The Clinical Significance of Subtle Distal Fallopian Tube Abnormalities: A Multicentre Prospective Observational Study.

Background: Subtle distal fallopian tube abnormalities are a group of diseases characterised by small variations in tubal anatomy. The clinical significance of these abnormalities need to be studied. Objectives: The purpose of this multicentre prospective observational study was to investigate whether subtle distal fallopian tube abnormalities are related to infertility and endometriosis. Materials and Methods: The investigation was carried out in five medical centres in China and France from February to July 2021 and included reproductive-age patients who underwent gynaecological laparoscopy. Subtle abnormalities included Hydatid of Morgagni (HM) , fimbrial agglutination, tubal diverticula, accessory ostium, fimbrial phimosis, and accessory fallopian tube. Results: 642 patients were enrolled in the study and 257 (40.0%) were diagnosed with subtle tube abnormalities. Hydatid of Morgagni was the most common abnormality (22.7%; n=146), followed by fimbrial agglutination (19.8%; n=127), tubal diverticula (6.9%; n=44), accessory tube (2.0%; n=13), and tubal accessory ostium (1.9%; n=12). Fimbrial phimosis was the least common abnormality (0.3%; n=2). The prevalence of subtle fallopian tube abnormalities was significantly higher among infertile patients (188/375, 50.1%) than those without history of infertility (69/267, 25.8%, ᶍ2=38.332, P=0.000). 209 patients were diagnosed with endometriosis during surgery, and the prevalence of subtle abnormalities was significantly higher in the endometriosis group than in those without endometriosis (61.2%, [128/209] vs. 29.8% [129/433], ᶍ2=58.086, P=0.000). Conclusions: Higher prevalence of subtle tubal abnormalities suggests that they may contribute to infertility. They are highly related to endometriosis and indicate fimbrial abnormalities of endometriosis. What is new?: This is the largest multicentre study to investigate the subtle distal fallopian tube abnormalities in infertile women. Compared to previous studies, this study includes the main subtle distal abnormalities and the control group patients without a history of infertility.

From complication to litigation: The importance of non-technical skills in the management of complications.

Complications do occur in daily clinical life and can sometimes lead to litigation, which adversely affect the entire health care system, leading to a loss of confidence in medical providers, an increase in defensive medical practice and high professional indemnity insurance costs. Some complications are inevitable but can be minimised by completing a structured training programme. The likelihood of litigation can be reduced when adequate and clear information is given to the patient preoperatively. Non-technical skills are essential in complication management and crucial if confronted with litigation. Checklists and documentation of medication and surgical steps should be routine in all surgeries. Awareness of the complexity of the planned operation, theatre set-up and equipment are important in preventing complications. Mental preparation of surgeons is of the utmost importance in order to be able to confront any problem. When complications occur, remaining calm, calling for assistance, effective team leadership and harmony in the team are important in managing the situation. Good and effective communication with the patient and relatives, offering explanations, apologies and timely intervention without delays reduce the risk of litigation and strengthen any defence in court.

Implementation of minimal invasive gynaecological surgery certification will challenge gynaecologists with new legal and ethical issues.

The introduction of a certification / diploma program in Minimal Invasive Surgery (MIS) is expected to improve surgical performance, patient's safety and outcome. The Gynaecological Endoscopic Surgical Education and Assessment programme (GESEA) and the ESHRE Certification for Reproductive Endoscopic Surgery (ECRES) provides a structured learning path, recognising different pillars of competence. In order to achieve a high level of competence a two steps validation is necessary: (a) the individual should be certified of having the appropriate theoretical knowledge and (b) the endoscopic psychomotor skills before entering in the diploma programme reflecting the surgical competence. The influence of such an educational and credentialing path could improve safety and offer financial benefits to the hospitals, physicians and healthcare authorities. Moreover the medicolegal consequences can be important when a significant amount of surgeons possess the different diplomas. As the programs are becoming universally accessible, recognised as the best scientific standard, included in the continuous medical education (CME) and continuous professional development (CPD), it is expected that a significant number of surgeons will soon accomplish the diploma path. The co-existence and practice of both non-certified and certified surgeons with different degrees of experience is unavoidable. However, it is expected that national health systems (NHS), hospitals and insurance companies will demand and hire doctors with high and specific proficiency to endoscopic surgery. When medico-legal cases are under investigation, the experts should be aware of the limitations that individual experience provides. The court first of all examines and then judges if there is negligence and decides accordingly. However, lack of certification may be considered as negligence by a surgeon operating a case that eventual faces litigation problems. Patients' safety and objective preoperative counselling are mandatory, directly connected to MIS certification while eliminating any dispute of surgeons' credibility.

Prospective evaluation of the learning curve of fertiloscopy with and without ovarian drilling.

