Falloposcopy in conjunction with laparoscopy: possibilities and limitations

Study of fallopian tube anatomy and mechanical properties to determine pressure limits for endoscopic exploration

Falloposcopy is the endoscopic examination of the fallopian tubes, which are challenging to access due to their deep body location, small opening from the uterus, and lumen filled with plicae. We and others have developed endoscopes that are inserted through the uterus guided by a hysteroscope into the tubal ostium. To better understand how to utilize these endoscopes either as standalone devices or in concert with everting delivery balloons, a preliminary study of anatomy and mechanical behavior was performed ex vivo on porcine and human fallopian tubes. Segments of fallopian tubes from the isthmus, ampulla and infundibulum were inflated with saline either to bursting or held at sub-burst pressures with saline or a saline-filled balloon. Formalin fixed, paraffin embedded tissue sections stained with Masson's trichrome were examined for damage to the mucosa and muscularis. Porcine fallopian tubes tolerated saline pressurization at 15 psi for 1 minute without morphological damage. Balloon inflation to 15 psi caused no apparent damage to the muscle layer or rupture of the fallopian tube, but balloon movement within the tube can denude the mucosal epithelial layer. Human fallopian tubes averaged higher burst pressure values than porcine tubes. Under pressurization, the external tube diameter expanded by minimal to moderate amounts. Human and porcine tissues were similar in histological appearance. These studies suggest that moderate pressurization is acceptable but will not appreciably expand the fallopian tube diameter. The results also indicate that pigs are a reasonable model to study damage from falloscopy as seen in human tissue.

Sub-millimeter endoscope demonstrates feasibility of in vivo reflectance imaging, fluorescence imaging, and cell collection in the fallopian tubes

SIGNIFICANCE

Most cases of high-grade serous ovarian carcinoma originate as serous tubal intraepithelial carcinoma (STIC) lesions in the fallopian tube epithelium (FTE), enabling early endoscopic detection.

AIM

The cell-acquiring fallopian endoscope (CAFE) was built to meet requirements for locating potentially pathological tissue indicated by an alteration in autofluorescence or presence of a targeted fluorophore. A channel was included for directed scrape biopsy of cells from regions of interest.

APPROACH

Imaging resolution and fluorescence sensitivity were measured using a standard resolution target and fluorescence standards, respectively. A prototype was tested in ex vivo tissue, and collected cells were counted and processed.

RESULTS

Measured imaging resolution was 88  μm at a 5-mm distance, and full field of view was ∼45  deg in air. Reflectance and fluorescence images in ex vivo porcine reproductive tracts were captured, and fit through human tracts was verified. Hemocytometry counts showed that on the order of 105  cells per scrape biopsy could be collected from ex vivo porcine tissue.

CONCLUSIONS

All requirements for viewing STIC in the FTE were met, and collected cell counts exceeded input requirements for relevant analyses. Our benchtop findings suggest the potential utility of the CAFE device for in vivo imaging and cell collection in future clinical trials.

Comparison of Pregnancy Outcome between Ultrasound- Guided Tubal Recanalization and Office-Based Microhysteroscopic Ostial Dilatation in Patients with Proximal Blocked Tubes

Background

The current research to the best of my knowledge is the first to compare the pregnancy outcome between ultrasound-guided tubal recanalization (UGTR) using a special fallopian tubal catheter, and office-based micrhysteroscopic ostial dilatation (MHOD) using the same tubal catherter in infertile women with previously diagnosed bilateral proximal tubal obstruction (PTO).

Materials and Methods

This prospective study reported the pregnancy outcomes for 200 women in private infertility care center in Arafa hospital in Fayoum and in El Minya University Hospital in the period between January 2010 and October 2013 treated as outpatients for their bilateral PTO after the routine hysterosalpingography (HSG). A Cook’s catheter, special fallopian tubal catheter, were used to recanalize the blocked tubes in 100 women (group A) under UGTR, and the same Cook’s tubal catheter was used through 2mm microhysteroscope to cannulate both ostia using MHOD in another 100 women (group B). Pregnancy outcome was determined after the procedures for a 12-month period follow-up.

Results

The number of the recanalization of PTO was not significantly different between two groups. As of the 200 blocked fallopian tubes in group A, 140 tubes (70%) were successfully recanalized by passing the ultrasound-guided special cannula, while 150 tubes (75%) were successfully recanalized in group B, using the same tubal catheter through a 2mm microhysteroscope. The cumulative pregnancy rate after the two procedures was not statistically different between two groups. It was 25.9% in group A, while it was 26.3% in group B, after a 12-month period follow-up.

Conclusion

UGTR is highly recommended as the first step to manage infertile women due to PTO, as it is easier procedure; however, there is possible to obtain nearly similar results after MHOD.

Renaissance of surgical recanalization for proximal fallopian tubal occlusion: falloposcopic tuboplasty as a promising therapeutic option in tubal infertility

STUDY OBJECTIVE

To assess the clinical effectiveness of falloposcopic tuboplasty in tubal infertility.

DESIGN

Retrospective cohort study (Canadian Task Force classification II-3).

SETTING

Infertility clinic.

PATIENTS

Three hundred forty-five infertile patients (≥2y) with a diagnosis of proximal tubal occlusion, either bilateral or unilateral, between January 2005 and January 2011.

INTERVENTION

Falloposcopic tuboplasty.

