2.1 The hydrosalpinx

It is of paramount importance to define accurately the tubal lesions. There is sometimes confusion between phimosis and hydrosalpinx. In phimosis there is still a certain degree of patency, whereas in hydrosalpinx there are no patency at all. This makes a very large difference in prognosis when operated since the tubal mucosa is usually healthy in phimosis but frequently altered in hydrosalpinx. However, in some cases there is what it looks like a normal fimbria, but when the dye test is performed it is very clear that the ampulla is totally blocked without any connection between the fimbria and the ampulla (Fig. 1).

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Fig. 1

Hydrosalpinx with still Cumbria without connection with ampulla (green arrow).

2.2 Adhesions

Adhesions are frequent since hydro or hemato-salpinges are usually the result of PID or endometriosis where inflammation is important, thus creating adhesions. It is necessary to pay attention to the quality of adhesiolysis: it should be accurate, atraumatic and complete. Various tools may be used such as cold scissors, monopolar hook or Plasmajet®. None has proven to be superior to the others so everything is useable providing to be precise. In our series, we usually used cold scissors or monopolar hook and Plasmajet in case of hydrosalpinges associated with endometriosis. Considering the role of adhesions in the prognosis of salpingoneostomy we used the AFS adhesion score (Table 1) and did not operate conservatively in case of frozen pelvis (score equal to 16 or above).

2.3 The techniques of salpingoneostomy

The conservative operation is called salpingostomy or even better salpingoneostomy (since a “new” ostium is created). There are two kinds of salpingostomy: the terminal neostomy and the medio ampullary neostomy. In the latter case, a part of the distal ampulla (usually one or two centimeters) is removed. This technique, which was popular in the eighties, is abandoned today, since the results are not at all competitive with results obtained with IVF. So, in this paper salpingoneostomy refers to terminal salpingoneostomy exclusively.

There are two techniques of terminal salpingostomy: the cuff salpingostomy (Fig. 3)and the racket form (Fig. 2). In our series, whenever it was possible, we practiced the cuff salpingostomy and the racket form otherwise. In fact, cuff salpingoneostomy is only possible when the tubal wall is thin and non sclerotic. In cases where only the racket is possible the tube is not in a good condition. That will be reflected by the results described below. All hydrosalpinx do not have the same prognosis. The key factors are the quality of tubal mucosa and the thickness of the tubal wall.

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Fig. 2

Racket form salpingostomy.

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Fig. 3

Cuff salpingostomy.

The tubal mucosa is probably the most important parameter allowing surgery to be conservative or not, as demonstrated by Brosens and Puttemans(4,5). They described a “tubal score” where stage 1 is normal, in stage 2 the mucosal folds are decreasing, in stage 3 there are additional focal intra ampullary adhesions, and in stage 4 and 5 folds are totally flattened or absent and ampulla is full of adhesions with the “honey comb” aspect (Table 2). When tubal mucosa is stage 3–5, the pregnancy rate after salpingostomy is very low, between 17% and 0% in stage 5, with a risk of ectopic pregnancy of more than 10%. Therefore, in these cases, salpingectomy is the only option prior to IVF.

The second parameter is the thickness of the tubal wall. In case of a sclerotic tubal wall, prognosis of conservative treatment is not good, even if the hydrosalpinx is quite small. In case of big hydrosalpinx, if the tubal wall is thin, the prognosis is fairly good. This is not well known, since many authors consider that “big” hydrosalpinges should be treated radically.^6,7 In our series, we only consider for reconstructive surgery patients with a mucosal score stage 1 or 2. In stages 3–5 we recommended salpingectomy followed by IVF.

We performed all salpingoplasty through laparoscopy using the technical requirements recommended by Gomel and Winston^8,9 in the eighties and used at that time through microsurgical laparotomy. Today, the prerequisites of tubal surgery such as magnification and gentleness are perfectly doable by laparoscopy. We applied strictly these principles in our series.

In case of hydrosalpinx, the conservative operation is called salpingostomy or even better salpingoneostomy, consisted first in finding the place of the old ostium to start the opening. Once that was done, stellar incisions following the fibrotic tissue were done by cutting or gently distracting the tissue with two atraumatic forceps. In case of a thin wall, we used the technique of cuff salpingoneostomy. When the tubal wall was a little thicker, only the racket form was doable. When eversion was performed, it was maintained with micro-sutures, usually 6 × 0 or 7 × 0 monofilament sutures. Three to four stitches were sufficient to maintain the obtained eversion. It was important to try to cover all the tubal serous area damaged by coagulation in order to prevent adhesion formation on those areas. At the end of the procedure, tubal patency was tested, through the cervix by injection of methylene blue, and copious pelvic irrigation was done. We routinely use 4% icodextrin (Adept®)^10,11 due to its antiadhesion properties demonstrated in several trials, and 300–500 cc was left in place at the end of the procedure.