Tubal patency tests

1. The role of tubal patency tests and tubal surgery in the era
of assisted reproductive techniques
Yalanadu N SureshMRCOG,
1,
* Nitish N NarvekarMD FRCOG
2
1
Consultant in Obstetrics & Gynaecology, Great Western Hospital, Marlborough Road, Swindon, Wiltshire SN3 6BB, UK
2
Consultant in Reproductive Medicine and Minimal Access Surgery, Kings College Hospital, Denmark Hill, London SE5 9RS, UK
*Correspondence: Yalanadu Suresh. Email: [email protected]
Accepted on 4 September 2013
Key content
The pathogenesis of infertility is multi-factorial; investigative and
treatment approaches should therefore be individualised.
There are many tests for tubal patency with their relative
usefulness, but none address all aspects of tubal function.
There is often a clear need for in vitro fertilisation (IVF) in the
management of infertility.
This article reviews the current best available evidence and
provides an expert insight on the role of tubal patency tests in the
era of assisted reproductive techniques (ART).
Learning objectives
To understand the relative advantages and limitations of
laparoscopy, hysterosalpingogram, hysterosalpingo contrast
sonography, selective salpingography and tubal catheterisation,
trans-vaginal hydrolaparoscopy, salpingoscopy and fertiloscopy as
tests for tubal patency.
To understand the role ofChlamydia trachomatisserology in tubal
patency testing.
To evaluate the role of tubal patency test in the hierarchy of
investigations for infertility.
To understand the role of tubal surgery in modern management
of infertility.
To understand the importance of medical history taking
in infertility.
Ethical issues
Counselling patients about benefits and risks of tests, surgery and
need for assisted conception.
Should primary care trusts fund tubal surgery in patients who are
not otherwise eligible for IVF?
There may be psychosocial issues or anxiety so a multidisciplinary
approach is important.
Keywords:assisted reproductive techniques / HyCoSy / in vitro
fertilisation / laparoscopy / tubal surgery / tubal testing
Please cite this paper as:Suresh YN, Narvekar NN. The role of tubal patency tests and tubal surgery in the era of assisted reproductive techniques.The Obstetrician
& Gynaecologist2014;16:37–45.
Introduction
The life-time incidence of infertility is widely reported to be
17% (1 in 6 couples);
1
however, the incidence and prevalence
has been shown to vary significantly depending on the
population studied and methodology used to define
infertility. Nevertheless, there is a clear year-on-year
increase in the demand for artificial reproductive
technology (ART) particularly in-vitro fertilisation (IVF).
2
IVF was primarily developed as an alternative to surgery
for the treatment of tubal factor infertility. However, its
superior success even in the presence of severe tubal disease
and safe repeatable use on an outpatient basis has led to
it replacing tubal surgery in the modern management
of infertility.
This article reviews the current best available evidence as
well as provide an expert insight on the role of tubal patency
tests and tubal surgery in the era of ART.
Tubal patency tests
The availability of a plethora of tests to assess tubal patency
suggests that there is no perfect test. The various tests are
extensively reviewed in other publications
3–5
and
summarised in Table 1.
Laparoscopy
Laparoscopy is widely considered to be the gold-standard test
for tubal patency; however there is no evidence base to
support its ‘gold-standard’ attribute due to lack of a proven
alternative comparator. As such, the performances of other
tests are compared to those of laparoscopy.
Laparoscopy enables a direct visual inspection of the entire
external length of the fallopian tube and the pelvis which
improves its diagnostic and prognostic ability. Opportunistic
treatment of mild/minimal endometriosis and peri-adnexal
adhesions confers significant therapeutic benefit.
6,7
However,
ª2014 Royal College of Obstetricians and Gynaecologists 37
DOI: 10.1111/tog.12070
The Obstetrician & Gynaecologist
http://onlinetog.org
2014;16:37–45
Review

2. it requires general anaesthesia in most cases and is
associated with a 0.13% risk of bowel, urological or
vascular complications.
8
Hysterosalpingogram
Hysterosalpingogram (HSG) is cheap and widely available
and due to the longevity of its use, has the largest evidence
base to rule out unilateral or bilateral tubal block. It has a low
sensitivity of 53% and a high specificity of 87%
9
–i.e. a
positive test correctly identifies blocked fallopian tubes in
53% of cases whereas a negative test correctly identifies
patent fallopian tubes in 87% of cases. Therefore, given its
widespread availability, it is a good screening test to rule out
unilateral or bilateral tubal block. Limitations include failed
catheterisation or instrumentation and/or incomplete seal
around the cervix, false positive due to tubal spasm or debris
and reporting errors. The ideal time for the test is menstrual
cycle day 7–12 (i.e. after the end of menstruation but before
ovulation) and depending on the clinical setting, there can be
delays and cancellations due to scheduling problems.
Radiation exposure from this is significantly higher than
that of a standard chest X-ray
10
and there is a 1–3% risk of
pelvic infection.
