HSG Recommended Female Infertility Tests

Recommended Female Infertility Tests

Posted on July 6, 2015 by Janet Chiaramonte

In March 2015, the Practice Committee of the American Society of Reproductive Medicine (ASRM) published a report identifying the recommended methods for evaluating female infertility. These evaluative infertility tests are summarized in this blog.

This evaluation is indicated for women who fail to achieve a successful pregnancy after one year of regular unprotected intercourse. In women over the age of 35, this evaluation would be warranted after just 6 months of trying to conceive since there is an age related decline in fertility as women approach the age of 40. Other reasons to seek an evaluation regardless of age, include a history of amenorrhea (absence of menses), a diagnosis of advanced endometriosis and suspected fertility problems of the male partner. An evaluation of both partners should begin at the same time.

Consultation

The initial consultation should include a comprehensive medical, reproductive and family history as well as a thorough physical exam.  Subsequent visits should be conducted in a cost-effective manner so as to identify all relevant factors with initial emphasis on the least invasive methods for detection of the most common causes of infertility.

Tests for Assessing Ovulation

The first assessment would be directed at determining whether or not a woman is ovulating regularly. The most common causes of ovulatory dysfunction include polycystic ovary syndrome (PCOS), obesity, thyroid disorders and elevated prolactin levels.  To assess these conditions, the following tests are performed:

transvaginal ultrasound to evaluate the size and number of developing follicles,

measurement of height, weight and body mass index serum blood tests of TSH (thyroid-stimulating hormone) and

Prolactin levels.

Ovarian Reserve Testing

The next assessment addresses ovarian reserve. This term describes reproductive potential as a function of the number and quality of a woman’s eggs. Diminished ovarian reserve describes women who are having regular menses but whose response to ovarian stimulation would be reduced compared to women of the same age. Tests to evaluate ovarian reserve include:

measurement of cycle-day 3 serum blood levels of FSH (follicle stimulating hormone) and Estradiol. High values of FSH (>10) have been associated with both poor ovarian stimulation and the failure to conceive

determination of AFC (antral follicle count) through transvaginal ultrasound.  A low AFC is considered to be 3-6 total antral follicles and is associated with poor response to ovarian stimulation but does not reliably predict failure to conceive

measurement of serum levels of AMH (anti-mullerian hormone).  Lower AMH levels (<1) have been associated with poor response to ovarian stimulation, poor embryo quality, and poor pregnancy outcomes in IVF cycles.

Tests for Assessing the Structure and Function of the Female Reproductive Tract. Tests that are used to evaluate the uterus and fallopian tubes include

HSG (hysterosalpingography) is the standard test for determining if the fallopian tubes are open.  It is also used to define the size and shape of the uterine cavity and can reveal developmental abnormalities such as a septate uterus.

HSN (hysterosonogram) is the standard test for detection of intrauterine pathology such as polyps or fibroids.

Hysteroscopy is reserved for the further evaluation and treatment of abnormalities discovered through an HSG or HSN.

Laparoscopy should not be performed routinely but may be warranted when there is an indication of advanced stage endometriosis or pelvic adhesions (scar tissue).

Other tests that were commonly used in the past to assess female infertility are no longer recommended.  These include post coital testing of cervical mucus and endometrial biopsy. These tests have not been found to be predictive of reproductive success.

If you are curious about your inability to conceive, and schedule an appointment with one of InVia’s Board Certified physicians at one of our four Chicagoland locations.

Tubal catheterization (TC): indications and techniques. Part I

Posted on July 1, 2013 by Dr. Vishvanath Karande

Tubal factor is a major cause of female infertility.  Evaluation of the fallopian tubes is routinely done as part of an infertility work up.  Several techniques have been used to evaluate the fallopian tubes.  These include X-ray (hysterosalpingogram, HSG); ultrasound (hystero-contrast-sonography (HyCoSy); three-dimensional Doppler tubal flow measurements); and laparoscopy.  HSG remains the most commonly used technique for evaluating the tubes.  The question is, what can be done if the tubes are blocked?  The answer (in selected cases) is tubal catheterization (TC).  At InVia Fertility Specialists, we will often do a HSG and immediately proceed with TC if there is tubal blockage.  TC is less invasive and more cost-effective than other options such as laparoscopy, tubal microsurgery or in vitro fertilization (IVF).  The best part is that it is simple and it works!

When is TC indicated?

TC can be done when there is proximal tubal occlusion (PTO; the tubes are blocked at the uterine end).  Patients with distal tubal occlusion (the tubes are blocked at the fimbrial end) often have hydrosalpinx and are NOT candidates for TC.  TC is not indicated when there has been a tubal ligation.  In patients with salpingitis isthmica nodosa; TC should be deferred as IVF is the treatment of choice in these patients.

