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14 Evaluation of Tubal Patency (HyCoSy, Doppler)
185
Fig. 14.4 3D HyCoSy with Echovist dye showing the cavity
specialities such as vascular studies. Blood fl ow
is an ultrasound technique developed to analyse
blood fl ow. It does not employ the Doppler principle; rather, the refl ected amplitudes of scattering particles (e.g. erythrocytes) are imaged by
subtraction modes of two or four image vectors
along one line. Therefore, moving particles are
imaged and stationary structures (such as vessel
walls) can be subtracted. Blood-fl ow data can
then be combined with B-mode information to
enable a better amplitude visualisation of fl ow.
With this technique, water can be used, and
tubal patency is demonstrated with blood-fl ow
technique.
Although the application of blood fl ow is not
yet an established method of assessment for tubal
patency, increased experience and knowledge of
it is likely to lead to more widespread use of this
modality in the assessment of tubal function
(Fig. 14.5 ).
Colour-coded Doppler imaging can be used as
an adjunct to greyscale imaging in order to
Fig. 14.5 HyCoSy with B-fl ow technique: this is a form
of inversion mode where movement of fl uid is captured in
greyscale and the rest of the image appears dark. The grey
images below the tube represent the bowel peristalsis
visualise the fl ow of media through the tubes.
Doppler imaging has been shown to be valuable
in cases where HyCoSy has been inconclusive
[ 20 ]. When 3-dimensional power Doppler imag-
ing (3D-PDI) is employed in conjunction with
186
D. Vinayagam and K. Ojha
HyCoSy, it allows visualisation of contrast media
throughout the entire tubal length. The use of
3D-PDI has clear advantages over the use of
HyCoSy alone. It has been shown that visualisation of distal tubal spill occurs twice as often
when 3D-PDI is employed [ 21 ]. As the procedure
does rely on the technical ability of the clinician
performing the procedure and, in the case of
3D-PDI, time for analysis, this has not been routinely implemented in clinical practice.
Conclusion
Being one of the commonest causes of subfer-
tility, tubal patency is an essential component
of the subfertility workup. In this chapter, we
have provided an overview of the gold stan-
dard technique of chromopertubation and clas-
sical methods such as the hysterosalpingogram
and then covered the use of ultrasound in
slightly more detail. We hope we have pro-
vided the reader with a good understanding of
these newer techniques involving ultrasound
as well as a foundation for a technique that we
employ. The methods we have outlined above
are by no means exclusive, and the readers are
encouraged to develop their own techniques
when carrying out the procedures discussed.
As the boundaries of investigative medicine
continue to be expanded, there will be further
development of the above employed methods
as well as newer modalities. What is certain is
that ultrasound does and will continue to play
a pivotal role in the armamentarium we have at
our disposal in the investigation of our patients.
References
1. Steinkeler JA, Woodfi eld CA, Lazarus E, Hillstrom
MM. Female infertility: a systematic approach to
radiologic imaging and diagnosis. Radiographics.
2009;29:1353–70.
2. Lim CP, Hasafa Z, Bhattacharya S, Maheswari A.
Should a hysterosalpingogram be a fi rst-line investigation to diagnose female tubal subfertility in the
modern subfertility workup? Hum Reprod. 2011;
26(5):967–71.
3. Watrelot A, Hamilton J, Grudzinskas JG. Advances in
the assessment of the uterus and fallopian tube
function. Best Pract Res Clin Obstet Gynaecol.
2003;17(2):187–209.
4. Lanzani C, Savasi V, Leone FP, Ratti M, Ferrazzi E.
Two-dimensional HyCoSy with contrast tuned imaging technology and a second-generation contrast
media for the assessment of tubal patency in an infertility program. Fertil Steril. 2009;92:1158–61.
5. Coppus SFPJ, Opmeer BC, Logan S, Van der Veen F,
Bhattacharya S, Mol BWJ. The predictive value of
medical history taking and Chlamydia IgG ELISA
antibody testing (CAT) in the selection of subfertile
women for diagnostic laparoscopy: a clinical prediction model approach. Hum Reprod. 2007;22:1353–8.
