- Email: [email protected]
Transcervical Fallopian Tube Recanalization
ment. ment. With With NF, rvF, maternal mate rn al age has the greatest effect on outcome. outcome.
Conclusions Conclusions IVF and and tubal surgery are complementary rather than competitive competitive procedures. Adequate Adequate selection of patients is is the the key key to to finding fi nding the best therapeutic approach.
References References 1. 1. Diamond MP, ed. Infertility Infertility Surgery, Su rgery,
Clinical Practice of Gynecology: Vol. 3, No.1; No. 1; 1991.
2. 2. diZerega diZe rega G, et aI, aI, eds. eds. Pelvic Surgery: Adhesion Formation and Prevention. Springer-Verlag; 1997. 3. 3. Speroff Speroff L, et ai, aI, eds. Clinical Gynecologic Endocrinology no logy and In1ertility, Infertility, 6th Edition. Philadelphia, PA Lippincott Williams Will iams & Wilkins; Wilkins; 1999. 4. 4. Diedrich Diedrich K, K, Felberbaum Felberbaum R, R, eds. ART in the year 2000, 2000. ESHRE Campus Workshop. Hum Reprod Rep rod 1999; 1999; 14(suppl 1). 14(suppl I ). 12:30 12:30 pm
Transcervical Transcervica1 Fallopian Tube Recanalization Amy Amy S. S. Thurmond, Thurmond, MD MD Me1idan Men·dan Park Park Hospital Tualatin, Tualatin, Oregon
Pro ximal Tubal Obstn.Jction Obs truction Proximal The intramural intramural portion of the fallopian fallopia n tube is an average The of 11 cm em in length length and and has a luminal lum inal diameter of about 1 of mm. Its Its course is straight or slightly curved in 60% of mm. cases and and convoluted or tOrtuous tortuous in 400/0 (l). (1). A large cases number of pathologic pa tho logic conditions can affect this part ooff number the tube tube and their relative frequency varies depending the on the population. Infection and subsequent on the patient population. inflammation or fibrosis are leading causes of proximal inflammation tuba l occlusion occlusion and and are frequently the consequence of tubal chlamydial or gonococcal salpingitis or postpartum enchlamydial dometritis (2). Interestingly, dometritis Interestingly, about half of patients with proximal tubal tuba l obstruction well -documented well-documented bilateral prOXimal very loca lized disease with no pelvic 'adhesions ·ad hesions have have very localized the m idea l cand idates for an attempt at (3,4), making (3,4), making them ideal candidates tuba l catheterization for establishment of patency. tubal catheterization for Cathe te rization Technique Catheterization The instruments ins[Jum en ts and techniques techn iques for fluoroscopic falloThe pian tube tube catheterization, ca theterizalio n, selective salpingography, sa lpingography, and pian reca nalization have been described (5). The procedure is recanalization performed during the follicular phase of the menstrual menstru al performed cycle, utilizing uti lizing sterile sterile technique and with antibiotic procycle, phylaxis (usually (usua lly doxycycline 100 mg orally twice daily da ily phylaXis Sma ll doeses of intravenous sedation and fo r five five days). Small for pain medication medication may be given but are usually not necpain essary. ItIt is not necessary to ro dilate the cervix cervix. or give essary. para cervical anasthesia. paracervical anasthesia. Briefly, our medlod consists consislS of gaining access (0 (0 the Briefly, utcms with a vacuum cup hypersalpingography devices utCnJS with a vacuum cup hypersalpingography devices (Thunmond-Rosch Hysterocath; Hysterocath; Cook, Cook, Bloomington, BlOOmington, IN). IN). (Thuffilond-Rosch This provides a sterile condui( through which a series This provides a sterile conduit through which a series of of
44
coaxial catheters and gu gUidewires can be be introduced introduced and and idewires can to the uterus without without the the application application of of aa allows trauion traaion to HSG with with diluted diluted water-solu water-soluble tenaculum. A A conventiona conventionall HSG ble tenaculum. perfoffiled initially, which which localizes localizes the the contrast medium is performed cornua without widlOut obscuring obscuring the catheters. catheters. A A coaxial coaxial uterine comua (9-FF Teflon sheath and 5.5-F 5.5-F polyethylene polyethylene catheter system (90.035-inch-diameter (0.089 (0.089 catheter) is advanced over a 0.035-ineh-diameter guide uterine cornu. COffiU. (This (This coaxial coaxial system system cm) J gu ide wire to the uterine em) allows the the flexibility flexibility of 3 devices is advantageous in that itit allows catheterize the ostia in flexed or distorted distorted uteri). uteri). The The to cadleterize gUide wire wlre is removed and full-strength contrast contrast agen agentt ininjected (selective salpingography). If If pproximal tubal obstJlJCroximal tubal obstnlcO.OlS-inch-diameter (0.038 cm) cm) guide guide wire wire tion persists, a 0.015-inch-
