IMPORTANTE ACRESCENTAR QUE UTILIZAMOS MEDICAMENTOS MAIS ESPECIFICOS E MODERNOS, DIFERENTE DO TRABALHO ABAIXO, MAS MESMO ASSIM ELES OBTIVERAM BONS RESULTADOS.
East African Medical Journal Vol. 86 No. 1 January 2009
HYDROTUBATION IN THE MANAGEMENT OF FEMALE INFERTILITY:
OUTCOME IN LOW RESOURCE SETTINGS
A. G. Adesiyun, FWACS, Department
of Obstetrics and Gynaecology, Ahmadu
Bello University Teaching Hospital, Shika – Zaria Kaduna State,
Nigeria, B. Cole, MBBS, Echo Scan Services
Limited, 4, Katsina Road – Kaduna, Kaduna State, Nigeria and P. Ogwuche,
MBBS, Alba Clinic and Medical
Center, 25, Constitution Road – Kaduna,
Kaduna State, Nigeria
Request
for reprints to: Dr. A.
G. Adesiyun, P. O.Box 204, Kaduna - Kaduna State, Nigeria
HYDROTUBATION
IN THE MANAGEMENT OF FEMALE INFERTILITY: OUTCOME IN LOW RESOURCE SETTINGS
A.
G. ADESIYUN, B. COLE and P. OGWUCHE
ABSTRACT
Objectives: To
determine the outcome of therapeutic hydrotubation (tubal flushing)
in
patients with tubal infertility and unexplained infertility.
Design: Prospective
non-randomised observational study.
Setting: Alba
hospital, a five bed multidisciplinary private hospital in Kaduna city, Nigeria.
Subjects: Infertile women with
tubal and unexplained infertility.
Results: Two hundred and fifty seven patients
that had therapeutic hydrotubation over 7.5 years were analysed.
The age range was 21 to 44 years with mean of 34.5 years. Secondary infertility was found
in 209 (81.3%) patients and primary infertility in 166 (64.6%) patients. Of the 257 patients, 134 (52.1%) had had induced
abortion. Indications for hydrotubation were bilateral perifimbrial adhesion (incomplete tubal occlusion)
47.9%, bilateral fimbrial end occlusion 24.9%, bilateral cornual
blockage 16% and unexplained infertility in 11.3%
of cases. One hundred and nine conceptions were recorded in this study
and the overall
conception rate was 42.4%. Likewise, percentage ratio of conception in these 154 patients with evidence of post – hydrotubation tubal patency was 70.8%. Pregnancy
outcome of the 109 conceptions are term pregnancy
84.4%, preterm pregnancy
9.2%, miscarriage 4.6% and ectopic
pregnancy in 1.8% of the conceptions. Recorded
complications were pelvic pain in 177 (68.9%)
patients and vaginal bleeding
in 63 (24.5%) patients.
Conclusion: With good case selection, therapeutic hydrotubation may be beneficial in resource poor countries, especially in patients with incomplete tubal occlusion (bilateral
perifimbrial adhesions) and as part of treatment for unexplained infertility.
INTRODUCTION
Infertility remains
a major reason for gynaecological
consultation in developing countries. It is associated
with social consequences like marital
instability, divorce,
polygamy, prostitution
and suicide
in extreme cases. In the tropics,
tubal factors remain a common cause of female
infertility (1). This is due to
high prevalence of sexually
transmitted diseases in our setting. Optimal
diagnosis and treatment of tubal
factor, though standardised,
vary from place to place,
depending on how developed the health care services are. Methods of managing tubal factors in infertility
range from gaseous
insufflation, hydrotubation,
microsurgery, hysteroscopic catheterisation
and
in vitro fertilisation (2).
Microsurgical operations and hysteroscopic catheterisation technology are not available
in our setting. Although there are very few in vitro
fertilisation (IVF) units,
the services
are
usually unaffordable and out of reach to majority of patients
that may benefit from it.
The recently introduced
National Health Insurance Scheme in
the country
does
not cater for this service. It costs between
four to six thousand United
States Dollars for one IVF cycle.
Against this background, we performed
hydrotubation on
most of these patients as
a last resort.
MATERIALS AND METHODS
This was a prospective
study carried out in a privately owned 50 bed multidisciplinary hospital in Kaduna City, Nigeria. The study period was from January
1999 through to June
2006. During this period, 291 hydrotubation (HTB)
procedures were done, but 257
cases that were followed up for at least six months post-procedure
were analysed in this study.
