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Reproductive surgery for proximal and distal tubal occlusion, as well as for reversal of tubal ligation, may be an alternative or an adjunct to IVF. Surgery for adenomyosis and endometriosis, including endometriomas, may be considered for the treatment of infertility and/or pelvic pain but carries the risks of surgical complications and diminished ovarian reserve. A greater understanding of the pathogenesis of postoperative peritoneal adhesion formation is needed to develop more effective preventive measures to optimize the clinical results of surgery., (Copyright © 2019 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To determine whether hysterosalpingo-foam sonography (HyFoSy) is a less painful first line tubal patency test than serial hysterosalpingography (HSG)., Design: A two-center, prospective, open-label, randomized, controlled trial., Setting: University hospital and teaching hospital., Patient(s): 40 subfertile women, ages 18 to 41 years, with an indication for tubal patency testing as part of the fertility workup according to the Dutch Nederlandse Vereniging voor Obsteterie & Gynaecologie-guidelines., Intervention(s): Tubal patency testing by HyFoSy versus serial HSG., Main Outcome Measure(s): Visual Analogue Scale (VAS) pain scores during tubal patency testing., Result(s): The median VAS score for pain perception during the HyFoSy procedure was 1.7 cm (interquartile range: 2.1) compared with 3.7 cm (interquartile range: 4.2) during HSG. The HyFoSy procedure also had a statistically significantly shorter procedure time compared with HSG, with a median of 5.0 minutes (interquartile range: 3.0) for HyFoSy versus 12.5 minutes (interquartile range: 16.0) for HSG., Conclusion(s): The HyFoSy procedure is a less painful and less time-consuming tubal patency test compared with HSG., Clinical Trial Registration Number: Netherlands National Trial Register NTR3457., (Copyright © 2014 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To study fertility among women treated by means of ultrasound-guided drainage and antibiotics for tubo-ovarian abscess (TOA)., Design: Retrospective cohort study., Setting: A tertiary referral center., Patient(s): One hundred women of reproductive age treated for TOA between June 1986 and July 2003., Intervention(s): Transvaginal ultrasound-guided drainage of TOA was performed in all patients. The procedure was repeated if a substantial amount of pus was seen using ultrasonography 2-5 days after the initial aspiration, and repeated later if necessary., Main Outcome Measure(s): Frequency of naturally conceived pregnancies., Result(s): Twenty of 38 (52.6%; 95% CI 36.5-68.9%) women who intended to have a child achieved pregnancy naturally and became mothers. In addition, 7 (50%) of 14 women who were not on birth control on a regular basis became pregnant. No ectopic pregnancies were registered., Conclusion(s): Ultrasound-guided drainage of TOA in combination with antibiotics seems to preserve fertility in approximately half of the patients., (Copyright © 2012 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To describe a case of pelvic tuberculosis presenting as primary infertility and discuss the various diagnostic modalities., Design: Case report., Setting: Academic reproductive medicine center., Patient(s): A 28-year-old nulliparous Indian immigrant presenting with primary infertility and known tubal pathology., Intervention(s): Laparoscopic bilateral salpingectomy and adhesiolysis and diagnostic endometrial sampling., Main Outcome Measure(s): Acid-fast bacilli were obtained on polymerase chain reaction and culture of endometrial sample., Result(s): The patient was diagnosed with pelvic tuberculosis and treated with a directly observed multidrug regimen., Conclusion(s): Tuberculosis is an important cause of gynecologic morbidity and should be considered in the appropriate patients., (Copyright © 2011 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To build an evaluation scoring system using the results of salpingoscopy, and to evaluate the relationship between this scoring system and the outcome of pregnancy., Design: Retrospective study., Setting: Sugiyama Clinic., Intervention(s): Using salpingoscopy, we observed the tubal lumen, paying attention to the following six results: adhesions, loss of mucosal folds, rounded edges of mucosal folds, debris, foreign bodies, and abnormal vessels., Patient(s): From April 2008 through June 2009, 104 women in whom unexplained infertility had been diagnosed underwent salpingoscopy. The F scores were evaluated related with various clinical results or pregnancy rates., Main Outcome Measure(s): The F score expressed the sum of the abnormal results, and one abnormal result was given a 1-point F score., Results: Approximately 60% of the patients showed an F score of 0, and the percentages of patients who showed 1, 2, 3, and ≥4 points were 19.2%, 11.5%, 4.5%, and 4.5%, respectively. After evaluation, 23 patients achieved pregnancy within a year. The pregnancy rates for patients with F scores of 0 and 1 point were 30.6% and 20.0%, respectively, and the rate of patients with an F score of 0 was significantly higher than the rate of patients with high F scores (F score ≥2; 9.1%)., Conclusion(s): The patients showing a lower F score (0 or 1) showed higher fecundity than those showing an F score of ≥2., (Copyright © 2010 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

