 min). In the first 289 patients, due to 10 with one remaining tube, salpingoscopy was tried in 568 tubes. It was possible to perform complete salpingoscopy (reach the isthmoampullary junction) in 303 tubes (53.3%) and subtotal salpingoscopy (visualize the first 2 cm of ampulla) in 112 (19.7%). Thus the procedure was considered satisfactory in 415 tubes (73%). It was possible to perform salpingoscopy at least in one tube in 252 women (87%). It was possible to enter the tubes without using grasping forceps in 176 tubes (121/415, 29.1%). In the second period, microsalpingoscopy was attempted in 422 tubes. It was possible to perform complete salpingoscopy-microsalpingoscopy (reach the isthmoampullary junction) in 187 tubes (44.3%) and subtotal procedure (visualize the first 2 cm of ampulla) in 185 (43.8%). Thus salpingoscopy was considered satisfactory in 372 tubes (73%). Among the 211 patients, it was possible to perform salpingoscopy at least in one tube in 174 (82.5%). Microsalpingoscopy (and of course salpingoscopy) was possible in 372 (88.1%) of 422 tubes. It was possible to enter the tube without grasping it in 187 tubes (187/392, 47.7%), which is significantly higher than in the first period (p <0.05). In all, among 990 tubes for both periods, 837 tubes were examined by salpingoscopy and 422 by salpingoscopy and microsalpingoscopy.
Operative Findings During salpingoscopy, we found abnormalities in 159 tubes (18.9%) in 98 patients (intraampullary adhesions with or without flattened folds). During microsalpingoscopy, we found abnormalities (stage B according to number of nuclear dye-stained nuclei) in 156 tubes (36.9%) in 81 women. Fertiloscopy findings are summarized in Tables 1 and 2. The correlation between salpingoscopic evaluation and microsalpingoscopic findings is summarized in Table 3. Histology Tissue for endometrial biopsy was taken during hysteroscopy. Correlation is shown in Table 4, taking into account cases in which endometritis was discovered. We performed tubal microbiopsy with 5F biopsy forceps in the 22 first cases of microsalpingoscopy and 18 of microsalpingoscopy. The pathologist was asked to note abnormalities of tubal epithelium consisting of increased number of intermediary cells and presence or absence of mast cells in mucosal folds. When these aspects were found together, the microbiopsy was considered abnormal. Table 5 shows the correlation between histologic findings and results of microsalpingoscopy. According to tubal microbiopsies, the positive predictive value of microsalpingoscopy was 83.3% and the negative predictive value was 91%. Follow-up We evaluated pregnancy rates at 12 months. In the first period, when only salpingoscopy was performed, 456
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TABLE 1. Salpingoscopic Findings in 252 Patients (first period) According to External Aspect of Tubes
Phimosis Hydrosalpinx Periadnexal adh. Endometriosis No pathology Totals, no. (%)
No. (%)
No. Normal
No. (%) Abnormal
11 (4.3) 3 (1.1) 28 (11.1) 52 (20.6) 158 (62.3) 252
4 0 10 48 137 199 (82.3)
7 (66) 3 (100) 18 (63) 4 (8.3) 21 (83) 53 (17.6)
TABLE 2. Results of Microsalpingoscopy and Salpingoscopy in 174 Patients (second period) According to External Aspect of Tubes
Phimosis Hydrosalpinx Periadnexal adhesions Endometriosis No pathology, no. (%) Totals, no. (%)
No.
Stage A
Stage B
10 1 20 28 115 174
2 0 8 23 72 105 (60.3)
8 1 12 5 43 (37) 69 (39.6)
TABLE 3. Correlation between Salpingogospy and Microsalpingoscopy
Microsalpingoscopy A Microsalpingoscopy B Totals
Normal Salpingoscopy, no. (%)
Abnormal Salpingoscopy, no. (%)
Number
103 51 (73.4) 153
2 (1.9) 18 20
105 69 174
TABLE 4. Correlation Between Microsalpingoscopy and Endometrial Biopsy Related to Endometritis
Microsalpingoscopy A Microsalpingoscopy B Totals
Number
Normal Biopsy
Endometritis, no. (%)
105 69 174
89 39 128
16 (15.2) 30 (43.5)a 46 (26.4)
ap <0.05.
