**8. Proximal tubal occlusion**

Usually diagnosed by HSG and confirmed by laparoscopic chromopertubation test. The most important job of the endoscopist is to find out contraindications for hysteroscopic tubal cannulation procedure which include:

florid infection

44 Enhancing Success of Assisted Reproduction

differentiate these conditions from a hydrosalpinx (67).

them or with the aid of fine sutures.

**7.5. Technical tricks of laparoscopic management of hydrosalpnix**

paratubal, paraovarian, or perineural cysts. In some cases, CT or MRI may be helpful to

a. **Salpingoneostomy:** One of the keys of success is to evaluate the tube externally and internally. If peritubal adhesions exist, microsurgical adhesiolysis should be performed at first. Be sure that the tube is freely mobile. Imagine the site of the new ostium before dealing with the hydroslpnix. It should be directed towards the pouch of Douglas to help ovum pick-up. Start by salpingoneostomy using a fine monopolar or bipolar needle. The finest the needle, the better ostium. Incise the distended distal part of the tube " + shaped" (cruciate incision). Then, evaluate the tubal mucosa using a salpingoscopy. Practically, use the diagnostic hysteroscopy which consists of a 4 mm telescope and a 5 mm outer sheath. Connect it to a normal IV infusion set and use saline as an irrigating fluid. Grasp the new ostium with an atruamatic grasping forceps and insert the hysteroscope with comment on the major and minor folds till reaching the narrowest part of the tube. If major and minor folds are lost this means that the prognosis is poor even after proper refashioning. The next step is to grasp the tubal lumen with atruamatic forcpes and to evert it outside. Lastly, fix the edges of the new ostium either with monopolar spray coagulation just distal to the incised parts to evert

b. **Salpingectomy:** This procedure is indicated if a pathologic unilateral huge hydrosalpnix is present to enhance spontaneous pregnancy or bilateral big hydrosalpnix before

IVF/ICSI. It is performed in the same manner as mentioned in the section of EP. c. **Tubal occlusion:** Once the peritoneal cavity is entered, a panoramic evaluation of the pelvis is performed. If the pelvis looked frozen or if access to the fallopian tubes is impossible, the patient is considered a failed laparoscopic approach. Those cases are subsequently treated by open laparotomic or hysteroscopic approach. If the procedure seems feasible, a third auxiliary puncture is carried out. Utilizing a bipolar forceps, the isthmic part of the fallopian tube is coagulated and incised to ensure complete tubal occlusion, as a case of tubal sterilization. The procedure is completed after securing hemostasis. The patient is discharged after 3-4 h under antibiotic prophylaxis. Laparoscopic salpingectomy or bipolar proximal tubal occlusion yielded statistically similar responses to controlled ovarian hyperstimulation and IVF-ET cycle outcome. Proximal occlusion might be preferable in patients who present with dense pelvic adhesions and easy access only to the proximal fallopian tube (68). Occlusion is considered a minimally invasive procedure, requires less experience, feasible in most cases, and has fewer burdens on the psychological status of those infertile women. Hysteroscopic approach is recently described by our team at Assiut University Institution (69). The cervix is primed in all cases using misoprostol (200 µg) 8 h prior to the procedure. The procedure is carried out immediately postmenstrual without specific preparation. Local paracervical, spinal or general anesthesia could be used. Selection of the anaesthetic technique is chosen according to patient preference after


Don't try to cannulate the tube in such cases as failure would be expected and you would be disappointed. In cases with isolated tubal occlusion, cannulation would be successful.
