Combining B-mode ultrasound with pulsed wave Doppler for the assessment of tubal patency

This study was conducted to determine whether the additional use of pulsed wave Doppler improves the diagnostic capacity in assessing tubal patency by hysterosalpingo contrast sonography (HyCoSy). A total of 210 women with a history of infertility were included in this study. HyCoSy was performed after intrauterine injection of Echovist 200. For the assessment of tubal patency B-mode scanning and pulsed wave Doppler ultrasound were performed in the proximal and distal tubal segments. With the combined sonographic procedure 297 tubes (74%) were rated patent, 35 (8%) incompletely obstructed and 70 (18%) completely obstructed. A total of 252 tubes were additionally examined by laparoscopy for reference purposes. Concordant results for both methods were found in 92% of tubes, nine had been rated false negative and 10 tubes appeared to have been rated false positive. The combined sonographic specificity was found to be 85% with a sensitivity of 95%. Peritubal adhesions detected by laparoscopy were found to be the reason for false positive sonographic results in 60% of cases. In conclusion, the combined B-mode and pulsed wave Doppler examination appears to be a non-invasive and low-cost test for the assessment of tubal patency, which should be performed during diagnostic work-up for infertility.

A randomized study comparing air to Echovist as a contrast medium in the assessment of tubal patency in infertile women using transvaginal salpingosonography

This study was undertaken to compare two different contrast media (air and Echovist) in the assessment of tubal patency using transvaginal salpingosonography (TSSG) in 32 infertile women referred to an infertility outpatient clinic. Altogether, 59 Fallopian tubes were examined with TSSG. Laparoscopic chromopertubation was used as a reference method. In group A (air), concordance was 90%, Cohen's kappa coefficient 0.71 [95% confidence interval (CI): 0.64-0.77], sensitivity 63%, specificity 100%, negative predictive value 88% and positive predictive value 100%. In group B (Echovist), the corresponding parameters were as follows: 93%, 0.71 (CI: 0.67-0.76), 60, 100, 93 and 100% respectively. No statistically significant differences were found between these two contrast media. Either one can reliably be used for assessing tubal patency with TSSG in infertile women as a primary phase examination modality.

Correlation between salpingoscopic score and subsequent pregnancy outcome in patients with tubal infertility

PURPOSE

This study evaluated the efficacy of the salpingoscopic scoring system of tubal function.

METHODS

Twenty-seven infertile patients, including 10 patients with proximal tubal occlusion, 12 with endometriosis and 5 with inflammatory hydrosalpinx, were studied. All 54 tubes were examined using a 0.5-mm-diameter salpingoscope and scored.

RESULTS

The mean scores for patients with proximal tubal occlusion, endometriosis, and inflammation were 18.6 +/- 2.0, 15.6 +/- 0.7, and 20.8 +/- 3.4, respectively. Eight patients (29.6%) conceived; their mean tubal score was 12.6 +/- 0.5 (12-16). Nineteen patients did not conceive, and their mean score was 18.8 +/- 1.4 (12-31). There was a significant difference between these two scores (P < 0.001).

CONCLUSIONS

Scoring of the tubes by salpingoscopic examination is useful for evaluating tubal function with regard to prediction of pregnancy and also for selecting IVF or tubal reconstructive surgery as the preliminary treatment.

Sterilization with fibrin sealant in a rabbit uterine horn model

OBJECTIVE

This study investigated the effects of a fibrin sealant with or without coagulation in obliterating the tubal lumen at the uterotubal junction in rabbits.

STUDY DESIGN

Twenty-three female rabbits were subjected to laparotomy and hysterotomy. They were randomly divided into four groups, and the fallopian tubes underwent different treatment: In group 1 (n = 14) both bipolar coagulation and the fibrin sealant were used. In group 2 (n = 10) only fibrin sealant without coagulation was used. In group 3 (n = 11) only coagulation was used. In group 4 (n = 10) no treatment was performed (control group). Two to three rabbits were euthanized on days 3 to 4, 7 to 11, 14 to 17, and 21 to 24 postoperatively. Both uterotubal junctions were excised, and step cross sections were obtained. The morphologic features including denuded epithelium with debris, submucosal fibrosis, hemorrhage, and fibrinoid matter in the tubal lumen and occluded lumen were observed.

RESULTS

Tubal lumina were successfully occluded in 10 of 14 tubes (71.4%) in group 1. In groups 2 and 4 none of the tubes were occluded, and in group 3 only three tubes were partially occluded. The difference between group 1 and other groups was significant (p < 0.05).