regnancy rate in Lhe 20%-400,,0 ine ppregnancy the 20%... 40% range, and an approximately 40/0 4% tubal pregnancy rate. The tubal reocc!usion cult to determine reocclusion rate is diffi difficult because in part it is time dependent. IInn patients who do not conceive by 6 months, it appears that about abou t 50% of the tubes reocc!uded. If we assume that the tubes are tube are reoccluded, patients who conceive, this gives an appatent in the patient ion rate of 25% (5). Repeat caLheter proximate reocclus reocclusion catheter recana lization is possible, and pregnancies have resulted recanalization after the second or even the third procedure.
and could be removed hysteroscopically, a hysterscopically-guided procedu re is warranted. If the patient has procedure had prior laparoscopy that showed absent or minimal pelv ic disease, or if Lhere pelvic there is low suspicion for concomitant pelv ic disease, the procedure may be best carried pelvic out with use of fluoroscopic guidance. AJso, Also, if the obstruction is in the isthmic part pan of the tube, 3-5 em cm from the tubal ostium, we havc have found that smaH small tapered ca theters and wires which are arc advanced fluoroscopically catheters can be advantageous (6).
Complications Mild uterine cramping and vaginal bleeding usually occur with fallopian tube catheterization. Intravenous sedation elation can be used u ed but is usually not oecessaly. necessary. Tubal perforation occurs about 4% of the time and is presumth e severity of underlying ably related predominantly to the tubal disease. No additional monitoring or treatment is necessal)' perfonnation occurs, though in general genera l necessary when perfonnalion [here there is no reason to persist in recanalization attempts after the tube is perforated. The radiation dose to the ovaries during fluoroscopic bas been documented to be less than catheterization has than]1 Rad (10 Gy) (25). -n1is (l0 This is in the same range as the radiation dose delivered during a barium enema or an intravenous pyelogram (IVP). The dose of course varies depending on Lhe the equipment and the amount of fluoroscopy used as well as the number of rad iographs exposed. radiographs
Technique gUidance for diagnosis and treatment treatmen t of o f PTO Ultrasound guidance ha ,15,16), The benefit.;; absence hass been described 03 03,15,16). benefits of abo ence of radiation exposure and ability to perform the proceighed by the dure in a gynecology office are far outwe outweighed laller o f inadequate tubal tuba l visualization visual ization (30). The latter risks of lpingitis isthmica nodosa, nodosa , factor precludes diagnosis of sa salpingitis fimbrial phimosis, or other tubal changes whic whichh may be relevant relevalll to patient management. It is also not possible with US to know when one has perforated the rube, tube, which could lead to continued attempts at catheterizacomp lications. It tion and unacceplable unacceptable tubal damage or Of complications. may be that, Ui pment and techniques develop, that, as the eq equipment there will wil l be a role for ultra sound guidance for evaluaultrasound lion and treatment o f d iseased tion of diseased tubes. However, we currently believe US should be used only for guidance of catheterization in normal tubes. The succe successs rates for recanalizing proximally-occluded oviduc ts with use of fluoroscopic guidance and oviducts hysteroscopic guidance are similar. Similar. The procedures, however, are not necessarily equivalent, in that some patien ts who have failed hys te roscopic catheterization patients hysteroscopic can be successfully treated wi th fluoroscopic cathetercat heterwith Lhis is not clear. It ization and vice versa. The reason for this may be that in some patients the ability to laparoscopilly straighten the tube for catheterization is an advanca cally tage, whereas, in others, the ability abil ity to radiographically define the tonuous tortuous lumen is an advantage.
