[Use of laparoscopy in the testing of fallopian tube patency].
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Fallopian Tube Patency Tests↗
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Tubal pregnancy and tubal patency.
The laparoscopic demonstration of a patent tube usually excludes the present of a tubal pregnancy. In the reported case tubal pregnancy was suspected. Tubal patency was tested because of equivocal laparoscopic findings, and an unexpected tubal pregnancy was diagnosed in the presence of tubal patency.
Adult↗
Investigation of tubal infertility by radionuclide migration.
Investigation of the tubal factor in infertility is limited to an assessment of anatomical structure and tubal patency. No test of ascendant tubal function is currently available. The migration of radionuclide (99mTc-labelled human albumin microspheres) through the genital tract in 96 infertile women was compared with pelvic findings at laparoscopy and chromopertubation. The radionuclide test correlated with laparoscopy in the diagnosis of patency or blockage in 83 cases (86%). In nine patients, where 'blockage' was diagnosed on the radionuclide test but patency found at laparoscopy, a higher prevalence of pelvic abnormality was found, compared to the 78 patients where both tests demonstrated patency (P less than 0.02). The radionuclide test may facilitate detection of diseased but patent tubes and, as an adjunct to laparoscopy and chromopertubation, may provide useful information about tubal function.
Endometriosis↗
[Criteria of selection of patients for organ-sparing operations in tubal pregnancy].
Rabbit experiments indicated that resection of a half of the oviduct anastomosed failed to impair its function and reproduction of viable progeny. With greatly varying diameters of sutured pieces, the valuable anastomosis was made by additional cuts of the narrow end of the oviduct. Analysis of 332 case histories and morphological studies of 10 control and 70 pregnant tubes suggested criteria for selection of patients, for organ-preserving surgeries. The latter could be performed nearly in 50% of females with tubal pregnancy in the form of stomatoplasty or anastomosis. The results of the study were tested in 8 females in the clinical setting who all exhibited a full recovery of tubal patency.
Adolescent↗
Radionuclide evaluation of tubal function.
The tubal capacity to transport radioactively labeled human albumin microspheres deposited in the vaginal fornix and cervical canal and to concentrate them on the ovarian surface was evaluated in a group of 34 patient-volunteers. One millicurie of technetium-99 was used to label human albumin microspheres of 20 mu in diameter, suspended in 1 ml of saline. The distribution of the radioactive material was imaged on a gamma camera at different intervals between 15 and 240 minutes. The radiation dose to the ovaries was estimated to be similar to that of a hysterosalpingogram. The results of the radionuclide evaluation were compared with the surgical findings at the time of laparoscopy or laparotomy performed for diagnostic or therapeutic reasons. The overall correlation was 87.1%. It would appear that as opposed to the traditional hysterosalpingogram, a radionuclide test may give a better understanding of the functional capacity of the tube and may also prove a useful method in the evaluation of the results of tubal microsurgical procedures.
Adult↗
A clinical comparison of sonographic hydrotubation and hysterosalpingography.
OBJECTIVE: To assess the value of vaginal sonographic hydrotubation as a preliminary test of uterine configuration and tubal patency in infertility investigation, and to compare this new test with hysterosalpingography. DESIGN: A prospective blind comparison of the two tests in an unselected group of infertile women. SETTING: Hillbrow Hospital, Johannesburg, South Africa. SUBJECTS: Sixty women undergoing routine infertility investigations agreed to participate in the study. There were no refusals. INTERVENTIONS: Within 4 weeks before or after hysterosalpingography sonographic hydrotubation was performed as follows: The uterus and tubes were identified using a 5 MHz vaginal ultrasound probe and between 10 and 20 ml of normal saline were injected into the uterine cavity through an endocervical catheter. MAIN OUTCOME MEASURES: The shape of the uterus and its cavity, the flow of saline through the tubes, the presence of hydrosalpinges before and after injection of saline and the presence of free fluid in the pouch of Douglas. RESULTS: The sonographic and hysterosalpingographic findings were similar in 82% of the women with respect to uterine assessment and in 72% with respect of tubal findings. In seven women (12%) found to have bipolar tubal disease on sonography and cornual block on hysterosalpingography, the sonographic diagnosis was confirmed at laparoscopy. Septate uterus in three women was diagnosed with greater certainty with sonographic hydrotubation. CONCLUSIONS: Sonographic hydrotubation is a simple office procedure which should be used in the preliminary assessment of the uterine cavity and fallopian tubes. Its use will reduce the need for hysterosalpingography and in some cases laparoscopy.
