AN ANALYSIS OF MACROSURGICAL AND MICROSURGICAL TECHNIQUES IN THE MANAGEMENT OF THE TUBOPERITONEAL FACTOR IN INFERTILITY

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1 FERTILITY AND STERILITY Cpyright 979 The American Fertility Sciety Vl. 32, N.4, Octber 979 Printed in U.s.A. AN ANALYSIS OF MACROSURGICAL AND MICROSURGICAL TECHNIQUES IN THE MANAGEMENT OF THE TUBOPERITONEAL FACTOR IN INFERTILITY ALVIN M. SIEGLER, M.D., D.Sc.* V ASILIOS KONTOPOULOS, M.D. Divisin f Reprductive Endcrinlgy and Infertility, Department f Obstetrics and Gyneclgy, State University f New Yrk Dwnstate Medical Center, Brklyn, New Yrk 203 One hundred and sixty tubal recnstructins were analyzed accrding t a classificatin which describes the type f tubal repair and the tubal segment treated. The results in 80 wmen wh were perated upn just prir t the applicatin f micrsurgical principles were cmpared with thse in 80 wmen in whm these techniques were emplyed. In expressing the results, n were excluded fr any reasn. Anatmical patency was nt evaluated, and functinal patency was measured by cnceptin (abrtin, tubal, r term pregnancy). Of the 80 wmen wh had tubplasty with cnventinal surgery, 0 (2.5%) successfully delivered at term, but 4 (7%) had tubal gestatins. Almst 28% f the wmen (22) had successful pregnancies after micrsurgery, but in 9 (%) extrauterine pregnancies resulted. The three wmen with current intrauterine pregnancies culd imprve the micrsurgical series t 3% successful pregnancies. Our initial experience with micrsurgical techniques seems t shw an increased number f term pregnancies, principally in wh have undergne anastmsis. Fertil Steril 32:377, 979 T gyneclgists, micrsurgery implies ptical magnificatin with either a magnifying lupe r perative micrscpe, gentle handling and cnstant irrigatin f tissues, hemstasis with biplar cautery, lysis f adhesins and tubal incisins with a uniplar micrelectrde, and the use f fine sutures and micrsurgical instruments. Thus far its principal use has been limited t reparative peratins n the fallpian tubes f infertile. Detailed views permit the perfrmance f intricate maneuvers with precisin and minimal trauma. The purpse f this presentatin is t cmpare the results in 80 wh were perated upn just prir t the applicatin f these micrsurgical principles with thse in 80 wmen in whm these Received December, 978; revised March 2, 979, and April 23, 979; accepted May 7, 979. *Reprint requests: Alvin M. Siegler, M.D., D.Sc., One Hansn Place, Brklyn, N. Y techniques were emplyed. In expressing the results, a classificatin f tubal peratins previusly described was used, and n were excluded fr any reasn (Table ). Anatmical patency was nt evaluated, and functinal patency was measured by cnceptin (abrtin, tubal, r term pregnancy). The use f magnificatin fr tubal surgery was first recrded by Walz 2 in 959. He used a clpscpe with a magnificatin f x 0 and an bjective f 200 mm fr tubal recnstructins n 25 wmen. The 000 catgut sutures appeared like "rpe." The general principles f gyneclgic micrsurgery as currently practiced were described initially by Swlin 3 in 967. Using magnifying lupes r the perating micrscpe, and a micrsurgical uniplar electrde t incise the terminally bstructed tube in its mst favrable area, he perfrmed ampullary salpingnestmy in 33. Antibitics, hydrpertubatin, and sterids were used in 377

2 378 SIEGLER AND KONTOPOULOS Octber 979 TABLE. Classificatin f Surgical Techniques" I. Implantatin A. Isthmus B. Ampulla Il. Anastmsis A. Intramural (interstitial). Isthmus 2. Ampulla B. Isthmus. Isthmus 2. Ampulla C. Ampulla. Ampulla Ill. Salpingnestmy A. inal B. Midampulla (medial) C. Isthmus (included linear salpingnestmy) IV. Fimbriplasty A. Deagglutinatin and/r dilatatin B. Incisin f peritneal ring C. Incisin f tubal wall V. Lysis f adhesins (classified accrding t adnexa with mildest adhesins) A. Mild (less than em f tube r vary invlved in band r strings) B. Mderate (partially surrund tube r vary) C. Severe (encapsulating peritubal r perivarian adhesins) VI. Cmbinatins A. Different peratins n right r left tubes B. Multiple peratins n same tube (i.e., implantatin and anastmsis) "Ad Hc Cmmittee fthe Ninth Wrld Cngress f Fertility and Sterility, April 