Original Article

Renaissance of Surgical Recanalization for Proximal Fallopian
Tubal Occlusion: Falloposcopic Tuboplasty as a Promising
Therapeutic Option in Tubal Infertility
Yudai Tanaka, MD, PhD*, Hiroto Tajima, MD, PhD, Shino Sakuraba, MD, Rise Shimokawa, MD,
and Kazuhiko Kamei, MD
From the Department of Obstetrics and Gynecology, Shonan IVF Clinic, Kanagawa, Japan (all authors).

ABSTRACT Study Objective: To assess the clinical effectiveness of falloposcopic tuboplasty in tubal infertility.
Design: Retrospective cohort study (Canadian Task Force classiﬁcation II-3).
Setting: Infertility clinic.
Patients: Three hundred forty-ﬁve infertile patients (R2y) with a diagnosis of proximal tubal occlusion, either bilateral or
unilateral, between January 2005 and January 2011.
Intervention: Falloposcopic tuboplasty.
Measurements and Main Results: Medical records for 345 patients with a diagnosis of proximal tubal occlusion were reviewed. Of the 345 patients, 304 underwent falloposcopic tuboplasty, with successful recanalization achieved in 248 patients(81.6%). Ninety-one of the 304 patients (29.9%) became pregnant. Of these, 18 patients (19.8%) miscarried, and 4 (4.4%) had
ectopic pregnancies in the recanalized tube. At 1-, 3-, 6-, and 9-month follow-up, the cumulative probability of conception was
23.1%, 50.6%, 73.6%, and 82.4%, respectively. Related complications included postsurgical infection (0.3%), perforation of
the fallopian tube (1.3%), and accidental breakage of the catheter (4.9%) or the falloposcope (1.3%).
Conclusions: Falloposcopic tuboplasty is safe and effective for treatment of tubal infertility. The pregnancy rate after falloposcopic tuboplasty is comparable to that after in vitro fertilization, which suggests that it can be an alternative to in vitro
fertilization in women with tubal infertility. Journal of Minimally Invasive Gynecology (2011) 18, 651–659 Ó 2011
AAGL. All rights reserved.
Keywords:

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Falloposcopic tuboplasty; Natural conception; Tubal occlusion

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Tubal obstruction has been recognized as a major cause
of infertility since the 19th century. It is responsible for
20% to 30% of infertility in women worldwide and is thesecond most common cause of infertility after unexplained
infertility [1]. Finding a solution for tubal obstruction, theThe authors have no commercial, proprietary, or ﬁnancial interest in the
products or companies described in this article.
Corresponding author: Yudai Tanaka, MD, PhD, Department of Obstetrics
and Gynecology, Shonan IVF Clinic, 1-6-3-3F Shonandai Fujisawa,
Kanagawa 252-0804, Japan.
E-mail: yudai_hello@yahoo.co.jp
Submitted May 16, 2011. Accepted for publication June 23, 2011.
Available at www.sciencedirect.com and www.jmig.org
1553-4650/$ - see front matter Ó 2011 AAGL. All rights reserved.
doi:10.1016/j.jmig.2011.06.014

lesions of which range from intrinsic intraluminal malformation of the cilia, mucosa, or muscularis to gross occlusion of the lumen, has preoccupied gynecologists for many
years [1,2].
The concept of fallopian tube cannulation originated in
the 19th century when Smith [3] introduced tools made ofwhale bone for use in treatment of proximal obstruction.
Since then, various attempts to recanalize occluded fallopian
tubes have been made; however, the results have varied
greatly and have been criticized for lack of convincing
evidence of efﬁcacy [1]. As a result, tubal recanalization
using a surgical approach has been almost abandoned [1].
However, there is no doubt that, if left untreated, complete
bilateral tubal obstruction hinders conception [4].

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Journal of Minimally Invasive Gynecology, Vol 18, No 5, September/October 2011

