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Outcome of Laparoscopy-Guided Hysteroscopic Tubal Catheterization for Infertility Due to Proximal Tubal Obstruction
Original Article
Outcome of Laparoscopy-Guided Hysteroscopic Tubal Catheterization for Infertility Due to Proximal Tubal Obstruction Hai Yan Hou, Ya Qiong Chen*, Tin-Chiu Li, Chun Xiu Hu, Xiao Chen, and Zhen Hua Yang From the Department of Obstetrics and Gynaecology, Affiliated Hospital of the Chinese People’s Armed Police Force Logistics College, Tianjin, China (Drs. Hou, Y.Q. Chen, Hu, X. Chen, and Yang), and Jessop Wing, Sheffield Teaching Hospitals, Sheffield, England (Drs. Hou and Li).
ABSTRACT Study Objective: To determine pregnancy outcomes after laparoscopy-guided hysteroscopic tubal catheterization and to report its role in the era of in vitro fertilization. Design: Clinical cases series (Canadian Task Force classification II-3). Setting: Reproductive surgery center. Patients: Patients with unilateral or bilateral proximal tubal obstruction as the only cause of infertility were included. Interventions: Laparoscopy-guided hysteroscopic tubal catheterization. Measurements and Main Results: Only the first spontaneous conception was considered. Cumulative conception rate (CCR) was calculated using Kaplan-Meier survival analysis. Of 168 women included, 107 (63.7%) had bilateral proximal obstruction and 61 (36.3%) had unilateral obstruction. The successful recanalization rate was 54.2% per tube and 61.9% per patient. In the 93 patients in whom at least 1 fallopian tube was successfully recanalized, 40 spontaneous pregnancies (43.0%) occurred within 24 months, of which 35 (37.6%) were intrauterine pregnancies and 28 (30.1%) resulted in live births. The CCR was 37.6% at 1 year and 43.7% at 2 years. Patients with unilateral obstruction in whom cannulation was successful had the highest CCR (60.7% at 2 years). Conclusion: Successful tubal cannulation led to significant improvement in the pregnancy rate, which suggests that women with a proximal tubal block could be considered for laparoscopy-guided hysteroscopic cannulation, which is still a viable alternative to in vitro fertilization. Journal of Minimally Invasive Gynecology (2014) 21, 272–278 Ó 2014 AAGL. All rights reserved. Keywords:
Hysteroscopic tubal catheterization; Infertility; Laparoscopy; Proximal tubal obstruction
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Disease of the fallopian tubes is responsible for 25% to 30% of female infertility worldwide [1]. Tubal damage may occur after pelvic inflammatory disease, pelvic and abdominal surgery, and endometriosis. About 10% to 25% of women with tubal disease have proximal obstruction [2], which may be associated with the presence of mucus plugs, debris, or fibrosis of the tubal lumen. Available therSupported by grant 11JCZDJC20000 from the Natural Science Funding of Tianjin and grant 81273977/H2902 from the National Natural Science Funding of China. The authors declare that they have no conflicts of interest. Corresponding author: Ya Qiong Chen, MD, Department of Obstetrics and Gynaecology, Affiliated Hospital of the Chinese People’s Armed Police Force Logistics College, Tianjin, China. E-mail: [email protected] Submitted May 27, 2013. Accepted for publication September 11, 2013. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2014 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2013.09.003
apeutic options include tubal surgery and in vitro fertilization (IVF). The National Institute of Clinical Excellence (NICE; London, UK) has recommended that for women with proximal tubal obstruction selective salpingography plus tubal catheterization or hysteroscopic tubal cannulation may be treatment options. Because these treatments improve the chance of pregnancy, tubal cannulation should be considered in women with proximal tubal blockage [3]. Tubal cannulation involves insertion of a guide wire within a fine catheter, guided either via fluoroscopy (selective salpingography) [4–15], laparoscopy [16–20], hysteroscopy [21], or ultrasonography [22]. Alternatively, it can also be performed via falloposcopy, which permits direct visualization of the lumen [23]. It is debatable which method of guidance produces the best result and is most cost-effective. A review of the literature (Table 1) showed that the mean successful cannulation rate is 70.7%, with a pregnancy rate of
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Table 1 Literature review of selective catheterization of proximal tubal obstruction Source, year Selective salpingography Sowa et al [4], 1993 Thompson et al [5], 1994 Woolcott et al [6], 1995 Ba et al [7], 1999 Atallah and Karam [8], 1999 Papaioannou et al [9], 2002 Hayashi et al [10], 2003 Rawal et al [11], 2005 Al-Jaroudi et al [12], 2005 Verma et al [13], 2009 Anil et al [14], 2011 Cobellis et al [15], 2012 Mean Laparoscopy-guided hysteroscopic cannulation Sakumoto et al [16], 1993 Allahbadia et al [17], 2000 Das et al [18], 2007 Mekaru et al [19], 2011 Chung et al [20], 2012 Mean Hysteroscopic cannulation Spiewankiewicz and Stelmachow [21], 1995 Ultrasound-guided selective salpingography Rahimunnisa et al [22], 2009 Falloposcopy Tanaka et al [23], 2011 Total, mean
No. of patients
Successful cannulation per patient, %
Pregnancy rate, %
Live birth rate, %
58 28 66 122 53 218 11 14 72 16 100 33
70.7 31.0 80.5 88.7 97.5 50.1 100 78.0 34.7 87.5 86.8 75.6 68.8
22.2 30.7 36.4 40.2 45.0 27.1 55.0a 28.6 31.9 35.0 36.8 48.5 34.0
NA NA NA 32.0 NA NA 36.0% NA NA NA NA NA 32.3
88 17 53 61 70
NA 88.2 67.9 37.1 71.4 61.5
43.0 23.5 33.3 27.7 35.8 35.1
NA 23.5 NA 14.8 NA 16.7
15
73.3
13.3
NA
25
84.0
16.0
NA
345
81.6 70.7
29.9 32.9
NA 26.6
NA 5 not available. a Only women with unilateral tubal block.
