SELECTIVE HYSTEROSALPINGOGRAPHY AND TUBAL RECANALIZATION

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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

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OBJECTIVE

• A review of the radiology departments
  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

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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

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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

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

Fallopian Recanalization Set Angiotech
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• 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

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• 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

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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

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• 170 patients 269 fallopian tube with PTB
• 176 SS-TR
• 1/ 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

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• Various findings after SS-TR
• Peritubal adhesions n 39
• Hydrosalpinx n 12
• Distal occlusion n 19
• Endometriosis n 10
• Phimosis n 10
• Salpingitis isthmica nodosa n 3
• Tubal 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

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• Complications
• Vascular opacification 6.4
• Fallopian tube perforation 3.5 (with no clinical
  manifestation )
• Infection /Uterin perforation 0
• 2/ MID-TERM FOLLOW-UP
• Only 88 patients had a 6 months or more follow
  up
• Intra uterine pregnancies 39.7 (35/88
  patients)
• Ectopic pregnancies 0

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• Case 1
• Mrs M 37 Y
• Primary hypofertility of 6 years
• Laparoscopy and dye test bilateral tubal
  blockage

c
b
a
a bilateral PTB bleft tubal recanalization by
guide wire crepeat selective intratubal
salpingogram showing a patent tube d-e
the right fallopian tube could not be negociated
at the intramural portion
d
e
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• Case 2
• Mrs L. 34 Y
• Primary hypofertility of 4 years
• Laparoscopy PTB of the right tube

c
a
b
a HSG showing right PTB in the intramural
portion. Left salpingogram showing peritubal
adhesions with a patent but vertically oriented
tube b-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
d
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• Case 3
• Mrs M 46 Y
• Secondary hyofertility of 8 years
• Mesdical 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 tube b-c intratubal right
salpingogram obtained after succesful guide wire
recanalization shows the catheter tip marked by a
radiopaque bead d repeat hysterosalpingogram
showing a patent right tube with a very weak
spillage of contrast medium concluding to a
tubal phimosis
a
b
d
c
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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 gt 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 gt 50 of
  infectious pelvic diseases
• STD sexually transmittes disease

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• 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

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• 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

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• 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

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• 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

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• 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

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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
• Its less costly and less invasive than the
  nonradiologic options of PTOs treatment with a
  diagnostic and therapeutic value