Prognostic factors of fimbrial microsurgery

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1 FERTILITY AND STERILITY Copyright The American Fertility Society Printed in U.SA. Prognostic factors of fimbrial microsurgery Jacques Donnez, M.D., Ph.D.* Fran.;oise Casanas-Roux, B.S. Physiology of Human Reproduction Unit, Department of Obstetrics and Gynecology, University of Louvain, Brussels, Belgium From January 1978 to December 1983,600 infertile women underwent microsurgery for tubal infertility. Only 257 women with the same extent of distal lesions on both sides or with unilateral occlusion (after contralateral salpingectomy) were considered. Patients were classified in four subgroups on the basis of the extent of occlusion. After fimbrioplasty for occlusion of degree I and salpingostomy for occlusion of degree II, the term pregnancy rate was more than 50%. After salpingostomy for occlusion of degrees III and IV, the term pregnancy rate was, respectively, 25% and 22%. The ectopic pregnancy rate was the highest (12%) after salpingostomy for occlusion of degree IV. After microsurgical salpingolysis, the term pregnancy rate reached 64%, whereas the ectopic pregnancy rate was as low as 2%. Ampullary dilatation, as determined by hysterosalpingography and laparoscopy, influences the postoperative pregnancy rate. Fimbrial microbiopsies were taken, and the ciliated cell percentage was obtained. Results suggest that the ciliation index is a valuable method of prognosis of tubal surgery. In conclusion, the pregnancy rate after distal surgery is related to the tubal morphologic findings: ampullary dilatation, fimbrial ciliated cell percentage, and tubal wall thickness. Fertil Steril46:200, 1986 Received January 22, 1986; revised and accepted April 14, *Reprint requests: Jacques Donnez, M.D., Ph.D., Physiology of Human Reproduction Unit, Department of Obstetrics and Gynecology, University of Louvain, Cliniques Universitaires St. Luc, Avenue Em. Mounier, 53, 1200 Brussels, Belgium. 200 Donnez and Casanas-Roux Fimbrial microsurgery Salpingitis frequently leads to several types of occlusions or adhesions and provokes sterility. Investigation of the oviduct in infertility is most often restricted to the evaluation of tubal patency and adhesions by hysterosalpingography (HSG) and laparoscopy with tubal hydrotubation. 1 However, determination of the fimbrial ciliated cell percentage has been shown to be valuable in estimating the success of tubal surgery. 2 Recently we demonstrated that the ciliated cell percentage was related to the extent of distal occlusion as determined by HSG and laparoscopy.3,4 Consequently, a classification of fimbrial occlusion in four subgroups was proposed.3 The purpose of this report is to present the results of microsurgery in relation to our classification and fimbrial histologic findings. MATERIALS AND METHODS Two hundred fifty-seven infertile women underwent microsurgery for tubal infertility by techniques previously described by other authors. 5-7 Patients with endometriosis and those taking hormonal medication were excluded. The tubes were classified into four subgroups on the basis of the extent of occlusion, as previously described3: degree I (Fig. 1A), conglutination of the fimbrial folds (phimosis) with tubal patency (n = 132 women); degree II (Fig. 1B), complete distal occl.usion with normal ampullary

