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Genitourinary Imaging |
1 Department of Radiology, Legacy Meridian Park Hospital, 19300 SW 65th Ave, Tualatin, OR 97062 (A.S.T.)
2 Department of Obstetrics and Gynecology, Oregon Health Sciences University, Portland, Ore (A.S.T., M.J.G.)
3 Department of Diagnostic Radiology, Mayo Clinic, Rochester, Minn (K.R.B.).
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Abstract |
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 TOP Abstract IntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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MATERIALS AND METHODS: Twenty-four women with tubal obstruction after ligation reversal surgery underwent selective salpingography and tubal recanalization.
RESULTS: Patency was established in 26 (68%) of 38 anastomotic tubes without complication. In the 13 patients who were followed up and who could conceive only via a recanalized anastomotic tube, there were six (46%) pregnancies: two (15%) successful uterine pregnancies, two (15%) early spontaneous abortions, and two (15%) tubal pregnancies. The mean time from procedure to conception was 2 months.
CONCLUSION: Patency of fallopian tubes not visualized at hysterosalpingography after ligation reversal surgery can be established 68% of the time with selective salpingography. In some patients, selective salpingography can be therapeutic. If subsequent conception occurs in these patients, it occurs shortly after the catheterization procedure.
Index terms: Fallopian tubes, interventional procedure, 853.1267 • Fallopian tubes, stenosis or obstruction, 853.459 • Sterility • Uterus, radiography, 853.1282
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Introduction |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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MATERIALS AND METHODS |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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Twenty-four of the women (mean age, 35 years; age range, 26–45 years) with tubal obstruction had a history of tubal ligation reversal surgery 2–48 months before the catheterization procedure (mean, 22 months). Women with a history of fimbriectomy reversal were excluded because this involves distal tubal reconstruction and not tubal resection and reanastomosis. Details regarding the original surgical ligation procedure were available in 18 women: Nine had cauterized tubes, six had Pomeroy ligations, and three had Falope rings. Eighteen women had been delivered of at least one child before tubal ligation; however, five had never had a term pregnancy before tubal ligation, and in one, pregnancy history was unknown. At the time of referral for catheterization, one couple was being treated for a low sperm count, and one patient had a history of endometriosis and pelvic pain; otherwise, there were no known additional infertility factors.
In the 24 women, 38 tubes were obstructed, seven tubes were patent, and three tubes had been removed. The patients underwent transcervical fluoroscopically guided catheter recanalization as previously described (Fig 1) (3). Briefly, a vacuum cup hysterosalpingographic device (Thurmond-Rösch Hysterocath; Cook, Bloomington, Ind) is used to gain access to the uterus. This provides a sterile conduit through which a series of coaxial catheters and guide wires can be introduced and allows traction on the uterus without the application of a tenaculum. Conventional hysterosalpingography is performed with approximately 10 mL of a diluted water-soluble contrast agent initially to localize the uterine cornua without obscuring the catheters. A coaxial catheter system consisting of a 9-F Teflon sheath and a 5.5-F polyethylene catheter is advanced over a 0.035-inch-diameter (0.089-cm) J-tipped guide wire to the uterine cornu. This coaxial system of three devices is advantageous in that it allows the flexibility to catheterize the ostia in flexed or distorted uteri. The guide wire is removed and undiluted contrast agent is injected to perform selective salpingography.
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When the guide wire passes the obstruction, the guide wire is removed and the contrast agent is injected through the 3-F catheter. Once the recanalization is completed, the 3-F catheter is removed, and the contrast agent is injected through the 5.5-F catheter still wedged in the tubal ostium to better delineate the tube and depict the site of recanalization. Hysterosalpingography after recanalization can then be performed if desired. Other than 100 mg of doxycycline (Doryx; Warner Chilcott, Rockaway, NJ) taken by mouth twice a day for 5 days for antibiotic prophylaxis, no routine medications, including sedation or pain medication, are given. The patient can usually be dismissed within 30 minutes after the procedure.
