Sperm-Egg Transport Solving Tubal Problems

When to Perform an HSG
When the woman's complaints or history indicates the possibility of tubal problems, the HSG will give me an excellent first look at the problem. I will order an HSG if she:

Has a history of repeated     vaginal infections
Suffered from one or more episodes of PID or postpartum infection
Has unexplained infertility
Has a history of abdominal surgery or ruptured appendix
Has had one or more ectopic pregnancies
If she has not conceived after sterilization reversal surgery

Purpose of the HSG
By squirting an opaque dye into your reproductive tract and taking X rays, we can see an outline of the inside of your uterus and tubes. The picture will reveal uterine abnormalities as well as tubal problems such as blockage and dilation (hydrosalpinx). If I'm planning a sterilization reversal, I can also see where the tubes are blocked and how much normal tube remains attached to the uterus. The X-ray study will not only help me plan the laparoscopy and possible surgery but also help corroborate my other findings.

Performing the HSG
To ensure that an early pregnancy is not exposed to potentially harmful X-ray dosage, your doctor will perform the HSG a few days after your period stops. Before you have the X ray, you may be premedicated with a non-steroidal anti-inflammatory drug such as: Aleve, Ultram or Motrin, for example, or given a local anesthetic. Your doctor will insert a small tube through the cervical opening. By forcing a syruplike X-ray dye into your uterus, the X ray can take a picture of the outline of your uterine cavity. As the dye travels into your fallopian tubes, it outlines the tiny passages and spills into your abdominal cavity. This lets us know that your tubes are open.

Interpreting HSG Findings
If the tubes are not blocked by adhesions or scar tissue, the dye will pour into the abdominal cavity. Demonstrating tubal patency is one good sign; however, it does not guarantee that the tubes will function normally.

The X-ray pictures also give us a rough estimate of the quality of the tubal structure and the status of the tubal lining. If the tube bulges, for example, we suspect a hydrosalpinx. And if we do not see the folds inside the tube, we know there may be serious abnormalities of the internal tubal architecture.

We can also see endometrial polyps, submucus fibroids, intrauterine adhesions (Asherman's Syndrome, synechia), congenital uterine cavity abnormalities (ie.,uterine septum & bicornuate uterus), or the aftereffects of genital tuberculosis.

Proximal tubal obstruction is a condition where the tubes appear blocked where they join the uterus. In some patients this may be due to tubal spasm and will not be seen on a repeat HSG. For other women, proximal tubal obstruction indicates severe damage to the portion of the fallopian tube where it crosses the uterine wall or merely debris clogging the tubal opening. I can often correct this problem by performing a recanalization procedure This involves passing a tiny wire through the uterine cavity, and into the fallopian tube thereby dislodging the offending debris. This procedure successfully restores tubal patency in at least one fallopian tube for up to 85% of patients. While up to one third of patients undergoing this procedure will conceive, it is of little or no benefit if the ends of the tube are also damaged.

Approximately 4 percent of infertile patients will have an abnormal HSG indicating salpingitis isthmica nodosa, a little-understood condition that responds very poorly to surgery. These couples could benefit most from in vitro procedures. The X-ray study may or may not detect pelvic adhesions, mild hydrosalpinx, endometriosis, tubal phimosis (clubbing of the fimbria at the end of the tube), or immobility of the tube.

Therapeutic Effects from the HSG
Although the primary purpose for ordering the HSG is not therapeutic, sometimes forcing the dye through the tubes will dislodge material blocking the tube. Without further treatment a number of women have become pregnant following the HSG.

Potential Complications from the HSG Procedure
Although complications from an HSG are infrequent, there is always the possibility for bleeding, infection, cramping, and the termination of an exposed pregnancy.

Advances in ultrasound have provided significant improvements in our ability to evaluate the uterus, ovaries and fallopian tubes. Sonohysterography placing a small amount of liquid into the uterus to better visualize the uterine cavity.