6. Swart P, et al. The accuracy of hysterosalpingography
in the diagnosis of tubal pathology: a meta-analysis.
Fertil Steril. 1995;64(3):486–91.
7. den Hartog JE, Lardenoije CM, Severens JL, Land JA,
Evers JL, Kessels AG. Screening strategies for tubal
factor subfertility. Hum Reprod. 2008;23:1840–8.
8. National Collaboratry Centre for Women’s and
Children’s Health. Fertility: Assessment and
Treatment for People with Fertility Problems.
Commissioned by the National Institute for Clinical
Excellence (NICE). London: RCOG Press 2004.
ISBN 1-900364-97-2.
9. Broeze KA, Opmeer BC, Van Geloven N, Coppus
SFPJ, Collins JA, den Hartog JE, et al. Are patient
characteristics associated with the accuracy of
hysterosalpingography in diagnosing tubal pathology? An individual patient data meta-analysis. Hum
Reprod. 2011;17:293–300.
10. Spring DB, et al. Potential therapeutic effects of
contrast materials in hysterosalpingography: a prospective randomised controlled trial. Radiology.
2000;214:53–7.
11. Hart D, Hillier MC, Wall BF. HPA-RPD-029-doses to
patients from radiographic and fl uoroscopic X-ray imaging procedures in the UK – 2005. Review. 2009;2010:95.
12. Tur-Kaspa I, Seidman DS, Soriano D, Greenberg I,
Dor J, Bider D. Hysterosalpingography with a balloon
catheter versus a metal cannula: a prospective, randomized, blinded comparative study. Hum Reprod.
1998;13:75–7.
13. Nanini R, Chelo E, Branconi F, Tantini C, Scarselli
GF. Dynamic echohysteroscopy: a new diagnostic
technique in the study of female infertility. Acta Eur
Fertil. 1981;12:165–71.
14. Campbell S, Bourne T, Tan S, Collins W.
Hysterosalpingo-contrast-sonography (HyCoSy) and
its future role within the investigation of infertility in
Europe. Ultrasound Obstet Gynecol. 1994;4:245–53.
15. Spieldoch RL, Winter TC, Schouweiler C, Ansay S,
Evans MD, Lindheim SR. Optimal catheter placement
during sonohysterography: a randomized controlled
trial comparing cervical to uterine placement. Obstet
Gynecol. 2008;111:15–21.
16. Ayida G, Chamberlain P, Barlow D, Koninckx P,
Golding S, Kennedy S. Is routine diagnostic laparoscopy for infertility still justifi ed? A pilot-study
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assessing the use of hysterosalpingo-contrast sonography and magnetic resonance imaging. Hum Reprod.
1997;12(7):1436–9.
17. Tanawattanacharoen S, Suwajanakorn S, Uerpairojkit
B, Boonkasemsanti W, Virutamesan P. Transvaginal
hysterosalpingo-contrast sonography (HyCoSy) compared with chromolaparoscopy. J Obstet Gynaecol
Res. 2000;26:71–5.
18. Exacoustos C, Di Giovanni A, Szabolcs B,
Binder- Reisinger 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;34:609–12.
19. Zhou L, Zhang X, Chen X, Liao L, Pan R, Zhou N,
Di N. Value of three-dimensional hysterosalpingocontrast sonography with SonoVue in the assessment
of tubal patency. Ultrasound Obstet Gynecol.
2012;40(1):93–8.
20. Kalogirou D, Antoniou G, Botsis G, Kassanos D,
Vitoratos N, Zioris C. Is colour Doppler necessary in
the evaluation of tubal patency by hystero-contrastsonography. Clin Exp Obstet Gynecol. 1997;24(2):
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21. Sladkevicius P, Ojha K, Campbell S, Nargund G.
Three-dimensional power Doppler imaging in the
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Obstet Gynecol. 2000;16(7):644–7.
Hydrosalpinx
Dale W. Stovall and Mark W. Austin
1 5
Introduction
The fallopian tubes derive their name from the
sixteenth-century Italian anatomist, Gabriel
Fallopius. The fallopian tubes originate embryologically from the most cephalad portion of the
Mullerian ducts. In the developing embryo, this
occurs at 6–8 weeks’ gestation. The fallopian
tubes serve as the site for oocyte pickup, sperm
transport, fertilization, early embryonic development, and transport of the embryo to the uterine
cavity. However, as the fallopian tubes are indirectly connected to the lower genital tract, they
are vulnerable to sexually transmitted infections.
