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Table 1.  

Etiology of Proximal Tubal Obstruction.

Box 1.  

Fallopian Tube Recanalization Techniques.

Table 2.  

Summary of Results Following Various Endoscopic Fallopian Tube Recanalization Techniques.


Fallopian Tube Recanalization: Lessons Learnt and Future Challenges

  • Authors: Gautam N. Allahbadia, MD; Rubina Merchant, PhD
  • CME Released: 7/2/2010
  • Valid for credit through: 7/2/2011
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Target Audience and Goal Statement

This activity is intended for primary care clinicians, infertility specialists, gynecologists, and other specialists who care for women with fallopian tube obstruction.

The goal of this activity is to review procedures for the diagnosis of fallopian tube obstruction and its management to improve fertility outcomes.

Upon completion of this activity, participants will be able to:

  1. Describe the prevalence of false-positive and false-negative diagnoses of proximal tube obstruction (PTO) with hysterosalpingography
  2. Describe the frequency of PTO as a cause of subfertility
  3. Identify indications for and contraindications to transluminal salpingoplasty
  4. List different uses of falloposcopy in the management of PTO
  5. Identify advantages and disadvantages of falloposcopy over hysterosalpingography and laparoscopy in PTO


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  • Gautam N. Allahbadia, MD

    Deccan Fertility Clinic, Mumbai, India; Rotunda -- Center for Human Reproduction, Mumbai, India


    Disclosure: Gautam N. Allahbadia, MD, has disclosed no relevant financial relationships.

  • Rubina Merchant, PhD

    Rotunda -- Center for Human Reproduction, Mumbai, India


    Disclosure: Rubina Merchant, PhD, has disclosed no relevant financial relationships.


  • Elisa Manzotti

    Editorial Director, Future Science Group, London, United Kingdom


    Disclosure: Elisa Manzotti has disclosed no relevant financial relationships.

CME Author(s)

  • Désirée Lie, MD, MSEd

    Clinical Professor, Family Medicine, University of California, Irvine, Orange, California; Director of Research and Patient Development, Family Medicine, University of California, Irvine, Medical Center, Rossmoor, California


    Disclosure: Désirée Lie, MD, MSEd, has disclosed the following relevant financial relationship:
    Served as a nonproduct speaker for: "Topics in Health" for Merck Speaker Services

CME Reviewer(s)

  • Sarah Fleischman

    CME Program Manager, Medscape, LLC


    Disclosure: Sarah Fleischman has disclosed no relevant financial relationships.

  • Marilyn W. Edmunds, PhD, CRNP

    CME Accreditation Specialist, Nurse Practitioner Alternatives


    Disclosure: Marilyn W. Edmunds, PhD, CRNP, has disclosed no relevant financial relationships.

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Fallopian Tube Recanalization: Lessons Learnt and Future Challenges: Clinical Discussion


Clinical Discussion

Evolution of Tubal Cannulation

Rapid progress has been made regarding minimally invasive access to the human Fallopian tube. Although the diagnosis of tubal occlusion relies primarily on HSG, hysteroscopy and laparoscopy, advances in ultrasound technology and fiberoptics have enhanced our ability to accurately and noninvasively diagnose and treat tubal pathology with innovative diagnostic procedures (e.g., sonosalpingography, falloposcopy and selective salpingography) and have enabled the visualization of the tubal endosalpinx, a portion of the reproductive tract that has evaded endoscopic evaluation. Endosalpingeal changes can be quantitated in the presence of hydrosalpinges, and possibly with endometriosis, and these changes measured with a scoring system.[17] Tubal cannulation has emerged as an excellent alternative to microsurgical tubal anastomosis to treat patients with cornual obstruction, avoiding a laparotomy and extended disability.[3]


