Tests of Tubal Patency
Marvin A. Yussman
Table Of Contents
Marvin A. Yussman, MD
In 1910, Rindfleisch injected a watery paste of bismuth into the uterine cavity of a young woman in an attempt to diagnose a possible pregnancy. The roentgenogram obtained demonstrated the uterine cavity and the left fallopian tube. In 1913, Rubin and Cary demonstrated tubal patency by roentgenographic examination after intrauterine injection of Collargol, a silver salt. The first iodine preparation, Lipiodol, was used in 1925.1 In his original use of this technique, Rubin used an oily contrast medium. Oil-based media remained popular until the 1960s. Their popularity was based on their ability to demonstrate a good delayed film when image-intensified fluoroscopy was not universally available. Because most hysterosalpingography (HSG) is now performed by image-intensified fluoroscopy, most experts2,3 (but not all) conclude that oil-based media should no longer be used, due to the availability of safer water-soluble preparations. The advantage of the good delayed film is less important because fluoroscopic observation and short-term delay films give equal information.
HSG remains an outpatient procedure. It should be performed in the proliferative phase of the cycle to reduce the possibility of radiation exposure of an early embryo. In addition, it obviates the unlikely possibility of inducing an ectopic pregnancy by performing the procedure after fertilization and delaying embryo transport through the fallopian tube. The procedure usually requires no sedation, although the gynecologist is well advised to inform the patient that she will experience some discomfort. A positive and comforting attitude by the gynecologist, combined with careful attention to technical details, will leave the patient with only minor and transient discomfort.
The patient is placed on the x-ray table in the lithotomy position. A radiolucent speculum is used to expose the cervix. If a radiolucent speculum is not available, a metal speculum may be used temporarily. After adequately cannulating the cervical canal, the speculum should be removed so as not to obscure visualization of the cervical canal during injection of contrast. The cervix is cleansed with an antiseptic solution and the anterior lip of the cervix grasped with a single toothed tenaculum. A cannula fitted with a rubber acorn tip is applied into the cervical canal. The tip of the cannula should not protrude farther than 1 cm into the cervical canal. The acorn tip should be fitted so as to prevent reflux of the contrast medium. A locking device on the cannula can be used to fix the cannula to the tenaculum, allowing the two to be moved in tandem during fluoroscopy. It also decreases the likelihood of leakage of the medium from the cervical canal.
The water-soluble contrast medium is then slowly introduced through the cannula into the cervical canal. The cannula should be completely filled with the contrast medium before injection to avoid introducing air into the endometrial cavity. This would not only create confusing artifacts but also could possibly obstruct the fallopian tubes, giving a false-positive finding. Water-soluble medium is preferable to avoid the hazards of intra-abdominal oil (e.g., embolization and granuloma formation should the medium be trapped in pockets of intraperitoneal adhesions). It has also been noted that some thyroid function tests remain altered for several months after injection of the oil-based iodine preparations.3 Those persistent proponents of the use of oil-based media point out that a more intense image may be obtained and that embolization can be avoided by the early fluoroscopic observation of the contrast entering the vasculature.
The procedure is best observed under image-intensified fluoroscopy. If this is not available, the following procedure is recommended. The dye may be injected without manometric control, although such control has been suggested by some. Most gynecologists think it is sufficient to feel the resistance of the dye and to assess the patient's subjective complaint of discomfort to gauge the rate and pressure of contrast injection. About 1 mL of the contrast should be introduced into the endometrial cavity, and then an x-ray should be obtained. The film is then developed and used to decide if further injection is necessary or hazardous. This process is repeated until the tubes are filled and intraperitoneal spill is obtained. About 4 to 5 mL of contrast is usually required. If an oil-based medium has been used, a follow-up film 24 hours later may be obtained.
When the procedure is monitored under image-intensified fluoroscopy, the contrast is observed during its slow, steady injection. Spot films may be obtained during the injection. It is most important to observe the endometrial cavity during the early stages of filling to visualize endometrial defects that may be obscured as the cavity is completely filled with contrast. Defects that may be obliterated by full expansion of the uterus are endometrial polyps, intrauterine synechiae, and small myomata. The contrast material may then be observed traversing the fallopian tubes and ultimately spilling into the peritoneal cavity. Alternately, the flow of dye may be obstructed anywhere along the course of the tube, or it may enter a large hydrosalpinx, simulating spill into the abdominal cavity.
The observation of cornual obstruction should be taken with reservation, because this is occasionally due to functional spasm. Various drug regimens have been suggested for eliminating this spasm, such as the use of anticholinergic drugs, beta-mimetic drugs, tranquilizers, antispasmodics, spasmolytics such as amyl nitrite, and sedatives. It has also been suggested that general anesthesia may relieve the uterotubal spasm. However, none of these has consistently worked. The cornual closure cannot be accepted until confirmed by additional procedures such as selective cannulation or laparoscopy.