Furthermore, at the distal end of the fallopian
tubes are the fi mbriae; these are delicate structures that are particularly susceptible to injury
following infection, abdominal or pelvic surgery,
and subsequent healing. Damage to the fallopian
tubes can result in tubal occlusion, which is most
common at the distal end of the tube. Distal tubal
occlusion is commonly followed by the formation of a collection of fl uid inside the tube. When
a fallopian tube becomes fi lled with fl uid, it is
called a hydrosalpinx. The diameter and length of
a hydrosalpinx can vary widely from patient to
patient depending upon many variables. In any
D. W. Stovall , MD (*) • M. W. Austin , MD
Department of Obstetrics and Gynecology ,
Riverside Regional Medical Center ,
Annex Building, 2nd Floor, 500 J Clyde Morris Boulevard ,
Newport News , VA 23601 , USA
e-mail: dale.stovall@rivhs.com; mark.austin@rivhs.com
event, the fl uid within a hydrosalpinx functions
as an acoustic window that allows for ultrasonic
visualization of the tube without additional
administration of contrast media.
Occluded fallopian tubes serve as barriers to
conception. Initially, infertility specialists developed surgical techniques to repair damaged fallopian tubes. As the success of these procedures was
unsatisfactory, assisted reproductive techniques
(ART) were developed to specifi cally bypass the
various reproductive processes that occur within
the fallopian tubes. However, the presence of
hydrosalpinges has subsequently been shown to be
associated with a reduction in ART success rates.
These fi ndings lead to clinical trials that have evaluated the effect of various methods of treatment of
hydrosalpinges on ART success rates. This chapter will review the anatomy of the fallopian tube,
the prevalence and etiology of hydrosalpinges, the
assessment of hydrosalpinges, and the reproductive impact of this condition.
Anatomy of the Fallopian Tube
Similar to the uterus, the fallopian tubes are composed of an outer serosal surface, a middle muscularis layer, and an internal lumen that is lined
with both secretory and ciliated epithelial cells.
As both the uterus and the fallopian tubes are
formed from the Mullerian ducts, they are contiguous organs with a connecting lumen. The fallopian tubes range in size from 10 to 13 cm in
length and 0.5 to 1.2 cm in diameter. Anatomically,
L.A. Stadtmauer, I. Tur-Kaspa (eds.), Ultrasound Imaging in Reproductive Medicine,
DOI 10.1007/978-1-4614-9182-8_15, © Springer Science+Business Media New York 2014
189
190
D.W. Stovall and M.W. Austin
the fallopian tube can be divided into distinct
segments. The most proximal portion of the fallopian tube, which is connected to the lateral surface of the fundus of the uterus, is called the
interstitial segment. This segment of tube primarily functions as the tubal lumen’s entry into the
uterine cavity. For all practical purposes, this segment of the fallopian tube is contained within the
wall of the uterus. As the uterus contains several
smooth muscle layers, this portion of the fallopian
tubes’ lumen is surrounded by a thick smooth
muscle lining. The opening of the interstitial segment into the uterus is called the tubal ostea, and
it can be seen from inside the uterine cavity via
hysteroscopy. Moving distally from the uterus,
the next tubal segment is called the isthmic portion of the fallopian tube. It is approximately
2 cm in length. This segment is completely clear
from the serosal and muscular layers of the uterus
and contains the second thickest muscular layer
of the tube. However, the lumen of the isthmic
portion of the fallopian tube, like that of the interstitial segment, is very narrow. The next segment
of the tube is called the ampullary segment. The
ampula is approximately 7 mm in length and has
a relatively thin muscularis layer and a wide
internal lumen as compared to isthmic portion of
the tube. The mucosal lining of the ampullary
portion of the tube contains more pronounced
mucosal folds also known as rugal folds. The
next tubal segment is known as the infundibulum.
