Salpingoscopy: systematic use in diagnostic laparoscopy

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1 f FERTILITY AND STERILITY Copyright ~ 1992 The American Fertility Society Printed on acid-free paper in U.S.A. Salpingoscopy: systematic use in diagnostic laparoscopy Guillermo Marconi, M.D.* Luis Auge, M.D. Emilio Sojo, M.D. Edgardo Young, M.D. Ramiro Quintana, M.D. Instituto de Fertilidad, Buenos Aires, Argentina Objective: To evaluate the importance of salpingoscopy together with laparoscopy in the diagnosis of tubal pathology. Design: Salpingoscopy was performed as a complementary method in patients who were subjected to diagnostic laparoscopy. The relationship between the salpingoscopy and (1) the patient's previous history of tubal disease and (2) laparoscopic diagnoses was evaluated. Setting: Private patients referred to the Instituto de Fertilidad, Buenos Aires. Patients, Participants: Forty-two patients undergoing a diagnostic laparoscopy during the evaluation of their fertility or as a follow-up of previous therapy. Main Outcome Measure(s): Salpingoscopy was performed, using a colpomicrohysteroscope. We evaluated alterations in major and minor folds and their vascularization, the presence of microadhesions, and cellular nuclei dyed with methylene blue in the tubal lumen. Results: Fifty percent of the patients who had no previous history of tubal disease presented with endosalpingeal alterations, and in 37% of the normallaparoscopies the salpinx had unilateral or bilateral salpingoscopic abnormalities. Conclusions: Salpingoscopy is a useful method to evaluate oviducts, before assuming their normality, and consideration of these women for assisted reproductive technology. Fertil Steril 1992;57:742-6 Key Words: Salpingoscopy, laparoscopy, fallopian tube, endosalpinx Even though reproductive medicine has experienced important advances in the last decades, the fallopian tube has received little attention. Studies of this organ have primarily involved aspects ofpatency. Salpingoscopy facilitates the evaluation of tubal mucosal morphology in greater detail. This paper reviews experience of the Instituto de Fertilidad (Buenos Aires) using this method. We have studied the salpingeal folds, tubal components, and the relation existing between them. These salpingoscopic findings were then correlated with the patients' previous history and with her laparoscopic Received May 23, 1991; revised and accepted December 26, * Reprint requests: Guillermo Marconi, M.D., Instituto de Ginecologia y Fertilidad, Marcelo T. de Alvear 2261, 8#, (1122) Buenos Aires, Argentina. diagnosis to attain a prospective assessment of diagnostic and therapeutic clinical significance. MATERIALS AND METHODS Forty-two patients were evaluated using salpingoscopy. Each of them underwent a diagnostic laparoscopy during evaluation of their fertility or as a follow-up of previous therapy. Of the 42 patients, 20 (47.6%) had no previous history of tubal disease. Of the remaining 22, 4 (9.5%) had a prior induced abortion, and in 8 (19%) the abortion had been spontaneous. Nine had been subjected to a previous pelvic surgery (8 ectopic pregnancies [EPs] and 1 tubal operation). One patient had been treated for pulmonary tuberculosis during her adolescence. Laparoscopic findings included endometriosis (21.4%), peritoneal factors (28.5%), and no pathol- 742 Marconi et ai. Salpingoscopy and laparoscopy

