Second-look laparoscopy after ectopic pregnancy*

Transcription

1 FERTILITY AND STERILITY Copyright The American Fertility Society Printed on acid-free paper in U.S.A. Second-look laparoscopy after ectopic pregnancy* Per Lundorff, M.D.t Jane Thorburn, M.D., Ph.D. Bo Lindblom, M.D., Ph.D. Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, GOteborg, Sweden During the 4-year period of 1984 to 1987, 102 women with ectopic pregnancy (EP) underwent second-look laparoscopy 6 to 10 weeks after EP surgery. Benefits of this procedure, e.g., adhesiolysis and/or selection of women for further fertility interventions (in vitro fertilization [IVF], gamete intrafallopian transfer [GIFT], tubal microsurgery), were evaluated. On the basis of the second-look laparoscopy, 13% of the women were offered tubal microsurgery and 14% recommended for IVF. Patients without risk factors for EP developed adhesions as frequently as those with known risk factors and no specific surgical procedure was correlated to impairment of the pelvic status. Almost 40% of the patients presented with an impairment of adhesions on the affected side compared with the status at the time of EP surgery. Lysis of adhesions was performed during the secondlook laparoscopy in 42 patients (41 % ). We conclude that second -look laparoscopy should be recommended to all EP patients with a desire for pregnancy. Fertil Steril 53:604, 1990 Infertility after ectopic pregnancy (EP) is well documented. 1-3 To a certain extent the subsequent infertility may be the result of the operative trauma to the fallopian tubes and formation of new pelvic adhesions. Interest has therefore been focused on more conservative treatments ofep, including laparoscopic techniques. 4 Efforts also are directed toward early recognition of EP, and thereby earlier surgical intervention with reduced damage to the pelvic organs. The value of postoperative laparoscopy at intervals from 8 days to 8 weeks or longer after conventional microsurgery for infertility has been assessed by several authors. 5-8 An early second-look laparoscopy makes adhesiolysis easier and formation of thick and vascular adhesions is reduced. Received August 30, 1989; revised and accepted December 26, * Supported by grant 8683 from The Swedish Medical Research Council, Sweden, and by the Goteborg Medical Society, Goteborg, Sweden. t Reprint requests: Per Lundorff, M.D., Department of Obstetrics and Gynecology, Sahlgrenska Hospital, S Goteborg, Sweden. The wide use of laparoscopy for the investigation of a variety of gynecological conditions and the low rate of major surgical complications (2.1/1,000) makes laparoscopy a "safe" procedure,9,lo and favors second-look laparoscopic evaluation after EP surgery in patients with a desire for pregnancy. Mage et a1. 11 presented a preoperative classification scheme based on a scoring system according to tubal damage and adhesions intended for prediction of the intrauterine and EP rates after distal microsurgery. The American Fertility Societyl2 recently presented another standard classification scheme for mechanical problems associated with infertility and fetal wastage. In the present study, we hypothesized that a similar classification system could be applied to assess the pelvic status in connection with EP surgery. Our intention was to analyze whether various surgical procedures differ with respect to the pelvic status at the time of second-look laparoscopy. We also studied whether patients with known risk factors for EP develop adhesions more frequently, and whether it is possible to predict which patients will benefit from a second-look laparoscopy. Finally, we 604 Lundorff et al. Laparoscopy after ectopic pregnancy Fertility and Sterility

2 investigated to what extent second-look laparoscopy can serve as a guide for future interventions, e.g., in vitro fertilization (IVF) or microsurgery. Patients MATERIALS AND METHODS During the 4-year period from 1984 to 1987, 363 patients were treated for EP at the Department of Obstetrics and Gynecology, Sahlgrenska Hospital, Goteborg, Sweden. Of these women, 102 with a strong desire for pregnancy underwent second-look laparoscopy about 6 to 10 weeks after primary surgery. This study is based on records and peroperative illustrations from these 102 women. With available information from medical records, the anatomical characteristics were registered on a special form and classified on