Fallopian tube selective catheterization and disobstruction

Clinical History

Infertility in a 32 year old female patient.

Imaging Findings

A female patient, aged 32 years old, with a history of long- standing infertility. Abdominal US, HyCoSy (Hysterosalpingosonography with contrast medium) and HSG (hysterosalpingography) with selective catheterization and disobstrucion of the left fallopian tube. The patient had attempted pregnancy during a period of 2 years. Fertility tests performed on her male partner were unremarkable, and the patient underwent herself testing to assess fertility. All blood tests were normal. Abdominal US (both upper abdomen and pelvis) was unremarkable. The patient underwent transvaginal US which showed no abnormality. During this examination a HyCoSy (US-guided hysterosalpingography) examination was also performed. The contrast used was composed of galactose particles in palmitic acid (Levovist, Schering - Germany), having checked that the patient had no contraindications to galactose administration. HyCoSy was inconclusive as visualization of both fallopian tubes was unsuccessful. Only the right fallopian tube was clearly demostrated. A HSG was then performed to ascertain patency of both fallopian tubes. As only the right fallopian tube was patent, the left one was selectively catheterized using a flexible guidewire to restore patency. Contrast was injected post-cathterization and both fallopian tubes were visualized. No other investigation were performed and the patient was then sent home. The patient remained pregnant three months following the HSG procedure.

Discussion

Fallopian tube recanalization is a technique for treatment of proximal tubal obstruction caused by debris. In a large series of HSG performed in infertile women, Wadin and co-workers (1994) reported the frequency of bilateral tubal obstruction to be 3% while that of monolateral tubal obstruction 2%. We reviewed the current literature to evaluate the success rate in fallopian tube recanalization procedure: the reported success in selective catheterization of at least one fallopian tube, when attempted ranges from 94.4% (Mallarini et al., 1992) to 100% (Kamiyama et al., 2000). In this latter study the results were compared between two groups of infertile female patients: in the first group selective salpingography was performed, while the procedure was not performed in the second group; the difference in pregnancy rate (both cumulative and total) was found to be significantly higher in the patients in which selective salpingography was performed. Failures have been ascribed to obstructive organic disease, where it is impossible to overcome the stenosis with the catheter or the guidewire. No complications are reported in the studies we found, although ectopic pregnancy is a possibility following selective tubal catheterization, because of the mechanically re-established patency in a nonfunctioning tube. The agreement in the findings between HSG and surgery is very high in all the studies we found in the literature (ranging from 74% to 96.8%), thus these results encourage the application of selective salpingography and catheterization in infertile women, either a sole therapeutic approach or in association with other methods of assisted reproductive technology, and some authors advocate the use of selective salpingography even if their fallopian tubes are shown to be patent by HSG. The examination consists in the introduction through the cervical os of a balloon-tipped catheter, sized 7-12 F, in the uterine cavity (a Foley catheter of appropriate size or a specific salpingography kit can be used). The balloon is inflated in the uterine cavity to maintain its position. Contrast medium injection is thus performed (usually low osmolar, non-ionic contrast medium with a concentration of 200-300 mgI/ml). The injection of radiopaque contrast medium allows visualization of the uterine cavity and fallopian tubes, if patent, and spill of contrast medium in the abdominal cavity. If one or both fallopian tubes are not patent, disobstruction can be performed in the same setting through the catheter placed in the uterine cavity. A flexible guidewire is introduced coaxially through the catheter and selective catherization of the obstructed fallopian tube is attempted. This maneuvre allows the patency of the fallopian tube to be re-established. X-ray images are obtained throughout the procedure. The use of a digital equipment (with a "grab-on" system during fluoroscopy) allows to reduce the radiation dose both to the patient and the operator, without reduction in the quality of the images. In our institution we have used the 12F salpingography kit produced by PBN (Denmark) or the 7F salpingography kit produced by Boston Scientific (USA).

Differential Diagnosis List

Final Diagnosis

Fallopian tube selective catheterization and disobstruction

URL:	https://eurorad.org/case/526
DOI:	10.1594/EURORAD/CASE.526
ISSN:	1563-4086