Transcervical selective salpingography: a diagnostic and therapeutic approach to cases of proximal tubal injection failure

Tubal flushing for subfertility

BACKGROUND

Establishing the subgroup analysis of the fallopian tubes (tubes) is a commonly undertaken diagnostic investigation for women with subfertility. This is usually achieved by flushing contrast medium through the tubes and visualising patency on radiographs, ultrasonography or laparoscopy. Many women were noted to conceive in the first three to six months after tubal flushing, raising the possibility that tubal flushing could also be a treatment for infertility. There has been debate about which contrast medium should be used (water-soluble or oil-soluble media) as this may influence pregnancy rates. An important adverse event during tubal flushing is intravasation (backflow of contrast medium into the blood or lymphatic vessels),which could lead to embolism although it is asymptomatic in most cases.

OBJECTIVES

To evaluate the effectiveness and safety of tubal flushing with oil-soluble contrast media (OSCM) and water-soluble contrast media (WSCM) on subsequent fertility outcomes in women with subfertility.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group Specialised Register of controlled trials, MEDLINE, Embase, CENTRAL, PsycINFO, reference lists of identified articles and trial registries. The most recent search was conducted in April 2020.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing tubal flushing with OSCM, WSCM with each other or with no treatment, in women with subfertility.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the trials, assessed risk of bias and extracted data. We contacted study authors for additional information. The overall quality of the evidence was assessed using GRADE methods.

MAIN RESULTS

Fifteen trials involving 3864 women were included in this systematic review. Overall, the quality of evidence varied from very low to moderate: the main limitations were risk of bias, heterogeneity and imprecision. OSCM versus no treatment Four studies (506 women) were included in this comparison. Tubal flushing with OSCM may increase the odds of live birth (odds ratio (OR) 3.27, 95% confidence interval (CI) 1.57 to 6.85, 3 RCTs, 204 women, I² = 0, low-quality evidence). This suggests that if the chance of live birth following no treatment is assumed to be 11%, the chance following tubal flushing with OSCM would be between 16% and 46%. Tubal flushing with OSCM may increase in the odds of clinical pregnancy (OR 3.54, 95% CI 2.08 to 6.02, 4 RCTs, 506 women, I² = 18%, low-quality evidence). This suggests that if the chance of clinical pregnancy following no treatment is assumed to be 9%, the chance following tubal flushing with OSCM would be between 17% and 37%. No study measured intravasation or other adverse events such as infection, haemorrhage and congenital abnormalities. WSCM versus no treatment Only one study (334 women) was included in this comparison. We are uncertain whether tubal flushing with WSCM increase live birth compared to no treatment (OR 1.13, 95% CI 0.67 to 1.91, 1 RCT, 334 women, low-quality evidence). This suggests that if the chance of live birth following no treatment is assumed to be 21%, the chance following tubal flushing with WSCM would be between 15% and 33%. We are uncertain whether tubal flushing with WSCM increases clinical pregnancy compared to no treatment (OR 1.14, 95% CI 0.71 to 1.84, 1 RCT, 334 women, low-quality evidence). This suggests that if the chance of clinical pregnancy following no treatment is assumed to be 27%, the chance following tubal flushing with WSCM would be between 29% and 40%. One case with pelvic infection was reported in the WSCM group and no case with infection in the no treatment group in a one study (334 women). Meta-analysis was not performed due to the rare events. No study measured intravasation or other adverse events such as infection, haemorrhage and congenital abnormalities. OSCM versus WSCM Six studies (2598 women) were included in this comparison. Three studies reported live birth, including two with higher live birth in the OSCM group (OR 1.64, 95% CI 1.27 to 2.11, 1119 women; OR 3.45, 95% CI 1.97 to 6.03, 398 women); and one with insufficient evidence of a difference between groups (OR 0.92, 95% CI 0.60 to 1.40, 533 women). Given the substantial heterogeneity observed (I² = 86%), meta-analysis was not performed. Tubal flushing with OSCM probably increased in the odds of intravasation (asymptomatic) compared to tubal flushing with WSCM (OR 5.00, 95% CI 2.25 to 11.12, 4 RCTs, 1912 women, I² = 0, moderate-quality evidence). This suggests that if the chance of intravasation following tubal flushing with WSCM is assumed to be 1%, the chance following tubal flushing with OSCM would be between 2% and 9%. Tubal flushing with OSCM may increase the odds of clinical pregnancy (OR 1.42, 95% CI 1.10 to 1.85, 6 RCTs, 2598 women, I² = 41%, low-quality evidence). This suggests that if the chance of clinical pregnancy following tubal flushing with WSCM is assumed to be 26%, the chance following tubal flushing with OSCM would be between 28% and 39%. We are uncertain whether tubal flushing with OSCM decreases the odds of infection (OR 0.22, 95% CI 0.04 to 1.22, 2 RCTs, 662 women, I² = 0, very low-quality evidence) or haemorrhage (OR 0.65, 95% CI 0.40 to 1.06, 2 RCTs, 662 women, I² = 0, very low-quality evidence). Three neonates with congenital abnormalities were reported in the OSCM group while no congenital abnormality was reported in the WSCM group in one study (1119 women). No meta-analysis was performed due to the rare events.

