Preliminary experience with transcervical balloon tuboplasty

We developed a new technique, transcervical balloon tuboplasty, an adaptation of established balloon angioplasty techniques that facilitates recanalization of proximally occluded oviducts. Sixteen patients with obstruction of the proximal portion of one or two fallopian tubes (based on at least two hysterosalpingograms and one laparoscopic examination) were selected for the procedure. Four patients (25%) were found to have patent oviducts on intraoperative third tubal patency evaluation and were therefore excluded from study. Of the remaining 12 patients, tubal patency was achieved in at least one fallopian tube in 7 patients (58%), as demonstrated by hysterosalpingogram immediately after the transcervical balloon tuboplasty procedure. On follow-up 2 months to 1 year afterward, two pregnancies and one delivery occurred. We conclude that transcervical balloon tuboplasty appears to represent a useful and safe technique to achieve patency in selected cases of tubal interstitial obstruction. Reocclusion rates, long-term complication rates, and pregnancy rates after transcervical balloon tuboplasty remain to be established before the procedure should be considered a recommended alternative for either surgical tuboplasty or in vitro fertilization.     

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.     

腹腔镜监测下宫腔镜输卵管插管术治疗输卵管近端梗阻的疗效分析

目的：分析腹腔镜监测下宫腔镜输卵管插管术（laparoscopy-guided hysteroscopic tubal catheterization,LHTC）治疗输卵管近端梗阻的临床疗效。方法：回顾性分析2010年1月—2012年12月因单纯输卵管近端梗阻在中国人民武装警察部队后勤学院附属医院住院行LHTC的336例患者临床资料。术后随访2年,观察其术后妊娠率及妊娠结局。结果：LHTC术中总的输卵管复通率为54.70%,总的患者复通率为63.10%。术后至少一侧输卵管通畅组和未能复通组的术后2年自然妊娠率分别为43.40%和8.06%,活产率分别为33.96%和7.26%,差异均有统计学意义（P＜0.05）。结论：行LHTC治疗输卵管近端梗阻的疗效确切,该术式可以作为治疗输卵管近端梗阻的首选方法。     

Histopathologic changes in fallopian tubes subsequent to sterilization procedures

Longitudinal serial and serial step sections of fallopian tubes from more than 100 patients, subsequent to tubal sterilization procedures, were examined. Thirteen of these patients had pregnancies following their sterilizations. The histologic findings at the previous surgical sites were compatible with what would be expected for a normal healing process. Evidence for a unique tubal epithelial process, as suggested by the terms "endosalpingiosis" or "recanalization," was lacking. Likewise, the author found no evidence of tuboperitoneal fistula formation and/or the subsequent occurrence of pregnancy secondary to localized endometriosis. The histologic notations of proximal luminal dilatation, plical attenuation, chronic inflammatory infiltrates with pseudopolyp formation, and the findings of plical thickening in the distal segment of remaining tube after an interruption type of procedure seem to be associated with the length of time from the sterilization procedure. These may be factors related to the apparent reduced success rate, with time, of microsurgical reanastomotic procedures.     

Diagnosis and treatment of cornual obstruction using a flexible tip guidewire

Proximal tubal obstruction, either unilateral or bilateral, is a frequent finding on hysterosalpingogram (HSG). Approximately two-thirds of the fallopian tubes resected for proximal tubal obstruction reveal an absence of luminal occlusion. The distinction between true pathologic occlusion and either spasm or plugging is crucial in determining therapy. We combined hysteroscopic cannulation of the proximal fallopian tube with laparoscopy in 11 patients with proximal tubal obstruction diagnosed by HSG and confirmed at laparoscopy. Hysteroscopic cannulation was able to be performed in 72% of the fallopian tubes attempted, and there was a postcannulation patency rate by HSG of 73%. Six of the 11 patients became pregnant after tubal cannulation and adjunctive distal tubal surgery. Hysteroscopic cannulation of the fallopian tube is a safe diagnostic procedure that can be used to identify those patients with true proximal occlusion, and may also serve as a therapeutic procedure in some of these patients.     

Spontaneous recanalization of cornual tubal occlusion following a pregnancy achieved by in vitro fertilization

A patient with bilateral tubal occlusion conceived by IVF and delivered a healthy infant vaginally. Four months postpartum, the patient again conceived spontaneously and carried to term. Recanalization of one fallopian tube was demonstrated on HSG performed after delivery of the second infant. Mechanical stretching and pregnancy-induced hormonal changes may explain spontaneous recanalization of obstructed fallopian tubes.     

