Fertility and Sterility Interventions

Hysterosalpingography : Contrast injection into endometrial cavity with fluoroscopy/imaging

Selective salpingography : Direct selective catheterization of fallopian tubal ostium

• Contrast injection via catheter during imaging

Fallopian tube recanalization : Guidewire/catheter passage through occluded FT to reestablish patency

Fallopian tube occlusion : Placement of mechanical occluding device into fallopian tubes

Selective salpingography indications

• Differentiate spasm from true obstruction

• Inadequate fallopian tube opacification by HSG

Fallopian tube recanalization indications

• Tubal occlusion despite selective salpingography

Fallopian tube occlusion indications

• Prophylaxis against unwanted pregnancy

Selective salpingography

• Advance 4-5-French catheter over 0.035" guidewire; wedge tip in uterine cornual region

• Gently inject contrast medium; obtain images

Fallopian tube recanalization

• Advance catheter/guidewire through obstruction

Fallopian tube occlusion

• Place device in most challenging side 1st

• Engage 5-French catheter working port in tubal ostium

• Advance device until 3rd radiopaque marker at tubal ostium; deploy Essure coil

Fallopian tube recanalization

• Procedural success: 71-92%

Fallopian tube occlusion

• Efficacy rate of Essure preventing pregnancy: 99.8%

Hysterosalpingography (HSG) : Contrast injection via cervical canal into endometrial cavity with fluoroscopic monitoring/imaging

• Normally shows filling of uterine cavity

• Should also show bilateral fallopian tube (FT) filling

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    Tubal patency confirmed if contrast spills from tubes into abdominal cavity

• Sensitivity and specificity in detecting pathology

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    Bilateral tubal pathology: 46% and 95%

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    Any fallopian tube pathology: 53% and 87%

Selective salpingography : Direct selective catheterization of fallopian tubal ostium

• Contrast injection via catheter during imaging

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    Provides direct opacification of fallopian tube

Fallopian tubal anatomy

• 4 tubal segments

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    Interstitial (intramural)

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    Isthmic

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    Ampullary

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    Infundibular

• Uterotubal junction located at transition of intramural to isthmic segment of fallopian tube

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    Narrowest portion of fallopian tube

• Average tubal diameter: 0.8-2.0 mm

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    Increases as fallopian tube courses toward ovaries

• Average tubal length: 11 cm (range: 7-16 cm)

Fallopian tube recanalization (FTR) :Guidewire &/or catheter passage through occluded fallopian tube to reestablish tubal patency

• Fallopian tube disease accounts for up to 35% of infertility cases; various causes

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    Infection (chlamydia)

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    Postsurgical

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    Salpingitis isthmica nodosa

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      Inflammation of isthmic segment; characterized by nodular thickening causing obstruction

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    Peritubal adhesions

• Proximal tubal occlusion often caused by mucus plug/inflammatory debris; also caused by spasm

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    Involves interstitial segment/uterotubal junction

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    Responds fairly well to recanalization

• Less favorable outcomes with more distal occlusions

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    More often due to scarring/fibrosis

Fallopian tube occlusion (FTO) : Placement of mechanical occluding device into fallopian tubes

• Type of bilateral tubal sterilization

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    Hysteroscopic transcervical fallopian tube access

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    Placement of Essure device (Conceptus; Mountain View, CA) into fallopian tubes

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      Combined outer nitinol/inner stainless steel coil elicits tissue growth; occludes fallopian tubes

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      During first 3 months device not fully effective

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      Alternate birth control needed during this time