In the 24 patients, the hysterosalpingogram obtained before the procedure and the selective salpingogram obtained after recanalization were scrutinized, and the location of the obstruction on the hysterosalpingogram obtained before the procedure was categorized as follows: diffuse tubal underfilling without demonstration of patency in seven tubes (Fig 2), proximal obstruction within the first 2 cm of the tube in 12 tubes (Fig 1), and middle obstruction 2-4 cm from the uterine cavity in 19 tubes. After the procedure, the patients returned to their referring physicians for follow-up care and were contacted by telephone yearly to obtain information about pregnancy or other procedures.
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RESULTS |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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The success rates for establishing complete tubal patency were 100% (seven of seven) for underfilled tubes, 75% (nine of 12) for proximally obstructed tubes, and 53% (10 of 19) for tubes obstructed in the middle portion (Table 1). Nineteen (79%) of 24 patients had visualization of tubes not visualized at the time of hysterosalpingography. Subsequent pregnancies were related to the patients' tubal status after recanalization, as determined with selective salpingography (Table 2).
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Group B.—Five patients had a preexisting patent anastomotic tube and underwent successful recanalization of the contralateral anastomotic obstructed tube, therefore progressing from one patent tube to two patent tubes at the conclusion of the procedure. In this group, two patients were lost to follow-up, and there were two (67%) uterine pregnancies (one term delivery, one early miscarriage) and no tubal pregnancies in the three patients who were followed up (mean follow-up, 10 months; range, 7–16 months). The mean time from the procedure to conception was 7 months (range, 7–8 months).
Group C.—Two patients had a preexistent patent anastomotic tube and underwent unsuccessful recanalization of the contralateral anastomotic obstructed tube. They therefore had one patent tube at both the start and the conclusion of the procedure. In this group, one patient conceived 23 months after the procedure and had an early miscarriage, and the other adopted after 32 months without conceiving.
Group D.—In three patients, catheterization was not successful in opening a single remaining proximally blocked tube or either of two proximally blocked tubes; therefore, they had no patent tubes at both the start and the conclusion of the procedure. No pregnancies occurred among these patients (mean follow-up, 21 months; range, 7–49 months).
Three patients who did not conceive underwent follow-up hysterosalpingography 3–14 months (mean, 8 months) after the procedure. Four (80%) of five recanalized anastomotic tubes remained opened.
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DISCUSSION |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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Results in a smaller number of patients at a different institution were less successful (4,5). Fallopian tube recanalization in patients with obstructed tubes after ligation reversal was successful in only six (33%) of 18 patients. Failure was universal in tubes that demonstrated tubal-peritoneal fistulas on the preprocedural hysterosalpingograms.
The timing of the fallopian tube catheterization procedure in the 24 women in the current study was determined by the gynecologic surgeon primarily on the basis of his or her index of suspicion of a tubal problem. The timing did not appear to affect either the technical or pregnancy success rates.
Successful recanalization of an anastomotic tube unfortunately does not guarantee a successful reproductive outcome. This is in part because of our inability to know all the causes of infertility in some couples. Tubes that are underfilled at the time of hysterosalpingography may be patent or may be partially obstructed. Patients with one preexisting patent tube may be limited more by an unknown fertility factor than by the contralateral obstructed tube. This latter observation may explain why these women (groups B and C) took longer to conceive than the group A women, whose fertility was more clearly related to their blocked tubes.
Tubal underfilling or occlusion at hysterosalpingography after ligation reversal may imply an anatomically abnormal or dysfunctional tube and a predisposition to tubal pregnancy or reocclusion. The reocclusion rate was only 20% (one of five tubes); however, the tubal pregnancy rate was 15% among the 13 patients who could conceive only via a recanalized anastomotic tube (group A). Among this same group, however, there were two (15%) successful uterine pregnancies, including one in a 41-year-old woman (Fig 1), which indicates that opening these obstructed anastomotic tubes does allow some normal conceptions to occur. However, the number is still lower than the reported successful pregnancy rates of 23%–28% at 6 months and 60%–90% at 36 months after uncomplicated ligation reversal surgery (6).
