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.

Deaton JL, Gibson M, Riddick DH Jr: Diagnosis and treatment of cornual obstruction using a flexible tip guidewire. Fertil. Steril. 53, 232–236 (1990).
Allahbadia GN, Mangeshikar P, Pai Dhungat PB, Desai SK, Gudi AA, Arya A: Hysteroscopic Fallopian tube recanalization using a flexible guide cannula and hydrophilic guide wire. Gynaecol. Endosc. 9, 31–35 (2000).
Das S, Nardo LG, Seif MW: Proximal tubal disease: the place for tubal cannulation. Reprod. Biomed. Online 15, 383–388 (2007).
Watrelot A: Place of transvaginal fertiloscopy in the management of tubal factor disease. Reprod. Biomed. Online 15, 389–395 (2007).
Allahbadia GN, Naik P, Allahbadia SG: Should tactile-guided trans-uterine cannulation always be the first line treatment for all proximal tubal blocks or are there exceptions In: The Fallopian Tube. Allahbadia GN, Djahanbakhch O, Saridogan E (Eds). Anshan Publishers, UK 236–245 (2009).
Bhattacharya S, Logan S: Evidence-based management of tubal factor infertility. In: The Fallopian Tube. Allahbadia GN, Djahanbakhch O, Saridogan E (Eds). Anshan Publishers, UK 215–223 (2009).
Spiewankiewicz B, Stelmachów J: Hysteroscopic tubal catheterization in diagnosis and treatment of proximal oviductal obstruction. Clin. Exp. Obstet. Gynecol. 22, 23–27 (1995).
Punnonen R, Söderström KO, Alanen A: Isthmic tubal occlusion: etiology and histology. Acta Eur. Fertil. 15, 39–42 (1984).
Zhang D, Zeng Y, Chen X: Pathological findings of proximal tubal occlusive infertility [Article in Chinese]. Zhonghua Fu Chan Ke Za Zhi 30, 352–355 (1995).
Papaioannou S: A hypothesis for the pathophysiology and natural history of proximal tubal blockage. Hum. Reprod. 19, 481–485 (2004).
Kerin JF, Surrey ES, Williams DB, Daykhovsky L, Grundfest WS: Falloposcopic observations of endotubal isthmic plugs as a cause of reversible obstruction and their histological characterization. J. Laparoendosc. Surg. 1, 103–110 (1991).
•Reports on the therapeutic success of endoscopic tubal cannulation and their histological characterization.
Fortier KJ, Haney AF: The pathologic spectrum of uterotubal junction obstruction. Obstet. Gynecol. 65, 93–98 (1985).
•Reports on the pathologic spectrum of uterotubal junction obstruction.
Letterie GS, Sakas EL: Histology of proximal tubal obstruction in cases of unsuccessful tubal canalization. Fertil. Steril. 56, 831–835 (1991).
•Provides a classification of proximal tubal obstruction facilitating management.
Wiedemann R, Sterzik K, Gombisch V, Stuckensen J, Montag M: Beyond recanalizing proximal tube occlusion: the argument for further diagnosis and classification. Hum. Reprod. 11, 986–991 (1996).
Schill T, Bauer O, Felberbaum R, Küpker W, Al-Hasani S, Diedrich K: Transcervical falloscopic dilatation of proximal tubal occlusion. Is there an indication? Hum. Reprod. 14(Suppl. 1), 137–144 (1999).
Valle RF: Tubal cannulation. Obstet. Gynecol. Clin. North Am. 22(3),519–540 (1995).
•Discusses the advantages of tubal recanalization methods over traditional surgical methods.
Milad MP, Corfman RS: Falloposcopy. Curr. Opin. Obstet. Gynecol. 4, 406–411 (1992).
Smith WT: New method of treating sterility by removal of obstructions of the Fallopian tubes. Lancet I, 529–530 (1849).
Papaioannou S, Jafettas J, Afnan M: The use of selective salpingography and tubal catheterization in the management of infertility. In: The Fallopian Tube. Allahbadia GN, Djahanbakhch O, Saridogan E (Eds). Anshan Publishers, UK 180–190 (2009).
Kerin JF: New methods for transcervical cannulation of the Fallopian tube. Int. J. Gynaecol. Obstet. 51(Suppl. 1), S29–S39 (1995).
••Highlights the therapeutic advantages of endoscopic tubal recanalization methods.
Confino E, Friberg J, Gleicher N: Transcervical balloon tuboplasty. Fertil Steril 46, 963–966 (1986).
