Fallopian Tube Recanalization Techniques

Endoscopic Techniques

Falloposcopic Diagnosis of Tubal Disease. Falloposcopy provides a unique possibility to visualize and grade endotubal disease and may provide a valuable instrument for in vivo exploration of tubal physiology.^[32–35] It has been successfully used to characterize normal and abnormal epithelial changes, document endotubal lesions ranging from accumulated debris, nonobstructive intraluminal adhesions, stenosis, polyps, to total fibrotic obstruction, as well as the identification of the segmental location of tubal pathology without complications.^[36] A useful falloposcopic classification and scoring system of tubal lumen lesions is utilized to grade tubal damage.^[11] Using this scoring system, Kerin et al. classified endotubal lumens as falloposcopically normal (46%), to contain mild-to-moderate disease in 29%, or severe-to-obstructive disease in 25% cases.^[35] They reported endotubal lesions in 57% examinations in 55 women without complications and observed that the majority (70%) of lesions were confined to the medial third of the tube, between the UTJ and ampullary isthmic junction.^[36] Using a microendoscopic transvaginal technique incorporating guidewire cannulation and direct balloon tuboplasty, Kerin et al. characterized endotubal lesions into intramural stenosis (five cases); isthmic stenosis (ten cases); isthmic obstruction (five cases); salpingitis isthmica nodosa (two cases); nonobstructive endotubal disease from intraluminal adhesions, associated devascularization and epithelial atrophy in the intramural, isthmic and ampullary segments (ten cases); hydrosalpinx (two cases); and intratubal polyp (one case) in 35 of 43 falloposcopies performed, with normal falloposcopic appearance of the fimbrial, ampullary, isthmic and intramural tubal epithelium being observed in 18.6% cases.^[37]

Falloposcopic Tubal Cannulation. Falloposcopic cannulation has been performed hysteroscopically under laparoscopic guidance by dilation ^[15] and coaxial catheters,^[38–41] and nonhysteroscopically with the LEC.^[34,42] The results of the various endoscopic Fallopian tube recanalization procedures are presented in Table 2 . Higher recanalization success rates have been reported with falloposcopic cannulation using the LEC compared with those achieved with coaxial cannulation. Kerin et al. reported technical difficulties related to the failure to negotiate the entire tubal lumen in the absence of obstructive disease, and minor difficulties due to ostial spasm secondary to attempted guidewire cannulation.^[36] Technical and minor difficulties were experienced in 11 and 8%, respectively, of the 84 endoscopy cases, during coaxial falloposcopy.^[36] They suggested that while technical difficulties with catheterization may be partly overcome by the incorporation of smaller directional guidewires, softer distortion-free Teflon catheters, improved microendoscopes and the acquisition of new surgical skills necessary for safe and successful endoscopy of the Fallopian tube, minor difficulties are generally overcome once spasm ceases.^[36]

Falloposcopy may be used therapeutically for dislodging intraluminal debris and breaking down filmy adhesions in normal or minimally diseased tubes,^[32,35] and may additionally aid in differentiating between patients suitable for tubal surgery and those who should be referred for IV.^[33,34] Techniques of tubal aquadissection, guidewire cannulation, guidewire dilatation and direct balloon tubuloplasty under hysteroscopic–falloposcopic–laparoscopic control have been devised for attempting to breakdown intraluminal adhesions or dilate a stenosis. Following falloposcopic-directed, selected tubal cannulation and aquadissection techniques, isthmic plugs occluding the entire isthmic lumen have been successfully mobilized in 4% of the cases studies and tubal patency restored in all the cases.^[11] Using one or more of these techniques, obstruction in 81.4% tubes containing a lesion could be opened up,^[36] while a combination of guidewire cannulation and direct balloon tubuloplasty procedures under hysteroscopic–falloposcopic–laparoscopic control could breakdown nonobstructive intraluminal adhesions in 60% of cases, dilate intramural or isthmic stenoses in 40% of cases and negotiate an isthmic stricture secondary to salpingitis isthmica nodosa in 50% of cases. The techniques were unsuccessful in bypassing fibrotic obstructions.^[37] Using aquadissection, flexible wire cannulation or direct balloon tuboplasty, Kerin et al. reported conception rates of 21% in women whom at least one tube was normal and 9% in women with mild-to-moderate disease within 1 year of the procedure; no conception was obtained in women with severe endotubal disease.^[35] They concluded that while falloposcopic tuboplasty may have a therapeutic role in normal or minimally diseased tubes, the presence of severe disease remains resistant to the use of current endotuboplasty treatments, as reflected by poor pregnancy outcome, and such women should be provided with the option of microsurgical tubal repair or IVF and embryo-transfer procedures.^[35]

