Is there a place in infertility practice for the use of oil‐based tubal flushing?

Abstract

In the management of the sub-fertile couple the objective is to assist them in conceiving with the least amount of medical intervention possible using an efficacious treatment. Often this is achieved by simple lifestyle measures, and potentially education on the most fertile time of the menstrual cycle to attempt to conceive. However, in the current environment of couples postponing the initiation of starting a family until later in life, and certainly for couples compromised by impaired semen parameters or fallopian tube obstruction, there is increasing recourse to assisted reproductive technologies. Indeed, it is believed that currently 1 in 25 children born in Australia result from in-vitro fertilisation procedures.1 According to the most recent report of assisted reproductive technologies by the Australian National Perinatal Epidemiology and Statistics Unit, of IVF procedures performed in 2011 within Australia and New Zealand this resulted in the birth of 12,443 babies, with the enviable record of only 6.9% of births being multiples.2 Reproductive medicine is an exciting and rapidly evolving field where physicians and scientists are working synergistically to improve the chance of a couple conceiving and ultimately delivering a healthy term singleton. To this aim, the recent innovations in the field of embryology of optimising the chance of choosing the best embryo for transfer into the uterus with pre-implantation genetic screening, the process of complete genomic hybridisation after either cleavage stage embryonic biopsy or after biopsy at the blastocyst stage,3 and by the use of such innovations as time-lapse embryonic imaging to monitor embryonic growth through from fertilisation of the oocyte until the development of a blastocyst,4 have been recently embraced into current practice. Furthermore, in the comparatively unexplored area of embryonic implantation, the seemingly unusual procedure of the ‘endometrial scratch’, to improve endometrial receptivity, has been readily adopted by reproductive medicine specialists.5 However, this issue of ANZJOG presents two publications on the use of an oil based solution ‘Lipiodol’ to assist a woman conceiving without recourse to IVF treatment, potentially offering a couple a less invasive approach to fertility treatment.6, 7 The authors purport that the place of an oil-based tubal flushing procedure appears to be most efficacious in the treatment of a woman with endometriosis related subfertility and also in the situation of unexplained infertility. The rationale for the beneficial effects of the procedure is postulated to be by an alteration of the endometrial environment to a more favourable receptive endometrium by the oil-based liquid.6, 7 Indeed, albeit with very small numbers, the preliminary results of the use of oil-based tubal flushing prior to an IVF cycle appear very encouraging7 and we await the final results of this randomised study, as this may be another way to manipulate the endometrium prior to an embryo transfer along the lines of the ‘endometrial scratch’. Despite these same fervent supporters of tubal flushing with oil-based contrast media from New Zealand presenting and publishing their results of a randomised trial all the way back in 2004,8 and then subsequently performing a Cochrane review9 of the procedure, the flushing of the fallopian tubes with an oil based solution has not been embraced either within Australia or more indeed more globally. The UK NICE guidelines state that ‘The potential consequences of extravasations of oil-soluble contrast media into the pelvic cavity and fallopian tubes may be associated with anaphylaxis and lipogranuloma. Further randomised controlled trials are needed to evaluate the potentially therapeutic effects of tubal flushing with water-soluble media’,10 despite the evidence presented by the Auckland group suggesting that these complications are a very rare occurrence. Perhaps the reasons for the lack of adoption of this technique into standard care maybe purely due to organisational issues within a practice; relating to the specialist performing the procedure, either a radiologist or gynaecologist, or potentially the fear of a rare complication. Until more reproductive medicine specialists adopt the procedure of oil-based tubal flushing, and other units present their data, this technique may remain within a limited number of specialist units.