The Interest of Endoscopy in the Diagnosis of Fallopian Tubes Diseases at the Yaoundé Gyneco-Obstetric and Pediatric Hospital (Ygoph)

Introduction: Fallopian diseases are often implicated in female infertility. Several radiological and surgical explorations have been proposed in order to evaluate the severit y of lesions found in utero -adnexal pathology. Among tools that are used to investigate such pathologies, we have ultrasound, hy s- terosalpingography 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, hysterosalpin- gography (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 correla- tion between HSG/endoscopy and ultrasound/endosco py in the diagnosis of fallopian tube pathologies. The threshold was significant for a K -value > 0.20.

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 pr e- sented a past medical history of sexual ly transmitted infections and 41.7% did abortions before. Endoscopic lesions were dominated by a fallopian obstruc- How to cite this paper: Abega, C.L., Noa Ndoua, C.C., Kouna Tsala, I.N., Fonkou, A., Ngono Ateba, G., Ntsobe, T.E., Fouda, J.C., Mafoma, R. and Foumane, P. (2023) The Interest of Endoscopy in the Diagnosis of Fallopian Tubes Diseases at the Yaoundé Gyneco-Obstetric and Pediatric Hospital (Ygoph). Open Journal of Obstetrics and Gynecology, 13, 767-774. https://doi.org/10.4236/ojog.2023.134065 Received: March 9, 2023 Accepted: April 25, 2023 Published: April 28, 2023 Copyright © 2023 by author(s) and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/ Open Access C. L. Abega et al. DOI: 10.4236/ojog.2023.134065 768 Open Journal of Obstetrics and Gynecology tion in 54.5% of cases, 8.3% of adhesions, 33.9% of women prese nted uterine myomas, 37.8% of ovarian cysts and 1.3% of pelvic endometriosis. The K-values between HSG and endoscopy for distal and prox imal 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.

Fallopian Tube, Endoscopy, Hysterosalpingography, Ultrasound 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 ultr a- sound, hysterosalpingography and endoscopy. Out of interventional proposes in surgery, endoscopy is a new technology that is also used for diagnostic i nvestiga- tions. 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, g y- necology gastroenterology and ENT. This new technology is gradually impo rted towards developing countries. In Sub -Saharan Africa, the implementation of endoscopy in the practice is in process. Some countries like Cameroon intr o- duced 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 moti- vated 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 Pe- diatrics Hospital (YGOPH) compared to HSG and ultrasound. 2. Patients and Method This study has been approved by the E thical Committee of the Yaoundé Gyne- co-Obstetric and Pediatrics Hospital where the research has been conducted. The method was carried out in accordance with relevant guidelines and regul a- tions. An informed consent was obtained fr om each patient that we followed prospectively for participation in the study. We co nducted consecutive and e x- haustive sampling. Thus, any patient followed at YGOPH during the study p e- riod and meeting our inclusion criteria was recruited. We conducted a 3 month cross-sectional and descriptive study from March 1 st, 2017 to May 31 st, 2017 at the Yaoundé Gyneco-Obstetrics and Pediatric Department of the YGOPH. We studied the period of January 1 st, 2004 to December 31 st, 2016 and we included all women who presented infertility and underwent ultrasound, HSG and e n- C. L. Abega et al. DOI: 10.4236/ojog.2023.134065 769 Open Journal of Obstetrics and Gynecology doscopy at the YGOPH. Gynecologic ultrasound was performed by abdominal or vaginal root. We used ultrasound fr om 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 visualiza- tion 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 info r- mation 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 v o- luntary interruption of pregnancy was found in 41.7% of cases. 32.1% of patients suffered from sexually transmitted infections and were recognized to have u n- protected sexual intercourses. In additio n, 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 dis- tal tubal obstructions, and 20.5% of unilateral proximal tubal obstructions (Table 3). Table 1. Distribution of women according to socio-demographic characteristics N = 156. Variables Effective Percentage (%) Age groups (years) <25 8 5.1 [25 - 30[ 32 20.5 [30 - 35[ 60 38.5 [35 - 40[ 46 29.5 [40 and +[ 10 6.4 Marital status Bride 90 57.7 Bachelor 66 42.3 Occupation Private sector 16 10.3 Public sector 37 23.7 Small trades 92 59.0 Student 10 6.4 Household 1 0.6 C. L. Abega et al. DOI: 10.4236/ojog.2023.134065 770 Open Journal of Obstetrics and Gynecology Table 2. Distribution of women according to the results