Finas D, Diedrich K: Tubal catheterization: when and how In: The Fallopian Tube. Allahbadia GN, Djahanbakhch O, Saridogan E (Eds). Anshan Publishers, UK 222–227 (2009).
••Highlights the advantages of tubal cannulation methods over invasive surgical alternatives and its limitations.
Flood JT, Grow DR: Transcervical tubal cannulation: a review. Obstet. Gynecol. Surv. 48, 768–776 (1993).
Wenzl R, Kiss H, Schurz B, Huber J, Husslein P: Tuboscopy – new developments for accurate tubal diagnosis [Article in German]. Geburtshilfe Frauenheilkd. 54, 47–50 (1994).
Kiss H, Wenzl R, Egarter C: Tuboscopy. Initial experiences with microendoscopic tubal diagnosis [Article in German]. Wien Klin. Wochenschr. 105, 719–722 (1993).
Risquez F, Confino E: Transcervical tubal cannulation, past, present, and future. Fertil. Steril. 60, 211–226 (1993).
Confino E, Radwanska E: Tubal factors in infertility. Curr. Opin. Obstet. Gynecol. 4(2), 197–202 (1992).
Hayashi M, Hoshimoto K, Ohkura T: Successful conception following Fallopian tube recanalization in infertile patients with a unilateral proximally occluded tube and a contralateral patent tube. Hum. Reprod. 18, 96–99 (2003).
Hayashi N, Kimoto T, Sakai T et al.: Fallopian tube disease: limited value of treatment with Fallopian tube catheterization. Radiology 190, 141–143 (1994).
Li QY, Zhou XL, Qin HP, Liu R: Analysis of 1006 cases with selective salpingography and Fallopian tube recanalization [Article in Chinese]. Zhonghua Fu Chan Ke Za Zhi 39, 80–82 (2004).
Lang EK, Dunaway HE Jr: Salpingographic demonstration of ‘cobblestone’ mucosa of the distal tubes is indicative of irreversible mucosal damage. Fertil. Steril. 76, 342–345 (2001).
Lundberg S, Rasmussen C, Berg AA, Lindblom B: Falloposcopy in conjunction with laparoscopy: possibilities and limitations. Hum. Reprod. 13, 1490–1492 (1998).
•Discusses the possibilities and limitations of falloposcopy.
Menashe Y, Rosen DJ, Surrey E, Kerin JF: Falloposcopy – a new method for evaluation and treatment of infertility due to tubal factors [Article in Hebrew]. Harefuah 124(1), 8–12, 64 (1993).
Lee KK: Diagnostic and therapeutic value of nonhysteroscopic transvaginal falloposcopy with a linear everting catheter. Zhonghua Yi Xue Za Zhi (Taipei) 61, 721–725 (1998).
Kerin JF, Williams DB, San Roman GA, Pearlstone AC, Grundfest WS, Surrey ES: Falloposcopic classification and treatment of Fallopian tube lumen disease. Fertil. Steril. 57, 731–41 (1992).
••Reports on the success of tubal cannulation methods, its limitations and indications for alternative therapy.
Kerin J, Surrey E, Daykhovsky L, Grundfest WS: Development and application of a falloposcope for transvaginal endoscopy of the Fallopian tube. J. Laparoendosc. Surg. 1, 47–56 (1990).
••Examines the coaxial falloposcopy procedure, the characterization of tubal disease with endoscopic tubal cannulation, the technical difficulties with the procedure and how these may be overcome.
Kerin J, Daykhovsky L, Grundfest W, Surrey E: Falloposcopy. A microendoscopic transvaginal technique for diagnosing and treating endotubal disease incorporating guide wire cannulation and direct balloon tuboplasty. J. Reprod. Med. 35, 606–612 (1990).
Rimbach S, Wallwiener D, Bastert G: Tubal catheterization and Fallopian tube endoscopy for expanded diagnosis in tubal sterility. [Article in German]. Zentralbl Gynakol. 118, 87–93 (1996).
Surrey ES, Adamson GD, Nagel TC et al.: Multicenter feasibility study of a new coaxial falloposcopy system. J. Am. Assoc. Gynecol. Laparosc. 4, 473–478 (1997).
Rimbach S, Bastert G, Wallwiener D: Technical results of falloposcopy for infertility diagnosis in a large multicentre study. Hum. Reprod. 16, 925–930 (2001).
•Reports the technical difficulties with falloposcopic coaxial tubal cannulation and reports the failure rate.
Pennehouat G, Risquez F, Naouri M et al.: Transcervical falloposcopy: preliminary experience. Hum. Reprod. 8, 445–449 (1993).
