tubal factor is almost 30% of all female infertility causes.Hence evaluation of tubes is usulally the first of the testings. this presentation evaluates all the methods for evaluation of fallopian tubes

1. IMAGING FOR
TUBAL FACTORS IN
INFERTILITY
www.rainbowhospitals.org
NARENDRA MALHOTRA
LAXMI SHIRIKHANDE
JAIDEEP MALHOTRA
SONAL PANCHAL
NEHARIKA MALHOTRA BORA
PARUL MITTAL
(LATE SAKSHI MITTAL)
Agra

2. Incidence of tubal infertility
 Around 10-15 % couples are subfertile
 Main causes of infertility in women include
 anovulation,
 tubal 30-40 % of all female factors
 peritoneal factor,
 uterine,
 cervical, and
 idiopathic infertility

3. FALLOPIAN TUBES
 ISOECHOIC
 NOT SEEN NORMAL BY USG
 ONLY SEEN WHEN FLUID IN OR
AROUND THE TUBE
 PID SALPINGITIS VERY COMMON AND
CAUSE DAMAGE.
 CONTRAST MEDIUM USED TO STUDY
THE PATENCY AND LUMEN:POSITIVE
CONTRAST ECHOVIST(HYCOSY)
 NEGATIVE CONTRAST STERILE
SALINE(SONOSALPINGOGRAPHY)

4.  Tubal pathologic conditions are the
underlying causes in 30% to 40% of
infertility cases
 Increasing trend-
 PID,
 ectopic,
 IUCDs,
 endometriosis,
 previous pelvic surgeries,
 salpingitis,Berek JS. Berek and Novak’s Gynecology. 14th ed. Philadelphia, PA:
Lippincott Williams & Wilkins; 2007.

5. Are tubes merely a pipe ?
 Even if patent does not mean that it is normal
 Most people think of fallopian tubes as simple
pipes that allow egg and sperm to meet, and the
fertilized egg to reach the uterus.
 However, in actuality, a fallopian tube
is a much more dynamic organ.
 The effect of this negative pressure and sucking
action plays its best when the fimbrial end
expands and covers the ovulation site of the ovary
well.

6. This explains that it is not
sufficient to know that the tubes
are patent:
It is important to know
 The motility of the tube
 Condition of the tubal lumen and
fimbriae
 Tubo-ovarian relationship

7. Function tests vs Patency
tests
 While a full testing of tubal
functions in patients with
infertility is not possible,
 testing of tubal patency is
important as tubal obstruction
is a major cause of infertility.

8. Various tests for tubal
patency
Difficult organ to assess because deep,
small, tortuous and complex.
 Hystero-Laparoscopy- Gold standard
 Hysterosalpingogram (HSG)
 Hysterosonogram (HSN)
 Selective Hysterosalpingogram
 Magnetic resonance HSG
 Saline or Contrast Sonohysterogram (SHG)
 Hystero salpingo contrast sonography (HyCoSy)
 3D and 4 D contrast ultrasonography
 Rubin’s test

9. Tubal patency tests are not
done
 women who are having their period,
 are pregnant, or
 have a pelvic infection.

10. Rubin’s test
 Earlier was the only test available for
tubal assessment.
 Has been condemned since
decades.

11. Hystero-Laparoscopy
a complete evaluation tool
 Both tubal ostia
 Fimbrial assessement
 Tubo Ovarian relationship
 E/o Koch’s , PID , Endometriosis
 Diagnostic & operative
 Therapeutic effect
 General anesthesia
 Cost
 Invasive
 0.13% risk of surgical complications
 Every clinic may not have the Facility

12. Various tests
 laparoscopy is unsuitable for routine use
in subfertile women on a large-scale, as a
diagnostic tool(invasive)
 It remains the gold standard for those who
wish to have a definitive diagnosis and where
USG has picked up some abnormality
 However, all three (CAT, HSG and HyCoSy)
tests are proved to have similar accuracy in
terms of identifying women who should
have laparoscopy.

