SURGICAL TREATMENTS FOR TUBOPERITONEAL CAUSES OF INFERTILITY SINCE 1967

Transcription

1 FERTILITY AND STERILITY Copyright 1977 The American Fertility Society Vol. 28, No. 10, October 1977 Printed in U.S.A. SURGICAL TREATMENTS FOR TUBOPERITONEAL CAUSES OF INFERTILITY SINCE 1967 ALVIN M. SIEGLER, M.D., D.Se. Department of Obstetrics and Gynecology, State University of New York, Downstate Medical Center, Brooklyn, New York Operative procedures to reconstruct occluded tubes and those involved with significant adhesions have been described for more than a century. The historic development of this kind of surgery to overcome infertility is summarized in Table l.1 Restoring patency and freely movable tubes is the desired anatomical result in anticipation that fulfillment of these objectives will lead to an improvement in the capture ofthe ovum with its sticky cumulus, aiding its biologically programmed infundibular ampullary transport. The possibility for ascent of spermatozoa and the physiologic conditions for fertilization, nourishment, and maturation of the zygote and its timed transport into the uterine cavity must also be established in a successful salpingoneostomy, anastomosis, or implantation. Studies are being conducted on the tubal effects of steroids and prostaglandins,2 the significance of the ampullaryisthmic junction,3 the isthmic noradrenergic sphincter,4 a- and.f3-receptors,5 characteristics of ciliary currents,6 relationships between secretory and ciliary cells,7 contractility patterns of the myosalpinx in all tubal segments, and the dynamics and character of tubal fluids. 8, 9 Yet some patients conceive with distorted (presumably damaged) tubes, others become pregnant after ampullary implantations which bypass the interstitial and isthmic segments, and occasionally pregnancy occurs years after a tubal sterilization. The purpose of this review is to describe changes during the last decade in concepts and procedures for the surgical treatment of infertility caused by tuboperitoneal disease. Many infertile women with diseased fallopian tubes do not have tuboplasty because contraindications exist such as their age, a history of pelvic tuberculosis, obesity, a recent adnexal infection Received July 13, with residual pelvic tenderness, or infertility studies revealing seminal inadequacy, poor sperm migration, or ovular dysfunction. When the limited chances of success are described, some women refuse operations. In a recent report by Murray10 on 2148 infertile women, 311 (14.5%) were operated upon but only 86 (4%) had tuboplasty. Crane and Woodruff,ll in reporting their experiences with 96 tuboplasties, maintained that proper selection of the patient and the extent of peri adnexal adhesive disease greatly influenced the prognosis. O'Brien and colleagues 12 reviewed 173 tuboplastic operations (67 private patients) followed by a 35% pregnancy rate. Of 1126 clinic patients evaluated for infertility during a 10-year period, 424 (37%) had tubal disease but only 112 came for reconstructive surgery. The incidence of tubal disease reported as a cause of infertility in any series varies with the types of patients studied. Peterson and Behrman13 noted that 5% of women with unexplained m- TABLE 1. Historic Development of Tubal Surgery for Infertility Author Year Tuboplasty Contribution operations Schroder Unilateral ampullary cuff Skutsch Bilateral ampullary cuff; first to use term "salpingostomy" Martin First reported postoperative pregnancy (aborted) Polk Described salpingolysis Ries First uterotubal implantation; first to use term "metrosalpingoanastomosis" Gouillioud First illustration of ampullary cuff salpingostomy with partial tubal resection Burrage Dorsal slit salpingostomy Ferguson Intraoperative tubal testing prior to tuboplasty Turck Term pregnancies following bilateral uterotubal implantations (2 patients)

2 1020 SIEGLER fertility had tubal pathology at subsequent laparoscopy. Corson and Bolognesel4 found tubal disease in 145 (58%) of 249 patients undergoing laparoscopy for infertility. SELECTION OF PATIENTS Results from conventional nonoperative tests for tubal patency, such as uterotubal insullation and hysterosalpingography, sometimes are misleading or disagree. The accuracy of these diagnostic procedures depends upon the physician's technique, careful interpretation, and awareness of their limitations. A presumptive diagnosis of tubal occlusion during insullation is made if passage of carbon dioxide does not occur below 200 mm Hg, kymographic oscillations are absent, and no shoulder pain follows the test. Rubin IS noted initial pressures of 200 mm Hg on one or two occasions in 42 (7.1%) of 590 infertile women who eventually became pregnant, but none ofthem had conceived after three negative tests. In a similar group of 296 women, Sieglerl6 found only one patient who became pregnant after three nonpatency tests. These observations suggest that repeated failure of carbon dioxide to pass through the fallopian tubes is a poor prognostic sign. Uterotubal insullation is not too accurate in the presence of dilated, occluded ampullae, resulting occasionally in misleading or false positive tests. Salpingography reveals the size of a distally obstructed tube but not the condition of its fimbriae, the degree of tubal fixation, or endosalpingeal destruction. Persistent, localized, collections observed on the follow-up x-ray film suggest terminal tubal disease. Boyd and HoW 7 made a diagnosis of hydrosalpinx by hysterosalpingography in 130 instances, and subsequent laparotomies disclosed only four (3.1%) patent tubes. Hysterosalpingographic interpretations of distal obstruction without dilatation is less accurate because at laparoscopy many tubes show patency with peritubal adhesions. Young and colleagues18 performed tuboplasties on 112 infertile clinic patients, confirming the observations of Charas,19 who correlated postoperative pregnancy rates following salpingoneostomy with preoperative radiologic rugal markings. Their presence indicated minimal endosalpingeal disease, 60% of the patients conceiving after tuboplasty, while in the absence of rugal markings only 7% became pregnant. Swolin and Rosencrantz20 compared findings at laparoscopy and hysterosalpingography in 143 patients, both methods agreeing in the diagnosis of October 1977 partial or complete tubal obstruction and tubal adhesions in 90 instances (63%). Different degrees of significant tubal abnormalities were seen with both techniques in 24 other patients (17%). Normal laparoscopic findings were found in 14 women (9%) whose hysterosalpingograms were interpreted as abnormal. Bilateral tubal patency was detected in a previous hysterosalpingogram in 12 patients (8.3%), but partial obstruction was noted on laparoscopy. Radiologic studies before ovulation were performed with water-soluble media followed the next day by laparoscopy using methylene blue or indigo carmine with saline. Maathius and colleagues21 and Coltart22 found that most errors occurred because significant peritubal adhesions were missed by radiologic techniques. Although insullation and salpingography can be diagnostic and sometimes therapeutic,23 endoscopy is needed to evaluate the extent of tubal abnormalities.24 Frangenheim25 no longer employs hysterosalpingography in infertile women, advising laparoscopy to evaluate the pelvis and recommending tuboplasty