Hysterosalpingography is the study which has been utilized for the initial evaluation of patients with infertility. Besides offering a morphological assessment of uterine cavity, hysterosalpingography provides important information about the anatomy of the Fallopian tubes and tubal patency (Fig. 9.1). The distribution of contrast material into pelvic cavity can be documented and a possible peritoneal factor inferred indirectly. Nevertheless, the results for the diagnosis of the tubal occlusion (sensibility of 65 % and specificity of 83 %) are limited when compared with laparoscopy [2]. For this reason, other techniques were, and are, being constantly tested for the evaluation of the tubal patency. In routine ultrasound, Fallopian tubes cannot be visualized unless they are dilated or when a sufficient amount of fluid exists in the pelvic cavity that allows individualization within the wide ligament [3]. Another technique consists in carrying out a sonographic evaluation after an injection of saline solution into the pelvic cavity. In these cases, the tubal patency is not evaluated, but only tubal diameters. A modified technique is denominated sonohysterosalpingography, in which saline solution is injected through the cervical canal and distention of uterine cavity is under control by ultrasound [4, 5]. This technique does not allow the evaluation of the tubal anatomy. Nuclear medicine was also used in the assessment of tubal patency with radionuclide detection in the peritoneal cavity that had previously been placed at the end of the vagina. This technique is denominated nuclear hysterogram, which has limitations in the morphologic evaluation of the tubes and in the detection of unilateral tubal obstructions [6]. Recently, different experiences in the evaluation of uterine tubes with MRI were published [7–9]. Although the results are promising, limitations exist with regards to spatial resolution and, henceforth, in the complete visualization of tubes and intratubal anatomy. Definite diagnosis and treatment of tubal disease is carried out with surgical intervention either with a laparoscopy or a laparatomy. When combining the direct visualization of the tubes with the blue methylene injection via hysteroscopy, the patency is proven. The internal evaluation of tubes can be achieved by introduction of the laparoscope through a tiny incision done by the surgeon. In this way the fold and mucus pattern can be visualized, especially in the ampullar or dilated region of the tubes. This technique is called falloscopy. A complete internal visualization can also be accessed through the canulization of a microhysteroscope, known as a salpingography. In recent years, the selective salpingography guided by fluoroscopy was developed, an interventionist procedure for patients with proximal tubal occlusion [10]. The success rates of repermeabilization and visualization of the distal anatomy of the tube were of 76–95 %. However, reocclusion was observed in 15–30 % of the cases and there was a prevalence of 10 % of ectopic pregnancies after the procedure. All novel techniques described still require an adequate evaluation with large controlled and randomized studies in search of high levels of scientific evidence [11].

Tubal pathology is classified from the radiological point of view in those that affect tubal visualization, caliber, filling defects and their morphology. Partial or absent tubal visualization may be due to a variety of technical factors or pathologic processes. Hence, this finding is nonspecific and can be related to an insufficient amount of contrast, cornual spasms or mucous plugs [12]. During the VHSG study, these circumstances are avoided with an adequate preparation of the patient and a protocol procedure [13]. The administration of oral antispasmodics an hour before the exam prevents cornual spasms and the presence of mucosal plugging within the tubes [14]. While employing a controlled administration of the contrast medium with an injector pump, the exact moment of the image acquisition is calculated, verifying a volume of contrast that is enough for the complete opacification of the uterine cavity and of the tubes. An excessive quantity would be non productive for the tubal visualization due to the fact that the contrast material poured into the peritoneal cavity could hide the tubes. Hence, the calculation of the moment of the image acquisition becomes of vital importance for the success of the study; it avoids rescan which means an increase in the radiation dose. Pathological obstructions can occur at any level. Inflammatory obstruction typically affects the ampullary portion (Fig. 9.2). On the other hand, when the occlusion is post-surgery (salpingectomy or tubal ligation), in general the visualization is partial and the obstruction is at the level os the isthmus (Fig. 9.3).

The tubal dilatations are due usually to inflammatory pelvic diseases or endometriosis (Fig. 9.4). Dilatation may be associated with complete obstruction (hydrosalpinx) or with some peritoneal spillage (Fig. 9.5).

The filling defects within the tubes are rare and can be visualized as elevated endoluminal lesions in the virtual endoscopic images. The presence of air bubbles introduced during the procedure of the study is easily identified due to its density, and should not be considered pathological (Fig. 9.6). The tubal polyps are the most frequently observed in the proximal region to the tubes (Fig. 9.7). On the other hand, in the ampullar region, linear and irregular filling defects that correspond to intratubal synechiae are observed more frequently, in general related to inflammatory processes (Fig. 9.8).

The alterations of the tubal morphology manifest themselves as irregularities of their edges or with a beaded pattern that alternates stenosis and segmental dilatations. The salpingitis isthmica nodosa is presented as multiple and small pseudodiverticula dilatations of the tubes that generally compromise the isthmic portion (Fig. 9.9). Other inflammatory processes and postsurgical changes can alter the tubal outline and simulate a salpingitis isthmica nodosa, although the most usual presentation form is the beaded pattern (Figs. 9.10 and 9.11) [15].