Proximal Tubal Obstruction Research Articles

Evaluation of hysteroscopic tubal cannulation under laparoscopic control versus intracytoplasmic sperm injection in cases with proximal tubal obstruction

Evaluation of hysteroscopic tubal cannulation under laparoscopic control versus intracytoplasmic sperm injection in cases with proximal tubal obstruction

Long‐term reproductive outcome after hysteroscopic proximal tubal cannulation – an outcome analysis

The optimal therapeutic method for proximal tubal obstruction (PTO) has yet to be defined. In addition, the reported successful recanalisation rate and reproductive outcome from hysteroscopic proximal tubal cannulation have been inconsistent. To examine the morbidity and efficacy of laparoscopic-hysteroscopic proximal tubal cannulation for treating PTO. This was a retrospective study evaluating 70 infertile women with PTO who underwent laparoscopic-hysteroscopic proximal tubal cannulation in The Prince of Wales Hospital, a university-affiliated hospital, from January 2005 to December 2010. Demographical data and operative details were reviewed. Women were then contacted by phone and completed a structured questionnaire. Recanalisation rate, intra-operative complication, pregnancy rates and pregnancy outcomes were examined. Fifty women had successful proximal cannulation on at least one side of the tube, providing an overall successful recanalisation rate of 71.4% per woman and 67.0% per tube. The overall pregnancy rate after successful hysteroscopic proximal cannulation of at least one tube is 55%. The overall mean time to become pregnant from natural conception or via clomiphene induction after successful unilateral or bilateral hysteroscopic cannulation was 10.5 ± 8.9 months. The procedure is associated with minimal morbidity. No prognostic factors were significantly associated with recanalisation and pregnancy rate. Laparoscopic-hysteroscopic cannulation for proximal obstruction is a procedure with minimal morbidity and a reasonable successful recanalisation rate. It should be considered as an alternative to in vitro fertilisation.

Selective salpingography: preliminary experience of an office operative option for proximal tubal recanalization

To evaluate treatment efficacy and patient acceptability of the new Radiographic Tubal Assessment Set (RTAS) (Cook Ireland Ltd., Limerick, Ireland) for selective salpingography (SSG). 33 women, between 23 and 38 years old, referred to the Fertility Centre of the Department of Obstetrics, Gynecology and Reproductive Science, Second University of Naples, for sterility problems, underwent an office operative SSG with the RTAS. Of the 33 women, 12 had bilateral tubal obstruction (Group A) and 21 had unilateral tubal obstruction (Group B). Patients who did not regain tubal patency were referred for laparoscopic surgery. To verify patient acceptability, a visual analogue score (VAS 1-10) of pain was completed immediately after the procedure. From a total of 45 obstructed fallopian tubes, 34 were recanalized, giving a success rate for the procedure of 75.6% (p<0.001). Nine patients with bilateral tubal obstruction (Group A) had the tubes recanalized and five obtained a spontaneous pregnancy. Sixteen patients with monolateral tubal obstruction (Group B) had the tubes recanalized and nine obtained a spontaneous pregnancy. A total of seven patients were sent for operative laparoscopy: four of them had the tubes recanalized and two obtained a spontaneous pregnancy. One patient was lost to follow-up. The evaluation of the level of pain felt during the procedure on the 10 cm VAS showed mean pelvic pain 2.9 ± 2.2, and an incidence of no discomfort±low pain significantly higher than moderate±severe pain (p<0.0001). The RTAS can be considered a safe and effective tool to perform this office operative procedure for tubal recanalization, with a high acceptability for the patient. The "see and treat" approach in patients with proximal tubal obstruction (PTO) suggests for the future the use of this device under sonographic guidance, taking into account accurate patient selection.

