Distal Tubal Occlusion Research Articles

An update on surgical management of tubal disease and infertility

Reproductive surgery remains an important option and is complementary to assisted reproductive technologies. A spectrum of tubal disease of varying severity is recognized at laparoscopy. Pathology may vary from peritubal adhesions, damaged fimbriae or distorted tubal anatomy to tubal blockage or hydrosalpinx (a fluid-filled distension of the fallopian tube in the presence of distal tubal occlusion). Reproductive surgery should be considered as first-line treatment: when the correction of infertility pathology is achievable and a good result is expected; when the pathology is causing the patient pain or discomfort; and when if left uncorrected infertility pathology will compromise the results or increase the risks of assisted reproductive technology. The success of surgical infertility treatment depends on the careful selection of cases using appropriate investigative techniques, with procedures performed in centres with sufficient expertise. For both specialized reproductive and general gynaecological surgery, it is paramount to follow strict microsurgical principles to avoid adhesion formation and conserve normal tubal and ovarian tissues.

Intraluminal Tubal Endometriosis Mimicking Hydrosalpinx: Report of an Unusual Case

Endometriosis is an estrogen-dependent disease causing pelvic pain and infertility and there is still limited knowledge of the pathogenesis. Hydrosalpinx is commonly seen in a heterogeneous spectrum of pathologies of distal tubal occlusion. In general, collection of fluid in uterine tubes occur as the end stage of pyosalpinx or as the advenced stage of endometriosis with pelvic adhesion. In this report we present a very rarely seen case that is called intraluminal tubal endometriosis mimicking hydrosalpinx without pelvic adhesion in an infertile patient. The clinical features and the management of intraluminal tubal endometriosis case which is very rare cause of enlarged tuba uterina in an infertile patient discussed.

Prediction of pelvic pathology in subfertile women with combined Chlamydia antibody and CA-125 tests

Objectives Chlamydia antibody test (CAT) has been proposed to predict tubal disease. A correlation between CA-125 and the extent of endometriosis has been found by others. In this study we explored whether a combination of the two tests adds to the predictive value of the individual tests for predicting tubal disease or endometriosis. We also used the combination of tests as a new index test to screen for severe pelvic pathology. Study design This retrospective study compares the findings of 240 laparoscopies with the serological test results. Findings were classified according to the existing ASRM scoring systems for adnexal adhesions, distal tubal occlusion and endometriosis. Severe pelvic pathology was defined as the presence of ASRM classes III and IV tubal disease or ASRM classes III and IV endometriosis. The predictive value was calculated for both tests separately and for the combined test. The combined test was positive if at least one test result was abnormal (CAT positive and/or CA-125 ≥35 IU/ml). Results 67/240 women had tubal disease, 81/240 had some degree of endometriosis. The odds ratios (ORs) of the CAT and the combined test to diagnose severe tubal disease were 6.6 (2.6–17.0) and 7.3 (2.9–19.3), respectively. The ORs of the CA-125 and the combined test to diagnose severe endometriosis were 15.6 (6.2–40.2) and 3.0 (1.2–8.0), respectively. Severe pelvic pathology was present in 65/240 women (27%). The ORs for severe pelvic pathology of the CAT, CA-125 and the combined test were 2.5 (1.4–5.3), 4.9 (1.9–9.6) and 6.6 (3.3–13.4), respectively. If the combined test was normal 15 out 131 women (11%) were shown to have severe pelvic pathology. Conclusions The combined test adds hardly anything to the predictive value of CAT alone to diagnose severe tubal disease. The combined test is better than the CAT to predict severe pelvic pathology, but is not significantly better than the CA-125. If both the CAT and CA-125 are normal one could consider not performing a laparoscopy.

