Invited lecture by Dr Sujoy dasgupta in the "Basic Subfertility" Workshop at AICOG (All India Congress of Onstetrics and Gynaecology), 2023 at Kolkata

1. Dr Sujoy Dasgupta
MBBS (Gold Medalist, Hons)
MS (OBGY- Gold Medalist)
DNB (New Delhi)
MRCOG (London)
Advanced ART Course for Clinicians (NUHS, Singapore)
M Sc, Sexual and Reproductive Medicine (South Wales, UK)
Consultant: Reproductive Medicine, Genome Fertility Centre, Kolkata
Managing Committee Member, BOGS, 2022-23
Executive Committee Member, ISAR Bengal, 2022-24
Clinical Examiner, MRCOG Part 3 Examination
Winner, Prof Geoffrey Chamberlain Award, RCOG World Congress, London, 2019
Tubal Tales Deciphered:
A Comparative Analysis of Tubal Patency Tests

2. Tubal Factors
• Tubal factor- 35-40% cases of infertility (Klein et al., 2022)

3. Tubal Patency Tests
• HSG
• SSG
• HyCoSy
• HyFoSy
• MRI-HSG
• Laparoscopy and Chromopertubation
• Fertiloscopy
• Hydrolaparoscopy
• Salpingoscopy
• Falloposcopy
• Chlamydia antibody testing

4. Tubal investigations (NICE, 2013)
Women NOT known to
have comorbidities (e.g,
PID, previous ectopic
pregnancy or
endometriosis)
hysterosalpingography (HSG) to screen for
tubal occlusion
•reliable test for ruling out tubal occlusion, less
invasive
•makes more efficient use of resources than
laparoscopy
Where appropriate expertise
is available
screening for tubal occlusion using
hysterosalpingo-contrast-ultrasonography
should be considered
•effective alternative to HSG for women
Women thought to have
comorbidities
Offer- Laparoscopy and dye test

5. Hysterosalpingogram (HSG)
• Most commonly used , commonly available
• Easy to perform
• Cheaper, noninvasive
• Oil-based contrast medium, may have some therapeutic benefit (Suresh
and Narvekar, 2014; Saunders et al., 2011; Wang, et al. 2019)
• Specificity- 87%- negative test correctly identifies patent tubes in 87%
cases.
• A good screening test in diagnosing tubal patency (Suresh and Narvekar, 2014
Verhoeve, 2010; Mol et al., 2010; Den Hartog et al., 2008; Bosteels et al., 2007)
• Sensitivity- 53%- positive test correctly identifies blocked tubes in 53%
cases (Suresh and Narvekar, 2014; Papaioannou et al., 2007)

6. Drawbacks of HSG
• Radiation exposure and infection (1-3%)
• Spasm of the smooth muscles of the tube → “false” impression
of “fallopian tube block” (Suresh and Narvekar, 2014)
• In 40-60% cases of B/L tube block diagnosed in HSG, at least
one tube may be found open on further investigations (repeat
HSG, SSG, laparoscopy) (Hajishafiha et al., 2009; Verhoeve et al., 2010;
Foroozanfard and Sadat, 2013)

7. Sonosalpingography (SSG)
• Relatively simple procedure
• Avoids radiation exposure and iodine allergy (Saunders, 2011; Suresh and
Naverkar, 2014, Maheux-Lacroix, 2014)
• Can assess tubal patency, uterine cavity, myometrium and the
ovaries in the same sitting
• Sensitivity- 93%, Specificity- 89% (Papaioannou et al., 2007 Suresh and
Narvekar, 2014)
• Can be combined with 3-D scan to evaluate the cavity and tubes
(Exacoustos, 2009; Sladkevicius, 2000)
• 3-D does not have any significant benefit over the 2-D. (Maheux-
Lacroix et al, 2014)

8. HSG vs SSG
• Fair agreement between HSG and SSG for tubal patency (k= 0.61 to
0.66) (Izhar , 2019; Luca, 2017)
• Oil-based media for tubal flushing in HSG vs saline in SSG (Wang,
2019; Luttjeboer, 2007)
• In women with PCOS- similar pregnancy rates between HSG and
SSG (Christianson et al., 2018)
• Meta-analysis- comparable sensitivity (95% vs 94%) and specificity
(93% vs 92%) between SSG and HSG for diagnosing tubal block,
compared with Laparoscopy (Maheux-Lacroix, 2014)
• The likelihood ratios in diagnosing tubal occlusion, of HSG and
SSG were similar, especially as the experience of the operator
increased (Dijkman, 2000)

