Tubal recanalisation (tubal reopening) - Prof. Antonio La Marca
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Prof. La Marca receives by appointment at the Policlinico di Modena.

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Prof. Antonio La Marca

Tubal recanalisation

Insight into performance

Tubal recanalisation (reopening of the tuba)

At our clinic, Prof La Marca personally handles the method. 
Endoscopic tubal recanalisation, where indicated, is today performed in only a few centres throughout Europe. Expertise is therefore concentrated in a limited number of experts capable of performing it correctly.
 
Tubal occlusion causes female infertility in 30% of cases and in 10-25% the occlusion is localised in the proximal tubal tract (PTO) 1,2. The most common causes of PTO include pelvic inflammatory disease, salpingitis isthmica nodosa, endometriosis, tubal polyps and surgical trauma.

DIAGNOSIS OF TUBAL PATENCY

There are different approaches to the diagnosis of tubal factor infertility. The laparoscopy with salpingocromoscopy is considered the gold standard in the assessment of tubal patency3. A further oedoscopic approach for the study of tubal damage is the salpingoscopy4 which consists of the introduction of a rigid salpingoscope during laparoscopy into the distal part of the tubes, allowing visualisation of the mucosa of the tubal ampulla. Hysterosalpingography (HSG)consists of injecting, via a catheter, a contrast medium into the uterus and tubes. A potential limitation of HSG are false positives secondary to tubal spasms, which occur especially if the contrast medium is injected too quickly5

Sonohysterosalpingography (SHG) with contrast medium is an alternative to hysterosalpingography for the assessment of tubal patency. Although ultrasound images are inferior to those obtained by fluoroscopy, SHG is more sensitive and more specific than HSG in detecting tubal occlusion6,7.

TREATMENT OF PROXIMAL TUBAL OBSTRUCTION

Therapeutic approaches for the treatment of proximal tubal occlusion depend on the type and degree of tubal dysfunction. The previous techniques of laparotomy and microsurgery have been largely replaced by the advent of tubal catheterisation and selective, fluoroscopic and hysteroscopic salpingography8. In addition to being an effective method in the treatment of tubal obstruction, tubal catheterisation also allows for an indirect assessment of tubal function by measuring intratubar pressure at the time of cannulation. Indeed, the persistence of high pressure after catheter insertion inside the tube suggests reduced compliance of the tubal wall and is associated with very low rates of spontaneous post-procedural pregnancy.9. Up to 75-85% of obstructions can be treated by selective salpingography and tubal catheterisation with a recurrence rate of around 30%. Fluoroscopic tubal cannulation is a procedure that carries a minimal risk of radiation exposure and has the advantage of having a short and rapid learning curve10  In a 2020 study conducted by Pyra, Szmygin et al. 248 PTO patients were treated with selective salpingography and tubal catheterisation with the 96% treatment efficacy 11. Hysteroscopic tubal cannulation allows visualisation of the entire uterine cavity and this may be useful in the diagnosis and simultaneous treatment of coexisting uterine pathologies. Tubal perforation is a possible procedural complication with a literature incidence rate of 3-11% but does not require treatment and heals spontaneously 12,13. In 2017, a systematic review and meta-analysis of 27 observational studies with 1720 patients undergoing tubal catheterisation for proximal tubal obstruction who attempted to conceive naturally after the procedure was prepared. The results of the analysis showed that in women with proximal fallopian tube obstruction, the chance of achieving a clinical pregnancy after tubal catheterisation is indeed high.

Bibliography

  1. Schlegel PN, Fauser BC, Carrel DT, Racowsky C. Biennial Review of Infertility, 3. Springer; 2013. p. 1-264. 
  2. Serafini P, Batzofin J. Diagnosis of female infertility: a comprehensive approach. J Reprod Med 1989;34:29 40. 
  3. Swart P, Mol BW, van der Veen F, van Beurden M, Redekop WK, Bossuyt PM. The accuracy of hysterosalpingography in the diagnosis of tubal pathology: a meta-analysis. Fertil Steril 1995;3:486-491. 
  4. Marchino GL, Gigante V, Gennarelli G, et al. Salpingoscopic and laparoscopic investigations in relation to fertility outcome. J Am Assoc Gynecol Laparosc 2001; 8:218-
  5. Novy M, Thurmond AS, Patton P, Uchida BT, Rosch J. Diagnosis of cornual obstruction by transcervical fallopiantube cannulation. Fertil Steril 1988; 50:434-40.
  6. Richman TS, Viscomi GN, Decherney AH, et al. Fallopian tube pathency assessed by ultrasound following fluid injection. Radiology1984;152:507-10.
  7. Holz K, Becker R, Schurmann R. Ultrasound in the investigation of tubal patency. A meta-analysis of three comparative studies of Echovist-200 including 1007 women. Zentralbl Gynakol 1997; 119:366-73.
  8. Chung JP, Haines CJ, Kong GW. Long-term reproductive outcome after hysteroscopic proximal tubal cannulation - an outcome analysis. Aust N Z J Obstet Gynaecol 2012;5:470-475. 
  9. Gleicher N, Karande V 1996 The diagnosis and treatment of proximal tubal disease. Human Reproduction 11,1823-1834.
  10. Papaioannou S, Afnan M, Girling AJ et al. 2002b The learning curve of selective salpingography and tubal catheterisation. Fertility and Sterility 77, 1049-1052. 
  11. Pyra K, Szmygin M, Dymara-Konopka W, Zych A, Sojka M, Jargiełło T, Leszczyńska-Gorzelak B. The pregnancy rate of infertile patients with proximal tubal obstruction 12 months following selective salpingography andtubal catheterization. Eur J Obstet Gynecol Reprod Biol. 2020 Nov;254:164-169
  12. Kodaman H, Arici A, Seli E. Evidence-based diagnosis and management of tubal factor infertility. Curr Opin Obstet Gynecol 2004;16:221-9
  13. Anil G, Tay KH, Loh SF, Yong TT, Ong CL, Tan BS. Fluoroscopy-guided, transcervical, selective salpingography and fallopian tube recanalisation. J Obstet Gynaecol (Lahore) 2011;31:746-50. 
  14. De Silva PM, Chu JJ, Gallos ID, Vidyasagar AT, Robinson L, Coomarasamy A. Fallopian tube catheterization in the treatment of proximal tubal obstruction: a systematic review and meta-analysis. Hum Reprod. 2017 Apr 1;32(4):836-852.