The inclusion criteria
and indications
for hydrotubation were
bilateral tubal pathology and unexplained infertility. Patients with hydrosalpinx,
occlusion in the mid portion of the fallopian tubes and unilateral patent tubes
were excluded from this
study. The patients were screened and appropriately treated for pelvic
infection before they were subjected
to hysterosalpingogram (HSG) and
subsequently hydrotubation. Patients
also had pelvic sonogram pre and post procedure. The essence
of the pre-HTB pelvic sonogram
was to rule out free fluid collection in the pelvis, so as not to
mistake it for successful HTB evidenced by free
fluid collection in the pelvis post-HTB. Laparoscopy and dye hydrotubation
was not done for most patients, due to affordability and availability to laparoscopic evaluation in low resource setting like ours.
Hydrotubation was carried out as an outpatient
procedure during the 6th to the 10th day of a menstrual
cycle. The patients received
short acting intravenous (sodium thiopentone)
anaesthetic agent. The cervix was canullated with a Leech-Wilkinsons
canullae and 50mls loaded syringe attached to the canullae was used to flush the
fallopian tubes. The solution for HTB was made up of normal saline, crystalline
penicillin and hydrocostisone; 50 to
100mls of the solution was used per procedure.
Post procedure, patients were transferred to the recovery
room, where they were given a dose of
injectable non-steroidal anti-inflammatory analgesia.
Following full recovery, they were discharged on
analgesics and prophylactic antibiotics. Repeat HTB was done for some patients in subsequent menstrual
cycle(s) due to marked resistance and
reflux of the solution.
They were
followed up in the gynaecological clinic. Their first visit was the next menstrual cycle, during which ultrasound scan
was performed to confirm ovulatory cycle and were
counselled on timed intercourse.
Those patients with anovulatory cycle were placed
on clomiphene citrate in subsequent
menstral cycles.
The 257 patients that had hydrotubation were divided
into four main groups as follows:
Group A: Patients that
had bilateral cornual
occlusion of the fallopian tubes on HSG.
Group B: Patients that
had bilateral fimbrial
end tubal occlusion on HSG.
Group C: Patients that had
bilateral peri-fimbrial adhesion evidenced by
loculated and restricted
spillage of contrast on HSG.
Group D: Patients with unexplained
infertility and evidence of patent tubes
on HSG.
RESULTS
A total
of 257 patients that had hydrotubation
over a period of 7.5 years
were analysed. Of the
257 patients,
154
(59.5%) had evidence of post – HTB patency of the fallopian tube(s) confirmed
with sonogram and
109
(42.4%) patients out of the latter went ahead to conceive.
Patients profile: The mean age of the patients was
34.5 years with age range of 21 to 44 years. Of the
357
patients, 99 (38.5%) had never delivered before and the highest number of childbirths amongst
the category
of patients
that had
delivered before was three. Seventy
five (29.2%)
patients had no history
of previous abortions. Spontaneous abortion
accounted for 48
(18.7%) patients of cases and
induced abortion 118 (45.9%)patients
while the remaining
six (6.2%) patients had both spontaneous
and induced
abortion. When extrapolated, 134 (52.1%)
(Table 1)
patients had previous history
of induced abortion.
Secondary infertility was the commonest type
of infertility
in 209 (81.3%) patients and 166 (64.6%)
patients had been infertile for
durations of 1 to 5 years. Frequency
of hydrotubation
in this
study showed that 233 (90.7%)
patients had it once, 21
(8.2%) patients twice and three
(1.2%) patients had it thrice.
Indications for hydrotubation and pregnancy
attainment: The
indications for hydrotubation showed
that patients with bilateral perifimbrial adhesions, that is incomplete tubal occlusion (group C) accounted for
123 (47.9%)
of cases. This was followed
by bilateral
fimbrial end blockage (group B) 64 (24.9%)
patients , bilateral
cornual blockage (group A) 41 (16%) patients
and patients with unexplained infertility (group D) accounted for 29 (11.3%)
patients of cases.
Percentage ratio of conception
per indications for hydrotubation,
showed that the highest conception per indication (56.1%) was achieved
in group C and the least (24.3%) in group
A. This reveals
that hydrotubation is
more effective in
treating
patients with incomplete tubal occlusion
(perifimbrial adhesions), followed by unexplained
infertility, perifimbrial occlusion and
cornual blockage (Table
2). In
this study, the
overall conception rate
following hydrotubation
was
42.4%.