2 ogy (19%). The remaining patients were distributed as follows: two had phimosis, five proximal tubal obstructions, three with hydrosalpinges, one had agglutination of fimbriae, one sacular distention of the tubal wall, and one salpingeal malformations. The colpomicrohysteroscope (Richard Wolf, Knittlingen, Germany) was used. The tubal ostium was localized by means of two atraumatic forceps. The salpingoscope without its sheath was then introduced through a second suprapubic incision. It was inserted through the ostium and advanced along the tubal lumen until the isthmic-ampullary junction was reached. The tubal lumen was distended by saline injected through the cervix of the uterus via a Rubin cannula. In patients presenting with proximal tubal obstructions, the salpingoscope was introduced with its sheath, and saline was injected through the sheath. We evaluated major and minor folds, their vascularization, the presence of microadhesions in the tubal lumen or its serosa, and the presence of absence of cellular nuclei stained with methylene blue. The fimbriae were examined by submerging them in saline accumulated in the pouch of Douglas. Hydroflotation allowed estimation of the configuration, degree of freedom, existence of adhesions, and vascularization of the fimbriae. The procedure was monitored laparoscopically via the umbilical incision. RESULTS Results were related to (1) the technique in itself and (2) the salpingoscopic findings. These were then correlated with the patients' previous history (3) and the laparoscopic diagnoses (4). Technique Localization of the tubal ostium and cannulation with the salpingoscope were quite simple and presented no difficulties. In cases with proximal obstruction when the sheath had to be used, cannulation was difficult if the ostium was narrow. This difficulty was overcome by gentle dilation of the ostium with forceps. Distention of the tubal lumen by instillation of saline solution was adequate, and an excellent view of the organ was obtained. Only two patients had complications during their procedures: in one the tubal epithelium was torn, and in another a tube was perforated. Bleeding was controlled and suturing was not required. Both patients have subsequently conceived. Salpingoscopic Findings Normal Tube Isthmic-Ampullary Junction. Minor folds extended from the beginning of the ampulla to the ostium in a longitudinal direction. They were separated by relatively large spaces, through which the tubal wall could be appreciated. Vascularization of minor folds was represented by a thin capillary positioned longitudinally in the direction of the axis of the fold. Occasionally, a collateral branch emerged. Tubal wall vessels ran subepithelially and had a thick diameter and a tortuous course. Ampulla. Marked and abundant protuberant major folds, practically occluding the tubal lumen, were evident. If the magnifying power was increased, multiple parallel capillaries were recognized. These gave a striped appearance to the structure. Fimbriae. These were made up of concentrated folds that were similar to those seen in the isthmicampullary junction. Hydroflotation allowed the fimbriae to appear as a pile of coins or a skirt with many petticoats. The Pathological Tube Twenty-four of the 42 patients had pathological tubes. These were characterized by alterations of their basic components: the major and minor folds and their pattern of vascularization. The folds flattened progressively until they were no longer recognizable. Vascularization lost its typical pattern, appearing as irregular forms, as en- 1arged capillaries, or as fragile vessels. Adhesions presented as thin veils seen over the axis of the fold or thick structures that bound and pasted the folds to each other. In tubes with inflammatory signs, cellular nuclei dyed with methylene blue were seen frequently. The complete absence of inner structures was a common finding in some of the hydrosalpinges. Remains of folds, vessels of the tubal wall, and tight groups of colored cells could be seen. Pathological alterations were unilateral in 11 patients, and bilateral in 13. In most of these, mixed pathology was found. Marconi et ai. Salpingoscopy and laparoscopy 743

