“A COMPARATIVE STUDY OF THE ASSESSMENT OF TUBAL PATENCY IN FEMALE INFERTILITY BETWEEN MR HYSTEROSALPHINGOGRAPHY AND CONVENTIONAL HYSTEROSALPHINGOGRAPHY WITH DIAGNOSTIC LAPAROSCOPY AS GOLD STANDARD” Dissertation submitted to THE TAMILNADU Dr.M.G.R. MEDICAL UNIVERSITY In partial fulfillment of the requirements of M.D. DEGREE EXAMINATION BRANCH – VIII– RADIODIAGNOSIS KILPAUK MEDICAL COLLEGE CHENNAI– 600 010 THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY CHENNAI – TAMILNADU, INDIA APRIL 2017
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“A COMPARATIVE STUDY OF THE ASSESSMENT OF TUBAL
PATENCY IN FEMALE INFERTILITY BETWEEN
MR HYSTEROSALPHINGOGRAPHY AND CONVENTIONAL
HYSTEROSALPHINGOGRAPHY WITH DIAGNOSTIC
LAPAROSCOPY AS GOLD STANDARD”
Dissertation submitted to
THE TAMILNADU Dr.M.G.R. MEDICAL
UNIVERSITY
In partial fulfillment of the requirements
of
M.D. DEGREE EXAMINATION
BRANCH – VIII– RADIODIAGNOSIS
KILPAUK MEDICAL COLLEGE
CHENNAI– 600 010
THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY
CHENNAI – TAMILNADU, INDIA
APRIL 2017
BONAFIDE CERTIFICATE
This is to certify that the dissertation entitled “A COMPARATIVE
STUDY OF THE ASSESSMENT OF TUBAL PATENCY IN
FEMALE INFERTILITY BETWEEN MR
HYSTEROSALPHINGOGRAPHY AND CONVENTIONAL
HYSTEROSALPHINGOGRAPHY WITH DIAGNOSTIC
LAPAROSCOPY AS GOLD STANDARD” is a bonafide original work
of Dr.M.S Fouzal Hithaya under the guidance of Dr.J.Devimeenal M.D.,
Professor of department of Radio diagnosis, Govt. Kilpauk Medical
College & Hospital, Chennai -10 in partial fulfillment of the regulations
for M.D RADIO DIAGNOSIS BRANCH VIII examination of the
TamilNadu Dr. M.G.R Medical University to be held in april 2017.The period
of postgraduate study and training is from 2014 to 2017.
PROF.J.DEVIMEENAL,
DMRD., MD.,DNB
Guide
Professor & Head of Department,
Department of RadioDiagnosis,
Govt Kilpauk Medical college & Hospital,
Kilpauk, Chennai - 600 010.
Prof. Dr.R.NARAYANA BABU,
M.D,DCH,
Dean,
Govt Kilpauk Medical college &
Hospital,
Kilpauk,Chennai - 600 010.
DECLARATION
I Dr.M.S.Fouzal Hithaya, solemnly declare that this
dissertation titled “A COMPARATIVE STUDY OF THE
ASSESSMENT OF TUBAL PATENCY IN FEMALE
INFERTILITY BETWEEN MR HYSTERSALPHINGOGRAPHY
AND CONVENTIONAL HYSTEROSALPHINGOGRAPHY WITH
DIAGNOSTIC LAPAROSCOPY AS GOLD STANDARD was
prepared by me at the Govt Kilpauk Medical College & Hospital,Chennai -
10, under the guidance and supervision of Dr. J.Devimeenal,Professor, Govt
Kilpauk Medical College &Hospital. This dissertation is submitted to The
Tamil Nadu Dr. M.G.R Medical University, towards partial fulfillment of
university regulations for the award of M.D branch VIII Radiodiagnosis.
Place: Chennai
Date: Dr.M.S Fouzal Hithaya
ACKNOWLEDGEMENT
I express my heartful gratitude to the Dean,
Prof.Dr.R.NARAYANA BABU,M.D.,DCH Govt Kilpauk Medical
College & Hospital,Chennai-10 for permitting me to do this study.