Coaxial Falloposcopy. The coaxial falloposcopy system consists of a hysteroscope, stabilizing device to maintain uterotubal alignment, a flexible coaxial catheter and guidewire and a 0.4-mm outer diameter (OD) falloposcope with enhanced fiberoptics.^[43] Coaxial falloposcopy is a transvaginal endoscopic technique that utilizes a small flexible microendoscopic instrument, the falloposcope (OD: 0.5 mm), for effective visualization of the entire length of the human Fallopian tube from the uterotubal ostium to the fimbria. Using a transvaginal approach, upon visualization of the tubal ostium, tubal cannulation is performed via the working channel of a small flexible operating hysteroscope (OD: 3.3–4.5 mm; operating channel diameters: 1.5–1.8 mm). Fluid is constantly administered via the flexible cannula. A coaxial technique, incorporating guidewire cannulation and placement of an over-the-wire Teflon catheter may be used, following which, the guidewire is replaced with a falloposcope for video documentation of the endotubal surface anatomy.^[36] Common problems associated with the technique include white-out due to the intense light in close proximity of the tissues and kinking leading to catheter damage and impediment of successful falloposcope insertion. Lastly, if the endometrium is in the advanced proliferative phase, it may be difficult to visualize the ostia.^[44]

Falloposcopy with the Linear Everting Catheter. Although falloposcopy initially involved the hysteroscopic insertion of a falloposcope through a flexible cannula, a miniature tubular balloon system that is rolled out along the Fallopian tube lumen by the use of hydraulic pressure, without the aid of a hysteroscope, under sedation or with local anesthesia, and that concurrently carries the falloposcope forward (linear eversion system), has recently been employed.^[45] The LEC has been developed to safely guide a falloposcope into the entire length of Fallopian tube in order to observe the tubal lumen, and may also be used therapeutically for the recanalization of occluded tubes^[42] and for intratubal gamete transfer.^[46] Falloposcopic tuboplasty has been established as a highly useful, less invasive and novel treatment for tubal infertility that may be useful in selected patients with proximal, mid and distal tubal occlusion^[42] with a good predictive value for future fertility.^[47] Sueoka et al. successfully accessed 85.3% of tubes with an overall patency rate of 79.4% on follow-up HSG with the LEC.^[42] Using the LEC, Dechaud et al. reported a tubal catheterization rate of 94.5% and a spontaneous pregnancy rate of 27.6% in patients who had normal tubes as defined by falloposcopy, whereas this dropped to 11.5% for mild and 0% for severe endotubal lesions.^[47] Trans-uterine falloposcopy, using the linear eversion, is a well-tolerated technique that can be performed in an outpatient clinic with high rates of luminal cannulation and visualization. Scudamore et al. reported successful identification of tubal damage in 66.67% of the tubes identified.^[48] Atraumatic access to the tube and visualization of its lumen offer exciting opportunities for diagnosis and treatment of tubal conditions.^[48] Among the 15 cases with hydrosalpinx or fimbrial obstruction following falloposcopy with a LEC and laparoscopy, Lee considered 67% of the cases with flattened mucosa in the endosalpinx and endotubal adhesions suitable for IVF, while 27% of cases with normal mucosa were suitable for tuboplasty.^[35] Interstitial tubal obstruction was overcome with the LEC.^[34]

Falloposcopic gamete intra-Fallopian transfer, using the LEC under laparoscopic control, has been reported to be a safe and efficient procedure and a less invasive alternative than laparoscopic transfer with a 20% delivery rate.^[46]

Coaxial Versus Balloon Catheter Set. A pilot study by Shinmoto et al. reported successful selective catheterization of the uterine cornu through a balloon catheter wedged at the internal uterine os in 87.5% of 16 occlusive Fallopian tubes (11 cases), a recanalization success rate of 75.0% of the affected tubes and a subsequent pregnancy rate of 27.27% of the cases.^[49] They concluded that the technique is convenient, safe and effective and it will be accepted as the first choice in the diagnosis and treatment of Fallopian tube obstruction.^[49] However, Rösch et al. concluded that the new hysterograph with the coaxial catheter set is more suitable for recanalization of the obstructed Fallopian tubes than the previously used balloon catheter set.^[50] Using this instrumentation, they accomplished a recanalization success in 96% of 28 PTOs in 25 women and in 33% of six midisthmic obstructions unrelated to surgery, following selective transcervical Fallopian tube catheterization of the uterine cornua. However, repeat recanalization attempts were met with tubal perforations without apparent clinical effects in four tubes, one with proximal and three with midisthmic postsurgical obstructions.^[50]