What are the instruments used for TC?

TC involves the use of specially designed coaxial catheter systems.  There is the uterine access balloon catheter (see above; A) that is used for performing HSG.  It has a balloon at its tip, which is inflated with air to hold it in place in the cervix or lower uterine cavity.  It also has a central channel, which allows introduction of other catheters.  The selective salpingography (SS) catheter (see above; B) can be inserted through the central channel of the cervical canulla.  It has a curved tip and can be manipulated into the tubal ostia (opening).  The third component is a wire-guide (see above; C).  This has a special coating that makes it slippery and easy to manipulate into the tubal lumen.

What is the technique for TC?

TC involves the use of specially designed coaxial catheter systems.  The first step (see above; A) is to do a HSG with the uterine access balloon catheter in place and confirm the diagnosis of PTO.  A SS catheter is then inserted coaxially through the cervical canulla and manipulated into the

tubal ostia (see above; B).  Dye can then be injected directly into the tubal opening and will often open up the blocked tube.  Should this fail; the wire-guide is inserted through the central channel of the SS catheter into the tubal ostia (see above; C).  It is then advanced past the occluded portion of the tube into the distal tubal lumen and is moved in a to and fro manner to further open up the tube.  This is similar to what a plumber does to open up a blocked pipe!

Does it hurt?

The discomfort experienced during TC is not much different than a HSG. We pre-treat patients with Ibuprofen 800 mg and give a local anesthetic (paracervical block) to further reduce any discomfort.

Commonly seen tubal abnormalities on hysterosalpingography

Posted on June 17, 2013 by Dr. Vishvanath Karande

In previous blogs, I have presented findings of a normal hysterosalpingogram (HSG) and abnormalities of the uterine cavity.  In this blog, the focus is shifted to the fallopian tubes.  There are several techniques used to evaluate fallopian tube patency.  These include HSG, ultrasound and laparoscopy.  We use all these modalities in our practice.  HSG, however, remains the most common technique for evaluating tubal patency.

In addition, HSG provides important information about the shape of the tube (contour) and the presence or absence of tubal folds (rugae).  The presence of the folds is a good sign and may indicate that the tube may be functional (see above).

Salpingitis isthmica nodosa (SIN), also known as diverticulosis of the fallopian tube, is a nodular thickening of the isthmic (narrow) portion of the fallopian tube.  It may be caused by inflammation.  As shown above, it consists of multiple contrast material–filled luminal pouches (arrowheads) projecting 2–3 mm outward from the isthmic portion of both fallopian tubes.  It can be on one side or both sides.  In severe cases, it leads to complete tubal blockage.  Patients with SIN are at an increased risk of having a tubal pregnancy.  IVF has now replaced surgery as the treatment of choice for this condition.

Proximal tubal blockage (occlusion).  The above picture shows the uterine cavity to be normal.  The dye, however, does not enter the fallopian tubes despite being injected forcefully.  It can be sometimes caused by “spasm” of the fallopian tubes.  We minimize this possibility by pre-treating patients with ibuprofen and injecting the dye gently.  Proximal tubal blockage (occlusion) can often be treated with tubal catheterization.

Distal tubal blockage (occlusion).  As shown above, the uterine cavity is normal.  The tubes fill up with dye.  They, however, are dilated and fill up like balloons with no spill of dye forming what is called as a hydrosalpinx.  In this case, no rugae are seen.  This indicates that the tubes cannot be surgically repaired.  It is now well established that IVF pregnancy rates are lower with hydrosalpinx.  This could be because of several mechanisms 1) the hydrosalpinx fluid flushes out the embryos, 2) the hydrosalpinx fluid is embryo toxic or 3) the hydrosalpinx fluid has a negative impact on certain cell-adhesion molecules (integrins) that are required for embryo implantation.  We will often remove hydrosalpinx via laparoscopy prior to doing IVF 

Essure HSG.  Patients can now have a tubal ligation using hysteroscopy.  Using the Essure technique, a metallic coil is inserted into the tubal lumen.  The coil in turn induces fibrosis and blocks the tube.  A HSG can be done 3 months later to confirm that the Essure device is in place and the tubes are blocked.

Scar tissue (adhesions) around the tube cannot be definitely diagnosed with HSG.  When there is a localized collection of dye (loculation); these can be suspected.  Pelvic endometriosis cannot be diagnosed with HSG.

The ovaries cannot be visualized on HSG. The uterine wall itself also cannot be seen on HSG.  These require a combination of ultrasound and laparoscopy for a definite diagnosis.

