1247 0361-803X/89/1 536-1 247 C American Aoentgen Ray SOCiety Stephen Karasick1 Saundra Ehrlich Received May 30, 1989; accepted after revision July 13, 1989 I Both authors: Department of Radiology, Thomas Jefferson University Hospital, 1 11 5 11th St, Philadelphia, PA 19107 Address reprint requests to S Karasick The Value of Hysterosalpingography Before Reversal of Sterilization Procedures Involving the Fallopian Tubes Knowledge of the length of the uterine end of the fallopian tube and the presence of tubal adhesions and fistulas is important when surgical reversal is undertaken in patients who have had tubal ligation We retrospectively studied hysterosalpingograms in 127 such patients to determine their value in providing this information The ligation was performed by using the Pomeroy technique in 57 patients Sixty-one patients had bipolar electrocautery, six had Falope rings inserted, and three had Hulka clips applied In all cases, the uterine ends of the tube were visualized to a point of obstruction The sites of occlusion after Pomeroy ligation were midtubal (46%), comual (16%), proximal ampullary (16%), proximal isthmic (14%), and intramural (8%) After the electrocautery procedure, the sites of occlusion were proximal isthmic (45%), intramural (20%), midtubal (19%), comual (15%), and proximal ampullary (1%) When Falope rings and Hulka clips were used, the most frequent site of occlusion was midtubal (50%) Tubal adhesions, consistent with successful occlusion, were detected in 16 patients on the basis of a small confined area of extravasation of contrast material at the site of ligation Tuboperitoneal fistulas, identified by the presence of contrast material spilled from the uterine end of the tube into the peritoneal cavity, were detected in five patients Our results show that hysterosalpingography is a useful technique for determining the status of the uterine end of the fallopian tube after ligation when reversal of ligation is planned AJR 153:1247-1250, December 1989 Tubal ligation is a popular method of contraception throughout the world; simple ligation of the tube (Pomeroy procedure) is performed most frequently Electrocautery and mechanical banding or crushing techniques are common alternatives There has been an increase in demand for reversal of the ligation, usually by excision of the ligation and reanastomosis Hysterosalpingography (HSG) before reversal of the ligation can be used to assess the length of the uterine end of the tube and to provide information about the uterine cavity, such as the presence of submucous myomas or intrauterine synechiae The length of residual tube, which depends on the type of sterilization procedure used, is a critical factor in tubal reanastomosis If the uterine end of the tube is too short or too long, laparoscopy is needed to assess the uterine and fimbriated portions of the tube for future uterotubal implantation or neosalpingostomy, respectively Tubopenitoneal fistulas may predispose the patient to an ectopic pregnancy in the fimbriated portion of the tube after correction of the ligation A retrospective study was performed to evaluate the uterine end of the fallopian tube on hystemosalpingogmaphy in those patients for whom reversal of sterilization was planned Materials and Methods Between 1982 and 1988, more than 2000 hysterosalpingograms were obtained at Thomas Jefferson University Hospital on infertile outpatients Hysterosalpingography (HSG) was
1248 KARASICK AND EHRLICH AJA:153, December 1989 performed by the reproductive endocrinologist during the early proliferative phase of the menstrual cycle All procedures were monitored fluoroscopically and interpreted by a radiologist The HSG studies were all considered by the radiologist to be technically satisfactory because sufficient contrast material showed pointed, not rounded, cornua[1] Poststerilization hysterosalpingograms in 127 patients (254 tubes) were obtained as part of the workup for sterilization reversal We evaluated 114 tubes ligated by the Pomeroy technique, 1 22 by bipolar electrocautery, 12 with Falope rings (Cabot Medical Corp, Langhome, PA), and six with Hulka clips (Richard Wolf Medical Instrument Corp, Rosemont, IL) The HSG was performed with oil-based contrast material (Ethiodol, Savage Laboratories, Melville, NY) Spot radiographs were obtained with the patient in the supine, anteroposterior, and oblique positions The sites of the obstruction were cornual, intramural, proximal isthmic, midtubal (usually at the isthmicampullary junction), and proximal ampullary Thirty-eight Pomeroy ligations were performed in the immediate postpartum period Adhesions, consistent with successful occlusion, were diagnosed at the site of tubal occlusion if a small amount of contrast material extravasation was localized at the tubal ligation site Free spilling of contrast material into the peritoneal