Hysterosalpingography (HSG) & Fallopian Tube Recanalisation

Tubal factor infertility is the most common cause of infertility in reproductive-age women, accounting for approximately 30% of cases. The proximal portion of the tube (intramural and isthmic segments) is implicated in 10 to 25%. The cause of occlusion of the proximal portion of the fallopian tube is commonly infection and inflammation, with less common causes including endometriosis and salpingitis isthmica nodosum. The proximal portion of the tube is very small in calibre (approximately 1 mm) and has a relatively thick muscular wall, making it more susceptible to occlusion. Infection and inflammation can cause a "mucous plug" to form, which is particularly amenable to fallopian tube recanalisation.

Hysterosalpingography (HSG), or hysterosalpingogram (HSG), is a radiologic (x-ray) procedure to examine the inside of the uterus and fallopian (ovarian) tubes via injection of a contrast dye into the uterus with a small catheter tube. It is highly accurate in demonstrating whether the fallopian tubes are patent (open) or occluded (blocked). Some advantages of hysterosalpingography (HSG) compared to other forms of tubal examination (e.g., hysterosalpingo-contrast-sonography HyCoSy or laparoscopy) is that it is is highly accurate in the diagnosis specifically of tubal occlusion, and provides the opportunity to perform Lipiodol flushing and/or Fallopian Tube Recanalisation in the same procedure. There is a small x-ray radiation dose involved (approximately 10mGy) to the ovaries, which is similar to a series of x-rays that may be taken to look for fractures in the pelvis.

Lipiodol is a safe oil-based contrast agent that has been used in Interventional Radiology (IR) practice for many decades in a variety of settings, including historically for many decades in hysterosalpingography (HSG) since 1924. Recent scientific trials have compared the use of water-based contrast and Lipiodol and demonstrated higher rates of pregnancy and live birth compared with Lipiodol.

Lipiodol flushing or use of Lipiodol during your hysterosalpingography (HSG) may be offered to you depending on your individual case, along with discussion of the risks and benefits. Lipiodol has a small risk of "intravasation," which refers to the Lipiodol leaking into a vein of the uterus and potentially travelling to another part of the body. This risk is significantly minimised with use of x-ray imaging, which is utilised in all Lipiodol HSG procedures at Specialist IR.

Effectiveness

• A key study showed that hysterosalpingography with Lipiodol resulted in a 39% rate of live birth compared to 28% in the water-based contrast group (Dreyer 2017)

Radiologic Fallopian Tube Recanalisation (Recanalization) refers to the Interventional Radiology (IR) procedure that can be performed in conjunction with hysterosalpingography (HSG) to reopen an occluded (blocked) fallopian tube. The procedure begins by passing a small catheter tube into the uterus and orientating it towards the occluded tube. A "selective salpingography" is then performed, which involves gentle injection of contrast agent directly into the tube. This is commonly sufficient to recanalise the tube by flushing away a simple mucous plug. If the tube remains occluded, a small guide-wire is then passed through the tube, which can dislodge and pushes away any residual mucous plus, cellular debris or scar tissue.

Effectiveness

• The technical success rate of Radiologic Fallopian Tube Recanalisation (FTR) is over 90% with experienced operators. This means that more than 90% of occluded tubes can be successfully recanalised (opened).
• Reported rates of live birth after FTR are approximately 34%, however there is wide variation in scientific publications

1. A specialist interventional radiologist will first consult with you, review previous imaging and investigations, and assess your suitability for Hysterosalpingography (HSG), Lipiodol flushing and Fallopian Tube Recanalisation (FTR). If you are unsuitable, Interventional Radiologist (IR) will discuss this with you and arrange referral to another specialist as appropriate.
2. The procedure is performed during the follicular phase of the menstrual cycle (typically day 7-10). A pregnancy test is not necessary if HSG is performed during the follicular phase.
3. HSG is performed under a twilight sedation and with local anaesthetic spray. A speculum is inserted and a thin catheter tube passed through the cervix.
4. Contrast dye is injected and x-ray images taken to visualise the inside of the uterus and fallopian tubes. This may be followed by Lipiodol flushing of the tubes if suitable.
5. If one or both of the fallopian tubes are occluded (blocked) at the ostium (part closest to the uterus), Fallopian Tube Recanalisation (FTR) may be performed. This involves orientating the catheter towards the opening of the blocked fallopian tube(s), injecting contrast dye, and passing a thin guide-wire.
6. The procedure is performed as a day-case, and almost all women are able to go home the same day, returning to usual activities including work within 1 to 2 days.
7. It is common to have some mild pelvic "cramps" and vaginal "spotting" of blood for up to 3 days following HSG and FTR.

The risk of complications during Hysterosalpingography, Lipiodol flush, and Fallopian Tube Recanalisation (FTR) is very low, but these may include:

• Infection (1%)
• Tubal perforation (<4%)
• Lipiodol intravasation
• Ectopic pregnancy

Interventional Radiologists (IRs) have been performing Hysterosalpingography (HSG) for over 100 years, combining the unique specialist imaging and procedural skillset. It was an Interventional Radiology (IR), Dr Amy Thurmond, who invented and pioneered the Radiologic Fallopian Tube Recanalisation (FTR) procedure in the 1980s, offering a minimally invasive treatment method for women with tubal occlusion, leading to countless pregnancies and live births.

Dr Matthew Lukies

Matthew has a particular interest in hysterosalpingography and fallopian tube recanalisation procedures, as minimally invasive investigations and treatments for tubal infertility. During time training as a resident doctor, Matthew completed an advanced certification in Obstetrics & Gynaecology with the Royal Australian and New Zealand College of Obstetricians & Gynaecologists (RANZCOG), with whom he maintains associate membership.

Matthew is coauthor, along with Dr Amy Thurmond, of the book chapter on Selective Salpingography and Fallopian Tube Recanalisation (FTR) in the leading international textbook for Interventional Radiologists titled "Image-Guided Interventions."

Hysterosalpingography, Lipiodol flushing and Fallopian Tube Recanalisation (FTR) are just a few of the tests and procedures that may be recommended and performed as part of fertility investigation and treatment. It is vital that you are under the care of a fertility specialist to guide you through the process and facilitate the next stages of care. The Interventional Radiologist may direct you to an appropriate fertility specialist if required.

If you would like to consult with an Interventional Radiologist about uterine artery embolisation, please send a referral for consultation, including the following

• Ultrasound and other imaging results (e.g., MRI)
• Records of consultations with other doctors and specialists
• Medical history

Public eligible patients can undergo the treatment with no out-of-pocket expense in the public system.