It is approximately 1 cm in length and is the widest portion of the fallopian tube. Extending off
the end of the tube are feather-like projections
known as the fi mbriae. These projections are
thought to assist in oocyte pickup after ovulation.
A long projection of the fi mbria, the fi mbria ovarica, is commonly connected to the ovarian surface to maintain the fi mbria in close proximity to
the ovarian surface.
Tubal Function
The fallopian tube is an integral part of the reproductive process. Beyond reproduction, however,
the fallopian tubes serve no further physiologic
function. After ovulation, the oocyte is picked up
by the fi mbriated end of the fallopian tube.
Assisted by tubal contractions and the tubal epithelial lining, the oocyte migrates to the ampullary portion of the tube. There, the oocyte is
fertilized. For spermatozoa to reach the ovulated
oocyte, they must travel from the vagina, through
the cervical os, into the uterus, through the small
tubal ostea, and fi nally to the ampullary segment
of the tube. Once fertilized, the embryo migrates
through the fallopian tube in the opposite direction of the aforementioned spermatozoa into the
intrauterine cavity where it subsequently
implants. The secretory cells within the fallopian
tube secrete electrolytes, calcium, glucose, and
protein that serve as nutrients for the spermatozoa, oocyte, and the developing embryo. The
fl uid within the fallopian tube also assists in the
transport of both gametes and embryos.
D e fi nition, Prevalence, and Etiology
Injury to the distal end of the fallopian tube can
result in either a hydrosalpinx or fi mbrial phimosis. Hydrosalpinges are fallopian tubes that are
completely occluded at their distal end and are
dilated with fl uid. In this case, the secretions
from within the fallopian tube accumulate within
the tube, distending primarily the ampullary portion of the fallopian tube. This occurs despite the
fact that the proximal portion of the tube remains
patent. Fimbrial phimosis results from a partial
obstruction of the distal end of the fallopian tube.
In this case the distal end of the fallopian tube is
still patent, but there is agglutination of the fi mbria and adhesive bands that surround the terminal end of the tube yielding a narrow phimotic
tubal opening.
The incidence and prevalence of hydrosalpinges is unknown. However, it is known that
approximately 25–35 % of female factor infertility is caused by tubal disease. Furthermore, more
than half of the cases of tubal disease arise from
salpingitis [ 1 ]. Salpingitis is part of the more gen-
eral process known as pelvic infl ammatory disease or PID. PID is an acute infection of the
upper genital tract which includes the uterus, fallopian tubes, and ovaries. The two most common
15 H ydr osalp inx
191
organisms associated with salpingitis are
Chlamydia trachomatis and Neisseria gonorrhoeae [ 2 ]. In general, the longer salpingitis is
allowed to go untreated, and the greater the number of infections, the greater the damage to the
fallopian tube and the greater the likelihood of
developing a hydrosalpinx. Therefore, patients
with a history of pelvic infl ammatory disease are
at risk for distal tubal occlusion and hydrosalpinx. Other risk factors for tubal occlusion and
hydrosalpinx include a history of endometriosis,
ectopic pregnancy, and prior pelvic surgery. For
patients with no risk factors, a negative chlamydia antibody test indicates that there is less
than a 15 % likelihood of tubal pathology [ 3 ].
Signs and Symptoms
The natural history of hydrosalpinges is not well
studied. In other words, it is not well known how
rapidly they develop from a given insult or how
commonly they resolve or recur. Furthermore, no
selected population of patients has been screened
by ultrasound or any other imaging method to
determine the incidence of the disease. Therefore,
the percentage of women with a hydrosalpinx
who are symptomatic is unknown. Clearly, some
women with hydrosalpinges do suffer from intermittent or constant lower abdominal pain and a
bothersome vaginal discharge. However, it is
possible that the majority either are asymptomatic or have infertility as their only clinical problem associated with their hydrosalpinges.