Discussion Alternative Therapies Alternatiw Tberapies -estabMicrosurgical tubocornua tubocornuall anastomosis is a well well-established procedure which was first firs t described describ d in 1977 by Gomel (26) and Winston (27). The long-term pregnancy rate among experienced surgeons is about abou t 58% and about 4% (28). tubal pregnancy rate is LUbal In vitro fertilization feltilization is an altemative therapy which bypasses the tubes altogether, and results in an approximately successful embryo emb!)'o transfer (29). 16% term pregnancy rate per successful Both these treatments are expensive and time-consu ming and shou ld be reserved for patients who fail suming should transcervica wbal catheterization uanscervicall tubal catheterization.. Patient Selection Patients with unilateral oorr bilateral obstruction of the falloem of the tube by hysteropian tube within the first 0-4 cm salpingography or lapamscopy laparoscopy are candidates for transceftranscervica vicall fallopian tube catheterization. T'he The patient selection process for fluoroscopic Or or hysteroscopic catheterization will vary from one imtitution institution to another. It will depend somewhat upon individual levels of expertise and the degree of coopcf'"J.tion cooperation octween between radiologLsts radiologists and gynecoloing gists in a given practice sctting. setting. We have used the follow following lly for more than 10 years: protocol successfu successfully If a patient has not had laparoscopy, and has a history histolY of pelvic inflammatory disease, proximal tubal obstruction (PTO) may be best evaluated using combined hy.')hysteroscopy/laparoscopy. Also, if there is a uterine cavity mass that may interfere with catheterization or fertility
Current Controversies It is imperative impera tive to establish a close working relationship with the gynecologists and fertility specialists. When thc the tubes are open, couples may need additional additiona l fertility t'ubes ld. More treatments, which are out of a radiologist's fie field. wi ll get no referra ls if the th e gynecolimportanlly, a patient pa Lient will importantly, referrals ogists do not know who she is or doesn't tn.I St her. trust theif patients, Establishing other services which benefit their imaging-gu ided breast biopsies and uterine arsuch as imaging-guided telY embolization, can be vely helpful.
References 1. Merchant RJ"I, Ri\l, Prabhu SR, Chou gale A. Uterotu bal Chougale
junClion: morphology and clinical cl inical aspects. 100J Fend junction: Int] Fenil 1983; 28,199-205 1983; 28:199-205. 2. Musich JR, Behrman Sj. Surgical Su rgical management of tubal obstruction at the uterotubal junction. Ferti! Steril 1983; 40:423-441. 400423-441.
5
3. Wilshire G, Bohrer M, Blotner M. Bilateral cornual tubal occlusion is not associated with an increased risk of distal tubal pathology. Presented at the American Fertility Society annual meeting, New Orleans, LA, November 1992. 4. Thurmond AS, RoschJ, Patton PE, et al. Fluoroscopic transcervical fallopian tube catheterization for diagnosis and treatment of female infertility caused by tubal obstruction. RadioGraphies RadioGraphics 1988; 8:621-640.
Rosch J. J Device for hysterosalpingography and fallopian tube catheterization. Radiology 1990; 174:571-572
5. Thurmond AS, Uchida
6. Thurmond AS, Rosch J. J Fallopian tubes: improved technique for catheterization. Radiology 1990; 174: 572-573. 572- 573.
J.J Nonsurgical fallopian tube recanalization for treatment of infertility. Radiology 1990; 174:371-374. 174:371-374.
7. Thurmond AS, Rosch
8. Segars JH, Herbert CM III, Moore DE, et al. aL Selective fallopian tube cannulation: initial experience in an infertile population. Fertil Steril 1990; 53:357-359.
9. Confino E, Tur-Kaspa I, DeCherney A, et al. a1. Tf'dnscervical balloon tuboplasty: a multicenter trial. triaL JAl'v:!A 1990; 264:2079-2082. JAlV[A a1. 10. Kumpe DA, Zwerdlinger SC, Rothbarth LJ, et al. Proximal fallopian tube occlusion: diagnosis and treatment with transcervical fallopian tube catheterization. Radiology 1990; 177:183-187.