32.9% and live birth rate of 26.6%. Nevertheless, the results published by various authors varied widely, with spontaneous crude pregnancy rate (CPR) ranging from 13.3% to 55.0%. An important determinant of the pregnancy rate after tubal cannulation is whether only one or both tubes are blocked and, in the case of bilateral blockage, whether only one or both tubes were successfully cannulated. Another important determinant of the pregnancy rate is the duration of followup. Most previous publications reported the CPR only, without allowing for the duration of follow-up and the number of patients lost to follow-up by reporting on the cumulative conception rate (CCR). The literature data summarized in Table 1 showed that the 2 most popular methods of guidance used for tubal cannulation are fluoroscopy or laparoscopy. Fluoroscopy has a number of advantages; it is less costly and can be performed as an outpatient procedure. In experienced centers, it is possible to measure the pressure within the tube, which seems to provide additional prognostic information [9]. However, a caveat of fluoroscopy is radiation exposure. In contrast, laparoscopy-guided hysteroscopic cannulation is more costly, more invasive, and involves use of general
anesthesia. However, it has a number of advantages. Laparoscopy is considered the criterion standard for assessment of tubal patency [24], and it permits thorough examination of the pelvis and fallopian tubes, which provides information about the underlying disease such as peritubal adhesions or endometriosis. More important, it provides additional information about the distal end of the fallopian tube, which cannot be ascertained with fluoroscopy if there is also a proximal block. It is well accepted that bipolar tubal disease is a contraindication for tubal surgery including tubal cannulation [25]. Hysteroscopic examination before cannulation also provides useful information about the uterine cavity including the possibility of a small myoma or of polyps or adhesions obstructing the tubal ostia, all of which can be viewed easily during hysteroscopy. As for ultrasound-guided hysteroscopic cannulation, despite its attractiveness because it is relatively simple, inexpensive, and can be performed in the outpatient setting (as in the case of fluoroscopy), its diagnostic accuracy is considered inferior to that with fluoroscopic or laparoscopic guidance. Few investigators have used this particular approach [22]. Finally, falloposcopic cannulation of
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the fallopian tubes is rather expensive and requires a high level of technical expertise, and currently is rarely used [23]. Herein we report our experience with laparoscopy-guided hysteroscopic tubal cannulation, with an analysis of outcome separately for unilateral and bilateral proximal block based on both the CPR and the CCR. Material and Methods Patients Data were collected from an Access database of patient records that included medical history, investigations, reproductive surgery, and follow-up outcomes. From January 2008 to October 2010 in our infertility unit, 650 women with hysterosalpingograms that showed a proximal block and no other identifiable cause of infertility underwent laparoscopic assessment. In 71 women, both tubes were found to be normal and patent; therefore, cannulation was not indicated. In 411 women, there was evidence of either bipolar tubal disease (i.e., both proximal and distal block), severe peritubal adhesions, or endometriosis; therefore, tubal cannulation was not performed, and these women were not included in the study. One hundred sixty-eight patients with unilateral or bilateral proximal tubal obstruction were considered suitable for laparoscopy-guided hysteroscopic cannulation of the fallopian tubes because they fulfilled the following inclusion criteria: i) proximal tubal block confirmed during laparoscopy; ii) absence of concurrent distal tubal occlusion; and iii) absence of other important infertility factors including male infertility (using World Health Organization definitions), ovulation disorder, endometriosis, severe pelvic adhesions, and abnormal uterine cavity. Surgery Laparoscopic surgery was performed during the follicular phase of the menstrual cycle by an experienced gynecologic endoscopist (C.Y.Q, C.X, H.C.X, Y.Z.H.). For 3 days starting on the day of surgery, patients received premedication consisting of 0.5 mg atropine sulphate injected subcutaneously and antibiotic prophylaxis with metronidazole. A routine pelvic and speculum examination was performed before the laparoscopic procedure to exclude any vaginal or pelvic inflammatory disease. The cervix and vagina were visualized using a vaginal speculum and were cleansed using povidone iodine. Laparoscopy was performed with the patient under general anesthesia, with trocars inserted at 3 sites. Mild pelvic adhesions were identified and treated. Chromopertubation was performed via slow infusion of indigo blue dye to assess tubal patency. Hysteroscopy was performed before hysteroscopic cannulation of fallopian tubes. Hysteroscopic cannulation was performed using a 5F catheter with a J guidewire (0.035 inch, 150 cm; Terumo
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Corp., Tokyo, Japan), inserted into the interstitial and isthmic segments of the fallopian tube. Entry of the catheter and guidewire into the fallopian tube was visualized and monitored via concurrent laparoscopy (Fig. 1). Afterward, the guidewire was withdrawn, and methylene blue dye was injected into the catheter to verify whether the tube had now become patent (recanalization). At the conclusion of the surgery, normal saline solution was used to irrigate the pelvic cavity, and an anti-adhesion agent (Absorbable Adhesion Barrier; Ethicon, Inc., Somerville, NJ) was applied to the site of previous adhesions, if any. After the surgery, regular follow-up via telephone consultation was performed at 3, 6, 12, 18, and 24 months. Information about pregnancy and its outcome was documented. Women who decided to proceed with assisted conception treatment were considered dropouts. In women who conceived more than once, only the first conception during the study period was included in the analysis. Statistical Analysis The CCR was obtained using Kaplan-Meier survival analysis. Log-rank tests were performed to evaluate the difference in pregnancy rates among different groups of patients. A p value of , .05 was considered statistically significant. Results One hundred sixty-eight women with proximal tubal obstruction as the only cause of infertility were included in the analysis. Their mean (SD) age was 31.5 (3.8) years (range, 21–39 years), and duration of infertility was 5.2 (3.3) years (range, 1–18 years). Fifty-three women (31.5%) had primary infertility, and 115 (68.5%) had secondary infertility. Of those with secondary infertility, 24 (14.3%) had had .1 delivery and 11 (6.5%) had had an ectopic pregnancy with medical treatment. Of the 168 patients included in the study, 107 (63.7%) had bilateral proximal tubal obstruction and 61 (36.3%) had unilateral obstruction. Laparoscopy revealed mild peritubal adhesions in 111 women (66.1%). The outcome of attempted tubal cannulation in women with bilateral or unilateral proximal tubal occlusion is given in Table 2. The overall successful tubal cannulation rate was 54.2% per tube and 61.9% per patient. The successful cannulation rate per tube in unilateral or bilateral tubal occlusion was similar (54.1% vs 54.2%, respectively). Among the 168 patients studied, 14 were lost to follow-up. Overall, the spontaneous CPR was 43.0%. The pregnancy rate among women who had bilateral or unilateral tubal block and successful or failed cannulation are given in Table 3. Patients who had unilateral tubal occlusion successfully cannulated had the highest spontaneous pregnancy rate, 60.7%. Patients who had at least 1 blocked tube successfully cannulated had a significantly higher (p , .05) spontaneous pregnancy
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Fig. 1 Laparoscopy-guided hysteroscopic tubal catheterization using a guidewire. (A) Catheter is inserted into interstitial segment of tube. (B) Backflow of blue dye is observed. (C) Guidewire is inserted into interstitial segment of tube during hysteroscopy. (D) Guidewire is inserted from interstitial segment to fimbria during laparoscopy.