tuboplasty, and women in group 3 were referred to intrauterine insemination (IUI) followed by IVF after three to four IUI failures. In the second period, we added a fourth group, patients with normal findings but pathologic microsalpingoscopy. Therefore group 1 had 20 patients, group 2, 19, group 3, 92, and group 4, 43. Group 4 was subdivided in two subgroups: in the first, 21 patients were directly referred to IVF; in the second, 22 women gave consent to be enrolled in a pilot study in which we tried to treat abnormal mucosa . For this purpose, minocycline 100 mg/day was given for 2 months. Then second-look fertiloscopy was proposed, and if the findings were the same, patients were referred to IVF; if microsalpingoscopy was normal, a series of six IUIs was proposed. All 22 women were enrolled in the pilot study. During antibiotic treatment, two (9%) became pregnant.
TABLE 5. Correlation between Tubal Microbiopsy and Microsalpingoscopic Findings in 40 Patients Microbiopsy, no. (%)
Microsalpingoscopy A Microsalpingoscopy B Totals
Abnormal
Normal
p
2 15 (83.3%) 17
20 (91) 3 23
<0.01 <0.01
the 252 patients were divided in three groups: group 1 with abnormal salpingoscopy (53, 21%), group 2 with normal salpingoscopy but with tubal or peritubal lesions (62, 24.6%), and group 3 in which everything was normal including salpingoscopy (137, 54.3%). Patients in group 1 were referred directly to IVF, those in group 2 were recommended to have laparoscopic
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In the remaining 20, second-look microsalpingoscopy was stage A in 9 (41%) and B (no change) in 11 (45%). In the first nine women we obtained three pregnancies after IUI and two after further attempts at IVF. In the second group of 10 patients, 3 pregnancies were achieved after one to three IVF attempts.
interest, especially if a medical therapeutic approach can be proposed, as we did in our pilot study in which antibiotics were given to try to improve the quality of tubal mucosa. Prospective studies will be necessary to validate this hypothesis. Correlation between salpingoscopy and microsalpingoscopy was high. Histologic correlations were satisfactory between microsalpingoscopy and tubal microbiopsy. In case of microsalpingoscopy stage A, microbiopsy was also normal in 91% of cases, and when microsalpingoscopy was stage B, microbiopsy was abnormal in 83%. This slight difference was explained by the frequent heterogenicity of tubal lesions, and therefore in some cases microbiopsy was possibly done in a nonrepresentative area of tubal mucosa. Even if the aim of this work was not to evaluate the predictive value of salpingoscopy and microsalpingoscopy, it was interesting to assess the follow-up of these women. Results 1 year after fertiloscopy suggest at that stage that the therapeutic decision taken according to the aspect of the tubal mucosa gave a pregnancy rate relevant to that parameter. In particular, patients referred to tubal surgery had a good pregnancy rate due to the relative healthy condition of their tubes. Moreover in women who had IUI, the pregnancy rate was quite satisfactory; meaning that when the tube is in good condition with a normal mucosa, IUI is effective. Although our study was retrospective, it shows that salpingoscopy and microsalpingoscopy are simple to perform after a rather short learning curve. We believe they should be a routine part of the infertility assessment. Additional studies are necessary to evaluate carefully the implication of abnormal microsalpingoscopy on fertility and its possible reversibility with medical treatment.
