Hysteroscopic cannulation for proximal tubal obstruction: a change for the better?*

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1 FERTILITY AND STERILITY Copyright ~ 1995 American Society for Reproductive Medicine Vol. 63, No.5, Month 1995 Printed on acid-free paper in U. S. A. Hysteroscopic cannulation for proximal tubal obstruction: a change for the better?* Kamalini Das, M.D.t Theodore C. Nagel, M.D.t John W. Malo, M.D.:j: Reproductive Health Associates, St. Paul, and University of Minnesota, Minneapolis, Minnesota Objective: To compare overall the results of hysteroscopic tubal cannulations and resection anastomosis for proximal tubal occlusion. Design: Nonrandomized retrospective analysis of patients operated on by two surgeons. Setting: University and large tertiary referral private practice. Patients: Seventy-four patients over a 10-year period, with bilateral or unilateral proximal occlusion of a single tube. Interventions: Hysteroscopic cannulation, resection anastomosis, or both. Main Outcome Measures: Intrauterine and ectopic pregnancy rates, long-term tubal patency, and pathology of tubal segments. Results: In patients with normal distal tubes, intrauterine pregnancy rates were similar (121 21,57% versus 12/24,50%) and ectopic pregnancy rates were lower (0/21,0% versus 7124, 29.1 %) in the cannulation group. One-year patency rates in nonpregnant patients was higher in the anastomosis group (12/15, 80% versus 3/8, 33%). Conclusions: Hysteroscopic cannulation should be first choice in the management of proximal tubal obstructions in selected patients. It may be a treatment option for delayed occlusion after successful cannulation or resection anastomosis. Fertil Steril 1995;63: Key Words: Hysteroscopic tubal cannulation, resection anastomosis, proximal tubal obstruction, salpingitis isthmica nodosa, bipolar disease The last decade has seen changes in the surgical management of proximal tubal obstructions from resection anastomosis toward trans cervical cannulations. Advantages cited in favor of cannulations include patient convenience, ease, and decreased cost of procedure. However, resection anastomosis remains the gold standard in terms of pregnancy rates for patients with proximal tubal obstruction (1). The results of the study by Novy et al. (2) suggested Received June 13, 1994; revised and accepted November 21, * Submitted in part to the World Congress of Gynecological Endoscopy, AAGL 22nd Annual Meeting, Santa Fe Springs, California, November 10 to 14, t Present address: Department of Obstetrics and Gynecology, St. Paul Ramsey Medical Center, St. Paul, Minnesota. :\: Department of Obstetrics and Gynecology, University of Minnesota. Reprint requests: Theodore C. Nagel, M.D., Reproductive Health Associates, P.A., 360 Sherman Street, Suite 350, St. Paul, Minnesota (FAX: ) promismg outcomes of hysteroscopic methods of tubal cannulation. A number of reports on fluoroscopic cannulations have appeared in the literature over the last few years (3-5). However, after the initial reports on hysteroscopic cannulation (2, 6), little new information is available on the long-term success rates and the prognosis for fertility in patients treated by this method. There is also no study that directly compares the results of resection anastomosis to transcervical cannulation procedures. We compared the results of resection anastomosis done for proximal tubal obstruction before the advent of hysteroscopic tubal cannulation with resection anastomosis and hysteroscopic tubal cannulation done after hysteroscopic tubal cannulation was a therapeutic option. In all patients, the procedure, whether resection anastomosis or hysteroscopic tubal cannulation, was done by two surgeons in a large reproductive surgery center. This allowed for standardization of results and enabled us to determine the contribution of hysteroscopic tubal cannulation to the Das et al. Hysteroscopic cannulation versus anastomosis 1009

2 management of proximal tubal obstruction at this center. Table 1 Pregnancy Rates After Successful Hysteroscopic Tubal Cannulation or Resection Anastomosis Excluding Patients in all Groups with Distal Disease MATERIALS AND METHODS Over a 10-year period between 1983 and 1993, 79 women with bilateral or unilateral proximal obstruction of a single remaining tube were investigated and treated at this center. Women not considered for surgical treatment because of either severity of disease or their choice for assisted reproductive techniques were not included in this study. In all 79 women, the diagnosis of proximal tubal obstruction was made on both hysterosalpingography (HSG) and laparoscopy. Between 1983 and 1989 (prehysteroscopic tubal cannulation era), 31 of these women aged 23 to 38 years