SELECTIVE HYSTEROSALPINGOGRAPHY

AND TUBAL RECANALIZATION : WHEN TO

DO

N.BOUCHNAK, L.BENFARHAT, A.MANAMANI, N.DALI, L.HENDAOUI

Radiology department, Mongi Slim Hospital, LaMarsa,Tunisia

OBJECTIVE

A review of the radiology department’s experience with selective salpingography and tubal recanalization comparing to the litterature features and to the others techniques in the management of infertility caused by proximal tubal blockage

DESIGN and SETTING

• Retrospective study November 1991- July 2010

• 170 patients

• Primary or secondary female hypofertility for more than 1 year of unprotected intercourse

• Uni or bilateral proximal tubal blockage (PTB) confirmed by HSG or laparoscopy and dye test

TECHNIQUE

• Outpatient basis

• Follicular phase of menstrual cycle (6th-10th day)

• Five day course of Antibiotic prophylaxis by Doxycyclin 200mg/day

• Fluoroscopic guidance

• Spasmolytic agent (Natispray)

• Hysterosalpingography device

Fallopotorque (Cook,Schemoul –Zorn,Angiotech) selective salpingography(SS)- tubal catheterism (TC) catheter system

Fallopian Recanalization Set Angiotech

HSG PTB Selective salpingography (SS) 5F and 3F SS catheter placed into tubal ostium + Dye

injection

obstruction overcome persisting obstruction =

Tubal contour outlined tubal recanalization (TR)

with contrast agent gentle push of a guidewire advanced

through the 3F catheter in the isthmic portion

Success Failure

success criteria• Short –term success = tubal

patency patency of intramural and isthmic

fallopian tube +/- visualization of distal tubal anatomy and spillage of contrast medium in peritoneal cavity

• Mid-term success = spontaneous conception rate after 1 to 6 months’ follow up

RESULTS • 170 Patients • 24 – 46 years ( average 31.74 Y) • Hypofertility duration : 1 - 19 years primary hypofertility : 75 p secondary hypofertiltiy : 95p• Past record Therapeutic abortion n = 11 Myomectomy n = 9

Pelvic adhesions n = 8 Tuboplasty n = 3 Spontaneous abortion n = 7 Endometriosis n = 4

Uterin deformity n = 3 Chlamydia genital infection n = 4 Extrauterine pregnancy n = 3

• 170 patients : 269 fallopian tube with PTB

• 176 SS-TR1/ SHORT TERM SUCCESS RATE Selective success 49.4% (133 tubes) salpingography 269 T failure 50.6% (136 t )

Tubal success 58.3% (91t)recanalization 156 T failure 41.7% (65t)

SUCCES OF SS-TR 83.3%

Various findings after SS-TR

Peritubal adhesions n = 39

Hydrosalpinx n = 12 Distal occlusion n = 19 Endometriosis n = 10 Phimosis n = 10Salpingitis isthmica nodosa n

= 3Tubal synechiae n = 4

Failure of SS-TR in 65 cases due to

Peritubal adhesions n = 2

Obstructif hydrosalpinx n = 10

Tubal synechiae n = 4 Endometriosis n = 3 Infectious sequela n = 2 Impassable obstruction n =

44 intramural n = 13 isthmic n = 10 distal n = 21

Complications• Vascular opacification 6.4 % • Fallopian tube perforation 3.5% (with no

clinical manifestation )• Infection /Uterin perforation : 0%

2/ MID-TERM FOLLOW-UPOnly 88 patients had a 6 months or more follow up

• Intra uterine pregnancies : 39.7% (35/88 patients)

• Ectopic pregnancies : 0%

Case 1Mrs M… 37 Y Primary hypofertility of 6 yearsLaparoscopy and dye test : bilateral tubal blockage

a b c

d e

a : bilateral PTBb:left tubal recanalization by guide wire c:repeat selective intratubal salpingogram showing a patent tube d-e : the right fallopian tube could not be negociated at the intramural portion