Discussion Interest in salpingoscopy is clear,3 as is interest in tubal endoscopy.7 Nevertheless salpingoscopy is rarely performed routinely due to its relative complexity, which necessitates a second set of surgical instruments with telescope, videocamera, irrigation, and cold light supply. Fertiloscopy allows salpingoscopy to be done with the same scope in a simple manner. The natural position of the fimbrial end close to the tip of the endoscope eased the procedure. It was therefore possible to enter the tube without stabilizing it in 29.1% of cases in the first period and 47% in the second. That fact is probably related to operator experience, which seemed to have some influence in the ability to penetrate the ampulla. A learning curve of 20 cases is estimated to be sufficient to succeed in salpingoscopy in most patients. When performed under local anesthesia, salpingoscopy did not seem to cause pain. In our series, only 19.6% of patients chose local anesthesia. This low rate is probably due to local habits, but we clearly showed the feasibility of fertiloscopy, including salpingoscopy, in such manner. Whatever the choice of anesthesia, fertiloscopy was always performed as an outpatient procedure. If we consider its safety, we can consider it to be the best approach for salpingoscopy.8 The failure rate was not very high and seemed to decrease with operator experience. Moreover, in patients with bilateral salpingoscopy and microsalpingoscopy, very few were discordant from one side to the other. Therefore, when salpingoscopy is possible in only one tube, it nevertheless gives an acceptable overview of both tubes. It was possible to enter at least in one tube in more than 85% of women. In patients in whom no pathology existed at the time of fertiloscopy, salpingoscopy was abnormal in only 8.2%, but microsalpingoscopy appeared to be abnormal in 37% of those in whom no pathology was found. Abnormal findings are related to a low rate of conception.5 Thus, much so-called unexplained infertility is probably associated with tubal factor, even if tubes have normal patency. This fact could be of great
References 1. Henry-Suchet J, Loffredo V, Tesquier L, et al: Endoscopy of the tube (tuboscopy): Its prognostic value for tuboplasties. Acta Eur Fertil 16:139–145, 1985 2. Cornier E, Delafontaine D: L’ampullosalpingoscopie transcoelioscopique: Une méthode diagnostique et thérapeutique de certaines stérilités inexpliquées. Contracept Fertil Sex 13:1153–1156, 1985 3. Brosens I, Boeckx W, Puttemans P, et al: Salpingoscopy: A new preoperative diagnostic tool in tubal infertility. Br J Obstet Gynaecol 94:768–773, 1987
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4. Marana R, Rizzi M, Muzzi L, et al: Correlation between the American Fertility Society classification of adnexal adhesions and distal tubal occlusion salpingoscopy and reproductive outcome in tubal surgery. Fertil Steril 64:924–929, 1995
7. Surrey E: Microendoscopy of the human fallopian tube. J.Am Assoc Gynecol Laparosc 6:383–389, 2000
8. Watrelot A: Fertiloscopy. In Atlas of Operative Laparoscopy and Hysteroscopy, 2nd ed. Edited by J Donnez, M Nisolle. New York, Parthenon Publishing, 2001
5. Marconi G, Quintana R: Methylene blue dyeing of cellular nuclei during salpingoscopy, a new in vivo method to evaluate vitality of tubal epithelium. Hum Reprod 13:3414–3417, 1998
9. Gordts S, Watrelot A, Campo R, et al: Risk and outcome of bowel injury during transvaginal endoscopy. Fertil Steril 76(6):1238–1241, 2001
6. Watrelot A, Dreyfus JM: Manual of Fertiloscopy, a Stepby-Step Guide. Tuttlingen, Germany, Endopress, 2001
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The Journal of the American Association of Gynecologic Laparoscopists
Systematic Salpingoscopy and Microsalpingoscopy during Fertiloscopy A. Watrelot, M.D., J. M. Dreyfus, M.D., and M. Cohen, M.D.
Abstract Study Objective. To assess the feasibility of routine salpingoscopy and microsalpingoscopy by the vaginal route during fertiloscopy. Design. Retrospective continuous series (Canadian Task Force classification II-2). Setting. Private reproductive center. Patients. Five hundred infertile women with no obvious pathology. Interventions. Fertiloscopy with salpingoscopy followed by microsalpingoscopy. Measurements and Main Results. Salpingoscopy was possible in 85% of women. In those with no pathology, only 8.2% had abnormal salpingoscopy but 37% had abnormal microsalpingoscopy. Conclusion. Fertiloscopy allows salpingoscopy and microsalpingoscopy to be performed in a reproducible and simple manner. Thus intratubal exploration should be integral to infertility assessment. (J Am Assoc Gynecol Laparosc 9(4):453–459, 2002)
Materials and Methods
Salpingoscopy was described first by two groups in France1,2 and another in Belgium.3 The last authors emphasized the importance of salpingoscopy and proposed a scoring system to aid therapeutic decisions. Lack of concordance between the outer aspect of the tubes and inner findings was reported.4 More recently, microsalpingoscopy was introduced, with the number of nuclear nuclei stained by methylene blue as a predictor of chance to conceive in women with tubal infertility.5 As all these studies were carried out during laparoscopy or even laparotomy,1 it was rather complicated to perform salpingoscopy. The need for an additional telescope with irrigation and cold light supply also make the procedure complicated. Moreover a risk of trauma exists when tubes are grasped and mobilized in order to enter them with the scope. It is probably for all these reasons that salpingoscopy is rarely performed on a routine basis.