directly underwent microsurgical proximal tubal resection anastomosis for proximal tubal obstruction (group I) after proximal tubal obstruction was confirmed by both HSG and chromotubation at laparoscopy. From 1989 until the end of 1992 (posthysteroscopic tubal cannulation era), the remaining 48 women aged 23 to 41 years were evaluated. Hysteroscopic tubal cannulation was done if there had been no prior laparoscopy or if a prior laparoscopy showed adhesions or other abnormalities not treated by the referring physician. If there was no clinical evidence of proximal tubal disease such as dilatation, nodularity, thickening, or fibrosis at laparoscopy, hysteroscopic tubal cannulation under laparoscopic guidance was performed (group II, 28 women). If there was clinical evidence of proximal tubal disease such as nodularity, thickening, or fibrosis at laparoscopy, laparotomy with microsurgical resection anastomosis was performed (group III, 20 women). The reported pathology of tubal segments of all patients who underwent resection anastomosis was reviewed. Patients were categorized based on the appearance of the least affected tube, e.g., if one tube was occluded proximally or distally and one appeared to be normal aside from proximal block she was placed in the normal group. Patients were classified as having bipolar disease only if they had bilateral hydrosalpinges or severe adhesions bilaterally by American Fertility Society criteria. Three patients who failed hysteroscopic tubal cannulation and five who developed obstruction after successful cannulation underwent subsequent proximal tubal resection anastomosis. Three other women, who developed reobstruction after an initially successful resection anastomosis, underwent hysteroscopic tubal cannulation. The pathology of these tubal segments was reviewed and compared with patients undergoing resection anastomosis as the initial procedure Das et al. Hysteroscopic cannulation versus anastomosis Pregnancy* Patient Groups number Intrauterine Ectopic Hysteroscopic tubal cannulation Normal tubest (57.1) o (O):\: Resection anastomosis Normal tubest (50) 7 (29.1) Thickening of the proximal tubal segment 12 4 (33.3) 2 (16.6) Bipolar diseasell 17 1 (5.9) 2 (11.8) * Values in parentheses are percentages. t Patients in these groups had proximal tubal occlusion with normal appearing tubes at laparoscopy or laparotomy. :\: P = using x 2 analysis between the groups. Patients in this group had proximal tubal occlusion with clinical evidence ofthickening of the proximal tubal segment at laparoscopy or laparotomy. II All patients with distal tubal disease whether treated by hysteroscopic tubal cannulation or resection anastomosis are in this group (bipolar disease). Within the setting of this retrospective nonrandomized study, to obtain as comparable groups as possible, all patients with clinical evidence of nodularity, thickening of the proximal tubal segment, and those with associated distal tubal disease (bipolar disease) were excluded from both the resection anastomosis and the hysteroscopic tubal cannulation groups (Table 1). The comparisons were then made within these two groups in Table 1: resection anastomosis versus hysteroscopic tubal cannulation done on normal-appearing tubes. The pregnancy rates include only the first pregnancy occurring after the surgical procedure, whether resection anastomosis or hysteroscopic tubal cannulation. Subsequent pregnancies are mentioned in the results but not included in the final figures in the tables. Microsurgical Proximal Tubal Resection Anastomosis Microsurgical proximal tubal resection and anastomosis was done in the follicular or early luteal phase of the cycle in the majority of cases. In most instances a Pfannenstiel incision was used. In very obese patients a Maylard incision was used. A wound protector and self-retaining retractor were inserted. The technique used was essentially as described by Gomel (7). Every attempt was made to avoid implantation. The anastomotic site varied from juxtamural to juxtacavitary. In two instances in group I tubal implantation was required (7). One patient had the isthmic segment implanted and had two subsequent live births. The second had no normal isthmus and Fertility and Sterility

