The limited value of hysterosalpingography in assessing tubal status and fertility potential

Hysteroscopic evaluation of tubal peristaltic dysfunction in unexplained infertility

It has been realised that rhythmic peristalsis of the ostia and tubes can be observed during hysteroscopy. The aim of this study was to examine the presence of tubal peristaltic dysfunction in unexplained infertility (UI). Hysteroscopy was performed in 35 women with UI and in 37 healthy fertile women. Bilateral tubal peristalses were assessed hysteroscopically by the observation of methylene blue injection and its transport to the Fallopian tubes. Tubal patency was evaluated with laparoscopic chromopertubation. Two women in control group (6.67%) and eight women in UI group (30.77%) had no tubal peristalsis, at least one tube with normal tubal patency. The difference was statistically significant (p = .019). Tubal peristaltic dysfunction may be a hidden cause of subfertility in women with bilateral patent Fallopian tubes. There is a definite need for larger trials to identify tubal peristaltic dysfunction as a cause of UI. Impact statement What is already known on this subject? Unexplained infertility has no identified pathophysiologic basis. It has been realised that rhythmic peristalsis of the ostia and tubes can be observed during hysteroscopy. What do the results of this study add? Tubal peristaltic dysfunction was detected in two tubes (3.70%) in a control group and nine tubes (19.57%) in women with unexplained infertility, when the tubes were patent. The difference was statistically significant (p = .012). What are the implications of these findings for clinical practice and/or further research? In cases of bilateral patent Fallopian tubes such as in unexplained infertility, tubal peristaltic dysfunction may be a hidden additional cause of subfertility.

Pressure dynamics in the non-gravid uterus: intrauterine pressure cannot confirm tubal occlusion after non-surgical permanent contraception

OBJECTIVE

The objective was to determine if intrauterine pressure can distinguish bilateral tubal occlusion (BTO) from unilateral or bilateral tubal patency (TP) in women following a permanent contraception procedure.

STUDY DESIGN

We used a small inline pressure sensor to continuously monitor intrauterine pressure during hysterosalpingogram (HSG) in a cross-sectional study that enrolled women having HSGs for any indication. The primary outcome was the peak intrauterine pressure compared between women with BTO and TP as verified by HSG.

RESULTS

We enrolled 150 subjects, of which 111 (74.0%) provided usable pressure readings. Of these, 98/111 (88.3%) had TP, and 13 (11.7%) had BTO. There was no difference in peak intrauterine pressure for subjects with TP (mean 293.8±58.7 mmHg) compared to those with BTO (292.7±71.3 mmHg, p=.95). Among parous women, peak intrauterine pressure in subjects with BTO (311.9±78.0 mmHg) was higher but not significantly different from subjects with TP (282.7±49.2 mmHg, p=.20). In linear regression analysis, peak intrauterine pressure was not associated with age, body mass index, gravidity or having at least one prior live birth.

CONCLUSIONS

Measurement of peak intrauterine pressure does not distinguish between women with patent and blocked fallopian tubes. This approach would not be clinically useful to verify occlusion following permanent contraception.

IMPLICATIONS

Peak intrauterine pressure does not differ between women with patent and occluded fallopian tubes and cannot be used to confirm tubal occlusion after nonsurgical permanent contraception.

The history and current status of fallopian tube pressures - developing alternate methods for confirmation of tubal occlusion

Permanent contraception with hysteroscopic tubal ligation is an increasingly popular choice for women around the world. However, inconveniences associated with the required confirmation test for tubal occlusion can be prohibitive. As new methods of permanent contraception are being investigated, ways of making all aspects of the procedure more accessible and comfortable for women should be considered. Means of examining tubal patency in the infertility population, such as tubal perfusion pressures measured at the time of hysterosalpingogram (HSG), provide inspiration for alternative methods of tubal occlusion confirmation after contraception. Evaluation of intrauterine pressures measured by a manometer attached to an intrauterine balloon catheter could serve as a preliminary tool for verification of tubal occlusion; higher pressures would indicate tubal occlusion and lower pressures would indicate the need for confirmatory HSG. The development and validation of this technique is ongoing and could reduce overall costs and patient burdens associated with the current tubal occlusion confirmation procedure.

