MRCOG PART 2 SBAs and EMQs
| Course PAID | ||
| notes | 336 | |
| EMQ | 1502 | |
| SBA | 2115 | |
Do you realy want to delete this discussion?
Forum >>
ESSAY 147 - SUB-FERTILITY
|
Posted by narmin B. |
||
| Around 15% of primary and 30%of secondary subfertility is due to tubal factor. Various methods are available for assessment of tubes.The choice of method depends on the availability of the technique, its cost, side effects and aims of investigation. Laparoscopy and dye test (Lap &dye) is the gold standard for tubal assessment. It involves injection of methylene blue through the cervix into the uterine cavity and spillage of dye through the tubal ostia into the peritoneal cavity can be seen via laparoscope. This procedure not only permits assessment of tubal patency but also peritubal adhesions, endometriosis can be identified and treated. It is an invasive procedure and has the risks of laparoscopy such as damage to bowel, vessels and bladder and also anaesthetic problems. Precise site of occlusion cannot be identified. Another method is hysterosalpingography. It involvoles injection of contrast medium through the cervix into the uterine cavity and spillage of the medium into the peritoneal cavity can be seen by using radiographic technique. It can be uncomfortable and also has the risk of transferring lower genital tract infection to upper parts. False positive result due to tubal spasm can be seen. It is cheaper than lap&dye test. Its results corresponds to lap &dye in 80% of cases. Peritubal adhesions can not be assessed with this method. Another method is hystrosalpingo contrast sonography (HyCoSy). This method involves the injection of contrast medium through the cervix into the uterine cavity and performing trans vaginal or trans abdominal sonography to assess patency of tubes. Sonography makes it possible to identify other abnormalities such as fibroid and polycystic ovaries. It is a raidiation free test. The disadvantages of this method is difficulty in determining the unilateral or bilateral tubal occlusion and difficulty in assessing peritoneal adhesions . This technique needs special skill and experience and is not available in all hospitals. Flloposcopy involves hysteroscopy or laparoscopy and visualising tubes. It is useful in determining the site of occlusion and division of adhesions is possible at the same time. It is an invasive technique and therefore has complications of surgery and anaesthsia. Selective salpingography is injection of contrast medium into the fallopian tubes. Accurate site of occlusion can be identified. Before tubal surgery this is an ideal method. This method cannot determine intraperitoneal problem therefore it is not a good choice where such an assessment is required. Rubin test is an old fashioned tubal assessment method .It is an out patient technique and involvoles passage of gas via cervix into the uterine cavity and fallopian tubes. Nowadays it has not a place in assessment of tubes. New techniques involve placing a radiosensitive material inside the cervix and identifying it in the peritoneal cavity. This method has risk of radiation which is similar to HSG. It is not available routinely for tubal assessment and it cannot determine unilateral or bilateral tubal blockage. |
||
|
Posted by Sarwat F. |
||
| Different methods for assessing tubal function in this woman include laparoscopic chromopertubation, hysterosalpingogram, contrast hysterosonography, gas hydrotubation, fallopiscopy and salpingography. Laparoscopic chromopertubation is the gold standard for checking tubal function. It provides the opportunity to not only see the dye spillage in the peritoneal cavity but to see the tubal motility as well which is not possible with other procedures like hysterosalpingogram. At the sametime It gives the opportunity to look for other pelvic pathology for example peritubal adhesions and endometriosis. Certain other procedures like adhesiolysis of peritubal adhesions, salpingoscopy, hysteroscopy or tubal reconstructive surgery can also be undertaken at the same time. There is no risk of exposure to radiations. However its disadvantages include need for hospital admission, risks associated with anaesthesia and surgery. These risks include complications of general anaesthesia like aspiration of gastric contents, mendelsons syndrome, Adult respiratory distress syndrome, cardiac arrest and death. Surgical complications include trauma to gut, damage to blood vessels, insufflation difficulties and rarely ureteric damage. Also with this procedure exact site of obstruction can be difficult to determine. Hystersalpingogram can also give information regarding tubal function. Its advantages include that it can be carried out as an out patient procedure, it is cheap noninvasive, not associated with any anaesthetic and surgical complications. It also outlines the uterine cavity giving information about any intrauterine pathology like polyps etc. It has also been claimed that pregnancy rates are