CONCLUSIONS

The effects of bipolar coagulation in enhancing the inflammatory reaction on the mucosa and scar formation induced by fibrin sealant at the uterotubal junction in the rabbit were demonstrated. This sterilization method with the use of fibrin sealant may be developed into an outpatient procedure in humans and may be a new method for female sterilization in the future.

A natural experiment on the effects of ovarian hormones on cardiovascular risk factors and stress reactivity: bilateral salpingo oophorectomy versus hysterectomy only

To test the effects of declining ovarian hormone levels on cardiovascular risk factors, blood pressure, lipids, weight, and physiological responses to stress were evaluated in 29 middle-aged premenopausal women prior to and following elective hysterectomy and/or bilateral salpingo oophorectomy (BSO). Prior to surgery, there were no group differences in standard or putative risk factors, with the exceptions of body composition measures and total cholesterol level. After surgery, women who had undergone BSO (n = 10) had higher levels of atherogenic lipids and stress-induced lipids and tended to have higher circulating levels of epinephrine and stress-induced systolic and diastolic blood pressure than women who had undergone hysterectomy only (n = 19). This study is consistent with the hypothesis that presence of ovarian hormones plays a key role in determining women's risk factor status.

Spontaneous heterotopic pregnancy presenting with tubal rupture

We present the case of a woman who sought pregnancy termination but who, in the interval between consultation and surgical termination, presented with clinical signs of a ruptured ectopic pregnancy. This was managed as such, but post-operative follow-up soon revealed that she also carried a viable intrauterine pregnancy.

Radionuclide hysterosalpingography with radiolabeled spermatozoa

OBJECTIVE

To evaluate the efficiency of radionuclide hysterosalpingography (HSG) by using 99mTc hexamethyl propyleneamine oxime (HMPAO)-labeled human spermatozoa in the assessment of fallopian tube patency in infertile couples.

DESIGN

Fifteen infertile female patients were inseminated with their husbands' radiolabeled spermatozoa immediately after cessation of menses.

SETTING

University-based academic hospital.

MAIN OUTCOME MEASURE(S)

The time course of radioactivity and scintigraphic images of the uterus and the parauterine tissues implying tubal patency were evaluated and compared by using laparoscopy and HSG.

RESULT(S)

We demonstrated Tmax (time to peak radioactivity at periovarian sites) for right and left tubes to be 6.74 +/- 2.66 and 5.91 +/- 2.93 minutes (means +/- SD), respectively. We also found 72% sensitivity and 75% specificity of spermatozoa labeled radionuclide HSG compared with laparoscopic findings for tubal patency.

CONCLUSION(S)

Radionuclide HSG with the husband's spermatozoa seems to be a potentially useful method of assessing patency of the fallopian tubes. The safety dose of this procedure is comparable to conventional HSG. However, more comparative studies are needed to evaluate advantages and disadvantages of this technique.

Relation between endometrial wavelike activity and fecundability in spontaneous cycles

OBJECTIVE

To determine whether endometrial activity is related to the occurrence of pregnancy in spontaneous menstrual cycles.

DESIGN

Prospective observational ultrasound evaluation of endometrial activity during fertility screening cycles.

SETTING

University hospital-based infertility clinic.

PATIENT(S)

Fifty-nine fertility screening cycles (ultrasound monitoring of follicle growth and ovulation, postcoital test, semen analysis, midluteal P, Chlamydia antibody determination, and tubal patency testing) were performed in 47 couples complaining of infertility. In 33 couples (37 cycles), no fertility impairing factors were found. Endometrial activity was analyzed in these cycles.

INTERVENTION(S)

Ultrasound examination was performed transvaginally throughout the cycle.

MAIN OUTCOME MEASURE(S)

Endometrial activity, wave pattern, pregnancy.

RESULTS(S)

Nine women conceived within the cycle studied. Conception cycles showed less-activity compared with nonconception cycles. Endometrial wavelike activity increased throughout the follicular phase and decreased after ovulation in conception and nonconception cycles.

CONCLUSION(S)

Endometrial activity is related to fecundability in a spontaneous cycle.