AUTHORS' CONCLUSIONS

The evidence suggests that compared to no treatment, tubal flushing with OSCM may increase the chance of live birth and clinical pregnancy, while it is uncertain whether tubal flushing with WSCM improves those outcomes. Compared to tubal flushing with WSCM, OSCM may improve clinical pregnancy while meta-analysis was impossible for live birth due to heterogeneity. Evidence also suggests that OSCM is associated with an increased risk of asymptomatic intravasation. Overall, adverse events, especially long-term adverse events, are poorly reported across studies.

Frequency of Proximal Tubal Obstruction in Patients Undergoing Infertility Evaluation

Fallopian tube recanalization is a technique for treatment of proximal tubal obstruction caused by debris. The true frequency of infertile women for whom this treatment is suitable is not well known. In this study all hysterosalpingograms (HSGs) performed over a 3-year period (1986–88) were reviewed. The HSGs were performed as part of an infertility evaluation program in 494 women, with a mean duration of infertility of 2.4 years. Bilateral proximal tubal obstruction was found in 3% and unilateral proximal obstruction in 2% of the cases. In women examined in the first 2 years (1986–87) (n = 328), the birth frequency after HSG was 25%. When HSG was performed with optimal technique the number of patients who were suitable for Fallopian tube recanalization was low.

Tubal flushing for subfertility

BACKGROUND

Establishing the patency of the fallopian tubes is a commonly undertaken diagnostic investigation for women with subfertility. This is usually achieved by flushing contrast medium through the tubes and taking radiographs. However, it has been noted that many women conceive in the first three to six months after the tubal flushing, which has raised the possibility that tubal flushing could also be a treatment for infertility. There has been debate about which contrast medium should be used (water-soluble or oil-soluble media) as this may influence pregnancy rates.

OBJECTIVES

To evaluate the effect of flushing fallopian tubes with oil- or water-soluble contrast media on live birth and pregnancy rates in women with subfertility.

SEARCH METHODS

We searched the Cochrane Menstrual Disorders and Subfertility Group Specialised Register of trials, MEDLINE, EMBASE, Biological Abstracts, trial registers and reference lists of identified articles. The most recent search was conducted in June 2014.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing tubal flushing with oil-soluble or water-soluble contrast media, or with no treatment, in women with subfertility.

DATA COLLECTION AND ANALYSIS

Two authors independently selected the trials, assessed risk of bias and extracted data. We contacted study authors for additional information. The overall quality of the evidence was assessed using GRADE methods.

MAIN RESULTS

Thirteen trials involving 2914 women were included, of whom 2494 were included in the analysis. Oil-soluble contrast media (OSCM) versus no interventionThe OSCM group had a higher rate of live birth (odds ratio (OR) 3.09, 95% CI 1.39 to 6.91, 1 RCT, 158 women, low quality evidence) and ongoing pregnancy (OR 3.59, 95% CI 2.06 to 6.26, 3 RCTs, 382 women, I(2) = 0%, low quality evidence) than women who had no intervention. Our findings suggest that among subfertile women with a 17% chance of an ongoing pregnancy if they have no intervention, the rate will increase to between 29% and 55% if they have tubal flushing with OSCM. Water-soluble contrast media (WSCM) versus no interventionThere was no evidence of a difference between the groups in rates of live birth (OR 1.13, 95% CI 0.67 to 1.91, 1 RCT, 334 women, very low quality evidence) or ongoing pregnancy (OR 1.14, 95% CI 0.71 to 1.84, 1 RCT, 334 women, very low quality evidence). OSCM versus WSCMTwo RCTs reported live birth: one found a higher live birth rate in the oil-soluble group and the other found no evidence of a difference between the groups. These studies were not pooled due to very high heterogeneity (I(2) = 93%). There was no evidence of a difference between the groups in rates of ongoing pregnancy, however there was high heterogeneity (OR 1.44, 95% CI 0.84 to 2.47, 5 RCTs, 1454 women, I(2) = 76%, random-effects model, very low quality evidence). OSCM plus WSCM versus WSCM aloneThere was no evidence of a difference between the groups in rates of live birth (OR 1.06, 95% CI 0.64 to 1.77, 1 RCT, 393 women, very low quality evidence) or ongoing pregnancy (OR 1.23, 95% CI 0.87 to 1.72, 4 RCTs, 633 women, I(2) = 0%, low quality evidence).There was no evidence of a difference between any of the interventions in rates of adverse events, but such events were poorly reported in most studies.

