title: Laparoscopic Treatment of Distal Tubal Occlusion-Reocclusion and Pregnancy Rate
abstract: There is still controversy about the question of which approach is best to treat tubal infertility: microsurgery, laparoscopic treatment, or in vitro fertilization. Our study comprised 161 patients with distal tubal occlusion. Various instruments (argon laser, CO2 laser, Nd:YAG laser, monopolar electrical needle, scissors) were used for laparoscopic salpingostomy, and a variety of techniques applied for tubal wall eversion (flowering technique according to Bruhat with and without suturing, suturing alone, or no eversion at all). Thirty-seven women with a total of 63 laparoscopically treated tubes were followed over a period of 2-72 months. Tubal patency was 38.9%. The reocclusion rate correlated with severity of tubal wall pathology and state of reduction of the tubal mucosa. After laser treatment tubal patency proved to be higher (41.1%) compared with treatment with conventional instruments. The Argon laser scored best results. The majority of patent tubes in the follow-up were found in the cohort with "perfect" and "good" eversion (95.8%), whereas none of the tubes where eversion was classed "insufficient" remained patent. The technique according to Bruhat without the use of additional suturing yielded better results regarding tubal patency (66.6%) than the other eversion methods described (33.4%). The pregnancy rate could be assessed in 81 out of 161 laparoscopically treated cases. A total of 19 patients (23.3%) became pregnant. In 9.8% pregnancy was intrauterine and in 13.5% extrauterine. The highest intrauterine and lowest extrauterine pregnancy rate was seen in the group with "mild" distal tubal occlusion (according to AFS classification). In 84.2% of women who had conceived postoperatively, tubal wall eversion had been done by the Bruhat technique without suturing. Taking into account tubal wall pathology, tubal patency, eversion techniques, and rate of intrauterine pregnancies, it can be concluded that patients with thin-walled tubes allowing "perfect" or "good" eversion will benefit most from laparoscopic salpingostomy.
authors.affiliation: Center for Minimally Invasive Surgery, Frauenklinik Dr. Wilhelm Krusmann KG, Schmiedwegerl 2-6, D-81241 Munich, Germany.
authors.initials: V
authors.lastname: Sasse
authors.initials: E
authors.lastname: Karageorgieva
authors.initials: J
authors.lastname: Keckstein