Pregnancy rates after operative endoscopic treatment of total (neosalpingostomy) or near total (salpingostomy) distal tubal occlusion

[Results of tubal plasty: ruslts of a Tunisian study]

L'infertilité d'origine tubo-péritonéale est toujours d'actualité, sa fréquence reste stable, sinon croissante. La coelioscopie permet à la fois d'affirmer l'atteinte tubaire et de proposer un geste thérapeutique adapté. Le but de notre travail est d’évaluer les résultats de la chirurgie laparoscopique des pathologies tubaires en termes de grossesses obtenues. Il s'agit d'une étude rétrospective descriptive, analytique et longitudinale. Nous avons colligé les patientes suivies pour infertilité et opérées pour pathologies tubaires distales au service A du centre de maternité et de néonatologie de Tunis. Nous avons étudié les caractéristiques épidémiologiques et cliniques des patientes, les résultats de l'imagerie et détaillé les gestes chirurgicaux réalisés. Les résultats de la chirurgie tubaire distale étaient exprimés en termes de grossesses obtenues avec un recul minimal de 12 mois et maximal de 5 ans. 898 patientes étaient prises en charge dans le service pour une infertilité dont 52 patientes avaient répondu aux critères d'inclusion à l’étude. La sensibilité de l'hystérosalpingographie en matière de lésions tubaire était de 69% et la spécificité de 100%. Selon le score d'opérabilité tubaire distale, 23% des lésions étaient classées au stade 4 et 13.46% au stade 1. Le taux de grossesses spontanées était de 8.69%, soit 13% des fimbrioplasties et 4% des néosalpingostomie. Le délai de conception allait de 4 à 9 mois. Les antécédents ou stigmates d'infection pelvienne étaient retenus comme facteur de mauvais pronostic. Une sélection rigoureuse des patientes à partir des données de l'hystérographie et de la coelioscopie est indispensable afin de déterminer les patientes candidates à une chirurgie réparatrice ou à une fécondation in vitro

Tubal factor infertility: diagnosis and management in the era of assisted reproductive technology

Tubal factor infertility accounts for a large portion of female factor infertility. The most prevalent cause of tubal factor infertility is pelvic inflammatory disease and acute salpingitis. The diagnosis of tubal occlusion can be established by a combination of clinical suspicion based on patient history and diagnostic tests, such as hysterosalpingogram, sonohysterosalpingography, and laparoscopy with chromopertubation. Depending on several patient factors, tubal microsurgery or more commonly in vitro fertilization with its improving success rates are the recommended treatment options.

Laparoscopic surgery for subfertility associated with endometriosis

BACKGROUND

Endometriosis is the presence of endometrial glands or stroma in sites other than the uterine cavity. It is variable in both its surgical appearance and clinical manifestation often with poor correlation between the two. Surgical treatment of endometriosis aims to remove visible areas of endometriosis and restore anatomy by division of adhesions.

OBJECTIVES

To assess the efficacy of laparoscopic surgery in the treatment of subfertility associated with endometriosis. The review aims to compare outcomes of laparoscopic surgical interventions compared to no treatment or medical treatment with regard to improved fertility.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group's specialised register of trials (searched Feb 2000), the Cochrane Controlled Trials Register (The Cochrane Library, Issue 2, 2000), MEDLINE (1966-July 2001), EMBASE (1980-July 2001), the National Research Register (Issue 1, 2000) and reference lists of articles.

SELECTION CRITERIA

Trials were selected if they were randomised and compared the effectiveness of laparoscopic surgery in the treatment of subfertility associated with endometriosis versus other treatment modalities or placebo.

DATA COLLECTION AND ANALYSIS

Two studies had data appropriate for inclusion within the review. These studies compared laparoscopic surgical treatment of minimal and mild endometriosis compared with diagnostic laparoscopy only. The recorded outcomes included live birth, pregnancy, fetal losses and complications of surgery.

MAIN RESULTS

Meta-analysis of the two randomised trials show improvement in infertility associated with endometriosis with laparoscopic surgery. The largest trial (Marcoux 1997) clearly supports this outcome with an increased chance of pregnancy (OR 2.03, 95% CI 1.28 to 3.24) and ongoing pregnancy rate after 20 weeks (OR 1.95, 95% CI 1.18 to 3.22) but the smaller trial (Gruppo Italiano 1999) does not show benefit (pregnancy OR 0.76, 95% CI 0.31 to 1.88; livebirth OR 0.85, 95% CI 0.32 to 2.28). Combining ongoing pregnancy and live birth rates there was a statistically significant increase with surgery (OR 1.64, 95% CI 1.05 to 2.57).

