Tubal Obstruction After Ligation Reversal Surgery

Tubal Obstruction after Ligation Reversal Surgery:
Results of Catheter Recanalization

1. Amy S. Thurmond, MD,,
2. Kathleen R. Brandt, MD and
3. Marsha J. Gorrill, MD
+ Author Affiliations
1. Department of Radiology, Legacy Meridian Park Hospital, 19300 SW 65th Ave, Tualatin, OR 97062
(A.S.T.)
2. Department of Obstetrics and Gynecology, Oregon Health Sciences University, Portland, Ore (A.S.T.,
M.J.G.)
3. Department of Diagnostic Radiology, Mayo Clinic, Rochester, Minn (K.R.B.).
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Abstract
PURPOSE: To evaluate the role of transcervical fallopian tube catheterization in restoring tubal
patency after ligation reversal surgery.
MATERIALS AND METHODS: Twenty-four women with tubal obstruction after ligation reversal surgery
underwent selective salpingography and tubal recanalization.
RESULTS: Patency was established in 26 (68%) of 38 anastomotic tubes without complication. In the
13 patients who were followed up and who could conceive only via a recanalized anastomotic tube,
there were six (46%) pregnancies: two (15%) successful uterine pregnancies, two (15%) early
spontaneous abortions, and two (15%) tubal pregnancies. The mean time from procedure to
conception was 2 months.
CONCLUSION: Patency of fallopian tubes not visualized at hysterosalpingography after ligation

