Assesing Tubal Factors in Infertili

Dr. Jyoti Mishra MD, Dip. In Endoscopy(Germany), Training in Endoscopy(Bombay Endoscopy Academy & Centre for Minimally InvasiveSurgery), Mumbai, Tata Cancer Hospital, Mumbai : 

Dr. Jyoti Mishra MD, Dip. In Endoscopy(Germany), Training in Endoscopy(Bombay Endoscopy Academy & Centre for Minimally InvasiveSurgery), Mumbai, Tata Cancer Hospital, Mumbai Senior Consultant Primus SuperSpeciality Hospital, New Delhi Fortis La Femme, New Delhi, Max SuperSpeciality Hospital, New Delhi

Assesing Tubal Factors in Infertility : 

Dr. Jyoti Mishra 2 Assesing Tubal Factors in Infertility Having a child of her own is the most intense desire & right of every woman. Inability to conceive can devastate her emotionally, socially & financially. Tubal pathologies constitute >25% of all causes of infertility

Slide 3: 

Dr. Jyoti Mishra 3 Fallopian tubes first described in 1561 by Gabriele Fallopian from Italy as ‘the seminal duct originating from the cornu uteri & looking like a nerve. After a short distance it begins to broaden & coil like a tendril. It shows extremities of the nature of skin & color of flesh, the utmost end being very ragged & crushed like the fringe of worn out clothes. Further, it has a great hole which is held closed by the fimbria which overlap one another’.

Evolution of various diagnostic techniques : 

Dr. Jyoti Mishra 4 Evolution of various diagnostic techniques Rubin first described the insufflation technique of testing tubal patency in 1920 Hysterosalingography (HSG) gained popularity in 1940s In late 1960s & 1970s Laparoscopy with chromopertubation became a widely used procedure In 1980s Ultrasonography made tremendous progress & Hystersalpingo contrast sonography (HyCoSy) came into use Kerin made the first successful endoscopic evaluation of the lumen of tubes from intramural to fimbrial end, in 1990 by introducing 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 : 

Dr. Jyoti Mishra 5 Rubin’s Tubal Insufflation Test Done in the postmenstrual phase, this involves the pushing of air via a canulla fitted in the cervix. A stethoscope placed in the suprapubic area auscultates the sound produced by air, escaping through the fimbrial end.   Benefits Easy, inexpensive, OPD procedure needs no special training.   Drawbacks Cannot diagnose unilateral blocks. Can be false positive in large hydrosalpinx. No information about peritubal adhesions. Risk of air embolism. Results are very subjective.

Hysterosalpingography (HSG).. 1 : 

Dr. Jyoti Mishra 6 Hysterosalpingography (HSG).. 1 This test precedes Laparoscopy in most of the patients.   Timing Test is performed between days 8 & 10 of LMP No risk of pregnancy Endometrium is at its thinnest, hence better visibility of ostia If done in secretary phase, thick endometrial fragments may get dislodged & block the ostia. No risk of pushing the menstrual blood into the peritoneal cavity No exposure to X-Rays at the time of ovulation   Media Oil soluble media are obsolete now. Benefit was better resolution. Adverse effects included severe inflammatory reaction & risk of oil embolism. Water-soluble contrast media are used. Urograffin 76%.

Slide 7: 

Dr. Jyoti Mishra 7 Technique Instrumentation Cannulation of cervix Dye injection Taking three films is necessary  Postoperative care Analgesics & antibiotic cover is given Hysterosalpingography (HSG).. 2

Interpretation of results : 

Dr. Jyoti Mishra 8 Interpretation of results Normal look: Uterus is seen as a triangular cavity with slightly concave lateral walls. Tubes show slight tortuosity. Rugae can be seen in a good film

General appearance : 

Dr. Jyoti Mishra 9 General appearance Absence of usual tortuosity- peritubal adhesions Hypoplastic short tubes with narrow fimbrial opening- Congenital anomalies Beaded appearance, lead pipe like, leapordskin lesions, intravasation of dye, uterine synechiae- Tuberculosis SIN (Salpingitis Isthmica Nodosa)- white speckled look, dye goes into diverticulae above & below the normal filled part

