5.1 Background
In the workup of infertility, tubal disease comprises up to one-third of female factor etiologies [1]. In the current era of increasing in-vitro fertilization (IVF) success rates, the clinician must decide how best to manage tubal factor infertility – surgical repair or bypassing the fallopian tubes and proceeding directly to IVF.
Risk factors for compromised tubal function include pelvic inflammatory disease, endometriosis, ectopic pregnancy, and prior pelvic surgery. Subsequent deleterious outcomes of tubal disease include primary or secondary infertility and increased risk for ectopic pregnancy. The location and extent of tubal disease influence the treatment plan and, therefore, it is essential to make an accurate diagnosis for effective management.
5.1.1 Diagnosis
Hysterosalpingogram (HSG) is the first-line diagnostic test to assess tubal patency [2]. The hysteroscopic features of hydrosalpinges, such as size and the presence of mucosal folds, help to estimate the potential for performing a neosalpingostomy. A distally dilated tube with free spill is consistent with fimbrial phimosis, which may be managed by fimbrioplasty. The loculation of contrast after spilling from the tube is suspicious for peritubal adhesions.
The negative predictive value of HSG is relatively high [3]. However, a finding of proximal tubal occlusion is usually due to functional spasm of the utero-tubal ostium as over 60% of patients will be patent on a repeat HSG 1 month later [4]. Similarly, over half of the patients will have normal fill and spill of dye during chromopertubation at the time of laparoscopy [3]. While direct visualization during laparoscopy is the gold standard, it is not absolutely definitive, as spontaneous pregnancies have occurred after bilateral tubal occlusion was reported [5].
Other forms of diagnostic evaluation have been used to investigate risks for tubal occlusion including sonohysterosalpingography and transvaginal hydrolaparoscopy with chromotubation; however, these have not become widespread and positive and negative predictive values remain suboptimal [6–8]. Testing for chlamydia antibodies can provide additional information to help rule out likelihood of tubal disease. It, however, has a high incidence of false-positives and cannot provide information regarding actual tubal patency [9].
At the present time, HSG remains the least invasive, first-line diagnostic tool for investigating tubal patency in the infertile patient. It also provides a therapeutic effect, presumably from clearing mucus and/or debris from the proximal tubal lumen, as higher pregnancy rates have been reported in the first few months following the procedure [10].
5.1.2 Treatment Considerations
The primary question regarding the infertile patient with a tubal factor diagnosis is to proceed with attempting surgical correction versus immediate IVF. Treatment options depend on a number of factors including pathology and clinic site-specific factors. The patient’s age, desired number of children, treatment preference, and religious beliefs, as well as ovarian reserve and semen parameters should be considered. The potential for a good reproductive outcome following tubal repair based on the surgeon’s experience should be compared to the success rates of the IVF clinic, taking financial considerations into account.
Throughout the United States, IVF success rates are tracked through a uniform registry (SART.org) and in 2013 patients with tubal factor infertility had a live-birth rate of just over 32% for all age groups per cycle initiated [11]. Unfortunately, there is no comparable registry for tubal surgery outcomes. Surgical results are all gathered from retrospective studies, many of them older than 20 years. They are heterogeneous with variable follow-up intervals and report success as cumulative pregnancy rates. Thus, pregnancy rates are based on the percentage of patients conceiving within a given time interval as opposed to IVF pregnancy rates per cycle.
Because it is difficult to directly compare the ultimate outcome of pregnancy success rates, it is imperative to evaluate and discuss potential risks and benefits of each procedure with the patient. The benefits of IVF include high chances of pregnancy, particularly in the short term, and a less invasive procedure. However, it can be considerably more expensive as insurance coverage is less pervasive in this area and more than one cycle may be necessary to achieve the desired number of children. IVF also requires a more medically intensive experience with daily injections and frequent monitoring, and carries the risk of multiple gestations and ovarian hyperstimulation syndrome. Fetal risks associated with IVF have also been reported, including pre-term delivery, low birth weight, and congenital malformations [13–15].
Tubal surgery is generally a one-time, minimally invasive outpatient procedure. In experienced hands, it has minimal risks; however, there are always risks of surgical complications and postoperative discomfort and pain. Corrective tubal surgery allows for repeated attempts at conception and has the potential of multiple conceptions without medical intervention. However, there is an increased risk for ectopic pregnancy, and tubal reocclusion can occur. If pregnancy does not occur following surgery, IVF is recommended, which increases the risks and costs to achieve a pregnancy.
5.2 Proximal Tubal Obstruction
Up to a quarter of tubal disease is due to proximal tubal occlusion [1]. When proximal occlusion is diagnosed on HSG, or no fill is witnessed on chromopertubation at the time of laparoscopy, it can be attributed to transient spasm of the utero-tubal ostia, obstruction from mucus or debris, or a true tubal blockage. True proximal occlusion results most often from salpingitis isthmica nodosa (SIN), PID, or endometriosis and the resulting fibrosis. As noted earlier, a diagnosis of proximal occlusion is due to tubal spasm approximately two-thirds of the time, especially if unilateral. Bilateral proximal occlusion poses a greater concern for real anatomic obstruction.
