Abstract:
A method and apparatus for assessing bodily cavities and lumens utilizing an integrated, automated aerating device is described. The aeration device can selectively supply a gas a liquid during ultrasound and radiographic procedures for enhanced visualization of the uterine cavity and fallopian tubes.

Description:
[0001]    This application claims priority to U.S. Provisional Application No. 62/005,355, filed May 30, 2014; U.S. Provisional Application No. 61/977,478, filed Apr. 9, 2014; U.S. Provisional Application No. 62/007,339, filed Jun. 3, 2014, and U.S. Provisional Application No. 61/902,742, filed Nov. 11, 2013, which are incorporated by reference herein in their entireties. 
     
    
     BACKGROUND 
       [0002]    For assessing the inner morphology of the uterine cavity, or the patency of the fallopian tubes, physicians can utilize a variety of fluids and media for providing visualization during ultrasound and radiographic procedures. In some situations, the visualization quality of the ultrasonic imaging can be enhanced with additional echogenic constituents within the fluid media such as particles, air bubbles, CO2 bubbles, and other contrasting materials that provide additional reflection and echogenicity for ultrasound. For uterine cavities, physicians evaluate the inner morphology of the cavity for the presence of disease while observing surrounding tissues and structures. 
         [0003]    Fallopian tubes are potential spaces unless an intra-tubal insert is in situ, or in the presence of fallopian tube disease. These disease states can distort, occlude, or distend the fallopian tube walls in cases such as hydrosalphinges, inflammation, or when the culmination of bodily materials build up as deposits or detritus, or when remnants of previous ectopic pregnancies are present in the fallopian tube lumens. For assessing the inner morphology of the fallopian tubes, the patency of fallopian tubes, or the presence of tubal inserts, sufficient intra-uterine pressure needs to be generated to push or force the flow of media through the tubes. Literature indicates that the required amount of fluid pressure delivered at the endocervix through transcervical hysterosalpingography catheters to allow the flow of media through the fallopian tubes is on average 70 mmHg and pressure values using CO2 or fluid media have ranged higher and lower than that average value. 
         [0004]    A prior version for enhancing image quality utilizes the addition of a foaming agent or foam within a catheter system with subsequent injection into the uterine cavity. The foam is prepared by the operator through agitation of the foam and typically a fluid media such as saline. A catheter is introduced into the uterine cavity and a seal is created at the internal cervical os by a balloon or at the exocervix through the use of an occluding member or stopper at the cervical opening. The goal of these occluding devices is to maintain a seal within the uterine cavity so that sufficient pressure can be created through the injection of the foam/fluid media mixture to fill and distend the uterine cavity for inner surface examination. With additional pressure, up to the average 70 mmHg as reported in literature, the foam/fluid media mixture can infiltrate the fallopian tubes. Upon complete infiltration through the fallopian tubes and into the peritoneal cavity, the physician can make the assessment that the fallopian tubes are patent, or open, as evidenced by the spillage of fluid through the tubal lumen and into the peritoneal cavity or by visualization of bubbles traversing the fallopian tubes. This information can be useful for counseling women and couples for infertility and also for post-tubal insert implantation for permanent contraception. As an example, a foam agent can trap air particles or bubbles within a media prior to injection into the body. The foam mixture can be created manually by the operator by agitating a gel media with saline with two inter-connected syringes to create bubbles. Once turned to a foam consistency, the mixture is instilled into the body during sonographic procedures. 
         [0005]    As an alternative, the art discloses the benefits of small sized gas bubbles for enhanced visualization of the fallopian tubes as well as the use of various gels and higher viscosity fluids for reducing the leakage of media out of the cervical canal during diagnostic uterine cavity procedures. The small sized gas bubbles, as one example, create greater sonographic reflections or echogenicity of the fluid during ultrasound diagnostic procedures. 
         [0006]    Several uses of multiple syringe mechanisms for introducing two contrasting materials into a bodily cavity are known. For example, a first and second pump can supply sterile saline and micro-filtered air into the body for improved visualization during diagnostic procedures. The second pump filled with air is used to inject air into the saline and supplying the saline and air mixture into the body. 
         [0007]    The use of two syringes: one syringe filled with a media comprised of small sized or micro-bubbles, and the other syringe filled with saline for simultaneous injection into the body is also known. The mixture is designed for improved visualization during sonographic procedures and evaluation of fallopian tube patency. 
         [0008]    Yet another known method for enhancing visualization with ultrasound during fallopian tube diagnostic procedures uses a double barrel syringe for the injection of air and saline into the uterine cavity. When loading the system with saline, a second syringe barrel is drawing up room air. Once connected to a catheter and upon the depression of a plunger on the double barrel syringe, saline and air is combined at the base of the syringe through a y-fitting and then travels through the length of the catheter and into the uterine cavity. As the air bubbles combine with saline at the y-fitting, the coalescence of the bubbles occurs rapidly and echogenicity degrades as the air bubbles and saline traverse the length of the catheter. Importantly, the instructions for use in these double barrel catheter systems note that the bubbles employed in the media can create artifact while visualizing the uterine cavity since the bubbles may obscure anatomical features inside or on the inner cavity wall of the uterus. 
         [0009]    In regards to bubble creation and venturi effect mechanisms, a micro bubble generating mechanism for shower heads is known. Other examples include nebulizing catheter systems for use in the pulmonary organs, and microparticulate introduction within perfluorocarbon liquid medications. A catheter with an aeration element within the distal end of the catheter for improving visualization within the uterine cavity and fallopian tubes is also known. Other applications depict a venturi mechanism attached to the proximal luer connector on the proximal portion of a catheter for the simultaneous infusion of air and saline within the uterine cavity. 
         [0010]    A deflecting surface adjacent to the distal opening of an elongated catheter for directing a member or a fluid is known. As is an internal mandrel for selectively straightening a curved catheter for insertion into the uterine cavity. As another representative example of related art, a steerable catheter is known that provides articulation of the distal end. 
         [0011]    Echogenicity can be altered (e.g., increased) with micro-bubbles or smaller bubbles. Ultrasound artifact by the presence of larger, obscuring air bubbles, can be reduced with the reduction of larger bubbles since the presence of the larger bubbles have been reported to obscure polyps or inner cavitary lesions. 
       SUMMARY OF THE INVENTION 
       [0012]    An enhanced diagnostic visualization system for sonographic and radiographic imaging of the uterine cavity and fallopian tubes is disclosed. The system can be utilized in other natural or created bodily cavities and lumens. The system provides an integrated aeration device within a catheter for selectively providing echogenic air bubbles into a media that is injected into the body. The aeration device can be connected to a gas supply lumen that provides bubbles automatically to a flowing media without the need for special pumps, syringes, or other actuation members. Alternatively the air supply lumen can be connected to a gas source filled with CO2 or other gaseous mixtures suitable for use in the body as substitutes for room air. In addition, the air supply lumen can selectively be reduced or occluded by the physician or operator to reduce or eliminate the infusion of air in the media. The liquid can be water, saline, or other fluid used in imaging applications for evaluating interior structures in the body. Additional agents for improving visualization can be provided in the form of gels and foams that alone or in combination with fluid media can provide additional contrast and an enhanced visual image for the diagnostic procedure. 
         [0013]    The system can utilize an integrated automatic aeration device or tool at the distal end of the catheter to facilitate ultrasonic, radiographic, and endoscopic visualization through the use of bubbles within the pathway of the delivered liquid. The aeration component can be selectively turned on or off by manual or actuated occlusion of the air supply lumen at the proximal end of the catheter. 
         [0014]    The system can be self-contained or automated in that no other external component or apparatus needs to be attached to the device for the delivery or cessation of air bubbles. The system can have an integrated aeration device that can selectively utilize room air through a gas lumen that is contained within the catheter and terminates with an opening, for example a lateral gas port, to room atmosphere in the proximal section of the catheter or system handle. 
