Pednekar R*, Parulekar SV(* Assistant Professor, **Professor and Head, Department of Obstetrics and Gynecology, Seth G. S. Medical College and KEM Hospital, Mumbai, India.)
This is an interesting finding where we came across a fallopian tube going and adhering to the other side’s fallopian tube in such a way that the loop so formed is like a “skipping rope” moving anterior and posterior to the uterine fundus. This is the first case of this type in the world literature.
Infertility due to fallopian tubal adhesions may be due to pelvic inflammatory disease, past pelvic surgery or endometriosis. The fallopian tubes may be adherent to adjacent structures like the ovaries, broad ligament, uterus, bowel and/or omentum. Adhesion of one fallopian tube to the other forming a skipping-rope-like structure has not been described in the literature so far. We present such a case in which the two tubes were adherent to each other to form a half loop that could be swung to the back and front of the uterus freely.
A 33 years old woman, married for 9 yeas, para 1, death 1 with no living issue, presented to us for reversal of interval tubal ligation done 6 years ago. Her menstrual cycles were regular, every 28- days, with bleeding for 3-4 days. She had a normal delivery 8 years ago, and an interval sterilization operation done by minilaparotomy 4 years ago. Baby died at 7 years of age , 1 yr back due to jaundice. Details of the operation were not available. There was no significant medical or surgical illness in the past. There was no history suggestive of pelvic inflammatory disease or tuberculosis. There were no bowel or bladder complaints. She had a normal vaginal delivery at home 8 yrs back. On examination her vital parameters were normal. General and systemic examination revealed no abnormality. Abdominal examination showed a 2 cm long suprapubic vertical midline scar. There was no tenderness, guarding or rigidity. Per speculum examination was normal. Per vaginally uterus was found to be of normal size, anteverted, smooth, firm, mobile, non-tender. Bilateral fornices were free. Reports of investigations for fitness for anesthesia were normal. Her husband’s semen analysis was normal. Her pelvic ultrasonography revealed no abnormality. Her hysterosalpingography showed partial opacification of both the fallopian tubes with intravasation of contrast, suggestive of bilateral midsegment tubal block.
Figure 1. Hysterosalpingography. Site of tubal blocks (yellow arrows), intravasation of the dye (pink arrows).
A laparoscopy was performed, with a plan to perform a tubal reconstruction surgey if the fallopian tubes were found to be salvageable. The uterus and both the ovaries were found to be normal. The left fallopian tube showed a small hydrosalpinx, the lateral part of that tube being adherent to bowel. The right fallopian tube was found adherent to the medial third of left fallopian tube by its fimbrial end and the loop so formed was freely mobile over the uterine fundus. Actually it was found to be in the uterovesical pouch of peritoneum when the laparoscope was inserted into the peritoneal cavity and the uterus was anterverted with a uterine manipulator inserted into the uterocervical canal. It could be moved freely anteriorly and posteriorly. There were minimal omental adhesions to the side wall. No other significant finding noted.
Figure 2. Laparoscopy findings: site of adhesion of the right fallopian tubal fimbriae to the left fallopian tube (arrow).
Figure 3. Laparoscopy findings: loop formed by adherent fallopian tubes (arrows).
With these findings, the decision of tubal recanalization was abandoned as left fallopian tube had mild hydrosalpinx with fimbrial adhesions to bowel and the fimbria of right fallopian tube was damaged too due to adhesions to other tube thus leading to poor prognosis for pregnancy in the future, had the recanalization and repair been attempted. Only the fimbria of the right fallopian tube was separated from left tube with the help of bipolar electrocautery and scissors to release the loop. The patient made an uneventful recovery. She was counseled to undergo in vitro fertilization and embryo transfer.
Fallopian tube is around 8 to 14 cm long tubular structure extending from uterine cornu, one on each side, into the broad ligament, which is then called mesosalpinx. The fallopian tube is divided into an interstitial portion, isthmus, ampulla, infundibulum and fimbrial extremity. Congenital fusion of fimbrial ends is not possible as the development of fallopian tubes is from paramesonephric ducts which fuse medially in the pelvis to form the uterus, whereas the lateral free portions develop into fallopian tubes. Therefore the fusion of fimbrial region to each other has to be acquired secondary to either previous surgery, pelvic inflammatory disorder or endometriosis.[1,2,3] Endometriosis has been described to cause adhesion of the ovaries to each other behind the uterine corpus. There is no description of adhesion of the fallopian tubes to form a skipping-rope-like structure in the literature, due either to endometriosis or any other cause. In our case the patient had no signs and symptoms or examination and operative findings which would suggest either pelvic inflammatory disease or endometriosis. She only had prior interval tubal ligation by open method which is the only inciting factor leading to such type of adhesions and owing to the longer length of the tube which had given rise to “a skipping rope” type of loop with that much mobility; which, we thought, was interesting to note. A tubal reconstructive surgery was not done in view of extensive tubal damage, including formation of hydrosalpinx, loss of fimbriae.[5,6,7,8] We released the right fallopian tube from the left one surgically so as to prevent internal herniation and intestinal obstruction in future.
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- Yoon TK, Sung HR, Kang HG, et al. Laparoscopic tubal anastomosis: fertility outcome in 202 cases. Fertil Steril. 1999;72:1121–1126.
Pednekar R, Parulekar SV. “Skipping” Fallopian Tube - An Interesting Finding! JPGO 2017. Volume 4 No. 5. Available from: http://www.jpgo.org/2017/05/skipping-fallopian-tube-interesting.html