I express my gratitude to Prof. Dr. J.DEVIMEENAL,
D.M.R.D., M.D., DNB., Head of the Department, Govt Kilpauk medical
college &Hospital, for her valuable guidance in doing the dissertation
work.
I owe a lot to Prof. Dr. J.DEVIMEENAL, D.M.R.D., M.D.,
DNB., who is also my guide whose expert guidance, constant
encouragement created an interest for me to pursue this study on MR
hysterosalphingography. It is her constant supervision and support that
made me possible to finish this study without much difficulty.
I am extremely thankful to my Professors,
Dr.P.CHIRTARARASAN, M.D., Dr. K.GOPINATHAN, M.D.,DNB.,
and Assistant professors Dr.R.KANAGASABAI, D.M.R.D., M.D.,
Dr.V.SUDHAKAR, M.D., Dr. G.USHA NANDHINI M.D.,DNB.,
DR.G.ARUN DILIP M.D., Dr.S.SUMEENA,DMRD., D.N.B,
Dr.D.PORKODI, DMRD., DR.S.SENTHILKUMAR DMRD., in the
Govt Kilpauk Medical College for their constant support,
encouragement and advice during my study.
I am extremely thankful to Dr.T.K.SHANTHI GUNASINGH,
M.D., DGO., Prof. and HOD Department of Obstetrics and
Gynaecology, Kilpauk Medical College, for guiding and encouraging
me throughout the study.
I also thank my fellow postgraduates DR.P.PRASANNA and
DR. N.SUDHIR and junior postgraduates who helped me in carrying
out my work and preparing this dissertation.
I thank all Radiology technicians including Mr.VIJAY and
Mrs.GRACE MARY, Staff Nurses and all the Paramedical staff
members and workers including Mrs.JEYA in Department of
Radiology, for their co- operation in conducting the study.
I thank my husband Dr.BASHEER AHAMED, my parents
Mrs.& Mr. SYED MOHAMED, my sister HAMZA, daughter RIFA
SABURA for their understanding and co-operation in completion of
this work.
Last but not the least; I owe my sincere gratitude to the patients
and their relatives who co-operated for this study, without whom the
study could not have been possible.
INDEX
Sl.No. CONTENTS PAGE
1 INTRODUCTION 1
2 AIMS AND OBJECTIVES 3
3 REVIEW OF LITERATURE 4
4 MATERIALS AND METHODS 36
5 CASES 42
6 STATISTICAL ANALYSIS AND RESULTS
RRESRESULTS
52
7 DISCUSSION 77
8 CONCLUSION 84
9 BIBLIOGRAPHY
ANNEXURE:
ABBREVIATIONS
ETHICAL COMMITTEE APPROVAL
PLAGIARISM
PROFORMA
CONSENT FORMS
MASTER CHART
INTRODUCTION
The World Health Organization defines infertility as “ A disease of the
reproductive system defined by the failure to achieve a clinical pregnancy after
twelve months or more of regular unprotected sexual intercourse”(1). .
Secondary infertility is defined as the inability to become pregnant, or to carry
a pregnancy to term, following a previous pregnancy or the birth of one or
more biological children.
The global prevalence of primary infertility is about 2% and secondary
infertility is 3 %( 2). The factors attributed to infertility are divided into male
and female factors. The female factors are classified into ovarian, uterine, tubal
causes. Tubal factors are the commonest factors contributing to 30 – 40% of
the cases (3).
Hysterosalphingography is the radiographic technique used in the
evaluation of uterus, fallopian tubes. It is used as the first line of investigation
in the evaluation of tubal factors in infertility (4). Sonosalphingography is yet
another technique used in the evaluation of tubal patency.
Although these techniques are feasible enough they are not without
pitfalls which include limited evaluation of congenital abnormalities of
uterus and extra uterine pathologies. Further more conventional
hysterosalphingography carries an unavoidable risk of exposure of the female
reproductive organs to radiation in young and potentially fertile women.
Most of the women undergoing conventional hystersalphingography
further require transabdominal and transvaginal ultrasound for further
anatomical details and identification of pathologies.