The aims of this work were to see if salpingoscopy could be performed easily during fertiloscopy, and to try to corroborate earlier work on microsalpingoscopy5 and especially the value of nuclear dye staining in evaluating the healthiness of the tubes. We performed 500 fertiloscopies in women with no obvious tuboperitoneal pathology, and in particular with hysterosalpingogram (HSG) considered normal or doubtful. When adnexal pathology was evident, laparoscopy was the preferred method of investigation. We excluded patients with evident adnexal pathology on HSG. In addition, in cases of severe male factor infertility leading to recommendation for intracytoplasmic sperm injection (ICSI), it was not necessary to examine the tubes, and these women did not undergo fertiloscopy. Women with suspicion of tubal disease based on positive Chlamydia serology or history were
From the Centre de Recherche et d’Etude de la Stérilité, Lyon, France (all authors). Address reprint requests to A. Watrelot, M.D., Centre de Recherche et d’Etude de la Stérilité, “Le Britannia” 20 Boulevard Eugene Deruelle, 69003 Lyon, France; fax 334 77 360 773. Presented at the 29th annual meeting of American Association of Gynecologic Laparoscopsits, Orlando, Florida, November 15–19, 2000. First place winner, Golden Minisite award. Dr. Watrelot is a consultant for Soprane SA, France. Accepted for publication April 12, 2002. Revised May 1, 2003
453
Salpingostomy and Microsalpingoscopy during Fertiloscopy Watrelot et al
included if HSG appeared normal or doubtful. Fertiloscopy was proposed routinely before referring the patient to in vitro fertilization (IVF). We tried to perform salpingoscopy at that time, as it was considered an integral part of the procedure. Microsalpingoscopy was added later.
tubal patency with dye. Salpingoscopy consisted of introducing the same scope into the tube through fimbriae normally located in front of the lens (Figures 3, 4, and 5). It was sometimes necessary to stabilize but not mobilize the fimbriae thanks to a micrograsping forceps introduced through the operative channel of the fertiloscope. In this case it was necessary to grasp a fimbrial fold at 12 o’clock and to push the scope gently. When tubes were fixed with adhesions it was sometimes possible to perform salpingoscopy after adhesiolysis. A bipolar probe, either VersaPoint (Gynecare, Somerville, NJ) or Ovadrill (Erbe-Soprane, France), was passed trough the operative channel to perform adhesiolysis.
Operative Technique Our technique is divided into five steps using the disposable fertiloscope kit (Soprane SA, France; Figures 1 and 2): hydropelviscopy, dye test, salpingoscopy, microsalpingoscopy, and hysteroscopy.6 Fertiloscopy was performed under either local or general anesthesia, based on patient’s choice. Local anesthesia was paracervical block with lidocaine; no sedation was added. Salpingoscopy was done after checking
FIGURE 2. Principles of fertiloscopic salpingoscopy. FIGURE 1. Principles of fertiliscopy.
FIGURE 3. Grasping the fimbriae.
FIGURE 4. Normal ampulla.
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FIGURE 5. Intraampullary adhesions.
FIGURE 6. Microsalpingoscopy, stage A (normal).