Table 1
Profile of patients (n = 257)
Variable No. (%)
Age (years)
20 – 30 89 34.6
31 – 40 134 52.2
41 - 50 34 13.2
Previous delivery
0 99 38.5
1 113 44.0
2 28 10.9
3 17 6.6
Previous abortion
Nil abortion 75 29.2
Spontaneous 48 18.7
Induced 118 45.9
Spontaneous and
induced 16 6.2
Type of
infertility
Primary 48 18.7
Secondary 209 81.3
Duration of
infertility (years)
1 – 5 166 28.0
6 – 10 72 64.6
>11 19 7.4
Frequency
|
of
|
hydrotubation
|
||
Once
|
233
|
90.7
|
||
Twice
|
21
|
8.2
|
||
Thrice
|
3
|
1.2
|
||
Table 2
Group
distribution of patients and post hydrotubation
attainment of conception (n = 257)
Group Attainment of Percentage
ratio of conception conception per group
No.
|
(%)
|
No.
|
(%)
|
(%)
|
|
A
|
41
|
16.0
|
10
|
9.2
|
24.3
|
B
|
64
|
24.9
|
19
|
17.4
|
29.7
|
C
|
123
|
47.9
|
69
|
63.3
|
56.1
|
D
|
29
|
11.3
|
11
|
10.1
|
38.0
|
Overall rate
of conception =
42.4%
Post hydrotubation tubal
patency and attainment of conception:
Tubal
patency was confirmed in 154
patient post – HTB with pelvic sonography and
109 conceptions were subsequently recorded. All patients that conceived in this
study had evidence of tubal patency
post – HTB. This gives
us an overall percentage ratio
of 70.8% conceptions following post
–
HTB evidence of tubal patency.
Except for patients
with unexplained infertility (group D),
the percentage
ratio of conception positively correlated with evidence of tubal patency following hydrotubation (Table 3). This means that patients with post HTB
confirmation of tubal
patency with sonogram have
more chances to conceive compared to patients
with no evidence
of post – HTB
tubal patency.
Post hydrotubation attainment of conception with or without clomiphene citrate: From Table 4, a significant
percentage (63.6%)
of patients
with unexplained infertility (group
D) had to use clomiphene citrate before
they could conceive post hydrotubation.
On the contrary, greater
percentage of patients in group A (80%), group B (68.4%) and group C (79.7%)
did not use clomiphene citrate
before
they achieved conception
post hydrotubation.
Complications of hydrotubation and pregnancy
outcome: There
was no major complication recorded in this
study that warrants hospitalisation. Minor complication/complaints encountered were
pelvic pain in 177 (68.9%) patients
and vaginal bleeding
in
63
(24.5%) patients. These patients were
treated on outpatient basis.
The outcome of the 109
conceptions revealed that 92 (84.4%)
ended up in term pregnancy,
10 (9.2%)
in preterm
delivery and five (4.6%) in
miscarriage. Two (1.8%) conceptions
were ectopic
pregnancies (Table 5).
Table 3
Evidence
of post hydrotubation tubal patency
and conception rate in the groups
Group Post – HTB Attainment of Percentage
ratio
tubal
No.
|
patency
|
(n =
(%)
|
154)
|
conception
No.
|
(n
|
= 109)
(%)
|
of conception
post–HTB patency (%)
|
|
A
|
17
|
11.0
|
10
|
9.2
|
58.8
|
|||
B
|
26
|
16.9
|
19
|
17.2
|
73.1
|
|||
C
|
82
|
53.3
|
69
|
63.3
|
84.1
|
|||
D
|
29
|
18.8
|
11
|
10.1
|
37.9
|
Overall percentage ratio
of conception following
evidence of post – HTB
tubal patency = 70.8%
*HTB=Hydrotubation
Table 4
Group distribution of patients and post-HTB conception with or
without clomiphene citrate
Group
|
Number of conception
|
Conception
Clomiphene
|
with
Citrate
|
Conception
Clomiphene
|
without
Citrate
|
A
|
10
|
8
|
80.0%
|
2
|
20.0%
|
B
|
19
|
13
|
68.4%
|
6
|
31.6%
|
C
|
69
|
55
|
79.7%
|
14
|
20.3%
|
D
|
11
|
4
|
36.4%
|
7
|
63.6%
|
* HTB=Hydrotubation
Table 5
Outcome of pregnancy (n = 109)
series, is that more than half of our patients
had had induced abortion,
most likely
in an
unsafe
environment due to illegality attached
to it in our
Variable No. (%)
Term pregnancy
|
92
|
84.4
|
Preterm
pregnancy
|
10
|
9.2
|
Miscarriage
|
5
|
4.6
|
Eccyesis
|
2
|
1.8
|
DISCUSSION
The assessment of fallopian tubes patency is an integral and pertinent step in the evaluation of female
infertility (3). Also, the treatment
of tubal factor in
infertility management is most difficult and subject to debates (2). In this
study, hysterosalpingogram was used to assess
patency of the fallopian tubes though not as accurate
as laparoscopy
and dye test, it
has been reported to have positive
predictive value between 61.7 to 73% (4,5).