AUTHORS' CONCLUSIONS

The evidence suggests that tubal flushing with oil-soluble contrast media may increase the chance of pregnancy and live birth compared to no intervention. Findings for other comparisons were inconclusive due to inconsistency and lack of statistical power. There was insufficient evidence on adverse events to reach firm conclusions. Further robust randomised controlled trials are needed.

Proximal tubal disease: the place for tubal cannulation

Tubal disease is the cause of subfertility in approximately 30% of women, and 10-25% of these are due to proximal tubal obstruction. False-positive diagnosis of proximal tubal obstruction can be as high as 50%. A decrease in expertise in tubal microsurgery has resulted largely from the use of IVF as the treatment option for most causes of infertility and more specifically for tubal factor infertility. Selective salpingography and tubal cannulation have a unique role in the management of tubal infertility and should be offered to selected candidates prior to IVF. Tubal cannulation can be used effectively to restore patency in a proportion of cases of proximal tubal obstruction thus avoiding the need for expensive assisted reproductive techniques. This review examines the evidence supporting the effectiveness of tubal cannulation and aims to enhance awareness of the procedure as an option for the management of female subfertility secondary to isolated proximal tubal obstruction.

Tubal flushing for subfertility

BACKGROUND

A possible therapeutic effect of diagnostic tubal patency testing has been debated in the literature for half a century. Further debate surrounds whether oil-soluble or water-soluble contrast media might have the bigger fertility-enhancing effect.

OBJECTIVES

To evaluate the effect of flushing a woman's fallopian tubes with oil- or water-soluble contrast media on subsequent fertility outcomes in couples with infertility.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group's specialised register of trials (searched 31 January 2007), MEDLINE, EMBASE, Biological Abstract and reference lists of articles.

SELECTION CRITERIA

All randomised trials comparing tubal flushing with oil-soluble contrast media or tubal flushing with water-soluble media or with no treatment in women with subfertility.

DATA COLLECTION AND ANALYSIS

Four authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We collected adverse effects information from the trials.

MAIN RESULTS

Twelve trials involving 2079 participants were included. Tubal flushing with oil-soluble media versus no intervention was associated with a significant increase in the odds of live birth (Peto OR 2.98, 95% CI 1.40 to 6.37) and of pregnancy (Peto OR 3.30, 95% CI 2.00 to 5.43). For the comparison of tubal flushing with oil-soluble media versus tubal flushing with water-soluble media, the increase in the odds of live birth for tubal flushing with oil-soluble versus water-soluble media (Peto OR 1.49, 95% CI 1.05 to 2.11) was based on two trials where statistical heterogeneity was present and the higher quality trial showed no significant difference; there was no evidence of a significant difference in the odds of pregnancy (Peto OR 1.21, 95% CI 0.95 to 1.54). The addition of oil-soluble media to flushing with water-soluble media showed no evidence of a significant difference in the odds of pregnancy (Peto OR 1.28, 95% CI 0.92 to 1.79) or live birth (Peto OR 1.06, 95% CI 0.64 to 1.77). There were no serious adverse event reported.

AUTHORS' CONCLUSIONS

There is evidence of effectiveness of tubal flushing with oil-soluble contrast media in increasing the odds of pregnancy and live birth versus no intervention. Future robust randomised trials, comparing oil-soluble versus water-soluble media, water-soluble media versus no intervention and tubal flushing versus established treatments for infertility would be a useful further guide to clinical practice.

Tubal flushing for subfertility

BACKGROUND

A possible therapeutic effect of diagnostic tubal patency testing has been debated in the literature for half a century. Further debate surrounds whether oil-soluble or water-soluble contrast media might have the bigger fertility-enhancing effect. Historically a variety of agents have been used to 'flush' the fallopian tubes, although tubal flushing does not currently form part of routine practice in the treatment of fertility delay.

OBJECTIVES

To evaluate the effect of flushing a woman's fallopian tubes with oil- or water-soluble contrast media on subsequent fertility outcomes in couples with infertility.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group's specialised register of trials (searched 2 March 2004), MEDLINE (1966 to Mar 2004), EMBASE (1980 to Mar 2004), Biological Abstract (1980 to Mar 2004) and reference lists of articles.

SELECTION CRITERIA

All randomised trials where tubal flushing with oil-soluble contrast media or tubal flushing with water-soluble media was compared with one another or with no treatment were considered for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Eleven randomised controlled trials were identified and included in this review. All trials were assessed for quality criteria. The studied primary outcome was live birth (and ongoing pregnancy), with secondary outcomes pregnancy, miscarriage, ectopic pregnancy, treatment complications including pain, intravasation of contrast medium, infection and haemorrhage, and image quality.