Tubal cannulation reemerged in the 1990s for treatmentof cornual obstruction. Falloposcopy, ﬁrst developed in theearly 1990s, was originally a diagnostic device for direct
visualization of the fallopian tube lumen [5–9], but
provided no therapeutic value for occluded tubes. With
reﬁnement of falloposcopy, the technique of falloposcopic
tuboplasty was developed as an endoscopic catheterization
procedure for treatment of occluded fallopian tubes [10,11].
In 1997, the US Food and Drug Administration approved
the falloposcopic tuboplasty catheter system. In Japan, theMinistry of Public Health has listed falloposcopic
tuboplasty as an approved treatment for occluded fallopian
tubes, and since 1998, 70% of the cost of the procedure has
been covered by National Medical Insurance.
Falloposcopic tuboplasty has not yet achieved widespread clinical acceptance [12]. In the 1980s, in vitro fertilization (IVF) emerged, and has quickly spread worldwide.
As IVF became the ﬁrst choice for treatment of tubal infertility, tubal recanalization attracted less interest from gynecologists. However, there is a considerable population ofpatients with tubal infertility who do not wish to abandon
trying for natural pregnancy and want to recover tubal
patency for subsequent natural conception [2]. Hence, wewould like to reintroduce falloposcopic tuboplasty as a potential therapeutic option in women with tubal infertility.
Previously, in a short communication, we reported a case series of falloposcopic tuboplasty with a successful recanalization rate of 94.8% and a clinical pregnancy rate of 28.9% [2].
In the present report, we retrospectively reviewed the medical records of 304 patients with tubal infertility who underwent falloposcopic tuboplasty between January 2005 andJanuary 2011. The technique, clinical outcomes, and risks
were examined in detail. We hope the present report willprompt physicians engaged in treating infertility to reconsider tubal recanalization.
Materials and Methods
We retrospectively reviewed the medical records ofpatients with a diagnosis of tubal occlusion between January
1, 2005, and January 31, 2011. Indications for falloposcopic
tuboplasty included infertility for at least 2 years, a diagnosisof either bilateral or unilateral proximal tubal occlusion, andregular menstrual cycle without other ovulatory disorders
such as polycystic ovarian syndrome. Patients were excluded
if their partner’s semen analysis demonstrated oligospermia
or asthenozoospermia according to criteria of the World
Health Organization [13]. Proximal tubal occlusion was
diagnosed using either hysterosalpingography (HSG) or
hydrotubation using dilute indigo carmine solution during
laparoscopic surgery, as described elsewhere [14]. Because
transient tubal occlusion may be induced by uterine andtubal contraction due to pain and may lead to misdiagnosisof tubal occlusion, occlusion was always conﬁrmed using
either HSG on 2 occasions or HSG and intraoperativehydrotubation on 1 occasion, as described previously [2].

In addition, HSG was always repeated to conﬁrm theoccluded side and portion in patients who were referredfrom another clinic because of tubal infertility (135 patients[39.1%]). Patients with midsegment or distal tubal obstruction and those who had previously undergone unilateral salpingectomy were excluded. After the diagnosis of proximal
tubal occlusion was conﬁrmed, all 345 patients were offered
2 therapeutic options, IVF or falloposcopic tuboplasty.
Forty-one patients (11.9%) preferred IVF, and the remaining
304 patients (88.1%) decided to undergo falloposcopic tuboplasty. All 345 patients were included in this retrospective
analysis. Written informed consent was obtained fromeach patient before the operation.
Falloposcopic tuboplasty was always performed bilaterally regardless of whether the tubal occlusion was bilateralor unilateral. Tubal recanalization was deﬁned as successful
only when the inner sheath of the linear eversion catheter
was extended to its full length of 11 cm, giving a clear imageof the intralumen of the tubes bilaterally. The procedure wasconsidered to have failed if the ipsilateral tube remained
occluded. Pregnancy was attempted by either timed intercourse or intrauterine insemination during the natural ovulatory cycle at any time after the surgery. Patients who
received ovarian hyperstimulation were excluded from thestudy.
Procedure
All procedures were performed using a falloposcopic
tuboplasty catheter system (Imagyn Medical, Inc., Laguna
Niguel, CA). The optimal time to perform falloposcopic tuboplasty is during the mid-follicular phase of the menstrual
cycle because the ostium can be visualized easily in theabsence of blood and a thick endometrial lining [14–16].
Intravenous prophylactic antibiotic therapy is given justbefore surgery.
Patients were placed in the lithotomy position, andanesthesia was administered intravenously. A speculum wasinserted into the vagina, and the posterior uterine cervix
was grasped with a tenaculum ﬁrmly connected to the speculum via a speciﬁc attachment. The basic structure of the
falloposcopic tuboplasty catheter system consists of 3 units:a charge-coupled device video camera with a light source, a falloposcope, and a linear eversion catheter (Fig. 1). The linear
eversion catheter consists of inner and outer catheter bodies(0.8 and 2.8 mm in diameter, respectively) joined circumferentially at their distal tips via a distensible polyethylene membrane. This membrane is used as a pressurized balloon, andcan be unrolled from within a plastic polymer cannula after
the falloposcope is preloaded into its lumen (Fig. 2). The pressure in the enclosed balloon space is controlled at 2 to 10 atm(1 atm is equivalent to approximately 760 mm Hg) via an
inﬂation device ﬁlled with normal saline solution.
The high-resolution falloposcope, outer diameter 0.6 mm,
contains 6 light ﬁbers, achieving a 5000-pixel image resolution. It passes through the central channel of the linear

