Anterior Intramural Fibroid

Assesing Tubal Factors in Infertility

by Dr. Jyoti Mishra- Gynaec. Endoscopist & Infertility specialist

Having a child of her own is the most intense desire & right of every woman. Inability to conceive can devastate her emotionally, socially & often financially. Tubal pathologies constitute >25% of all causes of infertility.
Various diagnostic techniques have evolved over time. Rubin first described the insufflation technique of testing tubal patency in 1920. As the results of this technique could not be documented, hysterosalingography (HSG) evolved in 1940s. It was since late 1960 that laparoscopy with chromopertubation became a widely used procedure. As ultrasonography made tremendous progress, hystersalpingo contrast sonography (HyCoSy) came into use. The first successful endoscopic evaluation of the lumen of tubes from intramural to fimbrial end was made in 1990, by the introduction of salpingoscopy & falloposcopy.
The evolution of so many techniques itself indicates that no single method is self-sufficient.Most of the time they complement each other.

Rubin’s Tubal Insufflation Test

Done in the postmenstrual phase, this test involves pushing of air via a canulla fitted in the cervix. A stethoscope placed in the suprapubic region auscultates the sound produced by air, escaping through the fimbrial end. Though this is an easy, inexpensive, OPD procedure which needs no special training, the test has several drawbacks. It cannot diagnose unilateral blocks, can be false positive in large hydrosalpinx.
In addition to this there is a definite risk of air embolism and the results are very subjective.

Hysterosalpingography (HSG)

This test precedes Laparoscopy in most of the patients. The test is performed between days 8 & 10 of LMP for the following reasons
a No risk of pregnancy.
a Endometrium is at its thinnest, hence better visibility of ostia.
a Done in secretary phase, thick endometrial fragments may get dislodged & block the ostia.
a No risk of pushing the menstrual blood into the peritoneal cavity.
a No exposure to X-Rays at the time of ovulation.

Media
Oil soluble media whose benefit was better resolution, are obsolete now, as they may cause severe inflammatory reaction and oil embolism..
Now we use water-soluble contrast media like urograffin 76%. Still better are non-ionic media such as echovist, which although expensive, markedly reduce the chance of allergic reaction.

Technique
The technique involves positioning of a screw tipped canulla into the cervical canal. About 3ml of medium is pushed to outline the uterine cavity & tubes & the first film is obtained. After pushing in more dye, a second film is obtained. Usually 2 films are sufficient to make a diagnosis. If spill is not seen, giving head low & taking a delayed film helps in most cases. Postoperatively analgesics & antibiotic cover is given.

Interpretation of results
A normal uterus is seen as a triangular cavity with slightly concave lateral walls. Tubes show slight tortuosity. Rugae which may be seen in a good quality film indicate a good prognosis in terms of achieving pregnancy.

Abnormalities of cornua
Uni/bilateral blocks may be due to true organic lesions or they may be false positive results of conual spasm, mucus plug, debris, or pressure of fibroids. To prevent spasm, a spasmolytic oral tablet may be given 1 hour prior, in addition to explaining the procedure to the patient.

Other Pathologies
There may be evidence of SIN( Salpingitis Isthmica Nodosa), tubercles, intraluminal adhesions (leapordskin appearance) or hydrosalpinx. Adhesions can lead to fimbrial phimosis. Loculation of dye around distal end suggests peritubal adhesions.

This is a cheap OPD procedure which gives adequate information about intraluminal features of tubes. It exactly pinpoints the site of block and is often therapeutic.
The drawbacks include risk of allergy to the medium, flaring up of PID, pain and radiation exposure.The test is contraindicated in presence of active PID.

Laparoscopy :
Diagnostic laparoscopy is indicated in any situation where inspection of pelvic organs will help in further management. Often it will be converted into operative laparoscopy.

Technique:
General anaesthesia with endotracheal intubation
Patient position.
Uterine manipulator, catheterization.
Pneumoperitoneum, confirmation.
Insertion of primary trocar & cannula, laparoscope.
Insertion of secondary trocar & cannula.
Systematic inspection of abdominal & pelvic organs:
a Panormic view
a Uterus
a Anterior cul-de-sac
a Rt. fallopian tube
a Rt. ovary
a Rt. uterosacral ligament & POD
a Lt. side of pelvis
a Upper abdomen

Chromopertubation
Dilute (1:20) methylene blue solution is injected through a cervical cannula. Patency of each tube should be established individually.

Tubal Pathologies seen frequently on Laparoscopy:
Blocks
Peritubal adhesions
Isthmus- tubercles, fusiform swelling-SIN
Hydrosalpinx, Thickened walls
Fimbrial phymosis
Tuboovarian Relation, Fimbria ovarica

Benefits:
A diagnostic procedure can be converted into a therapeutic one.
Other peritoneal, ovarian factors can also be diagnosed.

Complications:
Anaesthesia related
Procedure related
Pneumoperitoneum, Gas embolism
Bladder injury
Bowel injury
Vessel injury
Perforation of uterus
Others; costly, training needed

Sonosalpingography -Sion Test

Normal TVS cannot show tubes, which are isoechoic. Injecting saline through the cervical canal & through the tubes will surround them with fluid & enable them to be visualized. A non-invasive test, which can show tubal patency, any gross pathology & perifimbrial adhesions. By seeing fluid in POD, uni/bilateral patency is not known.

Hysterosalpingo-contrast-sonography (HyCoSy)
Echovist is used. Tubes patent if forward flow of dye, with turbulence at fimbrial end. False positive in large hydrosalpinx.

Selective Salpingography

Under fluoroscopic control, a radio-opaque catheter is passed through the cervical canal & then wedged into the ostium. Medium is injected. Tubal Spasm , flimsy blocks are overcome. If resistance, a guide wire is passed further. Medium is pushed again .In 80% of patients, tubal spasms, & flimsy organic blocks are treated. Complication- false passage.

Hysteroscopic transcervical cannulation

Indicated in Proximal tubal block.
Needs operative sheath, Catheter, Obturator, Guide wire & simultaneous laparoscopy.
Anatomy of intramural part of tube should be known. Perforation common in intramural& ampullary parts. Patency rate-75-80%, Pregnancy rate 40%.

Tuboscopy
Salpingoscopy: Visualization of endosalpinx through the fimbrial end. After a diagnostic laparoscopy is done, fimbria are stabilized by an atraumatic grasper. A 3mm endoscope is advanced along with a continuous flow of saline, which keeps tube distended. This can show upto isthmo-ampullary junction. Normal mucosa is pink, velvety with rugosities.

Falloposcopy: Seeing the endosalpinx through the cornual end. Hysteroscopic tubal catheterization is done. Guide wire is passed beyond the fimbria & catheter over it. Guide wire is withdrawn & a 0.5 mm endoscope is passed. Visualization is done in a retrograde manner.
Tests based on transportation of particles

Ascending: Human albumin particles labeled with technitium99 are placed on cervix. Gamma camera measures radioactivity at fimbria.

Descending: Starch is placed in POD by culdocentesis. If detected in cervical mucus, confirms patency of tubes.
Is a pain free test, but does not tell about uni/bilateral blocks.

Conclusion

Some of these tests have become obsolete & some are still in a nascent stage to get widely accepted. To hold the test of time a preliminary HSG followed later, if needed, by a hystero-laparoscopy with chromopertubation would be the ideal way of assessing tubal factors. Still better would be to add tuboscopy to the armamentarium.