A review of selective salpingography and fallopian tube catheterization.

Use of selective salpingography and fallopian tube recanalization has revolutionized the diagnosis and treatment of infertility. Selective salpingography, a diagnostic procedure in which the fallopian tube is directly opacified through a catheter placed in the tubal ostium, has been used since the late 1980s to differentiate spasm from true obstruction and to clarify discrepant findings from other tests. In fallopian tube recanalization, a catheter and guide wire system is used to clear proximal tubal obstructions. The recanalization procedure is simple for interventional radiologists to perform and is successfully completed in most patients (71%-92%). Pregnancy rates after the procedure have been variable, with an average rate of 30%. The combination of selective salpingography with fallopian tube recanalization has improved the overall management of infertility caused by tubal obstruction. The same catheterization technique used in fallopian tube recanalization is currently being explored for use in tubal sterilization.

Static and dynamic MRI of a urinary control intra-vaginal device.

The aim of this study was to describe by MRI, in dynamic conditions at rest and straining, the anatomical modifications induced by a commercially available intravaginal device (IVD) aimed at relieving female stress urinary incontinence. Ten female patients complaining of stress urinary incontinence (SUI) had pelvic MRI with static and dynamic sequences, without and with a self-inserted IVD. We studied positions and angulations of the IVD in the pelvis. Paired t-test allowed comparisons of: position of the bladder neck; urethral angulation with the pubis axis; position of the urethra; and posterior urethro-vesical angle (PUVA) without and with IVD. At rest, in ten of ten cases IVD laid cranial to the pubo-rectal muscle; with an average angulation of 95 +/- 10 degrees with the pubis axis, laterally tilted in three of ten cases. In maximum straining with IVD bladder neck descent was lower by an average of 5.2 +/- 3.1 mm (p = 0.001), pubo-urethral angle opening was smaller by an average of 22 +/- 20 degrees (p = 0.015), and bladder neck to pubis distance was shorter by an average of 5.7 +/- 4 mm. Posterior urethro-vesical angle was not significantly modified. Dynamic MRI allowed a non-invasive assessment of the mode of action of an IVD. The main modifications were a support of the bladder base and bladder neck, with a superior displacement of the urethra toward the pubis.

Tubal obstruction after ligation reversal surgery: results of catheter recanalization.

PURPOSE: To evaluate the role of transcervical fallopian tube catheterization in restoring tubal patency after ligation reversal surgery. MATERIALS AND METHODS: Twenty-four women with tubal obstruction after ligation reversal surgery underwent selective salpingography and tubal recanalization. RESULTS: Patency was established in 26 (68%) of 38 anastomotic tubes without complication. In the 13 patients who were followed up and who could conceive only via a recanalized anastomotic tube, there were six (46%) pregnancies: two (15%) successful uterine pregnancies, two (15%) early spontaneous abortions, and two (15%) tubal pregnancies. The mean time from procedure to conception was 2 months. CONCLUSION: Patency of fallopian tubes not visualized at hysterosalpingography after ligation reversal surgery can be established 68% of the time with selective salpingography. In some patients, selective salpingography can be therapeutic. If subsequent conception occurs in these patients, it occurs shortly after the catheterization procedure.

Cesarean section scar as a cause of abnormal vaginal bleeding: diagnosis by sonohysterography.

A previously undescribed cause of abnormal uterine bleeding is presented. Nine of 310 women evaluated by sonohysterography for abnormal bleeding demonstrated an 8 to 17 mm gap in the anterior lower uterine segment myometrium at the site of prior cesarean deliveries. All women were premenopausal and had a history of 2 to 12 days of postmenstrual spotting. Presumably a lack of coordinated muscular contractions occurs around the cesarean scar, allowing the defect to collect menstrual debris. Subsequently, the debris leaches out through the cervix for several days after the majority of menstrual flow has ceased.

Women's imaging fellowships: development and future.

Fellowships, which consist of training in predominantly breast imaging and in gynecologic and obstetric sonography, have steadily increased in number since 1992. There are currently 10 such fellowships, and the majority of these are called "women's imaging fellowships." All 19 fellows (100%) trained between 1992 and 1996 have immediately gained employment upon completion of the training, compared with the 86% employment rate of radiology fellows in general. Indications are that women's imaging fellowships will continue to provide subspecialists in radiology oriented to the imaging requests of obstetrician-gynecologists and other physicians who take care of women.

Endoscopic transvaginal approach to the rabbit uterine cervix: improvement in the technique of selective tubal catheterization.

