Diagnosis treatment of cornual obstruction using a flexible tip guidewire

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FERTILITY AND STERILITY

Vol. 53, No.2, February 1990

Printed on acid-free paper in U.S.A.

Copyright It! 1990 The American Fertility Society

Diagnosis and treatment of cornual obstruction using a flexible tip guidewire*

Jeffrey L. Deaton, M.D. Mark Gibson, M.D. Daniel H. Riddick, M.D., Ph.D. John R. Brumsted, M.D. t The University of Vermont, College of Medicine, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, Burlington, Vermont

Proximal tubal obstruction, either unilateral or bilateral, is a frequent finding on hysterosalpingogram (HSG). Approximately two-thirds of the fallopian tubes resected for proximal tubal obstruction reveal an absence of luminal occlusion. The distinction between true pathologic occlusion and either spasm or plugging is crucial in determining therapy. We combined hysteroscopic cannulation of the proximal fallopian tube with laparoscopy in 11 patients with proximal tubal obstruction diagnosed by HSG and confirmed at laparoscopy. Hysteroscopic cannulation was able to be performed in 72% of the fallopian tubes attempted, and there was a postcannulation patency rate by HSG of 73 %. Six of the 11 patients became pregnant after tubal cannulation and adjunctive distal tubal surgery. Hysteroscopic cannulation of the fallopian tube is a safe diagnostic procedure that can be used to identify those patients with true proximal occlusion, and may also serve as a therapeutic procedure in some of these patients. Fertil Steril53:232, 1990

Unilateral or bilateral proximal tubal obstruction is documented in 10% to 20% ofhysterosalpingograms (HSG) performed as part of an infertility evaluation. 1- 3 A recent report4 in the literature suggests that up to two-thirds of fallopian tubes resected for proximal tubal obstruction reveal an absence of transmural or luminal pathology. Because traditional therapy for proximal tubal obstruction has been laparotomy with tubocornual reconstruction, the distinction between true pathologic tubal occlusion, and either amorphous plugging or tubal spasm is important. The specific aim of this study is to evaluate the diagnostic and potential therapeutic advantages of hysteroscopic cannulation of the fallopian tube in Received March 28, 1989; revised and accepted October 3, 1989. * Presented in part at the 44th Annual Meeting of The American Fertility Society, Atlanta, Georgia, October 10 to 13, 1988. t Reprint requests: John R. Brumsted, M.D., University of Vermont, Given C-252, Burlington, Vermont 05405.

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11 women with proximal tubal obstruction by examining postcannulation patency rates (by HSG), pregnancy rates, and tubal pathology when available. All cases of proximal tubal obstruction were documented by both a preoperative HSG and laparoscopic chromopertubation.

MATERIALS AND METHODS

From July 1987 through October 1988, 11 women with radiologic evidence of proximal tubal obstruction were evaluated. They ranged in age from 24 to 38 years, and the duration of infertility was from 2 to 7 years. Proximal tubal obstruction was diagnosed by HSG and confirmed at laparoscopy. All women completed a full infertility evaluation including a postcoital test (PCT), endometrial bi0psy, and a normal semen analysis. Two patients had poor PCTs consistent with a cervical factor, one woman was found to be anovulatory, and one woman had a proliferative endometrial biopsy. An Fertility and Sterility

HSG was performed under fluoroscopic control using a water soluble contrast material both before the hysteroscopic cannulation, and between 2 and 6 months after the procedure. Hysteroscopy was performed using a 7 mm operating hysteroscope (Karl Storz Endoscopy America Inc., Culver City, CA). Concurrently, a laparoscopy was performed in all 11 patients. Once the diagnosis of proximal tubal obstruction was confirmed by chromopertubation, a urological stainless steel guidewire (Cook Company, Bloomington, IN, catalogue #638403) with a flexible tip was introduced into the operating channel of the hysteroscope. The guidewire has a diameter of 0.97 mm (0.038 inches) and is intended for one-time use. The tip of the guidewire was placed at the tubal ostia and pressure was applied. Often, the end of the hysteroscope had to be placed within 2 mm of the ostia to provide extra stability to the guidewire. After the tip of the guidewire could be seen to have entered the tubal ampulla, as documented by laparoscopy, the wire was withdrawn and patency was confirmed using either 32% Dextran 70 (Hyskon; Pharmacia, Piscataway, NJ) or indigo carmine dye. RESULTS

