- Email: [email protected]
Reproductive performance after selective tubal catheterization
Journal of Minimally Invasive Gynecology (2005) 12, 150-152
Instruments and techniques
Reproductive performance after selective tubal catheterization Dania Al-Jaroudi, MD, Milton J. Herba, MD, and Togas Tulandi, MD From the Department of Obstetrics and Gynecology (Drs. Al-Jaroudi and Tulandi), and Department of Radiology (Dr. Herba), McGill University, Montreal, Quebec, Canada.
KEYWORDS: Proximal tubal occlusion; Cornual blockage; Selective tubal catheterization; Transcervical tubal cannulation
STUDY OBJECTIVE: To evaluate the reproductive performance of women after selective tubal catheterization. DESIGN: Retrospective study (Canadian Task Force classification II-3). SETTING: University teaching hospital. PATIENTS: Ninety-eight infertile women with hysterosalpingographic findings of proximal tubal occlusion. INTERVENTION: Hysterosalpingography and selective tubal catheterization. MEASUREMENTS AND MAIN RESULTS: Repeat hysterosalpingography examination before selective tubal catheterization in 98 patients revealed bilateral tubal patency in 14 patients and patency of one of the tubes in 12 others (12.2%). True proximal tubal occlusion was encountered in 72 patients (139 tubes). Successful recanalization of both tubes was achieved in 25 patients (34.7%), and successful recanalization of at least one tube was achieved in 44 patients (61.1%). Of the 72 patients who underwent selective tubal catheterization, 23 patients conceived. The cumulative probability of conception was 28%, 59%, and 73% at 12, 18, and 24 months of follow-up, respectively. The median procedure-conception interval was 16.2 months. CONCLUSION: One-quarter of patients diagnosed with bilateral proximal tubal occlusion on hysterosalpingography do not have tubal obstruction. Among those with true occlusion, selective tubal catheterization leads to an overall pregnancy rate of 31.9%. © 2005 AAGL. All rights reserved.
The findings of proximal tubal occlusion (PTO) or cornual occlusion on hysterosalpingogram can be due to several reasons including tubal spasm, mucus plugs, debris, or true cornual blockage.1 In order to distinguish between true cornual obstruction and other lesions, several methods including laparoscopy have been advocated. During laparoscopy, tubal patency can be assessed, and some surgeons also can perform tubal reconstruction. A less-invasive technique than tubal surgery is selective tubal catheterization (STC) or Corresponding author: Togas Tulandi, MD, Department of Obstetrics and Gynecology, McGill University, 687 Pine Avenue West, Montreal, Quebec, Canada, H3A 1A1. E-mail: [email protected].
1553-4650/$ -see front matter © 2005 AAGL. All rights reserved. doi:10.1016/j.jmig.2005.01.013
transcervical tubal cannulation.2 Selective tubal catheterization can be done using balloon angiographic catheters or guidewires under fluoroscopic, hysteroscopic, or ultrasound guidance. The reported successful cannulation of at least one fallopian tube is 79% with a pregnancy rate of 34%.3
Materials and methods We examined the medical records of all women with hysterosalpingographic findings of bilateral PTO who subsequently underwent STC at McGill University Health Center, Montreal, from January 1994 through January 2001. All procedures were done by one operator (MJH).
Al-Jaroudi et al
Tubal Catheterization
As in our standard practice, all patients had complete infertility investigations, including a transvaginal ultrasound examination and a semen analysis of the male partner. Only patients with possible tubal factor infertility were included in the study. Starting 1 day before the STC procedure, patients were given 100 mg of oral doxycycline twice daily. Repeat hysterosalpingography was performed first. If the tubes were not visualized during a period of up to 1 minute, a Torcon curved 5F catheter (Cook, Inc., Spencer, Indiana) was introduced into the cornua, and radio-contrast (Omnipaque, Sanofi, Inc., Ontario, Canada) was re-injected. If this failed, a 3F catheter loaded with a guidewire was introduced coaxially and passed into the middle or distal third of the fallopian tube. The wire was then removed, and the contrast was injected. If another obstruction was encountered, attempts were made to cross it with the guidewire. During the procedure, several images were taken. At the completion of the procedure, a conventional hysterosalpingography was performed. Information regarding pregnancy was obtained from the medical file and by contacting the patient. For the purpose of analysis, only the first conception was taken into account. For statistical analysis, pregnancy rate was evaluated using a life table analysis.