Fluoroscopy-guided, transcervical, selective salpingography and fallopian tube recanalisation

This study is a retrospective review of the transcervical fluoroscopy-guided fallopian tube recanalisation (FTR) procedures done in a multi-ethnic south-east Asian population, over 9 years. A total of 100 patients with infertility and documented proximal tubal obstruction (PTO) were referred for FTR. On-table hysterosalpingography under sedation demonstrated true PTO in 96 patients. At selective-salpingography, the PTO cleared in 16 patients; 78 required FTR and two had fimbrial blockage. The technical success rate of FTR was 86.8% and the post-FTR pregnancy rate was 36.84% at a mean follow-up interval of 12.2 months. There were no major, immediate procedure-related complications. There was an ectopic pregnancy in a single treated patient. Fluoroscopy-guided FTR is a safe treatment option in patients with infertility from PTO, with high technical success rate, low complication rate and increased chances of pregnancy; therefore it should be preferred before attempting more expensive and resource-intensive procedures.

Hysteroscopic tubal catheterization under laparoscopy for proximal tubal obstruction

The purpose of this study was to investigate the fertility outcomes of infertile patients having proximal tubal obstruction treated with hysteroscopic tubal catheterization (HCT) for recanalization under diagnostic laparoscopy. From January 2000 to December 2008, diagnostic laparoscopy was used to assess the tubal status of 61 patients with unilateral or bilateral proximal tubal obstruction, as confirmed by hysterosalpingography. Among them, 35 patients with tubal obstruction confirmed by chromopertubation under laparoscopy subsequently underwent HCT. The pregnancy outcomes and success rates of recanalization were investigated. In the 35 patients with confirmed tubal obstruction, HCT was performed in 54 fallopian tubes. The success rate of recanalization was 25.9% (14/54) per tube and 37.1% (13/35) per patient. Of the patients in whom tubal patency was restored, 4 achieved pregnancy, including 1 tubal pregnancy and 1 miscarriage. Among the 61 patients, excluding 14 who underwent in vitro fertilization-embryo transfer (IVF-ET) after laparoscopy, 13 were pregnant (27.7%), 9 gave live births, 1 had tubal pregnancy, and 3 had miscarriages. HCT under laparoscopy is an option for couples with tubal infertility who do not prefer IVF-ET.

Is there still a role for reconstructive microsurgery in tubal infertility?

To review the current role of tubal reconstructive surgery in the era of assisted reproductive techniques (ARTs). After tubal reconstructive surgery, couples may have unlimited attempts to conceive naturally. Operative risks are low; the risk for ectopic pregnancy after surgery is 4-10%. ART is associated with a number of potential complications: severe ovarian hyperstimulation syndrome (0.25-2%), multiple pregnancies (up to 25%), a higher rate of major malformations and stillbirths, and ectopic pregnancy (1-13%). Birth rates following ART differ between 19 and 35%, depending on different laws governing the fertilization of a limited number of oocytes and the number of embryos transferred. Resterilization is a main indication for microsurgery with resulting pregnancy rates up to 84%. Salpingostomy and dense adhesiolysis have the lowest success rates (term pregnancy rates: 3-65%). Proximal tubal obstructions can be successfully treated by tubocornual anastomosis. Hydrosalpinges should be removed prior to in-vitro fertilization if they cannot be reconstructed. ART is recommended for patients older than 37-38 years, for women with severe tubal pathology, after repeated ectopic pregnancies, and in case of male infertility. Tubal reconstructive surgery still plays a role in infertility treatment. ART has not replaced microsurgery routinely as first-line treatment for tubal infertility.

