Pregnancy outcomes following fluoroscopy-guided tubal recanalization: a comparison of spontaneous conception and intrauterine insemination-a retrospective cohort study.

This retrospective cohort study evaluated pregnancy outcomes in 139 women aged 21–40 years who underwent successful FGTR for tubal occlusion between January 2021 and May 2024. After excluding 15 patients with unsuccessful recanalization and 6 patients who subsequently underwent IVF, 80 patients were included in the spontaneous conception group and 59 in the IUI group. The mean operative time was 12.1 ± 2.31 min for unilateral recanalization and 24.7 ± 4.4 min for bilateral recanalization. Baseline characteristics of the two groups are summarized in Table 1 . There were no statistically significant differences between the two groups with respect to age (32.2 ± 4.5 vs. 31.6 ± 4.1 years, p  = 0.397), parity [1 (0–3) vs 1 (0–2), p = 0.085], type of infertility (primary: 26 (32.5%) vs. 24 (40.7%), p  = 0.321), duration of infertility (16.1 ± 3.3 vs. 16.8 ± 3.6 months, p  = 0.818), site of obstruction (Bilateral: 44 (55%) vs 35 (59.3%), p  = 0.801) or type of obstruction (Proximal: 39 (48.8%) vs 35 (59.3%), p  = 0.217). Table 1 Baseline characteristics. Spontaneous ( n  = 80) IUI ( n  = 59) p Age (years) 32.2 ± 4.5 31.6 ± 4.1 0.397 Parity 0 32 (40%) 28 (47.5%) 0.210 1 26 (32.5%) 23 (39%) 2 20 (25%) 8 (13.6%) 3 2 (2.5%) - Type of infertility Primary 26 (32.5%) 24 (40.7%) 0.321 Secondary 54 (67.5%) 35 (59.3%) Duration of infertility 12 to 24 months 78 (97.5%) 57 (96.6%) 0.756 24 to 36 months 2 (2.5%) 2 (3.4%) Type of obstruction Unilateral Proximal 24 (30%) 17 (28.8%) 0.505 Unilateral Distal 12 (15%) 7 (11.9%) Bilateral proximal 32 (40%) 30 (50.8%) Bilateral Distal 12 (15%) 7 (11.9%) Positive pregnancy 41 (51.2%) 34 (57.6%) 0.976 Time to pregnancy (months) 6.4 ± 2.8 5.9 ± 2 0.360 6 month tubal patency Bilateral patency 39 (48.8%) 27 (45.8%) 0.820 Unilateral Patency 12 (15%) 8 (13.6%) No patency 3 (3.8%) 1 (1.7%) IUI = intrauterine insemination; HSG = hysterosalpingography. Baseline characteristics. IUI = intrauterine insemination; HSG = hysterosalpingography. Table 2 highlights the association between the type of tubal obstruction and 6-month post-recanalization patency. It shows that women with bilateral proximal obstruction had a significantly higher rate of bilateral patency (50%) compared to those with unilateral patency (30%) and no patency (0%) (p = 0.001). Table 2 Association between type of tubal obstruction and 6 month post-recanalization. Obstruction type 6-month patency on HSG p 2 Bilateral Patency Unilateral Patency* No Patency* S ( n = 39) IUI ( n = 27) p 1 S ( n  = 12) IUI ( n  = 8) S ( n  = 3) IUI ( n  = 1) Bilateral proximal 18(46.2%) 15(55.6%) 0.238 4(33.3%) 2(25%) 0.001 Bilateral distal 3(7.7%) 9 (33.3%) 6(50%) 4(50%) 3(100%) 1(100%) Unilateral proximal 9(23.1%) 3(11.1%) 1(8.3%) - Unilateral distal 9(23.1%) – 1(8.3%) 2(25%) HSG = hysterosalpingography, S = Spontaneous conception group, IUI = Intrauterine insemination group * Statistical comparison was not performed due to insufficient sample size in the respective groups. p 1 : p-value for the comparison between spontaneous