Pregnancy outcome following microsurgical fimbrioplasty

Transcription

1 FERTILITY AND STERILITY Copyright c 1982 The American Fertility Society Printed in U.SA. Pregnancy outcome following microsurgical fimbrioplasty Grant W. Patton, Jr., M.D.* Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, South Carolirw, A microsurgical technique of fimbrioplasty has been utilized in 40 patients operated on by the author. The subdivisions of deagglutination and incision of a peritoneal ring or tubal wall are described diagrammatically. Sixty-three percent of 35 patients who had a pure microsurgical fimbrioplasty conceived postoperatively. One of these 22 pregnancies was ectopic. In five patients who had a mixed procedure, all conceived postoperatively and one of five pregnancies was ectopic. Overall, pregnancy occurred in 68% of 40 patients. Uterine pregnancy was achieved in 63% and ectopic pregnancy in 5% of this series. It is of interest that 44% of those patients achieving a pregnancy did so within 3 months of surgery. Fertil Steril37:150, 1982 In an attempt to standardize the classification of infertility surgical techniques involving the oviduct, a nomenclature was agreed upon by an ad hoc committee at the 9th World Congress on Fertility and Sterility in Miami Beach, Florida, April 12, The following categories were listed to describe the surgical correction of partial fimbrialocclusion. Fimbrioplasty: A. Deagglutination and/or dilatation of fimbria. B. By incision of peritoneal ring. C. Incision of tubal wall. A recent review of the literature by the author revealed little data relating to the surgical repair of partially sealed fimbria. In fact, the actual surgical procedure identified above as fimbrioplasty has not been clarified. One author has considered fimbrioplasty to be the repair of a totally occluded distal oviduct in which fimbria are recovered following surgery. 2 Rock et ai., 3 Gomel and McComb, 4 nor I feel this was the intention of the new nomenclature. In the report that follows, Received April 1, 1981; revised and accepted September 28, *Reprint requests: Grant W. Patton, Jr., M.D., 315 Calhoun Street, Charleston, South Carolina Patton Pregnancy after microsurgical fimbrioplasty "fimbrioplasty" will refer to a surgical procedure performed for repair of partial occlusion of the fimbriated end of the oviduct. Partial occlusion may occur in mild degree as agglutination of two or three folds or may appear as an infolding of fimbria surrounded by a fibrous band, giving the appearance of almost total occlusion. A tuft of fimbria usually protrudes through this opening. If any opening exists in the distal tube, the author would classify the restorative procedure as fimbrioplasty. In contrast, "salpingoneostomy" refers to the repair of a totally occluded distal tube. The present report includes all patients operated on by the author during 1978 and 1979 in whom tubal disease in the form of partial fimbrial occlusion was noted. A microsurgical approach to fimbrioplasty is discussed, and the techniques of deagglutination of fimbria and incision of a peritoneal ring or tubal wall are clarified by drawings. MATERIALS AND METHODS During the years 1978 and 1979 the author performed 146 infertility operations. Forty-two of these patients were found at surgery to have agglutinated or partially sealed fimbria as the cause of infertility. Two patients who had a double tubal block involving the cornu and fimbria, thus requiring cornual resection with uterotubal anastomosis in addition to a fimbrioplasty on the af- Fertility and Sterility

2 fected oviduct, have not been included in this report. The remaining 40 patients were divided into two groups. Thirty-five patients who had a bilateral fimbrioplasty or a fimbrioplasty procedure on a single remaining oviduct were classified as pure ftmbrioplasty cases. Five patients were found at surgery to have partial occlusion of one oviduct and complete occlusion of the opposite tube. In these patients a mixed procedure involving fimbrioplasty and salpingoneostomy was performed. These patients are included in this report since the surgical approach to a patient with varying degrees of fimbrial disease has not been established. The extent of tubal and ovarian adhesions encountered at the time of fimbrioplasty was not evaluated in this