Initial attempts in the treatment of proximal obstruction involved the use of a whalebone bougie positioned in the uterine cornua to dilate the proximal tube by Smith as early as 1849.[18] Although it was considered impossible to atraumatically pass probes along the intramural segment of the human oviduct due to its tortuosity and small caliber until recently, these difficulties have been largely overcome by the miniaturization of cannulation devices and the development of coaxial catheter systems with flexible atraumatic guidewires initially used for coronary angioplasty and vascular embolectomy. Selective salpingography, transcervical cannulation and the injection of contrast medium directly into the Fallopian tube was first performed in 1966, using a curved metal cannula.[19] Technological advances have led to major improvements in the design and application of Fallopian tube cannulation devices using the transcervical approach.[20] Since the first description of fluoroscopic cannulation in 1985 and transcervical balloon tuboplasty a year later,[21] there have been numerous reports of successful cannulation using ureteral catheters, ureteral stents, 19-gauge epidural catheters, guidewires and, more recently (and commonly), the coaxial systems.[5] Presently, such transcervical cannulation systems, incorporating a very fine endoscopic fiber, are being used to visualize the lumen of the Fallopian tube, displace debris that may block the tube, eliminate proximal endoluminal plaques, breakdown intraluminal adhesions, perform intratubal insemination or embryo deposition to facilitate conception and thus overcome infertility, or conversely, to facilitate the option of sterilization reversal.[20] After proven mild or moderate tubal pathology, blasting of proximal incomplete obstructive disease by the use of transcervical balloon catheter dilatation or tuboscopy-guided transcervically everting balloon catheter system is possible.[22]

Although Fallopian tube cannulation with coaxial catheters began under fluoroscopy and was adaptive to cornual cannulation, coaxial catheter systems are now being used with hysteroscopy, fluoroscopy, ultrasonography and tactile sensation with consistent success.[23] FTR can be performed with catheters, guidewires or balloon systems under sonographic, fluoroscopic or hysteroscopic guidance Figures 2–7 illustrate laparo–hysteroscopic guidewire cannulation. Figure 8 illustrates the Cook Fallopian tube recanalization catheter used for transcervical fluoroscopically guided catheter recanalization. Figures 9–11 illustrate tactile catheterization. Coaxial catheters and balloon systems have been used with similar success rates. However, the simplicity of coaxial catheters, particularly with the use of the hysteroscope and under laparoscopic control simplifies the technique, enables direct observation of the UTJs, tubal cannulation and evaluation of the entire pelvis, and avoids exposure to radiation.[16] Wenzl et al. introduced a specially developed linear everting catheter (LEC) in combination with a microendoscope that enables the visualization of the complete tubal mucosa from a vaginal approach.[24] With the development of the LEC system, it is now possible to evaluate the tubal lumen and to diagnose changes in the tubal wall or the tubal mucosa by direct visualization. Advantages of the new LEC system include both the ability to inspect the tubal ostium without cervical dilation or concomitant hysteroscopy, and virtually atraumatic access to the tube by means of an endoscope measuring 0.5 mm in diameter and with a magnification of 40.[24] With adequate experience, this technique may also be performed in an outpatient setting.[25] Other potential applications of this new technology are the intratubal transfer of gametes and embryos, conservative treatment of tubal pregnancy, direct visualization of the tubal epithelium (falloposcopy) and contraception.[23,25] Collectively, these techniques offer the ability to define tubal pathology more precisely, facilitating proper directed therapy.[23]

Figure 2.


The Wallace ET Catheter that we Used for Hysteroscopic Fallopian Tube Recanalization.

Figure 3.


The Wallace ET Sheath in the Left Ostium.

Figure 4.


The Guidewire Seen Entering the Left Tubal Ostium.

Figure 5.


Laparoscopic View of the Guidewire Traversing the Blocked Left Ostium.

Figure 6.


Laparoscopic View of the Guidewire Exiting the Fimbrial End of the Tube.

Figure 7.


Laparoscopic View of the Free Spill of Dye Post-Fallopian Tube Recanalization.

Figure 8.


The Cook Fallopian Tube Recanalization Catheter in the Right Ostium.

Figure 9.


Tactile Fallopian Tube Recanalization with the Labotect Cannula in Progress.

Figure 10.


The Labotect Fallopian Tube Recanalization Cannula Snugly in Place in the Right Ostium.

Figure 11.


The Guidewire Seen Exiting the Bulbous Tip of the Labotect Fallopian Tube Recanalization Cannula.