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ORIGINAL RESEARCH |
From the Departments of Obstetrics and Gynecology and Biomedical Engineering, Wright State University School of Medicine, Dayton, Ohio.
Address reprint requests to: William W. Hurd, MD, 3800 Weber Building, 128 East Apple Street, Dayton, OH 45409-2793; E-mail: william.hurd{at}wright.edu.
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ABSTRACT |
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 ABSTRACT MATERIALS AND METHODSRESULTSDISCUSSIONREFERENCES |
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METHODS: In patients in whom unilateral proximal tubal obstruction was detected during hysterosalpingography performed for standard clinical indications, the patient was rotated on her hip approximately 45° such that the obstructed tube was first superior (ventral) to the patent tube, and dye was reinjected. If obstruction did not resolve, the patient was rotated in the opposite direction so that the obstructed tube was inferior (dorsal) to the patent tube and dye reinjected.
RESULTS: Unilateral tubal obstruction was found in 15% of cases (24 of 156). Rotating the patient with obstructed tube superior to the patent tube never resulted in tubal patency, whereas rotating the patient with the obstructed tube inferior resulted in resolution of tubal patency in 63% of cases (15 of 24).
CONCLUSION: Unilateral cornual obstruction during hysterosalpingography is often resolved by rotating the patient such that the obstructed tube is more inferior. Although this observation may be the result of dislodging smaller air bubbles, from a fluid dynamics perspective a more likely explanation is unkinking of the more inferior tube.
More than 200,000 hysterosalpingography procedures are performed annually in the United States to evaluate the uterine cavity and fallopian tubes.1 A common finding during hysterosalpingography is proximal tubal obstruction, which refers to the inability to inject dye beyond the point where the tubal lumen narrows to 0.5 mm or less in the uterine cornual region.2 Bilateral proximal obstruction on hysterosalpingography is strongly associated with tubal pathology. In contrast, unilateral proximal tubal obstruction, which is found in 10–24% of hysterosalpingograms, is often temporary and has limited prognostic significance for fertility.3,4 Subsequent injection of dye during laparoscopy or repeat hysterosalpingography will reveal a normal patent tube in 16–80% of cases where unilateral proximal obstruction has been previously documented by hysterosalpingography.5–7
The etiology of temporary proximal tubal obstruction remains uncertain. Theories include tubal spasm, plugging with mucus or debris, and lodging of air bubbles in the cornual region.8 Despite numerous medications and techniques designed to resolve unilateral obstruction, this common finding during hysterosalpingography continues to lead to additional testing and patient anxiety.
A novel explanation of temporary proximal tubal obstruction is tubal kinking, because the tubes and ovaries are almost always situated dorsal to the uterine fundus in the supine position. If the tubes are sometimes kinked at the uterotubal junction in the supine position, the result could be transitory proximal tubal obstruction that resolves with rotation in the appropriate direction. We designed this study to evaluate the effect of patient rotation on apparent proximal tubal obstruction discovered during hysterosalpingography. We hypothesized that if small bubbles or tubal kinking are causal factors in view of unilateral proximal tubal obstruction during hysterosalpingography, rotating the patient so that the obstructed tube is inferior (dorsal) to the patent tube would result in tubal patency by either displacing bubbles or unkinking the tube.
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MATERIALS AND METHODS |
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All patients were pretreated with ibuprofen (600 mg orally) 1 hour before the procedure. After signing a consent form to participate in the study in the radiology suite, each patient was placed in a dorsal lithotomy position. A bivalve speculum was placed into the vaginal canal and the cervix rinsed with a Betadine solution. The cervix was grasped with a single-toothed tenaculum, and a metal uterine injector device was placed in the cervix. Alternatively, a hysterosalpingography balloon catheter (Cook Catheters, Bloomington, IN) was placed in the uterus and also inflated with 2 mL of air. Approximately 10 cc of water-soluble nonionic contrast medium (Idoquamide Meglurine-Sinograpfin; Bracco Diagnostic, Princeton, NJ) was injected into the uterus. Each hysterosalpingography was performed and interpreted by a reproductive endocrinologist in conjunction with a radiologist.
