Two hundred patients have been reviewed in whom culdoscopy or laparoscopy was performed for infertility study. During these two procedures, methylene blue was injected through an endocervical cannula for detection of tubal patency under direct visualization. When compared with 89 patients tested by utero-tubal insufflation and hystero-salpingography, results indicated that direct visualization of the tubes and dye hydrotubation appears to be the most reliable method. HSG proved to be the second most reliable method with a failure rate of 19.2%. The least accurate procedure in this study was UTI with CO2 gas, where the failure rate was 24.7%. The latter lest, however, is the most efficient one for detecting tubal spasm

Afsari, Asghar

Thompson, Robert J.

English

Henry Ford Health System Scholarly Commons

Henry Ford Hospital Medical Journal Volume 20 Number 3 Article 2 9-1972 Current Tests for Tubal Patency: Their Study and Comparison Asghar Afsari Robert J. Thompson Follow this and additional works at: https://scholarlycommons.henryford.com/hfhmedjournal  Part of the Life Sciences Commons, Medical Specialties Commons, and the Public Health Commons Recommended Citation Afsari, Asghar and Thompson, Robert J. (1972) "Current Tests for Tubal Patency: Their Study and Comparison," Henry Ford Hospital Medical Journal : Vol. 20 : No. 3 , 125-130. Available at: https://scholarlycommons.henryford.com/hfhmedjournal/vol20/iss3/2 This Article is brought to you for free and open access by Henry Ford Health System Scholarly Commons. It has been accepted for inclusion in Henry Ford Hospital Medical Journal by an authorized editor of Henry Ford Health System Scholarly Commons. enry Ford Hosp. Med. Journal ol. 20, No. 3, 1972 ivasculi vascul; npariso racted Current Tests for Tubal Patency Their Study and Comparison Asghar Afsari, MD* and Robert J . Thompson, MD** Two hundred patients have been reviewed in whom culdoscopy or laparoscopy was per formed for infertility study. During these two procedures, methylene blue was injected through an endocervical cannula for detection of tubal patency under direct vis-ualization. When compared with 89 patienis tested by utero-lubal insuff lat ion and hystero-salpingography, results indicated that direct visualization of the tubes and dye hydrotubation appears to be the most reliable method. HSG proved to be the second most reliable method with a failure rate of 19.2^. The least accurate procedure in this sludy was UTI with C O J gas, where the failure rate was 24.7''f. The latter lest, however, IS the most efficient one for detecting tubal spasm. Because fertilization takes place in the erine liihal lumen, patency ofthe lubes of great imporlance. In patients wilh feniliiy. a tubal factor is the most fre-ent problem. While a variety of diag-l^ic procedures have been advocated to ^i for luminal patency, the following tee techniques have proven to be most P>ctical: -L'tero-iubal insufflation (UTI). Hystero-salpingography (HSG). Direct visualization of the tubes thru 'he culdoscope or the laparoscope, during injection of dye (methylene l^ue) thru the uterine cannula (MBI). The relalive value of these three proce-^^"< \\ill be compared here. V!-P<^ meni of Gynecology-Obstetrics. HFH Medical Center. Jack-* at Duval Fla. reprint requests to Dr. .\. .Afsari, care "y Ford Hospital. Detroit. Mi 48202 Material We reviewed a lolal of 200 cases of patients who have UIUICIKOIIC culdoscopy or laparascopy in the five years from March 1965 through February 1969. One hundred and eleven of these patienis who had either UTI or HSG prior lo culdoscopy or laparascopy have been excluded. .All three tests were com-pleted in the remaining 89 patienis. Method The UTI was peiformed in the office without sedation, using a tirafax Model insufflator, charged with carbon dioxide gas, (75 to 100 cc of CO2 for each pro-cedure). Either the Rubin cannula with acorn lip or the Calvin cannula wilh screw tip was employed. Ihe prtKcdiire was nol performed in the presence of local infection, uterine bleeding, or possi-ble pregnancy. For alleviation of shoulder pain, which oflen developed afier U T I , the patients were placed in semi knee-chest position wilh hips elevated over a pillow. 