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Int J Clin Exp Med 2017;10(12):15950-15959 www.ijcem.com /ISSN:1940-5901/IJCEM0067596

Review Article Diagnosis and treatment of obstruction: a literature review

Xiaojie Liu1, Haipo Cui1, Wei Chen2, Xueting Xuan1, Xueke Guo1, Yongchu Hu2

1Department of Medical Instrument and Food Engineering, University of Shanghai for Science and Technology, Shanghai 200093, China; 2Department of anesthesiology, Shanghai Changzhen Hospital, Second Military Medi- cal University, Shanghai 200003, China Received October 20, 2017; Accepted October 30, 2017; Epub December 15, 2017; Published December 30, 2017

Abstract: 15% of couples in the world suffer from , and tubal obstruction caused by inflammatory is one of the main causes. The incidence rate of this infertility has increased year by year, corresponding diagnosis and treat- ment methods also have a rapidly development. At present, commonly used methods are: 1. Diagnosis: Hystero- salpingography (HSG), hysterosalping-contrast sonography (HyCoSy), uterine ; 2. Treatment: traditional drugs, and laparoscopic surgery, interventional therapy. This paper describes the relevant clinical studies of each method and their respective advantages and disadvantages, indicating that can be used as a preliminary diagnosis of tubal obstruction. Laparoscopy can be used for further pelvic-related disease examination. Select Hysterosalpingography and interventional therapy can be used as a micro-invasive, low cost and efficient diagnosis and treatment program. In addition, patients with complex conditions should be based on specific circumstances and use a single or integrate multiple methods to achieve the purpose of diagnosis and treatment.