Fallopian Tube Recanalization: Lessons Learnt and Future Challenges

Technological advances in fiberoptics and endoscopy have resulted in the development of minimally invasive transcervical tubal catheterization procedures with the potential of improved diagnostic accuracy of tubal disease and transcervical treatment of proximal tubal obstruction (PTO) with reduced risks, costs and morbidity compared with surgical procedures. Fallopian tube recanalization can be performed with catheters, flexible atraumatic guidewires or balloon systems under endoscopic (falloposcopy/hysteroscopy/laparoscopy), sonographic, fluoroscopic or tactile guidance. Falloposcopy provides a unique possibility to accurately visualize and grade endotubal disease, characterize and document endotubal lesions, identify the segmental location of tubal pathology without complications, objectively classify the cause of PTO and guide future patient management. This is in contrast to the surgical and radiological gold standards, laparoscopy and hysterosalpingography, respectively, that are often associated with poor or misdiagnosis of PTO. Nonhysteroscopic transuterine falloposcopy using the linear eversion catheter is a successful, well-tolerated, outpatient technique with a good predictive value for future fertility. Hysteroscopic-falloposcopic-laparoscopic tubal aquadissection, guidewire cannulation, guidewire dilatation and direct balloon tubuloplasty may be used therapeutically to breakdown intraluminal adhesions or dilate a stenosis in normal or minimally diseased tubes with high patency and pregnancy rates. However, guidewire cannulation of proximally obstructed tubes yields much lower pregnancy rates compared with other catheter techniques, despite the high tubal patency rates. Laparo-hysteroscopic selective tubal catheterization with insufflation of oil-soluble radiopaque dye has been reported to be an effective treatment for infertility associated with endometriosis. The various disadvantages associated with fluoroscopic and sonographic techniques limit their application, despite the reportedly high patency and intrauterine pregnancy rates. Recanalization is contraindicated in florid infections and genital tuberculosis, obliterative fibrosis and long tubal obliterations that are difficult to bypass with the catheter, severe tubal damage, male subfertilitY and previously performed tubal surgery. Distal tubal obstruction is not amenable to catheter recanalization techniques. Tuberculosis, salpingitis isthmica nodosa, isthmic occlusion with club-changed terminal, ampullar or fimbrial occlusion, and tubal fibrosis have been cited as reasons for recanalization failure. In lieu of the poor pregnancy outcomes in patients with severe tubal disease and poor mucosal health following tubal recanalization, as well as poor available technical skills and results with microsurgery, in vitro fertilization and embryo transfer is a valid option in such women. Despite the high diagnostic and therapeutic power of falloposcopic interventions, technical shortcomings with falloposcopy must be overcome before the procedure gains widespread acceptance.

Diagnostic Value of Sonohysterography in the Determination of Fallopian Tube Patency as an Initial Step of Routine Infertility Assessment

Infertility is defined as the failure to conceive after 1 year of regular unprotected intercourse. It affects 10% to 15% of couples. Sonohysterography (SHG) is an accurate method for the assessment of fallopian tube patency, reflected in its high positive predictive value compared with hysterosalpingography (HSG) and laparoscopy with chromopertubation. In this study, our goal was to determine the diagnostic value of SHG for the diagnosis of bilateral tubal obstruction by comparison of SHG with HSG and laparoscopic results. This study was based on the evaluation of tubal patency by SHG and by the combination of HSG and laparoscopy in 40 patients. All patients underwent HSG as a routine infertility workup, and all patients with bilateral proximal tubal obstruction diagnosed by HSG subsequently underwent SHG. Among 1024 infertile women referred to an infertility clinic, 117 (11.4%) had a diagnosis of a tubal factor as the cause of their infertility. Forty-two patients with HSG findings of bilateral proximal tubal obstruction were enrolled. Forty patients underwent SHG. In 32 patients (80%), at least 1 fallopian tube was patent, and 8 patients (20%) were reported to have bilateral tubal obstruction. Those 8 patients with SHG evidence of bilateral tubal obstruction underwent laparoscopy. Eventually, 6 of those were laparoscopically confirmed to have bilateral tubal obstruction. Sonohysterography is an accurate method for the determination of fallopian tube patency. It is a simple, safe, and well-tolerated technique with a low risk of adverse effects and severe complications.