End-to-end tubal anastomosis using an absorbable stent.

Using absorbable suture as a stent, end-to-end anastomosis of previously ligated or cauterized fallopian tubes was performed in 15 cases. Luminal patency of at least one fallopian tube has been achieved in all cases, and thus far seven pregnancies have occurred in six cases. The technique for inserting the absorbable suture into the distal and proximal portions of the tube is fully described, and the importance of repeated hydrotubations to maintain tubal patency is emphasized.     

Outcome of Laparoscopy-Guided Hysteroscopic Tubal Catheterization for Infertility Due to Proximal Tubal Obstruction

Study ObjectiveTo determine pregnancy outcomes after laparoscopy-guided hysteroscopic tubal catheterization and to report its role in the era of in vitro fertilization.DesignClinical cases series (Canadian Task Force classification II-3).SettingReproductive surgery center.PatientsPatients with unilateral or bilateral proximal tubal obstruction as the only cause of infertility were included.InterventionsLaparoscopy-guided hysteroscopic tubal catheterization.Measurements and Main ResultsOnly the first spontaneous conception was considered. Cumulative conception rate (CCR) was calculated using Kaplan-Meier survival analysis. Of 168 women included, 107 (63.7%) had bilateral proximal obstruction and 61 (36.3%) had unilateral obstruction. The successful recanalization rate was 54.2% per tube and 61.9% per patient. In the 93 patients in whom at least 1 fallopian tube was successfully recanalized, 40 spontaneous pregnancies (43.0%) occurred within 24 months, of which 35 (37.6%) were intrauterine pregnancies and 28 (30.1%) resulted in live births. The CCR was 37.6% at 1 year and 43.7% at 2 years. Patients with unilateral obstruction in whom cannulation was successful had the highest CCR (60.7% at 2 years).ConclusionSuccessful tubal cannulation led to significant improvement in the pregnancy rate, which suggests that women with a proximal tubal block could be considered for laparoscopy-guided hysteroscopic cannulation, which is still a viable alternative to in vitro fertilization.     

Case report of failed tubal occlusion using Essure pbc (permanent birth control) hysteroscopic sterilisation procedure

The device previously known as STOP, now called the Essure pbc device, is a dynamic expanding microinsert, placed in the proximal section of the fallopian tube, occluding the tube. Initial reports about the device are promising with occlusion of the tubes in 100% with no reported pregnancies and a high rate of safety and patient acceptability. This report documents the first reported failure of tubal occlusion of an appropriately placed Essure pbc device.     

Reproductive outcome after microsurgery for proximal and distal occlusions in the same fallopian tube

The reproductive outcome after microsurgery for both proximal and distal occlusions in the same fallopian tube has been reported in only small numbers of women. Our case series is in agreement with other series and shows that microsurgery for correction of both proximal and distal occlusions in the same fallopian tube yields only modest fertility and may predispose to ectopic tubal pregnancies.     

Bilateral tubal pregnancies after a single‐embryo transfer

Case

To present an extremely rare case of bilateral tubal pregnancies following a single‐embryo transfer in a woman with a 4 year history of infertility prior to seeking assisted reproductive technology.

Outcome

A pregnancy resulted from the transfer of an embryo that had been thawed from a frozen blastocyst during a hormone replacement cycle. An ultrasound that was performed at 5 weeks and 5 days of gestation revealed a gestational sac, embryo, and heartbeat in the right fallopian tube and similar signs of a gestational sac in the left fallopian tube. A laparoscopy revealed clear signs of an ectopic pregnancy in the ampulla of the right fallopian tube. Signs of swelling also were seen in the ampulla of the left fallopian tube. As the possibility of bilateral tubal pregnancies could not be ruled out, both fallopian tubes were removed. Pathological tests revealed chorionic villi and trophoblasts in both the left and right fallopian tubes.

Conclusion

All previously reported cases of bilateral tubal pregnancies have been a result of multiple ovulations or multiple‐embryo transfer and no case of bilateral tubal pregnancies after a single‐embryo transfer has ever been reported. No genetic testing was performed; thus, it cannot be definitively stated that the divided chorionic villi and trophoblasts came from only one embryo.     

