Lady with infertility with B/L tubal block at cornua. Best method of management is :
Ans. is 'a' i.e. Laparoscopy and hysteroscopy There is no treatment of choice or best treatment for proximal tubal obstruction (PTO) without proper evaluation of the tube because although proximal tubal obstruction is a frequent finding on hysterosalpingography (HSG) approximately 213rd of PTO reveals an absence of luminal obstruction.False positive diagnosis of PTO ranges from 16-40% and can be as high as 50%.Therefore careful evaluation of the fallopian tube prior to therapy is an absolute requirement.The distinction b/w true pathological occlusion, spasm or plugging and abnormality of the mucosa is crucial in determining therapy.Conventional HSG does not differentiate cornual spasm or other temporary causes from true obstruction.Selection of patients with tubal disease for future therapeutic management is based on tubal lesion including the state of tubal mucosa and tuboperitoneal assessment and the severity of tubal damage is key in determining the outcome.Proximal tubal occlusion is most treatable since it often occurs because of the accumulation of mucus or debris which forms an impacted plug in the interstitial or proximal isthumic portion of the tube.Until recently the treatment of PTO was a domain of microsurgery or I.V.F., but now days, tubal recanalization also plays an important role in the management of proximal tubal occlusion.In patients with documented tubal disease, options for management includes.Expectant managementMicrosurgeryI.V.F.Until recently, the management of proximal tubal obstruction was the domain of either microsurgery or I.V.F.Since microsurgery was technically very difficult and did not yield good results. So PTO's were frequently referred for I.V.F.Now day's Proximal tube recanalisation (PTR) with catheters or guidewires has gained wide application in treatment and diagnosis of proximal tube obstruction Proximal tube recanalisation is a non invasive method for the diagnosis and treatment of proximal tubal obstruction.Now IVF is required only in cases where the tubal mucosa is severely damaged and the obstruction is distal eg.Poor mucosal healthObi iterative fibrosisDistal tube obstructionBipolar tube damage The safety, efficacy. noninvasiveness reduced risk, costs and morbidity and encouraging results with fallopian tube recansalisation in the treatment and evaluation of proximal tubal obstruction makes them an excellent alternative to surgical invasive procedure and should be offered as the initial treatment in all patients with PTO.Hysteroscopy and LaparoscopyHysteroscopic tubal catherization in patients with PTO can be used both as a diagnostic and considerably effective therapeutic method.With laparoscopy, the hysteroscopic approach enables tubales cannulation and evaluation of the entire pelvic.Treatment of additional problems affecting the fallopian tubes particularly adhesion and endometriosis is possible.While laparoscopy helps monitor the procedure and visual assessment of tubal patency, the ability to observe theUTJ's directly by hysteroscopy provides an excellent approach for tubal cannulation.Laparoscopic hysteroscopic tubal cannulation with or without guidewire cannulation has yielded an average recanalization success rate as high as 39%.Combined laparoscopy and hysteroscopic cannulation is a patients with proximal tubal obstruction.
Laparoscopy & Hysteroscopy
Hydrotubation
IVF
Tuboplasty
Miscellaneous (Gynae)