to one-third of his patients. Laparoscopy is used to verify tubal patency with hydrotubation, to assess tubal obstruction and fimbrial involvement, to evaluate tubes for possible tuboplasty, and for lysis of peritubal adhesions From these studies it seems that tubes showing filling and peritoneal spilling on the delayed film rarely are occluded at laparoscopy. A tube radiographically diagnosed as hydrosalpinx (distal tubal occlusion with ampullary dilatation and localized persistence of contrast material on the delayed film) is found to be a normal tube at laparoscopy in fewer than 10% of patients. The largest discrepancies between the findings from these tests relate to the inability of the salpingogram to detect accurately peritubal adhesions and the false negative diagnosis of cornual obstruction.29, 30 In the latter group it is important to record the amount of contrast media used, the degree of leakage, the force and resistance to instillation, and the patient's complaint of pain. Intramural and isthmic opacification can influence the selection of the type of tubal reconstruction. The clinical significance of these discrepancies, that is, the need to alter a planned procedure because of different information, is not as great as is implied by some reports. Congenital or inflammatory luminal fibrosis and salpingitis isthmic a nodosa are the most common causes for organic proximal obstruction. Proximal obstruction is suspected if (1) nonpat-

3 Vol. 28, No. 10 SURGICAL TREATMENTS FOR TUBOPERITONEAL CAUSES OF INFERTILITY 1021 ency to CO 2 insufflation occurs at 200 mm Hg for 2 minutes at a flow rate of 30 mllminute with increasing suprapubic pain and no subsequent shoulder pain; (2) opacification of no more than 2 to 3 cm of the fallopian tube is seen after adequate amounts of contrast material are injected without any dispersion; (3) no tubal filling with colored solution is observed at laparoscopy with increasing resistance to the injection of dye through a patent cervical cannula. The exact site of occlusion in this segment is difficult to locate, but occasionally isthmic distention and blanching are seen proximal to the obstruction. Salpingitis isthmica nodosa can be missed on hysterosalpingography, and at laparoscopy careful observation, palpation, and manipulation of the tubal isthmus with a tactile probe are essential. Laparoscopy is important in these patients to evaluate the distal tubal segment. Repeat intrauterine injection of dye is attempted at laparotomy<to prove occlusion before transection, anastomosis, or implantation, because occasionally this maneuver causes tubal filling despite previous evidence of cornual obstruction. Even with this corroboration of bilateral occlusion, subseqent histologic examinations of excised segments as reported by Boyd and Ho1t17 proved normal in 34% of cases. Grant31 could verify occlusion histologically in only 7 of 67 specimens (10%). Ampullary obstruction is suggested by increasing lower-quadrant pain during CO2 insufflation. The degree of distention and the character of mucosal folds seen on hysterosalpingography indicate the severity, large terminal dilatations without luminal markings being a poor prognostic sign. In a retrospective study, Ozaras19 found that only patients who had slight dilatation and linear mucosal markings conceived after ampullary salpingoneostomy. If ampullary disease is associated with salpingitis isthmic a nodosa, tuboplasty is contraindicated. Rigid luminal contours indicate chronic, advanced salpingitis, with fibrosis suggestive of tuberculous salpingitis. At laparoscopy the consistency of the dilated tube is probably more important than its size. A firm, slightly dilated tube that fills poorly during pertubation is not amenable to tuboplasty because isthmic salpingoneostomy would probably be required. The larger, softer, tube, distended and blue because of injected fluid, often becomes normal in size after ampullary salpingoneostomy. If terminal tubal segments are fixed in the cul-desac, some spill of dye behind occlusive adhesions is a favorable sign. An occasional hydrosalpinx fills with dye during chromotubation, ruptures, and extra va sates material into the mesosalpinx, thus explaining abnormal patency to CO2 or contrast medium in some of these patients. Associated multiple myomas and endometriomas reduce the chances for a successful tuboplasty. In fimbrial phimosis caused by endosalpingeal adhesions, some fimbriae are noted with tubal filling and dilatation, and minimal spillage of dye at laparoscopy. In the absence of peri tubal adhesions, this condition initially is treated by repeated hydrotubation. Such a tube is also surgically corrected during laparoscopy by insertion of probes and forceps into the small terminal opening, thus dilating it.32 The procedure requires extreme care and skill so as to avoid bleeding from the endosalpinx. As measured by the number of patients who have become pregnant postoperatively, the results of such therapy are good Several authors35-37 have described their experiences with repeated hydrotubation in patients having tubal occlusions according to insufflation and salpingography. Some regimens included three treatments each week for several weeks; there were few complications, and the procedures were recommended also as preoperative therapy. EXPERIMENTAL TECHNIQUES It has been demonstrated that ovulated ova from the ovarian surface can be fertilized by capacitated sperm, and these ova cleave under proper in vitro conditions. The zygote can survive outside of a tubal environment, develop, and be transferred to a surrogate or a properly prepared host uterus. Steptoe and Edwards38 published a report of one patient in whom such a procedure was attempted but a tubal pregnancy resulted. Little can be added to the review of tubal replacement and bypass procedures written by Cognat39 in No recent reports of successfully developed prostheses or other artificial conduits have been published. Ovarian implantations are no longer considered of therapeutic value in overcoming infertility. Transplantation is another technical attempt to bypass unsalvageable or absent fallopian tubes.40 Homografts and autografts have been performed on rats,41 rabbits,42 dogs,43 and monkeys.44 The technology is apparently available, because anastomosis of 2-mm vessels presents no significant problem of vascular thrombosis due to the use of microsurgical techniques.45 A theoretical