         [0015]    The aeration device can be integrated into a catheter system that contains an insertion catheter on the distal end. A system handle can be connected to the proximal end of the catheter. Manipulation controls on the system handle can be operated by the operator or physician to manipulate the catheter and tools. The system handle can contain a fluid supply or reservoir, a fluid injection system or pump, and control knobs and buttons for actuating components on or in the catheter. For instance, the system handle can have a pump lever for manually injecting media from the fluid reservoir. The media can be sterile saline and/or other media such as contrast agents, foams, gels, and other media and fluid for use in the body for diagnostic sonographic and radiographic procedures. The control knobs on the handle can include buttons for changing the physical curvature of the insertion catheter, rotating the insertion catheter, advancing the length of the insertion catheter, and altering the aeration device by turning on, off, or reducing the flow of bubbles into the media. The bubbles can be turned off and restarted. The system handle can provide a one-handed procedure for the physician. One-handed operation can allow the freedom to use the other hand for manipulation of other instruments or operation of the diagnostic system like an ultrasound probe (either vaginal or abdominal) and the physical keyboard, joy stick, roller ball, or buttons of the ultrasound machine. The freedom to use the contralateral hand also provides the ability to palpate or manipulate the patient and specific patient anatomy while simultaneously performing the procedure without requesting for additional help from other resources or staff personnel. The handle can be configured to allow the physician to operate all of the catheter mechanisms with only one hand position and does not require the physician to alter, re-grip, or re-position his/her hand throughout the entire operation of the catheter system and procedure. 
         [0016]    The aeration device can be integral to the catheter system for an automated injection of air bubbles in response to the flow of media through the aeration device. The aeration device can be self-contained and integrated within the insertion catheter without the need of secondary pumps or syringes. The aeration device can have a proximal lumen for accepting media from the fluid supply and a nozzle connected to the air supply. The flow of media (e.g., liquid) by the nozzle connected to the air supply pulls air into the flowing media and into a funnel at the distal end of the aeration device. 
         [0017]    The aeration device can utilize the Bernoulli principle where the flow of media or fluid, with a known pressure, is forced through a flow restriction (a venturi). When passing through the restriction, the flow velocity of the fluid increases and the pressure within the fluid decreases. Contained in the restriction area of the aeration device is the nozzle opening of the air supply that is connected to an air supply lumen that can be selectively open to room air. The decrease in pressure in the fluid pulls or entrains room air gas, which is at a higher atmospheric pressure, into the flowing fluid which then passes through a funnel opening distal to the restriction with an opening angle less than 15 degrees. This is also known as a Venturi Effect. The system utilizes this principle as a built in component within the catheter system for supplying air bubbles into a flowing media used for sonographic and radiographic procedures. As such, the aeration of the flowing media is self-contained and integral to the catheter system for automatically supplying air bubbles when media is injected into the body, such as the uterine cavity and fallopian tubes. 
         [0018]    The aeration device can be placed at a location in the catheter system immediately distal or at any point along the insertion catheter distal from the fluid supply source. For instance the aeration component can be integrated within the fluid supply system a centimeter from the fluid source outlet within the catheter system. In some configurations, placing the aeration component within the catheter system may reduce the overall diameter of the catheter that is being placed into the body. In other embodiments, the placement of the aeration component at the most distal location in the insertion catheter can provide additional benefits. The amount of air bubble coalescence is proportional to length of travel within the catheter system prior to exiting into the bodily cavity. Positioning the aeration component at the most distal end of the insertion catheter reduces the coalescence of these air bubbles. Once the flow of fluid passes through the aeration device, air bubbles can be entrained into the media and pass through the insertion catheter. The insertion catheter can have a distal opening (e.g., an outlet port) for placing the media into the body or uterine cavity. In practice, the insertion catheter is provided with a malleable distal section to facilitate manipulation and passage through the cervical canal. The distal end opening can have a slightly rounded or bulbous shape to reduce trauma and facilitate passage of the catheter through the cervix. A malleable section is advantageous for bending the distal section in the presence of anteverted or retroverted uteri, or stenotic cervical canals. 
         [0019]    The catheter can be curved deliver the distal opening of the aeration device in close proximity to the fallopian tube ostia. The insertion catheter can be in a generally straight configuration for insertion or passage through the cervix. This straight portion at the distal end of the catheter can have an internal malleable section to facilitate passage of the insertion catheter through the cervix. 
         [0020]    The aeration device can be located at the most distal location in the insertion catheter 1 to 9 millimeters to 1 to 4 centimeters prior to the opening at the distal end. This embodiment can mix the air into the media at a location immediately prior to injection into the body, thereby increasing the echogenicity of the media by reducing the time allowed for the air bubbles to coalesce into the media.  FIG. 1  below demonstrates the principles in an aeration device within a distal angled ball tip of an insertion catheter. The aeration device can be constructed from softer durometer materials, such as 63 durometer polyether block amides (e.g., Pebax® from Arkema of Colombes, France) or polypropylene that allow for greater flexibility for inserting the device into a bodily cavity or lumen than higher durometer Pebax® or nylon. There are numerous choices for biocompatible polymers, metals, and material blends that can be substituted for this application. 
         [0021]    The system can provide site specific, aerated media for information on the patency of individual fallopian tubes. This diagnostic information can be utilized in assessing infertility or determining the effectiveness of a tubal insert for permanent contraception. The entire procedure including the instillation of fluid, the directionality of the aerated media, the size of the aeration bubbles, the quantity of aeration bubbles, and the ability to turn the aeration feature on or off, can be actuated by the operator using one hand on the handle and one hand position on the proximal portion of the catheter. The system can be used to deliver drugs, therapeutic devices, and can collect a diagnostic specimen with collection mechanisms to and from target sites, such as bodily cavities, lumens, and fallopian tubes. The system can be used to deliver fallopian tube tools with ultrasound, radiographic, or endoscopic elements. The system can be utilized for the delivery of inserts and materials into the fallopian tube within a specific fallopian tube for enhancing echogenicity, or determination and identification of the fallopian tube lumen for the placement of the fallopian tube device. The system can allow for the staging of multiple fallopian tube devices through a tool lumen. The devices can be a cytology, cellular, or fluid sampling tool. The system can use an endoscope for visualization of the fallopian tube ostia with an integrated aeration system that provides on demand bubbles to allow for the direct visualization of lumen patency through the imaging of bubbles passing into the tubal ostia within distension media. 
     
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
         [0022]      FIG. 1  illustrates a variation of the aeration system having a handle and an aeration device. 
           [0023]      FIGS. 2   a  through  2   c  are perspective, top and side views of a variation of the aeration device. 
           [0024]      FIGS. 3   a  through  3   d  illustrate variations of partial lengths of cross-section A-A. 
           [0025]      FIG. 4  illustrates a variation of cross-section B-B. 
           [0026]      FIG. 5  illustrates a variation of a portion of cross-section C-C. 
           [0027]      FIGS. 6 and 7  illustrate variations of cross-section A-A showing methods for using the aeration device. 
           [0028]      FIG. 8  is a graph of the ratio of the volume of air generated by a variation of the aeration system to the liquid flow rate through the system. 
           [0029]      FIG. 9  illustrates a variation of a method for rotating the distal end of the system. 
           [0030]      FIG. 10   a  illustrates the distal end of the system in a straight configuration. 
           [0031]      FIG. 10   b  illustrates the distal end of the system in a curved configuration. 
           [0032]      FIGS. 11   a - c  illustrates variations of methods for using the system. 
           [0033]      FIGS. 12   a  through  12   c  illustrate a method for deploying a tool through the system. 
           [0034]      FIG. 13  illustrates a variation of a method for using a tool concurrent with the system. 
       
    
    
     DETAILED DESCRIPTION 
       [0035]      FIG. 1  illustrates that an aeration system  2  can have a system handle  4  and an aeration device  6 . The aeration system  2  can be used to deliver aerated liquid  120  to a target site within a patient, for example, delivering saline infused with air bubbles within a uterus  140 . The liquid can be aerated with air, carbon dioxide, nitrogen, oxygen, or combinations thereof. 
         [0036]    The aeration device  6  can have a catheter  8 . The catheter  8  can have a catheter longitudinal axis  10 . The aeration device  6  can have one or more indicia markings  18 , for example the catheter markings  18  in or on the catheter  8 , and/or overtube markings  108  in, on, or under an overtube  102 , described below. The indicia markings  18  can be visible, radiopaque, echogenic, or combinations thereof. 
