The multicentre transcervical balloon tuboplasty study: conclusions and comparison to alternative technologies

The Prevalence of Fallopian Tube Occlusion in Women with Polycystic Ovary Syndrome Seems Similar to Non-Subfertile Women: A Retrospective Cohort Study

There are limited data on how non-infectious risk factors influence tubal patency in women with subfertility. With hormonal shifts influencing tubal secretions, it has been argued that subfertile women with polycystic ovary syndrome (PCOS) have lower tubal patency. In a retrospective study, 216 women, who underwent diagnostic evaluation for PCOS and infertility, were included. Fallopian tube patency was tested using HSG, HyCoSy, and laparoscopic chromopertubation in 171 (79.2%), 28 (13.0%), and 17 (7.9%), respectively. Bilateral patency was found in 193 women (89.4%), unilateral patency in 13 (6.0%) and bilateral occlusion in 10 (4.6%) patients. Women with PCOS phenotypes C (odds ratio, OR 0.179, 95% CI: 0.039–0.828) and D (OR 0.256, 95% CI: 0.069–0.947) demonstrated lower risks for Fallopian tube occlusion. In conclusion, our data suggest that about 5% of infertile women with PCOS also have bilateral tubal occlusion, which seems similar to the rate in non-subfertile women. With 11% of participants having unilateral or bilateral tubal occlusion, this should reassure women with PCOS that their hormonal challenges do not seem to increase their risk for tubal factor subfertility.

Renaissance of surgical recanalization for proximal fallopian tubal occlusion: falloposcopic tuboplasty as a promising therapeutic option in tubal infertility

STUDY OBJECTIVE

To assess the clinical effectiveness of falloposcopic tuboplasty in tubal infertility.

DESIGN

Retrospective cohort study (Canadian Task Force classification II-3).

SETTING

Infertility clinic.

PATIENTS

Three hundred forty-five infertile patients (≥2y) with a diagnosis of proximal tubal occlusion, either bilateral or unilateral, between January 2005 and January 2011.

INTERVENTION

Falloposcopic tuboplasty.

MEASUREMENTS AND MAIN RESULTS

Medical records for 345 patients with a diagnosis of proximal tubal occlusion were reviewed. Of the 345 patients, 304 underwent falloposcopic tuboplasty, with successful recanalization achieved in 248 patients (81.6%). Ninety-one of the 304 patients (29.9%) became pregnant. Of these, 18 patients (19.8%) miscarried, and 4 (4.4%) had ectopic pregnancies in the recanalized tube. At 1-, 3-, 6-, and 9-month follow-up, the cumulative probability of conception was 23.1%, 50.6%, 73.6%, and 82.4%, respectively. Related complications included postsurgical infection (0.3%), perforation of the fallopian tube (1.3%), and accidental breakage of the catheter (4.9%) or the falloposcope (1.3%).

CONCLUSIONS

Falloposcopic tuboplasty is safe and effective for treatment of tubal infertility. The pregnancy rate after falloposcopic tuboplasty is comparable to that after in vitro fertilization, which suggests that it can be an alternative to in vitro fertilization in women with tubal infertility.

Fallopian tube recanalization: lessons learnt and future challenges

Technological advances in fiberoptics and endoscopy have resulted in the development of minimally invasive transcervical tubal catheterization procedures with the potential of improved diagnostic accuracy of tubal disease and transcervical treatment of proximal tubal obstruction (PTO) with reduced risks, costs and morbidity compared with surgical procedures. Fallopian tube recanalization can be performed with catheters, flexible atraumatic guidewires or balloon systems under endoscopic (falloposcopy/hysteroscopy/laparoscopy), sonographic, fluoroscopic or tactile guidance. Falloposcopy provides a unique possibility to accurately visualize and grade endotubal disease, characterize and document endotubal lesions, identify the segmental location of tubal pathology without complications, objectively classify the cause of PTO and guide future patient management. This is in contrast to the surgical and radiological gold standards, laparoscopy and hysterosalpingography, respectively, that are often associated with poor or misdiagnosis of PTO. Nonhysteroscopic transuterine falloposcopy using the linear eversion catheter is a successful, well-tolerated, outpatient technique with a good predictive value for future fertility. Hysteroscopic-falloposcopic-laparoscopic tubal aquadissection, guidewire cannulation, guidewire dilatation and direct balloon tubuloplasty may be used therapeutically to breakdown intraluminal adhesions or dilate a stenosis in normal or minimally diseased tubes with high patency and pregnancy rates. However, guidewire cannulation of proximally obstructed tubes yields much lower pregnancy rates compared with other catheter techniques, despite the high tubal patency rates. Laparo-hysteroscopic selective tubal catheterization with insufflation of oil-soluble radiopaque dye has been reported to be an effective treatment for infertility associated with endometriosis. The various disadvantages associated with fluoroscopic and sonographic techniques limit their application, despite the reportedly high patency and intrauterine pregnancy rates. Recanalization is contraindicated in florid infections and genital tuberculosis, obliterative fibrosis and long tubal obliterations that are difficult to bypass with the catheter, severe tubal damage, male subfertilitY and previously performed tubal surgery. Distal tubal obstruction is not amenable to catheter recanalization techniques. Tuberculosis, salpingitis isthmica nodosa, isthmic occlusion with club-changed terminal, ampullar or fimbrial occlusion, and tubal fibrosis have been cited as reasons for recanalization failure. In lieu of the poor pregnancy outcomes in patients with severe tubal disease and poor mucosal health following tubal recanalization, as well as poor available technical skills and results with microsurgery, in vitro fertilization and embryo transfer is a valid option in such women. Despite the high diagnostic and therapeutic power of falloposcopic interventions, technical shortcomings with falloposcopy must be overcome before the procedure gains widespread acceptance.