Proximal tubal disease: the place for tubal cannulation

Tubal disease is the cause of subfertility in approximately 30% of women, and 10-25% of these are due to proximal tubal obstruction. False-positive diagnosis of proximal tubal obstruction can be as high as 50%. A decrease in expertise in tubal microsurgery has resulted largely from the use of IVF as the treatment option for most causes of infertility and more specifically for tubal factor infertility. Selective salpingography and tubal cannulation have a unique role in the management of tubal infertility and should be offered to selected candidates prior to IVF. Tubal cannulation can be used effectively to restore patency in a proportion of cases of proximal tubal obstruction thus avoiding the need for expensive assisted reproductive techniques. This review examines the evidence supporting the effectiveness of tubal cannulation and aims to enhance awareness of the procedure as an option for the management of female subfertility secondary to isolated proximal tubal obstruction.

Physiology of Upward Transport in the Human Female Genital Tract

The uterus and fallopian tubes represent a functionally united peristaltic pump under the endocrine control of ipsilateral ovary. We have examined this function by using hysterosalpingoscintigraphy (HSS), recording of intrauterine pressure, electrohysterography, and Doppler sonography of the fallopian tubes. An uptake of labeled particles into the uterus was observed during the follicular and luteal phases of the cycle after application into the vagina. Transport into the oviducts, however, could only be demonstrated during the follicular phase. Furthermore, the predominant transport was into the tube ipsilateral to the ovary containing the dominant follicle. The pregnancy rate following spontaneous intercourse or insemination was higher in those women in whom ipsilateral transport could be demonstrated. The amount of material transported to the ipsilateral tube was increased after oxytocin administration, as demonstrated by radionuclide imaging and by Doppler sonography following instillation of ultrasound contrast medium. An increase in the basal tone and amplitude of contractions was observed after oxytocin administration. These results support the idea that the uterus and fallopian tubes act as a peristaltic pump, which increases transport of sperm into the oviduct ipsilateral to the ovary bearing the dominant follicle. Oxytocin appears to play a critical role in this peristaltic pump. A failure of the peristaltic mechanism is possibly responsible for infertility. We propose the term tubal transport disorder (TTD) as a nosological entity. Results from HSS could be a useful adjunct for choosing treatment modalities in patients with patent fallopian tubes suffering from infertility. These patients may be better served with in vitro fertilization (IVF).

The value of Chlamydia trachomatis-specific IgG antibody testing and hysterosalpingography for predicting tubal pathology and occurrence of pregnancy

We assessed two diagnostic methods, Chlamydia trachomatis-specific IgG and hysterosalpingography (HSG), as a screening test for the likelihood of tubal damage or occurrence of pregnancy before laparoscopy in 178 subfertile women who were randomly assigned to HSG followed by laparoscopy or immediate laparoscopy. The diagnostic accuracy and prognostic value of both C. trachomatis-specific IgG antibody testing and HSG are comparable but show poor performance.

Unexplained infertility: does it really exist?

Recent medical literature has quite extensively addressed the use of various terminologies within the field of reproductive medicine. This discussion has, however, so far overlooked the fact that one of the most frequently made diagnosis, so-called unexplained infertility (UI), not only didactically but, even more importantly, clinically, appears unsustainable as an independent diagnosis. The arguments in support of such a contention are manifold. The diagnosis of UI is highly subjective. It is dependent on which diagnostic tests have been performed (or have been omitted) and at what level of quality. Paradoxically, a diagnosis of UI will, therefore, be more often reached if the diagnostic workup is incomplete or of poor quality. Supported by evidence from the literature, the argument is made that the conditions, most frequently misdiagnosed as UI, are endometriosis, tubal infertility (especially distal and peritubal disease), premature ovarian ageing and immunological infertility. Because of the obvious unreliability of a diagnosis of UI and the widely reported unevenness in diagnostic criteria, we recommend the abandonment of UI as a formal infertility diagnosis. Better efforts to reach infertility diagnoses more accurately should improve the diagnostic accuracy of hitherto frequently missed diagnoses, which often falsely have led to a diagnosis of UI.

Progress in transvaginal hydrolaparoscopy

Reproductive performance is now more than ever determining the choice of treatment for each individual couple. The easy access to ART treatments, their financial benefits, and the relative high success rate per cycle are at the basis of a liberal referral to these treatments without an accurate diagnosis. The easy and comprehensive investigation by a transvaginal endoscopy as a first-line diagnostic procedure allows for an accurate diagnosis and the choice of the most appropriate treatment.

The role of GnRH analogue therapy in the management of proximal fallopian tube occlusion

Ten infertile women were diagnosed as having bilateral or unilateral proximal tubal occlusion in the presence of minimal to mild endometriosis. They were treated with GnRH analogue for 3 months. The aim was to assess the usefulness of therapy in reversing the tubal block. Diagnosis was based on hysterosalpingography, laparoscopy and hysteroscopy. At completion of therapy tubal patency was confirmed by hysterosalpingography. Three patients had bilateral cornual block whereas seven had unilateral. All patients had achieved bilateral tubal patency immediately following therapy. Four women achieved pregnancy during a follow-up of 3-20 months. Our results show that if early endometriosis causes proximal tubal occlusion (without fibrosis) GnRH analogues may be considered as the first line of treatment.