In rare cases of hydrosalpinx not diagnosed by HSG, it was possible to create a small hole at the apex of the hydrosalpinx in order to insert the telescope. In all cases, the telescope was gently pushed if possible until the isthmoampullary junction was reached. During the whole procedure it was necessary to irrigate the tube through the sheath of the telescope to ensure limited dilatation of the ampulla. A tap located on the sheath of the telescope allowed for in-flow adjustment to avoid too high pressure in the ampulla, even if only gravity was used to irrigate the pelvis and tubes. By rotating the telescope on its axis and due to the 30-degree lens, each portion of the ampulla was examined. For salpingoscopy, no magnification was added. All pathologic findings were carefully identified, such as intraampullary adhesions or flattened folds. We classified salpingoscopy as abnormal only in cases of intratubal adhesions, because that is the only condition always correlated with pregnancy outcome.3,4 Fertiloscopy is performed with the 2.9-mm Hamou II telescope (Karl Storz, Tuttlingen, Germany), which achieves magnification up to 180 times by rotating the wheel near the eyepiece. Given this feature, microsalpingoscopy was possible with the same scope. Microsalpingoscopy was performed after the dye test (Figures 6 and 7), thus it was possible to examine the number of dye-stained nuclei on tubal epithelium. These are either intermediary cells on epithelium or inflammatory cells in the middle of tubal folds. The number of dye-stained nuclei allows one to classify the tubes in four stages from normal (stage 1), in
FIGURE 7. Microsalpingoscopy, stage B (dye-stained nuclei).
which no nuclei are stained, to pathologic (stage 4), in which a great number of cells appear to be stained.5 As this classification is somewhat subjective, we divided our findings in two groups: A, no or very few nuclear dye-stained nuclei were observed, and B, staining was evident on several epithelial folds associated with nuclei stained between the folds. Tubal biopsy was performed at this stage through a 5F operative channel of the endoscope. Hysteroscopy was the last step and was done with the same scope. Endometrial biopsy was performed at this time if pathology was suspected, especially
455
Salpingostomy and Microsalpingoscopy during Fertiloscopy Watrelot et al
Failure was mostly due to inability to enter the tube and follow its curves with the scope. It was necessary to perform adhesiolysis in 15 (31.5%) of 48 women with periadnexal adhesions before entering the tubes. In fact some fixity of the tubes was more helpful than not, except when tubes were attached behind the ovaries.
to look for correlation between tubal mucosa and endometrium. At the end of the procedure, the telescope was removed and saline ran out freely. It was not important to remove all the saline, as what remained was spontaneously reabsorbed over the next few hours. No sutures were required on the small vaginal scar. Patients were discharged immediately if fertiloscopy was done under local anesthesia, and in a few hours if it was done with general anesthesia. Due to the small vaginal scar, the only recommendations to patients were to avoid using vaginal tampons and to abstain from intercourse for 6 days.
Anesthesia Among the 500 patients, 98 (19.6%) chose local anesthesia. It was possible to enter 164 tubes (83.6%). There was no significant difference between failure and ability to enter the tube without grasping it based on type of anesthesia. A surprise, salpingoscopy, even when grasping the fimbriae, was not painful, but if the procedure took too long (>15 min), patient position was not well tolerated and the procedure had to be finished quickly. That was the cause of two failures.
Results We divided our study in two periods, from 1997 to 1999 when only salpingoscopy was performed, and after January 1999 when microsalpingoscopy was systematically added. Therefore, 289 patients were included in the first period and 211 in the second. Mean time for all steps of fertiloscopy was 13 minutes (range 9–22 min). In the first 289 patients, due to 10 with one remaining tube, salpingoscopy was tried in 568 tubes. It was possible to perform complete salpingoscopy (reach the isthmoampullary junction) in 303 tubes (53.3%) and subtotal salpingoscopy (visualize the first 2 cm of ampulla) in 112 (19.7%). Thus the procedure was considered satisfactory in 415 tubes (73%). It was possible to perform salpingoscopy at least in one tube in 252 women (87%). It was possible to enter the tubes without using grasping forceps in 176 tubes (121/415, 29.1%). In the second period, microsalpingoscopy was attempted in 422 tubes. It was possible to perform complete salpingoscopy-microsalpingoscopy (reach the isthmoampullary junction) in 187 tubes (44.3%) and subtotal procedure (visualize the first 2 cm of ampulla) in 185 (43.8%). Thus salpingoscopy was considered satisfactory in 372 tubes (73%). Among the 211 patients, it was possible to perform salpingoscopy at least in one tube in 174 (82.5%). Microsalpingoscopy (and of course salpingoscopy) was possible in 372 (88.1%) of 422 tubes. It was possible to enter the tube without grasping it in 187 tubes (187/392, 47.7%), which is significantly higher than in the first period (p <0.05). In all, among 990 tubes for both periods, 837 tubes were examined by salpingoscopy and 422 by salpingoscopy and microsalpingoscopy.
