THE IMPORTANCE OF HYSTEROSCOPY IN INFERTILITY EVALUATION. THE VALUE OF OSTIUM TUBAE EXAMINATION
Authors: Dr. CONSTANTIN OLARU, Professor Dr. DUMITRU CÎTU, Dr. DORIN GRIGORAS and Student FLAVIUS OLARU
OBJECTIVES
Overview of the results of ostium tubae hysteroscopic investigation on women with primary or secondary sterility and selecting those cases that can benefit of microsurgery or laparoscopic endoscopy.
MATERIAL AND METHODS
The research included 154 patients who ambulatory addressed the „GENESIUM” medical cabinet in order to establish the cause of their primary or secondary sterility and whom hysteroscopy was practiced.
The tubal patent was studied by ostium tubae examination, followed by methylen blue instillation through OLYMPUS hysteroscope 4,5 mm evacuation channel.
The distension media used was CO2, physiologic solution and the ISPIROL product (Glycine + Mannitol) made by Haemopharm Vrsac (Yugoslavia).
The anesthesia used in most cases was cervical blocking with local XILINE+XYLOCAINE (Lidocainum), or - in 10 cases - intravenous anesthesia with DORMICUM+Propopholium.
Also, DOXYCYCLINE was administered 48 hours before and after the procedure. The tubal ostium evaluation was performed immediately after menstruation.
Considerations
The examination of the ostium tubae is, in our opinion, of utmost importance in the evaluation of the infertile woman. The magnification in close panoramic view offers the examiner the opportunity to define the contour of the ostium in detail. For the purpose of this demonstration, further magnification was occasionally utilized, by connecting a 2x converter to the camera.
In order to reach the ostium at the nearest possible point, the optic must be brought into a particular position, shown in Fig. 1. At the same time, the optic is turned over 90 degrees sideways, to the contralateral side (for compensation of the 30-degree-forward-directed angle of view).
Fig. 1. Position of the hysteroscope for examination of the tubal ostium. The tip of the endoscope is brought as close to the tubal ostium as possible. To obtain this position, the eyepiece is moved to the contralateral side and the optic turned over 90ø, counterclockwise (left ostium) or clockwise (right ostium).
For estimation of the diameter of the tubal ostium, comparison is made with the width of the track left by the hysteroscope, which is 4,5 mm in diameter, pressed into the endometrium.
Interpretation of post-infectious changes of the ostium cannot be compared to the corresponding histology, because the potential trauma involved in taking a biopsy is to be avoided in infertile patients. However, similar lesions can be seen in elderly women, then probably due to an aging process.
Anatomy
The tubal orifice, from a hysteroscopic point of view, can be defined as the transition of the endometrium to the endosalpinx. The first millimeters of the intramural part of the oviduct can be visualized. Viewing the ostium during menstruation proves this, as the endosalpinx does not desquamate (Fig. 2). In order to evaluate the tubal orifice, it is necessary that the uterine cavity be well distended. This is best achieved immediately following menstruation. In most cases, the intramural part of the oviduct has only a slight lateral angle in relationship to the cornu uteri. The intramural part cannot be visualized in those few cases where the angle of the tubal passage is too acute.
The normal tubal orifice is circular and forms a slight mark between the cone-shaped cornu uteri and - in continuation - the first millimeters of the intramural part of the oviduct.
Under continuous insufflation of CO2, a rhythmical movement (flap valve) of the ostium can be observed. The cornu uteri manifest itself as a kind of sphincter, thus causing this movement.
A normal ostium is round to oval in shape with a diameter of approximately 2 mm (in the „open” position). This is somewhat less than half the track left by the hysteroscope when pressed into the rear wall of the uterine cavity.
Fig. 2. Tubal ostium seen during menstruation. The transition between the endometrium and endosalpinx is easily seen because the endometrium is desquamating, whereas the endosalpinx is not.
Fig. 3. Cervical mucus lodged in front of the right tubal ostium.
Fig. 4. Unsatisfactory evaluation of the tubal ostium. The transition between endometrium and endosalpinx cannot be seen on close panoramic vision. The ostium appears very narrow („pinpoint”).
