According to the World Health Organization, in the 21st century, infertility will become the third most common disease after tumors and cardiovascular diseases. At present, the incidence of infertility in China is increasing year by year, accounting for about 12,5-15% of the total population. According to survey statistics, among all infertility cases, 35-45% are caused by female factors, 25-33% are caused by male factors, 20-22% are caused by both male and female factors, and 8-15% are caused by unknown reasons.
Among the many factors causing female infertility, tubal obstruction is one of the most common causes of female infertility, and its incidence has been reported in the literature as a percentage of female infertility patients. Proximal tubal obstruction accounts for about 15%-25% of tubal infertility, and most of its causes are due to non-specific inflammatory diseases, such as inflammation of the reproductive system, tuberculosis, post-abortion infection, etc. The diagnosis and treatment of tubal infertility is another common diagnostic and therapeutic problem in infertility, and there are many clinical methods used to diagnose and treat tubal obstruction, with different diagnostic accuracy and efficacy. Due to the special anatomical location and morphology of the fallopian tubes, it is difficult to achieve satisfactory results with drug treatment, and laparoscopic examination and dissection are technically complicated and traumatic, so their application is limited.
Uterine iodine oil imaging, lysis test and anti-inflammatory treatment have unsatisfactory results. Routine uterine tubal iodine oil imaging has up to 30% false positives due to spasm, membranous adhesions, mucus plug obstruction and manipulation. Tubal recanalization is an emerging technique combining traditional hysterosalpingography with modern interventional radiology technology. With the mechanical movement of the guidewire, it can play the role of loosening and separating the adhesions in the tubal lumen, and can be treated with drug injection via microcatheter. Interventional tubal recanalization opens up a new treatment route for patients with obstruction and is an effective, simple, safe and economical method.
I. Principle and value of interventional treatment for tubal obstruction
Selective tubal angiography is to increase the hydrostatic pressure in the fallopian tubes directly and produce therapeutic effect by squeezing and separating the contrast agent, avoiding the spasm of the tubal sphincter and the painful dilatation of the uterine cavity caused by the conventional contrast agent. For those tubes that cannot be recanalized at all, tubal recanalization is then performed to separate the adhesions in the tubal lumen with the help of the expansion of the guidewire, resulting in a significant increase in the recanalization rate.
Interventional recanalization has visualization, which avoids the blindness and illusion that traditional tubal lavage is judged only by the doctor’s subjective feeling, drug injection resistance and experience, and therefore helps to diagnose the site, degree and nature of tubal obstruction, so that most of the obstructed tubes can be recanalized to achieve therapeutic effect, and some of the patients can achieve the goal of conception.
Indications
1. Selective tubal angiography and lysis is feasible in all tubal obstructions.
2.Trial tubal recanalization can be performed for obstruction from the interstitial part to the abdomen.
3. If conventional hysterosalpingography cannot be completed because the cervical opening is too loose, selective hysterosalpingography can be performed on a trial basis.
Contraindications
(1) The distal part of the jugular abdomen and umbilical segment obstruction are not suitable for recanalization by guidewire.
2. Severe occlusion of the uterine horn, obstruction after tubal anastomosis by ligation.
3.Severe heart failure, active tuberculosis.
4.Iodine allergy.
5.Acute onset of genital inflammation.
6, Fever, menstrual period.
7. If tubal tuberculosis is diagnosed, recanalization with guidewire is not recommended due to decreased tubal compliance.
Patient preparation
1. The intervention should be performed within 3~5 days after menstruation.
2. Routine blood tests, chest X-ray, ECG, pelvic ultrasound or CT examination should be done before surgery.
3.Signing procedure for interview and iodine allergy test.
V. Complications and treatment
1. Subplasmic perforation of the oviduct and muscle wall injury. Gentle and skilled operation is required.
2.myometrial wall, venous and lymphatic duct contrast reflux. Since water-soluble contrast agent is used, there are no serious reactions. Replacing iodinated oil with non-ionic contrast agent for routine and selective hysterosalpingography can avoid complications such as pulmonary embolism.
3, tubal pregnancy: tubal pregnancy is mostly seen in the abdomen, far from the site of cannulation, and is caused by lesions in the distal part of the fallopian tube, rather than as a result of injury to the proximal cannula.
4. Excessive operation time causes uterine cavity infection. Prolonged operation time should be avoided and postoperative anti-infection treatment should be given.
5. Abdominal pain and small amount of vaginal bleeding. Mostly caused by the injury, generally this symptom disappears within 2~5d after surgery, and symptomatic treatment can be given.
VI. Postoperative management
1. Ask the patient to lie down and observe for 1~2h after surgery, and leave only if there is no special discomfort.
2. To prevent tubal re-adhesion after surgery, postoperative lavage treatment should be accompanied by strengthening anti-infection treatment; postoperative anti-infection treatment for 1 week, routine penicillin drip 8 million U once a day; routine gynecological uterine tubal lavage should be done 2~3 d after surgery, with 1 d interval, for a total of 2 times, to keep the tubal patent after recanalization. And perform uterine lavage for 3~7d after menstruation for 3 consecutive months, 2 times a month to consolidate the tubal patency.
3. Perform eugenics to prevent the occurrence of ectopic pregnancy. We ask patients to get pregnant after 3 months of intervention. Because of the exposure to X-rays during the intervention, conception after an interval of several months is conducive to eugenics. Moreover, after 3 months of outpatient maintenance lavage treatment, the chance of tubal pregnancy can be reduced. Intercourse is prohibited for 1-2 months after treatment or condoms must be used to prevent ectopic pregnancy.