Operative Findings During salpingoscopy, we found abnormalities in 159 tubes (18.9%) in 98 patients (intraampullary adhesions with or without flattened folds). During microsalpingoscopy, we found abnormalities (stage B according to number of nuclear dye-stained nuclei) in 156 tubes (36.9%) in 81 women. Fertiloscopy findings are summarized in Tables 1 and 2. The correlation between salpingoscopic evaluation and microsalpingoscopic findings is summarized in Table 3. Histology Tissue for endometrial biopsy was taken during hysteroscopy. Correlation is shown in Table 4, taking into account cases in which endometritis was discovered. We performed tubal microbiopsy with 5F biopsy forceps in the 22 first cases of microsalpingoscopy and 18 of microsalpingoscopy. The pathologist was asked to note abnormalities of tubal epithelium consisting of increased number of intermediary cells and presence or absence of mast cells in mucosal folds. When these aspects were found together, the microbiopsy was considered abnormal. Table 5 shows the correlation between histologic findings and results of microsalpingoscopy. According to tubal microbiopsies, the positive predictive value of microsalpingoscopy was 83.3% and the negative predictive value was 91%. Follow-up We evaluated pregnancy rates at 12 months. In the first period, when only salpingoscopy was performed, 456
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TABLE 1. Salpingoscopic Findings in 252 Patients (first period) According to External Aspect of Tubes
Phimosis Hydrosalpinx Periadnexal adh. Endometriosis No pathology Totals, no. (%)
No. (%)
No. Normal
No. (%) Abnormal
11 (4.3) 3 (1.1) 28 (11.1) 52 (20.6) 158 (62.3) 252
4 0 10 48 137 199 (82.3)
7 (66) 3 (100) 18 (63) 4 (8.3) 21 (83) 53 (17.6)
TABLE 2. Results of Microsalpingoscopy and Salpingoscopy in 174 Patients (second period) According to External Aspect of Tubes
Phimosis Hydrosalpinx Periadnexal adhesions Endometriosis No pathology, no. (%) Totals, no. (%)
No.
Stage A
Stage B
10 1 20 28 115 174
2 0 8 23 72 105 (60.3)
8 1 12 5 43 (37) 69 (39.6)
TABLE 3. Correlation between Salpingogospy and Microsalpingoscopy
Microsalpingoscopy A Microsalpingoscopy B Totals
Normal Salpingoscopy, no. (%)
Abnormal Salpingoscopy, no. (%)
Number
103 51 (73.4) 153
2 (1.9) 18 20
105 69 174
TABLE 4. Correlation Between Microsalpingoscopy and Endometrial Biopsy Related to Endometritis
Microsalpingoscopy A Microsalpingoscopy B Totals
Number
Normal Biopsy
Endometritis, no. (%)
105 69 174
89 39 128
16 (15.2) 30 (43.5)a 46 (26.4)
ap <0.05.
tuboplasty, and women in group 3 were referred to intrauterine insemination (IUI) followed by IVF after three to four IUI failures. In the second period, we added a fourth group, patients with normal findings but pathologic microsalpingoscopy. Therefore group 1 had 20 patients, group 2, 19, group 3, 92, and group 4, 43. Group 4 was subdivided in two subgroups: in the first, 21 patients were directly referred to IVF; in the second, 22 women gave consent to be enrolled in a pilot study in which we tried to treat abnormal mucosa . For this purpose, minocycline 100 mg/day was given for 2 months. Then second-look fertiloscopy was proposed, and if the findings were the same, patients were referred to IVF; if microsalpingoscopy was normal, a series of six IUIs was proposed. All 22 women were enrolled in the pilot study. During antibiotic treatment, two (9%) became pregnant.