Keywords: Fallopian tube obstruction, diagnosis, therapies

Introduction of diagnosis include hysterosalpingography, hysterosalpingo contrast sonography, gyneco- Fallopian tubes are an important site for the logical endoscope, serological exam- - binding, and their normal function- ination. A variety of therapies are available, ing serves as a prerequisite for natural concep- which are dominated by hysteroscope, laparo- tion. Obstruction of fallopian tubes, a kind of scope, and interventional therapy. Other thera- common disease, is also one of the main pies available include use of traditional Chinese causes of infertility. It is urgently hoped by such and psychological interventional ther- patients to unblock the obstructed fallopian apy. The paper gave a brief review of diagno- tubes and restore the reproductive functions. sis and treatment of the infertility caused by Obstruction of fallopian tubes is mostly caused obstruction of fallopian tubes, and illustrated by . With increasing in the merits, demerits and corresponding clinical , especially in the “items” application of each therapy, respectively. of infection sources, the patients troubled with Examination and diagnosis obstruction of fallopian tubes also grow day by day. The infertile women caused by obstructed The tubal infertility can be diagnosed by a fallopian tubes and account for number of ways, including hysterosalpingogra- 30-40% of all the infertile population [1]. Among phy (HSG), Hysterosalpingocontrast sonogra- the factors of infection, there is general bacte- phy (HyCoSy), gynecological , and rial infection as well as some special pathogen serological chlamydia examination. infection caused by , , hominis, Hysterosalpingography (HSG) and protozoon. Thus accurate diagnosis and optimum chosen therapy are critical for the HSG means to inject iodinated oil, a kind of high treatment of infertility. Now the common ways specific gravity substance, into the uterine cav- Diagnosis and treatment of fallopian tube obstruction ity through the so that the forms by combining the HyCoSy with two-dimensional significant artificial contrast with surrounding ultrasonography to diagnose gynecological dis- tissues under X-ray and the physician can get to eases. The contrast agent evolves from the nor- know the conditions of the and fallopian mal saline to hydrogen peroxide, and ultrasonic tube lumen. It can not only prompt about the contrast agents of 1st and 2nd generations, blockage and its location in fallopian tubes but whereas the ultrasonography technology devel- also reveal the uterine shape. This way of exam- ops from the normal B-type gray-scale ultrason- ination is relative safe without significant pain ic imaging to color doppler blood flow imaging, and anaesthesia, thus it is a typical approach energy diagram, and all sorts of new imaging used frequently to judge the smoothness or not techniques so that the diagnosis becomes of the and fallopian tubes [2]. The increasingly accurate. The limitation of two- diagnostic criterion of this method are: 1. Tubal dimensional ultrasound contrast lies in follow- patency: no resistence while injecting the con- ing aspects: it can’t display the whole curved trast agent; X-ray results show normal fallopian tube on different planes; the contrast morphology with engorged contrast agent; con- agent can’t be distinguished from the echo of trast agents are evenly distributed in the pelvic intestinal canal due to high similarity; it is cavity after 24 h. 2. Tubal partial obstruction: impossible to get the coronal section of uterus some resistance while injecting contrast agent; and the information about uterine diseases is contrast agent filled in oviduct but showed tor- limited. Three-dimensional ultrasound contrast tuous, narrow, sticky and acute sometimes; fal- is produced to conquer the shortcomings of lopian tubes may present stiff or local thick- two-dimensional one. With the updated con- ness; contrast agents are unevenly distributed trast agent and imaging technology, 3D-HyCoSy in the after 24 h. 3. Fallopian tube can obtain 3D stereo images of the fallopian obstruction: do not develop or develop tubes and display three sections (namely coro- partially while injecting contrast agent; no con- nal section, sagittal section, and cross section) trast agent outflow from tubes; contrast agent vertical to each other at the same time, thus it do not appear or present crumby structure in can better evaluate the shape, smoothness or pelvic. Some studies [3] evaluated the accura- not, and obstructed site of the fallopian tubes cy of HSG diagnosis and compared it with the [5]. laparoscopy, and found that HSG was highly sensitive in the diagnosis, useful in the prelimi- Wang et al. [6] employed three-dimensional nary examination of obstruction of fallopian ultrasound contrast to diagnose 52 cases of tubes, and advantageous in such aspects as obstructed fallopian tubes. In accordance with minor invasiveness, low cost and complication the CLP diagnosing criteria, the diagnosing sen- incidence. On the other , it is not as effec- sitivity, specificity, positive predictive value and tive in identifying such diseases as pelvic negative predictive value of 3D-HyCoSy were inflammation, , and salpingor- 82.4%, 88.3%, 77.9%, and 90.2%, respectively. rhexis with low value for diagnosis [4]. The The application of 3D ultrasound significantly aforesaid diseases can be further examined raises the sensitivity and specificity of the diag- and diagnosed with laparoscopy. To sum up, nosis [7]. It is noteworthy that the three-dimen- HSG is convenient in operation and low in cost, sional imaging is built on the basis of two- so it is still widely promoted and used in the dimensional images, so the latter’s quality can primary schools. directly affect the effect of the former. With nar- Hysterosalpingocontrast sonography (HyCoSy) row scope of observation, three-dimensional transvaginal ultrasound examination is inappli- HyCoSy is to inject contrast agent into the cable to the women pregnant for 8-10 weeks. lumen so as to dilate the closed uterine cavity Moreover, when the lump in the adnexa area is and fallopian tubes and form ultrasonic imag- quite large or has complicated structure, it may es. It is mainly used to diagnose the diseases intervene with the display of tubal reconstruc- concerning uterine cavity and evaluate the tion. The 3D HyCoSy can’t well reveal the smoothness of the fallopian tubes. At first, interior of the fallopian tubes, especial the dis- the researchers at home and abroad mainly eases concerning tubal mucosa and pelvic focused on two-dimensional ultrasonic imaging .

