Intraoperative verification of hysterosalpingographic and laparoscopic examination in cases of oviductal infertility

There has been made an analysis of 45 cases of women's oviductal infertility qualified to surgical treatment. In search of the reasons of infertility these patients underwent hysterosalpingographic examination and 24 of them additionally, diagnostic laparoscopy with chromotubation. Positive intraoperative verification of HSG and laparoscopy, as a confirmation of tubal obstruction, they obtained at 40 women (88.9%) that made possible to carry out microsurgical operations in them. Such a big percentage of correct diagnoses makes sure, that both hysterosalpingography and laparoscopy are indispensable for proper qualification of a patient to microsurgical treatment of oviductal infertility.     

Diagnostic laparoscopy in primary and secondary infertility

PURPOSE: Our purpose was to compare the diagnostic efficacy of laparoscopy between primary and secondary infertility and to define a subgroup in which the positive findings are low. METHODS: A retrospective review of the cases of 206 infertile women who underwent laparoscopy was conducted. RESULTS: Eighty-two (39.8%) patients were found to have evidence of pelvic disease--20 (22.2%) with primary infertility and 62 (54.3%) with secondary infertility. The ratio of positive findings in secondary infertility was significant in comparison with the positive findings in primary infertility. In only 3 of the 20 patients with primary infertility was there no history of an abdominal operation, pelvic inflammatory disease, or an abnormal hysterosalpingography. Of the 62 women who suffered secondary infertility and had positive findings in laparoscopy, 15 had no history of suspect findings. CONCLUSIONS: The diagnostic yield of laparoscopy for primary infertility in the absence of indications of mechanical factors is low. Therefore the need for diagnostic laparoscopy in these cases should be reconsidered.     

Chemiluminescence response of whole blood in patients undergoing urological operations

We compared falloposcopy employing a new coaxial system with traditional laparoscopic chromotubation and hysterosalpingography in a prospective, multicenter clinical trial at five tertiary infertility centers. Based on findings at hysterosalpingography or laparoscopic chromotubation, the 16 women (22 tubes) in group 1 had a presumed diagnosis of proximal tubal obstruction, and the 4 (7 tubes) in group 2 had unexplained infertility. Cannulation was successfully achieved in 83.3% of tubes. In group 1, 85% (17/20) of visualized tubes were patent and 35% (7/20) were normal. In group 2, 40% (2/5) of visualized tubes were abnormal. Management was changed in 52.4% of women as a result of falloposcopic findings. Falloposcopy with this new coaxial system allows improved visualization with less bulky and less traumatic instruments. The system provides valuable information regarding the fallopian tube lumen that correlates poorly with that obtained with more traditional techniques.     

Chlamydial genital infections and laparoscopic findings in infertile women

Several studies have shown that previous chlamydial genital infection, reflected by serological markers, is strongly associated with tubal damage leading to tubal infertility. In 105 women undergoing laparoscopy, multiple samples were collected from the lower (urethra and cervix) and upper (endometrium, peritoneal fluid, tubal lumen) genital tract, in order to isolate Chlamydia trachomatis in cell culture. Chlamydia trachomatis was isolated from at least one site in 13 (30.9%) of 42 infertile women with tubal infertility, in 5 (12.1%) of 41 women with unexplained infertility, in 1 of 4 women affected by acute salpingitis and in 1 (5.5%) of 18 women with endometriosis or uterine malformations. The latter group was the control group. Thirteen (65%) of the 20 positive women harboured Chlamydia trachomatis in their upper genital tract alone and 16 women were positive in one or both tubes. Only one of the positive women showed laparoscopic signs of acute pelvic infection. Four of the 5 positive women with unexplained infertility harboured Chlamydia trachomatis in the tubal lumen. This study confirms that chlamydial infection is strongly associated with tubal damage. It suggests that cervical cultures are inadequate for excluding a tubal infection and that chlamydial colonization of the tubal mucosa is possible in the absence of symptoms and laparoscopic signs of active infection.     