Effects on Pregnancy
Complete bilateral distal tubal occlusion produces sterility. However, even the presence of a
unilateral hydrosalpinx can have a signifi cant
effect on fertility. In this regard, one must realize
that there are numerous causes for infertility, and
therefore, it is very likely that patients with a unilateral hydrosalpinx and infertility are likely to
be a very heterogeneous group. This heterogeneity may involve not only multiple causes for
infertility (e.g., endometriosis, PCOS, and male
factor infertility) but heterogeneity in regard to
the contents within their hydrosalpinx, the condition of their contralateral tube, and adhesions
within the pelvis. It has been well documented
that the fl uid within a hydrosalpinx may contain
microorganisms, debris, toxins, cytokines, and
prostaglandins. Furthermore, it is known that
even though a fallopian tube may be completely
occluded distally and contain a signifi cant collection of fl uid within its ampullary region, its proximal end may still be patent, allowing for drainage
of fl uid into the uterine cavity. Thus, tubal fl uid
contents may come into direct contact with the
endometrium, gametes, and embryos.
To better assess these contents and to determine their effects on fertility, Beyer et al. studied
the contents of tubal fl uid from infertile women
with hydrosalpinges and the effects of this fl uid on
murine embryonic development. They found that
as compared to values for normal human tubal
fl uid, fl uid from hydrosalpinges tended to be normal with respect to components such as sodium,
chloride, and bicarbonate and with respect to pH
and osmolarity. However, they found that hydrosalpinx was relatively low in regard to the concentrations of potassium, calcium, phosphate,
glucose, and protein. Although there was some
variability within the biochemical components of
the hydrosalpinx fl uid, murine embryonic development was inhibited by this fl uid [ 4 ]. These
investigators concluded, however, that it was
likely a lipophilic embryotoxic factor(s) and not
the differences in the biochemical components
found between “normal” and hydrosalpinxderived tubal fl uid that was responsible for the
reduction in embryonic development. To date,
the embryotoxic effects of hydrosalpinx fl uid
have not been documented in human embryos.
Other studies have evaluated the effects of
hydrosalpinges on endometrial receptivity. Meyer
et al. prospectively studied the endometrium of
103 women with hydrosalpinges for three integrin markers of endometrial receptivity and compared those results to 55 infertile and 44 fertile
controls. They also looked at the effects of tubal
occlusion or resection on endometrial receptivity
markers. These investigators found that women
with hydrosalpinges expressed signifi cantly less
192
D.W. Stovall and M.W. Austin
αvβ1 integrin as compared to controls. Based
on these data, they concluded that hydrosalpinges may have a direct impact on endometrial
receptivity [ 5 ]. Subsequently, these investigators
demonstrated a restoration of αvβ1 integrin following surgical treatment for hydrosalpinx. In
addition, other investigators have found potential
defects in embryo implantation that are associated with hydrosalpinges. In this regard, the
expression of HOXA10, a transcription factor for
embryo implantation, was shown to be decreased
in women with hydrosalpinges and the expression of this transcript was restored after salpingectomy [ 6 ]. Finally, the effects of hydrosalpinx
fl uid on sperm motility and velocity have been
studied. These investigators found that sperm
motility and velocities remained unchanged after
a 5-h incubation period with various concentrations of hydrosalpinx fl uid but that the percentage
of motile spermatozoa were signifi cantly reduced
after 24 h of incubation [ 7 ]. Therefore, it appears
that there are several possible etiologies for the
negative effects of hydrosalpinx- derived fl uid
on reproduction beyond simple tubal occlusion.
Whether unilateral salpingectomy is appropriate
for women with infertility who have a unilateral
hydrosalpinx and are undergoing infertility therapy with induction of ovulation with or without
insemination has not been well studied.