MRI of pelvis is the investigation of choice, because of its spatial and
contrast resolution in defining the anatomy as well as the pathologies of the
female reproductive tract as a whole. MRI well delineates the possible
abnormalities in the reproductive organs including congenital abnormalities,
myomas, endometriosis, ovarian cysts, polycystic ovaries etc.
MR hysterosalphingography (5) is a novel evolving technique that is
aimed at evaluating the tubal patency. Having the inherent advantage of
imaging the pelvis, MR hysterosalphingography is an innovative tool in female
infertility evaluation.
MR hysterosalphingography may be used as a single stop investigation
in detecting uterine, ovarian and tubal pathologies(6). There is no risk of
exposure of reproductive organs to radiation. MR hysterosalphingography as a
single investigation avoids the young women from undergoing a series of
varying investigations.
MR hysterosalphingography is a novel technique with very few pioneer
studies conducted at national as well as international levels. This prospective
study being done at Kilpauk Medical College is considered about the
introduction of this novel technique, designing the methodology of doing it,
and evaluating its diagnostic accuracy, thereby incorporating it in the infertility
evaluation protocol in the near future.
This study’s chief objective is to assess the feasibility and efficacy of
MR hysterosalphingography in identifying tubal patency in female infertility.
AIM
To assess tubal patency in female fertility using dynamic MR
hysterosalphingography
OBJECTIVES
1. To assess the efficacy of dynamic MR hysterosalphingography in
identifying tubal patency in female infertility.
2. To directly compare the results of dynamic MR
hysterosalphingography with conventional hysterosalphingography
with diagnostic laparoscopy as gold standard.
REVIEW OF LITERATURE
ANATOMY OF FEMALE REPRODUCTIVE SYSTEM
The female reproductive organs are divided into internal and external
organs. The internal organs include uterus with a pair of fallopian tubes and a
pair of ovaries (7).
The uterus is a hollow, firm, thick walled muscular organ. It is the child
bearing organ. It is situated in the pelvis, anteriorly is the urinary bladder and
posteriorly is the rectum. The adult uterus has the shape of an inverted pear. It
measures approximately 7.5 cm (superoinferior), 5cm (transverse), 2.5 cm
(antero posterior). It weighs about 30 – 40 grams.
PARTS OF THE UTERUS
The uterus has two parts: body and cervix. The body is the upper
expanded portion and forms upper two thirds whereas the cervix is the lower
cylindrical portion which forms the lower one third of the organ. The
constriction situated between the body and cervix is called the isthmus.
POSITION OF UTERUS(8)
VERSION
Version is defined as the angle formed between the long axis of the
uterine body with the long axis of the vagina in sagittal plane. Normally the
uterus is anteverted and the angle of version is 90o and open forwards. When
the uterus is retroverted, the body of the uterus is tilted posteriorly.
FLEXION
Flexion is defined as the angle between the long axis of the uterus with
the cervix. Normally the uterus is anteflexed. The angle of anteflexion is 1250.
In retroflexed position, the uterus is flexed posteriorly. Normally the uterus is
anteverted and anteflexed such that the long axis of uterus corresponds to the
pelvic inlet and the long axis of vagina corresponds to the pelvic outlet.
Angle of anteversion
Angle of anteflexion
BODY OF UTERUS: (9,10)
Body of the uterus has Fundus, anterior/ vesical surface, posterior/
intestinal surface and two lateral borders.
Fundus: Forms the convex dome of the uterus. It lies above the level of
openings for fallopian tubes.
Anterior surface: Flat and is related to the urinary bladder. Forms
posterior border of vesicouterine pouch.
Retroverted, Anteflexed
Retroverted, Retroflexed
Anteverted, Anteflexed
Anteverted, Retroflexed
Posterior surface: Is convex and related to the bowel loops. Forms
anterior border of rectouterine pouch or Pouch of Douglas.
Lateral border: Rounded and convex. Gives attachment to the broad
ligament which attaches it to the lateral pelvic wall.
Uterine cavity: Uterine cavity is slit like and is compressed
anteroposteriorly. It is triangular in shape with base upwards and apex
downwards. At the superolateral angles the cavity becomes continuous with the
fallopian tubes on either sides through the cornua. At the apex the cavity
becomes continuous with the cervical canal through the internal os.
