Nonsurgical fallopian tube recanalization for treatment of infertility

Outcomes after successful fallopian tube recanalization: A single institution experience: Observational Retrospective study

PURPOSE

To determine outcomes after successful fallopian tube recanalization (FTR) in women who suffer infertility with documented tubal occlusion on hysterosalpingogram.

METHODS

A retrospective review of consecutive successful FTR procedures from January 2010 to December 2016 was performed. 53 women who had hysterosalpingogram confirmed unilateral or bilateral tubal occlusion from a single tertiary academic medical center and successful FTR were eligible for inclusion. 35 (66.0%) patients had follow up at 12 months after FTR, with 13 conceiving within 1 year of the procedure. Data was collected from the medical record. Complication, conception, and take-home-baby (THB) rates were recorded. The average age of patients was 32.3 years (range 26-42 years). All patients received peri- and post-procedure antibiotics. The study was conducted with institutional IRB approval.

RESULTS

Average follow-up after FTR was 1335 days. All patients tolerated the procedure well with no immediate complications. One patient had a urinary tract infection a week after FTR. 13 (37.1%) became pregnant after FTR. Of these women, 2 had ectopic pregnancies and 2 patients had spontaneous abortions. The THB rate after FTR for all patients was 25.7%. The THB rate in women who became pregnant after FTR was 69.2%. Of those women who did not become pregnant after FTR, 19 (84.6%) went to assisted reproductive techniques, and of those, 8 (42.1%) became pregnant.

CONCLUSION

Infertility affects 8.4% of U.S. women, with tubal disease a major causative factor. In our study, successful FTR led to pregnancy in over a third of the patients with the majority giving birth to healthy babies. Given the success of obtaining pregnancy in combination with a low complication rate, FTR is a viable option in women who suffer from tubal infertility.

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.

What family physicians should know about interventional radiology?

Interventional radiology (IR) is a rapidly evolving specialty. The minimally invasive nature of the procedures has led to a paradigm shift in treating many disease processes from conventional surgery to interventional techniques that have become the first choice and the preferred method for the treatment of peripheral vascular disease, many aortic pathologies, and venous diseases. Interventional oncology procedures have become widely available for the treatment of solid hepatic and renal tumors. This includes palliative techniques for many advanced malignancies, and fluid drainage that is exclusively performed by interventional radiologists in many hospitals all around the world. Women's health-related procedures such as uterine fibroid embolization, fallopian tube recanalization, and embolization for pelvic congestion syndrome have become attractive choices for many patients. Family physicians (FPs) are the main source of patient referral to hospitals. However, there is a notable knowledge deficiency of IR among FPs in Saudi Arabia. This may be due to poor communication between FP and IR or the lack of FP's awareness of IR procedures. This is a nonsystematic review to introduce some IR procedures to FPs pertinent to their practice to optimize patient referral and management with the use of IR services. We focused on the most commonly performed IR procedures paying special attention to their clinical indications, benefits, and alternatives.

Hysterosalpingosonography Is Not as Effective as Hysterosalpingography to Increase Chances of Pregnancy

OBJECTIVE

This study sought to examine whether hysterosalpingosonography (sono-HSG) is as effective as hysterosalpingography (HSG) in facilitating conception by comparing pregnancy rates in the 6 months following the procedures.

METHODS

This retrospective noninferiority study (Canadian Task Force classification II-2) was conducted at a tertiary university centre. The investigators studied 440 consecutive eligible infertile women. Bilateral tubal occlusion, severe male infertility, and having undergone both procedures were exclusion criteria. Tubal testing, as part of the infertility workup, was performed by either sono-HSG or HSG. The primary outcome was pregnancy, defined as a positive fetal heartbeat on ultrasonographic examination, in the 6 months following the procedure.

RESULTS

A total of 57 pregnancies (26%) were observed in the HSG group and 33 (15%) in the sono-HSG group. Adjusted and non-adjusted relative risks of pregnancy in the 6 months following sono-HSG compared with HSG were 0.61 (95% CI 0.42-0.89) and 0.58 (95% CI 0.39-0.85). Adverse events were infrequent with both procedures (sono-HSG, 1%; HSG, 4%; P = 0.16).