Transcervical tubal embryo-stage transfer (TC-TEST)

Ultrasound-guided transcervical tubal cannulation (TC-TEST) was used to replace embryos to the fallopian tubes in 17 women whose fallopian tubes were inaccessible by the abdominal route but where at least one tube was shown to be freely patent on a preliminary hsterosalpingogram investigation. In two further cases, the fallopian tubes proved impossible to cannulate, and along with two instances where difficulty was experienced, a common underlying feature was an arcuate or septate configuration of the uterus. Three pregnancies ensued (17%) in cases where the procedure was free of difficulty and the transfers were demonstrably intratubal: two went to term and the third resulted in an ectopic pregnancy. The procedure has so far not shown a benefit over conventional IVF-ET and probably should be avoided in women with any type of tubal disorder.     

宫-腹腔镜联合输卵管复通术再通输卵管的效果评价

目的：评价宫-腹腔镜联合输卵管复通术的术后输卵管复通率及输卵管不同部位的复通率。方法：对2008年1月—2009年12月880例不孕症患者共1 760条输卵管进行宫-腹腔镜联合输卵管复通术,观察其术后的输卵管复通率。结果：宫-腹腔镜联合输卵管复通术的复通率为74.5%。其中,间质部为65.8%,峡部为56.5%,壶腹部为36.7%,伞端为86.0%。术后随访2年自然妊娠率39.6%。结论：输卵管伞端复通率最高,间质部次之,壶腹部复通率最低。     

The role of selective salpingography and tubal catheterization in the management of the infertile couple

PURPOSE OF REVIEW: This review is intended to update the reader about recent developments in the field of selective salpingography and tubal catheterization, to offer an interpretation of the information presented and to suggest further research links. RECENT FINDINGS: The measurement of tubal perfusion pressures at selective salpingography and tubal catheterization has offered a new dimension in the evaluation of the fallopian tube. A classification of infertile women based on tubal perfusion pressures is presented, and this is correlated with the possibility of spontaneous fertility, thus giving selective salpingography and tubal catheterization a prognostic profile in addition to diagnostic and therapeutic functions. Experience derived from the use of the technique in unselected infertile women (i.e. not with proximal tubal blockage) is presented. The use of selective tube catheterization for sterilization purposes joins the mainstream with the publication of the encouraging results of a multinational trial. The debate on the validity of the diagnosis of proximal tubal blockage is enriched by the suggestion that simply rotating the patient during hysterosalpingography will resolve most cases of the condition. The fertility gain by single-tube recanalization in women with unilateral proximal tubal blockage is given further support. The use of oil-based media for selective salpingography and tubal catheterization is discussed. A hypothesis on the pathophysiology of proximal tubal blockage is presented. SUMMARY: The evidence clearly supports the use of selective salpingography and tubal catheterization for infertile women with proximal tubal blockage. The potential of the technique to play a wider role in the management of infertility is demonstrated by recent research.     

Conservative surgical management of isthmic ectopic pregnancies

During the 12-month study interval ending March 30, 1986, there were 203 ectopic pregnancies at Grady Memorial Hospital, a ratio of one ectopic gestation per 34 deliveries. Twenty patients with isthmic ectopic pregnancies were selected for treatment by one of three operative modalities. Seven patients with ruptured isthmic ectopic pregnancies underwent segmental tubal resection without reanastomosis. All four patients who underwent segmental tubal resection with primary microsurgical reanastomosis had postoperative hysterosalpingograms demonstrating bilateral tubal patency. One pregnancy has occurred in this group. Nine patients underwent linear salpingostomy. In five of the six patients who had postoperative hysterosalpingography, patency of the involved fallopian tube was demonstrated. Four of these nine patients, including one patient with contralateral tubal occlusion, have conceived. We conclude that linear salpingostomy for isthmic ectopic pregnancies is as effective as segmental tubal resection with primary microsurgical reanastomosis in achieving tubal patency.     

Investigation of the uterine cavity and fallopian tubes using three-dimensional saline sonohysterosalpingography.

