Anatomy

Question 1

Course of ureter

Question 2

What do sertoli cells secrete?

Answer 2

ABP, AMH, estradiol,
and inhibin

Question 3

What fibroid classification do you use?

Answer 3

FIGO
0-8 classification
0- completely intracavitary
7- serosal pedunculated
8- parasitic/cervical

Question 4

Work up prior to UAE?

Answer 4

CBC, CMP (assess renal function for contrast), pap smear/endometrial biopsy, MRI/TVUS

Question 5

Causes of proximal tubal disease

Answer 5

plugs of mucus, amorphous debris, spasm or occlusion (SIN, PID, or endo)

Question 6

What proportion of tubal disease is proximal?

Answer 6

10-25%

Question 7

How do you perform proximal tubal cannulization?

Answer 7

Make sure no distal disease and must not suspect SIN
* Fluoroscopic guided coaxial catheter system
* Hysteroscopy with laparoscopic confirmation
o 5.5F cannula with obturator introduced through operating channel
o Obturator removed
o 3F catheter with flexible guide wire is introduced through the outer catheter and directed to uterotubal ostium
o When the corneal portion of the tube is entered or resistance is encountered, selective salpingogram performed
o Methylene blue or indigo carmine is injected
o Simultaneous laparoscopy confirms patency
o If obstruction not overcome then true occlusion is assumed
 93% SIN, chronic salpingitis or obliterative fibrosis
 IVF better to resection and microsurgical anastomosis

Question 8

Success rates after tubal cannulization

Answer 8

Bilateral: relieved in 85% of tubes, 50% conceive, 33% reocclude

Ongoing pregnancy rates are higher with HSC > Fluoroscopy

Question 9

Unilateral proximal tubal obstruction

Answer 9

Optimal treatment is not determined

Similar pregnancy rates with COH/IUI with untreated unilateral obstruction v. UI

Question 10

Hydrosalpinx

Answer 10

complete distal obstruction

Question 11

Fimbrial phimosis

Answer 11

distal adhesions with narrow phimotic opening

Question 12

Prognostic factors for distal disease

Answer 12

“Rock Criteria”
 Size of dilation (<3 cm)
 Fimbrial architecture and wall thickness (thin pliable walls versus thick and fibrotic)
 Peritubal adhesions (filmy > dense): may impair ability of intrinsically normal tubes from capturing oocyte by mechanically interfering with the anatomy
 Rugal pattern of endosalpinx (preserved mucosal folds > sparse/absent mucosal folds)

Question 13

Success rate after distal repair with good versus poor prognosis (eg. IUP rate after neosalpingostomy) and ectopic rate

Answer 13

70% versus 0-20%
5% versus 0-20%

Question 14

Tubal anatomy

Answer 14

o Internal mucosa (endosalpinx)
o Intermediate muscular layer (myosalpinx)
o Outer serosa – an epithelial layer continuous and histologically indistinguishable from the peritoneum of the broad ligament and uterus, the upper margin of which is the mesosalpinx.

Question 15

Varicocele

Answer 15

dilation of the pampiniform plexus of spermatic veins in the scrotum (L&raquo_space; R because of lower blood flow in left spermatic vein)

Symptoms including: dull, aching pain worse when standing and relieved with laying flat. Possible atrophy of the left testicle secondary to loss of germ cell mass by induction of apoptosis and slightly increased scrotal temperature
Recommend repair with large symptomatic varicoceles or in those infertile men with abnormal semen analyses and large grade 3 varicoceles
NNT of varicoceles for additional pregnancy was 17 (low quality of evidence and not live births)
Would not repair if there is severe oligo or azoospermia, high FSH, and small testes because they will have severe germ cell damage and a lower likelihood of fertility after repair
No evidence that repair improves outcomes in NOA
Treatment: surgical ligation versus percutaneous venous embolization, sclerotherapy
Delay treatment x 6 months

Question 16

Pharmacokinetics of vasopressin

Answer 16

The half-life of intramuscular vasopressin is 10 to 20 minutes and the duration of action is two to eight hours.