Evaluation of hysteroscopic tubal cannulation under laparoscopic control versus intracytoplasmic sperm injection in cases with proximal tubal obstruction

Objective The aim of this study was to present the diagnostic findings, the immediate and the remote tubal patency rates, and the reproductive outcome in patients with proximal tubal obstruction (PTO) treated with hysteroscopic tubal cannulation (TC) under laparoscopic guidance and to compare the reproductive outcome of PTO patients treated with TC with those treated with IVF/intracytoplasmic sperm injection (ICSI). Design Prospective clinical study. Setting Tanta University Hospital and private centers (AL-Salam and Egyptian Consultants IVF/ICSI centers). Patients and methods Eighty-five infertile patients with bilateral PTO on repeat hysterosalpingogram (HSG) and confirmed by laparoscopy constituted the study population of the present study. Patients were recruited from Tanta University Hospital (Egypt) and at private work during the period from August 2008 to July 2012. The study population was distributed, after counseling, according to their personal preference between two modalities of therapy: 35 patients selected hysteroscopic TC and 50 patients selected IVF/ICSI. In group I (35 patients), a coaxial cannulation set composed of a Labotect flexible guide cannula, a 3-Fr end-hole Teflon ureteric catheter, and a Teflon-coated stainless-steel urologic guidewire was utilized for hysteroscopic TC under laparoscopic guidance. Group II was subjected to ICSI. Main outcome measures were the immediate on-table success of TC evidenced by intraoperative laparoscopic chromopertubation, the long-term persistence of achieved tubal patency documented by HSG performed 6 months after the procedure, and the reproductive outcome following the hysteroscopic TC compared with the IVF/ICSI group. Results Successful TC and achievement of tubal patency were evident in 48 (68.6%) tubes present in 27 (77.1%) patients. Initial total failure of the procedure was evident in eight (22.9%) patients. Tubal perforations led to complicated cannulation of five (7.1%) tubes. Twelve women (34.3%) achieved intrauterine pregnancies and two patients (5.7%) had a tubal ectopic pregnancy. HSG, performed 6 months after TC for the patients who did not conceive, indicated preservation of tubal patency in eight (22.9%) patients and bilateral tubal reocclusion in 13 (37.1%) patients. In group II (50 patients with PTO subjected to IVF/ICSI), clinical pregnancy was achieved in 16 patients (32%). Conclusion Hysteroscopic TC is a safe and cost-effective procedure that has clear diagnostic and therapeutic benefits for infertile patients with PTO. Considering the success rate of hysteroscopic TC, about two-thirds of patients with PTO managed by this technique are recommended to attempt to conceive naturally instead of being referred to IVF/ICSI or microsurgery.