A recent multicentre prospective cohort study evaluating
fecundity rate ratios (FRRs) in 3301 patients who underwent
HSG (n=2043), laparoscopy (n=747) or both HSG and
laparoscopy (n=511), reported an FRR (95% confidence
interval [CI]) of 0.81 (0.59–1.1) for unilateral tubal pathology
and an FRR of 0.28 (0.13–0.59) for bilateral tubal pathology
at HSG.
11
The FRRs for unilateral and bilateral tubal
pathology at laparoscopy were 0.85 (0.47–1.52) and 0.24
(0.11–0.54) respectively. Fecundity rate (FR) represents the
probability of spontaneous intrauterine pregnancy (IUP) per
time unit elapsed, derived from analysing the cumulative
probability of pregnancy over the study duration. Only
women trying to conceive are included in the calculation, and
women who have conceived using additional treatments are
excluded after the start of their additional treatment. FRR is
Table 1.Tubal patency tests
4,50
Test
Sensitivity (Sens.);
Specificity (Spec.)
Reliability
(kappa values)
Prognosis
(FRRs unless
stated otherwise) Effectiveness Safety
Operation
time
(minutes)
Lap and dye Unknown Unknown Unilateral
0.85 (0.47–1.520)
Bilateral
0.24 (0.11–0.54)
Unknown Bowel/urological/
vascular injury
0.13%
30
HSG Sens. 53%
Spec. 87%
Inter–observer
0.85 PTO
0.69 DTO
Intra–observer
0.89 PTO
0.72 DTO
Unilateral
0.81 (0.59–1.1)
Bilateral
0.28 (0.13–0.59)
LBR OSM vs. no
intervention
OR 2.98 (1.40–6.37)
LBR OSM vs. WSM
OR 1.49 (1.05–2.11)
Anaphylaxis
PID 3.1%
Radiation
exposure~2 Gray
~10
HyCoSy Sens. 93.3%
Spec. 89.7%
Intra–observer
0.61 for B/L
0.70 for R
0.37 for L
Unknown Unknown PID ~12
SSTC Unknown Unknown Unknown Unknown Tubal perforation 2%
THL Unknown Unknown Unilateral
0.59 (0.24–1.5)
Bilateral
0.00 (0.00–0.80)
Rectal injury 0.61% ~15
Fertiloscopy Sens. 86%
Spec. 100%
Inter–observer
0.80
Unknown Unknown Rectal injury 0.61%
Uterine perforation
~30
Salpingoscopy Unknown Unknown Unknown Unknown Same as lap and dye ~45
Fallaposcopy Unknown Unknown Classi fication
Normal
Mild disease
Severe ds
Pregnancy rate
27.6%
11.5%
0%
Tubal perforation 5.1%~20
CAT Sens. 21 –90%
Spec. 29–100%
Assay variation Unknown Unknown Unknown N/A
B/L=bilateral; CAT=chlamydia antibody test; ds=disease; DTO=distal tubal obstruction; FRR=fecundity rate ratio; HSG=hysterosalpingogram;
HyCoSy=hysterosalpingo contrast sonography; L=left; LBR=live birth rate; OR=odds ratio; OSM=oil-soluble medium; PID=pelvic inflammatory
disease; PTO=proximal tubal obstruction; R=right; SSTC=selective salpingography and tubal catheterisation; THL=transvaginal hydrolaparoscopy;
WSM=water-soluble medium
38 ª2014 Royal College of Obstetricians and Gynaecologists
Tubal tests and tubal surgery in the era of ART

3. the ratio of fecundity between women with a specific test
finding (for example, unilateral or bilateral pathology) and
those without the test finding. Therefore, the results of this
study, which addressed methodological deficiencies of
previous large-scale studies, suggest a 72% reduction in
fecundity for HSG and 74% for laparoscopy when the test
indicated bilateral tubal pathology. The prognostic ability of
unilateral tubal pathology with regard to fecundity for both
tests was unclear as the 95% confidence interval crossed the
line of unity of no effect.
The use of oil-soluble contrast medium has been shown to
confer a therapeutic benefit compared to no intervention
(odds ratio [OR] for live birth 2.98 [1.40–6.37]) and
water-soluble contrast medium (OR for live birth 1.49
[1.05–2.11]).
12
Despite this, water-soluble medium is
preferred due to superior image quality and safety
(oil-soluble medium is associated with complications such
as oil embolisation and granulomas).
Hysterosalpingo contrast sonography
Hysterosalpingo contrast sonography (HyCoSy) is a
transvaginal ultrasound technique in which a water-soluble
contrast medium is injected into the uterine cavity using a 5F
or 7F catheter. The test is performed in an outpatient setting
with the woman in a semi-lithotomy position which allows
easier access for cervical catheterisation. HyCoSy allows
simultaneous examination of the endometrial cavity, uterine
morphology (3D) where available and fallopian tubes while
avoiding radiation exposure. Significant technical difficulty
may be encountered in obese women and those with acute
uterine retroversion and high ovaries.