In the group that could conceive only via a recanalized anastomotic tube (group A), there were six pregnancies, and they all occurred within 5 months of the catheterization procedure, with a mean time from procedure to conception of 2 months. The experience of Lang and Dunaway (4) was similar. In their two patients who underwent successful recanalization after ligation reversal, one conceived 4 months after the procedure and the other had not conceived by 40 months, despite continued tubal patency at hysterosalpingography.
These observations have implications for patient treatment. In general, after successful tubal ligation reversal with continued tubal patency, patients may be followed up for 2 years or longer without other intervention because the number of pregnancies increases over time (6). The information from the small number of patients in our study with anastomotic tubes that require recanalization indicates that the prevalence of pregnancies does not increase over time. Rather, if conception is going to occur, it is likely to occur within the first 6 months after the catheterization procedure. Following up patients beyond 6 months without offering them alternative therapy such as adoption, in vitro fertilization, or in select cases repeat surgery may waste valuable time.
The underlying disease in anastomotic tubes that occlude after ligation reversal has not been clearly defined. Most of our patients had occlusion 2–4 cm from the uterine cavity in the expected location of the anastomosis. These were also the most difficult tubes to open; only 10 (53%) of 19 were successfully recanalized. The underlying disease in most of these women is presumably fibrotic scar tissue at the surgical site. The easiest tubes to open (seven of seven [100%]) were those affected by tubal underfilling, and presumably the underlying cause is partially obstructing material in the tubal lumen or perhaps patent tubes not adequately filled at hysterosalpingography. To our knowledge, why the latter occurs has never been fully explained. Proximally obstructed tubes were recanalized 75% of the time (nine of 12 tubes), and these were presumably affected by the amorphous debris known to lodge in the interstitial portion of the tubes (7).
The options are limited for women in whom ligation reversal surgery fails. The tubes are already shortened because of the resection of the ligated and damaged area before anastomosis. Repeat surgery to removed the occlusion shortens the tube even more and risks interfering with the normal tube and ovary relationship. In vitro fertilization bypasses the tubes altogether but is expensive, and to some couples it is emotionally and physically draining or not acceptable for religious reasons. Adoption is also expensive and not acceptable to some.
We recommend that patients with tubal obstruction after ligation reversal surgery undergo fluoroscopic tubal recanalization with selective salpingography because it establishes tubal patency in 79% (19 of 24) of women. If it is successful and the tube is patent without apparent distal disease, the patient can attempt pregnancy with some caution advised regarding the risk of tubal pregnancy. Any other concurrent fertility factors should be corrected, if possible. If pregnancy does not occur within 6 months, the patient should be counseled regarding her other options.
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Footnotes |
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Address reprint requests to A.S.T.
A.S.T. has a royalty agreement with Cook related to the Hysterocath device.
From the 1994 RSNA scientific assembly.
Author contributions: Guarantor of integrity of entire study, A.S.T.; study concepts and design, A.S.T.; definition of intellectual content, A.S.T.; literature research, M.J.G., K.R.B.; clinical studies, A.S.T.; data acquisition, K.R.B.; data analysis, M.J.G., K.R.B., A.S.T.; manuscript preparation, A.S.T.; manuscript editing and review, M.J.G., K.R.B., A.S.T.
Received June 2, 1997;
revision requested July 8, 1997; revision received July 21, 1998;
accepted September 28, 1998.
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References |
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TOPAbstractIntroductionMATERIALS AND METHODSRESULTSDISCUSSIONReferences |
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This article has been cited by other articles:
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  S. Papaioannou, M. Afnan, A. J. Girling, A. Coomarasamy, B. Ola, O. Olufowobi, J. M. McHugo, N. Hammadieh, and K. Sharif Long-term fertility prognosis following selective salpingography and tubal catheterization in women with proximal tubal blockage Hum. Reprod., September 1, 2002; 17(9): 2325 - 2330. [Abstract] [Full Text] [PDF]
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 A. S. Thurmond, L. S. Machan, A. J. Maubon, J.-P. Rouanet, D. M. Hovsepian, A. Van Moore, R. J. Zagoria, K. W. Dickey, and J. C. Bass A Review of Selective Salpingography and Fallopian Tube Catheterization RadioGraphics, November 1, 2000; 20(6): 1759 - 1768. [Abstract] [Full Text] [PDF]
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