Fertiloscopy represents an alternative to laparoscopy in the diagnostic evaluation of unexplained infertility or for the purpose of ovarian drilling. The learning curve of fertiloscopy in an experienced laparoscopic surgeon was evaluated in a prospective multicentre observational trial. A total of 110 fertiloscopies were carried out. At Centre 1, a beginner, and at Centre 2, an expert in fertiloscopy, performed the procedures. In three cases in Centre 1, and in 0 cases in Centre 2, the procedure was converted to transabdominal laparoscopy owing to intraoperative complications. Median operating time was longer at Centre 1 during the first 40 procedures (P < 0.001) and equal thereafter. Analyzing fertiloscopies with and without ovarian drilling separately, operating time was only longer for the first 20 procedures in each group (P < 0.001 and P = 0.002). In a multivariate analysis, intraoperative complications and fertiloscopy with ovarian drilling (compared with diagnostic fertiloscopy) were associated with longer duration of surgery (P < 0.001 for both parameters). An increasing consecutive number of fertiloscopies was associated with shorter duration of surgery (P < 0.001). Experienced laparoscopists should consider a transition towards fertiloscopy in the diagnostic workup of unexplained infertility or for the purpose of ovarian drilling.

[Using an ovarian drilling by hydrolaparoscopy or recombinant follicle stimulating hormone plus metformin to treat polycystic ovary syndrome: Why a randomized controlled trial fail?]. / Drilling ovarien par fertiloscopie ou stimulation par FSH plus metformine dans le traitement du syndrome des ovaires polykystiques : pourquoi un essai thérapeutique peut être un échec.

OBJECTIVES: To evaluate pregnancy rates after randomized controlled trial (RCT) between ovarian drilling by fertiloscopy or ovarian hyperstimulation+insemination+metformine after clomifène citrate (cc) treatment fails. PATIENTS AND METHODS: Randomized controlled trial with 126 patients in each arm in 9 university centers. After 6-9 months of stimulation by cc, 2 groups were randomized: group 1, ovarian drilling with bipolar energy versus group 2: 3 months treatment by metformine followed by 3 hyperstimulation by FSH+insemination. The success rate was pregnancy rate above 12 weeks. RESULTS: RCT was stopped after the screening of 40 patients. In spite of the low number of patients, the pregnancy rate is significantly higher in medical group 8/16 versus 3/18 (p=0.04). CONCLUSION: The causes of fail of RCT were in relationship with difficulties of inclusion, with absence of final agreement by team included. Moreover, RCT between medical and surgical management is often root of difficulties for patients who decline surgical strategy. However, medical treatment appeared better than drilling in this RCT.

Computerized in vivo classification of methylene blue stained fallopian tube mucosal damage: preliminary results.

OBJECTIVE: Fertiloscopy is a simple minimal invasive method which allows salpingoscopy and microsalpingoscopy in order to examine the mucosa of the fallopian tubes of patients with unexplained infertility. Infectious tubal damage is a common cause of tubal infertility. In 1998 it was demonstrated that nuclear staining of cellular nuclei during microsalpingoscopy with methylene blue provides a simple in vivo method to evaluate cellular damage of the tubal epithelium. The purpose of this study was to introduce and statistically test a new computerized method to objectively evaluate the extent of tubal damage. DESIGN OF RETROSPECTIVE STUDY: Cooperation of two Departments of Gynecology and Obstetrics (Krankenanstalt Rudolfstiftung, Vienna, Austria and CRES Center, Hôpital Natecia, Lyon, France) with the University of Art and Design, Linz, Austria and University Hospital, Vienna, Austria. MATERIALS AND METHODS: Microsalpingoscopic images from ten female patients, aged between 18 and 45 years with primary infertility, showing stained nuclei in damaged intrafallopian tubal epithelium were provided by Antoine Watrelot, CRES Center, Hôpital Natecia, Lyon, France. These images were evaluated by an experienced medical expert staff examiner and a computerized standard method called cross-correlation and template matching. The obtained numbers of nuclear stainings were statistically evaluated. RESULTS: Computerized evaluation of nuclear staining of damaged intrafallopian epithelial cells in female patients with infertility obtains similar but more reproducible results compared to manual evaluation (p = 0.007). CONCLUSION: Normalized cross-correlation can be used to measure tubal damage diagnosed by in vivo methylene blue dyeing during microsalpingoscopy and might facilitate the decision for in vitro fertilisation in patients with unclear unexplained infertility in further studies.

[Operative fertiloscopy results. About 67 cases]. / Résultats de la fertiloscopie opératoire. À propos de 67 cas.

