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ObjectiveThe aim of this study was to determine whether pelvic inflammation contributes to the pathogenesis of ovarian cancer or other malignancies.DesignThis article is a cohort study.SettingThe study was conducted in a tertiary university and provincial cancer referral institutions.Population SampleThe population sample was composed of women referred for fertility surgery and women diagnosed with ovarian cancer in British Columbia.MethodsWe conducted a cohort study using prospectively collected data on fertility surgery patients. Eight hundred eighty-eight women with past pelvic inflammation, as diagnosed by characteristic findings at fertility surgery, and 552 women without were compared for the subsequent development of malignancy, during the period of 1981 to 2012. Logistic regression was used to estimate adjusted odds ratios and 95% confidence intervals. Standardized incidence ratios were also calculated using age-specific cancer incidence rates among all women in British Columbia.ResultsThe adjusted odds ratio for ovarian cancer, after past inflammation, was 5.56 (95% confidence interval, 0.52–59.40). Age-adjusted ovarian cancer incidence was significantly elevated among women with previous pelvic inflammation (standardized incidence ratio, 3.99; 95% confidence interval, 1.46–8.68). The rates of other malignancies were similar in both cohorts.ConclusionThe rate of ovarian cancer was not significantly elevated in women with past pelvic inflammation compared with the controls. However, a significantly increased risk for ovarian cancer was apparent among women with pelvic inflammation when compared with the general population. Pelvic inflammation may be a contributory factor in the pathogenesis of ovarian cancer.

Objective: To evaluate a technique that converts a blind hysteroscopic procedure to a "septum" division. Design: Open noncomparative clinical study. Setting: Tertiary care center. Patient(s): Six women with Asherman's syndrome; five with complete and one with incomplete obliteration of the uterine cavity. Intervention(s): The patients underwent recreation of the uterine cavity by the hysteroscopic-laparoscopic technique described to establish the correct dissection plane. Main Outcome Measure(s): The ability to reestablish the uterine cavity; postoperative resumption of menses and fertility. Result(s): In all patients, the cavity of the uterus was restored; menses resumed in all women who were previously amenorrheic; and 5 women conceived, of whom four had live births and one a missed abortion. At hysteroscopy, two women incurred perforations and in another hemorrhage occurred. Conclusion(s): This technique appears to be effective and safe for the reconstruction of a functional endometrial cavity in women with Asherman's syndrome.

Taking a history is useful in the evaluation of women with tubal factor infertility. A clinical history also predicts those women who will benefit from surgical therapy.

Objective To determine the prognostic variables effecting the successful pregnancy outcome of reversal of sterilization. Design Demographic and clinical history data were collected prospectively. Setting Division of Infertility and Reproductive Endocrinology, Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, Canada. Patients and Intervention Between 1981 and 1992, 217 consecutively referred patients underwent reversal of sterilization by a single surgeon using microsurgical techniques. Main Outcome Measures Prognostic variables associated with success were examined using logistic regression and expressed as odds ratios with corresponding 95% confidence intervals. Results Age at reversal was a significant factor with the odds of a successful outcome for those ≤35 years compared with those >35 years being 2.3 with a 95% confidence interval of 1.3 to 4.1. There was some evidence that average tubal length as categorized in 2-cm intervals was a significant prognostic factor with the odds of a successful outcome for those with an average length of >4 cm to those ≤4 cm being 5.3 with a 95% confidence interval of 1.4 to 20.0. Conclusions Nonsubjective analysis of the prognostic variables of reversal of sterilization associates only age and tubal length of >4 cm with intrauterine pregnancy.

Background. The relationship between tubal cornual polyps and endometriosis and ovulatory disorders in infertile women is unclear. Our objective was to determine such an association from our database and review the literature.Methods. Twenty-two infertile women with tubal cornual polyps were assessed for coexistence of oligoovulation/anovulation and endometriosis with stratification for polyp diameter (large: ≥5 mm diameter, small Result(s). Oligoovulation/anovulation was more prevalent in women with large versus small tubal cornual polyps (P=0.0048). Endometriosis was associated with both large and small polyps.Conclusion(s). This case series confirms the association of tubal cornual polyps with oligoovulation/anovulation and endometriosis in infertile women. This case series is limited by a lack of controls.

