Correlation between sajpingoscopic and laparoscopic staging in the assessment of the distal fallopian tube*

Transcription

1 1. s FERTILITY AND STERILITY Copyright c 1996 American Society for Reproductive Mediciue Vo. 65, No.2, February 1996 Printed on acid free paper in U. S. A. n g n f. d, e, Correation between sajpingoscopic and aparoscopic staging in the assessment of the dista faopian tube* Eric S. Surrey, M.D.t Mark W. Surrey, M.D. Center for Reproductive Medicine and Surgery, Bevery His, and Department of ObstetricsGynecoogy, University of Caifornia, Los Angees Schoo of Medicine, Los Angees, Caifornia Objective: To correate the severity and extent of intraumina tuba abnormaities assessed by transfimbria sapingoscopy with traditiona criteria for evauating dista tuba at aparoscopy. Design: Prospective 2year cinica tria with ongterm foowup. Setting: Universityaffiiated tertiary care reproductive medicine and surgery practice. Patients: Fiftyfive infertie women with suspected dista tuba or unexpained infertiity. Interventions: Transfimbria sapingoscopy was performed at the time of aparoscopy and termina neosapingostomy when appropriate. Sapingoscopic and aparoscopic findings of 91 faopian tubes were scored independenty. Resuts: No correation between aparoscopic and sapingoscopic findings was noted in group I tubes (n = 51) categorized as having minima or no pathoogy by traditiona staging. In contrast, a strong correation was noted between findings obtained from these two techniques in group II tubes (n = 4) diagnosed as having moderatetosevere tuba at aparoscopy. Intrauterine pregnancy was achieved in 38.9% (7/18) of patients with mean sapingoscopy scores s 12 versus 3.8% (1/26) of patients with mean scores > 12. Lifetabe anayses of cumuative estimated pregnancy rates were significanty different between the groups. Concusions: Faopian tubes with minima pathoogy appreciated at aparoscopy may have more significant intraumina appreciated at sapingoscopy. In contrast, aparoscopic and sapingoscopic findings do correate we in cases of more severe dista. Eevated mean sapingoscopy scores are associated with an extremey poor prognosis for conception. Ferti Steri 1996; 65:26771 Key Words: Faopian tube, sapingoscopy, aparoscopy, hydrosapinx Assessment of the faopian tube represents an integra portion of the evauation of the infertie coupe. Traditionay, indirect findings obtained at hysterosapingography, aparoscopy, or aparotomy have been empoyed to accompish this task. In cases of suspected dista tuba, investigators have empoyed the extent of tuba wa thickness, ampuary diation, presence of mucosa fods, and perituba adhesions as the primary criteria for predicting Received May 22, 1995; revised and accepted October 17, * Presented in part at the 43rd Annua Meeting of the Pacific Coast Fertiity Society, Coronado, Caifornia, Apri 26 to 3, t Reprint requests: Eric S. Surrey, M.D., Center for Reproductive Medicine and Surgery, 9675 Brighton Way, Suite 42, Bevery His, Caifornia 921 (FAX: ). successfu function (13). Others have suggested that the appearance of the fimbria and ampuary mucosa may paya more significant roe (4). Transfimbria sapingoscopy represents an aternative diagnostic too to accompish this task (5, 6). This procedure, performed at the time ofaparoscopy, is a microendoscopic approach for directy visuaizing the endotheia ining and umen of the dista faopian tube from the ampuaryisthmic junction to the fimbria. We hypothesized that the resuts of staging systems based on endosapingea abnormaities appreciated at sapingoscopy may not aways correate with those derived from findings made at aparoscopy aone. This report presents the resuts of a argescae prospective tria with ongterm foowup addressing this issue in women presenting with unexpained infertiity or suspected dista. Vo. 65, No.2, February 1996 Surrey and Surrey Sapingoscopy and aparoscopy: correation 267

2 \ MATERIALS AND METHODS Fiftyfive women with suspected dista tuba or unexpained infertiity (mean age, 34.3 years; range, 23 to 44 years) were evauated after informed consent was obtained. A patients were noted to have either tuba patency or evidence of dista tuba obstruction during prior hysterosapingography or chromotubation and were beieved to be candidates for diagnostic aparoscopy. Norma semen anayses, documentation of ovuatory status, and eary foicuar phase serum FSH eves < 2 miu/ml (conversion factor to SI unit, 1.) were obtained in a coupes before surgery. A procedures were performed during the eary foicuar phase of the menstrua cyce under genera anesthesia after administration of prophyactic intravenous antibiotics. Mutipepuncture aparoscopy was performed to maximize visuaization of the pevis. Fexibe fiberoptic