Unsatisfactory evaluation
The above term should not be used to denote the ostium that cannot be observed because some gas bubbles were trapped in the uterine horn, or because mucus was pushed into the cavity and lodged in front of the ostium (Fig. 3). Rather the ostium is seen as a pinpoint hole in the endometrial surface of the cornu, „there, where you would expect the ostium to be 'located'!” „Unsatisfactory evaluation” should be used to refer only to those cases in which the transition between endometrium and endosalpinx cannot be visualized (Fig. 4). This occurs in approximately 5% of infertility patients. Recent histologic studies have demonstrated that the endometrium actually trespasses the uterotubal junction and replaces the normal mucosal lining of the lumen of the oviduct. The question remains open as to whether this condition is acquired (e.g. secondary to an infection or through the process of metaplasia) or congenital. The prevailing clinical impression is that this condition is encountered more often in patients presenting with primary infertility.
Congenital anomalies
CORNUAL SEPTUM (Fig. 5)
The tip of the cornu uteri is divided by a tiny septum. The ostium tubae is located at one side, the other side being a dead end. We diagnosed one case with this pathology. The defect was bilateral and the tubal ostium was located medially from the septum. The significance of this anomaly is unknown. In this case, laparoscopy failed to show any further congenital defects.
Fig. 5. Cornual septum. A close panoramic view of the left tubal ostium reveals a tiny septum, leaving a blind pouch laterally. The ostium itself is very narrow, as in „unsatisfactory evaluation”.
Acquired anomalies
FIBROSIS - MILD (Fig. 6)
The tubal orifice shows no apparent alteration on panoramic survey, i.e. it has retained its global structure. At close viewing, a disturbance of the endosalpinx is visible, manifesting itself as rough irregularities along its entire contour, with occasional remnants of neovascularization.
Fig. 6. Mild fibrosis of the tubal ostium. The mucosal lining of the endosalpinx is rough, presenting with vessels originating from the endometrium.
FIBROSIS - SEVERE (Figs. 7 and 8)
The post-inflammatory alterations are so far advanced that the global form of the orifice has disappeared. Scar tissue surrounds the distorted ostium, which can be completely occluded. The ostium may occasionally even be overgrown by the endometrium.
Fig. 7. Severe fibrosis of the tubal ostium. Gross deformation of the tubal ostium with scar tissue surrounding it.
Fig. 8. Severe fibrosis; occlusion of the tubal ostium. The tubal ostium is totally filled with scar tissue that is still vascularized.
DISTENSION - MILD (Fig. 9)
Here the intramural part of the oviduct can be visualized in nearly its entire length. The orifice appears to have doubled itself. This slight expansion, or „intramural hydrosalpinx” is demonstrated, above all, in cases where there is a proximal occlusion, as, e.g. following sterilization.
Fig. 9. Mild distension of the ostium. The tubal ostium is 2-5 mm in diameter and slightly obscured by an endometrial „veil” which, in fact, marks the transition between the endometrium and the endosalpinx.
DISTENSION - SEVERE (Fig. 10)
The distension is termed severe when the diameter of the lumen of the intramural part of the oviduct measures more than 5 mm, as compared to the track made in the endometrium by the hysteroscope. This condition is rarely observed and has until now been demonstrated only in connection with thin-walled sactosalpinges.
Fig. 10. Severe distension of the tubal ostium. The tubal ostium is 5 mm in diameter. One can look very deep inside the intramural part of the tube. (It is difficult to differentiate between a deep cornu and severe distension.)
INTRAMURAL POLYP (Fig. 11)
Only those polyps located near the transition with the cornu uteri can be seen. This intramural polyp is usually solitary, pear-shaped and implanted distally from the tubal orifice in the intramural part of the oviduct. If this polyp were to prolapse into the uterine cavity, it would be described as having an hourglass shape.
Fig. 11. Intramural polyp. Two elongated polyps are seen emerging from the intramural part of the left oviduct. The vasculature is clearly visible.
ENDOSALPINGEAL HYPERPLASIA (Fig. 12)
Hyperplasia first manifests itself as many small polyps, actually highly elevated mucosal folds. In cases of so-called salpingitis isthmica nodosa (SIN), one can usually demonstrate hyperplasia of the endosalpinx. Hyperplasia is not, however, pathognomonic for SIN.
Fig. 12. Endosalpingeal hyperplasia. The endosalpinx shows a wave-like appearance.
Functional pathology
Changes in the rhythmic movement of the tubal orifice are usually seen in conjunction with organic pathology of the orifice. The amplitude and frequency of these movements vary. As yet, we have not been able to catalog the different patterns as to either frequency or amplitude. Obviously, too many variables interfere, making any evaluation impossible in just one routine procedure. At the present time, we simply note the presence or absence of these movements. Nonetheless, in the presence of fibrosis, these rhythmic movements consistently disappear.