To assess the effect of the removal of ovarian surface epithelium on repair, a standard injury was induced in the ovaries of 10 rabbits. In one ovary the surface cells were denuded, and in the other they were left intact. The effect on adhesion formation was assessed at 12 days. Adhesions were assessed by visual inspection at laparotomy and histological examination of adhesion formation, including a stereological assessment of scar volume. On visual assessment the overall adhesion scores for the denuded ovaries were greater than for the intact ovaries. Histology showed the adhesions were attached only to the site of injury. The Fallopian tube was adherent to 35 and 4% of the denuded and intact ovarian segments respectively (P = 0.003). The scar volumes for each side were similar. After 12 days there was only partial re-epithelialization on the denuded ovaries. Electron microscopy confirmed the slow healing, with much of the surface still covered by a fibrinous-like exudate. The findings of this small study lend further weight to the importance of the surface epithelium in the control of adhesion formation. Standard surgical procedures may generate adhesions by the inadvertent denuding of surface epithelium from adjacent healthy tissues, possibly by the loss of plasminogen activator activity that is found in the mesothelium of the peritoneum. This study highlights the importance of controlling for inadvertent cell loss whilst investigating methods for adhesion prevention.

Background Retrograde menstruation is thought to initiate and potentiate endometriosis in women with non-communicating uterine anomalies. The effect of removing a non-communicating uterine horn on the persistence or recurrence of endometriosis is unknown. Case A 29-year-old woman with a non-communicating uterine horn and endometriosis underwent surgical removal of the non-communicating horn with cautery of the endometriosis. A laparoscopy done two years later showed endometriosis similar in stage to that found at the initial procedure. Conclusion Removal of a non-communicating uterine horn in a woman with endometriosis did not reduce the risk of persistence or recurrence of the disease.

Our objective was to assess the influence of preliminary counseling that provided information about age-related fertility rates on the decision of women to undergo reversal of sterilization. There was no apparent influence; this raises the question as to whether couples seeking fertility therapy base their decision making on factual information provided by the clinician.

Objective To determine if the new technique laparoscopic lateral transposition of the ovaries before pelvic radiotherapy for anal canal carcinoma prevents radiation-related ovarian failure. Design A case report. Setting The operating room of a Canadian teaching hospital. Patients A single patient with anal canal carcinoma, requiring pelvic radiotherapy, who desired preservation of ovarian function. Interventions Laparoscopic ovarian transposition to the level of the pelvic brim. Main Outcome Measures Follow-up clinical and laboratory evidence of ovarian failure. Results Initially ovarian failure was confirmed with the appearance of postmenopausal symptoms and the elevation of serum gonadotropins. These symptoms resolved by 8 months after radiotherapy, normal menstrual cycles resumed, and normal FSH levels were detected at that time. Conclusions The laparoscopic, lateral transposition of this patient’s ovaries was effective at preventing radiation-related ovarian failure.

Torsion of the adnexa has traditionally been treated by adnexectomy because of the fear of emboli departing from thrombosed ovarian veins. Several recent reports have described successful conservative management with unwinding of the twisted adnexa. As the trend toward conservative management progresses, the incidence of recurrent adnexal torsion may increase. We present a case of a 33 year old gravida 3, para 2 Caucasian female who presented at 7 weeks gestation complaining of symptoms similar to those experienced during an episode of right ovarian torsion treated by laparoscopic unwinding 6 years earlier. Colour Doppler sonography revealed absent flow in the right adnexa. The twisted right adnexa containing the presumed corpus luteum of pregnancy was laparoscopically unwound. Using an extracorporeal suturing technique, a laparoscopic oophoropexy was performed to prevent any further rotatory movement. This appears to be the first reported case of laparoscopic oophoropexy for a recurrent ovarian torsion ; we encourage the use of this simple, minimally invasive procedure in cases of recurrent adnexal torsion.

Background: Interstitial pregnancy (IP) accounts for two to four percent of all ectopic pregnancies. There have been two accepted surgical methods of treatment for IP in the past; either cornual resection or hysterectomy. Recently, less radical surgery by means of hysterotomy or laparoscopic excision has been described. Cases: We report here three cases of unruptured interstitial pregnancy and describe a new laparoscopic technique for the conservative management of IP. The elements of the technique are: infiltration with vasopressor solution, sharp incision of the myometrium, and healing by secondary intention. Conclusion: Our study suggests that the principles of operative laparoscopic surgery may be applied, as one would for a linear salpingotomy, to properly selected patients with unruptured interstitial pregnancies with consistency and safety. This needs to be confirmed in subsequent studies.

