Phalloscopy

The condition of the fallopian tube epithelium is important for determining their functionality. Phalloscopy - direct visual examination of the intratubal epithelium allows assessing its condition, identifying possible pathology, and also assessing the likelihood of pregnancy after microsurgical operation during in vitro fertilization (GIFT, ZIFT).

An attempt at direct visual inspection of the lumen of the fallopian tube was made in 1970 by Mohri et al., who used a 2.4 mm diameter fiber optic endoscope. However, due to the technical imperfection of the endoscope, the attempt was unsuccessful.

Improvements in fiber optics, the creation of powerful light sources and video monitors contributed to the development of endoscopy. Kerin et al. in 1990 invented the technique and described the method of transcervical direct visual examination of the lumen of the fallopian tube - falloposcopy.

A falloposcope is a microendoscope with a diameter of 0.5 mm. Falloposcopy should be distinguished from salpingoscopy, in which a rigid endoscope is inserted into the fallopian tube through the fimbrial section (usually during laparoscopy).

At the first stages, the falloposcopy technique consisted of the following: first, the fallopian tube was hysteroscopically cannulated with a flexible guidewire with an external diameter of 0.3-0.8 mm, under the control of a laparoscope. A Teflon cannula with an external diameter of 1.3 mm was inserted along this guidewire from the outside. After that, the flexible guidewire was removed, and a falloposcope was inserted through the Teflon guidewire. A flushing system using a saline solution facilitated the movement of the endoscope inside the cannula and improved visibility, constantly flushing and deflecting the epithelium from the endoscope lens.

Subsequently, Bauer et al. in 1992 invented a system for falloposcopy consisting of a catheter with a polyethylene balloon, which was based on the principle of hydraulic pressure of the deployable balloon for atraumatic cannulation of the tube and feeding the endoscope into the cavity of the tube (The Linear Eversion Catheter - LEC). This system, manufactured by Imagine Medical Inc. (Irvine, CA, USA), can be used without a hysteroscopic guide. The catheter is made of plastic, its base diameter is 2.8 mm, inside it is a steel guide with a diameter of 0.8 mm. A soft, non-stretchable polyethylene balloon is attached to the catheters, serving as an elastic gasket between the endoscope and the wall of the tube, protecting both the endoscope itself and the wall of the tube from damage. A falloposcope is inserted into this system. The installation of fluid increases the pressure inside the balloon, and when the steel inner conductor moves, the balloon rotates away from the tip of the catheter so that the double layer of the balloon and the endoscope are inserted into the lumen of the tube. The balloon lifts (stretches) the tissue in front of the endoscope, facilitating the examination of the lumen of the tube and protecting it from damage. One of the advantages of LEC technology in falloposcopy is the possibility of its implementation without anesthesia in an outpatient setting.

Kerin et al. (1989, 1992) described the state of the fallopian tube cavity both in normal conditions and in pathology based on falloposcopy data: inflammatory diseases of the fallopian tubes, tubal pregnancy, intratubal polyps and adhesions, zones of nonspecific devascularization, atrophy and fibrosis.

Normal condition. The proximal part of the tube looks like a tunnel with a smooth, straight wall. The isthmic part of the fallopian tube has 4-5 longitudinal folds of epithelium. Usually, the lumen of these two segments is completely visible. Then the distal part of the tube becomes wider, its lumen cannot be fully examined during falloposcopy. There are also longitudinal folds of epithelium here, moving under the flow of the injected fluid.

Pathology. Significant narrowing of the lumen of the proximal section of the tube is revealed by stenosis; during falloposcopy it can be eliminated using balloon tuboplasty. Complete closure of the proximal section looks like a blindly ending tunnel; when it is significantly damaged, uneven outlines of the lumen of the tube with well-defined bridges are visualized. With occlusion of the distal section of the fallopian tube (phimosis, slight hydrosalpinx), the epithelium still retains folds, but their movements are less pronounced. With significant stretching of the tube, the folds disappear, the relief of the wall is almost smoothed out, the lumen of the tube looks like a dark cavity. The worst prognostic option is intratubal synechia (adhesions).

During visual examination of the lumen of the fallopian tube, under fluid pressure, mucous plugs may be washed out of the proximal section and delicate adhesions may be destroyed. Occlusion of the proximal section of the fallopian tube may be caused by several reasons: spasm, mucous plugs, accumulation of mucous membrane fragments, adhesions, stenosis, true fibrosis. Transcervical balloon tuboplasty, tubal catheterization under X-ray control, hysteroscopic catheterization of the fallopian tubes and lavage under pressure used in this case do not allow identifying the cause. Only falloposcopy can determine the cause of occlusion of the proximal section of the fallopian tube and decide on the method of its elimination.

In 1992, Kerin et al. proposed a classification of intratubal pathology using a scoring system that takes into account changes in the folds of the fallopian tube epithelium, the nature of vascularization, the size of the lumen, the presence and nature of adhesions and zones of nonspecific devascularization. Depending on the degree of damage to the proximal part of the fallopian tubes, the probability of pregnancy (in percent) and the tactics of patient management are determined.

Similar classifications have been proposed to predict the results of treatment of pathology of the distal part of the fallopian tube.

Hysterosalpingography remains the main screening method for infertility, allowing to suspect pathology of the fallopian tubes. But only falloposcopy can accurately determine the nature of the changes. But even with normal results of hysterosalpingography (passable fallopian tubes), falloposcopy can diagnose intratubal pathology in women with infertility of unclear genesis.

There are also cases described where hysterosalpingography revealed occlusion of the proximal part of the fallopian tubes, while falloposcopy showed them to be passable. Discrepancies between hysterosalpingography and falloposcopy data were found in 40%.

Risquez et al. in 1992 demonstrated the possibility of diagnosing ectopic pregnancy by transcervical falloposcopy and proposed treatment by injecting methotrexate directly into the ovum under visual control.

Thus, falloposcopy complements the generally accepted methods of infertility examination, such as hysterosalpingography, laparoscopy, salpingoscopy. This endoscopic method allows to examine and evaluate the lumen and epithelium inside the fallopian tubes, as well as to choose a method of further treatment (tuboplasty, laparoscopic surgery on the fallopian tubes or methods of in vitro fertilization).

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