The role of selective salpingography and tubal catheterization in the management of the infertile couple

PURPOSE OF REVIEW

This review is intended to update the reader about recent developments in the field of selective salpingography and tubal catheterization, to offer an interpretation of the information presented and to suggest further research links.

RECENT FINDINGS

The measurement of tubal perfusion pressures at selective salpingography and tubal catheterization has offered a new dimension in the evaluation of the fallopian tube. A classification of infertile women based on tubal perfusion pressures is presented, and this is correlated with the possibility of spontaneous fertility, thus giving selective salpingography and tubal catheterization a prognostic profile in addition to diagnostic and therapeutic functions. Experience derived from the use of the technique in unselected infertile women (i.e. not with proximal tubal blockage) is presented. The use of selective tube catheterization for sterilization purposes joins the mainstream with the publication of the encouraging results of a multinational trial. The debate on the validity of the diagnosis of proximal tubal blockage is enriched by the suggestion that simply rotating the patient during hysterosalpingography will resolve most cases of the condition. The fertility gain by single-tube recanalization in women with unilateral proximal tubal blockage is given further support. The use of oil-based media for selective salpingography and tubal catheterization is discussed. A hypothesis on the pathophysiology of proximal tubal blockage is presented.

SUMMARY

The evidence clearly supports the use of selective salpingography and tubal catheterization for infertile women with proximal tubal blockage. The potential of the technique to play a wider role in the management of infertility is demonstrated by recent research.

Modification of the coaxial technique for selective salpingography with measurement of tubal perfusion pressures

This article describes the use of the fallopotorque catheter system for transcervical selective salpingography and tubal catheterization under fluoroscopic guidance for the diagnosis and treatment of obstruction of the proximal Fallopian tube. The technique of tubal perfusion pressure assessment during the procedure, using the same catheter system, is also described. The relative advantages of this method of selective salpingography and tubal catheterization are then discussed in the background of previously described techniques.

Diagnostic and therapeutic value of selective salpingography and tubal catheterization in an unselected infertile population

OBJECTIVE

To present diagnostic findings and fertility outcome after selective salpingography and tubal catheterization in an unselected infertile population.

DESIGN

Cohort study.

SETTING

Tertiary reproductive medicine unit.

PATIENT(S)

One hundred ten consecutive infertile women. No exclusion criteria were applied. Follow-up ranged from 16 to 54 months.

INTERVENTION(S)

Selective salpingography and tubal catheterization under fluoroscopic guidance as the primary test for the assessment of the fallopian tubes.

MAIN OUTCOME MEASURE(S)

Incidence of tubal disease at selective salpingography, therapeutic effectiveness of tubal catheterization, and fertility outcome after the procedure.

RESULT(S)

Tubal disease was present in 31.4% of the tubes examined. Of tubes proximally blocked at selective salpingography, 52.1% were found to be normal after tubal catheterization. Proximal tubal blockage (bilateral or unilateral) was detected in 34.8% of women. This was reduced to 5.5% after tubal catheterization. Spontaneous conceptions occurred in 21.9% of the women. In total, 36.2% conceived without IVF or ICSI.

CONCLUSION(S)

Selective salpingography and tubal catheterization can be useful as a primary tubal assessment tool in the investigation of infertility. In cases of proximal tubal blockage, an effective see-and-treat approach can be adopted. More research into the possible therapeutic benefits of the procedure is justified.

The learning curve of selective salpingography and tubal catheterization

OBJECTIVE

To determine the effect of increasing experience in fluoroscopically guided selective salpingography and tubal catheterization on radiation doses and screening times, thus establishing a learning curve for the procedure.

DESIGN

Retrospective case note analysis.

SETTING

IVF center of an academic teaching hospital.

PATIENTS

Three hundred sixty-six patients with infertility seen over 3.5 years.

INTERVENTION(S)

Fluoroscopically guided selective salpingography and tubal catheterization.

MAIN OUTCOME MEASURE(S)

Reductions in radiation doses and screening times for different categories of selective salpingography and tubal catheterization, expressed as percentage reductions during the study period and reductions per 10 procedures.