CONCLUSION

This study suggests that uterine flushing as performed during sono-HSG is not as effective as when performed during HSG to increase the chances of pregnancy, but further studies will be required because of bias related to the retrospective study design.

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.

Hysteroscopically guided transvaginal ultrasound tubal catheterization-a novel office procedure

OBJECTIVE

Investigate a novel office hysteroscopic tubal catheterization therapeutic method for proximal tubal occlusion.

STUDY DESIGN

Prospective cohort study in a tertiary referral center. We evaluated the procedure on a group of 27 patients that were referred to our unit for proximal tubal occlusion demonstrated by hysterosalpingography, 9 (33.3%) of them with primary infertility and 18 of them (66.6%) with secondary infertility. The intervention included the usage of the modified Novy cornual cannulation set which was inserted through a 5F working cannel during an office operative hysteroscopy, followed by fallopian tube irrigation with saline-air mixture under ultrasonographic imaging.

RESULTS

Our series revealed no complication during or after the procedure; anesthesia was not required. One patient lost from follow-up. Of the remaining 26, 10 patients (38.4%) conceived either spontaneously or with treatment by clomiphene or gonadotropine associated with intrauterine insemination. The median time to conception was 5 months (range 4-17).

CONCLUSION

We therefore concluded that office hysteroscopic tubal catheterization is a simple (without anesthesia required) option for the treatment of patients suffering from proximal tubal occlusion. Fertility outcomes in our series are comparable to other treatments options for tubal catheterization. Therefore, tubal catheterization should not delay the assisted reproducted techniques if indicated but we propose to include it in a global integrated approach.

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.

Tubal factor infertility: diagnosis and management in the era of assisted reproductive technology

Tubal factor infertility accounts for a large portion of female factor infertility. The most prevalent cause of tubal factor infertility is pelvic inflammatory disease and acute salpingitis. The diagnosis of tubal occlusion can be established by a combination of clinical suspicion based on patient history and diagnostic tests, such as hysterosalpingogram, sonohysterosalpingography, and laparoscopy with chromopertubation. Depending on several patient factors, tubal microsurgery or more commonly in vitro fertilization with its improving success rates are the recommended treatment options.

Prophylactic antibiotic guidelines in modern interventional radiology practice

Modern interventional radiology practice is continuously evolving. Developments include increases in the number of central venous catheter placements and tumor treatments (uterine fibroid therapy, radio- and chemoembolization of liver tumor, percutaneous radiofrequency and cryoablation), and new procedures such as abdominal aortic aneurysm stent-graft repair, vertebroplasty, kyphoplasty, and varicose vein therapies. There have also been recent advancements in standard biliary and urinary drainage procedures, percutaneous gastrointestinal feeding tube placement, and transjugular intrahepatic portosystemic shunts. Prophylactic antibiotics have become the standard of care in many departments, with little clinical data to support its wide acceptance. The rise in antibiotic-resistant strains of organisms in all hospitals worldwide have forced every department to question the use of prophylactic antibiotics. The authors review the evidence behind use of prophylactic antibiotics in standard interventional radiology procedures, as well as in newer procedures that have only recently been incorporated into interventional radiology practice.

Fluoroscopy-guided, transcervical, selective salpingography and fallopian tube recanalisation

This study is a retrospective review of the transcervical fluoroscopy-guided fallopian tube recanalisation (FTR) procedures done in a multi-ethnic south-east Asian population, over 9 years. A total of 100 patients with infertility and documented proximal tubal obstruction (PTO) were referred for FTR. On-table hysterosalpingography under sedation demonstrated true PTO in 96 patients. At selective-salpingography, the PTO cleared in 16 patients; 78 required FTR and two had fimbrial blockage. The technical success rate of FTR was 86.8% and the post-FTR pregnancy rate was 36.84% at a mean follow-up interval of 12.2 months. There were no major, immediate procedure-related complications. There was an ectopic pregnancy in a single treated patient. Fluoroscopy-guided FTR is a safe treatment option in patients with infertility from PTO, with high technical success rate, low complication rate and increased chances of pregnancy; therefore it should be preferred before attempting more expensive and resource-intensive procedures.

