Hydrotuhation

Separate Examination of the Patency of Each Tube

with Isotonic Saline Solution

Hideo Yagi, M.D.

.
HYDROTUBATION is a tenn which I introduced in 1929 to describe a new
technic for diagnosing patency of the fallopian tubes by means of isotonic
saline solution instead of air or carbon dioxide. 2 The idea came from the
experience of performing hysterosalpingographies in the diagnosis of steril-
ity. With hysterosalpingography, I was struck with the following observa-
tion: If more than 10 cc. of iodized oil can be injected easily under low
manometric pressure, it is almost a positive indication that one or both of
the tubes are patent, as may be verified by roentgenography. On the other
hand, if there is tubal closure or stenosis, resistance is encountered, and
when added pressure is applied, oil will leak from the uterus into the vagina.
This led me to conclude that tubal patency could be tested with the use of
a nonradiopaque medium such as isotonic salt solution, without the aid of
x-ray pictures. Isotonic salt solution, at body temperature, is an ideal non-
irritating medium. Its use is free from the potentially dangerous after effects,
notably embolism, that are sometimes associated with the use of radiopaque
oils.

METHOD
In applying the test, salt solution at a pressure of 2 m. is used instead of
air or carbon dioxide. By noting the quantity and speed of flow, we can

From the Department of Obstetrics and Gynecology, Okayama University Medical School,
Okayama, Japan.
550
 Vol. 6. No.6. 1955 HYDROTUBATION 551

estimate the degree of tubal patency. The resulting data can be plotted as a
hysterosalpingogram and may be kept as a permanent record.
My original paper describing this method was published in 19303 and
simplified in 1936. 8 The English translation4 brought forth immediate re-
sponse in other countries 5 • 6. 7 as exemplified by Slamova's citation of my
technic in 1937. In 1944, I worked out a new technic for the separate hydro-
tubation of the individual tubes. 9 • 10 The principle of the new method lies in

Fig. 1. The principle of separate hydrotubation lies in blocking one of the tubes with
the tip of the cannula while injecting the salt solution into the other.
-.,
blocking one of the fallopian tubes at its uterine cornu with the tip of the
special cannula, which resembles the end of a uterine sound, and then
injecting the salt solution into the other tube through openings below the
tip of the cannula (Fig. 1).
The cannula is 22 cm. long. The tip, measuring 7 cm., is made of malle-
able silver and resembles the common uterine sound. Two openings are
situated 1 and 2 cm. respectively from the tip, on the side of greater curva-
ture of the cannula. An adjustable rubber cone or olive surrounds the
cannula. Mter measuring the uterine depth-the distance between the ex-
ternal cervical os and the tubal ostium-the cone is properly set with a metal
screw and applied closely against the cervix with a M useux forceps which
552 VAGI Fertility & Sterility

is attached to the cannula. After testing one tube the cannula is partially
withdrawn, rotated through an arc of 180 degrees, and then directed against
the other side. By this method, separate hysterosalpingograms can be
prepared for each tube.
The test is performed with patients having either primary or secondary
sterility. Prior to the test, pelvic examination is performed to exclude uterine

Fig. 2. Apparatus for hydrotubation. Note openings near end of cannula tip.

bleeding and acute and subacute infectious conditions which are contra-
indications for the test. Additional tests should include bacteriologic exam-
ination of cervical secretions and the usual tubal insufflation and x-ray
salpingography.
Hydrotubation may be performed at any time except during the pre-
menstrual and menstrual periods. However, the optimal period is between
one and two weeks following the cessation of menstruation.
 Vol. 6, No.6, 1955 HYDROTUBATION 553

Equipment
The special cannula devised for the purpose of separate hydrotubation is
used. A graduated glass cylinder of 50 cc. capacity is employed as a reser-
voir for the sterile salt solution and is connected with the cannula with a
sterilized narrow rubber or nylon tube. The upper surface of the salt solu-
tion is initially raised to a level of 2 m. above the uterus. This gives a

'"1

Fig. 3. Schematic representation of apparatus in use.

pressure approximately equal to that of 150 mm. of mercury. The solution

is permitted to flow by gravity (Figs. 2 and 3).

