Diagnosis of cornual obstruction by transcervical fallopian tube cannulation

Interstitial fallopian tube obstruction (IFTO) occurs in 15% of hysterosalpingograms (HSG) performed for infertility. Conventional HSG or laparoscopy may not differentiate cornual spasm or other temporary cause from true obstruction. We used transcervical cannulation of the proximal oviduct with a 3-F Teflon catheter and flexible guidewire 0.018 inch (0.043 cm) in diameter under hysteroscopic or fluoroscopic guidance to evaluate IFTO in 28 patients. Fluoroscopic catheterization techniques with selective salpingography demonstrated patency in 84% of obstructed tubes. Hysteroscopic cannulation with direct visualization by laparoscopy or laparotomy was successful in 92%. In one patient, perforation of the isthmus occurred without sequelae. Transcervical coaxial cannulation of the proximal oviduct is an effective method for evaluating cornual obstruction.     

Investigation of the uterine cavity and fallopian tubes using three-dimensional saline sonohysterosalpingography.

OBJECTIVE: To compare three-dimensional saline sonohysterosalpingography (SHSG) to X-ray hysterosalpingography (HSG) for the evaluation of the uterine cavity and fallopian tubes. PATIENT POPULATION: Fifteen infertile women on whom X-ray HSG had been performed within 1 year prior to this study. METHOD: Fifteen infertile women underwent three-dimensional power Doppler examination of the uterus and fallopian tubes with three-dimensional SHSG during the follicular phase. Distension was achieved using sterile saline injected through a 5 French HSG catheter. Peritoneal accumulation of free fluid surrounding the ovary and tube was required for a diagnosis of a patent tube. Fluid accumulation in the cul-de-sac without visualization of the tubes was considered consistent with at least one tube being patent. RESULTS: three-dimensional saline SHSG was completed in 14 patients. One patient had cervical stenosis and the procedure could not be performed. No significant intrauterine pathology was identified by either X-ray HSG or sonography. Three-dimensional saline SHSG made false positive diagnoses of tubal occlusion in four out of seven fallopian tubes (57%). The sensitivity and specificity for detecting tubal occlusion was 75 and 83%, respectively, with a positive predictive value of 40% and negative predictive value of 95%. Detection of fallopian tube architecture was not possible with three-dimensional saline SHSG in any patient. Simultaneous use of three-dimensional Doppler did not clearly identify the flow of saline through the fallopian tubes. CONCLUSIONS: Transvaginal three-dimensional saline SHSG provides good visualization of the uterine cavity and myometrial walls in three orthogonal planes. However, it does not diagnose tubal occlusion or depict architecture of the fallopian tube as accurately as X-ray HSG. Although we were able to visualize the distal fallopian tube and fimbria with real-time imaging, we were not able to satisfactorily image the proximal tube with three-dimensional power Doppler. This technique may be reserved as an initial screening test to evaluate the uterine cavity and test patency. Patients at high risk for tubal disease by history or with suspected tubal occlusion on three-dimensional saline SHSG should be evaluated by either X-ray HSG or laparoscopy with chromopertubation. Further improvements of three-dimensional technology and contrast materials will, it is hoped, make this method comparable to X-ray HSG.     

Hysterosalpingography in the preoperative evaluation of tubal anastomosis candidates

The value of the hysterosalpingogram (HSG) in the investigation of women requesting reversal of tubal sterilization has never been established. Accordingly, we reviewed the preoperative HSGs performed on 54 women and the surgical findings of these and 27 additional patients who underwent laparoscopy and/or laparotomy for tubal anastomosis. The observation of interstitial, isthmic, and ampullary obstruction by HSG correctly correlated with surgical findings in 12%, 94%, and 69% of cases, respectively. The decision to perform an anastomosis was made in 14 of 17 (82.4%) tubes with interstitial obstruction, 45 of 51 (88.2%) tubes with isthmic occlusion, and 26 of 36 (72.2%) tubes with ampullary occlusion. When distal tubal occlusion was demonstrated by HSG (36/104 tubes, 34.6%), 10 had no repairable ampullary segments. The site of tubal occlusion on HSG was not predictive of a repairable tube. We conclude that the routine HSG is not warranted in the preoperative evaluation of candidates for tubal anastomosis.     

Hysteroscopic selective salpingography.