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Falloposcopic Tuboplasty as Option in Tubal Infertility

653

Fig. 1
The falloposcopic tuboplasty catheter system consists of 3 parts: a charge-coupled device video camera (A), a light source (B), and an irrigation pump, linear
eversion catheter, and falloposcope (C).

eversion catheter (i.e., in the middle of the balloon) and isconnected to the charge-coupled device, video camera, andlight source. As the balloon unrolls, it carries the falloposcope within the inner catheter into and along the tubal lumen to a full length of 11 cm, preventing the tube andfalloposcope from damaging one another and negotiating

Fig. 2
Schema of the linear eversion (LE) catheter. The balloon is attached at
the tip of the outer sheath. The balloon is inﬂated using the falloposcopic
tuboplasty (FT) dilator using normal saline solution. As the inner sheathis pressed forward, the balloon and the falloposcope within it are
advanced into the tubal intralumen. IV 5 intravenous.

the curves and strictures without exerting any shearing
forces on the tube wall.
Once the tubal ostium is identiﬁed, the outer catheter isheld in position and connected to the tenaculum. Then, the linear eversion catheter with the falloposcope inside it is gently
advanced into the fallopian tube. When the inner catheter ispushed forward, 6 to 8 atm pressure is applied to the balloon
using a ﬂuid-ﬁlled syringe, resulting in linear eversion of theballoon into the fallopian tube. As a result, the falloposcope iscarried forward at twice the speed of the balloon. Thus, attention must always be given to the falloposcope tip, which
resides within the protective cover of the everting membrane,
to prevent damage to the delicate endoscope [15,16].
After the inner sheath is extended to its maximal length of
11 cm, the inﬂation pressure is set at 2 atm, and the falloposcope is retracted gently until the balloon is placed completely inside the outer sheath. During this retrograde
process, the tubal lining can be continuously imaged, andthe recanalized portion can be observed clearly. A schemaof the progress of the linear eversion catheter and releaseof tubal occlusion are shown in Fig. 3. When the balloon
encounters an obstruction, it is felt as resistance to theforward advancement of the balloon. When this occurs, theinﬂation pressure is gradually increased to 8 to 10 atm tobreak down the adhesion inside the tubal lumen.
Patients are discharged either on the day of surgery or thefollowing day, depending on their recovery from anesthesia.

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Journal of Minimally Invasive Gynecology, Vol 18, No 5, September/October 2011

Fig. 3
Progress of the linear eversion (LE) catheter and release of the tubal occlusion. Corresponding falloposcopic images are to the left of each drawing. (A) The
linear eversion catheter is moved into the tubal lumen. The occluded part is identiﬁed ahead of the falloposcope (arrows). (B) The outer sheath is thenextended to break down the occlusion with the balloon pressurized up to 10 atm. As the outer sheath is advanced, the falloposcope is pulled back gradually
so that it remains within the outer sheath to prevent any damage. Note that the green color of the polyethylene balloon membrane is visible (arrows). (C) The
occlusion is released. The falloposcope is extended to the surface of the balloon so that the intralumen can be observed. Note that the gyruslike mucosa hasrecovered after release of the adhesion.

Determination of IgG Antibodies to Chlamydia
trachomatis
Before surgery, each patient was tested for serum IgG
antibodies to Chlamydia trachomatis because chlamydial
infection is a common cause of tubal occlusion [17]. The
antibody was detected using a VIR-ELISA Anti-Chlamydia
IgG Kit (Viro-Immune Labor-Diagnostika GmbH, Oberursel, Germany). According to the manufacturer’s documentation, titers of more than 1:320 are considered positive fora history of chlamydial infection [18].
Statistical Analysis
Statistical analysis was performed using SPSS for
Windows statistical software (version 11.0; SPSS, Inc.,
Chicago, IL). Data were analyzed using the t test or c2 analysis, as appropriate. All statistical tests were 2-tailed, andp ,.05 was considered statistically signiﬁcant.
Results
Mean (SD; 95% CI) age of patients who underwent falloposcopic tuboplasty was 34.5 (3.5; 34–35), years and of those

