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In 30 years, 1,669 patients underwent open microsurgery for tubal diseases. Several techniques like adhesiolysis, reanastomosis, fimbrioplasty, salpingoneostomy, proximal reconstruction, isthmo-ostial anastomosis and reimplantation are described. Results were excellent for patients with a favourable prognosis (1,517 patients) and with very high pregnancy rate: 80% pregnancies with delivery for tubal reversal, 68% for proximal diseases, 75.1% for fimbrioplasty and 55% for salpingoneostomy. Risks of ectopic pregnancy were very low: 1.5% for tubal reversal (because the tubes were healthy), 4% for proximal diseases, 4% for fimbrioplasty and 6.7% for salpingoneostomy. Results were very low for patients with a poor prognosis (152 patients): 10% pregnancies with delivery for distal diseases, less than 20% for proximal diseases and 22% ectopic pregnancies. Open microsurgery can still be helpful in treating tubal infertility: results are better than those obtained with laparoscopic reconstructive surgery and better than those obtained with in vitro fertilization for patients with a favourable prognosis. Patients are only operated one time and can have several pregnancies. Open tubal microsurgery is a minimal invasive surgery and saves costs (it requires a small number of instruments and minimises sutures; patients can return home 4 days after surgery, at the latest). Results on fertility are very favourable.
Between 1977 and 2007, 1,669 patients underwent a minilaparotomy for tubal diseases. Minilaparotomy means a laparotomy with minimal tissue injury, applying microsurgical principles and procedures. One of the first principles we followed was the temporary but absolute contraindication for surgery in case of active infection and active inflammation (for example endometriotic red lesions). We also applied the following principles:
gentle handling of tissues
atraumatic manipulation of the tubal serosa and mucosae, of the ovary and of the peritoneum
selective bipolar coagulation: only the vessels (and not the surrounding area) must be dessicated by fine bipolar microelectrodes
continuous irrigation to keep the surgical area clear at all times and to avoid the tissue from drying out (and especially the tubal serosa and the ovary)
perfect protection of the abdominopelvic cavity against infection risk using the sterile “wound drape”
complete resection of pathologic tissues
complete restoration of the serosa: closure of all peritoneal defects to avoid formation of de novo adhesion and recurrence of previous adhesion (peritoneal defects in case of adnexal disease due to previous infection or inflammation do not scar easily and quickly because the subserosal tissue is not a normal tissue; it is usually rich in inflammatory cells). A peritoneal closure with fine material and inverted stitches scars better and faster than a large defect without peritoneal closure
use of very fine resorbable sutures 7/0 and 8/0
last, use of a well mastered surgical technique: the surgery must be successful the first time. Repeat surgery never gives favourable results
Most of these principles were described by Gomel [1] in 1977. Open microsurgery is a method that proves to be cost efficient: the same microscope has been used for 17 years. Sets of instruments were only changed every 4 to 5 years. We only need one suture of 7/0 and one of 8/0 for two tubes. The maximum length of hospital stay is 4 days (only 3 days for 40% of the patients). Materials and methodsPatient characteristics
bifocal tubal lesions (distal and proximal occlusion in the same tube)
distal tubal lesions with poor prognosis: extended dense adhesion, sclerohypertrophic tube, intra-ampullary adhesions, lack of mucosal folds [2]
significant and extended proximal lesions including the isthm, the intramural segment and the ostium uterinum
After 1987, when in vitro fertilization (IVF) results became acceptable, we abandoned reconstructive surgery for these lesions and decided to perform salpingectomy in order to increase IVF results. We only operated tubal lesions with a favourable prognosis. As a consequence, 1,517 patients with a favourable prognosis underwent reconstructive microsurgery between 1977 and 2007: 485 tubal reversals 527 distal tubal lesions 505 proximal tubal lesions MaterialsFrom 1977 to 1994, we used a Zeiss OPMI 6 microscope. A Leica-Wild M-690 was introduced after 1994. Five instruments of 15 and 18 cm long were needed:
two Moria forceps with very fine extremity (0.5 and 0.2 mm)
one Martin–Landanger microscissor
one Jacobson–Aesculap needle holder
one Codman forceps for bipolar coagulation
For two tubes, one 7/0 and one 8/0 polydioxanone sutures are usually sufficient.
MethodsPreoperative investigationsAll patients had complete investigations: hormonal analysis, male analysis, hysterosalpingography, hysteroscopy and sometimes recanalisation, diagnostic laparoscopy with blue dye test. Results were written down before surgery and then compared with operative images (all surgery were taped first with 8-, then 16-mm film camera Beaulieu, and then with 3-CCD Sony DXC 930 P video camera) and with postoperative histological examination of all resected lesions. The analysis is therefore not entirely retrospective.
