Laparoscopy Laparoscopy is considered the gold standard for diagnosing tubal and peritoneal disease. It allows visualization of all pelvic organs and permits detection and potential concurrent treatment of intramural and subserosal uterine fibroids, peritubal and periovarian adhesions, and endometriosis. Abnormal findings on HSG can be validated by direct visualization on laparoscopy using chromopertubation, which involves the transcervical installation of a dye such as indigo carmine to directly visualize tubal patency and fimbrial architecture (212). However, even laparoscopy has been reported to have a false-positive rate of 11%
Treatment of Tubal Factor Infertility for proximal tubal occlusion when resected tubal segments are examined pathologically (218).
Other Diagnostic Modalities Falloposcopy is used in conjunction with hysteroscopy and allows direct fiberoptic visualization of tubal ostia and intratubal architecture for identification of tubal ostial spasm, abnormal tubal mucosal patterns, and even intraluminal debris causing tubal obstruction (218,219). At present, instrumentation availability and technical complications, including tubal perforation, limit its routine use (219). Alternatively, sonohysterography offers a much less invasive method of diagnosing fallopian tubal obstruction. The use of contrast media during sonohysterography is preferred to improve accuracy in documenting fallopian tubal patency, but these contrast agents are not available in the United States. As a substitute, the use of agitated saline (air-saline) during sonohysteroscopy provides good negative predictive value when compared to HSG or laparoscopy (220).
As success rates for ART continue to improve, the indications for surgical approaches in the treatment of tubal infertility have become increasingly limited (221). Still, surgery can be effective in several situations and may be the optimal approach in some patients.
Proximal Tubal Occlusion Proximal tubal catheterization and cannulation performed either via HSG or hysteroscopy can restore tubal patency in up to 85% of obstructions, although the reocclusion rate approaches 30%. The best candidates for proximal tubal catheterization or cannulation have muscle spasm, stromal edema, amorphous debris, mucosal agglutination, or viscous secretions, while nonresponders include those with luminal fibrosis, failed tubal reanastamosis, fibroids, congenital atresia, or tuberculosis. Occlusion from salpingitis isthmica nodosa, endometriosis, synechiae, salpingitis, and cornual polyps only occasionally will respond to catheterization or cannulation (10). Catheterization involves passage of a soft catheter into the tubal ostia, while cannulation passes a guidewire thru the ostia and injects contrast media or colored dye. Tubal perforation, typically minor, occurs in 1.9% to 11% of cases (10,211,218). Catheterization under ﬂuoroscopy during HSG is referred to as selective salpingography (222). Visualization of patency with the hysteroscopic approach can be accomplished using laparoscopy or ultrasound (10,218). Ongoing pregnancy rates following proximal tubal catheterization or cannulation are 12% to 44% regardless of hysteroscopic or HSG approach. If occlusion persists or recurs, IVF is usually recommended. Microsurgical tubocornual anastomosis is an option with small studies reporting pregnancy rates of up to 68% (10). This procedure typically is performed via laparotomy and involves excision of the tubal isthmus, followed by reimplantation of the residual tube into a new opening made through the uterine cornua (211).