increased after HSG especially after use of oil based dye as compared to water based dye but it is not proven. However its disadvantages include exposure to radiation and that it cannot be used to differentiate between tubal spasm and blockage and it has high false positive rate 85 % sensitivityand specificity as compared to lap and dye. Also tubal motility cannot be checked using this method. It is associated with pain during the procedure which may necessitate use of nonsteroidal anti inflammatory drugs. There is a small less than 1% risk of pelvic infection. Patient should be assessed prior to the procedure for any evidence of preexisting pelvic infection by taking history, performing examination and certain investigations. In this woman if the history and examination are not suggestive of any pelvic pathology HSG will be the investigation of choice. Contrast sonohysterography involves use of galactose microparticles which outline the tubes giving dynamic information regarding tubal patency. It is also an outpatient procedure devoid of stress of hospitalization and anaesthetic and surgical complications as well as free of risk of radiation exposure. It is less expensive and painful and its sensitivity and specificity is comparable to HSG. However its disadvantages include that it require trained personnel in transvaginal songraphy who can accurately perform the procedure. Also it cannot differentiate between unilateral and bilateral patency and fluid within hydrosalpinges may be misinterpreted as indicative of tubal patency . Methylene blue test and gas hydrotubation is simple procedure without any risk of radiation exposure or anaesthesia. However its disadvantages include it cannot differentiate between unilateral and bilateral tubal blockage and accurate culdocentesis is also required. Selective salpingography and fallopioscopy enables better selection of candidates who will benefit from tubal surgery and treatment can be done at the same time by balloon tuboplasty. It allows a firm diagnosis to be made. It can be performed hysteroscopically or under radiological control and may therefore require general anaesthesia, day surgery and laparoscopy with their associated risks. There is a small risk of cornual perforation with this procedure. Another method uses technetium 99 labelled albumin particles to measure radioactivity in the pelvis. It is Pain-free and therefore anaesthesia not required. Disadvantages include Radiation exposure – similar to HSG. It may not differentiate between unilateral and bilateral patency . Also migration into hydrosalpinges may be mistaken as evidence for patency and it does not permit assessment of pelvic pathology |
||
|
Posted by Iman B. |
||
| Tubal Function: Before any method of tubal assessment is used the patient should either be screened for Chlamydia or given prophylactic antibiotics. All methods of assessment depend on observation of passage of contast material through the cervical canal into the pelvic cavity. Laparoscopy with methylene blue dye test remains the gold standard, especially when associated with hysteroscopy for visualisation of the uterine cavity. It is useful in patients whose history suggests pelvic pathology. Eg. Previous history of pelvic inflammatory disease, or endometriosis(deep dyspareunia, secondary dysmenorrhoea ) It is more expensive, and will necessitate use of general anaesthesia, and admission to a day surgery. Laparoscopy carries the risk of injury of internal organs, should be performed by a sufficiently trained gynaecologist, or one under supervision. There is pain following the operation, though usually relieved by nonsteroidal anti inflammatory drugs(NSAIDS). It will also not distinguish the exact site of the pathology in the tube. But the advantages include detection and management of pelvic pathology as adhesiolysis, ovarian drilling and diathermy or ablation of endometriotic lesions, hysteroscopy will identify any pathology in the uterus as polyps or septae or submucous fibroids. Hysterosalpingeography, remains the option for those with no history inclining to pelvic pathology. It is cheap, and consists of the passage of a water based contrast medium through the cervical canal past the tubes into the pelvic cavity, visualised by a radiation screen. It will identify any uterine pathology, as well as defining the site of the obstruction in the tube. There is some discomfort in injection of dye, which may be relieved slightly by giving NSAIDs prior to the procedure, it avoids the need for anaesthetic but it gives no idea on any pelvic pathology. HyCoSy; is the abbreviation for hysterosalpingeocontrastsonography, where a contrast medium is injected into the cervical canal and visualised by using transvaginal ultrasound. It avoids the need for either general or radiation to visualise the contrast medium. Contrast used is either galactose particles (evista) or saline, or dextran. It allows good visualisation or the uterine cavity, and identifies any pathology