Salpingoscopy in tubal endometriosis

A 35-year-old woman underwent diagnostic laparoscopy for primary infertility of 3-year duration, without associated pain symptoms. No ovulatory or male factors of infertility were present. She had previously undergone hysterosalpingography, which had revealed bilateral tubal patency 18 months before laparoscopy.

Laparoscopy revealed endometriosis implants on the right tube, with mild peritoneal scarring (Fig. 1). Both tubes were readily patent at blue dye injection. Minimal peritoneal endometriosis was present on the ipsilateral posterior leaf of the broad ligament and on the ipsilateral ovary.

Fig. 1

Endometriosis implants on the tubal serosa as seen at laparoscopy

The surgeon faced the decision whether to treat or not the implants visible on the tubal serosa. If, on one side, there is sound scientific evidence that the peritoneal endometriosis implants should be treated [1], the treatment of tubal implants on the other side is not clear cut, being this a rare occurrence. Surgical treatment of implants on the tubal serosa, either by excision or ablation, may in fact carry the risk of creating additional scarring and retraction.

The surgeon decided to perform intraoperative salpingoscopy, with a 2.9-mm diagnostic hysteroscope and a 3.7-mm single-flow diagnostic sheath introduced through an accessory port. Salpingoscopy is still routinely used in our departments in case of tubal disease, despite the fact that it is not generally included in the evaluation of the infertile couple elsewhere [2]. Lately, we have been using a small-caliber hysteroscope, as in this case, instead of the original instrumentation for salpingoscopy [3], since it is more readily available and does not need dedicated instruments. The endoscopic evaluation of the tube (Fig. 2) revealed a normal tubal mucosa (class 1 according to Brosens' classification [3]), no evidence of endometriosis in the tubal mucosa, and no evidence of stenosis of the tubal wall. It was, therefore, decided to leave the tubal endometriosis untreated.

Fig. 2

Salpingoscopy with visualization of the tubal mucosa at the level of the serosal endometriosis revealed no intraluminal disease

Three months after surgery, the patient spontaneously conceived an intrauterine pregnancy.