Opportunistic Tubal Cannulation at the Time of Endometriosis Excision

INTRODUCTION: Tubal occlusion is found incidentally in upwards of 25% of women undergoing excision of endometriosis, with its prevalence increasing with disease severity. The optimal treatment of unilateral tubal occlusion has not been determined in patients for whom tubal patency is desired. OBJECTIVE: We aim to review the prevalence of tubal occlusion in infertile patients, review ideal candidate selection for tubal cannulation, and to review tubal cannulation technique. To our knowledge, there has not been a high-quality hysteroscopic demonstration of this technique. METHODS: After the tubal ostium is visualized, the introducing catheter is directed towards the tubal orifice and wedged against the ostium. Methylene blue is injected while assessing for tubal patency laparoscopically. When no spillage is observed, the inner catheter is advanced into the proximal fallopian tube to confirm tubal blockage and rule out temporary tubal spasm. The intramural portion of the fallopian tube is then cannulated by first advancing the guide wire, then with the inner catheter. The flexibility of the guide wire tip increases as the length exiting the catheter increases. The advancement of the wire guide is assessed laparoscopically by observing for characteristic arching of the tubal isthmus. The tube is constantly interrogated for patency. The distance the catheter passes into the tubal isthmus may be determined by observing the distance markings along the catheter. The inner catheter is then advanced over the guide wire until resistance is felt. However, if significant resistance is met, the wire should not be advanced. The guide wire is then removed and methylene blue is injected, observing laparoscopically for spillage. RESULTS: Tubal cannulation of an occluded left tube is successfully demonstrated. CONCLUSIONS: Hysteroscopic tubal cannulation is a minimally invasive management option for proximal tubal occlusion and can be performed at the same time as endometriosis resection. It can be a cost-effective method to optimize fertility, especially in patients who may not have access to other fertility interventions due to cost, geography, or other systemic barriers.