conception and IUI groups within the bilateral patency category for a given obstruction type. p 2 : Overall p-value for the association between obstruction type and patency status in the entire cohort (S + IUI combined). Association between type of tubal obstruction and 6 month post-recanalization. Bilateral distal HSG = hysterosalpingography, S = Spontaneous conception group, IUI = Intrauterine insemination group * Statistical comparison was not performed due to insufficient sample size in the respective groups. p 1 : p-value for the comparison between spontaneous conception and IUI groups within the bilateral patency category for a given obstruction type. p 2 : Overall p-value for the association between obstruction type and patency status in the entire cohort (S + IUI combined). The positive pregnancy rate was 51.2% (41/80) in the spontaneous conception group and 57.6% (34/59) in the IUI group ( p  = 0.976). The mean time to pregnancy was 6.4 ± 2.8 months in the spontaneous conception group and 5.9 ± 2 months in the IUI group ( p  = 0.360). Analysis of pregnancy outcomes based on tubal obstruction type revealed significant findings (Table 3 ). No pregnancies occurred among women with bilateral distal obstruction ( p  = 0.001). In contrast, patients with unilateral proximal obstruction (46.7%) and bilateral proximal obstruction (45.3%) demonstrated higher pregnancy rates. Women with distal occlusions, especially bilateral, were significantly less likely to conceive. Figure  4 shows pregnancy rates within the first 12 months following tubal recanalization. Table 3 Comparison of obstruction types in pregnant and non-pregnant patients. Obstruction type Pregnant (n = 75) No pregnancy (n = 64) p 3 S ( n = 41) IUI ( n  = 34) p 1 S ( n  = 39) IUI ( n  = 25) p 2 Bilateral proximal 16(39%) 18(52.9%) 0.164 16(41%) 12(48%) 0.067 0.001 Bilateral distal -– – 12(30.8%) 5(20%) Unilateral proximal 23(56.1%) 12(35.3%) 1(2.6%) 5(20%) Unilateral distal 2(4.9%) 4(11.8%) 10(25.6%) 3(12%) S = Spontaneous conception group, IUI = Intrauterine insemination group. p 1 : p-value for the comparison between S and IUI groups within the pregnant category for each obstruction type. p 2 : p-value for the comparison between S and IUI groups within the no pregnancy category for each obstruction type. p 3 : Overall p-value for the association between obstruction type and pregnancy outcome in the entire cohort (S + IUI combined). Fig. 4 Comparison of pregnancy rates within the first 12 months following tubal recanalization. Comparison of obstruction types in pregnant and non-pregnant patients. S = Spontaneous conception group, IUI = Intrauterine insemination group. p 1 : p-value for the comparison between S and IUI groups within the pregnant category for each obstruction type. p 2 : p-value for the comparison between S and IUI groups within the no pregnancy category for each obstruction type. p 3 : Overall p-value for the association between obstruction type and pregnancy outcome in the entire cohort (S + IUI combined). Comparison of pregnancy rates within the first 12 months following tubal recanalization. No major complications related to the recanalization procedure were reported.