In this prospective clinical study, ultrasound-guided transvaginal aspiration and sclerotherapy with 98% ethanol was performed before the IVF cycle in 33 patients with hydrosalpinx. The results showed that ultrasound aspiration and sclerotherapy could improve the endometrial receptivity and outcomes of IVF, with no recurring sign of the hydrosalpinx and no adverse effect on ovarian reserve or responsiveness during the IVF procedure., (Copyright © 2010 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Hysterosalpingography is the primary technique in providing coarse information on the morphology of endometrial cavity and fallopian tubes. In this preliminary study, 64-detector computed tomography was used for three-dimensional imaging of endometrium and fallopian tubes., (Copyright 2010 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To review radiation exposure during hysterosalpingography (HSG) examinations with use of a mobile C-arm fluoroscopic imaging system with advanced features including pulsed fluoroscopy and last-image-hold capability., Design: Retrospective clinical study., Setting: Freestanding outpatient radiology office., Patient(s): Two hundred consecutive patients who were referred for HSG examinations to evaluate fertility or status of tubal ligation., Intervention(s): Pulsed fluoroscopy (eight frames per second) and continuous fluoroscopy were used with automated exposure control and last image hold for static image capture., Main Outcome Measure(s): Fluoroscopy time (seconds), field of view (12 in., 9 in., 6 in.), mode (continuous, pulsed), and dose area product (mGycm(2)) were recorded for each patient. The total estimated surface dose then was calculated., Result(s): One hundred forty-seven patients had normal results on hysterosalpingograms, and 57 patients had abnormal results on hysterosalpingograms. Selective salpingography was performed in 26 of the 38 patients with fallopian tube occlusions. Mean fluoroscopy time for normal, abnormal, and selective catheterization was 4.17, 14.3, and 56.1 seconds, respectively. Mean estimated surface dose for normal, abnormal, and selective catheterization was 2.6, 6.9, and 46.7 mGy, respectively., Conclusion(s): A mobile C-arm fluoroscopic imaging system with pulsed fluoroscopy and last-image-hold capability may be a desirable alternative for HSG to achieve lower radiation exposure with improved operator convenience and patient comfort., (Copyright 2010 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the tolerability, side effects and complications of hysterosalpingocontrast sonography (HyCoSy)., Design: Prospective study., Setting: University hospital., Patient(s): 669 infertile women., Intervention(s): All patients were examined with HyCoSy and monitored for 30 minutes after the procedure. A telephone interview was subsequently carried out to record possible late side effects and postprocedural complications., Main Outcome Measure(s): Tolerability to the procedure was evaluated by means of an 11-point (0 to 10) numeric rating scale of the pain experienced. Postprocedural fever, pelvic infections, peritonitis, hemorrhage were recorded., Result(s): Of 660 patients who completed the examination, 483 (73.2%) completed the telephone follow-up after a period of 14.7 +/- 9.9 months from the procedure. The mean patient age was 34.5 +/- 4.3 years, and mean infertility duration was 28.1 +/- 23.2 months. The mean numeric rating scale was 2.7 +/- 2.5, and 10 patients (2.0%) required postprocedural drug treatment for pain relief. Mild vasovagal reactions were experienced in 20 cases (4.1%), and four patients (0.8%) had a severe vasovagal reaction. No late complications were reported. No patients required hospital admission after the procedure., Conclusion(s): In our series, HyCoSy was a well-tolerated examination with a very low rate of side effects and no late complications that required no atropine or anti-inflammatory drugs. These data support the safety of HyCoSy when performed as described, but further work is needed to estimate the rate of late complications and side effects in other settings.

Objective: To describe a case report of hydrosalpinx that changed dramatically in size during the menstrual cycle., Design: Case report., Setting: University teaching hospital reproductive endocrinology and infertility practice., Patient(s): A 32-year-old woman with a history of medical and surgical treatments of endometriosis who sought infertility treatment., Intervention(s): Transvaginal ultrasonography performed sequentially during menstrual cycles., Main Outcome Measure(s): Size of hydrosalpinx-like image., Result(s): The size of the hydrosalpinx-like image in the left adnexal region varied; it peaked during the ovulatory period and then remarkably diminished in a cyclic manner. Laparoscopy revealed a dense adhesion between the left tubal fimbriated end and the posterior uterine wall, which led to terminal obstruction of the tube., Conclusion(s): Change in the volume of the hydrosalpinx in this case was speculated to reflect the normal tubal fluid production regulated by ovarian hormones.