cavity from the occlusion site indicated the presence of a tuboperitoneal fistula [2, 3] Results C a 0 C U a SIte of Tubal OcclusIon HSG showed that the sites of occlusion in the 57 patients who had the Pomeroy ligation were midtubal in 26 (46%), comual in nine (1 6%), proximal ampullary in nine (16%), proximal isthmic in eight (1 4%), and intramural in five (8%) However, 17 of 18 tubes visualized to the proximal ampullary region were in patients who had the Pomemoy procedure performed immediately postpartum In 61 tubes that were cauterized, HSG showed that the sites of occlusion were proximal isthmic in 27 (45%), intramural in 12 (20%), midtubal in 12 (1 9%), cornual in nine (1 5%), and proximal ampullary in one (1 %) Of the 18 tubes mechanically banded on crushed (1 2 Falope rings, six Hulka clips), the most frequent site of occlusion was midtubal in nine (50%) (Fig 1) In the group who had Pomeroy ligation, six patients had adhesions and three had tubopenitoneal fistulas at the site of ligation In the group who had tubes cauterized, 10 adhesions and two tuboperitoneal fistulas were seen at the site of cautery Utemme abnormalities such as intrauterine synechiae and submucous myomas were seen in only a few patients Discussion The length of the tube remaining after tubal ligation is significant in the prognosis forfutune pregnancy when reversal of the procedure is attempted [4] In normal tubes, the average length of the extrauterine portion is 11 cm, excluding the intramural portion, which is 1-2 cm long [5] The chances of pregnancy occurring are good if the total tubal length (uterine and fimbrial portions) after ligation is 3-4 cm or more with an intact 1 cm of ampulla and fimbniae [4, 6, 7] This is important information to have before surgery to excise the ligation is attempted If HSG shows a short uterine portion of the tube, theme may be a small amount of functional proximal tube for anastomosis; utemotubal implantation is a less desirable alternative with more postoperative complications Conversely, if on HSG there is a long fimbnial portion of tube, there may be minimal uterine portion available, requiring neosalpingostomy, which has a much lower pregnancy success mate than tubal anastomosis [8] The radiographic appearance of the fallopian tube after ligation varies according to the sterilization method used Approximately half of the 250,000 tubal ligations performed annually in the United States are done by the Pomeroy procedure in the postpartum period [9] In this technique, the fallopian tube is grasped in its midportion, a loop is tied off at its base with absorbable suture, and the loop is excised above the ligature About 3 cm of tube are usually destroyed in this process The most common site of occlusion after the Pomeroy procedure in our study was midtubal (46%); 16% had occlusion in the proximal ampullamy region Bipolar electmocautery has replaced the unipolam metfrod as the most common laparoscopic sterilization procedure This method differs from the unipolam method in the use of openating forceps that contain both the active and the return electrode, allowing the current to pass through only the tissue grasped between the prongs of the forceps and not through the patient s body to a ground plate A bipolar burn is localized and discrete, as opposed to the inherent risks of burns of the Fig 1-Graph of sites of occlusion found on hysterosalpingogramsafter sterilization by Pomeroy (n = 114) and cautery (n = 122) techniques in 118 patients (236 tubes)
AJR:153, December1989 POSTSTERILIZATION HYSTEROSALPINGOGRAPHY 1249 Fig 2-Hysterosalpingogram after sterilization with spring-loaded Hulka clips shows tubal obstruction at proximal isthmus (arrows) at a distance from crushing clips This is an average length of proximal tube after cautery, indicating a fairly good prognosis for reversal Fig 3-Hysterosalpingogram after sterilization with Pomeroy technique shows filling of proximal tubes to level of left ampullary and right mldtubal ligations (arrows) Fig 4-Hysterosalpingogram after sterilization with Pomeroy technique shows localized extravasation of contrast material into adhesions at ligation site on right side (arrow) Unsuspected intrauterine synechiae also were present Fig 5-Hysterosalpingogram after sterilizalion with bipolar electrocautery shows bilateral proximal isthmic occlusions and extravasation of contrast materlal(arrow), which dispersed en subsequent radiographs, consistent with a tuboperitoneal fistula intmaabdominal viscera with unipolam instruments In the bipolar system, two or more contiguous areas of the tube are coagulated in their most mobile portion, resulting in destruction of about 1 cm of tube However, additional destruction occurs as the tube contracts under coagulation with more than 3 cm of tube eventually destroyed [9, 1 0] The most common site of occlusion in the