RESULT(S)

During the study period, The median dose of radiation decreased by 62.6%-71.9%, and the median screening time declined by 61.5%-78.5%. Reductions per 10 procedures were 2.5%-4.2% and 2.7%-5%, respectively.

CONCLUSION(S)

Significant reductions in radiation doses and screening times start early in a clinical team's practice of selective salpingography and tubal catheterization and continue even as trainees are added to the pool of operators.

Use of copper intrauterine devices and the risk of tubal infertility among nulligravid women

BACKGROUND

Previous studies of intrauterine devices (IUDs), many of which are no longer in use, suggested that they might cause tubal infertility. The concern that IUDs that contain copper--currently the most commonly used type--may increase the risk of infertility in nulligravid women has limited the use of this highly effective method of birth control.

METHODS

We conducted a case-control study of 1895 women recruited between 1997 and 1999. We enrolled 358 women with primary infertility who had tubal occlusion documented by hysterosalpingography, as well as 953 women with primary infertility who did not have tubal occlusion (infertile controls) and 584 primigravid women (pregnant controls). We collected information on the women's past use of contraceptives, including copper IUDs, previous sexual relationships, and history of genital tract infections. Each woman's blood was tested for antibodies to Chlamydia trachomatis. We used stratified analyses and logistic regression to assess the association between the previous use of a copper IUD and tubal occlusion.

RESULTS

In analyses involving the women with tubal occlusion and the infertile controls, the odds ratio for tubal occlusion associated with the previous use of a copper IUD was 1.0 (95 percent confidence interval, 0.6 to 1.7). When the primigravid women served as the controls, the corresponding odds ratio was 0.9 (95 percent confidence interval, 0.5 to 1.6). Tubal infertility was not associated with the duration of IUD use, the reason for the removal of the IUD, or the presence or absence of gynecologic problems related to its use. The presence of antibodies to chlamydia was associated with infertility.

CONCLUSIONS

The previous use of a copper IUD is not associated with an increased risk of tubal occlusion among nulligravid women whereas infection with C. trachomatis is.

Prospective randomized trial comparing the outcome and cost of in vitro fertilization with that of a traditional treatment algorithm as first-line therapy for couples with infertility

OBJECTIVE

To determine whether IVF or a standard infertility treatment algorithm results in better outcome and/or lower cost when used as first-line therapy for couples with infertility.

DESIGN

Prospective, randomized clinical study.

SETTING

University-affiliated infertility clinic.

PATIENT(S)

Couples with newly diagnosed infertility and no prior treatment.

INTERVENTION(S)

Couples were randomized to undergo either IVF (group 1, n = 46) or a standard infertility treatment algorithm (group 2, n = 50) as initial therapy for infertility.

MAIN OUTCOME MEASURE(S)

Pregnancy rates and costs per couple, per month of treatment, and per pregnancy.

RESULT(S)

Pregnancy rates were higher in group 2 than in group 1. Costs per couple were not statistically different, although a trend toward higher costs was apparent in group 1, reflected by a higher median cost per clinical pregnancy established and a higher cost per month of treatment. Whereas cost differences between the groups diminished over time, pregnancy rates remained the same.

CONCLUSION(S)

In vitro fertilization currently does not represent an appropriate first-line treatment option for couples with infertility. The use of a standard infertility treatment algorithm results in a higher pregnancy rate and lower cost and therefore should be the preferred treatment approach.

Transvaginal salpingoscopy: an office procedure for infertility investigation

OBJECTIVE

To evaluate the feasibility of salpingoscopy as an office procedure using transvaginal access to the pelvic cavity.

DESIGN

Descriptive study.

SETTING

Gynecology office.

PATIENT(S)

Infertile women with no obvious pelvic pathology.

INTERVENTION(S)

Transvaginal Veress needle puncture and peritoneal distension by saline.

MAIN OUTCOME MEASUREMENT(S)

Visualization of distal tubal segment. cannulation, and salpingoscopy.

RESULT(S)

The fimbriae were visualized in all patients. Cannulation of the distal tubal segment was achieved without manipulation of the tube in 20% before ovulation and 55% in the early luteal phase.

CONCLUSION(S)

Transvaginal fimbrioscopy and salpingoscopy can be performed as an office procedure in patients without obvious pelvic pathology. In combination with hydrolaparoscopy and dye hydrotubation, the technique provides comprehensive screening of the tuboovarian structures in the early stage of infertility investigation.

Is hysterosalpingography an important tool in predicting fertility outcome?

OBJECTIVE

To determine the prognostic significance of hysterosalpingography (HSG) for fertility outcome.

DESIGN

Retrospective cohort study.