The role of interventional radiology in obstetric and gynaecology practice

Interventional radiology is continuing to reshape current practice in many specialties of clinical care. It is a relatively new and innovative branch of medicine in which physicians treat diseases non-operatively through small catheters guided to the target by fluoroscopic and other imaging modalities. The aim is to provide image-guided, minimally invasive alternatives to traditional surgical and medical procedures in suitable cohorts of patients. Procedures which previously required major surgery can now be performed by interventional radiologists, sometimes on an outpatient basis, with little patient discomfort. In this review, we highlight the importance of interventional radiology in treating a comprehensive range of obstetric and gynaecological pathologies.

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.

Reliability of clinicians versus radiologists for detecting abnormalities on hysterosalpingogram films

OBJECTIVE

To evaluate the consistency of the identification of abnormal findings on hysterosalpingogram (HSG) and compare the reliability of clinicians to that of radiologists.

DESIGN

Evaluation of reliability of diagnostic test.

PATIENT(S)

Women undergoing evaluation for infertility.INTEVENTION(S): Retrospective review of 50 HSG films by three reproductive endocrinologists and three radiologists. Each film was reread 30 days later in a blinded fashion.

MAIN OUTCOME MEASURE(S)

The consistency of each individual reader, the reliability of detecting specific abnormalities, and the consistency of clinicians compared with radiologists was evaluated with a kappa (K) statistic and interclass correlation coefficient (ICC).

RESULT(S)

Average intrareader reliability was high for the detection of normal uterus, normal tubes, and tubal obstruction and low for the detection of hydrosalpinx, uterine adhesions, and pelvic adhesions. Inter-reader reliability was high in the detection of normal uterine contour, normal tubal patency, and uterine filling defect and lower for the detection of a hydrosalpinx. The reliability of detecting pelvic adhesion or salpingitis isthmica nodosa was poor.

CONCLUSION(S)

Intrareader reliability was generally good, especially for the detection of normal findings. Agreement among different readers is lower in detecting rare outcomes such as hydrosalpinx and pelvic adhesion and salpingitis isthmica nodosa. Clinicians more reliably diagnose hydrosalpinx and tubal obstruction, while radiologists more reliably detect the more subtle findings of salpingitis isthmica nodosa or uterine adhesions.

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.

Ultrastructural evaluation following catheterization of the fallopian tube with a hysteroscopic catheter

PURPOSE

Our purpose was to assess the morphology and ultrastructural changes in the tubal epithelium following catheterization of the fallopian tube.

METHODS

Fallopian tubes were obtained from 20 women who had undergone hysterectomies. Catheterization was performed in 20 tubes using a catheter developed for hysteroscopic tubal embryo transfer. The catheter has a 3-French diameter, tapering to 2 French (0.66 mm) at the tip portion. The 20 contralateral tubes served as controls and were not catheterized. Ultrastructural changes were examined by scanning electron microscopy and transmission electron microscopy.

RESULTS

Scanning electron microscopy showed no transformation or defects of the tubal epithelium surface in catheterized or control tubes. Transmission electron microscopy showed no significant differences in the percentage of abnormal desmosomes and the percentage of basement membrane in ciliated and nonciliated cells between catheterized and noncatheterized tubes. No transformation or defects were observed in catheterized or noncatheterized tubes.

CONCLUSIONS

These findings suggest that catheterization of the tube using a hysteroscopic catheter caused no acute damage to the tubal epithelium.

Elevated tubal perfusion pressures during selective salpingography are highly suggestive of tubal endometriosis

OBJECTIVE

To investigate the possible etiologies of elevated tubal perfusion pressures.