report. All patients had undergone preoperative evaluation of ovulation and sperm factors. A preoperative hysterosalpingogram. was performed in 36 of the 40 patients included in this report. The 4 patients who did not have a hysterosalpingogram underwent preoperative laparoscopy. Thirty of36 preoperative hysterosalpingograms were found to be abnormal. These included 5 patients in the mixed group, all of whom had an abnormal hysterosalpingogram. Among the 35 pure fimbrioplasty cases a hysterosalpingogram had been performed preoperatively in 29 and found to be abnormal in 20 patients. Representative radiologic findings of partial fimbrial occlusion are included in Figure l. Diagnostic laparoscopy was performed preoperatively in 35 of 40 patients. Three of five patients in the mixed group underwent endoscopic examinations, as did 32 of the patients in the pure fimbrioplasty group. Review of the roentgenogram findings in the 3 patients who did not undergo preoperative laparoscopy revealed significant tubal abnormalities. In 1 patient the single remaining oviduct demonstrated "almost complete distal occlusion with some preservation of linear mucosal markings." In the other 2 patients a hydrosalpinx was noted involving the end of one tube, with evidence of distal tubal disease bilaterally. Primary infertility was present in 18 patients and secondary infertility in 22. Twelve patients had utilized an intrauterine device for birth control prior to attempting a pregnancy. Previous abdominal surgery, excluding a dilatation and curettage, was noted in 19 patients. The ages of the patients in this report at the time of infertility evaluation revealed 9 patients between 21 and 24 years, 16 between 25 and 29 years, and 15 patients 30 years of age or older. The microsurgical technique employed in this study will be described briefly. During 1978 ocular loupes 2.5 x and 4.5 x were employed (Designs for Vision, New York, N. Y.). A fiberoptic headlamp was used in combination with the ocular loupe to provide accessory lighting. During 1979 the author utilized a Zeiss OPMI-7ph operating microscope (Carl Zeiss, Inc., New York, N. Y.) equipped with an X-Y axis during all procedures involving fimbrial disease. A 200-mm and 250-mm objective lens, 12.5 x eyepiece, and 125 binocular tube were used with this microscope. A special Kifa flat-top table (Kifa, Stockholm, Sweden) permitted the surgeon to sit comfortably on the left side of the patient while using the operating microscope. The surgeon did not find it necessary to change sides of the table when using the sitting technique, since the microscope head was easily angled to either the right or left adnexal areas. Movement of the microscope head by means of the X-Y axis controlled by a foot pedal permitted scanning of each adnexal area during surgery. In contrast, a standing position Patton Pregnancy after microsurgical fimbrioplasty Figure 1 The photograph shown above was taken from a hysterographic study of a patient who demonstrated total occlusion of the distal (fimbrial) end of the left fallopian tube and partial occlusion of the fimbriated end of the right oviduct. Three roentgenogram findings associated with partial fimbrial occlusion demonstrated in this study are dilatation of the distal ampullary segment, preservation of rugal folds, and a narrow "jet" stream of dye often seen only at fluoroscopy squirting from the constricted fimbrial opening. 151

3 Figure 2 Sites of fimbrial agglutination are elevated with a glass rod and cut with fine microelectrode. Bipolar coagulation is employed to coagulate small bleeding vessels. was assumed when the loupe and headlamp technique were employed, and the surgeon found it necessary to change sides of the table when using this technique. A monopolar microsurgical needle was employed with the Elektrotom 60-GP electrosurgical generator (Elmed Corp., Addison, Ill.). Bipolar coagulation was provided by the Valley Lab SSE electrosurgical generator (Valley Laboratories, Boulder, Colo.). Glass rods, angled vascular scissors, microforceps, and a Winston probe were found to be useful. An irrigating solution composed of 5000 units of heparin diluted in 500 mm of lactated Ringer's solution was utilized during these procedures. fimbria. The fimbrial elements appear to have been enfolded inward by this process, which