Infertility is defined as the inability to become pregnant after a year of attempting conception. It is estimated that 10-15% of reproductive age couples in the United States are infertile. There are both male and female causes of infertility, with 30-40% of infertility cases being due to male factors (including a varicocele).
Common Causes of Female Infertility
The most common cause of female infertility is problems with ovulation, which accounts for up to 40% of infertility in women. Causes for this include abnormal hormone levels, polycystic ovary syndrome, endometriomas, thyroid disease, low body fat, obesity, Cushing’s Syndrome and other chronic medical problems.
Uterine and cervical abnormalities are common in infertile women as well. These include congenital uterine abnormalities (e.g., septate uterus, bicornuate uterus), fibroids, endometrial polyps, intrauterine adhesions (Asherman’s Syndrome), and problems with cervical mucus production. Abdominal problems such as endometriosis and pelvic adhesions can also be responsible for infertility in women.
Infertility Caused by Fallopian Tube Disease
Fallopian tube disease can account for up to 25-35% of all infertility cases. Many patients with fallopian tube disease will require either tubal reconstructive surgery or in-vitro fertilization. There are, however, patients that have a proximal tubal occlusion due to the accumulation of mucus and/or inflammatory debris, that can potentially be treated with a less invasive procedure.
The exact cause of this type of occlusion is unknown, but may be due to retrograde menstrual flow from the uterus into the fallopian tubes, Chlamydia infection, and abnormal function of the fallopian tubes. Laparoscopy is often performed in these patients in order to diagnose a blockage of the fallopian tube(s) as a potential cause for infertility.
Diagnosis of Fallopian Tube Occlusion
Hysterosalpingogram: This is typically the first test performed to assess whether or not the fallopian tubes are open (patent) or shut (occluded). This procedure is performed through the vagina. A speculum is placed inside the vagina to visualize the cervix, which is the opening into the uterus.
Once this is visualized, a small catheter (tube) is placed through the cervix and into the uterus. This catheter has a small balloon on its tip, which prevents it from falling out of the uterus. Once the catheter is within the uterus, dye is injected into the catheter.
In a normal patient, this dye will travel from the inside of the uterus into the fallopian tubes. If the tubes are open, the dye will pass through the tubes into the abdomen. This is otherwise known as “free spill into the peritoneal cavity.” If a tube is blocked, the dye will only pass from the uterus to the point of the blockage.
Interventional Treatment of Fallopian Tube Occlusion
Fallopian Tube Recanalization: This procedure is performed in patients with occlusion of one or both fallopian tubes. It is typically scheduled somewhere between day 5-10 of the menstrual cycle, which is after menses has completed but before ovulation.
Technically, the procedure is performed through the vagina. A speculum is placed inside the vagina to visualize the cervix, which is the opening into the uterus. Once this is visualized, a small catheter (tube) is placed through the cervix and into the uterus. A second catheter is passed through the first catheter and directed towards the expected location of the fallopian tube. The opening to the fallopian tube is gently probed with a small wire until it enters the tube.
At this point, the catheter is advanced over the wire and past the blockage within the fallopian tube. Dye is then injected through the catheter to confirm that the remaining portion of the fallopian tube is normal in appearance. The catheter is then removed, since just placing the catheter through the blockage creates enough of a channel to open the tube.
The outcomes after fallopian tube recanalization can be described in terms of technical success, which is the ability to open a blocked fallopian tube, or clinical success, which is essentially the pregnancy rate after the procedure.
Technical success rates ranging from 71-98% have been reported with this procedure and pregnancy rates have ranged from 26-47%. Complications associated with this procedure are rare, and include ectopic pregnancy (3%), tubal perforation (2%), bleeding, and infection.
