Is there a Role for Conservative Treatment in Those With Unilateral Tubal Occlusion?

HSG is the accepted standard to diagnose tubal patency. In contrast to bilateral tubal occlusion where therapy is directed towards laparoscopic correction or IVF, treatment of unilateral tubal occlusion (UTO) is less clear, including conservative OI and IUI directed towards the patent tube. We assessed the value of conservative OI-IUI and pregnancy outcomes in those with UTO. Methods: We evaluated patients diagnosed on HSG with UTO (n=24) (proximal [n=7] and mid-distal or distal occlusion [n=17]). Inclusion included women <38 years; regular menstrual cycles; normal sperm parameters; and normal spill from 1 fallopian tube on HSG.  Controls underwent donor insemination (n=87 in 275 cycles) with bilateral tubal spill. Treatment included LH testing and time intercourse (n=5) or OI-IUI with Clomiphene Citrate or Letrazole (n=19 in 36 cycles). All treatment cycles were monitored by ultrasound; hCG was given when lead follicle size reached >18mm (unless recruited follicle on obstructed side); and IUI was performed 24-36 hours later. The primary outcome measured was clinical pregnancy (CP). Results: Baseline demographics including age (32.2±4[±SD] vs 33.4±2 yrs, p-NS) and BMI (27.9±7 vs 28.2±8 kg/m², p-NS) were similar between UTO and control groups. Between HSG and treatment, spontaneous pregnancy occurred in 5 (21%) women with UTO (1 proximal, 4 distal). In those undergoing OI-IUI treatment, CP rates/patient (32%, n=6/19 and 24%, n=21/87, p=0.56) and CP/cycle (17%, 6/36 and 8%, 21/275, p=0.10) were similar for UTO and control groups.  Overall, CP occurred in 2 (29%) and 9 (53%) patients with proximal and mid-distal or distal UTO, p=0.005, respectively. Twenty-nine (81%) cycles recruited a dominant follicle on the patent side (19% CP/cycle), in contrast no pregnancies occurred (0%, 0/7) if recruitment occurred on the side of UTO, p=0.3. Conclusions: Pregnancy rates are not compromised in women with UTO and conservative treatment with OI-IUI appears justified as a first line approach, obviating more aggressive therapies including laparoscopy and IVF.