2 t 6, 977, Miami Beach, Fla. additin t precise cagulatin fr hemstasis. MATERIALS AND METHODS The 60 peratins in this study were analyzed accrding t a classificatin which describes the type f perative repair and the tubal segment treated. The ages f the wmen ranged frm 20 t 38 years with an average f28 years. One hundred and fur were n the private service and the remainder were n the ward service, but ne f the authrs (A. M. S.) was the principal surgen in each instance. Infertility studies included seminal analysis, pstcital tests, endmetrial bipsy r semen prgesterne, a hystersalpinggram, and (usually) laparscpy as a prelude t definitive surgery. On the basis f these results, n significant cause f infertility was detected except fr the tubperitneal factr. Patients were cunseled preperatively with regard t the nature f the cntemplated surgery, the need fr peri perative medicatin and treatment, and the chances fr a term pregnancy. With the evlutin f surgical techniques and the develpment f new insights, changes were cnstantly made during bth the macrsurgical and micrsurgical series evaluated in this presentatin. Fr the latter grup, wet lapartmy pads were inserted int the vagina t tilt the uterus frward and almst all had transverse suprapubic incisins. The uterus was elevated by packing the cul-de-sac with saked lapartmy pads, and the adnexa were individually manipulated with glved fingers and mbilized as necessary by dissectin with uniplar micrelectrdes. The patient was placed in a mderate Trendelenburg psitin with a lateral tilt f apprximately 5. The surgen sat ppsite the tube t be treated, which was stabilized by lapartmy pads saked in saline slutin. Either magnifying lupes f x4 r an perating micrscpe with an bjective lens f 250 t 300 mm were used. A remte zm cntrl with a ft pedal kept the hands free fr surgery. Hemstasis was btained with biplar frceps. Sutures in micrsurgery fr tubal recnstructin were 8-0 r smaller (22 t 55 MID) mnfilament nyln r synthetic absrbable types made f plyprpylene r plyglyclic acid. The wire diameter varied frm 70 MID t 30 MID, and the needles were three-eighths circles, usually taper-pinted. The perating micrscpe enables the surgen t see the scarring and terminal prtin f the hydrsalpinx clearly as a white band and t select the mst apprpriate site fr tubal incisin. A glass catheter r rd is inserted int the nestmy, enabling a clear delineatin f additinal areas fr tubal incisin. Althugh the endsalpinx may be sft, tan, and easily identified, nrmal mucus membrane is smetimes nt seen until the tube has been pened fr several centimeters. Digital manipulatin fthe tube is preferable t the use f frceps r clamps. In distal tubal cclusin, by palpatin the ccluded segment smetimes feels firm and ndular. This can indicate ccult fimbriae cvered by peritneal adhesins. Careful dissectin f the adherent terminal segment frm its varian at- TABLE 2. Methd and Type f Implantatin Implantatin Tenn Isthmus Ampulla

3 Vl. 32, N.4 MACROSURGICAL AND MICROSURGICAL TECHNIQUES FOR TUBOPERITONEAL FACTOR 379 TABLE 3. Methd and Type f Anastmsis Anastmsis Intramural-isthmus Intramural-ampulla Isthmus-isthmus Isthmus-ampulla 4 0 Ampulla-ampulla Presently pregnant tachment with a fine micrelectrde needle under ptical magnificatin will cause fimbrial extrusin. The fimbriae appear edematus and cngested but are easily identified. Fr anastmsis the mre recent techniques include remval f the ccluded tubal ends serially with micrscissrs until patency is ascertained, the distal segment being tested with ml f indig carmine by retrgrade fimbrial perfusin. The patency f the prximal segment is tested by thumb pressure n a syringe attached t an intrauterine pediatric Fley catheter. One end f 00 nyln is inserted in the uterine cavity and the ther int the cut end f the distal segment as described by Williams. 4 This was the character f splintage used temprarily (up t 2 weeks pstperatively) t facilitate placement f sutures and t stabilize the tubal segments. The endsalpinx was included in the tw-layer clsure. The technique fr the uterine incisin in implantatin varied frm creating the crnual pening with either a 6-mm reamer r sharp dissectin, r the psterir fundal apprach described by Petersn and clleagues. 