MR Imaging Findings of Hydrosalpinx: A Comprehensive Review

Hydrosalpinx is a common adnexal lesion that may occur either in isolation or as a component of a complex pathologic process (eg, pelvic inflammatory disease, endometriosis, fallopian tube tumor, or tubal pregnancy) that leads to distal tubal occlusion. On magnetic resonance (MR) images, hydrosalpinx appears as a fluid-filled C- or S-shaped tubular structure that arises from the upper lateral margin of the uterus. Although hydrosalpinx is most often seen on ultrasonographic images, it also may be delineated on multiplanar MR images. MR imaging also may be useful for determining the cause of a hydrosalpinx or its associated adnexal process by characterizing the nature of the contents of the dilated tube. Tubal fluid with high signal intensity on T1-weighted images is suggestive of hematosalpinx associated with endometriosis and tubal pregnancy. A thickened wall of a dilated fallopian tube that displays variable or heterogeneous signal intensity may be indicative of pyosalpinx as a component of a tubo-ovarian abscess. The presence of an enhancing solid mass within a dilated tube is suggestive of fallopian tube carcinoma, whereas enhancement of the dilated tubal wall surrounding a saclike cystic mass may be indicative of a tubal pregnancy. Understanding the pathogenesis and clinical manifestations of conditions associated with hydrosalpinx may aid in the timely diagnosis of complex adnexal masses at MR imaging, enabling avoidance of unnecessary procedures.

Surgical management of tubal disease and infertility

A spectrum of tubal disease of varying severity is recognised at laparoscopy. Pathology may vary from peritubal adhesions, damaged fimbriae or distorted tubal anatomy to tubal blockage or hydrosalpinx (a fluid-filled distension of the fallopian tube in the presence of distal tubal occlusion). Reproductive surgery remains an important option and complement to assisted reproductive technologies. Reproductive surgery should be considered as first-line treatment: when the correction of infertility pathology is achievable and a good result is expected; when the pathology is causing the patient pain or discomfort; and when if left uncorrected infertility pathology will compromise the results or increase the risks of assisted reproductive technology. The success of surgical infertility treatment depends on the careful selection of cases using appropriate investigative techniques, with procedures performed in centres with sufficient expertise. For both specialised reproductive and general gynaecological surgery, it is paramount to carefully follow the microsurgical principles to avoid adhesion formation and conserve normal tubal and ovarian tissues.

Hysterosalpingographic Tubal Abnormalities and HIV Infection among Black Women with Tubal Infertility in Sub-Saharan Africa

Background: Tubal factor remains a common cause of infertility. The association of HIV infection and tubal infertility is a cause for concern. Objective: To determine hysterosalpingographic tubal abnormalities and HIV infection among patients with tubal infertility. Results: Over a 4-year period, 207 patients were analyzed. Of these, 174 (84.1%) presented with secondary infertility and 33 (15.9%) with primary infertility. The patients’ age range was 21–48 years and mean age was 36.2 years. One hundred and two (49.3%) patients had a history of induced abortion. Concordant bilateral tubal occlusion was found in 139 (67.2%) patients while 68 (32.8%) had discordant bilateral tubal occlusion. Of the 414 fallopian tubes studied, proximal tubal occlusion was found in 66 (15.9%) cases and distal tubal occlusive pathology occurred in 348 (84.1%). An HIV positivity rate of 13.5% was recorded. Distal tubal occlusion with hydrosalpinx was more associated with HIV infection in this series. Conclusion: A high HIV positivity rate was recorded among the patients with tubal infertility compared to the general population. There is prepondence of distal tubal occlusion in infertile women with tubal factor.

Indications to tubal reconstructive surgery in the era of IVF

In recent years, the treatment of tubal infertility has witnessed a shift from reconstructive surgery to in vitro fertilization. However, tubal surgery retains specific advantages, and appropriate preoperative evaluation allows improved selection of patients who are candidates for tubal reconstructive surgery by identifying the patients with good reproductive prognosis. Of pivotal importance in the selection of patients is the intratubal direct evaluation performed at salpingoscopy. Term pregnancy rates of approximately 70% and 65% may be obtained in patients with periadnexal adhesions and bilateral distal tubal occlusion, respectively, when a normal tubal mucosa is observed at salpingoscopy.

Infertility surgery is dead: only the obituary remains?

Despite the multiple advantages of assisted reproductive technology compared with surgery, there remain several diagnoses for which surgery is still widely performed: distal tubal occlusion, regret of permanent sterilization, and endometriosis. Assisted reproductive technology is superior to surgery and should be offered as first-line treatment.