MEASUREMENTS AND MAIN RESULTS

Medical records for 345 patients with a diagnosis of proximal tubal occlusion were reviewed. Of the 345 patients, 304 underwent falloposcopic tuboplasty, with successful recanalization achieved in 248 patients (81.6%). Ninety-one of the 304 patients (29.9%) became pregnant. Of these, 18 patients (19.8%) miscarried, and 4 (4.4%) had ectopic pregnancies in the recanalized tube. At 1-, 3-, 6-, and 9-month follow-up, the cumulative probability of conception was 23.1%, 50.6%, 73.6%, and 82.4%, respectively. Related complications included postsurgical infection (0.3%), perforation of the fallopian tube (1.3%), and accidental breakage of the catheter (4.9%) or the falloposcope (1.3%).

CONCLUSIONS

Falloposcopic tuboplasty is safe and effective for treatment of tubal infertility. The pregnancy rate after falloposcopic tuboplasty is comparable to that after in vitro fertilization, which suggests that it can be an alternative to in vitro fertilization in women with tubal infertility.

Assessing tubal damage

The fallopian tube plays an important role in the mechanical transport and physiological sustenance of the gametes and early conceptus. Complex and coordinated neuromuscular activity, cilial action and endocrine secretions are required for successful tubal function. Compromised tubal damage can occur after external or internal injury, inhibiting the normal transport of gametes. The overall prognosis for fertility depends principally on the insult and the severity of the tissue damage; hence, assessment of tubal damage plays a major role in predicting occurrence of pregnancy and the likelihood of developing ectopic pregnancy.

Fallopian tube recanalization: lessons learnt and future challenges

Technological advances in fiberoptics and endoscopy have resulted in the development of minimally invasive transcervical tubal catheterization procedures with the potential of improved diagnostic accuracy of tubal disease and transcervical treatment of proximal tubal obstruction (PTO) with reduced risks, costs and morbidity compared with surgical procedures. Fallopian tube recanalization can be performed with catheters, flexible atraumatic guidewires or balloon systems under endoscopic (falloposcopy/hysteroscopy/laparoscopy), sonographic, fluoroscopic or tactile guidance. Falloposcopy provides a unique possibility to accurately visualize and grade endotubal disease, characterize and document endotubal lesions, identify the segmental location of tubal pathology without complications, objectively classify the cause of PTO and guide future patient management. This is in contrast to the surgical and radiological gold standards, laparoscopy and hysterosalpingography, respectively, that are often associated with poor or misdiagnosis of PTO. Nonhysteroscopic transuterine falloposcopy using the linear eversion catheter is a successful, well-tolerated, outpatient technique with a good predictive value for future fertility. Hysteroscopic-falloposcopic-laparoscopic tubal aquadissection, guidewire cannulation, guidewire dilatation and direct balloon tubuloplasty may be used therapeutically to breakdown intraluminal adhesions or dilate a stenosis in normal or minimally diseased tubes with high patency and pregnancy rates. However, guidewire cannulation of proximally obstructed tubes yields much lower pregnancy rates compared with other catheter techniques, despite the high tubal patency rates. Laparo-hysteroscopic selective tubal catheterization with insufflation of oil-soluble radiopaque dye has been reported to be an effective treatment for infertility associated with endometriosis. The various disadvantages associated with fluoroscopic and sonographic techniques limit their application, despite the reportedly high patency and intrauterine pregnancy rates. Recanalization is contraindicated in florid infections and genital tuberculosis, obliterative fibrosis and long tubal obliterations that are difficult to bypass with the catheter, severe tubal damage, male subfertilitY and previously performed tubal surgery. Distal tubal obstruction is not amenable to catheter recanalization techniques. Tuberculosis, salpingitis isthmica nodosa, isthmic occlusion with club-changed terminal, ampullar or fimbrial occlusion, and tubal fibrosis have been cited as reasons for recanalization failure. In lieu of the poor pregnancy outcomes in patients with severe tubal disease and poor mucosal health following tubal recanalization, as well as poor available technical skills and results with microsurgery, in vitro fertilization and embryo transfer is a valid option in such women. Despite the high diagnostic and therapeutic power of falloposcopic interventions, technical shortcomings with falloposcopy must be overcome before the procedure gains widespread acceptance.

Technical results of falloposcopy for infertility diagnosis in a large multicentre study

Despite increasing evidence of its potential clinical value, falloposcopy has not yet found widespread use. In a large prospective international multicentre study we investigated the hypothesis that limited technical reproducibility may be of crucial significance in this regard. From 1994 to 1998, data on 367 patients with 639 tubes were recorded from 18 centres (median number of falloposcopies 22). Falloposcopy was performed using hysteroscopic ostium access, coaxial tubal cannulation and retrograde visualization under laparoscopic control. The procedure was successful in 69.6% of the tubes. Failures occurred in 6.1% during hysteroscopy, in 10.6% during the cannulation step and in 16.4% during visualization. While predominantly intracavitary pathology or thick endometrium were found to interfere with hysteroscopic ostium access, technical insufficiencies resulting in catheter damage or vision disturbing light reflexions were identified to be responsible for most cannulation and visualization failures, confirming the importance of these factors. The number of patients who received a complete falloposcopic evaluation did not exceed 57%. Additionally, 23.7% of patients may have profited from unilateral success depending on the individual indication. As a consequence of these technically limited results it was concluded that the method currently qualifies for selected indications rather than for routine clinical application.