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Reversal of Kroener fimbriectomy sterilization.

Sterilization by fimbriectomy has been thought to be irreversible. The present report describes the surgical approach and results in nine patients after microsurgical tubal reconstruction and indicates that repeated pregnancy is possible after fimbriectomy reversal. Preoperative radiographic studies were used to document cornual patency and to evaluate the length, width, and rugal pattern of the ampullary segment. A new ostium was created by transverse salpingostomy and a cuff-eversion technique by means of microsurgical methods. A tubal patency rate of 83% and an intrauterine pregnancy (IUP) rate of 44% was achieved. The mean interval from operation to conception was 6 months. There were no ectopic pregnancies. The ideal candidate for fimbriectomy reversal has tubal remnants 8 cm or longer, an ampullary width of 1 cm or greater, rugal patterns on x-ray film, and minimal peritubal adhesions. Successful reversal was associated with protrusions of the endosalpinx to form a neofimbria. The success of fimbriectomy sterilization probably depends more on complete ampullary occlusion than on absence of the infundibulum with fimbria. The role of the fimbria in ovum pickup is discussed. The IUP rate after microsurgical fimbriectomy reversal compares favorably with the IUP rate after macrosurgical end-to-end anastomosis and exceeds the reversibility rate of laparoscopic electrocoagulation sterilization.

Adult

Experience in a series of fimbriectomies.

In a series of 247 consecutive sterilizations by fimbriectomy performed at the Denver General Hospital, a failure rate of 2.4% was found. The literature is reviewed, and these results are compared with results of other series. In several of the fimbriectomy series with more successful outcome, modifications of the technique originally described were used. The difficulties associated with the Kroener technique are discussed. The fimbriectomy failures were caused by either lack of resection of all of the fimbriae or the presence of tuboperitoneal fistulas, both congenital and acquired. Fimbriectomy should not be regarded as the method of choice for sterilization unless one can ensure adequate surgical exposure and complete removal of the fibria, including the fimbria ovarica.

Adult

Failures following fimbriectomy: a further report.

In 1977 we reported on seven patients who presented with intrauterine pregnancy in spite of previous fimbriectomy; in a detailed morphologic study one tuboperitoneal fistula was documented in each of four patients. In the present study three more patients are reported with pregnancy following fimbriectomy, and another four tuboperitoneal fistulas are morphologically investigated and their possible etiology is discussed. In spite of a failure rate of almost 2.6%, the concept about the reliability of fimbriectomy need not necessarily be condemned. This concept can be judged only if information is available both about the total number of fistulas subsequent to a certain technique and about the number of those fistulas which contributed to pregnancy.

Fallopian Tubes

Fertility following fimbriectomy and tubo-ovarian microsurgery in the rabbit.

It is generally believed that tubal fimbriae function as a highly specialized and indispensable component of the ovum pickup mechanism. The present study was undertaken to examine the feasibility of creating a functional tubo-ovarian relationship following fimbriectomy. Fourteen New Zealand White rabbits underwent unilateral microsurgical fimbriectomy followed by creation of a distal ampullary flap which was oversewn to the exposed ovarian cortex. Two weeks after surgery, the animals were inseminated and induced to ovulate with an intravenous injection of 100 IU of human chorionic gonadotropin. Thirteen of fourteen uterine horns on the control side and ten of fourteen on the operated side became pregnant. The ratios of ova ovulated to those which implanted were 73.2% on the control side and 37.8% on the operated side. Morphologic studies revealed a normal complement of ciliated and secretory cells lining the endosalpinx of the juxtaposed ampullary flap. The portion of ovarian cortex covered by the flap similarly exhibited no morphologic abnormalities. These findings indicate that fertility can be maintained in the absence of fimbriae and suggest a surgical technique for restoration of fertility following elective sterilization by fimbriectomy or following pathologically induced destruction of the fimbriae.

Animals

A new selection criterion for fimbriectomy reversal.

OBJECTIVE: To assess a new criterion for selection of patients who request reversal of fimbriectomy sterilization. DESIGN: Prospective study. SETTING: Division of reproductive endocrinology and infertility in an academic center. PATIENTS: Eight patients undergoing reversal of fimbriectomy using microsurgical techniques. The prerequisite inclusion criterion was the presence of more than 50% ampulla as shown at hysterosalpingography. This is easily determined, because the isthmic length approximates one half the ampullary length. RESULTS: The cumulative intrauterine pregnancy rate was 50%. There were no ectopic pregnancies. CONCLUSION: Similar pregnancy rates for reversal of fimbriectomy have been reported based upon different absolute selection criteria (viz., tubal length of > or = 8 cm and ampullary width of > or = 1 cm). By contrast, our new selection criterion is based upon the more readily determined proportion of ampulla that is available for surgical neostomy.

Female

Failures following fimbriectomy.

From 1970 through 1973, 388 bilateral fimbriectomies were performed. By the end of 1974, seven pregnancies had occurred, and in four of these patients a resterilization laparotomy was performed. All four cases showed a unilateral tuboperitoneal fistula. These fistulas were examined and compared morphologically with congenital tuboperitoneal fistulas. This proved that all four fistulas were acquired and that they were probably caused by the catgut ligatures used for ampullary ligation. The rather frequent occurrence of hydrosalpinx after fimbriectomy is mentioned. Finally, it seems of questionable advantage to resect the infundibulum as part of a fimbriectomy using the three-ligature technique.

Fallopian Tubes

Ovum capture and fertility following microsurgical fimbriectomy in the rabbit.