Patients were identified from a prospectively maintained database of women undergoing FGTR at our institution. The study was approved by the Institutional Review Board. All patients provided informed consent for the procedure and data analysis. The inclusion criteria for this study were as follows: women aged between 21 and 40 years; a diagnosis of unilateral or bilateral tubal occlusion confirmed by (HSG) or laparoscopy; successful FGTR of at least one fallopian tube, defined as tubal patency demonstrated by post-procedure HSG or laparoscopic chromopertubation; normal ovulatory function, as evidenced by regular menstrual cycles and mid-luteal serum progesterone levels; and a partner with normal semen parameters according to the World Health Organization (WHO) criteria 7 . Not all patients in our study underwent diagnostic laparoscopy. However, for the subgroup of women who did undergo laparoscopy due to clinical suspicion of pelvic pathology, any detected adhesions or structural abnormalities were surgically treated during the same session. Importantly, only those patients with persistent tubal occlusion confirmed by laparoscopic chromopertubation after adhesiolysis or other surgical corrections were included in the study. If chromopertubation demonstrated tubal patency following the surgical intervention, such patients were excluded from our analysis, as they no longer fulfilled the inclusion criterion of tubal occlusion. Thus, only cases with confirmed and persistent tubal blockage post-adhesiolysis were considered eligible. Exclusion criteria included bilateral tubal occlusion not amenable to recanalization as determined by pre-operative imaging; the presence of significant pelvic adhesions, endometriosis, or other pelvic comorbidities identified during laparoscopy; a history of conception via in vitro fertilization (IVF); and inability to complete follow up for at least 12 months after recanalization. Patient selection and flow through the study process are illustrated in Fig.  1 . Fig. 1 Flowchart of patient selection, inclusion, exclusion, and allocation to treatment groups. Flowchart of patient selection, inclusion, exclusion, and allocation to treatment groups. The procedure was performed using a digital subtraction angiography system (Canon INFX-8000 V) available in the Department of Radiology. All FGTR procedures in this study were performed by a single experienced interventional radiologist using a standardized protocol. Tubal recanalization was performed using a 5F angled vertebral catheter (0.046″), a 0.035″ hydrophilic guidewire, and, if necessary, a 3F micro-catheter (0.027″) with a 0.018″ micro-guidewire. Following the application of an antiseptic disinfectant to the skin/genital area, a speculum is inserted. Once the cervical external os is visualized, a catheter is placed into the uterine cavity under aseptic conditions. The previously detected tubal occlusion on HSG is reassessed by administering contrast medium under fluoroscopic guidance. A 5F, 0.046 angled-tip catheter is then advanced to the tubal ostium, and a 0.035 hydrophilic guidewire is introduced. The guidewire is carefully manipulated under real-time fluoroscopy until it advances beyond the proximal two-thirds of the fallopian tube. Once positioned, the guidewire is removed, and contrast medium is injected through the catheter to evaluate peritoneal contrast spillage, confirming tubal patency. Figure  2 illustrates the recanalization technique used for proximal tubal occlusion. Fig. 2 Fluoroscopic view demonstrating recanalization technique for left proximal tubal occlusion. Fluoroscopic view demonstrating recanalization technique for left proximal tubal occlusion. If the 0.035 hydrophilic guidewire is unable to traverse the occlusion, a micro catheter and micro-guidewire system is introduced through the 5F catheter positioned at the tubal ostium. Under fluoroscopic guidance, the micro-guidewire is carefully advanced through the tubal lumen, followed by the micro catheter. Once the micro catheter reaches the desired location, the micro-guidewire is withdrawn, and contrast medium is injected to assess peritoneal passage. Figure  3 demonstrates the recanalization technique for distal tubal occlusion. Fig. 3 Fluoroscopic view demonstrating recanalization technique for right distal tubal occlusion. Fluoroscopic view demonstrating recanalization technique for right distal tubal occlusion. Following the procedure, the patient is prescribed doxycycline and is observed briefly before discharge. Additionally, if pregnancy does not occur by the 6th month post-cannulation, an HSG is performed to evaluate tubal patency. Treatment Groups : Following successful FGTR, patients were counseled regarding options for conception, including expectant management (spontaneous conception group) and intrauterine insemination (IUI group). The choice of treatment was based on patient preference and physician recommendation, considering factors such as age, duration of infertility, and semen parameters. The spontaneous conception group ( n  = 80) attempted to conceive naturally, while the IUI group ( n  = 59) underwent IUI cycles with ovarian stimulation using clomiphene citrate or letrozole. Outcome Measures : The primary outcome measure was the positive clinical pregnancy rate, defined as the presence of a gestational sac on ultrasound. Secondary outcome measures included time to pregnancy (in months) and the association between the type of tubal occlusion (e.g., proximal vs. distal) and pregnancy outcomes. Statistical Analysis : Statistical analysis was performed using SPSS version 26.0 (IBM Corp., Armonk, NY). Continuous variables were expressed as mean ± standard deviation and compared using Student’s t -test. Categorical variables were expressed as frequencies and percentages and compared using the chi-square test or Fisher’s exact test, as appropriate. Pregnancy rates over a 12-month period were analyzed using Kaplan–Meier survival analysis, and differences between groups were assessed with the log-rank test. A p -value of < 0.05 was considered statistically significant.

