TY - JOUR
AU - Sharif, Khaldoun
AB - Abstract BACKGROUND: Selective salpingography enables us to measure the Fallopian tube perfusion pressure which, when high, can be effectively reduced with the use of transcervical guide-wire tubal catheterization. Whether fertility prognosis improves as a result is currently unknown. Our objective was to clarify the issue. METHODS: Infertile women undergoing selective salpingography were classified into poor, mediocre and good tubal perfusion pressure groups, based on the distribution of tubal perfusion pressures in an unselected infertile population. Of 325 women, 150 (46.1%) were classified in the poor group and underwent guide-wire tubal catheterization. RESULTS: Complete pregnancy and tubal perfusion pressure data were available for 104 (69.4%) subjects. Following tubal catheterization, 29 women (group A) could be classified in the good, 25 (group B) in the mediocre, while 50 women (group C) remained in the poor tubal perfusion pressure group. Survival analysis showed that the pregnancy rate in group A was significantly higher than the rates in groups B and C (P = 0.036 and 0.005 respectively). CONCLUSIONS: Reductions of tubal perfusion pressures achieved with transcervical guide-wire tubal catheterization resulted in an improved fertility prognosis for women. Selective salpingography and tubal catheterization might have a wider role in the management of the infertile couple than currently believed. infertility, proximal tubal obstruction, selective salpingography, tubal catheterization, tubal perfusion pressure Introduction Selective salpingography (SS), the transcervical cannulation and direct injection of contrast medium into the Fallopian tube, was first described in 1966 (Corfman and Taylor, 1966). When proximal tubal blockage is encountered during SS, transcervical guide-wire tubal catheterization (TC) can be employed in an attempt to unblock the Fallopian tube. Several published series of selective salpingography and tubal catheterization under fluoroscopic guidance (SS/TC) have attested to the effectiveness of this method in recanalizing proximally blocked Fallopian tubes and restoring fertility (Thurmond and Rosch, 1990; Capitanio et al., 1991; Ferraiolo et al., 1995; Lang and Dunaway, 1996). With SS, in contrast to either hysterosalpingography (HSG) or laparoscopy and dye test, individual Fallopian tubes are assessed. The opportunity therefore exists to record the tubal perfusion pressure (TPP). Limited information is available about the practical applications of TPP measurements in the management of the infertile couple. TPP measurements are thought to enhance the diagnostic capability of SS/TC in that patent Fallopian tubes with normal compliance (and therefore normal TPP) can be differentiated from patent but non-compliant Fallopian tubes (with high TPP) (Gleicher et al., 1992; Gleicher and Karande, 1996). A significantly higher pregnancy rate can be expected in women with normal TPPs in comparison with women with elevated TPPs after controlled ovarian stimulation with either gonadotrophins or clomiphene citrate (Karande et al., 1995a). Tubal catheterization techniques have been successfully used not only in cases of proximally obstructed oviducts in an attempt to unblock them, but also in cases of patent Fallopian tubes with elevated TPPs, in order to lower them (Hilgers and Yeung, 1999). Whether such reductions result in improvements in conception rates remains uncertain. The aim of this study was to evaluate the effect of TC induced reductions in TPPs on subsequent fertility. Materials and methods Study population and TPP classification In the 3 year period starting April 1996, 325 consecutive infertile women underwent SS/TC. Average age (± SD) was 32.4 (± 5.2) years and median duration of infertility at the time of the procedure was 3.25 years (range 0.4–23.4 years). Of them, 138 (42.5%) women presented with primary and 187 (57.5%) with secondary infertility. In 219 (67.4%) of the cases, SS/TC was performed because of proximal tubal blockage diagnosed by HSG (32.3%), laparoscopy and dye (15.4%) or both (19.7%). In the remaining 106 (32.6%) cases, the procedure was performed as a first-line tubal assessment test. Amongst these 106 women, there were 40 who had normal tubes (as judged by the opacification pattern during SS) and for who complete TPP data were also available. The distribution of TPP values was skewed with the 10th, 50th (median) and 90th percentiles at 120, 300 and 500 mmHg respectively. Using the above median and 90th percentile TPP values as cut-offs, Fallopian