| [Background and Objective]Infertility is defied that the couple with normal sexual life who can not conceive two years without contraception. Never conceiving is called primary infertility, while having conceived ever before is named secondary infertility. Infertility is defined as one year of frequent, unprotected intercourse during which pregnancy has not occurred. Clinical evaluation is indicated after 12 months, because by that time 85% of couples attempting conception will have been successful. But it can be initiated earlier if infertility is suspected based on history or if the female partner is older than 35 years. The morbidity among fertility women is between 1.01% and 19.08% (average 6.89%).The etiopathogenisis include the relevant factors about each or both of the couple. The tubal factors takes 25%-35% Of female infertility patients, and about 25-30% patients have proximal tubal occlusion, raising from salpingitis isthmica nodosa (SIN),chronic salpingitis,endometriosis,non-crystal materials caused of mucous plug and spasm,congenital dysplasia of tubal,conservative therapy of tubal pregnancy and so on.The fallopian tubes (or oviducts) are musculomembranous canals that range from 7 to 14 cm in length. Each oviduct consists of a mucosal membrane, a muscular layer, and serosa. The mucosa joins directly with the muscularis, which is composed of two layers of smooth muscle. The inner layer has circular or spiral bundles and the outer layer is mainly longitudinal, with no distinct transition between layers. The proximal tubal contains intramural portion and part of isthmic segment, as well as Utero-tubal junction (UTJ). The intramural segment ranges from 1.5 to 2.5 cm, with an average luminal diameter of 1.1 mm, the narrowest of whole oviduct, and changes with the relaxation or contraction of smooth muscle. The isthmic segment stretches out from uterine wall and extends for 2-3cm outwards, with an average luminal diameter of approximately 1～2 mm. Its muscle layer is the thickest of the outer parts. Both animal trails and clinical studies indicated that it had no impacts on fertility while lacking of partial isthmic segment. The muscle composition of UTJ is very complex, being the turning point of the uterine and oviduct muscle layers. The longitudinal myofiber from the inner layer of intramural segment display as crew intersection and enter into isthmic segment encircling lumen. Animal experiments certified that UTJ has little influence on reproduction as well. Tubo-Uterine Implantation (TUI) needs to excise part of isthums and gains pregnancy rate of 50% approximately. This also proved the point further more. There is evidence that the unique anatomy and physiology of the proximal Fallopian tube may predispose this tubal segment to a 'physiological' blockage, by tubal secretions and/or material back flowing from the uterine cavity, during the estrogen-dominant phase of the menstrual cycle. This would normally be reversed during the subsequent progesterone-dominant phase. However, if this reversal process is defective, organization of this material can occur, which can lead to initially incomplete and then complete tubal obstruction as anatomical or functional obstruction without tubal wall damage. As is the case with other body functions (e.g. information, immune reaction), the un-reversible fibrosis with complete obliteration of the tubal lumen can be the result of chronic stasis inside the narrow proximal tubal segment.According to a large mount of articles and our own studies and practices, the liable approach to diagnosing proximal tubal occlusion, PTO is hysteroscopic selective cannula hydrotubation under laparoscopy. It as well as has therapic function. In the case of existence of proximal tubal occlusion, it will obtain a high recanalization rate by catheterization. Thanks to the different degree of tubal obstruction, a few of blocked oviduct can't be recanalized successfully even using wire. We identify them as true tubal occlusion, which demand other treatments such as salpingoplasty and assistant reproductive technology. Salpingoplasty mainly includes microsurgical Tubouterine Implantation and tubocornual anastomosis. In order to make occlusive oviducts reconstructed and patients fertility naturally and if the patients has indications, they should be suggested to accept surgery managements as far as possible. But they should have some tests to evaluate other factors involved in infertility preoperatively, so as to judge the surgical feasibility. Tubocornual anastomosis was a microsurgery as a treatment for proximal tubal occlusion of 60 or 70 eras in 20th century, connecting healthy oviduct segment and the other segment inside uterine wall directly. It contains isthmic-cornual anastomosis and ampulla-cornual anastomosis. The latter has been almosteliminated because of its dismal prognosis. Compared with tubal implantation, the advantages of tubocornual anastomosis are as follows:There is less bleeding; less uterine and tubal tissue is removed; there is a reduced chance of uterine rupture should pregnancy result; Cesarean delivery is not needed because the uterine wall is not weakened. Implantation remains a good choice when the tubal damages seriously and deep to uterine cavity.Recently, with the outcome and quickly development of laparoscopic equipments and techniques, the conception of "minimally invasive surgery" has been rooting in people's hearts gradually. Most surgeries came true which once considered impossible or even not imagined. Meanwhile, laparoscopic tubal anastomosis is very successful and pervaded all over the word. To be in tune with times, we attempted to combine tubocornual anastomosis and endscopic technologies for the sake of trying a much better surgery for proximal tubal occlusion treatment, called laparoscopic tubocornual anastomosis (TCA). We have been doing the preliminary clinical research about this surgery's indications,contradictions,surgical-procedure, prognosis and so on.