Case 2Mrs L…. 34 YPrimary hypofertility of 4 yearsLaparoscopy : PTB of the right tube

a: HSG showing right PTB in the intramural portion. Left salpingogram showing peritubal adhesions with

a patent but vertically oriented tubeb-c : right tubal recanalization with a 0.035  than a 0.032 inch guidewire.d : repeat hysterosalpingogram showing successful procedure with a patent right fallopian tube and spillage of contrast medium in the peritoneal cavity

a c

d

b

Case 3Mrs M… 46 YSecondary hyofertility of 8 yearsMesdical history : 2 therapeutic abortions

a : Initial hysterosalpingography showing a right proximal tubal blockage in the intramural portion and a distal occlusion of the left fallopian tubeb-c : intratubal right salpingogram obtained after succesful guide wire recanalization shows the catheter tip marked by a radiopaque beadd : repeat hysterosalpingogram showing a patent right tube with a very weak spillage of contrast medium concluding to a tubal phimosis

a

d

b

c

DISCUSSION• Tubal factor account for up to 25-40% of

female infertility in Europe and 26.5 – 55% in Tunisia

• Proximal tubal obstruction ( PTO) is the underlying cause in 10-25% of these cases

Main causes of PTO 1. Pelvic infection : > 50% PTO - STD or after miscarriage, termination of pregnancy,

puerperal sepsis or intrauterine contraceptive device

- Tubal damage depend on severity and number of episodes

- Chlamydia trachomatis : > 50% of infectious pelvic diseases

STD: sexually transmittes disease

2. Tubal spasm 20-40% of PTO - Revesible spasm of intramural portion - can not be distinguished from tubal occlusion at

radiography - spontaneous regression or after administration of

spasmolytic agent such as Trinitrine, Glucagon to relax the uterine muscle

3. Tubal plug 40% of PTO - amorphous materials occluding the tubal lumen

4. Salpingitis isthmica nodosum (SIN) 40-50% - usually bilateral - HSG shows a small outpouchings or diverticula from the

isthmic portion of the fallopian tube

5. Pelvic inflammatory disease (PID) - most common cause of tubal occlusion - Scarring in the peritoneal cavity surrounding the

fallopian tube leading to peritubal adhesions - radiography shows a loculated spill, a vertical tube,

a pertubal halo or an ampullary dilatation

6. Anothers causes - Endometriosis - Tubal polyp - Tubal tumors

When should SS – TR be done ? Each time a correctly done

hysterosalpingography ( as described in ‘technique’) shows an obstruction or occlusion of the intramural portion (2cm) and the isthmic portion ( 2-4cm) of the fallopian tube

When not to do the SS- TR ? Absolute contre indications - Distal tubal occlusion

- Confirmed genital infection - Confirmed intra uterine pregnancy

Relative contre indications - post operative tubal obstruction

- metrorrhagia

Advantages of SS-TR

- Simple and non invasive

- Outpatient treatment - Quick ( 15 to 40 min ) - minimal complications - Avoid surgical treatment of PTO

- Success rate of SS in the litterature : 75% - Success rate of TR in the litterature : 50% - Cumulative success rate of SS-TR in the litterature: 71 to 96% ( 83.3% in our study) - Pregnancy rate : 7 – 60% in the littérature ( 39.7% in our study)

- Radiation dose delivered to ovaries during fluoroscopically guided SS-TR is less than 1 rad

- The less expansive procedure treating PTB comparing to laparoscopy and assisted reproduction

Others techniques in the management of PTB

Lparoscopy - failure of SS-TR

- Distal occlusion - peritubal adhesions - Expansive and invasive - High risk of infectious or hemmoragic complications

Tubal micro surgery - PTB due to SIN impossible to recanlize by SS-TR

- Tubal endometriosis or peritubal fibrosis - Expansive and difficult

In vitro fertilization - the most expansive treatment

- Failure of SS-TR and of laparoscopic procedures

CONCLUSION

Selective salpingography and tubal recanalization is recommanded by the

American Society for Reproductive Medicine (ASRM) and the WHO to be the first line

tubal assessment tool in the treatment of proximal tubal occlusions

It’s less costly and less invasive than the nonradiologic options of PTO’s treatment with a diagnostic and therapeutic value