4 1022 SIEGLER advantage over embryo transfer arises from the frequent coexistence of ovarian adhesions with unsalvageable tubes preventing aspiration of ova; if the transplant remains viable it presents a permanent cure for blocked fallopian tubes. Although the graft could survive, transplants probably would have to be done so that they would remain viable for at least one cycle for conception before possible rejection. Further developments with immunosuppression and histocompatibility are prerequisites to successful fallopian tube transplants before this technique attains clinical significance in the treatment of human infertility. If oviducts were partially privileged immunologically, rejection might be a low-grade process or require minimal immunologic suppression. The author believes that it is probably not reasonable to manipulate the unique immunologic characteristics of an individual In order to overcome a problem of infertility. MICROSURGERY Gynecologic microsurgery is a comparatively new field presenting special problems to designers of instruments and to manufacturers. The binocular microscope is essential and by far the most expensive piece of equipment employed. 46 The difficulties encountered with the initial uses ofthe microscope are problems in focusing, achieving conversions for a stereoscopic view, retaining the operative area within the field, handling new instruments under microscopic control, avoiding fatigue, and proper preparation.47 Patience and practice improve confidence and dexterity. Microsurgery is a promising, specialized discipline affording the opportunity for accurate and delicate dissection because of the stereoscopic view, high magnification, and excellent illumination. Its provision of near-perfect vision of small structures is an inherent advantage and may justify the increased time required in using this technique. Temporarily, interested gynecologists have borrowed most of their equipment from other surgical disciplines, especially ophthalomology,48 otolaryngology,49 and neurosurgery. 50 As judged by the recently reported experimental and clinical successes in tubal reconstruction and the numerous requests to visit operating rooms where microsurgery is being performed, the field will continue to expand. After the microscope is positioned over the operative field, the surgeon sits on a stool to afford stability not achievable by standing for long October 1977 periods. The stool, microscope, and operating table are properly adjusted so that the forearms rest comfortably on the table. Initially, instruments are brought into the circle of light under direct vision, the eyes are shifted to the oculars, and the sectioning or suturing is performed. Sometimes the assistant guides the surgeon's hand into the operative field. Finger motions for manipulations of instruments are more important than wrist motion. Tissues are moistened to prevent drying. Observation by an assistant is accomplished with magnifying loupes or with a beam splitter to which a monocular or other binoculars are attached. The observer tubes offer the same choice of magnification and field of vision as does the main microscope, and the image is manipulated by adjustment of the prism (with a slight loss of brightness). Ideal dissecting instruments enable performance of fine maneuvers without structural alterations of them or tissue. Blades of micro scissors and teeth of forceps become misaligned or bent unless carefully used. A surgeon should limit the number of instruments for tuboplasty and become familiar with their characteristics at various magnifications. Attention to detail and constant practice are necessary to maintain important skills. The basic trends and designs are toward light instruments which can be held by the fingertips, and longer, heavier types with miniaturization of the working ends. Those used for tubal reconstruction are separately sterilized, packaged, identifiable at a glance, and easily accessible to the surgeon. Scissors have spring handles rather than box locks and are very delicate for fine, fingertip control. For dissection of periadnexal adhesions or for cutting fine sutures individually, the scissors are short (3 to 5 inches in length), angled or straight, and have 6- to 12-mm blades. Alternatively, very fine microsurgical needles are available for electrosurgical dissection. Bayonet type forceps have tips which come to a needle-like point; other forceps are short, curved or straight, serrated or smooth, having fine tips. These forceps facilitate tying the fine sutures. Although counter-resistance is accomplished with a forceps by picking up tissue edges, it weakens the site and causes trauma. Vein retractors, nerve hooks, and glass rods hold structures on tension, facilitate dissection, and improve access to the tube and ovary. Irrigation and aspiration techniques are important in microsurgery of the fallopian tubes. They are particularly effective in

5 Vol. 28, No. 10 SURGICAL TREATMENTS FOR TUBOPERITONEAL CAUSES OF INFERTILITY 1023 locating bleeding capillaries, preventing drying of tissues, and removing small clots. Malleable silver probes of different diameters (0.4 mm to 1 mm) are used to gently dilate a tubal segment, as a guide for artificial tubings, in searching for tubal ostia, or to stabilize tubal ends during anastomosis. Special clamps are available to occlude the lower uterine segment while testing tubal patency by transfundal injection of colored dye. Extensive studies have been performed on various sizes and types of sutures to evaluate their holding strength, resistance to breakage on direct pull, provocation of granulomatous reactions, and methods of sterilization. 51 Polyglycolic acid sutures have a more clearly defined time for absorbability (2 weeks) then do protein, collagen sutures (5 days to 2 months). Nylon, a polyamide, is depolymerized in tissue and slowly absorbed. When knots are tied correctly it is always possible to remove excess thread to the level of the knot at x 10 to x 15 magnification without its becoming untied. Although biodegradation eventually takes place, it does not occur until long after healing. Fine microsurgical needles require careful handling, and the surgeon must be aware of the position at which they can best be grasped by the needle holder by observing their penetration of tissue and exiting under high magnification. They are held at about their center or point of balance and not at the tip. The directional stability is lost if the needle is held too close to the shank. Tissue damage results from a needle that does not penetrate well or pass easily. Ideally, a microsurgical needle should be tapered, about 3 to 6 mm in length, having a curvature of about and a wire diameter of 50 to 130 jlm. For hemostasis, cautery with a bipolar forceps is preferred. 52 The latter has the damped current shaped to provide coagulation at low voltage, being restricted to the path between the electrode tips, and no ground is needed. The current is short-circuited if the tips touch, and no coagulation occurs. The vessel or tissue to be coagulated is held between the electrode tips so that the tips do not contact each other. Irrigation with sterile solution minimizes heating, shrinkage, and sticking. way minimal standards for success, the best operative techniques, and the distribution of procedures in a series can be ascertained. At the 1977 meeting of the International Fertility Society in Miami Beach, Fla., an ad hoc committee under the guidance of Dr. Raoul Palmer agreed on the following nomenclature, which is used in this review: I. Implantation A. Isthmus B. Ampulla II. Anastomosis A. Intramural (interstitial) 1. Isthmus 2. Ampulla B. Isthmus 1. Isthmus 2. Ampulla C. Ampulla 1. Ampulla III. Salpingoneostomy A. Terminal B. Midampulla (medial) C. Isthmus (includes linear salpingoneostomy) IV. Fimbrioplasty A. Deagglutination and/or dilatation B. Incision of peritoneal ring C. Incision of tubal wall V. Lysis of adhesions (classified according to adnexa with mildest adhesions) A. Tube and/or ovary 1. Mild (less than 1 cm of tube or ovary involved in band or strings) 2. Moderate (partially surround tube or ovary) 3. Severe (encapsulating peritubal or periovarian adhesions) VI. Combinations A. Different operations on right and left tubes B. Multiple operations on same tube (i.e., implantation and anastomosis) VII. Other A. Transplantation B. Ovarian implantation C. Tubal prosthesis CLASSIFICATION OF OPERATIONS FOR THE TUBOPERITONEAL FACTOR IN INFERTILITY Operations must be carefully classified to enable comparison of results for analysis. In this IMPLANTATION These operations involve implantation of either the isthmic or ampullary segment, but few series are divided sufficiently to ascertain the segment