constricts the distal opening in various degrees. The mild form may represent the condition referred to as tubal phimosis, 4 while in the severe form the tube appears very similar to a hydrosalpinx until a small opening is located, usually identified by a small fragment of fimbria (Fig. 3). Under magnification provided by either an ocular loupe (4.5 x) or the operating microscope, the avascular line of scar formation can easily be seen and cut. Elevation of this area with the glass rod and incision with a microelectrode have been demonstrated (Fig. 4). Scissors were also employed for this purpose when a clear avascular line was noted. The fimbria were seen to "pop out" following this line of incision and in most cases appeared almost completely normal. Addition of the X-Y axis to the Zeiss OPMI-7ph operating microscope was a valuable asset that permitted the author to scan the adnexal area without changing position or moving his hands from the operating field. In each patient an attempt was made to preserve the fimbria ovarica and mesotubarium ovarica. One or two sutures of 8-0 synthetic absorbable material were often employed to cover denuded serosal surfaces with fimbrial folds. The outcome of microsurgical fimbrioplasty is demonstrated in Figure 5. Anterior uterine suspension 6 was employed only in those patients in whom severe adhesions and multiple denuded peritoneal surfaces were present following fimbrial repair. All patients TECHNIQUE OF DEAGGLUTINATION AND DILATATION The author no longer uses the dilatation technique offimbrioplasty described earlier,5 because under magnification it is possible to see the exact site offimbrial agglutination. Large coiled fimbrial vessels will be seen in each fimbrial strand and easily avoided. In the accompanying drawings (Fig. 2) the glass rod is used to identify and to elevate a site of fimbrial adhesion. This adhesion is usually firm and requires surgical separation with either a microelectrode or scissors. Small bleeding sites are coagulated with bipolar coagulation. INCISION OF PERITONEAL RING AND/OR TUBAL WALL The most commonly encountered condition requiring microsurgical fimbrioplasty appears as a ring of scar tissue that has compressed a tuft of 152 Patton Pregnancy after microsurgical fi,mbriopiasty Figure 3 Partial occlusion of the distal fallopian tube often appears as ~ constricted area resulting in a small opening through which protrudes tufts of fimbria. Fertility and Sterility

4 r Figure 4 A glass rod has been used to elevate the line of adhesion which is cut with the monopolar microelectrode. were treated with preoperative and postoperative promethazine and dexamethasone in the regimen described by Horne et al. 7 Thirty-two percent Dextran-70 was not employed in these patients, and postoperative hydrotubation was not performed. All patients were seen postoperatively, and all were contacted again within 6 months of this report. prior to the onset of tubal disease was reviewed. Nine of the patients were in the pure fimbrioplasty group, and all nine conceived postoperatively. Three patients in the mixed group conceived postoperatively. There were no ectopic pregnancies in this group. The group of 19 patients who had abdominal surgery prior to the diagnosis of tubal disease were also reviewed. Nine of these patients were among the group of 14 patients who failed to conceive following microsurgical fimbrioplasty. A summary of this group of patients is presented in Table 2. At the time of this report, pregnancy had occurred in 74% of those patients operated on during 1978, compared with 59% of those patients who underwent surgery in Although the shorter postoperative interval may account for part of this difference, it was also found that 61% of patients operated on in 1978 achieved a pregnancy during the 12-month interval following surgery, compared with 41% who did so following a surgical procedure in The interval between surgery and postoperative pregnancy was recorded in the 27 patients who conceived and is presented in Table 3. A RESULTS Pregnancy occurred in 68% of 40 patients who had microsurgical fimbrioplasty during 1978 and A uterine pregnancy occurred in 25 patients (63%), and two additional pregnancies were ectopic. The ectopic pregnancy rate in the entire series was 5% (2/40 patients). Sixty-three percent