Secondary Logo

Share this article on:

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

Soliman, Ahmed T.; Salem, Hesham A.

Journal of Evidence-Based Women’s Health Journal Society: August 2013 - Volume 3 - Issue 3 - p 147–153
doi: 10.1097/01.EBX.0000431014.27511.a1
Original articles

Objective The aim of this study was to present the diagnostic findings, the immediate and the remote tubal patency rates, and the reproductive outcome in patients with proximal tubal obstruction (PTO) treated with hysteroscopic tubal cannulation (TC) under laparoscopic guidance and to compare the reproductive outcome of PTO patients treated with TC with those treated with IVF/intracytoplasmic sperm injection (ICSI).

Design Prospective clinical study.

Setting Tanta University Hospital and private centers (AL-Salam and Egyptian Consultants IVF/ICSI centers).

Patients and methods Eighty-five infertile patients with bilateral PTO on repeat hysterosalpingogram (HSG) and confirmed by laparoscopy constituted the study population of the present study. Patients were recruited from Tanta University Hospital (Egypt) and at private work during the period from August 2008 to July 2012. The study population was distributed, after counseling, according to their personal preference between two modalities of therapy: 35 patients selected hysteroscopic TC and 50 patients selected IVF/ICSI. In group I (35 patients), a coaxial cannulation set composed of a Labotect flexible guide cannula, a 3-Fr end-hole Teflon ureteric catheter, and a Teflon-coated stainless-steel urologic guidewire was utilized for hysteroscopic TC under laparoscopic guidance. Group II was subjected to ICSI. Main outcome measures were the immediate on-table success of TC evidenced by intraoperative laparoscopic chromopertubation, the long-term persistence of achieved tubal patency documented by HSG performed 6 months after the procedure, and the reproductive outcome following the hysteroscopic TC compared with the IVF/ICSI group.

Results Successful TC and achievement of tubal patency were evident in 48 (68.6%) tubes present in 27 (77.1%) patients. Initial total failure of the procedure was evident in eight (22.9%) patients. Tubal perforations led to complicated cannulation of five (7.1%) tubes. Twelve women (34.3%) achieved intrauterine pregnancies and two patients (5.7%) had a tubal ectopic pregnancy. HSG, performed 6 months after TC for the patients who did not conceive, indicated preservation of tubal patency in eight (22.9%) patients and bilateral tubal reocclusion in 13 (37.1%) patients. In group II (50 patients with PTO subjected to IVF/ICSI), clinical pregnancy was achieved in 16 patients (32%).

Conclusion Hysteroscopic TC is a safe and cost-effective procedure that has clear diagnostic and therapeutic benefits for infertile patients with PTO. Considering the success rate of hysteroscopic TC, about two-thirds of patients with PTO managed by this technique are recommended to attempt to conceive naturally instead of being referred to IVF/ICSI or microsurgery.

Department of Obstetrics and Gynecology, Faculty of Medicine, Tanta University, Tanta, Egypt

Correspondence to Ahmed T. Soliman, MD, Department of Obstetrics and Gynecology, Faculty of Medicine, Tanta University, Tanta, Egypt Tel:+20 111 010 2233; fax: +0403339091;e-mail: tawfeekcenter@hotmail.com

Received January 14, 2013

Accepted April 25, 2013

Back to Top | Article Outline

Introduction

Tubal disease is the cause of infertility in ∼30% of women and 10–25% of these are because of proximal tubal obstruction (PTO) and frequently is an isolated finding, with otherwise normal pelvic anatomy 1. PTO has been a diagnostic and therapeutic dilemma since its recognition more than 100 years ago. Unilateral or bilateral PTO is documented in 10–20% of hysterosalpingograms (HSGs) performed as part of an infertility evaluation 2; however, 16–40% of these apparent PTO are false positives 3. Even laparoscopy and dye test, considered to be the optimum method for assessment of tubal patency, may not determine whether a visualized blockage is because of true anatomic occlusion or a temporary functional cause 3.

