An Evaluation of the PSP (Speck) Test for Tubal Patency. M. Edward Davis, M.D., Mildred E. Ward, M.D., and Albert G. King, M.D.

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1 An Evaluation of the PSP (Speck) Test for Tubal Patency M. Edward Davis, M.D., Mildred E. Ward, M.D., and Albert G. King, M.D. IN 1948 Speck described an ingenious procedure for the demonstration of tubal patency. Its apparent simplicity, economy, and accuracy provided sufficient appeal for a more extensive evaluation of the method. If phenolsulfonphthalein ( PSP) is injected into the uterine cavity of a woman who has patent fallopian tubes, it passes through the oviducts and into the peritoneal cavity from which it is absorbed rapidly and appears in the urine within the first half-hour. The absence of the dye in the urine at the end of this time is indicative of tubal closure, for phenolsulfonphthalein is absorbed very slowly, if at all, through the vaginal mucosa, uterine endometrium, and tubal mucosa. In a total of 210 Speck tests which had been collected and reported prior to May, 1950, the accuracy of the procedure was reported as perfect. Israel and Freed in July, 1950, carried out the Speck test in three groups of patients. In the first group of women, in whom cornual resections had been done, the procedure gave negative results in all cases but one, in which the result was questionable. In the second group of women the dye was introduced into the peritoneal cavity at the time of laparotomy. It appeared in the urine in all cases although in some there was some delay, probably because of the postoperative condition of the patient and the interference with urinary secretion. In the third group of patients, who were subjected to culdoscopy, whenever the dye could be seen escaping From the University of Chicago and the Chicago Lying-in Hospital. 217

2 218 DAVIS ET Al. [Fertility & Sterility from the tubal ostium it invariably appeared in the urine within half an hour. These observations confirmed the principles of the Speck test, although the authors commented that this procedure would not supplant the timehonored methods of studying tubal patency. Brown, in his discussion of this paper by Israel and Freed, reported that follo\ving the insertion of dye-saturated tampons into the vagina no PSP appeared in the urine but the introduction of the dye into the uterine cavities of these same patients gave positive tests. Rosset in October, 1950, reported a study in which he attempted to correlate the results of the Speck test and the condition of the oviducts at the time of operation. He injected phenolsulfonphthalein into the uterine cavity of 25 women the day prior to surgery, noted the presence or absence of the dye in the urine and then studied the fallopian tubes after they were removed. He found that the results of the Speck test were accurate in 14 patients, questionable in 6 and incorrect (false positives) in 5. He suggested that diseased oviducts may allow a greater absorption of the dye into the circulation resulting in false positive tests. Hofmann in 1951 could not confirm the accuracy of the Speck test. He reported that he obtained 41 positive tests in women in whom tubal closure had been demonstrated by other methods as well as in all but one woman who had patent oviducts. He concluded that the procedure was unreliable and of little value. The present study is an attempt to reconcile some of these divergent views and to determine the diagnostic and prognostic value of this latest tool in the study of sterility in women. The results of the PSP test were correlated with the classic Rubin uterotubal insufflation procedure and uterosalpingograms. A special group of women in whom puerperal tubal ligation of the oviducts was done were subjected to the Speck test. In general the technic suggested by Speck was followed. It is recognized that although the Speck test was evaluated in comparison with the standard procedures, the latter are not 100 per cent accurate. UTEROTUBAL INSUFFLATION AND THE SPECK TEST In 24 patients uterotubal insufflation under kymographic control preceded the instillation of PSP into the uterine cavity. The only variation in the standard technic described by Rubin was that a catheter was inserted into the bladder. Following the completion of uterotubal insufflation with