of 35 patients who had a pure procedure conceived. The uterine pregnancy rate in this group was 60% and the ectopic rate, 3%. Five patients who had a mixed procedure involving microsurgical fimbrioplasty and salpingoneostomy conceived postoperatively. Four of these pregnancies were intrauterine, and one was ectopic. The single ectopic pregnancy occurred in the midsegment of the tube following microsurgical salpingoneostomy. The pregnancy results following microsurgical fimbrioplasty are summarized in Table 1. The obstetrical outcome following microsurgical fimbrioplasty in 12 patients who had utilized an intrauterine device (IUD) for birth control Figure 5 The normal-appearing fimbria. One or two sutures of 8-0 synthetic absorbable material are employed when indicated. Patton Pregnancy after microsurgical {imbrioplasty 153

5 Table 1. Pregnancy Following Microsurgical Fimbrioplasty Group No. pa Uterine Ectopic Total tients pregnancy (%) (%) (%) Pure (21)a 3 (1) 63 (22) Mixed 5 80(4) 20 (1) 100 (5) Total anumbers of patients listed in parentheses. maximum follow-up interval of 24 months was utilized for the purpose of this study, although patients operated on in late 1979 have been followed for a shorter interval. Forty-four percent of those patients who conceived did so during the initial 3-month postoperative interval, and 55% of conceptions occurred during the 6-month postoperative interval. Seventy-eight percent of the conceptions occurred during the 1st year following surgery. The chance of pregnancy during each interval was also calculated (Table' 3). Thus, in the 3-month postoperative interval, pregnancy occurred in.12 out of 40 patients, or 30%. However, during the interval 7 to 12 months after microsurgical funbrioplasty, pregnancy occurred in 6 of the remaining 25 patients, or 24%. After the 1st postoperative' year 19 patients remained infertile. During the ensuing 12 months (13-24 months after operation) pregnancy occurred in 6 patients, or 32% of those patients attempting a pregnancy. DISCUSSION There are only a few clinical reports that describe a group of infertility operations that clearly fit into the category offunbrioplasty. Palmer in 1960 performed "... gentle separation of agglutinated fimbria" in 10 patients, and 5 became pregnant, although one was a tubal ectopic pregnancy.8 In addition, 41 patients in Palmer's series had a terminal salpingostomy that resulted in a postoperative pregnancy rate of 20%. The technique of macrosurgical funbrioplasty (funbriolysis) was described in detail by Kistner and Patton. 5 The. only large series of patients in whom this technique was utilized were reported by Home et al. 7 Listed as dilatation of the fimbria, this. author described the surgical' technique as follows. Fimbrioplasty involved "... dilatation and stretching by the use of probes and/or clamp technique of the strictured end of an otherwise normal-appearing tube without suturing." These authors reported that 62% of 45 patients had a 154 Patton Pregnancy after microsurgical fimbrioplasty uterine pregnancy following surgery, and 2 patients (4.4%) had an. ectopic pregnancy. Overall, pregnancy occurred in 67% of these patients. A microsurgical approach to fimbrioplasty appears to have been first described by Swolin. 9 In this classic report of microsurgical salpingostomy (1967), in addition to' 33 patients who underwent repair of a totally occluded distal tube (salpingostomy), there were 10 patients on whom, Swolin performed "salpingolysis." Only 2 of these patients, who presumably had a funbrioplasty, subsequently conceived. Siegler and Kontopoulos reported 11 patients who underwent macrosurgical funbrioplasty and 9 who underwent funbrioplasty by a microsurgical technique. 