Transcervical tubal cannulation, past, present, and future

Modern trends FERTILITY AND STERILITY

Vol. 60, No.2, August 1993

Copyright c 1993 The American Fertility Society

Printed on acid-free paper in U.

s. A.

Transcervical tubal cannulation, past, present, and future

Francisco Risquez, M.D.* Edmond Contino, M.D. Centro Medico Docente La Trinidad, Caracas, Venezuela, and Mount Sinai Hospital Medical Center and Rush Medical College, Chicago, Illinois

Objective: To evaluate publications that introduced novel diagnostic and therapeutic transcervical procedures on the fallopian tubes. Design: Major studies that conceptually changed the therapeutic approach to the fallopian tubes were reviewed. Minor publications were also included if they introduced a new concept or contributed to the topic. Clinical publications were selected if they involved transcervical diagnosis and treatment of fallopian tubes. Results: Transcervical tubal catheterization procedures for diagnosis of tubal disease, tubal obliteration, tubal recanalization, and tubal medication are minimally invasive procedures that can improve our understanding and diagnostic accuracy of tubal disease. These procedures allow transcervical treatment of proximal tubal occlusion. Further improvements in equipment and methodology are promising. Transcervical tubal occlusion, gamete and embryo deposition, and treatment of ectopic pregnancy may all be performed using the transcervical approach. Conclusion: Transcervical tubal catheterization can replace microsurgery and IVF in selected patients with proximal tubal occlusion, improve the diagnostic accuracy of tubal disease, and deliver medications to the fallopian tubes. Cumulative knowledge suggests that transcervical tubal catheterization should become a universally accepted, taught, and practiced approach in the diagnosis and treatment of the fallopian tubes. Fertil Steril 1993;60:211-26 Key Words: Transcervical tubal catheterization, tubal obliteration and recanalization, balloon tuboplasty, selective salpingography, falloposcopy, ectopic pregnancy HISTORICAL PERSPECTIVE OF TUBAL CANNULATION

Early attempts to cannulate fallopian tubes through the uterine cervix date back to the 19th century. Smith (1) recanalized proximally obstructed fallopian tubes using whale bone sound as early as 1849 (1). This procedure relied primarily on tactile impression and introduced the concept of mechanical dilatation of proximally obstructed fallopian tubes. Approximately at the same time period, Friorep (2) applied silver nitrate to the cornual areas through a cervical cannula (2). The purpose ofFroriep was to achieve noninvasive tubal obliteration. Transcervical tubal obliteration remained lit-

Received December 4, 1992. Reprint requests and present address: Francisco Risquez, M.D., Avenue La Castellana Number 69, Caracas, Venezuela. Vol. 60, No.2, August 1993

erally unchanged through the 19th century and well into the 20th century when different authors attempted tubal occlusion using a number of caustic materials. Introduction of electric current at the end of the 19th century was an attractive improvement in the existing technology at that time and resulted in the early reports of electrocautery of the uterine cornua by Kocks in 1878 (3). Electrocautery of the tubal cornua remained unchanged in the following years except for technical improvements in controlled delivery of electric current to cause tissue damage. This approach was refined at the turn of the 20th century by Dickinson (4) and Prudnikoff (5). Success rates of transcervical tubal occlusion varied but did not exceed 80% to 90% bilateral tubal obliteration (6, 7). Transcervical tubal electrocautery relied heavily on the expertise of the performer, the adequacy of Risquez and Contino Tubal cannulation

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tubal visualization, and the effectiveness of the equipment used by different surgeons. Although the noninvasive approach to obliterate the fallopian tubes remained attractive, the inherent difficulty to uniformly perform the technique and technical problems with adequate cannulation of the uterine cornua persisted throughout the entire 20th century. Transcervical tubal electrocautery was largely replaced by abdominal surgical tubal interruption techniques that resulted in success rates close to 100%. Surgical interruption of fallopian tubes did not rely on cornual visualization and did not involve subjective evaluation of the amount of tissue destroyed during electrocautery. Selective salpingography using curved metal cannula was described by Corfman and Taylor in 1966 (8). The authors believed that such an instrument had a potential use in the study of oviduct physiology, pathology, and in transcervical production of temporary and permanent sterilization. The concept of transcervical tubal cannulation for diagnosis and treatment of tubal obstruction, as well as tubal obliteration, remained dormant for approximately 20 years after this pioneering report. During the mid-1980s, a number of different centers worldwide reintroduced retrograde transcervical noninvasive cannulation to approach the fallopian tubes. Although differences exist between the different devices, the principles remain quite similar. All investigators used variations on currently existing catheters, which allow initial cannulation ofthe uterine cervix, followed by imaging of the uterine cavity, followed by selective cannulation of the tubal ostium. These parallel attempts focused on improvements of the diagnosis of tubal pathology and subsequently developed noninvasive transcervical methods to recanalize proximally obstructed fallopian tubes with wires and balloon catheters (9-11). It is only natural that these efforts culminated in the pioneering attempts to deposit gametes into the fallopian tubes using a noninvasive transcervical approach (12). Catheter technology, which gave a significant push to the transcervical approach to the fallopian tubes, was developed primarily for angiography and related medical areas. The diameter and anatomy of small vessels resemble in many ways the anatomy ofthe fallopian tubes (13). Therefore only minor modifications were required for the development of tubal catheters. Earlier attempts to cannulate the tubal ostia under direct hysteroscopic and laparoscopic visualization were followed by rela212

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tively easier fluoroscopic cannulation of the fallopian tubes (9, 14, 15). Improvements in sonographic resolution in the mid -1980s allowed tubal visualization for the first time, and catheters could be tracked in the uterus without the use of fluoroscopy. Although sonography eliminated minimal radiation to the ovaries during fluoroscopic procedures, it lacked the high resolution of fluoroscopy and required advanced sonographic skills to catheterize the fallopian tubes (12). Ongoing improvements in sonographic equipment and significant reduction in the radiation delivered to the pelvis during radiologic visualization may change in the future the perception of which method is the superior one for transcervical tubal cannulation. The century-old concept of tubal cannulation under tactile impression was also reintroduced during the late 1980s. Tactile cannulation of fallopian tubes relies primarily on fingertip evaluation of the resistance and trajectory of the catheter to appropriately reach the uterine fundus, rotate the catheter toward the cornua, and wedge it into the cornual area. Tactile tubal cannulation is inexpensive. It involves simple manipulation of the catheters and remains an attractive modality to some investigators. Tactile tubal cannulation, however, lacks objectivity, reproducibility, and documentation of successful cannulation, typical of other methods (Risquez F, Zorn JR, abstract). Improvements in fiberoptic technology in the 1980s, received enthusiastically, allowed reduction of the endoscope's diameter. This technological breakthrough resulted in the construction of flexible falloposcopes with diameters that can negotiate the proximal tube and the acute curves ofthe isthmic fallopian tube. Optic resolution was reasonable, and it is expected to improve in the near future (16). Falloposcopy improved the diagnostic accuracy of tubal disease and our understanding of microendotubal pathology. Future developments of falloposcopy may allow even access to and diagnosis of ectopic pregnancies (EPs) (17). An increasing number of reports during the mid and late 1980s documented the feasibility of transcervical tubal cannulation as a valuable diagnostic and therapeutic tool and repeatedly demonstrated that catheter technology may replace major abdominal surgery and IVF in selected patients with proximal tubal occlusion (10, 18). Early skepticism was replaced with increasing enthusiasm, documented by the increasing number of publications on noninvasive transcervical tubal catheterFertility and Sterility