MAIN RESULTS

Tubal flushing with oil-soluble media versus no intervention (three trials including 381 participants) was associated with a significant increase in the odds of live birth (Peto OR 2.98, 95%CI 1.40 to 6.37) and of pregnancy (Peto OR 3.30, 95%CI 2.00 to 5.43). There were no data from RCTs to assess tubal flushing with water-soluble media versus no intervention. For the comparison of tubal flushing with oil-soluble media versus tubal flushing with water-soluble media (six trials including 1,483 participants), the increase in the odds of live birth for tubal flushing with oil-soluble versus water-soluble media (Peto OR 1.49, 95%CI 1.05 to 2.11) was based on two trials where statistical heterogeneity was present and the higher quality trial showed no significant difference; there was no evidence of a significant difference in the odds of pregnancy (Peto OR 1.24, 95%CI 0.97 to 1.57). The addition of oil-soluble media to flushing with water-soluble media (water-soluble plus oil-soluble media versus water-soluble media alone; three trials including 555 participants) showed no evidence of a significant difference in the odds of pregnancy (Peto OR 1.18, 95%CI 0.82 to 1.70) or live birth (Peto OR 1.06, 95%CI 0.64 to 1.77). Adverse event data were only available for the comparison OSCM versus WSCM: OSCM carried a significantly higher chance of intravasation (Peto OR 5.41, 95%CI 2.57 to 11.37) but a significantly lower chance of immediate pain (Peto OR 0.53, 95%CI 0.34 to 0.84), prolonged pain (Peto OR 0.26, 95%CI 0.15 to 0.45) and post-procedure bleeding (Peto OR 0.22, 95%CI 0.15 to 0.31), and no serious adverse events were reported.

AUTHORS' CONCLUSIONS

There is evidence of effectiveness of tubal flushing with oil-soluble contrast media in increasing the odds of pregnancy and live birth versus no intervention. The limited evidence of an increase in the odds of live birth from tubal flushing with oil-soluble contrast media versus water-soluble contrast media must be interpreted cautiously. Further robust randomised trials, comparing oil-soluble versus water-soluble media and comparing water-soluble media versus no intervention, would be a useful further guide to clinical practice. Further research is merited to ascertain the mechanism of the fertility enhancing effect of oil-soluble media, as to whether this is a 'tubal flushing' phenomenon, an effect on the intraperitoneal environment, or an implantation enhancing effect on the endometrium.

Modification of the coaxial technique for selective salpingography with measurement of tubal perfusion pressures

This article describes the use of the fallopotorque catheter system for transcervical selective salpingography and tubal catheterization under fluoroscopic guidance for the diagnosis and treatment of obstruction of the proximal Fallopian tube. The technique of tubal perfusion pressure assessment during the procedure, using the same catheter system, is also described. The relative advantages of this method of selective salpingography and tubal catheterization are then discussed in the background of previously described techniques.

Diagnostic and therapeutic value of selective salpingography and tubal catheterization in an unselected infertile population

OBJECTIVE

To present diagnostic findings and fertility outcome after selective salpingography and tubal catheterization in an unselected infertile population.

DESIGN

Cohort study.

SETTING

Tertiary reproductive medicine unit.

PATIENT(S)

One hundred ten consecutive infertile women. No exclusion criteria were applied. Follow-up ranged from 16 to 54 months.

INTERVENTION(S)

Selective salpingography and tubal catheterization under fluoroscopic guidance as the primary test for the assessment of the fallopian tubes.

MAIN OUTCOME MEASURE(S)

Incidence of tubal disease at selective salpingography, therapeutic effectiveness of tubal catheterization, and fertility outcome after the procedure.

RESULT(S)

Tubal disease was present in 31.4% of the tubes examined. Of tubes proximally blocked at selective salpingography, 52.1% were found to be normal after tubal catheterization. Proximal tubal blockage (bilateral or unilateral) was detected in 34.8% of women. This was reduced to 5.5% after tubal catheterization. Spontaneous conceptions occurred in 21.9% of the women. In total, 36.2% conceived without IVF or ICSI.

CONCLUSION(S)

Selective salpingography and tubal catheterization can be useful as a primary tubal assessment tool in the investigation of infertility. In cases of proximal tubal blockage, an effective see-and-treat approach can be adopted. More research into the possible therapeutic benefits of the procedure is justified.

The learning curve of selective salpingography and tubal catheterization

OBJECTIVE

To determine the effect of increasing experience in fluoroscopically guided selective salpingography and tubal catheterization on radiation doses and screening times, thus establishing a learning curve for the procedure.

DESIGN

Retrospective case note analysis.

SETTING

IVF center of an academic teaching hospital.

PATIENTS

Three hundred sixty-six patients with infertility seen over 3.5 years.