3 Table 1 Salpingoscopic Findings in Relation to the Patients' Previous History No. of Total pat. no. of Normal Pathological Antecedents patients tubes tubes tubes Induced abortion 4 8 Spontaneous abortion 8 16 Previous surgery t 1 2 EPt 8 8 Tuberculosis 1 2 No antecedents * Values in parentheses are percents. t Tubo tubal anastomosis. t Contralateral tube Salpingoscopic Results In Relation to the Patients' Previous History Abortion 6 (75.0)* 6 (37.5) 2 (100.0) 4 (50.0) 2 (100.0) 15 (37.5) In two of four patients who previously had an induced abortion, one tube was normal and the remaining tube had folds that were flattened. There were adhesions and severe alterations of the endosalpinx. Six of the eight tubes were pathological (75%) (Table 1). Only four of the eight patients who had experienced spontaneous abortion, had normal tubes. In two of these patients tubal pathology was unilateral and bilateral in the remaining two patients. Six of the 16 (37.5%) tubes were pathological (Table 1). Previous Surgery Only one patient had undergone surgical correction for bilateral proximal obstruction. Salpingoscopy revealed flattening of tubal folds (Table 1). Ectopic Pregnancies Of the eight patients, seven had only one tube. The remaining patient had both tubes. Three of these seven patients had normal endosalpinges, whereas the remaining four (57.1%) patients had alterations. In the patient with both tubes, the tube that had contained the EP had only moderate lesions, whereas the contralateral oviduct was normal. It is therefore concluded that 50% of contralateral tubes in cases of EP may be pathological (Table 1). Tuberculosis Salpingoscopy revealed a severely damaged endosalpinx, with flattened folds and thick, pasty adhesions that held the folds together. Abnormal vascularization was noted. The patient had contracted pulmonary tuberculosis when 14 years old, and radiologic and laparoscopic studies were normal. No Antecedent History Of 20 patients with no previous history of tubal disease, 10 presented flattening of the folds, adhesions, and/or vascular alterations. In 5, the pathology was bilateral, and in the remaining 5 it was bilateral (i.e., 37.5% of the tubes presented pathology, Table 1). One of the patients with unilateral disease subsequently had an EP in the pathological tube. Salpingoscopic Findings in Relation to Laparoscopic Diagnoses Normal Laparoscopy In 8 of 42 patients the laparoscopic findings were normal, but 3 of these 8 patients had abnormal salpingoscopic findings: flattening of folds with a few adhesions of one tube in 2 patients and complete destruction of the mucosa in both tubes in 1 patient. This patient had a history of tuberculosis. Thus, 37.5% of the patients with normal laparoscopic findings had tubal pathology diagnosed at salpingoscopy (Table 2). Endometriosis Nine patients had endometriosis. In 55.5% ofthe patients, the salpingoscopic study was normal. One patient had salpingoscopic alterations in both tubes, and three patients had alterations in a single tube (Table 2). Flattening of folds, small adhesions, and some inflammatory cells stained with methylene Table 2 Salpingoscopic Findings in Relation to Laparoscopic Diagnosis Salpingoscopy Patients Patients with with pathological tubes No. of normal Laparoscopy patients tubes Unilateral Bilateral Normal 8 5 (62.5) * 2 1 Endometriosis 9 5 (55.5) 3 1 Peritoneal factor 12 5 (41.6) 2 5 Malformations, sacular dilatations 2 0(0.0) 1 1 *Values in parentheses are percents. 744 Marconi et al. Salpingoscopy and laparoscopy

4 blue were observed. The lesions observed by salpingoscopy did not correlate with the stage of endometriosis. Peritoneal Factor Peritoneal factors encountered ranged from film adhesions covering one or both ovaries, and/or the tubes, to severe adhesions that compromised unilaterally or bilaterally the adnexa and bowels. Of the 12 patients with peritoneal factors, 5 (41.6%) did not reveal any salpingoscopic lesion. In the remaining 7 patients, tubes were affected by either single or combined pathologies. In 2 of these 7 patients, the pathology was unilateral (Table 2). Lesions observed by salpingoscopy did not correlate with the degree of severity of the peritoneal factor. Tubal Obstruction Eleven patients were found to have distal obstruction or proximal tubal disease (Table 3). In phimosis and agglutination of fimbriae, loss of folds was found unilaterally. However, in the three hydrosalpinges, there was absence of endosalpingeal components, presence of isolated rests of fimbriae, and a high incidence of inflammatory cells. In the five patients with proximal tubal obstruction, three were postinfectious and two were posttubal ligation. In two of the three infectious ones, there was flattening of folds and adhesions between them. In the remaining patient and in the two patients with tubal ligation, the mucosa was normal. Malformations and Dilatations In one patient there was a congenital mesotubal shortening. The only alteration evidenced in the salpingoscopy was a marked flattening of the folds. In another patient, sacular dilatation in both tubes with chromotubation passage was observed. Salpingoscopy showed a tube with no structures in this dilatation, whereas the rest of the organ was normal (Table 2). DISCUSSION Salpingcoscopy provides morphological data that widens the horizons of tubal evaluation and facilitates a more detailed analysis of therapeutic possibilities. In the present work, salpingoscopy was performed as a complementary method in 42 patients subjected to diagnostic laparoscopy. Table 3 Salpingoscopic Findings in Relation to Laparoscopic Diagnosis * Salpingoscopy Patients Patients with with pathological tubes No. of normal Laparoscopy patients tubes Unilateral Bilateral Tubal obstruction Phimosis and agglutination Hydrosalpinx Proximal tubal obstruction Infectious Tubal ligation Total 11 3 (27.2)t 3 5 * Obstructions. t Value in parentheses is percent. Fifty percent of the patients who had no previous history of tubal disease had endosalpingeal alterations, and in 37% of the normal laparoscopies, the salpinx had unilateral or bilateral salpingoscopic abnormalities. Salpingoscopy should be completed in all cases and not carried out only according to the pathology found at laparoscopy as proposed by Brosens et al. (1) or as a methodology to decide on surgical treatment, as suggested by Shapiro et al. (2). In accordance with the literature (2, 3), we observed the concordance between salpingoscopic and laparoscopic pathological findings when an inflammatory infectious factor had been the origin of the pathology. In 58.4% of peritoneal factors, endosalpingeal alterations were found in the form of microadhesions and/or the presence of cells of a probable inflammatory origin. These cells could be lymphocytes, which, because of a compact chromatin nuclear content, could be colored more easily than the rest of the cells. An exception was the drastically altered salpinx of the patient who had suffered from tuberculosis, who presented a normal laparoscopy. In the case of EPs, 50% of the contralateral tubes evidenced alterations in accordance with histologic findings described in the literature (4). Salpingoscopic alterations were observed in 72.7% of patients suffering from obstructive tubal disease. According to Shapiro et al. (2), the idea of a microsurgical reconstruction in patients who have tubal obstruction with a severe alteration of the endosalpinx should be re-evaluated. In these situations, in vitro fertilization-embryo transfer should be con- Marconi et al. Sa/pingoscopy and laparoscopy 745