Guidewire Cannulation. According to Gleicher et al., although guidewire cannulation of proximally obstructed tubes achieves tubal patency in a large percentage of cases, comparable to other catheter techniques, it yields much lower pregnancy rates.^[51] They suggested that guidewire cannulation alone does not represent adequate treatment for patients with proximally occluded Fallopian tubes. Guidewires, used with coaxial and balloon catheter systems, are not responsible for the pregnancy success reported for these procedures.^[51]

Free-hand Cannulation Technique. In a feasibility study on 66 patients with proximal and/or distal suspected tubal damage, Pennehouat et al. performed transcervical falloposcopy under laparoscopic control, catheterization being performed with either a transhysteroscopic or a free-hand tubal cannulation technique.^[41] They demonstrated that the transcervical free-hand cannulation technique with the tubal embryo transfer catheter was as effective as the transhysteroscopic approach and this technique is a simple and effective aternative to the transhysteroscopic approach.^[41]

Falloposcopy Versus Laparoscopy/Hysterosalpingography. Current diagnostic techniques, such as laparoscopy and HSG, can detect only a fraction of the causes of tubal infertility and in many cases, misdiagnosis results.^[33] Although interstitial Fallopian tube obstruction has been reported in 15% of HSG performed for infertility, conventional HSG or laparoscopy may not differentiate cornual spasm or other temporary causes from true obstruction.^[52] Falloposcopy offers the advantage of objectively classify the cause of PTO and demonstrating that isthmic plugs can cause reversible proximal PTO.^[11] Comparing falloposcopy employing a new coaxial system with traditional laparoscopic chromotubation and HSG in a prospective, multicenter clinical trial at five tertiary infertility centers, Surrey et al. concluded that falloposcopy with the new coaxial system allows improved visualization with less bulky and less traumatic instruments.^[39] The system provides valuable information regarding the Fallopian tube lumen that correlates poorly with that obtained with more traditional techniques. Management was changed in 52.4% of women as a result of falloposcopic findings.^[39]

Despite increasing evidence of its potential clinical value, falloposcopy has not yet found widespread use.^[40] Lundberg et al. were able to obtain endosalpinx images in 60.5% of the women; however, none of the images were of sufficient quality to describe the entire tubal mucosa in detail.^[32] They concluded that although falloposcopy represents a unique tool for visualization of endotubal disease and a valuable instrument for in vivo exploration of tubal physiology, certain technical problems limit the usefulness of this method in routine clinical practice, and these problems must be solved before falloposcopy can achieve a central position in the investigation and treatment of tubal disease.^[32] In a large prospective international multicener study, Rimbach et al. reported 6.1% failures during hysteroscopy (10.6% during the cannulation step and 16.4% during visualization) following falloposcopic coaxial tubal cannulation using hysteroscopic ostium access and retrograde visualization under laparoscopic control.^[40] Predominantly intracavitary pathology or thick endometrium were found to interfere with hysteroscopic ostium access, while technical insufficiencies, resulting in catheter damage or vision disturbing light reflections, were identified to be responsible for most cannulation and visualization failures. The number of patients who received a complete falloposcopic evaluation did not exceed 57%. The authors concluded that owing to the technically limited results, the method currently qualifies for selected indications rather than for routine clinical application.^[40] Hence, although falloposcopy provides information regarding the condition of the tubal mucosa that is unavailable by any other technique, adding precision to surgical techniques when they are deemed necessary while directing other patients to assisted reproductive technologies, it is still in its infancy and data from larger studies are needed.^[53]

Hysteroscopic Tubal Cannulation. Advances in hysteroscopy in the past decade, including the introduction of small-caliber endoscopes, microhysteroscopy, the flexible steerable hysteroscope and the use of video systems in monitoring hysteroscopic evaluations, have extended the application of hysteroscopy to tubal cannulation both for treating cornual obstruction and in conjunction with new reproductive technologies.^[54] While cannulation with coaxial catheters began under fluoroscopy, the use of the hysteroscope simplifies the technique. Hysteroscopic tubal catheterization in patients with PTO can be used both as a diagnostic and considerably effective therapeutic method.^[7] Initial attempts with hysteroscopic proximal tube catheterization and balloon dilatation for recanalization proved intraoperatively successful in more than 80% of the cases.^[55] With laparoscopy, the hysteroscopic approach enables tubal cannulation and evaluation of the entire pelvis. Treatment of additional problems affecting the Fallopian tubes, particularly adhesions and endometriosis, is possible. While laparoscopy helps monitor the procedure and visual assessment of tubal patency, the ability to observe the UTJs directly by hysteroscopy provides an excellent approach for tubal cannulation^[5] (Figures 4–7).