2 Figure 1 Classification of distal tubal occlusion on the basis of degree of dilatation seen on HSG. (A), Degree I, conglutination of the fimbrial folds (arrow) with tubal patency. (B), Degree II, complete distal occlusion with normal ampullary diameter. (C), Degree III, complete distal occlusion with ampullary dilatation of 15 to 25 mm in diameter. (D), Degree IV, occlusion with ampullary distension > 25 rom. diameter (n = 27 women); degree III (Fig. Ie), complete distal occlusion with ampullary dilatation 15 to 25 mm in diameter (n = 16 women); and degree IV (Fig. ID), occlusion with ampullary distension more than 25 mm, also called hydrosalpinx simplex (n = 40 women). Only women with the same extent of tubal lesions on both sides or with unilateral tubal occlusion (after contralateral salpingectomy) were considered for the study. Patients with a medical history of tuberculosis were excluded. Women with thick-walled hydrosalpinx where ampullary folds were not observed by HSG were also excluded because of the poor results of microsurgery obtained in a previous study. 4 Indeed, the postoperative pregnancy rate of this group was 0%.4 Another group of patients consisted of 42 women who underwent salpingo-ovariolysis. In this group, adhesions were restricted to the ampullary area or the ovarian surface. The fimbria was macroscopically normal, with free fimbrial folds. In women with distal occlusion of degree I, a fimbrioplasty was performed. As described by Patton, 7 the operative technique consisted essentially of the reconstruction of the fimbria by serosal incision and deagglutination of fimbrial folds. In women with distal occlusion of degrees II, III, and IV, terminal salpingostomy was performed, as described by Gomel 5 and Winston. 6 During the microsurgical procedure, reperitonealization was performed by the approximation of the peritoneal edges with 8-0 nylon sutures when serosal denudation occurred. Ringer's lactate was used as an irrigation solution. A solution of 500 ml of 20% dextran 70 was instilled into the pelvis before completing closure of the peritoneum. Antibiotics administration (ampicillin, 2 to 3 gm/day, and metronidazole, 1.0 to 1.5 gml day), which was initiated before the operation, was continued for 10 to 15 days after surgery. After surgery, hydropertubation was not performed, and corticosteroids were not administered. During the surgical procedure, in most cases, a fimbrial biopsy specimen, 1.5 to 2.0 mm in diameter, was taken with the use of the microsurgical scissors. Bipolar coagulation forceps were used to prevent light bleeding. After fixation and embedding, 2 f-lm-thick sections were stained with Gomori's trichrome8 or toluidine blue, and the percentage of ciliated cells and the epithelial height were estimated as previously described. 3, 9 Results are expressed ~s the mean ± standard devidonnez and Casanas-Roux Fimbrial microsurgery 201

3 Table 1. Pregnancy Rate After Microsurgery and Ciliated Cell Percentage in Cases of Distal Tubal Occlusion No. intrauterine No. ectopic Ciliated cell Type of operation No. patients pregnancies pregnancies percentage" Fimbrioplasty Occlusion of degree I (60%) Salpingostomy Occlusion of degree II (48%) Occlusion of degree III 16 4 (25%) Occlusion of degree IV 40 9 (22%) 2 (2%) 55.1 ± ± (6%) 43.2 ± (12%) 28.4 ± 10.6 Total (31%) Salpingolysis (64%) amean ± standard deviation. 6 (7%) 1 (2%) 50.7 ± 11.0 ation (SD). The control group consisted of 98 fimbrial biopsy specimens obtained from 65 fertile women during an ovulatory cycle. 9 Student's t-test and the Wilcoxon test were used for statistical analysis. RESULTS The results of microsurgical operations were assessed more than 1 year after surgery. The maximum follow-up period was 6 years. FIMBRIOPLASTY Among the 132 patients who underwent a fimbrioplasty (Table 1), a term pregnancy rate of 60% was achieved. This rate significantly (P < 0.001) differs from the rate of 31 % obtained after salpingostomy. During the first year after surgery, 62% of conceptions occurred; 35% occurred during the second year. When 42 patients whose husbands had subfertile semen and whose postcoital test was poor were removed from the study, the term pregnancy rate reached 71% (64 pregnancies in 90 patients). The fimbrial ciliated cell percentage (Table 1) was 55.1 ± 8.6, significantly different (P < 0.001) from the percentage on normal ovulatory women (63.2% ± 10.1%).9 SALPINGOSTOMY Among the 83 patients who underwent a salpingostomy for distal occlusion of degrees II, III, and IV, a term pregnancy rate of 