13
Data pooled from multiple studies indicate a high
sensitivity, specificity, and patient tolerability.
14
On a
comparative basis, HyCoSy is more sensitive and specific
than HSG;
27,28,30
however, one study of 103 women reported
a higher likelihood of uncertain (neither patent nor
occluded) findings with HyCoSy compared to HSG (8.8%
HyCoSy versus 0.5% HSG).
15
Another study reported poor
intra-observer reliability (repeat test by same observer after
3 months) for left-sided patency and pathology
16
and offered
explanations such as right handedness of the operator and a
true finding to explain this statistical anomaly.
A variety of contrast media have been used for HyCoSy–
in our experience, the best medium for cavity check is normal
saline (saline infusion sonography or SIS) and that for tubal
check is hysterosalpingo foam sonography (ExEm

Foam
[De Smit Medical Systems, Bristol]).
8
Selective salpingography and tubal catheterisation
Selective salpingography involves the direct injection of
radiopaque dye into the tubal ostium through a catheter
introduced transcervical under fluoroscopic control as a
result of which it significantly reduces false positives due to
tubal spasm and debris. Therefore the test is mainly used
second-line to improve the accuracy of HSG or laparoscopy
in the diagnosis of proximal tubal obstruction.
17
It also
allows direct measurement of tubal perfusion pressures which
has been shown to have prognostic value.
3
Selective salpingography can be combined with tubal
catheterisation to treat proximal tubal obstruction. Although
successful catheterisation rates are high (62–90%), pregnancy
rates are much lower (around 30%).
18
This may be due to
re-occlusion or the presence of co-existing inflammatory
pathology such as salpingitis isthmica nodosa (SIN) which is
best treated by tubal resection and anastomosis (see later).
The risk of tubal perforation during catheterisation is 2% and
of ectopic pregnancy is 3%. The procedure adds to operator
time and radiation exposure to that from a standard HSG. A
close working relationship between radiology and fertility
teams is necessary for correct interpretation and surgical
planning in order to maximise the value of the test. A lack
of such working relationships in many clinics due to
the challenges inherent to joint working may explain
its limited use despite the widespread availability of
interventional radiography.
Transvaginal hydrolaparoscopy, salpingoscopy,
falloposcopy, fertiloscopy
Transvaginal hydrolaparoscopy (THL) involves insufflation
of the pelvis with 0.4–0.6 litres of a fluid medium through an
insufflating needle inserted into the posterior fornix, followed
by the introduction of a small diameter rigid angled
endoscope to visualise the pouch of douglas (POD), pelvic
side-walls, adnexa and tubal patency (the dye injected
transcervically). The test is performed in an outpatient
setting under local anaesthetic and minor operative
procedures such as ovarian drilling, adhesiolysis, diathermy
to endometriosis and salpingostomy can be performed
through the operative channel.
19
The single biggest risk is
bowel injury, either at the time of insufflation or
introduction of the endoscope. Pooled data from large case
series (n=4232) report a recto-sigmoid injury rate of 0.61%,
all of which were managed either by primary repair or
conservatively with no long-term sequelae.
20
The
complication rate is much higher than that observed with
laparoscopy and the test is not suitable for women with
significant obliteration of POD due to PID, endometriosis
and fibroids.
Salpingoscopy is the endoscopic visualisation of the
endosalpinx of the tubal infundibulum and ampulla at
laparoscopy and/or THL, whereas falloposcopy is the
endoscopic visualisation of the whole endosalpinx at
hysteroscopy. Although these techniques provide significant
additional information, currently there is no universally
agreed and validated system to classify normal and abnormal
findings and therefore, there is a lack of prognostic ability.
ª2014 Royal College of Obstetricians and Gynaecologists 39
Suresh and Narvekar

4. Fertiloscopy is an outpatient technique that combines
hysteroscopy, THL and salpingoscopy.
21
A prospective
multicentre study (n=92) reported a high degree of
concordance between fertiloscopy and laparoscopy.
22
Fertiloscopy was performed first, followed by laparoscopy,
by two separate operators chosen by random allocation.
Videotape findings of the procedures were reviewed by two
other central independent observers to resolve differences.
Only 20% of women had normal findings whereas the
remainder (80%) had minor abnormalities.
Medical history
A systematic review and meta-analysis of the available
evidence on the association between items reported during
medical history taking and tubo-peritoneal pathology
reported a strong association for history of complicated
appendicitis (OR 7.2, 95% CI 2.2–22.8), pelvic surgery (OR
3.6, 95% CI 1.4–9.0), PID (OR 3.2, 95% CI 1.6–6.6),
ectopic pregnancy (OR 16.0, 95% CI 12.5 –20.4),
endometriosis (OR 5.9, 95% CI 3.2–10.8) and sexually
transmitted disease (OR 11.9, 95% CI 4.3–33.3).
23
Women
with such a medical background should therefore be offered
laparoscopy first-line because of its therapeutic potential.