Layers of uterus
1. Endometrium: The inner mucosal layer is specialized for menstrual and
reproductive function
2. Myometrium: Muscular layer that forms the uterine volume. It is divided
into outer myometrium and inner myometrium. The inner myometrium is
called the junctional zone (11) and normally measures < 8mm. It is made up of
tightly packed compact smooth muscles with little amount of water content and
extra cellular matrix.
3. Perimetrium: Outer serosal layer.
CERVIX
Cervix is the lower cylindrical part of uterus. It measures approximately
2.5 cm in length. The lower part of cervix projects into the vagina which
divides the cervix into two parts:
1. Supravaginal part
2. Vaginal part
Supravaginal part: Anteriorly related to the urinary bladder, separated
by parametrium made of fibrous tissue, posteriorly covered by the peritoneum
which reflects over the rectum forming the recto uterine pouch containing
small bowel loops, laterally extends the parametrium containing the ureters and
uterine arteries(12).
Vaginal part: The vaginal part projects anteriorly into the vagina.
Fornices are the spaces between the cervix and vaginal wall. There are anterior,
posterior and two lateral fornices.
Cervical canal: The cervical canal is fusiform in shape. It
communicates above with the uterine cavity through the internal os and below
opens into the vagina through the external os. The external os is bounded by
anterior and posterior lips. The walls have multiple mucosal folds called arbora
vitae uterine because they arborise like branches of a tree. These mucosal folds
interlock with each other so that the cavity is closed.
FALLOPIAN TUBES
Also called the uterine tubes. They are paired structures that extend
laterally from the cornua and open into the peritoneal cavity via the fimbrial
ends. The fallopian tube is 10 – 12 cm in length and 1 – 4 mm in diameter. It
bridges between ovaries laterally and uterus medially.
PARTS
1. Interstitial / Intramural segment: situated within the myometrium.
2. Isthmus: lateral to it the isthmus which is the narrowest segment, about
2 – 3 cm in length.
3. Ampulla: widest part , about 4 mm in diameter, 6 – 7 cm in length
4. Infundibulum: funnel shaped lateral end of the tube which contains
multiple finger like processes called fimbriae. Ovarian fimbria is the one
which is the longest and is attached to the ovary.
OVARIES
A pair of female gonads, situated within ovarian fossa which lies in the
posterior wall of true pelvis. Each ovary is ovoid in shape and measures
approximately 1.5 x 3cm and weighs 2 – 8 grams. The central part is the
medulla and outer is the cortex. Ovarian follicles are situated within the stroma
of the ovarian cortex. The follicles are in varying stages of development and
degeneration.
BLOOD SUPPLY
UTERINE ARTERY
Arises from the anterior division of the internal iliac artery. It crosses the
ureter anteriorly and it traverses through the broad ligament and ends by
anastamosing with the ovarian artery.
BRANCHES
Arcuate arteries to uterus: Arcuate arteries divide into radial arteries
which in turn penetrate the myometrium. At the endometrial level they divide
into basal and spiral arteries.
Tubal branch, Ovarian branch, Vaginal branch, Branch to round
ligament are the other branches.
OVARIAN ARTERY
Anterolateral branch from the abdominal aorta inferior to the level of
renal artery and superior to the level of inferior mesenteric artery. Supplies
ovary, fallopian tube and ends by anastamosing with ovarian branch of uterine
artery.
VENOUS DRAINAGE
Uterine veins drain into internal iliac veins.Right ovarian vein drains
into inferior vena cava. Left ovarian vein drains into left renal vein.
NERVE SUPPLY
UTERUS: Supplied by branches from ovarian and hypogastric plexuses,
third and fourth sacral nerves.
OVARY: Ovarian plexus is formed by branches from aortic, renal,
superior hypogastric and inferior hypogastric plexuses.
SUPPORTS OF UTERUS (13)
BROAD LIGAMENT
Formed by two layers of the peritoneum that drape over the uterus and
extend to the lateral pelvic walls on either sides from the uterus.
