101. Is Laparotomy Still Indicated for Tuboplasty? 103. Neosalpingostomy: Comparison of 24- and 72-Month Follow-Up Group and Individ- "

Transcription

1 the control subjects is reasonably constant at ~ 12%. With the forms of ovarian stimulation available, it is clear that eggs of differing nuclear maturity are harvested at a single laparoscopy. Follicular fluid protein analysis makes it possible to assess the degree of maturity without disturbing the cumulus or the corona and to vary the preinsemination time accordingly. This has resulted in a significant increase in the pregnancy rate in a clinical IVF program. This work adds further weight to the evidence obtained from pregnancy rates in association with multiple embryo transfer, suggesting that the eventual success rate that might be obtained with IVF is ultimately determined by the quality of the egg at the time of its recovery. SURGICAL INFERTILITY ( ) 101. Is Laparotomy Still Indicated for Tuboplasty? KURT SEMM. Department of Obstetrics and Gynecology, Christian-Albrechts-University of Kiel and Michaelis-Midwifery School, Kiel, West Germany. For gynecologic correction of tubal disease we developed the surgical pelviscopy in Kiel. The technical preconditions therefore are the electronically controlled pneumoperitoneum (OP Pneu-Electronic), the possibility of flushing the lower pelvis for an optimal view also in case of bleeding (AQUAPURATOR), the possibility of hemostasis such as the endocoagulation technique (ENDOCOAGULATOR), and endoscopic loop ligation for sutures with intra- or extracorporeal knotting. For tubal surgery we use a twoto sixfold magnification of the endoscopic ocular picture. The surgeon is required to sit and rest his shoulders to be able to operate with both hands. The pelviscope is fixed at the operating table with a flexible device which directs the scope to the operation area. Using this new endoscopic microsurgical technique, we perform 95% of peripheric tubal surgery by pelviscopy, such as general adhesiolysis in the whole abdomen, salpingolysis, ovariolysis, fimbrioplasty, and salpingostomy. In cases of endometriosis, we treat the tubal factor according to the newly introduced endoscopic endometriosis classification (EEC). Following three-step therapy, the first step surgical, the second hormonal, 448 Abstracts the third surgical, the pregnancy rate in cases of tubal factor in the presence of endometriosis is 48% (n = 771). If the peripheric tubal damage was caused by infection, the pregnancy rate in our clinic after microsurgical correction is 21% (n = 857). The results leave us with the following question: Is a laparotomy justified today when microsurgical tube repair can be performed under endoscopic conditions? 102. Absorbable External Stents for Anastomosis of the Fallopian Tubes: A Feasibility Study. H. P. WEINRIB, AND W. P. DMOWSKI. Departments of Plastic Surgery and Obstetrics and Gynecology, Rush Medical College, Chicago, Illinois. Surgery-to restore patency of the human fallopian tube is frequently followed by occlusion at the site of anastomosis. Internal stents made of nonabsorbable material and designed for subsequent removal have been used in the past to maintain patency in the immediate postoperative period. This study was performed to evaluate the feasibility of an absorbable external stent designed for the same purpose. Adult Sprague-Dawley female rats were used as experimental animals. Stents were manufactured of polyglycolic acid in the shape of a rigid ring and were designed to be absorbed within 20 to 30 days. The internal diameter of each stent was 1.5 to 1. 7 times larger than the outer diameter of the rat fallopian tube so that the tube could remain open after suturing the stent. Fallopian tubes were divided and microsurgically reconstructed using conventional technique or external stent. All animals were bred 3 to 4 weeks postoperatively when absorption of the stent was complete. Pregnancy was achieved in all five animals with the stent. The site of anastomosis was patent and there were no histologic alterations. Three of the five animals operated upon with the conventional technique conceived, while tubal obstruction occurred in two. We conclude from this preliminary study that an external stent made of absorbable material may be suitable for anastomosis of the human fallopian tube. Advantages of such a device should include shortening of the operative procedure and higher success rates Neosalpingostomy: Comparison of 24- and 72-Month Follow-Up Group and Individ- " Fertility and Sterility