Chlamydia antibody test
Chlamydia trachomatisis the single largest cause of acquired
tubal pathology and evidence of both current and past
infection can be easily measured usingC. trachomatis
antibody test (CAT). The sensitivity (21–90%) and specificity
(29–100%) varies depending on the cut-off value used to define
a positive result.
24
A recent meta-analysis evaluating the
accuracy of three different CAT assays, reported a significantly
better performance of MIF (micro-immune-fluorescence)
compared to ELISA (enzyme linked immunosorbent assay)
or IF (immune-fluorescence) assays.
25
The optimal cut-off value of CAT should be adjusted as
per the individual patient’s need; for example, a value that
delivers a high sensitivity should be chosen when it is more
important to detect tubal pathology with high certainty,
whereas a value delivering high specificity should be chosen
when it is more important to rule out tubal pathology to
avoid unnecessary invasive testing.
Routine or selective use of tubal patency test?
The prevalence of tubal factor infertility varies from 11 to
30% depending on the setting and population;
26
other causes
of infertility include male factor (20–30%), anovulation
(20%) and unexplained (25–30%). Therefore, the initial
investigations of an infertile couple should be confined
to assessment of sperm (seminal fluid analysis), pelvic
anatomy (transvaginal ultrasound scan), and ovulation
and ovarian reserve (follicular phase gonadotrophins,
mid-luteal progesterone).
Invasive tubal patency test should be offered after taking
into account the overall treatment needs of the woman or
couple; the most effective treatment of male factor and
long-standing (more than 5 years) unexplained infertility
and moderate to severe endometriosis is IVF. Ovulation
induction (OI) is the treatment of choice for women with
anovulation, whereas, IUI is usually reserved for the
treatment of women not exposed to sperm on a regular
basis; these include partners with azoospermia, and erectile
or ejaculatory dysfunction and single women and same-sex
couples. There is strong evidence to suggest that women who
are otherwise ovulating and exposed to sperm on a regular
basis (unexplained or mild male factor infertility) do not
benefit from clomiphene citrate or IUI.
27
Therefore, invasive tubal testing can be avoided in a vast
majority of women, and only offered to those who choose or
need OI, IUI or natural conception. In low-risk
treatment-na€ıve women undergoing OI or IUI, we do not
advocate the routine use of a tubal patency test prior to
initiating treatment. The majority of such women who
conceive, do so within the first three attempts and therefore
failures beyond this are offered IVF (or FSH therapy if
ovulatory failure with clomiphene citrate) and only women
keen to proceed with further OI or IUI treatment are offered
a tubal patency test. Our current practice is in keeping with
data from other studies that confirm a lack of therapeutic and
prognostic benefit of routine tubal patency testing prior to
initiating IUI in low-risk women.
28,29
Patient choice
While there is much debate about the place of tubal patency
testing in the infertility work-up and the physician’s choice of
test, patient choice has not been adequately researched. A
recent UK community-based questionnaire study reported
women’s attitudes towards four tests of tubal patency;
laparoscopy, HSG, HyCoSy and fertiloscopy.
30
A total of 68
women, with an average age of 30 years attending a GP
surgery in London, were included in the survey and the
response rate was 94% (64/68). The majority of women
(34%), who were otherwise na€ıve about these tests and were
only informed by means of an information leaflet describing
each test, preferred fertiloscopy as first choice due to its
ability to visualise the interior of the fallopian tube and the
avoidance of general anaesthesia and surgical scars.
Tubal surgery
Destructive tubal surgery
There is clear evidence of harm to implantation from the
presence of hydrosalpinx and therefore surgical treatment of
hydrosalpinx, either by salpingectomy or tubal occlusion is
now considered standard treatment prior to IVF.
31
The
evidence base for this correlates with disease severity and
40 ª2014 Royal College of Obstetricians and Gynaecologists
Tubal tests and tubal surgery in the era of ART

5. therefore is strongest for ultrasound visible and bilateral
disease.
32,33
There is a theoretical concern of reduced ovarian
reserve and responsiveness due to interference in ovarian
blood supply following salpingectomy. However,
well-designed observational trials have not shown any
difference in ovarian responsiveness and egg yield between
treated and untreated sides.
34–36
Routine 2D transvaginal ultrasound has a sensitivity of
84.6% and a specificity of 99.7% for the diagnosis of
hydrosalpinx.
37
Therefore, the need to perform tubal
patency test to rule out a hydrosalpinx that is not obvious
on routine ultrasound examination is debatable and should
be reserved for women with recurrent implantation failures
despite the transfer of high-quality embryos. Indeed there is
strong evidence, albeit without any biological plausibility,
of the therapeutic benefit of cavity check by hysteroscopy
in women with at least two IVF implantation failures.
38
Therefore the ideal test in women with such a
background is HyCoSy which combines cavity check with
tubal assessment.
Reconstructive tubal surgery
Tubal pathology is classified as proximal, distal or bipolar
(proximal and distal). The indications and success of various
tubal surgical interventions are summarised in Table 2.