Objective To determine the fertility potential of women with congenital ampullary atresia of the fallopian tube. Design Case report and review of literature. Setting University-affiliated tertiary care infertility clinic. Patient(s) Six infertile women with congenital ampullary atresia of the oviduct. Intervention(s) Salpingostomy and fimbrial approximation. Main outcome measure(s) Pregnancy. Result(s) Of six reported cases of congenital ampullary atresia of the fallopian tube who underwent surgery, four women conceived intrauterine pregnancies (IUP) and another, a pregnancy of undetermined site. Conclusion(s) Salpingostomy and fimbrial approximation is a therapeutic option for infertile women with congenital ampullary atresia of the fallopian tube.

Objective: To determine pregnancy rates after laparoscopic salpingostomy in occlusive distal tubal disease. To evaluate the relative impact of various historical, physical, and operative factors on pregnancy outcome using a multivariate statistical analysis. Design: Prospective cohort. Setting: University-affiliated tertiary care infertility clinic. Patient(s): One hundred thirty-nine infertile women with occlusive distal tube disease. Intervention(s): Laparoscopic salpingostomy. Main Outcome Measure(s): The occurrence of intrauterine (IUP) and ectopic pregnancy (EP). Result(s): The overall IUP and EP rates were 24.5% and 16.5%, respectively. Analysis of historical variables, assessed independently, demonstrated a significantly higher IUP rate with a positive history of gonorrhea and a significantly higher EP rate with a positive history of pelvic inflammatory disease, lack of history of intrauterine device (IUD) usage, or the performance of a bilateral procedure. The logistic regression model to predict intrauterine pregnancy had an overall predictive value of 77.5% and included the following significant variables: secondary infertility, positive history of gonorrhea, and the operative finding of moderate periadnexal adhesions. The logistic regression model to predict ectopic pregnancy had an overall predictive value of 89.0% and included the following significant variables: previous ectopic pregnancy, negative history of IUD use, positive history of PID, a bilateral procedure, and perihepatic adhesions. Conclusion(s): Operative laparoscopy may be effective for the correction of hydrosalpinges in selected patients. The probability of achieving an intrauterine or an ectopic pregnancy can be predicted based on combinations of significant variables.

The sites of ectopic pregnancies in women who underwent various types of reconstructive tubal surgery were analysed and compared to the controls. Overall, ectopic pregnancies subsequent to all types of tubal surgeries were more often implanted proximally compared to the control population.

A surgeon at University Hospital-Shaughnessy Site in Vancouver, British Columbia in Canada has used a new suturing instrument that enters the peritoneal cavity to permit microsutures of size 6-0 or less and 75 cm in length during laparoscopy. Surgeons can use this instrument to perform female sterilizations as well as removal of the gall gladder and appendix and repair of the bowel, bladder, and ureteric injuries. As of April 1992, the suturing instrument was not yet commercially available. It consists of a partial hollow 30 cm x 2 mm (inside diameter) tube with the end that does not enter the peritoneal cavity being occluded. The suturing instrument enters the peritoneal cavity via a standard 5 mm deflection valved trocar sleeve with a 3 mm reduction sleeve or with a 3 mm inside diameter occlusive rubber washer instead of the standard 5 mm washer. The suture must have sufficient tensile strength and have low coefficients for static and for sliding surface frictions. Once the suture and needle are inside the body, forceps which have entered via another cannula detach them from the suturing instrument. A 3 mm laproscopic needle driver replaces the suturing instrument at this point. The surgeon guides the needle through the intended tissues and then withdrawn with the needle driver through the 5 mm sleeve. The surgeon ties the knot outside the body and slides it down the length of the suture to apply it to the tissue. He/she repeats this 1 more time. Scissors inserted through the other opening then cut the suture. Once mastered, this process takes only a few minutes to complete. In all 11 cases or restoration of uterine tube patency done by the surgeon in Vancouver using the new technique, tubal patency has not been hindered. 2 assessed sterilization reversals have been successful.