Other techniques for introduction of the dye have been suggested. A radiopaque suction cannula of the Semm variety that fixes to the cervix and introduces the dye at the external os is available. This is a recommended procedure that allows good visualization of the cervical canal and prevents obstruction by the cannula. Other available commercial devices deliver the dye into the uterine cavity, but they have the disadvantage of obscuring detail of the cervical canal.
If there appears to be bilateral cornual obstruction, the possibility of cornual spasm or small amounts of debris obstructing the small intramural portion of the tube must be considered. Under these circumstances, the appearance of the endocervical canal is not of immediate importance, and a device that allows increased intrauterine pressure can be used. Devices that inflate a balloon at the internal and external cervical os are available; these allow such pressures to be used carefully in an effort to overcome tubal spasm or to force out small amounts of intraluminal debris.
A pediatric Foley catheter for the introduction of the dye has been used for many years.4 In this procedure, a No. 5 pediatric Foley catheter is introduced into the cervical canal. The balloon is then insufflated with about 2 mL of water, which obstructs the cervical canal. Contrast is then introduced through the Foley catheter. The advantage of this procedure reportedly is decreased pain and bleeding that may be caused by the tenaculum. The patient may be more comfortably moved into the various positions for better visualization. I have used this procedure intermittently and find it to be a most acceptable alternative to the use of the acorn-fitted metal cannula. It is particularly suitable for defining such anomalies as uterus didelphys. Its disadvantage is that it does not allow uterine manipulation. When the bulb is allowed to enter the endometrial cavity, it completely obscures the detail of the endocervical canal and also obscures the anatomy of the endometrial cavity. There are commercially available HSG insufflation cannulas that can be used to reproduce the Foley catheter technique. When using these devices, it is frequently necessary to allow the bulb to enter the endometrial cavity to obtain the traction necessary to manipulate the uterus into a good frontal position. When this is done, the endometrial cavity must be viewed fluoroscopically as the bulb is being deflated and before the evacuation of the contrast to observe the detail of the endometrial cavity adequately.
Generally, the choice of contrast medium is between an oil-based medium and a water-based medium. The oil-based medium previously was the medium of choice because of the intense contrast it provided and because of the ability to obtain good delayed film. Currently, this medium is less commonly used because of concern that the intraperitoneal oil may be associated with intraperitoneal granuloma. Miyamoto and associates5 compared water-soluble contrast with Lipiodol, an oil-soluble material administered intraperitoneally to rabbits at doses of 100 mg of iodine per kilogram. Retention in the body was investigated by x-ray imaging, plasma kinetics, and urinary and fecal excretion. Irritability in the abdomen was investigated by histologic examination. The water-based material was entirely excreted into the urine within 2 days. The oil contrast was excreted with a half-life of 50 days and retained 21 days in the abdomen. The water-soluble material induced no inflammatory reaction, whereas the oil-based product induced a marked abdominal inflammatory reaction, including granuloma formation. Although this has been well demonstrated in experimental animals, it has not been documented in women. The oil-based product remains in use by some gynecologists because of the excellent contrast it provides. In addition, pregnancy rates after the use of oil contrast have been reported to be significantly higher than rates after water-based contrast,6 particularly in cases of unexplained infertility. It is presumed that this effect is the result of dislodging intraluminal debris or disrupting minor degrees of perifimbrial adhesion. Such claims are difficult to evaluate because of the spontaneous pregnancy rate of about 30% that occurs generally in patients with unexplained infertility. Water-based contrast specifically designed for HSG is available (Sinografin). This material provides excellent imaging but is quite expensive. Other generally available water-based contrast media (e.g., Hypaque) may be used, although contrast is less than optimal.
A pneumoperitoneum performed at the time of HSG may be helpful because it allows the demonstration of peritubal adhesions. Pneumoperitoneum can be achieved by insufflating CO2 through the fallopian tubes before instilling contrast. Pneumoperitoneum can also be obtained with a cul-de-sac puncture using a Verres-type needle or by means of transabdominal injection, as in laparoscopy. Although this combination approach achieved some popularity in the 1960s, the accuracy of HSG alone equals that of HSG associated with pneumography as judged by subsequent laparoscopy. This combined procedure, therefore, is now rarely used. With the increased availability of vaginal transducers for pelvic ultrasonography, the combination of HSG and ultrasonography achieves imaging both of the intraluminal and extraluminal portions of the uterus. This is important in defining the extent of intrauterine defects such as submucous leiomyomata. It is also helpful in differentiating uterus didelphys from uterus bicornus.
Obstruction of the endocervical canal is occasionally encountered after cauterization, cryosurgery, or cone biopsy of the cervix. Under these circumstances, severe stenosis of the cervical os makes cannulation and contrast introduction difficult. Dilation of the cervical canal may be done before HSG. If necessary, angiodilators, as described by Yoder and Pfister,7 can be used.