rate than did patients who did not. Among those in whom cannulation was successful and who conceived, the pregnancy rate was 47.8% (33/69), the live birth rate was 34.8% (24/69), the miscarriage rate was 12.1% (4/33), and the ectopic pregnancy rate was 15.2% (5/33). Among 154 patients who had follow-up information after successful tubal cannulation, the pregnancy rate in women with adhesions was 27.0% (30/111), not significantly different from that in those without adhesions, 35.1 (20/ 57) (p . .05). The overall CCR of the 93 patients in whom at least 1 fallopian tube was successfully cannulated is shown in Figure 2A. The CCR for the entire group was 37.6% at 1 year, and 43.7% at 2 years after tubal recanalization. The CCR for the 4 subgroups, i.e., unilateral obstruction and sucTable 2 Results of fallopian tube catheterization in 168 patients Variable Bilateral occlusion Bilateral cannulation successful Unilateral cannulation successful Cannulation unsuccessful on either side Unilateral occlusion Cannulation successful Cannulation unsuccessful Overall rate of successful cannulation Per tube cannulated Per patient
No. of patients (%) 107 (63.7) 45 (42.1) 26 (24.3) 36 (33.6) 61 (36.3) 33 (54.1) 28 (45.9) 149/275 (54.2) 104/168 (61.9)
cessful cannulation, bilateral obstruction and both sides successfully cannulated, unilateral obstruction and failed cannulation, and bilateral obstruction and 1 tube successfully cannulated, are shown in Figure 2B. Patients who had unilateral obstruction that was successfully cannulated had the highest CCR. Log-rank test results showed significant differences between the 4 groups (p 5 .03). Discussion In the present study, we examined the outcome of laparoscopy-guided hysteroscopic cannulation of the fallopian tubes. In women with a proximal tubal block, we achieved a successful cannulation rate of 61.9% per patient, comparable to an average result of 61.5% published in the literature (Table 1). The successful cannulation rate of laparoscopy-guided hysteroscopic cannulation seems to be lower than what may be achieved with other methods including fluoroscopic guidance (68.8%), ultrasound guidance (84.0%), and falloposcopy (81.6%). At first glance, laparoscopy-guided hysteroscopic cannulation seems to be inferior to other methods. However, further examination of the results given in Table 1 show that laparoscopy-guided hysteroscopic cannulation yielded the highest pregnancy rate (35.1%) as compared with other methods including fluoroscopic guidance (34.0%), ultrasound guidance (16.0%), and falloposcopy (29.9%). There are several possible explanations for the discrepancy in successful cannulation rate and pregnancy rate. With fluoroscopic guidance, ultrasound selective salpingography, and falloposcopy, important data about the distal
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Table 3 Pregnancy outcome after tubal cannulation of proximal blocka,b Variable
Spontaneous pregnancy
Live birth
Miscarriage
Ectopic pregnancy
Bilateral obstruction Bilateral cannulation Unilateral cannulation No cannulation Unilateral obstruction Cannulation successful Cannulation unsuccessful
25/99 16/41 (39.0)b 7/24 (29.2)d 2/34 (5.9)f 25/56 17/28 (60.7)h 8/27 (29.6)j
19 13 (31.7)c 4 (16.7)e 2 (5.9)g 18 11 (39.3)i 7 (25.9)
4 1 (2.4) 3 (12.5) 0 3 3 (10.7) 0
2 2 (4.9) 0 0 4 3 (10.7) 1 (3.7)
NS 5 not significant. a Values are given as number of patients (%). b p Values: b vs d (NS); b vs f (p , .05); d vs f (p , .05); h vs j (p , .05); c vs e (NS); c vs d (p , .05); e vs g (p , .05); i vs k (NS).
fallopian tube are often missing. Our own data suggest that the 63.2% of patients considered as having proximal tubal disease at hysterosalpingography were found to have bipolar tubal disease. The prognosis in this group of patients is poor indeed, and accounts for the relatively poor pregnancy rate
despite a high tubal cannulation rate in some series. In contrast, after thorough endoscopic examination, we also found in our series that just over 10.9% of patients did not have tubal blockage. Tubal cannulation in this group of patients is not necessary, and its inclusion would only serve
Fig. 2 Cumulative conception rate (CCR) after tubal cannulation to treat proximal block. (A) CCR of spontaneous pregnancy in patients with at least 1 tube successfully cannulated. Blue line indicates Kaplan-Meier estimates. Time is measured from date of cannulation. (B) CCR in 4 subgroups. Log-rank test showed a significant difference between groups (p 5 .03).
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to increase the successful cannulation rate (by approximately 10%) without necessarily improving the pregnancy rate because the underlying cause of the infertility is not related to tubal disease. A combination of these factors would explain why fluoroscopy, ultrasound, and falloposcopy yield an apparently higher successful cannulation rate but a lower pregnancy rate. It also serves to strengthen the argument that tubal cannulation should be performed after careful assessment of the pelvis via laparoscopy. Comparison with Literature Data In our series, we achieved a pregnancy rate of 43.0% and a live birth rate after successful cannulation of 34.8% (24/69), which is higher than the mean results achieved in other series involving laparoscopy-guided hysteroscopic cannulation, 16.7% (Table 1). We believe that the primary reason for the improved outcome after tubal cannulation is the opportunity to manage concurrent pelvic disease via laparoscopy during the cannulation procedure, such as division of peritubal adhesions.
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Excellence, 2004) but also for financial reasons because it seems to be a more cost-effective option in China, although this may not necessarily be true in other parts of the world. The cost-effectiveness consideration above refers only to women with confirmed proximal block without concurrent distal tubal disease. However, our data show that most patients in our series had bipolar disease (63%) and were not candidates for tubal surgery. If the cost of a diagnostic laparoscopy ($1471) in these patients with bipolar disease is added to the overall cost calculation, the cost-effectiveness of the 2 strategies, tubal cannulation followed by IVF if tubal cannulation was not successful or not indicated and IVF in all patients, is broadly similar. However, the advantage of IVF is shorter time to conception, which is immediate in most cases except frozen embryo transfer. For women who underwent tubal cannulation, the CCR was 30.1% at 6 months and 37.6% at 12 months. Although the complication rate for hysteroscopic cannulation and laparoscopy is considered to be low, the complication rate for IVF is likely even lower.