Hydrotubation for therapeutic intervention was employed as a last resort of treatment
for these patients because it is a simple, cheap and minimally invasive procedure
with low risk of complications. The inclusion of antibiotic (crystalline
penicillin) and steroid (hydrocortisone) in the formulation of hydrotubation
solution used in this study, was based
on study by Johnson and Watson (6)
that reported reduced infection and increased pregnancy
with live birth rate when used after reproductive pelvic surgery
to enhance fertility.
Other studies (7,8) have reported fertility
enhancing effect of tubal flushing especially with oil soluble
medium, we used saline
solution
in our study due to the side
effects of oil media
and because our intervention was principally for therapeutic reason. Oil media have been associated with
persistent contrast medium within the pelvis, allergy or anaphylaxis reaction
from intravasation and formation of
lipogranuloma on a long term. It is therefore not surprising that we only recorded
minor complaints with the use of water medium in our study. The patients in our series had pre – HTB screening for pelvic infection and post – HTB antibiotic prophylaxis. We were guided in this direction by the
recommendation of the Royal College of Obstetricians
and Gynaecologists (9) for women going for uterine
instrumentation and the finding
of clinical infection following hysterosalpingogram by Forsey et al (10).
Secondary infertility was predominant in our study. Similarly, Bello
(11) found tubal pathology to be significantly associated with secondary infertility than primary infertility. Also noteworthy
from our
country. Therefore, the contribution of unsafe abortion
in the
aetiopathogenesis of tubal
disease in our infertile women
cannot be overestimated.
We employed post – HTB
sonogram to assess patency of the
fallopian tube(s) following the procedure. This was based on results
of other studies that reported accuracy
rate of diagnostic saline HTB ranging from 82.9 to 87.1%
(5,12). Excluding patients with unexplained infertility, our results show
that the chances
of conception increased with evidence of post
– HTB tubal patency. Furthermore, evidence of post
– HTB tubal
patency is of most
predictive value in terms of conception rate
in patients with perifimbrial
adhesions and least in patients with unexplained infertility. On the whole, the 70.8% conception rate
recorded
in patients with post – HTB evidence of tubal
patency, also help to buttress the effectiveness of hydrotubation in the evaluation of tubal
patency.
In this
study, the
overall conception rate
of
42.4%
recorded
in 257 patients that had therapeutic hydrotubation is encouraging, when we considered
the “hopeless” nature of these cases
in a resource constrained setting like ours. We also found this procedure to
be more effective
in patients
with perifimbrial adhesions
(incomplete tubal occlusion), followed by patients with
unexplained infertility when combined with clomiphene citrate for ovulation
induction. The hypothesis by Sulak et al (13)
that proximal tubal blockage is
caused by plugs of amorphous materials that occlude the
tubal lumen without the presence of any tubal
wall damage, made us
to include bilateral cornual end tubal
blockage as one of the indiccution for hydrotubation. The pregnancy
outcome is also encouraging, with term pregnancies mainly recorded. Outcome
of pregnancies
are comparable to figures reported
with the use of oil-soluble media (14). Though use of oil-soluble contrast is associated with an increase in the odds if
live births but not pregnancy rates
when compared with water soluble
media (14).
The reliability on HSG
for assessing
the fallopian tubes was a major
limitation of this study.
Nonetheless, we found therapeutic HTB beneficial in the management of female
infertility, especially incomplete tubal
occlusion and unexplained
infertility in resource poor settings, where modern technology for management are mostly unavailable
and expensive. However, a randomised
controlled trial with pre – HTB laparoscopic evaluation of the fallopian tubes is recommended, more especially for cases
with
incomplete tubal occlusion and
unexplained infertility.
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