FALLOPOSCOPY - 07/09/11
Resumen |
The role of the human fallopian tube in reproduction is more than a passive conduit. The organ is involved in oocyte pick-up, fertilization, and embryo transport. Metabolic substrates, cytokines, and immunoglobulins have been identified within the tubal lumen.2, 3, 8, 9, 17, 18, 26 Complex and coordinated endocrine secretions, neuromuscular activity, and cilial action are required for successful tubal function.
Tubal dysfunction has been associated with infertility in 11% to 16% of patients based on early clinical trials.4, 24 Traditional means of assessing tubal patency and, hence, normalcy, have included hysterosalpingography, laparoscopy with chromotubation, and, more recently, sonohysterography. Unfortunately, all of these techniques are fraught with inaccuracy. A recent meta-analysis of 20 previously published investigations comparing the accuracy of diagnosis of tubal patency or peritubal adhesions by hysterosalpingography versus laparoscopy yielded an overall sensitivity of 65% and specificity of 83%.23 This implies that although tubal patency is likely in the presence of an abnormal hysterosalpingogram, such patency does not rule out pathology. Even laparoscopy, which has been considered the gold standard for tubal evaluation, provides little information regarding the tubal lumen because access can be obtained only to the most distal aspect. The true cause of proximal tubal obstruction, in particular, can only be presumed by these techniques and cannot be visualized. Thus, a patent tube with normal-appearing fimbriae may still harbor unrecognized lumenal defects that may have a deleterious effect on fertility.
Falloposcopy is a transcervical transvaginal approach for visualizing the lumen of the fallopian tube from the uterotubal junction to the fimbria. The first reports of the successful use of this microendoscopic technique were provided in 1990 by Kerin and co-workers.10, 11 Although the majority of data regarding both diagnostic and therapeutic applications of falloposcopy have been derived from procedures performed under general anesthesia in a hospital setting, the potential for office-based falloposcopy is great.
The primary indication for the performance of falloposcopy is the assessment of the infertile woman with suspected proximal tubal disease after hysterosalpingography or in whom hysterosalpingography is contraindicated (Table 1). Before a patient undergoes microsurgical anastomosis at laparotomy or tubal bypass employing the assisted reproductive technologies, a thorough assessment of the tubal lumen may reveal findings such as spasm of the uterotubal ostium, intralumenal polyps, or mucous plugs, leading to less invasive therapy. Similarly, the finding of an irreparably damaged tubal lumen may allow the patient to avoid laparoscopy altogether and be referred directly for in vitro fertilization and embryo transfer.
The patient with hydrosalpinges diagnosed radiologically may also benefit from this outpatient procedure. Although falloposcopy provides no information regarding peritubal disease, should the endothelial lining prove to be badly damaged beyond repair, further surgical investigation would be unwarranted. In contrast, a patient with less severely damaged endothelial lining noted at falloposcopy could then undergo laparoscopy to assess the extent of peritubal disease and potentially perform endoscopic tubal reconstruction.
A third indication is the patient with otherwise unexplained infertility after a standard evaluation. Patients with normal findings at hysterosalpingography and laparoscopy have been noted to have intralumenal adhesions and abnormal endothelial vascular patterns during tubal microendoscopy.2 In addition, the use of falloposcopic visualization of the tubal lumen to confirm appropriate catheter placement prior to transcervical gamete transfer on an outpatient basis has been reported.12
Falloposcopy should not be performed in patients with active pelvic infection or uterine bleeding or in patients unable to tolerate local anesthetic agents when the procedure is performed under conscious sedation. Patients with endometrial pathology such as synechiae or submucous myoma preventing visualization and access to the uterotubal ostium (UTO) are poor candidates as well.
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| Address reprint requests to Eric S. Surrey, MD, Reproductive Medicine and Surgery Associates, 9675 Brighton Way, Suite 420, Beverly Hills, CA 90210 |
Vol 26 - N° 1
P. 53-62 - mars 1999 Regresar al número
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- COMPLICATIONS OF HYSTEROSCOPY
- Keith B. Isaacson
- ULTRASOUND GUIDANCE DURING ENDOSCOPIC PROCEDURES
- Gerard S. Letterie
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