Although a detailed discussion of interpreting HSGs is beyond the scope of this chapter, it should be understood that demonstrating tubal patency is not completely reliable. An apparent blockage should be regarded only as suggestive, because about 10% of patients with apparent bilateral blockage by HSG have become pregnant without further therapy.2 Even patency may be questionable, because a large hydrosalpinx may mimic intraperitoneal spill of contrast material.1
In Siegler's series1 of 1,000 patients, 58% had bilateral patent fallopian tubes, 20.5% had cornual obstruction, 12.6% had distal obstruction, and 5.7% had midtubal obstruction. Topkins8 found fimbrial occlusion to be the most common reason for obstruction. Sanfilippo and colleagues9 reported that 54.3% of HSGs performed in infertile couples demonstrated bilateral tubal patency. Tubal abnormalities were demonstrable in the remainder. Cornual obstruction was noted in 5.3%; the largest number of obstructions occurred at the fimbria. Gabos10 found bilateral cornual obstruction in 13% of patients, and Hutchins11 in 15%. In a study by Ostry,12 27 of 209 patients demonstrating bilateral cornual obstruction spontaneously achieved pregnancy.
CONTRAINDICATIONS AND COMPLICATIONS.
Some patients are completely intolerant of HSG as an outpatient maneuver. Under these circumstances, the test may be performed under general anesthesia. The technique under anesthesia is the same as in the outpatient procedure. If general anesthesia is considered, the gynecologist may want to consider a combination of HSG and laparoscopy.
HSG is contraindicated in patients who exhibit evidence of active pelvic infection. In addition, active uterine bleeding, recent pregnancy, and curettage should also be considered contraindications. Even without one of the accepted contraindications, one should not hesitate to abandon the procedure if the patient experiences unusual pain during its performance.
Generally, only insignificant complications occur from HSG. There have been only 10 deaths collected from the literature.10,13 All but one of these occurred in early use of the procedure and were associated with the use of oily media. In most instances, the deaths were due to anaphylaxis or embolization. The most recent report of a death, which occurred after the injection of water-soluble contrast medium, was published in 1986. There have been other complications such as allergic reaction, extreme pain, uterine rupture, tubal rupture, and hemorrhage. Cardiac arrhythmias and vagal responses resulting in severe abdominal pain and bradycardia have been reported. Patients have also noted chemical and toxic complications, such as granulomas and iatrogenic thyroid dysfunction. Intravasation of contrast has occurred, but this is of little concern with the use of water-soluble contrast.
It is generally reported that patients are exposed to less than one rad of irradiation during HSG. In a study by Sheikh and Yussman,14 29 patients undergoing HSG were monitored with a dosimeter in the upper vagina. The dosimeter measured between 75 and 500 millirads. The variation was due to the number of spot films obtained and the duration of fluoroscopic exposure. This work was confirmed by others,15,16 who have measured from 60 to 2,500 millirads during HSG.
Radiologic Selective Cannulation of the Fallopian Tube
Radiologically demonstrated cornual obstruction in the absence of other demonstrable tubal disease remains an enigma for the radiologist and the gynecologist. The differential diagnosis is tubal spasm, true mechanical blockage, such as salpingitis isthmica nodosa, or plugging of the 0.5-mm intramural lumen with mucus or inspissated uterine detritus. Occasionally, these obstructions were approached surgically. The cornu was resected or the tube transected, probed, and then reanastomosed. About two thirds of the fallopian tubes resected for proximal tubal obstruction fail to reveal luminal occlusion when examined microscopically.17 Selective fluoroscopic transcervical fallopian tube catheterization to help clarify such situations was first performed by Thurmond and colleagues in 1988.18
The procedure is performed on an outpatient basis and requires only mild sedation. The precautions and contraindications are the same as for HSG. The patient is positioned and draped in the lithotomy position on the x-ray table. Some prefer to perform the procedure on a cardiac catheterization table to allow better positioning of the patient. The cervix is prepared as for HSG. A vacuum cup applied to the cervix allows manipulation of the cervix and also allows the introduction of a series of coaxial catheters and guide wires into the cervical canal. A preliminary HSG is obtained to confirm cornual occlusion. A 5.5 French curved catheter is introduced through the cervical vacuum cup into the uterine cavity and advanced into the uterine cornu. A J-wire may be used to guide the catheter to the region of the cornu. The J-wire is removed and replaced with a small-diameter guide wire tipped with soft platinum. An effort is made to introduce the guide wire into the intramural and isthmic portion of the fallopian tube. This is usually accomplished with short and gentle intermittent probing. When the guide wire is judged to have entered the fallopian tube, a 3 French Teflon catheter is advanced over the guide wire until an obstruction is encountered. The guide wire and catheter are alternately advanced until the catheter is judged to have entered the isthmic portion of the fallopian tube. The soft platinum tip can usually follow the tortuosity of the fallopian tube without difficulty, allowing the Teflon catheter to follow. The guide wire is then removed and contrast material injected through the catheter. If patency is not obtained, the coaxial guide wire and catheter can be advanced until an unremitting obstruction is encountered or until patency is obtained. Several attempts at positioning the catheters may be necessary if there is a question of proper placement. Once patency is obtained or the procedure is abandoned on one side, the process is repeated at the other tubal ostium.
