DR/ ADEL FAROUK M.D.

ASSISTANT PROFFESOR of
Obstetrics & Gynecology
Cairo university
Infertility III
 Tubal factor
•Physiology.
•Etiology.
•Diagnosis:
1-History
2-Examination
3-Investigations:
Tubal patency tests
 Tubal factor
• Physiology: The physiological role of the tube
for pregnancy is:
• 1-The fimbriae of the tube should move at the
time of ovulation to embrace the ovary and to
pick up the ovum.
• 2- The tubal fluid should be non-hostile to
sperms or ovum.
• 3- The tube should be patent.
• 4-The tubal cilia and peristalsis should be
normal to help transport of the ovum and then
the zygote.
• Etiology of the tubal factor of infertility: see
before.
 Tubal factor
• Diagnosis:
• (1) History:
• History suggestive of salpingitis (acute abdominal pain,
fever and discharge).
• History of puerperal sepsis.
• History of previous operation on the tubes or other pelvic
operations.
• History suggestive of endometriosis (dysmenorrhea,
dyspareunia and irregular bleeding).
• (2) Examination:
• Inflammatory tubal swellings felt on bimanual
examination or nodules in Douglas pouch (in
endometriosis).
 Tubal patency tests
Idea: Tubal patency tests depend upon
injection of air, carbon dioxide, radio
opaque contrast or colored material
through the cervix. If the tubes are patent,
the injected gas or material will pass
through them into the peritoneal cavity
and its presence can be detected or
demonstrated there. On the other hand, if
the tubes are blocked no leakage will
occur.
 Tubal patency tests
Precautions:
The tests should be done under complete
aseptic conditions.
Carbon dioxide is better than air because it is
soluble in the blood (less risk of embolism).
The tests should be carried 3-5 days
postmenstrual to avoid the risk of embolism,
false +ve results (from blockage of tubal cornu
by thick endometrium), theoretical risk of
endometriosis due endometrial implantation in
the peritoneal cavity or risk of disturbing an
already present pregnancy.
The pressure should not exceed 200 mm.Hg.
High pressure increases the risk of embolism or
might rupture closed tubes.
 Tubal patency tests
Contraindications:
History or signs suggesting a chronic infection
in the tubes, cervix or vagina.
Premenstrual periods (it should be
postmenstrual) to avoid the risk of disturbing
already present pregnancy, to decrease the risk
of endometriosis and false results
During menstruation or uterine bleeding (can
cause embolism or endometriosis).
Women in whom pregnancy or anesthesia is
contraindicated.
 Tubal patency tests
Complications:
Ascending pelvic infection.
Air or oil embolism.
Endometriosis.
Abortion of undiagnosed pregnancy.
Rupture of closed tubes.
Allergic reaction to iodine.
Advantages:
Although these tests are primarily diagnostic, they have
also a therapeutic value. The therapeutic values of tubal
patency tests are attributed to:
May dislodge mucus plug blocking the tubes.
It may dissolve thin tubal adhesions.
It may overcome fimbrial stenosis.
It may eliminate utero-tubal spasm
 Tubal patency tests
Rubin’s insufflation: T shaped tube, the
vertical limb is connected with a manometer. One
end of the horizontal limb is connected with a CO2
source or a bulb and the other horizontal limb is
connected to a cannula passed through the cervix.
Criteria of tubal patency:
1- Drop of pressure in the manometer.
2- Auscultation of hissing sound over the lower
abdomen.
3- Shoulder pain.
4- Sub-diaphragmatic pneumoperitoneum by X
Ray.
Disadvantages: does not determine the
site of the block, type of the block, uni or
Rubin’s insufflation
T shaped tube
connected to a
manometer, CO2
source and cannula
 Sharman’s Kymography
The manometer in Rubin’s insufflation test is
replaced by a lever recording the pressure on a
rotating drum.
Can differentiate tubal block from spasm,
stenosis
Precautions, contraindications and
complications: As tubal patency tests
Disadvantages:
It cannot localize site of lesion (corneal,
isthmical, ampullary or fimbrial obstruction), the
prognosis of tubal block is better in cases of
fimbrial compared by cornual obstruction.
It does not differentiate uni from bilateral
Sharman’s Kymography
Tubal patency:
The gas pressure
oscillates between
40-60 mm Hg. where
5-10 oscillations per
minute are observed
(caused by
intestinal
peristalsis).
Sharman’s Kymography
• Tubal block: There
is steep rise of
pressure to 200 mm
Hg. where it is
maintained followed
by fall when the gas
is shut off.
Sharman’s Kymography
• Tubal spasm:
there is steep rise to
200 mm Hg.
Followed by normal
curve.
Sharman’s Kymography
• Tubal stenosis:
there is a rise of
pressure to 150 mm
Hg. Followed by a
slow fall.
 Hysterosalpingography
Idea:
Injection of a radio-opaque material in the uterine
cavity using a canula fixed to the cervix.
X Ray is taken showing the outline of the uterine
cavity and tubes.
A second film is taken later to show peritoneal
spill due to scattering of the dye by intestinal
movements.
The shadow of radio-opaque material may be
visualized during injection using image
intensifier.
 Hysterosalpingography
Technique:
Timing 2-3 days after the end of menstruation.
Dorsal position. Cervix is exposed by a
speculum and grasped by a volsellum.
No anesthesia (except if dilation is needed in
cases of cervical stenosis).
Complete aseptic precautions.
Antispasmodics: to overcome tubal spasm.
The cannula is introduced into the cervical
canal.
 Hysterosalpingography
Contrast media:
Lipiodol: oily medium (40% organic iodine in poppy- seed
oil).
- Valuable for detection of peritubal adhesions in control
film.
- The second film is taken 24 hours later with risk of oil
embolism or oil granuloma.
Urografin: water soluble, second film is taken 10- 30
minutes later.
- No risk of oil embolism or oil granuloma.
- Sharp outline of the uterus and tubes, not valuable for
detection of peritubal adhesions.
Amount of contrast medium: The capacity of the normal
uterine cavity is 6-8cc. larger amounts may be needed
when the cavity is enlarged e.g. uterine fibroids.
 Hysterosalpingography (contrast
medium)
Item Lipidol Urografin