INTERVENTION(S)

Fluoroscopically guided selective salpingography and tubal catheterization.

MAIN OUTCOME MEASURE(S)

Reductions in radiation doses and screening times for different categories of selective salpingography and tubal catheterization, expressed as percentage reductions during the study period and reductions per 10 procedures.

RESULT(S)

During the study period, The median dose of radiation decreased by 62.6%-71.9%, and the median screening time declined by 61.5%-78.5%. Reductions per 10 procedures were 2.5%-4.2% and 2.7%-5%, respectively.

CONCLUSION(S)

Significant reductions in radiation doses and screening times start early in a clinical team's practice of selective salpingography and tubal catheterization and continue even as trainees are added to the pool of operators.

A review of selective salpingography and fallopian tube catheterization

Use of selective salpingography and fallopian tube recanalization has revolutionized the diagnosis and treatment of infertility. Selective salpingography, a diagnostic procedure in which the fallopian tube is directly opacified through a catheter placed in the tubal ostium, has been used since the late 1980s to differentiate spasm from true obstruction and to clarify discrepant findings from other tests. In fallopian tube recanalization, a catheter and guide wire system is used to clear proximal tubal obstructions. The recanalization procedure is simple for interventional radiologists to perform and is successfully completed in most patients (71%-92%). Pregnancy rates after the procedure have been variable, with an average rate of 30%. The combination of selective salpingography with fallopian tube recanalization has improved the overall management of infertility caused by tubal obstruction. The same catheterization technique used in fallopian tube recanalization is currently being explored for use in tubal sterilization.

A second hysterosalpingography reduces the use of selective technique for treatment of a proximal tubal obstruction

OBJECTIVE

To assess whether a second hysterosalpingography (HSG) can permit tubal patency, reducing the use of selective salpingography in patients with proximal tubal obstruction.

DESIGN

Prospective study.

SETTING

University hospital.

PATIENT(S)

The study population consisted of 360 infertile women.

INTERVENTION(S)

In patients with unilateral or bilateral proximal tubal obstruction, a second HSG was performed after about 1 month. In those cases with persistent obstruction, an immediate selective salpingography and tubal catheterization were performed.

MAIN OUTCOME MEASURE(S)

Tubal opacification.

RESULT(S)

Forty patients underwent a second HSG procedure for proximal tubal occlusion. Among these, 24 achieved bilateral tubal patency. Thus, repetition of a conventional HSG after 1 month avoided unnecessary salpingography in 60% of patients.

CONCLUSION(S)

In infertile women with proximal tubal obstruction, we believe it is best to perform a second HSG. HSG is easy to carry out and subjects patients to a lower dosage of radiation and fewer risks than selective salpingography. The latter technique should be reserved for unsuccessful cases.

Oil-soluble versus water-soluble media for assessing tubal patency with hysterosalpingography or laparoscopy in subfertile women

BACKGROUND

There has been debate in the literature for more than 40 years as to whether flushing of the Fallopian tubes enhances fertility and whether this presumed therapeutic effect is greater with oil-soluble media than with water-soluble media. A meta-analysis of the therapeutic role of oil-soluble contrast media at hysterosalpingography was published in March 1994 (Watson 1994). This Cochrane Review is an expansion and update of that overview.

OBJECTIVES

To evaluate the effect of flushing the Fallopian tubes with oil- or water-soluble contrast media on subsequent pregnancy rates in infertility patients.

SEARCH STRATEGY

1. For randomised controlled trials (RCTs): we searched the Cochrane Subfertility Review Group specialised register of controlled trials. 2. For non-randomised controlled studies: Medline and manual search of eight relevant journals.

SELECTION CRITERIA

Six RCTs and six non-randomised controlled studies. In two studies tubal flushing was compared with no treatment-controls. Eleven studies, comprising a total of 2635 subjects, compared oil- with water-soluble media.

DATA COLLECTION AND ANALYSIS

Independently by first 2 authors for: 1. Methodological trial characteristics 2. Characteristics of participants 3.

OUTCOMES

the main studied outcome was pregnancy rate per patient

MAIN RESULTS

In comparison with no treatment, a significant benefit on pregnancy rates was seen by flushing the tubes with oil-soluble media (OR 1.80, 95% CI 1.29-2.50) but not with water-soluble media (OR 0.87, 95% CI 0.50-1.52). In the direct comparison of oil- and water-soluble media the former lead to significantly higher pregnancy rates (OR 1.92, 95% CI 1.60-2.29). The treatment effect appeared similar in RCTs and non-RCTs. Subgroup analysis suggested the therapeutic benefit was greatest for patients suffering from unexplained infertility and least for those with tubal factor infertility.