Imaging
Hysterosalpingogram (HSG)
Hysterosalpingography is a well-established
method used for imaging of the intrauterine cavity
and the fallopian tubes. The technique utilized is
oft published and well known [ 8 ]. Briefl y, the pro-
cedure is performed between menstrual cycle days
5 and 12, that is, after the cessation of menses, but
before ovulation and thus the possibility of pregnancy. An NSAID such as ibuprofen is commonly
prescribed to be taken approximately 1 h before
the procedure to ameliorate cramping. A prophylactic antibiotic such as doxycycline may be given
to those patients with a history of PID or evidence
of same at the time of the procedure. The patient
is placed in the dorsal lithotomy position on the
examination table in the fl uoroscopy suite, and a
bimanual pelvic examination is performed. In the
absence of any evidence of acute pelvic or cervical infection, the procedure can commence. The
patient’s perineum is draped with sterile cloth
or paper, the uterine cervix is visualized using a
sterile speculum, and the cervix is cleaned with
an iodine solution. If the Jarcho cannula is to be
used, the cervix is grasped with a tenaculum. The
cannula is fi lled with an iodinated, radio-opaque,
water-soluble contrast medium, taking care to
expel any trapped air. The prefi lled cannula is
placed into the cervical os and held in place by a
spring-loaded mechanism. If a balloon HSG catheter is used, one may be able to dispense with the
tenaculum; however, the fi lled balloon may cause
discomfort to the patient as well. A randomized
trial failed to demonstrate the effi cacy of the intrauterine instillation of 2 % lidocaine prior to HSG
for the relief of pain [ 9 ]. Typically, a scout fi lm
is taken prior to the instillation of dye to look for
pelvic calcifi cations. Contrast media are slowly
injected under fl uoroscopic control, and an image
is taken during this fi lling phase to look for intrauterine cavity fi lling defects. A second image is
taken when the uterus appears to be distended,
and a third documents the dye fi lling the fallopian
tubes. Lastly, an image of the contrast media spilling from the tubes and fl owing freely in the pelvis
is obtained. At the conclusion of the procedure,
the cannula or catheter is withdrawn, the tenaculum is removed, and the speculum is withdrawn.
Normal tubes appear thin, with a smooth contour. Rugae are often visible. Hydrosalpinges
appear enlarged and irregular, with absent rugae,
and contrast medium is most often not visible spilling from the tubes into the pelvis. In a
meta- analysis of studies that evaluated HSG and
laparoscopy fi ndings independently, the authors
calculated a point estimate of 0.65 for sensitivity and 0.83 for specifi city [ 10 ]. The authors
concluded that although HSG is of limited use
for detecting tubal patency because of its low
sensitivity, its high specifi city made it a useful
test for detecting tubal obstruction. Of more relevance, Mol et al. studied the reproducibility and
accuracy of hysterosalpingography in diagnosing
15 H ydr osalp inx
193
a
b
Fig. 15.1 Hysterosalpingogram image of a patient with
bilateral hydrosalpinges
hydrosalpinges. The authors found the inter- and
intraobserver reproducibility of the interpretation of hydrosalpinx to be only “substantial” (k
0.64 and 0.68). Compared with fi ndings at diagnostic laparoscopy, for hydrosalpinx, the likelihood ratio of a positive test was 5.8 (4.4–7.6).
Fig. 15.2 ( a ) “Waist sign” of a hydrosalpinx, marked by
the asterisks , as seen with 2-D ultrasound. ( b ) “Beads on
a string” sign of a hydrosalpinx demonstrated by 2-D
ultrasound
However, the likelihood ratio of a negative test
was 0.64 (0.54–0.76). The authors concluded that
HSG is a useful test to detect hydrosalpinx, but
an imperfect test to rule out hydrosalpinx [ 11 ].
Obviously, in the presence of proximal tubal
occlusion, HSG will fail to reveal the presence of
hydrosalpinx. Figure 15.1 shows a HSG of bilat-
eral hydrosalpinges.
shape was found in 14 hydrosalpinges and one
other mass (likelihood ratio of 22.1). The authors
concluded that when these combinations are
identifi ed in a cystic adnexal mass that does not
have solid-appearing areas or features characteristic of hemorrhagic cysts, endometriomas, or
dermoid cysts, one can make the diagnosis of
hydrosalpinx with a high level of confi dence.
Waist sign (Fig. 15.2a ) and beads on a string
Ultrasound Appearance
(Fig. 15.2b ) are classic features of a hydrosalpinx
on ultrasound.
Using standard transabdominal or transvaginal
ultrasonography, the appearance of a hydrosalpinx is that of a hypoechoic cystic adnexal mass.