13. Hysterosalpingography
 HSG has been widely used for assessment
tubal patency.
 It opacifies the endometrial cavity and both
fallopian tubes at a time and also shows spill if
the tube is patent.

14. Hysterosalpingography
 It has an advantage
 To study the endometrial cavity and diagnose
mullerian abnormalities and endometrial lesions
 To assess the whole tube, condition of the lumen.

15. Hysterosalpingography
 But carries disadvantages of..
 Using iodinated contrast
 Exposure to radiation
 Is extremely painful
 Needs sedation and sometimes even anesthesia
 Needs to be done in a radiology set up
 More over it is a static picture and
fimbrial condition can not be assessed.

16. HSG-advantages
 outpatient procedure
 is relatively inexpensive,
 does not require general anesthesia, and
 is associated with a therapeutic effect.
Speroff L. Clinical Gynecology and Infertility. 7th ed. Philadelphia, PA: Lippincott
Williams & Wilkins; 2005.

17. HSG needs a correct
interpretation by an fertility
expert
 Spilling of the dye, however, does not always
indicate normal fallopian tubes.
 It takes an experienced expert to correctly
interpret "normal" tubal anatomy on HSG.
 Indeed, the interpretation of HSG films is the
most frequently falsely interpreted test in
medicine!
 We constantly see patients with diagnosis
of "normal tubes" on HSG, who, when we
closely examine their X-ray films, turn out
to have obvious tubal disease.

18. HSG needs a correct
interpretation by an fertility
expert
 Our radiology colleagues focus on whether the
tubes are "open" when they perform and
interpret HSG.
 This is a fundamentally different question from
what we, fertility specialists, try to answer by
HSG:
 For us, the question is whether the tubes are
"normal.“
 Normal tubes, of course, have to be open;
open tubes, however, are not always normal.!

19. TVS as a mode for tubal
assessment
 A normal fallopian tube is not seen with
regular ultrasound.
 Even if the fallopian tube is blocked, it may
still be difficult to see on regular
ultrasound unless there is hydrosalpinx

20.  Transvaginal ultrasound brought a revolution
in assessment of pelvic organs, uterus and
ovaries.
 Though it was not possible to assess normal
fallopian tubes with only potential lumen.
 Sonohysterosalpingography was an
answer for assessment of fallopian tubes
by ultrasound.

21. SHG
 SHG uses ultrasound to watch the movement
of normal saline injected into the uterus.
 SHG does not use X-rays or an iodine dye.

22. SHG adverse effects
 The adverse effects of SHG experienced
during the study consisted of pain and
vasovagal reactions.
 Stenosis of the cervix is the most common
cause of the SHG failure.
Jeanty P, Besnard S, Arnold A, Turner C, Crum P. Air-contrast
sonohysterography as a first step assessment of tubal patency. J
Ultrasound Med 2000; 19:519–527.

23. SHG-contraindications
 acute sexually transmitted diseases,
 PID,
 abnormal uterine bleeding,
 fluid in the cul-de-sac before the procedure,
and
 positive pregnancy test

24. SHG-advantages
 out-patient setting,
 associated with minimal patient discomfort
and a low risk of infection.
 noninvasive
 easy to perform in almost any medical setting
 does not require sedation or anesthesia,
 nor does it have any adverse effects or severe
related complications
Tunis Med. 2013 Jun;91(6):387-90.
The value of sonohysterography in the diagnosis of tubal patency among infertile
patients.
Malek-Mellouli M, Gharbi H, Reziga H.

25. SonoHSG – When to do ?
 Follicular phase of menstruation
 6 to 10 days after LMP
 After menstruation
 2 to 3 days after bleeding stops
 Before ovulation

26. Sonohysterosalpingography(
SSG)
 On gynec couch
 Lithotomy or like position
 Clean with betadine
 Premedicate with atropine( 0.5mg) and
glucagon(1mg)
 Oral antibiotic cover may help.