15951 Int J Clin Exp Med 2017;10(12):15950-15959 Diagnosis and treatment of fallopian tube obstruction

Gynecological endoscopy indicators of research objects, sorted out the data through statistical approaches, and ana- 1. Laparoscopy is a golden criterion for the lyzed the relation between the tubal infertility diagnosis of tubal infertility [8] with high sensi- and some reproductive tract inflammatory fac- tivity and specificity and ability in evaluating the tors and pathogens. Their results revealed the and other pelvic structures. positive indicators in observation group were LIU et al. [9] carried out hydrotubation and HSG significantly higher than those in control group, towards 120 cases of tubal infertility under and positive rates of C-HSp60, IL-6 and IFN-γ laparoscopy. The results revealed the sensitivi- for patients suffering from tubal infertility grew ty and specificity of HSG in diagnosis of tubal obviously and could be used as serological indi- obstruction were 84.62% and 69%, while those cators for clinical screening of tubal infertility. of laparoscopy were 94.87% and 83%. It indi- Such examination can provide a new approach cated that the laparoscopy was better in diag- for the clinical diagnosis of tubal infertility. nosing such obstruction. But for the patients, the laparoscopy was an invasive examination Therapies demanding high cost. It is improper to be used as primary tool of diagnosis due to many fac- Tubal recanalization under assistance of tors concerning environment and conditions endoscopy [10]. Some researchers insisted that the lapa- roscopy was more advantageous in the diagno- Tubal obstruction therapy under assistance of sis of pelvic diseases [11], and it could be used hysteroscopy-laparoscopy: The cause of dis- in the further diagnosis in case of missed diag- ease can be determined under the direct view nosis with HSG [12, 13]. with hysteroscopy-laparoscopy so as to per- form following procedures on the basis of the 2. Hysteroscopy: one of the primary strengths determined cause: salpingolysis, oophorocys- of the hysteroscopy is its ability to enable the tectomy, hysteromyoma, polycystic drill- physicians to directly examine the inside of ing operation, intrapelvic abnormality reductive uterine cavity and make accurate judgment surgery, pelvic adhesiolysis, tubal fimbrioplasty about the diseases, determine the organic and neostomy. Proximal intubation, pressuriza- causes within the cavity for some infertility or tion and hydrotubation under hysteroscopy can recurrent , and remedy the shortcom- be performed for the middle and proximal ings of traditional diagnosis and treatment obstruction, needle electrode separation for methods. Molinas et al. [14] believed that it pro- intrauterine adhesion, and loop electro-surgi- vide a direct view of the inner part of uterine cal excisional procedure, bipolar vaporization, cavity, the hysteroscopy can become primary or scissor cutting for . tool of diagnosis for the infertility caused by obstructed aperture of fallopian tubes. Some Tube recanalization under assistance of hyster- studies [15-17] even pointed out that the com- oscopy: The patient took orally 1 h bined examination of hysteroscopy with lapa- before taking the operative treatment. After roscopy could improve significantly the accura- normal and anaesthesia, the uter- cy of the diagnosis. us was distended, hysteroscopy was inserted into the uterus and then into the fallopian tube Serological chlamydia examination to reach the interstitial portion with adjustment of the ostium. Mixed solution of normal saline, The physiological functional disorders concern- gentamicin, dexamethasone and methylene ing fallopian tubes or tubal infertility are mostly blue was injected into the catheter. Attention caused by tubal mucositis and perisalpingitis was paid to the return of recanalization liquid. F after appearance of all sorts of pelvic infec- Yang [20] divided 60 patients of tubal infertility tions. Now some studies have proved [18] that into two groups, and performed normal intuba- the tubal infertility is related to chlamydia tra- tion recanalization and intubation recanaliza- chomatis (CT). Li Yuhua et al. [19] conducted tion under assistance of hysteroscopy on them. relevant lab examinations in two groups According to the results, the successful rate of [CT-DNA, UU-DNA, antibody to heat shock pro- incubation recanalization under hysteroscopy tein 60 (C-HSp60), IL-6, IFN-γ and bacterial cul- was 93.3% (28/30) while that in case of tra- ture], recorded the positive rates of all the test ditional incubation recanalization was 67.7%

