Tubal Reversal Blog December, 2007

Salpingitis Isthmica Nodosa

Salpingitis isthmica nodosa is a nodular swelling of the isthmic segment of the fallopian tube. This fallopian tube abnormality is sometimes encountered at the time of tubal reversal surgery. It often involves the interstitial portion of tube that is within the uterine muscle. The nodule is due to thickening of the muscular wall of the tube around ingrowths or projections of the inner mucus membrane tubal layer into the muscle.

History of Salpingitis Isthmica Nodosa: Scholarly Publications

This tubal abnormality was first described and named by Chiari in 1887 .⁽¹⁾ The name he gave it reflected his belief this was an inflammatory condition. (Salpingitis means inflammation of the fallopian tube.) His contemporary, Kossman, also thought this was an inflammatory condition.⁽²⁾ An alternate theory of causation was suggested by Recklinghausen in 1896 who believed it to be a congenital abnormality.⁽³⁾ A third possibility, suggested by Benjamin and Beaver in 1951, is that SIN is an acquired, noninflammatory condition.⁽⁴⁾ They believed that the lesion begins as an overgrowth of the inner tubal lining that penetrates into the tubal muscular wall. Then cysts form and the tubal muscular wall becomes enlarged and fibrotic. This has also been termed endosalpingosis, a condition closely related to uterine adenomyosis (a form of endometriosis in which the uterine endometrium grows into the uterine muscle).

HSG Diagnostic Findings

Salpingitis isthmica nodosa can be diagnosed radiographically. A hysterosalpingogram or HSG shows multiple small diverticuli or outpouchings of of x-ray dye protruding from the tubal lumen into the wall of the isthmic portion of the fallopian tubes. Because of its appearance at HSG, radiologists call it tubal diverticulosis.⁽⁵⁾

Clinical Implications

Salpingitis isthmica nodosa is associated with increased rates of infertility by interfering with upward sperm migration and ectopic pregnancy by trapping the fertilized egg within the tube.

Treatment During Tubal Reversal

Salpingitis isthmica nodosa may be encountered at the time of tubal reversal surgery. Because of the dense abnormality of the fallopian tube at its connection with the uterus, tubotubal anastomosis is not possible. In this situation, tubouterine anastomosis or tubouterine implantation can be performed.

Tubal Reversal Scholarly Publications

Early Experimental Studies in Animals

In 1969, David, Brackett and Garcia ⁽¹⁾ reported using microsurgical techniques for uterotubal anastomosis after removing the uterotubal junction from one side in 25 rabbits. Among 11 (44%) of the animals that became pregnant, fewer implantations occurred on the operated side than on the unoperated side. This showed that the uterotubal junction has a role, but is not absolutely required, in transferring embryos from the fallopian tube into the uterus for implantation.

In 1974, Paterson and Wood ⁽²⁾ divided the isthmic segment of one fallopian tube and then performed tubal anastomosis in 10 rabbits. They removed the fallopian tube and ovary on the other side so that any pregnancies that followed could be attributed to the repaired fallopian tube. The pregnancy rate was 60%. These investigators suggested that tubal anastomosis could be applied successfully to humans for reversal of tubal sterilization.

Hulka and Ulberg ⁽³⁾ in 1975 were the first to perform a successful reversal of tubal sterilization under experimental conditions. Six weeks after applying Hulka clips to the isthmic portion of fallopian tubes in 8 pigs, they removed the clipped portion of tubes and performed tubal anastomosis using an absorbable, multifilament suture (6-0 Dexon). Six (75%) of the animals subsequently became pregnant.

In 1975 Winston ⁽⁴⁾ reported an experiment in rabbits in which the experimental variables were different suture materials and duration of tubal splinting. In one group of 25 rabbits, he removed a portion of the tubal isthmus or ampulla and then performed tubotubal anastomosis with a nonabsorbable, nonreactive, monofilament suture (10-0 nylon). Using microsurgical technique, Winston took special care to include only the 2 outer layers (muscularis and serosa) of the fallopian tube in the suture line, avoiding the inner tubal layer (endothelium). He stabilized the anastomotic sites with polyethylene splints that were removed before closure of the abdominal cavity. Twenty-three (92%) of the animals became pregnant. This was the highest pregnancy rate reported so far after tubal anastomosis in animal studies. When either 8-0 catgut was used as the suture material or the tubal splint was left in place for 1 week after surgery, the pregnancy rate dropped in half.

Winston’s results were subsequently corroborated using microsurgical tubal anastomosis with 11-0 nylon, intraoperative splinting, and avoiding mucosal trauma from suture in the reconstruction of rabbit oviducts six weeks after application of Falope rings. Eighteen (82%) of 22 rabbits became pregnant after two matings.

Comment

Experimental studies in animals demonstrated excellent pregnancy rates following reconstruction of the fallopian tube by tubal anastomosis. They provided the basis for tubal reversal surgery as a clinical treatment. The best results came using microsurgical techniques with non-reactive, monofilament suture material, intraoperative tubal splints, and avoiding the introduction of suture in the inner layer of the tube.

Dr. Berger uses these surgical techniques in his tubal reversal procedures. For a more complete description of the early history of tubal reversal surgery, read Dr. Berger’s book chapter, Reversal of Female Sterilization: An Evaluation of Results ⁽⁵⁾.

References

1. David A, Brackett BG, Garcia CR: Effects of microsurgical removal of the rabbit uterotubal junction. Fertil Steril 20:250, 1969
2. Hulka JF, Ulberg LC: Reversibility of clip sterilization. Fertil Steril 26:1132, 1975
3. Paterson P, Wood C: The use of microsurgery in the reanastomosis of the rabbit fallopian tube. Fertil Steril 25:757, 1974
4. Winston RML: Microsurgical reanastomosis of the rabbit oviduct and its functional and pathological sequelae. Br I Obstet Gynaecol 82 :513, 1975
5. Berger GS: Reversal of female sterilization: An evaluation of results. In JM Phillips, editor, Microsurgery in Gynecology, Chapter 33. American Association of Gynecologic Laparoscopists, Downey, California, 238-243, 1977.