there, patency of the tubes depends on seeing the contrast medium passing into the pelvic cavity. It gives no idea whether the pathology is unilateral or bilateral, the presence of hydrosalpinges, will give a false positive patency, as fluid in the tubes may be mistaken for patency in the tubes. It gives no idea on any pathology in the pelvis, and requires a high level of expertise in transvaginal scanning. Tubal cannulation is more accurate, as it involves directly cannulating the tubes under either a radiation screen or along with laparoscopy and hysteroscopy. It may relieve an obstruction that is inside the tube. It is more expensive as it is usually performed in a surgery unit, along with laparoscopy. It carries the risk of perforation of the cornua. Albumin labelled with technicium 99 is one option where albumin granules are inserted into the cervical canal and there progress up towards the pelvic cavity viewed through a gamma screen. The main disadvantage is like the HyCoSy, it cannot identify whether any pathology is unilateral or bilateral, as well as the fact that presence of hydrosalpinges may give false positive results of patency. It gives no idea on any possible pathology in the pelvis. |
||
|
Posted by Iman B. |
||
| Tubal Function: Before any method of tubal assessment is used the patient should either be screened for Chlamydia or given prophylactic antibiotics. All methods of assessment depend on observation of passage of contast material through the cervical canal into the pelvic cavity. Laparoscopy with methylene blue dye test remains the gold standard, especially when associated with hysteroscopy for visualisation of the uterine cavity. It is useful in patients whose history suggests pelvic pathology. Eg. Previous history of pelvic inflammatory disease, or endometriosis(deep dyspareunia, secondary dysmenorrhoea ) It is more expensive, and will necessitate use of general anaesthesia, and admission to a day surgery. Laparoscopy carries the risk of injury of internal organs, should be performed by a sufficiently trained gynaecologist, or one under supervision. There is pain following the operation, though usually relieved by nonsteroidal anti inflammatory drugs(NSAIDS). It will also not distinguish the exact site of the pathology in the tube. But the advantages include detection and management of pelvic pathology as adhesiolysis, ovarian drilling and diathermy or ablation of endometriotic lesions, hysteroscopy will identify any pathology in the uterus as polyps or septae or submucous fibroids. Hysterosalpingeography, remains the option for those with no history inclining to pelvic pathology. It is cheap, and consists of the passage of a water based contrast medium through the cervical canal past the tubes into the pelvic cavity, visualised by a radiation screen. It will identify any uterine pathology, as well as defining the site of the obstruction in the tube. There is some discomfort in injection of dye, which may be relieved slightly by giving NSAIDs prior to the procedure, it avoids the need for anaesthetic but it gives no idea on any pelvic pathology. HyCoSy; is the abbreviation for hysterosalpingeocontrastsonography, where a contrast medium is injected into the cervical canal and visualised by using transvaginal ultrasound. It avoids the need for either general or radiation to visualise the contrast medium. Contrast used is either galactose particles (evista) or saline, or dextran. It allows good visualisation or the uterine cavity, and identifies any pathology there, patency of the tubes depends on seeing the contrast medium passing into the pelvic cavity. It gives no idea whether the pathology is unilateral or bilateral, the presence of hydrosalpinges, will give a false positive patency, as fluid in the tubes may be mistaken for patency in the tubes. It gives no idea on any pathology in the pelvis, and requires a high level of expertise in transvaginal scanning. Tubal cannulation is more accurate, as it involves directly cannulating the tubes under either a radiation screen or along with laparoscopy and hysteroscopy. It may relieve an obstruction that is inside the tube. It is more expensive as it is usually performed in a surgery unit, along with laparoscopy. It carries the risk of perforation of the cornua. Albumin labelled with technicium 99 is one option where albumin granules are inserted into the cervical canal and there progress up towards the pelvic cavity viewed through a gamma screen. The main disadvantage is like the HyCoSy, it cannot identify whether any pathology is unilateral or bilateral, as well as the fact that presence of hydrosalpinges may give false positive results of patency. It gives no idea on any possible pathology in the pelvis. |
||
|
Posted by Nibedita R. |
||