A case of a genital tuberculosis found during laparoscopic evaluation for recurrent acute pelvic pain is presented. The symptoms of genital tuberculosis can vary greatly, and a laparoscopic approach is effective for making the diagnosis. Clinicians should consider tuberculosis as a differential diagnosis when encountering clinical presentations of pelvic pain and ascites.

Objective: To compare endometrial and subendometrial blood flows among patients with and without hydrosalpinx (HSP) during in vitro fertilization treatment as measured by a three-dimensional power Doppler ultrasound., Design: A prospective observational study., Setting: A tertiary assisted-reproduction unit., Patient(s): Twenty-one patients with HSP were compared with 42 matched controls without HSP., Intervention(s): None., Main Outcome Measure(s): Endometrial thickness, endometrial pattern, endometrial volume, pulsatility index (PI) and resistance index (RI) of uterine vessels, and the vascularization index (VI), flow index (FI), and vascularization flow index (VFI) of endometrial and subendometrial regions were measured on the day of oocyte retrieval., Result(s): The proportion of the non-multilayered endometrial pattern was significantly higher in the HSP group than in the non-HSP group. Patients in the HSP group had significantly lower endometrial and subendometrial VI and VFI. Endometrial thickness, endometrial volume, uterine PI, uterine RI, and endometrial and subendometrial FI were similar between the two groups. No significant differences were observed in endometrial and subendometrial VI, FI, and VFI among patients with unilateral and bilateral HSP., Conclusion(s): A change in endometrial pattern and a decrease in endometrial and subendometrial blood flows may be the reasons for impaired implantation in patients with HSP.

Objective: To study the apparent association between interstitial fallopian tube polyps and isthmic tubal dilatation., Design: Retrospective clinical study., Setting: Tertiary academic medical center., Patient(s): Sixty-five patients with normal hysterosalpingograms and 40 patients with interstitial tubal polyps (25 unilateral and 15 bilateral)., Intervention(s): None., Main Outcome Measure(s): Proximal, medial, and distal isthmic diameters were measured digitally and normalized according to an internal standard. Polyp volumes were measured and divided into four groups according to increasing volume (<2 mm3, 2-5 mm3, 6-12 mm3, >12 mm3)., Result(s): There was a significant increase in proximal isthmic tubal diameter in patients with interstitial polyps. Mean diameter increased from 0.6 mm to 0.9 mm. There was no significant change in more distal isthmic diameters. Larger polyps tended to be associated with larger luminal diameters., Conclusion(s): Interstitial fallopian tube polyps are associated with a significant increase in proximal isthmic luminal diameter as determined on hysterosalpingography. Although these polyps are nonobstructing and thus thought by most investigators not to affect fertility, their association with altered luminal diameter and perhaps altered function might be of clinical interest.

Objective: To characterize endometrial development in unexplained and tubal factor infertility., Design: Prospective study of 20 women with unexplained infertility, 22 with tubal factor infertility, and 21 fertile controls in the midproliferative, periovulatory, and midluteal phases of the menstrual cycle., Setting: Reproductive Medicine Department of St. Mary's Hospital, Manchester, United Kingdom., Patient(s): Women awaiting assisted conception., Investigation(s): Serum hormone assays, transvaginal ultrasound, Doppler, and midluteal endometrial biopsies., Main Outcome Measure(s): Serum levels of E2, P, and LH, endometrial ultrasound morphometry, uterine and subendometrial artery Doppler, and endometrial histology and biochemistry., Result(s): Women with unexplained infertility demonstrated significantly reduced uterine artery flow velocity in all phases, significantly elevated uterine and subendometrial artery impedance in the periovulatory and midluteal phases, and significantly reduced endometrial texture in the midproliferative phase. Women with tubal factor infertility demonstrated significantly reduced uterine artery flow velocity, without a concomitant increase in impedance, and significantly greater expression of endometrial glandular and luminal keratan sulphate., Conclusion(s): Unexplained infertility is associated with a profound impairment of endometrial perfusion that might be amenable to treatment by perfusion enhancers. Tubal factor infertility is associated with endometrial developmental defects that might be corrected by salpingectomy. Endometrial ultrasound and Doppler studies are likely to become a vital tool in the investigation of infertility.