FGTR is an effective treatment for women with tubal occlusion. Both spontaneous conception and IUI offer comparable pregnancy outcomes, with no significant differences in pregnancy rates or time to conception. This suggests that spontaneous conception may be a viable first-line option, with IUI reserved for patients who do not conceive within a certain period. Further studies are needed to identify predictors of success in these groups. Specifically, research should focus on identifying which patient characteristics (e.g., age, duration of infertility, specific tubal pathology) are most predictive of success with spontaneous conception versus IUI.

This study examined pregnancy outcomes in women who underwent FGTR for tubal occlusion, comparing spontaneous conception with intrauterine insemination (IUI). Both strategies yielded similar pregnancy rates (51.2% vs. 57.6%) and time to conception, indicating that in appropriately selected patients, natural conception after FGTR can be as effective as IUI. This is particularly relevant when tubal pathology is the only infertility factor, as recanalization directly addresses the primary barrier to conception. In such cases, the absence of other infertility causes may explain the comparable outcomes between spontaneous and assisted conception. These findings are consistent with previous literature reporting post-recanalization spontaneous pregnancy rates of 30–60% without further interventions 8 – 10 . Pregnancy outcomes in our cohort varied according to both the laterality and site of obstruction. Proximal occlusions—often functional in origin and related to mucus plugs or debris—showed favorable outcomes after FGTR, in line with earlier reports 11 , 12 . In our data, unilateral and bilateral proximal obstructions achieved pregnancy rates of 46.7% and 45.3%, respectively. In contrast, distal disease—especially when bilateral—was associated with markedly lower pregnancy rates, and no pregnancies occurred in women with bilateral distal occlusion. Unilateral distal obstruction also reduced fertility potential, consistent with findings by Lin et al. 13 . These differences likely reflect the irreversible structural damage, fibrosis, and ciliary loss common in distal pathology 4 , 11 , 13 . Although IVF is widely recommended for distal disease, catheter-based recanalization is not an absolute contraindication. Several studies have demonstrated feasibility and occasional success in distal interventions. Sueoka et al. achieved pregnancies after falloposcopic tuboplasty in bilateral cases including distal involvement 14 , and Li et al. reported outcomes following hysteroscopic tubal catheterization and hydrotubation 15 . Allahbadia and Merchant emphasized that, while technically demanding and prognostically less favorable, distal recanalization can be justified in carefully selected patients who understand the limitations and prefer a less invasive option before proceeding to IVF 4 . In our center, such patients were thoroughly counseled, informed consent was obtained, and alternative options discussed. Including these cases allowed us to present real-world outcome data for a subgroup often excluded from studies, thereby helping to inform future patient counseling. Importantly, women with unilateral tubal occlusion comprised a significant portion of our cohort. This is noteworthy because existing literature indicates that pregnancy rates remain relatively high in such patients, even without intervention on the occluded side. In cases of unilateral blockage, the contralateral patent tube can often compensate functionally, allowing for natural conception, especially in women with normal ovulatory cycles and favorable semen parameters 13 . Nevertheless, several studies have indicated that recanalization of the occluded tube may further improve reproductive outcomes even in this context. Schill et al. demonstrated better outcomes in unilateral proximal obstruction compared to bilateral disease, while Hayashi et al. found high pregnancy rates when the contralateral tube was patent 11 , 12 . Our results support these observations and highlight that both laterality and anatomical location should guide post-FGTR management strategies. Patients with unilateral proximal occlusion may be ideal candidates for expectant management, whereas those with distal involvement—regardless of laterality—require closer follow up and potentially earlier