6 1024 SIEGLER giving better results. 53 No significant changes in operative techniques for preparing the tubal segment for implantation have been reported since After the tube is detached from the uterus, the patency of the segment to be implanted is tested by retrograde instillation of fluid through the fimbriated end. Either two small l-cm incisions are made to bivalve the isthmus or the tubal isthmus is incised only along its antimesosalpingeal border. For ampullary implantation no tubal incisions are needed because the lumen is ample. The two sutures for the flap, varying from 3-0 chromic catgut to 6-0 nylon, are inserted through all three layers and are held without tying. Loupes for magnification facilitate the incisions and the placement of sutures. It has been suggested that the entire patent portion of the tube be preserved even if the implanted part has a smaller lumen, because it is likely to result in a more favorable conduit for the transport of gametes and the fertilized ovum. If artificial rods or tubings are used they are inserted through the tubal segment at this time on an appropriately sized malleable probe. Shirodkar54 emphasized the need for a 2-mm lumen for implantation and he removes enough tube to accommodate this diameter of artificial device. Hemostasis is obtained effectively with bipolar coagulation, and the tissues are moistened with saline solution. The ascending branch of the uterine artery near the contemplated uterine incision is coagulated. If the decision is made to implant the tube, the uterus is opened. In most instances two separate cornual holes are made in the uterine cavity with either a 5- to 7-mm sharpened reamer or a small scalpel. The bluestained endometrium identifies the uterine cavity promptly. Bleeding points in the myometrium are coagulated, and the extirpated intramural tubal segments are identified and fixed in formalin separately for later histologic examination. Other types of uterine incisions include a transfundal approach so that a direct implantation may be performed under visual control. 54 Recently Peterson and colleagues 55 described a posterior, transverse, uterine incision at the level of the ovarian ligaments into which both tubes were inserted. In the absence of artificial intratubal devices, the previously placed tubal sutures are drawn into the uterine cavity to pass through the myometrium about 2 cm from the cornual holes and are held until additional sutures are made to fix the tube and to relieve tension on the implant. If splints are used, they are tied together or to an October 1977 intrauterine device and inserted into the uterine cavity. In the survey by Williams 56 of 107 conceptions (15%) following 639 implantations performed for all causes of intramural or isthmic occlusion, 71 (66%) were delivered at term, 16 (15%) were aborted, and 20 (19%) were tubal pregnancies. Although implantation suturing techniques are quite similar, the term pregnancy rates vary in reported series from 10% to 50%. Reocclusion postoperatively results from closure of the implanted tube by fibrosis or infection, or its extrusion because of failure of the anchoring sutures to hold. Despite the presence of postoperative patency in the majority of patients, pregnancies still do not occur in most women, possibly because the shortened tubal segment results in the premature arrival of the egg in the peritoneal cavity or interference with ovum pickup.57 ANASTOMOSIS In accordance with the proposed new nomenclature, five types of anastomosis are possible, each having special technical problems and a different prognosis. They are intramural-isthmic, intramural-ampullary, isthmic-isthmic, isthmicampullary, and ampullary-ampullary anastomoses. Infrequently, anastomoses are required because of congenital absence of the segment following a localized salpingitis or excision of a tubal pregnancy. These operations are most often performed to reconstruct previously sterilized tubes. Anastomosis theoretically has advantages over implantation because the intramural portion remains intact, less chance exists of tubal regurgitation of menstrual fluid, the myometrium is not weakened by cornual excision, and vaginal delivery rather than cesarean section is more likely. Requests for restoration of fertility from previously sterilized women are still quite infrequent in most countries, but as sterilization becomes a more popular method for contraception throughout the world, requests for operative reversal must also increase. The reasons cited are similar from country to country, most frequently being remarriage after divorce or death of a husband, death of one or more children, an improved economic situation, and a psychologic desire to overcome supposed ill-effects of tubal sterilization. 58 For some women, the choice of a permanent method of contraception-sterilization-is not final despite the fact that the decision was

7 Vol. 28, No. 10 SURGICAL TREATMENTS FOR TUBOPERITONEAL CAUSES OF INFERTILITY 1025 made after careful thought and consultation. An inevitable outcome of the increase in surgical sterilization, divorce, and changing life-styles is the current increase in requests for reversal. It is occasionally difficult to decide whether to accept the challenge to reverse the tubal sterilization previously meant to be permanent. While the operative procedure may be acceptable to the patient, the surgeon's enthusiasm should be tempered by his evaluation of the total circumstances surrounding the case. Special attention is given to the patient's general health and her potential for fertility. Berger59 has clearly shown the limited experience of individual surgeons and the variable success of existing techniques. Rosenfeld and Garcia60 emphasize the need for laparoscopy to search for extensive adnexal adhesions, damaged fimbriae, or insufficient remaining tube which would make tubal reconstruction inappropriate. The techniques described for anastomosis include identification ofthe proximal obstructed end by intrauterine instillation of colored solution after occlusion of the lower uterine segment as the distal obstruction is located by retrograde fimbrial perfusion. The obstructed ends are resected with a scalpel, fine scissors, or microsurgical electrode while careful hemostasis is obtained with bipolar coagulation. Palmer61 does not use any splints to bridge the gap or optical magnification to faciliate the repair. Williams62 manipulates one end of a 2-0 monofilament nylon thread having an external diameter of less than 0.3 mm through the uterotubal junction; the other end is passed through the distal tube and out of the fimbriated end. Nylon mattress sutures (6-0) approximate the seromuscular coat. Diamond,63 Gomel,64 and Winston65 suggest splints or nylon threads during microsurgical reconstruction, which are either removed immediately postoperatively or remain in situ from 