Ectopic Pregnancy In the literature, there are 2 different methods of reporting the ectopic pregnancy rate after tubal cannulation, i.e., ectopic pregnancy per subjects who underwent successful cannulation and ectopic pregnancy per confirmed pregnancy. The former method produces a lower rate than the latter method; however, we believe that the latter method of reporting is more meaningful. In our series, of 50 pregnancies, 6 (12.0%) were ectopic (12.0%), similar to that reported by other investigators, e.g., 10.7% by Papaioannou et al [9]. The risk of ectopic pregnancy after tubal surgery was recently reviewed by Schippert et al [26]: the overall ectopic pregnancy rate after tubal surgery was approximately 77% higher than that after an assisted reproductive treatment procedure. IVF vs Cannulation Women with proximal tubal disease as the cause of infertility have 2 treatment options, i.e., tubal surgery, including hysteroscopic cannulation, and IVF. IVF has gained increasing popularity because of continuing improvement in the live birth rate, which is 32.4% in each cycle for women with tubal-associated infertility [27]. Our results suggest that laparoscopy-guided hysteroscopic cannulation has a similar, if not better, overall live birth rate of 34.8%. In women with unilateral proximal block successfully cannulated, the live birth rate is even higher, at 39.3%. However, the laparoscopy-guided hysteroscopic cannulation procedure is less costly than IVF. In China, the cost is approximately $2452, compared with IVF treatment cost of $5723 [28]. It would seem that hysteroscopic cannulation in women with proximal tubal block may be recommended not only on clinical grounds (National Institute for Health and Clinical
Bilateral vs Unilateral Block In the present study, we found that the pregnancy rate and live birth rate after hysteroscopic cannulation depends on whether 1 or both tubes were blocked. Women who had unilateral tubal block successfully cannulated had the highest pregnancy rate, 60.7% compared with 39.0% in those with bilateral tubal block successful cannulated. Our literature review of the outcome of tubal cannulation (Table 1) showed that the series with the highest pregnancy rate of 55.0% [10] was based on women with only unilateral block. We analyzed separately the results for unilateral and bilateral tubal block; however, many previous investigations seem to have combined them. It is sometimes disputed that women with unilateral tubal disease do not require treatment because, given time, they will be able to conceive via the contralateral normal tube. However, our data showed convincingly that the pregnancy rate after successful cannulation of a unilateral blocked tube (60.7%) is significantly higher than when cannulation failed (29.6%) (p 5 .02). The pregnancy rate in the latter group is strikingly similar to that in women with bilateral tubal obstruction in whom only 1 tube was successfully cannulated (29.2%). In our series, 2 women conceived spontaneously and had live births despite unsuccessful cannulation. This implies that at least 1 of the tubes must have been patent. A possible explanation is that spasm of the proximal end of the tube resulted in temporary blockage during the procedure. One possible weakness of our study is that we did not routinely perform tubal patency data in the postoperative period and thus were unable to correlate this information with pregnancy outcomes.
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In conclusion, laparoscopy-guided hysteroscopic cannulation produces results comparable to those with IVF and should be offered to patients as an alternative to IVF. Acknowledgments We thank all of the women who participated in this research, and the research assistants who performed the initial extensive data abstraction from the medical files and imported them into the database. We also thank the attending gynecologists at our clinics for making the initial data collection possible. References 1. Serafini P, Batzofin J. Diagnosis of female infertility: a comprehensive approach. J Reprod Med. 1989;34:29–40. 2. Honore GM, Holden AE, Schenken RS. Pathophysiology and management of proximal tubal blockage. Fertil Steril. 1999;71:785–795. 3. National Institute for Clinical Excellence. Fertility: assessment and treatment for people with fertility problems. Clinical guideline. London: National Institute for Clinical Excellence; 2004. 4. Sowa M, Shimamoto T, Nakano R, Sato M, Yamada R. Diagnosis and treatment of proximal tubal obstruction by fluoroscopic transcervical fallopian tube catheterization. Hum Reprod. 1993;8:1711–1714. 5. Thompson KA, Kiltz RJ, Koci T, Cabus ET, Kletzky OA. Transcervical fallopian tube catheterization and recanalization for proximal tubal obstruction. Fertil Steril. 1994;61:243–247. 6. Woolcott R, Petchpud A, O’Donnell P, Stanger J. Differential impact on pregnancy rate of selective salpingography, tubal catheterization and wire-guide recanalization in the treatment of proximal Fallopian tube obstruction. Hum Reprod. 1995;10:1423–1426. 7. Ba SD, Badiane M, Ba AA, Niang EH, Ba AL, Agaicha A. Selective salpingography in the treatment of infertility caused by proximal tubal obstruction: apropos of 122 cases treated in Dakar [in French]. Sante. 1999;9:81–84. 8. Atallah N, Karam R. Selective salpingography and transcervical tubal recanalization: technique, indications, results. apropos of 53 proceedings [in French]. J Med Liban. 1999;47:154–158. 9. Papaioannou S, Afnan M, Girling AJ, et al. Long-term fertility prognosis following selective salpingography and tubal catheterization in women with proximal tubal blockage. Hum Reprod. 2002;17: 2325–2330. 10. Hayashi M, Hoshimoto K, Ohkura T. Successful conception following Fallopian tube recanalization in infertile patients with a unilateral proximally occluded tube and a contralateral patent tube. Hum Reprod. 2003;18:96–99. 11. Rawal N, Haddad N, Abbott GT. Selective salpingography and fallopian tube recanalisation: experience from a district general hospital. J Obstet Gynaecol. 2005;25:586–588.
Journal of Minimally Invasive Gynecology, Vol 21, No 2, March/April 2014 12. Al-Jaroudi D, Herba MJ, Tulandi T. Reproductive performance after selective tubal catheterization. J Minim Invasive Gynecol. 2005;12: 150–152. 13. Verma A, Krarup K, Donuru A. Selective salpingography and fallopian tube catheterisation by guidewire. J Obstet Gynaecol. 2009;29: 315–317. 14. Anil G, Tay KH, Loh SF, Yong TT, Ong CL, Tan BS. Fluoroscopyguided, transcervical, selective salpingography and fallopian tube recanalisation. J Obstet Gynaecol. 2011;31:746–750. 15. Cobellis L, Argano F, Castaldi MA, et al. Selective salpingography: preliminary experience of an office operative option for proximal tubal recanalization. Eur J Obstet Gynecol Reprod Biol. 2012;163: 62–66. 16. Sakumoto T, Shinkawa T, Izena H, et al. Treatment of infertility associated with endometriosis by selective tubal catheterization under hysteroscopy and laparoscopy. Am J Obstet Gynecol. 1993;169:744–747. 17. 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. Gynaecol Endosc. 2000;9: 31–35. 18. Das S, Nardo LG, Seif MW. Proximal tubal disease: the place for tubal cannulation. Reprod Biomed Online. 2007;15:383–388. 19. Mekaru K, Yagi C, Asato K, Masamoto H, Sakumoto K, Aoki Y. Hysteroscopic tubal catheterization under laparoscopy for proximal tubal obstruction. Arch Gynecol Obstet. 2011;284:1573–1576. 20. Chung JP, Haines CJ, Kong GW. Long-term reproductive outcome after hysteroscopic proximal tubal cannulation: an outcome analysis. Aust N Z J Obstet Gynaecol. 2012;52:470–475. 21. Spiewankiewicz B, Stelmachow J. Hysteroscopic tubal catheterization in diagnosis and treatment of proximal oviductal obstruction. Clin Exp Obstet Gynecol. 1995;22:23–27. 22. Rahimunnisa S, Tanwar R, Prasad S. Ultrasound versus tactile cannulation in the treatment of proximal tubal obstruction. Int J Gynecol Obstet. 2009;106:216–217. 23. Tanaka Y, Tajima H, Sakuraba S, Shimokawa R, Kamei K. Renaissance of surgical recanalization for proximal fallopian tubal occlusion: falloposcopic tuboplasty as a promising therapeutic option in tubal infertility. J Minim Invasive Gynecol. 2011;18:651–659. 24. Mol BW, Collins JA, Burrows EA, van der Veen F, Bossuyt PM. Comparison of hysterosalpingography and laparoscopy in predicting fertility outcome. Hum Reprod. 1999;14:1237–1242. 25. Singhal V, Li TC, Cooke ID. An analysis of factors influencing the outcome of 232 consecutive tubal microsurgery cases. Br J Obstet Gynaecol. 1991;98:628–636. 26. Schippert C, Soergel P, Staboulidou I, et al. The risk of ectopic pregnancy following tubal reconstructive microsurgery and assisted reproductive technology procedures. Arch Gynecol Obstet. 2012;285: 863–871. 27. Society for Assisted Reproductive Technology. 2012 Clinic Summary Report. Available at: www.sart.org. Accessed January 17, 2013. 28. Zheng XY, Qiu Y. Disease burden of infertility in China. Chin J Public Health. 2012;28:257–260.