RESULTS
The results of this study are the following:
- 66 patients (42,85%) presented a normal anatomic and functional status for both ostium tubae. 30 patients (19,48%) were investigated also by laparoscopy for ovarian drilling.
- 63 patients (40,9%) presented an anatomic and functional normal ostium tubae with tubal patent while the other tubal ostium presented:
- Mild fibrosis with functional pathology in 16 cases (10,38%);
- Severe fibrosis with functional pathology in 10 cases (6,49%);
- Mild distension with functional pathology and no tubal patent in 8 cases (5,19%);
- Severe distension with functional pathology and no tubal patent in 16 cases (10,38%);
- Intramural polyp (with valve effect in one case) in 5 cases (3,24%);
- Endosalpingeal hyperplasia with functional pathology and no tubal patent in 5 cases (3,24%).
- For 3 patients the evaluation was unsatisfactory.
- In 25 cases (16,23%) we found no tubal patent and the following injuries:
- 1 case (0,65%) presented bilateral uterine cornu septum (congenital anomaly);
- 2 cases (1,3%) presented severe fibrosis at one uterine cornu and no tubal patent at the other (we note that both cases had a history of 2 ectopic pregnancies and at the second pregnancy they suffered conservatory oviduct surgery - salpingotomy with ectopic gestational sac evacuation and reparatory suture of the oviduct).
- 10 patients (6,49%) presented severe fibrosis at one of the tubal ostium (history of ectopic pregnancies) and severe distension at the other tubal ostium with functional pathology (hydrosalpinx revealed by laparoscopy).
- 4 cases (2,59%) presented bilateral severe fibrosis with functional pathology and associated uterine cornu injuries following several complicated abortions.
- 1 case (0,65%) presented mild distension with functional pathology at one tubal ostium, following a mild distension without functional pathology but with a laparoscopic revealed hydrosalpinx of great dimensions that suggested by distension a tubal patent at this tubal ostium.
- In 2 cases (1,3%) we had an unsatisfactory evaluation of tubal ostium, due to rich cellular detritus that obstructed the region visibility.
- In 5 cases (3,24%) we found associated injuries like severe distension with endosalpinx hyperplasia, intramural polyps and functional pathology.
From a total of 25 cases with bilateral tubal patent absence, 21 (13,63%) benefit by laparoscopy.
We note that none of this cases received microsurgical treatment due to the absence of such services in our Department of Obstetrics and Gynecology.
GRADUL DE PREZENTA AL PATENTEI TUBARE LA CAZURILE STUDIATE
DISCUSSION
Some comment is needed. Tiny changes in the appearance of the ostium, pointing towards remnants of an inflammatory reaction, which we called mild fibrosis, are in some cases not so obvious. It is therefore advisable to examine some tubal ostia, which are supposed to be normal (e.g. previous to insertion of an IUCD).
Mild distension is a difficult entity, both to note and to discuss. Actually, the ostium is arrested in the open position, although it may continue to present some rough outline of a rhythmic movement. This gives the impression of doubling of the ostial contour. A confusing feature, moreover, is the appearance of an endometrial „veil” due to the distension of the uterine cavity, when the endometrium has reached its maximal height. There is an abrupt flattening of the endometrium towards the ostium. This, added to the distension of the cornu uteri during insufflation, provokes this phenomenon. This „veil” may simulate or mask the double-contour sign of the distension (Fig. 13)! In addition, observation of the ostium must be long enough to assure the observer than he/she is not dealing with a normal ostium that has simply remained in the open position a bit longer.
A distended ostium may also present signs of fibrosis. Both features may be noted, but fibrosis prevails.
In this context, we would like to mention that the tubal ostium presents a typical appearance following sterilization (in the mid-isthmic portion). The endosalpingeal mucosa presents with multiple buds. The surface is irregular and somewhat resembles the appearance of mild fibrosis.
Fig. 13. Endometrial „veil”. An endometrial veil, marking the transition between endometrium and endosalpinx, may sometimes make it difficult to assess the morphology of the ostium (normal in this case) accurately.
CONCLUSION
Hysteroscopy of the ostium tubae is a valuable adjuvant tool in the evaluation of the infertile woman. We are personally convinced that the hysteroscopic appearance of the tubal ostium is a valuable addition to the criteria used in selecting which patients with tubal infertility would benefit from microsurgery and which will require in vitro fertilization (IVF).
Further investigation is needed to penetrate the mystery of the numerous patterns of the flap valve mechanism.
An even more exciting goal is the evaluation of the ostium tubae as a prognostic factor for the risk of ectopic pregnancy.