The potential value of tubal perfusion pressures measured during selective salpingography in predicting fertility

BACKGROUND: The value of tubal perfusion pressures assessed during selective salpingography and tubal catheterization in predicting fertility has not been investigated. METHODS: A total of 325 infertile women underwent selective salpingography and tubal catheterization. Pregnancy information was collected in 256 (78.7%). The 50th (300 mmHg) and 90th (500 mmHg) centiles of the tubal perfusion pressure distribution in women with normal tubes on selective salpingography were used as thresholds. Women were divided into three tubal perfusion pressure groups: good (both tubes <300, or one tube <300 and the other 300-500 mmHg), mediocre (both tubes 300-500, or one tube <300 and the other >500 mmHg) and poor (both tubes >500, or one tube > 500 and the other 300-500 mmHg). RESULTS: The pregnancy rate in the good perfusion pressure group was significantly higher than that in the poor perfusion pressure group, both when all non-IVF/ICSI first conceptions (P = 0.001) as well as when spontaneous first conceptions only were considered (P = 0.010). The pregnancy rate in the mediocre group lay between the good and the poor groups, though none of the comparisons reached statistical significance. CONCLUSIONS: Selective salpingography can provide additional diagnostic information in comparison with other tubal assessment tests. Tubal perfusion pressures may be predictive of future fertility.     

A hypothesis for the pathogenesis and natural history of proximal tubal blockage

This paper reviews the literature on the proximal Fallopian tube and attempts to synthesize the available information into an hypothesis to elucidate the pathogenesis and natural history of proximal tubal blockage (PTB). There is evidence that the unique anatomy and physiology of the proximal Fallopian tube may predispose this tubal segment to a 'physiological' blockage, by tubal secretions and/or material back flowing from the uterine cavity, during the estrogen-dominant phase of the menstrual cycle. This would normally be reversed during the subsequent progesterone-dominant phase. However, if this reversal process is defective, organization of this material can occur, which can lead to initially incomplete and then complete tubal obstruction. Tubal wall damage does not normally exist in these cases. This sequence of events is supported by our experience in transcervical tubal cannulation. Flushing and/or guide-wiring the tubes can re-establish tubal patency and fertility. The tubal perfusion pressure, assessed during transcervical tubal cannulation procedures, can serve as a marker of the severity of PTB and the success of recanalization.     

Surgery: Diagnosis and treatment of proximal tubal obstruction by fluoroscopic transcervical Fallopian tube catheterization

The efficacy of fluoroscopic transcervical Fallopian tube catheterizationin treating patients with proximal tubal obstruction was investigated.In 11 (15.9%) of the 69 patients who entered the study, patencyof the proximal Fallopian tubes was shown by a pre-treatmenthysterosalpingogram or an ostial selective salpingogram. TranscervicalFallopian tube catheterization attested to the success of recanalizationin at least one of the obstructed tubes in 41 of our 58 patients(70.7%). Of 92 obstructed tubes, 56 (60.9%) were successfullyrecanalized. However, normal tubal visualization was possiblein only 13 tubes (23.2%). Most of the recanalized tubes wereconsidered to be peritubal adhesions (64.3%). Eight of 36 (22.2%)patients who had been successfully recanalized achieved pregnancies;12 patients demonstrated normally appearing salpingograms afterthe procedure, and five (41.7%) had an intra-uterine pregnancy.Suspected peritubal adhesions were exhibited on post-operativesalpingograms of 24 patients, one of whom had an intra-uterinepregnancy, while two had tubal pregnancies. Transcervical Fallopiantube catheterization is a simple and effective method for evaluatingand treating proximal tubal obstruction. Most of the patients(70.7%) in whom recanalization was successful showed significantsigns of distal tubal damage. This procedure can also be usedto arrive at a prognosis regarding conception.     

