[Radiologic versus ultrasound fallopian tube imaging. Painfulness of the examination and diagnostic reliability of hysterosalpingography and hysterosalpingo-contrast-ultrasonography with echovist 200]

Imaging techniques for assessment of tubal status

Fallopian tubes make a vital portal for transfer of gametes and embryo. Tubal factor is responsible for infertility in 25-35% of cases. Hysterosalpingography (HSG) has been used to evaluate the uterine cavity and the tubal status since decades. It uses iodinated contrast and X-rays and is painful and inconvenient for patient. Laparoscopy is considered to be the gold standard for tubal evaluation, but is an operative procedure and needs anesthesia. Though ultrasound is a modality of choice for assessment of uterus and ovaries, it does not allow assessment of the fallopian tube unless there is any fluid surrounding it or inside the lumen. This fluid interface can be created artificially by introducing saline in the uterine cavity and fallopian tubes and scanning simultaneously. The procedure is named Saline infusion HSG. Saline infusion sonohysterosalpingography (SIS) can be done with B mode US and Doppler. SIS can demonstrate a patent tube but if blocked, the site of block cannot be demonstrated. Ultrasound contrast agents can be used for tubal assessment using contrast mode on the scanners. This procedure is known as hystero-contrast sonography (HyCoSy). This actually shows the passage of hyperechoic contrast agent through tubal lumen and delineates it and locates the site of block. Using the volume ultrasound may even make the demonstration of tubal status and fimbriae better. Results of HyCoSy have been found to correlate well with laparoscopic findings, which are a gold standard. It is recommended by National Institute for Health and Clinical Excellence as a primary investigation for tubal assessment in patients without any positive history of tubal damage and also can replace a second look laparoscopy.

Could antispasmodic drug reduce pain during hysterosalpingo-contrast sonography (HyCoSy) in infertile patients? A randomized double-blind clinical trial

OBJECTIVE

To assess the effectiveness of an antispasmodic drug, hyoscine-N-butylbromide, in reducing pain during hysterosalpingo-contrast sonography (HyCoSy).

METHODS

Eight hundred and sixteen patients undergoing HyCoSy were randomized to receive 10 mg hyoscine-N-butylbromide (n = 408) or placebo (n = 408) per os, 30 min before the procedure, in a double-blind randomized controlled trial. Immediately after the procedure, the patient was asked to describe any pain experienced in comparison with pain usually suffered during the menstrual cycle, and the operator assigned a pain score between 0 and 4 as follows: 0 (no reaction or discomfort), 1 (slight pain, less than menstrual pain), 2 (moderate pain, exceeding menstrual cramps but no vasovagal reaction), 3 (vasovagal reaction or pain requiring observation in a hospital) and 4 (vasovagal reaction or pain requiring resuscitation). The primary aim was to estimate the difference in pain score, considered as a categorical value, between the active arm of the trial and the control group. The secondary aim was to evaluate if pain is related to tubal patency.

RESULTS

There was no difference in pain score between the hyoscine-N-butylbromide group and the placebo group (P = 0.807). There was a negative correlation between pain and tubal patency, regardless of treatment group (P < 0.0001).

CONCLUSIONS

Administration of 10 mg antispasmodic drug hyoscine-N-butylbromide does not reduce pain in patients undergoing HyCoSy.

Comparison of the pain experienced by infertile women undergoing hysterosalpingo contrast sonography or radiographic hysterosalpingography

OBJECTIVE

To evaluate the pain and cause of pain experienced by women undergoing hysterosalpingography (HSG) and contrast hysterosalpingo sonography (HyCoSy) with air in a saline solution for the assessment of uterine and tubal patency.

METHOD

In this prospective study, 121 infertile women undergoing these 2 procedures measured the pain incurred using a digital/analog scale (1-10). We looked for correlations between pain level and variables pertaining to the procedures. Vagal effects and their persistence were also recorded.

RESULTS

The pain was less during HSG (median, 5) than during HyCoSy (median, 7). It was greater than menstrual pain for 38.8% of participants during HSG and for 70.5% of participants during HyCoSy. There was no correlation between pain and difficult catheter passage, degree of tubal obstruction, volume of contrast medium injected, or presence of IgG antibodies to Chlamydia when these variables were studied for HyCoSy alone. However, the strong correlation between pain score and volume of contrast medium injected during each procedure seems to explain the significantly higher pain levels during HyCoSy (P<0.001). In 65.3% and 57.8% of participants, respectively, the pain disappeared immediately after the HSG or HyCoSy. Only mild vagal effects were recorded following both procedures, in 0.8% of participants after HSG and 2.5% of participants after HyCoSy.

