chapter  13
Proximal Tubal Obstruction
Pages 24

Obstruction of the proximal tube has been a well-recognized entity in gynecology since the early 1800s. A technique for tubal cannulation to relieve proximal tubal obstruction (PTO) was described in the mid-1800s. Forward thinking and insightful, Smith attempted to cannulate proximally obstructed fallopian tubes by using a whale bone bougie in 1849.1 The procedure was described as “a new uterine operation” (Figure 13-1) and, ironically, is an early, rudimentary form of selective salpingography and transcervical cannulation. Smith’s procedure relied on tactile feedback as the bougie was advanced through the cervix and uterus. Though not widely used, its importance was in the concept of mechanical dilatation of proximally obstructed tubes. Management for PTO varied considerably as surgical techniques evolved but remained problematic and frustrating for clinicians. In 1896, the first tubal implantation was performed by Watkins in a patient with a myoma blocking the uterotubal junction. After the procedure, a pregnancy was reported but ended in a miscarriage.2 In 1921, a case report described a uterotubal implantation that resulted in the first living child after this procedure.3 However, success after surgical repair remained uniformly poor, prompting investigations to bypass the tube entirely. With this intent, Estes

described a procedure for direct approximation of the ovary into a uterine window (Estes’ operation). It was abandoned because of poor outcomes. A similar procedure involved placement of the ovary into the uterine cavity (Tuffier’s procedure) and had similar poor results.4