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11/1/2013

Proximal Tubal Occlusion

Proximal tubal occlusion is a common finding on hysterosalpingogram, occurring in up to 15% of studies. The occlusion is seen at the utero-tubal junction, where radiographic contrast fails to enter the isthmic fallopian tube. In a high proportion of cases, the proximal occlusion may be functional. Occlusion is an important finding because tubal peristalsis is necessary for gamete transport. The interstitial portion of the fallopian tube is a complex region anatomically where the myometrium of the uterus transitions into the three layers of muscle that make up the fallopian tube. Instrumentation of the uterus during the HSG procedure often leads to bilateral tubal spasm and non-filling of the tubes. However, the occlusion may be due to a number of pathologic conditions such as acute or chronic salpingitis, salpingitis isthmica nodosa, cornual fibroids, pelvic adhesive disease, endometritis, prior ectopic pregnancy, and adenomyosis. SIS detects the accumulation of fluid in the pelvis by ultrasound as evidence of tubal patency, but the false positive rate for the diagnosis of tubal occlusion may exceed that of HSG.

Many techniques have been described to overcome tubal occlusion. These include transcervical tubal cannulation by fluoroscopy, simultaneous hysteroscopy and laparoscopy, transcervical balloon tuboplasty, falloposcopy, and saline infusion sonohysterography (SIS). All of these methods have some utility, but most require anesthesia and significant experience.

The simplest way to confirm the presence of pathologic proximal tubal occlusion may be to repeat the HSG a month later. In a study of 40 patients with proximal tubal occlusion seen on the initial examination, repeat HSG demonstrated patency in 60% of cases. HSG requires no anesthesia, minimal lost time from work, and may be the best approach to evaluate for tubal patency. It does require some operator skill, as it is possible for factors such as excessive uterine manipulation, cold contrast, or intrauterine trauma to precipitate tubal spasm and temporary occlusion of the isthmic region of the fallopian tube.

Office hysteroscopy is not clinically useful. Three-dimensional ultrasound alone can help detect the presence of fibroids, but does not assess tubal patency.

If it is confirmed that the fallopian tubes are occluded, in vitro fertilization is often the best treatment option. Pregnancy rates after IVF for tubal disease are age-related, but the nationally reported live birth rate per cycle for patients under age 35 is approximately 40% (SART).

Further Reading:

Practice Committee of the American Society for Reproductive Medicine. Committee opinion: role of tubal surgery in the era of assisted reproductive technology. Fertil Steril. 2012 Mar;97(3):539-45. doi: 10.1016/j.fertnstert.2011.12.031. Epub 2012 Jan 29. PMID: 22285747.

Dessole S1, Meloni GB, Capobianco G, et al. A second hysterosalpingography reduces the use of selective technique for treatment of a proximal tubal obstruction. Fertil Steril. 2000 May;73(5):1037-9.

Initial approval: November 2013; Revised: September 2018. Reaffirmed March 2020. Revised November 2023

 

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