[Key Points of Examination after Breast Augmentation and Our Clinic's Algorithm of Immediate Reconstruction Using Silicone Implant for Breast Cancer Patient after Breast Augmentation].

Recently, the cases of breast augmentation for cosmetic purposes are rapidly increasing, there are more opportunities to examine for patient with breast augmentation history than before. In some cases, breast cancer screening is difficult due to the effects of breast augmentation. At our clinic, even in cases diagnosed with breast cancer after breast augmentation, we actively perform immediate breast reconstruction using silicone implant. However, it is necessary to consider the condition and type of breast augmentation at the time of diagnosis and also treatment. We will share our algorithm for immediate breast reconstruction using silicone implant for breast cancer after augmentation mammaplasty.

Long-term outcomes of patients with cirrhosis presenting with bleeding gastric varices.

AIM: To establish a therapeutic strategy for cirrhosis patients with gastric variceal bleeding. METHODS: The outcomes of 137 patients with bleeding gastric varices were evaluated. RESULTS: The bleeding source was gastroesophageal varices (GOV) in 86 patients, and gastric fundal varices (FV) in 51 patients. The Child-Turcotte-Pugh classes were A, B, and C in 26, 79, and 32 patients, respectively; 34 patients (24.8%) had hepatocellular carcinoma (HCC), of which 11 also had complicating portal venous tumor thrombosis (PVTT). Patients with GOV were treated by endoscopic variceal ligation or endoscopic injection sclerotherapy (EIS) with ethanolamine oleate, while those with FV were treated by EIS with cyanoacrylate; 29 patients with FV also underwent additional balloon-occluded retrograde transvenous obliteration (BRTO). Hemostasis was successfully achieved in 136 patients (99.3%), and the cumulative 1-year, 3-year, and 5-year rebleeding rates were 18.1%, 30.8%, and 30.8%, respectively, in the patients with GOV, and 2.2%, 12.5% and 12.5%, respectively, in the patients with FV. The overall 1-year, 3-year, and 5-year survival rates were 79.7%, 71.5% and 64.4%, respectively, in the patients with GOV, and 91.0%, 76.9% and 59.5%, respectively, in the patients with FV. Multivariable analysis identified PVTT and alcoholic cirrhosis as a significant risk factor associated with rebleeding, model for end-stage liver disease (MELD) score and PVTT as significant factors associated with survival. CONCLUSIONS: Endoscopic therapies with or without BRTO appeared to be useful therapeutic strategies to prevent rebleeding in patients with gastric variceal bleeding, and favorable outcomes were obtained, except in patients with underlying HCC associated with PVTT and/or severe liver damage.

Two Cases of Intraabdominal Bleeding Caused by Hepatocellular Carcinoma Rupture Soon after the Initiation of Chemotherapy with Lenvatinib.

We herein report two patients with hepatocellular carcinoma (HCC) who exhibited intraabdominal bleeding caused by tumor rupture soon after lenvatinib initiation. A hypervascular nodule was present in the lateral segment manifesting extrahepatic protrusion in an 81-year-old-man and in the caudate lobe, which was completely occupied by the tumor, in an 83-year-old-man. Both patients were given lenvatinib, and epigastralgia occurred suddenly three and five days later. Computed tomography revealed high-attenuation areas suggesting bleeding around the left and caudate lobes. Considering the strong antiangiogenic effects by lenvatinib, transcatheter arterial embolization should be performed before lenvatinib initiation in patients with subcapsular HCC.

Therapeutic efficacy of lenvatinib for patients with unresectable hepatocellular carcinoma based on the middle-term outcome.