ization. The enthusiasm is also reflected in an increasing number of international meetings that are specifically dealing with improvements in technology and understanding of the transcervical approach. The transcervical approach is safe, effective, minimally invasive, and inexpensive. It is expected that after more than a century of dormancy tubal catheterization will bring more exciting developments in the 1990s.

ANATOMICAL CONSIDERATIONS DURING TRANSCERVICAL TUBAL CATHETERIZATION

Understanding the anatomy of the uterus and fallopian tube is of utmost importance during the development and use of transcervical catheters. Recognition of anatomical variations is also important to introduce modifications in catheters' design, to address interpersonal differences in tubal diameters, and tubal length. The extrauterine part ofthe fallopian tube has an average length of approximately 10 to 11 cm, and the segment proximal to the intramural portion of the tube is approximately 2 to 3 cm long and forms the tubal isthmus (19). The diameter of the fallopian tube in the isthmus is 0.4 mm, with a range of 0.1 to 1 mm. The mucosa has typically three to six primary folds and is surrounded by a firm and thick muscular wall (20). The intramural or interstitial portion of the fallopian tube connects the isthmic portion to the cornual angle ofthe endometrial cavity. The interstitial portion of the fallopian tube may be convoluted in many patients during dissections and after fixation (21, 22). However, when observed in vivo and during application of intraluminal pressure of contrast material, this portion seems to be relatively straight, and the only area that forms an acute curve is the isthmic uterine junction (23). The course of the fallopian tube at this point changes its orientation and typically follows a posterior inferior trajectory, dictated by the longitudinal axis of the uterus. This acute angle is usually in the area that introduces major difficulty during cannulation of the fallopian tubes. The intramural, or interstitial portion of the fallopian tube, is usually resistant to perforation because the thick muscular layer of the uterus supports the endotubal lumen. The isthmic-uterine junction is easy to perforate' during catheterization. This bottle-neck requires recognition of individual patients' anatomy and mandates the use of flexible Vol. 60, No.2, August 1993

catheters to negotiate both the acute curve and the pinpoint lumen. Secretions inside the fallopian tube may also affect the passage of catheters within the lumen. During the late proliferative phase, uterine and tubal secretions may serve as lubricants and protect the tubal mucosa (24, 25). Some contrast materials used during fluoroscopy may have a lubricating effect. Catheterization without distension medium must rely on the catheter's smoothness and natural lubrication only. The ampulla of the fallopian tube increases in diameter and introduces yet another challenge to endosalpingoscopy. The convoluted folds of the ampullary portion form a complex structure that increases significantly in diameter compared with the isthmic portion ofthe fallopian tube. This anatomical change creates inherent difficulty during visualization of the ampullary portion with transcervical falloposcopes. The reduction in diameter of falloposcopes designed to negotiate the interstitial and isthmic portions of the fallopian tube results in relatively narrow view angle and short focal length. Once the falloposcope is advanced into the ampullary portion of the fallopian tube, only a small portion of the ampulla is visible. Only future variable focus fiberoptics will allow not only changing focal length but also widening of the visual field of falloposcopes to address this difficulty. An additional obstacle during falloposcopy results from the funnel shape of the ampullary portion of a normal fallopian tube. The normal ampulla may not distend adequately during flushing. Distension media easily flow out of a patent fallopian tube, and lateral and tangential pressure may not be generated. Variations in tubal length involve both intrapersonal and interpersonal differences. Pregnancy-induced hypertrophy and smooth muscle hyperplasia result in significant lengthening of the fallopian tube. Patients who have undergone microsurgical tubal cornual anastomosis for reversal of previous sterilization have, to a varying degree, shortened fallopian tubes. Others may subsequently present with normal length fallopian tubes, observed during cesarean section, suggestive of tubal hypertrophy (26). Catheters designed for transcervical tubal cannulation must address variations in both tubal length and diameter. The diameter at the tubal isthmus may be <0.5 mm. Understanding tubal anatomy will prevent unnecessary perforations or traumatic attempts to cannulate the fallopian tubes with large diameter catheters and wires. Any Risquez and Contino

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resistance to cannulation represents either obstruction of the lumen or a narrow normal tubal lumen, which cannot accommodate the catheter. Recognition of tubal diameters is reflected in the design of early stents placed during microsurgical tubal cornual anastomosis. The diameter of these stents was reduced to 0.6 mm to accommodate atraumatically the tubal bottleneck (26). The resilience and elasticity of the fallopian tube depends also on tubal contractility, thickness ofthe myosalpinx, patient's age, previous infections, and vascularity of the fallopian tube. Stretching of the fallopian tube during transcervical tubal catheterization may accommodate catheters that are larger than the tubal lumen without causing damage to the endosalpinx. It is difficult to determine all these factors before the performance of trans cervical tubal cannulation. Resistance during catheterization may indicate in some cases false route, spasm, stenosis, maladjustment of the catheter, or a peristaltic wave. Once tubal spasm is suspected, propagation of wires and catheters should be temporarily discontinued. Evaluation of information on the anatomy of the fallopian tube, such as tubal convolutions, adhesions, and stenoses is invaluable. Previous video laparoscopy or hysterosalpingogram (HSG) can be used to study individual anatomical details before tubal cannulation. METHODOLOGY OF TRANSCERVICAL TUBAL CANNULATION

Transcervical tubal cannulation does not require extensive preoperative preparation, laboratory evaluation, or antibiotic prophylaxis. The very low morbidity of tubal catheterization is probably comparable with the one reported with hysterosalpingography. Patient preparation includes counseling of alternative procedures, basic evaluation of ovulatory functions, evaluation of male factor, and thorough medical history and examination. Catheterization of the cervix involves relatively low levels of discomfort and pain. Therefore, tubal cannulation can be performed under minimal analgesia, intravenous sedation, paracervical block, and, only in rare occasions, general anesthesia. If simultaneous laparoscopy is performed under general anesthesia, tubal cannulation can be performed at the same time or later during the same operative session. Selection of either endoscopic procedure, fluoroscopy or sonography, depends on the physician's expertise, availability of the equipment, and familiarity 214