27. Sonohysterosalpingography
 Catheter 8 Fr.( ext. diam.
1.6mm, int.diam.1.1mm)
through the cervix, with
balloon just above the
internal os.
 Distend the balloon by 1.5
– 2 ml of fluid

28. Sonohysterosalpingography
 Introduce the probe into the vagina after
removing the speculum and tenaculum, but with
catheter in situ.
 Slowly inject 5 – 10 ml of normal saline with 20
ml syringe
 Concentrate scanning on uterus and ovary
in transverse section and observe any fluid
dribbling out around the ovary.
 Repeat the procedure on opposite side.

29. Applying pulsed doppler
 In cases where there is a doubt about patency
on B mode...
 Doppler gate is placed at the site of suspected
block
 Brief injection (<5 sec) of saline is made
 Patent tube will give long, drawn out noise
band thet gradually decreases in intensity.
 Block is seen as short steep doppler shift
followed by no noise signals.

30. SHG/Hysteroscopy
 diagnostic accuracy of SHG is comparable
with that of hysteroscopy.
 Although hysteroscopy enables visualization
and evaluation of the uterine cavity only, SHG
allows evaluation of both the uterus and
adnexa.
J Ultrasound Med.2009 Dec;28(12):1671-7.
Diagnostic value of sonohysterography in the determination of fallopian tube patency as an initial step
of routine infertility assessment.Hajishafiha M, Zobairi T, et el

31. Comparison of SSG, HSG and
Laparoscopy
 Sensitivity of SSG is 97.3% for open tubes and
specificity of 92% and of laparoscopy is 94.6
%, where as sensitivity of HSG is 94.5 % but
with a specificity of only 84%.
Seal Subrata et al, J. Obstet and Gynecol India 2007; 57(2);
158-61,

32. Comparison of SSG, HSG and
Laparoscopy
 Results of SSG correlated positively with
laparoscopy in 97% and SSG and HSG
showed 93% correlation.
Kore S. et al, J. Obstet and Gynecol India 2000;50(2);63-6

33.  Can be used as an initial investigation for
infertile patients and laparoscopy can be
deferred for 6 months.
 Meanwhile endocrinological and immunological
causes are ruled out and then if required
laparoscopy may be done.
Seal Subrata et al, J. Obstet and Gynecol India 2007; 57(2);
158-61.

34. Sonohysterosalpingography
 Same procedure can be done using colour
doppler instead of only B mode, concentrating
on the adnexa for passage of fluid.

35.  Adding colour doppler may increase the efficiency
and accuracy of SIS for assessment of tubal
patency.
 Kalogirou D, et al, Clin Exp Onstet Gynecol 1997; 24(2):
101-3.

36. HYCOSY WITH ECHOVIST

37. WHAT IS A HYCOSY
 Hysterosalpingo-contrast-sonography (usually
shortened to HyCoSy) is a simple and well-tolerated
outpatient ultrasound procedure used to assess the
patency of the fallopian tubes, as well as detect
abnormalities of the uterus and endometrium.

38. HycoSy procedure
 Hysterosalpingo contrast sonography
(HyCoSy) is a transvaginal ultrasound
technique in which a mixture of air and saline
is infused into the uterine cavity and observed
to flow along the fallopian tubes to assess
tubal patency.
 The bright echoes generated by the saline
and air bubbles makes tubal visualization
possible.
 The procedure is also called sonographic
hysterosalpingogram or Sono HSG.

39. HYcoSy-Tubes not seen
 Spasm of the uterus at the opening of the
fallopian tubes, which temporarily prevents the
flow of contrast from the uterus into the tube
 Permanent tubal occlusion, secondary to an
underlying problem such as pelvic adhesions
 Technical factors may hinder visibility during
the ultrasound, such as uterine fibroids, size of
the patient abdomen, and bowel in the pelvis.

