The intussusception salpingostomy technique for the therapy of distal oviductal occlusion at laparoscopy.

A new technique of salpingostomy by laparoscopy for treatment of distal oviductal occlusion is described. This technique uses sharp dissection and can be performed rapidly. The intussusception salpingostomy is undertaken by making a relatively short incision in the hydrosalpinx and then prolapsing the tubal mucosa through this neostium. The borders of the incision thus act as a restrictive collar to maintain the mucosa in this newly everted configuration. In a series of 40 women subjected to this procedure, 22 were followed for more than 12 months postoperatively; the term pregnancy rate was 22.7%. This fertility is similar to that after salpingostomy by microsurgical laparotomy.

Microsurgical tubocornual anastomosis for occlusive cornual disease: reproducible results without the need for tubouterine implantation.

Microsurgical tubocornual anastomosis (TCA) and tubouterine implantation are the two primary operations used to treat proximal tubal occlusion (PTO). Tubouterine implantation usually has been reserved for cases of PTO in which the occlusion spans the entire intramural tubal segment. Yet TCA has proven to be more likely to lead to successful pregnancy than tubouterine implantation. In this series, all PTO was treated by TCA. The article compares the reproducibility of results of TCA by two different operators and establishes the usefulness of TCA in all cases of PTO without resort to tubouterine implantation. Fifteen of 26 women achieved viable intrauterine pregnancies, a rate virtually identical to that published earlier by Gomel. Microsurgical TCA can be used to the exclusion of tubouterine implantation to achieve higher pregnancy rates, despite complete intramural occlusion.

Microsurgical transposition of the human fallopian tube and ovary with subsequent intrauterine pregnancy.

This is the report of a case of a single left unicornuate uterus in a woman whose ipsilateral tube and ovary had been removed subsequent to a left tubal pregnancy. On the right side were present an ovary and a short oviduct (composed of infundibulum and ampulla) immobilized high on the pelvic side wall. Surgical transposition of the right ovary and tube with preservation of their vascular supply permitted anastomosis between the left intramural and the right ampullary tubal segments. The ovary was mobilized to restore a proper spatial relationship with the fimbrial extremity of the tube. In the third postoperative cycle, the patient was successful in achieving an intrauterine pregnancy and has now been delivered of a normal live infant. The potential of microsurgical techniques in restoring fertility in the face of unusual pelvic anatomy is reiterated.

The influence of fallopian tube length on fertility in the rabbit.

The correlation between the length of the oviduct and degree of fertility was studied in 16 New Zealand White rabbits subjected to microsurgical resection of differing lengths of fallopian tube involving the isthmus in each case. A highly significant (P less than 0.005) linear correlation was found, suggesting that more than 47% of an oviduct must remain distally before fertility can be anticipated. Absence of the isthmic segment of the fallopian tube was found to be associated with supracervical fetal implantations in the uterus. The importance of the assessment of tubal length as a prelude to reconstructive surgery, especially for reversal of sterilization, is emphasized.

PIP: Evidence suggests that fertility subsequent to tubal reconstruction greatly depends on the length and functional quality of the oviduct. To test the validity of this statement, this study was conducted. 16 sexually mature New Zealand white rabbits were used for the study. Rabbits were used as they have a duplex genital tract to the level of 2 cervices; hence, each animal served as both case and control. The rabbits were preoperatively subjected to alternating 12-hour periods of light and dark and were given standard rabbit diet with liberal water. Aseptic microsurgical techniques were used during the operation. Length of the oviduct was measured with sterile paper tape. Segmented resection and anastomosis were performed on the left oviduct of each rabbit, while the right oviduct was anastomosed after simple transection and served as a control. The ratio of experimental to control pregnancies and the fraction of oviduct remaining distally correlated significantly (P 0.005), indicating that 47% or more of the fallopian tube must remain distally before fertility can be expected to return. In rabbits with a relatively small resected segment of tube (between 4% and 18% of the total tubal length), the uterus revealed normally spaced fetuses; in contrast, rabbits with large resected segment (between 40% and 46% of total length of oviduct) had pregnancies in the proximal supracervical region of the uterus. The findings suggest that oviductal length is a critical factor in achieving subsequent fertility following reversal of sterilization.

Unknown intrauterine devices and infertility.