Objective To assess the significance of pathological midtubal occlusion in infertility. Design Retrospective descriptive case review. Setting Tertiary referral center. Patients Sixteen women, 26 to 38years of age presenting with infertility and diagnosed as having midtubal occlusion. Interventions Assessment of the etiology of the occlusive disease and yield of microsurgical tubotubal anastomosis. Main Outcome Measures Histologic examination of occluded tubal segment and fertility outcome subsequent to anastomosis. Results Occlusion was because of tuberculous salpingitis (n=6), resolved tubal pregnancy (n=3), endometriosis (n=2), chronic inflammatory reaction (n=1), tubal cyst (n=1), intratubal adhesions (n=1), infant hernia repair (n=1), and calcification (n=1). Of eight women (including the patient with tuberculous salpingitis) who underwent tubal anastomosis only for midtubal occlusion, three had subsequent term deliveries, two had tubal pregnancies, and three women did not conceive. Conclusion Midtubal occlusion of the tube because of an infectious process is rare. Excluding tuberculous salpingitis, microsurgical anastomosis yields satisfactory fertility, albeit with significant risk of ectopic pregnancy.

The reproductive outcome after microsurgery for both proximal and distal occlusions in the same fallopian tube has been reported in only small numbers of women. Our case series is in agreement with other series and shows that microsurgery for correction of both proximal and distal occlusions in the same fallopian tube yields only modest fertility and may predispose to ectopic tubal pregnancies.

A unilateral tubocornual anastomosis and a contralateral salpingostomy for unilateral proximal and contralateral distal occlusive disease yield similar fertility as does pure tubocornual anastomosis for proximal occlusive disease. Ascending inflammation is postulated as the mechanism for tubal occlusion, with distal sparing from disease if the initial insult results in initial occlusion of the proximal portion of the oviduct.

Objective To assess a new criterion for selection of patients who request reversal of fimbriectomy sterilization. Design Prospective study. Setting Division of reproductive endocrinology and infertility in an academic center. Patients Eight patients undergoing reversal of fimbriectomy using microsurgical techniques. The prerequisite inclusion criterion was the presence of more than 50% ampulla as shown at hysterosalpingography. This is easily determined, because the isthmic length approximates one half the ampullary length. Results The cumulative intrauterine pregnancy rate was 50%. There were no ectopic pregnancies. Conclusion Similar pregnancy rates for reversal of fimbriectomy have been reported based upon different absolute selection criteria (viz., tubal length of ≥8 cm and ampullary width of ≥1 cm). By contrast, our new selection criterion is based upon the more readily determined proportion of ampulla that is available for surgical neostomy.

Our findings support the clinical use of vasoconstrictor solution within the ovary to achieve hemostasis. This will allow the gynecologist to avoid the thermocoagulative injury to the ovary by replacing electrosurgery and laser surgery with sharp incision accompanied by vasoconstrictor injection.

A nonconcurrent prospective study of 273,454 sigleton deliveries in South Carolina from 1989-1993 was conducted to determine the relationship between fetal mortality and rural status of maternal residence. Four geographic areas were identified based on the population of the largest city in the county(rural [R], moderately rural [MR], moderately urban [MU], and urban [U]). The fetal mortality rate for the R, MR, MU, and U groups were 13.6, 12.1, 10.3, and 8.7, respectively. There were no geographic differences in gravidity. With increasing rurality, there was a linear increase in preterm deliveries, low birth weight, Black ethnicity, single marital status, low education, and teenage pregnancies. Late entry into prenatal care and delivery in large volume hospitals demonstrated `U-shaped' distributions. Controlling for population socio-demographic differences with logistic regression, rural groups remained at increased risk for fetal death (R:OR 1.4; MR:OR 1.3; MU:OR 1.2; U:OR 1.0 ref). The unadjusted fetal mortality rate was increased for deliveries in large volume hospitals in all geographic areas. This was directly related to a four fold increase in the percent of very low birth weight deliveries in these larger hospitals since the VLBW specific mortality was lower for larger hospitals (see figure). Hospital size, location of VLBW deliveries, and rurality appeared to be the most significant factors in differences in fetal mortality. Controlling for hospital size of delivery, there were no statistical differences in fetal mortality by rural status. The adjusted odds ratios were: R:OR 1.1 (0.9-1.3); MR: 0.8 (0.7-1.0); and MU: 0.9 (0.8-1.0). These data suggest that residential differences in birth weight and size of hospital of delivery are significantly associated with geographic differences in fetal mortality.