transition to assisted reproductive technologies. Follow up imaging proved valuable in prognostication. Six-month HSG demonstrated that bilateral patency correlated with higher pregnancy rates, while recurrent or persistent occlusion predicted poorer outcomes. This supports the recommendation by Schankath et al. for repeat HSG within 3–6 months to guide timely IVF referral 16 . From a clinical perspective, FGTR offers several advantages: it is minimally invasive, performed under fluoroscopic guidance without the need for general anesthesia, and has a short recovery period. For proximal obstruction, it can restore fertility without resorting to more invasive surgery or expensive ART. However, FGTR has limitations. Technical difficulty increases with complex or distal lesions, and the procedure requires specialized equipment and operator expertise, limiting availability. Radiation exposure, while generally low with modern techniques, remains a consideration for reproductive-aged women, particularly if multiple imaging procedures are needed. Alternative treatments include laparoscopic tuboplasty or tubal re-anastomosis, which may be indicated in selected distal disease or post-sterilization reversal cases. These surgical options, however, require general anesthesia, involve longer recovery times, and carry higher procedural risks. IVF remains the most effective approach for advanced distal disease or in cases with poor tubal mucosal integrity, but it is costlier, invasive, and emotionally demanding. The strengths of our study include a relatively large, well-defined cohort and the fact that all FGTR procedures were performed by a single experienced interventional radiologist, minimizing operator variability. Strict inclusion criteria ensured a homogeneous study population. Limitations include the retrospective design, potential selection bias due to non-randomized treatment allocation, and relatively short follow up limited to pregnancy rather than live birth rates. In summary, FGTR is an effective, minimally invasive option for women with tubal factor infertility, particularly for proximal disease. In carefully selected patients without other infertility factors, spontaneous conception following FGTR can be considered a first-line approach, with IUI or IVF reserved for those who do not conceive within a reasonable timeframe. Anatomical site and laterality of obstruction, as well as follow up patency assessment, should guide individualized treatment planning to optimize reproductive outcomes.

Infertility affects approximately 10–15% of couples worldwide, with tubal factor infertility accounting for nearly 30–40% of cases 1 . In women, the most frequent causes include ovulatory disorders and problems related to the fallopian tubes 2 . Tubal factor infertility is a significant contributor, estimated to be responsible for 11% to 67% of infertility diagnoses 2 . This type of infertility can arise from blockages within the fallopian tubes, structural abnormalities resulting from inflammation or infection, or pelvic adhesions that hinder the normal function of the tubes. Fallopian tube blockages can occur near the uterus (proximally). These proximal blockages often consist of accumulated debris forming a plug 3 . Blockages further down the tube (distally) are typically the result of prior infections, potentially leading to hydrosalpinx, characterized by a widened fallopian tube and the absence of dye spillage during a hysterosalpingography (HSG) 4 . Tubal occlusion can result from infections, pelvic inflammatory disease, endometriosis, or prior surgical interventions 5 . Fluoroscopy-guided tubal recanalization (FGTR), a minimally invasive procedure, has emerged as an effective treatment for restoring tubal patency and improving the chances of natural conception 6 . The optimal management strategy after FGTR, whether to pursue natural conception or use fertility interventions such as intrauterine insemination (IUI) remains a topic of debate. Although both methods are widely used, there is limited evidence directly comparing their effectiveness in women who have undergone FGTR. Understanding the relative success rates and time to conception between these two approaches is essential for optimizing fertility treatment strategies. This study aims to evaluate pregnancy outcomes following FGTR, comparing spontaneous conception rates and pregnancy outcomes achieved through IUI.