Abstract
Abstract
Objective:
Proximal tubal obstruction is diagnosed with 15% of hysterosalpingograms performed for patients who have infertility. The accepted management is tubal catheterization. The aim of this research was to determine the success of this procedure in patients who had proximal tubal obstruction.
Materials and Methods:
A retrospective analysis was performed, using the data for 37 patients who were evaluated for infertility. Ultimately, the charts of 36 patients who completed the procedure were reviewed. According to the charts, these patients underwent fallopian tube catherization under fluoroscopy with interventional radiology. The charts also showed that, in 14 patients, there was bilateral proximal tubal obstruction, and, in the remaining 22 patients, there was only unilateral tubal blockage.
Results:
There were 4 unsuccessful catherization procedures; the success rate of the catherizations was 88.8%. After catherization, 13 patients achieved pregnancy rate of 40%.
Conclusions:
Tubal catherization has replaced microsurgery for treating proximal tubal obstruction with excellent results, with a clinical pregnancy rate of 13.3%–55%. Interventional radiology for tubal catherization leads to great patency and pregnancy rates, with short stays in the hospital and quick recovery.
Introduction
Proximal tubal obstruction is discovered usually during hysterosalpingography for patients with infertility. The incidence is almost 15% of hysterosalpingograms. The etiology is variable including spasm of the muscular wall of the tube that can result from rapid distension of the uterus with the dye during hysterosalpingography. Other causes include infection of the fallopian tubes, endometriosis, salpingitis isthmica nodosa, and uterine fibroids. 1
Anatomy of the fallopian tube
The fallopian tubes are named after Gabriele Fallopio (1523–1562
The fallopian tubes are a pair of musculomembranous ducts that arise from the proximal portion of the Müllerian ducts. The tube has two muscle layers—an inner circular or spiral layer and an outer longitudinal layer. The muscle layers are lined with a mucous membrane that has ciliated cells and secretory cells. The fallopian tube is contained in the upper part of the broad ligament. Each fallopian tube measures ∼7–14 cm. in length. Each tube has interstitial, isthmic, ampulla, and fimbriated segments. The fallopian tubes have sympathetic and parasympathetic nerve fibers arising from the nerve plexus in the cul-de-sac. The fallopian tubes have estrogen, progesterone, and prostaglandin receptors. 3
The proximal portion of the fallopian tube includes the interstitial segment and isthmic segment. The luminal diameter is ∼1 mm. The tube has a straight or curved course in 60% of women and a convoluted course in 40% of women. This can facilitate obstruction of the tube from accumulated secretions or scarring resulting from infection. 4
The fallopian tube picks the oocyte from the ovarian surface by its fimbriated end. The tube facilitates fertilization in the ampulla, and then the motion of the embryo to the uterus for implantation.
Proximal tubal obstruction interferes with the sperm motion through the tube, preventing fertilization and pregnancy, thus, causing infertility.
Fallopian tube catheterization
The American Society for Reproductive Medicine recommended tubal catheterization as the first step in treating cases of proximal tubal obstruction, because this allows the treating physician to study the rest of the tube, when performing this procedure in a patient with such an obstruction. In addition, the pregnancy potential following such a procedure is ∼60% if the tube is found to be normal. 5
The idea of tubal catheterization started in 1849 with a whalebone that was used to probe a woman's blocked fallopian tube. During the same year, a German physician used silver nitrate to cauterize another woman's tubes to prevent pregnancy.6,7 This information stimulated the interest of gynecologists, especially with the introduction of hysteroscopes. In the mid 1980s, several reports appeared in the literature about tubal catheterization and its success rate. 8 The American Society of Reproductive Medicine supported this concept in the society's practice guidelines published in 1993. 5 The procedure is now easier to perform with interventional radiology, thus avoiding the use of a hysteroscope that requires more equipment and that can lengthen the time taken to accomplish the same goal.
Materials and Methods
This study was a retrospective analysis of data for 37 patients who were evaluated for infertility. Ultimately, the charts of 36 patients who completed the procedure were reviewed.
Relevant document(s) were reviewed, and it was determined that this study was exempt from institutional review board approval, according to federal regulations. However, each patient signed a consent document to be included in the study.
Hysterosalpingograms were performed to evaluate each patient's uterine cavity and fallopian tubes. The patients were usually started on 100 mg of oral doxycycline twice per day for 24 hours before the procedure (and continued for 4 days after the procedure). The patients were also instructed to take 600 mg of ibuprofen orally 1 hour before the procedure to prevent pain during the procedure and to avoid spasms of the fallopian tubes. If a patient was allergic to ibuprofen, she was asked to take 325 mg (2 tablets) of Tylenol® instead, also 1 hour before the procedure.
The procedure was performed during the second week of each patient's menstrual cycle. She was usually given intravenous sedation to prevent her from feeling the various instruments used to probe her uterine cavity and fallopian tubes.
The procedure started with insertion of a multichannel #9 catheter in the uterine cavity with a balloon inflated at the cervix. Through this catheter, a #5 French catheter was introduced and its tip was directed to the cornual tubal opening. Then, a guidewire was introduced and directed to the tubal opening and moved inside the interstitial portion of the tube to remove any obstruction. Following that, the guidewire was removed and dye was injected to outline the tube throughout its full length. This was performed to gain additional information about the rest of the fallopian tube.
Results
Analysis of the results on the charts showed the patient's ages were ages 28–51. The hysterosalpingograms showed normal uterine cavities in all of the patients. In 14 patients, there was bilateral proximal tubal obstruction, and in the remaining 22 patients, there was only unilateral tubal blockage. The data showed 4 unsuccessful catherization procedures with a success rate of 88.8%. The pregnancy rate after catherization was 40% (13 patients).
Discussion
Proximal tubal obstruction is usually discovered during evaluation of infertility using hysterosalpingography. One of the causes is a history of pelvic infection. Tubal blockage occurs in 11% of patients after 1 episode of pelvic inflammatory disease. The incidence increases with the increase in the episodes of pelvic infection.
Another factor for proximal tubal obstruction is salpingitis isthmica nodosa. The etiology is not known. Some scientists favor infection as an explanation, and others favor other factors, including hormonal factors or congenital predispositions.
Endometriosis is a factor in which the disease affects the proximal tube, invading the muscle layer and causing fibrosis and obstruction. This causes 7%–14%of isthmic obstructions.
Tubal spasm is a significant factor that leads to proximal obstruction of the fallopian tubes. This results from the use of instruments, such as a tenaculum to stabilize the cervix or the cannula that delivers the radio-opaque solution for the hysterosalpingogram, as well as distension of the uterus during the procedure. Ibuprofen or Tylenol may help prevent tubal spasm during a hysterosalpingogram.
Tubal catherization has been performed using hysteroscopy to enable the catheter to reach the ostium of the fallopian tube and facilitate the guidewire to enter into the proximal portion of the tube to remove the obstruction. Following that, the guidewire is removed and dye is injected. Usually, in these cases, laparoscopy is performed to visualize the spillage from the fimbriated end of the tube.9–11
Conclusions
In the present study, fluoroscopy with interventional radiology were used. As such, the whole procedure was visualized, and the patency of the patients' tubes was verified. The success rate was 88.9% and pregnancy rate was 33.3%. Other studies have produced similar results.
Tubal catherization has replaced microsurgery for proximal tubal obstruction with excellent results, with a clinical pregnancy rate of 13.3%–55%. The use of interventional radiology for tubal catherization leads to great patency and pregnancy rates, with short stays in the hospital and quick recoveries.12–14