Role of treatment with ovarian stimulation and intrauterine insemination in women with unilateral tubal occlusion diagnosed by hysterosalpingography

To assess the value of controlled ovarian hyperstimulation (COH) and IUI in women with unilateral tubal occlusion diagnosed by hysterosalpingography. Hysterosalpingography (HSG) is the most common screening test for tubal pathology. The management of patients with unilateral tubal occlusion is vague, and studies of treatment results with COH and IUI are scarce. Retrospective, case-controlled study. Referral infertility clinics of a national health service. The study group consisted of 62 consecutive patients treated at our centers for isolated unilateral tubal occlusion by HSG between 1998-2005. In all cases, menstrual cycles were regular, and day-3 FSH levels and sperm counts were normal. The control group consisted of 115 patients with unexplained infertility treated during the same time period. All patients were treated primarily with three consecutive cycles of COH and IUI, with the use of standard protocols of ovarian stimulation with gonadotropins. Data analysis included basic clinical parameters, response to ovarian stimulation, inseminated sperm parameters, and pregnancy rates (PRs). Cumulative PR for three cycles of COH and IUI. There were no between-group differences in basic clinical and sperm parameters. The cumulative PRs after three cycles of COH and IUI were 30.9% for the study group, and 42.6% for the control group. The cumulative PR in women with mid-distal or distal tubal occlusion was lower, but not of greater statistical significance, than in women with proximal tubal occlusion (19% versus 38.2%), and was significantly lower than in women with unexplained infertility (19% versus 42.6%). Controlled ovarian hyperstimulation with IUI should be suggested as the initial treatment of choice in patients with unilateral proximal tubal occlusion. The results are similar to those in patients with unexplained infertility. However, the outcome of COH with IUI is worse in patients with mid-distal or distal tubal occlusion on HSG, who should be referred for laparoscopic assessment or IVF.

Do host genetic traits in the bacterial sensing system play a role in the development of Chlamydia trachomatis-associated tubal pathology in subfertile women?

BackgroundIn women, Chlamydia (C.) trachomatis upper genital tract infection can cause distal tubal damage and occlusion, increasing the risk of tubal factor subfertility and ectopic pregnancy. Variations, like single nucleotide polymorphisms (SNPs), in immunologically important host genes are assumed to play a role in the course and outcome of a C. trachomatis infection. We studied whether genetic traits (carrying multiple SNPs in different genes) in the bacterial sensing system are associated with an aberrant immune response and subsequently with tubal pathology following a C. trachomatis infection. The genes studied all encode for pattern recognition receptors (PRRs) involved in sensing bacterial components.MethodsOf 227 subfertile women, serum was available for C. trachomatis IgG antibody testing and genotyping (common versus rare allele) of the PRR genes TLR9, TLR4, CD14 and CARD15/NOD2. In all women, a laparoscopy was performed to assess the grade of tubal pathology. Tubal pathology was defined as extensive peri-adnexal adhesions and/or distal occlusion of at least one tube.ResultsFollowing a C. trachomatis infection (i.e. C. trachomatis IgG positive), subfertile women carrying two or more SNPs in C. trachomatis PRR genes were at increased risk of tubal pathology compared to women carrying less than two SNPs (73% vs 33% risk). The differences were not statistically significant (P = 0.15), but a trend was observed.ConclusionCarrying multiple SNPs in C. trachomatis PRR genes tends to result in an aberrant immune response and a higher risk of tubal pathology following a C. trachomatis infection. Larger studies are needed to confirm our preliminary findings.

Evidence-based reproductive surgery: tubal infertility

The goal for any infertile couple is to explore all reasonable attempts to achieve pregnancy. The couple with infertility resulting from tubal disease has two therapeutic options to achieve this goal: reconstructive tubal surgery and in vitro fertilization. However, the increasing demand for new techniques of assisted reproduction has called into question the value of the more established methods of treatment for tubal infertility. There are some causes of tubal infertility for which surgery has virtually no chance of success. For these situations, in vitro fertilization is clearly the only therapeutic option. For other situations, the decision-making process requires detailed discussion on the effectiveness, adverse effects and cost of the procedures. Endoscopic evaluation of the tubal mucosa is essential for the selective application of tubal surgery. The available evidence shows that tubal surgery can be as, or more, effective as in vitro fertilization for cases of filmy adhesions, mild distal tubal occlusion and proximal obstruction. It may, however, be reasonable to discuss in vitro fertilization with any couple without pregnancy 12 months after tubal surgery. In women with moderate to severe distal tubal disease, the diminishing success rates from surgery suggest that in vitro fertilization should be considered as the first line of treatment. In the case of unsuccessful reconstructive surgery, or if a hydrosalpinx is irreparably damaged, a salpingectomy prior to in vitro fertilization has to be considered. Tubal surgery has indisputable benefits for the patient if infertility is cured by the intervention. A successful tubal repair gives the patient the possibility of conceiving more than once without further treatment. It also gives the couple the psychological advantage of being able to conceive spontaneously. Probably the most pragmatic viewpoint is to consider reproductive surgery and in vitro fertilization as complementary options that are directed towards increasing the overall probability of achieving a pregnancy in the most efficient manner.