the basis of the classification system described by Mage et al. ll in Although this classification was elaborated to predict the intrauterine and ectopic gestation rates after distal microsurgery, we used the system, with minor modifications, to classify pelvic findings during and after EP surgery, with respect to both tubal damage and adhesions. For obvious reasons, we found it improper to use the same scoring system for the tube containing the ectopic gestation, because the anatomical structures are completely different under such circumstances. Our analysis thus comprises: (1) a score for the contralateral tube and (2) a score for the adhesions of both sides. The grading was done according to the recommendations of Mage et al. ll i.e., grade 1 represented normal conditions and grade 4 the most severe adhesions and/or tubal damage. In addition to the above-mentioned score, we registered: (1) the presence of tubal rupture; (2) the size of the ectopic gestation; (3) the magnitude of blood loss; (4) the surgical procedure; and (5) the risk score for EP.13 Furthermore, peroperative intervention such as lysis of adhesions was noted. At the time of second-look laparoscopy, the same classification system was used and new scores were calculated, thus making it possible to determine a score change. Tubal patency for both tubes was registered, interventions such as lysis of adhesions were noted, and the prognosis for future fertility was evaluated for all patients. To determine whether patients with risk-factors for EP had a greater impairment ofthe tubal status, the patients were separated into two risk groups for EP, a highrisk group (risk score> 1.) and a low-risk group, with a risk score < The two risk groups were compared as to the score change (improved, unchanged, or impaired). Furthermore, the patients were separated into different groups according to the method of surgery to determine whether any method was superior with respect to patency ofthe oviducts or prevention of adhesions and tubal damage. Statistics The analysis was performed at Goteborg University Computing Center using the Statistical Analysis System (SAS) program package 14 and Pitman's nonparametric permutation test for correlations. 15 A P value < 0.05 was considered to be statistically significant. RESULTS Based on the risk score at the time of surgery for EP, 62 of the 102 patients were found to be at an increased risk for EP and 40 were found not to be at an increased risk for EP P The patients were thus separated into a high-risk group and a low-risk group. Six patients had previously undergone salpingectomy on the contralateral tube and 1 patient presented with a tubal ligation on the contralateral side. The tubal pregnancies were located in the ampulla or in the ampullary-isthmic junction in 83%, in the isthmic part in 8%, and elsewhere (infundibulum, uterine cornua) in 9%. A tubal rupture was present in 21 patients (20.6%). A mean blood loss volume of 200 ml was noted. Information on the size of the ectopic gestation could be obtained in 67 patients. Among these 67 gestations, 12 were <2 cm in diameter, 41 between 2 and 3 cm, and 14 were >3cm. Surgical Procedure Of all patients, 42% had a salpingotomy performed by laparotomy, 21 % underwent expressio ovii, 21% had a salpingotomy performed by laparoscopy, 12% had a tubal resection, and 3% had a salpingectomy performed. Two patients were evacuated from a Douglas pouch hematoma. Furthermore, 2 women who previously had a salpingectomy performed on the contralateral tube, were sterilized in connection with this EP surgery intended for future IVF treatment. Laparoscopic treatment, when used, was performed by electrocautery, linear salpingotomy, and suction-irrigation. No women underwent a laparoscopic salpin- Lundorff et al. Laparoscopy after ectopic pregnancy 605

