The Interest of Endoscopy in the Diagnosis of Fallopian Tubes Diseases at the Yaoundé Gyneco-Obstetric and Pediatric Hospital (Ygoph) ()
Abstract
Introduction: Fallopian diseases are often implicated in female infertility. Several
radiological and surgical explorations have been proposed in order to evaluate
the severity of lesions found in utero-adnexal pathology. Among tools that are
used to investigate such pathologies, we have ultrasound, hysterosalpingography
and endoscopy.
But, in many developing countries like Cameroon, the usage of endoscopy in
gynecology is not yet known by many practicians. The objective of our study was
to show the interest of endoscopy in the diagnosis of fallopian tube
pathologies. Methodology: We conducted a cross-sectional and descriptive study from March 1st,
2017 to May 31st, 2017 at the Gyneco-Obstetrics and Pediatric
department of our Hospital. We included all women who presented infertility and
underwent ultrasound, hysterosalpingography (HSG) and endoscopy at the Yaoundé
Gyneco-obstetrics Hospital. We analyzed epidemiological parameters, clinics,
ultrasound, hysterosalpingography and
endoscopic finding. We used Cohen’s Kappa test to determine the
correlation between HSG/endoscopy and ultrasound/endoscopy in the diagnosis of fallopian tube pathologies. The threshold was
significant for a K-value > 0.20. Results: We got a sample of 156
women; the mean age was 32.6 ± 4.5 years. The Secondary
infertility dominated in 66.7% of cases; 31.1% of women presented a past medical history of sexually transmitted infections and
41.7% did abortions before. Endoscopic lesions were dominated by a fallopian obstruction in
54.5% of cases, 8.3% of adhesions, 33.9% of women presented uterine myomas, 37.8% of ovarian
cysts and 1.3% of pelvic endometriosis. The K-values
between HSG and endoscopy for distal and proximal tube obstructions were
significant with respective thresholds of 0.25 and 0.30. The K-value between
ultrasound and endoscopy was not significant with a threshold of 0.015 for the
tubal hydrosalpinx. Conclusion: Endoscopy assessment appears as the most
efficient tool to investigate fallopian tube diseases.
1. Introduction
Fallopian tube diseases have a great responsibility in the development of female infertility. Many tools are used to investigate these pathologies such as ultrasound, hysterosalpingography and endoscopy. Out of interventional proposes in surgery, endoscopy is a new technology that is also used for diagnostic investigations. It allows direct visualization of tissues and appears less invasive than other radiologic assessments. Current authors are considering endoscopy as the “gold standard” to explore gynecologic roots [1] . Since the 20th century, endoscopy has been used in Europe and US for explorations and interventions in urology, gynecology gastroenterology and ENT. This new technology is gradually imported towards developing countries. In Sub-Saharan Africa, the implementation of endoscopy in the practice is in process. Some countries like Cameroon introduced endoscopy in 1992, Senegal in 1995 and Côte d’Ivoire in 1999 [2] . But, many gynecologists have not yet added endoscopic explorations to their practice. This may be due to their ignorance or the lack of equipment. We have been motivated to conduct this study that aimed to demonstrate the interest of endoscopy in the diagnosis of fallopian tube diseases at the Yaoundé Gyneco-Obstetrics and Pediatrics Hospital (YGOPH) compared to HSG and ultrasound.
2. Patients and Method
This study has been approved by the Ethical Committee of the Yaoundé Gyneco-Obstetric and Pediatrics Hospital where the research has been conducted. The method was carried out in accordance with relevant guidelines and regulations. An informed consent was obtained from each patient that we followed prospectively for participation in the study. We conducted consecutive and exhaustive sampling. Thus, any patient followed at YGOPH during the study period and meeting our inclusion criteria was recruited. We conducted a 3 month cross-sectional and descriptive study from March 1st, 2017 to May 31st, 2017 at the Yaoundé Gyneco-Obstetrics and Pediatric Department of the YGOPH. We studied the period of January 1st, 2004 to December 31st, 2016 and we included all women who presented infertility and underwent ultrasound, HSG and endoscopy at the YGOPH. Gynecologic ultrasound was performed by abdominal or vaginal root. We used ultrasound from 3.5 to 9 MHz, and a classic HSG was realized. We used a 4F or 5F catheter to flow the contrast agent inside fallopian tubes and an X-ray film was realized to appreciate the vacuity of fallopian tubes. Laparoscopy was performed with a rigid endoscope for a trans-uterine visualization of fallopian tubes and other adnexia of the uterus. Data were collected from patient files where we retrieved US, HSG and post operative reports. The information collected were the age of patients, gynecologic and surgical past medical history, US, HSG and endoscopic findings with a type of surgery realized. The Cohen’s Kappa test was used to determine the correlation between HSG/endoscopy and ultrasound/endoscopy in the diagnosis of fallopian tube pathologies. The threshold was significant for a K-value > 0.20. Data were analyzed with SPSS version 21.0, Epi info version 5.1, and Microsoft Excel 2010.
3. Results
156 women met inclusion criteria in our study. The mean age was 32.6 ± 4.9 years with extremities between 21 and 46 years. The modal group was represented by women aged between 30 and 35 years (Table 1). The past medical history of voluntary interruption of pregnancy was found in 41.7% of cases. 32.1% of patients suffered from sexually transmitted infections and were recognized to have unprotected sexual intercourses. In addition, 7.1% of women presented myomas and 1.3% ovarian cysts. 7.1% of women underwent myomectomy before; 3.8% underwent salpingectomy and 3.2% tubal plastic surgery indicated for ectopic pregnancy (Table 2). HSG assessment revealed 29.8% of bilateral distal tubal obstructions, 16% of bilateral proximal tubal obstructions, 10.9% of unilateral distal tubal obstructions, and 20.5% of unilateral proximal tubal obstructions (Table 3).