AIM: This study sought to clarify the usefulness of lenvatinib for patients with unresectable hepatocellular carcinoma (HCC). METHODS: The subjects were 69 patients with HCC receiving lenvatinib; the median age was 73 years, and 14 and 67 patients had been previously treated with regorafenib and/or sorafenib and therapies without molecular-targeted agents, respectively. Therapeutic efficacy was evaluated using contrast-enhanced CT images obtained 4-8 weeks after the start of lenvatinib and the middle-term outcome using Kaplan-Meier method. RESULTS: The baseline Child-Pugh scores were 5, 6 and 7 in 31, 32 and 6 patients, respectively, and the modified albumin-bilirubin (mALBI) grades were 1, 2a and 2b in 20, 20 and 29 patients, respectively. The Barcelona Clinic Liver Cancer (BCLC) stages following downsizing after prior treatment were A, B and C in 17, 22 and 30 patients, respectively. The therapeutic efficacy was evaluated in 54 patients, and the percentages of patients achieving CR, PR, SD and PD were 3.7%, 44.4%, 37.0%, and 14.8%, respectively. The ALBI scores deteriorated significantly between 4 and 12 weeks after the start of therapy, compared with the baseline. The cumulative survival rates at 48 weeks were significantly higher among patients achieving CR/PR (95.5%) than among those showing no response (54.3%). Multivariate analyses revealed that the BCLC stages and the serum AFP levels were significantly associated with therapeutic efficacy, while the mALBI grade was associated with the middle-term outcome. CONCLUSIONS: A favorable middle-term outcome was obtained in patients with HCC receiving lenvatinib, especially in those manifesting grades 1/2a mALBI at baseline, despite the deterioration in ALBI scores during treatment.

A case of colonic varices complicated by alcoholic cirrhosis treated using balloon-occluded retrograde transvenous obliteration.

A 44-year-old man with cirrhosis arising from alcohol abuse manifested melena caused by the rupture of esophageal varices. He received endoscopic variceal ligation for the initial hemostasis, followed by endoscopic injection sclerotherapy as an additional consolidation therapy. A CT examination performed at the time of admission revealed collateral veins developing around the ascending colon, in which the feeding and draining vessels were identified as the superior mesenteric vein and the right testicular vein, respectively. Moreover, large nodular varices were observed in the ascending colon during a colonoscopy. To prevent the rupture of the colonic varices, balloon-occluded retrograde transvenous obliteration (B-RTO) was performed through the right testicular vein using a microballoon catheter. A CT examination performed 4 days after the B-RTO procedure revealed the disappearance of blood flow with thrombosis formation in both the colonic varices and the feeding vein. The varices in the ascending colon had completely disappeared when examined during a colonoscopy performed 4 months after the B-RTO procedure. B-RTO is a useful and minimally invasive procedure for the treatment of colonic varices to prevent bleeding.

Chronic hepatitis caused by hepatitis C virus showing a discrepancy between serogroup and genotype because of intergenotypic 2b/1b recombination: A pitfall in antiviral therapy with direct-acting antivirals.

A 40-year-old male patient with virologic relapse after daclatasvir plus asunaprevir therapy for a serogroup 1 hepatitis C virus (HCV) infection visited our hospital for retreatment. Virologic examinations revealed that a genotype 2b HCV strain carrying both NS3-S122N / D168A and NA5A-R30Q / L31M / Q54H / Y93H mutations had relapsed. The patient received sofosbuvir plus ribavirin therapy, but virologic relapse occurred once again. Sequencing of the HCV genome clarified an intergenotypic recombination of 2b and 1b with an estimated crossover point between nucleotides 3114 and 3115, corresponding to the N-terminal end of the NS3 region (DDBJ/EMBL/GenBank databases accession no. LC273304). The NS5B-S282T mutation was not detected in the HCV strain, and resistance-association substitutions in the NS3 and NS5A regions were similar to those at baseline. Direct sequencing of the core and NS4A regions corresponding to the targeting sites of genotyping and serogrouping, respectively, is useful to determine the combination of direct-acting antivirals when a discrepancy is observed between the serogroup and genotype of HCV strains.

Retreatment with sofosbuvir/ledipasvir with or without lead-in interferon-ß injections in patients infected with genotype 1b hepatitis C virus after unsuccessful daclatasvir/asunaprevir therapy.