15952 Int J Clin Exp Med 2017;10(12):15950-15959 Diagnosis and treatment of fallopian tube obstruction

(20/30), and significant difference could be (27.78%) among the 19 primary infertile pa- detected between them. It indicates that the tients in the group of hysteroscopy. The recana- treatment of tubal obstruction with incubation lization rates was no significant difference recanalization under assistance of hysterosco- between 18 secondary infertile patients in the py can obtain good clinical effect. hysteroscopy group and the 22 primary infertile patients in the group of hysteroscopy in combi- Tube recanalization under assistance of lapa- nation with laparoscopy, which meant the treat- roscopy: The patients accept normal disinfec- ment effect of hydrotubation under hysteros- tion in the before the operation. Aseptic copy in combination with laparoscopy was towel should be spread and the anaesthesia significantly better than that of hysteroscopy adopts intratracheal inhalation. The patient is alone. The means of combined technology was asked to adopt lithotomy , and cut is especially effective for the secondary infertile formed below the navel as entrance for lapa- patients. roscopy. A small cut of 5 mm is also created in front of crista iliaca. The operation assistants Wire-guided tube recanalization under combi- prepare all the apparatus and instruments nation of hysteroscopy with laparoscopy: The required for the operation, and the uterine and operation takes lithotomy position and tracheal tubal recanalization is carried out. The selec- intubation is performed under general anaes- tion of operation plan depends on the condi- thesia. Laparoscope is inserted into the body to tions of the patients in order to ensure the detect the shape, size, and location of the pel- specificity and scientificity of the operation. vic cavity, uterus and ovary and find out wheth- After the operation, normal anti-inflammation is er the fallopian tubes have adhesion or distor- exerted and preventive measures against fallo- tion. Corresponding operative procedures are pian tube adhesion should be taken. The con- performed, such as separation of the pelvic crete operation procedures as well as the type adhesion (if any), and restoration of the organs and way of operation vary with the patients. In within the pelvic cavity to the normal shapes as general case, the operations include tubal fim- much as possible. The patients displaying fim- briae dilation, tubal end anastomosis, mass briae adhesion and dropsy should accept plas- release, and salpingostomy. Wang et al. [21] tic surgery or neostomy; those having mesosal- recanalized the obstructed fallopian tubes of pinx cyst should accept enucleation; those 63 patients under the assistance of laparosco- having focus of endometriosis should accept py. After the treatment, the smoothness rate of electrocoagulation on the focus or enucleation the patients achieved 49.2%, and no negative of chocolate cyst. The hysteroscopy is inserted effect or complication was found after the oper- to observe the thickness and color of the endo- ation. The prognosis was satisfactory. The lapa- metrium as well as the shape of uterine cavity. roscopy is proven to have good clinical effect Oviduct catheter is placed through the ostium and few intraoperative complications in treat- of fallopian tubes under hysteroscopy, and ing tubal infertility, thus it can be effective to mixed solution of methylene blue with normal clinical practice. saline is injected through the catheter as indi- cator so that the physician can get information The tube recanalization under combined hys- about the obstruction of fallopian tubes and teroscopy with laparoscopy: Li Hongmei [22] the detailed location through the indicator divided 80 patients suffering from tubal infertil- under laparoscopy monitoring. In case of great ity into two groups. About half of the patients in resistance or partial enlarged fallopian tube, it each group was of secondary infertility. Two indicates existence of tubal obstruction. Tube groups accepted tube recanalization with hys- recanalization is performed by inserting the RF teroscopy and its combination with laparosco- guide wire into the oviduct catheter and propel- py, respectively. The test results revealed that ling it from the near end to the remote end of the successful recanalization rate in the hyster- fallopian tubes in order to dredge the adhesion oscopy group was 55%, significantly lower than in interstitial portion, isthmus and ampullary that of hysteroscopy-laparoscopy group (85%). region of the fallopian tubes. The guide wire is In the group of hysteroscopy in combina- inserted until it reaches the fimbriae of the fal- tion with laparoscopy, the recanalization rate lopian tubes. After that, the wire should be among 21 secondary infertility patients was retreated, and diluted solution of methylene 85.71% which was significantly higher than that blue is again injected. Under the laparoscopy,

