Human Reproduction, Vol. 14, No. 8, 1960-1961,
August 1999
© 1999 European Society of Human Reproduction and Embryology
Total corporal synechiae due to tuberculosis carry a very poor prognosis following hysteroscopic synechialysis
Hacettepe University, Faculty of Medicine, Department of Obstetrics and Gynaecology, Ankara 06100, Turkey
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Abstract |
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Twelve consecutive patients with total corporal synechiae due to tuberculosis were reviewed in terms of intrauterine adhesion re-formation rate following hysteroscopic surgery. All patients presented with secondary amenorrhoea and infertility. The diagnosis was based on a `glove finger appearance' at hysterosalpingography and classical laparoscopic and tubal biopsy findings. Intrauterine synechiae re-formation was assessed by postoperative hysterosalpingograms performed 3–4 months after the procedure. The 12 patients underwent 15 attempts for hysteroscopic lysis of total corporal synechiae. Three perforations occurred and all were managed with laparoscopic extracorporal suturing. Ultimately, adequate uterine cavity was obtained in all cases. Total intracorporal synechiae recurred in all patients at control postoperative hysterosalpingograms. We conclude that total corporal synechiae caused by tuberculosis, unlike other causes, carry a poor prognosis following hysteroscopic lysis. Surrogacy may be the only option for fertility in such couples.
Key words: hysteroscopic surgery/tuberculosis/uterine synechiae
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Introduction |
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TopAbstractIntroductionMaterials and methodsResultsDiscussionReferences |
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In-vitro fertilization (IVF) and embryo transfer offers the only realistic chance of conception in women with infertility due to genital tuberculosis. Although the medical treatment is successful in eradicating the infection, fibrotic sequelae of the disease may prevent the occurrence of an intrauterine pregnancy. Endometrial involvement may be noted in over half of the affected cases and the uterine cavity may be partially or totally obliterated with intrauterine synechiae (Varma, 1991
). Despite the lack of data supporting its efficacy, hysteroscopic lysis of intrauterine synechiae is indicated in such patients, affected by genital tuberculosis, to restore the uterine cavity before they are subjected to IVF and embryo transfer. The aim of this study is to review the intrauterine adhesion re-formation rate following hysteroscopic lysis of total corporal synechiae due to tuberculosis.
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Materials and methods |
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TopAbstractIntroductionMaterials and methodsResultsDiscussionReferences |
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Twelve consecutive patients with total corporal synechiae (American Society for Reproductive Medicine Stage III) (American Fertility Society, 1988
) due to tuberculosis were included in the study. All patients presented with secondary amenorrhoea and infertility. Their median age was 25.8 years (range 19–28 years). The diagnosis was based on the `glove finger' appearance at hysterosalpingography (Figure 1) and the classical laparoscopic and tubal biopsy findings. All patients had a positive tuberculin test with >10 mm of induration. Five patients had a documented history of treatment for the active pulmonary tuberculosis. Their diagnostic laparoscopies were consistent with bilateral tuboperitoneal involvement due to tuberculosis and the distal tubal biopsy specimens were reported as granulomatous salpingitis. Of the remaining seven patients, two had had prior salpingectomies elsewhere for hydrosalpinges with the histology reported as `salpingitis with caseating granulomas and Langerhans type giant cells'. Five of them underwent prior diagnostic laparoscopies with tubal biopsy at our centre and all showed characteristic histological signs of tuberculosis.
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All interventions were performed by the same team which always included the three authors. In all patients, laparoscopy was used to assist the hysteroscopic procedure. With the patient under general anaesthesia, the cervix was dilated to accommodate the rigid 10 mm diameter hysteroscopic resectoscope (Hopkins 26157 B: Karl Storz, GmBH & Co., Tuttlingen, Germany). Glycine (Glisin 1.5%: Eczacibasi A.S., Istanbul, Turkey) was used as the distending medium. Lysis of synechiae was undertaken with the guidance of hysteroscopic illumination of the uterine cavity to judge the depth of the fundal dissection. Hysteroscopic synechialysis was continued until a normal panoramic view of the uterine cavity was noted. Once the procedure was completed, an intrauterine modified 8F Foley catheter (cut-tip) (Willy Rüsch AG, Kernen, Germany) was inserted and kept for 5 days. All patients received oral conjugated equine oestrogens (Premarin, Wyeth, Istanbul, Turkey) at a dose of 2.5 mg/day for 25 days and medroxyprogesterone acetate (Farlutal, Deva, Istanbul, Turkey) at a dose of 5 mg orally twice daily was administered for the last 10 days of this cycle. This regimen was applied for a total of three cycles. In addition, doxycycline (Tetradox, Fako, Istanbul, Turkey) 100 mg orally twice daily was prescribed for the first 5 days postoperatively. Intrauterine synechiae re-formation was assessed by postoperative hysterosalpingograms performed 3–4 months after the procedure.