The narrowest portion of the fallopian tube extending from the uterotubal ostium to the ampullary–isthmic junction is highly vulnerable to pathogenic organisms and other insults that often induce block of this narrow segment. However, the etiology of PTO is not always clear. Infection and subsequent inflammation and fibrosis, salpingitis isthmica nodosa, intraluminal endometriosis, cornual polyps, previous ectopic gestation, and congenital abnormalities have been cited as causes 4. In addition, temporary functional obstruction caused by cornual spasm and reversible loose mechanical blocks such as inspissated amorphous plugs, weak mucosal agglutinations, and weak intraluminal microadhesions may lead to an apparent PTO, despite the absence of a true anatomic obliteration of the tubal lumen 5.

Some reports in the literature suggest that up to two-thirds of fallopian tubes resected for PTO show, upon histologic examination, preservation of the tubal lumen with absence of transmural or lumenal pathology 4,5. This situation is frustrating because the currently available therapeutic options for PTO are either microsurgical repair or IVF; both are major interferences, costly, and require special instrumentations and skills. In addition, the success rates of microsurgical repair have varied considerably 6,7 and the possibility of failure of such procedures is often difficult for the patient and her surgeon to accept, especially when the obstruction itself cannot be histologically explained or even documented 4.

Improvement in the specificity of evaluation of the proximal tubal segment is, therefore, strongly needed resorting to a more reliable modality for the diagnosis and a less invasive and more cost-effective modality for the treatment of PTO.

A thin flexible probe, introduced through the uterine tubal ostium into the proximal end of the fallopian tube and advanced with gentle force along the tubal lumen, could be successful in differentiating between true anatomic occlusion and reversible blocks and in relieving spastic obstruction and reversible loose mechanical blocks 8.

The objectives of this study are to present the diagnostic findings, the immediate and the remote tubal patency rates, and the reproductive outcome in patients with PTO treated with hysteroscopic tubal cannulation (TC) under laparoscopic guidance and to compare the reproductive outcome of the PTO patients treated with TC with those treated with IVF/intracytoplasmic sperm injection (ICSI).

Back to Top | Article Outline

Materials and methods

Eighty-five infertile patients with bilateral PTO on repeat HSG and confirmed by laparoscopy constituted the study population of the present study. The study was approved by the ethics committees of the university. Patients were recruited from Tanta University Hospital (Egypt) and at private work during the period from August 2008 to July 2012. The study population were distributed, after counseling, according to their personal preference between two modalities of therapy.

  • Group I: Thirty-five patients selected hysteroscopic TC under laparoscopic guidance.
  • Group II: Fifty patients selected IVF/ICSI.

For clear evaluation and comparison of the outcome, the following precautions were considered:

  • Patients with significant defects in other fertility factors rather than PTO, for example cases with significant tubal damage, pelvic endometriosis, and extensive pelvic adhesions were excluded from the study.
  • The maximum age limit was 35 years.
  • All the selected patients had average ovarian reserve and BMI.
  • No previous attempts of endoscopic treatment or IVF.
Back to Top | Article Outline

Methods

All candidates in the present study were subjected to a complete standard diagnostic workup of infertility consisting of full assessment of history, complete systemic and gynecologic clinical examination, and the standard basic infertility investigations, including ultrasound pelvic examination, semen analysis, timed postcoital test, midluteal serum progesterone assay, serum prolactin assay, thyroid function tests, HSG, hysteroscopy, and laparoscopy with chromopertubation. HSG was performed 6 months after successful cannulation for patients who did not conceive in the hysteroscopic cannulation group.

The procedure of TC was performed once the diagnosis of isolated bilateral PTO was confirmed endoscopically, at the same setting of diagnostic laparoscopy and hysteroscopy, performed as part of the diagnostic workup of infertility (Figs 1–5).

Figure 1

Figure 1

Figure 2

Figure 2

Figure 3

Figure 3

Figure 4

Figure 4

Figure 5

Figure 5

Laparoscopy was performed in the standard double-puncture technique, under general anesthesia. A 5-mm second puncture probe was inserted suprapubically for manipulation. Proper, careful, systemic examination of the entire pelvis was carried out for detection of any relevant pelvic pathology and evaluation of the tubal status. At the end of the laparoscopic examination of the pelvis, tubal patency was tested by chromopertubation. In case of persistent PTO, hysteroscopic transostial selective chromopertubation was performed for final confirmation of the diagnosis. Once the diagnosis of PTO was finally established, hysteroscopic TC was directly carried out at the same setting.