OBJECTIVE: To compare three-dimensional saline sonohysterosalpingography (SHSG) to X-ray hysterosalpingography (HSG) for the evaluation of the uterine cavity and fallopian tubes. PATIENT POPULATION: Fifteen infertile women on whom X-ray HSG had been performed within 1 year prior to this study. METHOD: Fifteen infertile women underwent three-dimensional power Doppler examination of the uterus and fallopian tubes with three-dimensional SHSG during the follicular phase. Distension was achieved using sterile saline injected through a 5 French HSG catheter. Peritoneal accumulation of free fluid surrounding the ovary and tube was required for a diagnosis of a patent tube. Fluid accumulation in the cul-de-sac without visualization of the tubes was considered consistent with at least one tube being patent. RESULTS: three-dimensional saline SHSG was completed in 14 patients. One patient had cervical stenosis and the procedure could not be performed. No significant intrauterine pathology was identified by either X-ray HSG or sonography. Three-dimensional saline SHSG made false positive diagnoses of tubal occlusion in four out of seven fallopian tubes (57%). The sensitivity and specificity for detecting tubal occlusion was 75 and 83%, respectively, with a positive predictive value of 40% and negative predictive value of 95%. Detection of fallopian tube architecture was not possible with three-dimensional saline SHSG in any patient. Simultaneous use of three-dimensional Doppler did not clearly identify the flow of saline through the fallopian tubes. CONCLUSIONS: Transvaginal three-dimensional saline SHSG provides good visualization of the uterine cavity and myometrial walls in three orthogonal planes. However, it does not diagnose tubal occlusion or depict architecture of the fallopian tube as accurately as X-ray HSG. Although we were able to visualize the distal fallopian tube and fimbria with real-time imaging, we were not able to satisfactorily image the proximal tube with three-dimensional power Doppler. This technique may be reserved as an initial screening test to evaluate the uterine cavity and test patency. Patients at high risk for tubal disease by history or with suspected tubal occlusion on three-dimensional saline SHSG should be evaluated by either X-ray HSG or laparoscopy with chromopertubation. Further improvements of three-dimensional technology and contrast materials will, it is hoped, make this method comparable to X-ray HSG.     

Transcervical balloon tuboplasty

TBT is a new technique that by use of a balloon catheter technique in a fashion similar to that of balloon angioplasty allows reestablishment of tubal patency in selected cases of tubal occlusion. The case presented here describes the first transcervical dilatation and recanalization of a proximally occluded fallopian tube in a patient with infertility.     

Microinsert nonincisional hysteroscopic sterilization

OBJECTIVE: To assess the safety, effectiveness, and reliability of a tubal occlusion microinsert for permanent contraception, as well as to document patient recovery from the placement procedure and overall patient satisfaction. METHODS: A cohort of 518 previously fertile women seeking sterilization participated in this prospective, phase III, international, multicenter trial. Microinsert placement was attempted in 507 women. Microinserts were placed bilaterally into the proximal fallopian tube lumens under hysteroscopic visualization in outpatient procedures. RESULTS: Bilateral placement of the microinsert was achieved in 464 (92%) of 507 women. The most common reasons for failure to achieve satisfactory placement were tubal obstruction and stenosis or difficult access to the proximal tubal lumen. More than half of the women rated the average pain during the procedure as either mild or none, and 88% rated tolerance of device placement procedure as good to excellent. Average time to discharge was 80 minutes. Sixty percent of women returned to normal function within 1 day or less, and 92% missed 1 day or less of work. Three months after placement, correct microinsert placement and tubal occlusion were confirmed in 96% and 92% of cases, respectively. Comfort was rated as good to excellent by 99% of women at all follow-up visits. Ultimately, 449 of 518 women (87%) could rely on the microinsert for permanent contraception. After 9620 woman-months of exposure to intercourse, no pregnancies have been recorded. CONCLUSION: This study demonstrates that hysteroscopic interval tubal sterilization with microinserts is well tolerated and results in rapid recovery, high patient satisfaction, and effective permanent contraception.     

Tubal reanastomosis using absorbable stent.

A procedure for performing tubal reanastomosis using an absorbable stent is described. The procedure utilizes a microsurgical technique with an absorbable suture for a stent in end-to-end tubal reanastomosis. The procedure is described and diagrammed. Of 14 such operative procedures performed so far, patency of at least 1 fallopian tube has been achieved in all cases. 6 intrauterine pregnancies have resulted, 5 are too recent to determine success with regard to pregnancy, and 1 has elected to postpone pregnancy. The use of delicate instruments, fine suture materials, and adequate hemostasis are considered critical to the success of the procedure. The absorbable stent provides optimal healing at the site.