Preoperation and per operation procedures
Prior to the laparotomy, a Pezzer catheter is introduced into the uterine cavity. This catheter is brought into sterile fields and allows the preoperative injection of sterile dilute methylene blue solution for verification of the tubal patency. After a short Pfannenstiel incision (6/7 cm), we protect the pelvis with a “wound-drape”. The uterus and adnexa are elevated by packing the Douglas cul-de-sac with moistened compresses. Continuous irrigation of the surgical area using a physiological salt solution mixed with noxytioline and corticoid (permanently evacuated by a Redon drain positioned in the Douglas pouch) keeps the operating area always clear. It keeps the tissues always moistened to prevent tissue drying, avoids formation of adhesion and allows for bipolar coagulation. Extreme gentleness is exercised. Tissue traumatism is prevented by the gentle handling the tubes and the ovary with fingers rather than sharp instruments. At the end of the operating time, a meticulous cleaning of the pelvic cavity is useful.
For 30 years, several peritoneal instillates were used: Ringer’s lactate which is not compatible with noxytioline, 30% dextran 70, Intergel, icodextrin 4% solution, etc., but we think it is not necessary to use instillates if the microsurgical technique is perfect: minimal tissue traumatism, perfect haemostasis, no tissue necrosis, no infection risk. We do not use these instillates in case of tubal reversal because the tubes are healthy; there is no peritoneal defect and no risk of adhesion. Postoperation procedureAll patients (except tubal reversal) were treated with antibiotics and dexamethasone during the postoperative inflammatory time (18 to 25 days). Patients could return home 4 days after surgery (40% of them left hospital after 3 days). Ovarian induction was prescribed after the second postoperative menstruation. Hysterosalpingography was prescribed 6 months and laparoscopy 1 year after surgery if the patient failed to conceive. Follow-up procedureNinety-one percent of patients were followed up for at least 2 years. Loss of follow-up patients was classified as surgical failure because infertile women always inform their surgeon when they are pregnant or when they have an ectopic pregnancy.
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Azoospermia एक चिकित्सा स्थिति है जहां पुरुषों में वीर्य में कोई शुक्राणु नहीं मिलता है ।
हम मौहक IVF सेंटर इंदौर में, सस्ती कीमतों पर उच्च सफलता दर के साथ गुणवत्ता ivf उपचार के साथ प्रदान करते हैं । हमारा लक्ष्य आपके परवरिश के सपनों को सच बनाने के लिए है ।
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अवरुद्ध फैलोपियन ट्यूब आपके और आपके मातृत्व के बीच एक कारण हो सकता है । यदि आपको गर्भवती होने में कुछ कठिनाई होती है तो हमारे विशेषज्ञ के साथ अपनी समस्या साझा करें ।
हम मौहक IVF सेंटर इंदौर में आपको सबसे अच्छी गुणवत्ता IVF उपचार प्रदान करते हैं जो सस्ती कीमत पर उच्च सफलता दर के साथ है । हमारा लक्ष्य आपके परवरिश के सपनों को सच बनाने के लिए है ।
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AbstractBackground – Women with polycystic ovarian syndrome (PCOS) may undergo laparoscopic ovarian drilling (LOD). To find out whether endometrial scratch, at time of LOD, could improve live birth rate in subfertile women with PCOS, a randomized controlled trial was conducted.
Results –There was no evidence of a significant difference in cumulative live birth rate between women who had endometrial scratch at time of LOD and those who had LOD only (38.1% and 34.3% respectively, odds ratio 1.18, 95% CI (0.67, 2.07); p = 0.57). Conclusion – Women undergoing laparoscopic ovarian drilling should not be subjected to endometrial scratch as it does not lead to improvement in live birth rate. The study was prospectively registered on 25 April 2014 in ClinicalTrials.gov with identifier number NCT02140398.
Background Polycystic ovarian syndrome is the most common cause of anovulatory subfertility [1]. Weight reduction, lifestyle modification, and ovulation induction are the recommended initial management strategies [2, 3]. Laparoscopic ovarian drilling (LOD) has been suggested to induce ovulation in these women, especially those who fail to ovulate through ovulatory medications [4,5,6]. It has been suggested that the procedure is as effective as ovarian stimulation with exogenous gonadotropins [7], yet it does not increase multiple pregnancy rates or ovarian hyperstimulation syndrome (OHSS) rates. Many women may ovulate after LOD, yet they fail to conceive [8]. Those women may need to undergo IVF treatment in their pursuit for a baby.
