Hysterosalpingography

Incidence and Causes of Tubal Occlusion in Infertility: A Retrospective Cohort Study

Background and Objectives: Fallopian tubal pathology is a primary risk factor for female infertility, with simple proximal disease and proximal disease extending more distally being more common than pure distal occlusion. Proximal tubal occlusion is often attributed to ascending events, such as pelvic inflammatory disease. Conversely, while distal occlusion can also be attributable to ascending pelvic inflammatory disease, it can also have a pelvic origin, such as through endometriosis and ruptured appendicitis. The aim of this study was to identify certain causes of infertility and their association with tubal occlusion. The focus was on the location of tubal occlusion, uni- versus bilateral occlusion, and other causes of infertility, including male factors. Methods: In a retrospective study cohort study, 373 women aged between 18 and 40 years, treated from 1 January 2017 to 31 December 2022, were included. Fallopian tube patency was tested using either hysterosalpingography, hysterosalpingo-contrast sonography, or laparoscopic chromopertubation. Results: In total, 95 of 373 women (25.5%) revealed at least one occluded tube, with unilateral occlusion being more common than bilateral occlusion (60/95, 63.2% vs. 35/95, 36.8%). The majority of tubal occlusions occurred proximally (86.2%). According to the adjusted multivariate regression models, the presence of hydrosalpinx (odds ratio, OR, 13.323, 95% confidence interval, CI: 2.679-66.253, p = 0.002), myomas (OR 2.108, 95%CI: 1.008-4.409; p = 0.048), and an abnormal sperm test result of the male partner (OR 2.105, 95%CI: 1.156-3.833; p = 0.015) were statistically significant associated factors for tubal occlusion. Conclusions: Fallopian tube patency testing is still of major relevance in fertility evaluation. The presence of uterine myomas, hydrosalpinges, and a male factor significantly increase the risk.

Spontaneous Pregnancy after 4D-Hysterosalpingo-Sonography (HyCoSy) in the Same Menstrual Cycle: A Case Report and an Updating Review of the Current Literature regarding the Positive Impact of Tubal Flushing Effect on Fertility

Infertility is increasing worldwide, as well as in Italy, and fallopian tube pathology represents one of the most impacting causes of infertility for multiple women. Indeed, tubal patency assessment is a crucial step in medical evaluation for women attending an in vitro fertilization (IVF) center. Currently, different methods for tubal investigation are available, such as chromosalpingoscopy, hysterosalpingography (HSG), and hysterosalpingo-contrast sonography (HyCoSy). This diagnostic exam is performed by ultrasonography and an air-water-based contrast agent represented by air-water, or foam solution (HyFoSy). An additional side benefit of these assessment tests is a fertility-enhancing effect, thanks to a positive effect defined as "tubal flushing," which in current literature is more strongly associated with HyFoSy with respect to HyCoSy. In this report, we present a case of a 34-year-old woman presented to our attention at the Reproductive and Physiopathology Unit of Sandro Pertini Hospital, Rome, in 2023, with unexplained infertility for 3.1 years of free sexual intercourse with a partner who did not report sperm abnormalities. Subsequently, in this exam, the woman spontaneously conceived in the same menstrual cycle that the 4D-HyCoSy was performed, without any additional fertility enhancement interventions. In this case report, we also include an updating review of the current literature regarding the insurgence of spontaneous pregnancy after this technique in order to explore the physiopathological and etiopathogenetic mechanisms underlying the achievement of spontaneous pregnancy and to confront our case with other recent works published. According to our clinical experience and the current literature, 4D-HyCoSy is the easiest, safest, and cheapest diagnostic exam for investigating tubal patency, which can lead to medical success in some cases of "unexplained infertility" as the achievement of a spontaneous pregnancy.

Ambulatory Hysteroscopy: Evaluating Pain and Determining Factors

Study objective

To measure pain using a visual analogue scale (VAS) and analyse its relationships with variables such as menopausal status, parity, uterine and cervical pathology, procedure length, and anxiety in patients undergoing ambulatory hysteroscopy (AH).

Design

Prospective observational study.

Setting

Dr DY Patil Medical Hospital and Research Centre, Dr.D.Y. Patil Vidyapeeth, Pimpri, Pune.

Patients

Seventy-five women.

Intervention

Ambulatory hysteroscopy(AH).