| Tubal function tests generally provide evidence of tubal patency only. Although, normal tubal patency does not necessarily confirm a normal tubal function. Laparoscopy and dye insufflation should be considered as the ideal standard for fallopian tube assessment. This procedure requires laparoscopy and injection of methylene blue through the cervix into the uterine cavity and fallopian tubes which spills into the peritoneal cavity. It also allows visualisation of extratubal pathology such as endometriosis, adhesions and fibroids, which may be the cause of tubal blockage from outside. Tubal peristalsis would be seen in a normal functioning tube. Therapeutic procedures such as tubal surgery, diathermy of endometritic deposits and adhesiolysis can also be performed at the same sitting if consent has been obtained. The procedure, however, does not provide information about the site of block in the tube, cause of block whether simple tubal casts, intratubal adhesions or anatomical occlusions exists. Laparoscopy may give false positive results of dye tests due to technical failure or due to difference in the resistance between the two tubes. Being an invasive procedure it carries procedure related risks and the risk of general anaesthesia. Hysterosalpingogram (HSG) is used as a screening test especially in low risk women. Allows radiological assessment of uterine cavity and tubes by injecting a contrast medium through the cervix. Site and side of tubal blockage can be identified and information about the interior of uterine cavity such as synaechia or polyp may be obtained. Being an outpatient procedure with no need for GA, it is relatively cheaper than LAP-DYE test. However, it may be uncomfortable for some patients, is associated with high false positive results due to tubal spasm and there is risk of radiation exposure. Provide little or no information about peritubal adhesions and other pelvic pathology could impair tubal function. Hysterosalpingo-contrast-sonography is another test, performed by TAS/TVS along with a media containing galactose microgranules, saline or dextrose. This procedure does not require radiation exposure or GA and allows detection of uterine and adnexal pathology. Limitations includes, inability to differentiate unilateral/bilateral tubal patency, does not provide information about endometriosis or adhesions, is associated with false positive results due to misinterpretation of fluid inside hydrosalpynx as tubal patency and is highly operator dependent. Selective salpingography is performed to confirm proximal tubal blockage by introducing a tubal catheter through cervix and advanced through the tubal ostium under fluoroscopic guidance. A contrast dye is then injected at a constant rate to outline tubal contour radiologically. This procedure overcomes tubal spasm and obstruction like mucous plug thus minimises false positive results. Therapeutic procedures can be performed by introducing a guidewire, to break intratubal adhesions. It also allows measurement of tubal perfusion pressure, which can be an indicator of tubal compliance (high perfusion pressure means stiff tube). Normal tubal perfusion pressure is good predictor of future fertility. It carries risk of radiation exposure and risk of perforation of the tube (5-10%). Falloposcopy is used to examine the inside of fallopian tube using a telescope introduced through proximal or distal end of tube along with laparoscopy or hysteroscopy under GA. Technically difficult and require greater expertise. There is another noninvasive test, which involves spontaneous transfer of particles from lower to upper genital tract and its visualisation in peritoneal cavity. Most of the tests are invasive and associated with risk of PID and prophylactic antibiotic should be recommended for high risk women. There are varieties of procedures available through which tubal function can be tested. Selection of one would rather depend on individual patient, availability of expertise and other resources, setting of the unit and its cost effectiveness. |
||
|
Posted by Vaijayanti R. |
||
| Tubal factor involvement is seen in about 14% of infertile couples ; 40% of infertile women. Evaluation of tubal status is restricted to documentation of patency, there is no accurate method to assess tubal physiological function available yet. The method of tubal evaluation in this woman is based upon her history and examintion findings. Past history suggestive of endometriosis ( pelvic pain ; dyspareunia ), pelvic-abdominal surgery,pelvic inflamatory disease,inflamatory bowel disease, appendicitis ? would indicate the need for investigations such as Laparoscopy In the absence of any significant past history or examination findings( restricted mobility of uterus), tubal evaluation can be done with the Hysterosalpingogram(HSG) The HSG is recommended by the RCOG as the primary investigation in low risk women.It involves introduction of radio opaque dye through the cervix into the uterus; periodic X rays are taken to visualize the passage and spill of the dye throughthe tubes.The procedure is simple, easy to do, done on an OPD basis,evaluates the uterus and the proximal tubes.But, does not evaluate the distal