3 Fallop Tüp Patolojisi Distal tubal hastalık Bipolar hastalık %85; Pelvik inflamatuvar koşullar sonucu oluşurEnfeksiyon, endometriozis, abdomino-pelvik cerrahiHidrosalpenksBipolar hastalıkTüpün hem proksimal, hem de distal ucunun etkilendiği durumdurDistal tubal disease may account for up to 85% of tubal infertility and is the result of any pelvic inflammatory condition including infection, endometriosis and abdomino-pelvic surgery. The endpoint of distal tubal disease is the formation of a hydrosalpinx, which constitutes the collection of fluid in the tube.The term bipolar tubal disease is used when both proximal and distal aspects of a tube are affected.
4 Tanı HSG USG: HyCoSy (HyFoSy) CAT Hidrolaparoskopi Selektif SalpingografiSelective salpingography is another promising tech- nique that can be used in the assessment of proximal disease. It is based on the direct opacification of the fal- lopian tube with the use of a catheter directly placed in the tubal ostium. It is useful in differentiating tubal spasm from true obstruction and clarifying discrepant findings from other tests. It can be used therapeutically when combined with fallopian tube recanalisation to treat mild obstructions. The recanalisation procedure is simple for interventional radiologists, sometimes alongside gynaecologists and is performed with the use of a catheter and a guide wire system. The success rates reported range between 62% and 90%, and the aver- age pregnancy rates following the procedure are 30% (Thurmond et al., 2000).For patients with no risk factors, a negative chlamydia antibody test indicates that there is less than a 15% likelihood of tubal pathology (6). However, chlamydia antibody test- ing is limited by false positives from cross-reactivity with chlamydia pneu- moniae IgG and does not distinguish between remote and persistent infec- tion nor does it indicate whether the infection resulted in tubal damage (6). Therefore, hysterosalpingography (HSG) is the standard first-line test to evaluate tubal patency (7).
6 Tubal Cerrahi Gelişimi 1970’lerdeki mikrocerrahi kuralları başarıyı artırmıştır.The development of microsurgery (minimal tissue trauma, use of fine nonabsorbable sutures and intraoperative magnification, avoidance of tissue dessication, exquisite hemostasis and repair of all peritoneal surfaces) has offered great improvement in the outcome of reconstructive surgery.The residual length, the presence of chronic inflammation or tubal inclusion in the tubal wall and the presence of tubal endometriosis are all factors affecting the outcome of proximal reconstructive surgery that need to be con- sidered. Occasionally, proximal tubal patency can be restored by less invasive means via selective salpingog- raphy and tubal catheterisation (Sacks & Trew, 2004).
7 Distal tubal hastalık-Hidrosalpenks Peritubal adezyonlar değil, tubal mukozal adezyonlar en belirleyici faktördür (Vasquez 1995)Sınırlı filmsel adezyonlar, <3cm dilate ve ince, katmanlı duvarı olan tüpler,İyi korunmuş tubal mukoza varlığında hidrosalpenks için rekonstrüktif cerrahi sonrasında GH %77 ve ektopik GH %4 civarındadır (Boer-Meisel 1986)Tubal mukoza LS ve HSG tarafından değerlendirilebilir. Ancak salpingoskopik değerlendirme daha hassastır. (Déchaud 1998).Sık kullanılmayan bir yöntemdir.The state of the tubal mucosa has attracted significant attention as a strong patient selection criterion. Evidence level A (Puttemans et al., 2000; Strandell & lindhard, 2000).Interestingly mucosal adhesions were shown to be the most important factor in selection of patients, while peritubal adhesions did not seem to influence preg- nancy rates (Vasquez et al., 1995). Pregnancy rates as high as 77% and tubal ectopic rates as low as 4% have been reported following reconstructive surgery for hydrosalpinges with a well-preserved mucosa (Boer-Meisel et al., 1986). The tubal mucosa can be assessed by laparoscopy and indirectly by HSG. Both methods have a widespread use in the fertility work up. It has, however, been suggested that the combina- tion of HSG and laparoscopy is not as accurate in the assessment of the tubal mucosa as is endoscopic inspection (Déchaud et al., 1998). Salpingoscopy is the most accurate method for identifying mucosal ad- hesions, but, although it has been available for many years, it is still not part of normal clinical practice in most centres.A good prognosis is associated with patients who have no more than limited filmy adnexal adhesions, mildly dilated tubes (<3 cm) with thin and pliable walls, and a lush endosal- pinx with preservation of the mucosal folds (26). Peritubal ad- hesions from the above causes or endometriosis may impair the ability of intrinsically normal tubes to capture an oocyte by mechanically interfering with the anatomic relationship between the distal fallopian tube and the ovary. One study of 147 patients reported cumulative pregnancy rates of 40% at 12 months after adhesiolysis by laparotomy, versus 8% in an untreated group (27).