The results of the various hysteroscopic cannulation techniques employed to diagnose and treat PTO are presented in Table 2 . Laparo–hysteroscopic tubal cannulation with or without guidewire cannulation has yielded an average recanalization success rate of 76%% with an average intrauterine pregnancy rate as high as 39%.^[1,7,56,57] Using combined laparoscopy and hysteroscopic tubal cannulation, Deaton et al. concluded that 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.^[1] However, conception in their study was achieved after tubal cannulation and adjunctive distal tubal surgery confounding the results.^[1] Zhu et al. performed laparo–hysteroscopic cannulation of the proximal oviduct with a flexible guidewire to evaluate and treat intramural Fallopian tube obstruction, and also concluded that this procedure is an effective method for the evaluation and treatment of cornual obstruction.^[56]

Lin et al. described a soft and rigid operating fiberoptic hysteroscope (OD: 4.8 mm) that can be used clinically for transcervical tubocornual recanalization for the management of cornual occlusion.^[58] The functional part of the telescope consists of three sections: a soft, flexible front section; a rigid rotating middle section; and a semi-rigid, self-retaining rear section offering advantages of an easy, close and direct approach to the intrauterine target, usually with no cervical dilation or anesthesia, with the operator in a comfortable position and without reported complications. This new hysteroscope has proved to be a very useful tool for the treatment of intrauterine lesions in the theater or an office setting.^[58] Clinical results in 1503 women who underwent panoramic, televised fiberoptic hysteroscopy without cervical dilation suggest that the soft and rigid structure of the Fujinon diagnostic fiberoptic hysteroscope offers advantages over rigid scopes or conventional fiberscopes with full-length soft, malleable parts.^[59]

Hysteroscopic hydrotubation with a hydrotubation solution consisting of hydrocortisone (20 mg), gentamicin (160,000 IU) and procaine (80 mg) in 20 ml distilled water may be an alternative treatment for tubal blockage ^[60]. Although the addition of hydrotubation to hysteroscopic tubal catheterization resulted in low recanalization rates compared with laparo-hysteroscopic tubal cannulation ( Table 2 ),^[60,61] studies have reported effective recanalization of partially obstructed tubes, intramural tubal obstruction and distal tubal obstruction with an intrauterine pregnancy rate of 34.29% over a12-month follow-up after treatment.^[61] Laparo–hysteroscopic selective tubal catheterization with insufflation of oil-soluble radiopaque dye has been reported to be an effective treatment for infertility associated with endometriosis with higher conception rates compared with women without endometriosis (60 vs 36.5%).^[62] Combined hysteroscopic tubal cannulation with selective salpingography under fluoroscopic guidance has been reported as a safe and simple diagnostic method that has also been used to identify and successfully treat interstitial Fallopian tube obstruction.^[52,63] However, compared with the other hysteroscopic cannulation techniques, the addition of selective salpingography under fluoroscopic guidance to hysteroscopic tubal cannulation appears to have yielded the lowest patency and pregnancy rates ( Table 2 ). A systematic review of observational studies^[64] showed that hysteroscopic tubal cannulation was associated with a higher pregnancy rate (49%) than salpingography and tubal catherization (21%) in women with PTO.^[65]

Similar intrauterine and cumulative pregnancy rates and obstetric outcomes have been reported with both hysteroscopic cannulation as well as tubal microsurgery in patients with PTO.^[66,67] However, in lieu of the lower ectopic pregnancy rates in the cannulation group (none of 21 [0%] vs seven of 24 [29.1%]), hysteroscopic cannulation has been recommended as the first choice in the management of PTOs in selected patients. It may be a treatment option for delayed occlusion after successful cannulation or resection anastomosis.^[67] Hysteroscopic gamete intra-Fallopian transfer has been reported as an alternative, safe, effective and noninvasive technique for fertility problems with a satisfactory pregnancy rate^[68] and may be carried out in some cases where general anesthesia was not advisable or possible (i.e., difficulties in tubal catheterization due to pelvic adhesions, extended distal tubal damage, patients’ intolerance or lack of available operating theatre^[69]).

