Transcript SALPINGOGRAPHIE SELECTIVE RECANALISATION TUBAIRE

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
with contrast agent
Success
tubal recanalization (TR)
gentle push of a guidewire advanced
through the 3F catheter in the
isthmic portion
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 31.74 Y)
• Hypofertility
duration : 1 - 19 years
primary hypofertility : 75 p
secondary hypofertiltiy : 95p
• Past record
Therapeutic abortion n = 11
Pelvic adhesions n = 8
Spontaneous abortion n = 7
Uterin deformity n = 3
Chlamydia genital infection n = 4
Extrauterine pregnancy n = 3
Myomectomy n = 9
Tuboplasty n = 3
Endometriosis n = 4
• 170 patients : 269 fallopian tube with PTB
• 176 SS-TR
1/ SHORT TERM SUCCESS RATE
Selective
salpingography
269 T
Tubal
recanalization
156 T
success 49.4% (133 tubes)
failure 50.6% (136 t )
success 58.3% (91t)
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
d
b
e
c
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
c
a
b
d
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
Case 3
Mrs M… 46 Y
Secondary hyofertility of 8 years
Mesdical history : 2 therapeutic abortions
a
b
c
d
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
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 SSTR 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