AIM: To improve the therapeutic efficacy of sofosbuvir/ledipasvir (SOF/LDV) for the retreatment of patients after daclatasvir/asunaprevir (DCV/ASV), a customized therapy with or without lead-in interferon (IFN)-ß injections was formulated according to the types of resistance-associated substitutions (RAS) in the non-structural protein (NS)5A region of genotype 1b hepatitis C virus (HCV). METHODS: Thirty-three patients failing prior DCV/ASV received SOF/LDV for 12 weeks. Patients with HCV carrying unfavorable NS5A-RAS and/or those previously treated with simeprevir were given lead-in IFN-ß injections twice a day for 2 weeks; sequential changes in the NS5A-RAS during the injection period were evaluated using deep sequencing. RESULTS: Lead-in injections were not undertaken in 27 patients; a sustained viral response (SVR) was achieved in 26 patients, while viral relapse occurred in 1 patient with HCV carrying NS5A-L28M/R30H/Y93H mutations. Among the 6 patients receiving lead-in injections, viral relapse occurred in 2 patients who had an unfavorable IFN-λ3-related gene single nucleotide polymorphism allele; both patients had been previously treated with simeprevir, and HCV carrying NS5A-L31V/Y93H mutations had emerged after DCV/ASV. Deep sequencing revealed no changes in the NS5A-RAS profiles during the lead-in injection period in either patient. In contrast, in a patient with a favorable allele who was infected with similar unfavorable HCV strains, NS5A-L31/Y93 wild-type strains appeared during the injection period, enabling an SVR. CONCLUSION: Using customized therapies based on the NS5A-RAS profiles, a high SVR rate was obtained after SOF/LDV in patients failing prior DCV/ASV. Lead-in IFN-ß injections did not improve the efficacy in patients with HCV carrying unfavorable NS5A-RAS except in those with a favorable IFN-λ3-related gene allele.

Balloon-occluded retrograde transvenous obliteration as a procedure to improve liver function in patients with decompensated cirrhosis.

AIM: Portosystemic shunts aggravate liver function by decreasing portal blood flow. The usefulness of balloon-occluded retrograde transvenous obliteration (B-RTO), a standardized therapeutic procedure for gastric fundal varices (GFV), for the improvement of liver function was evaluated in cirrhotic patients with or without varices. METHODS: The subjects were 161 patients with portosystemic shunts. A balloon catheter was inserted into the shunts, followed by the injection of 5% ethanolamine oleate through the catheter under balloon inflation. The balloon was kept inflated for 6 to 48 h. RESULTS: B-RTO was performed as a therapy for GFV in 112 patients and for the improvement of liver function in 49 patients. The targets were splenorenal shunts in 104 patients (93.6%) in the former group and 33 patients (67.3%) in the latter group, and the procedures were successfully completed in 109 (97.3%) and 39 (79.6%) patients, respectively. In both groups, the serum albumin levels were increased and the serum ammonia levels were decreased at more than 1 month after the procedures, compared with the baseline levels, whereas significant improvements in the Child-Pugh scores and prothrombin times were only seen in the latter group. In these patients, the portal blood flows evaluated using Doppler ultrasound were increased at 1 week after the procedures, compared with the baseline levels. CONCLUSIONS: B-RTO is a useful therapeutic procedure for improving liver function even in patients without GFV by increasing the portal venous flow with successfully targeted, uncommon portosystemic shunts.

A case of liver cirrhosis with bleeding from stomal varices successfully treated using balloon-occluded retrograde transvenous obliteration.

A 66-year-old male patient with liver cirrhosis because of alcohol intake underwent a Hartmann's procedure for rectal cancer. Four months later, bleeding from the sigmoid stoma occurred and persisted for 2 months. A colonoscopic examination revealed bleeding from stomal varices. Three-dimensional computed tomography (CT) imaging demonstrated the inferior mesenteric vein and left superficial epigastric vein as the feeding and drainage vessels, respectively. Balloon-occluded retrograde transvenous obliteration (B-RTO) through the left epigastric vein was performed using a microballoon catheter inserted from the right femoral vein according to the Seldinger method. A CT examination performed 2 days after the B-RTO procedure revealed that the blood flow had disappeared, with thrombosis formation in both the stomal varices and the feeding vein. No recurrent bleeding from the stoma occurred. B-RTO using a microballoon catheter is useful as a therapeutic procedure for stomal varices to prevent bleeding, since the procedure can be performed with minimal invasion using the Seldinger method.

Long-term outcome of 154 patients receiving balloon-occluded retrograde transvenous obliteration for gastric fundal varices.