RATIONALE AND OBJECTIVES: The authors compared two methods of selective fallopian tube catheterization in female rabbits. METHODS: Technical success rates and procedure times in two groups of animals were compared. Group 1 consisted of 20 female rabbits catheterized with a fluoroscopic technique. Group 2 consisted of 55 rabbits catheterized with a combination of endoscopic and fluoroscopic guidance. RESULTS: The technique used in group 2 allowed a statistically significant reduction in the time required for cervical catheterization and the total procedural time (P < .01). There was a parallel statistically significant reduction in fluoroscopy time (P < .01). Technical success rates and adverse effects were similar for the two techniques. CONCLUSION: The combined endoscopic-fluoroscopic technique requires a shorter time than the established fluoroscopic technique and should be considered for future selective tubal catheterization experiments in rabbits.

Tubal sterilization by means of selective catheterization: comparison of a hydrogel and a collagen glue.

PURPOSE: To test, in an animal model, two potentially suitable materials for nonsurgical selective tubal sterilization. MATERIALS AND METHODS: A hydrogel that forms an in situ plug by phase inversion of a polymer solution was placed in four rabbit fallopian tubes, and a proprietary collagen glue was placed into three rabbit fallopian tubes by means of transvaginal fluoroscopic fallopian tube catheterization. As controls, 11 tubes were catheterized without sterilization material injection. The rabbits were bred, and the presence of embryos was confirmed with palpation and at autopsy. Histologic analysis was performed. RESULTS: The short-term contraception rate was 100% in the hydrogel group, 33% in the collagen glue group, and 0% in the control group (P < .001 hydrogel group, P not significant in collagen group). Inflammation was minimal in the three groups (P not significant). CONCLUSION: The collagen glue had an insufficient contraceptive effect and should be abandoned. The hydrogel used proved effective and biocompatible, and long-term studies of this compound are warranted.

PIP: The purpose of this study was to test, in an animal model, two potentially suitable materials for nonsurgical selective tubal sterilization. A hydrogel that forms an in situ plug by phase inversion of a polymer solution was placed in four rabbit fallopian tubes, and a proprietary collagen glue was placed into three rabbit fallopian tubes by means of transvaginal fluoroscopic fallopian tube catheterization. As controls, 11 tubes were catheterized without sterilization material injection. The rabbits were bred, and the presence of embryos was confirmed with palpation and at autopsy. Histologic analysis was performed. The short-term contraception rate was 100% in the hydrogel group, 33% in the collagen glue group, and 0% in the control group (P .001 hydrogel group, P not significant in collagen group). Inflammation was minimal in the three groups (P not significant). The collagen glue had an insufficient contraceptive effect and should be abandoned. The hydrogel used proved effective and biocompatible, and long-term studies of this compound are warranted.

Focal calcifications in otherwise ultrasonographically normal ovaries.

PURPOSE: To analyze the natural history, clinical importance, and need for follow-up in patients with discrete calcifications in otherwise ultrasonographically (US) normal ovaries. MATERIALS AND METHODS: US scans obtained in 28 women with ovarian calcifications but without masses or other structural abnormalities were retrospectively reviewed. Follow-up findings were available in 15 women (mean age, 38.0 years; range, 26-72 years). RESULTS: Two of the 15 women had trilateral calcifications. Thus, 17 ovaries had focal calcifications. Histopathologic confirmation was obtained in 10 cases; follow-up US findings, five cases; and follow-up laparoscopic findings, two cases. In 13 (76%) of the 17 ovaries, calcifications were not clinically important. In four (24%) of the 17, the calcification was the initial or only manifestation of a neoplasm. Lesions were benign in all four of these ovaries: There was one dermoid, one mucinous cystadenoma, and two adenofibromas. CONCLUSION: Until more data are available, findings of calcifications in ovaries with otherwise normal US findings warrant some form of follow-up.

Salpingitis isthmica nodosa: results of transcervical fluoroscopic catheter recanalization.

OBJECTIVE: To investigate the role of transcervical tubal catheterization in diagnosis and treatment of proximal tubal obstruction associated with salpingitis isthmica nodosa. DESIGN: Retrospective case study. SETTING: University hospital and outpatient radiology practice. PATIENTS: Fifty-two women with proximal tubal obstruction associated with salpingitis isthmica nodosa. INTERVENTION: Selective salpingography and catheter recanalization using fluoroscopic guidance. MAIN OUTCOME MEASURES: The number of tubes visualized to the fimbria as a percentage of the tubes with proximal tubal obstruction on the initial hysterosalpingogram was determined as a measure of diagnostic efficacy. To evaluate the treatment potential of catheter recanalization, the patients were grouped according to tubal status at the conclusion of the procedure and subsequent pregnancies were evaluated. RESULTS: Forty-seven of 65 tubes (72%) with proximal tubal obstruction were recanalized successfully. Among the 19 women who were able to conceive only via a recanalized salpingitis isthmica nodosa tube, there were 6 live births (32%) and two tubal pregnancies (10%). CONCLUSION: Selective salpingography allows complete tubal diagnosis in almost three fourths of patients with proximal tubal obstruction and salpingitis isthmica nodosa. The radiographic diagnosis of salpingitis isthmica nodosa may be pressure dependent. Intrauterine pregnancies occur via recanalized salpingitis isthmica nodosa tubes, therefore catheter recanalization may be attempted before tubal microsurgery or IVF in patients with proximal tubal obstruction and associated salpingitis isthmica nodosa.

