Successful conception following Fallopian tube recanalization in infertile patients with a unilateral proximally occluded tube and a contralateral patent tube

Masatoshi Hayashi1, Kazunori Hoshimoto and Takeyoshi Ohkura

Department of Obstetrics and Gynaecology, Koshigaya Hospital, Dokkyo University School of Medicine, 2–1-50, Minami-Koshigaya, Koshigaya-shi, Saitama 343–8555, Japan 1 To whom correspondence should be addressed. e-mail: mhayashi{at}lilac.plala.or.jp


    Abstract
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 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
BACKGROUND: There are many published case reports of successful conception following transcervical Fallopian tube recanalization (T-FTR) in patients with bilateral proximally occluded Fallopian tubes. However, no serial trials have been published with respect to successful conception following unilateral tubal recanalization in infertile patients with a unilateral proximally occluded tube and a contralateral patent tube. This study was designated to analyse the success rate of T-FTR and the pregnancy rate due to natural fertilization in the lumen of the recanalized tube in these patients. METHODS: We have encountered only 11 patients with this abnormality in our department in the past 10 years. T-FTR with fluoroscopic guidance was performed in these patients, confirmed by at least two hysterosalpingographies to exclude tubal spasm. The uterine catheter devised by us was used during the procedure. RESULTS: All 11 Fallopian tubes were successfully opened by T-FTR. In the six patients who conceived, a preovulatory follicle was demonstrated on the side of the cannulated tube during the conception. The success rate of recanalization, the pregnancy rate due to fertilization in the lumen of the recanalized tube and the successful delivery rate were 100, 55 and 36% respectively. CONCLUSIONS: Our findings suggest that a functional and/or organic disorder in the patent tube resulted in infertility in patients with unilateral proximal tubal obstruction. Our results further show that recanalization of occluded tubes is an effective treatment. Thus, recognition of successful conception following T-FTR in these patients will be beneficial to our clinical approach to this infertile condition.

Key words: Fallopian tube recanalization/fluoroscopic guidance/infertility/unilateral proximal tubal obstruction/uterine catheter


    Introduction
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
Patients with a unilateral proximally occluded tube and a contralateral patent tube are usually fertile because natural fertilization can occur in the patent tube. However, a small number of patients with unilateral proximal tubal obstruction (PTO) have been seen at our hospital with more than 2 years history of infertility.

A previous study showed that among 17 patients with unilateral PTO and a contralateral patent tube, eight tubes could be recanalized, and one pregnancy occurred (Schill et al., 1999Go). However, there have not been any serial trials published with respect to successful conception after natural fertilization in the recanalized tube following Fallopian tube recanalization in infertile patients with a unilateral proximally occluded tube and a contralateral patent tube. Patients with this abnormality may have the possibility of conceiving by natural fertilization in the lumen of the recanalized tube after T-FTR because a pregnancy rate of 47% (9/19) has been reported after transcervical Fallopian tube recanalization (T-FTR) for bilateral PTO (Thurmond and Rösch, 1990Go). Thus, we analysed the success rate of recanalization, and the pregnancy rate due to natural fertilization, in the lumen of the recanalized tube in these patients.

T-FTR using fluoroscopic guidance has been used to treat tubal occlusions in patients with PTO (Raymond, 1988Go; Rösch et al., 1988Go; Thurmond and Rösch, 1990Go; Woolcott et al., 1995Go; Lang and Dunaway, 1996Go; Hayashi et al., 1998Go).


    Materials and methods
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
Subjects
Over the past 10 years in our department, 23 patients were diagnosed as having a unilateral proximally occluded tube after the first hysterosalpingogram (HSG) with perfusion pressure below 26.7 kPa. However, both tubes proved to be patent in 12 patients at the second HSG performed with perfusion pressure of up to 53.3 kPa.

We have encountered only 11 patients with a unilateral proximally occluded tube and a contralateral patent tube. We have treated 2840 infertile patients over the past 10 years. Eleven patients represent only 0.4% of these patients.