Endometrial scratching is a procedure where the endometrium is subjected to physical trauma that caused injury to the functional layer of the endometrium mechanically [9,10,11,12]. It has been suggested that endometrial injury could improve IVF outcome in women with recurrent implantation failure after IVF [13]. Nonetheless, endometrial scratch has been also proposed to overcome subfertility in women with unexplained infertility [14]. Randomized controlled trials have also shown improvements of intrauterine insemination (IUI) results in women subjected to controlled endometrial injury prior to insemination [9, 10]. However, there were some other studies that have shown no benefit from the procedure [15, 16].
The aim of our study was to find out whether performing endometrial scratch at time of laparoscopic drilling would improve live birth rate in subfertile women with PCOS.
Patients and methods
Study design and participants – We conducted a parallel randomized controlled trial (RCT), approved by our university ethics committee. We approached all infertile women with anovulatory infertility due to PCOS referred for laparoscopic ovarian drilling in Mansoura University Teaching Hospitals in Mansoura, Egypt. Our hospital is a tertiary care center conducting between 600 and 700 laparoscopic surgeries per year for infertile women. The study was conducted during the period from April 2014 to April 2015 (last patient enrollment). Follow-up was continued for 9 months after laparoscopy. The last pregnancy was in December 2015. Last data collection was in September 2016. An informed written consent was obtained from all women who participated in the study.
Our inclusion criteria were women aged 20 and less than 39 and women with PCOS as diagnosed by Rotterdam criteria, fertile semen analysis according to WHO 2010, and bilateral tubal patency as demonstrated by hysterosalpingogram (HSG) [17, 18]. The exclusion criteria were suspected endometriosis, suspected uterine cavity anomaly or mass, associated male factor infertility, presence of endocrinopathy as thyroid dysfunction, and women subjected to endometrial curettage for any reason in the last 6 months.
Intervention
Women were admitted to our hospital 1 day before laparoscopic drilling. Women were randomized into two groups: group A (the intervention group) and group B (the control group). Randomization was through a computer-generated list of random numbers. Allocation of women to groups was through an opaque sealed envelope that had to be picked by a nurse in the operative theater. The surgeon was not blinded to the procedure while patients and data assessor were blinded to their allocation. All women underwent a three-puncture laparoscopy procedure where laparoscopic ovarian drilling (LOD) was achieved. Ovarian drilling was performed through monopolar coagulation diathermy. Four punctures were performed. Each penetrates about 4 mm depth, using 40-W power that lasts for 4 s. In the intervention group (group A), endometrial scratching was performed at the end of laparoscopy by endometrial curette. The curette was introduced gently through the cervix up to the uterine fundus then withdrawn for 1 or 2 cm. One act of scratching was performed on the posterior wall of the uterus after the end of drilling. The obtained specimens were sent for histopathology. The control group (group B) had LOD only, and no endometrial scratch was performed. Women in both groups were seen 3 months after laparoscopy and were asked whether they had a positive pregnancy test, still have oligomenorrhea, or had had regular periods. Women who had regular periods were subjected to folliculometry to confirm the establishment of ovulation while those with oligomenorrhea were subjected to ovulation induction with clomiphene citrate, tamoxifen, or letrozole. Women who did not respond to ovulatory oral medications were stimulated using exogenous gonadotropins using the low-dose step-up protocol with a 37.5 IU starting dose [19]. The primary outcome measure in this trial was live birth rate per woman randomized. Secondary outcome measures were clinical pregnancy rate, time to pregnancy, miscarriage rate, and multiple pregnancy rate. The study was registered in ClinicalTrials.gov with identifier number NCT02140398.
Definitions – Clinical pregnancy was defined as the presence of intrauterine gestational sac 1 or 2 weeks after positive pregnancy test in blood. Live birth was defined as the delivery of living fetus after 24 weeks gestation. Statistical analysis – We estimated that the pregnancy rate after laparoscopic ovarian drilling was around 50% [20]. The intervention was suggested to boost pregnancy rate up to 70%. We calculated that we will need to study 93 experimental subjects and 93 control subjects to be able to reject the null hypothesis that the failure rates for experimental and control subjects are equal with a study power (probability) of 80%. The type I error probability associated with this test of this null hypothesis is 0.05 [21]. To compensate for dropouts, we calculated that we needed to randomize 210 women. We used SPSS 15 program. We adopted the intention-to-treat analysis.
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