BACKGROUND AND AIM: This study aims to clarify the long-term outcome of therapeutic strategies including balloon-occluded retrograde transvenous obliteration (B-RTO) for patients with gastric fundal varices. METHODS: The subjects were 154 patients with gastric fundal varices fulfilling the criteria for receiving B-RTO. In patients showing variceal bleeding, endoscopic therapies and/or balloon tamponade was performed to achieve hemostasis. B-RTO was accomplished with injection of 5% ethanolamine oleate through a standard balloon catheter except for patients with atypical varices, in whom a microballoon catheter was used to occlude drainage vessels other than a gastrorenal shunt. In patients complicated with esophageal varices at baseline, endoscopic therapies were performed following B-RTO. RESULTS: Balloon-occluded retrograde transvenous obliteration was performed successfully in 147 patients (95%), including 15 patients using a microballoon catheter. Complete variceal obliteration was achieved in all patients. Additional endoscopic therapies for esophageal varices were performed in 31 patients. Gastric varices did not recur in any of these patients. The cumulative survival rates at 1, 3, and 5 years after B-RTO were 91%, 76%, and 72%, respectively. Child-Pugh scores and hepatocellular carcinoma complication were identified as prognostic factors associated with survival rates. The cumulative exacerbation rates of esophageal varices at 1, 3, and 5 years were 13%, 20%, and 27%, respectively, and rupture developed in six patients, which were successfully treated with endoscopic therapies. CONCLUSIONS: Therapeutic strategies including B-RTO with a microballoon catheter were useful to achieve a favorable outcome in patients with gastric fundal varices especially in those manifesting Child-Pugh class-A liver damage and/or those without hepatocellular carcinoma complication.

Transcatheter arterial chemoembolization for hepatocellular carcinoma: Comparison of the therapeutic efficacies between miriplatin and epirubicin.

AIM: The therapeutic efficacy of transcatheter arterial chemoembolization (TACE) using miriplatin was evaluated in comparison with that using epirubicin in patients with hepatocellular carcinoma (HCC). METHODS: Two hundred and eight-nine HCC patients receiving TACE were retrospectively enrolled; none of the patients gave a previous TACE history. The short-term therapeutic efficacy was evaluated by computed tomography (CT) performed 1 month later. In patients showing TE-4, CT and/or magnetic resonance imaging examinations were performed repeatedly and the long-term therapeutic efficacy was assessed based on local tumor recurrence. RESULTS: After exclusion of 68 patients (CT not performed at 1 month), 97 patients treated with epirubicin and 124 treated with miriplatin were analyzed. The percentage of patients showing TE-4 was 46.8% in the miriplatin-TACE group, being significantly higher than that in the epirubicin-TACE group (33.0%). The cumulative local recurrence rates at 18 months were 71.2% in the miriplatin-TACE group and 43.1% in the epirubicin-TACE group; multivariate analysis revealed higher local tumor recurrence rates in the miriplatin-TACE group than in the epirubicin-TACE group. CONCLUSION: For HCC patients, although miriplatin-TACE was superior to epirubicin-TACE in the short term, it proved inferior to the latter in the long term. The merits of TACE using miriplatin should be further investigated, because adverse effects appear to be minimal after miriplatin administration.

Balloon-occluded retrograde transvenous obliteration using a microballoon catheter for intractable gastric fundal varices.

BACKGROUND AND AIM: Balloon-occluded retrograde transvenous obliteration (B-RTO) is recognized as the standard therapy for patients with gastric fundal varices in Japan; however, the procedure is difficult when drainage veins other than the gastrorenal shunt developed. The efficacy and safety of B-RTO using a microballoon catheter for such patients were evaluated. METHODS: The subjects were 99 patients with gastric fundal varices who fulfilled the criteria for receiving endoscopic and/or interventional therapies. Among these, 95 patients underwent B-RTO. Of the 95 patients, 14 were treated with the use of microballoon catheters, including nine in whom the left inferior phrenic vein was found as a secondary drainage vein in addition to the gastrorenal shunt, and five in whom a gastrorenal shunt was absent. The B-RTO procedure performed using a microballoon catheter inserted through the left inferior phrenic vein in 13 patients, and through the pericardiophrenic vein in one patient. RESULTS: The B-RTO procedure using microballoon catheters was successful in 13 of the 14 patients (93%), while in the remaining one patient, multiple drainage veins were visualized on venography. Complete obliteration of the varices was achieved in all the 13 patients by injection of 5% ethanolamine oleate iopamidol at a median volume of 25 mL (range, 11 to 40 mL) through the catheters. None of the patients showed injuries of the drainage veins or any systemic complications. CONCLUSIONS: B-RTO using a microballoon catheter is useful for the treatment of gastric fundal varices in which drainage veins other than the gastrorenal shunt developed.

