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Abstract
Tubal disease accounts for 25- 35% of infertility in women which still constitutes one of the common problems in gynecologic practice and needs special techniques for evaluation and management. Proximal blockage of the fallopian tube occurs in 10-25 %of women with tubal disease. This study included 40 infertile females referred to the endoscopy unit, Zagazig university hospital with the diagnosis of proximal tubal obstruction as the only cause of infertility during the period from June 2005 to June 2006. All patients were subjected to careful history taking, general and pelvic examination and hysterosalpingography if no recent HSG (within 6 months) was available and present with her. Diagnostic hysteroscopy with special attention to the tubal ostia was performed to each patient, laparoscopy and methylene blue test was performed to explore the pelvis and confirm the diagnosis of proximal tubal obstruction. Laparoscopic guided hysteroscopic tubal cannulation was done under general anaesthesia if the presence of proximal tubal obstruction was confirmed by methylene blue test.
In this study, there was a concordance between the findings of both the hysterosalpingography and the laparoscopic methylene blue test in 82% of cases (P value ‹ 0.001).
Hysteroscopic tubal cannulation of proximally occluded tubes was challenged in 34 cases (19 with bilateral and 15 with unilateral obstruction) after exclusion of 6 female proved to have bilaterally patent tubes by methylene blue perturbation under guidance of laparoscopy. It was done using the modified Novy cornual cannulation set through the operative hysteroscope. It was successful in 26 tubes (49.1%) and failed in 27 tubes (50.9%). The pregnancy rate after 6- 18 months following successful cannulation was 27.77% (5 pregnancies out of 18 cases) with no cases of tubal pregnancy.
In this study there was no significant difference as regards successful tubal cannulation between cases of primary and those with secondary infertility and also between unilateral or bilateral proximal tubal obstruction.
Throughout the study complications have occurred in 5 cases (3 tubal perforations and 2 false passages) which didn’t necessitate any further management.
It could be concluded that:
Hysterosalpingography, hysteroscopy and laparoscopy complement each other rather than competing in assessment and treatment of the infertility resulting from proximal tubal obstruction.
HSG can serve as a screening method for diagnosis of proximal tubal blockage.
Tubal cannulation is effective, less invasive and relatively safe. It requires a much shorter learning curve and its results are much less dependent on surgical technique.