Whenever proximal obstruction was detected with low pressure injection, dye was injected at an increased pressure limited by the discomfort of the patient. In the case of persistent obstruction, the patient was asked to turn on her hip at an approximately 45° angle. So that each patient could serve as her own control, each patient with unilateral obstruction was first turned in the direction such that the obstructed tube was superior (ventral) to the patent tube. Dye was injected at an increased pressure limited by the patient’s comfort. If this did not result in opacification of both tubes, the patient was asked to rotate on the opposite hip such that the obstructed tube was inferior (dorsal) to the patent tube, and the injection was repeated. The ability to opacify a previously obstructed tube with these maneuvers was recorded for each patient. Spot radiograms were taken to document the results of the hysterosalpingography. Fluoroscopy was not continued during patient repositioning. No antispasmodic agents were used in any patient.
Patient characteristics were compared between groups using analysis of variance for continuous data and 
2 for nominal data. For the resolution of proximal obstruction when the patient was rotated in each direction, obstructed tube superior versus obstructed tube inferior was compared using the McNemar 2 for paired data. P values less than .05 were considered significant. A minimal sample size of 20 patients was calculated using a ß of .2 and an 
of .05 with an expected subsequent patency rate of 10% with the obstructed tube superior and 50% with the obstructed tube inferior.
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RESULTS |
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A metal uterine injector device was used in 140 patients, and a balloon catheter was used in 16. Of patients in whom a balloon catheter was used, one was found to have distal obstruction and one was found to have unilateral proximal obstruction. The remainder had patent tubes bilaterally.
Patients with patent tubes were similar to those with obstructed tubes in terms of age, height, weight, and body mass index (kg/m2) (Table 1
). Relative to patients with patent tubes or unilateral obstruction, those with bilateral tubal obstruction had a longer average duration of infertility and those with mid- or distal obstruction were more likely to have had pelvic surgery.
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2 test). In the four patients with bilateral proximal tubal obstruction, one tube became patent in the inferior position (25%; 95% CI 0%, 67%) and no tube became patent in the superior position (P = .25). |
DISCUSSION |
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We initially designed this study based on the hypothesis that unilateral cornual tubal obstruction might sometimes be due to lodging of small air bubbles in the cornual region, as first suggested by Morgan.8 A small bubble trapped in the tubal lumen could temporarily increase resistance on one side, resulting in preferential flow through the open side and apparent unilateral obstruction. Even if a bubble obstructing a tube were too small to be easily seen during fluoroscopy, rotating the patient with the obstructed side more dorsal (dependent) might dislodge the bubble as a result of buoyancy.
When analyzed from a fluid dynamics perspective, this "small bubble" hypothesis did not seem plausible. For example, if we assume a lumen diameter of 2 mm and the same length of lumen in the cornual region, then the Poiseuille flow resistance (ie, inversely proportional to the fourth power of diameter) is about 0.04 mm Hg/(mL per second). If fluid is injected at a rate of 1 mm per second, this results in a pressure drop in this region of 0.04 mm Hg. A bubble 1 mm in diameter would block 25% of the lumen area, resulting in a resistance increase of 50% or a pressure drop of 0.06 mm Hg. This calculated pressure drop is vastly overshadowed by the 50–75–mm Hg pressure generated in the uterus during hysterosalpingography.
Tubal kinking appears to be a more likely explanation of temporary proximal tubal obstruction from a fluid dynamics perspective. Because the tubes and ovaries are almost always situated dorsal to the uterine fundus in the supine position, the tube might become intermittently kinked at the uterotubal junction (Figure 1A). Rotating the patient such that the obstructed tube is more dependent would tend to unkink the tube, thus equalizing the transverse and anterior–posterior diameters and dramatically lowering the resistance (Figure 1B). During hysterosalpingography, any increase in pressure resulting from kinking of the tube at the uterotubal junction would be transmitted hydrostatically back to the narrow cornual region, causing a transitory proximal tubal obstruction.
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).10 When the lumen "flattens" so that the anterior–posterior diameter is 20% of the transverse diameter, the resistance is 14 times greater than a circular lumen. When this relationship is 15%, the resistance is 30 times greater. The findings of this study could explain many hysterosalpingography observations made over the years. The tubal obstruction rates we found (distal, 10%; unilateral proximal, 15%; and bilateral proximal, 3%) are similar to previously reported rates.11,12 Likewise, the resolution rate of unilateral obstruction after patient rotation with the obstructed side more dorsal (63%) is similar to the resolution rate reported for subsequent laparoscopy or repeated hysterosalpingography. This suggests that resolution of proximal tubal obstruction during a subsequent procedure might be related to unkinking of the tube from the random changes in tubal position relative to the uterus.