Insulin levels after portal and systemic insulin infusion differ in a dose-dependent fashion

BACKGROUND: Before the advent of the falloposcope, the endosalpinx usually evaded endoscopic evaluation. The healthy condition of the tubal epithelium and the patency of the tube are important for development and transportation of early stage embryos. METHODS: Twenty patients had tubal occlusion diagnosed by hysterosalpingography, including 10 cases of hydrosalpinx, five cases of interstitial occlusion and five cases of fimbrial occlusion. Falloposcopy with a linear everting catheter and laparoscopy were performed simultaneously to evaluate tubal lumens and peritubal conditions. RESULTS: An attempt was made to cannulate 30 fallopian tubes in 20 cases with a falloposcope, using a nonhysteroscopic transvaginal approach through a linear everting catheter. The success rate was 93% (28/30). In 15 cases of hydrosalpinx or fimbrial obstruction, 10 patients (67%) were considered to be suitable for in vitro fertilization because of flattened mucosa in the endosalpinx and endotubal adhesions. Normal mucosa was noted in only four patients (27%), who were advised to have tuboplasty. One patient (6%) had normal mucosa without tubal occlusion. In two of the five cases of interstitial occlusion, dye (methylene blue) could not pass the interstitial portion of the fallopian tube when chromopertubation was performed twice. This tubal obstruction was overcome with the linear everting catheter. One patient had the complication of an ampulla wall perforation. CONCLUSIONS: In patients with fallopian tube disease, falloposcopy is a useful technique for evaluating the endosalpinx and providing information for selecting further treatment. In some cases of interstitial occlusion, it may also have a therapeutic effect.     

Practicing a protected scope of oral and maxillofacial surgery

Pelvic ultrasound and human chorionic gonadotropin assays are currently the standard methodology to detect tubal pregnancy. We report a case of infertility investigated by hysterosalpingography in which a clinically unsuspected chronic tubal pregnancy was identified with the predisposing factor of bilateral salpingitis isthmica nodosa. The radiographic findings of this very rare cause of tubal filling defect are shown.     

Experience with the trans-uterine tubal coagulation with high frequency current and the thermo method under hysteroscopic control (author''s transl)

With the aid of the carbon dioxide hysteroscope, 152 patients underwent transuterine tubal sterilization. 106 women had high frequency current coagulations of the tubes. At follow-up examinations 62 tubes were occluded and 30 showed a unilateral tubal occlusion. These results did not improve by using the thermo coagulation method since only 10 out of 24 patients showed bilateral tubal occlusion and two unilateral tubal occlusions. Up to 20 months following the transuterine tubal sterilization, 28 of the 152 women became pregnant. Of these, 16 became pregnant in spite of hysterosalpingographic evidence of bilateral tubal occlusion. Two patients required emegency laparotomies because of small bowel injuries. Within the coagulation times and temperature ranges used in this series, the results of trans-uterine tubal sterilization are unsatisfactory. It is possible that other types of hysteroscopic tubal sterilizations which are now being developed will be more successful.     

Pharmacokinetics of the protease inhibitor KNI-272 in plasma and cerebrospinal fluid in nonhuman primates after intravenous dosing and in human immunodeficiency virus-infected children after intravenous and oral dosing

The aim of this study was to evaluate the feasibility of routine falloposcopy in infertile patients undergoing basic infertility investigations, and to determine its usefulness in comparison with other tubal investigation methods. Seventy-five infertile women were selected based on the following criteria: 2 years of infertility, age between 18 and 40 years, normal ovulation, and partner with normal spermatozoa. Based on the results of the classical means of tubal evaluation (hysterosalpingography and laparoscopy), these patients were classified in one of two groups: tubal or unexplained infertility. All patients underwent a falloposcopy under general anaesthesia. The procedures were performed by the same surgeon with the linear everting catheter. Based on the falloposcopic findings, these patients were then reclassified in one of two other groups: falloposcopic tubal or falloposcopic unexplained infertility. The mean outcome measures were catheterization rate, duration of the procedure, pregnancy rates, complication rate and predictive value of Falloposcopy. The tubal catheterization rate was 94.5%. The mean duration of falloposcopy was 19 min per tube. Based on a standard scoring system, the spontaneous pregnancy rates were 27.6% for a score <20; 11.5% for a score between 21 and 30; and 0% if the score was >30. Complication rate was 5.1% of pinpoint perforations of the tube. With Cox's statistical model, none of the parameters analysed was statistically predictive of intrauterine pregnancy. We conclude that the greater accuracy of diagnosis by falloposcopy may indicate that it should be incorporated into the initial screening of infertile patients.     