In their initial series, Thurmond and associates18 reported that 10 women conceived out of 35 women who had patent fallopian tubes after selective catheterization. One woman aborted twice and another had an ectopic pregnancy. The eight remaining patients had ongoing pregnancies at the time of that publication. In a follow-up publication in 1990, Thurmond and Rosch19 reported that they were able to obtain patency in at least 1 tube in 86 of 100 patients in whom selective fluoroscopic tubal cannulation was attempted. Twenty-six intrauterine pregnancies occurred in these 86 patients. Among these 100 patients, 20 were identified who had bilateral cornual obstruction with no other demonstrable cause for infertility. Tubal patency was obtained in 19 of these women. Nine patients conceived, and all the pregnancies were intrauterine. Eight of the 10 patients who did not conceive had subsequent HSG. Of these, four again showed bilateral cornual occlusion.
In a further series reported in 1995,20 the same group reported their experience with selective cannulation in cases of salpingitis isthmica nodosa. In this series, 47 of 65 tubes with proximal obstruction were recanalized successfully. Among the 19 women who were able to conceive via these recanalized salpingitis isthmica nodosa tubes, there were 6 live births and 2 tubal pregnancies.
Thompson and co-workers6 reported their results in 47 tubes with cornual obstruction. Of these, 11 (23.9%) were demonstrated to be patent on repeat HSG. An additional 6 (13%) obtained patency by simply injecting contrast after selectively wedging the obstructed ostium with a Teflon catheter. Nine of the remaining 30 tubes had successful wire recanalization (31%). One of these demonstrated distal obstruction. Other authors have also reported patency rates between 30% to 40% after selective cannulation, achieving pregnancy rates of 15% among those who obtained patency and ectopic pregnancy rates of 25% in patients who conceived.21,22
In institutions where interventional radiologists are available and interested, this technique has proven to be increasingly useful, particularly if bilateral cornual obstruction is identified in the absence of other causes for infertility. In addition, this technique may also be attempted before tubal microsurgery or in vitro fertilization in patients with salpingitis isthmica nodosa.20
Sonohysterography is the instillation of sterile saline or other contrast into the uterine cavity during ultrasonic observation of the pelvic structures for the purpose of delineating the endometrial cavity and demonstrating patency of the fallopian tubes. The contrast medium distends the endometrial cavity and provides a fluid interface that allows the identification of endometrial abnormalities such as polyps, intrauterine adhesions, leiomyomata, and septa.
Unlike HSG, sonohysterography generally can be performed in the gynecologist's office using available ultrasound equipment with the addition of a vaginal transducer. Sonohysterography has the same contraindications as HSG. No premedication is required because the procedure generally produces little discomfort. The patient, who has previously emptied her bladder, is placed on the ultrasound table in the lithotomy position. A routine vaginal ultrasound is performed, systematically observing the cervix, the myometrium, the endometrial stripe, the ovaries, and the cul-de-sac. A speculum then is placed into the vagina and the cervix cleansed with an antiseptic solution. At this point, one of a number of catheters may be placed into the endocervical canal. An insemination catheter, a No. 5 pediatric Foley catheter, or the specially designed 5.5 French Soules intrauterine catheter may be used. A tenaculum is rarely necessary. If a catheter with a bulb is used, it should just be in the cervical canal so as not to obscure the endometrial cavity. At this point, the speculum is removed and the vaginal transducer reintroduced either anterior (in the case of an anteverted uterus) or posterior (in the case of a retroverted uterus) to the intrauterine cannula. Sterile saline is then slowly introduced through the cannula to distend the endometrial cavity. During instillation, the uterus is scanned longitudinally. The transducer is then turned 90° to scan the uterus in a transverse manner.
The endometrial cavity can be well outlined using a saline contrast ultrasound. However, the fallopian tubes cannot be consistently or accurately visualized using this technique. Randolph and co-workers23 described the technique of instilling up to 200 mL of saline through the intrauterine cannula. The fluid was noted to collect in the cul-de-sac in the presence of tubal patency. The distal tube frequently could be seen silhouetted in the cul-de-sac fluid. In the presence of obstructed tubes, the cavity expanded without accumulation of cul-de-sac fluid. When compared to ultrasound, patency was correctly diagnosed in 91% of patients, although side-specific patency could be diagnosed only in 67% of patients.
Other contrast fluids have been used in an effort to delineate more accurately the fallopian tubes. Echovist is a suspension of galactose monosaccharide microparticles in an aqueous solution of galactose. The suspension is prepared immediately before use and instilled in the same manner as saline. To diagnose the patency of each tube, the contrast is observed to emerge into the cul-de-sac at the end of the fimbria. As an alternative, one should observe a steady tubal flow lasting at least 120 seconds in at least 1 imaged tubal section. This medium causes some degree of discomfort in half of the patients and occasionally causes significant discomfort. When compared to results obtained by HSG in the detection of tubal patency, Echovist showed excellent correlation when tubes were patent but overdiagnosed tubal obstruction.