tubes were classified as follows: L low pressure (if TPP ≤300 mmHg); I intermediate pressure (if TPP >300 mmHg and ≤500 mmHg); and B high pressure (if TPP >500 mmHg or absent Fallopian tube). Unilateral salpingectomy had been performed in 11 cases. Each subject with complete TPP information was then placed, on the basis of the combination of TPP values from both Fallopian tubes, in one of the following six TPP categories: LL, LI, LH, II, HI and HH. The TPP categories were combined in three groups, to define the subjects' TPP status as good (categories LL and LI), mediocre (categories LH and II) or poor (categories HI and HH). Equipment and technique used The method used has been described elsewhere (Papaioannou et al., 2002a,b). In brief, the Fallopotorque (Cook, Letchworth, Hertfordshire, UK) SS/TC catheter system was used. It includes a (roadrunner) guide-wire, which is 145 cm in length and 0.035 inch (0.89 mm) in diameter. Its surface is covered with a hydrophilic polymer coating, which attracts and holds liquids, thereby creating a low-friction surface. It terminates in a straight, 7-cm long tip, which tapers to 0.025 inch (0.64 mm). The fluoroscopic unit employed was the mobile Phillips Optimus BV29 with a C-arm system (Phillips Corporation, The Netherlands). The distal end of the selective salpingography catheter was connected by polyethylene tubing to a syringe pump (KMAR-400; Cook) and by means of a three-way stopcock to a pressure sensitive transducer, which conveyed information to a computer. The pump was activated to flush the catheter with contrast medium and the encountered background resistance was displayed as a pressure curve on the computer screen while a hard copy printout could be obtained (Figure 1). The radiation dose to the patient was measured as a dose-area product (DAP) with a fitted calibrated meter (PTW, Freiburg, Germany). The DAP is a measure of the total energy imparted to the patient for the complete examination. The fluoroscopic screening time was monitored by an automatic timer on the unit control panel. The precision of the screening times was limited by the minimal 6 s increments of the timer. SS/TC was performed during the follicular phase of the menstrual cycle. Local anaesthesia and lubrication were provided by instillation of 2% lignocaine gel (Instillagel; Farco-Pharma, Cologne, Germany) into the cervical canal. After waiting for ~3 min a single-toothed tenaculum was applied at the 12 o'clock position of the cervix. The selective salpingography catheter was forwarded through the cervical canal and was advanced by tactile sensation to the tubal ostium. Its position was checked fluoroscopically and if satisfactory, dye was injected. If the obstruction was overcome the tubal contour was outlined with contrast. If it persisted a guide-wire was threaded through the inner cannula and was advanced towards the obstruction. A gentle push was applied to overcome it. The guide-wire was then withdrawn and contrast medium was injected through the selective salpingography catheter to confirm patency. Data collection TPP data were extracted from TPP curves stored on computer (Figure 1). The maximum TPP value after TC, minus the system background pressure for each Fallopian tube was used in the analysis. Reproductive outcome was assessed with semi-structured questionnaires sent to women along with pre-paid reply envelopes in August 2000. A second mailshot was sent to women who had not responded in January 2001. Subsequently, we telephoned those women whose responses were unclear or incomplete as well as non-responders. If the telephone numbers in the patient's case notes were inaccurate, their family doctor or the health authority was contacted to identify the patient's current phone number. Statistical methods Only the woman's first conception during the study period was considered. Proportional hazards survival analysis was used. Both the Cox and the parametric Weibull models were fitted. Parameter-estimates from the Weibull model are presented because of their convenient interpretation as multiplicative factors operating directly on the time to conception (Collett, 1994). On an initial analysis, only spontaneous conceptions were counted as successes. Conceptions arising after medical intervention were considered as censored at the time of conception. Cases for whom no conception was reported were censored at the time of the mail or telephone follow-up. In a supplementary analysis the definition of success was extended to include all first conceptions except those arising from IVF or ICSI treatments. Thus, in