Nature Iodine in oil Iodine in water

Injection Difficult injection Easy injection

Value Slowly absorbed, Rapidly absorbed

shows peri-tubal shows integrity of
adhesions tubal mucosa

2nd film 2nd film after 24 2nd film after 15

hours minutes
Complications May cause oil
granuloma
Hysterosalpingography (advantages)
1- Diagnosis of uterine anomalies as bicornuate
uterus or submucous fibroid.
2- Diagnosis of unilateral or bilateral tubal lesions.
3- Diagnosis of the type of tubal lesion (stenosis,
occlusion or spasm).
4- Diagnosis of peritubal adhesions (second film)
normally show the presence of free peritoneal spill
due to scattering of lipiodol by intestinal
movements if the tubes are patent, loculated spill
may indicate peritubal adhesions and dilated
appearance of the tubes may suggest
hydrosalpinges.
Hysterosalpingography (advantages)
5- It cannot localize site of lesion (corneal,
isthmical, ampullary or fimbrial obstruction), the
prognosis of tubal block is better in cases of
fimbrial compared by cornual obstruction.
6- May suggest a specific pathology. (T.B) (dwarf
uterus, lymphatic intravasation and extensive
intra-uterine adhesions, pipe stem tubal rigidity,
beaded tube with extensive peritubal adhesions).
7- More beneficial therapeutic value: as the
hydrostatic pressure is more effective in
overcoming tubal spasm or dislodgement of
mucous plug and iodine may cause Lysis of thin
adhesions.
 Hysterosalpingography
(complications)
• Shock or collapse.
• Oil granuloma.
• Oil embolism.
• Intravasation lymphatic or venous.
• Allergic reaction to iodine.
• Infection (cervicitis and salpingitis).
Hysterosalpingography

Cannula for hysterosalpingography

Hysterosalpingography
• The technique of
hysterosalpingography
dye injection through
canula in the cervix
•
Hysterosalpingography
Bicornuate uterus
Hysterosalpingography
Hysterosalpingography
Hysterosalpingography
 Multiple filling
defect are seen
within the
uterine cavity
(polypi)
Right tube lead pipe +
Intravasation left side
 Hysterocontrast sonography
(HyCoSy)
This a modern, ultrasound bases
investigation using a negative (normal
saline) or positive (Echovist[galactose
microparticles]) contrast media injected
through the cervix (by a special cannula or
pediatric Foley’s catheter) under vaginal
ultrasound guidance to outline the uterine
cavity and the fallopian tubes (simple test
with no exposure to X- rays or anesthesia)
 Laparoscopy
Indications:
1-When hysterosalpingography shows a tubal
block or peritubal adhesions.
2- When all the investigations show no
abnormalities and pregnancy does not
occur within 6 months. it can detect some
factors as (endometriosis).
 Laparoscopy
Idea:
Injection of colored material (Methylene blue) into the
uterus to appear at the abdominal ostium of the tube.
Laparoscopy can also reveal the presence of pelvic
endometriosis, cystic ovaries, tuberculous salpingits, and
recent corpous luteum denoting ovulation or the rare
possibility of luteinized unruptured follicle syndrome.
Technique:
Under anesthesia, bladder evacuated, the cervix is exposed by
a speculum and grasped by a volsellum. A cannula is inserted
into the cervix. The patient shifted to Trendelenberg position
Pneumoperitoneum: 2-3 liters of CO2 are introduced in the
peritoneal cavity by a special needle inserted at the lower
margin of the umbilicus.
Trocar and cannula are introduced, the trocar is removed and
the laparscope is introduced through the cannula into the
peritoneal cavity.
Light source in connected to the laparoscopy through a
fiberoptic cable (cold light).
 Laparoscopy