Outcome of Laparoscopy-Guided Hysteroscopic Tubal Catheterization for Infertility Due to Proximal Tubal Obstruction Hai Yan Hou, Ya Qiong Chen*, Tin-Chiu Li, Chun Xiu Hu, Xiao Chen, and Zhen Hua Yang From the Department of Obstetrics and Gynaecology, Affiliated Hospital of the Chinese People’s Armed Police Force Logistics College, Tianjin, China (Drs. Hou, Y.Q. Chen, Hu, X. Chen, and Yang), and Jessop Wing, Sheffield Teaching Hospitals, Sheffield, England (Drs. Hou and Li).
ABSTRACT Study Objective: To determine pregnancy outcomes after laparoscopy-guided hysteroscopic tubal catheterization and to report its role in the era of in vitro fertilization. Design: Clinical cases series (Canadian Task Force classification II-3). Setting: Reproductive surgery center. Patients: Patients with unilateral or bilateral proximal tubal obstruction as the only cause of infertility were included. Interventions: Laparoscopy-guided hysteroscopic tubal catheterization. Measurements and Main Results: Only the first spontaneous conception was considered. Cumulative conception rate (CCR) was calculated using Kaplan-Meier survival analysis. Of 168 women included, 107 (63.7%) had bilateral proximal obstruction and 61 (36.3%) had unilateral obstruction. The successful recanalization rate was 54.2% per tube and 61.9% per patient. In the 93 patients in whom at least 1 fallopian tube was successfully recanalized, 40 spontaneous pregnancies (43.0%) occurred within 24 months, of which 35 (37.6%) were intrauterine pregnancies and 28 (30.1%) resulted in live births. The CCR was 37.6% at 1 year and 43.7% at 2 years. Patients with unilateral obstruction in whom cannulation was successful had the highest CCR (60.7% at 2 years). Conclusion: Successful tubal cannulation led to significant improvement in the pregnancy rate, which suggests that women with a proximal tubal block could be considered for laparoscopy-guided hysteroscopic cannulation, which is still a viable alternative to in vitro fertilization. Journal of Minimally Invasive Gynecology (2014) 21, 272–278 Ó 2014 AAGL. All rights reserved. Keywords:
Hysteroscopic tubal catheterization; Infertility; Laparoscopy; Proximal tubal obstruction
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Disease of the fallopian tubes is responsible for 25% to 30% of female infertility worldwide [1]. Tubal damage may occur after pelvic inflammatory disease, pelvic and abdominal surgery, and endometriosis. About 10% to 25% of women with tubal disease have proximal obstruction [2], which may be associated with the presence of mucus plugs, debris, or fibrosis of the tubal lumen. Available therSupported by grant 11JCZDJC20000 from the Natural Science Funding of Tianjin and grant 81273977/H2902 from the National Natural Science Funding of China. The authors declare that they have no conflicts of interest. Corresponding author: Ya Qiong Chen, MD, Department of Obstetrics and Gynaecology, Affiliated Hospital of the Chinese People’s Armed Police Force Logistics College, Tianjin, China. E-mail: [email protected] Submitted May 27, 2013. Accepted for publication September 11, 2013. Available at www.sciencedirect.com and www.jmig.org 1553-4650/$ - see front matter Ó 2014 AAGL. All rights reserved. http://dx.doi.org/10.1016/j.jmig.2013.09.003
apeutic options include tubal surgery and in vitro fertilization (IVF). The National Institute of Clinical Excellence (NICE; London, UK) has recommended that for women with proximal tubal obstruction selective salpingography plus tubal catheterization or hysteroscopic tubal cannulation may be treatment options. Because these treatments improve the chance of pregnancy, tubal cannulation should be considered in women with proximal tubal blockage [3]. Tubal cannulation involves insertion of a guide wire within a fine catheter, guided either via fluoroscopy (selective salpingography) [4–15], laparoscopy [16–20], hysteroscopy [21], or ultrasonography [22]. Alternatively, it can also be performed via falloposcopy, which permits direct visualization of the lumen [23]. It is debatable which method of guidance produces the best result and is most cost-effective. A review of the literature (Table 1) showed that the mean successful cannulation rate is 70.7%, with a pregnancy rate of
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Table 1 Literature review of selective catheterization of proximal tubal obstruction Source, year Selective salpingography Sowa et al [4], 1993 Thompson et al [5], 1994 Woolcott et al [6], 1995 Ba et al [7], 1999 Atallah and Karam [8], 1999 Papaioannou et al [9], 2002 Hayashi et al [10], 2003 Rawal et al [11], 2005 Al-Jaroudi et al [12], 2005 Verma et al [13], 2009 Anil et al [14], 2011 Cobellis et al [15], 2012 Mean Laparoscopy-guided hysteroscopic cannulation Sakumoto et al [16], 1993 Allahbadia et al [17], 2000 Das et al [18], 2007 Mekaru et al [19], 2011 Chung et al [20], 2012 Mean Hysteroscopic cannulation Spiewankiewicz and Stelmachow [21], 1995 Ultrasound-guided selective salpingography Rahimunnisa et al [22], 2009 Falloposcopy Tanaka et al [23], 2011 Total, mean
No. of patients
Successful cannulation per patient, %
Pregnancy rate, %
Live birth rate, %
58 28 66 122 53 218 11 14 72 16 100 33
70.7 31.0 80.5 88.7 97.5 50.1 100 78.0 34.7 87.5 86.8 75.6 68.8
22.2 30.7 36.4 40.2 45.0 27.1 55.0a 28.6 31.9 35.0 36.8 48.5 34.0
NA NA NA 32.0 NA NA 36.0% NA NA NA NA NA 32.3
88 17 53 61 70
NA 88.2 67.9 37.1 71.4 61.5
43.0 23.5 33.3 27.7 35.8 35.1
NA 23.5 NA 14.8 NA 16.7
15
73.3
13.3
NA
25
84.0
16.0
NA
345
81.6 70.7
29.9 32.9
NA 26.6
NA 5 not available. a Only women with unilateral tubal block.