Objective: To present diagnostic findings and fertility outcome after selective salpingography and tubal catheterization in an unselected infertile population., Design: Cohort study., Setting: Tertiary reproductive medicine unit., Patient(s): One hundred ten consecutive infertile women. No exclusion criteria were applied. Follow-up ranged from 16 to 54 months., Intervention(s): Selective salpingography and tubal catheterization under fluoroscopic guidance as the primary test for the assessment of the fallopian tubes., Main Outcome Measure(s): Incidence of tubal disease at selective salpingography, therapeutic effectiveness of tubal catheterization, and fertility outcome after the procedure., Result(s): Tubal disease was present in 31.4% of the tubes examined. Of tubes proximally blocked at selective salpingography, 52.1% were found to be normal after tubal catheterization. Proximal tubal blockage (bilateral or unilateral) was detected in 34.8% of women. This was reduced to 5.5% after tubal catheterization. Spontaneous conceptions occurred in 21.9% of the women. In total, 36.2% conceived without IVF or ICSI., Conclusion(s): Selective salpingography and tubal catheterization can be useful as a primary tubal assessment tool in the investigation of infertility. In cases of proximal tubal blockage, an effective see-and-treat approach can be adopted. More research into the possible therapeutic benefits of the procedure is justified.

Objective: To evaluate the consistency of the identification of abnormal findings on hysterosalpingogram (HSG) and compare the reliability of clinicians to that of radiologists., Design: Evaluation of reliability of diagnostic test., Patient(s): Women undergoing evaluation for infertility.INTEVENTION(S): Retrospective review of 50 HSG films by three reproductive endocrinologists and three radiologists. Each film was reread 30 days later in a blinded fashion., Main Outcome Measure(s): The consistency of each individual reader, the reliability of detecting specific abnormalities, and the consistency of clinicians compared with radiologists was evaluated with a kappa (K) statistic and interclass correlation coefficient (ICC)., Result(s): Average intrareader reliability was high for the detection of normal uterus, normal tubes, and tubal obstruction and low for the detection of hydrosalpinx, uterine adhesions, and pelvic adhesions. Inter-reader reliability was high in the detection of normal uterine contour, normal tubal patency, and uterine filling defect and lower for the detection of a hydrosalpinx. The reliability of detecting pelvic adhesion or salpingitis isthmica nodosa was poor., Conclusion(s): Intrareader reliability was generally good, especially for the detection of normal findings. Agreement among different readers is lower in detecting rare outcomes such as hydrosalpinx and pelvic adhesion and salpingitis isthmica nodosa. Clinicians more reliably diagnose hydrosalpinx and tubal obstruction, while radiologists more reliably detect the more subtle findings of salpingitis isthmica nodosa or uterine adhesions.

Objective: To determine the effect of increasing experience in fluoroscopically guided selective salpingography and tubal catheterization on radiation doses and screening times, thus establishing a learning curve for the procedure., Design: Retrospective case note analysis., Setting: IVF center of an academic teaching hospital., Patients: Three hundred sixty-six patients with infertility seen over 3.5 years., Intervention(s): Fluoroscopically guided selective salpingography and tubal catheterization., Main Outcome Measure(s): Reductions in radiation doses and screening times for different categories of selective salpingography and tubal catheterization, expressed as percentage reductions during the study period and reductions per 10 procedures., Result(s): During the study period, The median dose of radiation decreased by 62.6%-71.9%, and the median screening time declined by 61.5%-78.5%. Reductions per 10 procedures were 2.5%-4.2% and 2.7%-5%, respectively., Conclusion(s): Significant reductions in radiation doses and screening times start early in a clinical team's practice of selective salpingography and tubal catheterization and continue even as trainees are added to the pool of operators.

Objective: To compare selective salpingography and balloon tuboplasty for the treatment of tubal obstruction., Design: A retrospective evaluation of results of women treated for tubal obstruction by outpatient methods at a single center., Setting: Tertiary-care, university-affiliated hospital., Patient(s): A total of 3,424 infertile women, of whom 418 had bilateral tubal obstruction by hysterosalpingography, treated at Nihon Medical Center from 1982 to 1997., Intervention(s): Women with tubal obstructions who had visual evidence of an intact uterine tubal ostium at hysteroscopy were treated by selective salpingography. If selective salpingography could not establish patency, then transcervical balloon tuboplasty was performed with one of three catheter systems. Patients were followed expectantly for 1 year after treatment., Main Outcome Measure(s): Postoperative tubal patency and overall pregnancy rates (PRs) at 1-year of follow-up., Result(s): The overall patency rate was 67.5%, with 30% of these patients conceiving (20.2% of all subjects). Selective salpingography was associated with a 35. 7% patency rate, and 27.3% of these patients conceived. Of the subjects who failed selective salpingography and underwent balloon tuboplasty, 66.2% achieved patency, of whom 33% spontaneously conceived. Balloon tuboplasty was effective in restoring patency in many cases after selective salpingography had failed. Statistically significant differences were found between selective salpingography and balloon tuboplasty and for the different balloon tuboplasty catheters in terms of patency rates, while a trend was seen for PRs., Conclusion(s): Many women diagnosed as having tubal obstruction can be treated by outpatient methods that do not require general anesthesia. Achieving patency by these methods is associated with high PRs and avoids the need for assisted reproductive technologies in some cases. Balloon tuboplasty is a more effective treatment than selective salpingography. The choice of balloon tuboplasty catheter system may affect success rates.