5 sidered as an alternative to achieve pregnancy more rapidly and efficiently. On the other hand, salpingoscopy may complement techniques of assisted reproduction that use the tube for deposition of gametes or embryos. In altered tubes or tubes with intraluminal adhesions, these procedures should be reconsidered, to minimize the risk of EPs and possibly increase the percentage of viable pregnancy. Even though this work does not correlate salpingoscopic findings with radiologic results, the published literature has 42% of inconsistencies in favor of endoscopy (5). This technique only evaluates the ampullary portion of the tube, excluding the isthmic and intramural portion (6), but we believe that the ampullary portion of the tube plays an almost decisive function in the reproductive process. In conclusion, salpingoscopy increases our knowledge in the study of fertility, it improves salpingeal diagnoses, and it provides data that may assist in achieving pregnancy in less time and with less risk for the patient. REFERENCES 1. Brosens I, Boeckx W, Delattin PH, Puttemans P, Vasquez G. Salpingoscopy: a new preoperative diagnostic tool in tubal infertility. Br J Obstet GynaecoI1987;94: Shapiro B, Diamond MP, De Cherney AH. Salpingoscopy: an adjunctive technique for evaluation of the Fallopian tube. Fertil Steril1988;49: De Bruyne F, Puttemans P, Boeckx W, Brosens I. The clinical value of salpingoscopy in tubal infertility. Fertil Steril1989;51: Schenker JG, Evron S. New concepts in the surgical management of tubal pregnancy and the consequent postoperative results. Fertil Steril 1983;40: Henry-Suchet J, Loffredo V, Tesquier L, Pez J. Endoscopy of the tube (=tuboscopy): its prognostic value for tuboplasties. Acta Eur Fertil 1985;16: Kerin J, Daykhovsky L, Segalowitz J, Surrey E, Anderson R, Stein A, et a1. Falloposcopy: a microendoscopic technique for visual exploration of the human fallopian tube from the uterotubal ostium to the fimbria using a transvaginal approach. Fertil Steril 1990;54: Marconi et al. Salpingoscopy and laparoscopy

Results of microsurgical reconstruction in patients with combined proximal and distal tubal occlusion: double obstruction

FERTILITY AND STERILITY Copyright 987 The American Fertility Society Printed in U.S.A. Results of microsurgical reconstruction in patients with combined proximal and distal tubal occlusion: double obstruction