15953 Int J Clin Exp Med 2017;10(12):15950-15959 Diagnosis and treatment of fallopian tube obstruction when the diluted solution of methylene blue is at the ostium of the obstructed fallopian tube, found to flow out from the fimbriae end, it and insert guide wire into the catheter to sepa- means the fallopian tubes are successfully rate the adhesion. After a successful recanali- recanalized, but the solution should be injected zation, anti-inflammatory drug should be inject- still to prevent possible adhesion. In their stud- ed to treat the and anti-adhesion ies, Hou et al. [23] implemented tubal intuba- medicine to consolidate the effect of therapy. tion with hysteroscopy under the guidance of laparoscopy on 650 patients suffering from In a clinical study [24], 116 cases of tubal unilateral or bilateral proximal tubal obstruc- obstruction were randomly divided into experi- tion. As revealed by the results, successful mental group and control group to accept inter- tubal incubation can significantly improve the ventional tube recanalization therapy under pregnant rate, and the patients with unilateral imaging of digital subtraction angiography tubal obstruction are mostly possible to get (DSA). The patients in the experimental group pregnant after successful incubation. It means accepted tube perfusion with ozone water while the women with proximal tubal obstruction can those in control group with normal anti-inflam- consider accepting the hysteroscopy intuba- matory and adhesion . As revealed tion under guidance of laparoscopy as a by the experimental result, the successful substitute plan for the assisted reproductive recanalization rate, pregnant rate and recur- technology. rence rate were 93.1% (54/58), 79.3% (46/58), and 5.2% (3/58), respectively for the expe- Interventional treatment rimental group, and 91.4% (53/58), 60.3% (35/58) and 17.2% (10/58) respectively for the Interventional treatment is a minimally invasive control group. An analysis prompted about no approach for treating the obstruction of fallopi- statistical difference in respect of the success- an tubes by combining radiological apparatus ful recanalization rate between two groups, and with imaging equipment to realize intervention. lower pregnant rate and recurrence rate in the The way of diagnosis is to adopt selective experimental group. The experiment indicates salpingography, and the treatment methods that the interventional drug perfusion in treat- include tube recanalization and drug perfusion ment of tubal obstruction can effectively raise within fallopian tube lumen. The traditional the post-operation pregnant rate, and the per- per-X ray salpingography serves only as a me- fusion of fallopian tubes with ozone can substi- ans of detection that can find sites of adhesion tute the traditional anti-inflammatory and adhe- and obstruction but can’t exert treatment. By sion medicines. contrast, the selective salpingography increas- es the static pressure of liquid within fallopian Assisted treatment with traditional Chinese tubes, and conquers the pain caused by exces- medicine (TCM) sive expansion of the uterine cavity and pseu- do-positive factors of sphincter spasm, while Although the treatment of tubal obstruction by the recanalization makes use of the dilation of combining hysteroscopy with laparoscopy can the guide wire to separate the adhesion within improve the uterine rate, it is sus- fallopian tubes and restores unblocked fallopi- ceptible to recurrence of adhesion and obstruc- an tubes through the pushing static force of the tion after the operation. Some researchers [25- liquid. Meanwhile, it can also facilitate the iden- 27] found that the use of TCM can activate tification of the obstruction causes so as to blood circulation, dissipate stasis, and dredge achieve diagnosis and treatment at the same collaterals during or after the tube recanaliza- time. To perform salpingography is to use digi- tion, which can obtain better effect of tube tal subtraction angiography and apply oviduct recanalization treatment, effectively reduce the interventional recanalization apparatus under re-obstruction rate and improve the intrapelvic the monitoring with imaging equipment and environment, consolidate the operating effect, place the catheter at the fallopian tube lumen and raise the pregnant rate. In the opinions of for injection of contrast agent. If development TCM, the infertility caused by tubal obstruction fails at the far end of fallopian tubes, it is prov- can be mainly attributed to the accumulation of en that the near end gets obstructed, and fur- damp toxin, Qi-stagnation and blood stasis, ther tube recanalization should be performed. and obstructed . It is thus believed in TCM The tube recanalization is to place the catheter that the mission of tubal obstruction treatment