After dilating the cervix up to No. 6 Hegar dilator, a flexible catheter guide cannula with a ball-shaped tip (Tubal cannulation set; Labotect, Gottingen, Germany) was introduced into the uterine cavity along with its stilette. The guiding cannula is of varying flexibility and adapts well to the curvature of the uterus. At first, it was introduced with its curvature in the anteroposterior plane of the uterus and its tip pointing either anteriorly or posteriorly according to the uterine version-flexion; then, the cannula had to be turned through an angle of ∼90° either to the right or to the left to face either of both uterine tubal ostia.

A 4-mm 30° fore-oblique angle hysteroscope (Karl Storz, Tuttlingen, Germany) fitted to a 5-mm diagnostic sheath was then gently introduced into the uterine activity alongside the guide cannula. Normal saline was utilized as the uterine distending medium. Once the uterine cavity was entered by the hysteroscope, it was explored properly for detection of any uterine intracavitary lesions, and then both tubal ostia were carefully localized and examined. Then, the tip of the guide cannula was positioned exactly in front of the tubal ostium and lodged securely inside it under direct hysteroscopic vision.

A 3-Fr end-hole Teflon ureteric catheter with a tapered end (tapered to 2.5 Fr in its distal 3 cm) and a Teflon-coated stainless-steel urologic guidewire 0.018 inch (0.043 cm) in diameter with an atraumatic flexible blunt tip (Cook Co, Bloomington, Indiana, USA) were utilized for TC.

The 3-Fr Teflon catheter and guidewire were passed up the lumen of the catheter guide cannula and introduced coaxially into the tubal ostium. The guidewire always led and its flexibility was altered by varying the length of the guidewire that protruded from the 3-Fr catheter. As the guidewire exits from the catheter, it is relatively stiff; as the guidewire becomes longer, it becomes more flexible. Next, the guidewire and the catheter were maneuvered and advanced, under laparoscopic guidance, into the proximal part of the fallopian tube. Laparoscopic observation of the procedure shows the movement of the guidewire in the proximal oviduct and the associated characteristic arching of the tubal isthmus. Advancement of the guidewire and avoidance of misdirection and perforation were facilitated by straightening the proximal segment of the oviduct, adjusting and stabilizing it in the same direction of guidewire advancement. This was carried out by a tubal holding forceps introduced through the laparoscopic suprapubic second puncture. The guidewire was advanced till its tip was seen to enter the tubal ampulla or until significant resistance was met. If the guidewire could not be easily advanced into the tubal ampulla with application of gentle pressure and rotation, the tapered end of the 3-Fr catheter was advanced over the guidewire until the resistance was felt by the catheter, and then minimally withdrawn, leaving only a short length of the guidewire protruding from the tip of the catheter. This maneuver provides extra stability for the guidewire tip, makes it relatively more stiff, enables, with advancement of the guidewire, application of relatively greater force in the proper direction against the site of resistance, and minimizes the possibility of tubal perforation. Next, the 3-Fr catheter with the guidewire shortly protruding out of its tip was pushed with relatively greater force and gentle rotation to negotiate the locked area of the tube, and then advanced to reach the tubal ampulla. The guidewire was then withdrawn completely outside the body, leaving the 3-Fr catheter in place with its tip inside the uterine tubal ostium. Selective chromopertubation under laparoscopic observation was then performed to confirm tubal patency. The 3-Fr catheter was then withdrawn into the lumen of the catheter guide cannula. The cannula was rotated through 180° and positioned into the other internal tubal ostium. The procedure was then repeated on the other side.

At the end of the procedure, the guide cannula, the 3-Fr catheter, and the guidewire were removed from the uterus and tubal patency was checked once again using methylene blue.