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Results |
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The 12 patients underwent 15 attempts for hysteroscopic lysis of total corporal synechiae. Three perforations occurred and all were managed with laparoscopic extracorporal suturing. These three patients, whose surgery had been aborted, were subjected to another hysteroscopic procedure in 3 months which were all uncomplicated. Although the tubal orifices could not be visualized in any of these cases, an adequate uterine cavity, as assessed by the authors during the surgery, was obtained in all cases. One patient reported slight blood spotting only at the end of the first oestrogen–progestin cycle. Thereafter, she became amenorrhoeic. All other patients remained amenorrhoeic within the postoperative period. Total intracorporal synechiae recurred in all patients with the same `glove finger appearance' on the control postoperative hysterosalpingographies, which were performed 3–4 months after the operation.
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Discussion |
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TopAbstractIntroductionMaterials and methodsResultsDiscussionReferences |
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There has been a paucity of data on the results of hysteroscopic treatment of severe adhesions secondary to tuberculosis. In eight patients with severe adhesions secondary to causes other than genital tuberculosis, adhesion reformation rate of ~50% has been reported (Pabuccu et al., 1997
). In the same series, two patients with genital tuberculosis and severe adhesions were presented and their severe adhesions had all re-formed as well. In a series of 187 patients, term pregnancy rate of 31.9% was achieved after hysteroscopic adhesiolysis for severe adhesions, in contrast with 81.3% when operating with mild disease (Valle and Sciarra, 1988). The recurrence rate for severe adhesions was 48.9% and decreased to 35% after repeated treatment. Since the causes of adhesions in that study did not include tuberculosis, and almost all of them were secondary to antecedent endometrial trauma (except one with a history of acute endometritis), these values are not comparable with adhesions secondary to tuberculosis. Chen et al. (1997) treated seven patients with severe uterine synechiae by using laminaria tents in order to dilate the cervical canal and to distend the uterine cavity, in this way helping to find the appropriate dissection route prior to transcervical resectoscopy. All patients had normal menses and normal uterine cavity (Chen et al., 1997). However, again the causes were other than tuberculosis, being mainly elective or incomplete abortions. The nature of intrauterine synechiae associated with tuberculosis is invariably dense and cohesive. Finding the appropriate cleavage plane during hysteroscopic lysis may prove to be technically difficult with unavoidable myometrial damage. In addition, accidental uterine perforation may occur. Although the uterine cavity was restored to a great extent at the end of hysteroscopy in all patients, severe synechiae reformation rate in this series was 100%.
Moreover, the overall safety of any invasive procedure in patients with genital tuberculosis needs to be determined. A life-threatening disseminating tuberculosis has been reported as a result of surgical manipulations in the pelvis (Crafton and Douglas, 1981) and even after IVF procedures (Addis et al., 1988). In addition, there has been a recent case report from our institution, describing a patient with genital tuberculosis who conceived with IVF and suffered a uterine rupture at 36 weeks of gestation (Gurgan et al., 1996). Accidental uterine perforation had occurred in this patient during hysteroscopic lysis of a dense intrauterine synechia, simulating a septate uterus, which involved the anterior and posterior walls of the uterine cavity.
We conclude that total corporal synechiae due to tuberculosis, unlike other conditions, carry a poor prognosis following hysteroscopic lysis. Surrogacy may be the only remaining option for fertility when all other surgical attempts have failed.
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Notes |
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1 To whom correspondence should be addressed
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References |
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TopAbstractIntroductionMaterials and methodsResultsDiscussionReferences |
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Addis, G.M., Anthony, G.S., D'A. Semple, P. and Miller, A.W. (1988) Miliary tuberculosis in an in vitro fertilization pregnancy: a case report. Eur. J. Obstet. Gynecol. Reprod. Biol., 27, 351–353.[Medline]
American Fertility Society (1988) The American Fertility Society classifications of adnexal adhesions, distal tubal occlusion, tubal occlusion secondary to tubal ligation, tubal pregnancies, Müllerian anomalies and intrauterine adhesions. Fertil. Steril., 49, 944–955.[Web of Science][Medline]
Chen, F.P., Soong, Y.K. and Hui, Y.L. (1997) Successful treatment of severe uterine synechiae with transcervical resectoscopy combined with laminaria tent. Hum. Reprod., 12, 943–947.
Crafton, J. and Douglas, A. (1981) Miliary tuberculosis. In Crafton, J. and Douglas, A. (eds), Respiratory Diseases. Blackwell, Oxford, 257 pp.
Gurgan, T., Yarali, H., Urman, B. et al. (1996) Uterine rupture following hysteroscopic lysis of synechiae due to tuberculosis and uterine perforation. Hum. Reprod., 11, 291–293.
Pabuccu, R., Atay, V., Orhon, E. et al. (1997) Hysteroscopic treatment of intrauterine adhesions is safe and effective in the restoration of normal menstruation and fertility. Fertil. Steril., 68, 1141–1143.[Web of Science][Medline]
Valle, R. and Sciarra, J. (1988) Intrauterine adhesions: hysteroscopic diagnosis, classification, treatment and reproductive outcome. Am. J. Obstet. Gynecol., 158, 1459–1470.[Web of Science][Medline]
Varma, T.R. (1991) Genital tuberculosis and subsequent fertility. Int. J. Gynaecol. Obstet., 35, 1–11.[Medline]
Submitted on September 24, 1998; accepted on April 15, 1999.
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