3 thus had an ampullary implantation resulting in subsequent tubal pregnancy. Mter the anastomosis, chromotubation was done. Leakage at the anastomotic site was deemed acceptable provided there was good flow through the tube. If flow was inadequate the anastomosis was modified or redone until good flow was established. Hysteroscopic Tubal Cannulation The hysteroscopic cannulations were done under general anesthesia with concurrent laparoscopy. The cervix was grasped with a single-tooth tenaculum and gently dilated to size 7 Hegar. A Wolf model E telescope with a single channel insert (E ) operating hysteroscope was introduced with carbon dioxide as the distending medium. The Novy cannulation set (Cook OB/GYN, Spencer, IN) was used for the cannulation as described by Novy et al. (2). In summary, a 5.5-F outer cannula with a metal obturator is introduced through a nipple on the operating channel of the hysteroscope. This cannula is fitted with a plastic Y-adaptor ending in Luer-Iok tubes. Mter inserting the cannula, the obturator is removed and the end is sealed with a plastic cap or a syringe is attached for chromotubation. A 3-F Teflon catheter, tapered to 2.5 F over the distal 3 cm through which has been passed a Teflon-coated steel guide wire, is passed through the other arm of the Y-adaptor. The tubal ostium is visualized, and the 5.5-F outer cannula is directed toward the internal ostium. The 3-F Teflon cannula is directed toward the internal ostium. The 3-F Teflon cannula with the wire protruding slightly beyond the end was introduced into the tube. The wire and cannula were then advanced until the laparoscopist could identify the wire and cannula within the tube, or until it was clear the tube could not be cannulated. The tube always was cannulated beyond the previously identified area of obstruction as seen on HSG. The laparoscopist assisted by manipulating the tube to decrease the angle between the isthmus and the cornu to facilitate the cannulation. Mter cannulation, a tubal dye study was done to confirm patency. Patients not pregnant within 6 months to 1 year of the initial procedure had a HSG done. The records of all patients were reviewed to obtain information regarding pathology of tubal segments, intrauterine and ectopic pregnancy rates, and long-term tubal patency rates. An attempt was made to contact by phone all patients for whom follow-up information was unavailable. RESULTS In 74 of 79 patients undergoing the procedure, either resection anastomosis or hysteroscopic tubal cannulation was successful in obtaining patency of at least one tube at surgery. A summary of the significant data of groups I to III is shown in Table 2. Table 1 shows the results of the more comparable groups after excluding patients with thickening of the proximal tubal segment or associated distal tubal disease from both groups I and II. In group I, there were 31 patients with a total of 51 tubes. In all 31 patients, patency of at least one tube was achieved (100%). However, it was not possible to resect and anastomose an adequate length of three tubes because of severe intraluminal disease. Patency at surgery was obtained in 48 of 51 tubes (94.1 %). Associated bilateral distal tubal disease requiring surgical correction was seen in seven patients (23%), 14 tubes. Six patients required bilateral salpingostomies and one required lysis of severe adhesions. Overall, pregnancy was achieved in 23 women in this group (74.2%). Of23 women who conceived, 9 (29%) had an ectopic pregnancy. Fourteen (45%) had only intrauterine pregnancies and one had both (an initial ectopic pregnancy and a subsequent intrauterine pregnancy). Two of the ectopics occurred in patients who also had distal tubal disease at the time of resection anastomosis. All ectopic pregnancies were found distal to the site of anastomosis. Two of the ectopic pregnancies were delayed and occurred between 1 and 2 years after the procedure. Thirteen of 14 intrauterine pregnancies occurred within 1 year of the procedure. Five of the nonpregnant patients in this group had a follow-up HSG at 1 year, and in each instance there was patency of at least one tube (six of seven tubes). Of the pregnant patients, four had subsequent intrauterine pregnancies. Three of these patients had a prior intrauterine pregnancy and one had a prior ectopic pregnancy. Group II had 28 patients with 45 tubes who underwent an attempt at hysteroscopic tubal cannulation. In 25 patients (36 tubes) at least one tube was successfully cannulated (88.6% of patients). Bilateral distal tubal disease was found and surgically treated at the same time in seven tubes of four patients (14.3%). Three had severe adhesions and one required bilateral salpingostomies. Of successful cannulations, 14 of 25 patients conceived (56% conception rate). Of 14 women who became pregnant, 13 had only intrauterine pregnancies (52%) and one had an ectopic pregnancy (4%). All pregnancies occurred within 6 months of the procedure. The only ectopic pregnancy occurring in this group, without a prior intrauterine pregnancy, occurred in a tube Das et al. Hysteroscopic cannulation versus anastomosis 1011

