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.