5 Either the patent isthmic r ampullary tubal segments were implanted. Periperatively, crticsterids were used with prphylactic antibitics in almst all until the mst recent 40 peratins. Thereafter alternate wmen were treated with antibitics alne and n difference in pstperative infectius mrbidity was bserved in these tw small grups f wmen. Hydrtubatin was nt practiced rutinely in wh underwent tubal surgery fr distal tubal bstructin. RESULTS N term pregnancies resulted in the 20 wh had either ampullary r isthmic segments implanted (Table 2). The utcme was nt imprved by varying the site f implant frm crnu t the psterir uterine wall r utilizing micrsurgical methds fr preparing the tubal segment fr its implantatin. Tw f the had tubal pregnancies. Generally, indwelling stents were nt emplyed. Thirty-six had five pssible types f anastmses; twenty f them were dne withut ptical magnificatin (Table 3). Ofthe five wh became pregnant, three had tubal gestatins. Sixteen wmen had anastmses utilizing the surgical principles described fr micrsurgical recnstructin; six had term pregnancies, tw are currently pregnant, and ne tubal pregnancy resulted. Included in the series n anastmsis and implantatin are wh had attempts at reversal f sterilizatin and tubal bstructins frm ther causes. Thirty-eight wmen had either a terminal r midampullary variatin f salpingnestmy, fifteen f them befre the advent f micrsurgery (Table 4). Amng the latter, tw had a term pregnancy and three thers develped tubal TABLE 4. Methd and Type f Salpingnestmy Salpingnestmy patents Presently pregnant inal Midampulla Isthmus

4 380 SIEGLER AND KONTOPOULOS Octber 979 TABLE 5. Methd and Type ffimbriplasty Fimbriplasty Tenn Deagglutinatin r dilatatin Incisin f peritneal ring Incisin f tubal wall pregnancies. Micrsurgical salpingnestmy in 23 wmen resulted in five term pregnancies and three tubal gestatins. One patient currently has an intrauterine pregnancy. N isthmic salpingnestmies were perfrmed. The number f midampullary salpingnestmies (52.6%) in this grup is rather high. This prcedure is perfrmed whenever the cmpleted nestmy frmed frm the hydrsalpinx wuld be cnsidered t far frm the vary. Fimbriplasty by either deagglutinatin r dilatatin f phimtic tubal stia r incisins f an cclusive peritneal cvering were perfrmed in 20 wmen (Table 5). Of the in whm the cnventinal techniques were used, 2 wmen delivered at term and 2 thers had tubal gestatins. Micrsurgical prcedures were used in nine ; five f them subsequently delivered at term, but ne tubal pregnancy ensued. Adhesins causing disruptin f the nrmal tubal and varian juxtapsitin were the nly adnexal abnrmalities in 2, 5 f them having lysis by macrsurgery and six thers by micrsurgery (Table 6). Tw wmen in the latter grup delivered and ne had a tubal pregnancy, whereas three wmen had term pregnancies and three thers had tubal gestatins fllwing lysis f adhesins by cnventinal methds. This categry is used when it is the primary tubal peratin because many tubal recnstructins, such as salpingnestmy and fimbriplasty, als invlve lysis f periadnexal adhesins. Twenty-five had cmbined peratins n the ipsilateral r cntralateral tube resulting in five term pregnancies, fur f them fllwing a micrsurgical prcedure; tw tubal pregnancies ccurred in each surgical grup (Table 7). It is nt pssible t ascribe success t a particular categry f tubal peratin in the cmbined series. In summary, f the 80 wmen wh had tubplasty with cnventinal surgery, 0 (2.5%) successfully delivered at term but 4 (7%) had tubal gestatins. Almst 28% f the wmen (22) had successful pregnancies after micrsurgery, but in 9 (%) extrauterine pregnancies resulted. The three wmen with current intrauterine pregnancies culd imprve the micrsurgical results t 3% successful pregnancies (Table 8). DISCUSSION Since the turn f the 20th century, prcedures emplyed t restre patency t ccluded tubes and the criteria fr expressing and analyzing results have varied. Operatins fr tubperitneal causes f infertility must be carefully classified, and the extent f tubal damage assessed t enable physicians t evaluate their wn wrk and the studies f thers. In this way, the mst suitable will be detected, the