Back to Top | Article Outline

IVF/ICSI procedure (group II)

The policy of our unit for the first treatment cycle is to use the standard long protocol of stimulation starting with a GnRH agonist (Decapeptyl 0.1 mg; Ferring GmbH, Kiel, Germany) in the midluteal phase, followed by recombinant FSH (Gonal F; Serono S.P.A., Rome, Italy). The dose of gonadotropins was determined on an individual basis according to the age, day 3 FSH value, and number of antral follicles in the ovaries. Patients underwent serial transvaginal ultrasound starting on day 6 of ovarian hyperstimulation. When three or more leading follicles with a mean diameter of 18 mm were visualized, 10000 IU of human chorionic gonadotropin (Choriomon; IBSA, Lugano, Switzerland) was administered intramuscularly. Oocyte retrieval was performed transvaginally 34 h after the human chorionic gonadotropin injection. Embryo transfer was performed 48–72 h after oocyte collection.

Clinical pregnancy was defined as the ultrasonographic demonstration of an intrauterine gestational sac 4 weeks after embryo transfer.

Back to Top | Article Outline

Results

The clinical criteria of the study women are summarized in Table 1. The average age (±SD) of the patients was 27.3±3.5 and 29.2±3.4 years and the mean duration of infertility (±SD) was 3.6±1.2 and 4.1±3.1 years, respectively. Thirteen women (37.2%) presented with primary infertility and 22 women (62.8%) presented with secondary infertility in the TC group versus 34 women (68%) and 16 women (32%), respectively, in the IVF group.

Table 1

Table 1

The immediate on-table outcomes of TC attempted for these 35 women are shown in Table 2. Successful TC and achievement of tubal patency were evident in 48 (68.6%) tubes present in 27 (77.1%) patients. Initial total failure of the procedure (i.e. inability to achieve tubal patency in either of the tubes whether because of inability of TC or persistence of PTO after cannulation) was evident in eight (22.9%) patients.

Table 2

Table 2

Tubal perforations had complicated the TC of five (7.1%) tubes. Three of the perforations were associated with persistence of tubal occlusion and the other two perforations were associated with successful TC and restoration of tubal patency. These perforations were not associated with significant bleeding and did not require extra interferences or medications. TCs were not associated with other immediate or delayed harmful complications.

The remote outcomes of TCs are summarized in Table 3. Twelve women (34.3%) achieved intrauterine pregnancies and two patients (5.7%) had a tubal ectopic pregnancy. HSG, performed 6 months after TC for the patients who did not conceive, showed preservation of tubal patency in eight (22.9%) patients and bilateral tubal reocclusion in 13 (37.1%) patients.

Table 3

Table 3

The outcomes of 50 patients with PTO in group II subjected to IVF/ICSI are presented in Table 4. Clinical pregnancy was achieved in 16 patients (32%). The continued pregnancy rate was 28% and multiple pregnancies were evident in three of 16 patients who became pregnant (18.75%).

Table 4

Table 4

Back to Top | Article Outline

Discussion

The diagnosis of PTO, in most clinical settings, is still considered as an indication for either IVF treatment or tubal surgery. This is despite the substantial body of evidence that exists for the effectiveness of selective salpingography and tubal catheterization in recanalizing the proximally occluded oviduct and restoring fertility for many women diagnosed with PTO 10. Having gained recognition by professional societies in the management of PTO, fluoroscopic tubal catheterization and hysteroscopic tubal catheterization emerge as essential modalities for assessment of proximal tubal patency 11,12.

The histopathologic observations on the pathologic spectrum of PTO support the idea that the majority of patients with PTO have a reversible cause of their obstruction that does not require major surgery or IVF. In several cases, it may be possible to help the patient avoid major surgery and IVF and still have a successful pregnancy outcome 13. Sulak et al. 4 concluded that ‘histologic studies of our excised tubal segments were similar to the findings of others in that we were frequently unable to document tubal occlusion and, in some patients, we found completely normal tubes’. Similarly, in 1971, Grant 9 wrote ‘We have been considerably frustrated by the reports received from the pathologist, as he failed to find a block in many segments examined’.

HSG and laparoscopic chromopertubation has little hope of breaking through even a weak obstruction, because although considerable hydraulic pressure can be applied to the uterine cavity, the net force transmitted to the interstitial oviduct is quite weak because of its small cross-sectional area 15. Therefore, improvement in the specificity of evaluation of the proximal tubal segment and use of simpler and more cost-effective therapeutic approaches suitable for dealing with loose mechanical obstructions of the proximal tubal segment are required.