the supplementary analysis, conceptions resulting from clomiphene citrate, in-utero insemination or ovulation induction treatments were also counted as successes. StatView version five software (SAS Institute Inc., 1998) was used for statistical analysis. Results Of the original 325 subjects, 150 (46.1%) were found to be of poor TPP status during SS and subsequently underwent TC. Responses were collected from 111 (74%) women of whom TPP values after TC were available in 104 (69.4%). Their mean age (± SD) was 33 years (± 5.2). The median duration of infertility at SS/TC was 3.6 years (range 2.2–22.8). Of them, 49 women (47.1%) presented with primary and 55 (52.9%) with secondary infertility. Of the 104 women, subsequent to TC, 29 (27.9%) could be classified in the good (group A), 25 (24%) in the mediocre (group B), while 50 women (group C) (48.1%) remained in the poor TPP status group. Groups A, B and C were not statistically different in terms of age and duration of infertility at SS/TC, type of infertility (primary/secondary), presence of male factor, endometriosis and anovulation (Table I). The number of pregnancies by method of conception and the pregnancy outcome for groups A, B and C are shown in Table II. The age-adjusted cumulative conception rates for the same groups are shown in Figure 2. The pregnancy rate in group A was noticeably higher than the pregnancy rates in both groups B and C, both when first spontaneous conceptions only were considered (P = 0.073 and P = 0.019 respectively) as well as when all non-IVF/ICSI first conceptions were considered (P = 0.036 and P = 0.005 respectively). All but one of these comparisons achieved formal statistical significance. The pregnancy rate in group B was almost identical to the pregnancy rate of group C. Although proportionally there were more ectopic pregnancies in groups B and C than in group A, the numbers were too small for conclusions to be drawn. The numerical effects of changes in TPP status and age groups to the time to first conception are illustrated by the multiplicative factors shown in Table III. These are applicable to the time to first conception of an ideal case, i.e. a woman in group A, <30 years of age. For example, a woman <30 years of age but in group C would take on average 3.65 times longer to achieve a spontaneous pregnancy in comparison with the ideal case. The procedure was generally well tolerated. Patients were discharged home on average 30 min after SS/TC. Four patients (2.6%) complained of significant discomfort, not responsive to common oral analgesics for which opioids were used. There were four (2.6%) cases of tubal perforation. No special treatment was necessary for any of them. Laparoscopy had been performed in 110 (73.3%) of these patients. Endometriosis was identified in eight (7.3%) of them. After TC, these patients could be classified in the TPP groups as follows: group A one patient, group B two patients and group C five patients. The median values for the DAP and screening time were 48 cGy cm2 (interquartile range 46.5) and 76.5 s (interquartile range 75.25) respectively. Discussion This study shows that TC induced reductions of TPPs have a positive impact on conception rates. This is the case only when the magnitude of the reduction achieved is significant enough for the woman concerned to be classified in the good TPP status group (as defined here) after TC. Otherwise, the prognosis appears unchanged. Treatment of proximal tubal disease by guide-wire tubal catheterization is an integral part of most methods of selective salpingography, either under fluoroscopic (Thurmond and Rosch, 1990; Lang and Dunaway, 1996) or hysteroscopic control (Novy et al., 1988). No doubt exists about its effectiveness in achieving tubal recanalization (Gleicher et al., 1994). However, considerable skepticism has been expressed about the probability of intrauterine implantation after successful tubal recanalization with TC. Gleicher et al. in a series of 25 infertile women who underwent TC after unsuccessful selective salpingography, reported a single conception (an ectopic pregnancy) with follow-up periods of 5–17 months. This was despite a 77% successful tubal recanalization rate achieved in their series (Gleicher et al., 1994). In a similar group of seven women, Woolcott et al. reported a single conception (again an ectopic pregnancy) with mean follow-up of 17 months after recanalization by guide-wire alone (Woolcott et al., 1995). The authors concluded that, where guide-wire alone without catheterization is performed, the prognosis with regard to