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 July 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 Y) Hypofertility duration : 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-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%

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

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%

Case 1 Mrs M… 37 Y Primary hypofertility of 6 years Laparoscopy and dye test : bilateral tubal blockage a b c de a : bilateral PTB b: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 2 Mrs 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 than a 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 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 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