reversal surgery can be established 68% of the time with selective salpingography. In some patients,
selective salpingography can be therapeutic. If subsequent conception occurs in these patients, it
occurs shortly after the catheterization procedure.
Interruption of the fallopian tubes by transection and suture ligation, cauterization, or placement of
a mechanical ring or clip is intended as permanent sterilization. Sometimes because of divorce and
subsequent remarriage, death of children, or a new desire for children, reversal of the ligation
surgery is requested. The reversal surgery requires careful resection of the damaged segment of
tube and tubal anastomosis. Of women who do not conceive after the ligation reversal surgery,
about 20% have tubal occlusion (1). Options for women with postoperative tubal occlusion are
limited to repeat surgery, in vitro fertilization, or adoption. Fluoroscopically guided tubal
catheterization has been used to establish patency in tubes blocked in the interstitial and isthmic
portions, with a mean success rate of 82% (2). The role of this procedure in patients with blocked
tubes after ligation reversal surgery was evaluated.
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MATERIALS AND METHODS
From August 1987 to May 1994, 305 infertile women with unilateral or bilateral proximal tubal
obstruction gave informed consent and underwent coaxial catheter–guide wire tubal recanalization
by means of fluoroscopic guidance. The hysterosalpingographic diagnosis of tubal obstruction was
based on persistent tubal obstruction or underfilling of contrast agent in the tube within 4 cm of the
uterine cavity despite placing the patient prone and reinjecting contrast agent in 5 minutes to the
point of pelvic discomfort.
Twenty-four of the women (mean age, 35 years; age range, 26–45 years) with tubal obstruction had
a history of tubal ligation reversal surgery 2–48 months before the catheterization procedure (mean,
22 months). Women with a history of fimbriectomy reversal were excluded because this involves
distal tubal reconstruction and not tubal resection and reanastomosis. Details regarding the original
surgical ligation procedure were available in 18 women: Nine had cauterized tubes, six had Pomeroy
ligations, and three had Falope rings. Eighteen women had been delivered of at least one child
before tubal ligation; however, five had never had a term pregnancy before tubal ligation, and in one,
pregnancy history was unknown. At the time of referral for catheterization, one couple was being
treated for a low sperm count, and one patient had a history of endometriosis and pelvic pain;
otherwise, there were no known additional infertility factors.
In the 24 women, 38 tubes were obstructed, seven tubes were patent, and three tubes had been
removed. The patients underwent transcervical fluoroscopically guided catheter recanalization as
previously described (Fig 1) (3). Briefly, a vacuum cup hysterosalpingographic device (Thurmond-
Rösch Hysterocath; Cook, Bloomington, Ind) is used to gain access to the uterus. This provides a
sterile conduit through which a series of coaxial catheters and guide wires can be introduced and
allows traction on the uterus without the application of a tenaculum. Conventional
hysterosalpingography is performed with approximately 10 mL of a diluted water-soluble contrast
agent initially to localize the uterine cornua without obscuring the catheters. A coaxial catheter
system consisting of a 9-F Teflon sheath and a 5.5-F polyethylene catheter is advanced over a
0.035-inch-diameter (0.089-cm) J-tipped guide wire to the uterine cornu. This coaxial system of
three devices is advantageous in that it allows the flexibility to catheterize the ostia in flexed or
distorted uteri. The guide wire is removed and undiluted contrast agent is injected to perform
selective salpingography.
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Figure 1a.
Images obtained in a 41-year-old woman who conceived 2 months after undergoing transcervical
fluoroscopically guided catheter recanalization and who was delivered of a healthy neonate. (a)
Hysterosalpingogram shows that both fallopian tubes are occluded within 2 cm of the tubal ostia
(arrows). The J-tipped guide wire is advanced through the cervical-uterine junction. (b)
Hysterosalpingogram obtained as the guide wire, supported by the catheter, which is not visible, is
advanced to the right uterine cornu. (c) Hysterosalpingogram obtained after the J-tipped guide wire
was exchanged for the straight-tipped guide wire, which is used here to probe the proximal tube. (d)
Selective salpingogram, obtained during injection through the catheter lodged in the tubal ostium,
demonstrates a patent right tube (arrowheads). The tube is several centimeters shorter than normal,
which is the usual finding after ligation reversal.
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Figure 1b.
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Figure 1c.
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Figure 1d.
If proximal tubal obstruction persists, a 0.015-inch-diameter (0.038-cm) guide wire with a flexible
platinum tip and a 3-F Teflon catheter (Cook or Cook OB/Gyn) are advanced together into the
fallopian tube, and an attempt is made to recanalize the obstruction with gentle probing movements
of the guide wire. If there is an acute angle in the tube at the site of the obstruction, or if the
obstruction is in the isthmic portion of the tube, a softer tapered guide wire and catheter are used
(Tracker-18 catheter and Taper guide wire; Target Therapeutics, Fremont, Calif).
When the guide wire passes the obstruction, the guide wire is removed and the contrast agent is
injected through the 3-F catheter. Once the recanalization is completed, the 3-F catheter is
removed, and the contrast agent is injected through the 5.5-F catheter still wedged in the tubal
ostium to better delineate the tube and depict the site of recanalization. Hysterosalpingography after
recanalization can then be performed if desired. Other than 100 mg of doxycycline (Doryx; Warner
Chilcott, Rockaway, NJ) taken by mouth twice a day for 5 days for antibiotic prophylaxis, no routine
medications, including sedation or pain medication, are given. The patient can usually be dismissed
within 30 minutes after the procedure.
In the 24 patients, the hysterosalpingogram obtained before the procedure and the selective
salpingogram obtained after recanalization were scrutinized, and the location of the obstruction on
the hysterosalpingogram obtained before the procedure was categorized as follows: diffuse tubal
underfilling without demonstration of patency in seven tubes (Fig 2), proximal obstruction within the
first 2 cm of the tube in 12 tubes (Fig 1), and middle obstruction 2-4 cm from the uterine cavity in
19 tubes. After the procedure, the patients returned to their referring physicians for follow-up care
and were contacted by telephone yearly to obtain information about pregnancy or other procedures.
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Figure 2a.
fluoroscopically guided catheter recanalization. (a) Hysterosalpingogram demonstrates tubal
underfilling on the left (arrowheads) and proximal obstruction on the right (arrow). (b) Left selective
salpingogram demonstrates peritoneal spill (arrowheads). (c) Hysterosalpingogram demonstrates
right tube guide wire recanalization. Incidentally noted here and in d is an injected gas (∗) bubble in
the uterine cavity and just to the right of the catheter. (d) Selective salpingogram demonstrates the
right tube (arrowheads).
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Figure 2b.
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Figure 2c.
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Figure 2d.
To determine the technical success rate for achieving tubal patency, we analyzed the outcome of the
procedure in terms of individual tubes. To determine the ability of patients to conceive via
recanalized anastomotic tubes, we placed the 24 patients in four groups depending on their tubal
status at the conclusion of the procedure, and we tabulated the pregnancies per number of patients
in each group. Patients were followed up until the first pregnancy or other major procedure, such as
in vitro fertilization (n = 1), or adoption (n = 2). Patients who were lost to follow-up ( n = 3) were not
included in the denominator in determining the pregnancy rate.