or rigid sapingoscopes with camera attachments, an irrigating channe, and outer diameters ranging from 1.8 to 2.8 mm (Kar Storz, Cuver City, CA; Oympus Corp., Lake Success, NY; CirconACMI, Goeta, CA) were introduced into the peritonea cavity through a 3mm reducer paced in a 5mm accessory suprapubic trocar seeve. The serosa of the antimesenteric border of the faopian tube just proxima to the fimbria was stabiized with atraumatic grasping forceps introduced through the ipsiatera accessory 5mm trochar seeve. In patients with dista tuba occusion, a sma termina neosapingostomy just arge enough to accommodate the sapingoscope was made empoying microscissors or CO 2 aser. The fimbriated end of the faopian tube was cannuated with the sapingoscope to the ampuaryisthmic junction or unti a point of resistance was encountered. The tuba umen was distended with heparinized (5, UIL) Ringer's actate soution infused through extension tubing with a handhed syringe. Visuaization was performed in a retrograde fashion. Independent point scores were attributed to each tube on the basis of aparoscopic and sapingoscopic findings. Laparoscopic scores were based on a previousy described staging system for dista tuba with 16 points attributed for each of the foowing characteristics: extent of ampuary diation, tuba wa thickness, perituba adhesions, and preservation of mucosa fods (7). Scores for each tube coud range from 5 to 2 with point scores 2=: 9 associated with moderatetosevere. Sapingoscopy scores were derived for each tube on the basis of a staging system previousy described by Kerin et a. (8) for transcervica faoposcopy. One to three points were attributed separatey for the ampuary and fimbria regions of each tube for each of the foowing characteristics: patency, epitheia paor, vascuarity, diation, and intraumina adhesions. This faoposcopy staging system was modified by eiminating scores attributabe to the intramura and isthmic regions that are inaccessibe to the sapingoscope. Therefore, cumuative scores for each tube coud range from 1 to 3 with moderatetosevere associated with point scores > 12 based on the modification of the aformentioned description of Kerin and coworkers (8). Two groups were identified on the basis ofaparoscopic scores. Group I consisted of faopian tubes with a aparoscopy score ~ 8 compatibe with mid dista or absence of pathoogy. Group II consisted of tubes with point scores 2=: 9 compatibe with moderatetosevere. The reationships between sapingoscopic and aparoscopic scores in the two groups were assessed by cacuating Pearson's correation coefficients. Foowup information regarding conception and pregnancy outcome were obtained by teephone questionnaire and resuts evauated by modified KapanMeier ifetabe anayses. Log rank tests of equaity over strata were empoyed to compare summary data between the two groups. Mean sapingoscopy scores cacuated for each individua patient were empoyed in this anaysis. Statistica significance was associated with P vaues <.5. RESULTS Ninetyone faopian tubes were assessed by concomitant aparoscopy and sapingoscopy during this tria. The overa mean ± SEM aparoscopy score was 9.9 ±.2. Group I consisted of 51 tubes with a mean ± SEM score of 6.3 ±.2, whereas group II consisted of 4 tubes with a mean ± SEM score of 14.6 ±.8 (Fig. 1). The mean ± SEM sapingoscopy score of these tubes was 14.5 ±.5 of which 42 were noted to be norma or have ony minima by sapingoscopic staging, and 49 were noted to have moderatetosevere. No compications or untoward sequeae were noted during or after any of the procedures. A strong correation was noted between aparoscopic and sapingoscopic findings when both group I and group II were combined (r =.72). A simiary strong association was noted between scores for group II tubes noted to have moderatetosevere dista by traditiona aparoscopic criteria (r =.681). A inear reationship coud be described (Fig. 2). In marked contrast, however, no such correation coud be appreciated for group I tubes fet to be norma or demonstrate ony minima pathoogy by aparoscopic staging criteria (r =.114) (Fig. 3). 268 Surrey and Surrey Sapingoscopy and aparoscopy: correation Fertiity and Steriity