REVIEWER'S CONCLUSIONS

Flushing of the tubes with oil-soluble media increases subsequent pregnancy rates in infertility patients. The hypothesis that tubal "plugs" are a cause of proximal tubal occlusion and that oil-soluble media may flush them out, is supported by new techniques such as falloposcopy. Clinicians should consider flushing the tubes with OSCM before contemplating more invasive therapies.

A randomized, prospective, controlled study of laparoscopic dye studies and selective salpingography as diagnostic tests of fallopian tube patency

OBJECTIVE

To determine and compare the relative merits of laparoscopic dye (LD) studies and selective salpingography (SS) as diagnostic tests of fallopian tube patency.

DESIGN

Randomized, prospective, controlled study.

SETTING

University-associated assisted reproduction unit.

PATIENT(S)

Two hundred seventy-eight women undergoing investigation of infertility.

INTERVENTION(S)

Allocation to the performance of either LD studies followed by SS or SS followed by LD studies conducted sequentially under general anesthesia.

MAIN OUTCOME MEASURE(S)

Detection of fallopian tube occlusion, including the site of obstruction and evidence of peritubal or pelvic disease.

RESULT(S)

When diagnosis was compared by the first test used, 16 (11.9%) of 135 patients had proximal tubal occlusion at LD studies versus 5 (3.6%) of 138 at SS. Twelve (5.6%) of 122 patients had distal tubal occlusion at LD studies versus 14 (10.5%) of 133 at SS. Fifteen (11.1%) of 135 patients had peritubal disease at LD studies versus 3 (2.52%) of 119 at SS. When diagnosis was compared by individual tubes, the results were similar. Among patients who had proximal occlusion and otherwise normal tubes by both methods, endometriosis was present in 72.2%.

CONCLUSION(S)

Selective salpingography is a better diagnostic test of proximal tubal occlusion than are LD studies. There is no difference between SS and LD studies as a diagnostic test of distal tubal occlusion. Laparoscopic dye studies are a better diagnostic test for assessing peritubal disease than is SS. There may be an association between endometriosis and proximal tubal occlusion. Selective salpingography and LD studies are complementary investigations of the fallopian tubes.

Hysteroscopic selective salpingography

OBJECTIVE

To evaluate the effectiveness of hysteroscopic selective salpingography (HSS) as a method for diagnosing the tubal proximal occlusion shown by hysterosalpingography (HSG).

DESIGN

Prospective study.

SETTING

Outpatient Department of Obstetrics and Gynecology, Social Insurance Saitama Chuo Hospital, Urawa, Japan.

PATIENT(S)

A total of 572 infertile women underwent HSG. Forty-seven of 50 women with unilateral or bilateral proximal tubal occlusion demonstrated by HSG underwent HSS.

INTERVENTION(S)

Hysteroscopic selective salpingography was performed for the diagnosis of tubal occlusion in cases in which the proximal tubal occlusion was shown by HSG.

MAIN OUTCOME MEASURE(S)

Number of patients who underwent HSS and pregnancy rate after HSS.

RESULT(S)

Twenty-seven (79.4%) of 34 patients with unilateral occlusion diagnosed by HSG were shown to have normal patency by HSS. Of 12 women with bilaterally normal patent tubes confirmed by HSS, 8 (66.7%) achieved normal pregnancies within 1 year. Seven (53.8%) of 13 patients with bilateral occlusion found by HSG were shown to have normally patent tubes by HSS.

CONCLUSION

The simple method of HSS was clinically effective for evaluating the presence of proximal tubal occlusion.

Intratubal pressure before and after transcervical catheterization of the fallopian tubes

OBJECTIVE

To assess the intratubal pressure (ITP) and patency status of the fallopian tubes before and after transcervical catheterization of the fallopian tubes (TCFT).

DESIGN

Prospective procedural assessment.

SETTING

Pope Paul VI Institute for the Study of Human Reproduction.

PATIENT(S)

Two hundred thirty-four women with either primary or secondary infertility.

INTERVENTION(S)

Patients underwent selective hysterosalpingography and, in some cases, TCFT with measurement of the ITP before and after the procedure.

MAIN OUTCOME MEASURE(S)

The ITP before and after TCFT.

RESULT(S)

The mean (+/-SD) ITP in freely patent tubes was 0.53 +/- 0.06 atm, that in partially obstructed tubes was 1.23 +/- 0.52 atm, and that in completely obstructed tubes was 2.79 +/- 1.40 atm. After TCFT, the mean (+/-SD) ITP in partially obstructed tubes decreased to 0.64 +/- 0.31 atm and that in completely obstructed tubes decreased to 1.86 +/- 1.35 atm. The ITP was normalized in 76% of partially obstructed tubes and in 29.5% of completely obstructed tubes. In all cases of complete obstruction in which surgical correction was attempted, organic pathology was identified.

CONCLUSION(S)

The procedure described is a safe and easy means of obtaining reliable and significant information on the status of the proximal fallopian tube.

