Accuracy of endovaginal sonography for the detection of fallopian tube blockage

Modern assessment of the uterine cavity and fallopian tubes in the era of high-efficacy assisted reproductive technology

The high efficacy of modern assisted reproductive technology (ART) and increase in the number of noninfertile patients who are using ART for family building in the United States call into question the relevance of the standard, one-size-fits-all infertility evaluation. Here, we explore whether all patients presenting for ART need uterine cavity and tubal assessment and what tests are most appropriate, efficient, and cost-effective in current times.

[Results of tubal plasty: ruslts of a Tunisian study]

L'infertilité d'origine tubo-péritonéale est toujours d'actualité, sa fréquence reste stable, sinon croissante. La coelioscopie permet à la fois d'affirmer l'atteinte tubaire et de proposer un geste thérapeutique adapté. Le but de notre travail est d’évaluer les résultats de la chirurgie laparoscopique des pathologies tubaires en termes de grossesses obtenues. Il s'agit d'une étude rétrospective descriptive, analytique et longitudinale. Nous avons colligé les patientes suivies pour infertilité et opérées pour pathologies tubaires distales au service A du centre de maternité et de néonatologie de Tunis. Nous avons étudié les caractéristiques épidémiologiques et cliniques des patientes, les résultats de l'imagerie et détaillé les gestes chirurgicaux réalisés. Les résultats de la chirurgie tubaire distale étaient exprimés en termes de grossesses obtenues avec un recul minimal de 12 mois et maximal de 5 ans. 898 patientes étaient prises en charge dans le service pour une infertilité dont 52 patientes avaient répondu aux critères d'inclusion à l’étude. La sensibilité de l'hystérosalpingographie en matière de lésions tubaire était de 69% et la spécificité de 100%. Selon le score d'opérabilité tubaire distale, 23% des lésions étaient classées au stade 4 et 13.46% au stade 1. Le taux de grossesses spontanées était de 8.69%, soit 13% des fimbrioplasties et 4% des néosalpingostomie. Le délai de conception allait de 4 à 9 mois. Les antécédents ou stigmates d'infection pelvienne étaient retenus comme facteur de mauvais pronostic. Une sélection rigoureuse des patientes à partir des données de l'hystérographie et de la coelioscopie est indispensable afin de déterminer les patientes candidates à une chirurgie réparatrice ou à une fécondation in vitro

Three-dimensional ultrasound inversion rendering technique facilitates the diagnosis of hydrosalpinx

PURPOSE

To test the utility of three-dimensional (3D) ultrasound (US) inversion rendering technique in the evaluation of fluid-distended fallopian tubes.

METHODS

Fifty-two patients with fluid-filled adnexal masses suspected of being abnormal fallopian tubes were scanned by two-dimensional and 3D transvaginal ultrasound (TVUS). Six patients had bilateral disease. The acquired volumes were then "inverted" to display a cast-like appearance of the fluid-filled structures. The ipsilateral ovaries were identified in all patients. Five patients had acute tubal disease.

RESULTS

Fifty-two of the 58 inversion renderings yielded acceptable images of hydrosalpinges. Only in four patients were the two-dimensional images more informative than the 3D-rendered and inverted views. In nine patients adjacent corpora lutea, ovarian cysts, and follicles within normal ovaries were also identified, but appeared separate from the fluid-filled tubes. The tubes in the patients with acute disease were all successfully inverted.

CONCLUSIONS

The 3D inversion technique is a simple and effective way to render fluid-filled spaces, which may be tortuous and follow various directions. The rendered images increased the confidence in diagnosing hydrosalpinx.

The management of hydrosalpinges: tubal surgery or salpingectomy?

PURPOSE OF REVIEW

The clinical management of hydrosalpinges in infertile patients remains a contentious issue. This review aims to provide a critical analysis on the available treatments for hydrosalpinges, which have recently created a fierce debate between the promoters of salpingectomy and in-vitro fertilization and those who endorse tubal surgery.

RECENT FINDINGS

Hydrosalpinges have a detrimental effect on the outcome of in-vitro fertilization yet their mechanism is still unclear. Salpingectomy prior to in-vitro fertilization restores the likelihood of a successful outcome in a well defined group of patients with ultrasound-visible hydrosalpinges. However, not every woman with large hydrosalpinges should undergo salpingectomy as some fallopian tubes may be amenable to surgical repair. Preserved tubal mucosa indicates a good prognosis for tubal surgery, therefore an appropriate mucosal assessment should be routine prior to deciding upon further management.