Long-term fertility prognosis following selective salpingography and tubal catheterization in women with proximal tubal blockage

BACKGROUND: The possibility of conception following selective salpingography and tubal catheterization is believed to decline sharply a few months after the procedure. This observation may be due to the relatively small number of patients and short follow-up of previous studies. Furthermore, couples with other causes of infertility apart from proximal tubal blockage have usually been excluded. METHODS: Survival analysis of conceptions of 218 consecutive infertile women with proximal tubal blockage who underwent selective salpingography and tubal catheterization was performed. There were no exclusion criteria. Follow-up ranged from 16 to 56 months. RESULTS: A total of 47.2% of spontaneous conceptions and 43.2% of all conceptions, apart from those achieved by IVF or ICSI treatments, occurred after the first 12 months following selective salpingography and tubal catheterization. The decline in the possibility of pregnancy during the study period (conception hazard rate) was only minimal. CONCLUSIONS: In a population of infertile women with proximal tubal blockage, a significant proportion of conceptions occur after the first 12 months following selective salpingography and tubal catheterization. The presence of any additional causes of infertility in the couple should not be regarded as an absolute contraindication to the procedure.     

Long term safety of fluoroscopically guided selective salpingography and tubal catheterization

BACKGROUND: The irradiation of the ovaries of reproductive age women during fluoroscopically guided selective salpingography and tubal catheterization has raised concern about the safety of the procedure. In addition to the risk of cancer induction, which exists with the irradiation of all tissues, with the gonads, the induction of hereditary disorders is possible. The objective of this study was to estimate these risks and present them in a clinically meaningful way. METHODS: Retrospective analysis was undertaken of 366 consecutive cases of selective salpingography and tubal catheterization performed at the Birmingham Women's Hospital, UK. The radiation doses of different types of procedure were compared with the background annual radiation dose. The risks of cancer and genetic disorders induction were calculated using conversion coefficients published by the International Commission on Radiological Protection. RESULTS: The radiation dose women were exposed to during selective salpingography and tubal catheterization under fluoroscopic guidance was a fraction of the background annual radiation dose. The excess lifetime risks of cancer and hereditary disorders were in the order of four to 13 and two to six per million procedures respectively. CONCLUSIONS: The long term risks of selective salpingography and tubal catheterization under fluoroscopic guidance are low.     

Surgery: Selective salpingography with an insemination catheter in the treatment of women with cornual Fallopian tube obstruction

The effectiveness of selective tubal cannulation using a simpleand inexpensive tubal insemination catheter was evaluated in23 infertile patients with cornual obstruction demonstratedby hysterosalpingography. Selective fluoroscopic tubal catheterizationwas accomplished in 95% of the patients with resulting tubalpatency in 70% of the procedures (28 recanalizations out of40 Fallopian tubes). Eight patients (34.8%, eight out of 23)became pregnant, six went on to full-term deliveries and twoexperienced spontaneous first-trimester abortions. One womanconceived twice, and delivered a singleton pregnancy after thefirst recanalization and a twin gestation after the second salpingography.No complications were reported. The results of this study emphasizethe ease, cost effectiveness and safety of this method, encouragingits use in patients with cornual Fallopian tube obstructioneither as the sole therapeutic approach or in association withother assisted conception treatment alternatives.     

Physiology: Human tubal fluid: formation and composition during vascular perfusion of the Fallopian tube

A vascularly perfused preparation of the Fallopian tube hasbeen developed as a model to study the formation and compositionof human tubal fluid. An artery serving the tube was cannulatedand perfused at a rate of 0.7 ml/min for 1 h with Medium 199supplemented with bovine serum albumin, heparin and antibiotics.A cannula was also inserted into the lumen. Light and scanningelectron micrographs of control and perfused tubes showed thatthe epithelial lining was intact after perfusion. Tubal fluidwas collected in 13 out of 19 experiments. Fluid could alwaysbe collected from patients who were in the follicular phaseof their ovarian cycle. The mean rate of appearance was 48 µl/h.The glucose, lactate and pyruvate concentrations in the tubalfluid, as assessed by fluorescence microanalysis, were 0.53,8.58 and 0.17 mM respectively. There were no correlations betweenmetabolite concentration and the length of perfusion, cannulationtime, patient's age or condition. This technique provides acontrolled method with which to access and examine human tubalfluid and will allow the physiology of both healthy and diseasedtubes to be studied.     