Hysterosalpingokontrastsonographie zur Tubendiagnostik - Kontrolle der Untersuchungsergebnisse durch Laparoskopie - Hysterosalpingo-Contrast Sonography (HyCoSy) for Tubal Diagnostics: Check of the Examination Results by Means of Laparoscopy -

Objective: We studied the agreement between contrast hysterosalpingosonography and laparoscopic chromopertubation for assessing tubal patency. Methods: Contrast hysterosalpingosonography was performed in the initial evaluation of 402 patients with a total of 752 tubes. 124 patients (with a total of 242 tubes) subsequently underwent laparoscopy with chromopertubation. Results: Contrast hysterosalpingosonography indicated tubal patency in 487 (65%) of tubes. 78 of these tubes were pertubated at laparoscopy and 87% were patent. Hysterosalpingosonography indicated occlusion in 265 tubes (35%). 164 of these tubes were pertubated and the diagnosis of occlusion was confirmed in 90 (55%). False negative hysterosalpingosonography findings were more common in tubes with proximal occlusion. Hysterosalpingosonography findings indicating proximal occlusion were confirmed in 23% of tubes, as opposed to 88% for distal occlusion. Conclusion: Contrast hysterosalpingosonography can reliably detect tubal patency and distal tubal occlusion. Hysterosalpingosonography findings suggesting proximal occlusion should be evaluated with chromopertubation.

Spleen laceration, a rare complication of laparoscopy

A 31-year-old woman had secondary infertility of 4 years' duration. Hysterosalpingography revealed bilateral distal tubal occlusion with bilateral hydrosalpinx-like appearance. At laparoscopy, both oviducts were occluded with marked hydropic change. Salpingoplasty was performed to correct bilateral hydrosalpinges and reform the fimbriated tubal ends. The procedure was performed uneventfully by an experienced surgeon in 45 minutes. Nine hours after the operation an emergency exploratory laparotomy was performed due to massive intraabdominal bleeding. The cause was a small tear, 3 cm long and 1 cm deep, with active bleeding in the inferior splenic tail. The laceration was repaired successfully with 1–0 chromic suture. The etiology of splenic laceration during laparoscopic surgery is uncertain. Many complications of laparoscopy are physiologic, and this one might have occurred while establishing pneumoperitoneum. Distortion and stretching of small vascular adhesions of the spleen with the abdominal wall also may have played a role. Gynecologists must be aware of the physiologic insult to patients during laparoscopy.

The prognostic role of salpingoscopy in laparoscopic tubal surgery.

The present study was designed to evaluate the prognostic value of salpingoscopy in patients undergoing tubal laparoscopic surgery for infertility due to periadnexal adhesion or distal tubal occlusion. In addition, the clinical value of salpingoscopy was compared with a current classification system of adnexal adhesions and distal tubal occlusion. A total of 51 patients with either adnexal adhesions (24 patients) or hydrosalpinx (27 patients) were prospectively evaluated. Salpingoscopy was performed concomitantly with salpingo-ovariolysis or salpingoneostomy at the time of operative laparoscopy. There was no significant correlation between salpingoscopic classes and the classification system used for both the salpingo-ovariolysis and the salpingoneostomy groups of patients. The patients had a mean follow-up of 33 months. Patients with a normal tubal mucosa (salpingoscopic classes I and II) had a 71% cumulative term pregnancy rate in the salpingo-ovariolysis group and a 64% cumulative term pregnancy rate in the salpingoneostomy group. No intrauterine pregnancies were obtained in patients with intratubal damage (salpingoscopic classes III to V). There was a statistically significant correlation between the occurrence of a term pregnancy and the salpingoscopic classes, but not with the classification system used. These results suggest that patients with tubal infertility should be offered operative laparoscopy with salpingoscopy as the first step of treatment.

