Indications

When a diagnostic hysterosalpingogram (HSG) reveals obstruction of one or both fallopian tubes, the American Society for Reproductive Medicine recommends selective salpingography as the next step in evaluating infertility.¹⁴ An FTR procedure is indicated for a woman with bilateral PTO after initial HSG performed during an evaluation for infertility. At the time of the FTR procedure, repeat HSG is performed to reassess the fallopian tubes and exclude transient tubal obstruction or cornual spasm at the time of the initial HSG. Selective salpingography is performed in an attempt to clear any tubal blockage. If the PTO persists, an FTR is then attempted. If a patient has a unilateral patent tube discovered at the time of the FTR procedure, it is recommended that any PTO of the contralateral tube be treated with FTR to give the patient her best chance at conception.^15,16

Contraindications

The two main contraindications to performing selective salpingography/FTR are pregnancy and active pelvic infection at the time of the procedure. A urine pregnancy test should be performed on the day of procedure; if this test is positive, it is then confirmed with a serum β-human chorionic gonadotropin (β-hCG) level. Before the FTR procedure, the patient should have a pelvic examination by her gynecologist, with negative gonorrhea and Chlamydia cultures documented. FTR should not be performed in cases of known distal tubal blockage (Fig. 150-1) or if both fallopian tubes are patent on HSG or selective salpingography performed immediately before FTR. If one fallopian tube demonstrates tubal patency with free intraperitoneal spillage of contrast on initial diagnostic HSG, the contralateral blocked proximal tube should be treated, especially when the patent tube has an underlying intrinsic abnormality (e.g., salpingitis isthmica nodosa, tubal polyp, or synechiae).

Equipment

The optimal setup for performing fluoroscopy-guided FTR includes an all-purpose fluoroscopy room with a rotating C-arm and lithotomy stirrups. Foam padding beneath the pelvis allows for more room to manipulate the speculum, and padding behind the knees adds to patient comfort. A kit for sterilely preparing the perineum and vagina and draping the legs and abdomen is necessary. Either a resterilizable metal or a disposable plastic speculum can be used to access the cervix. A transcervical catheter is used (e.g., 12F Cook balloon cervical cannula with a 5F inner diameter and a side arm) for injecting contrast medium and saline. A sterile cervical tenaculum for traction and a sterile set of disposable cervical dilators should be available if needed. Long-handled sponge forceps are useful to keep the vaginal vault dry during and after the procedure. Iodinated contrast is used to perform the initial HSG with selective salpingography if necessary. The contrast is diluted with equal volumes of normal saline to improve visualization of the catheter and guidewire. A 40-cm angled-tip 4F or 5F catheter is preferred for selective salpingography. Both 0.018-inch and 0.035-inch hydrophilic angled-tip guidewires (Terumo Medical Corp., Somerset, N.J.) may be used to traverse the obstructed fallopian tube. A 3F microcatheter is useful to provide column strength for the microguidewire and additionally can be used for injections of contrast medium to better evaluate the distal tube.

The fallopian tube provides a conduit from the ovary to the uterus and is made up primarily of circular and longitudinal smooth muscle fibers with multiple epithelial folds. The smooth muscle layers become thinner as the tube tracks from the uterus to the ovary; the diameter of the tube also increases correspondingly. The average fallopian tube measures 11 cm (range 7-16 cm) in length and is divided into four segments (Fig. 150-2): intramural (interstitial), isthmic, ampullary, and infundibular.

The intramural segment is contained in the wall of the uterus beginning at the uterotubal ostium (UTO) and ending at the uterotubal junction (UTJ). It measures 1.5 to 2.5 cm in length, with a lumen of 0.8 to 1.4 mm in diameter observed in vivo specimens.¹⁷ The narrowest point of the fallopian tube is at the UTJ. The isthmus begins at the UTJ and ends at the ampullary-isthmic junction. Its length ranges from 2 to 3 cm, and its diameter is 1 to 2 mm, making it the narrowest extrauterine segment. The ampullary segment is the most variable; it ranges from 5 to 8 cm in length, with a diameter of 1.5 mm at the ampullary-isthmic junction to 10 mm at the ampullary-infundibular junction. The infundibular segment contains the fimbria and the opening to the peritoneal cavity.

The preprocedure workup includes documentation of a recent pelvic examination with a normal Papanicolaou smear and negative gonorrhea and Chlamydia cultures. The procedure is performed in the follicular phase of the patient’s menstrual cycle. Oral doxycycline is given for periprocedural antibiotic prophylaxis: 100 mg twice daily for 5 days, starting 2 days before the procedure. A negative pregnancy test is confirmed on the day of the procedure. The procedure can be performed with local anesthetic in the form of a paracervical block, but intravenous conscious sedation with midazolam and fentanyl is suggested for the procedure to ensure maximum patient comfort and relaxation. Unless contraindicated, 30 mg of intravenous or intramuscular ketorolac can be prophylactically administered before the procedure for abdominal and pelvic cramping. The patient is positioned, prepped, and sterilely draped as described earlier. The same equipment and techniques already described are used for cervical cannulation, HSG, and selective salpingography.