pregnancy is poor and that this should not be seen as treatment of proximal tubal occlusion. Our findings regarding tubal catheterization appear to be more optimistic. The smaller number of women, the absence of TPP measurements and the shorter follow-up in the previous studies might explain this discrepancy. Only 27.9% of our patients could be classified in group A after TC. If this percentage was similar in the previous studies, only nine of the 32 patients they included could be classified in the good prognosis group. Without knowing the TPP values after TC, it is plausible to assume that this number could have been even smaller. In our population pregnancies were reported throughout the follow-up period (range 16–56 months). Again, we may assume that, had the patients in the previous studies been followed up for longer, some benefit of TC might have become evident. Therefore, the problem might not lie with TC itself but rather with the absence of an objective means of assessing the results of the treatment. We believe that measurement of TPPs can fill this gap. The mechanism by which pregnancy rates for infertile women improve after reductions of raised TPPs achieved by tubal catheterization, might lie in the concept of proximal tubal disease (Gleicher and Karande, 1996). Proximal tubal disease is viewed as a continuum, with tubal patency and complete tubal blockage being only the extremes of a spectrum. Measurement of TPPs can uncover and probably quantify the severity of cases of partial tubal blockage. These, depending on aetiology as with complete proximal tubal blockage, can be successfully treated with tubal catheterization. The result of the intervention can be clinically assessed by measuring the magnitude of TPP reduction, which when significant, as defined in this paper, marks an improvement in prognosis. It is important to interpret the results presented in the light of the methodology used. As our study is of cohort design, it provides evidence of a possible association, but cannot guarantee protection against bias. If our results are prospectively confirmed by a randomized trial (which we plan to undertake) then TPP measurements should become an integral part of SS/TC, as they would contribute substantially to fertility treatment decision-making. Depending on the specifics of each case, women for whom good TPPs are achieved through TC may be followed up expectantly, and ovulation induction with either clomiphene citrate, gonadotrophins or intrauterine insemination (IUI) may be considered. Women that after undergoing TC remain in the poor or mediocre TPP status groups, even though the tubes are patent, should be advised that early resort to IVF is indicated. Fallopian tubes that are judged to be normal by opacification pattern may have elevated TPPs (Gleicher et al., 1992). Therefore, normal tubal opacification patterns alone, without TPP measurements, should not necessarily be regarded as consistent with good prognosis. The incorporation of TPP measurements in the routine performance of SS/TC appears to be justified, and the diagnostic information provided by TPPs might also support a wider role for SS/TC in the investigation and treatment of the infertile couple. The incidence of proximal tubal blockage in infertile women who present with tubal disease has been reported as 10–25% (Honore et al., 1999). There is no information about the incidence of elevated TPPs in infertile women that might present without any tubal problems on simple opacification or laparoscopy and dye studies and perhaps have been labelled as unexplained cases of infertility. Some of these patients could benefit from SS with TPP estimation, followed by TC. Despite its endorsement by respected professional bodies (American Fertility Society, 1993; Royal College of Obstetricians and Gynaecologists, 1998) SS/TC is still only offered by a few tertiary reproductive medicine units. The reasons for this have not been documented. Concern about the technical difficulty of the procedure and the consequences of the irradiation of the ovaries of reproductive age women, may partly explain this limited usage. Our group has addressed these issues with reassuring results (Papaioannou et al., 2002a,b). Another possible explanation is the fact that SS/TC has been seen, so far, as a method relevant only to infertile women with proximal tubal blockage, a relatively infrequent presentation. We would think that the information presented here and in our previous work, would create interest in the technique, which, by its relative simplicity and modest equipment