Abstract -
This study aims to estimate the proportion of significant mesosalpingeal adipose tissue condensation (lipomesosalpinx, at least of a caliber similar to the ampulla of the ipsilateral tube regardless of well-defined or poorly defined margins) among infertile women subjected to diagnostic laparoscopy. This study is a cross-sectional study set at a specialized endoscopic center. All infertile women scheduled for diagnostic/therapeutic laparoscopy during the period between July 1994 and December 2012 was included in this study. Interventions used were preoperative hysterosalpingography, transvaginal ultrasonography, as well as body mass index for all cases. Laparoscopic documentation of a significant mesosalpingeal condensation of adipose tissue as well as histopathologic assessment of the adipose tissues in some cases was observed. The main outcome measures included number of cases with unilateral or bilateral lipomesosalpinx. Significant lipomesosalpinx was diagnosed in 145 (5.7 %) out of 2,563 cases examined by laparoscopy. In all but seven cases, lipomesosalpinx was seen bilaterally (99.7 %). There was insignificant correlation between those cases and high body mass index when compared to the rest of the cases. Infertility was unexplained by laparoscopy in 621 cases (24.3 %) while laparoscopy diagnosed etiologic factors in 1,942 (75.7 %) cases. Lipomesosalpinx was seen in 46 (7.4 %) and 79 (3.9 %) of the unexplained and explained cases, respectively, without a statistically significant difference (P = 0.48). Despite being a rare laparoscopic finding, significant lipomesosalpinx should be reported and documented as a possible missed tubal factor of infertility. Whether to treat lipomesosalpinx or not, bilaterally or unilaterally and by which means, require further studies with proper second-look laparoscopy.
Introduction -
There is a general consensus among gynecologists that tubal patency at hysterosalpingography (HSG) is quite assuring about tubal factor and they proceed to investigate other factors or advise patients to try assisted reproduction. Actually, the fallopian tube is a complex paired organ, not a simple tubing. The classic tubal factors include post-inflammatory peritubal adhesions and prominal or diatal tubal occlusion [1] which can be easily diagnosed by most gynecologists based on HSG. Other rare tubal diseases are seldom investigated. For instance, salpingitis isthmica nodosa which is a nodular swelling of the isthmic segment of the fallopian tube are rarely reported [2]. Anatomically, mesosalpinx is defined as the part of the broad ligament enclosing a fallopian tube forming its mesentery. Histologically, it is formed of a thin layer of squamous epithelium and a small amount of loose areolar connective tissue [3, 4]. It contains sympathetic ganglia and plexuses [5]. Laparoscopically, mesosalpinx is a thin vascular layer without evident fat in most cases.
Unexplained infertility is a real challenge for gynecologists. It is idiopathic in the sense that its cause remains unknown even after an infertility work-up, usually including semen analysis in the man and assessment of ovulation and fallopian tubes in the woman [6]. In Assiut, we believe that diagnostic laparoscopy is an integral step of the diagnostic work-up of any infertile couple before saying the term “unexplained”. With time, interest to discover minute lesions that may affect fertility increased at our institution [7]. In practice, we observe some fatty tissue condensation in the mesosalpinx in some cases that deserve studying why it is present in some women. To make this study valuable, we considered mesosalpingeal adipose tissue significant if its caliber was at least similar or exceeds the caliber of the ampulla of the ipsilateral fallopian tube regardless of the appearance of its borders. The tested hypothesis is a significant lipomesosalpinx that would hinder tubal motility and would be a cause of infertility. This study aims to estimate the proportion of significant mesosalpingeal adipose tissue condensation (lipomesosalpinx) among infertile women subjected to diagnostic/operative laparoscopy.
Patients and methods
This study was conducted between July 1996 and December 2012 at the Endoscopic Unit of the Woman's Health University Hospital, Assiut University, Egypt. It was approved by the institutional review board (IRB) of the Faculty of Medicine. All patients gave a clear written consent to participate in this study. It prospectively comprised 2,563 infertile patients submitted to video-assisted laparoscopy for diagnostic or operative purposes (Table 1). Preoperative metric body mass index (BMI) estimation and transvaginal ultrasonography (TVS) were done as a routine for all of the cases. Metric BMI is calculated as weight in kilograms divided by height in meters squared. Meticulous evaluation of HSG was made to identify tubal shape and patency whenever available. At laparoscopy, a thorough visualization of the mesosalpinx for evidence of adipose tissue condensation was reported. We considered mesosalpingeal adipose tissue significant if its caliber was at least similar or exceeds the caliber of the ampulla of the ipsilateral fallopian tube (Fig. 1). In all cases, using tubal chromopertubation, tubal patency was assessed and the relationship of the mass to the tubal lumen was recorded. Moreover, observation of the range of mobility of the tubes to the Douglas pouch was reported.
Based on the recommendations of the IRB, only unilateral excision or lysis of significant lipomesosalpinx was performed even if it was seen bilaterally in an otherwise normal genital tract anatomy at laparoscopy. Since it is a preliminary study, ethics recommended if any intervention should be unilateral until clear results of better bilateral excision of lipomesosalpinx with second-look laparoscopies. The side of the tube that will be operated upon was recorded. If this fatty condensation is pedunculated, it was excised with a bipolar scissors. If nonpedunculated but localized, a small microsurgical incision of the mesosalpinx was made followed by extraction of the adipose tissue with a fine-grasping forceps. The mesosalpingeal defect was then coagulated with bipolar forceps. Sutures or monopolar diathermy were not used in any case to minimize the risk of peritubal adhesions or tubal damage. On the other hand, if the adipose tissue mass was diffuse and ill-defined, it was coagulated as far as possible from the fallopian tube utilizing a 3-mm bipolar needle till complete melting of the adipose tissue. In most cases, histopathologic examination of the adipose tissue biopsy (Fig. 2) was done.
Results
This study included 2,563 infertile patients submitted to diagnostic or operative laparoscopy (Table 1). They were in the child-bearing period with a mean age of 24.5 years and mean parity of 1. Preoperatively, TVS was done for all cases that failed to detect any paraovarian echogenic condensation in all cases. Body mass index was calculated for all cases. Its mean was 29.4 with statistically insignificant correlation to lipomesossalpinx (P = 0.12). Significant lipomesosalpinx was diagnosed in 145 cases (5.7 %). In all but seven cases, lipomesosalpinx was diagnosed bilaterally (99.7 %). Infertility was unexplained by laparoscopy in 621 cases (24.3 %) while the cause of infertility could be explained in 1,942 (75.7 %) of the cases. Lipomesosalpinx was diagnosed in 46 cases (7.4 %) and 79 (3.9 %) in both groups respectively without statistically significant difference (P = 0.48). Biopsy of lipomesosalpinx revealed a normal adipose tissue in all cases. Surgical management of lipomesosalpinx was done, but data were excluded according to the aim of this study.
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