Usefulness of transvaginal hydrolaparoscopy in investigating infertile women with Chlamydia trachomatis infection

Hiroaki Shibahara,1, Hiroyuki Fujiwara, Yuki Hirano, Tatsuya Suzuki, Hiromi Obara, Satoru Takamizawa, Sadayoshi Idei and Ikuo Sato

Department of Obstetrics and Gynecology, Jichi Medical School, 3311-1, Yakushiji, Minamikawachi-machi, Kawachi-gun, Tochigi 329-0498, Japan


    Abstract
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
BACKGROUND: A new technique called transvaginal hydrolaparoscopy (THL) was recently developed for the exploration of the tubo-ovarian structures in infertile patients without obvious pelvic pathology. This study was performed to investigate the usefulness of THL to evaluate Chlamydia trachomatis tubal infertility. METHODS: Forty-one women with primary and secondary infertility participated in this study. Fourteen had past C. trachomatis infection. In 38 (92.7%) of the 41, access to the pouch of Douglas was obtained. In total, 71 (93.4%) out of 76 adnexa were clearly visualized. Thirty-seven patients were analysed and compared their tubal passages and peritubal adhesions using both hysterosalpingography (HSG) and THL. Twenty-four tubes from 14 patients with past C. trachomatis infection and 44 tubes from 23 patients without a history of C. trachomatis infection were compared. RESULTS: For the diagnosis of the tubal passage, there were no significant differences in the discrepancy rates between HSG and THL, in patients with and without past C. trachomatis infection. In 14 (58.3%) of the 24 tubes from patients with past C. trachomatis infection and in eight (18.2%) of the 44 tubes from patients without infection, peritubal adhesion was diagnosed only by THL. There was a significant difference in the discrepancy rates of the diagnosis of peritubal adhesion between HSG and THL in the two groups (P = 0.0007 ). CONCLUSIONS: These results suggest that C. trachomatis infection is highly associated with peritubal adhesion which is difficult to diagnose by HSG. Therefore, in C. trachomatis antibody-positive patients, exclusion of tubal pathology by THL or standard laparoscopy should be carried out to consider appropriate treatments. Although THL is not a substitute for laparoscopy, it can be proposed as a first line procedure in the early stages of the infertility investigation.

Key words: Chlamydia trachomatis/laparoscopy/tubal infertility/transvaginal hydrolaparoscopy


    Introduction
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
Chlamydia trachomatis infection is the most prevalent sexually transmitted disease (STD) and is primarily a woman's health care issue since its manifestations and consequences are more damaging to the reproductive health of women than men. According to the World Health Organization, 90 million C. trachomatis infections are detected annually worldwide (Gerbase et al., 1998Go). Chlamydia trachomatis is the major cause of cervicitis, pelvic inflammatory disease (PID), ectopic pregnancy and tubal factor infertility in women. The clinical spectrum of Chlamydia PID includes endometritis, salpingitis, tubo-ovarian abscess, pelvic peritonitis, periappendicitis and perihepatitis.

Past Chlamydia infection is closely associated with tubal factor infertility. The diagnosis of tubal infertility has been routinely practised by hysterosalpingography (HSG); however, a meta-analysis for the accuracy of HSG in the diagnosis of tubal pathology identified 0.65 for sensitivity and 0.83 for specificity (Swart et al., 1995Go). Although laparoscopy is the gold-standard procedure for the diagnosis of tubo-peritoneal infertility, there are some risks including major vascular injuries (Chapron et al., 1997Go) and gastrointestinal injuries (Chapron et al., 1999Go). Recently, a new technique called transvaginal hydrolaparoscopy (THL) was introduced for the exploration of the tubo-ovarian structures in infertile patients (Gordts et al., 1998Go; Campo et al., 1999Go). THL is a less traumatic and a more suitable outpatient procedure than diagnostic laparoscopy. We also carried out THL with chromotubation using indigocarmine under local anaesthesia, with or without neuroleptanalgesia, and showed the usefulness in evaluating infertile patients with tubal pathology (Fujiwara et al., 2000Go). Our indications for THL in infertile women are as follows: (i) tubal obstruction and/or peritubal adhesion are suggested by the HSG, (ii) serum antibody against C. trachomatis is positive, (iii) diagnosis of early-stage endometriosis, and (iv) unexplained infertility. Here we report the significance of THL in patients with past C. trachomatis infection as compared with the HSG findings.