Transcervical cannulation of the fallopian tube has been used either as a diagnostic or as a therapeutic aid 6,7,14,16–19. Confino et al. 7 described hysteroscopic transcervical balloon tuboplasty in which the proximally obstructed fallopian tube was cannulated, opened, and dilated in a manner similar to balloon angioplasty.

In another case report, Daniell and Miller 17 reported a successful hysteroscopic transcervical TC, of a proximally occluded oviduct, by a Teflon-coated Newton guidewire ureteral catheter. Seven months after the procedure, the patient conceived an intrauterine pregnancy through the cannulated and the only functioning tube.

In a third case report, Sulak et al. 18 reported successful hysteroscopic transcervical TC of proximally obstructed oviducts in two patients using a 19-G epidural catheter passed through the operating channel of the hysteroscope.

Novy et al. 14 reported success rates for transcervical TC by either hysteroscopy (10 patients) or fluoroscopy (18 patients) in 28 patients. They were successful in 92 and 84% of the attempts, respectively. Two patients (20%) in the hysteroscopy group and five patients (27.77%) in the fluoroscopy group conceived 1–7 months after the procedure.

In the current study, 48 of 54 tubes (68.6%) were cannulated successfully with immediate (on-table) achievement of tubal patency. Immediate total failure of TC (inability to achieve tubal patency in either of both tubes) occurred in eight patients.

In agreement with the results of the present study, Deaton et al. 6 described successful hysteroscopic TC using a flexible tip guide in 13 (72%) of 18 tubes. Eight of 11 (73%) tubes remain patent when evaluated by HSG 6 months postoperatively.

Allahbadia et al. 16 described hysteroscopic recanalization of cornual obstruction using a Terumo hydrophilic guidewire passed through a flexible guide cannula under laparoscopic guidance. They could cannulate 30 of 34 tubes (88.23%). Four patients conceived within 8 months.

Abdallah et al. 19 reported success rates for transcervical hysteroscopic TC using a Novy cornual cannulation set under direct laparoscopic visualization in 10 women. They were successful in 100% of the attempts.

Several studies 13,15,20,21 have reported successful recanalization of proximally occluded oviducts by fluoroscopic TC. The results reported are comparable to those of hysteroscopic TC.

Fluoroscopic TC, although simple and can be performed without general anesthesia in an outpatient setting, is a blind technique that cannot provide information about the condition of the tubal wall and the distal tubal segment or screen for the presence of associated pelvic lesions such as endometriosis and pelvic adhesions, which are common concomitant findings in those infertile patients. Collection of these data is important in deciding on the overall plan of management of the patient and may even contraindicate or obviate the need for TC.

In the current study, before starting the tubal recanalization procedure, PTO was confirmed using three techniques: HSG, laparoscopic chromopertubation, and hysteroscopic/laparoscopic selective chromopertubation. Therefore, the possibility of false-positive PTO was excluded.

Failure of TC could represent either true pathologic occlusion of the proximal tubal segment, or tortuous and narrow uterotubal junction. In the current study, failure of TC occurred in 22 of 70 tubes attempted (31.4%), which roughly correlates with the reported incidence of true occlusion 4. This failure rate is almost similar to the failure rates of TC reported in other studies 6,20. These studies and others also attributed failures of TC to true pathologic occlusion of the proximal tubal segments 6,14,20.

In the 22 tubes that could not be cannulated, there were three perforations. Another two perforations occurred in two tubes cannulated successfully. These five perforations (7.1%) were not associated with significant bleeding or any other complication and did not require further treatment. Similar observations have been reported by other studies 6,14,17.

Tubal perforation, as seen in this study and in other studies 11,21, is more prone to occur in failed cannulation because both events, perforation and cannulation failure, are most likely attributable to true fibrous occlusion of the tubal lumen. However, tubal perforation may also occur in successfully cannulated tubes because of misdirection of the guidewire, which is more prone to occur if the proximal tubal segment is fixed by peritubal adhesions, losing its normal range of mobility, or if the tube is not aligned in the proper direction laparoscopically. The presence of laparoscopic guidance decreases the risk of an inadvertent tubal perforation during manipulations of the guidewire.