Diagnosis, Differential↗
Transvaginal fallopian tube catheterization in an animal model.
A rabbit model for testing the safety and effectiveness of diagnostic and interventional techniques of fallopian tube catheterization is presented. Hysterography with injection into the terminal portion of the uterine horn visualized the fallopian tube in only 6% of cases; however, this increased from 33% to 50% by pretreatment with progesterone, administration of glucagon or phentolamine, or increased pressure of injection with balloon obstruction of the uterine horn. Salpingography with a catheter introduced in the tubal ostium or directly inside the tube was most effective and resulted in a consistent (100%) visualization of the fallopian tube. The technique also allowed coaxial introduction of small diameter guidewires and catheters deep into the fallopian tube.
Animals↗
[Diagnosis of tubal function using intraluminal ultrasound--initial results].
The extremely small ultrasound transducers of the intraluminal ultrasound instruments, introduced via catheters, enable diagnosis to be made inside hollow organs. In order to test the possible uses and indications for this new method in gynaecology, we conducted preliminary examinations in the diagnosis of the uterus and tubes. We employed an intraluminal instrument supplied by Dornier. The intraluminal transducers of this instrument have a diameter of 3.5 and 5 F. Following in-vitro examinations, hysteroscopy and laparoscopy/laparotomy were performed in 15 patients during which the transducer was pushed up via the cervix uteri to the tubes with full vision. This was successful in all 15 patients; in 9 cases the transducer could be pushed as far as the distal end. The tubal walls were examined in detail by this method and for the first time it became possible to achieve functional diagnosis of the motility of the tubes. Strictures can be visualised. The endometrium of the uterus, however, cannot as yet be diagnosed exactly by the present-day state of examination technique. If image quality can be further improved, this method will be the first to enable a functional diagnosis of the tubes and the uterus.
Endometrium↗
Ovum recovery after microsurgical reanastomosis of the rabbit oviduct.
Causes for failure of pregnancy after tubal reconstructive surgery are incompletely understood. The impact of microsurgical resection reanastomosis on ovum recovery was studied in the rabbit oviduct. One hundred sixty rabbits were divided into three groups: one experimental group in which a resection reanastomosis was made in the ampullar or isthmic tubal segment, respectively, and two control groups. After mating, ovum recovery was evaluated. In ampullary operated oviducts the ovum recovery rate was significantly lower compared with recovery rates in isthmically operated and in control oviducts. Furthermore, in ampullary operated oviducts peritoneal transmigration of ova was frequently observed. Disturbances in ovum pickup from the ovarian surface or the peritoneal cavity seem to be responsible for the decrease in recovery rate found in the ampullary operated oviducts.
Animals↗
Comparison between tubouterine implantation and tubouterine anastomosis for repair of cornual occlusion.
Forty-four patients with partial or complete cornual occlusion of their tubes had undergone microsurgical repair in the form of either tubouterine implantation or tubouterine anastomosis. Eighteen of these patients had undergone the implantation procedure and 26 the anastomosis procedure. None of the patients in the implantation group had previous tubal sterilization, while in the anastomosis group 16 had tubal cauterization and 10 had other causes blocking the cornual end of their tubes. The patency rate in the implantation group was 70% and the pregnancy rate was 39%, while in the anastomosis group the rates were 94% and 69%, respectively. It is concluded that, when feasible, tubouterine anastomosis should be the procedure of choice for the repair of the cornual occlusion of the tube irrespective of the cause of obstruction.