Diagnosis and treatment of ectopic pregnancy by retrograde selective salpingography and intraluminal methotrexate injection: work in progress

Selective retrograde trans-cervical salpingography was carried out in four patients in whom ectopic pregnancy was suspected. The Fallopian tube was catheterized using a catheter set designed in our centre. The 6F catheter was placed in the cornua and an inner coaxial catheter was easily introduced into the proximal portion of the Fallopian tube, guided by tactile impression. Contrast medium was then injected and a round haloed mass was seen. Thereafter, the Fallopian tube was catheterized using a metallic guidewire until its tip was adjacent to the ectopic pregnancy. The coaxial catheter was then advanced along the guidewire and after removal of the latter, 5-35 mg of methotrexate was injected into the Fallopian tube. This new procedure was simple, well tolerated and had no side effects. A tubal pregnancy was demonstrated and surgery was avoided in all cases.     

Fallopian tube recanalization by selective salpingography: an alternative to more invasive techniques?

Selective salpingography was used in a total of 64 patients, engaged in evaluation for infertility and in whom standard hysterograms showed no tubal passage of contrast medium. Fallopian tube catheterization was successful in 92% of the cases; a peritoneal spill of contrast medium was obtained in 74% of the cases by manual injection. Recanalization of an obstructed oviduct was successful in 61% of the cases. Thus, after the procedure, 82% of the patients had at least one patent tube. We conclude that selective tubal catheterization, and recanalization when needed, should be included in the therapeutic procedures for tubal infertility, prior to in-vitro fertilization or tubal microsurgery.     

Assessing tubal patency with transvaginal salpingosonography after the reversal of tubal ligation for female sterilization

The objective of this study was to assess tubal patency usingtransvaginal salpingosonography (TSSG) among women treated bytubal ligation after sterilization and to compare these resultswith those obtained using X-ray hysterosalpingography (HSG).Twenty-one healthy women were recruited. Air was used as a contrastmedium in TSSG and Omnipaque® as a water-soluble contrastmedium in the HSG examination. All women underwent at leastone TSSG. If the woman did not become pregnant during the follow-upor had a miscarriage or tubal pregnancy, she was re-examinedwith a second TSSG and the results were compared with thoseof HSG undertaken during the same menstrual cycle. Because ofthe high pregnancy rate the final number of patients was reducedto 10. The observed agreement between the two TSSGs was 70%,which was low compared with our earlier results. The kappa coefficientwas only 0.41. The sensitivity of TSSG for the detection oftubal occlusion was 54%. This can be explained by the fact thatthe mean time interval between the two TSSGs was long (5.5 months)and results were not therefore comparable or repeatable. Wecan conclude that the women with patent tubes became pregnantafter the first TSSG while the women taking part in the secondTSSG had impaired tubal function. There were more occluded tubesobserved in the second TSSG than in the first. An analysis comparingthe second TSSG with HSG produced better results. The observedagreement was 84%, kappa coefficient 0.67, demonstrating a goodreproducibility of TSSG; the sensitivity of TSSG for the detectionof tubal occlusion was 83%, specificity 85%, positive predictivevalue 91% and negative predictive value 75%. Thus, TSSG shouldbe regarded as a reliable, rapid, safe and inexpensive methodfor testing tubal patency after reversal of tubal ligation forsterilization. It also allows simultaneous scanning of the uterinecorpus, endometrium and ovaries and may have a clearing actionon occluded tubes. TSSG can thus replace X-ray HSG in the primaryevaluation of tubal status, even in this special group of patients.     

Investigation of tubal infertility by radionuclide migration.

Investigation of the tubal factor in infertility is limited to an assessment of anatomical structure and tubal patency. No test of ascendant tubal function is currently available. The migration of radionuclide (99mTc-labelled human albumin microspheres) through the genital tract in 96 infertile women was compared with pelvic findings at laparoscopy and chromopertubation. The radionuclide test correlated with laparoscopy in the diagnosis of patency or blockage in 83 cases (86%). In nine patients, where 'blockage' was diagnosed on the radionuclide test but patency found at laparoscopy, a higher prevalence of pelvic abnormality was found, compared to the 78 patients where both tests demonstrated patency (P less than 0.02). The radionuclide test may facilitate detection of diseased but patent tubes and, as an adjunct to laparoscopy and chromopertubation, may provide useful information about tubal function.     