who chose IVF was 39.5 (2.4; 38.5–40.3) years. There was no
statistical difference between the ages of the 2 groups. IVF
pregnancies are not included in the statistics. The occlusion
was unilateral in 100 patients (32.9%), and bilateral in theremaining 204 (67.1%), twice the rate of unilateral occlusion. In 31 patients (11.3%), the occlusion was detected during laparoscopic surgery. In these patients, HSG wasscheduled at different menstrual cycles to conﬁrm the occlusion. Falloposcopic tuboplasty was performed after conﬁrmation of the diagnosis. Eighty patients (26.3%) werepositive for serum antibodies to C trachomatis. Mean operative time was 15 (4.03; 11–19) minutes. In 6 patients, laparoscopy was performed concomitant with falloposcopic
tuboplasty. The indications for laparoscopy were ovariancystectomy in 4 patients (3 because of endometrioma, and1 because of teratoma) and myomectomy in 2 patients.
Typical images of the fallopian tube intralumen at various
points are shown in Fig. 4. In normal fallopian tubes, the intralumen is ﬁlled with a mucosa containing folds (Fig. 5, A
and B), which can clearly be observed to move during irrigation with normal saline solution. In the abnormal intralumen,
the mucosa is completely absent, and the surface is ﬂat(Fig. 5, C and D).

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Falloposcopic Tuboplasty as Option in Tubal Infertility

655

Fig. 4
Images of the fallopian tube intralumen at various points inside the tube. (A) Tubal ostium. (B) Isthmus. (C) Mid-segment portion. (D) Ampulla.

Clinical outcomes are given in Table 1. The success rate
for recanalization was 81.6% (248 of 304 patients). During
the observation period, 91 patients (29.9%) conceived spontaneously, and 21 (23.1%) of these 91 patients conceived in
the month after falloposcopic tuboplasty. Of 91 patients whoachieved pregnancy, 69 (75.8%) conceived via timed intercourse, and 22 (24.2%) via intrauterine insemination. No patients received controlled ovarian hyperstimulation in either
the timed intercourse group or the intrauterine inseminationgroup. The cumulative probability of conception was 50.6%,
73.6%, and 82.4%, respectively, at 3, 6, and 9 months offollow-up (Fig. 6). Eighteen patients (19.8%) had miscarriages, and 4 (4.4%) had ectopic pregnancies. Complications
related to the procedure were observed in 24 patients (7.9%).
One patient (0.3%) who developed an infection at 3 days after the operation was readmitted and received intravenous
antibiotic therapy for 2 days until the fever subsided. Thispatient conceived naturally 2 months after falloposcopic tuboplasty. Accidental breakage of the linear eversion catheter
occurred in 15 procedures (4.9%), and of the falloposcope n
4 procedures (1.3%). In these cases, another linear eversion
catheter or falloposcope was used to complete the procedure.
The tube was perforated in 4 patients (1.3%); however, no
speciﬁc treatment was required.
To identify factors that may have contributed to thepatients’ ability to become pregnant, characteristics werecompared between patients who did and did not become
pregnant (Table 2). Among the characteristics studied,mean age and the presence of unilateral occlusion were signiﬁcantly different. The odds ratio (OR) of pregnancies between unilateral and bilateral occlusion was 2.02 (95%
conﬁdence interval [CI], 1.21–3.36). There was no difference in the history of chlamydial infection or any breakage
of instruments between the 2 groups.
The treatment ﬂow of all 345 patients after the diagnosis
of proximal tubal occlusion is shown in Fig. 7. All 56 patients (18.4%) in whom the tubes failed to be recanalized
underwent IVF. Of those, 27 patients (48.2%) conceived
via IVF. Of 157 patients in whom tubes were recanalized
but who had not conceived after falloposcopic tubuloplasty,
66 patients (42.0%) abandoned natural conception and proceeded to IVF. Of these 66 patients, 35 patients (53.0%) conceived via IVF. Of 6 patients (3.8%) who underwent
repeated falloposcopic tubuloplasty, none conceived naturally, and all proceeded to IVF. At present, 85 patients arestill trying for natural conception.
Discussion
Falloposcopic tuboplasty is an effective technique for recanalizing fallopian tubes. It offers hope of natural pregnancy
for women with a diagnosis of proximal tubal occlusions.
Herein, we demonstrated that falloposcopic tuboplasty is aneffective treatment for tubal infertility, yielding a pregnancy
rate comparable to that with IVF. According to a 2002 reportfrom the International Committee for Monitoring Assisted

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Journal of Minimally Invasive Gynecology, Vol 18, No 5, September/October 2011

Fig. 5
Images of normal and abnormal tube intralumen. (A) and (B) Normal intralumina. The intralumen is ﬁlled with a gyruslike mucosa (arrows). The mucosa iseasily distinguished during the operation because it moves during irrigation using normal saline solution. (C) and (D), Abnormal intralumina. Note that the
mucosa is completely absent and the surface is ﬂat.

