Tubal Plastic Surgery ADNAN MROUEH, M.D., ROBERT H. GLASS, M.D., and C. LEE BUXTON, M.D. TUBAL PLASTIC SURGERY is an accepted form of therapy in the treatment of infertility. However, reports have differed on the incidence of eventual pregnancy after tubal surgery,5-7 perhaps because of differences in the criteria used to determine operability. Evaluation of the results is also difficult because reports often fail to state whether one or both tubes required repair. It is therefore our purpose to report a series of tubal plastic operations emphasizing the evaluation of cases with reference to the type of surgery performed on each side of the pelvis. Buxton and Mastroianni reported 5 cases of tubal reconstructive surgery done at our clinic between 955 and 96. This report is a continuation of that series and comprises patients who underwent tubal surgery in an attempt to cure infertility. These patients were operated upon between Jan., 96, and Dec., 96. MATERIALS AND METHODS Thirty-six of the patients in this study had primary infertility while 8 had had at least pregnancy. The duration of infertility was from to 5 years. The period of follow-up ranged from to 0 months. Thirty patients had had previous abdominal surgery: fifteen had had laparotomy for a nonperforated appendix, 5 had had laparotomy for a perforated appendix, had had laparotomies for infertility, had had laparotomy for ectopic pregnancy, had had laparotomy for tubal ligation, and had had other abdominal or pelvic surgery. Five patients had a history of pelvic infections: four had had acute pelvic inflammatory disease and had had puerperal sepsis. All couples underwent a standard infertility investigation. Diagnostic techniques employed before operation to evaluate tubal patency included CO:.: insufflation, hysterosalpingography, and, in 9 cases, culdoscopy with From the Department of Obstetrics and Gynecology, Yale University School of Medicine, New Haven, Conn. 80
VOL. 8, No., 967 TUBAL P-LASTIC SURGERY 8 dye insuffiation. If the original CO insuffiation showed no passage of gas it was repeated with the aid of a paracervical block. Ethiodol* (ethiodized oil) was used for the hysterosalpingograms, which were performed with the aid of fluoroscopic visualization with an image intensifier. X-ray films were obtained while the dye was being injected and, in addition, -hr. follow-up films were obtained that proved very helpful in diagnosing pelvic adhesions, which often cause pooling of the dye. Paracervical block makes the procedure less uncomfortable and may relieve spasm at the uterotubal junction. Both CO insuffiation and hysterosalpingography may give erroneous results. Buxton and Southam reported that 8 of 7 patients in whom tubal closure was indicated both by CO insuffiation and hysterosalpingography became pregnant without surgical treatment. Because of this possibility of error, the hysterosalpingogram was supplemented by culdoscopy in 9 cases. Dilute methylene blue was injected into the cervical canal during the procedure and passage of the dye from the distal end of the tube was taken as proof of patency. In of the cases an identical surgical procedure was performed on both sides of the pelvis. In 9 cases the two sides were subjected to different surgical procedures. In 8 cases surgery was performed on only one side of the pelvis and the contralateral side was noted to be "normal." In cases no pelvic pathology was detected despite abnormal tubal patency tests. One patient had had a previous tubal ligation and technical difficulties at the time of attempted repair resulted in the termination of the procedure without tubal surgery being undertaken. Surgery was performed either by a senior staff member specializing in infertility or by the resident staff under senior supervision. RESULTS Surgery limited to lysis of adhesions offered the best results. After bilateral lysis of adhesions of 0 patients became pregnant (Table ). When only one tube was involved in adhesions of patients became pregnant. Bilateral fimbrioplasty resulted in pregnancy in of 7 cases. Pregnancy occurred in of patients who underwent unilateral fimbrioplasty. However, the contralateral tube had been normal at the time of surgery in the latter cases. No pregnancy occurred in 6 cases when bilateral tubal reimplantation *E. Fougerll- ~nd Co., Inc., Hicksville, Long IsI~nd, N. Y.