Reversal of sterilization due to application of quinacrine by means of transcervical tubal catheterization.

PIP: The cornual and intramural scarring associated with quinacrine-induced female sterilization has been presumed to make this method irreversible. However, this article presents the cases of two women from Calcutta, India, with successful reversal achieved through transcervical catheterization with recanalization under fluoroscopic guidance. The first woman, age 28 years, had been sterilized five years earlier by three treatments with 252 mg of quinacrine; the second, age 22 years, had been sterilized two years before reversal request with two quinacrine doses. Recanalization of the proximal right tube was achieved in both cases through use of two or three catheterization systems in sequential order; attempts to repair the left tube resulted only in venous intravasation. The gritty sensation during guide-wire recanalization was consistent with fibrosis in the intramural portion of the fallopian tube. The availability of this technique may increase the acceptability of quinacrine sterilization, especially in countries such as Egypt and Indonesia where national family planning programs require that sterilization techniques are reversible.^ieng

Circumvallate placenta: sonographic diagnosis.

We prospectively identified 12 patients who had a shelf at the margin of the placenta consistent with the diagnosis of circumvallate placenta. Ten patients were followed to delivery and three placentas were sent for pathologic analysis. Circumvallate placenta was diagnosed by gross inspection in all three but was confirmed by microscopic analysis in only two. One of these patients had placental abruption and cesarean delivery for fetal distress at 27 weeks. Circumvallate placenta is another cause of uterine band, sheet, or shelf. The finding can be associated with a normal obstetric outcome but may predispose to placental complications.

Selective tubal sterilization in rabbits: experience with a hydrogel combined with a sclerosing agent.

PURPOSE: To test a method of nonsurgical sterilization. MATERIALS AND METHODS: A hydrogel that forms an in situ plug by phase inversion of a polymer solution was placed into fallopian tubes of eight rabbits by means of transvaginal rabbits by means of transvaginal fluoroscopic fallopian tube catheterization. The rabbits were bred, and the presence of embryos was confirmed with palpation and at autopsy. RESULTS: Seven of the eight rabbits became pregnant. Six of these rabbits contained embryos in the control uterus but not in the uterus on the side of the hydrogel injection. The seventh rabbit had embryos in both uteri, but the hydrogel had been expelled. All seven tubes that contained hydrogel showed evidence of acute and chronic salpingitis and a foreign-body reaction. The tube from which hydrogel had been expelled and the eight control tubes were not inflamed. CONCLUSION: Transcervical catheter methods of tubal occlusion and sterilization are promising, but a non-reactive material is needed.

Localization of contraceptive implant capsules for removal.

Implanted contraceptive capsules occasionally cannot be removed by means of palpation with local dissection, and imaging guidance is necessary. The authors report obtaining a single antero-posterior radiograph of the upper arm followed by sonography to localize the capsule and to allow precise marking of the skin over the capsules. The method can be performed quickly and is inexpensive and effective, allowing the localization and removal procedures to be scheduled independently.

PIP: In Oregon, since some physicians could not remove contraceptive implant (Norplant) capsules, they referred three patients to Oregon Health Sciences University or the Kaiser Sunnyside Medical Center in Clackamas for implant removal. The physician was able to initially remove five of the six capsules in a 21-year-old mother of three. One month later, the physician tried again to remove the remaining capsule and did not succeed. Anteroposterior and lateral radiographs of the upper left arm could not detect the 6th capsule. The referral institution obtained a single anteroposterior radiograph (about 55 kVp and 10 mAs) that revealed the capsule in the subcutaneous tissue. Using landmarks on the radiograph, the capsule's location was estimated and scanned with a high frequency linear ultrasound probe that found the exact location of the capsule. The physicians marked the patient's skin along the length of the capsule and asked her to renew the mark every day until her own physician could remove it two days later. The complete imaging procedure lasted only 12 minutes. Two different surgeons attempted removal of three capsules in one woman. The second surgeon even used 15 minutes of intraoperative fluoroscopy. Another case was referred for imaging because her physician could not palpate one capsule. The referral institution used the same localization method (radiograph and ultrasound) to locate the capsule and mark its location. These cases show that clinicians can perform this inexpensive and effective localization method for undetectable implant capsules quickly. Localization of capsules and removal procedures can be scheduled at different times.