Methodology

AH was performed in seventy-five patients using vaginoscopic approach. At the end of the procedure, the intensity of pain was assessed using the visual analogue scale (VAS), from the score of 0 (no pain) to 10 (intolerable pain). The factors determining pain were assessed.

Results

Patients who underwent AH reported mild pain in 66% of cases, moderate pain in 22%, and severe pain in 12% of cases. The most frequent reason for referral was abnormal uterine bleeding (AUB).In the moderate pain group, the bivariate analysis was statistically significant for menopausal status (P values < 0.001), cervical pathology (< 0.001), and duration of procedure (0.001) and in multivariate analysis nulliparity (0.001) and menopausal status (0.001) were the significant determining factors.In severe pain group, the bivariate analysis was statistically significant for cervical pathology (P value = 0.001) and in multivariate analysis cervical pathology (0.003) and uterine pathology (0.002) were the significant determining factors.

Conclusion

Hysteroscopy is a safe, painless and a gold standard procedure. Pain experienced during AH was significantly influenced by cervical pathology. Gynaecologists in practise should receive training and start using AH to assess the endometrial cavity.

Comparison of fertility outcomes between oil‑based and water‑based contrast media during hysterosalpingography: A meta‑analysis

Water-based and oil-based contrast media are both widely used in clinical practice for patients receiving hysterosalpingography (HSG). However, minor controversy exists about whether the oil-based contrast medium has a superior fertility-enhancing effect during HSG. The present meta-analysis intended to comprehensively compare the fertility outcomes of patients receiving either an oil-based or a water-based contrast medium during HSG. Web of Science, PubMed, Excerpta Medica Database, Cochrane, China National Knowledge Infrastructure, Wanfang Data and China Science and Technology Journal Database were examined for literature comparing the fertility enhancement between oil-based and water-based contrast media during HSG up to November 10, 2022 and there was no cut off for studies published earlier than any given year. Data for clinical pregnancy, ongoing pregnancy, live birth, miscarriage and ectopic pregnancy were extracted and analyzed. A total of 11 studies with 2,462 patients receiving oil-based contrast medium and 2,830 patients receiving water-based contrast medium during HSG were included. Relative risks (RRs) and 95% confidence intervals (CIs) were presented for outcome assessment, and the random effects model was utilized for all analyses. Publication bias was analyzed using Egger's and Begg's tests. The results indicated that the rate of clinical pregnancy was increased using oil-based contrast medium compared with water-based contrast medium [relative risk (RR) (95% CI), 1.29 (1.07, 1.54); P=0.006]. In addition, the rate of ongoing pregnancy [RR (95% CI), 1.39 (1.22, 1.59); P#x003C;0.001] and live birth [RR (95% CI), 1.41 (1.07, 1.87); P=0.016] were also increased using oil-based contrast medium compared with water-based contrast medium. However, miscarriage [RR (95% CI), 1.06 (0.61, 1.86); P=0.833] and ectopic pregnancy [RR (95% CI), 0.66 (0.18, 2.36); P=0.518] were not affected by using oil-based or water-based contrast medium. Begg's test and Egger's test suggested that no publication bias of clinical pregnancy, ongoing pregnancy, live birth, miscarriage and ectopic pregnancy existed (all P>0.05), which indicated the stability of the present meta-analysis. In conclusion, the oil-based contrast medium enhances fertility outcomes compared with the water-based contrast medium in patients receiving HSG.

The SELFI Study: Iodine Excess and Thyroid Dysfunction in Women Undergoing Oil-Soluble Contrast Hysterosalpingography

CONTEXT

Hysterosalpingography (HSG) with oil-soluble contrast medium (OSCM) improves pregnancy rates. However, OSCM has high iodine content and long half-life, leading to potential iodine excess.

OBJECTIVE

This work aimed to determine the pattern of iodine excess after OSCM HSG and the effect on thyroid function.

METHODS

A prospective cohort study was conducted of 196 consecutive consenting eligible women without overt hypothyroidism or hyperthyroidism. All completed the study with compliance greater than 95%. Participants underwent OSCM HSG (Auckland, 2019-2021) with serial monitoring of thyrotropin (TSH), free thyroxine (FT4), and urine iodine concentration (UIC) for 24 weeks. The main outcome measure was the development of subclinical hypothyroidism (SCH), defined as a nonpregnant TSH greater than 4 mIU/L with normal FT4 (11-22 pmol/L) in those with normal baseline thyroid function.