5.2.1 Tubal Cannulization
Tubal cannulization may be performed under fluoroscopic guidance or hysteroscopically with laparoscopic confirmation. Both methods employ a coaxial catheter system with an outer guide catheter and a flexible inner catheter with a guide wire. While tubal patency rates of over 80% can be achieved with both, the subsequent ongoing pregnancy rates are significantly higher with hysteroscopic cannulation (48.9% vs 15.6%, respectively) [1]. This may be due to the added benefit of being able to simultaneously diagnose and treat other pelvic pathologies at time of laparoscopy or that direct visualization leads to gentler manipulation of the tube. The high patency rates with tubal cannulation are likely achieved by dislodging plugs of mucus and/or debris from the tubal lumen. Histologic evaluation of resected proximal tubal segments in cases where tubal cannulation was unsuccessful revealed true anatomic obliteration of the lumen in 93% of the cases [16].
5.2.1.1 Preoperative Considerations
If proximal tubal occlusion is diagnosed at initial HSG, it is often appropriate to proceed with laparoscopy to confirm the diagnosis and attempt surgical correction.
Before attempting surgical treatment of proximal obstruction, as with all tubal disease, patient-specific factors should be considered to ensure that tubal surgery would be the more appropriate route to achieve conception over IVF.
In addition, older patients with other infertility factors may also be better served bypassing tubal surgery for IVF. Unilateral or bilateral tubal obstruction should also play a role in the treatment decision, as the optimal treatment is currently unknown for unilateral obstruction, which may either be treated primarily as unexplained infertility or including tubal factor as the primary diagnosis.
5.2.1.2 Intraoperative Procedure
Hysteroscopic tubal cannulation is performed with a Novy cornual cannulation set (Cook Medical), which includes an outer catheter with a removable stylet and an inner catheter with a flexible guide wire (see Video 5.1). A surgical assistant performs laparoscopy concurrently.
Procedure
Once laparoscopic transcervical chromotubation with indigo carmine or methylene blue confirms proximal tubal occlusion, the operative hysteroscope is inserted using saline for uterine distention. We prefer to use the vaginoscopic technique without a speculum or tenaculum but they can be used if cervical dilation is needed.
The outer catheter with stylet is inserted through the operative channel of the hysteroscope. Then the stylet is removed and an end cap is used to seal the Luer hub. The inner catheter with guide wire is the placed through the side arm of the outer catheter (Figure 5.1).
Figure 5.1 The Novy tubal cannulation set consists of a rigid introducer (top), which is inserted into the straight channel of the outer catheter (middle) to facilitate placing the catheter through the operating channel of the hysteroscope. The introducer is removed and the channel capped with a stopper. The guide wire (not shown) is threaded through the inner catheter (bottom), which is then placed through the angled side channel of the outer catheter.
The outer catheter is advanced to the tubal ostium (Figure 5.2).
Figure 5.2 The outer catheter is directed to the tubal ostium.
The inner catheter and guide wire are gently advanced through the outer catheter while the laparoscopic surgeon straightens the isthmic segment of the tube. The catheter with guide wire can be seen to traverse the intramural tubal segment into the proximal isthmus (Figure 5.3).
Figure 5.3 The guide wire is cannulating the interstitial segment of the tube and the inner catheter is advanced in the tube over the guide wire.
The guide wire is removed and chromopertubation is performed by injecting dilute indigo carmine or methylene blue through the inner catheter to document complete tubal patency while observing laparoscopically (Figures 5.4 and 5.5).
Figure 5.4 The guide wire has been removed and the blue contrast is injected through the inner catheter.
Figure 5.5 Laparoscopy confirms tubal patency.
The guide wire may be replaced if the contralateral tube also needs to be cannulated. If the proximal occlusion does not yield to gentle pressure with the inner catheter and guide wire, the procedure should be aborted and true obstruction assumed. In these cases, IVF is discussed with the patient postoperatively.
Microsurgical resection and anastomosis may be considered for cannulation failure in patients where IVF is not an option. However, unlike reversal of tubal ligation, it involves pathologic tubes and cornual anastomosis, which is technically more difficult and carries a lower success rate.
Risks associated with tubal cannulization are rare and include
risks associated with hysteroscopy (bleeding, pain, fluid overload);
potential risk for tubal perforation, which is under 10% and is of no clinical significance [1];
risk of ectopic pregnancy in a previously blocked tube.
5.2.1.3 Postoperative Considerations
5.3 Distal Tubal Occlusion
Distal tubal disease is most often caused by a prior episode of PID. Other causes of peritonitis such as previous pelvic surgery, endometriosis, and ectopic pregnancy can also cause scarring and adhesions with subsequent tubal damage. A recent meta-analysis and systematic review evaluated 22 retrospective studies encompassing 2,810 patients who underwent salpingostomy in the treatment of hydrosalpinx and found a 27% natural clinical pregnancy rate [12]. However, the included studies were heterogeneous for the exclusion of other infertility factors, surgical technique, surgeon experience, length of follow-up, and especially the degree of tubal damage. Many of the studies did not use a classification system and no stratification was done by extent of disease by those who did. This is very important as only patients with a good prognosis for an intrauterine pregnancy should be considered for neosalpingostomy.
As expected, pregnancy rates are highest in those with mild disease, with rates reported anywhere from 58% to 77% and ectopic pregnancy rates from 2% to 8% [21,22]. Those with severe tubal disease have marginal rates of success (0–22%) and high rates of ectopic pregnancy (0–17%) [21]. Good prognosis features include no more than mild adnexal adhesions, tubal dilation <3 cm, thin pliable tubal walls, and normal-appearing endosalpinx upon opening the tube [18]. If these criteria are not met, the patient would be better served with a salpingectomy.
5.3.1 Neosalpingostomy and Fimbrioplasty
5.3.1.1 Preoperative Considerations
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