Color Doppler Sonography
Patel et al. evaluated the utility of four specifi c
sonographic fi ndings in diagnosing hydrosalpinges: incomplete septation, short linear projection,
tubular shape, and presence of a waist [ 12 ]. The
authors calculated the likelihood ratio for each
fi nding. The presence of a “waist” in a cystic collection refers to diametrically opposed indentations in the wall of the collection. The waist sign
in combination with tubular shape was found in
12 of 26 hydrosalpinges and no other masses
(likelihood ratio of between 18.9 and infi nity).
Small round projections combined with tubular
Color Doppler sonography is used to assess
blood fl ow in a given organ and assesses directional fl ow as well. The utility of color Doppler
to improve the evaluation of hydrosalpinges has
been studied. In this regard, the addition of color
Doppler does not seem to increase the accuracy
of standard 2-D transvaginal ultrasonography
in detecting hydrosalpinges. More specifi cally, Guerriero et al. prospectively evaluated
239 consecutive premenopausal, nonpregnant
women who shortly thereafter underwent sur-
194
D.W. Stovall and M.W. Austin
gery for adnexal masses, with transvaginal
B-mode ultrasonography with and without color
Doppler, and CA-125 measurements. The sensitivity, specifi city, and positive and negative predictive values were calculated and found to be
identical for each category, with color Doppler
and CA-125 levels adding nothing to the diagnostic accuracy of 2-D transvaginal ultrasonography alone [ 13 ].
Contrast Medium
As a fl uid contrast medium can serve as an
acoustic window for ultrasonography, one
might expect that adding contrast to enhance
ultrasound images would be advantageous in
the assessment of the fallopian tubes. As previously discussed in this text, this technique is
very useful in the basic infertility evaluation
to assess tubal patency. In regard to hydrosalpinges, however, there are no studies that
directly address the utility of sonographic contrast in the diagnosis of hydrosalpinx, per se.
In a study comparing HSG and transvaginal
2-D ultrasonography with an air/saline mixture as the contrast medium in the evaluation
of tubal patency, both had the same high concordance with laparoscopy, 86.7 and 86.7 %,
respectively [ 14 ]. Strandell et al. compared
transvaginal sonography utilizing a commercially available contrast agent (Echovist®) and
HSG to the gold standard laparoscopic evaluation and found similarly high concordance rates
(83 and 80 %, respectively) [ 15 ]. Therefore, it
appears that transvaginal ultrasound in combination with a contrast medium is a very good
method of assessing tubal patency. However,
to determine if a patient has a hydrosalpinx,
an ultrasound without contrast must fi rst be
performed. Otherwise, one might misdiagnose
a patient with a hydrosalpinx who instead has
distal tubal occlusion alone and no fl uid collection within the fallopian tube. In other words, if
contrast medium is used initially to evaluate the
fallopian tubes either by HSG or via ultrasound,
an “iatrogenic” hydrosalpinx may be misdiagnosed as a true hydrosalpinx.
Fig. 15.3 3-D ultrasound inversion rendering image
used to identify a hydrosalpinx
Three-Dimensional (3-D) Ultrasound
Three-dimensional ultrasonography may be helpful in the identifi cation of hydrosalpinges. In one
study, 21 consecutive patients scheduled to have
laparoscopy were recruited to undergo the 3-D
HyCoSy 2 days before the scheduled laparoscopy.
Echovist® (Schering AG, Berlin, Germany), the
ultrasound contrast medium, was injected into
the uterine cavity via a Foley catheter. The fl ow
of the medium in the fallopian tube was captured
by using three-dimensional power Doppler mode
and was stored for later analysis. The sensitivity
of 3-D HyCoSy for detecting tubal patency was
100 % with a specifi city of 67 %. The positive and
negative predictive values were 89 and 100 %,
respectively; the concordance rate was 91 % [ 16 ].
Finally, Timor-Tritsch et al. reported using 3-D
ultrasound inversion rendering to diagnose hydrosalpinges (Fig. 15.3 ). Fifty-two patients with
fl uid-fi lled adnexal masses suspected of being
abnormal fallopian tubes were scanned by twodimensional and 3-D transvaginal ultrasound. The
acquired volumes were then “inverted” to display
a cast-like appearance of the fl uid-fi lled structures. The authors concluded that the rendered
images increased their confi dence in diagnosing
hydrosalpinges [ 17 ]. Therefore, it appears that
15 H ydr osalp inx
195
3-D ultrasonography is a useful tool for the
diagnosis of hydrosalpinges and may be utilized
initially, or in addition to 2-D ultrasound imaging
when the results from 2-D images are equivocal.