PIP: The 3 cases described illustrate instances within a 12-month span where an IUD in situ had been the cause of infertility, unknown to the women involved. In many centers, laparoscopy is performed as the primary investigation of tubal patency and normalcy, with hysterosalpingography (HSG) performed subsequently or not at all. HSG should be performed first, with laparoscopy and possible hysteroscopy carried out later as complementary procedures. Each case is reviewed briefly to determine how best to avoid failure to detect a retained IUD. The source of error in each case was the same. HSG was not performed or was not performed properly, with a preliminary plain x-ray film. In each instance the patient had been referred to a gynecologist and in case 1 to a regional tertiary referral center for infertility. There was no lack of availability of HSG, but there was not a systematic infertility investigation.^ieng

A new suturing instrument that allows the use of microsuture at laparoscopy.

PIP: A surgeon at University Hospital-Shaughnessy Site in Vancouver, British Columbia in Canada has used a new suturing instrument that enters the peritoneal cavity to permit microsutures of size 6-0 or less and 75 cm in length during laparoscopy. Surgeons can use this instrument to perform female sterilizations as well as removal of the gall gladder and appendix and repair of the bowel, bladder, and ureteric injuries. As of April 1992, the suturing instrument was not yet commercially available. It consists of a partial hollow 30 cm x 2 mm (inside diameter) tube with the end that does not enter the peritoneal cavity being occluded. The suturing instrument enters the peritoneal cavity via a standard 5 mm deflection valved trocar sleeve with a 3 mm reduction sleeve or with a 3 mm inside diameter occlusive rubber washer instead of the standard 5 mm washer. The suture must have sufficient tensile strength and have low coefficients for static and for sliding surface frictions. Once the suture and needle are inside the body, forceps which have entered via another cannula detach them from the suturing instrument. A 3 mm laproscopic needle driver replaces the suturing instrument at this point. The surgeon guides the needle through the intended tissues and then withdrawn with the needle driver through the 5 mm sleeve. The surgeon ties the knot outside the body and slides it down the length of the suture to apply it to the tissue. He/she repeats this 1 more time. Scissors inserted through the other opening then cut the suture. Once mastered, this process takes only a few minutes to complete. In all 11 cases or restoration of uterine tube patency done by the surgeon in Vancouver using the new technique, tubal patency has not been hindered. 2 assessed sterilization reversals have been successful.^ieng

A new selection criterion for fimbriectomy reversal.

OBJECTIVE: To assess a new criterion for selection of patients who request reversal of fimbriectomy sterilization. DESIGN: Prospective study. SETTING: Division of reproductive endocrinology and infertility in an academic center. PATIENTS: Eight patients undergoing reversal of fimbriectomy using microsurgical techniques. The prerequisite inclusion criterion was the presence of more than 50% ampulla as shown at hysterosalpingography. This is easily determined, because the isthmic length approximates one half the ampullary length. RESULTS: The cumulative intrauterine pregnancy rate was 50%. There were no ectopic pregnancies. CONCLUSION: Similar pregnancy rates for reversal of fimbriectomy have been reported based upon different absolute selection criteria (viz., tubal length of > or = 8 cm and ampullary width of > or = 1 cm). By contrast, our new selection criterion is based upon the more readily determined proportion of ampulla that is available for surgical neostomy.

The effectiveness of CO2 laser and electromicrosurgery in adhesiolysis: a comparative study.

This study was undertaken to assess the relative effectiveness of the CO2 laser and electromicrosurgery in adhesiolysis. Intraperitoneal adhesions were produced in 44 female white rats by inflicting a standard and reproducible injury to the serosa of a specific area of the right uterine horn. At a second intervention, 2 weeks later, the adhesions formed by the initial injury were assessed and division of adhesions effected in a random manner, either with the use of the CO2 laser or with electromicrosurgery, adhering to accepted microsurgical techniques. At a third intervention, results were assessed. The results demonstrate that electromicrosurgery and the CO2 laser are equally effective for adhesiolysis in the rat model.

Simplified therapy for Asherman's syndrome.