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Table 1. Distribution of women according to socio-demographic characteristics N = 156.
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Table 2. Distribution of women according to the results of the anamnesis N = 156.
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Table 3. Distribution of women according to the level of tubal obstruction (TO) N = 156.
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Table 4. Distribution of women according to lesions found on ultrasound N = 62.
Uterine myomas were found in 17.3% cases with ultrasound examination (Table 4). Endososcopic explorarations found myomas in 33.9% cases, 37.8% of corpus luteum cysts and Hydrosalpinx associated to tubal adhesions were diagnosed in 58.3% of patients (Table 5). The Cohen’s Kappa test for the correlation between HSG and laparoscopy was significant with a value of 0.36 for tubal obstructions (Table 6) and the correlation between ultrasound and endoscopy was no significant with a value of 0.015 for hydrosalpinx (Table 7) [3] [4] [5] .
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Table 5. Distribution of women according to the different lesions observed on endoscopy N = 156.
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Table 6. Correlation between hysterosalpingography and endoscopy in tubal obstructions (OT) in general.
HSG*: hysterosalpingography.
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Table 7. Correlation between ultrasound and laparoscopy in hydrosalpinx.
4. Discussion
The mean age of our sample was 32.63 ± 4.92 years with a modal group ranged between 30 and 35 years. Mboudou et al. found a similar result in a study conducted at the YGOPH that presented a mean age of 31.8 ± 4.9 years [6] . Mehdi Kehila et al. conducted another study in Tunis and presented a mean age of 35.3 years [7] . This can be explained by the delay engagement in a couple’s life due to socio-economic conditions where women are interested by long studies first before marriage. Many studies reported sexually transmitted infections and voluntary interruption of pregnancy as major risk factors of infertility [8] [9] . Belley Priso et al. showed that 65% of women who consult for infertility have a past medical history of chlamydia trachomatis infection [10] . In a study conducted by Tshabu agumon et al. in Benin in 2014, he reported that many patients presenting infertility underwent pelvic surgery for myomectomy [11] . A similar result has been found in our study. In 2013, Mboudou et al. found ectopic pregnancy as a major risk factor of infertility in a cohort of patients where the majority underwent surgery for abnormal location of the fetus [6] . So myomectomy, voluntary interruption of pregnancy and sexually transmitted diseases lead to adherence which will cause fallopian tube obstruction and results to infertility [11] . Fallopian obstructions appear as the main lesion observed in our patients. It has been diagnosed in 79.3% with HSG and 54.50% with Endoscopy. Ultrasound was less sensitive for tubal obstruction detection in our sample. But with endoscopy we diagnosed 1.3% of endometriosis and 1.9% of ampullary masses. Endoscopy appears more specific than HSG. In a series of 120 patients Medhi Kehila et al. found endometriosis in 7% of cases and fallopian tube obstructions in 20% of women with endoscopy [8] . This difference can be explained by the size of his series which was less than ours. Out of diagnostic proposes, endoscopy has been used for adhesiolysis in 85.3% of cases. We also performed tubal fimbrioplasty and neosalpingostomy respectively in 15.4% and 63.5% of cases using endoscopy. A few years before in the same town, current authors used endoscopy for intervention proposes in gynecology. In a series presented by Mboudou et al. in 2013, he performed tubal adhesiolysis in 71.6% of cases [6] . Kasia et al. performed tubal adhesiolysis in 73.9% of women who consult for infertility. He realized fimbrioplasty and neosalpingostomy respectively in 46% and 56% of cases. This difference can be explained by the big size in their series respectively 415 and 402. We did the Cohen’s kappa test and the correlation between HSG and endoscopy for tubal obstruction in general was 0.36. This result is sensitive and similar to what Mehdi et al. reported in his series that was 0.42 [8] . Our study presented a good correlation between HSG and endoscopy in the detection of proximal tubal obstructions with a Cohen’s Kappa sensitivity of 0.30. Mehdi Kehila et al. reported also a significant K-value of 0.48 [8] . The treatment of tubal obstructions is well managed with endoscopy and several techniques have been presented by many authors in the previous literature in order to limit sollicitation of IVF for patients who consult for infertility [12] [13] [14] . Furthermore, no correlation was found between ultrasound and endoscopy for hydrosalpinx in our study. The relationship between hydrosalpinx and female infertility is well accepted with a fairly high prevalence in our study. Although ultrasound is mainly used to diagnose adnexial masses such as ovarian cysts, we have been using also for tubal permeability nevertheless it is not specific [15] . In total, we diagnosed (2.5%) of lesions. For hydrosalpinx, a non-significant correlation between ultrasound and endoscopy has been found in our study and the K-value was 0.015. This study was limited by the sample size that was short compared to other studies. The studied period was also short and we did not do a post operative follow-up of patients to present a short term results of endoscopy usage.
5. Conclusion
Endoscopy appears as the most efficient tool to diagnose and treat fallopian tube diseases. Although many gynecologists still lack experience in endoscopy usage in our country, they may either refer patients who consult for infertility to a reference hospital for better management or look for training to improve their skills in endoscopy.