3 Table 1 The Distribution Percentage of Adhesion and Tubal Scores in 102 Women at the Time of EP Surgery and at Second-Look Surgery for EP Second-look Adhesions Tube Adhesions Tubes Grade Affected side Contralateral side Contralateral side Affected side Contralateral side Affected side Contralateral side gectomy. At the time of EP surgery, lysis of adhesions was performed in 23 patients (22.5%). Of these 23 women, 7 presented with less adhesions at the second-look laparoscopy on the affected side, i.e., had a lower score. Nine patients were improved on the contralateral side and 5 patients were improved on both sides. At the second-look laparoscopy, lysis was performed in 42 patients (41.2%). In 4 patients, advanced adhesions hampered lysis via the laparoscope. In 2 patients, sterilization was performed with the intention of future IVF treatment. The distribution of adhesion scores and tubal scores at the time of EP surgery and at the second-look laparoscopy is presented in Table 1 and Figures 1 and 2. Classification of the Pelvic Status at the Second-Look Laparoscopy Tubal Patency In six cases, patency was not tested. Three of these had previously undergone salpingectomy on the contralateral tube and were sterilized in connection with EP surgery. Three patients were not examined because of technical circumstances. On the operated side, tubal patency was present in 70 patients out of96 examined (73%). In 26 cases with no passage, unilateral salpingectomy or resection had been undertaken in 12 cases at EP surgery. In 4 cases, salpingitis isthmica nodosa was found, 4 patients had endometriosis, and in 6 cases, no reliable passage was seen because of adhesions. In 5 patients, the incision line was not completely closed after the salpingotomy (in 3 patients after salpingotomy by laparotomy and in 2 patients after laparoscopic intervention). In the contralateral tube, patency was present in 68 patients out of 96 examined (71 %). Among the 28 cases with no passage, 3 women had previously undergone a unilateral salpingectomy and 1 presented with a unilateral tubal ligation. Four presented a distal tubal occlusion and 1 had a proximal obstruction due to closure after previous tubal im C u 50 ~ grade 4 grade 3 III grade 2 ~ grade 1 EP surgery Second look EP surgery Second look Adhesion scores, affected side Adhesion scores, contralateral side Figure 1 Adhesion score change on the affected side and the contralateral side in 102 patients between EP surgery and second-look laparoscopy. 606 Lundorff et al. Laparoscopy after ectopic pregnancy Fertility and Sterility

4 grade 4 II grade 3 III grade 2 ILl grade 1 Second look EP surgery Second look Tubal scores, allected aide Tubal scores, contralateral side Figure 2 Tubal score on the affected side at second-look laparoscopy and tubal score change on the contralateral side in 102 patients between EP surgery and second-look laparoscopy. plantation. Salpingitis isthmica nodosa was observed in 4 cases and severe adhesions in 5. In 10 cases, it was impossible to obtain reliable information from the hospital records. Tubal Status The status of the contralateral tube was evalu ~ted in 92 patients. Of the 10 cases not evaluated, 6 patients were previously salpingectomized and 1 patient had a ligated tube. In 3 cases, the tubal score could not be evaluated because of adhesions. An equal score was present in 80 patients (87%), 9 patients (10%) were impaired, and 3 patients (3%) were improved. Lysis of adhesions had been performed at the first surgical intervention in all 3 cases, where improvement was noted. (Table 2 and Fig. 2) Table 2 Classification of the Pelvic Status at the Second-Look Laparoscopy Tubal score b Affected side Unchanged 80 (87) 40 (39) Impaired 9 (10) 48 (47) Improved 3 (3) 14 (14) Values in parentheses are percents. b n = 92. 'n = 102. Adhesions' Contralateral side 23 (22) 68 (67) 11 (11) Adhesions On the affected side, impairment of the adhesions between the two surgical procedures was noted in 40 patients (39%). Forty-eight patients (47%) had an unchanged status, whereas 14 patients (14%) had an improved status. Seven ofthe latter women underwent lysis of adhesions during the first surgical intervention. (Table 2 and Fig. 1). On the contralateral side, 23 patients (22%) had an impairment of the adhesions, 68 patients (67%) were unchanged, and 11 patients (11%) presented an improvement, i.e., a lower score. Nine ofthe latter patients underwent lysis of adhesions during the first operation. Classification for Future Fertility In 67 cases, at least one tube was classified as normal and the anatomical condition of the pelvis was considered satisfactory. These patients were not subjected to further surgical intervention during the 1st year of observation. In 13 cases, the probability of future pregnancy was considered extremely low because of adhesions and/or tubal damage. These patients were therefore offered microsurgery. More advanced damage to the tubes or severe adhesions were found in 12 women, and microsurgery was considered meaningless, as it was in 2 patients sterilized at EP surgery. These 14 women were offered IVF treatment or recommended adoption. Gamete intrafallopian transfer Lundorff et ai. Laparoscopy after ectopic pregnancy 607