         [0037]    The catheter  8  can have a flexible or malleable distal tip  12 . The distal tip  12  of the catheter  8  can have an outlet port  14  at or near the distal terminal end of the catheter  8 . The distal tip  12  of the catheter  8  can have a gas inlet, such as a lateral gas port, in fluid communication through the catheter  8  with the outlet port  14 . (The gas inlet can be on a non-lateral side of the system  2 , such as extending from the proximal terminal end of the system handle  4 , but is referred collectively herein as the lateral gas port  16 .) The lateral gas port  16  can be an opening or orifice of the proximal opening of a gas lumen  48 . The lateral gas port  16  can extend out of the lateral side of the catheter  8  and multiple lateral gas ports  16  are possible. The indicia marking  18  can be proximal to or longitudinally overlap with the lateral gas port  16 . For example, the lateral gas port  16  can extend from the side of a catheter marking  18 . 
         [0038]    The length along the catheter longitudinal axis  10  from the lateral gas port  16  to the outlet port  14  can be an aeration length  20 . The aeration length  20  can be the length from the introduction of gas into the liquid being delivered by the device (e.g., the location of the tap or throat of the venturi, discussed below) to the outlet port  14 . The aeration length  20  can be, for example, from about 1 in. to about 9 in., more narrowly from about 1.5 in. to about 5 in., for example about 2 in. The aeration length  20  can be less than about 9 in., more narrowly less than about 5 in., more narrowly less than about 2 in. 
         [0039]    The proximal terminal end of the aeration device  6  can have an aeration device connector  22 . The aeration device connector  22  can be a widening of the catheter  8  and be placed on the catheter  8  adhesively, mechanically attached or bonded, secured by a clamp, a heat-shrink collar, or ring, threaded onto the catheter  8  by luer connectors, or combinations thereof. The aeration device connector  22  can be configured to attach to the system handle  4 . 
         [0040]    The aeration device  6  can have a device length  24  or catheter length from the distal terminal end (or outlet port  14 ) to the proximal terminal end of the aeration device  6 . The device length  24  can be from about 6 in. to about 18 in., more narrowly from about 9 in. to about 12 in., for example about 10.5 in. The ratio of the device length  24  to the aeration length  20  can be from about 2:1 to about 10:1, more narrowly from about 3:1 to about 6:1, for example about 5:1. The ratio of the device length  24  to the aeration length  20  can be greater than about 2:1, more narrowly greater than about 3:1, yet more narrowly greater than about 5:1, yet more narrowly greater than about 10:1. 
         [0041]    The distal terminal end of the system handle  4  can have a system handle connector  26 . The aeration device connector  22  can be configured to attach to the system handle connector  26 . 
         [0042]    The system handle  4  can have actuators or controls for manipulating the shape, position, orientation, or combinations thereof of the distal tip  12  of the aeration device  6 . The controls can be a rotation knob  28 , deflection slide  30 , of combinations thereof. The system handle  4  can have actuators or controls for the controlling the flow of air or gas within the aeration lumen, or the size and/or density of the air or gas bubbles within the aeration lumen. The controls can be a rotation knob  28 , deflection slide  30 , valve, or combinations thereof. 
         [0043]    The system handle  4  can have an inlet port  32  configured to receive a liquid. The system handle  4  can have a pump lever  34  rotatably attached to the remainder of the system handle  4 . 
         [0044]      FIGS. 2   a  through  2   c  illustrate that the distal tip  12  can have a neck  36  of the catheter  8  attached to or terminating in a head  38  at the distal terminal end of the distal tip  12 . The distal tip  12  can be straight in configuration with a rounded, smooth, atrumatic tip with an opened distal end, or side holes, or combination thereof. The head  38  can have a ball tip  40 , an outlet port  14 , and an outlet face  42  (i.e., distal end opening). The ball tip  40  can be rounded and atraumatic. The outlet port  14  can be recessed within the outlet face  42 . 
         [0045]    The outlet face  42  can extend along an outlet face plane  44 . The outlet face plane  44  can intersect the catheter longitudinal axis  10  at an outlet face angle  46 . The outlet face angle  46  can be from about 10° to about 90°, more narrowly from about 15° to about 45°, for example about 30°, also for example about 90° (i.e., perpendicular). 
         [0046]      FIG. 3   a  illustrates that the catheter  8  can have the gas lumen  48  and a liquid lumen  50 . The liquid lumen  50  can have a venture  52 . The venture  52  can have a converging inlet nozzle  56  ending at a venturi constriction  54 . The venturi constriction  54  can be the narrowest point or restriction in the venture  52 . The venturi  52  can have a diverging outlet diffuser  58  extending distally from the venturi constriction  54 . The liquid lumen  50  can have a liquid lumen longitudinal axis  60 . The surface of the diverging outlet diffuser  58  can form from about a 10° angle to about a 30° angle, for example a 15° angle with the liquid lumen longitudinal axis  60 . 
         [0047]    The liquid lumen  50  can distally terminate at the outlet port  14 . The liquid lumen  50  can distally terminate or merge into an outlet channel  62  in the distal tip  12  where the leading edge or head  38  of the insertion catheter  8  is located. The outlet channel  62  can have an outlet channel longitudinal axis  64 . The outlet channel longitudinal axis  64  can intersect the liquid lumen longitudinal axis  60  at an outlet angle  66 . The outlet angle  66  can be from about 0° (e.g., the outlet channel  62  can be a narrowing or widening of the liquid lumen  50 ) to about 90°, more narrowly from about 15° to about 45°, for example about 30°, also for example about 15°, also for example about 0°. The outlet angle  66  can be a non-zero angle. The diameter of the outlet channel  62  can be equal to, larger than, or smaller than the diameter of the liquid lumen  50 . 
         [0048]    The gas lumen  48  can be connected to an air supply, ambient air, or other gas supply. The proximal end of the gas lumen  48  can be attached to a pressurized gas source. The proximal end of the gas lumen  48  can be open to the environmental atmosphere or non-pressurized or low-pressurized gas source such as a small volume of gas within a rigid or flexible container. 
         [0049]    A gas injector channel  68  can extend from the gas lumen  48  to the venture  52 . The gas injector channel  68  can narrow at a nozzle or tap  160  where the gas injector channel  68  fluidly connects to the venturi  52  at a throat  70  of the venture  52 . The throat  70  can be at the venturi constriction  54 , distal to the venturi construction  54  (e.g., in the diverging outlet diffuser  58 ), proximal to the venturi constriction  54  (e.g., in the converging inlet nozzle  56 ), or combinations thereof. The gas injector channel  68  can extend through the lateral wall of the catheter  8  at the lateral gas port  16 . The gas injector channel  68  can have no lateral gas port  16 . 
         [0050]    A filter, such as a micro-filter, or a check valve  94  or one-way valve, can be on the lateral gas port  16  and/or within the channel of the gas lumen  48 . The micro-filter can be constructed with a porosity to provide a sterile air barrier, and supply sterile air bubbles into the fluid and to the target site (e.g., patient&#39;s body). The micro-filter can have a 3 micron porosity rating. The micro-filter can be used as a sterile air barrier or a mechanism to govern the amount of air flow within the air lumen. The micro-filter can have porosity levels, lower and higher than 3 micron, for example, to produce sterile air and the flow rate of about 1-10 ml/min of air bubbles into the fluid. The filter at the lateral gas port  16  or in the gas lumen  48  can filter fluid from entering the air lumen, for example for hydrophobic applications and/or when there is a risk of fluid or other unwanted liquids to get into the lateral gas port  16  or gas lumen  48 . A check or one-way valve may eliminate the flow of pressurized fluids from the bodily cavity from entering into the air supply lumen and through the catheter system. 
