Porximal tubal blockage can be treated
hysteroscopically, radiographically, or by microsurgical reanastomosis.
A meta-analysis documented an intrauterine pregnancy rate of 50% in
women undergoing surgery for proximal tubal blockages, with the
highest success rates achieved with selective salpingography and
transcervical cannulation. Laparoscopic removal of thin,
avascular adhesions involving the tube and ovaries offers a reasonable
chance for pregnancy, with a success rate up to 70% but with an
ectopic pregnancy rate of 20%.
Women with significant symptoms, such
as pelvic pain, secondary to adhesions or endometriosis, also benefit
from laparoscopic surgery. Removal of severe tubal adhesions and
treatment of hydrosalpinges by neosalpingostomy offers a less
predictable pregnancy rate. Repair of bilateral tubal damage -
proximal and distal tubal adhesions - has the lowest chance of an
intrauterine pregnancy and is not recommended. Studies suggest
that in some cases, there is an increased pregnancy rate if large
hydrosalpinges are removed or drained laparoscopically prior to IVF
when IVF is recommended due to other infertility factors. Thus,
tubal surgery prior to IVF increases the chance for successful
infertility treatment.
Laparoscopic surgery may not be the
treatment of choice in cases of severe tubal factor infertility.
IVF is often a superior treatment for these patients, offering a
reasonable chance for pregnancy, lowering the risk of ectopic
pregnancy, and avoiding the prolonged delay required to determine the
success of treatment.
Obstruction of the
fallopian tube close to its insertion into the uterus, which is
conventionally termed "proximal," is the most treatable because if
often occurs because of the accumulation of mucus or debris, which
forms an impacted plug in the interstitial or proximal isthmic portion
of the tube. Fallopian tube catheterization has developed as an
extension of hysterosalpingography. Tubal cannulation results in
improved visualization of the fallopian tube anatomy. It is also a
treatment for infertility caused by proximal tubal obstruction (10 to
20 percent of patients with tubal disease).
Tubal cannulation
has almost eliminated the real and false diagnosis of unilateral tubal
occlusion, identified patients with proximal and distal occlusion
("bipolar tubal occlusion"), and eliminated or postponed the need for
a costly hysteroscopy or laparoscopy. Distal obstruction in the tube
is caused by fibrosis and peritubal disease, which are not amenable to
catheter recanalization techniques.
The procedure should
not be performed if catheterization is unlikely to be successful, such
as patients with Mullerian anomaly, cornual fibroids, or severe
salpingitis isthmica nodosa (SIN). Both wire recanalization and balloon tuboplasty yield 80 to 90 percent tubal
patency, and 40 to 50 percent six-month pregnancy rates in selected
patients. In summary, the ® tubal cannulation and easy to
perform coaxial system allows versatile diagnosis and treatment of
cornual tubal occlusion, as well as isthmic tubal obstruction.
Occlusion that
develops more distally in the isthmus, or in the ampullary or
fimbriated portions of the tube is commonly due to previous pelvic
infection or endometriosis. It is more difficult to recanalize and
patients are less likely to have a successful intrauterine pregnancy.
To estimate the potential impact of fallopian tube recanalization (FTR)
depends on the percentage of cases in which the occlusion is proximal.
Early figures ranged between 20 and 25% (4,5), meaning that the number
of potentially treatable patients in the U.S. may be as high as
230,000. However, since the overall incidence of tubal disease in the
two populations is similar (219 patients or 44%), the implication is
that the number of treatable patients in the U.S. may be only 140,000
or less.
There is no
agreement between gynecologists and radiologists regarding the proper
sequence for diagnosing and treating obstructed fallopian tubes, nor
is there a consensus within either of those two disciplines. There are
also no established reporting standards, so it is difficult to make
accurate comparisons between techniques, success rates, and treatment
strategies. Pregnancy rates vary widely among authors, not so much
because of differences in technique, but because of how the results
are reported.
Most radiologists
and gynecologists who use fluoroscopic guidance have adopted some
version of the technique developed by Rösch and Thurmond. A
number of gynecologists, on the other hand, prefer ultrasound-guidance
or hysteroscopy for cannulation of the tubes, often in conjunction
with laparoscopy. Even the American Society for Reproductive
Medicine (formerly the American Fertility Society) recommends
selective salpingography as the next diagnostic step when non-filling
of one or both tubes is encountered at HSG.
Hysterosalpingography has been the traditional method for evaluating
the tubes, but it has limitations, even for confirming tubal patency.
For the most part, our understanding of tubal pathophysiology is
rudimentary at best. The non-filling tube may be patent, but continued
injection of contrast cannot overcome the resistance in the tube and
spillage from the open side often crosses over and obscures the
non-filling side.
When selective
salpingography fails to show the proximal tube, then efforts should be
made to place a catheter and/or guide wire into the tube to clear the
obstruction. However, in contrast to Gleicher et al., the patients
treated by Millward et al. had an intrauterine pregnancy rate of 23%.
Of the 30 patients recanalized by tubal catheterization, 17 became
pregnant (26% overall), and only one patient where the guide wire was
used became pregnant (2% overall), which was an ectopic pregnancy.
Unlike these analyses of specific recanalization techniques, most
authors group their patients together in the results, regardless of
treatment type.
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