Abstract
Fallopian tubes make vital portals for the transfer of gametes and the early conceptus, and were named after Gabrielis Fallopius (Italy, 1423–1562) who first described the structures. Reinier De Graaf (1641–1673), however, was the first to understand the function of the Fallopian tubes.
1 Introduction
Fallopian tubes make vital portals for the transfer of gametes and the early conceptus, and were named after Gabrielis Fallopius (Italy, 1423–1562) who first described the structures. Reinier De Graaf (1641–1673), however, was the first to understand the function of the Fallopian tubes. The Fallopian tubes were described as
The trumpets or tubes … are two in number either side of the uterus. Where they originate, at the fundus, they are quite narrow… As they pass through the substance of the uterus and for some distance outside they proceed in a straight course, gradually widening. When, however, they have attained an appreciable size, they curve perceptibly more and more and proceed, bending from side to side or twisting like vine-tendrils. In this way they get half way round the “testicles” at a distance from them.
It is estimated that one in six couples requires investigation and treatment of subfertility, and tubal factors account for about 14% of causes of infertility in women. The prevalence tends to be higher in India due to higher rates of unrecognised pelvic inflammatory disease and tuberculosis.
Alongside the investigation of tubal patency, the results of semen analysis and investigations to assess ovulation should be performed. Tubal blockage can involve either the proximal part (closest to the uterus), mid part or distal part (furthest from the uterus). The Fallopian tube is a dynamic and complex structure, and hence, it is important to understand that demonstration of tubal patency does not always correspond to tubal function. The combination of coordinated neuromuscular activity, cilial action and endocrine secretions are required for successful tubal function.
Compromised tubal damage can occur with any external or internal injury, hindering the normal transport of gametes. Causes of tubal disease include pelvic infection, endometriosis and previous abdominal surgery. Endometriosis, the presence of endometrial tissue occurring outside the uterine cavity causing peritoneal lesions, accounts for about 5% of female infertility.
An ‘ideal’ or ‘gold standard’ test for tubal patency would be sensitive (i.e. all true positives would be identified by a positive test result and a negative test result would rule out disease in all those without the disease) and specific (i.e. the test result would only be positive in women with the disease). There are many tests available in the assessment of tubal disease and this reflects the fact that there is no ‘ideal’ test; none yield perfect accuracy and predictive values. They are also subject to operator expertise and potential intraoperative or technical complications.
2 Methods of Assessing Fallopian Tube Patency
A comparison of the various tubal assessment methods is shown in Table 8.1.
| HSG | HyCoSy | Lap and dye | Falloposcopy | Salpingoscopy | CAT | |
|---|---|---|---|---|---|---|
| Gold standard – diagnostic and therapeutic | – | – | + | – | – | – |
| Widely available | + | – | + | – | – | – |
| Assess tubal patency | + | + | + | + | + | – |
| Assess tubal function | – | – | – | – | – | – |
| Learning curve | + | ++ | + | +++ | +++ | + |
| Cost | ++ | ++ | +++ | ++ | ++ | + |
| Requires general anaesthetics | – | – | + | +/- | +/- | – |
| Outpatient procedure | + | + | _ | +/- | +/- | + |
| Blood test | – | – | – | – | – | + |
| Ultrasound scan performed at the same time | – | + | – | – | – | – |
| Research only | – | – | – | + | + | +/- |
| Ascending Infection risk | + | + | + | + | + | – |
| Procedure associated discomfort | ++ | ++ | + | ++ | ++ | – |
2.1 Hysterosalpingography (HSG)
HSG is the radiographic evaluation of the uterus and Fallopian tubes; its main use is in assessing the whole tube, condition of the tubal lumen and site of block. It is useful in diagnosing endometrial and Mullerian abnormalities including congenital anomalies, leiomyomas, synechiae, polyps, tubal occlusion, salpingitis isthmica nodosum (also known as diverticulosis of the Fallopian tube), hydrosalpinx and peritubal adhesions.
An analgesic (e.g. NSAIDs) or antispasmodic medication may be given to the patient prior to the procedure to reduce lower abdominal cramping and chances of tubal spasm. HSG is usually performed in the early follicular phase; this avoids the possibility of pregnancy and facilitates maximum uterine visibility as the endometrium is thin in the proliferative phase. Patients are tested for chlamydia prior to undergoing HSG as pelvic infection is a contraindication; if required, prophylactic antibiotics are given.