Experimental nonsurgical female sterilization: transcervical implantation of microspindles in fallopian tubes.

PURPOSE: A nonsurgical method of female sterilization was investigated in rabbits. MATERIALS AND METHODS: A self-expanding microspindle (length 9-18 mm, diameter 1.5-2.0 mm) made from tubular metal mesh was implanted in a single fallopian tube of 12 rabbits via catheterization of a single uterus. The contralateral fallopian tube and uterus served as controls. Each rabbit was scheduled to undergo three cycles of breeding. Before delivery, absence of pregnancy on the side with the microspindle was verified with hysterography. RESULTS: Eight rabbits completed three cycles of breeding and pregnancy. Two rabbits had one pregnancy. Two rabbits did not conceive. Spindles were placed correctly in 11 rabbits. Successful contraception was achieved in nine rabbits, who had 25 gestations on the nonspindle side and no gestation on the spindle side. One rabbit, which received the shortest spindle, was bilaterally pregnant, indicating a failure of contraception on the spindle side. No spindles dislocated. Histologic study showed all spindles firmly embedded in the tubal wall without signs of inflammation. CONCLUSION: Microspindles of a certain minimum length have potential as a transcervically implantable, permanent intratubal contraceptive device.

PIP: A simple, nonsurgical female sterilization method involving fallopian tube catheterization under fluoroscopic guidance and implantation of microspindles was investigated in laboratory animals. A self-expanding microspindle made from tubular metal mesh was implanted in a single fallopian tube of 12 New Zealand Cross rabbits through catheterization of a single uterus. The contralateral fallopian tube and uterus served as controls. 8 rabbits completed three cycles of breeding and pregnancy; 2 rabbits had one pregnancy and 2 rabbits did not conceive (one presumably because of incorrect spindle placement). Successful contraception was achieved in 9 rabbits, who had 25 gestations on the nonspindle side and none on the spindle side. The rabbit with bilateral pregnancy (the recipient of the shortest spindle) represents one contraceptive failure in a total of 26 valid cycles. At autopsy, all spindles were firmly embedded in the tubal wall with no signs of inflammation. Complete obstruction of the interior space of the spindle was absent in all cases, indicating that complete occlusion of the tubal lumen was not the mechanism of action. A more likely explanation for the contraceptive effect observed in this study is the impairment of contractility of the spindle-carrying segment of the fallopian tube. These findings suggest that microspindles of a certain minimum length merit further investigation as a transcervically implantable, permanent intratubal contraceptive device.

An improved method of needle localized biopsy of nonpalpable lesions of the breast.

We have created a modified technique of localization biopsy of the breast that more easily identifies the position of the wire tip after placement and before biopsy. After wire placement, metallic skin markers are placed on the nipple and wire entry site. The patient is then positioned on a roentgenography table in the same position to be used during biopsy. A supine roentgenogram of the breast is obtained. At the time of the biopsy, this roentgenogram is aligned with the corresponding markers on the skin of the patient and the position of the wire tip is noted. A curvilinear incision along Langer's lines can then be made at that site. This procedure was used in 53 consecutive biopsies of nonpalpable mammary lesions. In all instances, the biopsy incisions were independent of the wire insertion sites and in each instance, the lesion was excised in a single specimen. Compared with other techniques, our method is simple, inexpensive, requires no special equipment and results in only a minimal increase in radiation dose to the breast (50 millirad). The decrease in the amount of tissue dissection without decreasing accuracy afforded by our technique can improve compliance with the American Cancer Society's recommended surgical guidelines for breast preservation therapy.

Transcatheter tubal sterilization in rabbits. Technique and results.

RATIONALE AND OBJECTIVES: A potential method of nonsurgical tubal sterilization was tested in rabbits. METHODS: Metal coils were designed which could be placed into the uterotubal junction using transvaginal fluoroscopic fallopian tube catheterization. These metal coils were successfully placed unilaterally in the uterotubal junction of 32 rabbits. The contralateral fallopian tube and uterus were used as a control. The rabbits were bred, and the presence of pregnancies was confirmed by palpation. RESULTS: In 21 rabbits (66%), the coil stayed in place. Sixteen rabbits had multiple gestations on the side without the coil and no gestations on the side with the coil. Three rabbits had gestations on both sides, even though the coil was in place, and two rabbits never conceived. In 11 rabbits (34%) the coil was dislodged as early as 5 days and as late as 18 weeks after the procedure. Five of these 11 rabbits had bilateral embryos, 4 had embryos only on the side contralateral to where the coil had been, and 2 never conceived. CONCLUSIONS: The metal coil does prevent conception if it stays in place at the uterotubal junction. However, the coil failed to prevent pregnancy in 3 of 19 rabbits, and was dislodged in 11 rabbits, giving an overall failure rate for contraception of 44%.