8 MROUEH ET AL. FERTILITY & STERILITY TABLE. Pregnancies after Tubal Plastic Surgery Procedure Pregnancies --------- Patency Cases Aborted Ectopic Term achieved SIMILAR BILATERAL SURGICAL PROCEDURE Fimbrioplasty 7 Lysis of adhesions 0 Cornual resection and polyethylene splint 6 5 7 DISSIMILAR BILATERAL SURGICAL PROCEDURE Fimbrioplasty, lysis of adhesions Fimbrioplasty, cornual resection Lysis of adhesions, cornual resection 5 UNILATERAL SURGICAL PROCEDURE Lysis of adhesions Fimbrioplasty Cornual resection was performed. Postoperative patency was achieved in only of these patients. One abortion and no term pregnancies occurred in 9 patients in whom different procedures were performed on each side of the pelvis. The one serious complication in the series involved the loss of polyethylene tubing into the peritoneal cavity. The polyethylene was extruded from the fallopian tube in the postoperative period. An abscess resulted which required laparotomy for drainage and removal of the tubing. Histologic examinations were performed in 8 cases. Endometriosis was diagnosed in cases. Postoperative patency was present in all these cases but only pregnancy, ending in abortion, resulted. Chronic salpingitis was present in cases and salpingitis isthmica nodosa in. In none of these cases was postoperative tubal patency demonstrable by CO insuffiation. DISCUSSION The true value of tubal plastic procedures can best be evaluated in patients undergoing similar bilateral surgery. In this series only term pregnancies resulted in such cases, both of which occurred in patients who had undergone lysis of peritubal adhesions. The results were no more successful when dissimilar bilateral procedures
VOL. 8, No., 967 TUBAL PLASTIC SURGERY 8 were carried out. In 9 such cases there were no term pregnancies and abortion. Siegler and Hellman have reported similar discouraging results in tubal plastic surgery. Only viable pregnancies resulted in patients who had undergone tubal surgery. Their series did not include patients undergoing lysis of adhesions only. Twenty-eight of our patients exhibited postoperative patency of the tubes upon CO insufhation or hysterosalpingography. Only 0 of these patients became pregnant. Patency of the tube, no sure index of tubal function, is an anatomical description that does not guarantee the adequacy of physiologic activities. The mammalian oviduct must perform a variety of functions in the transport and development of the gametes. Adhesions around the tubes interfere with ovum pickup or with tubal peristalsis. Patients with adhesions often have no intrinsic tubal disease and this would explain the relative success associated with lysis of adhesions for the treatment of infertility. In our series 6 of patients undergoing lysis of adhesions subsequently became pregnant. Ovum pickup is dependent upon the functioning of the fimbria. Westman viewed the muscular movements of the oviduct at the time of ovulation by means of an abdominal window in the rabbit and by means of a laparoscope in the monkey. In both animals the fimbria were noted to embrace the ovary. There is little support for the theory that ovum pickup is dependent on tubal suction alone. Transport of ova into the oviduct is not impaired when the tube is occluded by a ligature or if the distal third of the tube is severed and both ends are left open. It is difficult to envision tubal suction occurring when both ends of the tube are open. In this series bilateral cornual reimplantation of the tubes was uniformly unsuccessful in terms of patency and subsequent pregnancy. The poor results with reimplantation surgery may result from endometrial blockage of the tubal opening into the uterus. 6 In addition, experimental work has suggested special functions for the uterotubal junction. Mice and rabbits injected with estrogens will not pass fertilized ova from the tubes into the uterus because of estrogen stimulation of a sphincteric mechanism at the uterotubal junction. Progesterone releases the sphincteric mechanism and accelerates the passage of eggs. 0 It is possible that cornual resection removes the portion of the tube which contains a hormone-dependent sphincteric mechanism vital for keeping the egg in the tube until the endometrium is prepared for implantation. Delay in the transport of the human ovum into the uterus has been attributed to the activity of the subperitoneal musculature of the uterus which is arranged around the intramural portion of the tube. Vascular
8 MROUEH ET AL. FERTILITY & STERILITY rings have been described within the intramural portion of the tube which are accompanied by muscle bundles capable of constricting the tubal lumen,8 mechanisms that may be destroyed by cornual resection. It is our feeling that significant improvement in the results of tubal surgery will not come from further refinements of technic. Improvement must come from increased knowledge of tubal function and physiology so that a more rational selection of cases for surgery can be made. SUMMARY Forty infertile patients had surgical treatment of tubal occlusion or pelvic adhesions. Ten of these patients subsequently became pregnant, 7 bearing viable infants. However, only term pregnancies occurred among the patients in whom bilateral surgery was necessary. Yale University School of Medicine 88 Cedar St. New Haven, Conn. REFERENCES. BUXTON, C. L., and MASTROIANNI, L. Surgical treatment of infertility. Obstet Cynec 0:8, 96.. BUXTON, C. L., and SOUTHAM, A. L. Human Infertility. Hoeber, New York, 958.. BURDICK, H. 0., WmTNEY, R., and PINCUS, C. The fate of mouse ova tube-locked by injection of oestrogenic substance. Anat Rec 67:5, 97.. CLEWE, T., and MASTROIANNI, L. Mechanism of ovum pickup. Fe.rtil Steril 9:, 958. 5. PALMER, R. Discussion on modern methods of salpingostomy. Proc Roy Soc Med 58:57, 960. 6. SmRODKAR, V. N. Further experiences in tuboplasty. Aust New Zeal Obstet Cynaec 5:, 965. 7. SIEGLER, A. M., and HELLMAN, L. M. The tubal plastic operation: A critical analysis of cases. Fertil Steril:00, 96. 8. V ASEN, L. C. M. The intramural part of the fallopian tube. Int J Fertil :09, 959. 9. WESTMAN, A. A contribution to the question of the transit of the ovum from ovary to uterus in rabbits. Acta Obstet Cynec Scand 5:7, 96. 0. WISLOCKI, C. B., and SNYDER, F. F. The experimental acceleration of the rate of transport of ova through the fallopian tube. Bull Johns Hopkins Hosp 5:79, 9.