Assessment of tubal patency with transvaginal salpingosonography after treatment for tubal pregnancy

Tubal patency was studied in 32 patients who had previously undergone a laparoscopic or laparotomy procedure (salpingostomy, salpingectomy or tubal resection), or who had received a local injection of hypertonic glucose because of tubal pregnancy. Transvaginal salpingosonography (TSSG) was subsequently performed in the follicular phase of the menstrual cycle, and laparoscopic chromopertubation was carried out as a comparative method after TSSG. Of 32 patients (47 Fallopian tubes examined), the affected tube was observed to be patent by TSSG in 68%. The contralateral tube was patent in 93%. Nine patients became pregnant and were thus not subsequently assessed with laparoscopy. Two of these pregnancies ended in a miscarriage and one in a recurrent tubal pregnancy. A concordance of 86% for Fallopian tubes was achieved between the TSSG and laparoscopic chromopertubation methods. When checking the Fallopian tubes separately, the concordance for the results in the affected tubes was 67%, and 100% for the contralateral tube. Therefore TSSG appears to be a practical method for the primary examination of tubal patency in patients treated previously for tubal pregnancy. Guidelines for the treatment of infertility after tubal pregnancy can also be set out according to TSSG findings.

Autologous fibrin adhesive in experimental tubal anastomosis

OBJECTIVE

To evaluate autologous fibrin in rabbit oviduct anastomosis versus 7-0 vikryl, a conventional suture material used in tubal anastomosis.

METHODS

Thrombin was added to the autologous fibrinogen at the site of anastomosis to obtain a tissue adhesive. The anastomotic time, pregnancy rate, and litter size were evaluated. Three months later, a relaparotomy was done to evaluate patency and degree of adhesions, and a tubal biopsy was taken from the site of anastomosis.

RESULTS

Analysis of results showed a statistically significant (P < .001) shortened anastomotic time and superior histopathological union in the tissue adhesive group. Patency rate, pregnancy rate, and degree of adhesions were comparable in both groups.

The assessment of tubal functional status by tubal perfusion pressure measurements

The measurement of tubal perfusion pressures (TPP) is a recent advance in the field of gynaecoradiology. Measurement of TPP involves a standardized technique using transcervically placed tubal catheters which is reviewed in detail. TPP assesses the functional status of the Fallopian tubes, i.e. their ability to permit pregnancy. Infertile patients with normal TPP demonstrated a higher pregnancy rate (10 out of 23) than patients with elevated TPP (four out of 24, P < 0.05). Analysis of patients who had undergone a laparoscopy as well as measurement of TPP suggest that elevated TPP are highly indicative of tubal endometriosis. Tubal catheterization with wireguides was successful in reducing mildly elevated TPP. The impact of this procedure on pregnancy rates is not known. The use of the gynaecoradiological techniques discussed in this paper has reduced the need for diagnostic laparoscopy at our centre by >60%. This was achieved without compromise in pregnancy rates and has resulted in a considerable reduction in cost.

Uterine hyperperistalsis and dysperistalsis as dysfunctions of the mechanism of rapid sperm transport in patients with endometriosis and infertility

Women suffering from infertility in association with mostly mild endometriosis were subjected to vaginal sonography of uterine peristalsis during the menstrual period, the early, mid- and late follicular phases, and the mid-luteal phase of the menstrual cycle. The data obtained were compared with those of healthy controls. Women with endometriosis displayed a marked uterine hyperperistalsis that differed significantly from the peristalsis of the controls during the early and mid-follicular and mid-luteal phases. During the late follicular phase of the cycle, uterine peristalsis in women with endometriosis became dysperistaltic, arrhythmic and convulsive in character, while in controls peristalsis continued to show long and regular cervico-fundal contractions. Hysterosalpingoscintigraphy during the early, mid- and late follicular phases revealed that hyperperistalsis in the early and mid-follicular phases of patients with endometriosis resulted in a dramatic increase in the transport of inert particles from the vaginal depot, through the uterus into the tubes and also into the peritoneal cavity. During the late follicular phase of the cycle, the dysperistalsis observed in women with endometriosis resulted in a dramatic reduction of uterine transport capacity in comparison with the healthy controls. We consider uterine hyperperistalsis to be the mechanical cause of endometriosis rather than retrograde menstruation. Dysperistalsis in the late follicular phase of patients with endometriosis may compromise rapid sperm transport. Uterine hyperperistalsis and dysperistalsis are considered to be responsible for both reduced fertility and the development of endometriosis.

Color Doppler sonography of tubal torsion

These case reports illustrate the clinical and color Doppler sonographic findings in two cases of isolated tubal torsion. This condition may be associated with prior tubal ligation. The presence of high impedance or absent flow in a tubular structure in a patient with a history of tubal ligation should make one suspect this condition.