Tubal perforations, significant bleeding, infection, and potential reocclusion are possible complications that might occur during TC attempts. Proper training, instrumentation, and sterile technique would reduce the risk of these complicationsc 7,16,17. In the current study, and apart from tubal perforations, there were no other intraoperative or postoperative complications. The absence of harmful complications in this study and other studies 6,7,14,16–19 confers cannulation of the fallopian tube an acceptable margin of safety.

A theoretical hazard of restoring tubal patency through TC is that of tubal ectopic pregnancy, because the recanalized portion of the tube may still have an abnormal epithelial lining 15. After tubo-cornual reanastomoses and tubal reimplantations, ∼10% of pregnancies are ectopic. How this would compare with tubal probing is an important question 15. In this study, only two tubal ectopic pregnancies in the face of 12 intrauterine pregnancies occurred in patients whose tubes were cannulated successfully. Deaton et al. 6 reported that cannulation of 13 tubes in 11 patients resulted in six pregnancies, three of which were distal ectopics that occurred in the patients with distal tubal disease. Novy et al. 14 reported that cannulation of 38 tubes in 28 patients resulted in seven intrauterine pregnancies and no ectopic pregnancies. Allahbadia et al. 16 reported that cannulation of 30 tubes in 15 patients resulted in four intrauterine pregnancies and no ectopic pregnancies. Exclusion of the presence of distal tubal pathology before cannulation helps to minimize the incidence of ectopic pregnancies.

Long-term continuance of restored tubal patency, as seen in this study and other studies, 6,14,16,20 may suggest a long-term fertility-promoting effect of TC. Papaioannou et al. 13 reported that 47.2% of spontaneous conceptions and 43.2% of all conceptions occurred after the first 12 months following TC, and the decrease in the possibility of pregnancy during the follow-up period between 16 and 56 months was only minimal.

Fallopian tube catheterization is diagnostically useful and technically highly successful for the treatment of occluded tubes; however, patients with distally blocked tubes are not good candidates for this procedure 18,19. Letterie and Luetkehans 22 reported no pregnancies following Fallopian tube canalization and microsurgery in patients with bipolar tubal occlusion; they suggested that in lieu of the lower patency rates and higher recurrence rates of PTO, IVF, although more costly, may ultimately represent the most expedient and effective method of management of coexistent proximal and distal tubal disease (bipolar disease) 22.

Until the widespread use of IVF in the beginning of the 1980s, tubal surgery was the only available option for restoration of fertility in patients with PTO. Although tubal microsurgery and IVF may be complementary options in the management of patients with tubal obstruction following failed TC, and although microsurgery to correct localized damage has the advantage of long-standing restoration of fertility, poor pregnancy rates with tubal microsurgery in patients with severe tubal damage and the lack of technical skill required to perform these procedures have resulted in a liberal referral to IVF 2.

The relatively low incidence of PTO may partly explain the reluctance of many clinicians to invest time and money in acquisition of the skills necessary to perform hysteroscopic tubal cannulation and developing a relevant and more valuable treatment for this special group of patients 23.

Back to Top | Article Outline

Conclusion

The procedure of hysteroscopic TC is minimally invasive, simple, easy, safe, requires minimal training, is highly cost-effective, and does not require any special equipment in the operating theater. The procedure has clear diagnostic benefits, being able to screen for other pathology, evaluate the tubal condition accurately, and identify those patients with true pathologic occlusion for whom IVF or microsurgical tuboplasty is indicated. In addition, the procedure has an evident therapeutic benefit as it can relieve PTO caused by cornual spasm or loose mechanical blocks, thus providing an endoscopic method for the restoration of proximal tubal patency.

In the face of the success rate of hysteroscopic TC in the present study, about two-thirds of patients with PTO managed by this technique are recommended to attempt to conceive naturally instead of being referred to IVF/ICSI or microsurgery.

Back to Top | Article Outline

Acknowledgements

Conflicts of interest

There are no conflicts of interest.