requirements, as well as by its potential to reduce the utilization of more expensive diagnostic and therapeutic interventions, lends itself to more widespread use. High TPP values have been associated with the presence of tubal endometriosis (Karande et al., 1995b). In this study there was a higher proportion of laparoscopically diagnosed endometriosis patients in group C than in the other groups, although the actual numbers were small. The presence of peritoneal endometriosis does not necessarily imply the existence of tubal endometriosis and vice versa. Nevertheless, based on this fact, one could hypothesize that the presence of endometriosis in a patient is a negative prognostic factor as far as the possibility of successful TC reduction of elevated TPPs is concerned. The confidence intervals of the improvement rates noted were quite wide (Table III). More research would be necessary to clarify the exact magnitude of the improvement in fertility prognosis achieved by TC. The normal reference range for TPPs is still a matter of debate. Gleicher et al. felt that normal TPPs during selective salpingography were 40–350 mmHg (Gleicher et al., 1992). Using a different TPP measurement set-up, and in some cases laparoscopy, Hilgers and Yeung found that, in freely patent tubes, the mean (± SD) TPP was 403 ± 46 mmHg (Hilgers and Yeung, 1999). Both groups used fluoroscopic guidance, as was the case in our study. Different results were presented in abstract form (Kaseki et al., 1991). During hysteroscopic selective salpingography and using Indigo Carmine instead of water-soluble radiopaque medium, they recorded systolic and diastolic TPPs (mean ± SD) of 84.8 ± 41.6 and 72.3 ± 9.6 mmHg respectively. When carbon dioxide was used the respective values were 103.1 ± 15.2 and 86.6 ± 2 mmHg (Kaseki et al., 1991). Using a TPP measurement set-up similar to that proposed by Gleicher et al. we reached a similar conclusion. In conclusion, this study shows a clear benefit of transcervical guide-wire tubal catheterization in pregnancy rates, where the resulting fall in TPPs allows women to be reclassified in the good TPP status group, as defined above. Therefore, SS/TC combined with TPP measurements represents an intervention, which provides not only more accurate diagnosis of tubal condition, but also offers the opportunity for effective, minimally invasive treatment. Table I. Patient characteristics in the different TPP status groups. P-values derived from χ2_tests (for discrete covariates), analysis of variance (for age) and the Kruskal-Wallis test (for duration of infertility)   Total  Group A  Group B  Group C  NS = not significant; SS = selective salpingography.  a17 missing.      b1 missing.  c23 missing.  d18 missing.  e39 missing.  Age at SS (n) (NS)  104  29  25  50      Years  33.0 (5.2)  33.5 (5.7)  33.1 (3.9)  32.8 (5.5)  Duration of infertility (n)  87a  21  22  44      Years (SD)(NS)  3.6  3.2  3.2  4.1      Range  (0.7–23.4)  (0.8–16.2)  (0.9–15.0)  (0.7–23.4)  Type of infertility (n) (NS)  103b            Primary (%)  49 (48)  15 (54)  13 (52)  21 (42)      Secondary (%)  54 (52)  13 (46)  12 (48)  29 (58)  Male factor (n) (NS)  81c            Yes (%)  21 (26)  7 (32)  3  11 (27)      No (%)  60 (74)  15 (68)  15  30 (73)  Endometriosis (n) (NS)  86d            Yes (%)  8 (9)  1 (5)  2 (10)  5 (11)      No (%)  78 (91)  21 (95)  18 (90)  39 (89)  Anovulation (n) (NS)  85e            Yes (%)  16 (19)  5 (22)  2 (10)  9 (21)      No (%)  69 (81)  18 (78)  18 (90)  33 (79)    Total  Group A  Group B  Group C  NS = not significant; SS = selective salpingography.  a17 missing.      b1 missing.  c23 missing.  d18 missing.  e39 missing.  Age at SS (n) (NS)  104  29  25  50      Years  33.0 (5.2)  33.5 (5.7)  33.1 (3.9)  32.8 (5.5)  Duration of infertility (n)  87a  21  22  44      Years (SD)(NS)  3.6  3.2  3.2  4.1      Range  (0.7–23.4)  (0.8–16.2)  (0.9–15.0)  (0.7–23.4)  Type of infertility (n) (NS)  103b            Primary (%)  49 (48)  15 (54)  13 (52)  21 (42)      Secondary (%)  54 (52)  13 (46)  12 (48)  29 (58)  Male factor (n) (NS)  81c            Yes (%)  21 (26)  7 (32)  3  11 (27)      No (%)  60 (74)  15 (68)  15  30 (73)  Endometriosis (n) (NS)  86d            Yes (%)  8 (9)  1 (5)  2 (10)  5 (11)      No (%)  78 (91)  21 (95)  18 (90)  39 (89)  Anovulation (n) (NS)  85e            Yes (%)  16 (19)  5 (22)  2 (10)  9 (21)      No (%)  69 (81)  18 (78)  18 (90)  33 (79)  View Large Table II. Method of conception and pregnancy outcome in women of poor tubal perfusion pressure (TPP) status (assessed during selective salpingography), who