3 Vol. 3, No. 3, 1952] SPECK TEST 219 carbon dioxide gas, 10 cc. of PSP (one ampule containing 6 mg. of PSP was added to 9 cc. of sterile water) were injected into the uterine cavity, the stop-cock on the cannula was closed, and the patient was given 4 ounces of water to drink. She was then taken out of lithotomy position and allowed to remain flat on her back with the instruments in place. At the end of one-half hour the bladder was emptied and the indwelling catheter and the instruments were removed. The urine was examined for PSP by alkalinizing it. The results obtained in this group of women are tabulated in Table 1. In five instances the results of the PSP test varied from those obtained bv -' TABLE 1. Speck Tests,Compared with Uterotubal lnsufflations in 24 Patients Partial Patent blockade Occluded Questionable Speck test positive '' 2 Speck test negative Numbers in italics indicate patients in whom the Speck test was in error in comparison with uterotubal insufflation. * In one of these patients the Speck test was correct but uterotubal insufflation in error. uterotubal insufflation with gas. Uterotubal insufflation was repeated in these 5 cases and some patency to gas was demonstrated in 1 patient in whom a diagnosis of tubal blockade had been made. The 2 patients in whom the results of the dye test were considered questionable had tubal patency on uterotubal insufflation. SPECK TEST AND UTEROSAlPINGOGRAPHY In 86 patients who were being subjected to a complete sterility study the Speck test was carried out prior to the study of the fallopian tubes by means of uterosalpingography. The usual preparations for the visualization of the reproductive tract included the introduction of a catheter into the bladder. Ten cubic centimeters of dye was injected through the cannula into the uterine cavity and the patient was given 4 ounces of water to drink. Radiopaque oil ( Iodochlorol) was introduced into the uterine cavity under fluoroscopic control. The uterine cavity and oviducts were visualized. Routine roentgenograms were taken. At the end of one-half hour the catheter was undamped and the urine collected and examined for phenol-

4 220 DAVIS ET AL. [Fertility & Sterility sulfonphthalein. The patient returned the following day for another set of x-rays to complete the examination. The results of the Speck test in these patients are tabulated in Table 2. There were discrepancies in 16 patients. In 6 patients who had false negative tests both tubes were visualized and patent in 3 cases. One tube was patent in 2 cases and only partial tubal patency could be demonstrated in the sixth patient. In 10 patients in whom false positive tests were obtained absolute tubal blockade was demonstrated in 7 and on a second attempt at demonstrating tubal patency, some radiopaque oil escaped from one or both tubes in 3 of the patients. Thus, in these 3 instances the positive Speck tests were not in error. In 6 additional patients the results of the dye test TABLE 2. Both tubes patent One tube patent Partial patency Tubal occlusion Speck Tests Compared with Uterosalpingography in Speck positive * Speck negative Patients Speck questionable t Numbers in italics indicate patients in whom the Speck test was in error in comparison with uterotubal insuffiation. * The results of the Speck test were correct in 3 of these cases but uterosalpingography was in error. t Questionable Speck tests were considered accurate. were questionable but these were considered positive and there was some patency of one or both oviducts. DISCUSSION Table 3 is a summary of 110 patients who were studied by means of the Speck test and uterotubal insuffiation with gas or uterosalpingography. In 89 cases the results of the Speck test were in agreement with the standard procedures for the study of tubal patency. In 78 instances one or both tubes were patent; in 11 instances they were occluded. Of the 21 cases in which the results of the Speck test and the other diagnostic procedures were not in agreement, the results of the dye test were demonstrated to be wrong in 17 cases; 9 were false positives and 8 false negatives. It is of interest to review briefly these 17 errors of the Speck test in order to ascertain the causes for these failures

5 Vol. 3, No. 3, 1952] SPECK TEST 221 In 2 of the 8 false negative tests no unusual factors could be discovered to account for the result. Technical 'Variations may have contributed to the poor result in 2 cases. One patient neglected to drink water at the time the dye was injected. Although there was a sufficient amount of urine at the end of one-half hour for the test, it was rechecked at the end of an hour and still no dye appeared. In 1 patient some leakage of oil was visible following fluoroscopy. No dye escaped at the time of its injection but there may have been some leakage. In another patient there was a marked torsion TABLE 3. Summary of the Results of the Speck Test in 110 Patients Speck Speck Speck positive questionable* negative Tubal occlusion ( 20 cases) Uterotubal insufflation 2 2 Uterosalpingography 7 9 Tubal patency (90 cases) Uterotubal insufflation Normal 12 1 Partial blockade 3 1 Questionable patency 2 "Closed" 1 Uterosalpingography Bilateral patency Unilateral patency Partial blockade "Closed"f 3 Numbers in italics indicate patients in whom the Speck test was in error when compared to the other procedures. * Questionable Speck tests counted as accurate as explained in text. f "Closed" according to first test but recheck showed patency. These cases are listed elsewhere in the table. of the uterus and tubes which may have offered some resistance to the passage of the dye although the oil entered the uterine cavity and tubes without undue force. In the sixth patient who had a false negative Speck test the uterus was hyperactive and could have expelled some of the dye solution although no leakage of the dye or the oil was demonstrated. The seventh patient exhibited gross hydrosalpinx formation of both tubes but there was some patency of one of the oviducts. It is possible that the dye remained in the grossly dilated tubes whereas some of the oil escaped during the twenty-four hours following its instillation. The eighth patient