Reproductive Technology on 601 243 cycles of IVF in 53
countries, delivery rates per transfer for conventional IVF,
intracytoplasmic sperm injection, and frozen embryos were
22.4%, 21.2%, and 15.3%, respectively [19], compared with
Table 1
Clinical outcome in 304 patients who underwent falloposcopic
tuboplasty
VariableNo. (%)

Recanalization
Pregnancy
Miscarriage
Ectopic pregnancy
Complications
Breakage of linear eversion catheter
Breakage of falloposcope
Postsurgical infection
Tube perforation

248 (81.6)
91 (29.9)18 (19.8)
4 (4.4)15 (4.9)4 (1.3)1 (0.3)4 (1.3)

28.3% in the present study. Although the mechanism of thecatheter system seems complicated, no special technique isrequired to complete the procedure. Unlike laparoscopic orother endoscopic surgical procedures, approximately only
10 cases are required to master falloposcopic tuboplasty if
appropriate instruction is given by an experienced trainer.
However, although the potential value of falloposcopic
tuboplasty for treating tubal infertility was emphasized repeatedly in the 1990s, it has not yet achieved widespreaduse or entered routine clinical practice [13]. Little evidence pertaining to the clinical efﬁcacy of falloposcopic
tuboplasty is available. A search of PubMed (www.ncbi.
nlm.nih.gov/pubmed) using the keyword ‘‘Falloposcopic
tuboplasty’’ revealed only 4 articles published in the
1990s and none in the 2000s. According to Terumo
Corp (Tokyo, Japan), at present the sole distributor of falloposcopic tuboplasty catheter systems, they supply them
only to Japan. Even in Japan, fewer than 10 facilities are
currently capable of regularly performing falloposcopic
tuboplasty [2].

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Falloposcopic Tuboplasty as Option in Tubal Infertility

657

Fig. 6
Number of pregnancies and cumulative number of pregnancies after falloposcopic tuboplasty.

In the last 2 or 3 decades, IVF has become the ﬁrst option
worldwide for achieving pregnancy in women with tubal infertility. More than half of patients who visit our clinic hoping for natural conception via tubal recanalization have been
told by other clinicians that IVF is the only way to become
pregnant; however, they persevered because they continued
to hope for natural conception. The present study indicatesthat falloposcopic tuboplasty can be an alternative therapeutic choice to IVF for tubal infertility. Compared with theentire IVF procedure, conception after falloposcopic tuboplasty offers many advantages: there is no need for multiple
hormone injections for ovarian hyperstimulation or in vitro
handling of oocytes and embryos, and less chance of multiple gestations. In this study, 91 patients (29.9%) conceived
Table 2Comparison of characteristics in patients who did and did not become
pregnant
Variable

Pregnant

Not pregnant

P value

Total patients
Age, mean (SD), yr
Chlamydial infection,
No. of patients
Unilateral occlusion
Intraoperative breakage
of instruments

91
32.9 (4.3)
22 (27.5)

213
35.3 (4.2)
58,.001a
.58b

41
5

59
14

.02b
.84b

NS 5 not signiﬁcant.
aStudent t test.
b 2
c analysis.

naturally after falloposcopic tuboplasty. Thus, not choosing
IVF yielded successful results in these 91 patients.
The cumulative number of successful pregnancies demonstrated a characteristic tendency: Almost one-fourth ofthe patients (n 5 21) conceived within a month after falloposcopic tuboplasty, and 88% of pregnancies occurred within
the ﬁrst year. Conﬁno et al [20] and Gleicher et al [21] reported that pregnancy after transcervical balloon tuboplasty,
Fig. 7
Treatment ﬂow and outcome in 345 patients with a diagnosis ofproximal tubal occlusion. *Total pregnancy rate was calculated withdivision by 304 (number of patients who underwent falloposcopic
tuboplasty), not 248 (patients in whom recanalization was successful).
FT 5 falloposcopic tuboplasty; IVF 5 in vitro fertilization.

