Department of Obstetrics and Gynaecology, Koshigaya Hospital, Dokkyo University School of Medicine, 21-50, Minami-Koshigaya, Koshigaya-shi, Saitama 3438555, Japan 1 To whom correspondence should be addressed. e-mail: mhayashi{at}lilac.plala.or.jp
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Abstract |
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Key words: Fallopian tube recanalization/fluoroscopic guidance/infertility/unilateral proximal tubal obstruction/uterine catheter
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Introduction |
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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., 1999). 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, 1990
). 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, 1988; Rösch et al., 1988
; Thurmond and Rösch, 1990
; Woolcott et al., 1995
; Lang and Dunaway, 1996
; Hayashi et al., 1998
).
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Materials and methods |
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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 husbands 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 patients 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. (1985) 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., 1998) or the improved version, the modified-Hayashi (MH) catheter, was used. The T-FTR procedure has been described previously (Hayashi et al., 1998
).
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 patients 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., 1998).
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Results |
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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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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.
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Discussion |
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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 35 years. None became pregnant. All three patients declined laparoscopy and none of the three consented to IVFembryo 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.
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References |
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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, 194198.[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, 210215.[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, 15.[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), 137144.[ISI][Medline]
Thurmond, A.S. and Rösch, J. (1990) Nonsurgical fallopian tube recanalization for treatment of infertility. Radiology, 174, 371374.[Abstract]
Woolcott, R., Petchpud, A., ODonnell, 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, 14231426.[Abstract]
Submitted on January 3, 2002; resubmitted on June 5, 2002. accepted on September 26, 2002