Proximal tubal disease
Proximal tubal disease accounts for approximately 15% of
cases of tubal factor infertility; the most common cause is
salpingitis isthmica nodosa (SIN), a tubal disease of
inflammatory aetiology which is associated with other
infective PID stigmata such as distal tubal disease and
pelvic and peri-hepatic adhesions. The underlying
histopathology reveals endosalpingeal diverticula encased in
myosalpingeal hypertrophy and fibrosis resulting in a firm
proximal tubular nodule which can be seen on laparo-
scopic examination (Figure 1). As the disease involves both
endosalpingeal and myosalpingeal compartments, it is no
surprise that tubal resection and anastomosis (Figure 1) of
the diseased inflammatory area results in highest success
compared to tubal catheterisation or expectant management
irrespective of tubal patency.
39
An endometriotic nodule can
mimic SIN – bilateral proximal disease and associated
infective PID stigmata are pathognomonic of SIN.
Other known causes of proximal tubal disease include
tubal debris and intraluminal adhesions, which are amenable
to hysteroscopic or fluoroscopic tubal catheterisation.
Distal tubal disease
Distal tubal disease accounts for approximately 85% of cases
of tubal factor infertility. Hydrosalpinx is an end stage of
distal tubal disease and is best managed by salpingectomy
(Figure 2) followed by IVF.
31
The odds of ongoing pregnancy
rate increased two-fold (OR 2.14, 95% CI 1.23–3.73).
21
The
presence of bilateral disease, however, raises an ethical
dilemma as bilateral salpingectomy renders the woman
entirely dependent on IVF for conception. The long-term
fertility and psychological impact of such an approach is
unquantified and, therefore, management of these women
should be individualised based on age, presence of
co-aetiologies and the local and personal resources available
to fund continued IVF treatments. An interim salpingectomy
i.e. salpingectomy after previous failed IVF treatment, confers
equivalent benefit to primary salpingectomy and the
cumulative birth rate was shown to be similar after a
maximum of three completed IVF treatments.
40
Diseased tubes with a retention of>50% normal mucosa
have the best prognosis following reconstructive surgery.
Unfortunately, ultrasound criteria do not correlate with
endosalpingeal health, although 86% of hydrosalpinges that
were visible by ultrasound were found to have severe mucosal
damage.
32
Therefore suitability for reconstructive surgery is
best assessed at laparoscopy with recourse to salpingoscopy
where appropriate.
Table 2.Tubal surgery
Surgery Indication
Term pregnancy rate
[Mean (range)]
Ectopic pregnancy rate
[Mean (range)]
Salpingectomy Hydrosalpinx prior to IVF
(limited data for natural conception)
25% LBR (IVF) 1 –2%
Resection anastomosis SIN 44% (11 –57%) 7% (0 –12%)
Salpingo-ovariolysis Peri-adnexal adhesions 50% (17 –64%) 5% (0 –16%)
Fimbrioplasty Fimbrial phimosis 50% (15 –60%) 7% (2 –23%)
Salpingostomy Hydrosalpinx with >50% normal
mucosa or bilateral or well
informed patient
30% (0–42%) 9% (7 –24%)
Reversal of sterilisation Tubal sterilisation 52% (33 –86%) 5% (0 –14%)
Data derived from review Posaci et al 1999.
41
LBR=live birth rate; IVF=in vitro fertilisation; SIN=salpingitis isthmica nodosa.
ª2014 Royal College of Obstetricians and Gynaecologists 41
Suresh and Narvekar

6. The exact surgical technique used and the subsequent
prognosis depends on the extent and severity of disease; for
example greatest success is for salpingo-ovariolysis (division
of isolated peri-adnexal adhesions) followed by fimbrioplasty
whereas salpingostomy (Figure 2) which is used for treatment
of hydrosalpinx is least successful.
41
The main principle of
distal tubal surgery is to maximise functional length of the
fallopian tube particularly the ampulla
42
by achieving patency
as distally and close to the ovary as possible and to suture the
margins open where appropriate with the smallest possible
diameter non-absorbable suture.
43
The authors prefer 4–0
Prolene
TM
(Ethicon Inc., Menlo Park, CA, USA) (Figure 2) as
it can be used with existing standard laparoscopic needle
holders, thus minimising cost of additional equipment.
Reversal of tubal sterilisation
Surgical reversal of tubal sterilisation is just as successful as
IVF; however, it is not funded on the NHS (nor is IVF for this
patient group). Good prognostic factors include female age
<35 years and residual tubal length of more than 4 cm.
39
Laparotomy versus laparoscopy
The principles of microsurgery include atraumatic surgical
technique, magnification, complete excision of disease,
precise haemostasis, layered tissue re-anastomosis with
non-absorbable material and hydration of exposed tissue
surfaces. There are no comparative studies on the
performance of laparotomy versus laparoscopic tubal
surgery, but there is no underlying reason why
microsurgical principles cannot be applied to the
laparoscopic approach. The use of robotic surgery with its
multiple suturing angles negates the potential mechanical
difficulty in achieving optimal tissue anastomosis with
standard laparoscopy.