• Verrus needle (for peritoneal insuffulation) and

Troacar and Cannula used for laparoscopy
Laparoscopy
Laparoscopy
Laparoscopy
laparoscopy
 Laparoscopy
Complications:
1- Arrhythmias or cardiac arrest (due to pneumoperitoneum and
trendlenberg position).
2- Gas embolism (CO2 under high pressure).
3- Surgical emphysema: injection of CO2 in the tissues of
abdominal wall
4- Bowel injury (direct or electrocautery).
5- Bleeding from injury of blood vessels in the abdominal wall or
abdominal cavity.
6- Infection.
Laparoscopy has a therapeutic rule (salpingolysis or treatment
of endometriosis), should be performed at the same time
N.B: Some workers prefer to use H.S.G. to delineate tubal
mucosa and to do laparoscopy to assess pelvic adhesions as
H.S.G. gives very high incidence of false +ve and false -ve
results in diagnosing peritubal adhesions.
 Tubal patency tests
VI) Falloposcopy: Introduced from the
fimbrial end of the tube through
laparoscopy to visualize the interior of the
tube, its main role in cases of unexplained
infertility or abnormal salpingography. It
may have a therapeutic role.
Laparoscopy
Salpingitis (retort
shaped appearance
of the fallopian tube)
detected by
laparoscopy.
Laparoscopy
• PCO detected by
laparoscopy.
Laparoscopy
Adhesions around
the fallopian tube
seen on laparoscopy
Laparoscopy
• Endometriosis seen
at laparoscopy.
Laparoscopy

Positive hydrotubation
test
(a spill of methylen
blue dye is seen
coming out from the
fimbrial end of the
tube)
Laparoscopic treatment of pelvic
adhesions
 Treatment of tubal factor
• A- Conservative treatment:
• 1- Hydrotubation
• 2- Short wave therapy
• 3- Repeated insufflations
• B- Surgical treatment:
Operations to restore tubal patency (tuboplasty).
C-In vitro fertilization and embryo transfer (I.V.F. &
E.T).
 Treatment of tubal factor
A- Conservative treatment: It has a limited value in the
management of tubal occlusion (rarely used). It includes
1- Hydrotubation:
Repeated intrauterine injection of hydrocortisone,
streptomycin and α chemotrypsin is believed to have effect
especially in cases with peritubal adhesions. The procedure is
done in the pre-ovulatory period for several cycles.
2- Short wave therapy:
About 24 sittings should be given, it leads to temporary
hyperemia of the pelvic organs, which may help to resolve
some adhesions, (doubted effect).
3- Repeated insufflations.
It is important to determine whether antibodies to Chlamydia
trachomatis are present in the serum by measuring IgG
antibodies to this organism as there is a good correlation
between presence of these antibodies and tubal adhesions.
 Treatment of tubal factor
B- Surgical treatment: Operations to
restore tubal patency (tuboplasty). The aim of the
tubal surgery is to restore the normal anatomy.
Tubal damage has been graded depending upon
the severity of the disease with grade 1 being the
least damaged and grade 3 and 4 being severely
damaged and surgery is only indicated in grades
1 and 2. surgery can be done by laparoscopy or
by open laparotomy but following the
microsurgical techniques is essential with
complete hemostasis and minimal handling of
tissues
 Tuboplasty
• Indications:
• Young patients with
• Bilateral tubal occlusion,
• With no other cause of infertility and the
male is normal.
• Laparoscopy is performed for proper
assessment. Exclude active infection or T.B
of the genital tract. One of the following
operations may be done.
 Tuboplasty
• Salpingolysis: Freeing the tube from
surrounding adhesions.
• Fimbriolysis: Freeing the fimbrial end in
cases of partial fimbrial occlusion.
• Salpingostomy: Artificial ostium in cases of
fimbrial obstruction e.g. hydrosalpinx.
• Excision of stricture and end-to-end
anastmosis.
• Tubal re-implantation in the uterus: In
cornual occlusion.
 Tuboplasty
• Prevention of adhesions:
-Complete hemostasis.
Microsurgical techniques (minimal tissue trauma).
Antibiotics.
- Corticosteroids.
Anti-inflammatory agents.
• Prognosis: Success rate does not exceed 30-35%.
- Best results in salpingolysis (mucosa is not
affected).reversal of tubal sterilization achieve good
results as the tubal damage is unlikely and the
woman has proven fertility.
- Laparoscopy should be performed later on to assess
the results of the operation.
Tubal fimbria closed by salpingitis
Opening the closed fimbria
Neo- salpingostomy
Completing neosalpingostomy
Transcervical cannulation of the tube: in
cornual occlusion, done by either
falloposcopy or salpingograghy. In 50% of
these cases the obstruction is not organic
but due to thickened endometrium, tubal
spasm or tubal plugs.
A wire of soft platinum tip is passed through the
uterine opening of the tube, it is done through
hysteroscope, transvaginal sonography or
fluoroscopy, a catheter is then passed over the
giuide wire to perform selective salpigography to
confirm the diagnosis of organic cornual block prior
to treatment
Tubal cannulation for treatment of
proximal tubal block
 Treatment of tubal factor
C- In vitro fertilization and embryo
transfer (I.V.F. & E.T). : In irreparable tubal
damage in grade 3 and 4 tubal damage.
Steps: see assisted conception techniques
later