Hysteroscopic tubal cannulation under laparoscopic guidance for diagnosis and treatment of proximal tubal obstruction

ABSTRACT

The narrowest portion of the human fallopian tube extending from the uterotubal ostium to the ampullary-isthmic junction is exceptionally vulnerable to pathogenic organisms and other insults which often induce block of this narrow segment. Proximal tubal obstruction [PTO] exists in about 20% of patients with tubal infertility, and frequently is an isolated finding with otherwise normal pelvic anatomy. PTO presents a significant diagnostic and therapeutic problem. Several reports in the literature suggest that up to two-thirds of fallopian tubes resected for PTO reveal an absence of transluminal or luminal pathology. Conventional HSG or even laparoscopic chromopertubation may not determine whether the visualized obstruction is due to a temporary cause such as cornual spasm and loose mechanical blocks, or whether true anatomic occlusion exists. This differentiation is critical in determining the type of therapy offered to the patient. Only true pathologic tubal occlusion necessitates either IVF or microsurgical tuboplasty. To present the diagnostic findings, the immediate and the remote tubal patency rates, and the reproductive outcome following hysteroscopic tubal cannulation performed under laparoscopic guidance, for the patients with proximally obstructed fallopian tubes. PTO was diagnosed by three approaches HSG, laparoscopic transcervical chromopertubation, and hysteroscopic/laparoscopic transostial selective chromopertubation. Prospective observational clinical study presenting the laparoscopic/hysteroscopic findings in patients with proximal tubal occlusion, and discussing the immediate and the remote tubal patency rates and the reproductive outcome following hysteroscopic tubal cannulation under laparoscopic guidance. Tanta University Hospital and private centers. Thirty-nine consecutive infertile women who had bilateral PTO on HSG and subsequently underwent combined laparoscopy and hysteroscopy were evaluated. Seventeen women were found to have bilateral PTO as an isolated finding with otherwise normal pelvic anatomy and intact other fertility factors. In these 17 women the diagnosis of PTO was based on the initial findings of HSG, supported by the results of laparoscopic transcervical chromopertubation, and finally confirmed by hysteroscopic/laparoscopic transostial selective chromopertubation. In trial to relieve PTO in these 17 women, hysteroscopic tubal cannulation was performed. A coaxial cannulation set composed of a Labotect flexible guide cannula, a 3-French end-hole Teflon ureteric catheter, and a Teflon-coated stainless steel urologic guidewire were utilized for hysteroscopic tubal cannulation under laparoscopic guidance. The immediate on-table success of tubal cannulation evidenced by intraoperative tubal patency rate documented by laparoscopic chromopertubation, the long term persistence of achieved tubal patency evidenced by the remote tubal patency rate documented by HSG performed 6 months after the procedure for those patients who did not conceive, and the reproductive outcome following the hysteroscopic tubal cannulation meaning the pregnancy rate achieved during the follow up period of six months. The average age [ +/- SD] of the patients was 27.3 +/- 3.5 yean [range 22-35 years], and the mean duration of infertility [ +/- SD] was 3.61 +/- 1.2 years [range 2-7 years]. Fourteen women [35.90%] presented with primary infertility and 25 women [64.10%] presented with secondary infertility. Laparoscopic transcervical chromopertubation demonstrated proximall tubal patency in 7 [17.95%] out of the 39 women; and hysteroscopic/ laparoscopic transostial selective chromopertubation demonstrated tubal patenq in another 4 [10.26%] women. This means 28.21% false +ve results for HSG, and 10.26% false +ve results for laparoscopic transcervical chromopertubation. Successful tubal cannulation with achievement of immediate tubal patency was evident in 24 [70.59%] tubes present in 13 [76.47%] patients. Tubal patency was achieved bilaterally in 11 patients, and unilaterally in 2 patients. Initial total failure of the procedure [i.e. inability to achieve tubal patency in either of both tubes whether due to inability of tubal cannulation or due to persistence of PTO after tubal cannulation] was evident in 4 [23.53%] patients. Inability of tubal cannulation was evident in 6 [17.56%] tubes present in 4 patients. Persistence of tubal occlusion after cannulation was observed in 4 tubes [11.76%] present in 3 patients. Tubal perforations have complicated the tubal cannulation of 5 [14.70%] tubes, Three of the perforations were associated with persistence of tubal occlusion, and the other two perforations were associated with successful tubal cannulation and restoration of tubal patency. Six women [35.29%] achieved intrauterine pregnancies, and one patient [5.88%] had a tubal ectopic pregnancy. HSG, performed six months after tubal cannulation for the patients who did not conceive, revealed preservation of tubal patency in 4 [23.53%] patients, and bilateral tubal reocclusion in 2 [11.76%] patients. Hysteroscopic tubal cannulation under laparoscopic guidance has a major impact on the management and counseling of infertile wmen with PTO. IVF is a present first choice for treatment of tubal factor infertility, but IVF is still stressful economically and physically. On the other hand, pregnancies achieved naturally are not only inexpensive but also easy for the patients from all aspects. Hysteroscopic tubal cannulation is a safe and cost effective procedure which has clear diagnostic and therapeutic benefits for infertile patients with PTO. Considering the success rate of hysteroscopic tubal cannulation, about three-fourths of the patients with PTO managed by this technique are recommended to try to conceive naturally, instead of being referred for ART or microsurgery. Hysteroscopic tubal cannulation under laparoscopic guidance should be recommended as first choice for further diagnosis and treatment of infertile women with PTO