HSG is performed with the patient in the lithotomy position on the fluoroscopy table and aseptic precautions apply. A speculum exposes the cervix, and the vagina and cervix are cleaned using antiseptic solution. A tenaculum is used to grasp the anterior lip of the cervix, an HSG cannula is introduced and stabilised in the cervix. A very small amount of radiopaque contrast solution, warmed to body temperature, is introduced through the cannula into the uterus. The filling of the solution in the uterine cavity and passage through the Fallopian tubes, including its spill from the fimbrial end is observed and captured in the form of X-rays. Clear intraperitoneal spill must be demonstrated. If spill is not demonstrated, rotating the patient from side to side or gentle abdominal pressure may increase likelihood of intraperitoneal dispersion. It has been suggested that the use of intravenous smooth muscle relaxants such as terbutaline and prostaglandins may help to relieve spasm. Figure 8.1 shows a normal HSG.
Fig. 8.1 Normal Hysterosalpingogram showing cannulation of contrast, which fills the Fallopian tubes. There is free spillage of contrast from the patent tubes.
Both proximal and distal tubal blockage can be recognised in HSG. Proximal tubal blockage caused by salpingitis isthmica nodosa (SIN), also referred to as tubal diverticulosis, has a characteristic honeycomb appearance. There are multiple small diverticular collections of contrast protruding from the lumen into the wall of the isthmic portion of the Fallopian tube (Figure 8.2). White flecks of contrast material often persist at the site of suspected blockage even in the post drainage X-ray. In tuberculous salpingitis, there may be a similar calcification appearance; however, calcification of the uterus, ovaries and lymph nodes can also be present. The aetiology of SIN is unknown, but it is probably a post-infectious reaction. Distally obstructed tubes might have small club-shaped ends on HSG, representing the presence of hydrosalpinges. However, in most cases, distal tubal obstruction is detected by proximal filling with dye, but no spillage of dye into the peritoneum.
HSG is widely used for tubal evaluation in women presenting with subfertility and is a fairly accurate and easy way of identifying proximal tubal damage. The whole procedure is very quick, taking about 3–5 minutes. It is generally very safe and fairly cheap.
The risks associated with HSG include potential reaction to the iodine containing radiopaque contrast. The most common complication is cramping at the time of contrast injection. Premedication, minimising cervical trauma and a consideration to the emotional state of the patient may increase the tolerance of the procedure. Pelvic infection is a complication affecting 1–3% of women having HSG; prophylactic antibiotics should be given to those with risk factors for pelvic infection detected in the clinical history or examination. The procedure also exposes women to radiation, and as it is done in a radiology setting, the patient and operator may feel uncomfortable or embarrassed. Retrospective review of the images is only possible if the procedure is recorded in real time.
A meta-analysis of three studies gave pooled estimates of HSG sensitivity as 0.65 (95% CI 0.50–0.78) and specificity as 0.83 (95% CI 0.77–0.88) [1]. Because of HSG’s low sensitivity, it is of limited use for detecting tubal obstruction, but its high specificity makes it a useful test for ruling out tubal obstruction. A high false positive rate is a problem; the diagnosis of peritoneal adhesions based on HSG findings are unreliable and proximal tubal ‘occlusions’ may be due to transient tubal spasms (20% of cases), amorphous debris collections or minimal adhesions (40% of cases) [2]. Results from one review suggested that HSG may be used as a screening test for couples with no history of pelvic infection and if the test is abnormal, laparoscopic assessment should be performed [3].
The potential therapeutic effect of tubal flushing at HSG has been under speculation for more than 50 years. Historically, a variety of agents have been used to ‘flush’ the Fallopian tubes. At HSG, a water-soluble contrast media (WSCM) or oil-soluble contrast media (OSCM) is used. A Cochrane review collected evidence from 13 randomised controlled trials [4]. This review showed that women having OSCM tubal flushing had a higher rate of pregnancy and live birth compared to women with no intervention; evidence suggests that for subfertile women, the chance of an ongoing pregnancy will be increased from 17% without intervention to between 29 to 55% with intervention. Despite positive effects on pregnancy rates, extravasation of OSCM into the pelvic cavity has potentially serious adverse effects such as lipogranuloma formation, which occurs if there is accumulation of OSCM within a blocked tube leading to a chronic inflammatory reaction, or anaphylaxis if the OSCM enters blood vessels or lymphatics. There were no trials assessing tubal flushing with WSCM versus no treatment or WSCM versus OSCM. Further randomised controlled trials are needed to evaluate the potential therapeutic effects of tubal flushing with water-soluble media. There was no evidence of difference in the rates of adverse events between any of these interventions.
WSCM allows better imaging of the tubal mucosal folds and ampullary rugae (internal tube architecture) compared to OSCM. OSCM has a high viscosity which leads to slow filling of the tubes; often, this requires a late film after 24 hours. However, sometimes, this ‘late’ film can offer additional information, such as adhesions after slow peritoneal spillage. It is slower to resorb and remains in the pelvic cavity for longer. OSCM may be associated with less pain probably because there is less irritation of the peritoneum. WSCM is cheaper than OSCM.
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