RESULTS

Iodine excess (UIC ≥ 300 μg/L) was almost universal (98%) with UIC peaking usually by 4 weeks. There was marked iodine excess, with 90% and 17% of participants having UIC greater than or equal to 1000 μg/L and greater than 10 000 μg/L, respectively. Iodine excess was prolonged with 67% having a UIC greater than or equal to 1000 μg/L for at least 3 months. SCH developed in 38%; the majority (96%) were mild (TSH 4-10 mIU/L) and most developed SCH by week 4 (75%). Three participants met the current treatment guidelines (TSH > 10 mIU/L). Thyroxine treatment of mild SCH tended to improve pregnancy success (P = .063). Hyperthyroidism (TSH < 0.3 mIU/L) occurred in 9 participants (5%).

CONCLUSION

OSCM HSG resulted in marked and prolonged iodine excess. SCH occurred frequently with late-onset hyperthyroidism occasionally. Regular thyroid function tests are required for 6 months following this procedure.

The Prevalence of Fallopian Tube Occlusion in Women with Polycystic Ovary Syndrome Seems Similar to Non-Subfertile Women: A Retrospective Cohort Study

There are limited data on how non-infectious risk factors influence tubal patency in women with subfertility. With hormonal shifts influencing tubal secretions, it has been argued that subfertile women with polycystic ovary syndrome (PCOS) have lower tubal patency. In a retrospective study, 216 women, who underwent diagnostic evaluation for PCOS and infertility, were included. Fallopian tube patency was tested using HSG, HyCoSy, and laparoscopic chromopertubation in 171 (79.2%), 28 (13.0%), and 17 (7.9%), respectively. Bilateral patency was found in 193 women (89.4%), unilateral patency in 13 (6.0%) and bilateral occlusion in 10 (4.6%) patients. Women with PCOS phenotypes C (odds ratio, OR 0.179, 95% CI: 0.039–0.828) and D (OR 0.256, 95% CI: 0.069–0.947) demonstrated lower risks for Fallopian tube occlusion. In conclusion, our data suggest that about 5% of infertile women with PCOS also have bilateral tubal occlusion, which seems similar to the rate in non-subfertile women. With 11% of participants having unilateral or bilateral tubal occlusion, this should reassure women with PCOS that their hormonal challenges do not seem to increase their risk for tubal factor subfertility.

Perfecting hysterosalpingography: Limitations to the use of disposable balloon catheter and its solution

OBJECTIVE

To revive the use of the Kahn Uterine Trigger Cannula to overcome limitations associated with technical difficulties during hysterosalpingography (HSG) using the disposable balloon HSG catheter.

METHOD

A case series was conducted of 17 patients who encountered technically difficult or incomplete HSG study while using a disposable HSG balloon catheter, also leading to false-positive findings. Nine patients underwent a repeat HSG using a Kahn Uterine Trigger Cannula (Group 1). Eight patients underwent diagnostic laparoscopy and tubal perfusion testing using a Kahn Uterine Trigger Cannula (Group 2). The findings for each group in comparison to their initial HSG results using the disposable balloon HSG catheter are described.

RESULTS

All patients were noted to have patent fallopian tubes using a Kahn Uterine Trigger Cannula on repeat HSG or tubal perfusion testing during laparoscopy.

CONCLUSION

Providers who perform HSG studies should be familiar with the value of a Kahn Uterine Trigger Cannula when the traditional use of disposable HSG balloon catheter fails due to technical difficulty or incomplete study. The use of the Kahn Uterine Trigger Cannula in such situations can prevent inaccurate assessment and unnecessary interventions.

Protective effects of vitamin C and vitamin E against hysterosalpingography-induced epithelial degeneration and proliferation in rat endometrium

Aim

The aim of this study was to examine the protective effects of vitamin C (VC) and vitamin E (VE) against hysterosalpingography (HSG)-induced epithelial degeneration and proliferation in rat endometrium.

