Tubal Reversal Blog ‘HSG’

This is the fifth article of a series dedicated to women considering alternatives for pregnancy and tubal ligation reversal after the age of 40.  The previous article provided an overview of the benefits of tubal ligation reversal at Chapel Hill Tubal Reversal Center for women in their forties. This article focuses on the surgical and early pregnancy risks for older women having their ‘tubes untied’.

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In the Fall of 2008, I was preparing to meet with a patient who was traveling to Chapel Hill Tubal Reversal Center from Fort Campbell, Kentucky (KY) for a tubal ligation reversal. The patient’s name was Catrina. She is 33 years old and newly married to, Chris, an Army Staff Sergeant.

Catrina sent us an operative report from a diagnostic laparoscopy (camera surgery), that discovered she had a tubal ligation. During our interview, I asked her why her general gynecologist had done this surgery. I was surprised by the story she had to tell.

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The tubal reversal doctors at  Chapel Hill Tubal Reversal Center are specialists in fallopian tube repair.  Although most of patients come to Chapel Hill Tubal Reversal Center for tubal ligation reversal, others come for fallopian tube repair after a tubal infection or pelvic inflammatory disease (PID), ectopic pregnancy, or previous surgery involving the fallopian tubes.

Fallopian Tube Anatomy

The fallopian tube begins within the muscular wall of the uterus (interstitial segment), leads away from the uterine wall (isthmic segment), becomes wider (ampulla), extends to the widest area near the end of the tube (infundibulum), and ends next to the ovary (fimbrial segment).

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Patients often ask when they should have a hysterosalpingogram (HSG) to see if their fallopian tubes are open after tubal reversal surgery.

When to Have an HSG

Wait for at least 6 to 12 months after a tubal reversal procedure for this test of tubal patency. An HSG carries a risk of infection and often does not give conclusive results. It is best to give yourself a chance to become pregnant rather than rushing to have an HSG. Most patients conceive within this time frame and will avoid the need for an unnecessary and possibly misleading or harmful procedure.

Preparing for an HSG

To avoid unnecessary risks, an HSG should be performed only after menstruation is over and before ovulation occurs. Having an HSG after the time of ovulation may interfere with a pregnancy - before a pregnancy test can detect that conception has occurred. To minimize the risk of infection, use a betadine vaginal douche the evening before and the morning of the scheduled procedure and ask your doctor for a prophylactic antibiotic prescription. 600 mg of ibuprofen taken one hour before the HSG will minimize its discomfort.

What to Look For in an HSG

You can ask to watch the results on the fluoroscopy screen while the dye is being injected into the uterus.

At first, the dye will fill the uterine cavity. It is essential that the dye actually enter the fallopian tubes up to the point where the anastomosis was performed. Often, this does not occur due to spasm of the sphincter between the uterus and tubes (shown by the arrows) or from mucus or calcium deposits in the proximal tubal segments.

If the dye passes through the anastomosis sites, the fallopian tubes are open. Most radiologists do not consider the x-ray to show tubal patency (openness) unless dye spills into the abdominal cavity. When this happens, the diagnosis of tubal patency is conclusive.

We often see x-rays where dye has passed through the tubal  anastomosis site, but has not yet spilled into the abdominal cavity. This is due to an insufficient amount of dye being injected into the tubes. The radiologist may mistakenly believe the tube is blocked when in reality it is open.

Send Your X-Rays To Me

In order to be certain about whether an HSG demonstrates tubal patency, tubal occlusion, or is inconclusive, please instruct the radiologist to send the x-ray films to me to interpret. Having documented the anatomy and measurements of the fallopian tube segments during tubal reversal surgery, I can compare the x-ray findings with each patient’s operative report. This allows me to give the most accurate interpretation of HSG results.

Dr. Berger’s Comment

Hysterosalpingography is a widely available procedure to examine tubal anatomy. Unfortunately, it is often performed or interpreted inaccurately. An HSG also has risks as well as discomfort and cost. It is best to wait for at least 6-12 months after a tubal reversal procedure to have an HSG. Most patients will become pregnant after tubal reversal within a year and can avoid the problems associated with HSGs. Preparing properly for an HSG and sending the x-ray images to me will minimize the risks and errors associated with a hysterosalpingogram.

Tubal Ligation by Fimbriectomy

Fimbriectomy is an infrequent type of tubal ligation in the United States. This female sterilization method is performed by removing the fimbrial end of the fallopian tube. At the fimbrial end of the tube, the inner tubal lining faces outward towards the ovary. The tubal lining is rich in cilia that beat in coordinated waves to pull the egg into the tubal opening.

Many doctors think that tubal reversal cannot be successful following a fimbriectomy because of the loss of the egg-capturing fimbria. This is a mistaken notion. Cilia are abundant in the ampullary segment of the fallopian tube. The inner lining of the remaining ampullary tubal segment can be folded outward after opening the tube and can function as a new fimbrial end. The tubal reversal procedure for fimbriectomy reversal is called ampullary salpingostomy.

Fimbriectomy Reversal Pregnancy Rates

Chapel Hill Tubal Reversal Center publishes statistics updated annually regarding pregnancy rates and pregnancy outcomes for all of the women who have had tubal reversal procedures performed by Dr. Berger. The data for women who had tubal ligation procedures by fimbriectomy are from our Tubal Reversal Pregnancy Study Report 2007.

The overall pregnancy rate after fimbriectomy tubal reversal is 56% for patients at Chapel Hill Tubal Reversal Center. The following table shows the numbers and pregnancy rates according to womens’ ages at the time of their tubal reversal procedure.

Pregnancy Rates After Fimbriectomy Reversal

Recommendations for Fimbriectomy Reversal

The success of fimbriectomy reversal depends upon having an adequate length of ampullary segment of the fallopian tube. The length of the remaining ampullary tubal segment can be determined from a hysterosalpingogram (HSG) or from diagnostic laparoscopy.

I recommend having an HSG or choosing the screening laparoscopy option when tubal ligation has been performed by fimbriectomy. An HSG can be ordered by the patient’s local doctor and the x-ray films sent to me for examination prior to scheduling tubal reversal surgery. Alternatively, patients can omit having an HSG and schedule their reversal surgery to start with screening laparoscopy. This will show if ampullary salpingostomy will be effective. If so, the tubal reversal procedure will be performed at the same time while the patient is under anesthesia.