2 ual Patient Outcomes. A. H. DeCHERNEY, N. LAUFER, M. L. POLAN, AND F. NAFrOLIN. Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, Yale University School of Medicine, New Haven, Connecticut. We previously reported a 27.7% intrauterine pregnancy rate during 2 years of follow-up of 72 patients who underwent bilateral neosalpingostomy between 1976 and Fourteen percent of the patients had ectopic pregnancies. We have extended the follow-up period to 6 years in order to rule out chance differences due to other fertility factors that may have biased our 2-year outcome. During the next 4 years, another ten patients conceived intrauterine pregnancies and two more had ectopic pregnancies. This brings the 6-year intrauterine pregnancy rate up to 41.6%, while the ectopic pregnancy rate became 17% for the group. In further analysis, the data were correlated using life-table analysis predictions. There was excellent conformity between our 2-year and 6- year follow-up data. This study confirms the validity of life-table analysis of post-surgical fertility and the appropriateness of 24-month follow-up in determining group success rates after tubal surgery. Therefore, surgery should not be considered a failure if the patient has not conceived within 24 months of the original procedure Linear Ampullary Salpingotomy Heals Better by Secondary Versus Primary Closure. PETER F. McCOMB, AND VICTOR GOMEL. Department of Gynaecology, University of British Columbia, Vancouver, British Columbia, Canada. The conservative surgical management of ectopic pregnancy is often by linear ampullary salpingotomy. Yet a dilemma exists: should the salpingotomy wound be closed by primary suture, or left to heal by secondary intention to ensure optimal subsequent fertility. To resolve this issue, we bred 11 female rabbits. In early pregnancy, the oviductal ampulla was subjected to linear antimesenteric salpingotomy. One salpingotomy would was sutured and a second was left open (unsutured) in each doe. After delivery, the animals were bred once more, an abdominal chamber was inserted, and transport of surrogate ova was observed in vivo across the two different salpin- gotomy sites. Afterwards, the patterns of healing of the ampullary mucosal folds were studied in vitro for each type of operation. Ovum transport was more hesitant across the sutured salpingotomy site and delayed significantly in three of these rabbits (P < 0.05). In these same animals, the mucosal folds were oriented transversely to the direction of ovum transport as a result of the healing process. In women, ovum transport is also ciliary-dependent. One of our patients with a single oviduct has been subjected twice consecutively to linear salpingotomy for ectopic pregnancies without suture after removal of the conceptus. She has subsequently conceived an intrauterine pregnancy. We conclude that it probably is better to allow healing by secondary intention after linear salpingotomy Isthmic Ectopic Pregnancy: Segmental Resection and Anastomosis to Conserve Fertility. A. H. DeCHERNEY, F. NAFTOLIN, AND R. GRAEBE. Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, Yale University School of Medicine, New Haven, Connecticut. Ectopic pregnancy in the isthmic portion of the tube is rare, accounting for only 4% of all ectopic pregnancies. The important difference between isthmic and other forms of tubal ectopic pregnancy stems from the anatomic structure of the isthmic portion of the tube; its thick muscularis limits trophoblastic growth to the area of the lumen. Under these circumstances, linear salpingostomy is not the surgical treatment of choice. Since the lumen is destroyed, linear salpingostomy will most likely be followed by stenosis or closure of the adjacent isthmic portion of the fallopian tube. Segmental resection and anastomosis is necessary to retain fertility. While some authors suggest resection followed by an immediate anastomosis, we prefer to perform an interval anastomosis 2 to 4 months following the resection. Over the past 4-year period at our institution, ten cases of isthmic tubal ectopic pregnancy have been surgically treated in an attempt to retain fertility. Six patients had segmental resection followed by an interval anastomosis utilizing microsurgical technique. Five of six patients had a normal contralateral tube upon inspection at surgery; one had had a previous ectopic pregnancy and salpingectomy on the other side. After the procedure, all patients tried to conceive; three of the six attempts were successful. One aborted. Vol. 41, No.2, February 1984 Abstracts 458