of the anamnesis N = 156. Variables Effective Percentage (%) Gynecological history Abortion 65 41.7 sexually transmitted infection 50 32.1 Past history of dysmenorrhea 37 23.7 Dyspareunia 36 23.1 Tubo ovarian abscess 2 1.3 Gynecological pathologies Myomas 11 7.1 Surgical history Ovarian cysts 2 1.3 Myomectomy 11 7.1 Salpingectomy 6 3.8 tubal plastic surgery 5 3.2 caesarean section 3 1.9 Cystectomy 1 0.6 Appendectomy 6 3.8 Table 3. Distribution of women according to the level of tubal obstruction (TO) N = 156. Observed lesions Effective Percentage(%) Bilateral Distal TO 47 29.8 Unilateral Proximal TO 32 20.5 Bilateral Proximal TO 25 16.0 Unilateral Distal TO 22 10.9 Isthmic TO 3 1.9 Table 4. Distribution of women according to lesions found on ultrasound N = 62. Variables Effective Percentage (%) Uterine myomas 27 17.3 Ovarian cysts 19 12.2 Ovarian dystrophy 9 5.8 Chronic adnexitis 3 1.9 Hydrosalpinx 4 2.5 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 laparoscop y was significant with a value of 0.36 for tubal obstructions (Table 6 ) and the correlation between ultrasound and endoscopy was no signif- icant with a value of 0.015 for hydrosalpinx (Table 7 ) [3] [4] [5]. C. L. Abega et al. DOI: 10.4236/ojog.2023.134065 771 Open Journal of Obstetrics and Gynecology Table 5. Distribution of women according to the different lesions observed on endoscopy N = 156. Variables Effective Percentage (%) Uterine lesions Myomas 53 33.9 Ovarian lesions Ovarian cysts 59 37.8 Adhesions 28 17.9 Ovarian dystrophy 11 7.1 Unvisualized ovaries 2 1.3 Pyo ovary 1 0.6 Tubal lesions Distal tubal obstructions 32 20.5 Tubal adhesions 91 58.3 Proximal tubal obstructions 53 34.0 ampullary mass 3 1.9 Endometrial lesions Endometriosis 2 1.3 Table 6. Correlation between hysterosalpingography and endoscopy in tubal obstructions (OT) in general. Laparoscopy Total Kappa P-value Yes No HSG* Yes 46 (29.5%) 61 (39.1%) 107 (68.6%) 0.360 0.000 No 7 (4.5%) 42 (26.9%) 49 (31.4%) Total 53 (34.0%) 103 (66.0%) 156 (100.0%) HSG*: hysterosalpingography. Table 7. Correlation between ultrasound and laparoscopy in hydrosalpinx. endoscopy Total Kappa P-value Yes No Ultrasound Yes 3 (1.9%) 3 (1.9%) 6 (3.9%) 0.015 0.554 No 93 (59.6%) 57 (36.5%) 150 (96.1%) Total 96(61.5%) 60 (38.4%) 156 (100.0%) 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 co n- ducted 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 b e- fore marriage. Many studies reported sexual ly transmitted infections and volu n- C. L. Abega et al. DOI: 10.4236/ojog.2023.134065 772 Open Journal of Obstetrics and Gynecology tary interruption of pregnanc y 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 present- ing infertility unde rwent 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 u n- derwent surgery for abnormal location of the fetus [6]. So myomectomy, volu n- tary inter ruption of pregnancy and sexual ly transmitted diseases lead to adh e- rence 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 endos- copy we diagnosed 1.3% of endometriosis and 1.9% of ampullary masses. E n- doscopy appears more specific than HSG. In a series of 120 patients Medhi K e- hila 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, e ndoscopy has been used for adhesiolysis in 85.3% of cases. We also performed tubal fimbrio p- lasty and neosalpingostomy respectively in 15.4% and 63.5% of cases using e n- doscopy. 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. per- formed tubal adhesiolysis in 73.9% of women who consult for infertility. He re a- lized fimbrioplasty and neosalpi ngostomy 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 Ke- hila et al. reported also a significant K -value of 0.48 [8]. The treatment of tubal obstructions is well managed with endosco py and several techniques have been presented by many authors in the previous literature in order to limit sollicita- tion 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 in fertility 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 perm eability nevertheless it is not specific [15]. In total, we diagnosed (2.5%) of lesions. For hydrosalpinx, a non -significant correlation between ultr a- sound 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 st u- dies. The stu died period was also short and we did not do a post operative fo l- C. L. Abega et al. DOI: 10.4236/ojog.2023.134065 773 Open Journal of Obstetrics and Gynecology low-up of patients to present a short term results of endoscopy usage. 5. Conclusion Endoscopy appears as the mo st 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 w ho consult for infertility to a re f- erence hospital for better management o r look for training to improve their skills in endoscopy. Conflicts of Interest The authors declare no conflicts of interest regarding the publication of this p a- per.