3 d Laparoscopy (LSC) Sapingoscopy (SSC) 15 1 s Figure 1 Mean ± SEM endoscopy scores for patients undergoing concomitant aparoscopy (eft) and transfimbria sapingoscopy (right) in patients with dista tuba or unexpained infertiity. Tota Norma Mid (58) Moderatesevere (928) Tota Norma Mid (112) Moderatesevere (133) 5 o f t Eighteen of the 51 tubes (35.2%) incuded in this group had sapingoscopy scores> 12, suggesting moderatetosevere, despite the absence of such findings at aparoscopy aone. Foowup data were obtained successfuy from 42 patients during a mean ± SEM period of ± 1.45 months from surgery. Intrauterine pregnancies achieved without resorting to assisted reproductive technoogies were reported in 7 of 18 (38.9%) of patients with sapingoscopy scores :5 12, but in ony 1 of24 (4.1%) of those with scores> 12. Comparison of the resuts of ifetabe anayses reveaed a significant difference in estimated cumuative pregnancy rates (PRs) over time between the groups (P =.38) (Fig. 4). A pregnancies occurred within 11 months of surgery. A 27.3% (6/22) crude PR was achieved in those patients with mean aparoscopy Q) en > Co II) OJ 14 c: '.. 12 iii en o Laparoscopy Score scores < 9 (norma tubes and mid ) as opposed to 1% (2/2) of those with mean aparoscopy scores :2: 9 (moderatetosevere ). A singe ectopic pregnancy was reported in a patient who underwent biatera neosapingostomy with mean tuba scores of 16 and 17 by aparoscopy and sapingoscopy, respectivey. DISCUSSION In this study, we have compared findings obtained from two scoring systems designed to standardize observations from sapingoscopy and aparoscopy regarding faopian tube pathoogy. We have demonstrated that faopian tubes with minima pathoogy appreciated at aparoscopy may have more significant intraumina appreciated at sapingoscopy. In contrast, aparoscopic and sapingoscopic findings do correate we in cases of more severe dista tuba. 2 Q) 16 :: _ w o t~~~. _ ~ 12 :i1 _.. o '" 8 Ii ~ O+~~~..~~~,~~ o Laparoscopy Score Figure 2 Correation between sapingoscopy and aparoscopy scores in group II (n = 4 tubes) with moderatetosevere based on aparoscopic criteria. r =.681 Figure 3 Correation between sapingoscopy and aparoscopy scores in group I (n = 51 tubes) with norma findings or minima based on aparoscopic criteria. r =.114 Vo. 65, No.2, February 1996 Surrey and Surrey Sapingoscopy and aparoscopy: correation 269

4 ~'E ".J?~ EO ::Ie un. ""E ~~ E" iid.. W Figure 4. ' !,,,, Months Graphic representation of estimated cumuative spontaneous intrauterine PRs from time of surgery based on mean sapingoscopy scores based on resuts of ifetabe anaysis. * ( ): patients (n = 18) with mean sapingoscopy scores s; 12 (mean ± SEM foowup 11.7 ± 2.3 months); t (..): patients (n = 24) with mean sapingoscopy scores > 12 (mean ± SEM foowup 14.6 ± 1.9 months). * P =.38 versus patients with scores s; 12. * The staging system empoyed in this investigation for findings obtained aparoscopicay was that estabished by The American Fertiity Society for evauation of dista tuba (7). The primary prognostic variabes empoyed incude degree of ampuary diation, extent of perituba adhesions, and integrity of mucosa epitheium. A variety of invest i gators have empoyed simiar systems to predict intrauterine PRs after reconstruction of faopian tubes with dista tuba by microsurgica or aser techniques at both aparoscopy and aparotomy (14). In contrast, Dubuisson and coeagues suggested that aparoscopic evauation of the tuba mucosa is of paramount importance in predicting the outcome of fimbriopasty or neosapingostomy (4). Donnez and CasanasRoux demonstrated that morphoogica findings as refected by retention of norma fimbria ciiated ces pay a predominant roe in predicting successfu fimbria microsurgery (9). It woud be ony ogica to assume that more direct assessment of the tuba epitheium by sapingoscopy woud provide enhanced and perhaps more accurate information regarding the functiona integrity ofthe dista faopian tube. We have demonstrated that 35.2% of faopian tubes beieved to be norma or have ony minima by traditiona staging were shown to have moderatetosevere abnormaities by sapingoscopy (Fig. 3). Athough the correation between techniques was greater in group II patients with evidence of more severe at aparoscopy, 22.5% (9/4) were noted to have norma tubes or ony minima pathoogy during tuba endoscopy (Fig. 2). Without empoying a mathematica staging system, other investigators a,so have reported a discordance between aparoscopic and sapingoscopic findings. In a sma series of patients with suspected fimbria aggutination, Shapiro et a. (1) reported a 23.5% discordance in findings between interna and externa tuba evauation. These findings were confirmed by HenriSuchet and coeagues as we (38% discordance) (5). Marconi et a. (11) reported that 37% of patients with norma aparoscopies were noted to have endotheia abnormaities at sapingoscopy in a series of 42 patients undergoing concomitant aparoscopy and sapingoscopy performed with a copomicrohysteroscope. No scoring systems were empoyed in this investigation. Simiar discrepancies between findings at hysterosapingography and those appreciated at sapingoscopy aso have been reported (5, 12). The sapingoscopic staging system empoyed in this report was designed for transcervica faoposcopy