4 Table 2 Significant Data of Patients With Proximal Tubal Blocks in the Three Groups*t Patency Patient at Groups number surgery Group I resection anastomosis (before hysteroscopic tubal cannulation) (100) Group III tubal cannulation (88.6) Group III resection anastomosis (clinical thickening of the proximal tubal segment) (90) * All groups include patients with associated distal tubal disease. Pregnancies Distal Follow-up disease Intrauterine Ectopic Total patency 7 (23) 14 (45) 9 (29) 23 (74.2) 6/7 (85.3)+ 4 (14.3) 13 (52) (4)+ 14 (56) 3/8 (37.5) 8 (40) 3 (16.6) 1 (5.5) 4 (20) 5/8 (62.5)+ t Values in parentheses are percentages. + P < 0.05 using x 2 analysis between the groups. subjected to cuff salpingostomy at the time ofhysteroscopic tubal cannulation. One woman is divorced and is not attempting pregnancy. Tubal patency was confirmed at HSG, in 3 of 11 tubes, of three of eight patients not pregnant at 1 year. In the pregnant group, subsequent intrauterine pregnancies were achieved in three patients. One patient had two intrauterine pregnancies that terminated in spontaneous abortions at 8 and 10 weeks, respectively, and subsequently developed an ectopic pregnancy. Group III had 20 women (32 tubes) with proximal tubal obstruction and clinical evidence of disease (nodularity, thickening, or fibrosis of the proximal tube) who underwent resection anastomosis. Thirty tubes of 18 patients were successfully reanastomosed. Four pregnancies were obtained in this group (20%), of which three were intrauterine (16.6%) and one was ectopic (5.5%). Eight of these patients had severe bilateral distal disease. Patency of at least one tube at HSG was confirmed in five of eight nonpregnant patients (7 of 10 tubes) at 1 year. There were 8 women (15 tubes) who underwent subsequent resection anastomosis as a second procedure. Three ofthese were done after a failed hysteroscopic tubal cannulation, and five were done when tubal obstruction occurred after an initial successful hysteroscopic tubal cannulation. Patency was achieved in all tubes. One pregnancy occurred in this group, but only 1 of 13 tubes remained patent at the end of a year. Three other women who developed tubal reobstruction after resection anastomosis had successful hysteroscopic tubal cannulation, with patency of at least one tube. One patient had two subsequent successful intrauterine pregnancies. Table 1 shows the intrauterine and ectopic pregnancy rates in the hysteroscopic tubal cannulation and resection anastomosis groups after exclusion of all cases of associated distal tubal disease and clinically abnormal tubes in both groups. Intrauterine pregnancies were achieved in 12 of 21 (57%) and 12 of 24 (50%) in the hysteroscopic tubal cannulation and resection anastomosis groups, respectively (P = NS). Ectopic pregnancies occurred in 0 of 21 (0%) 1012 Das et al. Hysteroscopic cannulation versus anastomosis and 7 of24 (29.1%), respectively, in the same groups (P < 0.007, X 2 ). The prognosis for an intrauterine pregnancy in patients with bipolar disease treated with either hysteroscopic tubal cannulation or resection anastomosis was bleak: 1 of 17 (6%). The breakdown of pathology seen in the resected tubal segments is shown in Table 3. Serial sections of these tubes were not examined. The pathologic process was considered "occlusive" or "obstructive" based on the nature of the lesion (8-10). The lesion was considered "occlusive" if fibrosis or thickening of the proximal tubal segment was reported and "obstructive" for any other histologic diagnosis. The percentage of occlusive causes in groups I and III were 53.8% and 40%, respectively. All three patients who failed hysteroscopic tubal cannulation had occlusive causes of proximal tubal obstruction: two had fibrosis and one had thickening of the proximal tubal segment. All five patients who developed reobstruction after an initial successful cannulation had obstructive pathology with no evidence of thickening of the proximal tubal segment or fibrosis. Forty percent of group III patients with clinical evidence of proximal tubal disease at laparoscopy had endometriosis on histopathology examination. Only one patient in this group had clinically obvious endometriosis at laparoscopy. The only complication encountered during hysteroscopic tubal cannulation was perforation of a single tube in a patient who failed cannulation. Laparotomy with successful resection anastomosis was done subsequently. Fibrosis was noted on pathology ofthe segment. DISCUSSION Our results show that the option of hysteroscopic tubal cannulation has improved significantly the prognosis for intrauterine pregnancy in patients with proximal tubal obstruction in this large practice (Table 1). Total pregnancy rates were comparable, and this change mainly reflected the decrease in ectopic pregnancy rates in the hysteroscopic tubal can- Fertility and Sterility