OBJECTIVE: To assess the impact of operative fertiloscopy on fertility. PATIENTS AND METHODS: A retrospective study over a period of 3 years of 67 consecutive patients who received operative fertiloscopy and were followed over an 18 months period. RESULTS: The patients average age was 34 years (24-42) with a 3-year average infertility duration (1-15). We obtained 34 pregnancies (50.7%) (spontaneous or after intrauterine insemination) with 27 live births (38.8%). DISCUSSION AND CONCLUSION: The operative fertiloscopy seems to give good results. It is reserved for minimal or moderate endometriotic lesions and adhesions. These results must be confirmed by largest prospective controlled studies.

Current practice in tubal surgery and adhesion management: a review.

The diminished role of tubal surgery in infertile women following widespread access to IVF is now being reviewed as more patients and surgeons today consider tubal surgery as an effective alternative to assisted reproduction treatment in certain circumstances. The limitations of and lack of patient acceptance of assisted reproduction treatment for ethical and moral reasons have contributed to this change as well as advances in surgical techniques and instrument technology, notably developments in endoscopic surgery. Strategies in tubal surgery are largely unchanged but the mini-invasive nature of the endoscopic approach has added value because of less tissue trauma, better visualization of the operative field and more rapid healing, which make surgery using today's techniques an integral part of the treatment strategy in infertile couples.

Place of transvaginal fertiloscopy in the management of tubal factor disease.

In the case of tubal disease, selection of patients is critical to decide whether tubal surgery or IVF should be proposed as the therapeutic option. Selection is based on tubal lesions, including the aspect of tubal mucosa and tuboperitoneal environment. Therefore, non-invasive diagnostic methods have proved to be insufficient, and endoscopy is mandatory. Fertiloscopy represents an attractive alternative. Fertiloscopy is minimally invasive, reproducible, and at least as precise as lap and dye. Moreover, fertiloscopy and not laparoscopy allows the routine practice of salpingoscopy and microsalpingoscopy. On this basis, fertiloscopy should be adopted as the standard procedure for tubal evaluation in the management of tubal disease.

Is laparoscopy still the gold standard in infertility assessment? A comparison of fertiloscopy versus laparoscopy in infertility. Results of an international multicentre prospective trial: the 'FLY' (Fertiloscopy-LaparoscopY) study.

BACKGROUND: The aim of this prospective multicentre study was to compare the two endoscopic techniques of laparoscopy and fertiloscopy in routine evaluation of the pelvis in infertile women. METHODS: A total of 92 women was selected in 14 University Hospitals to undergo fertiloscopy followed by transabdominal laparoscopy by a team of two surgeons in each hospital. RESULTS: A high degree of concordance was observed between these two techniques, in that if fertiloscopy did not detect any abnormalities, this was also confirmed by laparoscopy. Discordance was observed in similar numbers of cases: eight after laparoscopy and nine after fertiloscopy. The diagnostic index for fertiloscopy and laparoscopy was calculated; sensitivity (86 and 87% respectively) and negative predictive value (64 and 67% respectively) were similar. The kappa index was also calculated for each of the six structures/regions (right/left tube; right/left ovary; peritoneum of pouch of Douglas; posterior uterus), and concordance (0.78 to 0.91) was considered almost complete. CONCLUSIONS: These results confirm fertiloscopy as a minimally invasive safe procedure that may be considered as an alternative to diagnostic laparoscopy in the routine assessment of women without clinical or ultrasound evidence of pelvic disease. On the basis of the additional advantages of fertiloscopy, namely salpingoscopy or microsalpingoscopy, it is considered that fertiloscopy could replace laparoscopy as a routine procedure in such women.

Systematic salpingoscopy and microsalpingoscopy during fertiloscopy.

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.

Risk and outcome of bowel injury during transvaginal pelvic endoscopy.

OBJECTIVE: To determine the risk and outcome of bowel injury associated with new techniques of transvaginal pelvic endoscopy. DESIGN: A multinational retrospective survey based on confidential, self-reported cases. SETTING: Tertiary referral centers for infertility. PATIENT(S): Infertile patients without obvious pelvic pathology. INTERVENTION(S): Transvaginal hydrolaparoscopy and fertiloscopy. MAIN OUTCOME MEASURE(S): Full-thickness bowel injury. RESULT(S): Thirty-nine responders reported a total of 24 bowel injuries (0.65%) in 3667 procedures. After initial experience, the prevalence of bowel injury was 0.25%. All of the injuries were diagnosed during the procedure. Twenty-two (92%) of the cases were managed without consequences. CONCLUSION(S): The bowel lesion caused by the new techniques of transvaginal pelvic endoscopy tends to be minor and under strict conditions can be treated expectantly.

Evaluation of the performance of fertiloscopy in 160 consecutive infertile patients with no obvious pathology.

