Laparoscopic tuboplasty for mild distal tubal disease

Abstract

Objective: To review tuboplasty techniques for alleviating fallopian tube blockage. Design: A step-by-step explanation of the techniques that comprise tuboplasty-fimbrioplasty, salpingo-ovariolysis, and salpingostomy-with surgical video footage. Setting: Academic medical center. Patient: A 28-year-old G0 female patient with primary infertility and bilateral fallopian tube occlusion wanting to avoid in vitro fertilization. Intervention(s): Tuboplasty and its component techniques of fimbrioplasty, salpingo-ovariolysis, and salpingostomy are demonstrated in a stepwise fashion for a case of mild tubal disease. Fimbrioplasty includes identifying the agglutinated or phimosed fimbrial end and gently opening it with fine forceps and blunt microdissection. Salpingo-ovariolysis is demonstrated with video and comprises: 1) surveying the anatomy; 2) applying traction to delineate the adhesions; and 3) transecting the adhesions with microsurgical scissors or electrosurgery. Finally, the steps of a salpingostomy are demonstrated, including: 1) identifying the length of the fallopian tube; 2) performing chromotubation to delineate tubal obstruction; 3) creating a salpingostomy at the terminal end; and 4) suturing open the salpingostomy site circumferentially to evert the edges. Main Outcome Measure(s): Successful restoration of normal tubal anatomy and identification of the location of tubal occlusion to guide salpingostomy site placement. Result(s): The fallopian tubes were assessed bilaterally and noted to have mild tubal disease and therefore were appropriate for tuboplasty. Normal tubal anatomy was restored bilaterally through salpingo-ovariolysis. Subsequent identification of the area of tubal occlusion bilaterally and salpingostomy were performed to create a patent fallopian tube able to pick up an oocyte from the ovary and facilitate fertilization. Conclusion(s):Tubal reconstructive surgery remains an important option to offer patients who want to avoid in vitro fertilization and who have mild tubal disease. (Fertil Steril Ò 2020;113:1330-2. Ó2020 by American Society for Reproductive Medicine.) El resumen está disponible en Español al final del artículo.

Tuboplasty, thank-you notes, and the revival of lost arts

“…In ''Laparoscopic tuboplasty for mild distal tubal disease,'' Norris et al (2) are also proposing a renaissance of-sorts. More than a decade ago, surgical intervention for infertility was pronounced dead because assisted reproductive technologies (ART) had completely replaced surgery as the first-line treatment for infertility (3).…”

“…The advantages of IVF are a 47% live birth rate per cycle (patient's own eggs, age <35 years), a faster time to pregnancy, and no need for surgical intervention. Meanwhile the disadvantages include the requirement of close monitoring, risk of obstetrical complications, such as multiple gestation, preterm delivery, fetal growth restriction, and congenital malformations, and the potential for ovarian hyperstimulation (2,5). Surgical intervention has the advantage of being a one-time, often minimally invasive, procedure that can result in multiple future pregnancies when successful.…”

“…Surgical intervention has the advantage of being a one-time, often minimally invasive, procedure that can result in multiple future pregnancies when successful. However, surgical intervention does incur the risks of anesthesia and intraoperative complications, including injury to reproductive organs and the result of a higher rate of ectopic pregnancy (2,5). Surgery also has a longer timeto-pregnancy interval, with 90% of pregnancies occurring within 6-12 months.…”

“…The authors of the video discuss this by describing favorable candidates as those that want to avoid ART and who present ''good surgical prognosis.'' They further describe good surgical candidates as those with mildly dilated tubes (<3 cm), only filmy adhesions, and a lush endosalpinx (2). While having criteria to identify those who would most benefit from surgery is helpful, it is equally important to have well trained reproductive surgeons capable of offering and performing these procedures.…”

“…In the video, the authors describe three common surgical techniques used to treat tubal disease: fimbrioplasty, salpingo-ovariolysis, and salpingostomy (2). Their chosen medium allows them to then walk the viewer step by step through a case in which they skillfully execute both salpingo-ovariolysis and salpingostomy.…”