RESULTS
Twenty-six (68%) of the 38 anastomotic obstructed tubes were successfully recanalized and
visualized in their entirety. Among the 12 tubes that were not recanalized, eight perforations
occurred and did not require treatment. There were no perforations among successfully recanalized
tubes. There were no other complications of the procedure, including excessive bleeding or pain, or
infection.
The success rates for establishing complete tubal patency were 100% (seven of seven) for underfilled
tubes, 75% (nine of 12) for proximally obstructed tubes, and 53% (10 of 19) for tubes obstructed in
the middle portion (Table 1). Nineteen (79%) of 24 patients had visualization of tubes not visualized
at the time of hysterosalpingography. Subsequent pregnancies were related to the patients' tubal
status after recanalization, as determined with selective salpingography (Table 2).
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TABLE 1. Technical Results in 24 Women Who Underwent Tubal Catheterization
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TABLE 2. Pregnancies in 24 Women Who Underwent Tubal Catheterization
Group A.—In 14 patients, recanalization was successful and resulted in a single patent anastomotic
tube or two patent anastomotic tubes. These patients progressed from no patent tubes to one or two
patent tubes at the conclusion of the procedure and therefore could conceive only via a recanalized
anastomotic tube. In this group, one patient was lost to follow-up, and there were four (31%) uterine
pregnancies (two term deliveries and two early spontaneous abortions) and two (15%) tubal
pregnancies among the 13 patients who were followed up (mean follow-up, 10 months; range, 1–35
months). In this group, the mean time from the procedure to conception was 2 months (range, 1–5
months).
Group B.—Five patients had a preexisting patent anastomotic tube and underwent successful
recanalization of the contralateral anastomotic obstructed tube, therefore progressing from one
patent tube to two patent tubes at the conclusion of the procedure. In this group, two patients were
lost to follow-up, and there were two (67%) uterine pregnancies (one term delivery, one early
miscarriage) and no tubal pregnancies in the three patients who were followed up (mean follow-up,
10 months; range, 7–16 months). The mean time from the procedure to conception was 7 months
(range, 7–8 months).
Group C.—Two patients had a preexistent patent anastomotic tube and underwent unsuccessful
recanalization of the contralateral anastomotic obstructed tube. They therefore had one patent tube
at both the start and the conclusion of the procedure. In this group, one patient conceived 23
months after the procedure and had an early miscarriage, and the other adopted after 32 months
without conceiving.
Group D.—In three patients, catheterization was not successful in opening a single remaining
proximally blocked tube or either of two proximally blocked tubes; therefore, they had no patent
tubes at both the start and the conclusion of the procedure. No pregnancies occurred among these
patients (mean follow-up, 21 months; range, 7–49 months).
Three patients who did not conceive underwent follow-up hysterosalpingography 3–14 months
(mean, 8 months) after the procedure. Four (80%) of five recanalized anastomotic tubes remained
opened.

DISCUSSION
By using fluoroscopic guidance and a standard coaxial technique, tubal obstructions in 26 (68%) of
38 tubes affected by a ligation reversal surgical anastomosis were successfully recanalized. As a
result, the tubes not visualized on the standard hysterosalpingograms were visualized in their
entirety in 19 (79%) of 24 patients. Diagnostic benefits of the procedure are immediate and
important. What is perceived by the surgeon and the patient as a failed tubal anastomosis is thereby
converted to a successful surgical result by means of the catheterization procedure.
Results in a smaller number of patients at a different institution were less successful (4,5). Fallopian
tube recanalization in patients with obstructed tubes after ligation reversal was successful in only six
(33%) of 18 patients. Failure was universal in tubes that demonstrated tubal-peritoneal fistulas on
the preprocedural hysterosalpingograms.
The timing of the fallopian tube catheterization procedure in the 24 women in the current study was
determined by the gynecologic surgeon primarily on the basis of his or her index of suspicion of a
tubal problem. The timing did not appear to affect either the technical or pregnancy success rates.
Successful recanalization of an anastomotic tube unfortunately does not guarantee a successful