9. Can SSG be used as a first test?
• SSG should be considered as “initial” test (Izhar , 2019; Rogerson et
al., 2002; Maheux-Lacroix, 2014)
• Recommendated by NICE
• Some studies even found better accuracy of SSG than HSG (Ali et
al., 2005; Chan et al., 2005)

10. “SSG cannot tell the site of block”
• Unilateral tube block (UTB)- the fertility potential remained as
same as in case of bilateral tubal patency (Lavy et al., 2004; Coppus et al.,
2007)
• Success rate of IUI in UTB = unexplained subfertility (Farhi et al.,
2007;. Tan et al., 2018; Yetkin et al., 2017; Berker et al., 2013, Selcuk et al., 2016)
• Distal tube block had significantly lower chance of pregnancy
in IUI (Farhi et al., 2007;. Tan et al., 2018; Berker et al., 2013)
• Issue of proximal versus distal UTB yet remains unresolved.
(Tan, 2018)

11. Hysterosalpingo-Contrast Sonography ( HyCoSy)
• Delineates exact site of block and peritubal adhesion (Luciano et al.,
2011)
• Meta-analysis-HyCoSy NOT superior to SSG (Maheux-Lacroix, 2014)
• Expensive, not easily available, not licensed- Echovist!
(Schering AG, Berlin) and SonoVue! (Bracco, Milan) (Exalto and
Emanuel, 2019)

12. Hysterosalpingo-Foam Sonography (HyFoSy)
• Foam is created by rigorously mixing 5ml
ExEm gel (containing hydroxyethyl cellulose
and glycerol) with a viscosity of 270 cc and
containing 94.12 % water
• Sufficiently stable to show echogenicity for at
least 5 minutes,
• Better accuracy than HyCoSy (Exalto and Emanuel,
2019)
• Needs further studies
• Not yet FDA-aproved

13. • Commonly advised as a confirmatory test (Hajishafiha, et al., 2009)
• Additional pathologies in the ovaries and peritoneum can be
diagnosed
• Treatment can be done in the same sitting
• Subtle changes in tubes/ fimbria/ peritoneum
• Functional potential of the fimbria to pick-up the ova (Sarkar, et al.
2008; Approbato et al., 2020; Elstein et al., 2008)
• Laparoscopy may be better predictor of fertility than HSG (Mol et
al.,1999; Verhoeve et al., 2010)
Laparoscopy with chromopertubation

14. Laparoscopy- as first line test?
• NICE guideline (2013)- laparoscopy as the initial tool for checking
tubal patency ONLY in those with risk factors for tubal block
• Diagnostic error still can happen in laparoscopy(Broeze et al., 2010;
Saunders et al., 2011; Luca et al., 2017; ASRM, 2015
• Invasive nature- Iatrogenic injury and anaesthetic risks
• Cannot be offered as the primary test in all women (Saunders et al.,
2011; Tan et al., 2018
• “Gold standard” ???? (Tan et al., 2018; Saunders et al., 2011; Lim et al., 2011;
Suresh and Narvekar, 2014)

15. Transvaginal Hydrolaparoscopy (THL),
Salpingoscopy, Falloposcopy, Fertiloscopy
• Insufflation of the pelvis with 0.4–0.6
litres of a fluid medium through an
insufflating needle inserted into the
posterior fornix
• Followed by the introduction of a
small diameter rigid angled endoscope
to visualise the POD, pelvic side-
walls, adnexa and tubal patency (the
dye injected transcervically)
• Complication rate higher than
Laparoscopy (Suresh and Narvekar, 2014)

16. Need of 2nd test after B/L tube block in HSG
Further diagnostic tests
• Repeat HSG
• SSG/ HyCoSy
• Laparoscopy- dye test
Treatment
• Fluoroscopic catheterization
• Hysteroscopic cannulation
• Tubal microsurgery
• IVF directly