         [0051]    One or more lateral gas ports  16  can extend from the gas lumen  48  through the exterior catheter wall proximal to, distal to, or at the location of the gas injector channel  68 . For example, a lateral gas port  16  can be located in the handle  4  (the gas lumen  48  and/or liquid lumens  50  can extend proximally into the handle  4 ), and the gas injector channel  68  can be located at the distal tip  12 . The system  2  can have one or more gas injector channels  68 , for example a first gas injector channel  68  in the handle  4  and a second gas injector channel  68  in the distal tip  12  of the device. One or more lateral gas ports  16  can also be selectively occluded or opened to increase, reduce, or eliminate the flow of gas within the fluid. 
         [0052]    The gas injector channel  68  can have a gas injector longitudinal axis  72 . The gas injector longitudinal axis  72  can intersect the liquid lumen longitudinal axis  60  at a tap angle  74 . The tap angle  74  can be from about 170° to about 10°, more narrowly from about 90° (i.e., perpendicular) to about 135°, for example about 90°, also for example about 105°. 
         [0053]    The aeration length  20  can be measured from the proximal end of the throat  70  or where the proximal end of where the tap  160  opens to the venture  52 , along the respective liquid lumen longitudinal axis  60  and outlet channel longitudinal axis  64  to the outlet port  14 . As shown, the total aeration length  20  can be the sum of the first partial aeration length  76  along the liquid lumen longitudinal axis  60  and the second partial aeration length  78  along the outlet channel longitudinal axis  64 . 
         [0054]    The distal end of the gas lumen  48  can terminate at the gas injector channel  68  or can have a gas lumen overrun  80  that extends distally past the gas injector channel  68 . The gas lumen overrun  80  can have a closed distal terminal end in the catheter  8 . 
         [0055]      FIG. 3   b  illustrates that the gas lumen  48  can have a narrowed length at the lateral gas port  16  and/or gas injector channel  68 . The gas injector channel  68  can be a constant radius, for example, the tap  160  is not narrowed with respect to the remainder of the gas injector channel  68 . 
         [0056]      FIG. 3   c  illustrates that the system handle  4  can have a system handle case  82 . The lateral gas port  16  can extend out of the side of the system handle case  82 . The gas lumen  48  can extend from the lateral gas port  16 , through the catheter  8  and to the gas injector channel  68 . The throat  70  can be located at the venturi constriction  54 . The system handle  4  case can have a gas slide  84 . The gas slide  84  can have a cover  86  in contact with the surface of the system handle case  82 . The cover  86  can be a sealing gasket, for example made from rubber, silicone, a polymer, or combinations thereof. 
         [0057]    The gas slide  84  can be configured to translate, as shown by arrow, with respect to the system handle case  82  to cover or partially cover, and seal (or uncover and unseal, or partially unseal, when translated opposite to the arrow shown) the lateral gas port  16 . When the gas slide  84  is in a position on the lateral gas port  16 , the cover  86  can cover and seal the lateral gas port  16 , preventing the gas (e.g., air) from flowing into the lateral gas port  16 . The lateral gas port  16  can be releasably sealed by the user&#39;s hand, such as a palm, thumb, finger, or combinations thereof. The user can controllably aerate and not aerate the liquid flowing through the liquid lumen  50  by sealing and unsealing the lateral gas port  16 . 
         [0058]    The gas slide  84  and/or other controller can be mechanically connected to an occluding mandrel (i.e., an occluding member  122 ) instead or in addition to being positioned to slidably close the lateral gas port  16 . The occluding mandrel can slidably occlude the gas injector channel  68  and/or the gas lumen  48 . The gas slide  84  and/or other controller can also be configured to open and close a valve and/or inflate and deflate an occluding balloon in the gas lumen  48  or gas injector channel  68 . 
         [0059]      FIG. 3   d  illustrates that the system can have a first gas injector channel  68   a , a second gas injector channel  68   b , and a third gas injector channel  68   c  that can be connected to a single venturi  52  or to first  52   a  and second  52   b  (or more) venturis, respectively. The gas injector channels  68  can connect to the venturi(s)  52 , for example, at the venturi constriction  54  and/or along the diffuser of the aeration device  6  to increase the amount of air bubbles to be entrained within the fluid media. As shown, the first gas injector channel  68  can connect to the first venturi  52   a  at a first venturi constriction  54   a , the second gas injector channel  68   b  can connect to the second venture  52   b  at a second venturi constriction  54   b , and the third gas injector channel  68   e  can connect to the second venture  52   c  at a second diverging outlet diffuser  58   b . The gas injector channel  68   s  can branch off one air supply lumen, as shown. Alternatively, multiple air supply lumens with multiple openings within the restriction area of the aeration device  6  can be employed to increase the amount of air bubbles within the fluid media. The air supply nozzles can be placed in multiple locations circumferentially around the throat(s)  70 . 
         [0060]    The gas lumen  48  can have a first lateral gas port  16   a , a second lateral gas port  16   b , and a third lateral gas port  16   c . For example, the second and third lateral gas ports  16   b , 16   c  can be on the catheter  8 , as shown, or multiple lateral gas ports  16  can be on the handle  4 . The first lateral gas port  16   a  can have a first gas slide  84   a , the second lateral gas port  16   b  can have a second gas slide  84   b , and the third lateral gas port  16   c  can have a third gas slide  84   c . The gas slides  84  can slide, as shown by arrows, over the respective lateral gas ports  16  independently or concurrently, for example, if mechanically or electrically (e.g., via one or more motors or solenoids connected to the same controller) connected to each other. 
         [0061]    The lateral gas ports  16  can be located along the catheter longitudinal axis  10  aligned or offset from the gas injector channels  68 . For example, the third lateral gas port  16   c  can be between the first gas injector channel  68   a  and the second gas injector channel  68   b.    
         [0062]      FIG. 4  illustrates that the catheter  8  can have the gas lumen  48 , the liquid lumen  50 , and a tool lumen  88 . A working tool (e.g., a biopsy tool, a scope, a sonogram probe, a cauterization tool, or combinations thereof) can be inserted through the tool lumen  88  and into the target site. 
         [0063]      FIG. 5  illustrates that the system handle  4  can have an inlet port  32 , an inlet-reservoir channel  164 , and a flexible liquid reservoir  92  or fluid supply container. The inlet port  32  can be a female luer fitting and connection. The inlet port  32  can be in fluid communication through the inlet-reservoir channel  164  with the flexible reservoir. The liquid reservoir  92  can be between the rigid pump lever  34  and a rigid system handle case  82 . The inlet port  32  can extend out of the proximal end of the system handle case  82 . The inlet port  32  can be configured to attach to a liquid source (e.g., a hose, tube, or supplemental reservoir configured to deliver the liquid through the inlet port  32  and to the liquid reservoir  92 ). The inlet port  32  can have a check valve  94  or one-way valve configured to allow flow to the liquid reservoir  92  and prevent backflow (e.g., proximal flow from the liquid reservoir  92  and out the inlet port  32 ). 
         [0064]    The system handle  4  can have a reservoir-liquid lumen channel  90 , and an outlet valve, such as a liquid check valve  94 . The liquid reservoir  92  can be in fluid communication through the reservoir-liquid lumen channel  90  with the liquid check valve  94 . The liquid check valve  94  can be in fluid communication with the liquid lumen  90 . The liquid check valve  94  can have a minimum cracking pressure, for example to allow fluid to flow to the liquid lumen  90  in the catheter  8 . The liquid check valve  94  can be a one-way valve and can prevent backflow (i.e., from the liquid lumen  90  of the catheter  8  to the liquid reservoir  92 ). 
         [0065]    The pump lever  34  can be rotatably attached to the system handle  82  case at a pump lever axle  116 . When the liquid reservoir  92  contains liquid, the pump lever  34  can rotate away from the system handle case  82 , as shown by pump lever rotation arrows  162 , as the liquid reservoir  92  inflates. The pump lever  34  can be rotated toward the system handle case  82  to compress the liquid reservoir  92 , for example, forcing liquid from the liquid reservoir  92 , through the reservoir-liquid lumen channel  90 , the outlet valve, the liquid lumen  50 , the outlet port  14 , and into the target site. 
         [0066]    The pump lever  34  can provide a pumping action to supply aspiration to withdraw fluid and materials into a separate specimen container (not shown). A spring within the lever  34  can facilitate the pumping action of the lever  34  to open the lever  34  (not shown) for each compression. 