reproductive outcome. This is in part because of our inability to know all the causes of infertility in
some couples. Tubes that are underfilled at the time of hysterosalpingography may be patent or may
be partially obstructed. Patients with one preexisting patent tube may be limited more by an
unknown fertility factor than by the contralateral obstructed tube. This latter observation may
explain why these women (groups B and C) took longer to conceive than the group A women, whose
fertility was more clearly related to their blocked tubes.
Tubal underfilling or occlusion at hysterosalpingography after ligation reversal may imply an

anatomically abnormal or dysfunctional tube and a predisposition to tubal pregnancy or reocclusion.
The reocclusion rate was only 20% (one of five tubes); however, the tubal pregnancy rate was 15%
among the 13 patients who could conceive only via a recanalized anastomotic tube (group A).
Among this same group, however, there were two (15%) successful uterine pregnancies, including
one in a 41-year-old woman (Fig 1), which indicates that opening these obstructed anastomotic
tubes does allow some normal conceptions to occur. However, the number is still lower than the
reported successful pregnancy rates of 23%–28% at 6 months and 60%–90% at 36 months after
uncomplicated ligation reversal surgery (6).
In the group that could conceive only via a recanalized anastomotic tube (group A), there were six
pregnancies, and they all occurred within 5 months of the catheterization procedure, with a mean
time from procedure to conception of 2 months. The experience of Lang and Dunaway (4) was
similar. In their two patients who underwent successful recanalization after ligation reversal, one
conceived 4 months after the procedure and the other had not conceived by 40 months, despite
continued tubal patency at hysterosalpingography.
These observations have implications for patient treatment. In general, after successful tubal ligation
reversal with continued tubal patency, patients may be followed up for 2 years or longer without
other intervention because the number of pregnancies increases over time (6). The information from
the small number of patients in our study with anastomotic tubes that require recanalization
indicates that the prevalence of pregnancies does not increase over time. Rather, if conception is
going to occur, it is likely to occur within the first 6 months after the catheterization procedure.
Following up patients beyond 6 months without offering them alternative therapy such as adoption,
in vitro fertilization, or in select cases repeat surgery may waste valuable time.
The underlying disease in anastomotic tubes that occlude after ligation reversal has not been clearly
defined. Most of our patients had occlusion 2–4 cm from the uterine cavity in the expected location
of the anastomosis. These were also the most difficult tubes to open; only 10 (53%) of 19 were
successfully recanalized. The underlying disease in most of these women is presumably fibrotic scar
tissue at the surgical site. The easiest tubes to open (seven of seven [100%]) were those affected by
tubal underfilling, and presumably the underlying cause is partially obstructing material in the tubal
lumen or perhaps patent tubes not adequately filled at hysterosalpingography. To our knowledge,
why the latter occurs has never been fully explained. Proximally obstructed tubes were recanalized
75% of the time (nine of 12 tubes), and these were presumably affected by the amorphous debris
known to lodge in the interstitial portion of the tubes (7).
The options are limited for women in whom ligation reversal surgery fails. The tubes are already
shortened because of the resection of the ligated and damaged area before anastomosis. Repeat
surgery to removed the occlusion shortens the tube even more and risks interfering with the normal
tube and ovary relationship. In vitro fertilization bypasses the tubes altogether but is expensive, and
to some couples it is emotionally and physically draining or not acceptable for religious reasons.
Adoption is also expensive and not acceptable to some.
We recommend that patients with tubal obstruction after ligation reversal surgery undergo
fluoroscopic tubal recanalization with selective salpingography because it establishes tubal patency
in 79% (19 of 24) of women. If it is successful and the tube is patent without apparent distal disease,
the patient can attempt pregnancy with some caution advised regarding the risk of tubal pregnancy.
Any other concurrent fertility factors should be corrected, if possible. If pregnancy does not occur
within 6 months, the patient should be counseled regarding her other options.

Tubal Obstruction After Ligation Reversal Surgery

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Tubal Obstruction After Ligation Reversal Surgery

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Tubal Obstruction after Ligation Reversal Surgery:

Results of Catheter Recanalization

CONCLUSION: Patency of fallopian tubes not visualized at hysterosalpingography after ligation

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TABLE 1. Technical Results in 24 Women Who Underwent Tubal Catheterization

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TABLE 2. Pregnancies in 24 Women Who Underwent Tubal Catheterization

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Successful recanalization of an anastomotic tube unfortunately does not guarantee a successful

Tubal underfilling or occlusion at hysterosalpingography after ligation reversal may imply an

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