Results Data from 98 women were included in the analysis. Three patients who were lost from follow-up immediately after the procedure were excluded. The average age of the patients was 33.2 ⫾ 5.0 years, and the mean duration of infertility was 2.9 ⫾ 2.2 years. Primary infertility was encountered in 32 patients (32.7%). Repeat hysterosalpingography examination just before STC in 98 patients revealed bilateral tubal patency in 14 patients (14.3%) and patency of one of the tubes in 12 others (12.2%). In these patients, STC was abandoned. True PTO was encountered in 72 patients (139 tubes). Successful recanalization of both tubes was achieved in 25 patients (34.7%), and successful recanalization of at least one tube was achieved in 44 patients (61.1%). Failure of tubal cannulation was encountered more on the left side (12 tubes) than the right side (1 tube). Abnormal radiologic findings encountered during recanalization were changes suggesting salpingitis isthmica nodosa (two patients, four tubes), hydrosalpinx (three patients, four tubes), and midtubal obstruction (two patients, four tubes). Perforation of the tube was encountered in two patients. They were given prophylactic oral antibiotics, and no further treatment was needed. Of the 72 patients who underwent STC, 23 patients conceived (crude pregnancy rate of 31.9%). Figure 1 shows the cumulative probability of conception following STC. The median procedure-conception interval was 16.2 months. All pregnancies were intrauterine. Three patients (13%) had a miscarriage.
151
Figure 1 Cumulative probability of conception after selective tubal catheterization.
Discussion During the past 5 years, STC has been used as a primary option in patients with hysterosalpingographic findings of PTO. The radiologic findings of PTO, however, have to be interpreted with caution. Indeed, we found a false-diagnosis rate of 26.5%. Also, in those with successful tubal cannulation, concomitant tubal pathology (hydrosalpinx and midtubal obstruction) was found in five patients. True occlusion was found in 72 out of 98 patients. Similar findings have been reported (hydrosalpinx 10.4%, midtubal obstruction 4.2%, and distal blockage 6.2%).4 For reasons that we cannot explain, failure was encountered more on the left side than the right (12 vs 1). In a review of 1079 patients, a patency rate of 62% and a crude pregnancy rate of 30% were reported.5 In our series, successful recanalization of both tubes was achieved in 25 patients (34.7%), and successful recanalization of at least one tube was achieved in 44 patients (61.1%). In agreement with others,3–5 our crude pregnancy rate was 31.9%. Using life table analysis, the cumulative probabilities of conception were 28%, 59%, and 73% at 12, 18, and 24 months, respectively. Others have reported a pregnancy rate of 47.2% 12 months after STC.6 The reported incidence of ectopic pregnancy following STC is 3%.5 In our series, all pregnancies were intrauterine. We treated patients in whom STC was not successful with in-vitro fertilization (IVF), and laparoscopy was seldom performed. One study7 randomized two groups of patients to either laparoscopic chromopertubation followed by STC or STC followed by laparoscopic chromopertubation. Proximal tubal occlusion was diagnosed in 11.9% during laparoscopy versus 3.6% during STC. Distal tubal occlusion was found in 5.6% during laparoscopy and 10.5% during STC. These data suggest that STC is a better diagnostic tool than laparoscopy for true cornual occlusion, while laparoscopy is better than STC in delineating peritubal disease. There is no difference between the two tests in diagnosing distal tubal obstruction. Another study8 analyzed the cost per live birth for different therapeutic approaches for PTO. The costs were $17 000 for tubal surgery, $12 000 for IVF, and $6400 for STC. These figures, along with the reported low complica-
152
Journal of Minimally Invasive Gynecology, Vol 12, No 2, March/April 2005
tion rate, suggest that STC is an alternative option to tubal surgery and IVF.