31% was achieved (Table 1). The ectopic pregnancy rate was 7%. Significant differences were noted when our classification was used. Indeed, after reconstruction surgery for occlusion of degree II, the term pregnancy rate was 48% and differed significantly (P < 0.005) from those obtained after sur- 202 Donnez and Casanas-Roux Fimbrial microsurgery gery for occlusion of degrees III and IV (25% and 22%, respectively). The ectopic pregnancy rate after salpingostomy for occlusion of degrees II, III, and IV was 0%, 6%, and 12%, respectively. All ectopic pregnancies occurred more than 8 months after surgery. The comparison of the cumulative pregnancy rates is shown in Figure 2. The delay between the surgical procedure and the conception was longer in cases of occlusion of degrees III and IV than in cases of occlusion of degree II. No significant difference was noted between the ciliated cell percentage obtained from occlusion of degree I (phimosis) and from occlusion of degree II (57.2% ± 8.2%), whereas a higher percentage of deciliation was observed in cases of distal occlusion of degree III (43.2% ± 13.2%). This value was significantly different from those of phimosis (P < 0.001) arid occlusion of degree II (P < 0.005). Severe deciliation occurred in occlusion of degree /-,-/' months Figure 2 Cumulative rate of pregnancy after microsurgery for distal tubal lesions., Salpingolysis (n = 42). 0, Fimbrioplasty (n = 132)., Salpingostomy (n = 27) (degree II occlusion). A, Salpingostomy (n = 16) (degree III occlusion). a, Salpingostomy (n = 40) (degree IV ocdusion).

4 IV. The percentage of ciliated cells was significantly smaller (P < 0.001) than in other degrees of distal occlusion. The epithelium was cuboidal, with scarce ciliated cells; however, occasional well-preserved mucosal folds with numerous ciliated cells (30% to 54%) could be seen. SALPINGOLYSIS After microsurgical salpingolysis, the term pregnancy rate reached 64%, whereas the ectopic pregnancy rate was as low as 2%. The delay between the surgical procedure and conception was shorter after salpingolysis than after any other surgical procedures (Fig. 2). The fimbrial ciliated cell percentage (50.7% ± 11.0%) was significantly different from the data of the control group. DISCUSSION Only a few clinical reports 7-10 describe a set of operations for infertility that clearly fit into the category of fimbrioplasty. A microsurgical approach to fimbrioplasty appears to have been first described by Swolin,u In our study, the term pregnancy rate (60%) obtained after fimbrioplasty is similar to that obtained in another study (63%).7 It appears that microsurgical fimbrioplasty results in a high incidence of postoperative pregnancy because the degree of fimbrial damage is reduced. When patients with complete occlusion were divided according to our classification, significant differences in pregnancy rates were noted. Indeed, salpingostomy for occlusion of degree II results in a high incidence of postoperative pregnancy. When the tube appears distended probably by previous damage suffered by the muscularis,12, 13 the pregnancy rate decreases significantly. In a previous study,13 we proved the depletion of adrenergic neurotransmitters in experimental and human hydrosalpinx. This adrenergic denervation and the subsequent disturbance of ovum myosalpingeal transport could explain the poor pregnancy rate. Ampullary dilatation seems to be an unfavorable prognostic factor of distal microsurgery. As proven in other experimental studies,14, 15 cilia play a major role in the ovum transport along the fimbrial surface. However, pregnancies were reported16 in women suffering from Kartagener's syndrome. Myosalpingeal ovum transport could account for the occurrence of occasional pregnancy in these patients. In the present study, no statistical difference in the ciliated cell percentage and in the postoperative pregnancy rate was found between degree I occlusion and degree II occlusion. A