OBJECTIVE: To evaluate a technique that converts a blind hysteroscopic procedure to a "septum" division. DESIGN: Open noncomparative clinical study. SETTING: Tertiary care center. PATIENT(S): Six women with Asherman's syndrome; five with complete and one with incomplete obliteration of the uterine cavity. INTERVENTION(S): The patients underwent recreation of the uterine cavity by the hysteroscopic-laparoscopic technique described to establish the correct dissection plane. MAIN OUTCOME MEASURE(S): The ability to reestablish the uterine cavity; postoperative resumption of menses and fertility. RESULT(S): In all patients, the cavity of the uterus was restored; menses resumed in all women who were previously amenorrheic; and 5 women conceived, of whom four had live births and one a missed abortion. At hysteroscopy, two women incurred perforations and in another hemorrhage occurred. CONCLUSION(S): This technique appears to be effective and safe for the reconstruction of a functional endometrial cavity in women with Asherman's syndrome.

Function and structure of the rabbit oviduct following fimbriectomy. II. Proximal ampullary salpingostomy.

Experiments were conducted in nine New Zealand White rabbits to determine the functional capacity of that part of the oviduct consisting of only the isthmus and proximal ampulla. The left fimbria and at least one-half of the adjoining ampulla were excised microsurgically and the remaining portion of the proximal ampulla was subjected to a cuff salpingostomy. Following a convalescence of 4 to 8 weeks and gonadotropin-induced ovulation, direct observations in vivo showed tht the modified oviduct was ineffective in transporting surrogate cumulus masses into the tubal lumen. Those surrogates that were accepted were in some cases regurgitated by contractions of the residual proximal ampulla. A subsequent in vitro search for ova proved that the modified oviducts were unsuccessful in retrieving ipsilaterally ovulated ova, whereas the contralateral control oviducts apprehended an average of 72% of those available. Scanning electron microscopy showed the everted mucosa of the proximal ampulla to be less richly endowed with cilia than that of the normal fimbria. This ovum capture appeared to be prevented by deficiencies in both the ciliary mechanism of the neofimbria and the ability of the remaining ampulla to retain the egg. This evidence indicates that the proximal ampulla is unsuitable for reconstruction of a functional fallopian tube.

Pregnancy, ciliary transport, and the reversed ampullary segment of the rabbit fallopian tube.

Pregnancy following reversal of an ampullary segment in the rabbit oviduct has occurred only sporadically, and then usually after repeated mating. To explain this phenomenon it has been postulated that the direction of ciliary beat in the reversed ampullary segment must revert to the normal pro-uterine direction. To test this hypothesis a segment of the ampulla was reversed by microsurgery in 10 rabbits. These were then bred repeatedly for as long as 28 weeks. A single pregnancy, at 10 weeks, ensued. Observation of ampullary transport in vivo showed that muscular activity in the reversed ampullary segment may occasionally overcome the adverse, pro-ovarian ciliary currents that were found to persist in subsequent in vitro examinations. Scanning electron microscopy confirmed normal ciliation in the reversed segment. These observations may explain the occasional transport of an ovum across the reversed ampullary segment and an isolated pregnancy in the mated rabbit.

Predictors of success of reversal of sterilization.

OBJECTIVE: To determine the prognostic variables effecting the successful pregnancy outcome of reversal of sterilization. DESIGN: Demographic and clinical history data were collected prospectively. SETTING: Division of Infertility and Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, Canada. PATIENTS AND INTERVENTION: Between 1981 and 1992, 217 consecutively referred patients underwent reversal of sterilization by a single surgeon using microsurgical techniques. MAIN OUTCOME MEASURES: Prognostic variables associated with success were examined using logistic regression and expressed as odds ratios with corresponding 95% confidence intervals. RESULTS: Age at reversal was a significant factor with the odds of a successful outcome for those < or = 35 years compared with those > 35 years being 2.3 with a 95% confidence interval of 1.3 to 4.1. There was some evidence that average tubal length as categorized in 2-cm intervals was a significant prognostic factor with the odds of a successful outcome for those with an average length of > 4 cm to those < or = 4 cm being 5.3 with a 95% confidence interval of 1.4 to 20.0. CONCLUSIONS: Nonsubjective analysis of the prognostic variables of reversal of sterilization associates only age and tubal length of > 4 cm with intrauterine pregnancy.