40. HycoSy
 The HyCoSy method is an acceptable, time-
efficient and well-tolerated alternative to HSG;
it has been found to have comparable
accuracy in the assessment of the uterine
cavity and tubal patency
Saunders RD, Shwayder JM, Nakajima ST. Current methods of tubal
patency assessment. Fertil Steril 2011; 95: 2171–2179.

42. Tubal block

43. Saline infusion HSG
 Agitated saline – Shaking the syringe containing air
and saline before infusion – microbubbles – bright
echoes
 Saline with air – Sion test – 20 ml – flow of saline
and micrometerised air bubbles
 Saline after air – continuous or dotted hyperechoic
line – air bubbles move rapidly with saline
 Colour doppler – forward of flow of saline – atleast 5
sec – pars intramuralis and isthmus tubae without
interruption, HS, fimbrial turbulance to cul-de-sac

44. Agitated Saline(Passage of the
fluid confirms patency)
 Agitated saline – Shaking the
syringe containing air and saline
before infusion – microbubbles –
bright echoes

45. Saline after air
 Saline after air – continuous or dotted
hyperechoic line – air bubbles move rapidly
with saline

46.  Probe is so set that uterus and ovary are
seen on the same section

47. Contrast is slowly and steadily injected into the
uterine cavity through the catheter.

48. Passage of contrast is observed across the
cornu, through adnexa, upto the ovaries on
both the sides one by one on contrast
enhanced mode.

49. Right distal tubal block

50. Comparative study of hydrosalpingosonography
with HyCOSy has shown following results:
Hydro
salpingography
HyCoSy
Sensitivity 91% 87%
Specificity 71% 84%
PPV 55% 69%
NPV 95% 94%
Lanzani C, et al, Fertil Steril 2009; 92(3): 1158-61.

51. But curved tubes can not be
completely seen on 2D

52. To fight out this problem, 3D has been tried
with contrast mode.
Volume is acquired as the contrast is seen
progressing from the tube.

53. FALLOPIAN TUBES EVALUATION

54. Magicut can be used on 3D
rendered image ...

55. The uterus and tubes can be
simultaneously and fully
studied.

56.  We prefer to use HD live with magicut for
these rendered images.
 Though if the images are zoomed in, whole
uterus and tubes can be included in a
single frame, we do not prefer to do that as
in smaller images, fimbrial details might not
be as clear.

60.  Individual volumes may be stored for each
side and reconstructed.
 These can be cut and paste together on
computer.

64. 3D:hydrosalpinx inversion
mode

65. Information derived by this
investigation
 Patency of the tube
 Site of block
 Condition of the tube
 Condition of the fimbriae
 Partial idea about tuboovarian relation.

66. Comparison of 3D HyCoSy with
diagnostic laparoscopy has
shown
 That 3D HyCoSy has 100% sensitivity, 67%
specificity, 89% PPV and 100% NPV for
tubal patency and concordance rate with
laparoscopy was 91%.
Chan CC et al, Acta Obstet Gynecol Scand, 2005, 84(9):
909-13.

67.  HyCoSy is recommended by the National
Institute for Health and Clinical
Excellence(NICE) as the investigation of
choice for otherwise asymptomatic women
who need fallopian tube patency
assessment as part of their assessment
for infertility.

68. HycoSy-pain score
 However, besides cervical stenosis, in some patients
severe pain (with or without vasovagal reaction) may
limit its success
Elsayes KM, Pandya A, Platt JF, Bude RO. Technique and diagnostic utility of saline infusion
sonohysterography. [Review] Int J Gynaecol Obstet 2009; 105: 5–9.
 Some authors showed that the HyCoSy technique is
equivalent to hysteroscopy and HSG for evaluation of
the uterine cavity, but it is less painful and invasive
Brown SE, Coddington CC, Schnorr J, Toner JP, Gibbons W, Oehninger S. Evaluation of
outpatient hysteroscopy, saline infusion hysterosonography, and hysterosalpingography in
infertile women: a prospective, randomized study. Fertil Steril 2000; 74: 1029–1034.