Fluoroscopic Fallopian Tube Recanalization

Selective Salpingography & Transcervical FTR. Selective salpingography and transcervical FTR is a fluoroscopically guided procedure that employs catheterization of the tubal ostium and visualization of the transcervical instillation of contrast media under fluoroscopic imaging. In the event of a PTO, this may be followed by tubal catheterization and guidewire cannulation, passing a soft 2 or 3 French catheter, loaded over a 0.015-inch guidewire, through the obstruction via the cornual catheter to clear the obstruction.^[47] The use of a 4F glide catheter with a 0.89 mm guidewire advanced transcervically streamlines the procedure. Fluoroscopic guidance may be used to negotiate the guidewire beyond the intramural portion of the tube and selective salpingography to document the outcome of the recanalization.^[70] A recanalization success rate ranging from 71 to 92% with an average pregnancy rate of 30% has been reported in the literature.^[71] Selective salpingography and tubal catheterization offer patient-friendly, less-invasive and cost-effective alternatives to tubal microsurgery and IVF in patients with tubal occlusion^[70,65] with high success rates and improved overall management of infertility caused by tubal obstruction.^[71] However, major disadvantages of the use of fluoroscopy include the difficulty in ruling out tubal spasm, inability to evaluate distal tubal disease and other pelvic abnormalities,^[16] and the risk of radiation exposure. Allergy to the contrast medium may be a contraindication to the use of the technique.^[6] Results with selective salpingography and tubal catheterization/guidewire cannulation suggest that while guidewire cannulation is the most effective method used to achieve tubal patency, the prognosis with regard to pregnancy is poor, and alternative therapy such as microsurgery or IVF should be considered early.^[72]

Fluoroscopically Guided Transcervical Balloon Tuboplasty. Fluoroscopically guided transcervical balloon tuboplasty, which utilizes a coaxial balloon catheter, has been reported as a safe, noninvasive, outpatient technique to treat PTO that may represent an alternative to IVF or microsurgical reanastomosis of Fallopian tubes.^[73,74] Balloon tuboplasty has reported to be more effective in restoring patency in cases with failed selective salpingography. However, the choice of balloon tuboplasty catheter system may affect success rates.^[75]

Sonographic FTR

Sonographically guided transcervical tubal catheterization and transcervical balloon tuboplasty may be successfully performed to diagnose and treat patients with PTO. It may be aided by fluoroscopy,^[76] color Doppler ultrasound-guided coaxial cannulation and transcervical wire tuboplasty,^[77] hysteroscopic/laparoscopic insertion of small intraluminal ultrasound transducers into catheters of diameters of 3.5 F and 5 F during transcervical Fallopian tube catheterization,^[78] and transvaginal sonography-guided trans-uterine cannulation of the tubes with the Jansen–Anderson catheter and injection of sterile fluid.^[79] However, the requirement of fluoroscopy in sonographically guided transcervical tubal catheterization and transcervical balloon tuboplasty for identification of the catheter tip and successful cannulation of the internal tubal ostia, entailing a risk of radiation exposure^[76] and the inability to differentiate between tubal epithelium and muscularis with the intraluminal ultrasound transducers despite successful catheterization,^[78] limit the application of these techniques. On the other hand, Lisse and Sydow reported high recanalization success rates (91.2%), patency rates (84.2%) and intrauterine pregnancy rates (31.6%) at a 6-month follow-up interval following laparoscopically controlled sonographic transvaginal catheterization in patients with bilateral PTO.^[80] They suggested that the technique may be used early in the diagnostic schedule of the infertile patient and call into question the application of microsurgical treatment of a selected group of patients.^[80] Transcervical wire tuboplasty with a coaxial catheter and guidewire cannulation under color Doppler mapping ultrasound guidance has been reported to be an effective technique with high 1-year patency (96%) and pregnancy rates (38%), while avoiding the risk of radiation and allergic reaction.^[77] Trans-uterine cannulation of the tubes with the Jansen–Anderson catheter and injection of sterile fluid under transvaginal sonography has been reported to be an easy and safe method to evaluate the tubal status, prove tubal patency in the early diagnostic stage and thus prevent loss of time and futile treatment cycles.^[79]