Surgical evaluation revealed bilateral proximal tubal obstruction with normal distal tubes in five women, bilateral proximal tubal obstruction with fimbrial agglutination or occlusion in two women, unilateral proximal tubal obstruction with fimbrial agglutination or occlusion in two women, and unilateral proximal tubal obstruction with normal distal tubes in two women. Additional findings at laparoscopy included adnexal adhesions with distal tubal disease in four patients, adnexal adhesions without distal tubal disease in two patients, Asherman's syndrome in one patient, and minimal endometriosis in one patient. See Table 1 for surgical findings. A summary of precannulation tubal status and postcannulation HSG findings is found in Table 2. Three of the seven women with bilateral proximal tubal obstruction had hysteroscopic cannulation of both fallopian tubes. Postcannulation HSG revealed bilateral tubal patency in two of these women and unilateral tubal patency in the other one. Three of the seven women with bilateral proximal tubal obstruction had hysteroscopic cannulation of one fallopian tube. Postcannulation HSG revealed patency in two of these tubes and proximal tubal obstruction in the other one. All three Vol. 53, No.2, February 1990

failed cannulations remained obstructed at the follow-up HSG. One of the seven women with bilateral proximal tubal obstruction had failed hysteroscopic cannulation of both tubes. She underwent laparotomy with bilateral isthmic-interstitial anastomosis, and pathology from her resected tubes revealed salpingitis isthmic a nodosa. This patient currently has an intrauterine pregnancy. Therefore, ofthe six women who had hysteroscopic cannulation of at least one tube, five had unilateral or bilateral tubal patency on follow-up HSG. Three of these five patients have become pregnant. Hysteroscopic tubal cannulation was performed in all four obstructed tubes in the four patients with unilateral proximal tubal obstruction, however, only three of the tubes were evaluated by postcannulation HSG (patient 8 became pregnant before follow-up HSG). Only one of these tubes was obstructed at postcannulation HSG. When examining the total number of attempted cannulations, 13 of the 18 tubes with proximal tubal obstruction could be cannulated, and 11 have been subsequently evaluated by HSG. Eight of these 11 fallopian tubes (73%) were patent at the postoperative HSG. Five of the 18 tubes with proximal tubal obstruction could not be cannulated and three have been subsequently evaluated. All three fallopian tubes remained obstructed at the postoperative HSG. During the initial hysteroscopic cannulation two of 18 fallopian tubes were perforated (11 %). The two tubal perforations occurred within 1 cm ofthe uterotubal junction and required no further therapy. There were no other complications from the procedure. A summary of the six pregnancies that occurred in the 11 women (54%) are listed in Table 3. The average time until conception was 6 months. There were three tubal pregnancies, all of which occurred in the ampulla of the fallopian tube in women who had evidence of distal tubal disease at their initial procedure. The three other pregnancies are ongoing and intrauterine; one following bilateral isthmic-interstitial anastomosis. DISCUSSION

Several authors have attempted to define the histologic and anatomic basis of proximal tubal obstruction. 4-6 Sulak et al.,4 reported on 18 patients who underwent tubal resection for proximal tubal obstruction, documented by both HSG and laparoscopic chromopertubation. In six patients (33%), amorphous material was present in the tubal Deaton et al.

Cannulation of the proximal tube

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Table 1

A Summary of the 11 Patients and Their Associated Findings and Operative Procedures Cannulation

Patient

Age

Length of infertility (years)

1

34

6!

Bilateral

Yes

Yes

2a

30

2

Bilateral

Yes

Yes

3a

24

4

Bilateral

Unable

Unable

4

28

3!

5

26

3!

SC

32

2!

Left blockage Right absent Right blockage Leftpatent Bilateral

7'

38

3

8a

30

g'

Preoperative tubal obstruction

Right

Left

Yes Yes

NOb

Yes

Yes

Right blockage Leftpatent

Yes

NOb

7

Right blockage Left hydrosalpinx

Yes

NOb

33

6!

Bilateral

Yes

Unable

10

35

3

Bilateral

Yes

Unable

11

31

3

Bilateral

Yes

Unable

a

b

Postoperative intrauterine pregnancy. Not attempted-patency documented by chromopertubation.

lumen, and in three (17%), the tubes were normal. Tubal occlusion, either fibrous obliteration or salpingitis isthmic a nodosa, was documented in only 7 of 18 patients (39%). Thus the differentiation between true pathologic occlusion (due to either fibrosis or salpingitis isthmica nodosa) and obstruction on HSG (due to either tubal spasm or amorphous plugging) is critical in determining the type of therapy offered to the couple. The accepted approach to the patient with proximal tubal obstruction evident on HSG has been to restrict laparotomy and tubocornual reconstruction to women whose findings persist with repeat HSG and laparoscopic chromopertubation. Despite the use of spasmolytic agents at the time of repeat HSG or the use of laparoscopic chromopertubation, an unacceptable rate of falsely positive proximal tubal obstruction persists. 2,7-9 Because these methods would not necessarily relieve tubal plugging, and because only true pathologic tubal occlusion necessitates either major surgery or in vi234