distributin f prcedures in a series ascertained, the perative techniques individualized, and standards fr success evlved. The plemics abut the duratin f fllw-up required fr inclusin f a given patient in a series must be reslved. Patients nt evaluated pstperatively by tubal patency tests are cnsidered clsed-tube failures if n cnceptin ccurs. Fr bvius reasns all perated upn must be included in a series, even thse wh had had tubal surgery nly a shrt time befre the published reprt, since sme wmen d cnceive within the first few mnths pstperatively. In tubal recnstructive surgery it is well knwn that a wide discrepancy exists between the rati f failure t success in terms f anatmical pstperative patency and pregnancy rates. Mst physicians wuld agree TABLE 6. Methd f Lysis f Adhesins Lysis f adhesins Mild Mderate 5 3 Severe

5 Vl. 32, N.4 MACROSURGICAL AND MICROSURGICAL TECHNIQUES FOR TUBOPERITONEAL FACTOR 38 TABLE 7. Methd and Types f Cmbinatins Cmbinatin Different peratins n each tube Multiple peratins n same tube that the nly measure f a successful tubal recnstructive peratin is a subsequent delivery. In apprximately ne-half f the wh are ptential candidates fr recnstructive tubal surgery, ther factrs intervene which interdict this type f peratin. At laparscpy anther 5% are fund t be inperable because f severe tubal disease r insufficient tubal length; 5% f pstpne the tubplasty, laparscpic lysis f adhesins is dne in 0%, and 20% f the grup have tubal recnstructins. 6 In mst, tubal cclusin is bilateral and there are always sme assciated adnexal adhesins. The tubal pregnancy rate is 0 times the nrmal incidence, and in thse wh have had a previus ectpic gestatin and a subsequent tubplasty, 50% fthe pregnancies are again extrauterine. The prgnsis fr success is reduced in with advanced age (ver 38 years) and in whm nly ne tube is repaired. With these clinical results the gyneclgist bviusly needs t search fr methds f technlgic imprvement. The majr prblems in recnstructin are establishing and maintaining tubal patency, and preventing adhesins, tubal pregnancy, and abrtin. Pauerstein 7 pstulated three majr prerequisites fr cmparing data in tubal recnstructin. They include the surgen's skill, in which either the same surgen uses different techniques fr cmparisn n alternate r different sur- gens f equal skill must use a specific methd and cmpare their results. In ur study neither fthese requirements was fulfilled. Althugh the same surgen (A. M. S.) perated upn all, the tw basic techniques were nt alternated n successive. Instead, the first series f 80 peratins with cnventinal techniques were cmpleted befre the secnd series f 80 peratins using micrsurgical principles began. Mst likely the skills imprved with experience. Pauerstein's secnd pstulate fr assessment f tubal damage is partially satisfied by the classificatin that ntes the lcatin f bstructin, but neither the grss appearance f the fallpian tube nr its histlgy is recrded in this study. The size f the hydrsalpinx in distal tubal bstructin and the histlgy f excised viductal isthmic segments in prximal tubal bstructin may be significant in the utcme in any given peratin. Pauerstein's third criterin invlves the methds f expressing and appraising the results. In this study the results are expressed by classifying the type f perative repair, and n have been excluded. The findings are appraised nly by physilgic patency, that is, the number f wh cnceived. These cnceptins were further evaluated as t their tubal r intrauterine lcatins. All wh underg tubal recnstructive peratins must be alerted t the symptms and TABLE 8. Summary f 60 Tubplastic Operatins Type f tubplasty Pregnanei es Tenn Presently pregnant Implantatin Anastmsis Salpingnestmy Fimbriplasty Lysis f adhesins Cmbinatin

