Proximal Tubal Disease

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 Once the guide wire has come out of the fimbrial end of the tube, it may be withdrawn and methylene blue dye then introduced into the catheter to verify if the tube has become patent (recanalization).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 %

^aOnly women with unilateral tubal block

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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