3 - The patient with a previous salpingectomy did not conceive a second time. Four patients were treated by linear salpingostomy for their isthmic ectopic pregnancy (one via laparoscopy, three via laparotomy); all four had occluded tubes demonstrated by hysterosalpingogram at the 4-month post-surgical follow-up. Segmental resection and anastomosis is the treatment of choice for isthmic ectopic pregnancy. This represents a different surgical disease entity from other, more frequent types of tubal ectopic pregnancy Laser Versus Conventional Microsurgery for Tuboperitoneal Infertility: Initial Report of the Intraabdominal Laser Study Group. MICHAEL P. DIAMOND, JAMES F. DANIELL, DAVID S. McLAUGHLIN, DAN C. MARTIN, WILLIAM K. VAUGHN, AND JOSEPH FESTE. Center for Fertility and Reproductive Research, Departments of Obstetrics and Gynecology and Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee; Miami Valley Reproductive Center, Dayton, Ohio; Memphis, Tennessee; and Obstetrical and Gynecologic Association, Houston, Texas. Microsurgery, as compared with macrosurgery,' has improved the prognosis for restoring fertility to women with tuboperitoneal causes of infertility. Yet, maintenance of tubal patency and prevention of postoperative adhesion formation remain as goals that are not always achieved. The carbon dioxide (C0 2 ) laser may be a beneficial therapeutic modality to improve these postsurgical results by virtue of its capability for precise incisions, reduction in tissue handling, minimization of bleeding, and shortened operating time. To evaluate this possibility, a prospective multicenter study was initiated in patients with tuboperitoneal causes of infertility. Procedures performed with the CO 2 laser included adhesiolysis, vaporization of endometriosis, salpingectomy, and fimbriolysis. Forty-seven of 106 patients (44.3%) had non-patent fallopian tube(s) at the initial procedure, as compared with 11 of 106 (10.3%) at second-look laparoscopy (P < 0.001). Similarly, the number of patients with hydrosalpinx decreased from 36 of 106 (34.0%) to 5 of 106 (4.7%) (P < 0.001), respectively. In contrast, using conventional microsurgery, the Adhesion Study Group (Fertil Steril 40:612, 1983) reported a reduction among dextran-treated patients with non-patent tubes from 31 of 55 (56.3%) to 23 of 51 (45.1%) (NS) and in hydrosalpinges from 36 of 55 (65.5%) to 5 of 51 (9.8%) (P < 0.01). Thus, while conventional and laser microsurgical techniques appear to be equally efficacious in the treatment of hydrosalpinges, only use of the laser was associated with a significant improvement in patency. Whether this improvement in tubal patency will correlate with eventual pregnancy rates is as yet uncertain. By the time of presentation, I-year follow-up will be available Evaluation of Histologic Tissue Reaction to Different Microsurgical Sutures. PEDRO J. BEAUCHAMP, WALDEMAR SCHMIDT, AND BEREL HELD. Departments of Obstetrics, Gynecology, Reproductive Sciences, and Pathology, The University of Texas Health Science Center, Houston, Texas. A study was designed to evaluate histologic tissue reaction to different microsurgical sutures. Fifteen mature New Zealand White rabbits underwent laparotomy and placement of 16 different sutures in the uterus. The suture materials evaluated were: polyglactin-910 (Vicryl); polyglycolic acid (Dexon); polypropylene (Prolene); nylon (Ethilon, Dermalon); and chromic catgut. Suture calibers ranged from 6-0 to The needles evaluated were: tapered 100 j.1. and 130 j.1., micropoint spatula 130 j.1., and atraumatic lancet 145 j.1.. Sutures were placed longitudinally in the uterine muscularis under 4.5 x magnification with loupes, tied, and tagged with hemoclips for identification. The animals were sacrificed at 16, 42, and 90 days after laparotomy and routine histologic hematoxylin and eosin preparations were made. The amount of fibrosis, inflammatory reaction, and granuloma formation around the suture were scored in a scale of 0 to 3 by an observer with no prior knowledge of suture type. The radius of tissue reaction around the suture was also measured. The following results were observed: (1) at 16 days, the least tissue reaction was seen in all 9-0. to 10-0 suture materials, irrespective of its needle type; (2) Dexon was generally associated with slightly increased tissue reaction when compared with Vicryl with equivalent suture caliber and needle type; (3) 8-0 Prolene was less reactive than Vicryl, Dexon, and nylon of same suture and needle size; (4) maximal tissue reaction was observed with all 6-0 and 7-0 suture materials (including chromic) irrespective of its needle type; (5) at 42 days, minimal reactioi} was observed with all the 468 Abstracts Fertility and Sterility

4 !', ~... " 1i r" 9-0 and 10-0 sutures; (6) comparable tissue reaction was seen in 6-0 to 8-0 suture calibers regardless of needle type and suture material, except chromic which had the largest tissue reaction; (7) at 90 days, all Dexon sutures had been absorbed and only scant fragments of Vi cry 1 remained; and (8) Vicryl had lower tissue reaction compared with Prolene or nylon at 90 days. Ethilon, in tum, was more reactive than Prolene or Dermalon. In conclusion, larger suture calibers incite larger tissue reactions. Persistent tissue reaction was higher with non-absorbable sutures; therefore, their use is not recommended. Tissue reaction is similar regardless of needle type and size (100 11, , or ) when used with similar suture material and caliber. Vicryl 8-0 to 10-0 show the