Assesing Tubal Factors in Infertility
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.
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.
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.
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.
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.
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.
General anaesthesia with endotracheal intubation
Uterine manipulator, catheterization.
Insertion of primary trocar & cannula, laparoscope.
Insertion of secondary trocar & cannula.
Systematic inspection of abdominal & pelvic organs:
a Panormic view
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
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:
Isthmus- tubercles, fusiform swelling-SIN
Hydrosalpinx, Thickened walls
Tuboovarian Relation, Fimbria ovarica
A diagnostic procedure can be converted into a therapeutic one.
Other peritoneal, ovarian factors can also be diagnosed.
Pneumoperitoneum, Gas embolism
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.
Echovist is used. Tubes patent if forward flow of dye, with turbulence at fimbrial end. False positive in large hydrosalpinx.
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%.
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.
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.
Frequently Asked Questions
Is it suggestible to go for hysterectomy at the age of 35 years for having 4.2 x 3.9 cm uterine wall fibroid?
complaint: heavy bleeding due to intramural anterior uterine wall fibroid compressing adjacent endometrial echo.
Discuss with gynecologist / suitable doctor, not with lay people on YA!
what is treatment of uterine fibroid?
my mother had two intramural fibroids of 15mm.12mm and 23mm.19mm ,in body region in anterior wall.an intramural fibroid of 12mm.10mm near right cornu. she had a recurrent leucorrhoea and with itching and burning.give me advice what i should do,
Uterine fibroids that have become a nuisance (or cause pain) can be surgically removed. Make an appointment with an OB GYN. They may refer her to a surgeon. It depends as to whether the doctor thinks its the right thing to do.
Tell your mother to insist that they get removed. So doctor think they know whats best without considering a patients quality of life.
can a fibroid get a biopsy? Is it necessary for me to have a hysterectomy?
This is a follow up question to my 1st question.
I am in menopause, and have bleeding (like a period, about once or twice a year) I was diagnose with leiomyomatous uterus with fibroid.The uterus is globular in shape and has irregular parenchymal echoes throughout. It measures 10.2×6.3×9.3 cm. There is a discrete anterior fundal intramural fibroid that measures 7.6×5.3×6.6 cm.
The normal appearing uniformly echogenic and thick endometrial stripe is identified measuring 4mm.
There is no sonographic evidence of free fluid in the cul-de-sac.
Help me understand exactly what this means???
by gerald/heather h Member since:
February 28, 2008
604 (Level 2)
your uteris is enlarged and has a cystlike growth the report says its probabaly not cancer- although they can never really tell that without actually biopsy, dont worry to much you r not dying
2 days ago
You r menopouse so don`t need uterus,i know surgery is invasive,but heavy bleeding=iron defeciency.i always prescribe to my patients PROGESTERON.they every day every 12hours 2 pills.
Fibroid questions, thanks?
Hi, I was wondering does anyone know what a anterior fundal subserosal fibroid is…where it is located? I don’t know what anteriior fundal means?
…also please: a right uterine body intramural fibroid, an anterior uterine body subserosal fibroid, a posterior uterine body intramural fibroid, thanks!
I was trying for ya! 🙂
When i typed it in it didn’t show me any links so i went to the one that it offered in the drop down part when you type it
subserosal anterior fundal fibroid Leiomyoma
If you go to this link after looking at the pics. go to the overview and it will explain everything. I could copy and paste but there is a lot of good info. you should read! Good Luck!
Fibroid during pregancy?
I am 30 yrs old and i have kid of 5 yrs old. i am pregnant now ( 35 days) and expericed light bleeding. After scanning doctor found out that i have Fibroid. the report says – “Retroflexed uterus with anterior wall intramural Subserous Fibroid measur 53 x 50 mm. Thickened endometrium-possiblity of early pregnancy”. Could anyone advice me is this a srious issue or not very serous at all. Doctor said not big issue but i am very much concerned abt this. Thanks
Hi and congratulations on your pregnancy!
I think as long as your doctor told you it’s not serious, you shouldn’t worry. The fibroid is anterior which means at the back side of the uterus, fibroids can be a nuissance if they are at a frontal position thus blocking the cervix. I also had the same kind of fibroid that measured 1cm x 1cm at the beginning of my pregnancy, it got 10cm x 10cm during my pregnancy because of the hormones and at my 6 week check up after labor it had already shrunk back to it’s original size. Don’t worry, fibroids are benign and very common!
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