Upper margin is formed by fallopian tubes medially and laterally is the
suspensory ligament of ovary. Lower margin ends in the cardinal ligament.
Between the leaves of broad ligament is parametrium which is formed by extra
peritoneal connective tissue and fat. Broad ligament encloses the round
ligament, ovarian ligament, ovarian and uterine blood vessels, nerves and
lymphatics.
ROUND LIGAMENT
Band of fibromuscular tissue extending from the anterolateral aspect of
uterine fundus takes a curved course, runs in inguinal canal to end in labia
majora.
CARDINAL/ TRANSVERSE CERVICAL/ MACKENRODT’S
LIGAMENT
Extends from the cervix, upper vagina laterally to blend with fascia
covering obturator internus muscle. Its is the major supporting structure.
UTEROSACRAL LIGAMENT Extends posteriorly from the cervix and
vagina at the level of internal os and curves towards the anterior body of
sacrum at S2, 3 level.
OVARIAN LIGAMENT Extends laterally from the uterus to the ovaries.
SUSPENSORY LIGAMENT OF OVARY
Extends from anterolateral aspect of ovary and blends with fascia
covering psoas muscle.
Cross sectional image showing the relationship of uterine body, ovaries
with broad, round ligaments.
EMBRYOLOGY OF UROGENITAL SYSTEM
The urogenital system is derived from the intermediate mesoderm(14,15)
from which develop the kidneys, gonads, reproductive and urinary tract.
Mesonephric or Wolffian duct develops and the ureteric bud branches from the
caudal end of Wolffian duct(16).Adjacent to the mesonephric duct develops the
paramesonephric duct or the Mullerian duct.
After sex determination the hormones – testosterone, anti mullerian
hormone(AMH), Insulin-like 3 (Insl3)(17) trigger the regression of Mullerian
duct and stimulate the development of male genital tract. In female fetus the
absence of these hormones stimulate the development of female reproductive
system from the Mullerian duct and the regression of the Wolffian duct.
From 6th to 11th week of gestation fusion of the paired Mullerian ducts
occur resulting in formation of uterus with cervix and also proximal 2/3rd of
the vagina. Bilateral fallopian tubes are formed from the unfused uppermost
part of the paired Mullerian ducts. The central uterovaginal septum gets
absorbed by 9- 12 weeks, failure of which results in persistence of intrauterine
septum.
The ovaries are developed from the primitive yolk sac and lower 1/3 rd
of vagina is developed from the sinovaginal bulb which explains why these
anomalies are not commonly associated with Mullerian duct anomalies.
Widespread classification of Mullerian duct anomalies is given by
American Society of Reproductive Medicine (previously called as American
Fertility Society AFS ) in 1998 (18).
The European Society of Human Reproduction and Embryology
(ESHRE) (19) and European Society for Gynaecological Endoscopy improvised
the classification system.
Advantages of the new ESHRE/ ESGE classification:
Anatomy as the primary basis and embryology as the secondary
characteristic, user friendly, clear and accurate.