6 382 SIEGLER AND KONTOPOULOS Octber 979 TABLE 9. Reprts f Recnstructin by Authr Year N. f Garcia and Aller!' Swlin' Diamnds Owen and Pickett-Heaps" Gmel' Winstn" Gmel" Siegler and Kntpuls 979 (Present study) "Sme in secnd trimester. Operatin pregnant Anastmsis 8 Nt stated Salpingnestmy Anastmsis Anastmsis Anastmsis 3 30a Anastmsis 25 24" Salpingnestmy Implantatin 0 Anastmsis 9 8a Salpingnestmy 9 6a 3 Fimbriplasty 6 5 Lysis f adhesins 3 2 Cmbinatin (50.8%) (39.4%) (7.2%) signs f tubal pregnancy. Sngraphy is ajustified precautin in wmen wh are suspected f pregnancy fllwing tubal recnstructin. Clearly, the methd f selecting the mst favrable patient and the techniques fr aviding pstperative ectpic pregnancies have nt been reslved. The effrts in delineating the mst precise and effective methds fr tubal recnstructin might be enhanced by the develpment f large enugh series, cllected prspectively by cperative investigatrs adhering t a predetermined prtcl with a minimum f variable factrs. Our initial experience with micrsurgical techniques seems t shw an increased number f term pregnancies, principally in wh have undergne anastmsis. Recently Diamnd,s Garcia and Aller,9 Gmel, 0. and Winstn2 have described their micrsurgical techniques and results. The published figures n tubal recnstructin by micrsurgery were cllected and tabulated (Table 9). The pregnancy rates fllwing reversals f tubal sterilizatins by skilled gyneclgic surgens wh did nt use a surgical micrscpe have been impressive. Petersn and c-wrkers 5 reprted a 50% term pregnancy rate in 6 fllwing implantatin. Williams4 had an initial series f successful pregnancies fllwing tubal anastmsis fr reversal f sterilizatin in 8 f 25. Mst recently he3 presented a series f 52, nting that 36 wmen had delivered at term. Jnes and Rck,4 utilizing a similar technique in 2 wmen, nted 0 successful pregnancies. SUMMARY Increasing experience with micrsurgical tech- niques fr tubal recnstructin suggests that this apprach des imprve the pstperative pregnancy rates and reduces the numbers f tubal pregnancies. N attempt was made in this presentatin t evaluate these peratins by pstperative tubal patency studies because basing success upn this finding is bviusly inadequate. It still remains difficult t islate all f the variables such as size f sutures and needles, periperative medicatins and treatments, and types and degree f ptical magnificatin, and t develp precise standardized methds f reprting results in a statistically significant number f. Added t these afrementined different surgical techniques are the selectin and exclusin f fr the peratin and the types f tubal pathlgy. The cmparisn f results frm the initial macrsurgical series with thse f the micrsurgical series that fllwed therefre must be viewed in light f these prblems as well as imprved perative techniques prbably resulting frm increasing clinical pprtunities. REFERENCES. Siegler AM: Surgical treatments fr tubperitneal causes f infertility since 967. Fertil Steril 28:09, Walz W: Sterilitatsperatinen an der Tube mit Hilfe eines Operatinsmikrskpes. Z Geburtshilfe GynaekI53:49, Swlin K: Fifty fertility peratins: I. Literature and methds. Acta Obstet Gynecl Scand 46:234, Williams EA: Aspects f fallpian tube surgery. In Recent Advances in Obstetrics and Gyneclgy, Edited by J Stallwrthy, G Burne, Lndn, Churchill Livingstne, 977, p Petersn EP, Musich JR, Behrman SJ: Utertubal implantatin and bstetric utcme after previus sterilizatin. Am J Obstet Gynecl 28:622, 977

7 Vl. 32, N.4 MACROSURGICAL AND MICROSURGICAL TECHNIQUES FOR TUBOPERITONEAL FACTOR Palmer R: Persnal cmmunicatin, Pauerstein CJ: Frm Fallpius t fantasy. Fertil Steril 30:33, Diamnd EP: Micrsurgical recnstructin f the tube in sterilized. Fertil Steril 28:203, Garcia CR, Aller J: Surgical apprach t tubal disease. Clin Obstet Gynecl 7:02, Gmel V: fr reversal ffemale sterilizatin. In Reversal f Sterilizatin, Edited by JJ Sciarra, GI Zatuchni, JJ Speidel. Hagerstwn Md, Harper and Rw, 978, p 95. Gmel V: Salpingstmy by micrsurgery. Fertil Steril 29:380, Winstn RML: anastmsis fr reversal f sterilizatin in 45 wmen. In Reversibility f Female Sterilizatin, Edited by I Brsens, RML Winstn. Lndn, Academic Press, 978, p Williams EA: Restratin f fallpian tube patency after sterilizatin. Presented at Stat Attuale Della Sterilizzazine Vlntaria Nell 'Ambit Della Cntraccezine, Rme, Nvember, Jnes HW Jr, Rck JA: On the reanastmsis ffallpian tubes after surgical sterilizatin. Fertil Steril29:702, Owen ER, Pickett-Heaps AA: The micrsurgical fallpian tube recnstructin. Aust NZ J Surg 47:300, Swlin K: Electrmicrsurgery and salpingstmy: lng term results. Am J Obstet Gynecl 2:48, 975