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.
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.
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.
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.
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.
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%).
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.
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.
Conflicts of interest
There are no conflicts of interest.
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Keywords:© 2013 Lippincott Williams & Wilkins, Inc.
hysteroscopic tubal cannulation; IVF/intracytoplasmic sperm injection; proximal tubal obstruction