Fig. 2.1
The Novy tubal cannulation catheter used in Jessop Hospital, Sheffield, England (Courtesy of Cook Medical, Bloomington, IN, USA)
Fig. 2.2
(a) The tubal cannulation catheter and (b) guide-wire used in The Affiliated Hospital of the Chinese People’s Armed Police Force Logistics College, Tianjin, China
The passage of the guide wire through the fallopian tube should be monitored and controlled by laparoscopy. From time to time, the segment of the tube ahead of guide wire needs to be straightened by an atraumatic instrument such as a palpeter or the tip of a pair of atraumatic grasping forceps to facilitate the cannulation process. Once the guide wire has come out of the fimbrial end of the tube, it may be withdrawn and methylene blue dye then introduced into the catheter to verify if the tube has become patent (recanalization). At the conclusion of the surgery, Hartman physiological solution should be used to irrigate the pelvic cavity to remove the methylene blue dye (Fig. 2.3). In some centers, catheters and guide wires with a “J” tip used in cardiac interventional procedures have been used instead but they are generally more expensive.
Fig. 2.3
Laparoscopy guided hysteroscopic tubal catheterization. (a) A catheter is being inserted into the interstitial segment of the tube; (b) Backflow of methylene dye was observed prior to successful cannulation; (c) A guide wire was inserted into the interstitial segment of the tube under hysteroscopic guidance; (d) Laparoscopic inspection confirmed that the cannulation was successful with the guide wire coming out of the fimbrial end of the tube (From Hou et al. [27], with permission)
Success Rate
Overall, LHTC has a successful tubal cannulation rate of 54.2 % per tube and 61.9 % per patient [27]. The crude pregnancy rate (PR) is around 43 % and live birth rate (LBR) is around 35 %. The cumulative conception rate is around 38 % at 1 year and 44 % at 2 years after LHTC. An important determinant of the pregnancy rate following tubal cannulation is whether only one or both tubes are blocked and in the case of bilateral blockage, whether only one or both tubes were successfully cannulated. It is often argued that women with unilateral tubal disease do not require treatment, as they will, given time, be able to conceive via the contralateral normal tube. Recent data showed convincingly that the PR following successful cannulation of a unilateral block tube is about twice higher than those whose cannulation failed, and similar to women with bilateral tubal obstruction who had only one tube successfully cannulated.
Other Methods of Tubal Cannulation
There are a number of other methods used to cannulate the fallopian tube, namely, selective salpingography (cannulation under fluoroscopy control), cannulation under ultrasound control, hysteroscopic cannulation alone without laparoscopic control and falloposcopy. The literature data on the various methods of tubal cannulation is summarised in Table 2.1. It showed that the two most popular methods used are tubal cannulation guided by fluoroscopy or laparoscopy. Fluoroscopy has a number of advantages; it is less costly and can be performed as an outpatient procedure. In experienced hands, it is possible to measure tubal pressure during selective salpingography, which appears to provide additional prognostic information [12]. On the other hand, fluoroscopy is associated with a risk of irradiation exposure.
Table 2.1
A comparison of the outcomes of tubal cannulation carried out by different methods
Method | Author | Year | No. | Successful cannulation per patient | Pregnancy rate | Live birth rate |
|---|---|---|---|---|---|---|
Selective salpingography | Sowa et al. [7] | 1993 | 58 | 70.7 % | 22.2 % | / |
Thompson et al. [8] | 1994 | 28 | 31.0 % | 30.7 % | / | |
Woolcott et al. [9] | 1995 | 66 | 80.5 % | 36.4 % | / | |
Ba et al. [10] | 1999 | 122 | 88.7 % | 40.2 % | 32.0 % | |
Atallah et al. [11] | 1999 | 53 | 97.5 % | 45.0 % | / | |
Papaioannou et al. [12] | 2002 | 218 | 50.1 % | 27.1 % | / | |
Hayashi et al. [13] | 2003 | 11 | 100.0 % | 55.0 %a | 36.0 % | |
Rawal et al. [14] | 2005 | 14 | 78.0 % | 28.6 % | / | |
Al-Jaroudi et al. [15] | 2005 | 72 | 34.7 % | 31.9 % | / | |
Verma et al. [16] | 2009 | 16 | 87.5 % | 35.0 % | / | |
Anil et al. [17] | 2011 | 100 | 86.8 % | 36.8 % | / | |
Cobellis et al. [18] | 2012 | 33 | 75.6 % | 48.5 % | / | |
Mean | 68.8 % | 34.0 % | 32.3 % | |||
Laparoscopic guided hysteroscopic cannulation | Sakumoto et al. [19] | 1993 | 88 | / | 43.0 % | / |
Allahbadia et al. [20] | 2000 | 17 | 88.2 % | 23.5 % | 23.5 % | |
Das et al. [21] | 2007 | 53 | 67.9 % | 33.3 % | / | |
Mekaru et al. [22] | 2011 | 61 | 37.1 % | 27.7 % | 14.8 % | |
Chung et al. [23] | 2012 | 70 | 71.4 % | 35.8 % | / | |
Hou et al. [27] | 2013 | 168 | 61.9 % | 43.0 % | 34.8 % | |
Mean | 62.8 % | 38.0 % | 23.4 % | |||
Hysteroscopic cannulation | Spiewankiewicz et al. [24] | 1995 | 15 | 73.3 % | 13.3 % | / |
Ultrasound guided selective salpingography | Rahimunnisa et al. [25] | 2009 | 25 | 84.0 % | 16.0 % | / |
Falloposcopy | Tanaka et al. [29] | 2011 | 345 | 81.6 % | 29.9 % | / |
Total | Mean | 69.8 % | 33.9 % | 27.4 % | ||
LHTC, on the other hand, is more costly, more invasive and involves a general anaesthetic. However, it has a number of advantages. Firstly, laparoscopy is considered the gold standard for assessment of tubal patency [28], it permits a thorough examination of the pelvis as well as the fallopian tubes, which provides information on the underlying pathology such as peritubal adhesions or endometriosis. More importantly, it provides additional information on the distal end of the fallopian tube, which cannot be ascertained with fluoroscopy. Hysteroscopy examination prior to cannulation also provides useful information about the uterine cavity, including the possibility of a small fibroid or polyps or adhesions obstructing the tubal ostia, all of which can be confirmed during hysteroscopy.
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