A low-dose "nonsuperovulation" scheme of ovulation induction (schedule 1: 15 treatment cycles in 13 women) was compared to a high-dose, individually adjusted "controlled-superovulation" scheme of human menopausal gonadotropin administration (schedule 2: 18 treatment cycles in 17 women, with four women also having been treated under schedule 1). In schedule 2 more human menopausal gonadotropin was employed, 17 beta-estradiol plasma levels were higher, and more ova were retrieved per treatment cycle (p less than 0.01) with a higher rate of mature ova (p = 0.001). Also, under this schedule all treatment cycles resulted in successful retrieval of ova, whereas under schedule 1, four cycles (27%) were abandoned before laparoscopy because the follicles had ovulated (p = 0.03). Furthermore, the proportion of embryos cleaving to the two- to four-cell stage were higher under schedule 2 (38 of 53, or 72%) as compared to schedule 1 (13 of 25, or 52%), but this was not statistically significant (p = 0.07). Two pregnancies were conceived under schedule 2 giving a rate of 11% per treatment cycle. It was concluded that schedule 2, the individually adjusted controlled-superovulation scheme of human menopausal gonadotropin administration, was the superior technique of ovulation induction in an in vitro fertilization program.

This study was undertaken to assess the relative effectiveness of the CO2 laser and electromicrosurgery in adhesiolysis. Intraperitoneal adhesions were produced in 44 female white rats by inflicting a standard and reproducible injury to the serosa of a specific area of the right uterine horn. At a second intervention, 2 weeks later, the adhesions formed by the initial injury were assessed and division of adhesions effected in a random manner, either with the use of the CO2 laser or with electromicrosurgery, adhering to accepted microsurgical techniques. At a third intervention, results were assessed. The results demonstrate that electromicrosurgery and the CO2 laser are equally effective for adhesiolysis in the rat model.

Between July 1982 and November 1983, two pregnancies were established using in vitro fertilization and embryo transfer (IVF and ET) procedures with three different schedules to induce follicular maturation. All women were cycling normally and had inoperable or absent fallopian tubes. Of 83 oocytes aspirated from 24 patients (31 cycles), 75% were considered mature and 25% immature by the morphological characteristics of the oocytes and cumulus cells. Oocytes were preincubated for 6–24 hours, and after insemination, 60% cleaved to the two-to-four-cell stage. The superovulation induction schedule employing hMG administered according to the individually adjusted treatment scheme established two pregnancies. This schedule was considered the superior regimen, as it gave the highest proportion of mature oocytes (89%) which cleaved (78%). The pregnancy-attaining follicle showed a high progesterone:estradiol-17β ratio (P4/E2) in its microenvironment of aspirated follicular fluid, culture media of granulosa cells, and oocyte-cumulus complex. Our observations indicate a high P4/E2 ratio in the pregnancy-attaining follicle, and thereby reflect a further parameter in influencing maturation of the oocytes most likely to implant.

The aim of this study was to compare the occurrence of adhesions after a standard uterine injury inflicted by laparoscopy or by laparotomy during which microsurgical principles were observed. The cross-sectional areas of adhesions involving the uterus were assessed and the 31 rats operated upon laparoscopically were compared with the 30 rats subjected to a laparotomy. The mean area of uterine adhesions formed in the laparotomy group was 4.29 mm2 and 8.88 mm2 in the laparoscopy group. The difference was not statistically significant. The results imply that a standard tissue injury to uterine tissue, whether conducted by laparoscopy or via laparotomy, carries the same potential to induce postoperative adhesions.