Common Abnormalities : 

Dr. Jyoti Mishra 10 Common Abnormalities Cornua Uni/bilateral blocks- True organic lesions. False positive results: Spasm, conual polyps, mucus plug, debris, pressure of fibroids, one tube has a wider lumen than the other. Isthmus H/O ectopic, SIN  Ampulla, Infundibulum Intraluminal adhesions- leapordskin appearance Hydrosalpinx  Fimbria Phimosis  Peritoneal Spill Loculation of dye around distal end- Peritubal adhesions

Slide 11: 

Dr. Jyoti Mishra 11 Benefits and Complications of HSG Benefits Cheap, OPD procedure, gives adequate information of intraluminal & intramural parts of tube. Shows exact site of block. Often therapeutic  Complications Allergy to medium, flaring up of PID, Pain, Radiation exposure Contraindications Active PID, Hypersensitivity to dye

Laparoscopy : 

Dr. Jyoti Mishra 12 Laparoscopy Indicated in situations where inspection of pelvic organs will help in further management Often it will be converted into operative laparoscopy

Laparoscopic Technique.. 1 : 

Dr. Jyoti Mishra 13 Laparoscopic Technique.. 1 Technique General anaesthesia with endotracheal intubation Patient position. Uterine manipulator, catheterization. Pneumoperitoneum, confirmation. Insertion of primary trocar & cannula, laparoscope. Insertion of secondary trocar, cannula & atraumatic grasper. Systematic inspection of abdominal & pelvic organs Panormic view Uterus Anterior cul-de-sac Rt. fallopian tube Rt. ovary Rt. uterosacral ligament & POD Lt. side of pelvis Upper abdomen

Slide 14: 

Dr. Jyoti Mishra 14 Chromopertubation Dilute (1:20) methylene blue solution is injected through a cervical cannula. Patency of each tube should be established individually.   Tubal Pathologies Blocks Peritubal adhesions Isthmus- tubercles, fusiform swelling-SIN Hydrosalpinx, Thickened walls Fimbrial phymosis Tuboovarian Relation, Fimbria ovarica Laparoscopic Technique.. 2

Slide 15: 

Dr. Jyoti Mishra 15 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 Laparoscopic Technique.. 3

Sonosalpingography -Sion Test : 

Dr. Jyoti Mishra 16 Sonosalpingography -Sion Test Normal tubes are not visible on TVS Saline in POD will surround the tubes & 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) : 

Dr. Jyoti Mishra 17 Hysterosalpingo – contrast -sonography (HyCoSy) Same as Sion test Echovist is used instead of saline Tubes patent, if forward flow of dye with turbulence at fimbrial end noted False positive in large hydrosalpinx.

Selective Salpingography : 

Dr. Jyoti Mishra 18 Selective Salpingography Under fluoroscopic control tubes are catheterised & medium injected Tubal Spasm , flimsy blocks are overcome. If resistance, a guide wire is passed. Treats tubal spasm & flimsy organic blocks in 80% of patients. Complication- false passage

Hysteroscopic transcervical cannulation : 

Dr. Jyoti Mishra 19 Hysteroscopic transcervical cannulation Indicated in Proximal tubal block Needs operative sheath, Catheter, Obturator, Guide wire & simultaneous laparoscopy Perforation common in intramural & ampullary parts. Patency rate-75-80%, Pregnancy rate 40%.

Tuboscopy : 

Dr. Jyoti Mishra 20 Tuboscopy Salpingoscopy Visualization of endosalpinx through the fimbrial end. Can show upto isthmo-ampullary junction. Normal mucosa is pink, velvety with rugosities. Falloposcopy Seeing the endosalpinx through the corneal end. Shows intramural & isthmic parts of the tube. Visualization is done in a retrograde manner.

Tests based on transportation of particles : 

Dr. Jyoti Mishra 21 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 : 

Dr. Jyoti Mishra 22 Conclusion Some of these tests have become obsolete & some are still in a nascent stage to get wider acceptance. To hold the test of time a preliminary HSG followed later, 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.

Thank You : 

Thank You