3 days to 3 weeks. Sutures vary from chromic catgut66, 67 inserted in two layers without magnification to 8-0 to 10-0 monofilament nylon placed under visual control with loupes or magnification as high as x 40. Diamond63 and Garcia and Aller68 include the endosalpinx with their microsurgical repair, while Gomel64 and Winston65 exclude it. Patency is sometimes tested by repeated transfundal perfusion with colored solution prior to adbominal closure. Postoperative management has included special medications (antibiotics, antihistamines, and corticoids) and hydrotubation with various frequencies, amounts of fluid, and combinations of medication. In 1951 Hellman69 reported using polyethylene tubing as splints in two patients during end-toend anastomoses years after Pomeroy tubal ligations. One of these women delivered a term infant 11 months postoperatively. In 1956 Siegler and Hellman70 published results ofa survey of191 anastomoses performed by 53 surgeons. In that series 7.8% of patients conceived, only one-half of them delivering at term. The number of anastomoses performed for reversals was not indicated. About a decade later, Garcia 71 reviewed 53 of these operations performed by 7 surgeons. Although 25% of the women became pregnant, the number of patients aborting, having tubal pregnancies, or carrying to term was not stated. Siegler and Perez72 collected reports of 178 operations performed for the purpose of reversing a previous tubal sterilization and added 23 of their patients. The over-all percentages of pregnancies were 39% following anastomosis and 19% after implantation, although the latter procedure was performed in 60% of the patients. The paucity of clear documentation of the procedures used for the sterilization and even the operative methods for reversal made it difficult to evaluate conception rates or to judge the merits of specific reconstructive techniques. In Williams' series73 of 16 patients, pregnancies followed in six: four delivered by cesarean section but two women aborted. All conceptions occurred after implantation procedures. Five of the patients were from the author's area in Great Britain and eleven were referred by gynecologists from other regions. The results by Peterson and co-workers55 of a 50% term pregnancy rate and a 77% tubal patency rate in 16 patients who had implantation as reversal for laparoscopic tubal sterilization by cautery compare favorably with those of most published series. Their technique differed from others previously described because the uterine incision was made transversely in the posterior fundus at the level of the ovarian ligaments, required less mobilization of the mesosalpinx, preserved more tubal vessels, and presumably represented the shortest distance to the endometrial cavity. No splints or special medications were used and most patients were delivered by cesarean section. Heretofore it seemed that anastomosis held more promise for restoring fertility to women who had been sterilized. Few reports have described results of reversal following sterilization by cautery during laparoscopy.55, 65, 67,74 Anastomosis under the operative microscope has resulted in a significant increase

8 1026 SIEGLER in the number of women who have delivered term pregnancies and has also shown a decrease in tubal gestations. Microsurgical techniques show special promise in this type of tubal repair. SALPINGONEOSTOMY This operation is performed for distal tubal obstruction in which no identifiable fimbriae are seen or recoverable. It can be terminal, midampullary, or isthmic, the latter being abandoned because of the very poor results. After the tube is freed of any adhesions by careful, sharp dissection, electrosurgery, or digital manipulation, the distal extremity is searched for its point of cicatrization. Techniques of establishing and maintaining patency in these instances are quite variable. Hydrosalpinges are opened sometimes by cutting the surrounding peritoneal band with microsurgical thermoelectric needles, needles or dilators can be inserted,63 and sometimes a scalpel or pointed scissors61 are employed. As necessary, cuffs are made with 6-0 to 8-0 sutures, and devices such as hoods, caps,79 or stents80 81 are utilized to maintain the established patency. A recent report describes seven patients who had ampullary salpingoneostomy performed under laparoscopic control followed by intrauterine pregnancy in three of them. 82 These surgical procedures, requiring a tubal incision and then cauterization for hemostasis, followed a previous salpingoneostomy by laparotomy in which the tube became reoccluded. Swolin75,76 advocated optical magnification, either with loupes or an operative microscope, a thermoelectric needle, 5-0 chromic catgut, postoperative antibiotics, hydrotubation, and extreme gentleness in handling adnexal structures with gloved fingers rather than instruments. Midampullary salpingoneostomy results in few successful pregnancies and is indicated for the very dilated, elongated hydrosalpinx which, unless resected, has the new opening far away from the ovary. On occasion, tubes are so densely adherent to the ovary that it is probably best to incise the ampulla for 3 to 4 cm at its antimesenteric border, obtaining hemostasis with electrocautery. The mucosal edges evert and are stitched to the serosa. Results from these operations are poor. The therapeutic role of hydrotubation postoperatively is difficult to ascertain, although GranPI reported significant improvement in his results through frequent treatments. The purpose of hydro tub at ion is to remove tubal agglutinations October 1977 and to flush out mucus and blood. Shirodkar83 evaluated hydrosalpinx according to its size, the number of associated peritubal adhesions, and the condition of the myosalpinx (normal, pale or overstretched, hard, or nodular). Cuffed ampullary salpingoneostomy followed with frequent postoperative hydrotubations resulted in pregnancy in only 5% of his patients. Following ampullary salpingoneostomy, the number of tubes that remain patent is about twice the number of patients who achieve successful pregnancies, and research has been directed to elucidating the reasons. Tubal pregnancies remain a serious complication and have their highest incidence following tubal reconstruction by salpingoneostomy. Neither studies on tubal fluid obtained from the hydrosalpinx nor hematoxylin and eosin stains have revealed significant information. Scanning electron microscopy has shown different proportions of ciliated and secretory cells in various parts of the fallopian tube during the menstrual cycle, and it is speculated that a required number of ciliated cells be present in the ampulla to "sweep up" the ovum FIMBRIOPLASTY The new nomenclature defines these operations as ostial stretching, dilatation or deagglutination, lysis of peritubal obstructive bands, or incisions through the tubal wall to recover fimbriae. Often the radiologic and gross appearance ofthese club-shaped tubes are not distinguishable from the hydrosalpinx requiring salpingoneostomy, the prognosis for the former being appreciably better. Fimbrioplasty should give good results because these obstructed tubes often require minimal surgery for their reconstruction. Recoverable fimbriae are seen in only 10% to 15% of distal occlusions. Fimbriae sometimes are everted and separated by increasing luminal pressure following application of a uterine-isthmic occlusive clamp and instillation of indigo carmine into the uterine cavity through the fundus. The tubal lumen is located by puncture of the cicatric area with a 22- or 23-gauge needle. Probes dilate this opening sufficiently to enable insertion of a small hemostat. The peritoneal adhesions are stretched over the hemostat and cut with an electrosurgical needle. Optical magnification aids in this maneuver and in the proper placement of sutures. A few fine interrupted sutures fix the endosalpinx to the serosa to maintain the everted edge. The opened tube is flushed with a solution of anti-