Reversible esophageal motility disorder in a patient with sarcoidosis

Hysterosalpingo-contrast sonography was compared with sonographically controlled selective tubal catheterization (STC) in 26 infertile women who complained of infertility. Both procedures were carried out on a single examination date. A group of 10 patients first underwent hysterosalpingo-contrast sonography followed by STC, while 16 first had STC followed by hysterosalpingo-contrast sonography. The main outcome measure was tubal patency. A total of 52 Fallopian tubes was assessed. Hysterosalpingo-contrast sonography showed 39 tubes (75%) and STC 46 (89%) to be patent, 13 tubes (25%) and six tubes (12%) were diagnosed to be proximally occluded, by means of hysterosalpingo-contrast sonography and STC respectively. Concordant diagnosis with both methods was made in 43 of 52 tubes (83%). When hysterosalpingo-contrast sonography was followed by STC, the concordance rate was 85%. When STC was followed by hysterosalpingo-contrast sonography, the concordance rate was 81%. In one patient the diagnosis of proximal occlusion of one tube as determined by hysterosalpingo-contrast sonography and STC had to be correlated in laparoscopy. In a patient, who after hysterosalpingo-contrast sonography and STC, was suspected to have bilateral proximal occlusion of the tubes, considerable bilateral proximal stenosis and distal occlusion was documented at laparoscopy. In conclusion, sonographically controlled STC may correct a misdiagnosis in cases where hysterosalpingo-contrast sonography leads to the finding of proximal tubal obstruction. The combination of hysterosalpingo-contrast sonography and STC as an out-patient investigation method for tubal patency assessment in infertile women avoids anaesthesia and radiation. For this reason we recommend the combination of sonographically controlled STC with hysterosalpingo-contrast sonography, at least in cases where proximal tubal occlusion is suspected after hysterosalpingo-contrast sonography. The influence of the order in which the two methods are used on the results of both should be investigated in a randomized study.     

Combining B-mode ultrasound with pulsed wave Doppler for the assessment of tubal patency

This study was conducted to determine whether the additional use of pulsed wave Doppler improves the diagnostic capacity in assessing tubal patency by hysterosalpingo contrast sonography (HyCoSy). A total of 210 women with a history of infertility were included in this study. HyCoSy was performed after intrauterine injection of Echovist 200. For the assessment of tubal patency B-mode scanning and pulsed wave Doppler ultrasound were performed in the proximal and distal tubal segments. With the combined sonographic procedure 297 tubes (74%) were rated patent, 35 (8%) incompletely obstructed and 70 (18%) completely obstructed. A total of 252 tubes were additionally examined by laparoscopy for reference purposes. Concordant results for both methods were found in 92% of tubes, nine had been rated false negative and 10 tubes appeared to have been rated false positive. The combined sonographic specificity was found to be 85% with a sensitivity of 95%. Peritubal adhesions detected by laparoscopy were found to be the reason for false positive sonographic results in 60% of cases. In conclusion, the combined B-mode and pulsed wave Doppler examination appears to be a non-invasive and low-cost test for the assessment of tubal patency, which should be performed during diagnostic work-up for infertility.     