The use of specialized protein solutions and color-flow Doppler ultrasound allows us to visualize the liquid as it travels through the fallopian tubes and disperses in the abdomen. While this technique avoids X-ray exposure, the cost of the dye and color-flow Doppler ultrasound equipment limits use of this technique.

When to Perform a Laparoscopy
Since the laparoscopy is a surgical procedure done under general anesthesia, I attempt to rule out all other male and female fertility factors before performing it.

Depending on the woman's age and history and the findings from the workup, however, I may choose a more aggressive diagnostic approach for a particular couple. I'm more likely to use the laparoscopy sooner if the woman is in her thirties and/or if I find pelvic pain.

Normally I will perform a laparoscopy for the following reasons:

Suspected endometriosis
Blocked fallopian tubes
Ovarian cysts
Unexplained pelvic pain
Uterine fibroids that are in the outer layer of the uterus
Abnormal hysterosalpingogram findings
History of pelvic infection or surgery
Pre- and postoperative evaluation of tubal surgery
Failure to conceive after ovulation induction therapy
Diagnosis of ectopic pregnancy

Purpose of the Laparoscopy
The laparoscopy lets me visually inspect your reproductive organs. I can see if the tubes are deformed, swollen, or trapped in adhesions; I can see if the ends of the tubes are open and the fimbria functional; and if adhesions are preventing the egg from migrating from the ovary to the tubes. I can also detect the presence of endometriosis and perform a number of surgical procedures to correct various abnormalities. I will usually combine the the laparoscopic procedure with a diagnostic hysteroscopy to evaluate the inside of the uterine cavity.

Micro-Laparoscopy
Recent advances in the development of surgical equipment allows us to visualize the abdominal cavity with instruments less than 3mm in diameter. Because the laparoscopic telescope is so small, it can be passed through a needle without making an incision in your abdomen. This requires a minimal amount of local anesthesia and sedation through an intravenous line. Most women who undergo this procedure are back to normal in a few hours. Unfortunately, structures inside your abdomen such as the fallopian tubes, small bowel and ovaries can be very sensitive to manipulation, this technique is best for insuring that things are normal. In most cases if a significant abnormality is found, you will be put to sleep and a standard laparoscopy can be performed to correct the problem.

Performing the Laparoscopy
Since the period of greatest fertility immediately follows the first surgery, I may recommend delaying surgery until a time when I have optimized all other fertility factors and the couple is ready to conceive.

If I suspect you have endometriosis, I will perform the laparoscopy shortly after your period stops. Excising the endometrial implants at this time results in less bleeding and may reduce the likelihood of adhesion formation. (See also chapter 17, which discusses endometriosis in detail.)

A laparoscopy can be performed on an outpatient basis. First, you are given a general anesthesia. Then your doctor will slip the laparoscope through a small incision in your belly button. Through a second puncture just above your pubic bone, your doctor will slip in a small probe to manipulate your organs. Pressurized carbon dioxide gas forces your abdominal wall up and away from the organs so your doctor can get a clear view. After you awake from the anesthesia, you can return home. You may, however, wish to take a day or two off from work following the surgery.

As with the HSG, your doctor will force a dye through your uterus and tubes to demonstrate tubal patency (chromoputerbation). Many times, however, the dye will flow through only one tube (preferential flow) because that tube provides the least resistance. This does not mean that the other tube is blocked; on the other hand, it does not rule out that possibility either.

Many corrective procedures can be performed during a laparoscopy, thus saving the need for major surgery. Bipolar electrosurgery and laser surgery offer the surgeon safe and effective tools for performing these repairs. Many different types of laser equipment can be used for laparoscopic surgery (carbon dioxide, KTP, argon, and YAG). The laser uses light energy to cut, vaporize or cauterize tissue. Each laser system has advantages and disadvantages. Often the cost when a laser is used can be as much as $2000 more.

Newer energy sources such as bipolar electrosurgery and the harmonic scalpel may be cheaper. Healing, adhesion formation, and pregnancy rates do not seem to depend on which method is used. Therefore, although most physicians prefer one or another surgical instrument, s/he will likely decide which instrument based on cost-effectiveness and the type of surgery planned.