A limitation of this study is that it was not doubly blinded, and therefore may have been susceptible to subconscious manipulation by the investigators. To counter this tendency, the patient was always rotated first in the direction opposite to that expected to help resolve obstruction (ie, the obstructed tube more superior). Although the finding that unilateral obstruction never resolved when the effected tube was more superior is probably related to the relatively small study numbers, this finding does suggest that the direction of rotation is important.
A second limitation is that the pressures used for dye injection were neither measured nor controlled. Because injection pressure can only be roughly estimated, another possible explanation for our findings is that less pressure was used during the first rotation and more during the last rotation. However, the findings that unilateral tubal obstruction never resolved with rotation such that the obstructed tube was more superior and that the rate of observed obstruction and resolution was similar to that reported in previous studies suggest that the direction of rotation is important.
The clinical implications of this study are obvious. The common finding of unilateral tubal obstruction during hysterosalpingography is of concern to the patient and often leads to further diagnostic procedures. With a false positive rate of more than 60%, a finding of unilateral proximal tubal obstruction is more often than not misleading. Although not specifically addressed by the present study, it follows that unilateral tubal occlusion not resolving with patient rotation might be more likely to represent tubal pathology. Using patient rotation to resolve many cases of temporary proximal obstruction at the time of original hysterosalpingography may be a useful way to minimize patient concern and the need for a second diagnostic procedure.
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Footnotes |
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Received November 12, 2002. Received in revised form January 2, 2003. Accepted January 23, 2003.
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REFERENCES |
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2. Sweeney W. The interstitial portion of the uterine tube–its gross anatomy, course, and length. Obstet Gynecol 1962; 19:3–8.
3. Swart P, Mol BWJ, van der Veen F, van Beurden M, Redekop WK, Bossuyt PM. The value of hysterosalpingography in the diagnosis of tubal pathology, a meta-analysis. Fertil Steril 1995;64:486–91.[Medline]
4. Mol BW, Swart P, Bossuyt PM, van der Veen F. Is hysterosalpingography an important tool in predicting fertility outcome? Fertil Steril 1997;67:663–9.[Medline]
5. Rice J, London S, Olive D. Reevaluation of hysterosalpingography in infertility investigation. Obstet Gynecol 1986; 67:718–21.[Medline]
6. Inagaki N, Sato K, Toyoshima K, Ito K, Kitai H, Gabionza DT, et al. Hysteroscopic selective salpingography. Fertil Steril 1999;72:733–6.[Medline]
7. Dessole S, Meloni GB, Capobianco G, Manzoni MA, Ambrosini G, Canalis GC. A second hysterosalpingography reduces the use of selective technique for treatment of a proximal tubal occlusion. Fertil Steril 2000;73:1037–9.[Medline]
8. Morgan D, Kenny P, Smith K, Koehler R. Hysterosalpingography with videofluoroscopy: Effect on radiologic practice in an academic medical center. Acad Radiol 1998; 5:480–4.[Medline]
9. Opsahl MS, Miller B, Klein TA. The predictive value of hysterosalpingography for tubal and peritoneal infertility factors. Fertil Steril 1993;60:444–8.[Medline]
10. White FW. Viscous fluid flow. New York: McGraw-Hill, 1974.
11. Stenchever M, Droegemueller W, Herbst A, Mishell D. Comprehensive gynecology. St. Louis: Mosby-Yearbook, Inc., 2001.
12. Fortier KJ, Haney AF. The pathologic spectrum of uterotubal junction obstruction. Obstet Gynecol 1985;65:93.
This article has been cited by other articles:
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  H. H. Sheikh, W. W. Hurd, E. T. Wyckoff, D. B. Reynolds, L. S. Amesse, J. S. Gruber, and G. M. Horowitz Patient Rotation and Resolution of Unilateral Cornual Obstruction During Hysterosalpingography Obstet. Gynecol., November 1, 2003; 102(5): 1088 - 1089. [Full Text] [PDF]
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