and has been modified subsequenty to eiminate scores attributabe to the intraumina and isthmic regions of the faopian tube that are inaccessibe to the sapingoscope (8). Vaidation of this staging system has been performed ony in sma trias (8), yet no other paradigm has been accepted more widey. Cassification of point scores into arbitrary stages is an inherent probem with any such system. One of the particuar weaknesses of this mode may be the fact that it is noninear in nature, which potentiay coud skew anaysis of resuts. Given the high eve of sensitivity of scores at the ow end of this system (112), a potentia for error in categorization may occur. Nevertheess, Bowman and coworkers empoyed a scoring system simiar to that used in the current investigation and noted a strong correation between intraumina pathoogy and pevic adhesions in patients with prior pevic infection but not in those with endometriosis (13). Good correation between faoposcopic and sapingoscopic findings refecting the dista faopian tube umen has been reported by Scudamore et a. (14). Hershag and coeagues (15) reported that severe tuba diagnosed at sapingoscopy correated with histoogic findings by ight and transmission eectron microscopy, further vaidating findings obtained at tuba endoscopy. Sapingoscopic scores truy achieve prognostic vaue and cinica utiity from their abiity to predict intrauterine conception. In this investigation, we have demonstrated that patients with severe endotheia and intraumina abnormaities appreciated at sapingoscopy possessed a significanty compromised potentia for spontaneous conception in marked contrast to those with norma tubes or minima (Fig. 4). In an effort to eiminate any potentia confounding effect of empoying mean sapingoscopy scores, crude PRs were recacuated on the basis of best and worst individua tube for each 27 Surrey and Surrey Sapingoscopy and aparoscopy: correation Fertiity and Steriity

5 patient. The rates for those patients with a best singe tuba sapingoscopy score :5 or > 12 were 33.3% (8/24) and % (/21), respectivey. The crude PRs for patients with worst singe tuba sapingoscopy score :5 or > 12 were 35% (7/2) and 4% (II 25), respectivey. No intrauterine pregnancies were achieved in any patient with a singe tuba sapingoscopy score> 14. A but one of the intrauterine pregnancies occurred in patients whose individua tuba sapingoscopy scores were :512. These resuts confirm those of other investigators who have demonstrated that sapingoscopic findings were vaid as predictors of pregnancy outcome for patients with dista tuba (5,16, 17) Our data suggest that sapingoscopy scores are perhaps better predictors of pregnancy outcome in patients with suspected dista tuba occusion or unexpained infertiity than more widey accepted vaues derived from aparoscopic findings. The sensitivity and specificity of sa pingoscopy scores were 87.5 and 67.6, respectivey, empoying mean vaues> 12 to refect moderatetosevere. In contrast, the sensitivity and specificity of mean aparoscopic scores ~ 9 refecting moderatetosevere were 75 and 52.9, respectivey. A pregnancies occurred within 11 months, thus suggesting that more proonged observation even in patients with minimay affected tubes may not be warranted. De Bruyne et a. (17) reported that no intrauterine pregnancies were achieved after microsurgica sapingostomy in patients with intratuba adhesions diagnosed at sapingoscopy in comparison with a 59% PR obtained in those without such findings. In concusion, transfimbria sapingoscopy represents a vauabe adjunct to the evauation of the human faopian tube. The abiity to directy visuaize intraumina adhesions and mucosa abnormaities provides vauabe information not otherwise obtained empoying more traditiona diagnostic techniques. The prognostic vaue of these findings provides support to the suggestion that this method shoud become a more routine component of the infertiity evauation. Universa acceptance of an individua scoring system awaits the resut of arger scae muticenter trias. Acknowedgments. We thank Mary Beth Sweetman, LV.N., for data coection, Ron Arzaga, B.A.. for typographica assistance, and the physicians of CedarsSinai Medica Center and Century City Hospita, Los Angees, Caifornia; West His Regiona Medica Center, West His, Caifornia; Community Memoria Hospita, Ventura, 'Caifornia; and Cottage Hospita, Santa Barbara, Caifornia, for their support and patient referras. REFERENCES 1. Mage G, Pouy JL, de Joiniere J, Chabrand S, Riouaon A, Bruhat MA. A preoperative cassification to predict the intrauterine and ectopic pregnancy rates after dista tuba microsurgery. Ferti Steri 1986; 46: BoerMeise M, te Vede E, Habbema J, Kardaun J. 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