Albunex (Molecular Biosystems, Inc., San Diego, CA), which is being tested as a contrast medium, is a suspension of 5% human serum albumin microspheres. These air-filled microspheres have a mean diameter of 3 to 5 microns. Albunex is injected after saline instillation. The contrast is observed as it fills the uterine cavity and can be seen traversing the fallopian tubes.24 Although the contrast can be observed in the cul-de-sac, indicating at least one patent tube, there currently is no evidence that side specificity can be consistently obtained.
Sonohysterography has excellent sensitivity and specificity for diagnosing intrauterine abnormalities, particularly endometrial polyps and submucous leiomyomata.25,26 However, the technique to date is less than 50% accurate in the diagnosis of tubal obstruction. It may be helpful in the detection of the less common combination of proximal and distal blockage.27
Color Doppler sonography, using saline as the contrast agent, increases the accuracy of assessing fallopian tubes. Using laparoscopy as the standard, the sensitivity is greater than 90% and the specificity is greater than 80% in the diagnosis of tubal occlusion.28,29,30 This technique is advantageous because it avoids radiation exposure, is less painful and less costly than HSG, avoids the potential for allergic reaction to contrast, and generally is more convenient both for patient and physician. The disadvantage is that it cannot accurately determine the site of tubal obstruction, nor can it delineate the architecture of the tubal lumen.
The diagnosis of tubal problems using the hysteroscope was for a long while considered inappropriate. This was because of the concern that the complex angulation of the intramural portion of the fallopian tube would be disrupted by efforts to visualize or probe the interior of the fallopian tube hysteroscopically. The recognition that two thirds of cornual obstructions failed to demonstrate anatomic defects provided the impetus for searching out new methods of evaluating the cornual portion of the fallopian tube. Thurmond and Rosch's pioneering work on fluoroscopic selective cornual catheterization provided the impetus to overcome this reluctance to approach the intramural portion of the fallopian tube hysteroscopically.
If HSG demonstrates consistent bilateral cornual occlusion, efforts can be made to cannulate the cornua selectively. It is not currently possible, however, to determine the extent of distal disease hysteroscopically. In two thirds of such cases, no anatomic abnormality can be demonstrated. The remaining third have salpingitis isthmica nodosa, concurrent distal disease, endometriosis, or another anatomic abnormality not immediately apparent with radiologic techniques. Laparoscopy, advisable in many of these cases, allows the physician to determine if the occlusion is confined to the cornu or involves significantly more of the fallopian tube. One can then assess if the obstruction can be repaired hysteroscopically or will require a laparoscopic or laparotomy approach. One can also assess, at this time, if the patient would be better served by in vitro fertilization.
If the obstruction is confined to the cornu, it is prudent to perform a hysteroscopic selective cornual cannulation at this time. This procedure is performed in much the same manner as the radiologic procedure. Any operating hysteroscope can be used. The hysteroscopy is performed in the usual manner. Any distention medium can be used, although sorbitol is most often selected. The instruments available for hysteroscopic cannulation of the cornu are similar to those for the radiologic procedure. There is no need for the suction cannula or the J-wire because the procedure is performed under direct observation.
The ostia of the tubes are identified. A 5.5 French polyethylene cannula with a slight curve at its end is introduced through the operating channel of the hysteroscope. The catheter usually can be manipulated into the tubal ostium with little difficulty. If the operator encounters difficulty placing the end of the catheter into the ostium, the curvature of the catheter end can be changed with the use of a trocar placed through the lumen of the catheter. When the catheter is adequately wedged into the ostium, dye is injected using a syringe attached to the Luer-Lok adapter on the catheter. Frequently, this maneuver alone serves to demonstrate the patency of the fallopian tube previously been thought to be occluded.
If the dye fails to traverse the cornu as demonstrated by laparoscopic observation, a coaxial set consisting of a guide wire and an overlying 3 French Teflon catheter is introduced through the larger catheter. The soft guide wire is manipulated through the cornu using gentle probing. Once the guide wire has entered the isthmic portion of the tube, the 3 French catheter is advanced. The alternating progression of the guide wire and the catheter ultimately allows cannulation past the cornu into the isthmus of the fallopian tube. The guide wire is removed and dye injected through the cannula to confirm patency.
Several studies have been published using this direct cannulation of the fallopian tube.17,31,32 Successful cannulation occurred in more than 70% of cases, and 60% to 75% of those cases remained patent. Pregnancy rates after this procedure have been high, but the number of cases reported to date have been too few to assess its therapeutic value. At present, it is prudent to consider selective cannulation of the fallopian tube as primarily diagnostic.
