The Fertility Guide: Getting Started with Treatment

There are basically two techniques available for evaluating the fallopian tubes: a hysterosalpingogram and a laparoscopy.

Hysterosalpingogram (HSG)

A hysterosalpingogram (HSG) is an X-ray procedure that does not require any anesthesia and can be performed in just a few minutes. It is performed at the time in the cycle after the period stops but before ovulation occurs. A regular speculum exam is performed in the X-ray department, and a small instrument is attached to the cervix. A special X-ray dye is then injected through the cervix, up into the uterus, and out into the fallopian tubes. This procedure allows visualization of the uterine cavity and of the fallopian tubes. If the tubes are open, the dye can be seen spilling into the abdominal cavity.

The advantages of the HSG include the fact that it is a nonsurgical procedure, does not require anesthesia, and is relatively inexpensive. A further advantage is the fact that if oil-soluble dye is used, pregnancy rates after a HSG are actually increased, thus rendering it therapeutic as well as diagnostic. (HSG can be performed using water-soluble contrast material or oil-soluble contrast material; postprocedure enhancement of conception rates has been demonstrated only following the use of oil-soluble contrast material.) The biggest disadvantage of the HSG is the inability to visualize other pelvic structures. Only the interior of the tubes and uterus can be seen, and thus adhesions, endometriosis, or other problems lying outside the tubes and uterine cavity may go undetected.

Laparoscopy

Laparoscopy is an outpatient surgical procedure performed under general anesthesia, although microinstruments are now available that allow this procedure to also be performed in the office under local anesthesia. A small telescopelike instrument is inserted into the abdominal cavity just beneath the umbilicus (navel). This allows visualization of the abdominal contents in their entirety, including the ovaries, tubes, uterus and the surrounding structures. Additional small incisions may be placed in the abdominal wall to allow insertion of specially designed instruments, including lasers.

Laparoscopy does not need to be a purely diagnostic procedure. Many physicians performing laparoscopic surgery have the ability to correct virtually any abnormality that they may encounter. Laparoscopy should probably be done as a potentially operative and therapeutic procedure each and every time it is done. Find out if your physician has the ability to treat endometriosis, remove adhesions, correct tubal blockage, and remove ovarian cysts through the laparoscope. Some surgeons prefer to do laparoscopy as a purely diagnostic procedure and then do major surgery to correct abnormalities they may encounter. While both approaches are equally effective, the latter has the disadvantage of requiring two surgeries and being significantly more expensive.

The biggest advantage of laparoscopy over the HSG is its potential for surgical correction of abnormalities. It does also allow direct visualization of the abdominal contents. The disadvantages of laparoscopy include the fact that it is invasive, requires general anesthesia, and is vastly more expensive than an HSG.

The decision as to which of these procedures should be used to evaluate the tubes must again be based on the individual circumstances. The findings on a pelvic exam must be considered. If there is significant, palpable endometriosis, or especially if ovarian endometriosis is noted on ultrasound, then laparoscopy may be indicated. Similarly, if the chlamydia titer is high, suggesting prior infection; if there is a history of prior infection; or if there has been previous pelvic surgery, then laparoscopy must be considered. Note that these are all specific indications for proceeding with a laparoscopy. There should be a very specific reason for choosing laparoscopy over HSG. If there is not some specific indication for doing a laparoscopy, then the HSG is the procedure of choice for tubal evaluation.