Materials and methods

A total of 28 female Wistar albino rats were randomized into four groups: G1 (n=7; abdomen was opened and closed), G2 (n=7; 0.1 mL Lipiodol [ethiodized oil] was administered to each uterine horn in conjunction with X-ray irradiation), G3 (n=7; 50 mg/kg of intraperitoneal (ip) VC was administered, followed by the administration of 0.1 mL of ethiodized oil into the uterine horns after 15 minutes), and G4 (n=7; 50 mg/kg of ip VE was administered, followed by the administration of 0.1 mL of ethiodized oil into the uterine horns after 15 minutes). After abdominal closure, rats in G2, G3 and G4 groups were exposed to whole-body X-irradiation three times with 2-minute intervals at a total dose of 15–20 mrad. Three hours after exposure, abdominal cavities of all the rats were reopened and uterine horns were removed. The right uterine horns were embedded into paraffin blocks after fixing in 10% formaldehyde for histopathological and immunohistochemical examination. Uterine horns on the other side were rapidly excised and stored at −80°C for the examination of expression of microRNAs (miRNAs) and oxidant, antioxidant, apoptotic and antiapoptotic gene expression using real-time polymerase chain reaction (RT-PCR) method.

Results

No differences were observed in terms of expression of miRNAs and oxidant, antioxidant, apoptotic and anti-apoptotic gene expression between the study groups. Congestion, epithelial degeneration and malondialdehyde immunoreactivity were significantly lower in G3 and G4 groups than in G2 group; no differences were observed between G1, G3 and G4 groups. Ki-67 immunoreactivity score was significantly higher in G2 group when compared with G1, G3 and G4 groups. Caspase-3 immunoreactivity was not statistically different between the groups.

Conclusion

VC and VE may confer cellular protection against radiation injury induced by HSG in endometrial epithelium.

Comparison of uterine and tubal pathology identified by transvaginal sonography, hysterosalpingography, and hysteroscopy in female patients with infertility

Background

The causes of female infertility are multifactorial and necessitate comprehensive evaluation including physical examination, hormonal testing, and imaging. Given the associated psychological and financial stress that imaging can cause, infertility patients benefit from a structured and streamlined evaluation. The goal of such a work up is to evaluate the uterus, endometrium, and fallopian tubes for anomalies or abnormalities potentially preventing normal conception. To date, the standard method for assessing these structures typically involves some combination of transvaginal sonography (TVS), hysterosalpingography (HSG), and hysteroscopy (HSC). The goal of this review is to compare the diagnostic accuracy of TVS, HSG, and HSC for diagnosing abnormalities in infertility patients to determine if all studies are necessary for pre-treatment evaluation.

Results

We identified infertility patients prior to initiation of assisted reproductive technology who had baseline TVS, HSG, and HSC within 180 days of each other. From medical record review, we compared frequencies of each finding between modalities. Of the 1274 patients who received a baseline TVS over 2 years, 327 had TVS and HSG within 180 days and 55 patients had TVS, HSG and HSC. Of the 327, TVS detected fibroids more often than HSG (74 vs. 5, p < .0001), and adenomyosis more often than HSG (7 vs. 2, p = .02). HSG detected tubal obstruction more often than TVS (56 vs. 8, p = .002). Four (1.2 %) patients had endometrial polyps on both HSG and TVS.

In the 55 patients with HSG, TVS, and HSC, HSC identified endometrial polyps more often than TVS (10 vs. 1, p = .0001) and HSG (10 vs. 2, p = .0007). TVS detected more fibroids than HSC (17 vs. 5, p < .0001). Tubal obstruction was identified more often by HSG than HSC (19 vs. 5, p < .0001).

Conclusions

TVS is superior for evaluation of myometrial pathology. HSG is superior for evaluation of tubal pathologies. Endometrial pathologies are best identified with HSC.

Hysterosalpingographic evaluation of primary and secondary infertility

Objective:

To determine the pathological patterns of fallopian tubes and uterus on hysterosalpingogrphy (HSG) examination in cases of infertility.

Methods:

Two years retrospective charts review of patients referred to our centre for HSG evaluation of infertility, from July 2008 to July 2010.

Results:

Four thousand one hundred eight hysterosalpingograms were carried out at our centre during the study period. Out of these, 1999 (48.6%) were primary infertility cases while the 2109 (51.3%) were of secondary infertility. Mean age of presentation for primary infertility was 30 years and 35 years for secondary infertility. Bilateral free peritoneal spill was noted in 60% of cases. Unilateral tubal blockage was present in 15% and bilateral tubal blockage in 10% of patients. Bilateral hydrosalpinx was present in 10% of patients and unilateral loculated spill was found in 5% of patients with primary infertility. Patients with uterine congenital anomalies were also evaluated and the frequency of bicornuate uterus was 4%, unicornuate uterus was 2% and uterine didelphys was 0.2%.