OBJECTIVE: To evaluate the effectiveness of hysteroscopic selective salpingography (HSS) as a method for diagnosing the tubal proximal occlusion shown by hysterosalpingography (HSG). DESIGN: Prospective study. SETTING: Outpatient Department of Obstetrics and Gynecology, Social Insurance Saitama Chuo Hospital, Urawa, Japan. PATIENT(S): A total of 572 infertile women underwent HSG. Forty-seven of 50 women with unilateral or bilateral proximal tubal occlusion demonstrated by HSG underwent HSS. INTERVENTION(S): Hysteroscopic selective salpingography was performed for the diagnosis of tubal occlusion in cases in which the proximal tubal occlusion was shown by HSG. MAIN OUTCOME MEASURE(S): Number of patients who underwent HSS and pregnancy rate after HSS. RESULT(S): Twenty-seven (79.4%) of 34 patients with unilateral occlusion diagnosed by HSG were shown to have normal patency by HSS. Of 12 women with bilaterally normal patent tubes confirmed by HSS, 8 (66.7%) achieved normal pregnancies within 1 year. Seven (53.8%) of 13 patients with bilateral occlusion found by HSG were shown to have normally patent tubes by HSS. CONCLUSION: The simple method of HSS was clinically effective for evaluating the presence of proximal tubal occlusion.     

选择性输卵管造影和再通术1006例随访分析

目的 探讨选择性输卵管造影(SSG)和输卵管再通术(FTR)治疗不孕症的临床疗效和实用价值。方法 对1006例经子宫输卵管造影(HSG)检查诊断为输卵管不同部位、不同程度梗阻的不孕症患者,用自制同轴导管行SSG和FTR,统计1年内的妊娠率和输卵管通畅度治疗的有效率,并结合术前、术后HSG及术中输卵管动态观察结果进行综合分析。结果 输卵管腔完全梗阻315例,共601条输卵管(部分患者曾因各种原因行一侧输卵管切除,完全梗阻组),528条获管腔再通,再通率87．9%．其中35.4％(187条)仅行SSG即获再通,64．6％(341条)在SSG同时行FTR获再通。术后1年内妊娠率为39．9％,异位妊娠发生率2,7％,管腔再闭塞率1．8%;未获再通者中4例为结核性输卵管炎,3例结节性输卵管炎,9例阻塞于峡部,末端呈杵状改变,6例阻塞于壶腹部和伞部,10例输卵管纤维化。管腔不全梗阻691例(不全梗阻组),其中输卵管通而欠畅105例,通而不畅357例,通而极不畅229例,行SSG术后共发现65例术前HSG结果对伞部粘连的诊断有误。1年内妊娠率随访显示,输卵管通而欠畅者为53.6％,通而不畅者为45.7%,通而极不畅者为26,8％,异位妊娠发生率1．4％。术后1年行HSG复查,治疗有效率(管腔通畅度好转)86．9％。两组中经SSG诊断伞端粘连明显或周围包裹形成者共有16例,同时进行了腹腔镜治疗,其手术符合率97．1％。结论 SSG和FTR对输卵管性不孕具有诊断和治疗双重作用,且简便、安全,疗效可靠,值得临床推广。     

Digital road mapping image--a novel fluoroscopic real-time guide for selective transcervical catheterization in the treatment of proximal tubal obstruction.

Ten infertile women 20 to 40 years of age, with a standard HSG diagnosis of unilateral proximal tubal obstruction, underwent a transvaginal catheterization and recanalization of the fallopian tubes. To set a fluoroscopic real-time guidance technique for improving the results of transvaginal catheterization and recanalization of the fallopian tubes and to increase its marginal safety, catheterization was performed under digital road mapping guidance. Transcervical catheterization resulted in an immediate patency of the obstructed tube in all 10 women. Three women conceived 2 to 3 months after the procedure. The improved catheterization technique enables good results in the diagnosis and treatment of proximal tubal obstructions.     

Comparison of assessing the patency of the Fallopian tubes during laparoscopy and during hysterosalpingography on television in infertile women with endometriosis