HSG is first performed as a routine part of the FTR procedure to evaluate the uterus and fallopian tubes; bilateral normal patent tubes can be present in up to 20% of patients referred for an FTR. Selective salpingography through the 4F or 5F angled-tip catheter is performed for any persisting tubal blockage or suboptimal opacification of the tube (Fig. 150-3). If a PTO is present after selective salpingography, FTR can be performed with a hydrophilic 0.035-inch or 0.018-inch guidewire (with or without a microcatheter) (Fig. 150-4). A repeat selective salpingogram is performed after the FTR to document tubal patency. Endpoints for FTR are a patent tube with free intraperitoneal contrast spillage, a patent proximal tube with a distal blockage, or inability to successfully recanalize the tube.

Controversies

The use of water- and oil-soluble contrast agents for HSG and FTR has been extensively debated. The subsequent live birth rate after use of these agents during the procedure is the most important consideration, with the pregnancy rate second. Pinto et al. retrospectively reviewed their cases of FTR, comparing pregnancy rates for patients who underwent successful FTR.¹⁸ The two groups included use of water-soluble contrast medium only and use of water-soluble contrast medium plus addition of an oil-soluble contrast agent after confirmation of tubal patency. In 93 patients, there was no significant difference in pregnancy rates between the two groups, but the mean time to conception was 3.3 months less for the group who underwent the addition of oil-soluble contrast. However, a larger number of patients in the water-soluble-only group were lost to follow-up, with possible skewing of the data. Thus far, Pinto’s work is the only study dealing with FTR. A Cochrane review in 2005¹⁹ found two randomized controlled trials for HSG using the same study groups as Pinto et al., but these demonstrated no significant benefit in pregnancy rates. Trials with other combinations of oil- versus water-soluble contrast media have shown increased pregnancy and live birth rates using oil-based contrast agents. Pinto’s work holds the most relevance because it was based on FTR using standard clinical practices. A prospective randomized trial will be useful in determining the role of oil-soluble contrast in FTR.

Tubal perfusion pressure (TPP) has received new attention in the field of female infertility. TPP is measured as the resistance encountered when injecting contrast agent during a selective salpingography. Work by Papaioannou et al.²⁰ relates poor TPP (>500 mmHg) to significantly lower pregnancy rates than a good TPP (<300 mmHg). Improved fertility was noted in women who had poor TPP at baseline and then underwent successful FTR, with TPP reduction. The concept of TPP for measuring tubal function is intriguing but has not received any attention in the radiology literature. There have been no controlled randomized trials to date to support its routine use in clinical practice.

Outcomes

About 30% of HSGs will demonstrate bilateral PTO. Selective salpingography alone can restore tubal patency in about one third of these previously blocked tubes. For the remaining PTO after selective salpingography, FTR will be technically successful in 80% to 90% of attempts. Reported pregnancy rates after successful FTR vary between 10% and 60% depending on the individual studies’ primary patient populations.²¹ Overall, an average unassisted conception rate after successful FTR can be expected in the 30% to 35% range. Patients with patent normal tubes after selective salpingography/FTR have a 50% to 60% chance of tubal blockage recurring within the first year after the FTR procedure.^22,23

Complications

No major complications resulting from an FTR procedure have been reported. Minor complications are uncommon, and the majority of these can be managed conservatively. Complications include tubal perforation, infection, bleeding, ectopic pregnancy, and contrast reaction. Tubal perforation occurs in 2% of cases using modern equipment and techniques.²³ This is self-limited and does not require any further treatment. Infection is a rare occurrence, and the risks can be minimized with prophylactic antibiotics. The vast majority of bleeding after the procedure is mild and can last 2 to 3 days after the procedure. The risk of an ectopic pregnancy is higher for patients who have undergone FTR, but this is thought to be primarily due to underlying tubal abnormalities rather than the procedure itself. Normal monitoring for pregnancy should be performed after FTR. The possibility of a reaction to the contrast agent during the procedure exists but has not been reported. If this does occur, it can be treated with standard medications.

One risk of the procedure that bears discussion is that of developing cancer or a genetic defect from the radiation exposure during the procedure. The patient should understand there is no radiation dose that is 100% safe. Papaioannou et al.²⁴ reviewed 366 cases of selective salpingography/FTR and retrospectively calculated the median effective dose for the various combinations of procedures performed during an FTR. This dose ranged from 0.087 millisieverts (mSv) for a unilateral selective salpingogram to 0.271 mSv for bilateral salpingography and FTR. From these doses, the excess risks of cancer and genetic defects were calculated and reported as the number of cases occurring per 1 million procedures performed. These risks ranged from 4.3 to 13.5 for cancer and from 1.9 to 5.9 for genetic defects. They concluded that the overall risks associated with the radiation doses observed in selective salpingography/FTR are low.

Postprocedural and Follow-up Care

After the procedure, the patient is taken to the recovery area and monitored by a nurse. The results and ramifications are discussed with the patient, including the expected postprocedure events (e.g., vaginal spotting and/or cramping) and normal activities. Sexual intercourse may be resumed as tolerated on the day after the procedure. Possible adverse events are reiterated, with instructions to return for excessive bleeding or cramping, foul-smelling discharge, or fever. The patient should follow up with her infertility specialist in the absence of any problems. If a patient with abnormal fallopian tubes does become pregnant, she is advised to consult with her obstetrician/gynecologist as soon as possible to exclude an ectopic pregnancy. For those patients who have one or both tubes that are patent and radiographically normal after an initial FTR procedure and do not conceive within 6 to 12 months, it is reasonable to perform a repeat HSG with selective salpingography/FTR if necessary, given the expense and inconvenience of the alternatives (i.e., IVF, tubal surgery).