Conclusion We conclude that the false-positive rate of hysterosalpingographic findings of PTO is high. In this situation, STC should be performed.
References 1. Sulak PJ, Letterie GS, Coddington CC, Hayslip CC,Woodward JE, Klein TA: Histology of proximal tubal occlusion. Fertil Steril 1987, 48:437-40. 2. Confino E, Tur-Kaspa I, Gleicher N: Sonographic transcervical balloon tuboplasty. Human Reprod 1992, 7:1271-3.
3. Flood J, Grow D: Transcervical tubal cannulation: a review. Obstet Gynecol Survey 1993, 48:768-76. 4. Papaioannou S, Afnan M, Girling A, et al: Diagnostic and therapeutic value of selective salpingography and tubal catheterization in unselected infertile population. Fertil Steril 2003, 79:613-7. 5. Thurmond A, Machan L, Maubon A, et al: A review of selective salpingography and fallopian tube catheterization. Radiographics 2000, 20:1759-68. 6. Papaioannou S, Afnan M, Girling A, et al: Long-term fertility prognosis following selective salpingography and tubal catheterization in women with proximal tubal blockage. Hum Reprod 2003, 17:2325-30. 7. Woolcott R, Fisher S, Thomas J, Kable W: A randomized, prospective, controlled study of laparoscopic dye studies and selective salpingography as diagnostic tests of fallopian tube patency. Fertil Steril 1999, 72:879-84. 8. Lang E, Dunaway H: Recanalization of obstructed fallopian tube by selective salpingography and transvaginal bougie dilatation: outcome and cost analysis. Fertil Steril 1996, 66:210-5.
Instruments and techniques
Reproductive performance after selective tubal catheterization Dania Al-Jaroudi, MD, Milton J. Herba, MD, and Togas Tulandi, MD From the Department of Obstetrics and Gynecology (Drs. Al-Jaroudi and Tulandi), and Department of Radiology (Dr. Herba), McGill University, Montreal, Quebec, Canada.
KEYWORDS: Proximal tubal occlusion; Cornual blockage; Selective tubal catheterization; Transcervical tubal cannulation
STUDY OBJECTIVE: To evaluate the reproductive performance of women after selective tubal catheterization. DESIGN: Retrospective study (Canadian Task Force classification II-3). SETTING: University teaching hospital. PATIENTS: Ninety-eight infertile women with hysterosalpingographic findings of proximal tubal occlusion. INTERVENTION: Hysterosalpingography and selective tubal catheterization. MEASUREMENTS AND MAIN RESULTS: Repeat hysterosalpingography examination before selective tubal catheterization in 98 patients revealed bilateral tubal patency in 14 patients and patency of one of the tubes in 12 others (12.2%). True proximal tubal occlusion was encountered in 72 patients (139 tubes). Successful recanalization of both tubes was achieved in 25 patients (34.7%), and successful recanalization of at least one tube was achieved in 44 patients (61.1%). Of the 72 patients who underwent selective tubal catheterization, 23 patients conceived. The cumulative probability of conception was 28%, 59%, and 73% at 12, 18, and 24 months of follow-up, respectively. The median procedure-conception interval was 16.2 months. CONCLUSION: One-quarter of patients diagnosed with bilateral proximal tubal occlusion on hysterosalpingography do not have tubal obstruction. Among those with true occlusion, selective tubal catheterization leads to an overall pregnancy rate of 31.9%. © 2005 AAGL. All rights reserved.