Back to Top | Article Outline

References

1. Papaioannou S.A hypothesis for the pathogenesis and natural history of proximal tubal blockage.Hum Reprod2004;19:481–485.
2. Allahbadia GN, Merchant R.Fallopian tube recanalization: lessons learnt and future challenges.Womens Health2010;6:531–549.
3. Mol BWJ, Collins JA, Burrows EA, Van Der Veen F, Bossuyt PMM.Comparison of hysterosalpingography and laparoscopy in predicting fertility outcome.Hum Reprod1999;14:1237–1242.
4. Sulak PJ, Letterie GS, Coddington CC, Hayslip CC, Woodward JE, Klein TA.Histology of proximal tubal occlusion.Fertil Steril1987;48:437–440.
5. Fortier KJ, Haney AF.The pathologic spectrum of uterotubal junction obstruction.Obstet Gynecol1985;65:93–98.
6. Deaton JL, Gibson M, Rid-dick DH, Brumsted JR.Diagnosis and treatment of comual obstruction using a flexible tip guidewire.Fertil Steril1990;53:323.
7. Confino E, Friberg J, Gleicher N.Transcervical balloon tuboplasty.Fertil Steril1986;46:963–966.
8. Fukuda A, Okada H, Kanbara Y, Oku H, Nakaoka Y, Morimoto Y.Outpatient falloposcopic tuboplasty should be an initial regimen for tubal factor infertility due to tubal lumen lesions before in vitro fertilization.Fertil Steril2002;78Suppl 1S194.
9. Grant A.Infertility surgery of the oviduct.Fertil Steril1971;22:496–503.
10. Dwivedi MK, Pal R, Jain M, Sherwani P, Nimbalkar N, Agrawal V, Taori K.Efficacy of fallopian tube catheterization for treatment of infertility.Indian J Radiol Imaging2005;15:521–523.
11. .Guidelines for tubal disease1993.Birmingham, AL:American Fertility Society.
12. .The management of infertility in secondary care1998.London:RCOG.
13. Papaioannou S, Afnan M, Girling AJ, Coomarasamy A, Ola B, Olufowobi O, et al..Long-term fertility prognosis following selective salpingography and tubal catheterization in women with proximal tubal blockage.Hum Reprod2002;17:2325–2330.
14. Platia MP, Krudy AG.Transvaginal fluoroscopic recanalization of a proximally occluded oviduct.Fertil Steril1985;44:704–706.
15. Novy MJ, Thurmond AS, Patton P, Uchida BT, Rosch J.Diagnosis of cornual obstruction by transcervical fallopian tube cannulation.Fertil Steril1988;50:434–440.
16. Allahbadia GN, Mangeshikar P, Dhungat PBP, Desai SK, Gudi AA, Arya A.Hysteroscopic fallopian tube recanalization using a flexible guide cannula and hydrophilic guide wire.Gynecol Endoscopy2000;9:31–35.
17. Daniell JF, Miller W.Hysteroscopic correction of cornual occlusion with resultant term pregnancy.Fertil Steril1987;48:490–492.
18. Sulak PJ, Letterie GS, Hayslip CC, Coddington CC, Klein TA.Hysteroscopic cannulation and lavage in the treatment of proximal tubal occlusion.Fertil Steril1987;48:493–494.
19. Abdallah MA, Nakajima S, Eblen AC.Hysteroscopic selective tubal cannulation under direct laparoscopic visualization revisited.Fertil Steril2002;78Suppl 1S114.
20. Segars JH, Herbert CM III, Moore DE, Hill GA, Wentz AC, Winfield AC.Selective fallopian tube cannulation: initial experience in an infertile population.Fertil Steril1990;53:357–359.
21. Tur-Kaspa I, Moscovici O, Meltzer S, Peled R, Rabinson J, Segal S.Transcervical tubal catheterization (TTC) is the treatment of choice for infertile women with proximal tubal obstruction: an experience with 1010 fallopian tubes.Fertil Steril2002;78Suppl 1S90.
22. Letterie GS, Luetkehans T.Reproductive outcome after fallopian tube canalization and microsurgery for bipolar tubal occlusion.J Gynecol Surg1992;8:11–13.
23. Papaioannou S, Afnan M, Girling AJ, Ola B, Olufowobi O, Coomarasamy A, Sharif K.Diagnostic and therapeutic value of selective salpingography and tubal catheterization in an unselected infertile population.Fertil Steril2003;79:613–617.
Keywords:

hysteroscopic tubal cannulation; IVF/intracytoplasmic sperm injection; proximal tubal obstruction

© 2013 Lippincott Williams & Wilkins, Inc.