The diagnosis and treatment of proximal tubal disease

The place of selective hysterosalpingography and tubal canalization among sub-fertile patients diagnosed with proximal tubal occlusion

OBJECTIVE

To evaluate the efficacy of selective salpingography and tubal canalization (TC) procedure among patients diagnosed with proximal tubal occlusion (PTO).

METHODS

We conducted a retrospective cohort study on 61 sub-fertile patients aged 32.6 ± 4.9 years that were referred between the years of 2011 and 2013 with the diagnosis of PTO by prior hysterosalpingography. Patients underwent TC and were classified as bilateral PTO or unilateral PTO. Information regarding the patient's reproductive outcome within the 12 months following the procedure was collected by a telephone survey.

RESULTS

During the study period, 58/61 (95 %) patients underwent TC, resulting in bilateral open tubes in 54 patients (93.1 %). 53/58 (91.3 %) patients answered our survey. There were 23/53 (43.4 %) patients with a successful procedure who conceived after spontaneous or COH + IUI resulting in 15/23 live births (65.2 %).

CONCLUSION

Tubal canalization is a safe and minimally invasive procedure that can be used effectively to restore patency in a proportion of cases of PTO thus avoiding the need for expensive and invasive procedures such as assisted reproductive techniques.

Assessing tubal damage

The fallopian tube plays an important role in the mechanical transport and physiological sustenance of the gametes and early conceptus. Complex and coordinated neuromuscular activity, cilial action and endocrine secretions are required for successful tubal function. Compromised tubal damage can occur after external or internal injury, inhibiting the normal transport of gametes. The overall prognosis for fertility depends principally on the insult and the severity of the tissue damage; hence, assessment of tubal damage plays a major role in predicting occurrence of pregnancy and the likelihood of developing ectopic pregnancy.

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.

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.