At InVia Fertility Specialists, we use all three modalities (as needed) to comprehensively evaluate our patients.

Commonly seen uterine abnormalities on hysterosalpingography

Posted on June 12, 2013 by Dr. Vishvanath Karande

Here are a few of the commonly seen abnormalities when we do a hysterosalpingogram (HSG).

To start with, here is a normal HSG

Endometrial polyps are probably the commonest abnormalities seen on HSG.  These appear as filling defects and have to be differentiated from air bubbles.  If there is any doubt, a hysterosonogram can be done to confirm the diagnosis.

Intrauterine adhesions appear in the form of irregular filling defects.  In severe cases, the patient will complain of absent or scant menses.  They can cause infertility.  After surgery, they can reform and sometimes they can result in the placenta becoming densely attached to the uterine musculature (placenta accreta).

A slight concavity of the uterine fundus is referred to as an “arcuate uterus”.

An uterine septum can be associated with miscarriages.  It is not possible to differentiate with certainty between an uterine septum and a bicornuate uterus on HSG.

A bicornuate uterus is another commonly seen uterine malformation.  It can cause the baby to lie sideways or breech.  It is associated with premature delivery.

A unicornuate uterus is another uterine anomaly where only one half of the cavity is present.  It cannot be surgically corrected.

A double uterus (uterus didelphys) is sometimes seen.  It can be associated with a single or two cervices.

These some of the commonest uterine abnormalities seen on HSG

Hysterosalpingography

Posted on June 10, 2013 by Dr. Vishvanath Karande

A hysterosalpingogram (hystero = uterus; salpingo = fallopian tubes; gram = X-ray) or HSG is a simple procedure where X-rays are used to evaluate the uterus and the fallopian tubes.

A HSG is a routine test done as part of an infertility work up.  It is to be done in the first half of the cycle so that we can be sure that the patient is not pregnant.  In experienced hands, a HSG is quick, efficient and can be painless.

Indications for HSG include:

Evaluation of the uterine cavity for polyps, malformations or scar tissue;

Evaluation of the fallopian tubes for patency and abnormalities such as hydrosalpinx.

The inner lining of the fallopian tubes can also be evaluated.  The presence of folds (rugae) in the tubes is a sign of a healthy tube.

To diagnose salpingitis isthmica nodosa (SIN); which is a condition associated with tubal blockage and increases the risk of a tubal pregnancy

Location of a foreign body in the uterus (lost IUD) Confirmation of tubal blockage after a hysteroscopic tubal occlusion

procedure (ESSURE)

How is a HSG performed?

The patient lies on her back with her legs in stirrups.  A pelvic exam is often performed.  A vaginal speculum is inserted to expose the cervix, which is then held with an instrument (single-toothed vulsellum).  A local

anesthetic can be given around the cervix (paracervical block).  A plastic canulla is inserted through the cervix into the uterine cavity where its balloon is inflated to hold it in place.  A radio-opaque dye is then (gently) injected into the uterus through the canulla.  As the dye is being injected, serial X-ray pictures are taken.  These can later be viewed in great detail.  Once the procedure is completed, the vaginal instruments are removed.  The entire process takes only a few minutes.

Does it hurt?

Patients may experience some cramping as the dye is being injected.  This can be worse if the tubes are blocked and there is resistance to the dye flowing through.  We encourage our patients to take ibuprofen 800 mg a few minutes prior to the procedure.

What are the complications of HSG?

A HSG is a very safe procedure and has been done for many decades.  Some of the complications associated with HSG include:

Some patients may feel faint after the procedure (vasovagal attack).  This is uncommon and the feeling passes off in a few minutes.

Pelvic infection.  Any vaginal procedure is associated with the risk of infection.  The risk is so small that we no longer routinely give an antibiotic after a HSG.  In some patients, however, e.g. diabetics or those with hydrosalpinx may benefit from antibiotics.

The exposure to X-rays is minimal and there is no increased risk to the patient.

What if my tubes are blocked?

It is now possible to use special catheters (selective salpingography and wire guides) to open up blocked tubes at the time of diagnosis.  We specialize in this “tubal catheterization” procedure and I will write a blog about it in the near future.

What are the limitations of a HSG?

A HSG only gives information about the inside of the uterine cavity.  You could have fibroids in the uterine wall and these will not be seen on HSG.  Also, it is not possible to visualize the ovaries on HSG.  At InVia Fertility Specialists, we use a combination of HSG and ultrasound to complete a thorough investigation of the pelvic structures.

An additional advantage of HSG is that it can increase the chance of a spontaneous pregnancy!  Just the “flushing open” of the tubes may enhance your fertility!