18. Maubon A, RouanetJP, Cover S, et ai. al. Fallopian tube recanalization by selective salpingography: an alternative to more invasive techniques? Hum Reprod 1992; 7:1425-1428.
al. Transvaginal 19. Sato M, Yamada R, Kimura M, et ai. fallopian tube catheterization-diagnostic and therapeutiC usefulness. Radiation Med 1993; 11:49-52. apeutic aL Selective fallo20. Hayashi N, Kimoto T, Sakai T, et al. pian tube catheterization: limited value in the treatment of fallopian tube diseases. Radiology 190:141-143. 190:141143. Bonn J, Eschelman D], DJ, et al. aL Fallo21. Hovsepian DM, Bonn], pian tube recanalization in an unrestricted patient population. Radiology 1994; 190:137-140. 22. Thompson KA, Kiltz RJ, Koci T, Cabus ET, Kletzky OA. Transcervical fallopian tube catheterization and recanalization for proximal tubal obstruction. Ferti! VJ.:.-"", ,.-,0"'1 Steril 1994; 61:243-247. 23. Ferraiolo A, Ferraro F, Remorgida V, Gorlero F, Capitanio GL, Cecco 1. Unexpected pregnancies after tubal recanalization failure with selective catheterization. Ferti! 63;299-302. Fertil Steril 1995; 63:299-302. 24. Thunnond AS. after selective salpingography and tubal recanaliZation. recanalization. Radiology 1994; 190: 190; 1113. 11-13.
11. Deaton JL, jL, Gibson M, Riddick DH, Brumsted JR nosis and treatment of cornual obstruction using a flexible tip guidewire. Fertil Steril 1990; 53:232-236.
25. Hedgpeth PL, Thurmond AS, Fry R. Radiographic Radiographie fallopian tube recanalization: absorbed ovarian radiation dose. Radiology 1991; 180:121-122.
12. Novy MJ, Thurmond AS. Proximal Tubal Obstruction. In: Decision Making in Reproductive Endocrinology, Sdllaff WD, Rock JA, eds. Boston, MA: Blackwell Scientific, 1993:477-487.
26. Gomel V. Tubal reanastomosis by microsurgery. Ferti! SterH Steril 1977; 28:59-65.
13. Stern JJ, Peters AJ, Coulam CB. Transcervical tuboplasty under ultrasonographic guidance: a pilot SterH 1991; 56:359-360. study. Ferti! Steril 14. Capitaneo GL, Ferraiolo A, Croce S, et al. Transcervical selective salpingography: a diagnostic and therapeutic approach to cases of proximal injection failure. Ferti! Steril SterH 1991; 55:1045-1050. 55:1045- 1050. ure 15. Lisse K, Sydow P. Fallopian tube catheterization and recanalization under ultrasonic observation: a simplified technique to evaluate tubal patency and open Ferti! Steril 1991; 56: proximally occluded tubes. Fertil 198-201. 16. Maroulis GB, Yeko TR. Treatment of cornual obstruction by transvaginal cannulation without hysteroscopy or fluoroscopy. Ferti! Steril SterH 1992; 57: 11361138. 0, Papageorgiou G, Fezoulidis I, et aL al. Se17. Kelekis D, transcervical recanalisation of fallopian tubes: lective transcervieal
6
a method for diagnosis and treatment of infertility.
Radiol 1992; 7:37-40. J Intervent Radial
27. Winston RML. Microsurgical tubocornual tubocomual anastomosis for reversal of sterilisation. Lancet 1977; 1:284-285. 28. Marana R, QuagliareHo Quagliarello JJ. Proximal tubal occlusion: occlusion; microsurgery versus I\lF: l\lF: a review. Int J Ferti! Ferri! 1988; 33338340. 33338-340. 29. Bustillo M. Assisted reproductive technology in the United States and Canada: 1992 results generated from the American Fertility Society/Society for Assisted Reproductive Technology RegiStry, Registry, Ferti! Ferri! Steri! Steril 1994; 62:1121-1128. 30. Thurmond AS, Patton PE, Hector DM, et a1. aL USguided fallopian tube catheterization. Radiology 1991; 180:571-572. 1:00 pm
Gynecologic Workup of Pelvic Pain Fred M. Howard, M5, MD, FACOG Rochester General Hospital Rochester, New York
Conclusions Conclusions IVF and and tubal surgery are complementary rather than competitive competitive procedures. Adequate Adequate selection of patients is is the the key key to to finding fi nding the best therapeutic approach.