REVIEWER'S CONCLUSIONS

The use of laparoscopic surgery in the treatment of minimal and mild endometriosis may improve success rates. The relevant trials have some methodological problems and further research in this area is needed.

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.

Laparoscopic treatment of hydrosalpinx: factors affecting pregnancy rate

STUDY OBJECTIVE

To evaluate the efficacy of laparoscopic surgery in a series of women with hydrosalpinx.

DESIGN

Prospective, observational study (Canadian Task Force classification II-2). Setting. University-affiliated hospital.

PATIENTS

Sixty-one women undergoing bilateral neosalpingostomy and restoration of tubal ovarian anatomy laparoscopically, and followed for 24 months.

INTERVENTION

Video-controlled operative laparoscopy using standard four-puncture technique.

MEASUREMENTS AND MAIN RESULTS

During 24-month follow-up, cumulative intrauterine pregnancy rates at 6-month intervals were 6.8%, 13.6%, 20.5%, and 20.5% for patients with only distal tubal obstruction and 12%, 23%, 29%, and 29% for those with mild degree of tubal disease and periadnexal adhesions. Miscarriage rate for intrauterine pregnancies was zero in both groups.

CONCLUSION

Operative laparoscopy seems to be an effective treatment for hydrosalpinx in terms of pregnancy outcome.

Controversies in the surgical management of hydrosalpinx

The surgical management of hydrosalpinges is a controversial subject. Chronic pathology of the fallopian tube with distal obstruction leads to the formation of a hydrosalpinx, and is associated with very poor pregnancy rates after surgery. In these cases, in-vitro fertilization has proved to be a much better alternative. However, several studies have shown that patients with hydrosalpinges have significantly lower pregnancy and implantation rates after in-vitro fertilization compared with patients with other forms of tubal damage. The exact mechanism by which the hydrosalpinx adversely affects in-vitro fertilization results is not yet fully understood. The value of performing a salpingectomy before in-vitro fertilization has been studied extensively. Currently, a clear benefit in salpingectomies has been proved for patients with ultrasonically visible hydrosalpinges.

Endoscopic surgery. The end of classic surgery?

Gynecological endoscopy is now a well-established procedure and it has been proved that the laparoscopic surgical technique can be used in the management of most gynecological disorders thus replacing conventional laparotomic procedures. The latest indications apply to such functional pathologic conditions as urinary incontinence and genital prolapse, and oncology (radical hysterectomy, lymphadenectomy). Hysteroscopy has afforded an easier surgical approach to certain pathologies such as septate uterus and endometrial ablation. Indications of conventional surgery are getting fewer. Yet conventional surgery should be part of the training of the gynecologist surgeon as the laparotomic approach is still the only solution in the most difficult cases.

Pregnancy outcome after laparoscopic fimbrioplasty in nonocclusive distal tubal disease

OBJECTIVE

To determine pregnancy rates (PR) after fimbrioplasty and salpingostomy in nonocclusive distal tubal disease. To evaluate the relative impact of various factors using contemporary statistical analysis.

DESIGN

Prospective cohort.

SETTING

Tertiary institutional infertility clinic.

PATIENTS(S)

Infertility patients.

INTERVENTION(S)

Fimbrioplasty and salpingostomy.

MAIN OUTCOME MEASURE(S)

Cumulative PR, monthly fecundity rates, monthly probability of pregnancy, crude PR, and cure rates.

RESULTS(S)

Thirty-five percent of patients conceived with a cure rate of 72.2%, monthly probability of pregnancy of 3.9%, and monthly fecundity rate of 3.9%. Cumulative PRs were 22%, 35%, and 58% at 6, 12, and 24 months, respectively. Pairwise comparisons (unilateral, bilateral, or either) failed to detect any statistical difference between the salpingostomy and fimbrioplasty groups. Salpingostomy patients initially may have a higher tendency to become pregnant but appear to lose that advantage after the first few months. When patients with tubo-ovarian adhesions are excluded from the analysis, patients who underwent a bilateral salpingostomy as their sole procedure had better outcome compared with those who only underwent bilateral fimbrioplasty. There was no significant association between pregnancy outcome and the presence of endometriosis, other infertility factors, or tubo-ovarian adhesions. The staging of adnexal adhesions and endometriosis did not predict pregnancy outcome.

CONCLUSION(S)

Laparoscopic fimbrioplasty and salpingostomy are clinically efficacious for the treatment of nonocclusive distal tubal disease. After accounting for statistical interactions of various factors among them, no particular association with pregnancy outcome could be identified. This illustrates the need for a revision of the classification of patients with distal tubal disease.