OBJECTIVES: Sterility become nowadays not only medical, but as well socio-economic problem. One of its major causes is endometriosis. Recurrent adnexitis--one of the most common symptoms of endometriosis might be the cause of fallopian tubes occlusion. The hysterosalpingography (HSG) can be helpful to diagnose this tubal pathology. DESIGN: To compare the assessment of fallopian tubes patency during HSG with the results of laparoscopy in infertile women with endometriosis. MATERIAL AND METHODS: 331 women with endometriosis who were diagnosed during laparoscopy examination between 1998-2002 due to sterility. The presence of endometriosis was confirmed during laparoscopy. In each patient the control of the patency of both fallopian tubes was performed. These data were confirmed with those from HSG performed during follicular phase on the television path. The absence of the contrast passage through fallopian tubes as well as the only trace contrast passage into abdominal cavity were classified as tubal obstruction. RESULTS: In patients during the HSG physiological uterine shape and size in 91.3%, the bicornis uterus in 6.6%, and the unicornis uterus in 2.1% were observed. During laparoscopy we diagnosed the physiological uterine shape and size in 88.8%, the bicornis uterus in 8.2%, and the unicornis uterus in 3.0%. The diagnostic compatibility of these both examinations was 90.6%. In HSG the correct anatomical course of both fallopian tubes without occlusions in 51.7%, the only unilateral patency in 36.7%, and bilateral occlusions in 11.6% were found. During laparoscopy we diagnosed the anatomical course of both fallopian tubes without occlusions in 36.7%, the only unilateral patency in 33.3%, and bilateral occlusions in 30.0%. The diagnostic compatibility of these both examinations was 49.6% for both fallopian tubes, and 34.2% for the only one fallopian tube. In 16.2% both results were incompatible. CONCLUSIONS: The incorrect contrast passage through the fallopian tubes and its increased pressure during HSG in women with the characteristic history and clinical symptoms can suggest endometriosis. In these cases laparoscopy is necessary as the additional examination in the diagnostics of fallopian tubes patency, but the only objective method in diagnosis of endometriosis.     

A novel use of vaginoscopic office hysteroscopy for prediction of tubal patency and peristalsis among infertile women: a preliminary study

The objective of this study is to test whether vaginoscopic office hysteroscopy (OH) can predict proximal tubal patency as compared with hysterosalpingography (HSG) and diagnostic laparoscopy (DL) and concomitantly tubal peristalsis in infertile women. This is a prospective cross sectional study. The setting is in the endoscopy unit of a tertiary hospital. A total of 85 infertile patients scheduled for laparoscopy are used as the sample of this study. The method used is the vaginoscopic OH in the outpatient infertility clinic to assess proximal tubal patency. The patency results will be compared to HSG and DL reports. Diagnostic accuracy of OH alone or in combination with HSG for assessment of proximal tubal patency in comparison to HSG and DL is the mean outcome measure. Office hysteroscopic bubble suction test was feasible in 78 cases (91.7 %). Patent tubes were diagnosed in 91 and 88.5, 92.3 and 91, and 93.6 and 93.6 % using OH, HSG, and DL on right and left sides, respectively. The percentage of agreement between OH and DL was 78 % while it was 84 % between HSG and DL regarding tubal patency testing. Diagnostic indices of OH were very close to those of HSG. Adding OH to HSG did not improve diagnostic accuracy. Positive osteal peristalsis was reported in 32 cases (42 %) and 28 cases (36.8 %) for right and left ostea, respectively. Hysteroscopic bubble suction test is a good initial screening test for tubal patency nearly comparable to HSG and DL. It should be attempted in every case of OH prior to referral for more invasive HSG or laparoscopic chromopertubation test. Hysteroscopic documentation of peristalsis of the proximal part of the tube is an interesting cofinding but requires more confirmatory studies.     

A new approach to hysteroscopic cannulation of the fallopian tube

Hysteroscopic cannulation of the fallopian tube has become an essential part of the treatment of interstitial fallopian tube obstruction. This report describes the use of a flexible instrument that can be introduced through a rigid hysteroscope for the purpose of hysteroscopic tubal cannulation.     

Selective fallopian tube cannulation: initial experience in an infertile population

We have studied a group of 19 patients presenting with proximal tubal occlusion. Seventy-three percent (22/30) of tubes attempted were successfully cannulated. Sixty-two percent (5/8) of tubes remained patent in limited follow-up at 3 to 6 months. We conclude that selective fallopian tube cannulation may provide an alternative to microsurgical tubal anastomosis in selected patients.     

Fallopian tube patency using color Doppler

OBJECTIVE: To evaluate a new test for tubal patency using color Doppler ultrasonography in infertile women. METHOD: Between October 1991 and March 1992 results of our new technique were compared with those of hysterosalpingography (HSG) and laparoscopy in 27 cases. The new technique of evaluating tubal patency using color Doppler has been described in detail. RESULT: There was 92.59% agreement, i.e. patency or occlusion of the fallopian tubes when the results of our test were compared with those of hysterosalpingography and laparoscopic chromopertubation. The HSG and laparoscopy findings were in 100% agreement. CONCLUSION: Color Doppler ultrasonography is now a very important investigation in the assessment of fallopian tube patency and compares favorably with the existing ‘gold standards’ namely HSG and laparoscopic chromopertubation.     

