Tubal flushing for subfertility

Johnson N, Vanderkerchove P, Lilford R, Harada T, Hughes E, Luttjeboer F, Mol BWJ, Torossian LG

Published Online:

November 10, 2010

Eggs travel from ovaries through fallopian tubes to reach the uterus (womb). If there is a blockage it may not be possible for the woman to conceive. The tubes can be tested by 'flushing' them with dye or medium (liquid) that will show up during laparoscopy (keyhole examination) or hysterosalpingogram (x-ray). The review of trials found some evidence that tubal flushing with oil-soluble media can increase women's chances of pregnancy, and this might be better than using water-based media. However, more research is needed, particularly to work out the mechanism through which oil-soluble media enhance fertility. Rather than a simple 'tubal flushing', this might be an effect inside the pelvic cavity near the ovary that influences the environment in which eggs grow, or an effect on the inner lining of the womb that improves the chance of en embryo implanting and establishing a pregnancy.

Abstract (click to read)

Background:

A possible therapeutic effect of diagnostic tubal patency testing has been debated in the literature for half a century. Further debate surrounds whether oil-soluble or water-soluble contrast media might have the bigger fertility-enhancing effect, although tubal flushing does not currently form part of routine practice in the treatment of fertility delay.

Objectives:

To evaluate the effect of flushing a woman's fallopian tubes with oil- or water-soluble contrast media on subsequent fertility outcomes in couples with infertility.

Search strategy:

We searched the Cochrane Menstrual Disorders and Subfertility Group's specialised register of trials (searched 31 January 2007), MEDLINE (1966 to Jan 2007), EMBASE (1980 to Jan 2007), Biological Abstract (1980 to Jan 2007) and reference lists of articles.

Selection criteria:

All randomised trials comparing tubal flushing with oil-soluble contrast media or tubal flushing with water-soluble media or with no treatment in women with subfertility.

Data collection and analysis:

Four authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We collected adverse effects information from the trials.

Main results:

Twelve trials involving 2079 participants were included. Tubal flushing with oil-soluble media versus no intervention was associated with a significant increase in the odds of live birth (Peto OR 2.98, 95% CI 1.40 to 6.37) and of pregnancy (Peto OR 3.30, 95% CI 2.00 to 5.43). For the comparison of tubal flushing with oil-soluble media versus tubal flushing with water-soluble media, the increase in the odds of live birth for tubal flushing with oil-soluble versus water-soluble media (Peto OR 1.49, 95% CI 1.05 to 2.11) was based on two trials where statistical heterogeneity was present and the higher quality trial showed no significant difference; there was no evidence of a significant difference in the odds of pregnancy (Peto OR 1.21, 95% CI 0.95 to 1.54). The addition of oil-soluble media to flushing with water-soluble media showed no evidence of a significant difference in the odds of pregnancy (Peto OR 1.28, 95% CI 0.92 to 1.79) or live birth (Peto OR 1.06, 95% CI 0.64 to 1.77). There were no serious adverse event reported.

Authors' conclusions:

There is evidence of effectiveness of tubal flushing with oil-soluble contrast media in increasing the odds of pregnancy and live birth versus no intervention. The limited evidence of an increase in the odds of live birth from tubal flushing with oil-soluble contrast media versus water-soluble contrast media must be interpreted cautiously. Further robust randomised trials, comparing oil-soluble versus water-soluble media and comparing water-soluble media versus no intervention, would be a useful further guide to clinical practice. Trials are also required to ascertain the place of flushing with oil-soluble contrast media compared to established treatments for unexplained infertility, such as intrauterine insemination and in vitro fertilisation and compared to laparoscopic removal of endometriosis. Further research is merited to ascertain the mechanism of the fertility enhancing effect of oil-soluble media, as to whether this is a 'tubal flushing' phenomenon, an effect on the intraperitoneal environment, or an implantation enhancing effect on the endometrium.

This record should be cited as:

Johnson N, Vanderkerchove P, Lilford R, Harada T, Hughes E, Luttjeboer F, Mol BWJ, Torossian LG. Tubal flushing for subfertility. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD003718. DOI: 10.1002/14651858.CD003718.pub3

Assessed as up to date:

April 16, 2007

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Primary Review Group:

Menstrual Disorders and Subfertility Group

Health topics:

Gynaecology > Surgery

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