5 Table 3 Pathology of Tubal Segments of Patients who Underwent Resection Anastomosis Obstructive Occlusive Thickening of Chronic the proximal Groups salpingitis Endometriosis Endosalpingiosis Normal Percent Fibrosis tubal segment Percent Group I resection anastomosis (before hysteroscopic tubal cannulation) 6 3 Group III resection anastomosis (clinical thickening of the proximal tubal segment) nulation group. Because the presence of distal tubal disease could account for the difference in ectopic pregnancy rates between the groups, the data were reanalyzed after excluding all patients in both hysteroscopic tubal cannulation and resection anastomosis groups with associated distal tubal disease and those with clinical evidence ofthickening ofthe proximal tubal segment (Table 1) to obtain as comparable groups as possible. In patients with normal-appearing proximal and distal tubes, ectopic pregnancies developed in 0% and 29% of patients in the hysteroscopic tubal cannulation and resection anastomosis groups, respectively. Also, 2 of 12 (16.6%) pregnancies were ectopic in the resection anastomosis group with clinical thickening of the proximal tubal segment. Our data raised the possibility that interruption of the proximal tubal musculature by resection anastomosis and the subsequent healing process may result in the higher occurrence of tubal motility abnormalities resulting in the failure of the zygote to move across the resection anastomosis site. This would explain the ectopics occurring distal to the anastomotic site. However, the patients were not randomized prospectively and therefore the increased incidence of ectopic pregnancy in the resection anastomosis group may indeed reflect more severe tubal disease rather than altered tubal function. On the other hand, because hysteroscopic tubal cannulation does not involve interruption of the tubal musculature, ectopic pregnancies in this group should be related only to the presence of associated distal tubal disease. Ectopic pregnancy rates after transcervical cannulation procedures have been reported to vary from 0% to 27% (10). Novy et al. (2) had no ectopics in the seven pregnancies in their series with both hysteroscopic and fluoroscopic tubal cannulation. Deaton et al. (6) reported three ectopics in 12 patients who underwent hysteroscopic tubal cannulation. All three occurred in patients who had associated surgical correction of significant distal tubal disease. No ectopic pregnancies have been reported after fluoroscopic tubal cannulations in three recent series (3, 11, 12). However, ectopic pregnancy after transcervical cannulation procedures is a possible event because of re-establishing patency in a previously blocked abnormally functioning tube. Ectopic pregnancy rates in patients after resection anastomosis have been reported as 7% to 30% in various series (13, 14). Donnez et al. (15) reported low ectopic pregnancy rates after resection anastomosis if the intramural portion of the tube was undamaged. However, when the intramural portion of the tube was occluded, or had diverticular lesions, ectopic pregnancy rates after resection anastomosis were two of five and two of three, respectively. A higher percentage of patients with intramural damage in our series may explain our high ectopic pregnancy rates after resection anastomosis. Intrauterine pregnancy rates with transcervical cannulation procedures for proximal tubal obstruction have been reported as 17% to 30% in various series (11). Intrauterine pregnancy rates with microsurgical resection anastomosis procedures vary from 25% to 65% (13, 14). However, many of the studies with resection anastomosis have included patients undergoing proximal tubal resection anastomosis for tubal sterilization reversal (16). Because pregnancy rates in this group of patients varies from 55% to 70%, this would elevate artificially the intrauterine pregnancy rates reported with resection anastomosis for proximal tubal obstruction. In a recent large series, the cumulative pregnancy rate after resection anastomosis for proximal tubal disease was 33% (14). Intrauterine pregnancy rates in our study with hysteroscopic tubal cannulation and resection anastomosis were 57% and 50%, respectively, when patients with severe bilateral distal tubal disease were excluded in both groups (Table 1). Similar intrauterine pregnancy rates are obtained whether resection anastomosis is done on normal-appearing tubes or tubes with clinical thickening of the proximal tubal segment: 50% versus 33.3% (Table 1). Also, review of the pathology of these tubal segments did not indicate a higher incidence of occlusive pathology such as fibrosis or thickening of the proximal tubal Das et al. Hysteroscopic cannulation versus anastomosis 1013