         [0067]    The deflection slide  30  can be slidably attached to a slide canister  96 . The slide canister  96  can be inside of and fixed to the system handle case  82 . The rotation knob  28  and the deflection slide  30  can be attached to a steering rod  98 . The steering rod  98  can extend through the system handle  4  and through the catheter  8 . The proximal end of the catheter  8  can be attached to a hemostasis valve  100 , for example a Tuohy-Borst adapter for allowing passage of the steering rod  98  without leaking fluid. The hemostasis valve  100  can fluidly seal the proximal end of the catheter  8 . The steering rod  98  can extend through the hemostasis valve  100 . The distal terminal end of the steering rod  98  can be fixed to the distal end of the inside of the catheter  8 . The rotation knob  28  can rotate the steering rod  98  in the handle  4 . The deflection slide  30  can translate the steering rod  98  in the handle  4 . 
         [0068]    The aeration device  6  can have an overtube  102  slidably positioned radially outside of the catheter  8 . The overtube  102  can be translated and rotated with respect to the catheter  8 , the translation shown by overtube-catheter translation arrow  104 . The overtube  102  can be coaxial with the catheter  8 . A stopper  106  can be attached to or integrated with the distal terminal end of the overtube  102 . The stopper  106  can be flexible and made from a soft plastic, rubber, gel, or combinations thereof. The stopper  106  can be configured to seal the cervix  136  around the catheter  8 , such as by plugging the external os of the cervix  136 . During use, the stopper  106  can be positioned relative to the catheter  8  and longitudinally fixed to the catheter  8  to control the depth of the distal tip  12  in the cervix  136  and uterus  140 . 
         [0069]    The overtube  102  can be transparent, translucent, opaque, or combinations thereof. For example, the overtube  102  can have one or more overtube markings  108 . An overtube first marking  108   a  can be at a proximal end of the overtube  102 . An overtube second marking  108   b  can be at a distal end of the overtube  102 . The overtube first and second markings  108   a ,  108   b  can be on the same side of the overtube  102  (e.g., an axis through the overtube first and second markings  108   a , 108   b  can be parallel with the catheter longitudinal axis  10 .) The overtube markings  108  can be hollow markings, for example shaped as empty ovals or circles so the surface of the catheter  8  adjacent to the inside of the overtube marking  108  is visible. 
         [0070]    The catheter  8  can have a catheter first marking  18   a , catheter second marking  18   b , and catheter third marking  18   c  at the proximal end of the catheter  8 . The catheter  8  can have a catheter fourth marking  18   d , catheter fifth marking  18   e , and catheter sixth marking  18   f  at the distal end of the catheter  8 . The catheter markings  18  can be collinear. The catheter markings  18  can be coplanar with the overtube markings  108 . 
         [0071]    The distances from the overtube first marking  108   a  to the overtube second marking  108   b , from the catheter first marking  18   a  to the catheter fourth marking  18   d , from the catheter second marking  18   b  to the catheter fifth marking  18   e , and from the catheter third marking  18   c  to the catheter sixth marking  18   f  can be equal. 
         [0072]    The overtube  102  can be translated relative to the catheter  8  to align the overtube markings  108  with the catheter markings  18  to control the position of the stopper  106  relative to the distal terminal end of the catheter  8 . During use, the proximal markings can be visible outside of the patient (e.g., as visible markings) and the distal markings can be visible inside the patient (e.g., as echogenic markings viewed with a sonogram) and, for example, invisible from outside of the patient. The position of the overtube  102  first marking with respect to the first, second, and third catheter markings  18   a ,  18   b , 18   c , can correspond to the position of the overtube second marking  108   b  with respect to the fourth, first, and sixth catheter markings  18   d ,  18   e ,  18   f , respectively. 
         [0073]    The proximal terminal end of the overtube  102  can be attached by a clip collar  110  to a releasable locking clip  112 . The releasable locking clip  112  can fix to the catheter  8 . The locking clip  112  can be fixed to the catheter  8  by rotating, as shown by arrow, a clip latch  114  into a locked position where the clip latch  114  presses against the catheter  8 , friction fitting the locking clip  112  to the catheter  8 . The releasable locking clip  112  can be unfixed from the catheter  8  by rotating the latch  114  in the opposite direction shown. 
       Methods for Using 
       [0074]      FIG. 6  illustrates that non-aerated liquid  118  can flow distally through the liquid lumen  50  before the tap  160  or throat  70 . When the non-aerated liquid  118  passes the tap  160  at the throat  70 , the gas from the gas lumen  48  can enter the non-aerated liquid  118  via the tap  160 , and aerate the liquid. The aerated liquid  120  can then pass through the outlet channel  62 , out of the outlet port  14 , and into the target site. 
         [0075]    The aeration device  6  can be selectively turned on or off by the operator by use of an actuator, such as the gas slide  84  or button on the system handle  4  and/or proximal end of the catheter  8 . The operator or physician can completely occlude or reduce the gas input to the gas lumen  48 , for example, by sliding the gas slide  84  or cap, turning a valve, or combinations thereof, that can plug the lateral gas port  16 . The user can manually occlude the lateral gas port  16  by closing the opening with his or her thumb, finger, palm or combinations thereof. The quantity of gas, and therefore, the amount of bubbles in the aerated liquid  120  can be selectively tuned or modulated (e.g., increased or decreased), for example depending upon the diagnostic visualization needs of the procedure. 
         [0076]    The gas lumen  48  or opening of the gas injector channel  68  can be selectively opened or closed, for example by the occluding mandrel, to modulate the amount of bubbles in the aerated liquid  120 . For example, the user can close the gas injector channel  68  or gas lumen  48  by sliding the occluding mandrel within the gas injector channel  68  by actuating the mandrel with a control, such as a slide or button, on the catheter  8  and/or system handle  4 , or actuating and turning a valve at the opening of the gas injector channel  68  or in the gas lumen  48  by rotating a connecting rod and gear at the valve, or inflating an occluding balloon in the gas injector channel  68  or gas lumen  48  by use of a separate inflation lumen, or other implements that will pinch or close the gas injector channel  68 . 
         [0077]    In experiments, plugging or occluding the gas lumen  48  opening for a 50 cc injection of saline liquid resulted in no or a minimal amount of aspirated room air being collected in the aerated liquid  120  expelled from the catheter  8 . In another demonstration of the system with the same 50 cc injection of saline liquid, for one half of the injection run, (i.e., 25 cc of saline), the gas lumen  48  was left unobstructed and was then obstructed for the injection of the remaining 25 cc of saline. The total volume of room air collected in the expelled aerated liquid was 2.25 cc or a 61% decrease in the amount of room air delivered in the aerated liquid  120 . 
         [0078]    The size of the gas (e.g., air) bubble or the total volume of gas (e.g., air) entering the liquid lumen  50  in the throat  70  can be controlled by the diameter opening of the gas injector channel  68 . A larger diameter opening of the gas injector channel  68  can produce larger bubbles. In laboratory experiments, a 20% change in the tap  160  from a tap inner diameter of 0.016″ to 0.020″ resulted in an increase of total air volume being delivered in 50 cc of saline liquid at a rate of 100 mL/min from provided 5.75 cc of room air for the 0.020″ ID compared to 3.8 cc of room air for the 0.016″ ID, which is a 51% increase in total room air delivered in the aerated liquid  120 . 
         [0079]    Laboratory experiments indicated that obstructing the gas lumen  48  by 44% of the internal area of the gas lumen  48  by inserting an internal occluding mandrel within the gas lumen  48  up to 1 cm form the distal end of the device resulted in 4.0 cc of room air being collected in the expelled media at a 30% reduction of total room air delivered in the media. 
         [0080]    The ability to reduce the quantity or rate of room air being injected into the target site, such as a bodily cavity, or the outlet channel  62  can improve visualization in certain bodily cavities like the uterine cavity  138  or reduce the possibility or occurrence of inducing an air embolism. The system can control the rate or volume of gas being injected into the body. 