[1] Zorom, B. (1999) Hysterosalpingography and Utero -Adnexal Pathology at the S a- nou Souro National Hospital in Bobo Dioulasso (CHNSS): About 408 Cases Col- lected in One Year. Doctoral Thesis, Ouagadougou University, Ouagadougou. [2] Pallas, G., Simon, F., Chapuis, O. and Jancovici, R. (2000) Inguinal Hernia in Africa and Laparoscopy: Utopia or Realism? Medecine Tropicale: Revue du Corps de sante colonial, 60, 3893-3894. [3] Kharmach, M. (2005) GEU and Interest of Diagnostic Laparoscopy. Series of 418 Cases of Clinical Suspicion of EP. Médecine du Maghreb, 124, 32-34. [4] Takacs, P . and Chakhtoura, N. (2006) Laparotomy to Laparoscopy: Changing Trends in the Surgical Management of Ectopic Pregnancy in a Tertiary Care Teaching Hospital. Journal of Minimally Invasive Gynecology, 13, 175-177. https://doi.org/10.1016/j.jmig.2006.01.007 [5] Marret, H., Tranquart, F., Sauget, S. and Lansac, J. (2003) Contribution of Doppler to the Diagnosis of Ovarian Tumours. Indications, Relevance of Diagnostic Criteria. Journal de Radiologie, 84, 1725-1731. [6] Mboudou, E., Foumane, P., Morfaw, F., Ze Minkande, J., Sama, D.J. and Mbatsogo, B.A.E. (2013) Female Infertility and Laparoscop ic Surgery: A Series of 415 Oper a- tions at the Yaoundé Gyneco Obstetric and Pediatric Hospital, Cameroon. Open Journal of Obstetrics and Gynecology, 3, 663-667. https://doi.org/10.4236/ojog.2013.39121 [7] Ngowa, J.D.K., Kasia, J.M., Georges, N.-T., Nkongo, V., Sone, C. and Fongang, E. (2015) Comparison of Hysterosalpingograms with Laparoscopy in the Diagnosis of Tubal Factor of Female Infertility at the Yaoundé General Hospital, Cameroon. The Pan African Medical Journal, 22, Article 264. https://doi.org/10.11604/pamj.2015.22.264.8028 [8] Kehila, M., Ben Hmid , R., Ben Khedher , S., Mahjoub, S. and Channoufi, M.B. (2014) Concordance and Contributions of Hysterosalpingography and Laparoscopy in Exploration of Pelvic and Tubal Infertility. The Pan African Medical Journal, 17, Article 126. https://doi.org/10.11604/pamj.2014.17.126.3567 [9] Kasia, J.M., Ngowa, J.D.K., Mimboe, Y.S., Ngassam, A., Noa, C.C., et al. (2016) La- paroscopic Fimbrioplasty and Neosalpingostomy in Female Infertility: A Review of 402 Cases at the Gynecological Endoscopic Surgery and Human Reproductive Teach- ing Hospital in Yaoundé-Cameroon. Journal of Reproduction & Infertility, 17, 104-109. C. L. Abega et al. DOI: 10.4236/ojog.2023.134065 774 Open Journal of Obstetrics and Gynecology [10] Nzintcheu, J., Foumane, P., Mboudou, E., Nana, P., Fomulu, J. and Doh, A. (2012) Percoelioscopic Discovery of Perihepatitis for Female Infertility at the Gyne- co-Obstetrics and Pediatrics Hospital of Yaoundé: Prevalence and Correlation with Tubo-Pelvic Lesions. Clinics in Mother and Child Health, 9. [11] Priso, E.B., Njamen, N.T., Imandy, G., Okalla, C., Obenchenti, T.E. and Doh, A.S. (2010) The Urgency of Sensitization on Genital Chlamydia Trachomatis Infections in Cameroon. Health Sciences and Disease, 11. http://hsd-fmsb.org/index.php/hsd/article/view/14 [12] Tshabu-aguemon, C., Ogoudjobi , M., Obossou , A., King , V., Takpara , I. and Ali- honou, E. (2014) Hysterosalpingography and Laparoscopy in Tubal Exploration in Infertility in Cotonou, Benin. Journal of West African College of Surgeons, 4, 66-75. [13] Khaled B .S. (2009) Ultrasonographic, Laparoscopic and Pathological Anatomo Confrontation— About 100 Cases. Tunisie Medicale, 87, 516. [14] Lavy, Y., Lev-Sagie, A., Holtzer, H. and Revel, A. (2004) Should Laparoscopy Be a Mandatory Component of the Infertility Evaluation in Infertile Women with Normal Hysterosalpingogram or Suspected Unilateral Distal Tubal Pathology? European Journal of Obstetrics & Gynecology and Reproductive Biology, 114, 64-68. https://doi.org/10.1016/j.ejogrb.2003.09.035 [15] Canis, M., Mage, G., Pouly, J.L. and Manhes, H. (1991) Laparoscopic Distal Tubop- lasty: Report of 87 Cases and a 4-Year Experience. Fertility and Sterility, 56, 616-621. https://doi.org/10.1016/S0015-0282(16)54589-0