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.

[Salpingoscopy: a new method for the evaluation of the tubal factors in sterility]

Salpingoscopy is a new endoscopic procedure that allows the direct vision of the tubal mucosa. Therefore, it is able to identify and evaluate intraluminal lesions not detected by hysterosalpingography or laparoscopy. The endoscopic evaluation of the tubal mucosa can predict the possibility of an intrauterine pregnancy or laparoscopic tubal surgery, permitting the selection of patients with the most favourable prognosis. This technique may also have a role in identifying patients at risk for a repeat ectopic pregnancy and patients with silent endosalpingitis.

[Ovarian and endometrial status in tubal and peritoneal sterility]

A total of 97 patients with laparoscopically confirmed tubal and peritoneal sterility were examined. Thirty-six patients presented with a normal biphasic menstrual cycle, the rest 61 with the lutein phase insufficiency. Follicular presence and size were examined by ultrasonography, the dominant follicle and endometrium volumes were estimated. Only in 17 of the 97 examinees all the examined parameters were found normal, in the rest deviations from the normal echographic picture were revealed. More marked changes were detected in the patients with the lutein phase insufficiency. The findings evidenced a direct correlation between ultrasonic data and rectal temperature, adhesion process severity and the results of ovarian biopsy specimen histologic examination. The authors recommend ultrasonic examination for the assessment of ovarian function in patients suffering from tubal and peritoneal sterility.

Pregnancy after fimbriectomy reversal: results of microsurgery augmented by gamete intrafallopian tube transfer and embryo transfer

In this study, fimbriectomy reversal resulted in a 43% intrauterine PR and a fecundability of 6.6%. The cumulative PR and the fecundability were 57% and 7.8%, respectively, when microsurgery was augmented by GIFT and embryo cryopreservation during the same treatment cycle and by subsequent embryo thaw and transfer.

Treatment of unruptured tubal pregnancy by local injection of methotrexate and prostaglandin F2 alpha in 52 patients

Uncomplicated tubal pregnancies were treated by local injection of methotrexate (25 to 50 mg) and PGF2 alpha (5 to 10 mg). Trophoblastic resorption occurred in 50 (96.1%) of 52 patients within 20 days after treatment and without side effects. Three months after treatment, the affected tube was patent in 43 (91.4%) of 47 patients continuing in the study, and the subsequent intrauterine pregnancy rate was 40.4%. The combined use of methotrexate and PGF2 alpha appears to be a promising treatment for tubal pregnancy and should be evaluated further.

A method for evaluating human tubal motility in vivo: a new approach for infertility investigation

The motility of the Fallopian tube plays an important role in the gametes and embryo transport. Disorders of the tubal motor function may be involved in a great number of patients with unexplained infertility. The aim of this study was to develop a method to measure the tubal motility by means of an hysteroscopic approach in humans. The following motor parameters were evaluated: 1) the basal pressure of each 1 cm tract of the tube; 2) amplitude and frequency of the tubal contractions; 3) the uterine intraluminal pressure eight patients in the follicular phase (FP group) and 8 in the luteal phase (LP group) of the menstrual cycle, were studied. The duration of the motility recording session was 12 +/- 3 minutes (range 7-19 minutes). No significant differences were shown between the two groups of patients, and no differences were found between the recordings obtained from the right and the left tubes.

Serial scintigraphic imaging for visualization of passive transport processes in the human fallopian tube

Spontaneous migration of a radionuclide tracer from the vagina to the peritoneum may be visualized by scintigraphic imaging (hysterosalpingoscintigraphy, HSS). A prospective study was designed to evaluate diagnostic criteria for normal tubal passage of a control group (n = 7) and to establish the predictive value of the HSS technique in defining functional deficiency in anatomically patent tubes. In 56 patients with tubal and unexplained infertility, a comparison between the results of the tracer migration study and of contrast hysterosalpingography and laparoscopy was made. The overall correlation was 65%. Clearly discrepant results (i.e. an abnormal migration pattern in anatomically patent tubes) were recorded in 18% and were positively, yet not significantly associated with tubal adhesive disease and with a history of tubal microsurgery. Interpretation of scans was equivocal in another 18% of patients due to undetectable ascension of the tracer to the uterus. It is suggested that the radionuclide is moved forward by the same passive transport processes which are concerned with support of the migration of spermatozoa to the ovum, and that failure of tubal migration of the tracer may render patients eligible for in-vitro fertilization/embryo transfer treatment.