    Materials and methods
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
Forty-one infertile women were investigated using THL (Circon ACMI, Stamford, CT, USA) between May 1999 and July 2000. The mean age of the subjects was 31.9 years (range 22–42) and the average infertility period was 3.6 years (range 1.0–10.0). Before C. trachomatis antibody titres in the sera of infertile women were examined in August 1999, C. trachomatis infection was diagnosed by detecting C. trachomatis antigen in the patient's uterine cervix. Chlamydia trachomatis antibody testing was performed by using enzyme-linked immunosorbent assay (ELISA; Peptide Chlamydia IgG and IgA; Labsystems Oy, Finland). Antibody titres >0.90 were considered as positive.

The procedure of THL was followed and modified by a published technique (Gordts et al., 1998Go). Briefly, premedication was given with intramuscular injection of 0.5 mg of atropine sulphate and 25 mg of hydroxyzine hydrochloride 30 min before starting THL. In the operation room, THL was performed in the lithotomy position, with the administration of a drip infusion. After disinfection with aqueous chlorhexidine solution, a Hys-cath (Sumitomo Bakelite Co. Ltd, Tokyo, Japan) was inserted into the uterine cavity for the use of chromotubation. Then the cervix was lifted with a tenaculum placed on the posterior lip and the central part of the posterior fornix was infiltrated with 2 ml of 1% lidocaine. The Veress needle was introduced 1.5 cm below the cervix and inserted in the pelvic cavity. Thirty mg of pentazocine was additionally given if the patients wished. Approximately 100 ml saline was instilled into the pouch of Douglas. A 3 mm blunt trocar was inserted by a stab incision in the posterior fornix, then a 2.7 mm diameter semi-rigid endoscope was used with an optical angle of 30°C and a flow channel attached to a 3 CCD digital videocamera. The saline irrigation was continued throughout the procedure to keep the bowel and tubo-ovarian structures afloat. The posterior of the uterus and the tubo-ovarian structures were carefully observed, and tubal passage using indigocarmine was confirmed. In some cases, a salpingoscopy could be performed. After the procedure, prophylactic antibiotics were prescribed orally for 5 days.

The condition of the pelvic cavity, area of observation, average time, and amount of irrigated normal saline were recorded. The data from THL were evaluated by comparing the results with HSG that the same patients had previously undergone. The discrepancy rates between HSG and THL in patients with or without past C. trachomatis infection were compared.

Statistical analysis of the data was carried out by {chi}2 analysis using Statview 4.5 (Abacus Conceps, Berkeley, CA, USA) for Macintosh, and P < 0.05 was considered significant.


    Results
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
Forty-one infertile women underwent THL for investigating their tubo-ovarian structures and re-evaluation of tubal passage. No complication was observed in this study period. As shown in Table IGo, access to the pouch of Douglas was obtained in 38 (92.7%) out of 41 patients. The cause of three failures was severe pelvic adhesion. Thus, 76 adnexa from 38 women were explored. The visualization was unilateral in five patients due to extensive adhesions. In all, 71 (93.4%) of 76 adnexa were clearly visualized. In 13 (18.3%) of 71 tubes, a salpingoscopy was performed. The endoscope was inserted from the fimbria and the distal part of the tubal mucosa could be observed. However, the clinical benefits of salpingoscopy under THL have not yet been firmly established.


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Table I. Results of transvaginal hydrolaparoscopy in 41 infertile patients
 
Fourteen women had a history of C. trachomatis infection as diagnosed by serum antibody titres (IgG and IgA) against C. trachomatis in 11 patients or C. trachomatis antigen collected from the uterine cervix in three patients. The discrepancy rates between HSG and THL in patients with or without past C. trachomatis infection were compared. Except for three patients with failed access to the pouch of Douglas by THL and one patient on whom HSG was not carried out, 37 out of 41 patients were analysed and their tubal passage and peritubal adhesions were compared using HSG and THL. Twenty-four tubes from 14 patients with past C. trachomatis infection and 44 tubes from 23 patients without a history of C. trachomatis infection were compared. As for the diagnosis of tubal passage, there was no significant difference in the discrepancy rates between HSG and THL in patients with and without past C. trachomatis infection (Table IIGo) . In 14 (58.3%) of 24 tubes from 14 patients with past C. trachomatis infection, peritubal adhesion was diagnosed only by THL. That was diagnosed in eight (18.2%) out of 44 tubes from 23 patients without the infection. There was a significant difference in the discrepancy rates of the diagnosis of peritubal adhesion between HSG and THL in the two groups (P = 0.0007 ) (Table IIGo).


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Table II. Comparison of the discrepancy rates of the diagnosis between hysterosalpingography (HSG) and transvaginal hydrolaparoscopy (THL) in infertile patients with or without past Chlamydia trachomatis infection
 

    Discussion
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
This study demonstrates that C. trachomatis infection in infertile women is highly associated with tubal pathology. Chlamydia trachomatis is the main agent of PID (Ripa et al., 1980Go; Gump et al., 1983Go; Faro, 1991Go). The problem is that the majority of cases with C. trachomatis infection is asymptomatic and often referred to as `silent PID' (Cates and Wasserheit, 1991Go; Ault and Faro, 1993Go). Some patients notice their C. trachomatis infection after experiencing infertility or an ectopic pregnancy.