9 Vol. 28, No. 10 SURGICAL TREATMENTS FOR TUBOPERITONEAL CAUSES OF INFERTILITY 1027 biotic and cortisone. De Maria 78 used Silastic hoods for fimbrioplasty in 41 patients; the procedure was followed by a laparotomy 8 weeks later to retrieve the devices. He reported that 27 women subsequently became pregnant. Roland and Leisten8! used spiral Teflon stents for 49 fimbrial tuboplasties and reported 11 conceptions postoperatively. REMOVAL OF PERITUBAL AND PERIOV ARIAN ADHESIONS Removal of peritubal or peri ovarian adhesions that distort the adnexal anatomy and prevent fimbrial-ovarian juxtaposition is occasionally the only operation needed to improve the patient's potential for fertility.86 A magnifying loupe or operative microscope facilitates this dissection, and a microsurgical electrode obviates the need for hemostatic sutures. Lysis and resection of adhesions under visual control are preferred to blunt digital manipulation. Palmer6! has advocated prophylactic subtotal omentectomy whenever extensive adhesions involve the adnexa. Denuded peritoneal surfaces are reperitonealized as they occur so that they are not forgotten before the abdominal cavity is closed. Ovaries firmly adherent to the posterior leaf of the broad ligament are sometimes difficult to liberate, but careful dissection usually enables full mobilization. Endometriosis is usually the cause of this condition. Adhesions are thin, stringlike, or thick, and occasionally totally encapsulate either the tube or ovary. The definitions of minimal, moderate, and severe adhesions are noted in classifying these operations, and the operation is designated according to the adnexa with the lesser disease. Thin, avascular adhesions are cut, cauterized, and removed during operative laparoscopy; thus withholding laparotomy in these patients for approximately 6 months is justified in hope that pregnancy occurs. Weinstein and Polishuk 87 reviewed 57 patients who had ovarian wedge resections and noted significant periadnexal adhesions in 8 of 19 patients who failed to conceive. COMBINED OPERATIONS Patients who have bipolar occlusions or who have different sites of occlusion on opposite tubes require combined procedures. When bipolar occlusion is present the chances of tubal reconstruction are severely limited and tuboplasty is contraindicated. Sometimes different tuboplasties are performed on contralateral tubes, and if pregnancy occurs it is quite difficult to attribute the success to a particular procedure. UNRUPTURED TUBAL PREGNANCIES Partial salpingectomy, tub ostomy with tubal incision followed by evacuation of the products of conception and tubal repair, or excision of an isthmic pregnancy followed by implantation are reserved for young patients with unruptured ectopic pregnancies. The affected tube should have good fimbriae. When the opposite tube is normal, salpingectomy is preferable. In a pregnancy located near the fimbriated end, the products of conception occasionally may be manually expressed and the entire tube preserved. With the conceptus implanted in the middle third, a linear incision is made over the enlargement in the least vascular area, the conceptus is removed, and the incision is closed with fine sutures. In most patients, tubal conservation is not feasible because of anatomical and pathologic tubal distortion. Since one-third of patients with tubal pregnancy have disease in the opposite tube, postoperative salpingography is important in women desiring future pregnancies and in those who have had a conservative operation for removal of an unruptured tubal pregnancy. Jarvinen and co-workers H8 performed conservative operations on 43 patients with tubal pregnancy in the middle or distal third of the tube followed by daily hydrotubations for 9 or 10 days. Hysterosalpingography performed an average of 5 months postoperatively showed the affected tube to be completely open in 24 of 32 patients examined. In ten patients having only the treated tube, five term pregnancies resulted but there were three repeated ectopic pregnancies and two miscarriages. Timonen and Nieminen 89 traced 743 of 1067 patients who had had tubal pregnancies, noting that in 185 patients (22%) the affected tube was treated conservatively. Operations included either tubal incision and removal of the conceptus, tubal resection, or (rarely) implantation. Since the incidence of recurrent tubal pregnancy was high, these authors recommended conservative operation only in the infertile woman in whom the contralateral tube was absent or irreversibly occluded. In conservative surgery for an unruptured tubal pregnancy, simple excision, removal of the gestation, and resuturing of the tubal defects sometimes are easy; in other instances either implantation or anastomosis is necessary, but this generally is delayed as an elective procedure in the nonpregnant patient.

10 1028 SIEGLER Stangel and colleagues 90 resected tubes for unruptured ectopic gestations in two patients and performed anastomoses with three mattress sutures of 6-0 nylon through the muscularis and serosa. The opposite tube was adherent to the lateral pelvic wall and occluded. One hydrotubation was performed on the 5th postoperative day and both patients conceived intrauterine pregnancies within 4 months postoperatively. Stromme91 reported 45 consecutive operations in which either the involved tube was reconstructed or the products of conception were evacuated. Although seven patients had recurrent tubal pregnancies, in three ofthem the opposite tube was involved. In five women the opposite tube was absent; each of these patients has had at least one subsequent viable pregnancy following conservative surgery for the tubal pregnancy. SPECIAL MATERIAL AND MEDICATIONS On the basis of results of animal experiments utilizing indwelling splints,92'94 the present consensus is to avoid the use of artificial devices to maintain tubal patency. The smallest Silastic tubing is 0.64 mm in its outside diameter and it is too large to pass easily through the intramural segment. The smaller polyethylene rods (about 0.4 mm) can be passed through this segment without causing tubal damage. Recent experiences with the operative microscope indicate that intraluminal devices help to stabilize the tubal segments during the anastomosis, but these tubings should be removed shortly after the operation. Shirodkar54 seemed convinced that at least a 2-mm indwelling catheter was needed to maintain tubal patency following anastomosis or implantation and suggested retention of these devices for at least 3 months. Hoods and stents are still used by gynecologists to maintain the neostomy following correction of distal tubal occlusion. During the last decade increasing attention has been directed toward understanding the cause of postoperative adhesions and developing methods to prevent them. Apart from the occurrence of reocclusion, the formation of adhesions is a significant cause of failure to conceive postoperatively. Trauma to the serosa containing mesothelial cells, mast cells, and capillaries causes release ofhistamines, "permeability factors," and kinins. Residual blood and prolonged drying also contribute to formation of adhesions. Constant irrigation and gentle handling of tissues with minimal use of tissue forceps and clamps reduce the damage. October 1977 Antihistamines and pharmacologic doses of corticoids preoperatively, intraoperatively, and postoperatively presumably prevent or reduce the physiologic response to trauma. 