Fallopian Tube Diseases↗
Sensitivity of hysterosalpingography after tubal surgery.
Hysterosalpingography (HSG) to assess tubal patency in the postoperative evaluation of the infertile patient has been well described. However, the sensitivity and specificity of HSG after tubal surgery has not been reported. We correlated HSG and laparoscopic findings in 25 patients who had tubal surgery (microsurgical tubal reanastomoses [11] and distal salpingostomies [14]). HSG provided a more reliable means of assessing tubal patency (sensitivity and specificity of 96% and 61% respectively) than in detecting pelvic adhesive disease (PAD) (sensitivity and specificity of 12% and 75% respectively) regardless of tubal surgical procedure. HSG was associated with a high false negative rate (60%) due primarily to the inability to detect PAD. Complete agreement between HSG and laparoscopy was noted in only 15% of cases. These data suggest that HSG is a sensitive means to determine tubal patency, but was not sufficiently sensitive or specific to detect PAD after tubal surgery. These limitations should be noted in the interpretation of HSG in any infertile patient with a history of tubal surgery, and severely limits the application of HSG to the management of the post-operative infertile patient.
Fallopian Tube Patency Tests↗
Diagnostic laparoscopy: a prognostic aid in the surgical management of infertility.
Laparoscopy was utilized as the final step in the infertility investigation of 155 indigent patients. Unnecessary laparotomy was avoided in 72 (46 per cent) of these patients. Depending upon the endoscopic findings, the presence of additional infertility factor(s) either positively or negatively affected prognosis. With the same anesthetic, 83 (54 per cent) of the 155 patients underwent conservative infertility operations. Unless even greater selectivity can be achieved by prior diagnostic laparoscopy, the postoperative term pregnancy rate (11 per cent) does not justify infertility operations in a population prone to pelvic inflammatory disease, particularly in those individuals with other infertility factors.
Adult↗
The effect of training in microsurgery.
One of the most important and fundamental prerequisites for successful microsurgery is serious and adequate training. This article presents the effect of microsurgical training on the functional end result of reanastomosis in the rabbit fallopian tube and evaluates the appropriate duration of laboratory training. In 50 New Zealand White female rabbits a microsurgical reanastomosis of the fallopian tube in its isthmic portion was performed. The rabbits were divided into five groups. In the first group only 30% of the rabbits conceived on the side operated on. The nidation index was only 0.269 as compared to 0.831 for the control side. Improvement in microsurgical skill following 100 isthmic anastomoses resulted in a 100% pregnancy rate for the last group. The nidation indexes in this group were the same on the side operated on and on the control side, 0.774 and 0.702, respectively. Scanning electron microscopic examination of the anastomosis site revealed a progressive increase in patency rate and in the amount of apposed mucosal folds in the three groups. A training program is recommended, which should bring about a nidation index and pregnancy rate that should not differ from the side operated on to the control side.
Animals↗
Observations on the mode of action of an intratubal device, the P-block.
A hydrogelic intratubal device, called P-block, Mark 9, was inserted hysteroscopically with local anesthesia in the intramural part of the fallopian tube of 25 women referred for the procedure as an alternative to abdominal sterilization. Hysterosalpingography revealing bilateral oviductal patency was followed by hysteroscopic checkup verifying bilateral presence of P-blocks, except in three patients who had expulsion of the P-blocks on one side. All of the 22 patients had retention of the P-blocks 6 to 7 months after insertion. None became pregnant. Thus it is suggested that an intratubal device in the isthmic part of the human fallopian tube acts as an intrauterine contraceptive device, preventing intratubal and intrauterine pregnancies. Endeavors to explain the contraceptive effect of a nonocclusive intratubal device are discussed on the basis of our present knowledge of tubal physiology. Distension of part of the human isthmus is likely to disturb normal gamete transport through the isthmus.
Adult↗
An experimental study of tubo-ovarian function following restoration of patency in hydrosalpinges.