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Cannulation of the proximal tube

Operative findings; -additional procedures 6 cm uterine fibroid -Myomectomy Minimal endometriosis - Laser ablation Salpingitis isthmica nodosa -Bilateral anastomosis Normal pelvic anatomy -None Uterine septum -Hysteroscopic metroplasty Bilateral adnexal adhesions; right fimbrial agglutination - Laparoscopic adhesiolysis Bilateral adnexal adhesions and distal tubal disease - Laparoscopic adhesiolysis and right neosalpingostomy Bilateral adnexal adhesions; right fimbrial agglutination - Laparoscopic adhesiolysis and right fimbrioplasty Bilateral adnexal adhesions and distal tubal disease - Laparoscopic adhesiolysis and right neosalpingostomy Right ovarian adhesions to sidewall - Laparoscopic adhesiolysis Intrauterine synechiae; right ovarian adhesions - Lysis of synechiae

, Postoperative distal tubal pregnancy.

tro fertilization, improvement in the specificity of evaluation of the proximal tube is required. Transcervical cannulation of the fallopian tube has been used as either a diagnostic or therapeutic aid.1O-14 Novy et al. lO recently reported success rates for transcervical tubal cannulation by either hysteroscopy or fluoroscopy in 28 women. They were successful in 92% and 84% of the attempts, respectively. In this large series, however, the diagnosis of proximal tubal obstruction was made only by HSG in some patients and there was no information given on postcannulation patency rates. Confino et al. 14 described transcervical dilatation and recanalization of a proximally occluded fallopian tube using balloon dilatation of the proximal oviduct under general anesthesia with concurrent laparoscopy. There have been two case reports of pregnancies after hysteroscopic cannulation of the fallopian tubey,12 This report is the first study documenting the outcome of hysteroscopic cannulation of the falloFertility and Sterility

Table 2 A Summary of Precannulation Tubal Status and Postcannulation Hysterosalpingogram Findings Postcannulation patency Precannulation tubal obstruction Bilateral Both cannulated One cannulated None cannulated Unilateral One cannulated Totals

No. of subjects

3 3" 1 4 11

Both

2

One

Neither

Pregnant

1

0

2

2

1

1 1b

2' 4

1 4

0 1

2 6

" Includes two perforations, each on the unsuccessful side. b Following tubal resection and anastomosis. , One patient became pregnant before follow-up HSG.

pian tube with follow-up hysterosalpingography. Before the procedure, proximal tubal obstruction was confirmed using at least two techniques. Therefore, only patients who would normally be candidates for major reconstructive surgery were included. Ten of 11 patients had either bilateral proximal tubal obstruction, unilateral proximal tubal obstruction with contralateral tubal disease, or unilateral proximal tubal obstruction with an absent contralateral tube, confirming that unilateral tubal disease on HSG is often a false-positive finding. l5 We were able to cannulate 13 of the 18 fallopian tubes attempted (72%). In the successful group, follow-up HSG confirmed patency in eight of 11 tubes studied and two patients became pregnant before follow-up HSG, thereby negating the need for laparotomy and tubocornual reconstruction. We were unable to cannulate five of 18 tubes attempted (28%) which roughly correlates with the reported incidence of true occlusion. 4 The failure rate of 28 % may reflect the type of patients studied, since all patients had proximal tubal obstruction documented by both HSG and chromopertubation. All tubes that we were unable to cannulate remained obstructed at follow-up HSG. Failed cannulations could represent either true occlusion, or tortuous and narrow uterotubal junctions. Two of the tubes, however, in the unsuccessful group were resected and showed pathologic evidence of salpingitis isthmic a nodosa and fibrosis. This further supports the concept that tubes unable to be cannulated may have true pathologic occlusion. In the five failed cannulations there were two tubal perforations that did not require further treatment. A smaller, more flexible guidewire might provide both a higher success rate and a lower perforation rate. The absence of harmful complications in both Vol. 53, No.2, February 1990