TECHNIC
The patient is placed in the lithotomy position. By pelvic examination,
the position and approximate size of the uterus is determined. A graduated
uterine sound is introduced to ascertain the distance between the cervical
os and the uterine cornu. The upper, malleable portion of the cannula is
 554 YAGI Fertility & Sterility

bent to fit the internal uterine contour. The cannula is then gently inserted
into the uterine cavity, the tip being pressed so as to occlude the right tube
at the uterine cornu. The rubber cone is moved into position to close, by
pressure, the cervical os, and is held by a screw. A Museux forceps is
applied to the cervix and is then clamped to the cannula.
While the operator watches for leakage of solution at the cervix, an
assistant regulates the height of the cylinder and notes the saline How,
minute by minute. If there is no leakage from the os and the amount of
solution escaping is more than lO cc., the tube tested is presumed to be
patent. In such case, the hysterosalpingogram reveals an ascending curve.

15

10

O~-----+------+2------~------+-----~----
1 .3 4 5 min.
Fig. 4. Flow of the salt solution is plotted against time. Note that the curves are of
the ascending type denoting that both tubes are open.

The cannula is now freed and turned 180 degrees so that its tip fits the ...'
opposite uterine cornu and the second test is carried out. A second curve
is then made for the right tube (Fig. 4).

ANALYSIS
The curve varies according to the tonicity and patency of the tubes. If
tonicity is weak or low, the curve may be very steep (Fig. 5). If, on the
other hand the tonicity is strong, a slowly ascending curve is obtained.
Thus, when the tube is patent, the hysterosalpingogram is always of the
ascending type. When tubal occlusion exists, the curve becomes horizontal
and runs parallel to the base line. When the curve is horizontal and very
Vol. 6, No.6, 1955 HYDROTUBATION 555

close to the base line, this indicates that the inflow of solution is very small
and that the occlusion is at the cornu itseH (Fig. 6). An ascending curve
which is followed by a horizontal curve extending further from the base
,
I
I

,,
I

I
cc
20 ,{I
,
I
15 ,~
I
I
P
10 .. p
,I
5 /1
'-d

0 5 min.
2 4
Fig.5. The steeply ascending curves denote low tonicity of the patent tubes.

ec
20

15

10

5
---...-
~---­ ---0--- -----0-- - -----0----
00---

0 5 min.
1 2
Fig. 6. Hysterosalpingograms of two tubes occluded at or near the uterine cornua.
Note flat or horizontal character of the curves denoting retention of the fluid.

line indicates occlusion nearer the abdominal end of the tube (Fig. 7).
When the fall of the column of water stops, as it may in some cases, we
''hold'' the pressure for a maximum of five minutes to rule out obstruction
due to temporary spasm in the uterine cornu or in the tube.
By this method, then, it is possible to diagnose the side and site of occlu-
 556 VAGI Fertility & Sterility

sion without recourse to x-ray pictures. The principle may also be applied
to the use of air or gas. The equipment is cheap and can be assembled by
practitioners. The test can be repeated, as necessary, without danger of
irritation of the pelvic peritoneum. Therapeutically, this procedure may be
employed to open some occluded tubes so that pregnancy may ensue.

cc
20

15

10

..,.4---
..cr.-----Q- - - - - - - - - - - - - -
5 J:>-------
o 1 2 4 5tnin.
Fig. 7. The initially ascending character of the curve shows that fluid is entering
the tubes. The curves on becoming "horizontal" indicate that the tubes on filling
take on no more fluid and are therefore presumed to be closed at their distal portions.

During the past 20 years, I have performed 3000 hydrotubations with

accurate diagnoses in 95 per cent of the cases as determined by follow-up
with laparotomy or by hysterosalpingograms.

REFERENCES
1. Sd.MOVA, B. Hydrotubation statt Pertubation. Zentralbl. f. Gyniik. 61 :938,
1937.
2. YAGI, H. Hydrotubation. Jap.]. Obst. & Gynec. 12, No.6, 1929.
3. YAGI, H. Hydrotubation. Jap. J. Obst. & Gynec. 13, No.3, 1930.
4. YAGI, H. Hydrotubation. Jap. ]. Obst. & Gynec. 13, No.4, 1930.
5. YAGI, H. Hydrotubation. Ber. Gyniik. 19, S. 214, 1931.
6. YAGI, H. Hydrotubation. Jahreok. f. Arztl. Fortbild., July, 1931.
7. YAGI, H. L'hydrotubation. Gynec. etobst. 23, No.5, 1931.
8. YAGI, H. The theory and application of hydrotubation. Diagnosis & Treatment
23, No.3, 1936.
9. YAGI, H. Jap. Kink Gyn. ]. 27, No.3, 1944.
10. YAGI, H. On hydrotubation. Clinical Medical Report 2, No.2, 1948.