15954 Int J Clin Exp Med 2017;10(12):15950-15959 Diagnosis and treatment of fallopian tube obstruction is to activate the blood circulation, dissipate tubal mucosa, but more for the assessment of the stasis and dredge the collaterals [28]. Chen surgical prognosis and adjustment of treat- G Y et al. [25] performed guide-wire dredging ment programs. Laparoscopic is the most reli- treatment under combination of hysteroscopy able method of examination. But, because of with laparoscopy on 89 patients with obstruct- the invasive and expensive, it is most used as a ed fallopian tubes in their study, and it was means of treatment. HSG is the main diagnos- found that 164 fallopian tubes of 84 patients tic method of tubal obstruction infertility. And it were successfully recanalized. Those 84 pati- can prove to be therapeutic at times [29]. ents were randomly and equally divided into However, HSG means producing a continuous two groups, namely Group A and B, after the pressure which was used to make the contrast operation. Each group was composed of 42 agent filled into uterine cavity. This condition patients. The patients in Group A accepted may induce patients with poor comfort, and TCM orally in combination with Kangfu Xiaoyan even produce pain. HyCoSy is also based on Suppository butt plug after the operation for similar principle in HSG, so there are also si- three courses of treatment (10 d per course), milar shortcomings. Selective salpingography whereas the patients in Group B received no (SSG), which can be used as diagnostic and special treatment. The follow-up one year later therapeutic method, greatly make up for the indicated that among the 86 patients who had shortcomings of HSG. But in terms of the oper- successful tube recanalization, 22 in Group A ability of the device, experienced doctors who and 12 in Group B realized intrauterine preg- can make a quick, accurate and painless oper- nancy with total intrauterine pregnant rate ation are needed. The therapies in early stage reaching 39.53% (34/86), and the difference in such as hydrotubation have such advantageous respect of intrauterine pregnant rate between as simple equipment, convenient operation, two groups was significant, but that in tubal and low cost, but they are also troubled with pregnancy was insignificant. In addition, those high misdiagnosis rate. They can’t determine failing to get pregnant 1 year after the opera- the site of the tubal obstruction or its severity tion accepted HSG. The examination prompted and property, and they may cause massive about 19.5% of re-obstruction rate in Group A hemorrhage with tubal rupture in case of ecto- and 39.3% in Group B. The difference between pic pregnancy. The appearance of the hysteros- two groups was significant. This proves that the copy-laparoscopy and salpingography enables combination with TCM after hysteroscopy-lapa- the physicians to make a comprehensive evalu- roscopy combined operation can improve the ation of the conditions of fallopian tubes, uter- intrauterine pregnant rate and the assisted ine cavity and pelvic cavity. The examination TCM therapy after tube recanalization has cer- with laparoscopy can evaluate the structure of tain reference value for treatment. fallopian tubes and relationship between fallo- pian tubes and other tissues and organs, accu- Discussion rately separate the tubal adhesion and pelvic adhesion, restore the shapes and activities of Among the infertile women, 30-40% of them fallopian tubes, and diagnose such diseases are caused by diseases concerning fallopian as endometriosis in pelvic cavity, and raise the tubes. The tubal diseases serve as a common pregnant rate among secondary infertile pa- factor inducing infertility and pose a tients when used concurrently [22]. When it is task for the infertility treatment. The pathogen- prompted that the fallopian tubes are obstruct- esis is quite complicated, including inflamma- ed in hydrotubation under hysteroscopy, guide tion in fallopian tubes, oviduct , wire recanalization can be directly carried out endometriosis, post-operation pelvic damage with monitoring of laparoscopy, which harvests and adhesion, and congenital aplasia. Among good treatment effect in respect of proximal them, the non-specific salpingitis is the most tubal diseases [30-36]. As for the distal obs- common cause for the obstruction of fallopian truction of fallopian tubes, some researchers tubes, accounting for one third of the tubal [37-39] pointed out the assisted laparoscopy infertility. There are many diagnostic methods therapy is of satisfactory clinical value in treat- about tubal patency, including imageological ing the patients with light to moderate distal diagnosis (HSG and HyCoSy), and hysteroscopy tubal obstruction; the post-treatment pregnan- and laparoscopy diagnosis. Endoscopy exami- cy or not is related to the severity of tubal dis- nation can visually observe the condition of eases; and early diagnosis and treatment are