12.5 Alsari and Thompson Figure I Hystero.salpingonraphy instrument vvith vacuum apparatus. HS(i was done in the Radiology Department with correlation of Depart-ment of Gynecology and Radiology. The instrument utilized was a suction cap type cannula and the medium, a water soluble contrast material containing 38% iodine (E. R. Squibb Co. — Sinographin)(Figure 1) A scout film was taken prior to applica-tion of the cannula. Pelvic examination was routinely performed lo evaluate the position of uterus prior to the pioceduie. In both procedures, careful aseptic technique was carried out. The tests were performed in the phase of preovulalion. A l the beginning of this sludy. direcl visualization of pelvic organs was done Ihrough a culdoscope. Bul, since Febru-ary, 1^ 68. laparoscopy has been employed. Using a fibro-optic and light source and l.ip.ii os^opc V. iih .1 u KIC .incic lens, 11 jnurc 2) . Either procedure was performed as the last step of the infertility evaluation and while the patient was hospitalized. The procedure was carried out accorc | to the technique described by Stepii^ j When visualization was satisfactorv. to 15 cc of 0.25% methylene blue»!l injected through an inlracervical cann:^  and the tubes were observed for spilt of the dye. Results The group ranged in age between 15' 38 years. Culdoscopy was perforn:!j on 40 patients (45%) and lapaioscopy-49 patients (54%). For the purpose comparison, the results of the three-cedures will be classified inlo patible"" and "incompatible"" P'^  (Table I). The compatible gioup. consisting''"] patients (.56.1%), had similar results i''' three procedures. Forty-two oft'"' (47.1%) demonstrated tubal palciK ' three tests. In three patients (3.3 '^ 126 Current Tests lor Tubal Patency Fiuurc 2 Laparascopy instruuu-nt lor visuali/ation and dyhydroliihation. tube was patent at the time of MBI . HSG and UTI were also positive, iree others (3.3%) had patency of the t lube only. In the other two patienis ^^), the three tests were negative, e of these patients had severe pelvic ^hesions due to previous surgery. The pier had had previous right salp-Sgeciomy and the dye did not spill from ie fimbriated end of the left tube. In Besetwo patients, the UTI was negative [•"Ithe HSG was compatible (Table I I ) . •he incompatible group was divided two sub-groups (Table I I I ) . The first group with 17 patients had similar '"It'' from the MBI and the U T I , but HSG did not match. The failure rate '^his category was 19.2%. The second group of 22 patienis (Table IV) had '^l^ r results from MBI and HSG, but J*ith UTI. The UTI failure rale was Discussion Utero-tubal insuf f la t ion , more popularly known as the Rubin test, was first described by I . C. Rubin in 1920. I he apparatus has been changed and modified, but the basic concepts remain the same. I f there is no leakage around the cervical insufflating cannula, the CO2 gas will enter the uterine cavity and, afier developing sufficient pressure, will pass thru the utero-lubal junction and the tubes to enter the peritoneal cavity. Patency is indicated by a sharp fall in the pressure shown on kymographic paper. I he controversy over the source of oscil-lation recorded on the kymographic paper has persisted for many years. Stabile, in 1958.' offered evidence that the oscilla-tions result from uterine muscle contrac-tions. Moreover, Sobrero," in a compara-tive study of UTI and HSG in 1961. reported significanl disagreement in the 127 Alsari and Thompson TABLE I Classification Compatible Group: Similar result of the three procedures. Incompatible Group: Variable results of the three techniques. A) Variable HSG. B) Variable UTI. TABLE II Compatible Group Method No. Cases % a) Bilateral tubal patency 42 47.1 b) Unilateral tubal patency 6 6.6 c) No patency 2 2.4 Total 50 56.1 TABLE III Incompatible Group, Variable HSG 17 Cases (19.2%) No. MBI UTI HSG Cases a Bilat. Pos. Rt. Patency 7 b Bilat. Pos. Lt. Patency 6 c Bilat Pos NO Patency 2 d Unilat Pos. NO Patency 2 TABLE IV Incompatible Group, Variable UTI 22 Cases (24.7^;) A False Positive 4 B False Negative 14 a Bilateral T Patent (MBI & UTI) .9 b Lt T Patent (MBI & UTI). .3 c. Rl T Patent (MBI & UTI). .2 C Spasm 4 test results: False negative 8.4%. fals< positive 31%. In another sludy. JefTcoale' reported 37% false negative and 15% false positive. Our results with UTI revealed a 24.71 tailure rate. Our false negative r; . 