[Methods]1,Clinical data:The proximal oviduct occlusive infertile women under thirty-five years old, discovered during laparoscopic exploration in our hospital from Apr 2009 to July 2010. All of them have taken routine examination in order to check some other factors affecting fertility as genital tracts'diseases,ovulation and immune system disordes,male infertility and so on. Twenty-three patients whose ill-oviducts were failed to be recanalized by catheterization took the laparoscopic tubocornual nanastomosis surgery. The age is 27.96±3.39 on average.12 (52.17%) cases are primary infertility, and the other 11 cases (47.83%) are secondary infertility. Among the total, there are 15 cases (65.22%) with bilateral proximal tubal occlusion, while 8 (34.78%) with unilateral PTO.2,The surgery procedure:①By laparoscope combined with hysteroscope, taking uterine and pelvic cavities detectives to discover existing pathological changes and make proper treatments, such as pelvic adhesiolysis,salpingostomy,cyst remove,uterus subseptus unicollis electrocision and so on. And then it's time to confirm POT by selective cannula hydrotubation and catheterization under laparoscope combined with hysteroscope.②Do the laparoscopic tubocornual anastomosis operation. Firstly, ligate uterine terminal artery and inject hypophysin diluent around uterine cornua Secondly, resect the occlusive tubal segment precisely and take hydrotubation of the two remain parts respectively to test their patency. Lastly, anastomose the two healthy tubal segments by one-stitch suture exactly and suture serous membrane at last.③irrigate pelvic cavity and leave adhesion-prevented medicated solution.3,Postoperative proposal:routine seven days anti-infection therapy after operation. In the case of severe pelvic adhesions, fourteen days anti-infection treatment must be taken. Early hydrotubation is not implemented.4,Fellow-up:Between the third and seventh day after the secondary menstruation postoperatively, the patients should come back for recheck in the approach of hysteroscopic selective hydrotubation under type-B ultrasonic to assess operated tubal patency. According to the injection resistance and the volume of solution backflow and entry of guild wire, we can assess tubal patency and make adequate remedial measures to treat some re-obstructed oviducts simultaneously using tubal catheterization。Then, we will guild them to intercourse while ovulation period. If one won't conceive in one year, HSG or other treatments will be complemented to her.[Results]1,All the twenty-three PTO cases were treated by laparoscopic tubocornual anastomosis successfully, without any complications. The results of pelvic exploration:normal sights without adhesion in 3 cases; moderate pelvic loose membrane adhesions and normal fimbriae of tube with visible orifice were found in 10 cases; serious adhesions with distal tubal sticking to ovary and bilateral or unilateral fimbriae atresia in 10 patients, and one of them has a small Chocolate cyst, another one has a few royal blue little nodules. Referring to tubal texture,5 oviducts' isthmus were obviously narrow and stiffness; the proximal parts of other 6 oviducts were underdeveloped and tenuity. Uterine cavity detectives were almost normal.2,23 cases have 45 oviducts in all(one had been excised before because of tubal pregnancy).31 oviducts diagnosed as PTO at last, with unilateral proximal tubal occlusion in 15 cases (65.22%) and bilateral PTO in 8 (34.78%).During the TCA operation, unilateral anastomosis took about 49.00±11.53min (X±SD) and bilateral operation took 82.50±18.32min. Total bleeding of the former was 24.00±10.56ml, the later was 38.75±15.95ml. All of the operated oviducts are longer than 5cm after ananstomosis.3,The results of postoperative recheck were as follow:21 of 31 oviducts (67.74%) were patent by hysteroscopic selective hydrotubation; 8 Fallopian tubes (25.81%) became patent after applying to catheterization; 2 tubes (6.45%) failed to be detected because of invisible orifice or reocclusion.[Conclusions]The result of our study suggested that undertaking a series of routine infertility workup, the cases with PTO, who was preliminary diagnosed by HSG and then made a definite diagnosis by selective cannula hydrotubation and catheterization under laparoscope combined with hysteroscope, are performed laparoscopic tubocornual anastomosis, with its patent rate coming up to 67.74%. Laparoscopic TCA is a reasonable surgery protocol for PTO treatment, having certain feasibility and clinical availability. And contrasted with conventional microsurgery, it has more advantages with litter trauma, less blood, clearer visual field and recovery quickly. We presume that laparoscopic TCA has the practically feasibility and certain clinical values. Summing up clinical experiences and lessons, our pilot study considers that laparoscopic TCA can complete smoothly. Since our original study limited by short time and the cases with multiple infertility factors, it is difficult to follow up the postoperative pregnancy rate. The further research must be focus on clinical treatment result of infertility in order to make laparoscopic TCA as a better choice for the treatment of PTO. |
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