Elevated tubal perfusion pressures during selective salpingography are highly suggestive of tubal endometriosis

OBJECTIVE

To investigate the possible etiologies of elevated tubal perfusion pressures.

DESIGN

Analysis of 48 consecutive female patients with infertility who underwent laparoscopy and a gynecoradiological investigation as part of their infertility work-up.

SETTING

Academically affiliated infertility center.

INTERVENTIONS

A gynecoradiological investigation was performed using a previously reported standardized contrast injection system. Laparoscopy was performed routinely.

RESULTS

Patients who demonstrated by laparoscopy to have endometriosis showed a significantly increased incidence of tubal blockage during initial hysterosalpingography (HSG) (12/26, 46.1%) compared with controls (2/14, 14.3%). Patients with endometriosis also demonstrated significantly more frequently elevated tubal perfusion pressures (22/26; 84.6%) than women without disease (2/14, 14.3%) and significantly higher mean tubal perfusion pressures than women with normal pelvises (576 +/- 264 versus 450 +/- 268 mm Hg).

CONCLUSION

Tubal blockage during initial HSG and elevated tubal perfusion pressures during selective salpingography are highly suggestive of tubal endometriosis. These data are the first evidence that tubal involvement with endometriosis may be more frequent than previously suspected. They also suggest that the performance of a gynecoradiological investigation, inclusive of selective salpingography, can greatly contribute to a presumptive diagnosis of endometriosis.

Laser scattering instrument for real time in-vivo measurement of ciliary activity in human fallopian tubes

Based on a laser light scattering technique and fibre optic probe, we have developed and tested a simple and practical device for real time measurements of ciliary activity in human Fallopian tubes during laparoscopy and laparotomy. A further aim was to investigate the relationship between the ciliary beat frequency (CBF) and the morphology of the ciliary epithelium. The mean +/- SE of CBF in the fimbria and in the ampulla were 5.4 +/- 0.3 Hz and 5.0 +/- 0.1 Hz respectively. Small pieces of fimbria and ampulla epithelium were taken from the same sites at which the CBF was measured, and the percentage of ciliary cells was determined by scanning electron microscopy. A high positive correlation was found between CBF and the percentage of ciliary cells in the fimbria (r = 0.84) and in the ampulla (r = 0.88). The instrument presented in this study provided, for the first time, a quantitative examination of the CBF in intact human Fallopian tubes and may be used for the investigation of ciliary activity in patients with infertility.

Laparoscopic rescue after tubal anastomosis failure

Laparoscopic rescue after tubal anastomosis failure is reported for the first time. The patient was a 33 year old woman sterilized by Pomeroy's method. Reconstruction of fertility was achieved by mini-laparotomy with isthmo-isthmic end-to-end anastomosis of bilateral tubes. Unfortunately, the patient did not become pregnant and tubal occlusion was diagnosed 6 months later by hysterosalpingography. Laparoscopic rescue with repeat isthmic-ampullary anastomosis and adhesiolysis was performed. Post-operatively, the patient had one menstruation and then achieved an intrauterine pregnancy. Instead of in-vitro fertilization/embryo transfer, laparoscopic rescue may be an alternative option for the patient with failed anastomosis.

Hydrosalpinx formation and its regeneration after microsurgical reconstruction--a functional and morphological study on rabbits

The development of mechanically induced hydrosalpinx and the subsequent regeneration of the uterine tube following correction were investigated with reference to morphological and functional parameters in 33 rabbits. Mechanically induced hydrosalpinx leads to reduced fertility. The characteristic morphological alterations are flattening of the folds, deciliation, reduced secretory activity and general de-differentiation of the epithelial cells. The intensity of these changes peaked as little as 4 weeks after induction of the hydrosalpinx. The deciliation is generally patchy. The division into different fields, islet formation and celestial chart phenomena reflect different degrees of vascularization and/or oxygenation. These alterations were completely reversible within 8 weeks after reconstruction. In isolated cases only the formation of polypose stumps was seen, which were, however, covered with a normal epithelial surface. The discrepancy between the reduced tubal function following reconstruction for hydrosalpinx and the complete regeneration of the tubal mucosa suggests that other regulatory mechanisms more important for the function of the uterine tube are impaired.