15.7%, false positive rate of 4.5% and the tubal spasm rale of 4.5% are in the sainf range as that reported by Rubin.'' * To eliminate false positive resulls. the cau-tions mentioned by Rubin and Sweenv should be observed: (a) Checking foi leakage in the tubing, the lank anJ ih; connections prior lo examination; (bi maintaining an initial flow rale of COjgas of not more than 60 cc per minute: anc (c) using no dilator or probe in the endocervical canal prior to insufflation. To eliminate false negative results the cannula should be patent, and rapic insufllation should be avoided; .il-position of the uterus should he cv iluaie prior lo the procedure, l l should he men tioned lhal. despite the definite sourcesof error in conduction and evaluation ofttit results, the UTI remains the most rel-able test for detection of tubal sp.ism. I he second melhod of evalualine luK; patency, the HSG, was first dcsciihed" Cary and Rubin in 1914. .Although the medium Collargol has been changed .in the lechnique altered.'- the basic concep-remains the same. (Figure 3) Ceriain errors in lechnique have adverse affev"'-on the roentgen pictures and inierfe; with interpretation: eg. foreign bod\ the syringe and cannula or use of too littie or too much contrast material. In^'-series, there was a 19.2% failure ratew'" HSG. I f proper technique is no: employed, the HSG is no better ^  indicator of tubal patency than UTI. Direcl visualization of the peb'-org;ins. either through the culdoscope' the laparascope, is a valuable diagnosi"-procedure." Decker and introduced culdoscopy in 1944. laparascopy procedure predates cul*^ ^ . . . . . 1 K.. i ivalo copy. Recently, there has been revi 12H Current Tests lor Tubal Patency Figure 3 Hysterosulpingogram picture. '"leresl in the abdominal approach to pel-vic endoscopy, and also in the testing for '"bal patency by means of dye hydro-'"baiion. With the improved instrumenta-"on now available, the view of pelvic "•^ gans Ihrough laparoscopy closely approximates that seen at laparotomy, shape and configuration of the inter-peritubal lesions are readily identified. '"e patient is under general aneslhesia at the time of the methylene blue injec-tion, tubal spasm is eliminated. Fxperi-ence has shown lhal methylene blue does nol produce localized peritoneal or tubal inflammation or reaction. Our resulls have indicated lhal the direcl visualiza-tion ofthe fallopian lubes and MBI is the most accurate and reliable method of diagnosing tubal patency. 129 Afsari and Thompson References 1. Steptoe. PC: Laparoscopy in Gynaecology. Edinburgh, E & S, Livingston ji*-2. Rubin, IC: Nonoperalive determination of patency of fallopian tubes in sterilir Intra-uterine inf la t ion with oxygen and production of an artificii pneumoperitoneum. Preliminary iQpovX.JAMA 74:1017-10 April 1920 3. Rubin, K : Rhythmic contractions and peristaltic movements in the intact hunii-fallopian lube as deiermined by peruterine gas insufflation and the kymograp' Am J Obst Gynec 14:557-72 Nov 1927 4 Rubin, IC: Uterotubal insujjhtion, St. Louis, Mosby, 1947 5. Stabile, A: The uterine origin of the rhythmical undulations recorded during Rubin lest: Experimental and clinical proofs, Int J Fertil 3:1-19, Jan-June 1958 ') SOIMCIO. . \ i et al: Tubal insufflation and hysterosalpingography. A comp;iraiii.| sludy in .500 infertile couples. ()h\tct-(i\necol 18:91-3, July 1961 7. JefTcoale, TNA: Tubal patency test, Proc Soc Study Steril, Fifth Liverpool Ccf-ference, 1953 8. Rubin. IC: Diagnoslic and iheiapeulic aspects of kymographic uterotubal insufflate-with comparative observations on hysterosalpingography, y Obstet GynaecS' Emp 54:733-45 Dec 1947 9. Rubin, IC: Comparison of carbon dioxide and opaque media in the diagnosis o:| tubal patency, Fertil Sterd 3:\79-S7, 1952 10. Decker, A and Cherry. TH: Culdoscopy — A new method in the diagnosis of peh-disease — a preliminary report. Am J Surg 64:40-4 Apr 1944 11. Oiiulotf. BH: The peritoneoscope in diagnosis of disease of the abdomen. J Radi'' 1:307, May 1920 12. Siegler, AM: Hysterosalpingography, New York, Harper & Row , 1967 13. Sweeney, WJ: Pitfalls in presenl-day methods of evaluating tubal function: I . Tubi insufflation. Fern/5/<'n7 13:113-23 1962 14. Sweeney, WJ: Pitfalls in presenl-day methods of evaluating tubal function: II- H)'| terosalpingography, Fmi7 5rt'n7 13:124-34 1962 130 

Current Tests for Tubal Patency: Their Study and Comparison

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Current Tests for Tubal Patency: Their Study and Comparison

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