our series and other reports lO- l2 gives cannulation of the fallopian tube an acceptable margin of safety. Four of the 11 patients (36%) had coexistent distal tubal disease, and two of the 11 patients (18%) had coexistent adnexal disease without distal tubal disease. Therefore, if the pelvic anatomy is unknown at the time of tubal cannulation, we advocate concurrent laparoscopy to evaluate and repair possible coexistent adnexal disease. Concurrent laparoscopy also allows for accurate documentation of the location of the tip of the guidewire. There were six pregnancies (54%), three of which were distal ectopics that occurred in the patients with distal tubal disease. Therefore, after successful cannulation, patients with coexistent distal tubal disease must be closely followed for an ectopic pregnancy. The other three pregnancies were intrauterine, one of these occurring in a woman with distal tubal disease repaired at the time of cannulation. There were no ectopic pregnancies in the proximal tube. In conclusion, patients with proximal tubal obstruction diagnosed by HSG and confirmed by chromopertubation are candidates for attempted hysteroscopic cannulation of the fallopian tube. While the procedure clearly is diagnostic and able to identify those patients with true pathologic occlusion who might benefit from tubocornual reconstruction, it may also be therapeutic in some patients, thus providing an endoscopic method for the restoration of proximal tubal patency. If the patient presents with unknown pelvic anatomy, a concomitant laparoscopy to evaluate potential coexistent adnexal disease is recommended. If tubal cannulation is successful in restoring patency, then patients with distal tubal disease need to be followed closely for an ectopic pregnancy. The safety and ease of the procedure, combined with the high postoperative patency rate, makes hysteroscopic cannulation of the fallopian tube a viable option before tubocornual reconstruction. Table 3 A Summary of the Pregnancies that Occurred After Hysteroscopic Cannulation of the Fallopian Tube

Normal distal tubes Abnormal distal tubes Total

Intrauterine pregnancy

Ectopic

Total

2"/7 1/4 3/11

0/7 3/4 3/11

2/7 4/4

6 b/11

"Includes one bilateral isthmic-interstitial anastomosis. b Average length of time until pregnancy, 6 months. Deaton et al.

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REFERENCES 1. Gomel V: Laparoscopy prior to reconstructive tubal surgery for infertility. J Reprod Med 18:251, 1977 2. Winfield AC, Pittaway D, Maxson W, Daniell J, Wentz AC: Apparent cornual occlusion in hysterosalpingography: reversal by glucagon. AJR 139:525, 1982 3. Holst N, Abyholm T, Borgersen A: Hysterosalpingography in the evaluation of infertility. Acta RadioI24:253, 1983 4. Sulak PJ, Letterie GS, Coddington CC, Hayslip CC, Woodward JE, Klein TA: Histology of proximal tubal occlusion. Fertil Steril48:437, 1987 5. Fortier KJ, Haney AF: The pathologic spectrum of uterotubal junction obstruction. Obstet GynecoI65:93, 1985 6. Musich JR, Behrman SJ: Surgical management of tubal obstruction at the uterotubal junction. Fertil Steril 40:423, 1983 7. Thurmond AS, Novy M, Rosch J: Terbutaline in diagnosis of interstitial fallopian tube obstruction. Invest Radiol 23: 209, 1988 8. Gerlock AJ, Hooser CW: Oviduct response to glucagon during hysterosalpingography. Radiology 119:727, 1976 9. World Health Organization: A new hysterographic ap-

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10.

11.

12.

13.

14. 15.

proach to the evaluation of tubal spasm and spasmolytic agents. Fertil SteriI39:105, 1983 Novy MJ, Thurmond AS, Patton P, Uchida BT, Rosch J: Diagnosis of cornual obstruction by transcervical fallopian tube cannulation. Fertil Steril50:434, 1988 Daniell JF, Miller W: Hysteroscopic correction of cornual occlusion with resultant term pregnancy. Fertil Steril 48: 490, 1987 Sulak PJ, Letterie GS, Hayslip CC, Coddington CC, Klein T A: Hysteroscopic cannulation and lavage in the treatment of proximal tubal occlusion. Fertil Steril48:493, 1987 Platia MP, Krudy AG: Transcervical fluoroscopic recanalization of a proximally occluded oviduct. Fertil Steril44:704, 1985 Confino E, Friberg J, Gleicher N: Transcervical balloon tuboplasty. Fertil Steril 46:963, 1986 Gibson M, Hickerson J: A review of the utility and reliability of hysterosalpingography. (Abstr. 163) Presented at the 40th Annual Meeting of The American Fertility Society, New Orleans, Louisiana, April 4 to 7, 1984. Published by The American Fertility Society, in the program supplement, 1984, p 69S

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