SUMMARY

As salpingectomy is a definitive procedure it should be performed when the hydrosalpinges are beyond repair or in cases of in-vitro fertilization failure. Tubal surgery should be preferred to salpingectomy in mild to moderate tubal disease. A comparative study of restorative tubal surgery versus salpingectomy and in-vitro fertilization in selected women with hydrosalpinges is needed and will significantly help this debate. Prophylactic salpingectomy prior to in-vitro fertilization and tubal surgery is not competing but complementary in the treatment of hydrosalpinges-related infertility.

Likelihood Ratio of Sonographic Findings in Discriminating Hydrosalpinx from Other Adnexal Masses

OBJECTIVE

The objective of our study was to describe the "waist" sign as a feature of hydrosalpinx and to calculate the likelihood ratio of sonographic findings for predicting that a cystic adnexal mass is a hydrosalpinx.

MATERIALS AND METHODS

Consecutive institutional records were reviewed to identify patients with surgically excised cystic adnexal masses and preoperative sonograms that had been used to identify the mass. Two radiologists blinded to outcome reviewed the sonograms and recorded the presence of five specific sonographic findings: incomplete septation, short linear projection, small round projection, tubular shape, and presence of a waist. The likelihood ratios of these signs and combinations of signs for the diagnosis of hydrosalpinx were calculated.

RESULTS

There were 55 patients with 67 cystic adnexal masses. Of the 67 cystic adnexal masses, there were 26 hydrosalpinges (39%), 36 cystic ovarian neoplasms (54%), and five paraovarian masses (7%). The likelihood ratios for the sonographic findings were as follows: incomplete septation, 2.1; short linear projection, 3.5; small round projection, 2.7; tubular shape, 10.5; and waist sign, 20.5. The waist sign in combination with tubular shape was found in 12 hydrosalpinges and no other masses (likelihood ratio of between 18.9 and infinity). Small round projection combined with tubular shape was found in 14 hydrosalpinges and one other mass (likelihood ratio of 22.1).

CONCLUSION

Hydrosalpinx can be diagnosed with the highest likelihood when a tubular mass with the waist sign or a tubular mass with small round projections is encountered. Incomplete septations and short linear projections are less discriminating findings of hydrosalpinx.

Controversies in the surgical management of hydrosalpinx

The surgical management of hydrosalpinges is a controversial subject. Chronic pathology of the fallopian tube with distal obstruction leads to the formation of a hydrosalpinx, and is associated with very poor pregnancy rates after surgery. In these cases, in-vitro fertilization has proved to be a much better alternative. However, several studies have shown that patients with hydrosalpinges have significantly lower pregnancy and implantation rates after in-vitro fertilization compared with patients with other forms of tubal damage. The exact mechanism by which the hydrosalpinx adversely affects in-vitro fertilization results is not yet fully understood. The value of performing a salpingectomy before in-vitro fertilization has been studied extensively. Currently, a clear benefit in salpingectomies has been proved for patients with ultrasonically visible hydrosalpinges.

Hydrosalpinx and ART: hydrosalpinx--functional surgery or salpingectomy?

The debate on the effect of the hydrosalpinx on medically-assisted reproduction has demonstrated the importance of understanding the complex pathophysiology of the hydrosalpinx in outlining the principles of its clinical management, whether it is by functional surgery or IVF, preceded or not by salpingectomy. New endoscopic techniques are available to accurately assess, both in the operating room and the office, the quality of the tubal mucosa. The direct endoscopic evaluation of the tubal mucosa in hydrosalpinges is at present the most reliable technique to select between functional surgery and preventive salpingectomy. In future, prospective randomized studies on salpingectomy will benefit greatly from accurate clinicopathological data.

Transvaginal ultrasonography associated with colour Doppler energy in the diagnosis of hydrosalpinx

The aims of this prospective study were to investigate the accuracy of B-mode transvaginal ultrasonography alone, using the typical finding of the presence of an elongated shaped mass with incomplete septa, in the screening of hydrosalpinx in women undergoing surgery for gynaecological diseases, and to determine the predictive value of this method combined with colour Doppler energy (CDE) imaging evaluation and CA125 concentrations in differentiating hydrosalpinx from other adnexal masses. In the first part of the study, 378 consecutive pre-menopausal non-pregnant women were submitted to transvaginal ultrasonography alone before surgery. In the second part of the study, 256 adnexal masses underwent transvaginal ultrasonography combined with CDE imaging evaluation associated with spectral Doppler analysis and plasma concentrations of CA125. Sensitivity and specificity for the ultrasonographic screening were 84.6 and 99.7% respectively, calculated for each adnexum (n = 756) and 93.3 and 99.6% respectively, calculated for each mass, for differentiating hydrosalpinx from other adnexal masses. The CDE imaging and the evaluation of CA125 plasma concentrations do not seem to increase the accuracy of B-mode transvaginal ultrasonography. Inter- and intra-observer agreement, expressed in terms of k-values, was high (0.87 and 0.93 respectively). In conclusion, transvaginal ultrasonography alone is a useful method of detection of hydrosalpinx.