Objective: To assess whether a second hysterosalpingography (HSG) can permit tubal patency, reducing the use of selective salpingography in patients with proximal tubal obstruction., Design: Prospective study., Setting: University hospital., Patient(s): The study population consisted of 360 infertile women., Intervention(s): In patients with unilateral or bilateral proximal tubal obstruction, a second HSG was performed after about 1 month. In those cases with persistent obstruction, an immediate selective salpingography and tubal catheterization were performed., Main Outcome Measure(s): Tubal opacification., Result(s): Forty patients underwent a second HSG procedure for proximal tubal occlusion. Among these, 24 achieved bilateral tubal patency. Thus, repetition of a conventional HSG after 1 month avoided unnecessary salpingography in 60% of patients., Conclusion(s): In infertile women with proximal tubal obstruction, we believe it is best to perform a second HSG. HSG is easy to carry out and subjects patients to a lower dosage of radiation and fewer risks than selective salpingography. The latter technique should be reserved for unsuccessful cases.

Objective: To evaluate the effectiveness of hysteroscopic selective salpingography (HSS) as a method for diagnosing the tubal proximal occlusion shown by hysterosalpingography (HSG)., Design: Prospective study., Setting: Outpatient Department of Obstetrics and Gynecology, Social Insurance Saitama Chuo Hospital, Urawa, Japan., Patient(s): A total of 572 infertile women underwent HSG. Forty-seven of 50 women with unilateral or bilateral proximal tubal occlusion demonstrated by HSG underwent HSS., Intervention(s): Hysteroscopic selective salpingography was performed for the diagnosis of tubal occlusion in cases in which the proximal tubal occlusion was shown by HSG., Main Outcome Measure(s): Number of patients who underwent HSS and pregnancy rate after HSS., Result(s): Twenty-seven (79.4%) of 34 patients with unilateral occlusion diagnosed by HSG were shown to have normal patency by HSS. Of 12 women with bilaterally normal patent tubes confirmed by HSS, 8 (66.7%) achieved normal pregnancies within 1 year. Seven (53.8%) of 13 patients with bilateral occlusion found by HSG were shown to have normally patent tubes by HSS., Conclusion: The simple method of HSS was clinically effective for evaluating the presence of proximal tubal occlusion.

Objective: To investigate whether radionuclide hysterosalpingography (radionuclide HSG), which has been suggested as a more functional approach to the diagnosis of tubal infertility than conventional patency tests, is predictive in the diagnosis of infertility., Design: A retrospective analysis of data from an inquiry form containing questions about pregnancy outcome after radionuclide HSG., Setting: University hospital-based, tertiary care infertility clinic., Patient(s): Two hundred sixteen women had an infertility work-up including radionuclide HSG performed between April 1986 and April 1993. Forty-one (18.9%) women were excluded from the study; 9 had moved to unknown addresses, 16 did not answer the inquiry, and 16 gave answers that were not interpretable. There were 175 (81.1%) women in the final study group., Intervention(s): An inquiry form containing questions regarding pregnancy was sent to 207 women who undergone radionuclide HSG as a routine procedure in their infertility workup., Main Outcome Measure(s): Occurrence of pregnancy related to outcome of radionuclide HSG and its test properties calculated., Result(s): Bilateral or unilateral tubal transport was demonstrated by radionuclide HSG in 129 women, of whom 66 (51%) later became pregnant. Of the pregnant women, 36 (55%) had successful infertility treatment, whereas 30 (45%) reported spontaneous pregnancy. Forty-six women showed no transport at radionuclide HSG. Twenty-five (54%) of these women became pregnant, 14 (56%) with infertility treatment and 11 (44%) without infertility treatment. The predictive values of transport and no transport radionuclide HSG were 0.51 and 0.46, respectively. The sensitivity of radionuclide HSG was 0.25, and the sensitivity was 0.73. Likelihood ratios for pregnancy when radionuclide HSG showed transport and no transport were 1.03 and 0.93, respectively., Conclusion(s): Our data strongly indicate that a single radionuclide HSG investigation is not able to predict fertility potential.