32.9% and live birth rate of 26.6%. Nevertheless, the results published by various authors varied widely, with spontaneous crude pregnancy rate (CPR) ranging from 13.3% to 55.0%. An important determinant of the pregnancy rate after tubal cannulation is whether only one or both tubes are blocked and, in the case of bilateral blockage, whether only one or both tubes were successfully cannulated. Another important determinant of the pregnancy rate is the duration of followup. Most previous publications reported the CPR only, without allowing for the duration of follow-up and the number of patients lost to follow-up by reporting on the cumulative conception rate (CCR). The literature data summarized in Table 1 showed that the 2 most popular methods of guidance used for tubal cannulation are fluoroscopy or laparoscopy. Fluoroscopy has a number of advantages; it is less costly and can be performed as an outpatient procedure. In experienced centers, it is possible to measure the pressure within the tube, which seems to provide additional prognostic information [9]. However, a caveat of fluoroscopy is radiation exposure. In contrast, laparoscopy-guided hysteroscopic cannulation is more costly, more invasive, and involves use of general
anesthesia. However, it has a number of advantages. Laparoscopy is considered the criterion standard for assessment of tubal patency [24], and it permits thorough examination of the pelvis and fallopian tubes, which provides information about the underlying disease such as peritubal adhesions or endometriosis. More important, it provides additional information about the distal end of the fallopian tube, which cannot be ascertained with fluoroscopy if there is also a proximal block. It is well accepted that bipolar tubal disease is a contraindication for tubal surgery including tubal cannulation [25]. Hysteroscopic examination before cannulation also provides useful information about the uterine cavity including the possibility of a small myoma or of polyps or adhesions obstructing the tubal ostia, all of which can be viewed easily during hysteroscopy. As for ultrasound-guided hysteroscopic cannulation, despite its attractiveness because it is relatively simple, inexpensive, and can be performed in the outpatient setting (as in the case of fluoroscopy), its diagnostic accuracy is considered inferior to that with fluoroscopic or laparoscopic guidance. Few investigators have used this particular approach [22]. Finally, falloposcopic cannulation of
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the fallopian tubes is rather expensive and requires a high level of technical expertise, and currently is rarely used [23]. Herein we report our experience with laparoscopy-guided hysteroscopic tubal cannulation, with an analysis of outcome separately for unilateral and bilateral proximal block based on both the CPR and the CCR. Material and Methods Patients Data were collected from an Access database of patient records that included medical history, investigations, reproductive surgery, and follow-up outcomes. From January 2008 to October 2010 in our infertility unit, 650 women with hysterosalpingograms that showed a proximal block and no other identifiable cause of infertility underwent laparoscopic assessment. In 71 women, both tubes were found to be normal and patent; therefore, cannulation was not indicated. In 411 women, there was evidence of either bipolar tubal disease (i.e., both proximal and distal block), severe peritubal adhesions, or endometriosis; therefore, tubal cannulation was not performed, and these women were not included in the study. One hundred sixty-eight patients with unilateral or bilateral proximal tubal obstruction were considered suitable for laparoscopy-guided hysteroscopic cannulation of the fallopian tubes because they fulfilled the following inclusion criteria: i) proximal tubal block confirmed during laparoscopy; ii) absence of concurrent distal tubal occlusion; and iii) absence of other important infertility factors including male infertility (using World Health Organization definitions), ovulation disorder, endometriosis, severe pelvic adhesions, and abnormal uterine cavity. Surgery Laparoscopic surgery was performed during the follicular phase of the menstrual cycle by an experienced gynecologic endoscopist (C.Y.Q, C.X, H.C.X, Y.Z.H.). For 3 days starting on the day of surgery, patients received premedication consisting of 0.5 mg atropine sulphate injected subcutaneously and antibiotic prophylaxis with metronidazole. A routine pelvic and speculum examination was performed before the laparoscopic procedure to exclude any vaginal or pelvic inflammatory disease. The cervix and vagina were visualized using a vaginal speculum and were cleansed using povidone iodine. Laparoscopy was performed with the patient under general anesthesia, with trocars inserted at 3 sites. Mild pelvic adhesions were identified and treated. Chromopertubation was performed via slow infusion of indigo blue dye to assess tubal patency. Hysteroscopy was performed before hysteroscopic cannulation of fallopian tubes. Hysteroscopic cannulation was performed using a 5F catheter with a J guidewire (0.035 inch, 150 cm; Terumo
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Corp., Tokyo, Japan), inserted into the interstitial and isthmic segments of the fallopian tube. Entry of the catheter and guidewire into the fallopian tube was visualized and monitored via concurrent laparoscopy (Fig. 1). Afterward, the guidewire was withdrawn, and methylene blue dye was injected into the catheter to verify whether the tube had now become patent (recanalization). At the conclusion of the surgery, normal saline solution was used to irrigate the pelvic cavity, and an anti-adhesion agent (Absorbable Adhesion Barrier; Ethicon, Inc., Somerville, NJ) was applied to the site of previous adhesions, if any. After the surgery, regular follow-up via telephone consultation was performed at 3, 6, 12, 18, and 24 months. Information about pregnancy and its outcome was documented. Women who decided to proceed with assisted conception treatment were considered dropouts. In women who conceived more than once, only the first conception during the study period was included in the analysis. Statistical Analysis The CCR was obtained using Kaplan-Meier survival analysis. Log-rank tests were performed to evaluate the difference in pregnancy rates among different groups of patients. A p value of , .05 was considered statistically significant. Results One hundred sixty-eight women with proximal tubal obstruction as the only cause of infertility were included in the analysis. Their mean (SD) age was 31.5 (3.8) years (range, 21–39 years), and duration of infertility was 5.2 (3.3) years (range, 1–18 years). Fifty-three women (31.5%) had primary infertility, and 115 (68.5%) had secondary infertility. Of those with secondary infertility, 24 (14.3%) had had .1 delivery and 11 (6.5%) had had an ectopic pregnancy with medical treatment. Of the 168 patients included in the study, 107 (63.7%) had bilateral proximal tubal obstruction and 61 (36.3%) had unilateral obstruction. Laparoscopy revealed mild peritubal adhesions in 111 women (66.1%). The outcome of attempted tubal cannulation in women with bilateral or unilateral proximal tubal occlusion is given in Table 2. The overall successful tubal cannulation rate was 54.2% per tube and 61.9% per patient. The successful cannulation rate per tube in unilateral or bilateral tubal occlusion was similar (54.1% vs 54.2%, respectively). Among the 168 patients studied, 14 were lost to follow-up. Overall, the spontaneous CPR was 43.0%. The pregnancy rate among women who had bilateral or unilateral tubal block and successful or failed cannulation are given in Table 3. Patients who had unilateral tubal occlusion successfully cannulated had the highest spontaneous pregnancy rate, 60.7%. Patients who had at least 1 blocked tube successfully cannulated had a significantly higher (p , .05) spontaneous pregnancy
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Fig. 1 Laparoscopy-guided hysteroscopic tubal catheterization using a guidewire. (A) Catheter is inserted into interstitial segment of tube. (B) Backflow of blue dye is observed. (C) Guidewire is inserted into interstitial segment of tube during hysteroscopy. (D) Guidewire is inserted from interstitial segment to fimbria during laparoscopy.