TABLE 5. Correlation between Tubal Microbiopsy and Microsalpingoscopic Findings in 40 Patients Microbiopsy, no. (%)
Microsalpingoscopy A Microsalpingoscopy B Totals
Abnormal
Normal
p
2 15 (83.3%) 17
20 (91) 3 23
<0.01 <0.01
the 252 patients were divided in three groups: group 1 with abnormal salpingoscopy (53, 21%), group 2 with normal salpingoscopy but with tubal or peritubal lesions (62, 24.6%), and group 3 in which everything was normal including salpingoscopy (137, 54.3%). Patients in group 1 were referred directly to IVF, those in group 2 were recommended to have laparoscopic
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Salpingostomy and Microsalpingoscopy during Fertiloscopy Watrelot et al
In the remaining 20, second-look microsalpingoscopy was stage A in 9 (41%) and B (no change) in 11 (45%). In the first nine women we obtained three pregnancies after IUI and two after further attempts at IVF. In the second group of 10 patients, 3 pregnancies were achieved after one to three IVF attempts.
interest, especially if a medical therapeutic approach can be proposed, as we did in our pilot study in which antibiotics were given to try to improve the quality of tubal mucosa. Prospective studies will be necessary to validate this hypothesis. Correlation between salpingoscopy and microsalpingoscopy was high. Histologic correlations were satisfactory between microsalpingoscopy and tubal microbiopsy. In case of microsalpingoscopy stage A, microbiopsy was also normal in 91% of cases, and when microsalpingoscopy was stage B, microbiopsy was abnormal in 83%. This slight difference was explained by the frequent heterogenicity of tubal lesions, and therefore in some cases microbiopsy was possibly done in a nonrepresentative area of tubal mucosa. Even if the aim of this work was not to evaluate the predictive value of salpingoscopy and microsalpingoscopy, it was interesting to assess the follow-up of these women. Results 1 year after fertiloscopy suggest at that stage that the therapeutic decision taken according to the aspect of the tubal mucosa gave a pregnancy rate relevant to that parameter. In particular, patients referred to tubal surgery had a good pregnancy rate due to the relative healthy condition of their tubes. Moreover in women who had IUI, the pregnancy rate was quite satisfactory; meaning that when the tube is in good condition with a normal mucosa, IUI is effective. Although our study was retrospective, it shows that salpingoscopy and microsalpingoscopy are simple to perform after a rather short learning curve. We believe they should be a routine part of the infertility assessment. Additional studies are necessary to evaluate carefully the implication of abnormal microsalpingoscopy on fertility and its possible reversibility with medical treatment.
Discussion Interest in salpingoscopy is clear,3 as is interest in tubal endoscopy.7 Nevertheless salpingoscopy is rarely performed routinely due to its relative complexity, which necessitates a second set of surgical instruments with telescope, videocamera, irrigation, and cold light supply. Fertiloscopy allows salpingoscopy to be done with the same scope in a simple manner. The natural position of the fimbrial end close to the tip of the endoscope eased the procedure. It was therefore possible to enter the tube without stabilizing it in 29.1% of cases in the first period and 47% in the second. That fact is probably related to operator experience, which seemed to have some influence in the ability to penetrate the ampulla. A learning curve of 20 cases is estimated to be sufficient to succeed in salpingoscopy in most patients. When performed under local anesthesia, salpingoscopy did not seem to cause pain. In our series, only 19.6% of patients chose local anesthesia. This low rate is probably due to local habits, but we clearly showed the feasibility of fertiloscopy, including salpingoscopy, in such manner. Whatever the choice of anesthesia, fertiloscopy was always performed as an outpatient procedure. If we consider its safety, we can consider it to be the best approach for salpingoscopy.8 The failure rate was not very high and seemed to decrease with operator experience. Moreover, in patients with bilateral salpingoscopy and microsalpingoscopy, very few were discordant from one side to the other. Therefore, when salpingoscopy is possible in only one tube, it nevertheless gives an acceptable overview of both tubes. It was possible to enter at least in one tube in more than 85% of women. In patients in whom no pathology existed at the time of fertiloscopy, salpingoscopy was abnormal in only 8.2%, but microsalpingoscopy appeared to be abnormal in 37% of those in whom no pathology was found. Abnormal findings are related to a low rate of conception.5 Thus, much so-called unexplained infertility is probably associated with tubal factor, even if tubes have normal patency. This fact could be of great
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