Microsurgical fimbriectomy with removal of the fimbria ovarica was performed on one side in 19 rabbits. The other tube was left intact as a control. In 10 animals the new ostium was left free, some distance from the ovary. In the remainder, the ostium was fixed to the ovarian capsule. Three animals with a fixed ostium developed mild hydrosalpinx even though the neostomy was patent. Of the remaining 16 rabbits, 15 conceived and became pregnant in both uterine horns. There was no significant difference between nidation index on the two sides. It is concluded that intact fimbriae with a fimbria ovarica are not essential for normal ovum capture. It is therefore suggested that methods for clinical salpingostomy may require re-evaluation.

Animals

Function and structure of the rabbit oviduct following fimbriectomy. I. Distal ampullary salpingostomy.

The fimbria has long been considered an indispensable portion of the fallopian tube. To test this hypothesis, the fimbria and up to one-half of the adjoining ampulla of the left oviduct were resected by microsurgery in 13 New Zealand White does. The remaining distal ampulla was subjected to a cuff salpingostomy. Following a convalescence of 4 to 8 weeks and induced ovulation, 6 of the 11 resected oviducts apprehended ova and 29% of the total number ovulated ipsilaterally, whereas the right control oviducts retrieved 77% of the corresponding ova. Direct observation in vivo showed that the ova adhered to the neofimbria and that subsequent transport across the everted, hypertrophied ampullary mucosal folds into the tubal lumen took place readily. Scanning electron microscopy of the "neofimbria" and adjoining distal ampulla demonstrated populations of ciliated and secretory cells that were similar to those of the contralateral intact fimbria. This information challenges the concept of fimbrial indispensability and depicts the fimbriated ostium of a distal ampullary cuff salpingostomy as having an adequate function, albeit less efficient than normal

Animals

Function and structure of the rabbit oviduct following fimbriectomy. II. Proximal ampullary salpingostomy.

Experiments were conducted in nine New Zealand White rabbits to determine the functional capacity of that part of the oviduct consisting of only the isthmus and proximal ampulla. The left fimbria and at least one-half of the adjoining ampulla were excised microsurgically and the remaining portion of the proximal ampulla was subjected to a cuff salpingostomy. Following a convalescence of 4 to 8 weeks and gonadotropin-induced ovulation, direct observations in vivo showed tht the modified oviduct was ineffective in transporting surrogate cumulus masses into the tubal lumen. Those surrogates that were accepted were in some cases regurgitated by contractions of the residual proximal ampulla. A subsequent in vitro search for ova proved that the modified oviducts were unsuccessful in retrieving ipsilaterally ovulated ova, whereas the contralateral control oviducts apprehended an average of 72% of those available. Scanning electron microscopy showed the everted mucosa of the proximal ampulla to be less richly endowed with cilia than that of the normal fimbria. This ovum capture appeared to be prevented by deficiencies in both the ciliary mechanism of the neofimbria and the ability of the remaining ampulla to retain the egg. This evidence indicates that the proximal ampulla is unsuitable for reconstruction of a functional fallopian tube.

Animals

Tubal sterilization and ovarian perfusion: selective arteriography in vivo and in vitro.

To determine whether there are changes in the utero-tubo-ovarian circulation after tubal sterilization, selective arteriograms were taken in vivo every 0.3--7.0 seconds with a Puck-type seriograph and also in vitro. A control arteriographic study was made. The operations performed were fimbriectomy and modified Pomeroy. The 30 patients studied were divided into two groups. One was formed by 20 nonpregnant women. The other ten patients were in the early puerperium. Arteriographic images with and without tubal sterilization were prepared, and the different techniques were compared. With the Pomeroy operations, the various tubal sites where surgery was performed were also compared. It was concluded that neither the modified Pomeroy sterilization nor fimbriectomy alters ovarian perfusion in either nonpregnant women or those in the early puerperium.

Adnexa Uteri

Effects of chronic nerve growth factor treatment on hippocampal [3H]cytisine/nicotinic binding sites and presynaptic nicotinic receptor function following fimbrial transections.

Recent studies with nerve growth factor (NGF) have identified the pharmacological actions of this neurotrophin in a variety of animal models that mimic some of the neurotransmitter deficits that occur in Alzheimer's disease (AD, for reviews see Refs 7, 15, 17, 19). Based upon extensive pharmacological studies, NGF has been characterized as a crucial maintenance factor for adult cholinergic neurons of the septo-hippocampal and basalo-cortical pathways. Among the reported actions of NGF is an attenuation of lesion-induced decrements in presynaptic and postsynaptic cholinergic markers and functions in the hippocampal formation. Thus, in studies that used partial fimbriectomies to parallel the cholinergic neurodegeneration that occurs in AD, intraventricularly administered nerve growth factor prevented the loss of choline acetyltransferase (ChAT) and acetylcholinesterase immunoreactivity in the septum and increased a variety of presynaptic cholinergic markers involved in the synthesis, storage and release of the neurotransmitter acetylcholine (for reviews see Refs 7, 17, 19). More specifically, chronic NGF treatment attenuates lesion-induced reductions in hippocampal ChAT activity and high-affinity choline uptake, the end-result of which is an enhanced capacity to synthesize acetylcholine. This increased acetylcholine synthesis, in turn, appears to translate directly into augmented vesicular storage and release of the neurotransmitter. For instance, not only does NGF treatment reverse lesion-induced reductions in maximal binding densities of the acetylcholine vesicular transport marker [3H]vesamicol, but it also enhances acetylcholine release and turnover rate. NGF treatment also appears to restore the sensitivity of postsynaptic muscarinic receptors to agonist-induced stimulation following partial fimbriectomies.(ABSTRACT TRUNCATED AT 250 WORDS)

Alkaloids