5 22E Table 3 Frequencies of Patent Tubes After Various Surgical Methods Surgical methods Total number of patients Patency tested on the operated side at second-look laparoscopy Patency found on the operated side at second look laparoscopy Correlations to patency Expressio ovii Salpingotomy Tubal resection Salpingectomy Laparoscopic surgery (70) 35 (88) 3 () 0(0) 16 (76) NS b positive correlation negative correlation Values in parentheses are percents. b NS, not significant. was offered in 1 case. The remaining 7 patients were recommended hysterosalpingography for further evaluation of the anatomical conditions. Comparison Between the Risk Groups No correlation between the risk groups and the blood loss volume, the frequency of tubal rupture, or the location of the EP was found. Furthermore, there were no correlations between the two risk groups and the different surgical procedures used. There was no statistical difference between the groups with respect to lysis of adhesions, tubal score, or tubal patency, and no significant difference was observed as to improvement or impairment of adhesions and tubal scores. Comparison Between Surgical Methods Tubal Rupture There was a negative correlation between salpingotomy and tubal rupture, the presence of a tubal rupture being less frequent among patients subjected to salpingotomy (P < 0.05). Furthermore, there was a negative correlation between laparoscopic intervention and tubal rupture. Rupture is seen less often in women operated on by this method (P < 0.01). Tubal Patency on the Operated Side Apart from a negative correlation between tubal resection and tubal patency (P < 0.05) and a positive correlation between salpingotomy and tubal patency (P < 0.001), there was no correlation between surgical methods and tubal patency. The frequencies of patent tubes after the various surgical methods are illustrated in Table 3. Tubal and Adhesion Score No surgical procedure was found to be correlated to improvement or impairment of adhesions or tubal score. Thus, a laparoscopic treatment did not imply less adhesions at second-look laparoscopy compared with conventional laparotomy. Complications At the time of EP surgery, there were few complications. One patient had her bladder perforated and one had a high temperature postoperatively. Both patients had a salpingotomy by conventional laparotomy performed. Three patients, of which two initially had a laparoscopic evacuation, developed postoperative complications demanding a second intervention; two because of hematomas and one because of retained trophoblastic tissue. No major complications were seen among the postoperative laparoscopies. DISCUSSION In this study, the scores given are based on information from hospital records and peroperative drawings and the results may therefore be biased. Subjective evaluation of the degree of adhesions by different surgeons may also have contributed to a certain bias. In spite of this, we found it most valuable to study possible benefits of a second-look laparoscopy in routine clinical practice and to investigate whether there were any special conditions leading to an impairment of the pelvic status after EPsurgery. The optimal time for second-look laparoscopy suggested by others varies from 8 days to 8 weeks. 5-8 Our investigation does not allow any further recommendation in this respect because of its retrospective nature and the varying time period (6 to 10 weeks) between first and second intervention. When the study commenced, the only available classification system suitable for evaluation of laparoscopy after EP surgery was the classification system of Mage et a1. 11 The American Fertility Society classification 12 of tubal pregnancies was only 608 Lundorff et at. Laparoscopy after ectopic pregnancy Fertility and Sterility

