Performing the Parryscope technique gently for office tubal patency assessment

This video shows how to assess office tubal patency through flexible office hysteroscopy via the Parryscope technique. It is gentle, accurate, fast, and clearly preferred by patients relative to hysterosalpingography.

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Volume 108, Issue 4, Page 718

Authors:

J. Preston Parry, M.D., M.P.H., Daniel Riche, Pharm.D., John Rushing, M.D., Brittany Linton, R.N., Vicki Butler, R.N., Steven R. Lindheim, M.D., M.M.M.

Abstract:

Objective

To demonstrate a novel approach to office tubal patency assessment through infusing air into saline during flexible office hysteroscopy. We also provide data addressing pain and patient experience relative to hysterosalpingography (HSG).

Design

Video presentation of clinical technique with supportive crossover data (Canadian Task Force classification II-1). Its University of Mississippi Medical Center Institutional Review Board protocol number is 2013-0230.

Setting

Academic hospital.

Patient(s)

Women undergoing office hysteroscopy and ultrasound, with a subset also having HSG.

Intervention(s)

Air infusion into saline during office hysteroscopy.

Main Outcome Measure(s)

The focus is on demonstrating how the technique appears and is performed, with supplemental Likert data addressing subjective pain and preference relative to HSG.

Result(s)

When performed as described, this office technique has 98.3%–100% sensitivity to tubal occlusion and 83.7% specificity. The gentle technique is central to accurate outcomes, which is facilitated through use of a small-caliber (<3 mm), flexible hysteroscope and avoiding uterine overdistention. Patients are far more likely to report maximum discomfort with HSG (relative risk = 110; P < .0001). Among patients who also had HSG, 92% somewhat or strongly prefer hysteroscopic assessment. Also, 96% of patients reporting maximum discomfort with HSG had mild to no discomfort with the described technique.

Conclusion(s)

Air-infused saline at flexible office hysteroscopy can accurately, gently, and rapidly assess tubal patency. Coupled with strong patient preference for this technique over HSG, it is a promising option for evaluating fertility.

Clinical Trail Registration Number

NCT02005263.


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Fertility and Sterility

Editorial Office, American Society for Reproductive Medicine

Fertility and Sterility® is an international journal for obstetricians, gynecologists, reproductive endocrinologists, urologists, basic scientists and others who treat and investigate problems of infertility and human reproductive disorders. The journal publishes juried original scientific articles in clinical and laboratory research relevant to reproductive endocrinology, urology, andrology, physiology, immunology, genetics, contraception, and menopause. Fertility and Sterility® encourages and supports meaningful basic and clinical research, and facilitates and promotes excellence in professional education, in the field of reproductive medicine.

3 Comments

Go to the profile of John Preston Parry, MD, MPH
John Preston Parry, MD, MPH about 3 years ago

We're excited about this approach, which seems accurate and very gentle. Patients describe it as a night and day difference from HSG. We're happy to answer questions here or by email!

Go to the profile of John Storment
John Storment about 3 years ago

Pres,  Thanks for a very nice presentation.   Clearly the impetus for looking for an alternative to HSG to determine patency is the pain and cost associated with HSG.   Your statistical analysis of over 100 patients demonstrates this improvement in pain.  We have a C-arm in our office (converted a standard exam room with no additional preparation) and perform all HSG's for our patients and referring doctors at a fraction of the cost of the hospital.   The entire process (from signing consent til discharge) averages 15 minutes. Though some patients describe the pain as a "10 out of 10", the average pain score is a "4" and it is short lived.  (lasting only a minute or so).   The entire cost to the patient is $500.    (average cost in a hospital setting is over $2000).    We also perform diagnostic flexible hysteroscopies for other indications and our experience is the opposite of your published data.   We frequently need a tenaculum because the nulliparous  cervix is less pliable and the pain associated with simply placing the scope is as much or more than the smaller and less rigid catheter with the HSG.  In addition, we have physical images that demonstrate the size of the hydro (if present) and the presence of suspected adnexal adhesions at the distal tube.  Though not painless, an HSG seems to give more information at potentially lower cost.   

1. What is the cost of the Parry-scope? (actual cost to the patient)

2. How many of your patients had a subsequent laparoscopy to confirm findings so you can get a true sensitivity and specificity?