Should PCTs fund reconstructive tubal surgery when
the patient is not eligible for IVF?
There is wide variation in the state funding for IVF within the
UK, with a majority (90%) of Primary Care Trusts surveyed
in 2005 funding one cycle only and none funding the full
three cycles recommended by the National Institute for
(a) (b)
(c) (d)
(e) (f)
Figure 1.(a) Left salpingitis ishtmica nodosa (SIN) with proximal tubal obstruction; (b) right SIN but patent tube (note methylene dye visible on
tubal serosa due to endosalpingeal diverticulae); (c) excision of left SIN; (d) anastomosis with 4-0 Prolene
TM
(Ethicon Inc., Menlo Park, CA, USA); (e)
first layer of sutures; (f) second layer of sutures.
42 ª2014 Royal College of Obstetricians and Gynaecologists
Tubal tests and tubal surgery in the era of ART

7. Health and Care Excellence (NICE).
44,45
While there have
been some improvements in equity since the last survey
46,47
full equitable application of the NICE guideline remains a
distant reality.
Local allocation of funds for fertility treatment is based on
the founding principles of the NHS i.e. cost-effectiveness (or
value for money) and rationing based on treating those at
most need. Therefore, a patient not eligible for IVF should
not be offered tubal surgery which is equally expensive but far
less effective. If an individual funding request (IFR) is
deemed appropriate, then it should be for IVF unless
there are strong personal or medical grounds to support
tubal surgery.
Historically, funded provision of IVF was agreed on the
premise that local units ‘switch over’ to IVF rather than
continue to offer tubal surgery. This model is flawed at
several levels including patient autonomy, safety and
effectiveness; for example, a population study published in
1991 where patients were offered a progressive choice of tubal
surgery followed by IVF, reported a much higher cumulative
success (up to 80%) for the progressive approach
48,49
than
could be achieved by either treatment alone. As surgical
techniques have altered very little and IVF technology and
success improved significantly since, there is a need to review
various models of service delivery and evaluate their efficacy
and cost-effectiveness. The modern cost of tubal surgery that
can safely be done by a 90-minute day-surgery laparoscopy
operation using diathermy scissors, needle holder and
non-absorbable sutures is far less expensive than cost
calculated based on traditional surgery, which involves
inpatient admission for laparotomy microsurgery. The
changing landscape of the NHS with commissioning
responsibility devolved to local Clinical Commissioning
Groups (CCGs) presents a real opportunity to engage
commissioners on the role and tariffs for tubal surgery
and offer a progressive choice to the patient in this era of
(a) (b)
(c) (d)
(e) (f)
Figure 2.(a) Left hydrosalpinx; (b) left salpingectomy; (c) right hydrosalpinx; (d) right terminal salpingostomy (note healthy mucosa and
marsupilsation of edges with 4-0 Prolene); and patient 2; (e) left cuff salpingostomy (note loss of mucosa and therefore poor prognosis); (f) right
linear salpingostomy.
ª2014 Royal College of Obstetricians and Gynaecologists 43
Suresh and Narvekar

8. ART–to start with, this is best done in units where the local
prevalence of tubal factor infertility is high.
Conclusion
In summary, a policy of universal invasive tubal patency testing
is to be discouraged; instead the investigation and management
of tubal factor infertility should be individualised to the needs
of patients and populations. The option of tubal surgery should
be explored in selected cases and new models of care provision
should be incorporated into the practice where appropriate.
Figure 3 presents a pragmatic, evidence-based approach to the
management of tubal infertility.
Disclosure of interests
None declared.
References
1Hull MG, Glazener CM, Kelly NJ, Conway DI, Foster PA, Hinton RA, et al.
Population study of causes, treatment, and outcome of infertility.Br Med J
(Clin Res Ed)1985;291:1693–7.
2Human Fertilisation & Embryology Authority.Fertility Treatment in 2011:
Trends and Figures. London: HFEA; 2013.
3Papaioannou S, Afnan M, Sharif K. The role of selective salpingography and
tubal catheterization in the management of the infertile couple.Curr Opin
Obstet Gynecol2004;16:325–9.
4Papaioannou S, Bourdrez P, Varma R, Afnan M, Mol BW, Coomarasamy
A. Tubal evaluation in the investigation of subfertility: a structured
comparison of tests.BJOG2004;111:1313–21.
Figure 3.An evidence-based approach to management of infertility.
31,32,48,49
AFC=antral follicle count; AMH=anti-mullerian hormone; CC=clomiphene citrate; DI=donor insemination; ds=disease; E2=oestradiol; FSH=
follicule stimulating syndrome; GNRH=gonadotrophin releasing hormone; HIV=human immunodeficiency virus; IM=intramural; IVF=in-vitro
fertilisation; LH=luteinising hormone; NC=natural conception; PCOS=polycystic ovary syndrome; P4=progesterone; SIN=salpingitis isthimica
nodosa; SM=submucous.