Elevated antitoxin titers in a man with generalized tetanus

STUDY OBJECTIVE: To compare the outcome of in vitro fertilization and embryo transfer (IVF-ET) after laparoscopic surgery in women with endometriosis with that of patients with tubal factor infertility. DESIGN: Retrospective survey of hospital and office charts using a computerized worksheet. SETTING: Lin-Kou medical center of Chang Gung Memorial Hospital. PATIENTS: Sixty-seven women with minimal to mild or moderate to severe endometriosis. Women with tubal factor infertility without other associated disorders (60 cycles) made up the control group. INTERVENTIONS: Seventy-five consecutive cycles of IVF-ET were performed in these patients who failed to conceive after laparoscopic conservative surgery. MEASUREMENTS AND MAIN RESULTS: The concentration of serum estradiol on the day of human chorionic gonadotropin (hCG) injection, the day of hCG injection, clinical pregnancy rates per transfer, number of follicles larger than 14 mm, number of embryos transferred, and implantation rate were not significantly different between women with endometriosis and those with tubal factor infertility. The number of oocytes retrieved and number fertilized were decreased, and the basal level of follicle-stimulating hormone on cycle day 3 was higher in women with both degrees of endometriosis. Women in both endometriosis groups received more follicle-stimulating hormone and human menopausal gonadotropin than those with tubal factor infertility. CONCLUSIONS: The outcome of IVF-ET in patients with endometriosis after laparoscopic surgery did not differ from that in the group with tubal factor infertility, but the former required more ampules of gonadotropin to achieve the same response. The advantages of laparoscopic surgery in women with endometriosis should be probably correlated with success of IVF-ET.     

Early warning of new health care technologies in the United Kingdom

OBJECTIVE: To evaluate fertility after salpingectomy performed for ectopic pregnancies (EPs). DESIGN: Retrospective cohort study. SETTING: Tertiary care university hospital. PATIENT(S): Three hundred forty patients (213 with surgery by laparoscopy and 127 by laparotomy) between January 1985 and July 1994, with a mean follow-up period of 73 months (36-162 months). INTERVENTION(S): Salpingectomy performed either by laparotomy or by laparoscopy as indicated. MAIN OUTCOME MEASURE(S): Rate of intrauterine pregnancy (IUP), live births, and recurrent EP. RESULT(S): Forty-seven (13.8%) patients were lost to follow-up, and 68 (20%) did not want to become pregnant. The overall rate of spontaneous conception was 70.4% in the laparoscopy group and 53.2% in the laparotomy group. The rate of live births was 50% and 37%, respectively; the mean time until conception was 11 and 17.2 months; and the rate of recurrent EP, 10.6% and 9.6%. The multivariate analysis showed a rate of IUP of 82.1% among women younger than 30 years of age with a normal contralateral tube, laparoscopic surgery, and no history of infertility. CONCLUSIONS: In this study of fertility after salpingectomy for EP, laparoscopic treatment was superior to laparotomic treatment. Fertility was equivalent to that after conservative treatment in a subgroup of young patients treated with laparoscopy and with no history of tubal pathology.     

"Crushed glass" appearance of particles observed in roentgenograms after hysterosalpingography as an indicator of pelvic abnormalities

OBJECTIVE: To evaluate the diagnostic value of the crushed glass appearance of particles observed on roentgenogram after hysterosalpingography in patients with pelvic abnormalities. DESIGN: Retrospective study of 32 patients whose roentgenogram had particles with a crushed glass appearance and 16 patients without crushed glass appearance, with laparoscopy conducted to determine the location and severity of the pelvic disease. SETTING: Fujita Health University Hospital, Aichi, Japan. PATIENT(S): A total of 240 patients underwent hysterosalpingography to determine the cause of infertility. MAIN OUTCOME MEASURE(S): We compared the location of the pelvic endometriosis and/or inflammation that was observed on roentgenogram as the crushed glass appearance versus definitive findings at laparoscopy. RESULT(S): A total of 30 of the 32 cases (93.8%) with the crushed glass appearance were confirmed as having pelvic abnormalities, such as endometriosis (73.3%) and pelvic inflammation (26.7%). The rate of the concurrence of the location of the crushed glass appearance observed on the film and that of the lesions verified by laparoscopy was 66.7%. Histopathological examination showed that specimens taken from endometriosis or inflammatory lesions that comprised the crushed glass appearance were lacking in epithelium in proportion to the size of the particles. CONCLUSION(S): Identification of the crushed glass appearance of particles was a useful noninvasive method of detecting pelvic abnormalities, such as pelvic endometriosis and inflammation, in infertile women.     