Adenomyosis Diagnosed by Hysteroscopy

Study Objective: This is a case of a patient with a history of secondary infertility, dysmenorrhea, menorrhagia and bilateral proximal tubal obstruction on hysterosalpingogram. The patient underwent hysteroscopy, resection of endometrial polyps and dilatation of the left tubal ostium.This video demonstrated the findings of adenomyosis at hysteroscopy. Results: Hysteroscopy can be used to diagnose adenomyosis.

Ultrasound versus tactile cannulation in the treatment of proximal tubal obstruction

Objective To compare the therapeutic effects of cannulation guided by ultrasound or tactile sensation in women with proximal tubal obstruction. Method This prospective randomized study reports on outcomes for 50 women treated as outpatients, 25 by the ultrasound-guided method and 25 by the tactile sensation method. Results Of the 50 fallopian tubes in each group, 42 tubes (84%) were successfully cannulated by the ultrasound-guided method and 32 (64%) by the tactile sensation method; and of the 50 patients, 8 (16%) conceived in the 6 months following cannulation. The difference in pregnancy rates between the 2 groups was not statistically significant. Conclusion Whether guided by ultrasound or tactile sensation, cannulation can be offered as a first-line outpatient procedure to women with proximal tubal obstruction.

Selective salpingography and fallopian tube catheterisation by guidewire

SummaryThe use of selective salpingography and tubal cannulation in the management of patients with proximal tubal obstruction in the UK is variable in spite of a National Institute of Clinical Excellence (NICE) recommendation. A retrospective review was performed of patients who underwent selective salpingography and fallopian tube catheterisation (SS/TC). A total of 16 patients underwent this procedure. Patency of at least one tube was achieved in 16 of the 20 tubes attempted. Pregnancy was achieved in 35% of patients after the procedure. The ectopic pregnancy rate was 7%. One pregnancy occurred in a patient after the procedure was repeated. The availability of laparoscopy findings was valuable in identifying tubes with established disease and where the procedure might be expected to be unsuccessful or result in a high risk of ectopic pregnancy. Hence, selective salpingography and tubal cannulation procedure should be considered as a therapeutic option for all patients with proximal tubal block before considering IVF or tubal surgery.

Office Ultrasound-Guided Hysteroscopic Tubal Cannulation

Study Objective: To assess the safety, efficacy and tolerability of ultrasound-guided office hysteroscopic tubal cannulation in patients with infertility caused by proximal tubal obstruction.

Evaluation of Selective hydrotubation under hysterofiberscopy

Objective: Tubal disease is the main cause of infertility and 10-25% of the cases are due to proximal tubal obstruction. Hysterosalpingography (HSG) is part of the standard diagnostic work-up for infertility; however, the diagnostic accuracy of HSG has been criticized. Selective hydrotubation is a useful tool by which to evaluate tubal obstruction. The aim of this study was to estimate the diagnostic findings and fertility outcomes after selective hydrotubation and to determine the prognostic significance of Chlamydia trachomatis infection for recanalization.Patients: Fifty-seven women undergoing selective hydrotubation for proximal tubal obstruction detected on HSG between January 2000 and December 2007 in the Department of Obstetrics and Gynecology of the University of Tokyo were studied.Results: Of the proximally occluded tubes detected by HSG, 41.9% were shown to be patent after selective hydrotubation. The success rate of recanalization by selective hydrotubation in unilateral obstruction (62.5%) was significantly higher than in bilateral obstruction (17.6%; P<0.01) . After recanalization by selective hydrotubation, 33.3% of the patients conceived without IVF or ICSI. With respect to C. trachomatis infection, the success rate of recanalization in patients with negative chlamydial antibodies was significantly higher (65.6%) than in patients with positive chlamydial antibodies (30.4%; P<0.01) .Conclusions: Selective hydrotubation is a useful tool in the diagnosis and treatment of proximal tubal obstruction detected by HSG. Especially in cases of proximal tubal obstruction with negative chlamydial antibodies, the success rate of recanalization can be high.

