BEYOND RECANALIZING PROXIMAL TUBAL OCCLUSION - THE ARGUMENT FOR FURTHER DIAGNOSIS AND CLASSIFICATION

Proximal tubal occlusion (PTO) accounts for 20% of tubal factor cases. The classification into nodular (salpingitis isthmica nodosa or endom etriosis), non-nodular (true fibrotic occlusion) and so-called pseudo occlusion (detritus, polyps, hypoplastic tubes) is essential. Using fa lloposcopy, PTO that is already diagnosed by laparoscopy and hysterosa lpingography (HSG) can be confirmed or bypassed (false PTO); patients with false PTO were placed on a temporary waiting period. Nodular and pseudo occlusion patients were pre-treated with gonadotrophin-releasin g hormone analogue (GnRH-a) for at least 6 weeks to shrink the underly ing pathology, after which tubal re-catheterization was performed. In a prospective study starting in July 1993, 53 patients prediagnosed as having PTO were examined by falloposcopy. Three of these patients had non-nodular occlusion and were directed to microsurgical repair (cons ervative treatment not possible). A total of 19 cases revealed patent tubes with healthy mucosa and no underlying pathology (false PTO). Of the remaining 31 patients, 18 were classified as nodular and 13 as pse udo occlusion. In all of these patients at least one tube was patent a fter GnRH-a treatment. After a 6 month period, 37% of the false PTO pa tients achieved a spontaneous pregnancy (6% per cycle). The spontaneou s pregnancy rate in the true PTO group was significantly lower (10% pe r patient, 1.6% per month; P < 0.05). Using assisted reproduction tech niques, in particular gamete intra-Fallopian transfer (GIFT), as a sub sequent treatment for the true PTO group, a pregnancy rate of 50% per cycle was achieved. A retrospective analysis of our entire PTO populat ion (n = 109) showed a spontaneous pregnancy rate after achieving tuba l patency (using falloposcopy and GnRH-a) that was dramatically low (1 .8%), with no difference between the nodular and pseudo groups. The ch ance for pregnancy can be enhanced significantly (P < 0.001) using ass isted reproduction techniques (GIFT) following tubal re-catheterizatio n and GnRH-a treatment.