Sueoka K, Asada H, Tsuchiya S, Kobayashi N, Kuroshima M, Yoshimura Y: Falloposcopic tuboplasty for bilateral tubal occlusion. A novel infertility treatment as an alternative for in-vitro fertilization Hum. Reprod. 13, 71–74 (1998).
Surrey ES, Adamson GD, Surrey M et al.: Introduction of a new coaxial falloposcopy system. J. Am. Assoc. Gynecol. Laparosc. 3(4 Suppl.), S48 (1996).
Deichert U, Schlief R, van de Sandt M, Göbel R, Daume E: Deichert for the assessment of Fallopian tube patency [Article in German]. Geburtshilfe Frauenheilkd. 50, 717–721 (1990).
Aghssa MM, Ansari S, Khazali K: Investigation of tubal disease. In: The Fallopian Tube. Allahbadia GN, Djahanbakhch O, Saridogan E (Eds). Anshan Publishers, UK 203–212 (2009).
Porcu E, Dal Prato L, Seracchioli R, Petracchi S, Fabbri R, Flamigni C: Births after transcervical gamete intraFallopian transfer with a falloposcopic delivery system. Fertil. Steril. 67, 1175–1177 (1997).
Dechaud H, Daures JP, Hedon B: Prospective evaluation of falloposcopy. Hum. Reprod. 13, 1815–1818 (1998).
•Predictive value of falloposcopy in terms of pregnancy outcome.
Scudamore IW, Dunphy BC, Cooke ID: Outpatient falloposcopy: intra-luminal imaging of the Fallopian tube by trans-uterine fibre-optic endoscopy as an outpatient procedure. Br. J. Obstet. Gynaecol. 99, 829–835 (1992).
Shinmoto H, Ido K, Sumi K et al.: Fallopian tube recanalization with a catheter system – experience in the use of a balloon catheter [Article in Japanese]. Nippon Igaku Hoshasen Gakkai Zasshi 51, 143–148 (1991).
Rösch J, Thurmond AS, Uchida BT, Sovak M: Selective transcervical Fallopian tube catheterization: technique update. Radiology 168, 1–5 (1988).
Gleicher N, Redding L, Parrilli M, Karande V, Pratt D: Wire guide cannulation alone is no treatment of proximal tubal occlusion. Hum. Reprod. 9, 1109–1111 (1994).
Novy MJ, Thurmond AS, Patton P, Uchida BT, Rosch J: Diagnosis of cornual obstruction by transcervical Fallopian tube cannulation. Fertil. Steril. 50, 434–440 (1988).
Grow DR, Coddington CC, Flood JT: Proximal tubal occlusion by hysterosalpingogram: a role for falloposcopy. Fertil. Steril. 60, 170–174 (1993).
Valle RF: Hysteroscopy. Curr. Opin. Obstet. Gynecol. 3, 422–426 (1991).
Rimbach S, Wallwiener D, Rauchholz M, Bastert G: New aspects in therapy of proximal tubal occlusion: hysteroscopic proximal tubal catheterization [Article in German]. Zentralbl Gynakol. 116, 230–235 (1994).
Zhu GJ, Luo LL, Lin H: Diagnosis and treatment of cornual obstruction by transcervical Fallopian tube cannulation under hysteroscopy [Article in Chinese]. Zhonghua Yi Xue Za Zhi 74, 203–205 (1994).
Burke RK: Transcervical tubal catheterization utilizing flexible hysteroscopy is an effective method of treating cornual obstruction: a review of 120 cases. J. Am. Assoc. Gynecol. Laparosc. 1(4 Pt 2), S5 (1994).
Lin BL, Iwata Y, Liu KH, Valle RF: Clinical applications of a new Fujinon operating fiberoptic hysteroscope. J. Gynecol. Surg. 6, 81–87 (1990).
•Discusses the clinical applications of a new Fujinon operating fiberoptic hysteroscope.
Lin BL, Iwata Y, Liu KH, Valle RF: The Fujinon diagnostic fiber optic hysteroscope. experience with 1,503 patients. J. Reprod. Med. 35, 685–689 (1990).
•Discusses the clinical results using the Fujinon operating fiberoptic hysteroscope.
Lei ZW, Xiao L, Xie L, Li J, Chen QX: Hysteroscopic hydrotubation for treatment of tubal blockage. Int. J. Gynaecol. Obstet. 34, 61–64 (1991).
Li SC, Liu MN, Hu XZ, Lu ZL: Hysteroscopic tubal catheterization and hydrotubation for treatment of infertile women with tubal obstruction. Chin. Med. J. (Engl.)107, 790–793 (1994).
Sakumoto T, Shinkawa T, Izena H et al.: Treatment of infertility associated with endometriosis by selective tubal catheterization under hysteroscopy and laparoscopy. Am. J. Obstet. Gynecol. 169, 744–747 (1993).