69. Hycosy-Modifications
 Gradually, HycoSy has developed from using a
negative contrast agent (saline solution) to a
positive contrast agent (microbubble agent)
 and from 2-dimensional (2D) to 3-dimensional
(3D)and even 4-dimensional (4D) imaging.
. Hysterosalpingo-contrast sonography (HyCoSy) using
Echovist-200 in the outpatient investigation of infertility
patients. Br J Radiol 1996; 69:910–913.
Automated sonographic tubal patency evaluation with three-
dimensional coded contrast imaging (CCI) during
hysterosalpingo-contrast sonography (HyCoSy). Ultrasound
Obstet Gynecol 2009; 34:609–612.

70. 3 D HycoSy-
 recruited 75 infertile patients
RESULTS:
 3D SonoVue-HyCoSy had a sensitivity of 93.5%, specificity of
86.3%, positive and negative predictive values of 87.8% and
92.6%, respectively, and diagnostic accuracy of 90.0%.
 The test-positive rates of 3D SonoVue-HyCoSy vs lap and
dye were not significantly different (82/150 vs 77/150, P >
0.05).
CONCLUSION:
 3D SonoVue-HyCoSy should be considered clinically
valuable as a practical, non-invasive, primary investigatory
tool for evaluating tubal patency.
•Ultrasound Obstet Gynecol. 2012 Jul;40(1):93-8. doi: 10.1002/uog.11085.
•Value of three-dimensional hysterosalpingo-contrast sonography with SonoVue in the assessment of tubal patency.
•Zhou L, Zhang X, Chen X, Liao L, Pan R, Zhou N, Di N.

71. 3 D HycoSy-adv
 it allows patients to avoid invasive surgery,
 is lower in cost compared with laparoscopy,
 avoids the risks that HSG carries of iodine
allergy and ionizing radiation exposure, and
 involves shorter examination times and
 potentially fewer side effects than has HSG.
Exacoustos C, Digiovanni A, Szabolcs B, Binder-Resinger H, Gabardi C, Arduini D.
Automated sonographic tubal patency evaluation with three-dimensional coded contrast imaging (CCI)
during hysterosalpingo-contrast sonography (HyCoSy). Ultrasound Obstet Gynecol 2009; 34: 609–612.

72. 4 D HycoSY
 A total of 192 fallopian tubes were assessed,
 The sensitivity, specificity, positive predictive
value, negative predictive value, for 4D
HycoSy versus laparoscopy were 81.8%,
90.5%, 81.8%, 90.5%, and 0.72 respectively
comparable to that of laparoscopy
First Experience Using 4-Dimensional Hysterosalpingo-Contrast Sonography
With SonoVue for Assessing Fallopian Tube Patency J Ultrasound Med July 1,
2013 32:1233-1243

73. HSG vs HycoSy
HSG Hycosy
Radiation exposure yes no
Reaction to iodine rarely no
Uterine problems Better seen
Radiology set up Required Not required
pain Less pain & better
tolerated

74. HycoSy vs HSG vs Lap
 HycoSy similar or perhaps somewhat superior to
those of HSG .
 In a recent review, Saunders et al reported rates
of 78.1% to 90.9% for concordance of HycoSy
with laparoscopy.
 The diagnostic accuracy of 3D HycoSy even
reached 90%.
Value of three-dimensional hysterosalpingo-contrast sonography with
SonoVue in the assessment of tubal patency. Ultrasound Obstet Gynecol
2012; 40:93–98.
. Current methods of tubal patency assessment.
Fertil Steril 2011; 95:2171–2179.