6 segment in the group with clinical evidence of proximal disease. The first intrauterine pregnancy after hysteroscopic tubal cannulation reported by Daniell et al. (17) was in a patient who had clinical evidence of proximal tubal thickening of the proximal tubal segment. Thus, our selection of patients for resection anastomosis or hysteroscopic tubal cannulation based on clinical evidence of proximal tubal disease may be arbitrary. It is possible that patients with clinical evidence of proximal tubal disease would respond as well to hysteroscopic tubal cannulation and this may not be a contraindication to hysteroscopic tubal cannulation. Tubal patency rates after transcervical cannulation have been reported to be from 30% to 75% (10-12). These vary depending on whether reported pregnancy rates include pregnant patients or are reported as a percentage of nonpregnant patients who underwent a follow-up study. Our results suggest that tubal patency rates at 1 year in nonpregnant patients were higher in patients who had resection anastomosis compared with hysteroscopic tubal cannulation. If pregnancy is not achieved within 6 months, intraluminal obstruction may reform earlier with time after hysteroscopic tubal cannulation. However, it should be possible to achieve tubal patency in these patients by another hysteroscopic tubal cannulation procedure. Patency was achieved by hysteroscopic tubal cannulation in all three patients who reobstructed after resection anastomosis, with one intrauterine pregnancy in this group. Only one pregnancy was obtained in patients who had resection anastomosis for failed cannulation and, hence, these may indicate more extensive tubal disease. However, if patency is achieved in either group as documented by an intrauterine pregnancy, these tubes remain functionally patent for a longer period of time, as indicated by subsequent intrauterine pregnancies. Transcervical cannulation procedures are effective in treating patients with mucous plugs, cellular debris, and tubal spasm (19, 20). On examination, these segments should show no occlusion ofthe tubal lumen and should have no or minimal pathological findings. Before hysteroscopic tubal cannulation, all patients with proximal tubal obstruction underwent resection anastomosis (group 1). A wide distribution of pathology was seen in these tubal segments. Only two of these patients (7.6%) had normal tubes on histology, similar to the results reported by Madelenat et al. (20). This may reflect the fact that all patients had at least two studies showing proximal occlusion before surgical intervention. This small percentage of patients with normal tubes would not explain the large number of patients (55.3%) who underwent successful hysteroscopic tubal cannula Das et al. Hysteroscopic cannulation versus anastomosis tion after Cannulations must have been successful in a number of patients with abnormal proximal tubal pathology. Failure of hysteroscopic tubal cannulation occurs in < 15% of patients with proximal tubal obstruction and may select out those with occlusive disease, such as thickening of the proximal tubal segment and fibrosis, more amenable to microsurgical resection anastomosis. Interestingly, 40% of patients with clinical "thickening of the proximal tubal segment" (group III) had histologic evidence of endometriosis. Medical management of endometriosis may be a therapeutic option for patients in this group who fail hysteroscopic tubal cannulation (21). Hysteroscopic tubal cannulation has a number of advantages over other transcervical cannulation techniques. First, it is done under direct vision through the hysteroscope under laparoscopic guidance after confirmation of proximal tubal obstruction by chromotubation. There are recent reports of large numbers of successful cannulations under fluoroscopic guidance done for proximal tubal injection failure at HSG (22). The diagnostic reliability of a single HSG for tubal disease is <75% (23). Hence, a number of these fluoroscopic cannulation procedures may have been undertaken unnecessarily. Confirmation of proximal tubal obstruction by chromotubation before hysteroscopic tubal cannulation will avoid these unnecessary cannulation procedures. Second, approximately 25% to 35% of patients with proximal tubal obstruction have associated distal tubal disease or other pelvic pathology. This can be diagnosed and treated through the laparoscope at the same time. Chromotubation at the end of the procedure can confirm tubal patency. If hysteroscopic tubal cannulation fails, resection anastomosis can be proceeded with if feasible. Third, if significant proximal and distal tubal disease (bipolar disease) is encountered at laparoscopy, intrauterine and ectopic pregnancy rates