**4.1. Subtle tubal endometriosis**

the other 215 were infertile one who have undergone diagnostic laparoscopy. Fertile Group (Group 1) consisted of women whom have become spontaneously pregnant without any kind of infertility management. These are planned to undergo C/S with different indications. Infertile group (Group 2) consisted of women diagnosed as unexplained infertility and planned to undergo diagnostic laparoscopy according to ASRM 2006 guidelines. The frequen‐ cy, number, and the bilaterality of the MH were evaluated during the C/S in fertile group and diagnostic laparoscopy in infertile group. SPSS was used for statistical analyses. The Morgagni hydatids (MH) frequency was higher in Group 2 than Group 1 (P < 0.05). The bilaterality of MHs was significantly higher in Group 2 than Group 1 (P < 0.05). The number of the MHs was significantly higher in Group 2 than Group 1 (P < 0.05). They concluded that these findings suggest a possible effect of MH on fertility. The theory of MH disturbing tubal motility with

Another non-randomized study [21] was conducted on two hundred and thirteen patients with unexplained infertility and hydatid of Morgagni diagnosed at laparoscopy were includ‐ ed. The laterality (bilateral vs unilateral), location (fimbrial vs juxta-fimbrial), number (single vs multiple) and diameter of the hydatids of Morgagni were recorded. Patients were allocated to a study group (n=127) who underwent laparoscopic excision of hydatid of Morgagni and a control group (n=86) who underwent no intervention. Patients were followed for six months without any infertility or hormonal treatment to detect spontaneous pregnancy. Patients missed during the follow-up or who received infertility treatment was excluded. Statistical analysis was done using Chi-square test and Student's t-test. To find the most important character of hydatid of Morgagni which impedes pregnancy, logistic regression analysis of the dependent variable (no pregnancy) and independent variables (different characters ofhydatid of Morgagni) was carried out in the control group. Hydatid of Morgagni was detected in 52.1% of patients with unexplained infertility compared to 25.6% of those with explained infertility (p<0.001). The pregnancy rate was higher in the study group than the control group (58.7% vs 20.6%, p<0.001). The pregnancy rate was significantly higher in the study group than the control group if the hydatid cystwas bilateral (85.7% vs 5.3%, p<0.001), fimbrial (85.6% and 9.1%, p<0.001), single (57.6% and 30.3%, p<0.001) or 1-2 cm in diameter (58.1% and 25.5%, p<0.001). Logistic analysis showed that the bilaterality and fimbrial location of thehydatid of Morgagni were the most significant characteristics impeding pregnancy (odds ratio=7.27 and 3.67 respectively). They concluded that Hydatid of Morgagni is a possible underestimated cause of unexplained infertility. Laparoscopic removal of hydatid of Morgagni in patients with unexplained infertility was followed with a high spontaneous pregnancy rate. This is partic‐

Sometimes during laparoscopy you may notice that the tubes are congenitally nearer to the lateral pelvic wall or even adherent to it. By this way, the tubes are expected to be out of function due to the wide distance between the fimbria and the pouch of Douglas. It is commonly seen

respect to the pick-up and transport of ovum appears logical in this aspect.

ularly obvious with bilateral and fimbrial hydatid of Morgagni.

**4. Undescended tubes**

6 Contemporary Gynecologic Practice

with some Mullerian duct anomalies.

These lesions are only seen by laparoscopy which may include: tubal sacculations. Diverticulae [22], convolutions, phimosis, fimbrial agglutination or other subtle lesions (red, white or vesicular lesions).

## **4.2. Typical tubal endometriosis**

Black or blue lesions could be seen on the surface of the fallopian tube. It may affect tubal motility, may cause tubal constriction or even occlusion. Generally, there is low fecundibility rate in such cases. Laparoscopic coagulation would lead to fibrosis and subsequent constric‐ tion. No clear publication on this point found in literature so far.

#### **4.3. Role of tubal functions in UI**

To achieve pregnancy, in addition to patency, two paradoxical types of peristaltic movements occur in the tubes. Muscular contractions of the distal part of tube and the cilia of its inner lining move the egg toward the interstitial segment of the tube which acts like a muscle sphincter and prevents the egg from being released into the uterus until it is ready for implantation. On the other hand, the proximal part of the tube expresses peristalsis to attract sperms to the site of implantation [23,24]. To date, tubal perstalsis and antiperstalsis are not well understood. Some invitro 3D studies were recently published but did not fully explain these complicated tubal phenomina [25]. Office hysteroscopy (OH) is a modern diagnostic tool with expanding popularity all over the world [26]. Adding vaginoscopic approach to office hysteroscopy is an extra simplification of the procedure with elimination of pain during examination [27].