Conclusions:

Infertile patients who underwent HSG were mostly in older age group with secondary infertility being slightly more common emphasizing early work up and care. Most of the patients with primary infertility had normal HSG examination. To our knowledge this is the largest data for HSG to be presented from Pakistan.

Application of office hysteroscopy in gynaecological practice

Introduction: Nowadays minimally invasive techniques are a leading factors in medicine. According to this trend, hysteroscopy has been used in gynecology more and more frequently. Office hysteroscopy gives opportunity for a faster examination with less costs and strain for the patient. Aim: The aim of this work was to get familiar with the novel method. The author examined the level of pain during hysteroscopy performed for different indications with different types of instruments. In addition, the novel method invented for evaluating tubal patency was compared to the gold standard laparoscopy in 70 tubes. Method: Office hysteroscopy was performed in 400 cases for indications according to the traditional method. All examinations were performed in University of Debrecen, Department of Obstetrics and Gynecology in an outpatient setting. A 2.7 mm diameter optic with diagnostic or operative sheet was used. Hysteroscopies were scheduled between the 4th and 11th cycle day. For recording pain level VAS was used in 70 cases. Comparison of hysteroscopic evaluation of tubal patency to the laparoscopic method was studies in 70 cases. Results: It was found that office hysteroscopy can be performed in an outpatient setting, without anesthesia. Pain level showed no difference among subgroups (nulliparous, non-nulliparous, postmenopausal, diagnostic, operative) (mean±SD, 3.5±1.01; p=0.34). For the evaluation of tubal patency, office hysteroscopy showed 92.06% accuracy when compared to laparoscopy. Conclusions: Office hysteroscopy has several advantages over traditional method. This procedure is fast, it has less strain for the patient. The novel method, rather than traditional hysteroscopy, should be used in the work-up of infertility as well. Orv. Hetil., 2014, 155(40), 1589–1597.

Evaluation of pain during hysterosalpingography with the use of balloon catheter vs metal cannula

Our aim was to investigate the use of a balloon catheter device in comparison with metal cannula for hysterosalpingography (HSG) in terms of patient comfort. A total of 168 patients were randomised for HSG either with a balloon catheter (n = 83) or metal cannula (n = 85). Scores of pelvic pain during insertion of the devices, injection of the contrast medium and 1 h after the procedure were evaluated using the Wong Baker Faces Pain Rating Scale; complications and reinsertion rates were also noted. The pain scores were significantly lower in the balloon catheter group (p < 0.001). The reinsertion rate of metal cannula was higher (8.2% vs 2.4%) as well as the incidence of nausea being the most common short-term adverse effect (14.1% vs 1.2%) in the metal cannula group (p = 0.002). Performing HSG with a balloon catheter is advantageous for decreasing the pain and side-effects related to the procedure, when compared with the use of a metal cannula.

New opportunities for the evaluation of infertility

Incidence of infertility increased in the past years and it affects 15% of couples. Female and male factors are responsible in 40% and 40% of the cases, respectively, while factors present in both females and males can be found in 20% of cases. Female factors can be further divided into organic and functional ones. Function of the female organs can be evaluated in an outpatient setting by well-developed laboratory techniques but evaluation of the uterine cavity and inspection of the tubal patency have been traditionally carried out in one-day surgery. However, the latter can be performed under ambulatory setting with the use of office hysteroscopy, so that the use of operating theatre and staff costs can be saved. Using selective pertubation for the evaluation of tubal patency via office hysteroscopy can reduce cost further. The new methods in infertility workup which can be performed in ambulatory setting have several advantages for the patients. Orv. Hetil., 2013, 154, 1287–1290.

The use of a new gel foam for the evaluation of tubal patency

AIMS

To evaluate the feasibility and the reliability of hysterosalpingo-foam sonography (HyFoSy) using gel foam in the assessment of tubal patency.

METHODS

Nonrandomized, observational, academic and single-center study of 20 women being investigated because of subfertility and scheduled for a laparoscopy with chromopertubation. A detailed description of HyFoSy with a newly developed gel foam is given in the way it proved to be most efficient in our hands. The results of HyFoSy are compared to the data regarding tubal patency testing during laparoscopy by chromopertubation.

