During the course of investigating a couple who attended for secondary infertility of
2 years’ duration, you opt to assess tubal function. (a) What radiological options will
you consider? (7 marks) (b) Critically appraise the non-radiological options.
(7 marks) (c) Outline the complications of these procedures. (6 marks)
Common mistakes
● Causes of tubal infertility – the question specifically asks about assessing tubal function
● Although tubal function can be assessed in the male partner, it is unusual for the gynaecologist to assess him
● Listing all the causes of infertility
● History, physical examination and investigations
● Treatment of causes of tubal infertility
● Comparing and contrasting
● Screening for Chlamydia antibodies, etc.
A good answer will include some or all of these points
(a) What radiological options will you consider? (7 marks)
● Hysterosalpingography (HSG):
● Cannula in the cervix
● Injection of oil-based contrast medium through the uterine cavity and Fallopian
tubes under fluoroscopy
● X-rays taken
● Outlines uterine cavity and Fallopian tubes
● Defines site of blockage, intrauterine adhesions
● Hysterosalpingo-contrast-sonography (HyCoSy):
● HyCoSy injected into the uterine cavity
● Ultrasound examination during injection
● Saline HSG. Enables ovarian cysts to be diagnosed. May be useful in the diagnosis of
Asherman’s syndrome. Requires skilled personnel and equipment. Contrast ultrasound (Echovist®) similar to saline ultrasonography
(b) Critically appraise the non-radiological options. (7 marks)
● Laparoscopy and dye test:
● Enables diagnosis of tubal adhesions, pelvic pathology such as endometriosis
● Option of treating the adhesions and endometriosis
● Unable to define uterine pathology and site of tubal blockage
● Requires general anaesthesia (GA) although could be done under local anaesthesia
(LA)
● Falloposcopy and salpingoscopy – useful to assess the internal anatomy of the tubes.
Requires GA and a very skilled operator and equipment. Unlikely to be available to all
patients
● Salpingoscopy
(c) Outline the complications of these procedures. (6 marks)
● Radiological – flare-up of subclinical pelvic inflammatory disease
● Allergic reaction to dye
● Pain from grasping the cervix leading to vasovagal attacks
● Trauma to the cervix and infections
● Risks of laparoscopy:
● GA
● Injury to viscera
● Infections
● Embolisation of dye and contrast – Echovist®
Sample answer
(a) What radiological options will you consider? (7 marks)
Tubal function can be assessed by radiological and non-radiological tests. The radiological
approaches to tubal function assessment include HSG and HyCoSy or saline.
Hysterosalpingography is an outpatient procedure, usually performed without GA. It
involves the administration of a contrast medium (e.g. Urografin®) through the cervical and
uterine canals into the Fallopian tubes. This allows visualisation of the course of the tubes, and
localisation of any blockage and peritubal adhesions. Where there is tubal blockage, it localises
the site of obstruction. It has the added advantage of being able to diagnose cervical weakness
(incompetence) and intrauterine adhesions/suspected polyps. In addition, pathognomonic
appearances may aid in the diagnosis of pelvic tuberculosis affecting the Fallopian tubes. The
major disadvantages of this procedure include flare-up of subclinical chronic PID, vasovagal
attacks and trauma to the cervix. In addition, false-positive tubal blockages may be reported
because of tubal spasm. Unfortunately, this procedure does not allow for the examination of
the rest of the pelvis and therefore the exclusion of other factors associated with infertility,
such as endometriosis.
Contrast or saline hysterosonography using ultrasound for tubal patency assessment is an
option that is increasingly being applied in most units. These procedures have the same advantages as those of HSG, but tubal function has to be assessed dynamically during the procedure.
The main advantage over the latter is the use of ultrasound, which may allow the exclusion of
ovarian pathology and intramural fibroids (a possible cause of infertility that laparoscopy may
not identify).
(b) Critically appraise the non-radiological options. (7 marks)
The non-radiological methods of assessing tubal function are mainly endoscopic. The first of
these and possibly the gold standard is a diagnostic laparoscopy and dye test. Although it can
be performed under sedation and LA, it is most commonly performed under GA in the UK.
The advantages include its ability to identify abnormal fimbriae and associated pelvic pathologies, such as adhesions and endometriosis. In addition, some of these pathologies may be
treated (e.g. adhesiolysis) during the procedure. Unfortunately, it does not define the site of
tubal obstruction and cannot exclude uterine pathology, such as synechiae. Skilled clinicians
need to perform the procedure, which is more expensive than HSG. Where IVF may be a treatment option for the infertility, it allows for the assessment of the ovaries vis-à-vis oocyte
retrieval.
Although the above two diagnostic procedures are most common, others, such as falloposcopy (examination of the internal surface of the Fallopian tubes through the uterine canal)
and salpingoscopy (examination of the internal surfaces of the Fallopian tubes through the
external ostium of the tubes at laparoscopy), are available for the assessment of tubal function;
these procedures are quite specialised and therefore are only available in a few units. They
require skill and expensive equipment. The advantage of both procedures is their ability to
identify intratubal pathologies, which neither of the other two methods will identify. These
include thinning of the epithelium and adhesions (synechiae). Again, they are commonly performed under GA, although they can be performed under sedation and LA. These additional
assessments may help in the counselling of patients on their suitability for tubal surgery.
(c) Outline the complications of these procedures. (6 marks)
The complications of these procedures for assessing tubal patency depend on the procedure
being undertaken. For the radiological procedures, the complications include allergic reaction
to the contrast, flaring up of pelvic inflammation, trauma from instrumentation, pain and
occasional vasovagal attack from pain. Secondary pelvic infection may result from the introduction of the cannula into the cervix. These complications are similar to those occurring with
HyCoSy.
The complications of the various endoscopic procedures include procedure-related complications such as injury to viscera, blood vessels, infections, gas embolism and emphysema
and anaesthetic-related complications such as atelectasis and respiratory tract infections.
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