Conception in unilateral right tubal blockage with herbomineral formulations: a case report

BACKGROUND AND OBJECTIVES

Infertility is a state of inability to conceive after unprotected intercourse for 1 year; it involves 1 in 6 couples in England. It is a complex problem with an incidence of 10%-15% and of these, 14% of infertilities are due to a tubal factor. The incidence of unilateral tubal blockage is 33%. Pregnancy can occur in unilateral tubal blockage. In the Unani system of medicine, many herbal drugs are used empirically for enhancing fertility. This case report was an effort to understand the role of Unani formulations in conception. This patient had unilateral tubal blockage and she was also resistant to clomiphene citrate.

LOCATION

This study was performed in the Outpatient Department of the National Institute of Unani Medicine, Bangalore, India.

INTERVENTIONS

A 25-year-old female patient with primary infertility for 2½ years was diagnosed with unilateral tubal blockage. She was given Unani treatment with Hab hamal 1 tablet t.i.d. for 5 days from the seventh day of the menstrual cycle, Majoon hamal amberi alvi khani 5 g, and Majoon supari pak 5 g b.i.d. for 1 month from the seventh day of menstrual cycle for two consecutive cycles.

OUTCOME MEASURES

The main outcome measure was to observe the conception in the patient.

RESULTS AND CONCLUSIONS

The patient conceived within 2 months of the treatment. These formulations might have assisted in conception as they are considered to have uterine tonic, vitalizer, and aphrodisiac properties in Unani medicine. Some of these drugs have been pharmacologically proved to assist in conception, such as Crocus sativus Linn, which is reported to improve fertility that may be attributed to crocetin and/or flavonoids. It is also reported that oysters, which contain zinc and calcium, might have been helped in enhancing fertility.

Autofluorescence imaging can identify preinvasive or clinically occult lesions in fallopian tube epithelium: a promising step towards screening and early detection

BACKGROUND

Optical imaging systems are robust, portable, relatively inexpensive, and have proven utility in detecting precancerous lesions in the lung, esophagus, colon, oral cavity and cervix. We describe the use of light-induced endogenous fluorescence (autofluorescence) in identifying preinvasive and occult carcinomas in ex vivo samples of human fallopian tube (FT) epithelium.

METHODS

Women undergoing surgery for an i) ovarian mass, ii) a history suggestive of hereditary breast-ovarian cancer, or iii) known serous ovarian cancer following neoadjuvant chemotherapy (NAC) were approached for informed consent. Immediately following surgery, FT's were photographed in reflectance and fluorescence at high resolution. Images included: (1) white-light reflectance of luminal/epithelial surface; (2) narrow-band green reflectance (570 nm) (3) green autofluorescence (405/436 nm excitation); and (4) blue autofluorescence (405 nm excitation). Areas revealing a loss of natural tissue fluorescence or marked increase in tissue microvasculature were recorded and compared to final histopathologic diagnosis (SEE-FIM protocol).

RESULTS

Fifty-six cases involving one or both fallopian tubes underwent reflectance and fluorescence visualization. Nine cases were excluded, either secondary to non-ovarian primary pathology (7) or excessive trauma (2) rendering tissue interpretation impossible. Of the 47 cases remaining, there were 11 high grade serous (HGS) and 9 non-serous ovarian carcinomas undergoing primary debulking surgery, 5 serous carcinomas having received NAC, 8 benign ovarian tumors, and 14 women undergoing risk-reducing bilateral salpingo-oophorectomy (RRBSO). Methodology was feasible, efficient, and reproducible. TIC or carcinoma was identified in 7/11 HGS, 3/5 NAC, and 1/14 RRBSO. Optical images were reviewed to determine test positive or negative based on standardized criteria. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for the entire cohort (73%; 83%; 57%; 91%) and in a subgroup that excluded non-serous histology (87.5%; 92%; 78%; 96%).