Li SC: Selective salpingography and tubal cannulation through hysteroscopy [Article in Chinese]. Zhonghua Fu Chan Ke Za Zhi 28, 411–413 (1993).
Sowa M, Shimamoto T, Nakano R, Sato M, Yamada R: Diagnosis and treatment of proximal tubal obstruction by fluoroscopic transcervical Fallopian tube catheterization. Hum. Reprod. 8, 1711–1714 (1993).
Honoré GM, Holden AE, Schenken RS: Pathophysiology and management of proximal tubal blockage. Fertil. Steril. 71, 785–795 (1999).
Ransom MX, Garcia AJ: Surgical management of cornual-isthmic tubal obstruction. Fertil. Steril. 68, 887–891 (1997).
Das K, Nagel TC, Malo JW: Hysteroscopic cannulation for proximal tubal obstruction: a change for the better Fertil. Steril. 63, 1009–1015 (1995).
Possati G, Seracchioli R, Melega C, Pareschi A, Maccolini A, Flamigni C: Gamete intraFallopian transfer by hysteroscopy as an alternative treatment for infertility. Fertil. Steril. 56, 496–499 (1991).
Seracchioli R, Possati G, Bafaro G et al.: Hysteroscopic gamete intra-Fallopian transfer: a good alternative, in selected cases, to laparoscopic intra-Fallopian transfer. Hum. Reprod. 6, 1388–1390 (1991).
Schmitz-Rode T, Neulen J, Günther RW: Fluoroscopically guided Fallopian tube recanalization with a simplified set of instruments [Article in German]. Rofo 176, 1506–1509 (2004).
Thurmond AS, Machan LS, Maubon AJ et al.: A review of selective salpingography and Fallopian tube catheterization. Radiographics 20, 1759–1768 (2000).
Woolcott R, Petchpud A, O’Donnell P, Stanger J: Differential impact on pregnancy rate of selective salpingography, tubal catheterization and wire-guide recanalization in the treatment of proximal Fallopian tube obstruction. Hum. Reprod. 10(6), 1423–1426 (1995).
Gleicher N, Confino E, Corfman R et al.: The multicentre transcervical balloon tuboplasty study: conclusions and comparison to alternative technologies. Hum. Reprod. 8, 1264–1271 (1993).
Lasry JL, Guillet JL, Madelenat P, Marotel M: Proximal tubal obstruction. Treatment by recanalization and transcervical dilatation [Article in French]. Presse Med. 22, 622–625 (1993).
Osada H, Kiyoshi Fujii T, Tsunoda I, Tsubata K, Satoh K, Palter SF: Outpatient evaluation and treatment of tubal obstruction with selective salpingography and balloon tuboplasty. Fertil. Steril. 76, 427–428 (2001).
Confino E, Tur-Kaspa I, Gleicher N: Sonographic transcervical balloon tuboplasty. Hum. Reprod. 7, 1271–1273 (1992).
Stern JJ, Peters AJ, Bustillo M, Coulam CB: Colour Doppler ultrasound guidance for transcervical wire tuboplasty. Hum. Reprod. 8(10), 1715–1718 (1993).
Sohn C, Wallwiener D, Rimbach S, Bastert G: Initial results of intraluminal ultrasound in gynecologic diagnosis. J. Am. Assoc. Gynecol. Laparosc. 2, 323–326 (1995).
Wiedemann R, Rösch T, Stuckensen J, Hepp H: Trans-uterine Fallopian tube catheterization – a noninvasive, ambulatory evaluation of Fallopian tube patency [Article in German]. Geburtshilfe Frauenheilkd. 54, 39–46 (1994).
Lisse K, Sydow P: Fallopian tube catheterization and recanalization under ultrasonic observation: a simplified technique to evaluate tubal patency and open proximally obstructed tubes. Fertil. Steril. 56, 198–201 (1991).
Elstein M: Tubal disease and fertility outcome. Reprod. Biomed. Online 16, 167–169 (2008).
•Discusses the fertility outcome in tubal disease and valid therapeutic alternatives.
Letterie GS, Luetkehans T: Reproductive outcome after Fallopian tube canalization and microsurgery for bipolar tubal occlusion. J. Gynecol. Surg. 8, 11–13 (1992).
•Discusses the significance of assisted reproduction in severe tubal disease inamenable to tubal cannulation.
Lang EK, Dunaway HH: Recanalization of obstructed Fallopian tube by selective salpingography and transvaginal bougie dilatation: outcome and cost analysis. Fertil. Steril. 66, 210–215 (1996).