Endoscopy of the fallopian tube was initially described in 1987.33 As initially described, access was gained only to the ampullary portion of the fallopian tube. A 3-mm rigid telescope was passed along the operating channel of a laparoscope and into the fimbrial opening of the fallopian tube to allow assessment of the infundibulum and ampulla. Lesions of the mucosa were detected that were not apparent by HSG or laparoscopy. Similar observations of the distal fallopian tube have been accomplished by introducing a pediatric fiberoptic cystoscope through a 5-mm second puncture site at the time of laparoscopy. Currently, flexible fiberoptic or rigid salpingoscopes 1.8 to 2.8 mm in diameter with camera attachments and irrigating channels are available from several manufacturers.
TECHNIQUE OF SALPINGOSCOPY.
The salpingoscope is introduced into the peritoneal cavity at the time of laparoscopy through a 3-mm reducer placed in a 5-mm second puncture cannula. The fallopian tube is stabilized by grasping the antimesenteric serosa immediately before the fimbria. In patients with an obstructed fallopian tube, a small opening can be obtained with scissors, laser, or unipolar needle. The salpingoscope is then introduced into the ampullary portion of the fallopian tube, which is distended with heparinized Ringer's lactate solution delivered by a hand-held syringe.34
The Surreys34 correlated salpingoscopic with laparoscopic findings in a group of patients with tubal disease. They showed that findings correlated well when the patients were demonstrated to have moderate to severe disease by laparoscopy. However, when laparoscopy showed only minimal disease, salpingoscopy was able to demonstrate significant intraluminal pathology in many cases. Marana and co-workers35 demonstrated that salpingoscopy had a greater prognostic value than the American Society for Reproductive Medicine (ASRM) classification of adnexal disease in patients undergoing tubal surgery. Salpingoscopy may also be useful in evaluating the remaining tube in patients who undergo salpingectomy for ectopic pregnancy. In a series of 18 such patients,36 8 of 13 who demonstrated normal mucosa in the remaining tube conceived an intrauterine pregnancy. None of these had a recurrent ectopic pregnancy. In the five patients with demonstrated intra-ampullary adhesions, three had repeat ectopic pregnancies.
Fiberoptic endoscopes 0.5 mm in diameter (falloposcopes) have been tested for observation of the cornual and isthmic endothelium. The endoscope is introduced into the uterine cavity through the operating channel of a flexible hysteroscope. The flexible hysteroscope is used to aim the falloposcope into the ostium of the fallopian tube. The scope is then advanced into the isthmus of the fallopian tube by gentle probing. Other ingenious scopes that allow the lens system to advance as the outer sheath unfurls in the tube have been devised to allow observation of the mucosa of the isthmus. These observations are made as the scope is slowly withdrawn. At this point, little clinical correlation with the use of these scopes is available, and they are used primarily for investigation.
After its introduction into this country in the mid-1960s, laparoscopy achieved the status of the ultimate test for demonstrating tubal patency and anatomic pelvic abnormality. The more recent success of selective cannulation of the uterine cornu and the promise of such experimental techniques as salpingoscopy and falloposcopy serve only to increase the importance of laparoscopy in the evaluation of tubal disease. This is because laparoscopy has proven to be an integral part or a convenient accompaniment to the newer techniques. It is not the purpose of this chapter to detail the technique of performing laparoscopy. However, it should be noted that laparoscopy has become the most commonly performed of all gynecologic surgical procedures and in competent hands should be considered among the safest of intra-abdominal operations.37,38 Except for the complications common to anesthesia, the complication rate for laparoscopy is only slightly higher than for other tubal diagnostic procedures.39 It is certainly the most accurate means available for demonstrating the extent of pelvic inflammatory disease and external tubal damage. However, it should not be used as the only indicator of tubal disease: 3% of patients with normal laparoscopic studies have demonstrated intrauterine abnormalities using other techniques. In addition, although lack of patency is apparent after chromotubation during laparoscopic observation, the point of obstruction and the extent of luminal obliteration cannot be observed. Laparoscopy is most effective when combined with HSG and other tests that are now evolving, such as salpingoscopy and selective cornual cannulation.
Laparotomy is a highly accurate and certainly the most direct approach to the evaluation of tubal patency. However, the “infertility laparotomy” is no longer an acceptable procedure, because laparoscopy provides a similar assessment with less morbidity. However, once laparotomy has been performed, the demonstration of tubal patency can be accomplished in the following manner. The cervix is occluded by digital manipulation, by a clamp such as the Buxton clamp, or by some other device designed for occluding the cervical canal during laparotomy. A 22-gauge 1.5 needle is inserted into the endometrial cavity through the fundus of the uterus. A dilute solution of indigo carmine dye is then introduced into the endometrial cavity by means of a finger-control syringe attached through intravenous extension tubing to the intrauterine needle. The dye can be observed flowing through the fallopian tube, confirming patency.
The difficulty with this procedure is that occasionally one has trouble entering the endometrial cavity through a transfundal puncture. As an alternative, a No. 5 pediatric Foley catheter may be placed in the endocervical canal before laparotomy for the purpose of later introducing the indigo carmine dye. Several commercially available devices may be used to introduce dye into the endometrial cavity to check tubal patency during a laparotomy. They fix into the endometrial cavity and are placed transvaginally before the laparotomy. However, these devices seem to have little advantage over a transfundal needle or the use of an intracervical pediatric Foley catheter.