DESIGN

Analysis of 48 consecutive female patients with infertility who underwent laparoscopy and a gynecoradiological investigation as part of their infertility work-up.

SETTING

Academically affiliated infertility center.

INTERVENTIONS

A gynecoradiological investigation was performed using a previously reported standardized contrast injection system. Laparoscopy was performed routinely.

RESULTS

Patients who demonstrated by laparoscopy to have endometriosis showed a significantly increased incidence of tubal blockage during initial hysterosalpingography (HSG) (12/26, 46.1%) compared with controls (2/14, 14.3%). Patients with endometriosis also demonstrated significantly more frequently elevated tubal perfusion pressures (22/26; 84.6%) than women without disease (2/14, 14.3%) and significantly higher mean tubal perfusion pressures than women with normal pelvises (576 +/- 264 versus 450 +/- 268 mm Hg).

CONCLUSION

Tubal blockage during initial HSG and elevated tubal perfusion pressures during selective salpingography are highly suggestive of tubal endometriosis. These data are the first evidence that tubal involvement with endometriosis may be more frequent than previously suspected. They also suggest that the performance of a gynecoradiological investigation, inclusive of selective salpingography, can greatly contribute to a presumptive diagnosis of endometriosis.

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.

The limited value of hysterosalpingography in assessing tubal status and fertility potential

DESIGN

To determine whether the diagnostic accuracy and prognostic value of hysterosalpingography (HSG) could be improved if routine spot films were replaced by an on-line recorded gynecoradiologic study.

SETTING

Medical school-affiliated private infertility center.

PATIENTS

In 1992, a review of 152 infertile women with infertility who demonstrated a normal HSG, by standard criteria of spot film evaluation, in 117 (77%). They were further investigated by gynecoradiologic study if the HSG revealed asymmetrical tubal filling, an increased perfusion pressure, and/or evidence for abnormal tubal spill. In 1993, 47 women with normal HSG by spot film criteria underwent bilateral selective salpingography and were subdivided into those with normal (group I, n = 23) and abnormal (group II, n = 24) tubal perfusion pressures.

INTERVENTION

Patients in both study groups then were treated for their infertility independently of pressure perfusion measurements.

MAIN OUTCOME MEASURE

Clinical pregnancy rates (PRs) over the ensuing 6 to 10 months.

RESULTS

Among 117 women with apparently normal spot film HSG, 64 (55%) demonstrated asymmetrical tubal filling, 32 (27%) demonstrated abnormal spillage into the peritoneal cavity, and 55 (47%) demonstrated abnormally elevated injection pressures. Among 98 women who underwent bilateral selective salpingography, 43 (44%) demonstrated bilaterally normal tubal perfusion pressures and 55 (56%) showed an abnormally elevated pressure in at least one oviduct. Of 47 women that were followed prospectively in 1993, patients with normal perfusion pressure (group I) demonstrated a significantly higher PR than women with elevated tubal pressure (group II) from 2 months and on after the procedure.

CONCLUSIONS

Routine spot film HSG is of limited value in assessing tubal status beyond the determination of tubal patency. Especially with regard to fertility potential, HSG should be replaced by gynecoradiologic study.

Effectiveness of infertility treatments: choice and comparative analysis

Choice of infertility treatments usually depends on a balance of the chances of conceiving with or without treatment, and with more or less complex and costly treatments, and on other factors such as duration of infertility and the woman's age. Pregnancies often occur independent of treatment and prospective controlled trials are needed. Comparability between reported results requires pregnancy and birth rates to be calculated in a time-specific or cycle-specific way. Cumulative rates are preferable to account for the usual tendency of fecundity to fall progressively. This review focuses on such published data in order to assess the relative effectiveness of treatments, both conventional and assisted conception methods. The main conclusions are: (1) The only treatments that can achieve a normal chance of pregnancy are the ovulation induction methods in cases of oligomenorrhea/amenorrhea, and the assisted conception methods for other female causes and unexplained infertility. (2) Tubal/pelvic infective damage and endometriosis require new severity classifications which are sensitive to functional potential before and after surgery, and in vitro fertilization (IVF) would often be indicated as the primary choice. (3) Duration of unexplained infertility determines the need and therefore benefit of any of the treatments used, of which the assisted conception methods are by far the most effective. (4) Interpretation of reported results of treatments for 'male factor' infertility is critically affected by the diagnostic accuracy of defining sperm dysfunction. (5) In cases of well-defined sperm dysfunction there is little or no therapeutic benefit to the chance of natural conception, nor by intrauterine insemination; there is moderate success by IVF, but no proven benefit over standard IVF by any micromanipulative method except probably intracytoplasmic sperm injection.