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Table 1 Reduction of Radiation to the Ovaries During Fluoroscopic Tubal Catheterization Fluoroscopy setting that delivers minimal radiation per unit time and yet preserves quality of imaging. Self-operation of fluoroscopy activation trigger to avoid command time gaps. Adjusting the tube's rotation status before patient's positioning on the table. Adjusting settings on patient's leg and not on the ovaries. Initiating fluoroscopy only when the tubal catheter is expected to emerge from the guiding catheter with coaxial systems. Reflecting on the findings while the fluoroscope is deactivated. Using video memory to avoid additional radiation delivered during standard roentgenogram. This involves some reduction in resolution of the images. Discontinuing fluoroscopy after approximately 10 minutes under standard settings.

with the technique. If endoscopy is selected, one should entertain the use of simultaneous laparoscopy in combination with hysteroscopy to allow visualization of the fallopian tubes. Although a second operating team is required, laparoscopy adds information on peritubal and distal tubal damage. Distension in the tube is seen through the laparoscope during advancement of the catheter. The inherent disadvantage of this method is that it does not provide adequate information on the level of obstruction beyond the visual field of the hysteroscope. Falloposcopy obviously eliminates this disadvantage. If fluoroscopy is used to visualize the uterus and tubes, cautious monitoring of the settings and the time elapsed during the procedure are mandatory. The amount of radiation delivered to the ovaries is typically <1 rad during tubal catheterization procedures lasting <10 minutes (27). Tubal catheterization performed in a radiology suite eliminates some of the expenses generated by the use of the operating room setting. The projected image during fluoroscopy is very easy to perceive and offers continuous visualization of the catheter in relation to the uterine cavity and the tubal obstruction. Although fluoroscopy is indeed safe and the small amount of radiation imposes very minor risk to the patient's future reproductive performance, all efforts should be made to further reduce the level of radiation delivered to the ovaries. Familiarity with the equipment, knowledge ofthe catheter's length within its guiding catheters, elimination of stat roentgenograms, the use of video memory, and operator self-triggered fluoroscopy can all contribute to further reduction of the radiation delivered to the ovaries. Table 1 summarizes Fertility and Sterility

the steps necessary to minimize radiation to the ovaries during tubal catheterization. Catheterization under sonography is obviously very attractive because of complete elimination of radiation to the ovaries. However, it currently requires a second experienced operator and does not provide the same level of resolution compared with fluoroscopy. CATHETER SELECTION FOR TRANSCERVICAL TUBAL CATHETERIZATION

A number of catheters, guidewires, balloontipped catheters, uterine and tubal probes were introduced during the last few years for transcervical tubal cannulation. It seems that more than one catheter design may be successfully used to recanalize occluded fallopian tubes. Therefore, catheter selection depends on the operator's familiarity and the indications for the procedure. Selective salpingography catheters require diameters that will easily wedge into the cornual area. Catheterization of the endosalpinx requires smaller diameter catheters and different flexibility to negotiate acute curves of the fallopian tubes. Tubal catheters' diameter is usually similar to the diameter of the tubal lumen, with a balance between resilience, flexibility, and smooth surface. Atraumatic propulsion of catheters remains an engineering challenge. Departure from the need for guidewires and the use of new concepts, such as balloon linear eversion technology, are promising. The latter technique involves unrolling a double wall catheter, acting similar to unrolling carpet. Linear eversion minimizes friction to the walls and results in forward catheter advancement (Confino E, Surrey B, Pearlstone A, McIntosh T, Johnson K, Stewart B, et aI., abstract). Tubal catheterization relies primarily on the propulsive power of the operator's hand. Catheter design and imaging must compensate for the inability to exactly identify the location of the catheter by tactile sensation only. Catheter design can also eliminate interoperator variations. Soft tapering catheters leave wider safety margins when used in less experienced hands. Basic safety measures universal to any uterine instrumentation, such as traction on the cervix to change the uterine attitude, improve catheter manipulation. Interpatient variations in anatomy, uterine attitude, shape, and size of the uterine cavity do not allow the creation of a universal catheter that will be a "one-size-fits-all" Vol. 60, No.2, August 1993

design. Therefore, availability of several catheters with different geometry and performance is advantageous during transcervical tubal catheterization. DIAGNOSTIC TUBAL CATHETERIZATION

Tubal occlusion is the principal cause of infertility in approximately one third of all infertile patients. Only 10% to 20% of those patients have proximal occlusion only. The vast majority of patients have distal and peritubal damage. Salpingitis, clinical or subclinical, may either completely resolve or cause variable damage to the endosalpingeal folds, myosalpingeal fibrosis, fimbrial agglutination, partial or complete distal and proximal occlusion. Salpingitis frequently results in the formation of periovarian and peritubal adhesions. Endometriosis, similar to salpingitis, may also cause both peritubal and endotubal damage (28). Tubal damage caused by endometriosis may be indistinguishable from inflammatory etiology in long-standing, treated, and healed patients with salpingitis. Salpingitis isthmic a nodosa, presumably of infective etiology, may destroy the endotubal lumen causing multiple channels and diverticles (28). Proximal tubal occlusion can be caused by endotubal processes such as microadhesions, complete or partial fibrosis, and severe stenosis of the tubal lumen. A more recently reported intraluminal pathology consists of endotubal microplugs. Tubal microplugs are casts of debris, cellular fragments, and proteinaceous material (29). They may represent late sequelae of salpingitis and impaired tubal disposal of postinflammatory debris. The unequivocal diagnosis of tubal disease is established by surgical removal and pathological examination. Some pathologies such as fine intratubal adhesions require direct visualization. Therefore, tubal catheterization replaces in some patients the need for surgical excision for diagnosis. Functional evaluation of the fallopian tubes by gas pressure measurements, introduced early during the century by Rubin, was notoriously inaccurate in the diagnosis of tubal pathology when compared with HSGs (30). Attempts were made recently to revive tubal pressure measurements using selective salpingography (31). Unlike tubal gas insufflation, HSG provides projected images of the uterine cervix, uterine cavity, fallopian tubes and documents peritoneal spillage of contrast material. Hysterosalpingogram remains a traditional, initial, most informative procedure that provides risk and cost-effective information on both uterine tubal Risquez and Contino