         [0081]    The lateral gas port  16  can be connected to a gas source such as a gas canister for the instillation of different gases such as CO2. The gas canister can be attached or integrated within the system  2  or catheter  8 , or connected via tubing from the gas source to the gas lumen  48 . For example, the lateral gas port  16  can have a female luer fitting or tubing connection to the gas source. The bubbles within the aerated liquid  120  can be entrained, for example when the gas is CO2. 
         [0082]    The system  2  can use a pressurized or non-pressurized gas source. The gas source can be a low pressurized rigid or flexible container. The gas source can be transportable or fixed (e.g., a gas line from a central high-pressure source in a hospital extending from a wall). The low pressurized container can be a built-in or integrated component of the system  2 . The gas, such as air or CO2, can be supplied in a low pressure foil bag. 
         [0083]    Gas, such as room air, can flow through the micro-filter in the lateral gas port  16  and/or gas lumen  48 . 
         [0084]    The liquid reservoir  92  can be filled with a liquid, foam and/or gel, such as saline or water. (Although described as liquid herein, the liquid lumen  50  can deliver foam and/or gel, and the description of the system and methods herein apply to liquids as it does to foams and/or gels.) The liquid can have or be supplemented with a drug, therapeutic agent, and/or surfactant. The liquid can be delivered through the inlet port  32  and check valve  94 . The liquid reservoir  92  can be filled before and/or during the procedure delivering aerated  120  or non-aerated liquid  118  to the target site. 
         [0085]    The gel can have a higher viscosity from a range of approximately 5% to about 75% to reduce the amount of leakage through the cervical canal or the fallopian tubes  142  to maintain distension within the uterine cavity  138 . The system  2  can aerate the gel and/or foam, as described for the liquid. For example, an aerated gel can be delivered to the uterine cavity  138  and then an alternate solution with a lower viscosity than the gel, such as an aerated foam or aerated saline, can be delivered by the system  2  to the cornu for assessing patency of the fallopian tubes  142 . 
         [0086]    The drugs, such as anesthetic or therapeutic agents such as lidocaine, can be delivered to the liquid reservoir  92  alone or in combination with other liquids. The drugs, aerated or non-aerated, can be delivered to the target site. The system can nebulize the drug during delivery to the target site. 
         [0087]    Increasing the ratio of surfactants in the liquid can increase the size and coalescence properties of the bubbles within the aerated liquid  120 . Additional surfactant can create or entrain more bubbles in the aerated liquid  120  during use of the system. The use of a surfactant can be therapeutic. For instance, the surfactant can be baby shampoo, for example to improve the wetting properties or mucus removal action of aerated liquid  120  within nasal and sinus cavities. 
         [0088]    The liquid lumen  50  can be connected to a vacuum source to remove media, including the delivered liquid, from the target site (e.g., a bodily cavity or lumen). The catheter  8  can have an aspiration lumen (e.g., the tool lumen  88  and/or liquid lumen  50  can be an aspiration lumen, or the catheter  8  can have a separate, devoted aspiration lumen). The pump lever  34  can be rotated to compress the liquid reservoir  92  and pump or deliver the liquid through the catheter  8  and to the target site. 
         [0089]    The liquid reservoir  92  can be resilient and the pump lever  34  can be rotated outwardly from the system handle  4  case to expand the liquid reservoir  92 , create suction or negative pressure in the liquid lumen  50 , and draw aspirant from the target site and through the liquid lumen  50  into the liquid reservoir  92  or a separate specimen container. 
         [0090]      FIG. 7  illustrates that an occluding member  122  can be inserted through the gas lumen  48  to reduce or eliminate the amount of air within the gas injection lumen. The outlet port  14  of the distal tip  12  can be placed adjacent to the fallopian tube os  166 , for example, for the passage of one or more tools  124 , such as instruments for the delivery of fallopian tube inserts, endoscopes, or diagnostic fluid, cytology, or cellular sampling devices through the liquid lumen  50  and exiting the outlet channel  62 . The openings for the introduction of one or more tools  124  within the liquid lumen  50  can be placed on or near the proximal handle  4  through the use of one or more Y-connector ports or valves. 
         [0091]      FIG. 8  illustrates that the amount of gas, such as room air, collected within the expelled aerated liquid  120  can be influenced by the rate in which the liquid, such as saline, is expelled through the liquid lumen  50  in the catheter  8  and ultimately, the rate the liquid is passing through the venturi constriction  54 . The rate of liquid passage can impact the turbulence of the fluid flow. In laboratory experiments, as shown in  FIG. 8 , the amount of room air collected in the expelled aerated liquid  120  varies for differing flow rates through the catheter system. The gas lumen  48  can have flow regulators and/or valves that can provide accurate amounts of air within the liquid. In addition,  FIG. 8  illustrates that a maximum amount of delivered air can be calculated as a result of flow turbulence in higher rates of flow. 
         [0092]    The location of the aeration component, such as the gas injector channel  68 , within the catheter  8  with respect to the output port  14  can impact the size of the bubbles of the gas in the liquid (e.g., saline). The gas can act as a contrast media (e.g., air), for example during ultrasound visualization. In laboratory experiments, the size of air bubbles within the aerated liquid  120  was observed to become larger for every 2.0 in. of traveled catheter length of the aerated liquid  120  due to bubble coalescence. 
         [0093]    For visualizing the interior walls of the uterine cavity  138  via ultrasound, the presence of air bubbles, large or small, can provide an artifact in observing the inner morphology of the uterine cavity  138  for defects or abnormalities. The system can selectively reduce or eliminate air bubbles delivered to the target site via the liquid within the ultrasound procedure. The lateral gas port  16  can be manually occluded by the physician, for example with a finger. In laboratory experiments with the air supply lumen opening unobstructed and 50 cc of saline liquid injected at a rate of 100 mL/min from provided 5.75 cc of room air bubbles within the saline media collected. Within the same conditions with the air supply lumen opening obstructed at the proximal end of the catheter  8 , no or a minimal amount of aspirated room air was collected within the expelled media (i.e., the liquid after exiting the outlet port  14 ). 
         [0094]      FIG. 9  illustrates that the distal tip  12  can be curved or rotated, as shown by tip rotation arrow  126 , for example when the deflection slide  30  is translated proximally  130 , as shown by slide translation arrow  128 , with respect to the system handle case  82 . 
         [0095]      FIG. 10   a  illustrates that distal tip  12  can have a straight configuration. The catheter longitudinal axis  10  can be substantially straight in the distal tip  12 . 
         [0096]      FIG. 10   b  illustrates that distal tip  12  can have a curved configuration. The catheter longitudinal axis  10  can have a catheter radius of curvature  132  from about 3 in. to about 36 in., more narrowly from about 6 in. to about 24 in. 
         [0097]      FIG. 11   a  illustrates that the distal tip  12  of the catheter  8  can be introduced through the external cervical os  134 , the cervical canal in the cervix  136 , and positioned into the uterine cavity  138  where a diagnostic or therapeutic procedure can be accomplished. The visible catheter markings  18  on the distal portion of the catheter  8  can indicate the depth of insertion of the catheter  8  into the cervix  136  and uterine cavity  138 . 
         [0098]    The stopper  106  can be pressed against the external cervical os  134  or exocervix, creating a liquid-tight seal. When the stopper  106  is in a desired position with respect to the catheter  8 , for example evaluated by the relative positions of the overtube markings  106  and catheter markings  18 , the overtube  102  can be fixed to the catheter  8 . 
         [0099]    Intra-uterine pressure can be created or increased by the injection of fluid into the uterine cavity  138  by the outlet port  14  to distend or separate the walls of the uterus  140 . In vivo, the uterine cavity  138  is typically a potential space. Uterine cavity  138  distension facilitates the visualization of the inner morphology of the cavity so that uterine abnormalities such as fibroids, myomas, polyps, or intra-uterine inserts like IUDs can be better visualized, diagnosed, and treated, for example by the system. The system can be used without the stopper  106 , for example, not sealing the external cervical os  134 . The system  2  can be used without distending the uterus  140 . Not distending the uterus  140  improves patient comfort and this may be desirable for evaluations of fallopian tube inserts, or when specific anatomical features or devices or being evaluated, such as an IUD. Evaluating the fallopian tube os  166   142  can be facilitated with a curved distal catheter  8 . 