The findings of proximal tubal occlusion (PTO) or cornual occlusion on hysterosalpingogram can be due to several reasons including tubal spasm, mucus plugs, debris, or true cornual blockage.1 In order to distinguish between true cornual obstruction and other lesions, several methods including laparoscopy have been advocated. During laparoscopy, tubal patency can be assessed, and some surgeons also can perform tubal reconstruction. A less-invasive technique than tubal surgery is selective tubal catheterization (STC) or Corresponding author: Togas Tulandi, MD, Department of Obstetrics and Gynecology, McGill University, 687 Pine Avenue West, Montreal, Quebec, Canada, H3A 1A1. E-mail: [email protected].
1553-4650/$ -see front matter © 2005 AAGL. All rights reserved. doi:10.1016/j.jmig.2005.01.013
transcervical tubal cannulation.2 Selective tubal catheterization can be done using balloon angiographic catheters or guidewires under fluoroscopic, hysteroscopic, or ultrasound guidance. The reported successful cannulation of at least one fallopian tube is 79% with a pregnancy rate of 34%.3
Materials and methods We examined the medical records of all women with hysterosalpingographic findings of bilateral PTO who subsequently underwent STC at McGill University Health Center, Montreal, from January 1994 through January 2001. All procedures were done by one operator (MJH).
Al-Jaroudi et al
Tubal Catheterization
As in our standard practice, all patients had complete infertility investigations, including a transvaginal ultrasound examination and a semen analysis of the male partner. Only patients with possible tubal factor infertility were included in the study. Starting 1 day before the STC procedure, patients were given 100 mg of oral doxycycline twice daily. Repeat hysterosalpingography was performed first. If the tubes were not visualized during a period of up to 1 minute, a Torcon curved 5F catheter (Cook, Inc., Spencer, Indiana) was introduced into the cornua, and radio-contrast (Omnipaque, Sanofi, Inc., Ontario, Canada) was re-injected. If this failed, a 3F catheter loaded with a guidewire was introduced coaxially and passed into the middle or distal third of the fallopian tube. The wire was then removed, and the contrast was injected. If another obstruction was encountered, attempts were made to cross it with the guidewire. During the procedure, several images were taken. At the completion of the procedure, a conventional hysterosalpingography was performed. Information regarding pregnancy was obtained from the medical file and by contacting the patient. For the purpose of analysis, only the first conception was taken into account. For statistical analysis, pregnancy rate was evaluated using a life table analysis.
Results Data from 98 women were included in the analysis. Three patients who were lost from follow-up immediately after the procedure were excluded. The average age of the patients was 33.2 ⫾ 5.0 years, and the mean duration of infertility was 2.9 ⫾ 2.2 years. Primary infertility was encountered in 32 patients (32.7%). Repeat hysterosalpingography examination just before STC in 98 patients revealed bilateral tubal patency in 14 patients (14.3%) and patency of one of the tubes in 12 others (12.2%). In these patients, STC was abandoned. True PTO was encountered in 72 patients (139 tubes). Successful recanalization of both tubes was achieved in 25 patients (34.7%), and successful recanalization of at least one tube was achieved in 44 patients (61.1%). Failure of tubal cannulation was encountered more on the left side (12 tubes) than the right side (1 tube). Abnormal radiologic findings encountered during recanalization were changes suggesting salpingitis isthmica nodosa (two patients, four tubes), hydrosalpinx (three patients, four tubes), and midtubal obstruction (two patients, four tubes). Perforation of the tube was encountered in two patients. They were given prophylactic oral antibiotics, and no further treatment was needed. Of the 72 patients who underwent STC, 23 patients conceived (crude pregnancy rate of 31.9%). Figure 1 shows the cumulative probability of conception following STC. The median procedure-conception interval was 16.2 months. All pregnancies were intrauterine. Three patients (13%) had a miscarriage.
151
Figure 1 Cumulative probability of conception after selective tubal catheterization.