CONCLUSIONS

Abnormal FT lesions can be identified using ex vivo optical imaging technologies. With this platform, we will move towards genomic interrogation of identified lesions, and developing in vivo screening modalities via falloposcopy.

The cost effectiveness of opportunistic chlamydia screening in England

BACKGROUND/AIM

The National Chlamydia Screening Programme (NCSP) is being implemented in England. This study aims to estimate the cost effectiveness of (a) the NCSP strategy (annual screening offer to men and women aged under 25 years) and (b) alternative screening strategies.

METHODS

A stochastic, individual based, dynamic sexual network model was combined with a cost effectiveness model to estimate the complications and associated costs of chlamydial infection. The model was constructed and parameterised from the perspective of the National Health Service (NHS) (England), including the direct costs of infection, complications and screening. Unit costs were derived from standard data sources and published studies. The average and incremental cost effectiveness ratio (cost per major outcome averted or quality adjusted life year (QALY) gained) of chlamydia screening strategies targeting women and/or men of different age groups was estimated. Sensitivity analyses were done to explore model uncertainty.

RESULTS

All screening strategies modelled are likely to cost the NHS money and improve health. If pelvic inflammatory disease (PID) progression is less than 10% then screening at any level is unlikely to be cost effective. However, if PID progression is 10% or higher the NCSP strategy compared to no screening appears to be cost effective. The incremental cost effectiveness analysis suggests that screening men and women aged under 20 years is the most beneficial strategy that falls below accepted thresholds. There is a high degree of uncertainty in the findings.

CONCLUSIONS

Offering an annual screening test to men and women aged under 20 years may be the most cost effective strategy (that is, under accepted thresholds) if PID progression is 10% or higher.

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.

A Review of the Use of Lipiodol Flushing for Unexplained Infertility

There has been speculation for decades regarding the role of flushing women's fallopian tubes in improving the chance of pregnancy. More recent evidence has highlighted a possible specific role for lipiodol (ethiodized oil), an oil-soluble contrast medium, in the enhancement of fertility by these means. This systematic review was designed to assess the effectiveness of tubal flushing with various contrast media in improving the chance of pregnancy. The review was performed using Cochrane guidelines, including only data from randomized controlled trials. Results confirm the effectiveness of flushing with lipiodol in improving the chance of pregnancy and live birth. Although there was limited evidence to suggest a possible benefit of oil- over water-soluble contrast media, the answer to this question remains unclear. The specific groups who appear to benefit most from lipiodol flushing are couples with unexplained infertility, but particularly couples where the woman has endometriosis in the context of normal patent fallopian tubes. As a simple, low-cost, minimally invasive intervention that carries a low risk of complications and no increased risk of multiple pregnancy, lipiodol flushing may prove an appealing alternative to established fertility treatments for many couples.

Evidence-based diagnosis and management of tubal factor infertility

PURPOSE OF REVIEW

The investigation for potential tubal disease is an essential step in the work-up of infertility. This review article provides an evidence-based overview of the diagnosis and management of tubal factor infertility.

RECENT FINDINGS

While laparoscopic chromopertubation remains the gold standard in the diagnosis of tubal disease and hysterosalpingography is still widely used, newer modalities offer some advantages. Sonohysterography with the use of contrast medium is superior to hysterosalpingography and comparable to laparoscopic chromotubation in diagnosing tubal blockage. Chlamydia serology is the most cost-effective and least invasive diagnostic test for tubal disease, and it is comparable to, if not better than, hysterosalpingography. Depending on the nature and degree of tubal dysfunction as well as the age and ovarian reserve of the patient, various treatments for tubal infertility are available. For proximal tubal obstruction, transcervical tubal cannulation with tubal flushing is a reasonable first approach. Surgical techniques for tubal repair, such as salpingostomy or fimbrioplasty for distal tubal obstruction, can provide good results. Still, tubal factor remains a major indication for in-vitro fertilization and embryo transfer, which bypasses the tubal problem altogether. In certain situations, such as the presence of hydrosalpinx, prophylactic surgery can be used in conjunction with in-vitro fertilization and embryo transfer.

