Evidence-based management of tubal disease and infertility

Treatment of Infertile Women with Unilateral Tubal Occlusion Diagnosed by Hysterosalpingography: The Role of Intrauterine Insemination

The optimal assisted reproductive treatment strategy for infertile women with unilateral tubal obstruction remains uncertain. To investigate the role of intrauterine insemination (IUI) in the treatment of infertile women with unilateral tubal occlusion, the data of 148 couples were retrospectively collected and analyzed. Seventy-eight infertile women with unilateral occlusion diagnosed by hysterosalpingography (HSG) were categorized as the study group and 70 others with unexplained infertility as the control group. The study group was divided into a proximal occlusion subgroup and a mid-distal occlusion subgroup for further analysis. The main outcomes, namely the clinical pregnancy rate (CPR), ongoing pregnancy rate (OPR), and live birth rate (LBR) per cycle, were analyzed. Our results showed a tendency of lower CPR, OPR, and LBR in the study group than in the control group, without statistical significance. Further investigations revealed that the unilateral proximal occlusion subgroup had similar CPR, OPR, and LBR as the control group, while the unilateral mid-distal occlusion subgroup had significantly lower CPR (5.1% vs. 20.0%, P=0.035), OPR (5.1% vs. 20.0%, P=0.035), and LBR (5.1% vs. 20.0%, P=0.035) than the control group. In conclusion, the clinical outcomes of IUI were worse in patients with unilateral tubal occlusion than in those with unexplained infertility. This might be primarily caused by the worse outcome of patients with unilateral mid-distal tubal occlusion instead of proximal occlusion.

Comparison of Assessment Methods for Fallopian Tubal Patency and Peritubal Adhesion Between Transvaginal 4-Dimensional Hysterosalpingo-Contrast Sonography and Laparoscopic Chromopertubation

OBJECTIVES

The purpose of this study was to compare transvaginal 4-dimensional hysterosalpingo-contrast sonography with laparoscopic chromopertubation and evaluate the former's clinical value in assessing fallopian tubal patency and peritubal adhesion.

METHODS

Fifty-six patients visiting infertility clinics were included in the study and underwent surgery by their own choice in 1 month. In total, 112 fallopian tubes were assessed. Twenty-five were primarily infertile, and the rest were secondarily infertile. Laparoscopic chromopertubation was taken as the reference standard.

RESULTS

In a comparison of fallopian tubal patency between transvaginal hysterosalpingo-contrast sonography and laparoscopic chromopertubation, the sensitivity, specify, positive predictive value, and negative predictive value of hysterosalpingo-contrast sonography for diagnosing blocked fallopian tubes were 88.4%, 85.2%, 90.5%, and 82.1% respectively. In a comparison of spray at the fimbrial end between the no-peritubal adhesion and peritubal adhesion groups, the spray score at the fimbrial end in the no-peritubal adhesion group was significantly lower than that in the peritubal adhesion group. In a comparison of periovarian diffusion between the no-peritubal adhesion and peritubal adhesion groups, the periovarian diffusion score in the no-peritubal adhesion group was significantly lower than that in the peritubal adhesion group. In a comparison of periovarian diffusion between the patent-tube and blocked groups confirmed by chromopertubation, the periovarian diffusion score in the patent group was significantly lower than that in the blocked group.

CONCLUSIONS

Transvaginal hysterosalpingo-contrast sonography is a method with high sensitivity and specificity for screening fallopian tubal patency and peritubal adhesion.

Sonohysterosalpingography: Comparison of foam and saline solution

PURPOSE

To compare sonohysterosalpingography (sono-HSG) with foam instillation (HyFoSy) versus saline solution (HyCoSy) in the evaluation of tubal patency.

METHODS

We prospectively enrolled 37 infertile women, scheduled for laparoscopy. The women were randomized into two groups: HyFoSy (group I) and HyCoSy (group II). The patients of both groups underwent laparoscopy with dye test. We assessed the diagnostic performance (sensitivity, specificity, and overall accuracy) of HyFoSy and HyCoSy, compared with laparoscopy and dye test, in the assessment of tubal patency.

RESULTS

Sono-HSG findings in tubal patency assessment obtained in the HyFoSy group were concordant with laparoscopic results in 94.4% of cases, with a sensitivity of 87.5% and a specificity of 100%, whereas in the HyCoSy group, concordance occurred in only 57.8% of examinations, with a sensitivity of 50% and a specificity of 66.6%.

CONCLUSIONS

HyFoSy allows a more accurate diagnosis of tubal patency compared with HyCoSy. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:67-71, 2017.