significant decrease of both the ciliated cell percentage and pregnancy rate was observed in cases of degree III distal occlusion, when compared with degrees I and II distal occlusion. In degree IV distal occlusion, the percentage of ciliated cells was very low. The postoperative pregnancy rate is similar to that observed after surgery for degree III occlusion. As suggested by Brosens and Vasquez,2 the ciliation index is valuable in the prognosis of tubal surgery. After salpingo-ovariolysis for periampullary adhesions, the pregnancy rate is high, and the interval between the surgical procedure and pregnancy is shorter than that observed after fimbrioplasty and salpingostomy. The observation of significant deciliation in tubes with macroscopically normal-looking and free fimbria and periampullary adhesions when compared with control groups confirms the data of Brosens and Vasquez2 and could explain the decreased fertility even when the fimbria is free. Thickness of the tubal wall is well known to be a prognostic factor. 6 Indeed, no pregnancy occurred after salpingostomy for thick-walled hydrosalpinx.4-17 For such patients, in vitro fertilization is the only remaining solution. In conclusion, the pregnancy rate after distal surgery is related to the morphology of the tube, ampullary dilatation, fimbrial ciliated cell percentage, and tubal wall thickness. Because of the significant differences in the pregnancy rates after salpingostomy according to occlusion degree, we propose the use of this classification in analyzing the results of microsurgery in the future. REFERENCES 1. Donnez J, Langerock S, Lecart C, Thomas K: Incidence of pathological factor not revealed by hysterosalpingography but disclosed by laparoscopy in 500 fertile women. Eur J Obstet Gynecol Reprod BioI 13:369, Brosens la, Vasquez G: Fimbrial microbiopsy. J Reprod Med 16:171, Donnez J, Casanas-Roux F, Ferin J, Thomas K: Fimbrial ciliated cells percentage and epithelial height during and after salpingitis. Eur J Obstet Gynecol Reprod BioI 17:293, 1984 Donnez and Casanas-Roux Fimbrial microsurgery 203

5 4. Donnez J: La trompe de Fallope. In Histophysiologie Normale et Pathologique, Edited by J Donnez. Leuven, Nauwelaerts Printing Publisher, 1984, p Gomel V: Salpingostomy by microsurgery. Fertil Steril 29:380, Winston RML: Microsurgery of the fallopian tube: from fantasy to reality. Fertil Steril 34:521, Patton GW: Pregnancy outcome following microsurgical fimbrioplasty. Fertil Steril 37:150, Gabe M: Les colorations topographiques. In Techniques Histologiques, Edited by M Gabe. Paris, Masson Publishers, 1968, p Donnez J, Casanas-Roux F, Caprasse J, Ferin J, Thomas K: Cyclic changes in ciliation, cell height, and mitotic activity in human tubal epithelium during Teproductive life. Fertil Steril 43:554, Siegler AM, Kontopoulos V: An analysis of macro surgical and microsurgical techniques in the management of the tuboperitoneal factor in infertility. Fertil Steril 32:377, Swolin K: Electromicrosurgery and salpingostomy: long term results. Am J Obstet Gynecol 121:419, Donnez J, Caprasse J, Casanas-Roux F, Karaman Y, Ferin J, Thomas K: Morphologic study of mechanically induced hydrosalpinges in rabbits. Acta Eur Fertil 16:257, Donnez J, Caprasse J, Casanas-Roux F, Ferin J, Thomas K: Loss of adrenergic innervation in rabbit induced hydrosalpinx. Gynecol Obstet Invest. In press, Odor DL, Blandau RJ: Egg transport over the fimbrial surface of the rabbit oviduct under experimental conditions. Fertil Steril 24:292, Eddy CA, Flores JJ, Archer DR, Pauerstein CJ: The role of cilia in fertility: an evaluation by selectivemicrosurgical modification of the rabbit oviduct. Am J Obstet Gynecol 132:814, Afzelius BA, Camner P,Mossberg B: On the function of cilia in the female reproductive tract. Fertil Steril 29:72, Donnez J: Microchirurgie et Fecondation in vitro: methodes concurrentes ou complementaires. Rev Med Brux 6:627, Donnez and Casanas-Roux Fimbrial microsurgery