least short- and long-term overall tissue reaction The Prevention of Adhesion Formation by Nonsteroidal Antiinflammatory Agents: An Animal Study Comparing Ibuprofen and Indomethacin. FRANK D. DeLEON, ANDREW TOLEDO, JOSEPH S. SANFILIPPO, GEORGE H. BARROWS, AND MARVIN YUSSMAN. Department of Obstetrics and Gynecology, University of Louisville, Louisville, Kentucky. This study was designed to compare the efficacy of two nonsteroidal antiinflammatory agents in the prevention of postoperative adhesions. Thirty-three guinea pigs were randomly divided into three groups: a control group (n = 11), an ibuprofen group (n = 11), and an indomethacin group (n = 11). All animals received standardized injuries consisting of transection of both uterine horns and abrasion of the uterus. This was followed by microsurgical reanastomosis of the left proximal and right distal horn, as well as a salpingostomy on the right proximal hom. The ibuprofen group received a dose of 12.5 mglkg intramuscularly 30 minutes prior to surgery, and postoperatively received 12.5 mg/kg three times daily for nine doses. The indomethacin group received a dose of 1 mgikg, and the control group received 0.5 ml normal saline at the same time intervals as the ibuprofen group. Four weeks after the initial surgery, another laparotomy was performed and adhesions were graded blindly. Both treatment groups had significantly less (P < 0.01) adhesions when compared with the control group. Histologic evaluation of the salpingostomy sites also revealed a trend of less adhesion formation in the treatment groups. It is concluded that both ibuprofen and indomethacin are equally effective in reducing postopera-. tive adhesions Evaluation of Progestogens for Postoperative Adhesion Prevention. PEDRO J. BEAU CHAMP, MARTIN M. QUIGLEY, AND BEREL HELD. Department of Obstetrics, Gynecol(Jgy, and Reproductive Sciences, The University of Texas Health Science Center, Houston, Texas. A study was designed to evaluate previously reported claims regarding the use of progestogens for postoperative adhesion prevention. Following standardized injury, comparisons were made of animals receiving no treatment, intraperitoneal saline, or intraperitoneal high molecular weight dextran. Forty-two mature New Zealand White rabbits were divided into six groups of seven animals each. 8ix standard injuries were made by laparotomy to induce pelvic adhesions: (1) abrasion of the left fimbria; (2) abrasion and scraping of 1.5 cm length of the left uterine hom serosa; (3) 1.5-cm long incision into the endometrial cavity of the right uterine hom to expose the endometrium; (4) crushing injury ofthe right fimbria; (5) 1.5-cm laceration of the right gutter peritoneum; and (6) 1.5-cm laceration of the left gutter peritoneum. Groups were treated as follows: group S intraperitoneal placement of20 ml normal saline; group IM-I0 mg progesterone-in-oil intramuscularly, daily, for 10 days before and after laparotomy (this group also received intraperitoneal saline as in group 8); group IP-500 mg of aqueous progesterone suspended intraperitoneally; group DP-500 mg medroxyprogesterone acetate (Depo-Provera) intraperitoneally; group H-I0 ml of 32% dextran 70 (Hyskon) intraperitoneally; and group C-no intramuscular or intraperitoneal medication. The animals were sacrificed 6 weeks after laparotomy and the adhesions were scored on a scale of 0 to 3 by an observer with no prior knowledge of treatment given. The following results were observed: (1) intraperitoneal saline (8) significantly reduces the amount of adhesions when compared with the control group C (P < 0.05); (2) no significant difference was observed when group 8 is compared with group H; (3) pre- and postoperative intramuscular progesterone (1M) did not cause further reduction in adhesions when compared with intraperitoneal saline (8) alone; (4) both intraperitoneal progesterone (IP) and Depo-Provera (DP) Vol. 41, No.2, February 1984 Abstracts 478

5 r groups had more adhesions than did the saline group (P < 0.01). These data fail to support previous claims regarding adhesion prevention by local or parenteral progesterone. Intraperitoneal progesterone or Depo-Provera suspension may possibly cause tissue irritation and further adhesion formation. Intraperitoneal saline and dextran both reduce postoperative adhesions when compared with the control group The Effect of 32% Dextran 70 (DEX), Dexamethasone (DEC), Promethazine (PRO), and Ibuprofen (lbu) in Preventing Postoperative Adhesions. z. BINOR, S. A. CARSON, R. HOXSEY, H. VAN der VEN, M. BALIN, R. RAO, AND A. SCOMMEGNA. Department of Obstetrics and Gynecology, Michael Reese Hospital and Medical Center, Chicago, Illinois. Postoperative peritoneal adhesions may retard the potential benefits of fertility-restoring surgery. Many drugs have been suggested to prevent adhesion formation. We designed a controlled prospective, double-blinded