15955 Int J Clin Exp Med 2017;10(12):15950-15959 Diagnosis and treatment of fallopian tube obstruction

Table 1. Advantages and disadvantages of diagnosis methods in fallopian tube obstruction Methods Characteristic Advantages Disadvantages Hysterosalpingography (HSG) Radiography (x-ray) Most commonly used, Limited disease diagnosis, x ray low cost radiation Hysterosalpingocontrast sonography (3D-HyCoSy) Ultrasonography No Radiation, few side ef- Patients suffer pain observation fects, diagnosis accuracy effect are susceptible to Interferent difficult operation for doctor Gynecological endoscopy Hysteroscopy/Laparoscope Gold standard Invasive, high cost Serological chlamydia examination FQ-PCR* -/- Potential methods *FQ-PCR(Fluorescence Quantitative-Polymerase Chain Reaction).

Table 2. Advantages and disadvantages of treatment methods in fallopian tube obstruction Methods Characteristic Advantages Disadvantages Tubal recanalization under assistance of endoscopy Hysteroscopy/Laparoscopy Comprehensive and accurate Invasive, high cost treatment Interventional treatment Integrated diagnosis and Non-invasive,low cost, Integrated x ray radiation treatment diagnosis and treatment Medical treatment Drugs Auxiliary treatment method Independent employment effect is not good

theless, relevant clinical studies reveal [25-27] the assisted use of TCM after the combined operation of hysteroscopy with laparoscopy can prevent recurrence of adhesion after the tubal recanalization so as to improve the the- rapeutic effect. In addition, the psychological factors of the patients also matter [43], which means psychological intervention can help with the treatment of tubal obstruction [44]. Figure 1. Hydrotubation for HSG, a new type of ap- paratus for HSG. To sum up, we summarized the diagnosis and treatment methods of tubal obstruction. We simply described the advantages and disad- more effective. In general, the use of hysteros- vantages in Tables 1 and 2. In diagnosis aspect, copy-laparoscopy can greatly help with the HSG is one of the most commonly used meth- treatment of tubal obstruction, but it is not ods for the diagnosis of fallopian tube obstruc- promoted in the application due to expensive tion. The cost is small and micro-invasive, but price. The interventional treatment with salpin- there are some uncontrollable factors in the gography and tubal recanalization causes little application of HSG. These factors can cause surgical injury when compared with the combi- the patient’s discomfort and the inaccuracy of nation of hysteroscopy with laparoscopy, but it the diagnosis. There are two main types of produces X-ray radiation [24]. instruments for HSG in the market: 1. The inva- The TCM therapy does obtain some effect in sive type: balloon catheter, which are the cur- treating the tubal obstruction-induced infertility rently main used instrument; 2. Minimally inva- [40-42], but it has its own shortcomings, such sive type: hydrotubation for HSG, a new type of as the lack of uniform differentiation criteria apparatus for HSG (Figure 1). Through the and effect evaluating standards in the clinical expansion of the cervix, the balloon catheter studies or quantitative classification of the was placed into the uterine cavities. Then we severity of tubal obstruction. On the other hand, can complete the injection of contrastagent this disease requires long-term treatment, but through outside mouth of the Balloon catheter. the TCM administration is not convenient. The Contrast agent goes into the uterine cavity acting mechanism of TCM remains unclear so through catheter, then we can judge the fallo- that the therapeutic effect is limited with lack pian tube and uterine cavity conditions with of specificity in the clinical treatment. Never- X-ray. However, because of balloon inflatable