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anatomy, pathology, and physiology. However, the roentgenogram diagnosis of bilateral proximal tubal occlusion can be false-positive in as high as 20% to 30% of patients when laparoscopic chromotubation is used as a "gold standard" (30). Tubal spasm may also mimic tubal occlusion. Introduction of smooth muscle relaxants may reduce falsepositive diagnosis of tubal occlusion because of tubal spasm (32). Hysterosalpingograms are performed usually in the early proliferative phase, late enough to avoid menstrual bleeding and early enough to avoid thick endometrial lining and ovulation. Lack of adequate endometrial lining results in intravasation of dye into the venous system, inability to generate adequate uterine pressure, and suboptimal evaluation of the fallopian tubes. The presence of concomitant pathology, such as uterine fibroids, may also interfere with correct interpretation of the results because of intravasation of contrast material into the abnormal venous network of these tumors. Timing of tubal catheterization should be identical to hysterosalpingography. Reflux of contrast material remains a major artifact that contributes to the false-positive diagnosis of tubal occlusion. If adequate wedging of the cervical cannula is not achieved, leaking contrast material into the vagina will interfere with the generation of adequate intracavitary pressure. In the presence of unilateral tubal occlusion, dye flowing into the open fallopian tube does not allow the generation of adequate pressure in the contralateral fallopian tube. Selective salpingography and catheterization of the side suspected for tubal occlusion eliminate this artifact. SONOSALPINGOGRAPHY

New developments in sonographic equipment revived early attempts to perform sonosalpingography (33). High-resolution transabdominal and vaginal probes and Doppler ultrasound (US) can outline the uterine cavity and demonstrate fluid flow in the fallopian tubes and in the peritoneal cavity. Improvements in contrast sonography media composition further improved the accuracy of sonosalpingography (34). Transcervical unilateral catheterization of fallopian tubes offers yet another advantage in those patients who demonstrate either unilateral tubal patency, or whenever clear diagnosis of tubal patency by sonography is not obvious (Confino E, Tur-Kaspa I, Gleicher N, abstract). An increasing number of reports on 216

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sonosalpingography for tubal catheterization is encouraging, and this approach is promising (35-39). Gray scale and Doppler US imaging remains today inferior in resolution when compared with radiologic imaging of the uterine cavity and the fallopian tubes. Inferior resolution places sonosalpingography, and for that purpose, sonographically guided tubal catheterization at a clear disadvantage. The use of this modality remains in today's state ofthe art technology in an experimental stage. Sonosalpingography can be applied during early inoffice screening for tubal factor of infertile patients. The cost-effective and minimally invasive nature of sonosalpingography represents an alternative test to immediately verify tubal patency and reserve radiologic tubal visualization for those patients who require detailed evaluation of the microanatomy of their fallopian tubes. TRANSCERVICAL FALLOPOSCOPY

Endoscopy remains the "gold standard" of accurate diagnosis of uterine cavity pathology and peritubal pathology. The projected radiologic image of the fallopian tubes, although very informative, may not detect quite a number of tubal pathologies that are pertinent to the successful achievement ofpregnancy (40-42). Hysteroscopy improves the diagnosis of fine periosteal adhesions and therefore is an invaluable adjunct to laparoscopy when patients with tubal occlusion are evaluated. Although chromopertubation during laparoscopy provides information on tubal patency, it does not provide adequate information on endotubal or periosteal pathology, which may result in the inability to transfer gametes and sperm. Falloposcopy, like hysteroscopy, increases the diagnostic accuracy of microendotubal pathology. Increasing experience with transcervical tubal catheterization, in conjunction with technological improvements in fiberoptics, reduced the diameter of the falloposcopes. These changes enabled the reproductive surgeon for the first time to visualize the entire lumen of the fallopian tube. Falloposcopy emerged as a natural sequel to other endoscopic procedures of the genital organs. Earlier attempts involved transabdominal introduction of rigid endoscopes into the fimbriated end of the fallopian tubes during laparoscopic procedures (43). These pioneering attempts demonstrated that direct visualization of the endotubal mucosa of the ampullary portion of the fallopian tubes added significant information to the one Fertility and Sterility

Table 2 Falloposcopically Visualized Microendotubal Pathology Tubal stenosis Tubal polyps Endotubal adhesions Tubal spasm Flattened mucosa Proteinaceous microplugs Complete obliteration "Violin string" adhesions Adherent endotubal folds Tubal pregnancy Openings of salpingitis isthmica nodosa Endotubal endometrioma

obtained by HSG only. This information could determine the chances of the fallopian tubes to successfully undergo microsurgical repair. A number of publications confirmed the validity of this report and increased the list of endotubal pathology visualized directly during falloposcopy (Table 2) (44-47). Endosalpingoscopy during the early 1980s remained sporadic because the isthmic and the intramural segments ofthe fallopian tubes remained unexplored. The diameter of the endoscopes was larger than the diameter of the proximal fallopian tube. Although tubal damage is frequently found in the ampullary portion of the fallopian tube, the proximal fallopian tube remains an important contributing factor to tubal infertility. The development of new flexible small fiberoptics and refinement in transcervical tubal catheterization techniques allowed pioneering attempts to approach the fallopian tubes through the tubal ostium for the first time (48). Transcervical falloposcopy required catheterization of the tubal ostium, introduction of a guidewire throughout the fallopian tube, and passage and advancement of the falloposcope over the guidewire into the intramural, isthmic, and ampullary portions of the fallopian tubes (48). Placement of guidewire inside the fallopian tube was found necessary because propagation of the falloposcope required tracking to avoid endotubal damage, negotiate curves, and to allow adequate visualization of the endotubal surfaces. Once the guidewire was removed from the endotubal lumen, flushing of the fallopian tube and slow withdrawal of the falloposcope visualized the microtubal anatomy. Wire catheterization of fallopian tubes may eliminate pathologies such as microplugs (49) or microadhesions. Future generations of falloposcopes will have to rely on propulsive systems that minimize artifacts, such as linear eversion catheters. Rapidly accumuVol. 60, No.2, August 1993

lating experience with falloposcopy resulted in the development of falloposcopic classification of endotubal disease (50). Assessment of the endotubal lining improves counseling of the patients and allows more rational choice of assisted reproductive procedures, such as deposition of gametes and embryos in the fallopian tubes versus IVF. Future applications of falloposcopy include introduction of balloon dilatation of strictured segments (16), development of microinstruments, point delivery of new medications, endotubal sampling, lasers, and diagnosis of tubal pregnancies (51). TRANSCERVICAL BALLOON TUBOPLASTY AND TUBAL CANNULATION FOR THE TREATMENT OF PROXIMAL TUBAL OCCLUSION