Objective: To test the role of transcervical fallopian tube catheterization under ultrasound (US) guidance using an ultrasound contrast agent., Design: Catheterization was performed under US guidance in a patient with bilateral proximal tubal obstruction., Setting: This study is a case report., Patient(s): Proximal tubal obstruction had been diagnosed on previous roentgenogram hysterosalpingography., Intervention(s): Salpingography and tubal cannulation., Main Outcome Measure(s): Tubal patency was assessed using Albunex (Mallinckrodt Medical, St. Louis, MO) enhanced US., Result(s): Transvaginal catheterization was successful in achieving tubal patency., Conclusion(s): This catheterization technique should be investigated for possible use in the treatment of proximally obstructed tubes.

Objective: To evaluate the efficiency of radionuclide hysterosalpingography (HSG) by using 99mTc hexamethyl propyleneamine oxime (HMPAO)-labeled human spermatozoa in the assessment of fallopian tube patency in infertile couples., Design: Fifteen infertile female patients were inseminated with their husbands' radiolabeled spermatozoa immediately after cessation of menses., Setting: University-based academic hospital., Main Outcome Measure(s): The time course of radioactivity and scintigraphic images of the uterus and the parauterine tissues implying tubal patency were evaluated and compared by using laparoscopy and HSG., Result(s): We demonstrated Tmax (time to peak radioactivity at periovarian sites) for right and left tubes to be 6.74 +/- 2.66 and 5.91 +/- 2.93 minutes (means +/- SD), respectively. We also found 72% sensitivity and 75% specificity of spermatozoa labeled radionuclide HSG compared with laparoscopic findings for tubal patency., Conclusion(s): Radionuclide HSG with the husband's spermatozoa seems to be a potentially useful method of assessing patency of the fallopian tubes. The safety dose of this procedure is comparable to conventional HSG. However, more comparative studies are needed to evaluate advantages and disadvantages of this technique.

Objective: To investigate the possible etiologies of elevated tubal perfusion pressures., Design: Analysis of 48 consecutive female patients with infertility who underwent laparoscopy and a gynecoradiological investigation as part of their infertility work-up., Setting: Academically affiliated infertility center., Interventions: A gynecoradiological investigation was performed using a previously reported standardized contrast injection system. Laparoscopy was performed routinely., Results: Patients who demonstrated by laparoscopy to have endometriosis showed a significantly increased incidence of tubal blockage during initial hysterosalpingography (HSG) (12/26, 46.1%) compared with controls (2/14, 14.3%). Patients with endometriosis also demonstrated significantly more frequently elevated tubal perfusion pressures (22/26; 84.6%) than women without disease (2/14, 14.3%) and significantly higher mean tubal perfusion pressures than women with normal pelvises (576 +/- 264 versus 450 +/- 268 mm Hg)., Conclusion: Tubal blockage during initial HSG and elevated tubal perfusion pressures during selective salpingography are highly suggestive of tubal endometriosis. These data are the first evidence that tubal involvement with endometriosis may be more frequent than previously suspected. They also suggest that the performance of a gynecoradiological investigation, inclusive of selective salpingography, can greatly contribute to a presumptive diagnosis of endometriosis.

Design: To determine whether the diagnostic accuracy and prognostic value of hysterosalpingography (HSG) could be improved if routine spot films were replaced by an on-line recorded gynecoradiologic study., Setting: Medical school-affiliated private infertility center., Patients: In 1992, a review of 152 infertile women with infertility who demonstrated a normal HSG, by standard criteria of spot film evaluation, in 117 (77%). They were further investigated by gynecoradiologic study if the HSG revealed asymmetrical tubal filling, an increased perfusion pressure, and/or evidence for abnormal tubal spill. In 1993, 47 women with normal HSG by spot film criteria underwent bilateral selective salpingography and were subdivided into those with normal (group I, n = 23) and abnormal (group II, n = 24) tubal perfusion pressures., Intervention: Patients in both study groups then were treated for their infertility independently of pressure perfusion measurements., Main Outcome Measure: Clinical pregnancy rates (PRs) over the ensuing 6 to 10 months., Results: Among 117 women with apparently normal spot film HSG, 64 (55%) demonstrated asymmetrical tubal filling, 32 (27%) demonstrated abnormal spillage into the peritoneal cavity, and 55 (47%) demonstrated abnormally elevated injection pressures. Among 98 women who underwent bilateral selective salpingography, 43 (44%) demonstrated bilaterally normal tubal perfusion pressures and 55 (56%) showed an abnormally elevated pressure in at least one oviduct. Of 47 women that were followed prospectively in 1993, patients with normal perfusion pressure (group I) demonstrated a significantly higher PR than women with elevated tubal pressure (group II) from 2 months and on after the procedure., Conclusions: Routine spot film HSG is of limited value in assessing tubal status beyond the determination of tubal patency. Especially with regard to fertility potential, HSG should be replaced by gynecoradiologic study.