RESULTS

All 20 HyFoSy were technically successful. Four of the 40 tubes, 1 right tube and 3 left tubes, were not patent at HyFoSy (3 tubes with proximal block and 1 tube with distal block). There was a 100% agreement between tubal patency data according to HyFoSy testing and laparoscopic chromopertubation testing.

CONCLUSION

HyFoSy is both feasible and accurate in the diagnosis of tubal patency.

Comparison of warm and cold contrast media for hysterosalpingography: a prospective, randomized study

OBJECTIVE

To compare the use of warm medium and cold medium for alleviating pain and side effects during hysterosalpingography (HSG).

DESIGN

Prospective randomized study.

SETTING

University hospital.

PATIENT(S)

Two hundred infertile women who needed HSG were recruited from January 2010 to June 2011. The exclusion criteria were acute low reproductive duct infection, known hypersensitivity to iodine, genital bleeding, or malignancy.

INTERVENTION(S)

Subjects were randomized to undergo HSG using a medium prewarmed to 37°C or a medium at room temperature.

MAIN OUTCOME MEASURE(S)

Incidence of vasovagal episodes and visual analog scale (VAS) pain scores during HSG.

RESULT(S)

Patients' VAS pain scores during HSG were significantly lower in the warm media group initially but showed no statistical difference at 30 minutes after injection. Medium temperature showed a linear association with VAS score. The total number of vasovagal episodes was higher in the cold medium group.

CONCLUSION(S)

Warm contrast medium alleviates the pain associated with HSG and decreases the incidence of vasovagal episodes during HSG.

CLINICAL TRIALS REGISTRATION NUMBER

NCT01339338.

How members of the Society for Reproductive Endocrinology and Infertility and Society of Reproductive Surgeons evaluate, define, and manage hydrosalpinges

OBJECTIVE

To describe the management of hydrosalpinges among Society for Reproduction Endocrinology and Infertility (SREI)/Society of Reproductive Surgeons (SRS) members.

DESIGN

Cross-sectional survey of SREI/SRS members.

SETTING

Academic and private practice-based reproductive medicine physicians.

PARTICIPANT(S)

A total of 442 SREI and/or SRS members.

INTERVENTION(S)

Internet-based survey.

MAIN OUTCOME MEASURE(S)

To understand how respondents evaluate, define, and manage hydrosalpinges.

RESULT(S)

Of 1,070 SREI and SRS members surveyed, 442 responded to all items, for a 41% response rate. Respondents represented both academic and private practice settings, and differences existed in the evaluation and management of hydrosalpinges. More than one-half (57%) perform their own hysterosalpingograms (HSGs), and 54.5% involve radiologists in their interpretation of tubal disease. Most respondents thought that a clinically significant hydrosalpinx on HSG is one that is distally occluded (80.4%) or visible on ultrasound (60%). Approximately one in four respondents remove a unilateral hydrosalpinx before controlled ovarian hyperstimulation (COH)/intrauterine insemination (IUI) and clomiphene citrate (CC)/IUI (29.3% and 22.8%, respectively), and physicians in private practice were more likely to intervene (COH: risk ratio [RR] 1.81, 95% confidence interval [CI] 1.31-2.51; CC: RR 1.98, 95% CI 1.33-2.95). Although laparoscopic salpingectomy was the preferred method of surgical management, nearly one-half responded that hysteroscopic tubal occlusion should have a role as a primary method of intervention.

CONCLUSION(S)

SREI/SRS members define a "clinically significant hydrosalpinx" consistently, and actual practice among members reflects American Society for Reproductive Medicine/SRS recommendations, with variation attributed to individual patient needs. Additionally, one in four members intervene before other infertility treatments when there is a unilateral hydrosalpinx present.

Hysteroscopic tubal sterilization with Essure intratubal devices: A case-control prospective with inert local anesthesia or without anesthesia

OBJECTIVE

The contraceptive efficacy of hysteroscopic sterilization is well documented. The objective of this study was to compare procedure success, patient tolerance, and procedure time of Essure micro-insert hysteroscopic sterilization with or without anesthesia.

STUDY DESIGN

Between February 2002 and May 2005, one operator performed 140 sterilization procedures in this prospective study: the first 70 were performed using local anesthesia and the following 70 began without administration of anesthesia. Analysis was based on intention-to-treat.