We have defined fertiloscopy as the combination in one investigation of transvaginal hydropelviscopy, dye-test, optional salpingoscopy, and hysteroscopy, performed on an outpatient basis under local anaesthesia or neuroleptanalgesia. We have applied this approach in a routine manner to 160 infertile patients with no obvious pathology. Fertiloscopy was achieved in 154 patients (96.2%). In five patients visualization was not satisfactory because of technical problem or adhesions in the pouch of Douglas. We had one (0.6%) rectal injury, which was treated conservatively. Sixty patients (37.5%) had normal fertiloscopic examination. Endometriosis was discovered in 21 patients (13.1%) post-pelvic inflammatory disease (PID) lesions in 58 cases (36.2%), and subtle abnormalities in 15 cases (9.3%). Salpingoscopy was completed when post-PID lesions were encountered. In 39% of cases only partial examination was possible because of external tubal adhesions, but it was nevertheless sufficient to obtain a good view of the first one-third of the ampulla. In all, 74 patients (46.2%) were referred directly to in-vitro fertilization (IVF) procedures, and so avoided a further laparoscopy. Quality of imaging, accuracy of the pelvic examination in a physiological manner, and safety of the procedure are the main advantages of this minimally invasive technique. Selection of the patients for surgery is therefore enhanced, and indication for IVF is better balanced, avoiding the performance of extensive procedures in patients who should thus benefit from this less traumatic alternative.

Is Reparative Tubo-Ovarian Surgery Obsolete?

With the availability of in vitro fertilization (IVF), reparative tubo-ovarian microsurgery is considered obsolete. In our institutions, salpingectomy has been performed for Mage score 4 and Brosen score 4 to 5 tubal occlusion. The results of reparative laparoscopic tubo-ovarian surgery (stages 1-3) are better for fimbrioplasty than for salpingoneostomy. The best result is for tubolysis and ovariolysis, often associated with fimbrioplasty. The procedure resulted in 27.7% intrauterine pregnancies and less than 10% ectopic pregnancies. The development of thin, atraumatic endoscopes will probably improve these rates and also reduce costs. We reevaluated reparative surgery after the failure of at least three cycles of IVF. With advances in salpingoscopy, the selection of patients improved for lesions of the ampulla. Women undergoing salpingoscopy had bifocal lesions, but also tubal occlusion with an unfavorable prognosis for the procedure's success. In women with hydrosalpinx, salpingectomy is supposed to improve the results of IVF. We reserve reparative and conservative surgery for women with good salpingoscopic score, which is probably one of the reasons for our encouraging results. For the proximal and isthmic part of the tube, the diagnosis remains difficult, despite the promising results of transcervical tuboscopy. The development of thin atraumatic endoscopes will probably continue to improve evaluation of tubal pathology and permit better patient selection for surgery.

Clitoral blood flow increases following vaginal pressure stimulation.

The vascular responses of clitoral arteries to vaginal pressure stimulation in 10 volunteer women were evaluated by Doppler ultrasonography. Pressure stimulations (20-160 mm Hg) along the lower third of the vagina increased blood velocity and flow into clitoral arteries in 9 of the 10 women. The latency and duration of the Doppler responses ranged from 0.1 to 1.6 sec and from 3.2 to 9.5 sec, respectively, and the response was associated with a blood flow increase of 4 to 11 times the baseline prestimulation level. This response parallels that recorded in the cavernous arteries in men when a similar range of pressure stimulations are applied to the glans penis. Similar responses evoked in the male and female suggest a sexual synergy that may occur during intercourse in that such physiological responses and reflexes may be reciprocally reinforced.

Gamete intra-fallopian transfer with cryopreserved donor semen following AID failure.

Results are presented of gamete intra-Fallopian transfer with cryopreserved donor semen in cases of male infertility with azoospermia or extreme oligozoospermia. The female partners had no detectable infertility problems and they had first received 10 cycles of intracervical AID without success. Forty-one GIFT cycles performed on 22 such patients gave an overall pregnancy rate of 26.8% (11/41). In 64% (9/14) of these cases, pregnancy occurred after the first GIFT attempt. From these results it is suggested that GIFT with donor semen may be a reasonable alternative after AID failure. The probable reasons for success of GIFT are discussed.

Ovary-oviduct distance and fertility experimental study, clinical application.

As the importance of ovary and fimbria relationships is well admitted in the phenomenon of oocyte captation, it has seemed interesting to the authors to try and evaluate, on an experimental plane, how fertility varies in function of ovary-fimbria distance, in view of possible therapeutic applications.

[Prevention of peritoneal adhesions. An experimental study using noxytiolin (author's transl)]. / Prévention de adhérences péritonéales. Etude expérimentale de la Noxytioline.

Numerous procedures have been used to try to prevent peritoneal adhesions following operations. Noxytiolin has been used experimentally in the rat in a double blind trial on 3 series of 30 rats. A reliable procedure for making adhesions is said to be always reproducible. Comparing two control groups this study shows that statistically significantly this product lessens the number and seriousness of adhesions that can form, although it does not totally stop them developing.