rate than did patients who did not. Among those in whom cannulation was successful and who conceived, the pregnancy rate was 47.8% (33/69), the live birth rate was 34.8% (24/69), the miscarriage rate was 12.1% (4/33), and the ectopic pregnancy rate was 15.2% (5/33). Among 154 patients who had follow-up information after successful tubal cannulation, the pregnancy rate in women with adhesions was 27.0% (30/111), not significantly different from that in those without adhesions, 35.1 (20/ 57) (p . .05). The overall CCR of the 93 patients in whom at least 1 fallopian tube was successfully cannulated is shown in Figure 2A. The CCR for the entire group was 37.6% at 1 year, and 43.7% at 2 years after tubal recanalization. The CCR for the 4 subgroups, i.e., unilateral obstruction and sucTable 2 Results of fallopian tube catheterization in 168 patients Variable Bilateral occlusion Bilateral cannulation successful Unilateral cannulation successful Cannulation unsuccessful on either side Unilateral occlusion Cannulation successful Cannulation unsuccessful Overall rate of successful cannulation Per tube cannulated Per patient
No. of patients (%) 107 (63.7) 45 (42.1) 26 (24.3) 36 (33.6) 61 (36.3) 33 (54.1) 28 (45.9) 149/275 (54.2) 104/168 (61.9)
cessful cannulation, bilateral obstruction and both sides successfully cannulated, unilateral obstruction and failed cannulation, and bilateral obstruction and 1 tube successfully cannulated, are shown in Figure 2B. Patients who had unilateral obstruction that was successfully cannulated had the highest CCR. Log-rank test results showed significant differences between the 4 groups (p 5 .03). Discussion In the present study, we examined the outcome of laparoscopy-guided hysteroscopic cannulation of the fallopian tubes. In women with a proximal tubal block, we achieved a successful cannulation rate of 61.9% per patient, comparable to an average result of 61.5% published in the literature (Table 1). The successful cannulation rate of laparoscopy-guided hysteroscopic cannulation seems to be lower than what may be achieved with other methods including fluoroscopic guidance (68.8%), ultrasound guidance (84.0%), and falloposcopy (81.6%). At first glance, laparoscopy-guided hysteroscopic cannulation seems to be inferior to other methods. However, further examination of the results given in Table 1 show that laparoscopy-guided hysteroscopic cannulation yielded the highest pregnancy rate (35.1%) as compared with other methods including fluoroscopic guidance (34.0%), ultrasound guidance (16.0%), and falloposcopy (29.9%). There are several possible explanations for the discrepancy in successful cannulation rate and pregnancy rate. With fluoroscopic guidance, ultrasound selective salpingography, and falloposcopy, important data about the distal
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Table 3 Pregnancy outcome after tubal cannulation of proximal blocka,b Variable
Spontaneous pregnancy
Live birth
Miscarriage
Ectopic pregnancy
Bilateral obstruction Bilateral cannulation Unilateral cannulation No cannulation Unilateral obstruction Cannulation successful Cannulation unsuccessful
25/99 16/41 (39.0)b 7/24 (29.2)d 2/34 (5.9)f 25/56 17/28 (60.7)h 8/27 (29.6)j
19 13 (31.7)c 4 (16.7)e 2 (5.9)g 18 11 (39.3)i 7 (25.9)
4 1 (2.4) 3 (12.5) 0 3 3 (10.7) 0
2 2 (4.9) 0 0 4 3 (10.7) 1 (3.7)
NS 5 not significant. a Values are given as number of patients (%). b p Values: b vs d (NS); b vs f (p , .05); d vs f (p , .05); h vs j (p , .05); c vs e (NS); c vs d (p , .05); e vs g (p , .05); i vs k (NS).
fallopian tube are often missing. Our own data suggest that the 63.2% of patients considered as having proximal tubal disease at hysterosalpingography were found to have bipolar tubal disease. The prognosis in this group of patients is poor indeed, and accounts for the relatively poor pregnancy rate
despite a high tubal cannulation rate in some series. In contrast, after thorough endoscopic examination, we also found in our series that just over 10.9% of patients did not have tubal blockage. Tubal cannulation in this group of patients is not necessary, and its inclusion would only serve
Fig. 2 Cumulative conception rate (CCR) after tubal cannulation to treat proximal block. (A) CCR of spontaneous pregnancy in patients with at least 1 tube successfully cannulated. Blue line indicates Kaplan-Meier estimates. Time is measured from date of cannulation. (B) CCR in 4 subgroups. Log-rank test showed a significant difference between groups (p 5 .03).
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to increase the successful cannulation rate (by approximately 10%) without necessarily improving the pregnancy rate because the underlying cause of the infertility is not related to tubal disease. A combination of these factors would explain why fluoroscopy, ultrasound, and falloposcopy yield an apparently higher successful cannulation rate but a lower pregnancy rate. It also serves to strengthen the argument that tubal cannulation should be performed after careful assessment of the pelvis via laparoscopy. Comparison with Literature Data In our series, we achieved a pregnancy rate of 43.0% and a live birth rate after successful cannulation of 34.8% (24/69), which is higher than the mean results achieved in other series involving laparoscopy-guided hysteroscopic cannulation, 16.7% (Table 1). We believe that the primary reason for the improved outcome after tubal cannulation is the opportunity to manage concurrent pelvic disease via laparoscopy during the cannulation procedure, such as division of peritubal adhesions.