A randomized, prospective, controlled study of laparoscopic dye studies and selective salpingography as diagnostic tests of fallopian tube patency

Objective: To determine and compare the relative merits of laparoscopic dye (LD) studies and selective salpingography (SS) as diagnostic tests of fallopian tube patency. Design: Randomized, prospective, controlled study. Setting: University-associated assisted reproduction unit. Patient(s): Two hundred seventy-eight women undergoing investigation of infertility. Intervention(s): Allocation to the performance of either LD studies followed by SS or SS followed by LD studies conducted sequentially under general anesthesia. Main Outcome Measure(s): Detection of fallopian tube occlusion, including the site of obstruction and evidence of peritubal or pelvic disease. Result(s): When diagnosis was compared by the first test used, 16 (11.9%) of 135 patients had proximal tubal occlusion at LD studies versus 5 (3.6%) of 138 at SS. Twelve (5.6%) of 122 patients had distal tubal occlusion at LD studies versus 14 (10.5%) of 133 at SS. Fifteen (11.1%) of 135 patients had peritubal disease at LD studies versus 3 (2.52%) of 119 at SS. When diagnosis was compared by individual tubes, the results were similar. Among patients who had proximal occlusion and otherwise normal tubes by both methods, endometriosis was present in 72.2%. Conclusion(s): Selective salpingography is a better diagnostic test of proximal tubal occlusion than are LD studies. There is no difference between SS and LD studies as a diagnostic test of distal tubal occlusion. Laparoscopic dye studies are a better diagnostic test for assessing peritubal disease than is SS. There may be an association between endometriosis and proximal tubal occlusion. Selective salpingography and LD studies are complementary investigations of the fallopian tubes.

Tubal surgery vs in vitro fertilization for the treatment of infertility due to distal tubal occlusion

Background: The optimal treatment of infertility due to tubal occlusion has not been established. Many practitioners feel that the success of tubal repair exceeds that of in vitro fertilization (IVF); however, previous studies of pregnancy after tubal surgery have been limited by bias in patient selection, follow-up, or surgical expertise. The purpose of the present study was to determine the outcome after repair of distal tubal occlusion performed by experienced surgeons in an unselected patient population with consistent follow-up. Design: Chart review with telephone contact of patients lost to follow-up. Methods: The records of all tubal surgery performed between 1989 and 1996 at the University of Alabama Hospital and The Kirklin Clinic outpatient surgery facility were reviewed. All women with infertility due to distal tubal occlusion, with or without pelvic adhesions, who had no other significant infertility factors were included for study. Details of the infertility history, operative procedure, and postoperative course were recorded. Patients lost to follow-up within 1 year after surgery were contacted by telephone for information regarding subsequent testing and treatment and pregnancy outcome. Results: Eighty-three women aged 19–39 years met the entry criteria for this study. Follow-up of at least 1 year was obtained in all but 11 patients. Tubal surgery was accomplished by laparotomy in 19 women; 64 women underwent tubal repair by laparoscopy. Within 1 year of surgery, 9 hysterosalpingograms, 51 clomiphene cycles, and 20 gonadotropin cycles were performed on the study group. Pregnancy was achieved within 1 year in 13 women; of these, there were 6 live births (9.6% birth rate per surgery), 2 spontaneous abortions, and 3 ectopic pregnancies. There were no live births among women who underwent tubal repair by laparotomy. None of the postoperative gonadotropin cycles resulted in pregnancy. Seven women underwent IVF within 1 year after surgery because of extensive tubal damage noted at surgery. Based on current charges for the infertility treatments performed, the cost of a live birth with tubal surgery exceeded $120,000, versus less than $50,000 per live birth with IVF using results obtained nationally or at UAB. Conclusions: The cost-effectiveness of reconstructive surgery in unselected patients with distal tubal occlusion is less than that of IVF. Empiric use of gonadotropins for ovarian stimulation does not improve pregnancy rates after tubal surgery. In our series, laparoscopic tubal repair seemed to give results superior to that of laparotomy.

How to use Chlamydia antibody testing in subfertility patients.

Screening for tubal factor subfertility by means of Chlamydia antibody testing (CAT) was introduced into the initial work-up of subfertile couples several years ago. The results reported, however, are heterogeneous, and no uniformity exists in cut-off levels of titres, or in definitions of tubal factor subfertility. We performed a prospective cohort study to evaluate the implications of varying the definitions of tubal pathology and of modifying the cut-off levels on the clinical impact of CAT in predicting tubal factor subfertility. In 227 consecutive patients who attended our fertility clinic, the Chlamydia IgG antibody titre was determined and related to tuboperitoneal abnormalities at laparoscopy as a reference standard. According to received operating characteristic (ROC) curve analysis, a titre of 16 is the optimum cut-off level. Increasing the cut-off level improves specificity and positive likelihood ratio (LR+), at the expense of sensitivity and negative LR (LR-). Changing the definition of tubal factor subfertility from unspecified tuboperitoneal abnormalities into extensive adhesions and/or bilateral distal tubal occlusion improves LR+, LR- and kappa significantly. We conclude that CAT is more accurate in predicting severe distal tubal pathology than unspecified tuboperitoneal abnormalities. Although from a statistical point of view a titre of 16 is the optimum cut-off level, from a clinical point of view 32 or 64 may be preferable, depending on the aim of screening and the inception cohort.