References References 1. 1. Diamond MP, ed. Infertility Infertility Surgery, Su rgery,
Clinical Practice of Gynecology: Vol. 3, No.1; No. 1; 1991.
2. 2. diZerega diZe rega G, et aI, aI, eds. eds. Pelvic Surgery: Adhesion Formation and Prevention. Springer-Verlag; 1997. 3. 3. Speroff Speroff L, et ai, aI, eds. Clinical Gynecologic Endocrinology no logy and In1ertility, Infertility, 6th Edition. Philadelphia, PA Lippincott Williams Will iams & Wilkins; Wilkins; 1999. 4. 4. Diedrich Diedrich K, K, Felberbaum Felberbaum R, R, eds. ART in the year 2000, 2000. ESHRE Campus Workshop. Hum Reprod Rep rod 1999; 1999; 14(suppl 1). 14(suppl I ). 12:30 12:30 pm
Transcervical Transcervica1 Fallopian Tube Recanalization Amy Amy S. S. Thurmond, Thurmond, MD MD Me1idan Men·dan Park Park Hospital Tualatin, Tualatin, Oregon
Pro ximal Tubal Obstn.Jction Obs truction Proximal The intramural intramural portion of the fallopian fallopia n tube is an average The of 11 cm em in length length and and has a luminal lum inal diameter of about 1 of mm. Its Its course is straight or slightly curved in 60% of mm. cases and and convoluted or tOrtuous tortuous in 400/0 (l). (1). A large cases number of pathologic pa tho logic conditions can affect this part ooff number the tube tube and their relative frequency varies depending the on the population. Infection and subsequent on the patient population. inflammation or fibrosis are leading causes of proximal inflammation tuba l occlusion occlusion and and are frequently the consequence of tubal chlamydial or gonococcal salpingitis or postpartum enchlamydial dometritis (2). Interestingly, dometritis Interestingly, about half of patients with proximal tubal tuba l obstruction well -documented well-documented bilateral prOXimal very loca lized disease with no pelvic 'adhesions ·ad hesions have have very localized the m idea l cand idates for an attempt at (3,4), making (3,4), making them ideal candidates tuba l catheterization for establishment of patency. tubal catheterization for Cathe te rization Technique Catheterization The instruments ins[Jum en ts and techniques techn iques for fluoroscopic falloThe pian tube tube catheterization, ca theterizalio n, selective salpingography, sa lpingography, and pian reca nalization have been described (5). The procedure is recanalization performed during the follicular phase of the menstrual menstru al performed cycle, utilizing uti lizing sterile sterile technique and with antibiotic procycle, phylaxis (usually (usua lly doxycycline 100 mg orally twice daily da ily phylaXis Sma ll doeses of intravenous sedation and fo r five five days). Small for pain medication medication may be given but are usually not necpain essary. ItIt is not necessary to ro dilate the cervix cervix. or give essary. para cervical anasthesia. paracervical anasthesia. Briefly, our medlod consists consislS of gaining access (0 (0 the Briefly, utcms with a vacuum cup hypersalpingography devices utCnJS with a vacuum cup hypersalpingography devices (Thunmond-Rosch Hysterocath; Hysterocath; Cook, Cook, Bloomington, BlOOmington, IN). IN). (Thuffilond-Rosch This provides a sterile condui( through which a series This provides a sterile conduit through which a series of of
44
coaxial catheters and gu gUidewires can be be introduced introduced and and idewires can to the uterus without without the the application application of of aa allows trauion traaion to HSG with with diluted diluted water-solu water-soluble tenaculum. A A conventiona conventionall HSG ble tenaculum. perfoffiled initially, which which localizes localizes the the contrast medium is performed cornua without widlOut obscuring obscuring the catheters. catheters. A A coaxial coaxial uterine comua (9-FF Teflon sheath and 5.5-F 5.5-F polyethylene polyethylene catheter system (90.035-inch-diameter (0.089 (0.089 catheter) is advanced over a 0.035-ineh-diameter guide uterine cornu. COffiU. (This (This coaxial coaxial system system cm) J gu ide wire to the uterine em) allows the the flexibility flexibility of 3 devices is advantageous in that itit allows catheterize the ostia in flexed or distorted distorted uteri). uteri). The The to cadleterize gUide wire wlre is removed and full-strength contrast contrast agen agentt ininjected (selective salpingography). If If pproximal tubal obstJlJCroximal tubal obstnlcO.OlS-inch-diameter (0.038 cm) cm) guide guide wire wire tion persists, a 0.015-inch-
regnancy rate in Lhe 20%-400,,0 ine ppregnancy the 20%... 40% range, and an approximately 40/0 4% tubal pregnancy rate. The tubal reocc!usion cult to determine reocclusion rate is diffi difficult because in part it is time dependent. IInn patients who do not conceive by 6 months, it appears that about abou t 50% of the tubes reocc!uded. If we assume that the tubes are tube are reoccluded, patients who conceive, this gives an appatent in the patient ion rate of 25% (5). Repeat caLheter proximate reocclus reocclusion catheter recana lization is possible, and pregnancies have resulted recanalization after the second or even the third procedure.