tubes or identify accurately the presence of peritubal adhesions.the procedure is painful, may be ssociated with a vasovagal attack. Spasm of the cornual end may give the false impression of a proximal tubal block.Apart from exposure to radiation, there is the risk of pelvic inflamatory disease( 1 to 3 %) Doing the procedure under fluoroscopic control, will help to accurately define the site of block and cannulaton can be attempted at the same sitting( fluoroscopic tubal cannulation) Other investigations that may be done in low risk women include the Hysterocontrast Salpingo sonography and the Sono salpingo Graphy.These methods involve the introduction of ultrasound contrast medium in case of HyCoSy or distilled water/ normal saline in Sonosalpingography through the cervix into the uterus. The passage of the medium/ fluid is observed by ultrasound.The main advantage is that other pelvic structures are assessed at the same sitting, no irradiation involved, simple procedure, easy to do and is done on an OPD basis. However it is not as accurate as the HSG, and is dependant on the sonographer.Use in clinical practice is restricted. Diagnostic Laparoscopy would be appropriate in this woman if she had any previous history suggestive of pelvic disease. This is considered to be the gold standard in tubal evaluation.Involves introduction of methylene blue through the cervix into the uterus and direct visualization of the dye passing through and spilling from the fimbrial end. Assessment of the other pelvic structures is done; accurate identification of peritubal adhesions. The main advantage is that lesions ? endometriosis, fibroids, adhesions can be treated at the same sitting.The procedure is done under general anesthesia, in a day care setting. Involves the risks associated with anesthesia, as well as inherent to the procedure ? bowel injury. Risk of major complications with a diagnostic procedure is about 0.06% and with operative procedures is about 1.3%.Would have to be combined with a Hysteroscopy to identify intrauterine pathology. Transvaginal Hydro Laparoscopy involves the introduction of the laparoscope through the posterior fornix; distending medium used is distilled water.Results are comparable with those obtained by traditional laparoscopy, and is less invasive. Use in clinicalpractise is still limited. Falloposcopy involves direct visualization of the mucosal lining of the tube. There is inadequate evidence regarding the significance of findings ? so it is not a widely used procedure. The couple are counselled in detail regarding the necessity of tubal evaluation, options available , risks associated with each procedure.Accurate information is given in an impartial manner. Written information is given in addition. Screening for Chlamydia is offered( recommended by the RCOG prior to any intrauterine manipulation), along with antibiotic prophylaxis ( metronidazole). Cervical cytology is offered if not done already/ she is due for a PAP smear. Finally the choice rests with the woman.Her wishes are confirmed to; any intervention/ procedure is done with informed documented consent. |
||
|
Posted by Abdul Aziz S. |
||
| Tests for tubal patency form one of the initial investigations of the infertility work up. About 15%of patients with subfertility are found to have tubal factor. Most commonly employed tests are LAPAROSCOPIC CHROMOTUBATION, HYSTEROSALPINGOGRAPHY,(HSG),HYSTEROSALPINGO CONTRAST SONOGRAPHY(HyCoSy). These tests employ a test medium flushed through the cervix into the tubes via uterine cavity. This puts the pt at increased risk of PID, 1%in general population and 3%in high risk patients with evidence of tubal disease at the time when test is performed or if there is immunological evidence of chlamydia trachomatis. Antibiotic prophylaxis should be given to all such pts. Also these tests can give false negative results due to a mobile flap of thickened endometrium preventing passage of substance to oviduct. Laparoscopic chromotubation is the gold standard.methylene blue dye is injected transcervically into the uterine cavity. Patency is demonstrated by observing the dye passing into the peritoneal cavity. Advantages include assessment of spiritual adhesions, endometriosis. The process can be combined with salpingoscopy or hysteroscpy allowing detection of uterine malformations, endometrial polyps, intrauterine adhesions and fibroids .Adhesiolysis and tubal reconstructive surgery cane performed at the time of investigative surgery. If the test is performed at the correct time visualization of corpus luteum will give evidence of ovulation. Disadvantages are, it is an invasive test requiring general anesthetic with its associated risks. There is small risk of visceral damage on insertion. Actual site of occlusion in any tube cannot be detected. HSGis done using a water soluble or oil soluble contrast media. Radiological screening is utilized as the medium is instilled. Advantages are, relatively cheap and simple, intrauterine