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Journal of Minimally Invasive Gynecology, Vol 18, No 5, September/October 2011

the other catheter technique used to treat tubal occlusion,
also occurred mostly within 6 months of the procedure.
Similarly, the pregnancy rate increased after HSG, but
only temporarily [21,22]. We suspect that recanalized
tubes do not remain patent permanently and eventually
become reoccluded, although there are no data to support
this hypothesis. However, based on our data, we advise
patients that natural conception after falloposcopic tuboplasty
is likely to occur only in the ﬁrst postoperative year and thatthey should proceed to IVF after this period.
Although it was not a signiﬁcant difference, the mean ageof patients who chose IVF was 4.9 years higher than that ofthose who chose falloposcopic tuboplasty. This indicatesthat patient age at diagnosis of tubal occlusion may be an important factor for patients to make the decision as to whether
IVF or falloposcopic tuboplasty is the most appropriate
option. The younger the patient, the longer she can try fornatural conception after falloposcopic tuboplasty. Howlong a patient should try for natural conception will dependon the patient’s age and requirements. If the patient wishes topersist in attempting natural conception for a prolonged
period, repeated HSG or falloposcopic tuboplasty should
be recommended to rule out reocclusion.
The present study included patients with both unilateraland bilateral proximal tubal occlusions. Even when theocclusion was unilateral, we always also tried tuboplasty inthe contralateral patent tube because we expected the dilating
effect of catheterization to act like the ﬂushing effect of HSG[22–25]. The pregnancy rate in women with unilateralocclusion was almost twice as high as that for women withbilateral occlusion (OR, 2.02; 95% CI, 1.21–3.36). This
result indicates that dilation of the normal tube may be
more effective than recanalization of the occluded tube.
Accordingly, we believe it is possible that the indications forfalloposcopic tuboplasty can be extended beyond proximal
tubal occlusion to unexplained infertility. Questions may beraised that patients with unilateral occlusion conceived
simply because ovulation occurred in the ovary on the sidein which the fallopian tube had been patent. However, every
patient involved in the study had been infertile for at least
2 years. Thus, we interpret that dilation of the nonoccluded
tube, not only the occluded tube, certainly contributed to theincreased pregnancy rate.
Tubal perforation by the tip of the catheter may occur
when the catheter is pushed forward too hard. However,this perforated hole is small and will close spontaneously
without any particular follow-up because the outer diameterof the linear eversion catheter is less than 1.0 mm [2]. Once
perforation occurs, the operation should be ended because
the catheter tends to advance into the perforation rather
than along the tubal lumen. These cases were considered
recanalization failures, and patients were advised to proceed
to IVF instead.
Pregnancy was attempted via either timed intercourse or
intrauterine insemination. Of 91 patients, 22 (24.2%) conceived via intrauterine insemination. It may be questioned

whether intrauterine insemination itself may have been responsible for subsequent pregnancy after the surgery. However, of 21 patients in the intrauterine insemination group,
8 (38.1%) had already undergone intrauterine inseminationelsewhere before they underwent falloposcopic tuboplasty.
A meta-analysis that compared intrauterine insemination
with timed intercourse showed that while intrauterine insemination with ovarian hyperstimulation is associated witha signiﬁcantly higher pregnancy rate than is timed intercourse with ovarian hyperstimulation (OR, 1.68; 95% CI,
1.13–2.50), no randomized controlled trials were foundthat compared intrauterine insemination and timed intercoursewith the natural cycle [26]. No patients in this study received
ovarian hyperstimulation. Given this information, we believethat the effect of intrauterine insemination on the pregnancy
rate after falloposcopic tuboplasty is not signiﬁcant.
The incidence of ectopic pregnancy has been increasing
since the late 20th century; in the United States, almost 2%of all pregnancies are ectopic [27]. In the present study,
4 pregnancies (5.1%) were ectopic. Three of the 4 patients(75%) had a history of previous ectopic pregnancy, and 2
patients (50%) tested positive for serum antibodies to
C tracomatis. This indicates that reopening of the fallopian
tube does not necessarily mean recovery of the ability totransport an embryo from the tube to the uterine cavity.
The incidence of ectopic pregnancy may be increased after
a previous ectopic pregnancy, which should be emphasizedwhen informed consent is obtained before surgery, especially if the patient has a history of ectopic pregnancy.
Technical problems have limited the usefulness of falloposcopic tuboplasty to the extent that the method has
not yet been adopted for routine practice [14,28]. We
encountered accidental breakage of the linear eversion
catheter in 15 procedures (4.9%), and of the falloposcopein 4 procedures (1.3%). No harm occurred to the patients inany of these cases, and there was no statistical difference inthe recanalization rate between the procedures in which
instrument breakage did or did not occur (data not shown).
However, another linear eversion catheter or falloposcope
was required to complete these procedure. A linear eversion
catheter is designed to be disposable, and a falloposcope
has a life span of about 10 uses. The fragility of theequipment in the falloposcopic tuboplasty catheter system
is an annoyance, and may be one of the obstacles tofalloposcopic tuboplasty gaining popularity.
In 1988, Thurmond et al [29] described tubal catheterization via selective HSG. They used a 3F to 9F Teﬂon catheterand dilated the occluded portion of the fallopian tube. They
reported that the pregnancy rate after selective HSG was
28% (10 of 36), which is similar to our observation. Similarreports had been published in the late 1980s [30,31].
Accordingly, it may be opined that selective HSG should
be sufﬁcient and considered ﬁrst and that falloposcopic
tuboplasty is unnecessary to reopen fallopian tubes.
However, a big advantage is that the tube intralumen
can be directly observed at falloposcopic tuboplasty. We