and could be removed hysteroscopically, a hysterscopically-guided procedu re is warranted. If the patient has procedure had prior laparoscopy that showed absent or minimal pelv ic disease, or if Lhere pelvic there is low suspicion for concomitant pelv ic disease, the procedure may be best carried pelvic out with use of fluoroscopic guidance. AJso, Also, if the obstruction is in the isthmic part pan of the tube, 3-5 em cm from the tubal ostium, we havc have found that smaH small tapered ca theters and wires which are arc advanced fluoroscopically catheters can be advantageous (6).
Complications Mild uterine cramping and vaginal bleeding usually occur with fallopian tube catheterization. Intravenous sedation elation can be used u ed but is usually not oecessaly. necessary. Tubal perforation occurs about 4% of the time and is presumth e severity of underlying ably related predominantly to the tubal disease. No additional monitoring or treatment is necessal)' perfonnation occurs, though in general genera l necessary when perfonnalion [here there is no reason to persist in recanalization attempts after the tube is perforated. The radiation dose to the ovaries during fluoroscopic bas been documented to be less than catheterization has than]1 Rad (10 Gy) (25). -n1is (l0 This is in the same range as the radiation dose delivered during a barium enema or an intravenous pyelogram (IVP). The dose of course varies depending on Lhe the equipment and the amount of fluoroscopy used as well as the number of rad iographs exposed. radiographs
Technique gUidance for diagnosis and treatment treatmen t of o f PTO Ultrasound guidance ha ,15,16), The benefit.;; absence hass been described 03 03,15,16). benefits of abo ence of radiation exposure and ability to perform the proceighed by the dure in a gynecology office are far outwe outweighed laller o f inadequate tubal tuba l visualization visual ization (30). The latter risks of lpingitis isthmica nodosa, nodosa , factor precludes diagnosis of sa salpingitis fimbrial phimosis, or other tubal changes whic whichh may be relevant relevalll to patient management. It is also not possible with US to know when one has perforated the rube, tube, which could lead to continued attempts at catheterizacomp lications. It tion and unacceplable unacceptable tubal damage or Of complications. may be that, Ui pment and techniques develop, that, as the eq equipment there will wil l be a role for ultra sound guidance for evaluaultrasound lion and treatment o f d iseased tion of diseased tubes. However, we currently believe US should be used only for guidance of catheterization in normal tubes. The succe successs rates for recanalizing proximally-occluded oviduc ts with use of fluoroscopic guidance and oviducts hysteroscopic guidance are similar. Similar. The procedures, however, are not necessarily equivalent, in that some patien ts who have failed hys te roscopic catheterization patients hysteroscopic can be successfully treated wi th fluoroscopic cathetercat heterwith Lhis is not clear. It ization and vice versa. The reason for this may be that in some patients the ability to laparoscopilly straighten the tube for catheterization is an advanca cally tage, whereas, in others, the ability abil ity to radiographically define the tonuous tortuous lumen is an advantage.