following guide-wire tubal recanalization, were of good (group A), mediocre (group B) or poor (group C) TPP status   Group A (%) n = 29  Group B (%) n = 25  Group C (%) n = 50  No. of pregnancies  n = 13  n = 4  n = 8  Method of conception            Spontaneous  10 (34.5)  3 (12)  7 (14)      Artificial insemination  1 (3.5)  1 (4)  1 (2)      Clomiphene  1 (3.5)  0  0      Ovulation induction  1 (3.5)  0  0  Pregnancy outcome            Birth (%)  8 (61.5)  2 (50)  4 (50)      Miscarriage (%)  4 (30.7)  0  2 (25)      Ectopic pregnancy (%)  1 (7.7)  2 (50)  2 (25)    Group A (%) n = 29  Group B (%) n = 25  Group C (%) n = 50  No. of pregnancies  n = 13  n = 4  n = 8  Method of conception            Spontaneous  10 (34.5)  3 (12)  7 (14)      Artificial insemination  1 (3.5)  1 (4)  1 (2)      Clomiphene  1 (3.5)  0  0      Ovulation induction  1 (3.5)  0  0  Pregnancy outcome            Birth (%)  8 (61.5)  2 (50)  4 (50)      Miscarriage (%)  4 (30.7)  0  2 (25)      Ectopic pregnancy (%)  1 (7.7)  2 (50)  2 (25)  View Large Table III. Multiplicative factors, with 95% confidence intervals (95% CI), applicable to time to first conception after SS/TC of a group A woman aged <30 years. Weibull model parametric survival analysis. P-values are adjusted for the presence of the other covariate   Spontaneous 1st conception only (95% CI)  1st conception excluding IVF/ICSI (95% CI)  TPP = tubal perfusion pressure.  TPP status group  (P = 0.041)  (P = 0.011)      Group B  3.72 (0.89–15.62)  4.38 (1.10–17.45)      Group C  3.65 (1.24–10.76)  4.85 (1.61–14.65)  Age (years)  (P = 0.035)  (P = 0.011)      31–35  3.14 (0.95–10.41)  3.12 (1.01–9.68)      >35  4.27 (1.30–14.08)  6.49 (1.78–23.63)    Spontaneous 1st conception only (95% CI)  1st conception excluding IVF/ICSI (95% CI)  TPP = tubal perfusion pressure.  TPP status group  (P = 0.041)  (P = 0.011)      Group B  3.72 (0.89–15.62)  4.38 (1.10–17.45)      Group C  3.65 (1.24–10.76)  4.85 (1.61–14.65)  Age (years)  (P = 0.035)  (P = 0.011)      31–35  3.14 (0.95–10.41)  3.12 (1.01–9.68)      >35  4.27 (1.30–14.08)  6.49 (1.78–23.63)  View Large Figure 1. View largeDownload slide Tubal perfusion pressure (TPP) curve. 1. Background system pressure: 240 mmHg. 2. Selective salpingography of the right Fallopian tube: fill and spill of dye, TPP 660 mmHg. 3. Guide-wire passed in the right tube, TPP decreased to 160 mmHg. 4. Selective salpingography of the left Fallopian tube: minimal fill, TPP >1000 mmHg. 5. Guide-wire passed in the left tube. Fill and spill of dye from a normal looking tube, TPP 170 mmHg. Note left-hand scale in y-axis applied to section 1 only. Figure 1. View largeDownload slide Tubal perfusion pressure (TPP) curve. 1. Background system pressure: 240 mmHg. 2. Selective salpingography of the right Fallopian tube: fill and spill of dye, TPP 660 mmHg. 3. Guide-wire passed in the right tube, TPP decreased to 160 mmHg. 4. Selective salpingography of the left Fallopian tube: minimal fill, TPP >1000 mmHg. 5. Guide-wire passed in the left tube. Fill and spill of dye from a normal looking tube, TPP 170 mmHg. Note left-hand scale in y-axis applied to section 1 only. Figure 2. View largeDownload slide — Group A, — group B, group C. Age-adjusted cumulative conception rates. Solid lines are estimates from the Cox model, dotted lines from the Weibull model, showing good agreement between the two. Estimates are adjusted to the age-category<30 years. As results for groups B and C were very similar, the respective survival curves are almost superimposed. (A) Survival analysis with only spontaneous conceptions counted as successes. (B) Survival analysis with all but IVF/ICSI first conceptions counted as successes. Figure 2. View largeDownload slide — Group A, — group B, group C. Age-adjusted cumulative conception rates. Solid lines are estimates from the Cox model, dotted lines from the Weibull model, showing good agreement between the two. Estimates are adjusted to the age-category<30 years. As results for groups B and C were very similar, the respective survival curves are almost superimposed. (A) Survival analysis with only spontaneous conceptions counted as successes. 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TI - The effect on pregnancy rates of tubal perfusion pressure reductions achieved by guide-wire tubal catheterization
JF - Human Reproduction
DO - 10.1093/humrep/17.8.2174
DA - 2002-08-01
UR - https://www.deepdyve.com/lp/oxford-university-press/the-effect-on-pregnancy-rates-of-tubal-perfusion-pressure-reductions-K5ZgEFL4j5
SP - 2174
EP - 2179
VL - 17
IS - 8
DP - DeepDyve
ER -