HLA-DQA1 in autochthonous Basques: description of a genocline for the DQA1*0201 allele in Europe

The aim of the paper was to estimate the results of microsurgical reconstruction involving the abdominal opening of the oviducts in 89 infertile women in relation to anatomical status of uterine adnexa. Following procedure, patency of abdominal openings of the oviducts documented by hysterosalpingography and/or by laparoscopic in 73.33% of the treated females. However if simultaneous supplementary (14 women) surgical connecting of impatent oviducts in isthmo-intramural segment was performed the patency restored 57.14%. Pregnancies resulting in delivery of viable infants were achieved in 30.37% and 7.14% in the studied groups respectively. The post operative effect correlated inversely with the intensity of periadnexal adhesions and the diameter of hydrosalpinx ampulla of oviducts.     

Systemic methotrexate therapy versus laparoscopic salpingostomy in tubal pregnancy. Part II. Patient preferences for systemic methotrexate

OBJECTIVE: To investigate patient preferences for systemic methotrexate therapy relative to laparoscopic salpingostomy in the treatment of tubal pregnancy. DESIGN: Preference assessment in controlled clinical study. SETTING: Four hospitals and one infertility clinic. PATIENT(S): Forty patients who had been treated for tubal pregnancy and 40 nonpregnant controls. INTERVENTION(S): Preference for methotrexate therapy relative to salpingostomy was established during an interview. Two scenarios were offered for methotrexate therapy: one with and one without preceding diagnostic laparoscopy. Hypothetical tubal patency rates after methotrexate therapy were varied in both scenarios until patients switched in their initial preference. MAIN OUTCOME MEASURE(S): Preference for systemic methotrexate therapy. RESULT(S): Only a few patients switched in their initial preference when the tubal patency rate after systemic methotrexate therapy was varied. Most preferred methotrexate therapy without an increase in the tubal patency rate in a scenario without preceding diagnostic laparoscopy. A small group never opted for methotrexate therapy even when it would guarantee a 100% tubal patency rate. CONCLUSION(S): Systemic methotrexate therapy would be preferred by most patients as part of a completely nonsurgical management strategy. Tubal patency was a decisive factor for treatment preference in a minority of patients only.     

Influence of external pH on ciliary beat frequency in human bronchi and bronchioles

To assess the efficiency of transvaginal ultrasonography (TVUS) in the screening of pelvic pathologies in the initial workup of infertile women, we carried out a prospective comparison of sonographic diagnosis with laparoscopic and pathological findings. Between February 1994 and April 1995, 133 premenopausal non-pregnant women underwent TVUS on the day before laparoscopy. The efficiency of TVUS in detecting pelvic pathologies was 90.2% with a sensitivity of 86.2%, a specificity of 97.8% and positive and negative predictive values of 98.6 and 78.8% respectively. If the six false-negative cases with a histological diagnosis of minimal endometriosis were defined as 'normal pelvis', sensitivity and specificity could be corrected to 92.5 and 98.6% respectively. Endometriomas were diagnosed by TVUS with an efficiency of 96.4%, with a sensitivity and a specificity of 90 and 96.7 % and with positive and negative predictive values of 75 and 99.1% respectively. The sensitivity of vaginal sonographic characterization of pelvic adhesions was 61.1% with a specificity and positive predictive value of 98.2 and 84.6%. The negative predictive value of TVUS was 94.1%. These data suggest that it is not possible to characterize pelvic adhesions, especially filmy adhesions, with acceptable accuracy. However, in the initial workup of infertile women, if the patient is young, if both hysterosalpingography and TVUS are negative, laparoscopy could be postponed. In couples with severe male factor infertility and for whom in-vitro fertilization or intracytoplasmic sperm injection is the treatment of choice, laparoscopy might be avoided where the TVUS is negative.     