Methotrexate therapy of tubal pregnancy

Reports of successful treatment of ectopic pregnancies by administrationof methotrexate have recently attracted a great deal of attention.This review summarizes the results of therapy with methotrexatein tubal pregnancy. Different technical approaches and pharmacologicaldoses have been reported. These methods, however, present variousproblems, including the occurrence of toxicity, long therapeuticperiods and treatment failure. With proper selection of patients,a success rate of 90% has been achieved. Preliminary assessmentof subsequent fertility provides promising results. However,the majority of the reports do not include controls.     

Transcervical tubal cannulation and falloposcopy for the management of tubal pregnancy.

This is the first report of transcervical salpingoscopic visualization of tubal pregnancy in two patients. The falloposcope was introduced through a catheter used routinely for transcervical tubal cannulation, guided by tactile impression. We have previously demonstrated that it is possible to diagnose and treat tubal pregnancies via a transcervical intra-Fallopian cannula. Falloposcopy could help select appropriate patients for transcervical intra-Fallopian therapy by verifying the site of implantation and the characteristics of the ectopic pregnancy.     

Infertility: Wire guide cannulation alone is no treatment of proximal tubal occlusion

Tubal catheterization procedures have become standard of careas a primary treatment of proximal tubal occlusions. They successfullyutilize a variety of catheter techniques, though all usuallyinclude a wire guide. This raises the question whether guidewire catheterizations alone can be used to treat proximal tubalocclusions. We therefore investigated consecutively 25 womenwith at least one proximally occluded oviduct by attemptingwire guide cannulations bilaterally in 10 and unilaterally in12 women with two tubes and in three women with a single tube.Among the 10 patients with bilateral occlusion, seven were recanalizedbilaterally (70%), one unilaterally (10%) and two not at all(20%). Among the 15 patients with unilateral tubal occlusion,12 (80%) were recanalized. In total, 27 out of 35 (77%) obstructedoviducts were recanalized. In a follow-up period of 5–17months only one pregnancy was, however, recorded and this wasa tubal pregnancy. We conclude that wire guide cannulation ofproximally obstructed tubes achieves tubal patency in a largepercentage of cases, comparable to other catheter techniquesreported in the literature. In contrast to those, however, wireguide cannulations alone result in much lower pregnancy rates.This observation strongly suggests that wire guides, used withco-axial and balloon catheter systems, are not responsible forthe pregnancy success reported for these procedures. Wire guidecannulation alone does not therefore represent adequate treatmentfor patients with proximally occluded Fallopian tubes.     

The effect on pregnancy rates of tubal perfusion pressure reductions achieved by guide-wire tubal catheterization

BACKGROUND: Selective salpingography enables us to measure the Fallopian tube perfusion pressure which, when high, can be effectively reduced with the use of transcervical guide-wire tubal catheterization. Whether fertility prognosis improves as a result is currently unknown. Our objective was to clarify the issue. METHODS: Infertile women undergoing selective salpingography were classified into poor, mediocre and good tubal perfusion pressure groups, based on the distribution of tubal perfusion pressures in an unselected infertile population. Of 325 women, 150 (46.1%) were classified in the poor group and underwent guide-wire tubal catheterization. RESULTS: Complete pregnancy and tubal perfusion pressure data were available for 104 (69.4%) subjects. Following tubal catheterization, 29 women (group A) could be classified in the good, 25 (group B) in the mediocre, while 50 women (group C) remained in the poor tubal perfusion pressure group. Survival analysis showed that the pregnancy rate in group A was significantly higher than the rates in groups B and C (P = 0.036 and 0.005 respectively). CONCLUSIONS: Reductions of tubal perfusion pressures achieved with transcervical guide-wire tubal catheterization resulted in an improved fertility prognosis for women. Selective salpingography and tubal catheterization might have a wider role in the management of the infertile couple than currently believed.     