Surgical treatment of proximal tubal occlusion involved traditionally excision of the presumably occluded segment of the fallopian tube and reconnection of the patent portion of the fallopian tube to the uterine cavity or to the adjacent patent segment ofthe tube (51, 52). Macrosurgery was largely replaced during the 1980s by microsurgical techniques that resulted in pregnancy rates (PRs) ranging between 50% and 60% (51-53). Excellent results were achieved in patients who had isolated proximal tubal occlusion. Whenever peritubal disease compounded endotubal occlusion, the postsurgical PRs were significantly reduced (53). Frequently, the excised segment of the fallopian tube was entirely normal upon pathological examination, and a number of patients underwent unnecessary major surgical intervention. Microsurgical anastomosis remains a major expensive invasive procedure, involving laparotomy and general anesthesia. In addition, microsurgery requires a long convalescent period. Patients with bilateral proximal tubal occlusion may choose IVF -ET to achieve pregnancy, with PRs between 20% and 30% and live delivery rates of <20% (54). In vitro fertilization is expensive and does not offer the advantage of more than a single chance of conception per attempt, without embryo freezing. A less expensive and less invasive alternative to either microsurgery or IVF is clearly needed to treat patients with proximal tubal occlusion. Transcervical tubal cannulation is a minimally invasive procedure that offers advantages over both microsurgery and IVF. Selective tubal cannulation resulted in pregnancies and reintroduced a century-old concept (9). GuideRisquez and Contino

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wires were directed under fluoroscopy into the proximal occlusion. Forward advancement of the guidewire into the occluded area resulted in recanalization of the fallopian tubes. Shortly after this report, transcervical balloon tuboplasty introduced a slightly different approach to proximal tubal occlusion (11). Balloon tuboplasty, in contrast to wire recanalization, applied lateral stretch on the tubal walls. Lateral tangential force resulted in tubal recanalization. The procedure was performed initially under hysteroscopic visualization to cannulate the tubal ostium. A second team observed simultaneously the fallopian tubes through a laparoscope (14). The balloon tuboplasty system was equipped with a guidewire for tracking the balloon into tubal strictures. These initial reports were extended to larger clinical studies. The Food and Drug Administration approved balloon tuboplasty multicenter clinical trial, enrolled 150 patients, and represents, to date, the largest prospective multicenter clinical trial of noninvasive tubal catheterization for the treatment of bilateral proximal tubal occlusion (18). In parallel, wire recanalization of fallopian tubes clinical trials were extended to allow adequate evaluation of this technique, with special emphasis on recanalization of bilateral proximal tubal occlusion (15,55,56). Selective salpingography with wire recanalization and balloon tuboplasty are easily performed under fluoroscopic guidance. Rapid acceptance of tubal catheterization resulted in the addition of sonographically guided tubal catheterization to allow elimination of hysteroscopy, laparoscopy, and fluoroscopy (38). Sonographic balloon tuboplasty can also be performed under the guidance of Doppler US (36). Doppler US demonstrates the direction and flow of microbubbles within the fallopian tubes and clearly visualizes tubal recanalization. It is expected that Doppler equipment will become more affordable. The resolution of both gray scale and Doppler US is inferior to fluoroscopy. This disadvantage currently limits the use of sonographic guidance during tubal catheterization for the treatment of proximal tubal occlusion. Extensive information on patient selection for noninvasive tubal recanalization is limited today to those women who have bilateral proximal tubal occlusion (18). The benefit of unilateral tubal recanalization remains unknown. Theoretically, unilateral recanalization may increase PRs if alternate right and left ovulations are assumed. The benefit of tubal catheterization of patients with previous 218

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history of tubal surgery for either proximal or distal tubal disease remains unclear. Severe anatomical distortion may occur because of previous surgical interruption of tubal continuity. It is possible that concentric fibrous adhesions may be dilated using combinations of wires, dilating catheters, and balloons. These patients, in theory, may have reduced chances of successful tubal catheterization and reduced PRs when compared with IVF. This approach is also unlikely to succeed whenever distal tubal damage causes the formation of hydrosalpinx. Severe anatomical distortion caused by uterine fibroids, uterine and tubal malformations, and peritubal adhesions require evaluation and therapy. Hysterosalpingography, hysteroscopy, and laparoscopy do not allow diagnosis of proximal multifocal tubal occlusions or complete obliteration of the tubal lumen because multifocal tubal occlusions present radiologically as a single cornual or proximal tubal occlusion. Therefore, exclusion of those patients is impossible. Those patients probably represent a very compromised subpopulation of women with proximal tubal occlusion. Tubal cannulation serves as both diagnostic and prognostic procedure to determine the extent of tubal damage. Patients who have granulomatous tubal disease are not likely to benefit from any tubal corrective intervention because of extensive damage to the fallopian tubes (57). In vitro fertilization may yield PRs that are higher than combined proximal and distal procedures. Until comparative studies are evaluated, transcervical tubal catheterization combined with neosalpingostomy is an experimental alternative to IVF-ET. Combined proximal and distal tubal reconstructive procedures have been notoriously unsuccessful; therefore, the combined invasive and noninvasive procedure is not likely to result in high PRs. Catheterization of fallopian tubes for proximal tubal occlusion results in tubal recanalization in approximately 8 to 9 of 10 patients. It is interesting that even with patient selection bias present in the studies quoted in Table 3, PRs within the first 6 to 12 months ranged between 23% and 39%. As expected, in patients with previous tubal damage, EPs occurred in 5% to 13% of the patients. Tubal pregnancies typically occurred in the ampullary portion of the fallopian tubes (18). This observation emphasizes that unrecognized distal tubal damage may exist in some patients with proximal tubal occlusion. Subtle endotubal damage was probably unrecognized during tubal catheterization. Fertility and Sterility

Table 3 Results of Selective Tubal Catheterization, Tubal Recanalization Rates, PRs, EP Rates, and 6-Month Patency Rates in Patients With Proximal Tubal Occlusion

Authors

No. of patients

Thurmond and Rosch (15) Platia and Krudy (9) Contino et al. (18) Capitanio et al. (56) Lisse and Syndow (38)