Pathophysiology and management of proximal tubal blockage

OBJECTIVE

To review the physiology, pathology, and treatment of proximal tubal disease.

DATA IDENTIFICATION

Relevant reports on the pathophysiology of proximal tubal disease were reviewed. All studies in English of microsurgery and macrosurgery, and of radiographic and hysteroscopic cannulation in women with proximal tubal blockage were identified through MEDLINE searches.

STUDY SELECTION

All studies of therapy for proximal blockage that included pregnancy rates were considered. Series of sterilization reversals, series of unilateral or combined procedures, and series in which the location of tubal blockage was not given were excluded from the data analyses.

DATA ANALYSIS

Raw data were assessed for homogeneity, then standardized and pooled. Total and ongoing pregnancy rates after microsurgery and macrosurgery, as well as radiographic and hysteroscopic transcervical cannulation, were compared by the chi2 test. Relative risks for total and ongoing pregnancies were calculated for all treatment methods.

RESULT(S)

This meta-analysis suggests that, overall, microsurgical anastomosis results in higher total and ongoing pregnancy rates than macrosurgery or radiographic tubal cannulation. However, pregnancy rates in selected series of transcervical tubal cannulation are similar to those reported for microsurgery.

CONCLUSION(S)

Ongoing intrauterine pregnancy rates near 50% can be achieved in patients with proximal blockage of the fallopian tube. Selective salpingography and transcervical cannulation under fluoroscopic guidance are effective at establishing patency in appropriately selected patients and are less invasive and costly than the surgical alternatives.

Multicenter feasibility study of a new coaxial falloposcopy system

We compared falloposcopy employing a new coaxial system with traditional laparoscopic chromotubation and hysterosalpingography in a prospective, multicenter clinical trial at five tertiary infertility centers. Based on findings at hysterosalpingography or laparoscopic chromotubation, the 16 women (22 tubes) in group 1 had a presumed diagnosis of proximal tubal obstruction, and the 4 (7 tubes) in group 2 had unexplained infertility. Cannulation was successfully achieved in 83.3% of tubes. In group 1, 85% (17/20) of visualized tubes were patent and 35% (7/20) were normal. In group 2, 40% (2/5) of visualized tubes were abnormal. Management was changed in 52.4% of women as a result of falloposcopic findings. Falloposcopy with this new coaxial system allows improved visualization with less bulky and less traumatic instruments. The system provides valuable information regarding the fallopian tube lumen that correlates poorly with that obtained with more traditional techniques.

Tubal sterilization by means of selective catheterization: comparison of a hydrogel and a collagen glue

PURPOSE

To test, in an animal model, two potentially suitable materials for nonsurgical selective tubal sterilization.

MATERIALS AND METHODS

A hydrogel that forms an in situ plug by phase inversion of a polymer solution was placed in four rabbit fallopian tubes, and a proprietary collagen glue was placed into three rabbit fallopian tubes by means of transvaginal fluoroscopic fallopian tube catheterization. As controls, 11 tubes were catheterized without sterilization material injection. The rabbits were bred, and the presence of embryos was confirmed with palpation and at autopsy. Histologic analysis was performed.

RESULTS

The short-term contraception rate was 100% in the hydrogel group, 33% in the collagen glue group, and 0% in the control group (P < .001 hydrogel group, P not significant in collagen group). Inflammation was minimal in the three groups (P not significant).

CONCLUSION

The collagen glue had an insufficient contraceptive effect and should be abandoned. The hydrogel used proved effective and biocompatible, and long-term studies of this compound are warranted.

New methods for transcervical cannulation of the fallopian tube

Technological advances have led to major improvements in the design and application of Fallopian tube cannulation devices using the transcervical approach. Presently such cannulation systems are being used to overcome infertility disorders. These transcervical access systems are now able to displace debris that may block the tube, break down intraluminal adhesions or place egg, sperm or embryos in the tube to facilitate conception. Conversely, these same or modified devices could be used to place sclerosing agents or occlusive devices within the Fallopian tubes using similar transcervical access technology. Transcervical delivery systems incorporating a very fine endoscopic fiber have also been developed to visibly assess the inside lumen of the Fallopian tube using a transcervical approach. Such a system could be used to accurately identify specific sites in the tube for placement of such devices. The potential for placing permanent or temporary devices in the tube and the option of reversible sterilization may become a possibility in the future. One of the biggest obstacles against a wide distribution of these devices, particularly in third world countries, will be cost and the relative technical complexity in using them. These factors will need to be addressed more carefully in assessing the overall strategy of population control. The pressure on governments and international agencies to place more resources into population control may facilitate the accelerated development, application and cost containment of these new devices and delivery systems.