Reduced pregnancy outcome in patients with unilateral or bilateral hydrosalpinx after in vitro fertilization

In a retrospective study, we compared 118 patients with hydrosalpinx and 157 patients with bilateral salpingectomy entering an established in vitro fertilisation programme between 1988 and 1992. Patients with unilateral or bilateral hydrosalpinx had a lower clinical pregnancy rate, a higher miscarriage rate, and a lower ongoing pregnancy rate than patients with absent Fallopian tubes.

Chlamydia trachomatis antibody testing is more accurate than hysterosalpingography in predicting tubal factor infertility

OBJECTIVE

To compare the likelihood of abnormal Chlamydia trachomatis antibody test results with that of abnormal hysterosalpingography (HSG) test results in patients with tubal factor infertility.

DESIGN

Anti-C. trachomatis immunoglobulin G antibodies were determined prospectively in 211 consecutive infertility patients by means of an indirect fluorescent antibody technique. The results were compared with the results of HSG with respect to their predictive value of tubal factor infertility. Likelihood ratio calculations were used.

SETTING

University hospital-based, tertiary care infertility clinic.

PATIENTS

A series of 211 consecutive infertility patients.

INTERVENTIONS

C. trachomatis antibody testing, HSG, laparoscopy.

MAIN OUTCOME MEASURES

Likelihood ratios for abnormal C. trachomatis antibody test results and abnormal HSG results in infertility patients, as assessed by laparoscopy.

RESULTS

The positive likelihood ratio for C. trachomatis antibody testing was 9.1, indicating a patient with tubal factor infertility to be 9.1 times more likely to have abnormal serology results than a patient without tubal factor infertility. This was superior to HSG, which had a positive likelihood ratio of 2.6 in our study and of 1.6 to 6.1 in the literature. The odds ratio of C. trachomatis antibody testing was 31.5 in our study. Its 90% confidence interval (8.3 to 138.5) did not overlap that of HSG as calculated from a meta-analysis of literature reports (5.3 to 7.9).

CONCLUSIONS

C. trachomatis antibody testing is simple, inexpensive, and causes minimal inconvenience to the patient. It is more likely than HSG to be abnormal in patients with tubal factor infertility. C. trachomatis antibody testing deserves to become an integral component of the initial fertility work-up.

[Evaluation of valvular mechanisms in uterine openings using endoscopic methods]

Endoscopic examination was made in 20 sterile women. Particular attention was drawn to the mechanism of uterine openings of the oviductus, viewed by hysteroscopy. Clinical condition end the flux of contrast via abdominal part of oviductus evaluated using laparoscopic technique. The hysteroscopic picture of valvular mechanisms is reliable element for evaluation of potency of oviductus. Combined laparoscopy and hysteroscopy brings a lot of information concerning the structure and function of oviductus.

Developmental steps for radionuclide hysterosalpingography

The active oviductal transportation capacity was studied in 73 infertile women by the use of a new deposition technique of radioactive particles into the internal cervical os. The main reason for this study was that a previous observation had shown that such a transportation capacity was lacking in 41% of the infertile patients with a normal hysterosalpingogram. The examination was performed in the immediate preovulatory phase, i.e. on days -3 to 0 before the ovulation, as measured by the basal body temperature during two preceding cycles. The deposition of 99mTc-labelled albumin particles of 0.2-1.0 micron at the internal cervical os and the interpretation of the radionuclide images are described in detail. The results show that the bilateral active tubal transportation capacity was present in 42 patients. An impaired transportation capacity was diagnosed in 22 patients. In 9 patients, the particles never reached the uterine cavity, or all activity leaked back to the vagina.

Preoperative diagnosis of primary fallopian tube carcinoma by transvaginal ultrasound, cytological finding and CA-125

Primary Fallopian tube carcinoma is rarely diagnosed preoperatively. We present the case of a 69-year-old woman with primary tubal carcinoma, which was diagnosed preoperatively on the basis of the cytological finding, characteristic features on transvaginal sonography, transvaginal color flow imaging and elevated CA-125. Transvaginal color Doppler imaging demonstrated the tumor revealed areas of neovascularization with characteristic low impedance (resistance index, 0.34 and pulsatility index, 0.62). Pathohistologic confirmation of the clearcell carcinoma has been done.

Intrauterine pregnancy in a patient with a sole remaining tube after local treatment of tubal pregnancy with hyperosmolar glucose

A spontaneous IUP occurred 8 months after laparoscopic instillation of hyperosmolar glucose solution into a tubal pregnancy in a patient with a sole remaining tube. This is the first unequivocal proof of intact tubal function after treatment of a tubal pregnancy with local hyperosmolar glucose.