Objective: To investigate the role of transcervical tubal catheterization in diagnosis and treatment of proximal tubal obstruction associated with salpingitis isthmica nodosa., Design: Retrospective case study., Setting: University hospital and outpatient radiology practice., Patients: Fifty-two women with proximal tubal obstruction associated with salpingitis isthmica nodosa., Intervention: Selective salpingography and catheter recanalization using fluoroscopic guidance., Main Outcome Measures: The number of tubes visualized to the fimbria as a percentage of the tubes with proximal tubal obstruction on the initial hysterosalpingogram was determined as a measure of diagnostic efficacy. To evaluate the treatment potential of catheter recanalization, the patients were grouped according to tubal status at the conclusion of the procedure and subsequent pregnancies were evaluated., Results: Forty-seven of 65 tubes (72%) with proximal tubal obstruction were recanalized successfully. Among the 19 women who were able to conceive only via a recanalized salpingitis isthmica nodosa tube, there were 6 live births (32%) and two tubal pregnancies (10%)., Conclusion: Selective salpingography allows complete tubal diagnosis in almost three fourths of patients with proximal tubal obstruction and salpingitis isthmica nodosa. The radiographic diagnosis of salpingitis isthmica nodosa may be pressure dependent. Intrauterine pregnancies occur via recanalized salpingitis isthmica nodosa tubes, therefore catheter recanalization may be attempted before tubal microsurgery or IVF in patients with proximal tubal obstruction and associated salpingitis isthmica nodosa.

Eight infertility patients with proximal tubal occlusion by HSG and at least one other independent method underwent falloposcopy to evaluate the etiology of uterotubal occlusion. Patency was established in 9 of 12 tubes evaluated. Falloposcopy revealed 5 tubes with multiple or extensive intratubal lesions that would be unsuitable for unilocular tubal resection with subsequent reanastomosis. In addition, 5 tubes were visually normal or had only minor pathological changes (2 of these patients became pregnant). Only 2 of the tubes examined in a single patient would be considered candidates for microsurgical correction at laparotomy. Falloposcopy will become a useful adjunct in the evaluation of the patient with suspected tubal infertility. It provides information regarding the condition of the tubal mucosa that is unavailable by any other technique, adding precision to surgical techniques when they are deemed necessary while directing other patients to assisted reproductive technologies. However, falloposcopy is still in its infancy and data from larger studies are needed.

Ten infertile women 20 to 40 years of age, with a standard HSG diagnosis of unilateral proximal tubal obstruction, underwent a transvaginal catheterization and recanalization of the fallopian tubes. To set a fluoroscopic real-time guidance technique for improving the results of transvaginal catheterization and recanalization of the fallopian tubes and to increase its marginal safety, catheterization was performed under digital road mapping guidance. Transcervical catheterization resulted in an immediate patency of the obstructed tube in all 10 women. Three women conceived 2 to 3 months after the procedure. The improved catheterization technique enables good results in the diagnosis and treatment of proximal tubal obstructions.

A new method for relief of cornual obstruction performed totally in the office is presented. We used the Jansen-Anderson catheter with 0.007-cm guide-wire for relief of the obstruction. Ultrasonography is used for demonstrating the position of the catheter and for tubal patency. Subsequent HSG is used for confirmation of tubal patency.

Objective: To test a sonoscopic technique developed for transvaginal catheterization and recanalization of the fallopian tube., Design: In a feasibility study, catheterization was performed with the use of laparoscopic control. Patients with bilateral proximal tubal obstruction underwent fallopian tube recanalization under ultrasonic observation., Setting: This study represents patients evaluated for primary or secondary infertility at Humboldt University Hospital., Patients, Participants: Proximal tubal obstruction had been diagnosed on previous hysterosalpingogram and with laparoscopy., Interventions: None., Main Outcome Measure: Tubal patency was assessed by hydrotubation under ultrasonic observation., Results: Transvaginal catheterization was successful in 31 (91.2%) of the 34 tubes. In 19 patients with proximal tubal obstruction, patency of both or at least one tube was achieved in 16 (84.2%) women. Five (31.6%) of 16 patients successfully recanalized were found to have an intrauterine pregnancy at a 6-month follow-up interval., Conclusion: This catheterization technique should be investigated for possible use in diagnostic schedule early in the evaluation of the infertile patient. Also, the transvaginal recanalization of proximally obstructed tubes calls into question the application of microsurgical treatment of a selected group of patients.