To demonstrate the point of obstruction during a microsurgical repair of the fallopian tubes, it is frequently necessary to inject concentrated dye solution through the endometrial cavity to stain the proximal portion of the fallopian tube. A concentrated dye also may be introduced through the fimbrial ostium to stain the distal portion of the fallopian tube. Under the operating microscope, serial incisions can then be made until well-stained endosalpinx can be observed. The stained lumina can then be reanastomosed. A small Foley catheter adapter is a good means of introducing the dye through the fimbrial ostium.
HSG Versus Laparoscopy
Many studies have compared the findings observed at laparoscopy with those of HSG. A few studies have compared HSG, laparoscopy, and tubal insufflation. In 1981, Philipsen and Hansen40 demonstrated agreement between HSG and laparoscopy in 57.7% of a group of infertile patients. However, among 54 patients whose HSGs were interpreted as normal, 29.6% exhibited abnormalities at laparoscopy. Among the 224 patients with abnormal HSGs, 24.6% had normal internal genitalia demonstrated at laparoscopy. Predictably, the greatest discrepancy between HSG and laparoscopic diagnoses was in the demonstration of peritubal adhesions. However, intrauterine abnormalities were diagnosed by HSG in 2.4% of laparoscopically normal patients. In 1977, Hutchins11 reported conflicting results in up to 65% of cases between the two procedures. In a 1978 study of 121 patients by Servy and Tzingounis,41 false-negative results were found in 29% of patients and false-positive results in 7.4% of patients by HSG.
Laparoscopy can demonstrate pelvic abnormalities in addition to tubal disease, including endometriosis, polycystic ovaries, and uterine leiomyomata. In a 1980 study performed by Portuondo and co-workers,42 335 infertile patients were evaluated by HSG and laparoscopy; in addition, tubal insufflation was performed. The results among the three methods agreed in 65% of patients. False results were found in 18% of patients by tubal insufflation, 9% by HSG, and 6.8% by laparoscopy. Nontubal pelvic pathology was detected by laparoscopy in 17% of the 336 patients. Pelvic adhesions and endometriosis were the pathologic entities most commonly undetected by HSG. It was apparent that evaluation both by HSG and laparoscopy was needed in 30% of the infertile patients.
A meta-analysis of 20 studies comparing HSG to laparoscopy for tubal patency and peritubal adhesions was reported by Swart and co-workers.43 A total of 4,179 patients with infertility culled from 20 studies were evaluated. For tubal patency, the reported sensitivity and specificity were 65% and 83%, respectively. The authors confirmed the usefulness of HSG for demonstrating tubal obstruction and its unreliability for demonstrating peritubal adhesions.
The interobserver and intraobserver variability in the interpretation of HSG was addressed by Mol and colleagues.44 Four observers evaluated 143 HSGs twice on proximal tubal obstruction, distal tubal obstruction, hydrosalpinx, and peritubal adhesions. Reproducibility between observers was almost perfect for proximal obstruction, substantial for distal obstruction and hydrosalpinx, and moderate for adhesions. Reproducibility within observers was perfect for proximal obstruction and substantial for distal obstruction, hydrosalpinx, and adhesions.
It is apparent to physicians experienced in evaluating infertile patients that HSG and laparoscopy have become procedures to be used as adjuncts.45,46 Laparoscopy can confirm such diagnoses as endometriosis and can demonstrate peritubal adhesions if the fallopian tubes are judged to be patent by HSG. In some situations, technical malfunctions during laparoscopy create difficulty in chromotubation of the fallopian tubes. Under these circumstances, a prior HSG that demonstrated patency of the tubes is reassuring. With chronically damaged fallopian tubes due to pelvic inflammatory disease, HSG can demonstrate the point of proximal obstruction, whereas laparoscopy can demonstrate the extent of distal obstruction. The observation of a distal hydrosalpinx combined with a proximal obstruction is considered by most pelvic surgeons to offer a poor prognosis for surgical repair.47
HSG before laparoscopy has been advised for the preoperative evaluation of previously ligated fallopian tubes to demonstrate the extent of intramural patency or proximal isthmic patency.48 With little proximal tube demonstrated by HSG, a reimplantation procedure rather than a microsurgical reanastomosis was occasionally performed. The prognosis was poorer under these circumstances, and cesarean section was more likely to be necessary should pregnancy occur. Under such circumstances, the patient may elect not to have a repair performed. A clearly identifiable amount of proximal fallopian tube observed by HSG, combined with an acceptable amount of distal fallopian tube observed laparoscopically, indicated that a microsurgical reanastomosis was feasible, and the prognosis thereby improved.