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Excellence, 2004) but also for financial reasons because it seems to be a more cost-effective option in China, although this may not necessarily be true in other parts of the world. The cost-effectiveness consideration above refers only to women with confirmed proximal block without concurrent distal tubal disease. However, our data show that most patients in our series had bipolar disease (63%) and were not candidates for tubal surgery. If the cost of a diagnostic laparoscopy ($1471) in these patients with bipolar disease is added to the overall cost calculation, the cost-effectiveness of the 2 strategies, tubal cannulation followed by IVF if tubal cannulation was not successful or not indicated and IVF in all patients, is broadly similar. However, the advantage of IVF is shorter time to conception, which is immediate in most cases except frozen embryo transfer. For women who underwent tubal cannulation, the CCR was 30.1% at 6 months and 37.6% at 12 months. Although the complication rate for hysteroscopic cannulation and laparoscopy is considered to be low, the complication rate for IVF is likely even lower.
Ectopic Pregnancy In the literature, there are 2 different methods of reporting the ectopic pregnancy rate after tubal cannulation, i.e., ectopic pregnancy per subjects who underwent successful cannulation and ectopic pregnancy per confirmed pregnancy. The former method produces a lower rate than the latter method; however, we believe that the latter method of reporting is more meaningful. In our series, of 50 pregnancies, 6 (12.0%) were ectopic (12.0%), similar to that reported by other investigators, e.g., 10.7% by Papaioannou et al [9]. The risk of ectopic pregnancy after tubal surgery was recently reviewed by Schippert et al [26]: the overall ectopic pregnancy rate after tubal surgery was approximately 77% higher than that after an assisted reproductive treatment procedure. IVF vs Cannulation Women with proximal tubal disease as the cause of infertility have 2 treatment options, i.e., tubal surgery, including hysteroscopic cannulation, and IVF. IVF has gained increasing popularity because of continuing improvement in the live birth rate, which is 32.4% in each cycle for women with tubal-associated infertility [27]. Our results suggest that laparoscopy-guided hysteroscopic cannulation has a similar, if not better, overall live birth rate of 34.8%. In women with unilateral proximal block successfully cannulated, the live birth rate is even higher, at 39.3%. However, the laparoscopy-guided hysteroscopic cannulation procedure is less costly than IVF. In China, the cost is approximately $2452, compared with IVF treatment cost of $5723 [28]. It would seem that hysteroscopic cannulation in women with proximal tubal block may be recommended not only on clinical grounds (National Institute for Health and Clinical
Bilateral vs Unilateral Block In the present study, we found that the pregnancy rate and live birth rate after hysteroscopic cannulation depends on whether 1 or both tubes were blocked. Women who had unilateral tubal block successfully cannulated had the highest pregnancy rate, 60.7% compared with 39.0% in those with bilateral tubal block successful cannulated. Our literature review of the outcome of tubal cannulation (Table 1) showed that the series with the highest pregnancy rate of 55.0% [10] was based on women with only unilateral block. We analyzed separately the results for unilateral and bilateral tubal block; however, many previous investigations seem to have combined them. It is sometimes disputed that women with unilateral tubal disease do not require treatment because, given time, they will be able to conceive via the contralateral normal tube. However, our data showed convincingly that the pregnancy rate after successful cannulation of a unilateral blocked tube (60.7%) is significantly higher than when cannulation failed (29.6%) (p 5 .02). The pregnancy rate in the latter group is strikingly similar to that in women with bilateral tubal obstruction in whom only 1 tube was successfully cannulated (29.2%). In our series, 2 women conceived spontaneously and had live births despite unsuccessful cannulation. This implies that at least 1 of the tubes must have been patent. A possible explanation is that spasm of the proximal end of the tube resulted in temporary blockage during the procedure. One possible weakness of our study is that we did not routinely perform tubal patency data in the postoperative period and thus were unable to correlate this information with pregnancy outcomes.
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In conclusion, laparoscopy-guided hysteroscopic cannulation produces results comparable to those with IVF and should be offered to patients as an alternative to IVF. Acknowledgments We thank all of the women who participated in this research, and the research assistants who performed the initial extensive data abstraction from the medical files and imported them into the database. We also thank the attending gynecologists at our clinics for making the initial data collection possible. References 1. Serafini P, Batzofin J. Diagnosis of female infertility: a comprehensive approach. J Reprod Med. 1989;34:29–40. 2. Honore GM, Holden AE, Schenken RS. Pathophysiology and management of proximal tubal blockage. Fertil Steril. 1999;71:785–795. 3. National Institute for Clinical Excellence. Fertility: assessment and treatment for people with fertility problems. Clinical guideline. London: National Institute for Clinical Excellence; 2004. 4. Sowa M, Shimamoto T, Nakano R, Sato M, Yamada R. Diagnosis and treatment of proximal tubal obstruction by fluoroscopic transcervical fallopian tube catheterization. Hum Reprod. 1993;8:1711–1714. 5. Thompson KA, Kiltz RJ, Koci T, Cabus ET, Kletzky OA. Transcervical fallopian tube catheterization and recanalization for proximal tubal obstruction. Fertil Steril. 1994;61:243–247. 6. Woolcott R, Petchpud A, O’Donnell P, Stanger J. Differential impact on pregnancy rate of selective salpingography, tubal catheterization and wire-guide recanalization in the treatment of proximal Fallopian tube obstruction. Hum Reprod. 1995;10:1423–1426. 7. Ba SD, Badiane M, Ba AA, Niang EH, Ba AL, Agaicha A. Selective salpingography in the treatment of infertility caused by proximal tubal obstruction: apropos of 122 cases treated in Dakar [in French]. Sante. 1999;9:81–84. 8. Atallah N, Karam R. Selective salpingography and transcervical tubal recanalization: technique, indications, results. apropos of 53 proceedings [in French]. J Med Liban. 1999;47:154–158. 9. Papaioannou S, Afnan M, Girling AJ, et al. Long-term fertility prognosis following selective salpingography and tubal catheterization in women with proximal tubal blockage. Hum Reprod. 2002;17: 2325–2330. 10. Hayashi M, Hoshimoto K, Ohkura T. Successful conception following Fallopian tube recanalization in infertile patients with a unilateral proximally occluded tube and a contralateral patent tube. Hum Reprod. 2003;18:96–99. 11. Rawal N, Haddad N, Abbott GT. Selective salpingography and fallopian tube recanalisation: experience from a district general hospital. J Obstet Gynaecol. 2005;25:586–588.
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