44 ª2014 Royal College of Obstetricians and Gynaecologists
Tubal tests and tubal surgery in the era of ART

9. 5Saunders RD, Shwayder JM, Nakajima ST. Current methods of tubal patency
assessment.Fertil Steril2011;95:2171–9.
6Marcoux S, Maheux R, Berube S. Laparoscopic surgery in infertile women
with minimal or mild endometriosis. Canadian Collaborative Group on
Endometriosis.N Engl J Med1997;337:217–22.
7Jacobson TZ, Duffy JM, Barlow D, Farquhar C, Koninckx PR, Olive D.
Laparoscopic surgery for subfertility associated with endometriosis.
Cochrane Database Syst Rev2010;(1):CD001398.
8Chapron C, Querleu D, Bruhat MA, Madelenat P, Fernandez H, Pierre F, et
al. Surgical complications of diagnostic and operative gynaecological
laparoscopy: a series of 29,966 cases.Hum Reprod1998;13:867–72.
9Broeze KA, Opmeer BC, Van Geloven N, Coppus SF, Collins JA, Den Hartog
JE, et al. Are patient characteristics associated with the accuracy of
hysterosalpingography in diagnosing tubal pathology? An individual
patient data meta-analysis.Hum Reprod Update2011;17:293–300.
10Hart D, Hillier MC, Wall BF. National reference doses for common
radiographic,fluoroscopic and dental X-ray examinations in the UK.Br J
Radiol2009;82:1–12.
11Verhoeve HR, Coppus SF, van der Steeg JW, Steures P, Hompes PG,
Bourdrez P, et al. The capacity of hysterosalpingography and laparoscopy to
predict natural conception.Hum Reprod2011;26:134–42.
12Luttjeboer F, Harada T, Hughes E, Johnson N, Lilford R, Mol BW. Tubal
flushing for subfertility.Cochrane Database Syst Rev2007;(3):CD003718.
13Hamilton JA, Larson AJ, Lower AM, Hasnain S, Grudzinskas JG. Evaluation
of the performance of hysterosalpingo contrast sonography in 500
consecutive, unselected, infertile women.Hum Reprod1998;13:1519–26.
14Holz K, Becker R, Sch€urmann R. Ultrasound in the investigation of tubal
patency. A meta-analysis of three comparative studies of Echovist-200
including, women.Zentralbl Gynakol1007;1997(119):366–73.
15Strandell A, Bourne T, Bergh C, Granberg S, Asztely M, Thorburn J. The
assessment of endometrial pathology and tubal patency: a comparison
between the use of ultrasonography and X-ray hysterosalpingography for
the investigation of infertility patients.Ultrasound Obstet Gynecol
1999;14
:200–4.
16Tekay A, Spalding H, Martikainen H, Jouppila P. Agreement between two
successive transvaginal salpingosonography assessments of tubal patency.
Acta Obstet Gynecol Scand1997;76:572–5.
17Woolcott R, Fisher S, Thomas J, Kable W. A randomized, prospective,
controlled study of laparoscopic dye studies and selective salpingography as
diagnostic tests of fallopian tube patency.Fertil Steril1999;72:879–84.
18Thurmond AS, Machan LS, Maubon AJ, Rouanet JP, Hovsepian DM, Moore
A, et al. A review of selective salpingography and fallopian tube
catheterization.Radiographics2000;20:1759–68.
19Gordts S, Puttemans P, Gordts S, Brosens I, Campo R. Transvaginal
laparoscopy.Best Pract Res Clin Obstet Gynaecol.2005;19:757–67.
20Gordts S, Campo R, Puttemans P, Gordts Sy, Brosens I. Transvaginal access:
a safe technique for tubo-ovarian exploration in infertility? Review of the
literature.Gynecol Surg2008;5:187–91.
21Watrelot A. Fertiloscopy.Gynecol Obstet Fertil2001;29:462–5.
22Watrelot A, Nisolle M, Chelli H, Hocke C, Rongifleres C, Racinet C, et al. Is
laparoscopy still the gold standard in infertility assessment? A comparison
of fertiloscopy versus laparoscopy in infertility. Results of an international
multicentre prospective trial: the‘FLY’(Fertiloscopy-LaparoscopY) study.
Hum Reprod2003;18:834–9.
23Luttjeboer FY, Verhoeve HR, van Dessel HJ, van der Veen F, Mol BW, Coppus
SF. The value of medical history taking as risk indicator for tuboperitoneal
pathology: a systematic review.BJOG2009;116:612–25.
24Mol BW, Dijkman B, Wertheim P, Lijmer J, van der Veen F, Bossuyt PM. The
accuracy of serum chlamydial antibodies in the diagnosis of tubal
pathology: a meta-analysis.Fertil Steril1997;67:1031–7.
25Broeze KA, Opmeer BC, Coppus SF, Van Geloven N, Alves MF, Anestad G, et
al. Chlamydia antibody testing and diagnosing tubal pathology in subfertile
women: an individual patient data meta-analysis.Hum Reprod Update
2011;17:301–10.
