• INTERVENTION IN FALLOPIAN TUBAL BLOCKAGE

DR CHIRANJIB MURMU,MD RADIOLOGY

Infertility: inability to conceive > 1 year of regular sexual intercourse without contraception or inability to carry pregnancy to live birth.

Incidence – 15% of couples of child-bearing age.

Primary infertility- no previous conceptions. Secondary infertility- previous birth but unable to

conceive now.

ANATOMY

ANATOMY

ANATOMY

• Tubal block accounts more than 20% of all causes of INFERTILITY.

Fallopian Tube Obstructions

“Hysterosalpingography” - X-ray Imaging

Radiologic exam of fallopian tubes using radiopaque dye. Catheter placed in cervix. Dye passes through filling uterus &

fallopian tubes. Structures/adhesions in uterus/tubes & tube patency assessed Dye “blows out” tubes – clears obstruction; infertility resolved.

TECHNIQUE• Outpatient basis

• Follicular phase of menstrual cycle (6th-10th day)

• Five day course of Antibiotic prophylaxis by Doxycyclin 200mg/day

• Fluoroscopic /US/Hysteroscopic guidance

• Spasmolytic agent (Natispray)

• Hysterosalpingography device

Fallopotorque (Cook,Schemoul –Zorn,Angiotech) selective salpingography(SS)- tubal catheterism (TC) catheter system

Fallopian Recanalization Set Angiotech

HSG PTB Selective salpingography (SS) 5F and 3F SS catheter placed into tubal ostium + Contrast injection

obstruction overcome persisting obstruction =

Tubal contour outlined tubal recanalization (TR) with contrast agent gentle push of a guidewire advanced through the 3F catheter in the

isthmic portion

Success Failure

Success criteria• Short –term success = tubal patency patency of intramural and isthmic fallopian tube +/- visualization

of distal tubal anatomy and spillage of contrast medium in peritoneal cavity

• Mid-term success = spontaneous conception rate after 1 to 6 months’ follow up

• 1990 in USA: 170 patients : 269 fallopian tube with PTB

1/ SHORT TERM SUCCESS RATE Selective success 49.4% (133 tubes) salpingography 269 T failure 50.6% (136 t )

Tubal success 58.3% (91t)recanalization 156 T failure 41.7% (65t)

SUCCES OF SS-TR 83.3%

Various findings after SS-TR

Peritubal adhesions n = 39 Hydrosalpinx n = 12 Distal occlusion n = 19 Endometriosis n = 10 Phimosis n = 10Salpingitis isthmica nodosa n = 3Tubal synechiae n = 4

Failure of SS-TR in 65 cases due to

Peritubal adhesions n = 2 hydrosalpinx n = 10 Tubal synechiae n = 4 Endometriosis n = 3 Infectious sequela n = 2 Impassable obstruction n = 44 intramural n = 13 isthmic n = 10 distal n = 21

Complications• Vascular opacification 6.4 % • Fallopian tube perforation 3.5% (with no clinical

manifestation )• Infection /Uterin perforation :

2/ MID-TERM FOLLOW-UP 6 months or more follow up

• Intra uterine pregnancies : 39.7% • Ectopic pregnancies :

Case 1Mrs M… 37 Y Primary infertility of 6 yearsHSG : bilateral tubal blockage

a b c

d e

a : bilateral PTBb:left tubal recanalization by guide wire c:repeat selective intratubal salpingogram showing a patent tube d-e : the right fallopian tube could not be negociated at the intramural portion

Case 2Mrs L…. 34 YPrimary infertility of 4 yearsHSG: PTB of the right tube

a: HSG showing right PTB in the intramural portion. Left salpingogram showing peritubal adhesions with a patent but vertically oriented tubeb-c : right tubal recanalization with a 0.035  than a 0.032 inch guidewire.d : repeat hysterosalpingogram showing successful procedure with a patent right fallopian tube and spillage of contrast medium in the peritoneal cavity

a c

d

b

Case 3Mrs M… 46 YSecondary infertility of 8 yearsMesdical history : 2 therapeutic abortions

a : Initial hysterosalpingography showing a right proximal tubal blockage in the intramural portion and a distal occlusion of the left fallopian tubeb-c : intratubal right salpingogram obtained after succesful guide wire recanalization shows the catheter tip marked by a radiopaque beadd : repeat hysterosalpingogram showing a patent right tube with a very weak spillage of contrast medium.

a

d

b

c

CASE

DISCUSSION• Tubal factor account for up to 25-40% of female infertility• Proximal tubal obstruction ( PTO) is the underlying cause

in 10-25% of these cases Main causes of PTO 1. Pelvic infection : > 50% PTO - STD or after miscarriage, termination of pregnancy, puerperal sepsis or intrauterine contraceptive device - Tubal damage depend on severity and number of episodes - Chlamydia trachomatis : > 50% of infectious pelvic diseases

STD: sexually transmittes disease

2. Tubal spasm 20-40% of PTO - Revesible spasm of intramural portion - can not be distinguished from tubal occlusion at radiography - spontaneous regression or after administration of spasmolytic agent such as Trinitrine, Glucagon to relax the uterine muscle

3. Tubal plug 40% of PTO - amorphous materials occluding the tubal lumen

4. Salpingitis isthmica nodosum (SIN) 40-50% - usually bilateral - HSG shows a small outpouchings or diverticula from the isthmic portion of the fallopian tube

5. Pelvic inflammatory disease (PID) - most common cause of tubal occlusion - Scarring in the peritoneal cavity surrounding the fallopian tube leading to peritubal adhesions - radiography shows a loculated spill, a vertical tube, a pertubal halo or an ampullary dilatation

6. Anothers causes - Endometriosis - Tubal polyp - Tubal tumors

When not to do the SS- TR ? Absolute contre indications - Distal tubal occlusion - Confirmed genital infection - Confirmed intra uterine pregnancy

Relative contre indications - post operative tubal obstruction - metrorrhagia

Others techniques in the management of PTB Lparoscopy - failure of SS-TR - Distal occlusion - peritubal adhesions - Expansive and invasive - High risk of infectious or hemmoragic complications

Tubal micro surgery - PTB due to SIN impossible to recanlize by SS-TR - Tubal endometriosis or peritubal fibrosis - Expansive and difficult

In vitro fertilization - the most expansive treatment - Failure of SS-TR and of laparoscopic procedures

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