Therapeutic strategy for patients with bleeding rectal varices complicating liver cirrhosis.

AIM: Although rupture of rectal varices is rarely encountered, it may provoke massive and fatal hemorrhage in patients with liver cirrhosis. We examined the clinical features of patients showing bleeding from rectal varices to establish a suitable therapeutic strategy for the lesions. METHODS: Twelve cirrhotic patients with bleeding rectal varices were enrolled. Surgical suture, endoscopic variceal ligation (EVL) or balloon tamponade was performed to achieve the initial hemostasis. Then, the feeding and drainage vessels of the varices were evaluated by computed tomography, and additional procedures were undertaken: EVL was performed when the sizes of the varices and feeding vessels were small. In contrast, in patients with varices of large sizes, balloon-occluded retrograde transvenous obliteration (B-RTO) was performed when single or two drainage vessels were identified, while endoscopic injection sclerotherapy (EIS) using ethanolamine oleate was carried out for varices with three or more drainage vessels. RESULTS: The Child-Pugh class was grade A in four, B in six and C in two patients. Eleven patients had received previous therapy for esophageal varices. Initial hemostasis was achieved by surgical suture in three patients, EVL in one patient and balloon tamponade in two patients. EVL, EIS and B-RTO were carried out as additional procedures in seven, three and one patient, respectively. Rebleeding from the rectal varices occurred in only one patient who underwent EVL as an additional procedure. CONCLUSION: Bleeding from rectal varices was controlled satisfactorily by the therapeutic strategy of selecting EVL, EIS or B-RTO as an additional therapy according to the size and hemodynamics of the varices.

Usefulness of miriplatin as an anticancer agent for transcatheter arterial chemoembolization in patients with unresectable hepatocellular carcinoma.

BACKGROUND: Injection of a suspension of miriplatin into the hepatic artery has been employed for the treatment of hepatocellular carcinoma (HCC). The efficacy and safety of transcatheter arterial chemoembolization (TACE) using miriplatin were evaluated. METHODS: A total of 236 patients with unresectable HCC received miriplatin administration through the hepatic artery, followed by embolization with porous gelatin particles. The efficacy of this treatment modality was evaluated by contrast-enhanced computed tomography performed 1 month later and its safety based on the Common Terminology Criteria for Adverse Events (CTCAE). RESULTS: Miriplatin was used at a median dose of 66 mg. The therapeutic efficacy was evaluated in 130 patients, and the overall and complete response rates were 70.0 and 37.7%, respectively. The efficacies differed depending on the staging and Japan integrated staging (JIS) scores of the HCCs, with the overall and complete response rates being 87.7 and 66.7% for stage I and stage II HCC, and 56.2 and 15.1% for stage III and stage IV HCC, respectively; the corresponding rates were 93.2 and 70.5%, respectively, for HCCs with score 0 and score 1, and 58.1 and 20.9%, respectively, for those with scores 2-4. The stage of HCC was a significant independent factor associated with curative effects of TACE using miriplatin. Grade 3 elevation of serum transaminase levels was found in 23.4% of the patients; however, the values returned to the baseline levels. CONCLUSIONS: Miriplatin is a useful and safe agent for TACE in patients with HCC stage I or II and/or JIS score 0 or 1 only when radiofrequency ablation and liver resection cannot be performed.

A case of gastric varices with gastropericardiac shunt successfully treated by balloon-occluded retrograde transvenous obliteration via the pericardiophrenic vein using a microballoon catheter.

Gastric fundal varices developed in a 72-year-old female patient with liver cirrhosis due to hepatitis C virus infection after endoscopic injection sclerotherapy for esophageal varices. Three-dimensional computed tomography (CT) imaging demonstrated that gastrorenal shunts were absent as the drainage vessels of the varices, and the blood flows drained mainly into the pericardiophrenic vein. Balloon-occluded retrograde transvenous obliteration (B-RTO) was performed using a microballoon catheter to prevent bleeding from the gastric varices. The left inferior phrenic vein detectable as the second drainage vessel by venography was embolized with metallic coils and ethanolamine oleate solution was injected into the varices following occlusion of blood flow with a microballoon located in the pericardiophrenic vein. CT examination performed 7 days following B-RTO therapy revealed that the blood flow had disappeared with thrombus formation in the varices. B-RTO therapy with a microballoon catheter may be a useful therapy for gastric fundal varices even in cases without gastrorenal shunts, if the main drainage vessels are determined.