PIP: This study was designed to determine which prognostic variables influence the successful pregnancy outcome of reversal of sterilization. The study is prospective, pertains to a single surgeon with the exclusive use of the microscope, uses nonsubjective grouping of prognostic factor categories, and examines the power of the study to detect clinically meaningful associations. Over the period 1981-92, 217 consecutively referred patients underwent reversal of sterilization by a single surgeon using microsurgical techniques. Logistic regression found age at reversal to be a significant factor, with the odds of a successful outcome for those aged 35 and younger compared with those older than 35 being 2.3 with a 95% confidence interval of 1.3-4.1. There was some evidence that average tubal length as categorized in 2-cm intervals was a significant prognostic factor, with the odds of a successful outcome for those with an average length of more than 4 cm to those less than or equal to 4 cm being 5.3 with a 95% confidence interval of 1.4-20.0. Nonsubjective analysis of the prognostic variables of the reversal of sterilization therefore associates only age and tubal length of more than 4 cm with intrauterine pregnancy.

Reproduction in rabbits after excision of the oviductal isthmus, ampullary-isthmic junction, and uteroisthmic junction.

The effect of total deletion of the isthmus, including the ampullary-isthmic junction and the uteroisthmic junction, upon reproduction was determined in 21 rabbits. None became pregnant on the side lacking isthmus, whereas all became pregnant on the intact control side. Eight does were studied using in vivo and in vitro techniques at 18 to 20, 64 to 65, and 136 to 137 hours after mating. Spermatozoa fertilized the ova, with evidence of polyspermy. However, the modified oviduct did not transport fertilized ova into the uterus at the normal time. Furthermore, degeneration was noted from the morula stage onwards. We conclude that the rabbit ova can neither develop normally past the morula stage nor enter the uterus at the normal time in a recognizable form in the total absence of isthmus, and infertility results.

The oviductal cilia and Kartagener's syndrome.

Women who have Kartagener's syndrome (primary ciliary dyskinesia) may or may not be fertile. The bronchial mucociliary clearance is reduced markedly in most of these women; this has led investigators to the conclusion that the cilia in the respiratory tract are immotile, and that "beating cilia may have no indispensable role in the female reproductive tract." Yet motile cilia are considered by many workers to be essential for normal ovum transport. More recently, bizarre ciliary motion has been described in the respiratory cilia of Kartagener's women. Our hypothesis was that the dyskinetic ciliary activity (or immotility) would be the same in both the respiratory and reproductive tracts and thus explain the fertility (or lack of it) in Kartagener's women. This report shows an identical ultrastructure and absolute immotility of cilia in both the respiratory tract and reproductive tract of a woman with Kartagener's syndrome who has never conceived. From this concordance, we suggest that the fertility of Kartagener's women is explained by the dyskinetic motion of oviductal cilia, and that the ciliated endosalpinx is essential for human reproduction.

Laparoscopic lateral ovarian transposition.

OBJECTIVE: To determine if the new technique laparoscopic lateral transposition of the ovaries before pelvic radiotherapy for anal canal carcinoma prevents radiation-related ovarian failure. DESIGN: A case report. SETTING: The operating room of a Canadian teaching hospital. PATIENTS: A single patient with anal canal carcinoma, requiring pelvic radiotherapy, who desired preservation of ovarian function. INTERVENTIONS: Laparoscopic ovarian transposition to the level of the pelvic brim. MAIN OUTCOME MEASURES: Follow-up clinical and laboratory evidence of ovarian failure. RESULTS: Initially ovarian failure was confirmed with the appearance of postmenopausal symptoms and the elevation of serum gonadotropins. These symptoms resolved by 8 months after radiotherapy, normal menstrual cycles resumed, and normal FSH levels were detected at that time. CONCLUSIONS: The laparoscopic, lateral transposition of this patient's ovaries was effective at preventing radiation-related ovarian failure.

Operative laparoscopy versus open abdominal surgery: a comparative study on postoperative adhesion formation in the rat model.

The aim of this study was to compare the occurrence of adhesions after a standard uterine injury inflicted by laparoscopy or by laparotomy during which microsurgical principles were observed. The cross-sectional areas of adhesions involving the uterus were assessed and the 31 rats operated upon laparoscopically were compared with the 30 rats subjected to a laparotomy. The mean area of uterine adhesions formed in the laparotomy group was 4.29 mm2 and 8.88 mm2 in the laparoscopy group. The difference was not statistically significant. The results imply that a standard tissue injury to uterine tissue, whether conducted by laparoscopy or via laparotomy, carries the same potential to induce postoperative adhesions.