CONCLUSION

Hysterosalpingo contrast sonography is similar to HSG regarding rapidity of pain disappearance, and infrequency and moderation of vagal effects, but the level of pain is slightly higher, probably due to the greater volume of medium injected.

Evidence-based diagnosis and management of tubal factor infertility

PURPOSE OF REVIEW

The investigation for potential tubal disease is an essential step in the work-up of infertility. This review article provides an evidence-based overview of the diagnosis and management of tubal factor infertility.

RECENT FINDINGS

While laparoscopic chromopertubation remains the gold standard in the diagnosis of tubal disease and hysterosalpingography is still widely used, newer modalities offer some advantages. Sonohysterography with the use of contrast medium is superior to hysterosalpingography and comparable to laparoscopic chromotubation in diagnosing tubal blockage. Chlamydia serology is the most cost-effective and least invasive diagnostic test for tubal disease, and it is comparable to, if not better than, hysterosalpingography. Depending on the nature and degree of tubal dysfunction as well as the age and ovarian reserve of the patient, various treatments for tubal infertility are available. For proximal tubal obstruction, transcervical tubal cannulation with tubal flushing is a reasonable first approach. Surgical techniques for tubal repair, such as salpingostomy or fimbrioplasty for distal tubal obstruction, can provide good results. Still, tubal factor remains a major indication for in-vitro fertilization and embryo transfer, which bypasses the tubal problem altogether. In certain situations, such as the presence of hydrosalpinx, prophylactic surgery can be used in conjunction with in-vitro fertilization and embryo transfer.

SUMMARY

As with infertility in general, the diagnosis and management of tubal infertility should be tailored to the individual patient. Future studies should help to further clarify the role of the various diagnostic tests and therapeutic approaches for tubal infertility.

Minimally invasive exploration of the female reproductive tract in infertility

Classically, invasive and non-invasive tests are performed to evaluate the causes of infertility. Transvaginal hydrolaparoscopy (THL) allows the exploration of the pelvic structures with a mini-endoscope, using a vaginal needle-guided trocar introduction technique and saline as a distension medium. A first study on 349 patients demonstrated the feasibility of the procedure and gave a high patient satisfaction. Access to the pouch of Douglas was achieved in 330 patients (94.5%) under local anaesthesia and in an ambulatory environment. The mean pain score measured on a visual analogue scale of 10 was 2.7, comparable to the score of mini-hysteroscopy only and significantly lower than the scores of hysterosalpingography with either metal cannula or balloon catheter. A total of 96% of the patients agreed to repeat the procedure under the same circumstances if required. The diagnostic accuracy of the technique was demonstrated in a prospective study, in which two independent endoscopists explored 10 patients with both THL and standard laparoscopy. The inter-observer agreement for ovarian adhesions was 75% for standard laparoscopy and 90% for THL. In addition, in patients with mild endometriosis, more peri-ovarian adhesions were detected with THL than with standard laparoscopy. A multinational survey to evaluate the risk and outcome of bowel injury during THL registered 24 (0.65%) cases in 3667 procedures. In all cases, the diagnosis was made immediately and the treatment was conservative without complications.

HyCoSy--as good as claimed?

Hysterosalpingo contrast sonography (HyCoSy) has been compared favourably in the literature with hysterosalpingography (HSG). It does not require ionizing radiation and demonstrates the uterus and ovaries. HyCoSy is reported as being a safe, well tolerated, quick and easy investigation of Fallopian tube patency. Over a 1-year period HyCoSy was performed by two operators on 118 consecutive women who were thought likely to have patent Fallopian tubes. The examinations were graded using a local scale to assess discomfort and were correlated with tubal patency. HSG was performed on 116 patients by the same operators and discomfort recorded. 15 patients underwent both examinations. The degree of pain or reaction was graded 0 (no pain) to 4 (maximum) according to a locally devised scale. Costs of the two examinations were estimated. 89 patients examined by HyCoSy were graded 0-2. However, 23 had severe protracted pain and/or vasovagal reactions with bradycardia and hypotension. Of these, seven required resuscitation owing to prolonged symptoms, requiring treatment with atropine. 19 of the 23 had bilaterally patent Fallopian tubes. Where subsequent HSG was performed, tubal occlusion was confirmed in 8 of 15 women. Other pathologies were noted in 29 of the HyCoSy patients and there were six technical failures. During the same period no severe adverse reactions occurred in 116 patients having HSG performed by the same operators. Three of the HSG examinations were technically unsuccessful. Discomfort following HyCoSy was much greater than that reported previously. Possible mechanisms are discussed but it does not appear to be related to tubal occlusion. Diagnostic accuracy, costs and discomfort compare unfavourably with HSG.