SUMMARY

As with infertility in general, the diagnosis and management of tubal infertility should be tailored to the individual patient. Future studies should help to further clarify the role of the various diagnostic tests and therapeutic approaches for tubal infertility.

Surgical intervention in infertility management

Despite improvement in the success of IVF, reproductive surgery will remain an important option and complement to assisted reproductive technologies (ART) for many couples. Reproductive surgery should be considered as the first-line treatment when the correction of infertility pathologies is simple and a good result is expected once corrected, when the pathology is causing symptoms such as pain or abnormal bleeding, or if uncorrected will compromise the results or increase the risks of ART. The success of surgical infertility treatment depends on the careful selection of cases using appropriate investigative techniques, with procedures performed in centres with sufficient expertise. For both specialized reproductive and general gynaecological surgery it is crucial to follow microsurgical principles to avoid adhesion formation and conserve normal tissues, especially tubal and ovarian. These aspects of reproductive surgery, and different surgical techniques used for various tubal, peritoneal, uterine and ovarian conditions to achieve the optimal reproductive outcome are discussed in this article.

Pregnancy outcomes after fallopian tube recanalization: oil-based versus water-soluble contrast agents

PURPOSE

To determine the pregnancy outcomes in patients undergoing fallopian tube recanalization (FTR) with use of oil-based versus water-soluble contrast agents.

MATERIALS AND METHODS

Ninety-three patients with unilateral or bilateral proximal tubal occlusion confirmed by hysterosalpingography or laparoscopy underwent FTR with use of water-soluble contrast material alone (n = 50) or also had an oil-based agent injected into each tube after recanalization (n = 43). Pregnancy rates and outcomes of the two groups were studied retrospectively.

RESULTS

With respect to differences between groups, only the body mass index proved to be a significant predictor (oil, 28.4; water, 24.7; P =.008). Mean age, duration of infertility, type of infertility, and initial diagnosis were comparable. There was a weak trend toward a higher pregnancy rate in the oil-based contrast material group, but it was not significant (P =.64). The average time to pregnancy was 4.4 months with use of oil-based contrast material, compared to 7.7 months with use of only water-soluble contrast material (P =.03).

CONCLUSION

The use of an oil-based agent had little effect on the rate of conception, but time to conception was reduced by more than 3 months.

Successful conception following Fallopian tube recanalization in infertile patients with a unilateral proximally occluded tube and a contralateral patent tube

BACKGROUND

There are many published case reports of successful conception following transcervical Fallopian tube recanalization (T-FTR) in patients with bilateral proximally occluded Fallopian tubes. However, no serial trials have been published with respect to successful conception following unilateral tubal recanalization in infertile patients with a unilateral proximally occluded tube and a contralateral patent tube. This study was designated to analyse the success rate of T-FTR and the pregnancy rate due to natural fertilization in the lumen of the recanalized tube in these patients.

METHODS

We have encountered only 11 patients with this abnormality in our department in the past 10 years. T-FTR with fluoroscopic guidance was performed in these patients, confirmed by at least two hysterosalpingographies to exclude tubal spasm. The uterine catheter devised by us was used during the procedure.

RESULTS

All 11 Fallopian tubes were successfully opened by T-FTR. In the six patients who conceived, a preovulatory follicle was demonstrated on the side of the cannulated tube during the conception. The success rate of recanalization, the pregnancy rate due to fertilization in the lumen of the recanalized tube and the successful delivery rate were 100, 55 and 36% respectively.

CONCLUSIONS

Our findings suggest that a functional and/or organic disorder in the patent tube resulted in infertility in patients with unilateral proximal tubal obstruction. Our results further show that recanalization of occluded tubes is an effective treatment. Thus, recognition of successful conception following T-FTR in these patients will be beneficial to our clinical approach to this infertile condition.