Recently, the necessity for HSG before tubal reanastomosis has been challenged. Tubal reimplantation has, for the most part, been superseded by cornual reanastomosis in the few instances where the cornua have been severely damaged by the sterilization procedure. Previously, such damage was created when laparoscopic sterilization was performed with unipolar cautery. Methods currently in use for sterilization (e.g., bipolar coagulation, clips, Silastic bands, and partial resection) should not damage the cornua, thus eliminating the need for HSG. This was clinically confirmed in a study by Groff and associates49 in which preoperative HSGs performed on 81 patients failed to add information that would alter the management of their sterilization reversal. HSG should no longer be considered a prerequisite for tubal reanastomosis.
HSG Versus Hysteroscopy
Hysteroscopy has been performed by a small group of clinicians for many years. Within the past 5 years, however, the procedure has come into general use. As expected, during these early assessments, there has been significant disagreement among clinicians regarding the relative usefulness of HSG and hysteroscopy. In 1986, Daly and co-workers50 concluded that abnormalities reported on hysteroscopy were of little clinical importance and that previously undetected abnormalities were rare in the patient who had undergone adequate HSG. They did, however, report three cases in which small, “strategically placed lesions” were found to explain the patients' previously unexplained infertility. They suggested that routine hysteroscopy be added when laparoscopy is performed. Their rationale was that hysteroscopy added little time and morbidity and occasionally revealed an otherwise undetectable abnormality.
A 1987 comparative study51 of 100 infertile patients reported that the sensitivity and specificity of HSG were 74.2% and 91.3% when compared to hysteroscopy. The authors suggested that a complete study should include both procedures. This opinion was somewhat different than that of Fayez and colleagues,52 who studied 400 infertile patients with both HSG and hysteroscopy. They concluded that carefully performed HSG revealed virtually all abnormalities later confirmed by hysteroscopy. However, the exact nature of the intrauterine lesion usually could be determined only by hysteroscopy.
A 1988 prospective multicenter study53 of 619 patients was designed to assess the relative value of these procedures. Examination of the tubal ostia by hysteroscopy revealed 26 patients with unilateral tubocornual polyps and 1 with bilateral polyps. There were hysteroscopically demonstrable lesions in 20% of the patients with normal results on HSG. In 35% of the cases, there were false-positive findings by HSG. The abnormalities demonstrated by hysteroscopy were confined to the uterine cavity or the cornual area.
The obvious limitation of hysteroscopy in the absence of salpingoscopy is inadequate assessment of the fallopian tubes. The promise of newer techniques and general availability of salpingoscopy may ultimately make HSG as antiquated as tubal insufflation. At this time, however, the combination of HSG and hysteroscopy is necessary for adequate assessment of both the endometrial cavity and the fallopian tubes.
Ultrasonography Versus HSG
Using saline as a contrast medium, patency of at least one tube, as indicated by the accumulation of fluid in the cul-de-sac, agreed with laparoscopy in 91% of patients. No patient with bilaterally obstructed fallopian tubes was interpreted as having cul-de-sac fluid. Side-specific tubal patency agreed with laparoscopy only 68% of the time. A hydrosalpinx could be demonstrated by the presence of a fluid-filled sac before the instillation of saline.23 The use of color Doppler increases the correlation with HSG to 92%30 and correlation with laparoscopy to 93%.29 However, in the diagnosis of myometrial and endometrial lesions such as polyps and leiomyomata, the use of saline contrast ultrasonography equaled that of hysteroscopy and laparoscopy and was superior to that of HSG.25,26
At present, ultrasonography is not the procedure of choice for the initial evaluation of the infertile couple because of its inability to define tubal patency. However, if myometrial and endometrial anatomy is more important than tubal patency, such as in the evaluation for in vitro fertilization or irregular bleeding, ultrasonography is more accurate, more convenient, more comfortable, and more cost-effective.
18. Thurmond AS, Rosch J, Patton PE et al: Fluoroscopic transcervical fallopian tube catheterization for diagnosis and treatment of female infertility caused by tubal obstruction. Radiographics 8: 621, 1988
21. Wolcott R, Petchpud A, O'Donnell P, Stanger J: Differential impact on pregnancy rate of selective salpingography, tubal catheterization and wire-guide recanalization in the treatment of proximal fallopian tube obstruction. Hum Reprod 10: 1423, 1995
23. Randolph JR, Ying YK, Maier DB et al: Comparison of real-time ultrasonography, hysterosalpingography, and laparoscopy/hysteroscopy in the evaluation of uterine abnormalities and tubal patency. Fertil Steril 46: 828, 1986
35. Marana R, Rizzi M, Muzii L et al: Correlation between the American Fertility Society classifications of adnexal adhesions and distal tubal occlusion, salpingoscopy, and reproductive outcome in tubal surgery. Fertil Steril 64: 924, 1995
51. La Sala GB, Sacchetti F, Degl'Incerti-Tocci F et al: Complimentary use of hysterosalpingography, hysteroscopy and laparoscopy in 100 infertile patients: Results and comparison of their diagnostic accuracy. Acta Eur Fertil 18: 369, 1987