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Author(s)

Gautam N. Allahbadia, MD

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

Disclosures

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

Rubina Merchant, PhD

Rotunda -- Center for Human Reproduction, Mumbai, India

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

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Elisa Manzotti

Editorial Director, Future Science Group, London, United Kingdom

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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

Disclosures

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

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Disclosure: Sarah Fleischman has disclosed no relevant financial relationships.

Marilyn W. Edmunds, PhD, CRNP

CME Accreditation Specialist, Nurse Practitioner Alternatives

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

CME

Fallopian Tube Recanalization: Lessons Learnt and Future Challenges

Authors: Gautam N. Allahbadia, MD; Rubina Merchant, PhD
CME Released: 7/2/2010
THIS ACTIVITY HAS EXPIRED
Valid for credit through: 7/2/2011

Start Activity

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:

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

Disclosures

Author(s)

Gautam N. Allahbadia, MD

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

Disclosures

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

Rubina Merchant, PhD

Rotunda -- Center for Human Reproduction, Mumbai, India

Disclosures

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

Editor(s)

Elisa Manzotti

Editorial Director, Future Science Group, London, United Kingdom

Disclosures

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

Disclosures

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

Disclosures

Disclosure: Sarah Fleischman has disclosed no relevant financial relationships.

Marilyn W. Edmunds, PhD, CRNP

CME Accreditation Specialist, Nurse Practitioner Alternatives

Disclosures

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

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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]

Instrumentation

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]