RESULTS

The groups were comparable in their demographic characteristics. Successful bilateral micro-insert placement in the first 70 cases, utilizing paracervical block, was 82.8% and did not differ significantly from the next 70 cases, without anesthesia (91.4%). A similar number of patients in each group received additional anesthesia. Report of procedure pain did not differ significantly between the groups: 87.1% reported moderate or less pain with the paracervical block, compared with 91.4% in the group without anesthesia. Duration of surgery was significantly shorter without anesthesia: 11.2+/-6.3 min vs. 25.0+/-8.0 min (p<0.001).

CONCLUSIONS

Administration of anesthesia does not appear to affect the procedure completion success rate or patient tolerance of this hysteroscopic sterilization procedure.

Pain relief in hysterosalpingography

BACKGROUND

Hysterosalpingography (HSG) is a method of testing for tubal patency. Various pharmacological strategies are available that may reduce the pain during the procedure.

OBJECTIVES

To compare the effectiveness of different types of pharmacological interventions for pain relief in women undergoing hysterosalpingography (HSG) for investigation of subfertility.

SEARCH STRATEGY

This review has drawn on the search strategy developed for the Menstrual Disorders and Subfertility Group. In addition MEDLINE and EMBASE were searched up to July 2006.

SELECTION CRITERIA

All randomised controlled trials investigating the pharmacological interventions for pain relief during HSG were investigated.

DATA COLLECTION AND ANALYSIS

Data were extracted independently by the first two authors. Differences of opinion were registered and resolved by the third author. Results for each study were expressed as mean pain score and standard error of the mean with 95% confidence intervals.

MAIN RESULTS

The included eight trials reported on 570 women undergoing HSG.Overall, there was no evidence of benefit of using any analgesia compared with placebo for pain relief during the procedure (standard mean difference (SMD) of -0.05 (95%CI -0.25 to 0.14) or up to 29 minutes after HSG SMD 0.17, (95%CI -1.00 to 1.34)). Four RCTs involving 219 women found evidence of benefit with any analgesia in comparison to placebo for pain relief more than 30 minutes after HSG, with the SMD of -0.82(95%CI-1.18 to -0.45). One RCT involving 91 women compared the effectiveness of opioid analgesics versus non-opioid analgesics and reported no evidence of difference in pain relief at any stage of the procedure. One RCT involving 20 women compared the use of topical analgesia with a paracervical block, with analysis demonstrating more benefit to be gained from using topical analgesia during HSG, with the SMD of -2.03 (95%Cl-3.16 to -0.91).

AUTHORS' CONCLUSIONS

There is little evidence of benefit in terms of pain relief of any of the interventions considered in this study during or immediately after HSG. However, there is limited evidence of pain reduction 30 minutes after the procedure. Further RCTs should consider the role of non steroidal antiinflammatories (NSAIDs) and intrauterine anaesthetic during HSG.

Comparison of the effect of single-dose and multiple-dose methotrexate therapy on tubal patency

OBJECTIVE

To compare tubal patency by using hysterosalpingography (HSG) in women with unruptured ectopic tubal pregnancy who were treated with either single-dose or multiple-dose methotrexate (MTX) regimen.

DESIGN

A case series with a retrospective statistical analysis.

SETTING

Maternity and teaching hospital in Turkey.

PATIENT(S)

Sixty-one patients treated with MTX therapy for unruptured tubal ectopic pregnancy.

INTERVENTION(S)

Thirty-one patients received single-dose and 30 multiple-dose MTX treatment. The HSG was performed 4 to 6 months after treatment to assess tubal patency.

MAIN OUTCOME MEASURE(S)

Ipsilateral and contralateral tubal obstruction rates.

RESULT(S)

Free passage through the ipsilateral tube was observed in 17 of 30 cases (56.7%) after multiple-dose, and 26 of 31 cases (83.9%) after single-dose MTX therapy. Patency of the contralateral tube was higher after single-dose than multiple-dose MTX treatment, although the value was not statistically significant. Binary logistic regression analysis was used to evaluate the parameters of age, gravida, parity, initial titers of beta human chorionic gonadotropin, size of the adnexal mass, and MTX regimen and their correlation with the HSG results after the clinical treatment for unruptured ectopic pregnancy. Only the type of MTX regimen was found to be used as a predictor of ipsilateral tubal obstruction.

CONCLUSION(S)

In terms of ipsilateral tubal obstruction, multiple-dose MTX therapy appears to have a greater negative effect on tubal patency than single-dose therapy.