SELECTIVE HYSTEROSALPINGOGRAPHY AND TUBAL RECANALIZATION : WHEN TO DO - PowerPoint Presentation

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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

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 criteriaShort –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 PTB176 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 = 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

ComplicationsVascular 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%

Case 1Mrs M… 37 Y

Primary

hypofertility

of 6

years

Laparoscopy

and

dye

test :

bilateral

tubal

blockageabcdea : 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 Y

Primary hypofertility of 4 years

Laparoscopy : 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 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

a

c

d

b

Case 3Mrs M… 46 YSecondary 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

d

b

c

DISCUSSIONTubal 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

CONCLUSIONSelective 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