study in an attempt to investigate the effect of combinations of dextran 70 (DEX), ibuprofen (IBU), promethazine (PRO), and dexamethasone (DEC) on peritoneal adhesion formation in rats. Surgery designed to stimulate adhesion formation was performed on 123 rats. The rats were divided into seven treatment groups receiving: (1) saline, (2) DEC + PRO, (3) IBU, (4) DEX, (5) DEC + PRO + DEX, (6) DEC + PRO + IBU, and (7) IBU + DEX. Each group was subdivided into three divisions. Division A was sacrificed 3 to 4 weeks postoperatively; division B at week 6; and division C during weeks 10 to 12. One investigator (S. A. C.), blinded to treatment, sacrificed all rats and scored the abdominopelvic adhesions from 0 to 4. Uterine sections were fixed and stained with hematoxylin-masson stain. Data were submitted to the Fisher permutation test. No statistical difference in adhesion formation between treatment groups was found after 3 to 4 or 6 weeks. However, after 10 to 12 weeks, rats given DEC + PRO, DEC + PRO + DEX, and IBU had fewer and smaller adhesions than the control animals. The groups receiving DEC + PRO in any combination had higher postoperative mortality than all the other groups. Microscopic evaluation revealed no difference in lym- phocytic infiltration or fibroblast content of the uterine wall in any group. In conclusion, postoperative adhesion formation was reduced by the administration of IBU, DEC + PRO, and DEC + PRO + DEX. However, animals receiving DEC + PRO had significantly higher mortality. Thus, IBU seems the most effective drug with the least risk The Significance of Hysteroscopic Lesions in the Infertile Woman. PATRICK J. TAYLOR, ARTHUR LEADER, AND H. ANTHONY PATTINSON. Endocrine/Infertility Clinic, Department of Obstetrics and Gynecology, University of Calgary, Calgary, Alberta, Canada. Combined laparoscopy and hysteroscopy were undertaken in 847 women with otherwise unexplained infertility, and in 153 women requesting reversal of a previous sterilization. Following a complete infertility workup, the endoscopic assessment was successful in 974 women. The failure and complication rates for laparoscopy were 0.4% and 0.3%, respectively, and for hysteroscopy, 2.5% and 0.9%, respectively. In primary and secondary infertility, both investigations were judged to be normal in 186 patients (22.6%). Abnormal hysteroscopic findings were noted in 89 patients whose laparoscopies were normal (32.4%). Of 547 abnormal laparoscopies, 352 (64.4%) were associated with normal uterine cavities and 195 (35.6%) with abnormal hysteroscopic findings. No significant difference in the incidence of intrauterine polyps, fibroids, or septa could be found among all groups. These hysteroscopic abnormalities did not appear to be related to primary or secondary infertility. The incidence of fine intrauterine adhesions in eumenorrheic women with otherwise unexplained secondary infertility was significantly greater when compared with women with primary infertility and with women requesting reversal of a previous tubal ligation. These intrauterine adhesions occurred independently of intraperitoneal adhesive disease and were related to the occurrence of a previous pregnancy. Lysis of these filmy intrauterine adhesions may improve a patient's fertility Usefulness of Double-Puncture Laparoscopy in the Infertility Workup. AUGUSTO P. CHONG, AND KENNETH W. ELLIGERS. Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, Mount Sinai Hospital, Hartford, 488 Abstracts Fertility and Sterility

6 Connecticut, and University of Connecticut School of Medicine, Farmington, Connecticut. A large percentage of patients referred to our Division after an unsuccessful infertility workup were found to demonstrate previously undiagnosed significant pelvic pathology with double puncture laparoscopy. In most of these cases, no previous laparoscopy had been performed before referral. Even in those cases in which a previous single-puncture laparoscopy had been performed, almost half demonstrated pathology at the time of second look double-puncture laparoscopy. Between January 1,1980 and July 31,1983, a total of 223 double-puncture laparoscopies were performed by our Division. Fifty-seven (26%) of these patients had a previous "complete" infertility workup without a diagnostic laparoscopy, and then revealed pelvic pathology at the time of our double-puncture laparoscopy. Of the 26 patients who had prior single-puncture laparoscopies, 11 (42%) had previously undiagnosed pelvic pathology at the time of our double-puncture laparoscopy. Of the 36 patients who had prior doublepuncture laparoscopies, 6 (16%) had previously undiagnosed pelvic pathology at the time of our double-puncture laparoscopy. Double-puncture laparoscopy is suggested after the initial infertility workup if the patient has not become pregnant within 6 months. Vol. 41, No.2, February 1984 Abstracts 498