Tanaka et al.

Falloposcopic Tuboplasty as Option in Tubal Infertility

believe that morphologic changes in the tubal mucosa are asimportant as tube patency; in some patients, the tubal
mucosa is sparse and the lumen is completely ﬂat. We
doubt that even after recanalization, lack of tubal mucosa
is a poor prognostic factor. A prospective survey of therelationship between the architecture of the tubal lumen
and pregnancy outcome has been conducted in our facility,
and we hope to report the results in the near future.
Conclusion
Falloposcopic tuboplasty is effective treatment for tuballyinfertile patients who still wish for natural pregnancy. The cumulative pregnancy rate after falloposcopic tuboplasty is
29.9%. The procedure is not difﬁcult to master, is less invasive
than other tubal surgeries, and complications are rare. We
propose that falloposcopic tuboplasty can be an alternative
therapeutic option for treatment of tubal infertility.
References
1. DeCherney AH. Tubal disease: surgery and in vitro fertilization. In:
Kase NG, Weingold AB, Gershenson DM, editors. Principles andPractice of Clinical Gynecology. 2nd ed. London, England: Churchill
Livingstone; 1990. p. 445–457.
2. Tanaka Y, Tajima H. Falloposcopic tuboplasty as an option for tubal
infertility: an alternative to in vitro fertilization. Fertil Steril. 2011;
95:441–443.
3. Smith TW. New method of treating sterility by the removal of obstructions of the fallopian tubes. Lancet. 1849;i:529–531.
4. Wheeler JE. Diseases of the fallopian tube. In: Kurman RJ, Ellenson LH,
Ronnett BM, editors. Blaustein’s Pathology of the Female Genital Tract.
6th ed. New York, NY: Springer-Verlag; 2010. p. 409–437.
5. Kerin J, Surrey E, Daykhovsky L, Grundfest WS. Development andapplication of a falloposcope for transvaginal endoscopy of the fallopian tube. J Laparoendosc Surg. 1990;1:47–56.
6. Pearlstone AC, Surrey ES, Kerin JF. The linear everting catheter: a nonhysteroscopic, transvaginal technique for access and microendoscopyof the fallopian tube. Fertil Steril. 1992;58:854–857.
7. Scudamore IW, Dunphy BC, Cooke ID. Outpatient falloposcopy: intraluminal imaging of the fallopian tube by trans-uterine ﬁbre-optic endoscopy as an outpatient procedure. Br J Obstet Gynecol. 1992;99:829–835.
8. Grow DR, Coddington CC, Flood JT. Proximal tubal occlusion by hysterosalpingogram: a role for falloposcopy. Fertil Steril. 1993;60:170–174.
9. Venezia R, Zangara C, Knight C, Cittadini E. Initial experience of a newlinear everting falloposcopy system in comparison with hysterosalpingography. Fertil Steril. 1993;60:771–775.
10. Sueoka K, Asada H, Tsuchiya S, Kobayashi N, Kuroshima M,
Yoshimura Y. Falloposcopic tuboplasty for bilateral tubal occlusion:a novel infertility treatment as an alternative for in-vitro fertilization?
Hum Reprod. 1998;3:71–74.
11. Kerin J, Daykhovsky L, Grundfest W, Surrey E. Falloposcopy: a microendoscopic transvaginal technique for diagnosing and treating endotubal disease incorporating guide wire cannulation and direct balloon
tuboplasty. J Reprod Med. 1990;35:606–612.