Role of laparoscopic salpingostomy in the treatment of hydrosalpinx.

OBJECTIVE: To determine pregnancy rates after laparoscopic salpingostomy in occlusive distal tubal disease. To evaluate the relative impact of various historical, physical, and operative factors on pregnancy outcome using a multivariate statistical analysis. DESIGN: Prospective cohort. SETTING: University-affiliated tertiary care infertility clinic. PATIENT(S): One hundred thirty-nine infertile women with occlusive distal tube disease. INTERVENTION(S): Laparoscopic salpingostomy. MAIN OUTCOME MEASURE(S): The occurrence of intrauterine (IUP) and ectopic pregnancy (EP). RESULT(S): The overall IUP and EP rates were 24.5% and 16.5%, respectively. Analysis of historical variables, assessed independently, demonstrated a significantly higher IUP rate with a positive history of gonorrhea and a significantly higher EP rate with a positive history of pelvic inflammatory disease, lack of history of intrauterine device (IUD) usage, or the performance of a bilateral procedure. The logistic regression model to predict intrauterine pregnancy had an overall predictive value of 77.5% and included the following significant variables: secondary infertility, positive history of gonorrhea, and the operative finding of moderate periadnexal adhesions. The logistic regression model to predict ectopic pregnancy had an overall predictive value of 89.0% and included the following significant variables: previous ectopic pregnancy, negative history of IUD use, positive history of PID, a bilateral procedure, and perihepatic adhesions. CONCLUSION(S): Operative laparoscopy may be effective for the correction of hydrosalpinges in selected patients. The probability of achieving an intrauterine or an ectopic pregnancy can be predicted based on combinations of significant variables.

Midtubal occlusion: etiology, management, and outcome.

OBJECTIVE: To assess the significance of pathological midtubal occlusion in infertility. DESIGN: Retrospective descriptive case review. SETTING: Tertiary referral center. PATIENTS: Sixteen women, 26 to 38 years of age presenting with infertility and diagnosed as having midtubal occlusion. INTERVENTIONS: Assessment of the etiology of the occlusive disease and yield of microsurgical tubotubal anastomosis. MAIN OUTCOME MEASURES: Histologic examination of occluded tubal segment and fertility outcome subsequent to anastomosis. RESULTS: Occlusion was because of tuberculous salpingitis (n = 6), resolved tubal pregnancy (n = 3), endometriosis (n = 2), chronic inflammatory reaction (n = 1), tubal cyst (n = 1), intratubal adhesions (n = 1), infant hernia repair (n = 1), and calcification (n = 1). Of eight women (including the patient with tuberculous salpingitis) who underwent tubal anastomosis only for midtubal occlusion, three had subsequent term deliveries, two had tubal pregnancies, and three women did not conceive. CONCLUSION: Midtubal occlusion of the tube because of an infectious process is rare. Excluding tuberculous salpingitis, microsurgical anastomosis yields satisfactory fertility, albeit with significant risk of ectopic pregnancy.

Reproductive outcome after unilateral tubocornual anastomosis and contralateral salpingostomy by microsurgery.

A unilateral tubocornual anastomosis and a contralateral salpingostomy for unilateral proximal and contralateral distal occlusive disease yield similar fertility as does pure tubocornual anastomosis for proximal occlusive disease. Ascending inflammation is postulated as the mechanism for tubal occlusion, with distal sparing from disease if the initial insult results in initial occlusion of the proximal portion of the oviduct.

The structural and functional impact of microsurgical anastomosis on the rabbit oviductal isthmus.

Microsurgical transection and anastomosis of the left isthmus in 7 rabbits caused fertility to be reduced 40%. Following rebreeding artificial eggs were introduced into the anastomosed and control oviducts. Sixty-three to 65 hours after mating, direct in vivo observations disclosed varied forms of motion of the artificial eggs within the isthmus, including both small oscillations and occasionally, large precipitous excursions covering more than 1 cm. Subsequent clearing of the genital tracts revealed that the anastomosis in the isthmus had detained most of the natural and artificial eggs, whereas both forms of ova were predominantly past the equivalent site on the control side; yet all anastomosed oviducts were fully patent. We conclude that the decreased fertility after isthmic anastomosis is due not to a physical obstacle but to an inability of the isthmus near the anastomosis to dilate as do other regions of the tube.