Title: Proximal Tubal Cannulation- An Audit

Authors: Dr Hira Fatima, ST6 James Cook University Hospital, Dr Shirsha Maitra Trust Registrar James Cook University Hospital, Dr Jennifer Ip , ST3 Royal Victoria Infirmary Newcastle, Dr Hany Mostafa, Consultant North Tees University Hospital

Introduction: 

Tubal disease is the cause of subfertility in approximately 30% of women and 10 25% of these are due to proximal tubal obstruction. False positive diagnosis of proximal tubal obstruction can be as high as 50%.

A decrease in expertise in tubal microsurgery has resulted largely from the use of IVF as the treatment option for most causes of infertility and more specifically for tubal factor infertility.

Selective salpingography and tubal cannulation have a unique role in the management of tubal infertility and should be offered to selected candidates prior to IVF.

Tubal cannulation can be used effectively to restore patency in a proportion of cases of proximal tubal obstruction thus probably avoiding the need for high cost

assisted reproductive techniques

PTC Pathway:

All fertility patients are offered a tubal patency test (HSG as first choice)

Cases with suspected proximal tubal block are offered combined laparoscopy , hysteroscopy and attempt of proximal tubal cannulation.

Selective tubal cannulation and Dye test plus the use of the guidewire to unblock intramural and isthmical tubal block.

Objective:

To examine the success rate of proximal tubal cannulation, associated complications and identify areas for improvement, and to compare the current practice to

NICE guidance (CG 156 )

Method:

Retrospective review of notes of all infertility patients in a hospital in North East of England who underwent proximal tubal cannulation for a suspected

unilateral/bilateral proximal tubal block, over 3 years, was done.

Cases were identified via inpatient records and theatre reports. Sample size was 9.

Main problems encountered were Identification of cases being very time consuming due to coding issues and the small number of cases.

Results:

Duration of infertility was 7 to 48 months. Primary infertility was found to be 56% and Secondary infertility was 44%

Male factor infertility was identified in 56%.

Evidence of tubal blockage confirmed on HSG was 100% in the selected cases ; unilateral 56%, bilateral44%.

Associated distal tubal block was found in 22% of cases, all bilateral.

Successful tubal cannulation was performed in 78% of the cases with dye test positive being positive in 71% of cases. No major complication was observed.

Discussion:

No controlled studies available. In 2 different studies successful cannulation was found to range between 77% (total 417) to 75%(total 234).

No complications detected with a 100% safety profile.

In the studies identified, the rate of tubal perforation ranged from 1% (4/417) to 11% (4/38), and the rate of tubal pregnancy from 0.4% (1/234) to 8%

(3/38).

Other reported complications were sepsis in 0.9% (2/234) of patients, and pain requiring medication in 3% (7/234 and 4/150) of patients.

Conclusion:

Our results are consistent with the international practice: 78% cannulated vs dye test positive 71%.

The procedure (proximal tubal cannulation) should be continued to be offered due to good efficacy and low complications.

Areas of good performance are Safety and success rate. However areas requiring improvement are patient literature and coding. A patient information leaflet

was developed and published for the said procedure as part of action plan.