The treatment of patients with polycystic ovarian syndrome by in-vitro fertilization and embryo transfer: a comparison of results with those of patients with tubal infertility

Sixteen patients with polycystic ovarian syndrome (PCO) were treated by in-vitro fertilization (26 treatment cycles). The results were compared with 37 normo-ovulatory women with tubal disease (37 treatment cycles). The oestradiol and progesterone levels were higher during the follicular phase in the PCO patients, but were statistically significantly higher only on the day after human chorionic gonadotrophin administration. Although more oocytes were recovered per cycle from the PCO group (19.3 +/- 6.1) than from the control group (5.4 +/- 2.9) with P less than 0.004, the mean numbers of embryos per cycle were similar in both groups (3.7 +/- 2.4 versus 3.6 +/- 2.2, respectively). The pregnancy rate was also comparable in both groups (30.7 versus 29.7%, respectively). The fact that more oocytes are recovered from PCO patients, balances their lower fertilization and cleavage rates. We conclude, therefore, that IVF treatment may be a viable solution for PCO patients resistant to an in-vivo protocol treatment regimes.     

Laparoscopic tubal anastomosis and reversal of sterilization.

Fallopian tube interruption is a common form of contraception worldwide. For a variety of reasons (e.g. change in marital status, wish for additional children, psychological factors), many of these women seek restoration of fertility. Laparoscopic tubal anastomosis is one of the newest of these procedures by which this can be achieved. Sixteen women underwent laparoscopic microsurgical anastomosis. We used a three-stitches technique with tubal cannulation adapted from methods described in the literature. Five pregnancies occurred, giving an overall pregnancy rate of 31.2%. Surgical outcome depends on the patient's age, the method of tube interruption and the length of Fallopian tube segments being anastomosed. In this study, the feasibility of laparoscopic tubal sterilization reversal is confirmed, as well as the benefits offered by laparoscopic procedures in terms of quality of life. Further improvement of surgical outcome will be achieved not only through better laparoscopic techniques but also through careful screening for surgical indications.     

Evaluation of the sites of ectopic pregnancies subsequent to reconstructive tubal surgery

The sites of ectopic pregnancies in women who underwent varioustypes of reconstructive tubal surgery were analysed and comparedto the controls. Overall, ectopic pregnancies subsequent toall types of tubal surgeries were more often implanted proximallycompared to the control population.     

Falloposcopic comparison of unilateral and bilateral proximal tubal ocdusive disease

The purpose of this study was to compare the appearance of theentire length of the oviductal canal in women with unilateralversus bilateral proximal tubal occlusion. Eleven women hadapparent unilateral disease and 18 had apparent bilateral occlusion.Proximal occlusion was confirmed both by hysterosalpingographyand laparoscopy. Falloposcopic examination was performed byretrograde visualization using the linear eversion catheter,in office. Bilateral apparent proximal occlusion was found tohave a significantly higher incidence of actual proximal occlusionand distal intralumenal abnormalities. However, five proximalsegments and six distal segments were found to be abnormal wherethe pre-examina-tion diagnosis was unilateral occlusion. Furthermore,the contralateral oviductal canal was found to be abnormal infour women with apparent unilateral disease, indicating thatapparent unilateral proximal tubal occlusion is associated withactual pathology. These data demonstrate the value of intralumenalassessment of apparent proximal occlusion.     

The value of Chlamydia trachomatis antibody testing in predicting tubal factor infertility

BACKGROUND: The objective of the present study was to compare the likelihood of abnormal Chlamydia trachomatis antibody test results with that of abnormal hysterosalpingography (HSG) test results in patients with tubal factor infertility. METHODS: Anti-C. trachomatis immunoglobulin G antibodies were determined prospectively in 295 infertility patients by means of an indirect fluorescent antibody technique. In 48 of the 295 patients both HSG and laparoscopy with chromotubation were performed. The results of C. trachomatis antibody testing were compared with the results of HSG with respect to their predictive value of tubal factor infertility. Likelihood ratios for abnormal C. trachomatis antibody and HSG test results were determined in infertility patients, as assessed by laparoscopy. RESULTS: The positive likelihood ratio for C. trachomatis antibody testing was 1.8. This was comparable with the HSG, which had a positive likelihood ratio of 1.7. CONCLUSIONS: The predictive value of C. trachomatis antibody testing was equal to that of HSG, but ratios of 1.7 and 1.8 indicate a poor test, so both C. trachomatis antibody testing and HSG have a poor predictive value. C. trachomatis antibody testing causes minimal inconvenience to the patient, in contrast to HSG, and therefore should be maintained in infertility examinations.