17. Repeat HSG
• After premedication with antispasmodics
• 60% cases initially “blocked” tubes were found open (Dessole et
al., 2000)
• can reduce the number of women referred for
laparoscopy (Dessole et al., 2000)
• Increased risk of radiation exposure and hypothyroidism (Hart
et al., 2009)

18. Can SSG affects the treatment decision?
• In 70-80% at least one tube is found open by SSG (Hajishafiha,
2009; Lanzani, 2009)
• Can avoid both laparoscopy and IVF
• Offer SSG for B/L proximal tube block diagnosed in HSG before
laparoscopy/ IVF (Hajishafiha, 2009)
If both HSG and SSG showing b/l block
• 80% cases B/L block seen in laparoscopy (Hajishafiha, 2009)
• Cost-effective- Directly going for IVF without laparoscopy (unless
there is any other indication for laparoscopy) (Swart et al., 1995)

19. • Age of the woman- ART act
• Ovarian reserve
• Sperm parameters
• Number of children desired
• Patient’s preferences
• Site and extent of the tubal disease
• Risk of ectopic pregnancy vs risk of OHSS
• Success rates of IVF programme
• Financial burden- “two consecutive medical procedures to achieve parenthood”
• Findings of pathology in diagnostic laparoscopy would NOT affect the success rate of
IVF
• Expertise of the surgeon
(Suresh and Narvekar, 2014; ASRM, 2015; Sandra et al., 2003)
Laparoscopy or IVF?

20. Our Data on B/L tube block in HSG (2018-2021)

22. Anything to do in Unilateral Tube Block?
• Most cases, laparoscopy would not change the management.
(Lavy et al., 2004; Mol et al., 1999)
• 64% chance of spontaneous subsequent pregnancy after
unilateral salpingectomy for ectopic pregnancy (Fernandez et al., 2013)
• Treat like unexplained subfertility (Farhi et al., 2007;. Tan et al., 2018; Yetkin
et al., 2017; Berker et al., 2013, Selcuk et al., 2016)

23. • Meta-Analysis
• Success rate of IVF - ∼25% (NNT- 4)
*European IVF-Monitoring Consortium (EIM) for ESHRE, 2016
Jacobson et al., 2010 Duffy et al., 2014
OR for ongoing pregnancy (95% CI) 1.64 (1.05– 2.57) 1.94 (1.20–3.16)
The number of infertile women that should
undergo destruction of superficial peritoneal
endometriosis
12 8
The prevalence of grade I/ II endometriosis among
women with unexplained infertility
≤50%
NNT 24 16
Laparoscopy if tubes are open

24. Routine or selective use of tubal patency
test?
Suresh and Narvekar, 2014
• Overall scenario
• In low-risk treatment-naive
women undergoing OI or IUI,
we do NOT advocate the
routine use of a tubal patency
test prior to initiating treatment.
• Only women keen to proceed
with >3 OI or IUI treatment
are offered a tubal patency test
NICE, 2013
• Women with a history s/o tubal
damage- tubal assessment
before IUI
• Women with no risk factors in
their history- tubal assessment
ONLY after 3 cycles of failed
IUI

25. Non-invasive screening test?
Chlamydia antibody test (CAT)
• Chlamydia trachomatis is the single largest cause of acquired tubal
pathology
• Can avoid unnecessary invasive testing.
• The optimal cut-off value of CAT ??? (Suresh and Narvekar, 2014)

27. Tubal Patency Tests (Suresh and Narvekar, 2014)

29. “Are the fallopian tubes OK”?
• Tubal patency ≠ normal function of the tube (Approbato
et al., 2020; Tan et al., 2018; Luca et al., 2017)
• Synchronized and intricate peristalsis and ciliary motion to
allow fertilization and intrauterine implantation.
• Confirmation of tubal patency even at laparoscopy does not
necessarily mean normal function of the tube (Approbato et al.,
2020; Tan et al., 2018; Luca, et al. 2017; Elstein et al., 2008)

30. Acknowledgement
• Dr Biswajyoti Guha
• Secretary, BOGS

31. Take Home Messages
• Check overall scenario before advising tubal patency test
• HSG/ SSG/ HyCoSy should be the first line of investigation
• Laparoscopy is useful in selected cases