Evaluation of the radiologic findings on hysterosalpingography by selective hydrotubation with flexible hysterofiberscope

PURPOSE

The objective of this study was to assess further the significance and accuracy of hysterosalpingography (HSG) by comparing the radiologic findings on HSG to selective hydrotubation (SHT) using a hysterofiberscope in 106 women with tubal occlusion.

RESULTS

Patency was successfully observed by SHT in 72 of 134 tubes and 62 of 106 patients. Proximal obstruction was divided into three groups according to the shape of cornual obstruction (sharp, dull, defect) on HSG. The success rate for SHT in unilateral obstruction (64%) were significantly higher than those in bilateral obstruction (39%). In the three groups of proximal obstruction, the success rates for SHT were 24, 75, and 30% in sharp, dull, and defect, respectively. The group of dull had significantly higher success rate than the groups of sharp and defect. Thirteen of 62 patients who successfully recanalized became pregnant at 9-month follow-up interval.

CONCLUSION

Careful evaluation of the cornual obstruction in radiologic findings on HSG may be important for the decision on further treatment. Furthermore, SHT using a hysterofiberscope is an effective method for evaluating tubal obstruction and for managing it in a selected group of patients with tubal obstruction.

A meta-analysis of the therapeutic role of oil soluble contrast media at hysterosalpingography: a surprising result?

OBJECTIVE

To evaluate the therapeutic effect of oil-soluble contrast media compared with water-soluble contrast media after hysterosalpingography (HSG) in infertile couples.

DESIGN

Meta-analysis of four randomized clinical trials (RCTs) and six nonrandomized controlled studies evaluating pregnancy rates after the use of oil- or water-soluble contrast media during HSG.

SETTING

Institute of Epidemiology and Health Services Research, Leeds, United Kingdom.

PATIENTS

Four identified RCTs studied 800 patients and six nonrandomized studies comprised an additional 1,806 patients, all experiencing primary or secondary infertility.

INTERVENTION

Hysterosalpingography as part of infertility investigation.

MAIN OUTCOME MEASURE

Pregnancy rates after HSG.

RESULTS

Pregnancy rates were significantly higher in the oil-soluble contrast media group compared with the water-soluble contrast media group in the RCTs. Inclusion of the six nonrandomized studies did not alter this conclusion. This apparent benefit was greatest for patients with unexplained infertility.

CONCLUSIONS

Oil-soluble contrast media have a therapeutic effect compared with water-soluble media and this effect is greatest for patients who have been diagnosed as having unexplained infertility. New techniques for the evaluation of tubal patency support the hypothesis that tubal "plugs" may be involved in proximal tubal blockage.

Transcervical tubal cannulation, past, present, and future

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.

Standardization of hysterosalpingography and selective salpingography: a valuable adjunct to simple opacification studies

OBJECTIVE

To investigate the correlation between opacification and perfusion pressures during hysterosalpingography (HSG) and selective salpingography under the assumption that the latter may add to the diagnostic capabilities of the procedures.

DESIGN

Perfusion pressures were uniformly evaluated by standardizing injection volume per time interval of contrast medium and the delivery system. Pressures were measured in a closed system through a digital manometer and recorded on tracing paper.

SETTING

Fully ambulatory gynecoradiology suite at academically affiliated infertility center.

PATIENTS

Thirty infertility patients.

INTERVENTION

Hysterosalpingography and selective salpingography for diagnostic purposes.

MAIN OUTCOME MEASURE

Correlation between opacification patterns and perfusion pressures.

RESULTS

The evaluation of perfusion pressures during HSG is unreliable because they may be affected by uterine factors and will only reflect the oviduct of least resistance. In contrast, perfusion pressures during selective salpingography are reflective of only the investigated tube. They appear to lie within a functionally normal range of up to 350 mm Hg. Tubes by opacification judged as normal exhibited a pressure range of 429 +/- 376 mm Hg, which was significantly lower than that of abnormally appearing oviducts (957 +/- 445 mm Hg; P = 0.001).

CONCLUSIONS

The concomitant performance of perfusion pressure studies during selective salpingography further enhances the diagnostic capability of selective salpingography over HSG in the diagnostic evaluation of fallopian tubes.

Digital road mapping image--a novel fluoroscopic real-time guide for selective transcervical catheterization in the treatment of proximal tubal obstruction

Ten infertile women 20 to 40 years of age, with a standard HSG diagnosis of unilateral proximal tubal obstruction, underwent a transvaginal catheterization and recanalization of the fallopian tubes. To set a fluoroscopic real-time guidance technique for improving the results of transvaginal catheterization and recanalization of the fallopian tubes and to increase its marginal safety, catheterization was performed under digital road mapping guidance. Transcervical catheterization resulted in an immediate patency of the obstructed tube in all 10 women. Three women conceived 2 to 3 months after the procedure. The improved catheterization technique enables good results in the diagnosis and treatment of proximal tubal obstructions.