95, 96 This regimen is contraindicated in patients with phlebitis, peptic ulcer, psychiatric problems, hypertension, or diabetes mellitus. The treatment does not seem to produce any significant adrenal or pituitary suppression, electrolyte disturbances, or water retention. Because adrenal steroids are anti-inflammatory and tend to mask infections, antibiotics are frequently administered concurrently.86 Polishuk and Bercovici 97 irrigated the peritoneal cavity of some patients with 10% lowmolecular dextran during reconstructive operations and, using another group of patients who had similar operations as controls, detected no significant differences. Neuwirth and KhalafJ8 instilled 50 ml of 32% dextran 70 (32 gm of dextran of 70,000 MW plus 10 gm of dextrose) into the peritoneal cavity of female rabbits following surgically produced injuries to the uterine horns and fallopian tubes. At laparotomy 6 weeks later the number of adhesions was significantly diminished in the 11 rabbits that had received intraperitoneal injections of dextan as compared with the number of adhesions in a control group of similarly injured but untreated animals. Seitz and co-workers99 studied the formation of adhesions in 43 Macaca mulatta monkeys and concluded that careful lysis of adhesions significantly reduced their degree of re-formation. Prophylactic treatment with neither intramuscular dexamethasone and promethazine nor dextran 40 administered intraperitoneally had more beneficial effect than physiologic saline. RESULTS Kistner and Patton too have written a comprehensive review of results following tuboplasty. Imprecise terminology has made comparisons difficult, but if future reports are made in accordance with the proposed new classification perhaps more meaningful information may be revealed. The distribution and type of procedure affect the eventual rate of success. In a prospective study on tuboplasties by Cohen and others,lol 75% of the operations were performed for distal tubal obstruction, almost one-half of these being terminal salpingoneostomies. Only 18 (4.5%) of the 405 patients operated upon by 16 surgeons had anastomosis, and 76 women (19%) had implantations. The high risk of tubal pregnancy has been

11 Vol. 28, No. 10 SURGICAL TREATMENTS FOR TUBOPERITONEAL CAUSES OF INFERTILITY 1029 noted in most series--especially in those patients who have had a history of a previous ectopic pregnancy. The outcome depends also upon the age of the patient at the time of operation, whether both tubes are repaired, and the duration of follow-up. Results vary according to the etiology of the tubal obstruction, the preoperative methods for testing tubal patency, the duration of infertility, the operability rate, and the postoperative care. Since isthmic salpingoneostomy, ovarian implantation, and combined operations on the same tube rarely are followed by a successful pregnancy, these procedures should not be done. Midampullary salpingoneostomy results in about one-half the number of pregnancies resulting from terminal salpingoneostomy. Anastomosis shows the best results in tubal reconstructive surgery apart from lysis of adnexal adhesions. In evaluating 100 tuboplasties, Lamb and Moscovitz10 2 noted no term pregnancies in 9 patients after implantations, 2 viable births following anastomoses in 8 patients, and 7 pregnancies subsequent to 37 ampullary salpingoneostomies. Fourteen term pregnancies followed lysis of peritubal or pelvic adhesions. Schutz and Altmann103 attributed their improved results following 125 tuboplastic procedures to hydrotubation, which they maintain is especially valuable following fimbrioplasty. Umezaki and colleagues 104 reported the pregnancy rate after 148 tuboplasties which were classified into five groups. In 28 patients lysis of adhesions was followed by 16 pregnancies (47%), fimbrioplasty in 52 patients resulted in 12 pregnancies (23%), anastomosis in 14 patients was followed by 6 pregnancies (43%), implantations in 26 patients was followed by 7 pregnancies (26%), and combined operations in 28 patients resulted in 4 pregnancies (14%). Tubal pregnancies and abortions occurred in each group. These authors theorized that more pregnancies would be reported with an increased duration of follow-up. Compared with an earlier study from the same hospital, the new results showed improvement; the only change in technique was the addition of hydro tub at ion following correction of distal tubal occlusion. Boyd and Holt17 carried out a retrospective study of 197 patients and found a gross pregnancy rate of 15% (32 pregnancies); 11% of the patients delivered at term. Not one of the patients who had an ampullary salpingoneostomy for hydrosalpinx carried a pregnancy to term. The best results followed lysis of peri tubal adhesions; ofthe women who became pregnant, 91% became pregnant within 18 months after the procedure. Mulligan,77 in comparing his results before and after hoods were used, found a doubling of the term pregnancy rate, from 10% to 20% in patients having had ampullary salpingoneostomy. Jessen l05 reported 13 pregnancies in 9 women following 25 bilateral ampullary salpingoneostomies or a salpingoneostomy on the only remaining tube. He did not use antibiotics or corticoids; two of the pregnancies were tubal, four were aborted, and three terminated in live births. One patient had two tubal pregnancies and an abortion before the term pregnancy. Another woman who had had a bilateral salpingoneostomy and a unilateral implantation was delivered of a term pregnancy 6 years postoperatively. Repeated tuboplasties are rarely indicated, and few reports deal with this problem. Chartier and colleagues106 described 15 patients who had had more than one tuboplasty, 2 conceiving after lysis of peri tubal adhesions that resulted from the initial reconstruction. In another woman a unilateral salpingostomy and contralateral salpingectomy were done 4 years after a bilateral ampullary salpingoneostomy. A subsequent tubal pregnancy was treated with conservative operation, and the patient conceived again and delivered at term. COMPLICATI.ONS Postoperative recurrent occlusion is the most common complication, and tubal patency tests can establish this diagnosis. Peritonitis rarely follows tuboplasty, and any postoperative pelvic infection dooms the reconstructive procedure. Pelvic abscess occasionally results following implantation, and bilateral pyosalpinx, intestinal obstruction, wound disruption, and evisceration have been reported. Complications occur from artificial devices or tubings having been "lost" in the peritoneal cavity. Silastic hoods have caused extensive foreign body reactions. Other problems relate to devices or artificial tubes having receded underneath the skin or fascia, not being recoverable vaginally, or passing into the peritoneal cavity. Reoperation becomes necessary in some instances. Delayed untoward effects include most importantly the occurrence of tubal pregnancy. All patients who have tubal reconstruction operations must be alerted to the symptoms and signs of this condition. Uterine rupture and sacculation have occurred during pregnancy following implantation procedures. l07 108