6 recently published. This classification will probably be even more valuable for future use because the system includes a special classification for EP. We conclude from this study that it is not possible to predict which women will develop an impairment of the pelvic status by separating them into different risk groups. Neither is it possible to predict the extent of adhesion formation after various surgical procedures. Based on results from our study, it is thus not possible to determine which patients will develop an impairment of adhesions after EP surgery. As we found that almost every second woman in our material presented an impairment of adhesions, we suggest that all patients with a desire for pregnancy should be offered a second-look laparoscopy. Our results further indicate that patency is not seen more frequently after laparoscopic treatment than after conservative treatment by laparotomy. Neither could we demonstrate less frequent adhesions after laparoscopic treatment than after conservative treatment by laparotomy. However, as this study is not a randomized prospective trial, no conclusions can be drawn in that respect. It is of interest to note the failure of tubal closure after salpingotomy, with leakage in five cases (cf. Cropp et al.).16 Whether such fistulas are of functional importance for ovum transport remains to be investigated. Surprisingly, we found that a large proportion of the patients had undergone lysis of adhesions at the EP operation. This is generally not recommended.17 Nevertheless, we observed that half of the patients subjected to lysis of adhesions at the time of EP surgery presented an improved status at the time ofthe second-look laparoscopy. Nearly 40% of all the patients presented an impairment of the pelvic status at the second-look laparoscopy and as many were treated by lysis of adhesions. To what extent such adhesiolysis will contribute to a better fertility prognosis is not possible to evaluate on the basis of this study. In connection with the second-look laparoscopy, almost one-third of the patients could be offered further treatment because of the diagnosed pelvic condition. Future studies may further highlight the value of second-look laparoscopy after EP and hopefully answer the ques- tion as to whether this procedure improves fertility. REFERENCES 1. Tuomivaara L, Kauppila A: Radical or conservative surgery for ectopic pregnancy? A follow-up study of fertility of 323 patients. Fertil Steril 50:580, Thorburn J, Philipson M, Lindblom B: Fertility after ectopic pregnancy in relation to background factors and surgical treatment. Fertil Steril49:595, Sherman D, Langer R, Sadovsky G, Bukovsky I, Caspi E: Improved fertility following ectopic pregnancy. Fertil Steril 37:497, Bruhat MA, Manhes H, Mage G, Pouly JL: Treatment of ectopic pregnancy by means oflaparoscopy. Fertil Steril33: 411, Trimbos-Kemper TCM, Trimbos JB, van Hall EV: Adhesion formation after tubal surgery: results of the eighth -day laparoscopy in 188 patients. Fertil Steril 43:395, Jansen RPS: Early laparoscopy after pelvic operations to prevent adhesions: safety and efficacy. Fertil Steril 49:26, DeCherney AH, Mezer HC: The nature of posttuboplasty pelvic adhesions as determined by early and late laparoscopy. Fertil Steril41:643, Raj SG, Hulka JF: Second-look laparoscopy in infertility surgery: therapeutic and prognostic value. Fertil Steril 38: 3, Frenkel Y, Oelsner G, Ben-Baruch G, Menczer J: Major surgical complications of laparoscopy. Eur J Obstet Gynecol Reprod BioI 12:107, Brantley JC, Riley PM: Cardiovascular collapse during laparoscopy: A report of two cases. Obstet Gynecol 159:735, Mage G, Pouly J-L, Bouquet de Joliniere J, Chabrand S, Riouallon A, Bruhat M-A: A preoperative classification to predict the intrauterine and ectopic pregnancy rates after tubal microsurgery. Fertil Steril46:807, The American Fertility Society: The American Fertility Society classification of adnexal adhesions, distal tubal occlusion, secondary to tubal ligation, tubal pregnancies, Milllerian anomalies, and intrauterine adhesions. Fertil Steril49: 944, Thorburn J, Philipson M, Lindblom B: Background factors of ectopic pregnancy. II. Risk estimation by means of a logistic model. Eur J Obstet Gynecol Reprod BioI 23:333, SAS Institute, Inc: User's Guide, 1983 edition. SAS Institute Inc., Cary, North Carolina, 1983, p Bradley JW: Distribution-Free Statistical Test. Englewood Cliffs, New Jersey Prentice Hall, 1968, p Cropp CS, Cowell PD, Rock JA: Failure of tubal closure following laser salpingostomy for ampullary tubal ectopic pregnancy. Fertil Steril48:887, Winston RML, Margara RA: Conservative management of ectopic pregnancy. Obstet Gyneco15:51, 1984 Lundorff et ai. Laparoscopy after ectopic pregnancy 609