659
12. Rimbach S, Bastert G, Wallwiener D. Technical results of falloposcopy
for infertility diagnosis in a large multicentre study. Hum Reprod. 2001;
16:925–930.
13. World Health Organization. Examination and Processing of Human
Semen. 5th ed. 2010; Available at: http://whqlibdoc.who.int/publications/
2010/9789241547789_eng.pdf. Accessed November 14, 2010.
14. Swart P, Mol BW, van der Veen F, van Beurden M, Redekop WK,
Bossuyt PM. The accuracy of hysterosalpingography in the diagnosisof tubal pathology: a meta-analysis. Fertil Steril. 1995;64:486–491.
15. Kerin J, Daykhovsky L, Segalowitz J, et al. Falloposcopy: a microendoscopic technique for visual exploration of the human fallopian tube
from the uterotubalostium to the ﬁmbria using a transvaginal approach.
Fertil Steril. 1990;54:390–400.
16. Kerin JF, Williams DB, San Roman GA, Pearlstone AC, Grundfest WS,
Surrey ES. Falloposcopic classiﬁcation and treatment of fallopian tube
lumen disease. Fertil Steril. 1992;57:731–741.
17. Paavonen J, Eggert-Kruse W. Chlamydia trachomatis: impact on human reproduction. Hum Reprod Update. 1999;5:433–447.
18. Malik A, Jain S, Rizvi M, Shukla I, Hakim S. Chlamydia trachomatis
infection in women with secondary infertility. Fertil Steril. 2009;91:
91–95.
19. deMouzon J, Lancaster P, Nygren KG, et al. World collaborative reporton assisted reproductive technology, 2002. Hum Reprod. 2009;24:
2310–2320.
20. Conﬁno E, Tur-Kaspa I, DeCherney A, et al. Transcervical balloon
tuboplasty: a multicenter study. JAMA. 1990;264:2079–2082.
21. Gleicher N, Conﬁno E, Corfman R, et al. The multicentre transcervicalballoon tuboplasty study: conclusions and comparison to alternativetechnologies. Hum Reprod. 1993;8:1264–1271.
22. Steiner AZ, Meyer WR, Clark RL, Hartmann KE. Oil-soluble contrast
during hysterosalpingography in women with proven tubal patency.
Obstet Gynecol. 2003;101:109–113.
23. DeCherney A, Kort H, Barney JB, DeVore GR. Increased pregnancy
rate with oil-soluble hysterosalpingography dye. Fertil Steril. 1980;3:
407–410.
24. Johnson N, Vandekerckhove P, Watson A, Lilford R, Harada T,
Hughes E. Tubal ﬂushing for subfertility. Cochrane Database Syst
Rev. 2005;18(2):CD003718.
25. Spring DB, Barkan HE, Pruyn SC. Potential therapeutic effects ofcontrast materials in hysterosalpingography: a prospective randomized
clinical trial. Radiology. 2000;214:53–57.
26. Verhulst SM, Cohlen BJ, Hughes E, Te Velde E, Heineman MJ. Intrauterine insemination for unexplained subfertility. Cochrane Database
Syst Rev. 2006;18:CD001838.
27. Cunningham F, Leveno K, Bloom S, Hauth J, Rouse D, Spong C.
Williams Obstetrics. 23rd ed. New York, NY: McGraw-Hill; 2005.
28. Lundberg S, Rasmussen C, Berg AA, Lindblom B. Falloposcopy inconjunction with laparoscopy: possibilities and limitations. Hum
Reprod. 1998;13:1490–1492.
29. Thurmond AS, R€osch J, Patton PE, Burry KA, Novy M. Fluoroscopictranscervical fallopian tube catheterization for diagnosis and treatmentof female infertility caused by tubal obstruction. Radiographics. 1988;
8:621–640.
30. Novy MJ, Thurmond AS, Patton P, Uchida BT, Rosch J. Diagnosis ofcornual obstruction by transcervical fallopian tube cannulation. Fertil
Steril. 1988;50:434–440.
31. R€osch J, Thurmond AS, Uchida BT. Diagnosis and treatment of
fallopian tube obstruction with selective salpingography and catheter
recanalization. Ann Radiol. 1988;31:123–126.