Imagerie de l’infertilité féminine

Medical treatment of a couple's infertility depends upon the cause(s) of infertility. The goals of imaging are to determine these causes (male, female, mixed, unexplained), to evaluate their severity and type on the female side central, ovarian, uterine, tubal, peritoneal, endometriosis, in order to propose an adapted treatment. Imaging modalities are essentially non ionising (US and MRI). Hysterosalpingogram retains its indication to study tubal patency, it can be completed by tubal catheterisation in cases of proximal tubal obstruction.

Comparison of Reproductive Outcome of Falloposcopic Tuboplasty for the Proximal Tubal Obstruction with or without Chlamydia Trachomatis Infection

Chlamydia trachomatis (CT) infection is a common cause of tubal factor infertility, and is considered a contra- indication for tubal surgery. In vitro fertilization with embryo transfer (IVF/ET) is the most widely used treatment for tu- bal factor infertility, including that caused by CT infection. Falloposcopy to re-canalize occluded tubes may also be useful therapeutically. It is unclear, however, what effect CT infection has on its efficacy. We examined the relationship between the efficacy of Falloposcopic tuboplasty (FT) and CT infection, retrospectively. Of 38 patients with tubal obstruction in which the surgery was performed, with follow-up, 21 patients had CT infections while 17 patients were not infected. In the Chlamydia positive group (CT+), 38 tubes were treated with FT and 29 tubes were treated in the Chlamydia negative group (CT-). Re-canalization rates per tube was 60% in the CT+ group and 79% in the CT- group. The success rate per case was 90% in the CT+ group and 94% in the CT- group. Cases were followed-up using either hysterosalpingography or second look laparoscopy, and a post-operative patency rate of 56% in the CT+ group and 75% in the CT- group was ob- served. In patients in followed for two years or more, the CT+ group had 5 spontaneous pregnancies (36%) and the CT- group had 9 spontaneous pregnancies (60%). There was a trend to better outcome in the CT- group, but there was no sig- nificant statistical difference between the two groups. In Conclusion, CT infection decreases fertility after FT. Despite CT infection having a negative impact on FT, the CT+ group had a post-operative pregnancy rate of 35.7%, which was com- parable to IVF-ET. Given this, we recommend FT for patients who have isolated tubal occlusion before beginning IVF/ET, even if the patients were previously infected with CT.

Proximal tubal disease: the place for tubal cannulation

Tubal disease is the cause of subfertility in approximately 30% of women, and 10–25% of these are due to proximal tubal obstruction. False-positive diagnosis of proximal tubal obstruction can be as high as 50%. A decrease in expertise in tubal microsurgery has resulted largely from the use of IVF as the treatment option for most causes of infertility and more specifically for tubal factor infertility. Selective salpingography and tubal cannulation have a unique role in the management of tubal infertility and should be offered to selected candidates prior to IVF. Tubal cannulation can be used effectively to restore patency in a proportion of cases of proximal tubal obstruction thus avoiding the need for expensive assisted reproductive techniques. This review examines the evidence supporting the effectiveness of tubal cannulation and aims to enhance awareness of the procedure as an option for the management of female subfertility secondary to isolated proximal tubal obstruction.

Hystérosalpingograhie et cathétérisme tubaire sous contrôle radiologique

Radiological exploration of hypofertility by means of hysterosalpingography is a method still valid but no longer sufficient. Tubal catheterization has thus become a necessary complementary exam in order to eliminate the pseudo-obturations of hysterosalpingography and, in case of proximal tubal obstructions, to obtain pregnancies. The conditions for the realization of hysteroalpingography and tubal catheterization are hereby described, with emphasis on the rigorous technique that is required together with careful listening to the patients.

