Etiology of Proximal Tubal Obstruction.
Fallopian Tube Recanalization Techniques.
Summary of Results Following Various Endoscopic Fallopian Tube Recanalization Techniques.
This activity is intended for primary care clinicians, infertility specialists, gynecologists, and other specialists who care for women with fallopian tube obstruction.
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In patients with documented tubal disease, options for management would essentially include expectant management, tubal surgery or IVF. Advances in minimally invasive endoscopic cannulation techniques and the soaring acceptance and applications of IVF question the surgical management of patients presenting with tubal damage. Until the widespread use of IVF in the beginning of the 1980s, tubal surgery was the only available option for restoration of fertility in patients with PTO. Although tubal microsurgery and IVF may be complementary options in the management of patients with tubal obstruction following failed FTR, and although microsurgery to correct localized damage has the advantage of long-standing restoration of fertility, poor pregnancy rates with tubal microsurgery in patients with severe tubal damage and the lack of technical skill required to perform these procedures has resulted in a liberal referral to IVF. Selection of patients with tubal disease for future therapeutic management is based on tubal lesions, including the aspect of tubal mucosa and tubo-peritoneal environment,[4] and the severity of the tubal damage and the health of the mucosa is key in determining the outcome. Where the mucosa is unhealthy, surgery is not justified; early referral for IVF is indicated.[81]
Fallopian tube catheterization is diagnostically useful and technically highly successful for treating occluded tubes; however, patients with distally blocked tubes are not good candidates for this procedure[28,29] and distal tubal obstruction, caused by fibrosis and peritubal disease, is often not amenable to catheter recanalization techniques. While a functional obstruction may be amenable to conservative management, true occlusion may require management by microsurgical techniques or IVF.[14] Cases of failed fluoroscopically guided tubal canalization have been attributed to severe intrinsic tubal disease and tubal occlusion rather than to the technique.[14] Significantly higher pregnancy rates have been reported in patients without distal disease than those with bipolar tubal disease (49 vs 12%, life table-adjusted rate; p = 0.0002) independent of underlying etiology for tubal disease.[73] Dechaud et al. reported no pregnancies in patients with severe endotubal lesions despite a high tubal catheterization rate following falloposcopically guided cannulation.[47] Following nonhysteroscopic falloposcopy under laparoscopic control, Lee reported that while interstitial tubal obstruction was overcome with the LEC, among the 15 cases with hydrosalpinx or fimbrial obstruction, 67% of the cases with flattened mucosa in the endosalpinx and endotubal adhesions were suitable for IVF and 27% cases with normal mucosa were suitable for tuboplasty.[34] Letterie and Luetkehans reported no pregnancies following Fallopian tube canalization and microsurgery in patients with bipolar tubal occlusion after 12 and 18 months follow-up.[82] They suggested that in lieu of the lower patency rates and higher recurrence rates of PTO when compared with data of prior studies, IVF, although more costly, may ultimately represent the most expedient and effective method of management of coexistent proximal and distal tubal disease (bipolar disease).[82] Microsurgical repair of bipolar tubal damage yields poor pregnancy rates and the expertise required to perform these techniques is not always available. Because distally obstructed tubes cannot be successfully catheterized, the potential impact of FTR depends on the percentage of cases in which the occlusion is proximal. Tubal surgery or IVF treatment is not influenced adversely by prior transcervical tubal recanalization and remains an option for patients who failed to attain pregnancy.[83]