100 21 77 108 41

Successful unilateral recanalizations

Early uterine PR

86 76 92 81

39 38 35 23 31

EP rate

Estimated 6-month patency

6 13 5 0 0

75 75 82 35 57

%

The effect of tubal catheterization on long-term patency of the fallopian tubes is also promising. In the five series in Table 3 long-term tubal patency ranges between 35% and 82%. It is quite remarkable that in a significant number of patients undergoing proximal tubal recanalization the fallopian tubes remain open on subsequent follow-up radiologic studies. The diversity of the results reflects most probably patient selection bias, differences in operator experience, and type of catheters. These differences do not allow conclusive comparison of wire recanalization of fallopian tubes, the use of coaxial systems for selective salpingography, and balloon tuboplasty. Wire recanalization of fallopian tubes typically uses a coaxial catheter system with decreasing diameters equipped with tipped geometry (10, 15). Tapering catheter tips can, in fact, cause some dilatation of the fallopian tubes. Similarly, the balloon tuboplasty system incorporates elements of wire recanalization. A balloon-tipped catheter allows forward advancement of the guidewire into obstructed areas, and it also allows the operator to stretch the obstructed area laterally. Both techniques apply comparable forces on the obstructed tubal area. Only prospective randomized clinical trials will establish the superiority of either technique. Potential complications of tubal catheterization include side effects of the procedure itself, analgesia, and anesthesia. Patients undergoing tubal catheterization require combinations of paracervical block and intravenous sedation. The likelihood of complications of this analgesia is relatively low. If general anesthesia is administered, complications related to anesthesia may be slightly higher but remain in a very low range. Neither salpingitis nor endometritis has been reported after tubal catheterization. Occasional flare-up of pre-existing dormant infectious focus may occur after tubal manipulation and catheterizaVol. 60, No.2, August 1993

84

tion, similar to any other procedure performed on the fallopian tubes. Recognition of the symptoms and immediate aggressive antibiotic treatment are of utmost importance to allow timely eradication of the infectious process. The source of potential infection during transcervical catheterization may be found in clinically inapparent cervical, uterine, or tubal presence of pathogens. Similar to any other transcervical procedure, it is advisable to prescreen all patients in a routine fashion with cervical cultures for chlamydia, gonorrhea, mycoplasma, and ureaplasma. The rationale to administer prophylactic antibiotics relies primarily on the early treatment of those rare patients with pre-existent dormant infection. The alternate decision to avoid antibiotic prophylaxis has to rely on cost-benefit considerations. Patients who demonstrate any clinical evidence of infection in the genital tract should not be subjected to any elective transcervical procedures. Hemorrhagic complications during both transcervical balloon tuboplasty and selective salpingography have not been reported. In theory, perforation of the uterine wall may lacerate major branches of the uterine artery or damage large pelvic vessels. During adequately performed transcervical catheterization, the tip of the cervical cannula and the tubal catheters are apparent and clearly visible. If the physician does not advance catheters without either fluoroscopic or direct visualization, hemorrhagic complication is highly unlikely. The small diameter of the catheters minimizes the theoretical chance to lacerate a major blood vessel or to cause uterine damage that will result in significant bleeding. Routine prescreening of patients is directed to identify history suggestive of abnormal clotting and to perform inexpensive clotting screening tests, such as prothrombin time and partial thromboplastin time. Tubal perforation with wire-loaded catheters was Risquez and Confino

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reported in <2% of patients undergoing balloon tuboplasty and 5% in patients undergoing selective salpingography (Table 3). Advancement of catheters into the fallopian tube causes lateral deflection observed during concomitant laparoscopy. The presence of a second laparoscopic team may not prevent pinpoint perforations during tubal catheterizations (17). Tubal and uterine perforations cannot always be prevented because the laparoscopic team cannot identify a false route created by the tip of the advancing catheter. Radiologic observation of the catheter tip does not prevent pinpoint perforations either. Tubal perforation prevention relies primarily on the use of adequate equipment and adherence to cautious catheterization technique, which relies on advancement of catheters in a predetermined and known trajectory. Incomplete damage to the endotubal mucosa may result in the formation of small lacunar accumulation of dye between the endotubal mucosa and the tubal wall with an overall shape of a small bleb. These submucosal perforations are probably of little significance and are not recognizable shortly after absorption of the dye and quick sealing of the mucosal damage (58). Patients undergoing tubal catheterization should be advised of an increased risk of tubal pregnancy and be subjected to more frequent early pregnancy monitoring. Early pregnancy monitoring with vaginal US will demonstrate the presence of an intrauterine sac. This approach is likely to identify early tubal pregnancies. Timely intervention will allow conservative management of EP. Transcervical catheterization of fallopian tubes and recanalization of proximal tubal occlusion using balloons and wires can replace major abdominal procedures and IVF in those patients who demonstrate normal anatomy of the distal portion of the fallopian tube. If patient selection excludes women with distal tubal disease, periovarian and peritubal adhesions, transcervical tubal cannulation may be attempted in an early stage to achieve patency and pregnancy. The noninvasive nature of the procedure and the cost savings, in combination with complete elimination of laparotomy necessary for microsurgical repair, make tubal cannulation very attractive. Transcervical tubal catheterization is a diagnostic procedure with therapeutic potential that can be performed during the early stages of tubal factor infertility evaluation. Patients selected for tubal catheterization before laparoscopy to determine the presence of a tubal factor will initially undergo HSG, followed by selective salpingography 220

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or transcervical balloon tuboplasty. If during this procedure large hydrosalpinges are diagnosed bilaterally, the patient may be counseled about the low chances of conception using conventional repair of distal tubal damage in the presence of proximal tubal occlusion. The patient may select to attempt IVF, which can yield probably higher PRs. Therefore, in some patients early tubal catheterization may replace and eliminate the need for laparoscopy. If tubal patency is achieved by either HSG, selective salpingography, or wire and balloon recanalization, the patient may be allowed to attempt conception and undergo further evaluation and counseling about assisted reproduction at a later stage. The flexible nature of tubal catheterization allows combinations of these procedures with other diagnostic and therapeutic procedures. If laparoscopy is performed during evaluation of patients with possible tubal factor infertility and bilateral proximal tubal occlusion is apparent during chromotubation, tubal catheterization may be a diagnostic and therapeutic intraoperative option. The role of tubal catheterization for patients with salpingitis isthmica nodosa has not been clearly determined. Salpingitis isthmica nodosa may be a progressive disease with different damage to the tubal and peritubal anatomy. Therefore, some patients with salpingitis isthmica nodosa with preserved tubal lumen may benefit from tubal catheterization or balloon tuboplasty (18). In patients with severe salpingitis isthmica nodosa damage to the fallopian tubes the likelihood of permanent recanalization decreases significantly. TRANSCERVICAL TUBAL STERILIZATION