Effect of Premedication Hyoscine-N-Butylbromide before Hysterosalpingography for Diagnosis of Proximal Tubal Obstruction in Infertile Women: A Randomized Double-Blind Controlled Trial

Study Objective

To assess the effect of hyoscine-N-butylbromide (HBB) as premedication on the rate of proximal tubal obstruction during hysterosalpingography (HSG).

A randomized, prospective, controlled study of laparoscopic dye studies and selective salpingography as diagnostic tests of fallopian tube patency

OBJECTIVE: To determine and compare the relative merits of laparoscopic dye (LD) studies and selective salpingography (SS) as diagnostic tests of fallopian tube patency. DESIGN: Randomized, prospective, controlled study. SETTING: University-associated assisted reproduction unit. PATIENT(S): Two hundred seventy-eight women undergoing investigation of infertility. INTERVENTION(S): Allocation to the performance of either LD studies followed by SS or SS followed by LD studies conducted sequentially under general anesthesia. MAIN OUTCOME MEASURE(S): Detection of fallopian tube occlusion, including the site of obstruction and evidence of peritubal or pelvic disease. RESULT(S): When diagnosis was compared by the first test used, 16 (11.9%) of 135 patients had proximal tubal occlusion at LD studies versus 5 (3.6%) of 138 at SS. Twelve (5.6%) of 122 patients had distal tubal occlusion at LD studies versus 14 (10.5%) of 133 at SS. Fifteen (11.1%) of 135 patients had peritubal disease at LD studies versus 3 (2.52%) of 119 at SS. When diagnosis was compared by individual tubes, the results were similar. Among patients who had proximal occlusion and otherwise normal tubes by both methods, endometriosis was present in 72.2%. CONCLUSION(S): Selective salpingography is a better diagnostic test of proximal tubal occlusion than are LD studies. There is no difference between SS and LD studies as a diagnostic test of distal tubal occlusion. Laparoscopic dye studies are a better diagnostic test for assessing peritubal disease than is SS. There may be an association between endometriosis and proximal tubal occlusion. Selective salpingography and LD studies are complementary investigations of the fallopian tubes.     

Tubal factors in infertility.

Proximal, distal, and peritubal damage can be caused by a number of pathologic processes such as inflammation, endometriosis, and surgical trauma. The diagnosis of tubal occlusion relies primarily on hysterosalpingography, hysteroscopy, and laparoscopy. A number of innovative diagnostic procedures such as sonosalpingography, falloposcopy, and selective salpingography improved our ability to accurately diagnose tubal pathology. The long-standing surgical corrective approach to treat tubal occlusion has been replaced by noninvasive methods in selected patients with endoluminal damage. The development of noninvasive transcervical catheter methods to recanalize proximally obstructed fallopian tubes also allows access to the fallopian tubes for deposition of gametes and embryos and improves the diagnosis and treatment of tubal pregnancies. Transcervical tubal cannulation reduces the risks, costs, and morbidity of surgical procedures. The diverse applications of the transcervical tubal approach may also replace surgical invasive procedures in assisted reproductive procedures. Although radical changes have occurred in the treatment of proximal tubal occlusion, the repair of distal and peritubal damage frequently yields disappointing results, and will probably remain the challenge of the 1990s.     

Hysteroscopic hydrotubation for treatment of tubal blockage.

In order to increase the effectiveness of hydrotubation, a plastic cannula was inserted into the fallopian tube under hysteroscopic control. Fifty women with tubal blockage confirmed by HSG were selected for treatment. Hydrotubation solution consisted of hydrocortisone (20 mg), gentamicin (160,000 IU) and procaine (80 mg) in 20 ml distilled water. Repeat HSG was performed. After three treatments, tubal patency (one or both tubes) was achieved in 20 women (40%), and seven pregnancies resulted within 1-18 months. Hysteroscopic hydrotubation may be an alternative treatment for tubal blockage.     