9 Puttemans Salpingoscopy Classification-1987 Grade Inormal mucosal foldsGrade IIMajor folds separated and flattened, however, otherwise normalGrade IIIFocal adhesions throughout the mucosal foldsGrade IVExtensive adhesions and/or flattened areas throughout the mucosal foldsGrade VTotal disappearance of mucosal foldsBoer-Meisel classification, 1986Group 1mucosa is normal with regular folds.Group 2moderate alterations to the ampullary mucosa, with areas of normal mucosa interspersed with areas where the mucosal folds are rare or non-existent (atrophic mucosa).Group 3mucosa has deteriorated considerably with either complete disappearance of the mucosa or the existence of intratubal synechiae (alveolar mucosa).
15 İntraoperatif Hidrotubasyon Fertiliteyi Artırıyor. Cerrahiden hemen sonra tubal yıkama gebelik oranlarını artırırken, post operatif yıkama veya hiç yıkamama gebelik oranları aynı kalır.20mm Ringer Laktat IU Gentamisin + 5 mg DekzametazonZhengyu, 2013 Arch Gynecol Obstet
19 Laparoskopik Adezyolizis Yazar # Takip IU-GH% Ekt-GH% DH%Bruhat, (orta) >18 ay 55 8 ?27 (şidd.) ?Fayez, yılDonnez, (avask) 18 ay ? ? 6222 (vask) ? ? 50Gomel, >9 ay
20 Contraindications to Tubal Surgery Frozen pelvisExtensive ampullo-infundibular tubal resections for sterilizationExtensive intra-ampullary and confirmed during the diagnostic phase of laparoscopy after opening the hydrosalpinxGenital tuberculosis or sequelaeAdditional infertility factorsAge is another contraindication.
21 Cerrahi Ektopik Gebelik Riskini Artırır TotalEktopik Gebelik PrediktörleriBilateral CerrahiOrta derecede hasar görmüş tubal mukozaDaha önceki PID atakları+ FHC SendromuIUPEPTaylor, Fertil Steril, 2001
22 Unilateral Salpinjektomi veya PTL Gebelik Şansını Artırır Ortalama gebe kalma süresi 5.6 ayEktopik gebelik yokSagoskin, Hum Reprod 2003
24 Tubal Hastalık ve IVFİlk insan IVF gebeliği intrauterin olmayıp, ektopik idi. Steptoe PC & Edwards RG, 1976“Proksimal tubal okluzyon Şiddetli tubal hastalığı olan hastalarda IVF öncesi uygulanmalıdır!” Steptoe PC, 1979“Tubal faktörü olan hastalar IVF’de daha az gebelik şansı vardır.” Englert Y, 1987
25 Results of 3 Meta-analyses Strandell A, Hum Reprod Update, 2000
32 Tubal Cerrahi mi? IVF mi?Şu ana kadar bu iki yöntemi karşılaştırmış randomize kontrollü çalışma bulunmamaktadır.
33 Tubal Anastomoz veya IVF Cetin, 2013 Laparoendosc Adv Surg Tech A
34 Tubal Anastomoz veya IVF Kümülatif GH (Boeckxstaens, 2007 Hum Rep)37y altı : IVF için %52, Cerrahi için %7237y üstü :IVF için %51, Cerrahi için %36Mikrocerrahi (Schippert 2011, Fertil Steril)Mikrocerrahi sonrası GH: %43, IVF sonrası GH:%28Ektopik Gebelik Riski (Schippert, 2012 Arch Gynecol Obstet)Cerrahi sonrası %7.9, IVF sonrası 5.6