**7.4. Laparoscopic management of distal tubal disease**

Distal tubal occlusion may be due to hydrosalpnix, pyosalpnix or peritubal adhesions. Obstruction of the distal fallopian tube is one of the most common causes of female infertility (58). In cases of pyosalpnix, just tubal opening, drainage of pus and proper peritoneal toilet are sufficient. Don't forget to take a tubal wall biopsy. Don't proceed for tubal occlusion at the same setting for fear of disseminating infection and the possibility of tubal bilharziasis with reported cases of spontaneous pregnancy after proper treatment. Nowadays, it is conceived that the presence of hydrosalpinx is associated with a compromised outcome for IVF/ ICSI. Hydrosalpinx is associated with lower implantation and fecundibility rates even if the contralateral tube is sound which may be attributed to alteration in endometrial receptivity (59) or direct embryo toxic effect. Furthermore, it is liable to be unintentionally punctured at the time of egg retrieval or it may disturb access to the ovary if it is too big. In a meta-analysis, it has been demonstrated that there is a reduction by half in the probability of achieving a pregnancy in the presence of hydrosalpinx, and an almost doubled rate of spontaneous abortion (60). In an animal study, hydrosalpinx fluid is shown to contain toxins that are potentially teratogenic (61). Proposed mechanisms of impaired implantation rate due to hydrosalpinges are well addressed in the literature (62). Selected patients with unilateral hydrosalpinges and a patent contralateral Fallopian tube may exhibit increased cycle fecundity after salpingectomy or proximal tubal occlusion of the affected tube, and may conceive without the need for IVF. In a retrospective case-control study, bilateral salpingectomy due to hydrosalpinges restored a normal delivery as well as implantation rate after IVF treatment compared to controls (63). Randomized controlled trials recommended performing laparoscopic salpingectomy prior to IVF, especially inpatients with ultrasound-visible hydrosalpinges (64). In a Cochrane review (65), it is concluded that further randomized trials are required to assess other surgical treatments for hydrosalpinx, such as salpingostomy, tubal occlusion or needle drainage of a hydrosalpinx at oocyte retrieval. Functionless hydrosalpinx can be defined as a large blocked tube with lost major and minor folds, as seen at salpingoscopy after laparoscopic salpingoneostomy.

**Figure 4.** Sonographic appearance of a typical hydrosalpnix.

42 Enhancing Success of Assisted Reproduction

**IVF/ICSI** 

**7.3. A suggested flowchart for management of functionless hydrosalpnix prior to** 

**Laparoscopic tubal surgery:** tubal factors include proximal tubal occlusion, distal tubal phimosis or occlusion or peritubal adhesions. Endoscopy (whether laparoscopy or

 Tubal pathology, particularly hydrosalpinx, is associated with a low embryo implantation rate in IVF as well as an increased risk for early pregnancy loss. The role of surgery for tubal disease to improve IVF outcomes, in the absence of

hysteroscopy) play a central role in the management of tubal disease.

**Figure 3. HSG:** Hysterosalpingography. **TVS:** Transvaginal ultrasonography.

Distal tubal occlusion may be due to hydrosalpnix, pyosalpnix or peritubal adhesions. Obstruction of the distal fallopian tube is one of the most common causes of female infertility (58). In cases of pyosalpnix, just tubal opening, drainage of pus and proper peritoneal toilet are sufficient. Don't forget to take a tubal wall biopsy. Don't proceed for tubal occlusion at the same setting for fear of disseminating infection and the possibility of tubal bilharziasis with reported cases of spontaneous pregnancy after proper treatment. Nowadays, it is conceived that the presence of hydrosalpinx is associated with a compromised outcome for IVF/ ICSI. Hydrosalpinx is associated with lower implantation and fecundibility rates even if the contralateral tube is sound which may be attributed to alteration in endometrial receptivity

**7.4. Laparoscopic management of distal tubal disease**

hydrosalpinx, requires further evaluation.

On sonography, the dilated fallopian tube presents as a thin- or thick-walled tubular fluidfilled structure that may be elongated or folded (figure). Longitudinal folds that are present in a normal fallopian tube may become thickened in the presence of a hydrosalpinx. The dilated fallopian tube may or may not show longitudinal folds. These longitudinal folds are pathognomonic of a hydrosalpinx . If the elongated nature of these folds is not noted, they may be mistaken for mural nodules of an ovarian cystic mass. Identification of a separate ovary helps distinguish a hydrosalpinx from a cystic ovarian mass, an important distinction because malignancy is rare with an extraovarian cystic adnexal mass. A significantly scarred hydrosalpinx may present as a multilocular cystic mass with multiple septa creating multiple compartments. These septa are generally incomplete, and the compartments can be connected. However, with more pronounced scarring, differentiation from an ovarian mass may not be possible (66). Potential pitfalls in the diagnosis of hydrosalpinx include

paratubal, paraovarian, or perineural cysts. In some cases, CT or MRI may be helpful to differentiate these conditions from a hydrosalpinx (67).

Endoscopy versus IVF: The Way to Go 45

proper explanation by the anaesthesiologist. The cervix is gently dilated with Hegar 10 and a rotatory continuous flow monopolar resectoscope is inserted. Once the peritubal bulge (the proximal part of the intramural segment of the tubeis clearly seen, a roller ball electrode (size: 3 mm) is introduced inside it and activated at 50 Watts for about 8 seconds. A thorough comment on the fundus and the rest of the endometrial cavity should be reported. The patients are usually discharged immediately if the procedure is carried out under local paracervical anesthesia, while the remaining cases are

Usually diagnosed by HSG and confirmed by laparoscopic chromopertubation test. The most important job of the endoscopist is to find out contraindications for hysteroscopic tubal

obliterative fibrosis and long tubal obliterations that are difficult to bypass with the

isthmic occlusion with club-changed terminal, ampullar or fimbrial occlusion, and tubal

Don't try to cannulate the tube in such cases as failure would be expected and you would be disappointed. In cases with isolated tubal occlusion, cannulation would be successful.

The impact of uterine myoma on the outcome of IVF/ICSI is a very controversial topic. Many centers are overdoing myomectomy for nearly all myomata regardless size and site considerations. Contrary, other investigators have shown that fibroids don't exert a

**9. The following is our protocol for tubal disease management** 

discharged a few hours later.

cannulation procedure which include:

previously performed tubal surgery.

coaxial TO: combined distal and proximal tubal occlusion.

 Small hydrosalpnix+ normal salpingoscope:OL Functionless hydrosalpnix: PTO then IVF

**10.1. Endoscopic myomectomy prior to IVF/ICSI** 

salpingitis isthmica nodosa.

 florid infection genital tuberculosis

catheter.

fibrosis

severe tubal damage.

 Pathologic PTO: IVF Isolated PTO: TC Midsegment O: IVF

 Combined PTO and DTO: IVF Peritubal adhesions: OL Vs IVF

**10. Endoscopic uterine surgery** 

**8. Proximal tubal occlusion** 