For strict selection of tubal sterility cases, we used the following inclusion criteria: (i) at least two HSGs confirming a unilateral proximally occluded tube and a contralateral patent tube in the absence of other pathology, (ii) at the second HSG, the perfusion pressure of up to 53.3 kPa was used to strictly diagnose tubal obstruction, (iii) clear evidence of spontaneous or induced ovulation, (iv) the husband’s semen analysis was normal, and (v) no history of pelvic inflammatory disease and/or endometriosis. The 11 patients were enrolled in this study by the above criteria. Informed consent was obtained from all subjects. The study was approved by our institutional review board. Among the 11 obstructed Fallopian tubes in the 11 patients, 10 were in the right tube and one was in the left tube.

Pelvic examination and blood hormone analyses were normal in these 11 patients.

Procedure for T-FTR
In the follicular phase of the patient’s menstrual cycle, T-FTR was performed 60 min after i.m. administration of 20 mg scopolamine butylbromide (Buscopan®; Tanabe Seiyaku, Osaka, Japan), a parasympathetic blocking agent that inhibits contraction of smooth muscle, to exclude tubal spasm. Alper et al. (1985Go) concluded that hyocine butylbromide (Buscopan) appeared to be a safe and effective drug to differentiate PTO due to mechanical causes from that caused by spasm.

We did not use scopolamine butylbromide (Buscopan) during preliminary HSGs because we wanted to confirm tubal patency under physiological conditions. In each case, there was no further attempt to show obstruction immediately before T-FTR except for the second (53.3 kPa) HSG.

All procedures were carried out under sterile conditions, on an outpatient basis, using a standard fluoroscopic unit with spot film capability. Initially, the tubal obstruction was reconfirmed by conventional HSG. The Iwasaki-Hayashi (IH) catheter (Hayashi et al., 1998Go) or the improved version, the modified-Hayashi (MH) catheter, was used. The T-FTR procedure has been described previously (Hayashi et al., 1998Go).

In the present study, higher therapeutic efficacy was obtained when the catheter was tightly fixed in the uterine cervix. The IH catheter or the MH catheter was fixed in the uterine cervix easily and tightly in all patients. The most difficult management issue during T-FTR was wedging the tip of the 5-F catheter in the target tubal ostium. The tip sometimes only extended to the opposite side of the uterus. In such cases, packing some pieces of gauze on the appropriate side of the vagina was beneficial. Although we judged whether the tip of the 5-F catheter was wedged in the target tubal ostium according to the findings of the X-ray monitor, it was only being wedged adjacent to the tubal ostium. Subsequently, we failed to insert the 3-F catheter with an internal 0.015-inch guide wire into the Fallopian tube; in which case, it was effective to move the 5-F catheter back and forth several times.

Since the patient’s ovaries are exposed to radiation during fluoroscopic T-FTR, measures were taken to minimize this radiation dose. In accordance with the recommended operative procedure, the exposed area was always kept to a minimum in order to avoid direct exposure of the ovary, as previously described (Hayashi et al., 1998Go).


    Results
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 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
Clinical outcomes
Of the 11 Fallopian tubes that underwent fluoroscopic T-FTR, all were successfully opened by the procedure. The success rate of recanalization was 100%. Images taken during T-FTR in patient 1 are shown in Figure 1.



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Figure 1. Images taken during T-FTR in patient 1. (A) Hysterosalpingography (HSG) showed right proximal tubal obstruction. (B) Catheterization of the right tube was successfully performed. (C) HSG shows that the right tube was successfully recanalized.

 
Six patients conceived, four delivered normal babies, and two had miscarriages at the third and fourth month of gestation respectively. In the six patients who conceived, a preovulatory follicle was demonstrated on the side of the cannulated tube during the conception cycle. The pregnancy rate due to fertilization in the lumen of the recanalized tube and the successful delivery rate were 55% (6/11) and 36% (4/11) respectively.

Patient profiles and clinical features of six patients who became pregnant are shown in Table I. Fallopian tubal patency before and after T-FTR and major diameters of follicles before pregnancy in these patients are shown in Table II.


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Table I. Patient profiles and clinical features of six women who became pregnant following T-FTR
 

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Table II. Fallopian tubal patency before and after T-FTR and major diameters of follicles before pregnancy in six women who became pregnant
 
All six patients had been examined by transvaginal ultrasonography shortly before ovulation, confirming which ovary had a leading follicle. Our study showed early pregnancy from ovulation on the cannulated side. Thus, fertilization appeared to have occurred in the Fallopian tube that had been recanalized by T-FTR. These results are also shown in Table II.