Efficacy ofFallopian tubecatheterization for treatment of infertility

Material and Methods: - Fluoroscopic transcervical fallopian tube catheterization was performed in two hundred and four patient with infertility in whom proximal tubal obstruction was documented by at least two hysterosalpingography procedures. Bilateral block in 147 and unilateral block was seen in 57 cases. All patients were submitted to selective salpingography, patients were followed up for six months at bimonthly interval. Results: - H.S.G revealed proximal tube obstruction in total of 264 tubes of these 258 tubes were successfully cannulated complete tubal patency was achieved in 249 cases. In 12 Cases recanalization was incomplete and hydrosalpinx was seen in 7 tubes. In six months follow up 72 out of 200 patients had pregnancy confirmed by material urine test for pregnancy and subsequent ultrasound examination. All pregnancies were intra uterine. Conclusion: - Fallopian tube catheterization is an effective procedure for infertility caused by proximal tubal obstruction.

Evidence-based diagnosis and management of tubal factor infertility.

The investigation for potential tubal disease is an essential step in the work-up of infertility. This review article provides an evidence-based overview of the diagnosis and management of tubal factor infertility. While laparoscopic chromopertubation remains the gold standard in the diagnosis of tubal disease and hysterosalpingography is still widely used, newer modalities offer some advantages. Sonohysterography with the use of contrast medium is superior to hysterosalpingography and comparable to laparoscopic chromotubation in diagnosing tubal blockage. Chlamydia serology is the most cost-effective and least invasive diagnostic test for tubal disease, and it is comparable to, if not better than, hysterosalpingography. Depending on the nature and degree of tubal dysfunction as well as the age and ovarian reserve of the patient, various treatments for tubal infertility are available. For proximal tubal obstruction, transcervical tubal cannulation with tubal flushing is a reasonable first approach. Surgical techniques for tubal repair, such as salpingostomy or fimbrioplasty for distal tubal obstruction, can provide good results. Still, tubal factor remains a major indication for in-vitro fertilization and embryo transfer, which bypasses the tubal problem altogether. In certain situations, such as the presence of hydrosalpinx, prophylactic surgery can be used in conjunction with in-vitro fertilization and embryo transfer. As with infertility in general, the diagnosis and management of tubal infertility should be tailored to the individual patient. Future studies should help to further clarify the role of the various diagnostic tests and therapeutic approaches for tubal infertility.

Patient Rotation and Resolution of Unilateral Cornual Obstruction During Hysterosalpingography

In Brief OBJECTIVE Unilateral obstruction of the proximal fallopian tube is identified in 10–24% of patients undergoing hysterosalpingography for evaluation of infertility. Upon further testing, this obstruction spontaneously resolves 16–80% of the time. We hypothesized that patient rotation during hysterosalpingography might resolve proximal tubal obstruction in some cases by altering either the location of intrauterine air bubbles or the spatial relationship of the tube to the uterine fundus. METHODS In patients in whom unilateral proximal tubal obstruction was detected during hysterosalpingography performed for standard clinical indications, the patient was rotated on her hip approximately 45° such that the obstructed tube was first superior (ventral) to the patent tube, and dye was reinjected. If obstruction did not resolve, the patient was rotated in the opposite direction so that the obstructed tube was inferior (dorsal) to the patent tube and dye reinjected. RESULTS Unilateral tubal obstruction was found in 15% of cases (24 of 156). Rotating the patient with obstructed tube superior to the patent tube never resulted in tubal patency, whereas rotating the patient with the obstructed tube inferior resulted in resolution of tubal patency in 63% of cases (15 of 24). CONCLUSION Unilateral cornual obstruction during hysterosalpingography is often resolved by rotating the patient such that the obstructed tube is more inferior. Although this observation may be the result of dislodging smaller air bubbles, from a fluid dynamics perspective a more likely explanation is unkinking of the more inferior tube. Unilateral cornual obstruction during hysterosalpingography is often resolved by rotating the patient such that the obstructed tube is more inferior.