Adhesion formation after laparoscopic surgery in tubal pregnancy: a randomized trial versus laparotomy

OBJECTIVE

Women with ectopic pregnancy (EP) who have been operated on by laparoscopy are thought to have improved subsequent fertility, probably because of less adhesion formation. We aimed to evaluate the adhesion formation after laparoscopy as compared with laparotomy in a randomized trial.

DESIGN

One hundred five patients with tubal pregnancy were stratified with regard to age and risk factors and randomized to surgery by laparoscopy or laparotomy. To evaluate adhesion formation and tubal status, 73 patients with strong desire of pregnancy underwent a second-look laparoscopy. The adhesion status at the ipsilateral and contralateral side at primary surgery was compared with the status at second-look laparoscopy.

RESULTS

Patients operated on by laparotomy developed significantly more adhesions at the operated side than patients operated on by laparoscopy (P less than 0.001). Substantially more patients in the laparotomy group underwent adhesiolysis at second-look laparoscopy than did patients in the laparoscopy group. Tubal patency did not differ between the groups.

CONCLUSIONS

Laparoscopic treatment of EP results in less impairment of the pelvic status compared with conventional conservative surgery.

[Functional evaluation of the effectiveness of experimental reconstructive and plastic operations on the uterine horns]

In the given experimental model, tubo-plastic surgery was done with the use of locally produced fibrin glue (Fk-1), and commercial product "Beriplast" (FRG). In the control group microsurgical technique was adopted in the uterine horn of rats. It was proved that Fibrin glue reduces the frequency of post operative adhesion formation in the area of anastomosis and the chance of pregnancy is increased in comparison to microsurgical techniques.

[Organ-sparing surgical treatment of tubal pregnancy]

With microsurgical techniques, 28 organ-preserving operations were made for tubal pregnancy in females aged 22-36 years. According to the nature of the interventions performed, the patients were divided into 4 groups. Uterine pregnancy was demonstrated to occur in 11 (39.3%) of 28 females. Organ-preserving operations were concluded to be widely introduced into everyday practice. The operations are gaining in importance in young females without inflammatory genital diseases.

[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.

Tubal and peritoneal factors in the infertile woman: use of patient history in selection of diagnostic and therapeutic surgical procedures

For facilities with both ambulatory and inpatient surgical capabilities, we have attempted to develop an efficient strategy for the evaluation of infertile women. The strategy was intended to (1) avoid inpatient laparoscopy, (2) minimize the number of patients having laparoscopy who subsequently required laparotomy, and (3) minimize hysterosalpingography (HSG). Patients were selected for ambulatory laparoscopy or inpatient laparotomy by means of an algorithm based on their history and the selective use of HSG. Laparoscopy was avoided in 18.1% of patients and HSG in 41.6% of patients. We conclude that, when both inpatient and outpatient surgical facilities are available, the evaluation of female infertility may not always require HSG or laparoscopy.

Low serum progesterone levels and tubal dysfunction--a possible cause of ectopic pregnancy

We analyzed 22 human oviducts by the suction electrode method for electrical activity (preceding and reflecting the mechanical activity), as related to serum progesterone levels. Eleven patients had high progesterone levels (greater than or equal to 20 nmol/L), but the other 11 patients had low levels. When the serum progesterone level was low, the oviductal electrophysiologic characteristics were those associated with poor ovum transfer: low probability of prouterine propagation of the activity at the fimbrial end of the tube: high-frequency but low number of electrical bursts, reflecting possible weak propulsive force; and a high occurrence rate of sine-wave-like activity and inactive areas where ovum retention can occur. These phenomena could be related to the higher incidence of ectopic pregnancies in patients with luteal phase defect.

Cornual fibroids: a conservative approach to restoring tubal patency using a gonadotropin-releasing hormone agonist (goserelin) with successful pregnancy

The administration of GnRH agonists to shrink fibroids, albeit temporarily, may be of benefit to those patients in whom tubal blockage by the fibroids has given rise to infertility. Tubal patency has been restored in two of our patients, resulting in pregnancy in one.

[Significance of prognostic factors in the treatment of tuboperitoneal infertility]

The results of microsurgical treatment for tubo-peritoneal infertility are reported in 78 patients. Neosalpingostomy, combined with salpingo-ovariolysis, was performed in 51 patients, fimbriolysis and fimbrioplasty, in 8, tubal anastomosis in 7, and combined operations, in 12. Anatomical and functional assessment of the postoperative tubes was made using roentgeno-television hysterosalpingography, tubal insufflation and dynamic scintigraphy. Postoperative rehabilitation was supplemented by physical factors affecting tubal motility (supratonic frequency currents, tubal electrostimulation) with regard to the type of functional tubal disorder. Tubal patency was regained in 74.4%, and reproductive capacity, in 20.5% of the patients.