Utility of Tubal Surgery
In regard to tubal surgery, patients with a good
prognosis are those who have no more than limited fi lmy adnexal adhesions, mildly dilated tubes
(<3 cm) with thin and pliable walls, and a lush
endosalpinx with preservation of the mucosal
folds [ 18 ]. The mean cumulative pregnancy rates
reported after terminal salpingostomy overall is
approximately 30 %, with an ectopic pregnancy
rate of 5 %. However, in poor prognosis patients
with large hydrosalpinges, thick non-pliable
walls, and loss of luminal rugae, the cumulative pregnancy rate may be as low as zero. In
comparison, the pregnancy rates following terminal salpingostomy in good prognosis patients
who are younger and have a more conserved
tubal anatomy may be as high as 80 % [ 19 , 20 ].
Unfortunately, it is diffi cult to determine the
presence of rugal folds with ultrasonography.
This is better evaluated via hysterosalpingogram. Nevertheless, an increased tubal diameter
is associated with a greater destruction of tubal
rugae and a more rigid tube. Therefore, ultrasonography is a reasonable tool for the assessment
of patients for tubal surgery with a hydrosalpinx.
However, pregnancy rates with IVF exceed the
chances for pregnancy with tubal surgery except
for the patients with the best prognosis after
surgery.
Assisted Reproduction
Hydrosalpinges have been shown to have an
adverse effect on both pregnancy and delivery rates in women undergoing IVF. Similar
to women with a unilateral hydrosalpinx and a
contralateral patent tube who are trying to conceive without IVF, women with either unilateral
or bilateral hydrosalpinges who are undergoing
IVF may experience drainage of hydrosalpinx
fl uid into their uterine cavities with adverse
reproductive consequences. In fact, this phenomenon has been widely studied. A meta-analysis
of 6713 IVF cycles compared the pregnancy
outcomes of women with and without a hydrosalpinx. This study found that the presence of a
hydrosalpinx was associated with approximately
a 50 % reduction in pregnancy rates and a twofold increase in the risk for spontaneous abortion
[ 21 ]. Another large study of women with tubal
disease who either did or did not have a hydrosalpinx revealed similar results [ 22 ]. Therefore,
it seems clear that the presence of a hydrosalpinx
has a signifi cant negative impact on both pregnancy and live birth rates after IVF.
Numerous procedural methods used to treat
unilateral or bilateral hydrosalpinges either
before an anticipated IVF cycle or during an
ongoing IVF cycle have been studied. Included
are laparoscopic salpingectomy, proximal tubal
occlusion via either laparoscopy or hysteroscopy, salpingostomy, and ultrasound-guided
needle aspiration. A Cochrane review, using
data from several randomized trials, evaluated
the utility of laparoscopic salpingectomy, laparoscopic proximal tubal occlusion, and ultrasound-guided aspiration of hydrosalpinges on
pregnancy rates with IVF [ 23 ]. These data
revealed that ongoing pregnancy rates were
increased by an odds ratio (OR) of 2.14 (95 %
CI, 1.23–3.73) after laparoscopic salpingectomy, that clinical pregnancy rates were
increased by an OR of 4.66 (95 % CI, 2.47–
10.01) after proximal tubal occlusion, and that
the clinical pregnancy rates were not signifi cantly increased (OR = 1.97, 95 % CI, 0.62–
6.29) after ultrasound-guided aspiration. Two
small reports have evaluated the use of hysteroscopic-guided proximal tubal occlusion using
the Essure® device [ 24 , 25 ]. Although these data
are very promising, the technique cannot be recommended at this time. However, it may be an
option for patients who are not candidates for
laparoscopy secondary to known extensive pelvic adhesion disease. Other data regarding the
effectiveness of laparoscopic salpingectomy on
IVF pregnancy rates has demonstrated that the
effectiveness of this procedure is greatest with