Discussion During the past 5 years, STC has been used as a primary option in patients with hysterosalpingographic findings of PTO. The radiologic findings of PTO, however, have to be interpreted with caution. Indeed, we found a false-diagnosis rate of 26.5%. Also, in those with successful tubal cannulation, concomitant tubal pathology (hydrosalpinx and midtubal obstruction) was found in five patients. True occlusion was found in 72 out of 98 patients. Similar findings have been reported (hydrosalpinx 10.4%, midtubal obstruction 4.2%, and distal blockage 6.2%).4 For reasons that we cannot explain, failure was encountered more on the left side than the right (12 vs 1). In a review of 1079 patients, a patency rate of 62% and a crude pregnancy rate of 30% were reported.5 In our series, successful recanalization of both tubes was achieved in 25 patients (34.7%), and successful recanalization of at least one tube was achieved in 44 patients (61.1%). In agreement with others,3–5 our crude pregnancy rate was 31.9%. Using life table analysis, the cumulative probabilities of conception were 28%, 59%, and 73% at 12, 18, and 24 months, respectively. Others have reported a pregnancy rate of 47.2% 12 months after STC.6 The reported incidence of ectopic pregnancy following STC is 3%.5 In our series, all pregnancies were intrauterine. We treated patients in whom STC was not successful with in-vitro fertilization (IVF), and laparoscopy was seldom performed. One study7 randomized two groups of patients to either laparoscopic chromopertubation followed by STC or STC followed by laparoscopic chromopertubation. Proximal tubal occlusion was diagnosed in 11.9% during laparoscopy versus 3.6% during STC. Distal tubal occlusion was found in 5.6% during laparoscopy and 10.5% during STC. These data suggest that STC is a better diagnostic tool than laparoscopy for true cornual occlusion, while laparoscopy is better than STC in delineating peritubal disease. There is no difference between the two tests in diagnosing distal tubal obstruction. Another study8 analyzed the cost per live birth for different therapeutic approaches for PTO. The costs were $17 000 for tubal surgery, $12 000 for IVF, and $6400 for STC. These figures, along with the reported low complica-
152
Journal of Minimally Invasive Gynecology, Vol 12, No 2, March/April 2005
tion rate, suggest that STC is an alternative option to tubal surgery and IVF.
Conclusion We conclude that the false-positive rate of hysterosalpingographic findings of PTO is high. In this situation, STC should be performed.
References 1. Sulak PJ, Letterie GS, Coddington CC, Hayslip CC,Woodward JE, Klein TA: Histology of proximal tubal occlusion. Fertil Steril 1987, 48:437-40. 2. Confino E, Tur-Kaspa I, Gleicher N: Sonographic transcervical balloon tuboplasty. Human Reprod 1992, 7:1271-3.
3. Flood J, Grow D: Transcervical tubal cannulation: a review. Obstet Gynecol Survey 1993, 48:768-76. 4. Papaioannou S, Afnan M, Girling A, et al: Diagnostic and therapeutic value of selective salpingography and tubal catheterization in unselected infertile population. Fertil Steril 2003, 79:613-7. 5. Thurmond A, Machan L, Maubon A, et al: A review of selective salpingography and fallopian tube catheterization. Radiographics 2000, 20:1759-68. 6. Papaioannou S, Afnan M, Girling A, et al: Long-term fertility prognosis following selective salpingography and tubal catheterization in women with proximal tubal blockage. Hum Reprod 2003, 17:2325-30. 7. Woolcott R, Fisher S, Thomas J, Kable W: A randomized, prospective, controlled study of laparoscopic dye studies and selective salpingography as diagnostic tests of fallopian tube patency. Fertil Steril 1999, 72:879-84. 8. Lang E, Dunaway H: Recanalization of obstructed fallopian tube by selective salpingography and transvaginal bougie dilatation: outcome and cost analysis. Fertil Steril 1996, 66:210-5.