#### **4.4. New horizons for tubal patency detection**

Since a long time, HSG is the classic tubal patency test. Lipiodol HSG has been shown to increase pregnancy rate which may be attributed to tubal patency or endometrial stimulation with possible enhanced receptivity of the endometrium to embryo implantation even in women with history of endometriosis [28,29]. Nevertheless, due to its well known drawbacks and complications (mainly pain), many women are afraid of doing HSG. Trials to improve its performance were described as elimination of traction on the cervix by tenaculum or usage of a pediatric Foley's catheter instead of the standard metal cannula [30] but still low patient acceptability of this invasive procedure is encountered. Saline infusion sonography (SIS) is an attractive alternative to HSG as it is a methodologically simple, cost effective, and time efficient comprehensive evaluation [31]. In 1999, we described a simplified technique of SIS utilizing a simple Nelaton catheter and 0.09% saline [32]. Despite its wide spread usage in many clinics, the main drawbacks of SIS are failure to localize the side of tubal patency and failure to properly visualize the tubes. Trials to improve results of SIS included the use of gel foam instead of saline [33], use of B-flow ultraspnography [34], 3D ultrasonography [35] or even sophisticated automated ultrasonography [36]. In the era of evidence-based medicine, Rubin pertubation tubal patency test is no longer implemented in modern practice [37] because it is very subjective and non-specific.

Definitely, hysteroscopy is the star of gynecologic endoscopy in recent years due to extended indications in modern practice. This position can be attributed to many factors including more technical refinement of instrumentation with better illumination and magnification, increased IVF/ICSI cycles practice and failures, increased interest in studying uterine factor of recurrent pregnancy loss (RPL), office usage with smaller caliber endoscopes omitting hospital admis‐ sion, and increased product promotion. Most important, vaginoscopic approach with elimi‐ nation of speculum insertion and traction on the cervix with a tenaculum had made hysteroscopy as simple as vaginal examination with high patient acceptability as shown in this study. OH saves money, omits stress for the patient, and improves health care services for the community at large. We believe that this attractive tool is not designed just to explore the endometrial cavity. The hysteroscopist should systematically examine the vagina, ectocervix, endocervical canal, endometrial cavity as well as the tubal ostea. Many tubal causes of infertility can be easily detected from the endoometrial cavity like polyps, fine adhesions or occlusion. These advantages are offered to the patient with minimal costs unlike other sophisticated and expensive approaches. For instance, MRI guided HSG was proved to be an effective patency test [38] but the costs and complicity of the technique are against the office principles.

Interest in hysteroscopic testing of tubal patency testing is not new. Hysteroscopic perturbation utilizing a fine catheter inserted into the tubal ostea followed by injection of methylene blue dye had been described [39]. If no reflux was seen, this means that the ostium was patent.

Unfortunately, they changed a simple office procedure into a complicated operation. They used a 5.5 mm operative bridge that would definitely increase pain. They used fine catheters and evaluated patency in a very subjective way without laparoscopic or even sonographic confirmation. Non-reflux of the dye doesn't necessarily mean patency. Intravasation or false passage due to unintentional perforation could be the cause. In short, their approach is similar to hysteroscopic tubal cannulation but in a blind manner without laparoscopic or sonographic monitoring.

On the other hand, hysteroscopic bubble suction test addressed in this study is a unique additional rapid costless step which could be done in every OH. What's new is to direct the attention of the hysteroscopist to its value. Not only did this study prove tubal patency, but it also clearly demonstrated an important tubal function which is tubal suction of sperms to the ampulla for fertilization which is mostly attributed to peristalsis of the proximal tube. This comes in accordance with recent interest in studying tubal function rather than just patency [40]. It should be mentioned that we didn't inject air into the tubal ostea but just observed tubal suction of the bubbles by the proximal part of the tube. Performing the procedure postmenst‐ rual (with less vascular completely healed endometrium) together with the generation of minimal bubbles (that could pass through tubal ostia) and when needed slow injection of less than 2 ml of air (inside the bulb of the infusion device and not the tube) almost eliminate any risk of air embolism [41].

Two important issues that would compromise this test should be highlighted. The effect of increased intrauterine pressure was not responsible for positive bubble suction as we observed bubble suction after a while following uterine distension in a periodic manner despite keeping the same intrauterine pressure all the time and no suction occurred in some cases despite increased pressure up to 200 mmHg. The second issue is the possible effect of negative intrauterine pressure which is again excluded by observing bubble suction after a while of uterine cavity distension.

In this study, tubal block (even after increasing pressure into 200 mmHg) was suspected in 11.5% of women examined by OH (out of 76 women). Tubal block in the same set of women was found in 7.2% when examined through laparoscopy. There was some overestimation towards OH that may be attributed to subjective errors or tubal spasm. OH reports thick adhesions related to the proximal tubal end in 6 women (3.9%). Regarding other tubal abnormalities, normal laparoscopy was found to yield no abnormalities in HSG in 97% of cases while abnormal laparoscopy is found to meet with only 54.5% of abnormal HSG.

When OH is combined with HSG, diagnostic indices for tubal block were lowered rather than improved. This can be explained by that both OH and HSG diagnosed all the cases of tubal block with 100% sensitivity, adding both methods to each other didn't add to the strength of the detection. Contrarily, the false positive rates of the 2 methods add to each other and slightly decrease the diagnostic accuracy. The degree of agreement between OH and laparoscopy in evaluation of tubal patency was also quite interesting. Small sample size is a clear drawback of this study. From this study, it is concluded that hysteroscopic babble suction test is a costless, feasible and tolerable provisional test for tubal patency that should be attempted in every OH done for infertile women. Observation of movement of the peritubal bulge during bubble suction suggesting tubal peristalsis is interesting but requires more confirmatory studies.