Transcervical tubal obliteration relies primarily on hysteroscopy. Electrocoagulation, cryocoagulation, nondestructive occlusion, formed-in-place plugs, injection of chemicals for permanent closure, and intratubal devices can all be delivered in transcervically placed catheters into the fallopian tubes and thus eliminate the need for hysteroscopy. Electrocoagulation of the intramural portion of the fallopian tubes results in 75% to 80% bilateral closure using single application and between 85% to 90% bilateral closure during the second application of electric current (59-61). The results and complications of hysteroscopic electrocautery are not uniform. A large collaborative study that involved 10 centers and 587 cases oftubal electrocautery yielded discouraging results. Only 57% of the Fertility and Sterility

patients had bilateral tubal occlusion during subsequent patency testing. Major complications included tubal and cornual EPs, bowel injury, peritonitis, uterine perforation, acute endometritis, hemorrhage, and a single death secondary to bowel perforation. Although the overall rate ofthese complications was low, hysteroscopic electrocautery for tubal occlusion was largely abandoned (60, 61). Cryocoagulation for transcervical tubal obliteration has not been tested enough. This technique may offer, in combination with application of other materials, some advantages. Cornual cryocoagulation needs further evaluation before wide clinical application (62,63). Very rapid regeneration of endometrial and endotubal mucosa contributed to high failure rates of both techniques and spontaneous tubal recanalization. Suboptimal tubal occlusion rates may improve if transcervical catheter delivery system of electrodes into the cornua is developed. This approach has not been entirely explored to date. Additional obstacles include the need for changes in electrocautery technology to eliminate the apparent major risks of damage to adjacent organs. Since the early reports of fallopian tube occlusion with silicone rubber plugs, a large data base has accumulated. Silicone was applied through a cornual cannula guided under fluoroscopy or through a hysteroscope. Although the original silicone plugs had retrieval loops, it became apparent that once the plug is formed in place, it is difficult to withdraw the entire silicone plug without tearing the thin proximal portion. Therefore, the occlusion should be considered permanent. The overall occlusion rates reported in the early 1980s were approximately 80% during the first instillation and 90% during two or three applications of silicone. Although this economical outpatient method of sterilization required only local anesthesia and avoided surgical incision, the almost 100% success rates of surgical tubal interruption resulted in limited acceptance of silicone tubal plugs (64,65). A number of uterotubal junction-blocking devices, mechanical occlusive devices, and other tubal plugs have been designed. Some of these devices were made from silicone rubber, with or without metal-anchoring spikes to allow placement of the devices within the uterine cornua. Initial studies in primates were very successful, and reversibility seemed to be quite good. However, testing the devices in 20 women resulted in 90% tubal patency after the devices were removed (66). Sterilization Vol. 60, No.2, August 1993

failures were unacceptably high; therefore, further clinical trials were deferred. Although this technique offers noninvasive tubal obliteration, at this point it is clearly inferior to surgical alternatives. Transcervical catheterization for delivery of devices for temporary or permanent tubal occlusion relies primarily on future development of efficient occluding devices. Various chemical agents and different delivery systems have been investigated in clinical trials (67-69). Clinical trials with methylcyanoacrylate started in 1972, and improvements in the technique were reported later (67). Unfortunately, methylcyanoacrylate was discontinued because of rapid tubal recanalization and subsequent failures. Alternative material tested for tubal obliteration was quinacrine (68). Quinacrine pellets were placed in the uterine cavity during the proliferative phase of the menstrual cycle. Timed release of quinacrine provided prolonged contact of the tubal ostia with this caustic material. Quinacrine causes tubal inflammation, secondary scarring of the ostia, and severe damage to the intramural epithelium of the fallopian tubes. The method requires several applications of quinacrine pellets at monthly intervals. Quinacrine pellet insertion was effective in 95% of patients who desired tubal obliteration. Quinacrine was tested in > 10,000 patients (68). Phenolatabrine (PAP) paste tubal obliteration has been performed in China since the 1970s on >0.5 X 106 subjects with a well-established safety record and a mechanism of action similar to quinacrine (69). Phenolatabrine paste causes endotubal necrosis, destroys the tubal epithelium, and inhibits regrowth of new lining. Late tissue granulation completes the obliteration process of the tubal lumen. Reversal of PAP tubal obliteration is unlikely. Delivery of this material into the uterus requires radiologic imaging of the uterine cavity. The simplicity of the procedure made this method very attractive in China (69). Although success rates of chemical tubal obliteration may be cost-effective in developing countries, improvements in those techniques are required to compete with the success rates of surgical sterilization. Transcervical catheterization of the fallopian tube is more accurate than transcervical deposition of materials via cannulas. Future improvements of transcervical tubal obliteration methods may hopefully bring chemical obliteration of fallopian tubes to the level of success obtained by surgical sterilization. Risquez and Confino

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TRANSCERVICAL TUBAL CANNULATION AND ASSISTED REPRODUCTION

Transcervical tubal cannulation for deposition of gametes evolved directly from tubal catheterization techniques (12, 70, 71). Gametes and embryos can be transferred through the proximal portion of the fallopian tube into the tubal ampulla. Ultrasoundguided retrograde tubal catheterization for deposition of gametes and embryos does not require laparoscopy and can be done in an ambulatory setting. The incidence of adverse side effects such as perforation and infection remains remarkably low, at the same range described during those procedures performed for recanalization of proximal tubal occlusion. The alternative transcervical method for tubal deposition of gametes and embryos involves tubal catheterization, using either flexible or rigid hysteroscopes. The premise of tubal deposition of gametes and embryos relies primarily on data suggesting that G 1FT and tubal embryo transfer (TET) are superior to IVF (72, 73). It is assumed that the tubal environment is more favorable for early embryo development, and this difference accounts for the improved PRs. Other explanations of improved PRs with GIFT and TET procedures assume better synchronization of the endometrial lining with embryo stage, resulting in better endometrial receptivity. The concept has been challenged by observations that some patients who have canceled GIFT cycles conceived spontaneously (74). Some of the conceptions during GIFT may result from procedural nonrelated events. The exact mechanism and the role of patient selection need to be established. Currently, the majority of TETs into the ampullary portion of the fallopian tube are performed during laparoscopically guided tubal cannulation. This procedure adds a second invasive surgical procedure requiring general anesthesia. The transcervical approach to the fallopian tube can obviously offer potential advantage over laparoscopy. Several studies have confirmed the feasibility of retrograde transfer of gametes and human embryos (75, 76). Pregnancy rates reported in small series of transcervical gametes and zygote intrafallopian depositions have so far been inferior to laparoscopic GIFT and TET (Scholtes MCW, Roozenburg A, Alberda TH, Zeilmaker GH, abstract) (Maleika F, Weiske WH, Maleika MC, abstract). In some cases gametes and embryos were deposited in the uterine cavity or flushed into the abdominal cavity. Intrauterine pregnancies that occurred 222