Women who have Kartagener's syndrome (primary ciliary dyskinesia) may or may not be fertile. The bronchial mucociliary clearance is reduced markedly in most of these women; this has led investigators to the conclusion that the cilia in the respiratory tract are immotile, and that "beating cilia may have no indispensable role in the female reproductive tract." Yet motile cilia are considered by many workers to be essential for normal ovum transport. More recently, bizarre ciliary motion has been described in the respiratory cilia of Kartagener's women. Our hypothesis was that the dyskinetic ciliary activity (or immotility) would be the same in both the respiratory and reproductive tracts and thus explain the fertility (or lack of it) in Kartagener's women. This report shows an identical ultrastructure and absolute immotility of cilia in both the respiratory tract and reproductive tract of a woman with Kartagener's syndrome who has never conceived. From this concordance, we suggest that the fertility of Kartagener's women is explained by the dyskinetic motion of oviductal cilia, and that the ciliated endosalpinx is essential for human reproduction.

Experiments were conducted in nine New Zealand White rabbits to determine the functional capacity of that part of the oviduct consisting of only the isthmus and proximal ampulla. The left fimbria and at least one-half of the adjoining ampulla were excised microsurgically and the remaining portion of the proximal ampulla was subjected to a cuff salpingostomy. Following a convalescence of 4 to 8weeks and gonadotropin-induced ovulation, direct observations in vivo showed that the modified oviduct was ineffective in transporting surrogate cumulus masses into the tubal lumen. Those surrogates that were accepted were in some cases regurgitated by contractions of the residual proximal ampulla. A subsequent in vitro search for ova proved that the modified oviducts were unsuccessful in retrieving ipsilaterally ovulated ova, whereas the contralateral control oviducts apprehended an average of 72% of those available. Scanning electron microscopy showed the everted mucosa of the proximal ampulla to be less richly endowed with cilia than that of the normal fimbria. This ovum capture appeared to be prevented by deficiencies in both the ciliary mechanism of the neofimbria and the ability of the remaining ampulla to retain the egg. This evidence indicates that the proximal ampulla is unsuitable for reconstruction of a functional fallopian tube.

The present study was undertaken to evaluate and compare histologic parameters of wound healing subsequent to a standard uterine incision with carbon dioxide laser and electromicrosurgery in the rat model. The following histologic parameters were assessed and scored: scar width; amount of particulate carbon and necrotic debris; number of polymorphonuclear leukocytes, lymphocytes, histiocytes, and giant cells; and extent of edema, exudate, and collagen in the scar. The incisions were evaluated on postoperative days 0, 4, 7, 14, and 21. The ensuing scars were similar with respect to scar width and the amount of collagen in the scar. Foreign body reaction, denoted by histiocytes and giant cells, was significantly more pronounced in the electromicrosurgery group. Carbon particles, along with necrotic debris, appear to induce a foreign body tissue reaction. The particulate carbon in the electromicrosurgical incisions was significantly more extensive and was associated with the pronounced and longer lasting foreign body reaction in this group. (AM J OssTET GYNECOL 1989;160:1062-7.)

Une etude hysterosalpingographique recente est necessaire pour detecter l'evolution de la salpingite isthmique moneuse

Pregnancy following reversal of an ampullary segment in the rabbit oviduct has occurred only sporadically, and then usually after repeated mating. To explain this phenomenon it has been postulated that the direction of ciliary beat in the reversed ampullary segment must revert to the normal pro-uterine direction. To test this hypothesis a segment of the ampulla was reversed by microsurgery in 10 rabbits. These were then bred repeatedly for as long as 28 weeks. A single pregnancy, at 10 weeks, ensued. Observation of ampullary transport in vivo showed that muscular activity in the reversed ampullary segment may occasionally overcome the adverse, pro-ovarian ciliary currents that were found to persist in subsequent in vitro examinations. Scanning electron microscopy confirmed normal ciliation in the reversed segment. These observations may explain the occasional transport of an ovum across the reversed ampullary segment and an isolated pregnancy in the mated rabbit.

Microsurgical transection and anastomosis of the left isthmus in 7 rabbits caused fertility to be reduced 40%. Following rebreeding artificial eggs were introduced into the anastomosed and control oviducts. Sixty-three to 65 hours after mating, direct in vivo observations disclosed varied forms of motion of the artificial eggs within the isthmus, including both small oscillations and occasionally, large precipitous excursions covering more than 1 cm. Subsequent clearing of the genital tracts revealed that the anastomosis in the isthmus had detained most of the natural and artificial eggs, whereas both forms of ova were predominantly past the equivalent site on the control side; yet all anastomosed oviducts were fully patent. We conclude that the decreased fertility after isthmic anastomosis is due not to a physical obstacle but to an inability of the isthmus near the anastomosis to dilate as do other regions of the tube.