The recovery of tubal function after restoration of patency in mechanically induced hydrosalpinges was studied in twenty sexually mature rabbits by correlating the morphological lesions of tubal damage and adhesion formation with the ovulatory function, pregnancy rate and nidation index at 2 and 4-8 weeks postoperative intervals. Two weeks after hydrosalpinx correction no implantations occurred although the oviducts had a patency rate of 63% and no or slight adhesions were present. From four weeks after hydrosalpinx correction implantations occurred. Morphological studies showed a partial or complete recovery of mucosal lesions in this group of rabbits. The number of ovulations correlated with the presence or absence of a moderate degree of postoperative adhesion formation.
Animals↗
Treatment of tubal pregnancy by local injection of prostaglandin: selection of patients and evaluation of subsequent tubal patency.
Thirty women who had a small unruptured tubal pregnancy were treated by laparoscopically guided injection of prostaglandin F2 alpha into the oviduct and into the corpus luteum. They had no side effects. The serum human chorionic gonadotropin (S-HCG) concentration decreased in 25 women to less than 20 IU/l in a median time of 8 days (range 1-45). Five women were operated on because of increasing S-HCG concentration. The median diameter of the oviduct at the site of the gestation, the tubal localisation and the gestational age was similar in the women treated by prostaglandin and those, who were operated on after failure of the procedure. Four of the 6 women, with S-HCG concentrations of more than 2000 IU/l, needed subsequent operative treatment, compared to only one of 24 with a lower concentration. The median duration of the hospital stay after treatment was 2 days for the group of women with a S-HCG concentration of less than 2000 IU/l. Hysterosalpingography 3 months after treatment showed patency on the side of the pregnancy in 12 of 14 women. Prostaglandin injection seems to be an appealing option for the treatment of selected ectopic pregnancies.
Animals↗
The use of carbon dioxide laser laparoscopy in the treatment of tubal ectopic pregnancies.
OBJECTIVE: The purpose of this study was to assess the efficacy of the treatment of unruptured tubal ectopic pregnancies by the use of carbon dioxide laser laparoscopy. STUDY DESIGN: A series of 125 consecutive ectopic pregnancies were treated laparoscopically; the tubal pregnancy was removed by a laparoscopic laser technique. Preoperative assessment included monitoring beta-human chorionic gonadotropin levels, use of vaginal ultrasonography, and preoperative and postoperative hematocrit levels. RESULTS: Laparoscopic laser surgery was successful for removal of tubal ectopic pregnancies in all but four patients, in whom a laparotomy was required. Hematocrit levels before and after surgery were similar. The time necessary for beta-human chorionic gonadotropin to fall to nondetectable levels averaged between 3 and 4 weeks. There were five patients who had complications requiring additional surgery and/or medical treatment. CONCLUSION: The techniques are easy to learn, and the use of laparoscopic laser surgery in the treatment of tubal ectopic pregnancies appears to be a safe procedure with definite advantages for both the patient and the physician. There are decreased operating times, shorter hospital stays, and lower medical costs compared with those for major surgery. Subsequent successful intrauterine pregnancy rates are comparable to those of conservative methods previously reported.
Adult↗
A two-year experience with the Falope ring sterilization procedure.
The use of cautery laparoscopic sterilization procedures has two major disadvantages: (1) occasional inadvertent thermal injury to organ structures other than the Fallopian tube and (2) the inability to limit the injury to the Fallopian tube in a manner that might allow subsequent reconstructive surgery. In an effort to avoid the use of thermal energy to effect female sterilization, the Falope ring laparoscope was developed. From October, 1973, through September, 1975, 4,390 sterilization procedures were completed employing this approach; 902 cases have been completed at the Woman's Clinic of the Johns Hopkins Hospital, 1,741 cases were completed by gynecologists in various cities in the United States, and 1,747 procedures were completed by physicians in various locations throughout the world sponsored by the International Fertility Research Program.
Cautery↗