First experience using 4-dimensional hysterosalpingo-contrast sonography with SonoVue for assessing fallopian tube patency

This study was conducted to describe our first experience using transvaginal 4-dimensional (4D) hysterosalpingo-contrast sonography with SonoVue (Bracco International BV, Amsterdam, the Netherlands) for diagnosis of fallopian tube patency. The study was prospective and conducted in a university hospital setting. The sonographic procedures included 2-dimensional transvaginal sonography for evaluating uterine and ovarian mobility, observing intubation, and determining the initial plane and 4D hysterosalpingo-contrast sonography for observing periovarian and pelvic diffusion. Ninety-six outpatients visiting infertility clinics underwent 4D hysterosalpingo-contrast sonography. All patients finished the examination successfully. A total of 192 fallopian tubes were assessed, of which 95 (49.5%) were classified as type A (the tube was patent, and the contrast agent flowed smoothly through it), 72 (37.5%) as type B (the tube was patent, but the contrast agent did not flow smoothly inside it), and 25 (13.0%) as type C (blocked). Sixteen patients underwent laparoscopy or laparoscopy combined with hysteroscopy; 28 tubes (87.5%) were concordant with laparoscopy. The sensitivity, specificity, positive predictive value, negative predictive value, and Youden index for 4D hysterosalpingo-contrast sonography versus laparoscopy were 81.8%, 90.5%, 81.8%, 90.5%, and 0.72 respectively. In total, 92.7% of patients did not require a hospital stay after 4D hysterosalpingo-contrast sonography, and none need resuscitation. The others stayed in the hospital for clinical observation because of a severe vasovagal reaction or severe pain but received only bed rest without any medical treatment. Forty patients (41.7%) felt slight pain; 39 (40.6%) felt moderate pain; and 15 (15.6%) had a vasovagal reaction. No procedure or postprocedure complications occurred in any patient. In conclusion, 4D hysterosalpingo-contrast sonography with SonoVue is an available screening method for assessment of tubal patency and is tolerable for most patients.

The Diagnostic Properties of Medical History in the Diagnosis of Tubal Pathology among Subfertile Patients

Objectives. To evaluate the diagnostic performance of medical history in the diagnosis of tubal pathology among subfertile patients. Patients and Methods. Prospective cross-sectional study was performed. Prior to tubal evaluation, medical history data were collected. Sensitivity, specificity, and likelihood ratios (LRs) for predicting tubal pathology as determined by laparoscopy and dye test were calculated for each issue of medical history. Results. 39.6 % (59/149) were diagnosed with tubal pathology. The sensitivity for the different issues ranged between 1.7 and 54.2% and the specificity between 75.6 and 97.8%. The estimated highest value of positive LR is attributed to the history of ectopic pregnancy and lowest of negative LR to pelvic inflammatory disease (PID) and abdominal surgery. Conclusion. The positive history of PID, sexually transmitted diseases (STDs), abdominal and laparoscopic surgery, and ectopic pregnancy are satisfactory screening tests for ruling the tubal pathology in. The negative history of evaluated issues is inappropriate for ruling the tubal damage out.

The value of medical history taking as risk indicator for tuboperitoneal pathology: a systematic review

BACKGROUND

Guidelines recommend diagnostic laparoscopy in subfertile women with known co-morbidities in their medical history. Aggregated evidence underpinning these recommendations is, however, currently lacking.

OBJECTIVE

The objective of this study was to perform a systematic review and meta-analysis of the available evidence on the association between items reported during medical history taking and tuboperitoneal pathology.

SEARCH STRATEGY

MEDLINE (from 1966 to May 2007), EMBASE (from 1960 to January 2007) and bibliographies of retrieved primary articles.

SELECTION CRITERIA

All relevant studies that compared medical history with the presence or absence of tubal pathology.

DATA COLLECTION AND ANALYSIS

Studies comparing medical history with the presence or absence of tubal pathology were included. A diagnosis of tubal pathology had to be made by hysterosalpingography, laparoscopy or a combination of both. In the absence of invasive tubal testing, tuboperitoneal pathology was considered to be absent in case of intrauterine pregnancy. Homogeneity between studies was assessed, and the association between medical history and tubal pathology was expressed as a common odds ratio with a 95% CI. No language restriction was applied.

MAIN RESULTS

We included 32 studies. In cohort studies, strong associations were found for a history of complicated appendicitis (OR 7.2, 95% CI 2.2-22.8), pelvic surgery (OR 3.6, 95% CI 1.4-9.0) and pelvic inflammatory disease (PID) (OR 3.2, 95% CI 1.6-6.6), and in case-control studies, for a history of complicated appendicitis (OR 3.3, 95% CI 1.8-6.3), PID (OR 5.5, 95% CI 2.7-11.0), ectopic pregnancy (OR 16.0, 95% CI 12.5-20.4), endometriosis (OR 5.9, 95% CI 3.2-10.8) and sexually transmitted disease (OR 11.9, 95% CI 4.3-33.3).

AUTHOR'S CONCLUSIONS

Subfertile women reporting a history of PID, complicated appendicitis, pelvic surgery, ectopic pregnancy and endometriosis are at increased risk of having tuboperitoneal pathology. In these women, diagnostic laparoscopy should be offered early in the fertility work-up.