75.  prospective observational cohort study 73 patients
 A non-toxic foam containing
hydroxymethylcellulose and glycerol was
applicated through a cervical applicator for
contrast sonography (HyFoSy).
CONCLUSIONS:
 HSG can be avoided in about 78% of infertility
cases.
 HyFoSy is a clean and safe, non(embryo-) toxic
and a less expensive alternative to HyCoSy, that
can be performed by a single operator in the office
or ambulatory setting as a first step test of tubal
patency.
Hum Reprod. 2012 Jan;27(1):114-7. doi: 10.1093/humrep/der367. Epub 2011 Nov 6.
First experiences with hysterosalpingo-foam sonography (HyFoSy) for office tubal patency testing.
Emanuel MH, van Vliet M, Weber M, Exalto N.
HyfoSY

76. HyfoSY
 All 20 HyFoSy were technically successful
 There was a 100% agreement between tubal
patency data according to HyFoSy testing and
laparoscopic chromopertubation testing.
CONCLUSION:
 HyFoSy is both feasible and accurate in the
diagnosis of tubal patency.
Gynecol Obstet Invest. 2013;75(3):152-6. doi: 10.1159/000345865. Epub 2012 Dec
28.
The use of a new gel foam for the evaluation of tubal patency.

77. MR HSG
 20 infertile women
 Test results were compared with the previous
conventional HSG or laparoscopy inspection results.
 Endometrial and pelvic conditions could be well
displayed in the course of pelvic MR scan; uterine
malformations, uterine fibroids and pelvic conditions
such as hydrosalpinx were also well displayed.
CONCLUSION:
 Routine MRI scan with MR-facilitated HSG can better
display the fallopian tubes, ovaries, uterus and pelvic-
related structures and therefore has clinical value in
the diagnosis of infertility.
J Reprod Med. 2012 Sep-Oct;57(9-10):435-40.
Fallopian tubal patency diagnosed by magnetic resonance hysterosalpingography.
Ma L, Wu G, Wang Y, Zhang Y, Wang J, Li L, Zhou W.

78. Dynamic MR HSG
 dMR-HSG was successfully completed in 33/37
patient with an average study time of 45 min.
 The uterine cavity was completely visualized and
bilateral fallopian tube patency was confirmed by
dMR-HSG in 27 of 33 patients
 CONCLUSION:
 dMR-HSG with cervical cannulation and
intracavitary gadolinium injection is feasible and
allows assessment of the uterus, the fallopian
tubes, and extra-uterine pelvic structures, while
avoiding all ionizing radiation in infertile women
aiming at pregnancy.Acta Radiol. 2010 Jul;51(6):693-701. doi: 10.3109/02841851.2010.482564.
Feasibility of dynamic MR-hysterosalpingography for the diagnostic work-up of infertile women.
Winter L, Glücker T, Steimann S, Fröhlich JM, Steinbrich W, De Geyter C, Pegios W.

79. Virtual HSG using CT
 multidetector CT is capable of depicting both the
external and internal surfaces of the uterus,
fallopian tubes, and other pelvic organs, providing
high-resolution data that are suitable for two- and
three-dimensional reconstructions and virtual
endoscopic views.
 may prove to be superior to other noninvasive
modalities for evaluating tubal patency.
 is painless.
 virtual hysterosalpingography with multidetector
CT may provide a diagnostic advantage in
complex cases.
Radiographics. 2010 May;30(3):643-61. doi: 10.1148/rg.303095732.
Virtual hysterosalpingography: a new multidetector CT technique for evaluating the female reproductive system.

80. Take Home Message
 Hystero-Laparoscopy is the gold standard but is not a
screening test for tubal assessment
 Various screening methods are HSG, SHG & HycoSy
 HSG remains the time tested method but it requires
expert interpretation
 Patent tubes are not always normal tubes
 All 3 are comparable to each other in selecting those
woman who further need laparoscopy

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