1 Reproductive Speciality Centre, 2315 North Lake Drive, Milwaukee, Wisconsin, 53211, USA and 2 Department of Obstetrics and Gynaecology, University College Hospital, London, UK
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Abstract |
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Key words: ectopic/laparoscopy/tubal blockage/tubal reanastomosis
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Introduction |
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Case 1 |
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The patient's general medical history was unremarkable, as was the physical examination. A recent hysterosalpingogram revealed ampullary obstruction of the left tube and absence of dye spill from the right Fallopian tube consistent with her previous salpingectomy. Her husband's semen analysis was within normal limits. Management options including IVF and microsurgical tubal reanastomosis by laparotomy or laparoscopy were discussed. The patient opted for surgery as her medical insurance did not cover IVF.
At laparoscopy, the right Fallopian tube consisted of a proximal stump 2 cm in length. The left tube showed ampullary obstruction 1.5 cm from the fimbrial end during retrograde chromopertubation and there were no periadnexal adhesions. Salpingoscopy of the distal segment revealed normal appearing mucosa without adhesions, and anastomosis was deemed feasible. Following injection with 1:30 dilute vasopressin the proximal stump was fashioned with a 150 µm microneedle-tip unipolar electrode with power settings of 1520 W for cutting and 15 W for fulgaration. Following this, the proximal tube was cut with a guillotine to reveal a 5 mm diameter lumen. Chromopertubation confirmed proximal segment patency and the distal stump was then cut with the guillotine to obtain a luminal diameter equivalent to the proximal stump. Following this, salpingoscopy of the proximal and distal stumps was performed. Using the Koh Ultramicro® instrumentation (Karl Stortz Endoscopy® America, Culver City, USA) two 6/0 proline sutures were inserted into the tubal mesentery followed by four 7/0 prolene sutures inserted through the muscularis and mucosa of the tubal ends at 6, 12, 9 and 3 o'clock respectively. Two further 7/0 prolene sutures were placed through the serosa and all sutures were tied intracorporeally completing an ampullaryampullary anastomosis. Chromopertubation revealed tubal patency and post-operative tubal length was 6 cm. The patient was discharged the day of surgery and conceived 2 months post-operatively but miscarried at 6 weeks gestation. Two years after tubal reanastomosis she conceived again and subsequently delivered at term.
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Case 2 |
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The patient's previous history was significant for chlamydial infection and bilateral ovarian cystectomy. Her physical examination was unremarkable. A current hysterosalpingogram revealed right ampullary obstruction and partial filling in the isthmic portion of the left tube consistent with salpingectomy. Her husband's semen analysis was within normal limits. The patient was counselled on the options of IVF versus surgery and opted for surgery because of her religious objection to IVF.
At laparoscopy, the left Fallopian tube was absent except for a 3 cm isthmic stump. Chromopertubation revealed mid-ampullary blockage of the right Fallopian tube with a proximal segment of 6 cm and residual products of conception at the site of tubal blockage (Figures 1A and B). The distal segment was 2.5 cm in length and salpingoscopy confirmed healthy appearing mucosa with rugae. Following vasopressin injection, dissection of the tubal serosa and removal of the residual tissue was undertaken. The blind ends of the proximal and distal stumps were then fashioned with the microelectrode and guillotined until healthy tubal mucosa was visualized. Chromopertubation revealed patency of both segments which had 4 and 5 mm luminal diameters respectively. Using the Koh Ultramicro instruments, an ampullaryampullary anastomosis was performed using a 6/0 prolene suture in the tubal mesentery followed by four 7/0 prolene sutures placed sequentially at 6, 12, 3 and 9 o'clock through the tubal muscularis and mucosa and tied intracorporeally (Figure 1C
). At the conclusion of the surgery Methylene Blue emerged from the distal end of the right Fallopian tube (Figure 1D
). Post-operative tubal length was 8 cm and the patient was discharged on the day of surgery. She conceived 2 months post-operatively and delivered at term. Eighteen months following surgery she again conceived, but miscarried at 6 weeks.
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Discussion |
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With the realization that ectopic pregnancy was associated with intrinsic tubal disease in <50% of cases, surgical treatment has evolved from salpingectomy to salpingotomy in an effort to preserve fertility. This is particularly relevant in patients with a single Fallopian tube where salpingectomy renders the patient sterile. A published report (Oelsner, 1987) has indicated that salpingotomy will provide the patient with a functional Fallopian tube along with an unknown risk of subsequent tubal blockage. The choice between surgery and assisted reproductive technology should be made after consideration of apparent Fallopian tube health. Dense periadnexal adhesions, absence of mucosal rugae and a tubal length of <4 cm predict a poor prognosis for pregnancy (Posaci et al., 1999
). In this situation IVF will offer the patient a better opportunity for pregnancy. However, our cases demonstrate that if post-ectopic tubal obstruction occurs in a healthy appearing Fallopian tube it may be successfully overcome with out-patient laparoscopic microsurgery via a technique first published in 1996 by Koh and Janik (Koh and Janik, 1996
). This offers an otherwise infertile patient an alternative to assisted reproductive technology in order to conceive. Other issues that may influence the patient's management decision include religious and financial concerns, which are especially relevant if the couple's insurance plan does not cover IVF.
Conservative surgery for tubal pregnancy carries a risk of recurrent ectopic pregnancy formation. In addition, the true success of salpingotomy often cannot be ascertained, since any further pregnancy may result from fertilization in either Fallopian tube. Oelsner described the reproductive outcome of 22 women with an ectopic pregnancy in a single Fallopian tube managed with open microsurgery (Oelsner, 1987). The majority of these women underwent linear salpingotomy while a single patient had segmental excision and reanastomosis. Of those patients trying to conceive, 75% were successful, with intrauterine and ectopic pregnancies occurring in 47 and 42.8% of women respectively.
In a contemporary setting such a high repeat ectopic pregnancy rate would be hard to justify and it is tempting to postulate that tubal resection and anastomosis could provide a better outcome by removing the area of tubal damage.
Our experience indicates that with proper case selection by salpingoscopy and true microsurgical technique, successful recanalization resulting in intrauterine pregnancies may be attained. Such blockages may occur not only from the initial surgery but also from the exclusive use of methotrexate. The surgeon considering laparoscopic tubal microsurgery should be competent with both the traditional techniques of microsurgery and intracorporeal microsuturing. Along with the possibility of intrauterine pregnancy, the patient should be carefully counselled about the potential for subsequent ectopic pregnancy.
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Acknowledgements |
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Notes |
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References |
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Oelsner, G. (1987) Ectopic pregnancy in the sole remaining tube and the management of the patient with multiple ectopic pregnancies. Clin. Obstet. Gynecol, 30, 225229.[ISI][Medline]
Posaci, C., Camus,M., Osmanagaoglu, K. and Devroey, P. (1999) Tubal surgery in the era of assisted reproductive technology: clinical options. Hum. Reprod, 14 (Suppl. 1), 120136.[Medline]
Tay, J.I., Moore, J. and Walker, J.J. (2000) Ectopic pregnancy. Br. Med. J., 320, 916919.
Submitted on July 23, 2001; accepted on January 14, 2002.