SETTING

Infertility department of an academic hospital.

PATIENT(S)

Consecutive patients undergoing HSG for subfertility between May 1985 and November 1987.

INTERVENTION(S)

Hysterosalpingography.

MAIN OUTCOME MEASURE(S)

Follow-up ended when pregnancy or tubal surgery occurred or at the day of last contact. Kaplan-Meier curves for the occurrence of spontaneous intrauterine pregnancy (IUP) were constructed for a normal HSG, a HSG with a one-sided abnormality, and a HSG with a two-sided abnormality. Fecundity rate ratios were calculated to express the association between HSG findings and the occurrence of spontaneous IUP.

RESULT(S)

Of 359 patients that were analyzed, 231 (64%) showed no tubal pathology on HSG, 67 (19%) had a one-sided tubal pathology, and 61 (17%) had a two-sided tubal pathology. The adjusted fecundity rate ratios were 0.81 (95% confidence interval 0.47 to 1.4) for a one-sided pathology and 0.30 (95% confidence interval 0.13 to 0.71) for a two-sided pathology. Correction for informative censoring and sensitivity analysis did not alter these results.

CONCLUSION(S)

One-sided tubal pathology detected on HSG has limited prognostic significance, whereas two-sided tubal pathology detected on HSG reduces fertility prospects considerably.

Observer variability in the diagnosis and management of the hysterosalpingogram

OBJECTIVE

To determine the reproducibility of hysterosalpingogram (HSG) interpretation and clinical management recommendations among trained observers.

DESIGN

Fifty HSG films were distributed to five fertility practitioners with a mean of 20 years clinical experience. Each observer evaluated components of uterine and tubal status and provided clinical recommendations for hysteroscopy and laparoscopy.

SETTING

University hospital-affiliated reproductive endocrine practice.

INTERVENTION(S)

None MAIN OUTCOME MEASURE(s): The level of agreement among observers for each uterine and tubal category as determined by the kappa(kappa) statistic. Determinants of clinical recommendation for further diagnostic studies were assessed.

RESULT(S)

The level of agreement between observers as determined by kappa ranged from 0.645 in the hydrosalpinx category, indicating fair reliability, to 0.111 for pelvic adhesions, indicating poor reliability. The composite kappa for uterine status was 0.345 whereas the composite kappa for tubal status was 0.430. Agreement among observers concerning management showed marginal reproducibility with a kappa of 0.261. Overall, more than one abnormality of either the cavity or the fallopian tubes led to a diagnostic recommendation for further workup in > or = 90% of cases.

CONCLUSION(S)

In a group of five experienced clinicians, there was considerable variability in the interpretation as well as the clinical management of the HSG. Physicians caring for infertile couples should be aware of this discrepancy and should, if possible, review carefully both the original films as well as the report of the attending radiologist in formulating their diagnostic evaluation and management plan.

What is the radiation exposure to patients during a gynecoradiologic procedure?

OBJECTIVE

To evaluate the risk of radiation exposure to infertility patients during a gynecoradiologic procedure.

DESIGN

Retrospective clinical study.

SETTING

Medical school-affiliated infertility center.

PATIENT(S)

Three hundred thirty-two consecutive infertility patients undergoing a gynecoradiologic procedure.

INTERVENTION(S)

Patients underwent a gynecoradiologic procedure as part of their infertility workup and the fluoroscopic exposure time was analyzed.

MAIN OUTCOME MEASURE(S)

The fluoroscopic exposure (rad time) during gynecoradiologic procedures, including hysterosalpingogram (HSG), selective salpingography, tubal catheterization, and others.

RESULT(S)

The rad time (mean +/- SD) was 63 +/- 54 seconds for normal HSG (n = 94, range 17 to 404 seconds), 100 +/- 61 seconds for abnormal HSG (n = 53, range 28 to 272 seconds), 111 +/- 57 seconds for unilateral selective salpingography (n = 36, range 31 to 324 seconds), 142 +/- 74 seconds for bilateral selective salpingography (n = 87, range 40 to 430 seconds), 176 +/- 77 seconds for unilateral tubal catheterization (n = 27, range 70 to 342 seconds), and 239 +/- 82 seconds for bilateral tubal catheterization (n = 30, range 110 to 381 seconds). Five patients had other procedures, such as lysis of intrauterine adhesions (n = 2) and resection of an uterine septum (n = 3), for which the rad time was in a range of 180 to 300 seconds.

CONCLUSION(S)

The radiation exposure of patients during a gynecoradiologic procedure, using previously described standard techniques, is well within established margins of safety.

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.