6 222 DAVIS ET AL. [Fertility & Sterility who had a false negative Speck test had a salpingostomy for tubal blockade. Uterotubal insuffiation three weeks after the operation indicated tubal blockade although the Speck test was positive. Three months after the operation uterotubal insuffiation with gas showed partial patency although at this time the Speck test was negative. A six months postoperative examination demonstrated adequate tubal patency by uterotubal insuffiation and a positive Speck test. It is possible that the edema resulting from the surgical trauma and its eventual subsidence can account for the discrepancies in the results of these examinations. A careful study of the 9 false positive results reveals equally few factors which may have interfered with the accuracy of the procedure. Four of these patients had closed tubes with hydrosalpinx formation. Three patients were examined after tubal ligation and neither uterotubal insuffiation nor uterosalpingography confirmed the positive dye test. In 1 patient who had a tubal ligation and in whom the test was positive a second examination which followed uterotubal insuffiation was negative. One of these patients would not return for continued investigation. An antispasmodic drug was used in conjunction with uterotubal insuffiation and the Speck test in the patients in whom there was a discrepancy in the results of the several procedures. It should be noted that there was a high incidence of false positive Speck tests in patients with tubal occlusion who had typical hydrosalpinx formation of the tubes. Rosset may be correct in postulating that the mucosa of the diseased oviduct may allow for an increased absorption of phenolsulfonphthalein. However, the errors of the procedure in the patients who had ligation of normal fallopian tubes in the immediate puerperium do not substantiate this explanation. In one of the patients who was studied it was noted at fluoroscopy that oil was escaping into the venous circulation. The introduction of this substance was stopped promptly. However, a Speck test carried out some fifteen or twenty minutes later was strongly positive. It is possible that minor traumas to the endometrium may have accounted for a false positive result. SPECK TEST FOLLOWING TUBAL LIGATION Ligation of the fallopian tubes in women in whom further childbearing is contraindicated is a common procedure. In a few women the procedure

7 Vol. 3, No. 3, 1952] SPECK TEST 223 fails to prevent conception. It was considered desirable to check the effectiveness of the operation by the Speck test. The routine operative procedure consisted of crushing and tying the tubes by the Madlener technic within the first twenty-four hours after delivery. Thirty patients were subjected to the Speck test three months or more after operation. In 6 of these women the Speck test was positive. Five of these 6 women were rechecked by uterotubal insufflation with gas and in only one instance was some patency demonstrated. The sixth patient had several positive Speck tests but she refused further studies. Thus, in at least 4 of 30 patients the Speck test was positive although the tubes were apparently occluded. None of these 30 patients has conceived thus far. SUMMARY The Speck test was carried out on a group of llo patients who were subjected to uterotubal insufflation or uterosalpingography concomitantly. The accuracy of this procedure in the demonstration of tubal patency was no more than 85 per cent. The 15 per cent error was almost equally divided between false positive and false negative results. The various factors which may have entered into the errors have been discussed. The basic principle of the test, its safety, economy, and simplicity are unquestioned. However, it offers no advantages over uterotubal insufflation and uterosalpingography in the study of sterility in the female. These standard procedures complement each other and provide much information concerning the uterus and oviducts beyond the simple demonstration of tubal patency. Although the Speck test offers little to the specialist it may find a place in medical practice carried out under the limited facilities available in many parts of the world. REFERENCES 1. Hofmann, T. R.: Am. J. Obst. & Gynec. 61:1154, Israel, S. L., and Freed, C. R.: Fertil. & Steril. 1:329, Rosset, E. M.: Am. J. Obst. & Gynec. 60:892, Speck, G.: Am. J. Obst. & Gynec. 55:1048, Speck, G.: J.A.M.A. 143:357, 1950.

The PSP (Speck) Test for Tubal Patency

The PSP (Speck) Test for Tubal Patency S. Leon Israel, M.D., and Charles R. Freed, M.D. SPECK recently advocated the intra-uterine instillation of phenolsulfonthalein as a test of the patency of the fallopian