Discussion Alternative Therapies Alternatiw Tberapies -estabMicrosurgical tubocornua tubocornuall anastomosis is a well well-established procedure which was first firs t described describ d in 1977 by Gomel (26) and Winston (27). The long-term pregnancy rate among experienced surgeons is about abou t 58% and about 4% (28). tubal pregnancy rate is LUbal In vitro fertilization feltilization is an altemative therapy which bypasses the tubes altogether, and results in an approximately successful embryo emb!)'o transfer (29). 16% term pregnancy rate per successful Both these treatments are expensive and time-consu ming and shou ld be reserved for patients who fail suming should transcervica wbal catheterization uanscervicall tubal catheterization.. Patient Selection Patients with unilateral oorr bilateral obstruction of the falloem of the tube by hysteropian tube within the first 0-4 cm salpingography or lapamscopy laparoscopy are candidates for transceftranscervica vicall fallopian tube catheterization. T'he The patient selection process for fluoroscopic Or or hysteroscopic catheterization will vary from one imtitution institution to another. It will depend somewhat upon individual levels of expertise and the degree of coopcf'"J.tion cooperation octween between radiologLsts radiologists and gynecoloing gists in a given practice sctting. setting. We have used the follow following lly for more than 10 years: protocol successfu successfully If a patient has not had laparoscopy, and has a history histolY of pelvic inflammatory disease, proximal tubal obstruction (PTO) may be best evaluated using combined hy.')hysteroscopy/laparoscopy. Also, if there is a uterine cavity mass that may interfere with catheterization or fertility
Current Controversies It is imperative impera tive to establish a close working relationship with the gynecologists and fertility specialists. When thc the tubes are open, couples may need additional additiona l fertility t'ubes ld. More treatments, which are out of a radiologist's fie field. wi ll get no referra ls if the th e gynecolimportanlly, a patient pa Lient will importantly, referrals ogists do not know who she is or doesn't tn.I St her. trust theif patients, Establishing other services which benefit their imaging-gu ided breast biopsies and uterine arsuch as imaging-guided telY embolization, can be vely helpful.
References 1. Merchant RJ"I, Ri\l, Prabhu SR, Chou gale A. Uterotu bal Chougale
junClion: morphology and clinical cl inical aspects. 100J Fend junction: Int] Fenil 1983; 28,199-205 1983; 28:199-205. 2. Musich JR, Behrman Sj. Surgical Su rgical management of tubal obstruction at the uterotubal junction. Ferti! Steril 1983; 40:423-441. 400423-441.
5
3. Wilshire G, Bohrer M, Blotner M. Bilateral cornual tubal occlusion is not associated with an increased risk of distal tubal pathology. Presented at the American Fertility Society annual meeting, New Orleans, LA, November 1992. 4. Thurmond AS, RoschJ, Patton PE, et al. Fluoroscopic transcervical fallopian tube catheterization for diagnosis and treatment of female infertility caused by tubal obstruction. RadioGraphies RadioGraphics 1988; 8:621-640.
Rosch J. J Device for hysterosalpingography and fallopian tube catheterization. Radiology 1990; 174:571-572
5. Thurmond AS, Uchida
6. Thurmond AS, Rosch J. J Fallopian tubes: improved technique for catheterization. Radiology 1990; 174: 572-573. 572- 573.
J.J Nonsurgical fallopian tube recanalization for treatment of infertility. Radiology 1990; 174:371-374. 174:371-374.
7. Thurmond AS, Rosch
8. Segars JH, Herbert CM III, Moore DE, et al. aL Selective fallopian tube cannulation: initial experience in an infertile population. Fertil Steril 1990; 53:357-359.
9. Confino E, Tur-Kaspa I, DeCherney A, et al. a1. Tf'dnscervical balloon tuboplasty: a multicenter trial. triaL JAl'v:!A 1990; 264:2079-2082. JAlV[A a1. 10. Kumpe DA, Zwerdlinger SC, Rothbarth LJ, et al. Proximal fallopian tube occlusion: diagnosis and treatment with transcervical fallopian tube catheterization. Radiology 1990; 177:183-187.