pat, position of tubal occlusion can be noted. Unilateralpatency can be differentiated from bilateral patency. There is no need for general anesthesia .It is useful in the diagnosis of salpingitis isthmica nodosa. Disadvantages are, pelvis including ovaries is exposed to radiation. Which could be h Harmful if pt had early pregnancy. Most patients experience pain following the procedure. HyCoSy consists of observing flow of media through the tubes by trans abdominal or transvaginal routes. Advantages are ,there is no radiation exposure or need for general anesthesia. Results are consistent with HSG.Disadvantages are presense of fluid does not differentiate between unilateral and bilateral occlusion.HyCoSy is contraindicated in patients with galactosemia.Operator expertise is required to perform transvaginal scanning. Methylene blue test ,Gas hydrotubation(Rubin test )have been superseded by HSG. .Thus high predictive value of finding bilateral tubal patency at HSG has lead to the conclusion that it should be used as an initial test in patients with a history not suggestive of tubal disease. Patients with unilateral or bilateral tubal occlusion may then undergo laparoscopy with sufficient theatre time for tubal surgery.. Selective salpingography and fallopioscopy enable direct canulation of fallopian tubes.Treatment can be done at the same time by balloon tuboplasty.advantages include avoidance of general anesthesia, surgery and expensive hospitalization. Disadvantage is it requires expertise, training and time. These tests have not been included in the routine practice. |
||
|
Posted by vijaya L. |
||
| Tubal factor contributes for 10-15% of Subfertility. The contribution is more in case of secondary Subfertility, and with previous history of pelvic inflammatory disease. The tubes are usually tested at secondary level of infertility care. The various methods available are Histero-salpingography(HSG), Laparoscopy and chromopertubation, Hystero-Contrast-Sonosalpingogram(HyCoSy), and Technetium 99. Majority of the tests except the last one, test the anatomical integrity and if normal, physiological integrity is often assumed to be normal. The fist line test for this couple would be HSG as this cheap, less invasive and reliable (as per the RCOG recommendations). But laparoscopy with tubal insufflation should be chosen over HSG if pelvic pathology like endometriosis and pelvic inflammatory disease are suspected. HSG is an outpatient procedure done during the proliferative phase. It involves injection of the radio-opaque medium through cervix and, pelvic X-rays are taken at the intervals to look for filling of the tubes, and spillage into the pelvic cavity. Site of the block can be localized well and contour of the uterine cavity can also visualized. Does not require anaesthesia there by avoiding the complications associated with it. But this procedure involves exposure to radiation, pain and discomfort sometimes leading to vasovagal shock, and false positive results due to tubal spasm. Adequate counseling and anti-spasmodics before the procedure would be of help. PID can get flared up hence infection should be ruled out before the procedure is undertaken. Diagnostic laparoscopy and chromopertubation is considered as gold standard and is done as a day case under general anesthesia. Direct visualization of the tubes and rest of the pelvis is possible thereby identifying the pelvic pathology and adhesions. If an adequate consent has been taken and expertise is available, therapeutic procedures like resection of endometrial implants and adhesiolysis can be carried out. Obesity and cardiac disease are contraindications for the laparoscopy. This procedure is associated with complications related to anesthesia and those due to laparoscopy like injury to the bowel or blood vessels. Intra tubal pathology can not be made out well by this procedure alone. This procedure can be combined with hysteroscopy with or without salpingoscopy to visualize the uterine lining and fallopian tubal lining respectively. But both are not recommended unless indicated probably earlier HSG findings. Salpingoscopy is employed only when tubes are not patent and are being assessed for the feasibility of the surgical correction. Isolated corneal blocks can some times be corrected by canulating the tubes through hysteroscope. This combination increases the rate of complications significantly. HyCoSy involves injection of saline and glycogen to create contrast and visualize the tubes by ultrasonography. This method avoids radiation and anaesthesia. It likely to cause pain and discomfort. This requires procedure related training, and is not widely available. Technetium 99 particles are placed at the cervix it is picked up form the pelvis by scintillating radiography. This simulates the movement of the spermatozoa and indicates the function of the upper genital tract |
||
|
Posted by Vaijayanti R. |
||
| Dr Paul Would be greatful if you could check my answer too |
||