Proximal tubal obstruction, either unilateral or bilateral, is a frequent finding on hysterosalpingogram (HSG). Approximately two-thirds of the fallopian tubes resected for proximal tubal obstruction reveal an absence of luminal occlusion. The distinction between true pathologic occlusion and either spasm or plugging is crucial in determining therapy. We combined hysteroscopic cannulation of the proximal fallopian tube with laparoscopy in 11 patients with proximal tubal obstruction diagnosed by HSG and confirmed at laparoscopy. Hysteroscopic cannulation was able to be performed in 72% of the fallopian tubes attempted, and there was a postcannulation patency rate by HSG of 73%. Six of the 11 patients became pregnant after tubal cannulation and adjunctive distal tubal surgery. Hysteroscopic cannulation of the fallopian tube is a safe diagnostic procedure that can be used to identify those patients with true proximal occlusion, and may also serve as a therapeutic procedure in some of these patients.

A brief review of the technique of hysterosalpingography is provided. It remains an important diagnostic study in searching for causes of infertility. HSG is a safe, simple procedure that enables the lumina of the uterine cavity and fallopian tubes to be outlined. Fundamentals in techniques have been stressed so as to limit the errors of omission and commission. During the course of many years, I have been honored by my colleagues, who have requested me to review interesting HSGs. Thus, I have been able to accumulate a series of x-rays that I can share with the readers of Modern Trends. Although these photographs seemed unique, many of them probably have been seen by other investigators. They are presented because of their important diagnostic features.

The diagnostic accuracy and therapeutic value of hysterosalpingography (HSG), laparoscopy, and hysteroscopy were evaluated in 77 women who underwent these procedures as part of their infertility evaluation. HSG revealed in 32 women (42%) evidence of tubal or peritoneal disease, and 16 other women (21%) had radiographic evidence of intrauterine abnormalities. These findings were confirmed by laparoscopy in 84% of patients and by hysteroscopy in 69%, giving false-positive rates of 16% and 31% for HSG. HSG had a false-negative rate of 13% for tubal or peritoneal disease as subsequently uncovered by laparoscopy, and 1.3% for intrauterine lesions as revealed by hysteroscopy. The data suggest that while laparoscopy is of value in detecting previously unsuspected tubal disease, hysteroscopy adds little information in the management of the infertile patient. For optimum evaluation, a combined approach using all three procedures is recommended, especially in patients with a history of uterotubal and peritoneal lesions.

A patient with bilateral tubal occlusion conceived by IVF and delivered a healthy infant vaginally. Four months postpartum, the patient again conceived spontaneously and carried to term. Recanalization of one fallopian tube was demonstrated on HSG performed after delivery of the second infant. Mechanical stretching and pregnancy-induced hormonal changes may explain spontaneous recanalization of obstructed fallopian tubes.

Controversy exists regarding the ideal contrast media for hysterosalpingography. A unique property of oil-base contrast media is the availability of a 24-hour delay radiograph for further assessment of tubal patency and adhesions. A review was undertaken of the delay films in 131 cases performed by use of oil-base contrast media with subsequent surgical confirmation of pelvic findings. A 97% predictive accuracy was achieved with regard to distal obstruction and a 79% accuracy with regard to pelvic adhesions. Objective criteria for the evaluation of 24-hour delay hysterogram films were developed and are illustrated.

Experiments were conducted in rabbits to test the effect of commonly used hysterosalpingographic media on tubal structure and function. A model of hydrosalpinx was created by ligating both ends of the oviduct, and the lumen was filled with test solutions. Three groups of animals were studied. Group 1 rabbits (operated controls) received Hanks' balanced salt solution or no solution. In the second group (unoperated controls), no solution or occlusive ligature was applied. Group 3 received either Ethiodol (Savage Laboratories, Missouri City, TX), an oil-soluble contrast medium (OSCM), or Sinografin (E.R. Squibb & Sons, Princeton, NJ), a water-soluble contrast medium (WSCM). Histopathologic changes in the endosalpinx were moderate in the doubly ligated oviducts, and no difference was found between the effects of OSCM and WSCM in group 3 or between groups 1 and 3. Ciliary transport rate on the ampullary endosalpinx of group 1 was 0.05 mm/second, i.e., half the normal rate in the unoperated controls (P less than 0.001) and OSCM-filled oviducts (P less than 0.01). The rate in WSCM oviducts was 0.01 mm/second, significantly slower than in the OSCM-filled oviducts (P less than 0.05).