A second hysterosalpingography reduces the use of selective technique for treatment of a proximal tubal obstruction

OBJECTIVE: To assess whether a second hysterosalpingography (HSG) can permit tubal patency, reducing the use of selective salpingography in patients with proximal tubal obstruction. DESIGN: Prospective study.Setting: University hospital. PATIENT(s): The study population consisted of 360 infertile women. INTERVENTION(s): In patients with unilateral or bilateral proximal tubal obstruction, a second HSG was performed after about 1 month. In those cases with persistent obstruction, an immediate selective salpingography and tubal catheterization were performed. MAIN OUTCOME MEASURE(s): Tubal opacification. RESULT(s): Forty patients underwent a second HSG procedure for proximal tubal occlusion. Among these, 24 achieved bilateral tubal patency. Thus, repetition of a conventional HSG after 1 month avoided unnecessary salpingography in 60% of patients. CONCLUSION(s): In infertile women with proximal tubal obstruction, we believe it is best to perform a second HSG. HSG is easy to carry out and subjects patients to a lower dosage of radiation and fewer risks than selective salpingography. The latter technique should be reserved for unsuccessful cases.     

Pregnancy following tubocornual anastomosis

We have reviewed the pregnancy rate and outcome of 25 patients who underwent tubocornual anastomosis for correction of proximal tubal occlusion at Yale-New Haven Hospital between 1977 and 1981. Tubal occlusion was the result of previous tubal sterilization in 17 patients (11 laparoscopic electrocautery and 6 tubal ligation) and previous tubal infection in 8. Fourteen of the patients conceived (56%). Viable pregnancy was achieved in nine patients (36%) and tubal pregnancy in three (12%). No significant difference in pregnancy rates was found between patients with diseased cornua and those previously sterilized by either electrocautery or tubal ligation. Tubal length of greater than or equal to 4 cm following corrective surgery as compared with less than or equal to 4 cm did not influence pregnancy rates. The patients with the shorter oviducts had a higher rate of early pregnancy wastage. All three tubal pregnancies occurred in patients with reoccluded fallopian tubes as demonstrated by a hysterosalpingogram. We conclude that tubocornual anastomosis still remains the treatment of choice for patients with proximal tubal obstruction.     

High incidence of tubal dysfunction is determined by laparoscopy in cases with positive<Emphasis Type="Italic">Chlamydia trachomatis</Emphasis> antibody despite negative finding in prior hysterosalpingography

Aim:  Hysterosalpingography (HSG) is one of the most commonly used methods in order to evaluate the condition of fallopian tubes in infertility clinics. In the present paper, we retrospectively compared the findings of HSG and laparoscopy to elucidate the relationship between tubal dysfunction and background factors, such as Chlamydia trachomatis infection, endometriosis and previous surgery.
Methods:  We retrospectively reviewed clinical records of 314 patients who were examined by both HSG and laparoscopy between 1996 and 2001 in the Department of Obstetrics and Gynecology, University of Tokyo.
Results:  When HSG findings were evaluated in reference to those of laparoscopy, sensitivity and specificity for tubal patency were 0.63 and 0.79, respectively, whereas those for peri-tubal adhesion were 0.65 and 0.61, respectively. We compared the percentage of existence of background factors between the patients who were diagnosed as normal by both HSG and laparoscopy (Group L[+]) and those whose fallopian tubes were observed as patent by HSG, but were not patent by chromopertubation under laparoscopy (Group L[–]). The percentage of patients with positive chlamydial antibodies in Group L(–) (42.9%, 15/35) was significantly higher than that of patients with positive chlamydial antibodies in Group L(+) (22.8%, 44/193, P  < 0.05).
Conclusions:  These finding suggested that even if HSG showed normally patent tubes in a patient with positive Chlamydia trachomatis antibodies, the possibility of tubal occulusion still remains high and further examination by laparoscopy is recommended. (Reprod Med Biol 2007; 6 : 39–43)     

Transcervical fallopian tube recanalization: a safe and effective therapy for patients with proximal tubal obstruction.

Over a 13-month period, 14 patients with proximal tubal obstruction underwent transcervical fallopian tube recanalization under fluoroscopic guidance in an outpatient setting at the hospital of the University of Pennsylvania. Twenty-one of 24 attempted tubal dilations (87.5%) were successful, as demonstrated by tubal opacification and contrast spillage into the peritoneal cavity at the conclusion of the procedure. Four intrauterine pregnancies, and no ectopic pregnancies, have followed the recanalization. One pregnancy ended in an early miscarriage, one patient delivered a healthy term female, and two pregnancies are ongoing at greater than twenty weeks' gestation. Two procedure-related complications occurred: in one patient, the isthmic segment of a fallopian tube was perforated, but healed without incident, and another patient experienced a low-grade fever, which resolved with p.o. antibiotics. We therefore conclude that fallopian tube recanalization is a well-tolerated, safe, and effective procedure for the treatment of proximal tubal occlusion.