The effect of total deletion of the isthmus, including the ampullary-isthmic junction and the uteroisthmic junction, upon reproduction was determined in 21 rabbits. None became pregnant on the side lacking isthmus, whereas all became pregnant on the intact control side. Eight does were studied using in vivo and in vitro techniques at 18 to 20, 64 to 65, and 136 to 137 hours after mating. Spermatozoa fertilized the ova, with evidence of polyspermy. However, the modified oviduct did not transport fertilized ova into the uterus at the normal time. Furthermore, degeneration was noted from the morula stage onwards. We conclude that the rabbit ova can neither develop normally past the morula stage nor enter the uterus at the normal time in a recognizable form in the total absence of isthmus, and infertility results.

The 3 cases described illustrate instances within a 12-month span where an IUD in situ had been the cause of infertility, unknown to the women involved. In many centers, laparoscopy is performed as the primary investigation of tubal patency and normalcy, with hysterosalpingography (HSG) performed subsequently or not at all. HSG should be performed first, with laparoscopy and possible hysteroscopy carried out later as complementary procedures. Each case is reviewed briefly to determine how best to avoid failure to detect a retained IUD. The source of error in each case was the same. HSG was not performed or was not performed properly, with a preliminary plain x-ray film. In each instance the patient had been referred to a gynecologist and in case 1 to a regional tertiary referral center for infertility. There was no lack of availability of HSG, but there was not a systematic infertility investigation.

The correlation between the length of the oviduct and degree of fertility was studied in 16 New Zealand White rabbits subjected to microsurgical resection of differing lengths of fallopian tube involving the isthmus in each case. A highly significant (P less than 0.005) linear correlation was found, suggesting that more than 47% of an oviduct must remain distally before fertility can be anticipated. Absence of the isthmic segment of the fallopian tube was found to be associated with supracervical fetal implantations in the uterus. The importance of the assessment of tubal length as a prelude to reconstructive surgery, especially for reversal of sterilization, is emphasized.Evidence suggests that fertility subsequent to tubal reconstruction greatly depends on the length and functional quality of the oviduct. To test the validity of this statement, this study was conducted. 16 sexually mature New Zealand white rabbits were used for the study. Rabbits were used as they have a duplex genital tract to the level of 2 cervices; hence, each animal served as both case and control. The rabbits were preoperatively subjected to alternating 12-hour periods of light and dark and were given standard rabbit diet with liberal water. Aseptic microsurgical techniques were used during the operation. Length of the oviduct was measured with sterile paper tape. Segmented resection and anastomosis were performed on the left oviduct of each rabbit, while the right oviduct was anastomosed after simple transection and served as a control. The ratio of experimental to control pregnancies and the fraction of oviduct remaining distally correlated significantly (P 0.005), indicating that 47% or more of the fallopian tube must remain distally before fertility can be expected to return. In rabbits with a relatively small resected segment of tube (between 4% and 18% of the total tubal length), the uterus revealed normally spaced fetuses; in contrast, rabbits with large resected segment (between 40% and 46% of total length of oviduct) had pregnancies in the proximal supracervical region of the uterus. The findings suggest that oviductal length is a critical factor in achieving subsequent fertility following reversal of sterilization.

Microsurgical tubocornual anastomosis (TCA) and tubouterine implantation are the two primary operations used to treat proximal tubal occlusion (PTO). Tubouterine implantation usually has been reserved for cases of PTO in which the occlusion spans the entire intramural tubal segment. Yet TCA has proven to be more likely to lead to successful pregnancy than tubouterine implantation. 1-3 In this series, all PTO was treated by TCA. The article compares the reproducibility of results of TCA by two different operators and establishes the usefulness of TCA in all cases of PTO without resort to tubouterine implantation. Fifteen of 26 women achieved viable intrauterine pregnancies, a rate virtually identical to that published earlier by Gomel. Microsurgical TCA can be used to the exclusion of tubouterine implantation to achieve higher pregnancy rates, despite complete intramural occlusion.