Comparison of cervical vacuum cup cannula with metal cannula for hysterosalpingography

OBJECTIVE

The aim of this study was to compare the use of a cervical vacuum cap cannula with the traditional metal cannula.

DESIGN

A prospective, randomised, single-blinded comparative study.

SAMPLE

Fifty consecutive infertile women undergoing hysterosalpingography for evaluation of infertility

METHODS

Hysterosalpingography was performed either with the traditional metal cannula (n = 25) or a cervical vacuum cap cannula (n = 25).

MAIN OUTCOME MEASURES

Length of procedure, fluoroscopic time, amount of contrast medium, pain to the patient while applying the cannula and injecting the contrast medium, level of difficulty to the performer, the need to reapply the cannula, complications, and results of the hysterosalpingography.

RESULTS

Using the cervical vacuum cap cannula, compared with the metal cannula, the duration of the procedure was significantly shorter (5.3 vs 9.3 minutes; P < 0.001), less fluoroscopic time was needed (0.9 vs 1.8 minutes; P < 0.001), a smaller amount of contrast medium was used (4.6 vs 15.7 mL; P < 0.001), the procedure caused less pain to the patient (3.2 vs 6.8, respectively; on a scale of 1-10; P < 0.001), and was easier for the physician to perform (1.4 vs 3.4; on a scale of 1-10; P < 0.001). No significant differences were encountered between the two groups in the need to reapply the cannula, in the rate of complications or in the results of the hysterosalpingography.

CONCLUSIONS

The cervical cap cannula appears to be superior to the traditional metal cannula for performing hysterosalpingography.

Infertility: is there a role for the surgeon

No matter how successful IVF and intracytoplasmic sperm injection become, there will always be a role for the infertility surgeon in the care of the woman with infertility. The challenge is to develop evidence-based protocols that will specify when surgery is clearly a better choice than IVF. It will also be important to develop training programs in pelvic surgery that will teach techniques and strategies designed to maintain or improve fertility as well as remove or destroy pelvic pathology. With a decreasing number of surgical procedures available to train residents in infertility surgery, it will become increasingly important to consider alternative models such as virtual reality and postresidency fellowships or preceptorships.

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.

Fluoroscopically guided transcervical fallopian tube recanalization of post-sterilization reversal mid-tubal obstructions

PURPOSE

To assess the technical success and early outcome of fluoroscopically guided transcervical fallopian tube recanalization (FTR) in mid-tubal occlusion following sterilization reversal surgery.

METHODS

From July 1995 to January 1998, patients with greater than 12 months secondary infertility underwent hysterosalpingography (HSG). FTR was performed in proximal or mid-tubal occlusion. Cases of FTR in mid-tubal occlusion were included in this study. Technical success (defined as complete tubal patency) using a standard guidewire and hydrophilic glidewire, the number of patients with at least one patent tube, and the intrauterine and ectopic pregnancy rates were determined.

RESULTS

Twenty-six infertile patients with previous sterilization reversal underwent HSG. Eight of 26 (31%) patients (mean age 32 years, range 23-37 years), had attempted FTR for mid-tubal occlusion at the site of surgical anastomosis. Fourteen tubes were attempted as there were two previous salpingectomies. Technical success was achieved in eight of 14 (57%) tubes attempted, resulting in five of eight (62%) patients having at least one patent tube. At follow-up (mean 18 months, range 12-28 months) in these five patients there was one intrauterine pregnancy. There were no ectopic pregnancies.

CONCLUSIONS

FTR in mid-tubal obstruction in infertile patients following sterilization reversal surgery is technically feasible and may result in intrauterine pregnancy. In this small group there was a lower technical success rate and lower pregnancy rate than in unselected proximal tubal occlusion.

Is lower-dose digital fluorography diagnostically adequate compared with higher-dose digital radiography for the diagnosis of fallopian tube stenosis?

PURPOSE

In an effort to reduce patient radiation dose during selective fallopian tube catheterization, the diagnostic adequacy of fluoroscopic images was compared with digital radiographic images in both a phantom study and a clinical study.