12 1030 SIEGLER SUMMARY Since non operative techniques for measuring tubal patency and interpretation of the findings can be misleading, endoscopy has become a prerequisite to tuboplasty. This method is accompanied by intrauterine injections of adequate amounts of dye, and tubal manipulations to eliminate attempts to reconstruct nonsalvageable tubes, to identify those with minimal disease, and to correct certain abnormalities under laparoscopic control. Although preliminary results of dilating or stretching phimotic ostia, lysis of obstructing periadnexal adhesions, and ampullary salpingoneostomy are encouraging, these maneuvers require extreme dexterity. The objective of tubal reconstructive surgery remains the establishment and maintenance of tubal patency, the avoidance of postoperative adhesions, and the prevention of abortion and tubal pregnancy. During the last decade some progress has been made in these areas. The establishment of tubal patency surgically is usually not difficult and depends upon locating and removing the site of obstruction. The operative results of tubal sterilization and attempts at reversal are not sufficiently predictable to enable a patient to consider the possibility of reversal in her initial decision-making process. Sterilization at present should be represented only as irreversible. Although the surgeon can offer tubal reconstruction, it is important to explain that the attempted reversal requires an operation under general anesthesia lasting 3 to 4 hours and demanding considerable skill and training. Initial experience with microsurgical techniques has doubled the term pregnancy rate (from 30% to 60%), and the incidence of tubal gestations has been reduced to 10%. Will this approach result in the long-awaited and hoped-for significant increase in terms of successful postoperative pregnancy? Which type of tubal occlusion is treated best by microsurgical techniques? How can gynecologists learn to select the proper patient for the procedure and to develop the skills necessary to repair or reconstruct the damaged tube under microscopic control? Transfer of information and surgical skill is vital. The outstanding successes in tuboplasty occasionally reported by investigators using these techniques have not been duplicated by others and therefore some skepticism is justified concerning microsurgery, despite preliminary findings showing significantly increased pregnancy rates. October 1977 Maintenance of the patent tube is a problem, and several procedures have been suggested. The trend has been to avoid intratubal devices, splints, or stents. Hoods are still utilized and their benefits are said to outweigh the disadvantage of the second laparotomy needed to remove them. Postoperative hydrotubation seems to be effective, and various combinations of medication and tubal washings have been advocated. Clearly, the method of selecting the most favorable patient and the techniques for avoiding postoperative ectopic pregnancies have not been solved. REFERENCES 1. Siegler AM: Tubal surgery for infertility. In Gynecology and Obstetrics, Vol III, Edited by J Sciarra. Hagerstown Md, Harper and Row Publishers, 1975, Chap 60B, pi 2. Brundin J: Hormonal regulation of egg transport through the mammalian oviduct. In Progress in Infertility, Edited by SJ Behrman, RW Kistner. Boston, Little, Brown and Co, 1975, p Winston RML, Frantzen C, Oberti C: Oviduct function following resection of the ampullary-isthmic junction (abstr). Fertil Steril 28:284, David A, Brackett BG, Garcia CR: Effects of microsurgical removal of the rabbit uterotubal junction. Fertil Steril 20:250, Lindblom B, Hamberger L, Philipson M, Wiqvist M: Human oviductal contractility, prostaglandins, and local adrenergic receptors (abstr). Fertil Steril 28:286, Eddy CA, Hoffman JJ, Pauerstein CJ: Pregnancy following segmental isthmic reversal of the rabbit oviduct. Experientia 32:1194, Ferenczy A, Richart RM, Agate FJ Jr, Purkerson M, Dempsey EW: Scanning electronmicroscopy of the human fallopian tube. Science 175:783, Mastroianni L Jr, Brackett BG: Intraluminal tubal environment. In Progress in Infertility, Edited by SJ Behrman, RW Kistner. Boston, Little, Brown and Co, 1975, p Moghissi KS: Human tubal fluid. 1. Protein composition. Fertil Steril 21:821, Murray EG: The peritoneal factor in female sterility. Fertil Steril 4:371, Crane M, Woodruff JD: Factors influencing the success of tuboplastic procedures. Fertil Steril 19:810, O'Brien JM, Arronet CH, Eduljee SY: Operative treatment offallopian tube pathology in human fertility. Am J Obstet Gynecol 103:52, Peterson EP, Behrman SJ: Laparoscopy of the infertile patient. Obstet Gynecol 36:363, Corson L, Bolognese RJ: Laparoscopy: an overview and results of a large series. J Reprod Med 9:148, Rubin IC: Uterotubal insuffiation. Value in the treatment of tubal obstruction to ovular migration. Fertil Steril 5:311, Siegler AM: Hysterosalpingography. New York, Medcom Press, 1974

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St. Louis, CV Mosby Co, Faulborn J, Leu J, Mackensen G: Animal experiments on an absorbable synthetic thread made of polyglycolic acid (PGA) in corneal surgery. Adv Ophthalmol30:43, Malis LI: Bipolar coagulation in microsurgery. In Microvascular Surgery, Edited by RMP Donaghy, MG Yasarigil. St Louis, CV Mosby Co, Palmer R, Gordji M, Matuchansky C: Resultats compares des implantations tubo-uterines, isthmiques et ampullaires. CR Soc Fr Gynecol 20:130, Shirodkar VN: Further experiences in tuboplasty. Aust NZ J Obstet Gynaecol 5:1, Peterson EP, Musich JR, Behrman SJ: Uterotubal implantation and obstetric outcome after previous sterilization. Am J Obstet Gynecol 128:662, 1977 _, 56. Williams GF J: Tubo-uterine implantation. Lancet 1:825, Mroueh A: Effect of tubal implantation on rabbit fertility. Fertil Steril 20:928, Schwykart WR, Kutner SJ: A reanalysis of female reactions to contraceptive sterilization. J Nerv Ment Dis 156: 354, Berger GS: Reversal of female sterilization: evaluation of results. Presented at the American Association of Gynecologic Laparoscopists Workshop for Laparoscopy and Microsurgical Repair of the Fallopian Tube, Irvine, Calif, April Rosenfeld DL, Garcia CR: Laparoscopy prior to tubal reanastomosis. J Reprod Med 17:257, Palmer R: Le traitement chirugical des sterilites tubaires. Bull Fed Soc Gynecol Obstet Lang Fr 20:130, Williams EA: Aspects offallopian tube surgery. In Recent Advances in Obstetrics and Gynecology, Edited by J Stallworthy, G Bourne. Edinburgh, Churchill Livingstone, 1977, p Diamond E: Microsurgical reconstruction of the uterine tubes in sterilized patients. Personal communication, Gomel V: Tubal reanastomosis by microsurgery. Fertil Steril 28:59, Winston RML: Microsurgical tubocornual anastomosis for reversal of sterilization. Lancet 1:284, 1977