cauterized group was at the proximal isthmic level (45%); 20% had intramural occlusion Lapamoscopic application of mechanical bands or crushing devices such as the silastic Falope ring give fairly consistent injuries, ranging from 1 to 3 cm of tube destroyed Proximal isthmic stumps are invariably present, allowing for some form of anastomosis [9] The Hulka clip, however, has a higher technical difficulty and failure mate, including bleeding, which is usually managed by application of additional clips or cautery Injury to the tube and/on mesosalpinx account for most complications associated with the Falope ring [1 1] Failures with the Falope ring usually can be attributed to spontaneous meanastomosis [12] With these tubal sterilization techniques, the occluded tubes show an abrupt end to the passage of contrast material, usually in the midportion of the tube [1 3] The tubal lumen is either normal in caliber or has a bulbous appearance at the site of occlusion (Fig 2) HSG shows obstruction of the tube anywhere from the comu to the proximal ampullary segment (Fig 3) Infrequently, contrast material locally extravasates from the end of the tube into a small area of adhesions at the ligation site (Fig 4) A tuboperitoneal fistula is diagnosed when theme is intraperitoneal spilling of contrast material from the ligation site (Fig 5) In this situation, an ectopic pregnancy may develop in the distal tube after reversal of the ligation as a result of sperm migration into the pentoneal cavity Because of the variability of tubal damage that occurs as a result of sterilization tubal ligations, HSG before a procedure to remove the obstruction is useful HSG shows the uterine end of the fallopian tube, the length of which is important for future successful pregnancy The radiographic information obtained with HSG is invaluable, particularly when the openative and pathologic reports of the sterilizaiton procedure are unavailable or incomplete Diagnostic lapamoscopy can be reserved for those patients in whom HSG shows an madequate tubal length [8]
1250 KARASICK AND EHRLICH AJR:153, December 1989 REFERENCES 1 Siegler AM Hysterosalpingography, 2nd ed New York: Medcom, 1974: 125-1 57 2 Sheikh HH Hysterosalpingographic follow-up of laparoscopic sterilization Am J Obstet Gynecol 1976;126: 181-184 3 Yoder IC Hysterosalpingography and pelvic ultrasound: imaging in infertility and gynecology Boston: Little Brown, 1988:84-105 4 Silber SJ, Cohen A Microsurgical reversal of female sterilization: the role of tubal length Fertil Steril 1980;33:598-601 5 Woodruff JO, Pauerstein CJ The fallopian tube Baltimore: Williams & Wilkins, 1969:22-32 6 Gomel V Microsurgical reversal of female sterilization: a reappraisal Fertil Steril 1980;33:587-597 7 Winfield AC, Wentz AC Diagnostic imagingofinfertility Baltimore: Williams & Wilkins, 1987:127-1 57 8 Mezer HC Tubal anastomosis Semin Reprod Endocrinol 1984;2: 154-1 59 9 Siegler AM, Hulka J, Peretz A Reversibility of female sterilization Fertil Steril 1985;43:499-510 10 Ansari AH, Marik JJ, Moore JG Laparoscopic tubal sterilization In: Siegler AM, ed The fallopian tube Mount Kisco, NY: Futura, 1986:307-309 1 1 Bhiwandiwala PP, Mumford SD, Feldblum PJ A comparison of different laparoscopic sterilization occlusion techniques in 24,439 procedures Am J Obstet Gynecol 1982;144:319-329 12 Rioux JE, Soderstrom A Review of techniques for tubal sterilization In: Sanz LE, ed Gynecologic surgery Oradell, NJ: Medical Economics Books, 1988: 304-318 13 Karasick 5, Karasick 0 Atlas of hysterosalpingography Springfield, IL: Thomas, 1987: 158-1 59 Society for Pediatric Radiology Research and Education Grants The Society for Pediatric Radiology (SPR) is requesting grant applications for a clinical or laboratory research project that will involve some aspect of pediatric imaging The purpose of these grants is to stimulate and advance careers in pediatric imaging On completion, the results of the research must be submitted for presentation to the SPR Eligible applicants include trainees in diagnostic radiology and pediatric radiologists The deadline for submission of applications is Feb 1, 1 990 The application must include a statement of purpose, methods, materials, planned analysis procedure, proposed budget details, and background discussion Copies of the curricula vitae of all investigators should be appended The maximal amount to be awarded for any one grant is $5000 Send applications to William H McAlister, MD, Dept of Radiology, Washington University Medical Center, 51 0 5 Kingshighway, St Louis, MO 631 1 0 For information by telephone: (31 4) 454-6229
This article has been cited by: 1 Isthmic and Mid-Tubal Obstruction 375-394 [CrossRef] 2 Stephen Karasick 1991 Hysterosalpingography Urologic Radiology 13:1, 67-73 [CrossRef] 3 A Leader 1989 Reversal of sterilization Advances in Contraception 5:4, 213-216 [CrossRef]