1 In the macrosurgical group 4 patients conceived postoperatively; however,'two of the pregnancies were ectopic. In contrast, 6 of 9 patients conceived after microsurgical funbrioplasty, and only one of the six preg~ nancies was ectopic. The report by Siegler is difficult to evaluate, however, since that surgeon has referred to fimbrioplasty as an operative procedure in which "the tubal lumen is located by puncture of the cicatricial area with a 22- or 23-gauge needle" and has stated that "often the radiologic and gross appearance of the clubshaped tubes are not distinguishable from the hydrosalpinx requiring salpingoneostomy, the prognosis for the former being appreciably better.,,2 Even Gomel, in a chapter describing microsurgical technique, stated that in the treatment of funbrioplasty "the ostium is gently entered with a mosquito clamp.,,4 This procedure is reminiscent of that described in Gomel has not reported his results with this technique. The microsurgical approach to funbrioplasty described in the present publication is a modification of that utilized during salpingoneostomy. There do not appear to have been earlier descriptions of this technique. Table 2. Previous Abdominal Surgery in Patients Requiring Microsurgical Fimbrioplasty Results of flmbriopla8ty Surgical procedure: No. patients Pregnant Not prepant Previous CIS Appendectomy (pure) Ectopic (pure) Exploratory lapa rotomy Ovarian cystectomy Salpingectomy (PID) Wedge resection Myomectomy Total Fertility and Sterility

6 Table'a. Interval Between Microsurgical Fimbrioplasty and Pregnancy Cumulative pregnancy Months Pregnancies rate Proportion of total pregnancies Chance of pregnancy Fraction % % % 44 12/ / /19 32 It would appear that microsurgical fimbrioplasty results in a high incidence of postoperative pregnancy because the degree of fimbrial damage is slight. The data presented in this publication may be compared to that of Rock et at,3 in which patients who underwent salpingostomy for total tubal occlusion were classified according to the extent of tubal damage. When excellent fimbria were encountered following surgical repair by salpingostomy as reported by Rock et al.,3 or following microsurgical fimbrioplasty as in the present study, excellent pregnancy results with a low rate of ectopic pregnancy were achieved. The treatment of different degrees of fimbrial damage occurring in the same patient has not been established. The unanswered question relates to the management of patients in whom total fimbrial occlusion is found in one tube and partial occlusion in the opposite tube. The lower uterine pregnancy rate and higher ectopic occurrence following repair of totally occluded oviducts would suggest the possible removal of this tube when partial occlusion is encountered in the opposite oviduct. All five patients in the mixed fimbrioplasty-salpingoneostomy group reported above conceived postoperatively, and only one of the five pregnancies was' ectopic. The single ectopic occurred in a tube that had undergone a microsurgical salpingoneostomy procedure. It is significant that the fimbria of the totally occluded oviducts in this series were graded as moderate or excellent in all five patients. Certainly, in those patients in whom a distal oviduct meets Rock's criteria for moderate or severe disease, the tube should be removed if the contralateral fimbria are almost normal. It appears, however, that the combination of partial and complete fimbrial occlusion usually reflects a mild inflammatory process, and it is therefore unusual to find severe disease in the presence of a contralateral oviduct that is partially occluded. The author encountered this condition in only three patients operated on during the interval. REFERENCES 1. 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, Siegler AM: Surgical treatment for tuboperitoneal causes of infertility since Fertil Steril 28:1019, Rock JA, Katayama KP, Martin EJ, Woodruff JD, Jones HW: Factors influencing the success of salpingostomy techniques for distal fimbrial obstruction. Obstet Gynecol 52:591, Gomel V, McComb B: Microsurgery in gynecology. In Microsurgery, Edited by SJ Silber. Baltimore, Williams & Wilkins Co, 1979, p Kistner RW, Patton GW: Atlas of Infertility Surgery. First Edition. Boston, Little, Brown & Co, 1975, p Kistner RW, Patton GW: Atlas of Infertility Surgery. First Edition. Boston, Little, Brown & Co, 1975, p Horne HW, Clyman M, Debrovner C, Griggs G, Kistner R, Kosasa T, Stevenson CS, Taymor M: The prevention of postoperative pelvic adhesions following conservative operative treatment for human infertility. Int J Fertil 18:109, Palmer R: Salpingostomy: A critical study of 396 personal cases operated upon without polyethylene tubing. Proc R Soc Med (Lond) 53:357, Swolin K: Fifty fertility operations. I. Literature and Methods. Acta Obstet Gynecol Scand 46:234, 1967 Patton Pregnancy after microsurgical fimbrioplasty 155