Current practice in tubal surgery and adhesion management: a review

Fallopian tube subtle pathology

The aim of the present review is to give a comprehensive overview of fallopian subtle lesions and suggest the impacts of these abnormalities on fertility. Tubal subtle variations, including tubal diverticula, Morgagni hydatids, accessory fallopian tube, accessory ostium of the fallopian tube, tubal phimosis, agglutination, and sacculation, have been described and cited as making significant contributions to infertility. This review summarizes characteristics of these subtle abnormalities and provides an update of recent knowledge of the diagnosis and management of these variations. We hope that the present contribution may help to bring more attention to the clinical field to recognize these abnormalities and consequently aid in improving fertility.

[Comparison of fertiloscopy versus laparoscopy in the exploration of the infertility: analysis of the literature]

BACKGROUND

Fertiloscopy is a recent technique designed to explore the tubo-ovarian axis in unexplained infertility. It is a simple outpatient technique, allowing to perform operative procedures, but its position relative to laparoscopy is yet to be defined.

MATERIAL AND METHODS

A thorough and extensive bibliographical search was undertaken to fully embrace the question, challenging Medline at the National Library of Medicine, Cochrane Library, National Guideline Clearinghouse, Health Technology Assessment Database. All the retrieved articles were classified as either descriptive or comparative studies and evaluated on a set of criteria.

RESULTS

Most of the papers described case series coming from a few teams, focusing mainly on the technical aspect of the procedure, like the access rate to the posterior cul-de-sac, the success rate in visualizing the pelvis, the complications rate (mainly rectal perforation), and its operative performance in drilling ovaries for resistant polycystic ovarian syndrome. Comparative studies numbered six trials. They all followed the same design, fertiloscopy preceding conventional laparoscopy in patients taken as their own control. The concordance rate between the two modalities reaches 80% in terms of tubal pathology, adherences and endometriosis, with an estimated reduction of laparoscopies varying from 40% to 93%.

CONCLUSION

The current literature shows a concordance between fertiloscopy and conventional laparoscopic findings for certain parameters in cases of tubal pathology, adherences and endometriosis. The relative positions of these two modalities in unexplained infertility still remain elusive.

The aromatase inhibitor letrozole reduces adhesion formation after intraperitoneal surgery in a rat uterine horn model

OBJECTIVE

To investigate, in an experimental animal study, the effects of letrozole and tamoxifen in the reduction of adhesion formation following abdominopelvic surgery.

STUDY DESIGN

Thirty female Wistar albino rats were included and divided into three groups. One group received 500 μg/d tamoxifen and a second group received 1 mg/kg/d letrozole through an enteric tube. A third group did not receive any drugs and served as the control group. On the fifth day, a laparotomy was performed and the right uterine horn was injured by monopolar cautery. The left uterine horn was incised with a scalpel and sutured. The preventive therapy protocols were continued for 7 days after surgery. On the 14th day after first surgery the animals were sacrificed, and the intraperitoneal macroscopic adhesion formation and microscopic adhesion features were evaluated. The Kruskal-Wallis test was used to compare the scores of the macroscopic adhesion scores and histologic features among the three groups, followed by a post hoc Mann-Whitney test. The total histological score was analyzed with a one-way ANOVA, followed by post hoc Bonferroni correction tests. p values ≤0.05 were considered statistically significant. The level of significance was set at p≤0.016 for the post hoc tests.

RESULTS

The letrozole and tamoxifen groups had significantly lower adhesion scores for the right uterine horn than the control group (p=0.005 and p=0.013, respectively). For the left horn, however, only the letrozole group had a lower macroscopic adhesion score than the controls (p=0.011). The total histological score was significantly lower in the letrozole group than in the control group (p=0.014), but no differences were found between the tamoxifen group and the control group (p=0.954). Inflammation, fibroblastic activity, collagen formation and vascular proliferation were significantly lower in the letrozole group compared with the control group (p<0.05). The foreign body reactions were similar among the three groups (p>0.05). Tamoxifen administration did not result in any significant effects on the histological scores (p>0.05).

CONCLUSION

Letrozole resulted in a significant decrease in postoperative macroscopic adhesion formation and the total histological scores, but tamoxifen did not demonstrate a similar effect on the histological scores.