Comparative Efficacy of Hysteroscopy Re-Canalization & Microsurgical Canalization in Proximal Tubal Obstruction

INTRODUCTION: Fallopian tubal disease is responsible for 20-30% of female infertility world wide (1) .Its importance as a major cause of infertility was recognized by Burns (1809). Patent fallopian tubes are prerequisite for normal human fertility. It has a crucial role in picking up eggs, also in sperm and ovum transport. It is the site of fertilization and important in nutrition of ovum. Such a highly specialized organ is vulnerable to infection and surgical damage that impair function by affecting the delicate fimbriae or the endosalpinx. The causes of tubal obstruction are pelvic inflammatory disease, endometriosis or history of previous surgery. This study deals with proximal tubal obstruction. AIM OF THE STUDY: 1. Comparing the efficacy of Hysteroscopic cannulation and Microsurgical tubal anastomosis as a method of tubal re-canalization in proximal tubal obstruction. 2. To assess the safety and relative complications between these two methods. MATERIALS AND METHODS: This study was conducted in the Institute of Social Obstetrics Government Kasturba Gandhi hospital from August 2006 to July 2007. The study was approved by the hospital ethical committee. Study Design : Prospective analytical study. Study Place : Institute of Social Obstetrics, Kasturba Gandhi hospital. Study sample : 50 infertile women with bilateral tubal occlusion. Study period : August 2006-July 2007 From women attending the Infertility clinic, based on the inclusion and exclusion criteria, HSG was performed in 186 women with infertility. Of the 186 women in whom HSG was performed, 99 patients had normal tubal spill , 13 cases had unilateral tubal block and 74 cases had bilateral tubal block. Of these, 38 patients had cornual block and 20 patients had suspicious finding of either tubal block or spill and they were subjected to laparoscopy for confirmation of tubal pathology. 16 patients had block in various parts of the tube other than cornua and hence were excluded from the study. SUMMARY: This prospective analytical study was undertaken in Government Kasturba Gandhi hospital, Chennai during the period of 2006-2007 among the 50 infertile women after confirming proximal tubal obstruction. The various observations are: 1. In this study, the significant number of women with primary and secondary infertility, belonged to the age group 26 to 28 years. 2. In this study longer the duration of marriage, more severe is the tubal disease, as there is increase number of sexual exposures. This showed statistical significance. 3. Type of infertility did not significantly alter the result of cannulation. 4. The tubal patency achieved by cannulation is 94% and the tubal patency achieved by microsurgical anastomosis was only 64%. 5. Tubal patency with both techniques achieved shows significant P value of 0.0331 by Fisher exact test. 6. Proximal tubal cannulation is the better option as mostly the obstruction is due to mucus plug or amorphous debris and is not due to true oclusion. CONCLUSION: This study is on the comparative efficacy of Hysteroscopic recanalization and Microsurgical tubal canalization in the management of proximal tubal obstruction. This study reveals proximal tubal obstruction, as a frequent cause for infertility. The incidence is higher with increasing age and also the duration of marriage. Hysteroscopic recanalization appears to be a better option for a successful outcome. The main drawback with this technique is that it can be performed only when the obstruction is without fibrosis or other associated complications. Microsurgical canalization, on the other hand, can be performed even in those severely affected cases. But the success rate is comparatively low and the procedure has a higher incidence of ectopic pregnancy. Hence both the methods can be used for a successful outcome if they are used in the appropriate patient and the appropriate technique is followed.