METHODS

For the phantom study polyethylene tubes with inner diameters of 1.30, 0.95, 0.80, 0.57, and 0.45 mm were used. Randomly selected tubes with/without stenoses, recorded by digital radiographic and last-image hold fluoroscopic images, were presented to five blinded radiologists, and receiver-operating characteristic (ROC) analyses were performed. For the clinical study tubal visualization as well as detectability of stenoses and occlusions were analyzed in 14 women using a 2-way analysis of variance for nonrepeated measures.

RESULTS

The phantom study showed no significant differences between the two imaging techniques for 0.57-mm-diameter and larger tubes; in contrast, fluoroscopic images provided significantly lower detectability of stenoses in 0.45-mm-diameter tubes (p < 0.05). The clinical study showed inferior tubal visualization and diagnostic performance for fluoroscopic images.

CONCLUSIONS

Although fluoroscopic images have inferior diagnostic capability in detection of tubal stenoses and occlusions, these images may be adequate for documenting tubal patency with spill into the peritoneal cavity.

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.

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.

Tubal obstruction after ligation reversal surgery: results of catheter recanalization

PURPOSE

To evaluate the role of transcervical fallopian tube catheterization in restoring tubal patency after ligation reversal surgery.

MATERIALS AND METHODS

Twenty-four women with tubal obstruction after ligation reversal surgery underwent selective salpingography and tubal recanalization.

RESULTS

Patency was established in 26 (68%) of 38 anastomotic tubes without complication. In the 13 patients who were followed up and who could conceive only via a recanalized anastomotic tube, there were six (46%) pregnancies: two (15%) successful uterine pregnancies, two (15%) early spontaneous abortions, and two (15%) tubal pregnancies. The mean time from procedure to conception was 2 months.

CONCLUSION

Patency of fallopian tubes not visualized at hysterosalpingography after ligation reversal surgery can be established 68% of the time with selective salpingography. In some patients, selective salpingography can be therapeutic. If subsequent conception occurs in these patients, it occurs shortly after the catheterization procedure.

Surgical management of cornual-isthmic tubal obstruction

OBJECTIVE

To examine the efficacy of microsurgical tubal anastomosis among patients having failed attempts to correct cornual-isthmic tubal obstruction by hysteroscopic tubal catheterization.

DESIGN

An open observational trial.

SETTING

A tertiary referral reproductive medicine practice.

PATIENT(S)

Forty-three patients with laparoscopically confirmed bilateral cornual-isthmic obstruction and otherwise normal fallopian tubes. Thirty-three control patients with a history of elective sterilization presenting for tubal anastomosis.

INTERVENTION(S)

All patients with bilateral cornual-isthmic obstruction underwent attempted hysteroscopic tubal cannulation. Those unsuccessfully catheterized proceeded with microsurgical resection and anastomosis. Candidates for reversal of sterilization underwent microsurgical repair in standard layered technique.

MAIN OUTCOME MEASURE(S)

Mean time to achieve pregnancy, as well as cumulative pregnancy rates for all three groups using life-table analysis, were calculated.

RESULT(S)

Cumulative pregnancy rates for patients with successful tubal catheterization, for those requiring microsurgical repair, and for reversal of elective sterilization were 0.68%, 0.56%, and 0.29%, respectively, at 12 months. Mean duration to achieve pregnancy was similar for both cornual-isthmic blockage-treated groups and was shorter than that for the sterilization-reversal group.

CONCLUSION(S)

Patients with cornual-isthmic obstruction and otherwise normal fallopian tubes who are treated successfully by either tubal catheterization or resection and microsurgical anastomosis demonstrate high pregnancy rates, short interval to achieve pregnancy, and similar obstetric outcome. If no pregnancy is achieved within 1 year of surgery, reevaluation and consideration for possible IVF and ET is indicated.