Visible and non-visible endometriosis at laparoscopy in fertile and infertile women and in patients with chronic pelvic pain: a prospective study

In 100 consecutive patients who were undergoing laparoscopy for infertility (group 1, n = 52), chronic pelvic pain (group 2, n = 18) or tubal sterilization (group 3, n = 30, asymptomatic fertile women), peritoneal biopsies were taken from areas of visually normal peritoneum of uterosacral ligaments. Twenty-six patients in group 1 (50%), eight patients in group 2 (44.4%) and 13 patients in group 3 (43.3%), were found to have laparoscopic evidence of endometriosis elsewhere in the pelvis. The majority of women (80.7% in group 1, 87.5% in group 2, and 100% in group 3) had stage I disease. The incidence of the distinctive appearances of the lesions was similar in the three groups of patients and 7% of all women or 15% (7/47) of those patients having endometriosis at laparoscopy had only subtle (non-?typical') endometriotic peritoneal lesions. Uterosacral biopsies showed the presence of endometriotic tissue in three cases (5.7%), two cases (11%) and three cases (10%) in groups 1, 2, and 3 respectively. One of the two patients in group 2 and two of the three patients in group 3 had no evidence of endometriosis at laparoscopy; thus histological study revealed the presence of endometriosis in normal peritoneum in 11% (5/47) of patients having macroscopic endometriosis and in 6% (3/53) of patients without endometriosis at laparoscopy. Previous oral contraceptive users were significantly higher among women having macroscopic and/or microscopic endometriosis than among women without the condition. In conclusion, our prospective study shows a high prevalence (45-50%) of endometriosis (including microscopic forms) in both patients with chronic pelvic pain and asymptomatic women (fertile and infertile), thus supporting the modern concept that in many women endometriosis may be a paraphysiological condition while probably only in some patients small amounts of endometriosis are an ?annoyance' with implications to their reproductive health and may produce symptoms (e.g. pelvic pain) and therefore should be defined as a ?dis-ease'. Previous use of oral contraceptives may increase the risk of developing endometriosis.     

Blockade of morphine-induced place preference by diazepam in mice

We assessed the efficacy of combined laparoscopic and minilaparotomy for outpatient microsurgical reversal of extensive tubal sterilization in 11 women undergoing the procedure and followed for a mean of 24.7 months. All patients desired reversal of extensive tubal sterilization, and had 4 cm or less of the longer oviduct remaining. The mean operating time was 110 minutes, and the mean total cost was $5067. There were no major complications. Two women were treated for uncomplicated cystitis within 1 month of surgery. Five (45%) of 11 women delivered viable infants; one patient had two ectopic pregnancies. These preliminary data suggest that outpatient combined laparoscopy and minilaparotomy may be effective in patients who desire restoration of fertility after extensive tubal sterilization.     

Hysterosalpingography and hysteroscopy in female infertility

A total of 323 women of reproductive age (19-40 years) were submitted to a complete investigation of infertility routinely including hysterosalpingography and hysteroscopy. In 177 cases (54.7%) no pathological conditions were found by either of the applied methods, while in 65 cases (20.1%) similar abnormalities were observed by hysterosalpingography and hysteroscopy with a global correlation of 74.8%. Hysterosalpingography also presented false positive results in 11.7% and false negative ones in 13.3% of all the studied cases. In conclusion, the combined use of these techniques in infertility investigation gives complete and accurate information about the uterine cavity, despite the disadvantages of hysterosalpingography due to false positive and false negative results.     

Falloposcopy in conjunction with laparoscopy: possibilities and limitations

Falloposcopy is a transvaginal microendoscopic technique to explore the human Fallopian tube from the uterotubal ostium to the fimbrial end. Falloposcopy provides a unique possibility to visualize endotubal disease and may be used therapeutically for removal of debris and for cutting down filmy intraluminal adhesions. To assess the clinical performance of falloposcopy as part of an infertility investigation, a total of 43 women scheduled for laparoscopy as part of an investigation of infertility had a falloposcopy performed in conjunction with the laparoscopy. All women were investigated at Danderyd Hospital, Stockholm and Akademiska Hospital, Uppsala, during 1995 and 1996. Images from the endosalpinx were obtained in 26 of 43 women (60.5%). In 10 women (23.3%), it was possible to obtain images from both tubes. No images were of sufficient quality to describe the entire tubal mucosa in detail. Falloposcopy represents a unique tool for visualization of endotubal disease and may provide a valuable instrument for in-vivo exploration of tubal physiology. However, certain technical problems limit the usefulness of this method in routine clinical practice. These technical problems have to be solved before falloposcopy can achieve a central position in investigation and treatment of tubal disease.