with either hysteroscopic tubal cannulation or resection anastomosis are 6% and 12%, respectively (Table 1). In this event, assisted reproductive techniques may be the best therapeutic option. Hence, hysteroscopic tubal cannulation offers a diagnostic and treatment modality for proximal tubal obstruction, which allows for individualized treatment of these infertile patients. In conclusion, in a large reproductive surgery center, with surgeons skilled in the techniques of microsurgical resection anastomosis, higher intrauterine pregnancy rates and lower ectopic pregnancy rates were achieved with hysteroscopic tubal cannulation. Hysteroscopic tubal cannulation requires a much shorter learning curve and its results are much less dependent on surgical technique than is microsurgical resection anastomosis. Hysteroscopic tubal can- Fertility and Sterility

7 nulation under laparoscopic guidance offers the option for individualized patient management and should be the treatment of choice for proximal tubal obstruction. It is also a therapeutic option when proximal tubal obstruction develops subsequent to an initially successful resection anastomosis or tubal cannulation procedure. Acknowledgments. We acknowledge the assistance of Carol Dudgeon, R.N., and the secretarial help of Ms. Starla Newhouse, Reproductive Health Associates, St. Paul, Minnesota. REFERENCES 1. Gomel V, Yarali H. Infertility surgery: microsurgery. Curr Opin Obstet Gynecol 1992;4: Novy MJ, Thurmond AS, Patton P, Uchida BT, Rosch J. Diagnosis of cornual obstruction by transcervical fallopian tube cannulation. Fertil Steril 1988;50: Capitanio GL, Ferraiolo A, Croce S, Gazzo R, Anserini P, Cecco L. Transcervical selective salpingography: a diagnostic and therapeutic approach to cases of proximal tubal injection failure. Fertil Steril 1991;55: Thurmond A, Rosch J, Patton PE, Burry KA, Novy M. Fluoroscopic transcervical fallopian tube catheterization for diagnosis and treatment of female infertility caused by tubal obstruction. Radiographics 1988;8: Rosch J. Thurmond AS, Uchida BT, Sovak M. Selective transcervical fallopian tube catheterization: technique update. Radiology 1988;168: Deaton JL, Gibson M, Riddick DH, Brumsted JR. Diagnosis and treatment of cornual obstruction using a flexible tip guidewire. Fertil Steril 1990;53: Gomel V. Microsurgery in female infertility. Boston: Little Brown & Co., DeCherney AH. Anything you can do I can do better... or differently! Fertil Steril 1987;48: Rubin IC. Uterotubal insufflation: value in the treatment of tubal obstruction to ovular migration. Fertil Steril 1954; 5: Hershlag A, Grainger D, Glickman M, DeCherney AH. Trans- cervical approaches to proximal tubal obstruction. Contemp Ob Gyn 1990;41: Isaacson KB, Amendola M, Banner M, Glassner M, Sondheimer SJ. Transcervical fallopian tube catheterization: a safe and effective therapy for patients With proximal tubal obstruction. Int J FertiI1992;37: Mallarini G, Zanon E, Ferraiolo A, Righi D, Giuliano A, Fonio P, et al. Tubal catheterization with selective salpingography in the diagnosis and therapy of fallopian tube obstruction. Radiol Med (Torino) 1992;83: Singhal V, Li TC, Cooke ID. An analysis offactors influencing the outcome of 232 consecutive tubal microsurgery cases. Br J Obstet Gynaecol 1991;98: McComb P. Microsurgical tubocornual anastomosis for occlusive cornual disease: reproducible results without the need for tubouterine implantation. Fertil Steril1986;46: Donnez J, Casanas-Roux F. Prognostic factors influencing the pregnancy rate after microsurgical cornual anastomosis. Fertil Steril 1986;46: Vilos GA. Intramural-isthmic fallopian tube anastomosis facilitated by the carbon dioxide laser. Fertil Steril 1991;56: Daniell JF, Miller W. Hysteroscopic correction of cornual occlusion with resultant term pregnancy. Fertil Steril 1987;48: Sulak PJ, Letterie GS, Hayslip CC, Coddington CC, Klein TA. Hysteroscopic cannulation and lavage in the treatment of proximal tubal occlusion. Fertil Steril 1987;48: Letterie GS, Sakas EL. Histology of proximal tubal obstruction in cases of unsuccessful tubal canalization. Fertil Steril 1991;56: Madelenat P, De Brux J, Palmer R. L'etiologie des obstructions tubaires proximales et son role dans Ie prognostic des implantations. Gynecologie 1977;28:47. Cited by Gomel p Ayers JWT. Hormonal therapy for tubal occlusion: danazol and tubal endometriosis. Fertil Steril 1982;38: Thurmond AS. Selective salpingography and fallopian tube recanalization. Am J Roentgenol 1991; 156: World Health Organization. Comparative trial of tubal insufflation, hysterosalpingography, and laparoscopy with dye hydrotubation for assessment of tubal patency. Fertil Steril 1986;46: Das et al. Hysteroscopic cannulation versus anastomosis 1015