Endometriosis as a cause of infertility

Although association between moderate or severe endometriosis and infertility is fairly well established, the link between lesser disease stages and infertility is more tenuous. The proposed mechanisms underlying this association are reviewed. These include mechanical factors, changes in the peritoneal fluid environment, activation of local or systemic immune response, and abnormalities of ovulation, fertilization, and early pregnancy.

An ovum capture inhibitor (OCI) in endometriosis peritoneal fluid: an OCI-related membrane responsible for fimbrial failure of ovum capture

The present study was conducted to assess the mechanism of in vitro interference with fimbrial ovum capture by the ovum capture inhibitor (OCI) which we have recently demonstrated in endometriosis peritoneal fluid (PF). A golden hamster oviduct exposed to either endometriosis or nonendometriosis PF for 20 minutes at 37 degrees C was examined by scanning electron microscopy. Exposure of the oviduct to endometriosis PF reduced fimbrial activity of ovum capture and developed an OCI-related membrane on the fimbria, by which fimbrial cilia were completely concealed. This was not the case for nonendometriosis PF. Subsequently, an oviduct having been exposed to endometriosis PF was retrogradely flushed, by which the OCI-related membrane was ballooned and removed. The flushed oviduct resumed its activity of ovum capture. The OCI-related membrane appeared a cause of OCI interference with fimbrial ovum capture by preventing the contact between the fimbrial cilia and the cumulus oophorus.

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.

[Effects of experimental salpingoplasty on fertility in the rabbit]

The present study was undertaken to determine the functional capacity of oviduct following distal ampullar salpingostomy and tubal anastomosis. In the first experiment using 6 rabbits, the left fimbria of an oviduct and adjoining ampulla were resected, and then the remaining distal ampulla was subjected to cuff salpingostomy. The contralateral oviduct of each rabbit served as a control. Ovulation was induced at 3 weeks after surgery. The mean number of corpora lutea per ovary in the salpingostomy oviduct (5.00 +/- 0.37) did not differ significantly from that observed in the control oviduct (5.17 +/- 0.31). Five of 6 salpingostomy oviducts contained ovulated ova. However, the retrieval rate was significantly (p less than 0.01) reduced in the salpingostomy oviducts (36.7%), as compared to that found in the control oviducts (93.5%). Scanning electron microscopy of the fimbria revealed morphological features of both ciliated and secretory cells that were comparable to those of the contralateral intact fimbria. The second experiment assessed pregnancy outcome following tubal anastomosis in 6 rabbits. Pregnancy was established in both oviducts of all rabbits. The rate of implantation did not differ significantly between anastomosis sides (75.0 +/- 8.9%) and contralateral controls (93.9 +/- 3.9%). The present data demonstrated that fimbriectomized rabbit oviduct can retrieve ovulated ova, albeit less efficiently than normally. However, information that the retrieval rate of ova after salpingostomy is lower than that found in anastomosis also suggests a significant role of fimbria in ovum retrieval.

Cumulative pregnancy rates for donor insemination according to ovulatory function and tubal status

From our study of 234 cases of AID with fresh semen, we conclude the following: (1) women who do not have other infertility problems, such as ovulatory dysfunction or evidence of tubal disease, have approximately a 90% chance of pregnancy if they stay in the program for up to 12 cycles; (2) with even greater persistence (i.e., greater than 12 cycles), it is predicted that virtually 100% of these women would conceive, but this conclusion is based on extrapolated data and therefore must be interpreted with caution; (3) women with ovulatory dysfunction who are treated with CC during their AID cycles ultimately achieve the same likelihood of pregnancy as women with normal ovulatory function, but at a slower rate; and (4) women with one patent tube (possibly a marker for generalized tubal damage) have a poorer outcome from AID than those with bilaterally patent tubes, from the standpoint of both the ultimate likelihood of pregnancy and the pregnancy rate per cycle.

Hysterosalpingographic evaluation of tubal patency after ectopic pregnancy

In the period 1983 to 1985, hysterosalpingography was performed in 76 women after laparotomy to manage ectopic gestations. Clinical characteristics of these women, including their operative findings, were then correlated with the follow-up hysterosalpingography. Study participants were classified into five groups according to surgical management of the ectopic gestation. In each of the five groups, a substantial percentage of those women with a nonpatent fallopian tube (contralateral to the tube bearing the ectopic gestation) on hysterosalpingography had a normal-appearing fallopian tube at laparotomy. Approximately 50% of women with a history of previous pelvic inflammatory disease were found to have nonpatent contralateral fallopian tubes on follow-up hysterosalpingography.