A case of liver cirrhosis due to hepatits C virus infection complicating giant anorectal varices treated with balloon-occluded retrograde transvenous obliteration.

A 73-year-old man with liver cirrhosis due to hepatitis C virus infection was admitted to our hospital because of massive bleeding from external varices. Colonoscopic examination revealed that giant anorectal varices had developed between the anus and rectal ampulla, and had ruptured at the perianal site. On three-dimensional computed tomography imaging, the feeding and drainage vessels of the varices were identified as the inferior mesenteric vein and right inferior hemorrhoidal vein, respectively. Endoscopic therapies were not employed for the bleeding varices, because the blood flow volume of the feeding vessel was extremely large. Balloon-occluded retrograde transvenous obliteration (B-RTO) was therefore carried out through the drainage vessels. The variceal blood flow disappeared after B-RTO therapy, and the varices decreased in size with thrombus formation verified by colonoscopy. Bleeding from the external varices also ceased. B-RTO therapy may be an effective approach for giant anorectal varices presenting as a complication in liver cirrhosis patients in whom the main drainage vessels can be determined.

Molecular mechanisms of cleft lip formation in CL/Fr mice.

CL/Fr mice have a high incidence of cleft lip and the cleft lip is the result of incomplete fusion between the medial and lateral nasal prominences and the maxillary prominence at about day 11.5 of gestation. However, little is known about the molecular mechanisms that are responsible for the incomplete fusion. We made a molecular pathological investigation using 11.5-day CL/Fr embryos. Five embryos were each examined for real-time polymerase chain reaction (PCR) analysis. During the first palatal formation in normal development, an epithelial seam is formed when the medial and lateral nasal prominences first make contact. Some epithelial cells of the epithelial seam then undergo apoptosis, with remaining cells transforming into a mesenchymal phenotype (epithelial-mesenchymal transition, EMT). Mesenchymal cells of the medial and lateral nasal prominences then merge across the previous boundary of separation. In CL/Fr mice with cleft lip, neither apoptosis nor EMT occurs in the epithelial cells. Increased expression of claudin 6 mRNA is seen in epithelial cells of epithelial seam in cleft lip compared with that in normal embryos. Slug mRNA expression was also significantly reduced whereas noggin was increased in CL/Fr embryos with cleft lip. We suggest that EMT is prevented in CL/Fr mice with cleft lip by increased expression of claudin 6 and coexistent downregulation of slug in cells of the epithelial seam, and these altered concentrations of transcription factors/repressors prevent fusion of the medial and lateral nasal prominences, leading to clefts of the lip.

High incidence of tubal dysfunction is determined by laparoscopy in cases with positive Chlamydia trachomatis antibody despite negative finding in prior hysterosalpingography.

Aim: Hysterosalpingography (HSG) is one of the most commonly used methods in order to evaluate the condition of fallopian tubes in infertility clinics. In the present paper, we retrospectively compared the findings of HSG and laparoscopy to elucidate the relationship between tubal dysfunction and background factors, such as Chlamydia trachomatis infection, endometriosis and previous surgery. Methods: We retrospectively reviewed clinical records of 314 patients who were examined by both HSG and laparoscopy between 1996 and 2001 in the Department of Obstetrics and Gynecology, University of Tokyo. Results: When HSG findings were evaluated in reference to those of laparoscopy, sensitivity and specificity for tubal patency were 0.63 and 0.79, respectively, whereas those for peri-tubal adhesion were 0.65 and 0.61, respectively. We compared the percentage of existence of background factors between the patients who were diagnosed as normal by both HSG and laparoscopy (Group L[+]) and those whose fallopian tubes were observed as patent by HSG, but were not patent by chromopertubation under laparoscopy (Group L[-]). The percentage of patients with positive chlamydial antibodies in Group L(-) (42.9%, 15/35) was significantly higher than that of patients with positive chlamydial antibodies in Group L(+) (22.8%, 44/193, P < 0.05). Conclusions: These finding suggested that even if HSG showed normally patent tubes in a patient with positive Chlamydia trachomatis antibodies, the possibility of tubal occulusion still remains high and further examination by laparoscopy is recommended. (Reprod Med Biol 2007; 6: 39-43).