Adverse effects of hydrosalpinx on pregnancy rates after in vitro fertilization-embryo transfer

OBJECTIVE

To determine the effect of hydrosalpinx on the establishment of pregnancy after IVF-ET.

DESIGN

Metaanalysis.

SETTING

University medical center.

PATIENT(S) AND INTERVENTION(S)

All published reports (n=13) and abstracts (n=10) in English that examined the relation between hydrosalpinx and IVF-ET were included in the analysis. The metaanalysis was performed by first calculating the odds ratios for each trial and then combining them to obtain a pooled estimate of the odds ratio and a 95% confidence interval.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy.

RESULT(S)

A total of 5,569 cycles was reviewed in the group without hydrosalpinx, and a total of 1,144 was reviewed in the group with hydrosalpinx. The clinical pregnancy rate was approximately 50% lower in patients who had hydrosalpinx. Similarly, the implantation rate was decreased by 50%. These effects were observed also in thawed ET cycles. The abortion rate was more than twofold higher in patients who had hydrosalpinx.

CONCLUSION(S)

This metaanalysis suggests that hydrosalpinx is associated with a reduced chance of implantation and an increased risk of pregnancy loss.

The management of hydrosalpinges before in-vitro fertilization and embryo transfer

Several recent studies have shown that the presence of hydrosalpinges adversely affects clinical pregnancy rates achieved with in-vitro fertilization and embryo transfer. Hydrosalpinx fluid may be toxic to the endometrium or embryo, or may mechanically interfere with implantation. Some authors recommend surgical correction of hydrosalpinges before in-vitro fertilization and have shown promising results with this approach. Proper patient selection for this therapy still needs to be defined.

The significance of hydrosalpinx in in vitro fertilization

OBJECTIVE

To review the effects of hydrosalpinx on IVF/ET and the role of salpingectomy.

DESIGN

The literature on hydrosalpinx, IVF/ET, embryotoxicity, and salpingectomy for hydrosalpinx was identified through MEDLINE searches and reviewed.

RESULT(S)

Hydrosalpinx has been associated with poor fertility prognosis. IVF/ET is a better alternative to tubal surgery for those patients with severe distal tubal disease, and it is also more cost effective. However, the presence of hydrosalpinx has a negative effect on IVF/ET by decreasing the pregnancy rates and implantation rates compared with patients undergoing IVF/ET for tubal disease but without hydrosalpinx. The hydrosalpingeal fluid has been demonstrated to be embryotoxic to developing embryos, thus leading to increased early pregnancy losses. Poor endometrial receptivity has also been demonstrated in the presence of hydrosalpinges. Removal of the hydrosalpinges leads to improved IVF/ET rates comparable to those patients without hydrosalpinx. Therefore, salpingectomy has been recommended for patients with hydrosalpinx who will be undergoing IVF/ET.

CONCLUSION(S)

The presence of hydrosalpinx has a negative effect on IVF/ET because of the suspected embryotoxicity of the hydrosalpingeal fluid. Surgical removal of the hydrosalpinx has been shown to improve IVF/ET rates.

The adverse effect of hydrosalpinges on in vitro fertilization pregnancy rates and the benefit of surgical correction

OBJECTIVE

To test the hypothesis that IVF-ET pregnancy rates (PRs) for patients with tubal factor infertility are decreased in patients with hydrosalpinges and that surgical correction reverses this effect.

DESIGN

Retrospective chart review.

SETTING

Private practice IVF-ET program.

PATIENT(S)

Patients (n = 160) undergoing 238 cycles of IVF-ET were stratified into groups based on the presence of hydrosalpinges and whether surgical correction had been performed. Patients >39 years old and patients with male factor infertility were excluded from the study.

INTERVENTION(S)

Patients with hydrosalpinges were offered surgical correction.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy defined by an intrauterine gestational sac.

RESULT(S)

Patients with hydrosalpinges had significantly decreased implantation rates and PRs per transfer (2.8% and 8.5%, respectively) than patients with tubal factor infertility but without hydrosalpinges (15.7% and 38.6%). Surgical correction improved implantation rates and PRs in patients with prior failed cycles (16.1% and 37.5%) and in patients undergoing surgery before IVF-ET (21.8% and 51.7%). The type of surgery performed did not affect success rates in the small number of patients evaluated.

CONCLUSION(S)

The presence of a hydrosalpinx during an IVF-ET cycle results in significant decreases in implantation rates and PRs. Surgical treatment of hydrosalpinges before IVF-ET cycles improves implantation rates and PRs.