Antibodies to the chlamydial 60 kilodalton heat shock protein in women with tubal factor infertility.

INTRODUCTION: Fallopian tube damage and subsequent infertility are common sequelae of upper genital tract infection with Chlamydia trachomatis. This fallopian tube damage is thought to be immune mediated. The 60 kilodalton chlamydial heat shock protein (hsp) may be the key antigen associated with this pathogenic response. Our objective was to study the relationship between antibody response to 60 kilodalton chlamydial hsp and tubal factor infertility (TFI). SUBJECTS AND METHODS: Twenty-three women with TFI and 33 women with male factor infertility (controls) were studied. Tubal factor infertility was defined as infertility for one year with hydrosalpinx or distal tubal occlusion. Patients' sera were tested for antibodies to the chlamydial hsp using an enzyme-linked immunosorbent assay (ELISA). A stepwise logistic regression was performed by each patient's age, race/ethnicity, self-reported history of chlamydia infection, gonorrhea, or pelvic inflammatory disease (PID), history of ectopic pregnancy, and antibodies to the chlamydial hsp. RESULTS: Eighteen of the 23 women with TFI had a positive result on the hsp ELISA (78.6%) versus 23.4% of controls. Risk factors for TFI were a history of PID (P = 0.022), "nonwhite" race (P = 0.004), history of ectopic pregnancy (P = 0.027), and antibodies to the 60 kilodalton chlamydial hsp (P < 0.001). CONCLUSIONS: Antibodies to 60 kilodalton chlamydial hsp are strongly associated with TFI.

Antibodies to the Chlamydial 60 Kilodalton Heat Shock Protein in Women With Tubal Factor Infertility

Introduction:Fallopian tube damage and subsequent infertility are common sequelae of upper genital tract infection withChlamydia trachomatis. This fallopian tube damage is thought to be immune mediated. The 60 kilodalton chlamydial heat shock protein (hsp) may be the key antigen associated with this pathogenic response. Our objective was to study the relationship between antibody response to 60 kilodalton chlamydial hsp and tubal factor infertility (TFI).Subjects and Methods:Twenty-three women with TFI and 33 women with male factor infertility (controls) were studied. Tubal factor infertility was defined as infertility for one year with hydrosalpinx or distal tubal occlusion. Patients’ sera were tested for antibodies to the chlamydial hsp using an enzyme-linked immunosorbent assay (ELISA). A stepwise logistic regression was performed by each patient’s age, race/ethnicity, self-reported history of chlamydia infection, gonorrhea, or pelvic inflammatory disease (PID), history of ectopic pregnancy, and antibodies to the chlamydial hsp.Results:Eighteen of the 23 women with TFI had a positive result on the hsp ELISA (78.6%) versus 23.4% of controls. Risk factors for TFI were a history of PID (P= 0.022), “nonwhite” race (P= 0.004), history of ectopic pregnancy (P = 0.027), and antibodies to the 60 kilodalton chlamydial hsp (P&lt; 0.001).Conclusions:Antibodies to 60 kilodalton chlamydial hsp are strongly associated with TFI.

The prognostic value of salpingoscopy.

Salpingoscopy enables the visual inspection of the ampullary mucosa during either laparotomy or laparoscopy. This prospective study correlates the salpingoscopic results with the postoperative pregnancy rates and evaluates the value of salpingoscopy against already existing classification systems. A total of 226 women diagnosed as having pelvic inflammatory disease were treated by microsurgery. There were no other causes of infertility in these patients. The collective was divided into patients with pure adhesive disease and those with supplementary distal tubal occlusion. Salpingoscopy was performed at the end of a microsurgical laparotomy. All laparotomies were performed between 1989 and 1992. The occurrence of pregnancy was checked after 42 months follow-up. A correlation between salpingoscopy and the American Fertility Society classification for each tube is discussed. The crude and cumulative intrauterine pregnancy rates are reported for the two patient groups.