         [0100]    Once the cervical canal is traversed, the catheter  8 , or a second catheter with a distal curved section, can be advanced further into the uterine cavity  138  and towards a corneal region. The second curved catheter can be selectively advanced, for example, by actuation of a sliding button, rod, or rotating gear. 
         [0101]    Before or after the distal tip  12  is inserted into the uterus  140 , the distal tip  12  can be curved or rotated, as shown by tip rotation arrow  126 , to position the outlet port  14  at the target site, such as the cornu  144 . The positioning of the distal terminal end of the catheter  8  and outlet port  14  at the cornu  144  can place the outlet port  14  in close proximity at a range of about 0 mm to about 3 mm to the fallopian tube ostia  166 . For example, the outlet port  14  can be from about 0 mm to about 10 mm from the fallopian tube ostia  166 , more narrowly from about 1 mm to about 5 mm, for example about 0 mm or about 1 mm. 
         [0102]    The distal tip  12  can be configured to occlude or seal the opening of the fallopian tube os  166 , for example to produce more distension pressure within the fallopian tube  142 . For example, the ball tip  40  can have a generally bulbous shape. The ball tip  40  can have a larger diameter than the catheter  8  adjacent to the ball tip  40 . The ball tip  40  can have an inflatable balloon with a central hole for the outlet channel  62 . The ball tip  40  can be deflated and wedged or positioned into the patient&#39;s cornu  144 , and then the ball tip  40  can be inflated, for example to seal the ball tip  40  at the cornu  144 , containing pressure and maintaining distension in the fallopian tube  142 . 
         [0103]    The system  2  can aspirate material including liquid and solids from the target site through an aspiration lumen or the liquid lumen  50 . 
         [0104]    As shown by the aerated liquid flow arrow  146 , the system can deliver aerated (and/or non-aerated  118 ) liquid  120  through the liquid lumen  50  and out the outlet port  14  to the cornu  144  and/or os of the fallopian tube  142 , and/or inside of the fallopian tube  142 . The aerated liquid  120  can have bubbles  148  that can coalesce in the liquid. The bubbles  148  can be visualized. The bubbles  148  can determine or confirm by ultrasound or other visualization whether the flow of liquid is traversing a specific fallopian tube  142 . Flow of the bubbles  148  through the fallopian tube  142  can be evidence that the fallopian tube  142  is patent or occluded (e.g., by an occlusion device, ligation and/or disease). 
         [0105]    Once the fluid has entered the fallopian tube  142 , the aspiration lumen can suction and collect the fluid in the fallopian tube  142  by use of pumping action in the system handle  4  or by use of an external vacuum source connected to the aspiration lumen (e.g., liquid lumen  50 , tool lumen  88 , and/or gas lumen  48 ). A specimen collection cytology brush, bag, or other container can be located at the proximal portion of the aspiration lumen and collect the aspirated material such as fluid, for example for pathological examination. The collection of fluid from the fallopian tube  142  can be used for assessing fallopian tube disease, detecting cancerous ovarian cells, or aspirating materials or media that may reside in the peritoneal cavity. 
         [0106]    The outlet port  14  can be offset from the distal terminal end of the device (e.g., the head  38  can be angulated, as shown in  FIG. 3   a ), the ball tip  40  can be a leading blunt edge for the catheter  8 . When the catheter  8  traverses the cervical canal, the leading ball tip  40  can atraumatically push the cervical canal and uterine cavity  138  open and not collect or scoop material into the outlet port  14 . 
         [0107]    The outlet port  14  can be at the distal terminal end of the device (e.g., the head  38  can be straight and at or near the central axis of the catheter  8 , as shown in  FIG. 3   b ). The head  38  can be the leading member of the device as opposed to the outlet port  14  of the catheter  8 . When the catheter  8  traverses the cervical canal, the head  38 , as the leading edge of the ball tip can push the cervical canal and uterine cavity  138  open and thereby minimize the materials that could be collected and/or gathered into the opening of the outlet port  14 . 
         [0108]    A lumen, such as the tool lumen  88 , of the catheter  8  can be configured with an internal straightening or stiffening mandrel, such as the occluding member  122  or a straightening mandrel. The straightening mandrel can have a greater stiffness than the catheter  8  without the straightening mandrel. The catheter  8  can be biased, for example having a shape memory material, to a have a curved distal tip. The curve in the distal tip of the catheter  8  can be formed by thermal forming, molding, or heat setting the catheter material. The straightening mandrel can be inserted into and advanced along the catheter  8 , extending into and/or through the distal tip  12 , before or during insertion of the catheter  8  through the cervix  136 . After the distal tip  12  traverses the cervical canal, the straightening mandrel can be retracted directly by pulling on the straightening mandrel or through the actuation of buttons, rods or gears on the system handle  4 . As the straightening mandrel is retracted, the distal tip  12  can return to a curved shape, for example curving toward the cornu  144 . 
         [0109]      FIGS. 11   b  and  11   c  illustrate that a curved guide tube  152 , curved overtube  102  or curved catheter  8  can be supplied with or within the primary catheter (i.e., the primary catheter is described elsewhere herein as the catheter  8 ). The curved guide tube  152  can be advanced directly or by sliding buttons, rods, or gears. Once the injection of air bubbles to the first fallopian tube os  166  is completed, the contralateral (i.e., second) fallopian tube  142   b  can be assessed, as shown in  FIG. 11   c , by retracting the curved guide tube  152  slightly, re-advancing the straightening mandrel, rotating the curved guide tube  152  180 degrees to the contralateral cornu  144 , as shown by arrows, retracting the internal straightening mandrel (if used), and re-advancing the curved guide tube  152  and aeration device  6  towards the contralateral cornu  144 . 
         [0110]    The curved guide tube  152  can be rotated, as shown, manually by the physician through manual rotation of the entire catheter system, or through the turning of the rotation knob  28 . The rotation knob  28  can be connected to the curved guide tube  152 . The curved guide tube  152  can direct the primary catheter  8  to either cornu  144  of the uterine cavity  138 . Each fallopian tube  142  can be diagnosed or treated individually. The aerated fluid can be released into the central body of the uterine cavity  138  or at the cornu  144 . 
         [0111]    The curvature of the catheter  8  can be controlled through the use of pull wires attached to an actuator on the handle  4 , such as the rotation knob  28  and/or deflection slide  30 . These actuators, such as the rotation knob  28  and/or deflection slide  30 , can be gear wheels or cams that pull a steering or deflection wire connected to the distal end of the catheter  8 , creating tension in the steering wire and catheter  8  that can curve the catheter  8 . 
         [0112]    The aeration device  6  can place air bubble-filled liquid within the fallopian tube ostia  166 . The outlet port  14  can direct the liquid at an upward angle, such as the outlet angle  66 , relative to the catheter longitudinal axis  10 , in a cranial direction of the patient. The upward angle of the outlet port  14 , or angled ball tip  40 , can position the air bubble-filled (aerated) liquid  120  immediately at or towards the ostia openings of the fallopian tubes  142  with the catheter  8 . When the catheter  8  is placed in the cornu  144  of the patient&#39;s uterine cavity  138 , the catheter longitudinal axis  10  can be pointed towards the lateral wall of the uterus  140 . The aeration device  6  can direct the air bubble-filled liquid in the cranial direction of the patient&#39;s uterine fundus  150  which can be the location of the patient&#39;s fallopian tube opening within the intramural or interstitial portion of the uterus  140 . 
         [0113]    The system  2  can be operated with one hand to inject liquid through the liquid lumen  50 , advance and retract the straightening mandrel, advance, articulate and rotate (e.g., to direct the catheter  8  to a specific cornu  144 ) the catheter  8  with the rotation knob  28 , deflection slide  30 , buttons, gears, and/or cams, control the amount and/or density of air bubbles in the aerated liquid  120 , or combinations thereof without re-gripping or re-positioning the hand on the system  2 . 
         [0114]    The device and features of the integrated aeration device  6  can be used in other natural or created bodily cavities or lumens such us the urethra, gastrointestinal tract, and others locations in the body. 