3.  What do you do with your results of bilateral occlusion?  Do you go directly to IVF or proceed with a laparoscopy? 

Go to the profile of John Preston Parry, MD, MPH
John Preston Parry, MD, MPH about 3 years ago

John,

Thank you for your insight, where as someone highly skilled in HSG, you have unique and valuable perspective on the HSG vs hysteroscopy perspective. With what you describe, I think your patients get a better HSG experience than most in the country on many levels. In answering/addressing several things you’ve raised, I may be more indirect than usual for two reasons. First, we have several text publications in preparation that will address some of your questions, particularly the patient experience and cost-effectiveness, and I’ll try to avoid scooping myself and colleagues. The second is in talking about this approach to tubal patency, we have to distinguish typical experience from that in expert hands. Even though this hysteroscopic approach has great potential, I’ve always thought that we will probably not teach the Michelangelo’s of HSG and sonosalpingography to paint with a different brush.

For procedural duration, our initial publication in May (Parry, et al., JMIG 2017; 24(4): 646-52) showed the average procedure to last four minutes and forty six seconds from speculum placement to removal. Though we do many vaginoscopically now, so the timing of the metric may not fully apply, it gives a reasonable sense of how long it takes. Of note, to move beyond expert hands, it took residents learning how to do hysteroscopy only a minute longer for their average. I don’t think debating which in office procedure is technically faster is critical, as this will often get in to statistical significance that is not clinically meaningful and depends on definitions. However, we all can agree that for those without a C-arm, if you can do an office procedure faster than you can park and walk to radiology, that saves time.
Cost is a complex issue that we can’t wait to present on. However, we can show this technique can be done more inexpensively than HSG and sonosalpingography on multiple levels. (I’m married to an economist by the way…)

Similarly, for pain there is so much more forthcoming that we can’t say at this time. Of note, with your having a very different experience for pain with hysteroscopy, I’m willing to bet your hysteroscope is a 3.1/3.5/4.1 mm (or even larger). In both publications and anywhere we can, we emphasize that for best results one has to use 2.9 mm or smaller. As a result, we find we need dilation in ~2% of patients and a tenaculum in <1%, and these are almost exclusively in patients with previous cryotherapy. (Off the top of my head, >85% of our patients have not had a previous vaginal delivery.) Even going to 3.1 mm in a nulliparous patient can have an effect.

For information, the question is not pure HSG vs pure hysteroscopy, but the sequential combination of ultrasound and HSG vs ultrasound and hysteroscopy, which is typical to patients across REI. Our imminent JMIG reply to authors addresses this, as will future articles, but we find it easier to achieve a more “information rich” experience with ultrasound and hysteroscopy, while recognizing that in expert hands such as your own, ultrasound and HSG can be powerful. For semantics, we distinguish the “technique” from the “Parryscope approach” which when combined with ultrasound assesses ovarian reserve through antral follicle count, uterine anatomy through combined ultrasound and hysteroscopy, and tubal disease through air infusion and sonographic findings, including sliding sign, shifts in cul de sac volume pre to post-hysteroscopy, and visualization of hydrosalpinges. While the JMIG article focused on sensitivity and specificity from the “technique,” when combined with ultrasound, more can be done through a larger “approach.” Patients want a single visit solution where they understand the core determinants of their fertility, which we feel the approach can provide.

Regarding true sensitivity and specificity, our central findings in JMIG were exactly this, comparing hysteroscopic findings to those in the OR. Of note, had our publication compared laparoscopy to sonosalpingography (instead of hysteroscopy), it would have been in the top five for sample size for papers published. Since we continued to collect data after manuscript publication, our current statistical power would make it the second largest, and comprise ~15% of the total world literature over the past >30 years comparing sonosalpingography to laparoscopy had we done sonosalpingography instead of hysteroscopy. (This gets at what is realistically achievable for assessing a technique’s accuracy.)

Finally, for managing bilateral tubal occlusion, that is a full article in itself. We recognize that hysteroscopy, HSG, and sonosalpingography all have false positive and negatives (as can laparoscopy, despite being a “gold standard” and we’ve had patients where hysteroscopy was a better predictor than laparoscopy, but that’s a longer story). The answer in medicine that is always right is “it depends.” For us in a non-mandated state, we can do three rounds of oral medication, sonography, and insemination for less than the cost of a confirmatory HSG or typical copays/deductibles for laparoscopy. Laparoscopy depends on the likelihood of anticipated findings changing management, but with hydrosalpinges, surgery is definitely indicated. We’re reluctant to go straight to IVF given the potential for findings falsely suggestive of occlusion, but when coupled with historical and sonographic findings, for some patients this may be reasonable.

Sorry for the long response—there is so much more to say even beyond this! I think whatever one’s preference, HSG, sonosalpingography, or hysteroscopy, a case can be made for each and an expert with any is preferable to minimal experience. (However, we have data that residents can function gently and accurately even with their first hysteroscopy.) As a result, resources, cost, patient preference, learning curve/experience and other factors matter for procedural choice. How we do right by our patients with the tools at hand is the central question for REI and medicine as a whole. Thank you for your curiosity and passion for exploring alternatives!

Pres Parry