15956 Int J Clin Exp Med 2017;10(12):15950-15959 Diagnosis and treatment of fallopian tube obstruction

Table 3. the comparation between Hydrotubation for HSG and balloon catheter Clinical application Hydrotubation for HSG (minimally invasive) Balloon catheter (invasive) Operation time 3-5 minutes 10-20 minutes Operator visibility Wide range of operator visibility Narror operator visibility in uterus Number of operators 1 2 Degree of difficulty Operator do not need training Operators need training Pain sensation of Subject Very little pain Obvious pain Application Range Can be used in different hunman Can not be used in Uterine abnormal- ity or deformity, cervix flabby, et al. Security Not entering the cervix, high safety performance Entering the cervix, low safety perfor- mance compression on uterus, the uterine morpholo- with other methods, interventional therapy can gy and problems might be partially obscured. be defined as a combinative methods in diag- Sometimes the inside catheter tip leans against nosis and treatment. It can be commonly used the cornua uteri. This condition may obstruct as a tubal obstruction diagnosis and treatment the opening of the fallopian tube, causing the methods. Howerver, because the equipment fallopian tube obstruction illusion. Because its for this methods is not yet perfect, doctors invasion on uterine cavity, this method belongs require expert operation. Therefore, in the fu- to invasive operation. Another method, the ture, in order to make this method more simple, hydrotubation for HSG, only need to put the feedback device of pressure and angle control- catheter into the and place at the ler should be added. So that, Even if the doctor outside of the cervix. Then the conditions who do not familiar with the operation can eas- of uterus and fallopian tube can be examined ily find the fallopian tube mouth, and then by injecting contrast agent with X-ray. So, we quickly and accurately operate diagnosis and defined this method as a minimally invasive treatment. type due to keeping out the cervix. Table 3 com- pares two methods and indicates that the mini- Acknowledgements mally invasive hydrotubation for HSG should gradually replace the invasive balloon catheter. This project was supported by the Shanghai HyCoSy developed rapidly in recent years. With Nature Science Foundation (No.15ZR14282- better imaging technique (from 2D to 3D imag- 00), PR China. ing), diagnostic results are more accurate, but Disclosure of conflict of interest the observation area of ultrasound diagnosis has some limitations, and observation effect None. are susceptible to Interferent. In the treatment aspect, hysteroscopy-laparoscopy produces Address correspondence to: Haipo Cui, Department significant effect on the treatment of tubal of Medical Instrument and Food Engineering, obstruction-induced infertility when used either University of Shanghai for Science and Technology, separately or in combination. Guide-wire recan- 516 Jungong Road, Yangpu District, Shanghai alization and later assisted medicine therapy 200093, China. Tel: +86-21-65032249; Fax: +86- can be adopted in view of the conditions of 21-55270695; E-mail: [email protected] patients in order to ameliorate the therapeutic effect and prevent relapse. But this method is References invasive and expensive, needs a long recovery period for patients. Moreover, the intervention- [1] Rezvani M, Shaaban AM. Fallopian tube dis- al treatment of tubal obstruction (SSG + fallo- ease in the nonpregnant patient. Radiograph- ics A Review Publication of the Radiological pian tube recanalization) is also significantly Society of North America Inc 2011; 31: 527. effective. Being minimally invasive, such treat- [2] Balasch J. Investigation of the infertile couple- ment can greatly relieve the patients’ pain and Investigation of the infertile couple in the era cut down the operation time. But this method of assisted reproductive technology: a time for needs experienced interventional doctors to reappraisal. Hum Reprod 2000; 15: 2251- ensure fast and painless treatment. Compared 2257.

15957 Int J Clin Exp Med 2017;10(12):15950-15959 Diagnosis and treatment of fallopian tube obstruction

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