Radiological evaluation of infertility

With unwanted infertility on the rise, the radiologist is becoming increasingly involved both in the diagnosis and treatment of these patients. Assessment of the six most common factors causing infertility should be performed during the initial clinical evaluation. These six factors include the cervical factor, endometrial-uterine factor, tubal factor, ovarian factor, peritoneal factor, and male factor. Each of these groups will be discussed in detail with special attention to optimal methods of diagnosis. Hysterosalpingography and ultrasound play the major roles in evaluation; however, there is an important emerging role for newer techniques such as MRI and selective fallopian tube catheterization.

Radiological diagnosis and management of proximal fallopian tube obstruction

Fluoroscopically guided transcervical fallopian tube catheterization is a valuable technique in the management of infertility, being applicable to occlusion of the proximal fallopian tube. It was first described in the literature in 1987. Our experience is discussed. Modifications to the usual technique are explained. The procedure has had a poor initial acceptance in Australia, but should replace tubal surgery or in vitro fertilization in a group of patients.

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.

Salpingitis isthmica nodosa: a review of the literature, discussion of clinical significance, and consideration of patient management

OBJECTIVES

To examine and discuss the pathology, diagnosis, incidence, and patient profile of salpingitis isthmica nodosa and to question its natural history, propose management strategies, and identify areas of promising research.

DESIGN

Over 50 studies were reviewed, evaluated, and compared to offer the clinician a foundation on which to generate treatment plans.

RESULTS

Salpingitis isthmica nodosa is diagnosed by the pathological presence of isthmic diverticula and may be suggested by characteristic changes on hysterosalpingogram. Its incidence in healthy, fertile women ranges from 0.6% to 11%, but it is significantly more common in the setting of ectopic pregnancy and infertility. There are no studies, retrospective or prospective, that clearly dictate appropriate therapy.

CONCLUSION

Given its progressive nature and probable deleterious effects on fertility, we propose that microtubal surgery be the definitive treatment for qualified women who have salpingitis isthmica nodosa.

Proximal tubal occlusion by hysterosalpingogram: a role for falloposcopy

Eight infertility patients with proximal tubal occlusion by HSG and at least one other independent method underwent falloposcopy to evaluate the etiology of uterotubal occlusion. Patency was established in 9 of 12 tubes evaluated. Falloposcopy revealed 5 tubes with multiple or extensive intratubal lesions that would be unsuitable for unilocular tubal resection with subsequent reanastomosis. In addition, 5 tubes were visually normal or had only minor pathological changes (2 of these patients became pregnant). Only 2 of the tubes examined in a single patient would be considered candidates for microsurgical correction at laparotomy. Falloposcopy will become a useful adjunct in the evaluation of the patient with suspected tubal infertility. It provides information regarding the condition of the tubal mucosa that is unavailable by any other technique, adding precision to surgical techniques when they are deemed necessary while directing other patients to assisted reproductive technologies. However, falloposcopy is still in its infancy and data from larger studies are needed.

Reproductive outcome after fallopian tube canalization and microsurgery for bipolar tubal occlusion

Surgical therapy for coexistent proximal and distal obstruction has consisted of combined proximal (reimplantation of reanastomosis) and distal (salpingostomy) repairs. Data suggest that successful relief of proximal obstruction by fluoroscopically guided tubal canalization (FTC) may be achieved in 60% to 95% of cases. We studied the use of FTC as a preoperative adjunct in 14 patients with coexistent proximal tubal obstruction (PTO) and distal tubal obstruction, progressing to surgical repair of distal disease if proximal patency was achieved. Unilateral (9/14) or bilateral (5/14) PTO was demonstrated on at least one hysterosalpingogram (HSG) and during chromotubation performed as part of the diagnostic laparoscopy. FTC was successful in four patients (28%). HSG revealed proximal reocclusion in two patients. Two patients had persistent proximal patency and underwent distal salpingostomies and adhesiolysis for mild hydrosalpinges and pelvic adhesive disease. No pregnancies have been achieved after 12 and 18 months follow-up. The lower patency rate and higher recurrence rates of PTO when compared to data of prior studies suggest that in vitro fertilization, though more costly, ultimately may represent the most expedient and effective method of management of coexistent proximal and distal tubal disease.

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.