Complications
During T-FTR, slight-to-moderate pain was felt around the uterus, but it was tolerable in all cases. Complications such as perforation of the Fallopian tube and continuous bleeding were not observed.


    Discussion
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
A success rate of 95% in opening tubes and a pregnancy rate of 47% have been reported for T-FTR in patients with bilateral PTO (Thurmond and Rösch, 1990Go). Our findings are similar to their results. Six patients with unilateral PTO were able to conceive after natural fertilization in the lumen of the Fallopian tube which had been recanalized by T-FTR and four patients gave birth normally. The results were remarkable. The patent tube appeared to have a functional and/or organic disorder and the occluded tube appeared to have been functionally normal except for the occlusion in those patients with unilateral PTO.

Patients with a history of pelvic inflammatory disease (PID) and/or endometriosis may have adhesions around the Fallopian tubes, resulting in a failure of oocyte pick-up leading to persistent infertility. T-FTR is not a useful treatment for this abnormality although surgical ablation is beneficial. Thus, patients with this history were excluded from this study.

During the recruitment period, there were three other patients diagnosed as having a unilateral proximally occluded tube after the first HSG. In each case there was a known history of PID. We did not enrol these three patients in this study according to the inclusion criteria. Thus, none of the three were treated with T-FTR. The durations of infertility ranged from 3–5 years. None became pregnant. All three patients declined laparoscopy and none of the three consented to IVF–embryo transfer.

Currently, unilateral proximally occluded tubes are not necessarily treated in infertile patients with a unilateral proximally occluded tube and a contralateral patent tube. This is the first report with respect to the high pregnancy rate (55%) due to natural fertilization in the lumen of the recanalized tube following T-FTR in these patients.

In conclusion, recognition of successful conception due to an oocyte fertilized in the lumen of the recanalized tube following T-FTR in infertile patients with unilateral proximally occluded tubes will be beneficial to our clinical approach to this infertile condition.


    References
 Top
 Abstract
 Introduction
 Materials and methods
 Results
 Discussion
 References
 
Alper, M.M., Garner, P.R. and Spence, J.E. (1985) Hyoscine butylbromide to relieve utero-tubal obstruction at hysterosalpingography. Br. J. Radiol., 58, 915.

Hayashi, M., Iwasaki, N., Kuramae, S., Izawa, Y., Murata, M. and Yaoi, Y. (1998) Transcervical fallopian tube recanalization under fluoroscopic guidance. The Iwasaki-Hayashi catheter. Gynecol. Obstet. Invest., 45, 194–198.[CrossRef][ISI][Medline]

Lang, E.K. and Dunaway, H.H. (1996) Recanalization of obstructed fallopian tube by selective salpingography and transvaginal bougie dilatation: outcome and cost analysis. Fertil. Steril., 66, 210–215.[ISI][Medline]

Raymond, C.A. (1988) Balloon catheterization in infertility clinic. JAMA., 259, 16.[CrossRef][ISI][Medline]

Rösch, J., Thurmond, A.S., Uchida, B.T. and Sonak, M.. (1988) Selective transcervical fallopian tube catheterization: technique update. Radiology, 168, 1–5.[Abstract]

Schill, T., Bauer, O., Felberbaum, R., Kupker, W., Al-Hasani, S. and Diedrich, K.. (1999) Transcervical falloscopic dilatation of proximal tubal occlusion. Is there an indication? Hum. Reprod., 14 (Suppl. 1), 137–144.[ISI][Medline]

Thurmond, A.S. and Rösch, J. (1990) Nonsurgical fallopian tube recanalization for treatment of infertility. Radiology, 174, 371–374.[Abstract]

Woolcott, R., Petchpud, A., O’Donnell, P. and Stanger, J. (1995) Differential impact on pregnancy rate of selective salpingography, tubal catheterization and wire-guide recanalization in the treatment of proximal fallopian tube obstruction. Hum. Reprod., 10, 1423–1426.[Abstract]

Submitted on January 3, 2002; resubmitted on June 5, 2002. accepted on September 26, 2002



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