11/1/2013

Proximal Tubal Occlusion

Author: Daniel R. Grow, MD

Editor: Daniel Martingano, DO, PhD, FACOG

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Evaluation of fallopian tubal patency is a very important part of a female infertility workup. Tubal, peritoneal, and adhesive disease are the main causes of infertility and account for 40% of all infertility problems Tubal obstruction refers to a temporary, potentially reversible condition such as tubal spasm or plugging by amorphous material, whereas tubal occlusion is permanent organ damage, which can results from condition such as pelvic inflammatory disease and severe endometriosis.

Proximal tubal occlusion (PTO) is a relatively common finding encountered during hysterosalpingography (HSG) evaluating for tubal patency, occurring in up to 20% of all studies. PTO is determined when radiographic contrast fails to enter the isthmic fallopian tube during HSG. Lack of filling of tubes during HSG may result from either tubal obstruction (transient) or tubal occlusion (permanent) as mentioned. The main causes of PTO include fibrosis secondary to pelvic infection or tubal ligation, SIN, intramuscosal endometriosis and chronic tubal inflammation.

Proximal tubal obstruction can be secondary to

tubal spasms
thickened mucus plugging of the proximal segment
or procedural errors/difficulties.

Proximal tubal occlusion can be classified into three different types:

nodular (salpinigitis isthemica nodosa or endometriosis)
non-nodular (true fibrotic occlusion)
pseudo occlusion (mucus plugs, detritus, polyps, and hypoplastic tubes)

Techniques have been described to overcome tubal occlusion including transcervical tubal cannulation by fluoroscopy, simultaneous hysteroscopy and laparoscopy, transcervical balloon tuboplasty, falloposcopy, and saline infusion sonohysterography. SIS can also serve as solely an alternative diagnostic test where it detects the accumulation of fluid in the pelvis by ultrasound as evidence of tubal patency, but the false positive rate for the diagnosis of tubal occlusion may exceed that of HSG.

HSG remains the initial, gold standard diagnostic modality to assess tubal patency mainly because of its high sensitivity in the diagnosis of tubal occlusions. This method is less invasive than chromotubation via laparoscopy and reveals information about the internal architecture of the fallopian tubes, which are considered in differential diagnosis of pathological conditions, proper intervention, and appropriate treatment. Office hysteroscopy is not clinically useful. Three-dimensional ultrasound alone can help detect the presence of fibroids, but does not assess tubal patency.

If it is confirmed that the fallopian tubes are occluded, in vitro fertilization is often the best treatment option for those desiring future pregnancies. If the occlusion is secondary to hydro salpinges, they must first be removed prior to IVF. Pregnancy rates after IVF for tubal disease are age-related, but the nationally reported live birth rate per cycle for patients under age 35 is approximately 40% (SART).

Further Reading:

Tjahyadi D, Udayana IS, Nisa AS, Rachmawati A, Djuwantono T. Comparison of salpingectomy and tubal occlusion for hydrosalpinx in in-vitro fertilization outcome. Ann Med Surg (Lond). 2024 Jan 3;86(2):886-890. doi: 10.1097/MS9.0000000000001548. PMID: 38333268; PMCID: PMC10849305.

Zafarani F, Ghaffari F, Ahmadi F, et al. Hysterosalpingography in the assessment of proximal tubal pathology: a review of congenital and acquired abnormalities. The British journal of radiology. 2021 Jun 1;94(1122):20201386.

Practice Committee of the American Society for Reproductive Medicine. Committee opinion: role of tubal surgery in the era of assisted reproductive technology. Fertil Steril. 2012 Mar;97(3):539-45. doi: 10.1016/j.fertnstert.2011.12.031. Epub 2012 Jan 29. PMID: 22285747.

Initial approval: November 2013; Revised: September 2018. Reaffirmed March 2020. Revised November 2023. Revised September 2025.

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