         [0115]    The flow of bubbles can be tracked to and possibly through the fallopian tubes  142  to determine the presence and effectiveness of tubal inserts or tubal ligation for permanent contraception, determining the presence of unilateral fallopian tube disease, or combinations thereof. The use of Doppler ultrasound can facilitate the visualization of fluid and bubble flow through the fallopian tubes  142 . 
         [0116]    The system  2  can deliver devices to the fallopian tube  142  during ultrasound, radiographic, and endoscopic visualization to monitor the system position, procedural progress, and diagnostic information. The system  2  can enter the fallopian tube orifice or os with or without uterine distention for visualization. The uterine cavity  138 , including the uterine fundus  150 , can be in natural flaccid, substantially untensioned state (e.g., reducing the tendency for fallopian tube spasm) during use of the system  2 . (Fallopian tube spasm can reduce the cannulation rate in the delivery of fallopian tube devices by hindering the passage of catheters  8  and devices.) The system  2  can be used to deliver inserts through the tube lumen into the fallopian tubes  142 . 
         [0117]    The bubbles  148  can create echogenic reflections, and therefore images, during ultrasound visualization. The bubbles  148  can create radiographic images during radiographic visualization, such as fluoroscopy. The movement of the bubbles  148  can be tracked by ultrasound and/or radiographic imagining as they progress into the fallopian tubes  142 . By depressing, squeezing, or rotating the lever  34  of the pump handle and concurrently allowing the lateral gas port  16  to remain open, the bubbles  148  in the aerated liquid  120  can be used to direct placement of the device, for example by enhancing the visualization capabilities of the user. 
         [0118]    A visual spectrum endoscope having a camera (e.g., CCD, CMOS) can be inserted through the tool lumen  88 , or adjacent to the catheter  8 , and to the target site. The uterus  140  can be distended, for example by inflation with the liquid or gas, for example opening the uterine cavity  138  to allow panoramic views of the uterine cavity  138  with the endoscope camera. The endoscope can have an outer diameter from about 0.4 mm to about 2.0 mm. The uterus  140  can be left undistended as the endoscope passes through and visualizes the uterine cavity  138 , cornu  144 , and fallopian tube os  166 . The catheter  8  can inject liquid to the undistended uterus  140  (e.g., at the cornu  144  or os of the fallopian tube  142 ) to create local inflation around (e.g., within 10 mm of) the outlet port  14  to open the potential space and expand the range of the field or depth of view of the endoscope camera. The endoscope camera can be positioned adjacent (e.g., within 3 mm) of the outlet port  14 . The endoscope can view the flow of bubbles  148  into the fallopian tube ostia  166  supplied selectively or on demand by the physician. The flow path of the bubbles  148  can indicate that the lumen or object immediately within the field of view of the endoscope is the fallopian tube ostia  166 . (e.g., Within the uterine cavity  138 , many objects can appear to be the fallopian tube  142  lumen even with high resolution endoscopes with full uterine distension and large fields of view.) The system  2  can deliver a tool  124  or fallopian tube instrument concurrent with bubbles  148 , for example, to confirm the location and identity of the fallopian tube  142 , as well as give the endoscopic viewer a sense of patency or fluid flow through the observation of a visual stream of bubbles into the fallopian tube lumen. 
         [0119]    A tool  124  can be delivered through the liquid lumen  50 , the gas lumen  48 , or the tool lumen  88  of the catheter  8 . 
         [0120]      FIGS. 12   a  through  12   c  illustrate that a tool  124  can be delivered through the tool lumen  88  and out of the head  38  of the catheter  8 . The tool  124  can exit the catheter  8  at the outlet port  14  or through a separate tool exit port. The tool  124  can be or be attached to an implant such as an intratubal insert  154  or fallopian tube insert. For example the intratubal insert  154  can be releasably attached to the distal terminal end of the tool  124 . The tool  124  and insert can be translated out of the distal end of the catheter  8 , for example, parallel with the catheter longitudinal axis  10  or deflected in an upward or cranial direction upon exiting the distal end of the catheter  8  (as shown). The intratubal insert  154  can be delivered into the fallopian tube  142  and then released from the tool  124 . The intratubal insert  154  can be left in the fallopian tube  142  and occlude the fallopian tube  142  (e.g., immediately and/or through a healing response from the fallopian tube tissue). 
         [0121]      FIG. 13  illustrates that the proximal end of the tool  124  can be connected to a tool handle  156 . The tool handle  156  can control the tool  124 , for example, steering, deflecting, extending, and retracting the tool  124 , and controlling the release and/or reattachment to the intratubal insert  154 . The tool  124  can be inserted through a terminal proximal opening of the tool lumen  88 . A first hand  158  can be used to hold and operate and manipulate the system, for example the system handle  4 , rotation knob  28 , pump lever  34 , and deflection slide  30 . A second hand (not shown) can be used to operate and manipulate the tool handle  156 , for example controlling the tool  124  and delivering the intratubal insert  154  to the fallopian tube  142 . Either or both hands  158 , or parts thereof such as the fingers, thumbs or palms, can be used to control gas flow into the gas lumen  48 , for example by covering (i.e., closing) and uncovering (i.e., opening) the lateral gas port  16  on the system handle  4  and/or catheter  8 . 
         [0122]    The intratubal insert  154  can be delivered through the liquid and/or gas lumen  50 , 48 . 
         [0123]    The intratubal insert  154  can be releasably attached to a tool  124  in the system  2 . The intratubal insert  154  can be in the delivery mechanism and can be advanced by use of an actuator on the handle  4 . The actuator can be gear wheels which roll the insert out of the outlet port  14  of the catheter  8 , a slideable button that manually advances the insert beyond the outlet port  14  and into the fallopian tube  142 , a rotating knob  28  that engages a threaded piston for advancing the insert  154 , other combinations of mechanical actuators for advancing a device in a catheter  8 , or combinations thereof. An electrical, battery powered, or pressurized mechanism can advance the insert  154 . 
         [0124]    The system  2  can have two intratubal inserts  154 , for example, to deliver one insert  154  to each fallopian tube  142  of a patient. 
         [0125]    The delivery device can be integrated with a sampling device or cytology brush for pathological examination of the fallopian tube lumen. The sampling can be done with an aspiration lumen for removing materials from the fallopian  142  for further examination. The aspiration lumen can be fitted with an irrigation source to first instill fluid into the fallopian tube lumen and then remove the fluid media for subsequent pathological analysis. The fluid media can alternatively be supplied by the internal fluid pathway within the aeration mechanism (venturi  52 ). 
         [0126]    The delivery device system can be used to deliver drugs, therapeutic agents, or biological material such as reproductive materials, into the fallopian tube  142 . 
         [0127]    The system  2  can instill CO2 for the delivery of distension media into the peritoneal cavity. This would obviate the need to puncture the abdominal wall with a Veress needle prior to laparoscopic examination in the patient with suspected difficulty in gaining peritoneal access due to anatomy, obesity, abdominal adhesions, prior surgery, or other indications. 
         [0128]    The system can deliver, for example through the tool lumen  88 , fallopian tube inserts for the purpose of creating permanent occlusion and contraception. One such insert is the Essure™ product offered by Bayer HealthCare Pharmaceuticals Inc. The system  2  can deliver drugs, an aspiration element (e.g., by vacuum pressure or negative pressure), biopsy brush, sampling devices, or combinations thereof to the uterus  140  or fallopian tube  142  for the evaluation of ovarian cancer, endometriosis and other gynecological and reproductive disorders. 
         [0129]    U.S. patent application Ser. No. 13/830,202, filed Mar. 14, 2013 is incorporated by reference herein in its entirety. 
         [0130]    It is apparent to one skilled in the art that various changes and modifications can be made to this disclosure, and equivalents employed, without departing from the spirit and scope of the invention. Elements of systems, devices and methods shown with any embodiment are exemplary for the specific embodiment and can be used in combination or otherwise on other embodiments within this disclosure. Furthermore, unless specified otherwise, the elements of methods described can be performed in various orders, not just the disclosed order.