Common Tubal Abnormalities Seen in Hysterosalpingography

In previous blogs, I have presented findings of a normal hysterosalpingogram (HSG) and abnormalities of the uterine cavity. In this blog, the focus is shifted to the fallopian tubes. There are several techniques used to evaluate fallopian tube patency. These include HSG, ultrasound and laparoscopy. We use all these modalities in our practice. HSG, however, remains the most common technique for evaluating tubal patency.

In addition, HSG provides important information about the shape of the tube (contour) and the presence or absence of tubal folds (rugae). The presence of the folds is a good sign and may indicate that the tube may be functional.

Salpingitis isthmica nodosa (SIN), also known as diverticulosis of the fallopian tube, is a nodular thickening of the isthmic (narrow) portion of the fallopian tube. It may be caused by inflammation. It consists of multiple contrast material–filled luminal pouches (arrowheads) projecting 2–3 mm outward from the isthmic portion of both fallopian tubes. It can be on one side or both sides. In severe cases, it leads to complete tubal blockage. Patients with SIN are at an increased risk of having a tubal pregnancy. IVF has now replaced surgery as the treatment of choice for this condition.

Proximal tubal blockage (occlusion). In this case the uterine cavity appears normal. The dye, however, does not enter the fallopian tubes despite being injected forcefully. It can be sometimes caused by “spasm” of the fallopian tubes. We minimize this possibility by pre-treating patients with ibuprofen and injecting the dye gently. Proximal tubal blockage (occlusion) can often be treated with tubal catheterization.

Distal tubal blockage (occlusion). In this case also the uterine cavity appears normal. The tubes fill up with dye. They, however, are dilated and fill up like balloons with no spill of dye forming what is called as a hydrosalpinx. In this case, no rugae are seen. This indicates that the tubes cannot be surgically repaired. It is now well established that IVF pregnancy rates are lower with hydrosalpinx. This could be because of several mechanisms 1) the hydrosalpinx fluid flushes out the embryos, 2) the hydrosalpinx fluid is embryo toxic or 3) the hydrosalpinx fluid has a negative impact on certain cell-adhesion molecules (integrins) that are required for embryo implantation. We will often remove hydrosalpinx via laparoscopy prior to doing IVF

Essure HSG. Patients can now have a tubal ligation using hysteroscopy. Using the Essure technique, a metallic coil is inserted into the tubal lumen. The coil in turn induces fibrosis and blocks the tube. A HSG can be done 3 months later to confirm that the Essure device is in place and the tubes are blocked.

Scar tissue (adhesions) around the tube cannot be definitely diagnosed with HSG. When there is a localized collection of dye (loculation); these can be suspected. Pelvic endometriosis cannot be diagnosed with HSG. The ovaries cannot be visualized on HSG. The uterine wall itself also cannot be seen on HSG. These require a combination of ultrasound and laparoscopy for a definite diagnosis.

At InVia Fertility Specialists, we use all three modalities (as needed) to comprehensively evaluate our patients.

To work with a fertility clinic with excellent IVF success rates offering a full range of fertility treatments, schedule an appointment at one of InVia's four Chicago area fertility clinics.