18. Maubon A, RouanetJP, Cover S, et ai. al. Fallopian tube recanalization by selective salpingography: an alternative to more invasive techniques? Hum Reprod 1992; 7:1425-1428.
al. Transvaginal 19. Sato M, Yamada R, Kimura M, et ai. fallopian tube catheterization-diagnostic and therapeutiC usefulness. Radiation Med 1993; 11:49-52. apeutic aL Selective fallo20. Hayashi N, Kimoto T, Sakai T, et al. pian tube catheterization: limited value in the treatment of fallopian tube diseases. Radiology 190:141-143. 190:141143. Bonn J, Eschelman D], DJ, et al. aL Fallo21. Hovsepian DM, Bonn], pian tube recanalization in an unrestricted patient population. Radiology 1994; 190:137-140. 22. Thompson KA, Kiltz RJ, Koci T, Cabus ET, Kletzky OA. Transcervical fallopian tube catheterization and recanalization for proximal tubal obstruction. Ferti! VJ.:.-"", ,.-,0"'1 Steril 1994; 61:243-247. 23. Ferraiolo A, Ferraro F, Remorgida V, Gorlero F, Capitanio GL, Cecco 1. Unexpected pregnancies after tubal recanalization failure with selective catheterization. Ferti! 63;299-302. Fertil Steril 1995; 63:299-302. 24. Thunnond AS. after selective salpingography and tubal recanaliZation. recanalization. Radiology 1994; 190: 190; 1113. 11-13.
11. Deaton JL, jL, Gibson M, Riddick DH, Brumsted JR nosis and treatment of cornual obstruction using a flexible tip guidewire. Fertil Steril 1990; 53:232-236.
25. Hedgpeth PL, Thurmond AS, Fry R. Radiographic Radiographie fallopian tube recanalization: absorbed ovarian radiation dose. Radiology 1991; 180:121-122.
12. Novy MJ, Thurmond AS. Proximal Tubal Obstruction. In: Decision Making in Reproductive Endocrinology, Sdllaff WD, Rock JA, eds. Boston, MA: Blackwell Scientific, 1993:477-487.
26. Gomel V. Tubal reanastomosis by microsurgery. Ferti! SterH Steril 1977; 28:59-65.
13. Stern JJ, Peters AJ, Coulam CB. Transcervical tuboplasty under ultrasonographic guidance: a pilot SterH 1991; 56:359-360. study. Ferti! Steril 14. Capitaneo GL, Ferraiolo A, Croce S, et al. Transcervical selective salpingography: a diagnostic and therapeutic approach to cases of proximal injection failure. Ferti! Steril SterH 1991; 55:1045-1050. 55:1045- 1050. ure 15. Lisse K, Sydow P. Fallopian tube catheterization and recanalization under ultrasonic observation: a simplified technique to evaluate tubal patency and open Ferti! Steril 1991; 56: proximally occluded tubes. Fertil 198-201. 16. Maroulis GB, Yeko TR. Treatment of cornual obstruction by transvaginal cannulation without hysteroscopy or fluoroscopy. Ferti! Steril SterH 1992; 57: 11361138. 0, Papageorgiou G, Fezoulidis I, et aL al. Se17. Kelekis D, transcervical recanalisation of fallopian tubes: lective transcervieal
6
a method for diagnosis and treatment of infertility.
Radiol 1992; 7:37-40. J Intervent Radial
27. Winston RML. Microsurgical tubocornual tubocomual anastomosis for reversal of sterilisation. Lancet 1977; 1:284-285. 28. Marana R, QuagliareHo Quagliarello JJ. Proximal tubal occlusion: occlusion; microsurgery versus I\lF: l\lF: a review. Int J Ferti! Ferri! 1988; 33338340. 33338-340. 29. Bustillo M. Assisted reproductive technology in the United States and Canada: 1992 results generated from the American Fertility Society/Society for Assisted Reproductive Technology RegiStry, Registry, Ferti! Ferri! Steri! Steril 1994; 62:1121-1128. 30. Thurmond AS, Patton PE, Hector DM, et a1. aL USguided fallopian tube catheterization. Radiology 1991; 180:571-572. 1:00 pm
Gynecologic Workup of Pelvic Pain Fred M. Howard, M5, MD, FACOG Rochester General Hospital Rochester, New York