26
Evers JL. Female subfertility.Lancet2002;360:151–9.
27Bhattacharya S, Harrild K, Mollison J, Wordsworth S, Tay C, Harrold A, et al.
Clomifene citrate or unstimulated intrauterine insemination compared with
expectant management for unexplained infertility: pragmatic randomised
controlled trial.BMJ2008;337:a716.
28Edmonds DK, Matthews CD, Cox LW. Tubal patency testing in a programme
of artificial insemination with donor semen.Br J Obstet Gynaecol.
1981;88:761–4.
29Stovall DW, Christman GM, Hammond MG, Talbert LM. Abnormalfindings
on hysterosalpingography: effects on fecundity in a donor insemination
program using frozen semen.Obstet Gynecol.1992;80:249–52.
30Jagadambe A, Oakeshott P, Ojha K, Hay PE. Methods of assessing tubal
patency.Sex Transm Infect2012;88:249.
31Johnson N, van Voorst S, Sowter MC, Strandell A, Mol BW. Surgical
treatment for tubal disease in women due to undergo in vitro fertilisation.
Cochrane Database Syst Rev2010;(1):CD002125.
32Strandell A, Lindhard A. Hydrosalpinx and ART. Salpingectomy prior to IVF
can be recommended to a well-defined subgroup of patients.Hum Reprod
2000;15:2072–4.
33Strandell A, Lindhard A, Waldenstr€om U, Thorburn J, Janson PO,
Hamberger L. Hydrosalpinx and IVF outcome: a prospective, randomized
multicentre trial in Scandinavia on salpingectomy prior to IVF.Hum Reprod.
1999;14:2762–9.
34Surrey ES, Schoolcraft WB. Laparoscopic management of hydrosalpinges
before in vitro fertilization-embryo transfer: salpingectomy versus proximal
tubal occlusion.Fertil Steril2001;75:612–7.
35Kamal EM. Ovarian performance after laparoscopic salpingectomy or
proximal tubal division for hydrosalpinx.Middle East Fertility Society Journal
2013;18:53–57.
36Strandell A, Lindhard A, Waldenstr€om U, Thorburn J. Prophylactic
salpingectomy does not impair the ovarian response in IVF treatment.Hum
Reprod2001;16:1135
–9.
37Guerriero S, Ajossa S, Lai MP, Mais V, Paoletti AM, Melis GB. Transvaginal
ultrasonography associated with colour Doppler energy in the diagnosis of
hydrosalpinx.Hum Reprod2000;15:1568–72.
38Suresh YN, Narvekar N. Role of surgery to optimise outcome of assisted
conception treatments.The Obstetrician & Gynaecologist2013;15:
91–8.
39Gomel V, McComb PF. Microsurgery for tubal infertility.J Reprod Med.
2006;51:177–84.
40Strandell A, Lindhard A, Waldenstr€om U, Thorburn J. Hydrosalpinx and IVF
outcome: cumulative results after salpingectomy in a randomized
controlled trial.Hum Reprod2001;16:2403–10.
41Posaci C, Camus M, Osmanagaoglu K, Devroey P. Tubal surgery in the era of
assisted reproductive technology: clinical options.Hum Reprod1999;14
(Suppl 1):120–36.
42McComb P, Boer-Meisel M, Gomel V. The influence of fallopian tube
ampullary length on the fertility of the rabbit.Int J Fertil1981;26:30–4.
43Beauchamp PJ, Guzick DS, Held B, Schmidt WA. Histologic response to
microsuture materials.J Reprod Med.1988;33:615–23.
44Kennedy R, Kingsland C, Rutherford A, Hamilton M, Ledger W; British
Fertility Society. Implementation of the NICE guideline - recommendations
from the British Fertility Society for national criteria for NHS funding of
assisted conception.Hum Fertil(Camb)2006;9:181–9.
45National Institute for Health and Care Excellence.Fertility: Assessment and
Treatment for People with Fertility Problems. London: NICE; 2004.
46Johnson G.Holding back the British IVF revolution? A report into NHS IVF
provision in the UK today. London: All Party Parliamentary Group on
Infertility; 2011. [http://www.garethjohnsonmp.co.uk/uimages/File/
appg_IVF_report.pdf]
47Department of Health.Primary Care Trust Survey: Provision of IVF in
England 2008. London: Department of Health; 2009.
48National Institute for Health and Care Excellence.Fertility: Assessment
and Treatment for People with Fertility Problems (Update). London: NICE;
2012.
49Audibert F, Hedon B, Arnal F, Humeau C, Boulot P, Bachelard B, et al.
Therapeutic strategies in tubal infertility with distal pathology.Hum Reprod
1991;6:1439–42.
50Papaioannou S, Afnan M, Jafettas J. Tubal assessment tests: still have not
found what we are looking for.Reprod Biomed Online2007;15:376–82.
ª2014 Royal College of Obstetricians and Gynaecologists 45
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