The association between C. trachomatis antibody in the sera of infertile women and tubal subfertility has been well known (Punnonen et al., 1979Go). Chlamydia trachomatis antibody can be determined at low cost and presents no burden for the patients. Chlamydia antibody testing is a simple screening test for tubal factor subfertility and is more accurate in predicting severe distal tubal pathology than unspecified tuboperitoneal abnormalities (Land et al., 1998Go). However, the Chlamydia antibody testing is based on the detection of previous infection. The discriminative capacity of C. trachomatis antibody in the diagnosis of any tubal pathology was analysed and it was comparable to that of HSG in the diagnosis of tubal occlusion (Mol et al., 1997Go). They also suggested that C. trachomatis antibody testing involved little burden but provided no details on the anatomy of uterus and tubes. Thus, C. trachomatis antibody testing does not seem to be useful in predicting the prognosis of fertility as it provides no information on the severity of tubal disease.

In current practice, HSG has been widely used to assess tubal patency and uterine anomalies. HSG has been a routine examination in many infertility centres as it is less costly and less invasive than laparoscopy. However, laparoscopy is superior in detecting peritoneal adhesions and endometriosis as compared with HSG (Corson, 1977Go). A recent study (Johnson et al., 2000Go) reported that a policy of selective laparoscopy in routine investigation for infertility, based on the result of the C. trachomatis antibodies and a woman's clinical features, was not supported. In the present study, THL was used for evaluating tubo-ovarian pathology in infertile women. THL is a less traumatic technique than standard laparoscopy (Gordts et al., 1998Go; Campo et al., 1999Go; Fujiwara et al., 2000Go). Transvaginal access and the systematic use of hydroflotation are potential advantages of THL for the exploration of tubo-ovarian structures in infertility. The advantages of THL include accurate and atraumatic inspection of adnexal structures without manipulation, with the opportunity to perform dye hydrotubation and salpingoscopy. The risks of a general anaesthetic are avoided, and there is less chance of trauma to major vessels. There was no complication by THL in this study period. To prevent complications including rectal perforation, it is important to select the standard laparoscopy in patients with a fixed retroverted uterus or severe endometriosis. Following a prospective comparative blind study, it has also been suggested that a retroverted uterus should be considered as a relative contra-indication to THL (Darai et al., 2000Go). They reported a case of rectal perforation that occurred in a woman with a retroverted uterus and pelvic endometriosis, although she was treated expectantly. Thus, history and gynaecological examinations as well as transvaginal ultrasonography should be done before proceeding to perform THL.

Inspection under fluid in THL improves the visualization of the distal tubal disease. The frequency of distal tubal disease increased in patients with serum C. trachomatis antibodies (Moore et al., 1982Go), indicating that THL is one of the ideal diagnostic tools for C. trachomatis-associated tubal disease. As for the discriminative capacity of C. trachomatis antibody testing, ELISA or (micro)immunofluorescence in the diagnosis of any tubal pathology revealed a better discrimination than using an immunoperoxidase assay (Mol et al., 1997Go). In this study, ELISA was used and the diagnosis of tubal passage and peritubal adhesion were compared between HSG and THL in patients with or without past C. trachomatis infection. There was no significant difference in the discrepancy rate of the diagnosis of tubal passage between HSG and THL in patients with and without past C. trachomatis infection. However, there was a significant difference in the discrepancy rate of the diagnosis of peritubal adhesion between HSG and THL in patients with and without past C. trachomatis infection (Table IIGo). These results suggest that C. trachomatis infection is highly associated with peritubal adhesion which is diagnosed by HSG with difficulty. Therefore, in Chlamydia-positive antibody testing, exclusion of tubal pathology by THL or standard laparoscopy should be carried out to consider appropriate treatments.

In conclusion, THL can be performed safely, and provides useful information on the status of the pelvic cavity especially in patients with a history of C. trachomatis. Although THL is not a substitute for laparoscopy, it can be proposed as a first line procedure in the early stages of the infertility investigation.


    Acknowledgements
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
This study was supported by The Japanese Foundation for Research and Promotion of Endoscopy Grant (1999).


    Notes
 
1 To whom correspondence should be addressed. E-mail: sibahara{at}jichi.ac.jp Back


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 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 Acknowledgements
 References
 
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Submitted on January 3, 2001; accepted on April 19, 2001.





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