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in patients with failed tubal catheterization and anecdotal reports of abdominal and tubal pregnancies suggest inappropriate deposition of embryos using the transcervical approach. Some failures may be related to a learning curve. Increasing experience with sonographic equipment and better tactile tubal catheterization will hopefully reduce the number of inappropriate TETs. Future application of falloposcopy will hopefully decrease the uncertainty in embryo placement. Falloposcopic visualization of the transitional area between the isthmic and the ampullary portions of the fallopian tube will result in a very precise deposition of embryos in the proximal ampulla. Additional factors that may affect PRs achieved by transcervical catheterization include microtrauma to the tubal lining, subclinical salpingitis, tubal spasm, activation of myosalpingeal contractions, embryo damage, excessive medium volume, and excessive injection pressures. Until all parameters are optimized, it is not expected that transcervical gamete and embryo deposition will result in PRs superior to laparoscopic TET. The necessary improvements include changes in catheter design to facilitate tubal access, the use of low pressure injection methods, injection or small volume of medium for suspension of gametes and embryos, careful assessment of the equipment to prevent embryo damage, and better patient selection. Therefore, larger prospective randomized clinical trials are needed to establish the value of transcervical gamete and embryo deposition in the fallopian tubes. TRANSCERVICAL CANNULATION FOR DIAGNOSIS AND TREATMENT OF EP

Early detection of EP introduced conservative medical and surgical therapy (77, 78). Medical treatment of EP, using agents such as methotrexate (MTX) or other substances that have cytoreductive effect, exposes patients to some side effects of the medication. Attempts are made to reduce the amount of medication administered into the EP by direct deposition of the material into the tube. Local deposition is more advantageous than systemic administration because it allows enhanced local cytoreductive effect. The accuracy of administration will, in theory, improve the efficacy of local application (79). Selective transcervical tubal cannulation under fluoroscopy and injection of contrast material may depict the exact location of the EP (80, 81). RadioFertility and Sterility

logic imaging of EP demonstrates either complete obliteration of the tubal lumen, filling defects inside the ampullary portion of the fallopian tube, or a crescent of contrast material. This crescent is visible whenever incomplete filling of the ampullary portion accumulates on one side of the EP. Selective salpingography is not diagnostic in patients in whom complete obliteration of the proximal fallopian tube occurs. Therefore, additional diagnostic measures must be taken to confirm the diagnosis. Once EP is located, transcervical catheterization allows close application of the catheter tip to the tubal ostium and deposition of materials such as MTX into the dilated portion of the proximal tube, between the EP and the cornua ofthe uterus. Deposition of MTX in this area is advantageous because the proximal tubal segment is relatively sealed compared with the ampullary portion of the fallopian tube. Instillation of any cytoreductive materials in this part will allow, in theory, longer effect of the material on the EP. Tubal catheterization for diagnosis and treatment of EP can be performed in an ambulatory setup or in a radiology suite. It requires minimal analgesia and intravenous sedation and offers an advantage over operative laparoscopy, which requires general anesthesia. The relatively short experience with tubal cannulation for EP requires further follow-up data. It seems that patient selection for this procedure may follow the same pattern described with other routes of administration of MTX for EP. If, indeed, transcervical tubal catheterization is similar or better than sonographically guided deposition of MTX into EPs, it is expected that patient selection would affect the results in a comparable fashion. The larger the EP and the higher the hCG levels, the more likely the procedure is to fail. In the presence of heart action and rising hCG levels, deposition of MTX into the fallopian tube may result in as high as 30% failures (82). It is therefore recommended that patients be selected with hCG levels that are low enough to allow effective action of MTX and exclude patients with a viable conceptus, heartbeat, and normally rising hCG levels. If selection of patients for transcervical cannulation for EP concentrates on those women who have ectopic gestations that have leveling or dropping hCG levels, the likelihood of failures may be eliminated (Confino E, Binor Z, Wood-Molo M, Radwanska E, abstract). Reproduction is unlikely to be impaired because of MTX injection into the tube (83). Side effects of medical treatment of EP are Vol. 60, No.2, August 1993

related to the nature of the material injected into the fallopian tube. Data from several clinical trials demonstrate that side effects related to MTX are negligible if a single dose is injected, and leucovorin rescue is not needed to prevent severe bone marrow depression (84). Alternative materials of cytoreductive potential may eliminate in the future side effects associated with tubal administration of MTX (85, 86). Adequate counseling ofthe patients and follow-up at 2- to 3-day intervals after injection ofMTX into the fallopian tube are mandatory. The physician should be prepared for an emergency surgical intervention if deterioration occurs. Transcervical falloposcopy for visualization of EP has also been reported (87). The falloposcope is introduced into the fallopian tube using a coaxial catheter system, and the ectopic mass can be visualized. The noninvasive nature of this approach, reduction in the amount of MTX delivered, and elimination of laparoscopy and radiation are obviously advantageous. The early experience with easy tubal catheterization of patients with EP may be secondary to hormonal changes, lower intratubal pressure because of muscle relaxation, and enlargement of the tubal ostium during pregnancy. Ectopic pregnancies that are already compromised may even be hydrodissected using pressure flushing, and the ectopic mass can be dislodged from the tubal wall. Hydrodissection is less likely to be successful whenever a viable EP is embedded in the tubal wall. Patients' motivation and compliance with close follow-up protocols and physicians' acceptance of the stress associated with patients with EPs treated conservatively are mandatory using the transcervical approach. Future progress in the methodology of transcervical catheterization and falloposcopy, as well as larger studies, will establish the role of falloposcopy in the treatment of EP. THE FUTURE OF TRANSCERVICAL TUBAL CANNULATION

Transcervical tubal cannulation reduces the risks, costs, and morbidity of many surgical procedures performed on the fallopian tubes. Various applications of tubal cannulation make this approach a valuable aid to the contemporary physician. Tubal catheterization is a rapidly expanding field, with fascinating future applications. Currently, tubal physiology and pathophysiology cannot be assessed because of our inability to sample the fallopian tube in a noninvasive fashion. Direct access into the fallopian tube may allow in the future Risquez and Confino Tubal cannulation

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sampling of both tubal fluid and exfoliative cytology. If this procedure proves to be cost-effective, additional measures may be added to the existing diagnostic tools to evaluate tubal normality and function. Tubal catheterization may allow local drug administration in diseases other than EP. Development of micro lasers and microinstruments to treat intratubal obstructive lesions, polyps, and tubal occlusions may also add another perspective to catheter recanalization of fallopian tubes. The advantage of the transcervical microsurgical approach is that micropathology can be selectively treated without unnecessary damage to healthy segments of the fallopian tube. Transcervical tubal cannulation is the quest of the 1980s and 1990s to add to our rapidly expanding knowledge of the endotubal microcosmos. Tubal catheterization should become an accepted, taught, and practiced approach in the diagnosis and treatment of fallopian tubes.

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