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Performances

Myolysis or thermoablation of uterine fibroids

Myolysis or Thermoablation is a technique currently only performed in a few centres. Prof La Marca personally handles the method and receives patients from all over the country to perform this innovative therapy.

Radiofrequency and microwaves for gynaecological pathology

Radiofrequency and microwaves have been introduced into our clinical practice with excellent results. Prof La Marca is considered among the pioneers for the use of this procedure in gynaecology and receives patients from all over the country for the ultra minimally invasive treatment of uterine fibroids and adenomyosis.

In vitro fertilisation

In vitro fertilisation is a therapeutic strategy that is far from standardised. Like all medical and surgical practices, it is greatly affected by the technical skills and cultural updating of the practitioners involved. The results are therefore by far operator-dependent. This aspect is very little known, both by clinicians and patients.

Gynaecological endocrinology

The ovarian and menstrual function of women is extremely delicate and responds to a complex interaction between the centres (hypothalamus-pituitary) and the periphery (ovary-uterus).

Transfer to the blastocyst stage

In in vitro fertilisation, fertilised oocytes (zygotes) are kept in the laboratory, in incubators, under controlled temperature conditions (37°C) and an atmosphere with 5% oxygen and 6% carbon dioxide.

Infertility

It is well known that a considerable percentage of couples experience difficulties in conceiving. It is estimated that 10-15% of the population can be classified as infertile.

Recurrent abortion

Miscarriage is defined as a termination of pregnancy that occurs spontaneously within 24 weeks of gestation.

Diagnostic and operative hysteroscopy

Diagnostic Hysteroscopy is an endoscopic technique that can be performed in an outpatient setting using a hysteroscope.

Heterologous fertilisation

For certain clinical conditions, couples desiring offspring must resort to gametes (oocytes and/or spermatozoa) from voluntary and disinterested donors in order to fulfil their reproductive desire.

Fertility preservation

Over the past three decades, a phenomenon has taken hold in the Western world that is likely to have major implications for birth rates: the scheduling of births at a significantly older age than in the past.

Gynaecology and obstetrics

Gynaecology and Obstetrics is the medical discipline par excellence in the care of women. The aim of this clinical speciality has always been to care for the patient in all phases of her life.

Diagnosis and treatment of adenomyosis

At our clinic, the diagnosis and therapy of adenomyosis is performed to the most up-to-date standards. Prof La Marca is among the clinicians with the most experience in treating adenomyosis with thermoablation, an innovative therapeutic strategy for this disease.

Diagnostic examinations

Diagnostic examinations in gynaecology and obstetrics are nowadays very accurate and their correct execution and interpretation are the basis for the right clinical picture of the patient and the most appropriate therapeutic strategy.

Fibroids therapy

Uterine leiomyomas, more commonly called fibroids, are benign solid neoformations and represent the most frequent gynaecological neoplasm in women of childbearing age.

Uterine anomalies

An arrest of the organogenic stages can cause uterine and vaginal abnormalities of varying degrees.

Endometriosis

Endometriosis is a chronic, oestrogen-dependent inflammatory disease characterised by the presence of functional endometrial tissue (glands and stroma) in extrauterine sites.

Menstrual cycle disorders

It represents the most obvious and measurable clinical sign of pubertal maturation and in most women it occurs about two to three years after the onset of telarche with an average age of around 12½ years.

Intrauterine insemination

A Level I medically assisted procreation procedure based on the deposition of spermatozoa directly inside the uterine cavity. This procedure is carried out after ovulation induction.

Outpatient ultrasound aspiration of ovarian cysts

At our clinic, Prof La Marca personally handles the method. Ultrasound-guided aspiration of ovarian cysts is an ultra-mini-invasive method that is only available in very few centres nationwide. If there are the right indications, the method allows a rapid and non-invasive solution for the pathology in question

Tubal recanalisation

At our clinic, Prof La Marca personally handles the method. Endoscopic tubal recanalisation, where indicated, is today performed in only a few centres throughout Europe. The expertise is therefore concentrated in a limited number of experts capable of performing it correctly.

Assisted laser hatching

Laser-assisted hatching (LAH) is a laboratory technique that consists of cutting a small section of the zona pellucida (ZP).

IMSI, intracytoplasmic sperm injection

This is a level II technique used in the field of in vitro fertilisation. It takes the form of a variant of traditional ICSI, both of which consist of the direct injection of a spermatozoon into the cytoplasm of the oocyte.