The prevalence of Mullerian duct anomalies is reported to be 0.16 – 10
% (20)
AMERICAN FERTILITY SOCIETY CLASSIFICATION
CLASS TYPE
I – MULLERIAN
AGENESIS OR
HYPOPLASIA
A- Vaginal
B- Cervical
C- Fundal
D- Fallopian
E- Combined
II – UNICORNUATE
UTERUS
A – Communicating rudimentary
horn with endometrial cavity
B – Noncommunicating rudimentary
horn with endometrial cavity
C - Rudimentary horn without
endometrial cavity
D - No rudimentary horn
III – UTERUS DIDELPHYS
IV- BICORNUATE
UTERUS
A – Complete
B - Partial
V – SEPTATE UTERUS A – Complete
B - Partial
VI – ARCUATE UTERUS
VII – DIETHYL
STILBESTEROL RELAED
ESHRE CLASSIFICATION
CLASS SUBCLASS
0 - NORMAL
I – DYSMORPHIC UTERUS a.T shaped
b.Infantile
II- SEPTATE UTERUS a.Partial
b.Complete
III – DYSFUSED UTERUS a.Partial
b.Complete
IV- UNILATERALLY FORMED a.Rudimentary horn with
cavity (Communicating/ Non
communicating)
b.Rudimentary horn without
cavity/ apalsia
V- APLASTIC/ DYSPALSTIC a.Rudimentary horn with
cavity (unilateral/ bilateral)
b. Rudimentary horn without
cavity (unilateral/ bilateral)/
aplasia
VI – UNCLASSIFIED
CO EXISTENT SUBCLASS CERVICAL/ VAGINAL ANOMALY
Cervix:
C0 – Normal
C1 – Septate
C2 – Double normal
C3 – Unilateral aplasia/
Dysplasia
C4 – Aplasia/ Dyspalsia
Vagina:
V0 – Normal
V1 – Longitudinal nonobstructing septum
V2 – Longitudinal obstructing septum
V4 – Transverse septum/ imperforate hymen
V5 – Vaginal apalsia
INFERTILITY
Infertility is a major clinical problem affecting 10 – 15% of couples in
the reproductive age group. The tubal factors contribute to about 30 – 40 % of
the causes.
The tubal pathologies include blocked tubes, hydrosalphinx, tubo
ovarian mass.(21)
The ovarian pathologies include polycystic ovaries, ovarian cysts.
Endometriosis is yet another important cause of infertility.
EVALUATION OF INFERTILITY(22)
Recommended guidelines for practice in evaluation of infertility:
1. Confirmation of ovulation by S.Progesterone on Day 21 in a cycle of 28
days or 7 days prior to the presumed day of onset of menstruation.
2. Hysterosalphingography to screen for uterine and tubal abnormalities
after excluding active pelvic infections and endometriosis.
3. Women with body mass index > 30 kg/m2 should be advised to loose
weight as it may restore ovulation.
4. Ovulation induction/ intrauterine insemination not to be offered in
women with unexplained infertility as it has not shown to increase
pregnancy rates.
Hysterosalphingography is the first line of investigation offered to
women to rule out uterine and tubal pathologies. As opposed to invasive
procedures like laparoscopy , hysterosalphingography is a minimally invasive
procedure with therapeutic effects also, hence considered prior to other
procedures.
The varying methods to assess tubal patency are complementary to each
other and any single method is not mutually exclusive.(23)
TUBAL FACTOR
It is an established fact that when a dominant follicle in the ovary grows
to maturity, there occurs a surge of Luteinizing hormone (LH). The LH surge
results in rupture of the follicle and release of the ovum. The ovary is covered
by the fimbrial end of the fallopian tube similar to a ball held in the palm (24).
Stephan et al (24) reported that the fimbriae get distended and the fimbrial
vessels get engorged and sweep gently. The pulsatile movements of the
fimbriae are synchronous with the heart beat of the patient and slowly pull the
released ovum into the fallopian tube.
TECHNIQUES FOR ASSESSING TUBAL PATENCY
1. Conventional Hysterosalphingography
2. Sonohysterosalphingography
3. Magnetic Resonance Hysterosalphingography
4. Diagnostic laparoscopy
CONVENTIONAL HYSTEROSALPHINGOGRAPHY
Earlier called as Uterosalphingography, (25) was first introduced by
Heuser in 1924 in a paper titled, “The Clinical value of
Hysterosalphingography”. The paper was published in the third Pan American
Scientific Congress in Lima, Peru in December 1924. The contrast used at that
time was iodine in oil based solutions. In recent years the number of
hysterosalphingograms done have increased dramatically. This is attributed to
the advances made in assisted reproduction and advanced maternal age.(4)
TECHNIQUE (4)
No specific patient preparation is required prior to doing
hysterosalphingography. A nonsteroidal anti inflammatory drug is given one
hour prior to the procedure. The procedure is done between Day 7 – Day12 of
the menstrual cycle. The patient is advised to avoid sexual intercourse till the
day of procedure in the cycle. This is so as to avoid any minimal chance of
pregnancy. Moreover this is the period of proliferative phase during which the
endometrium is thinned out and this facilitates better interpretation of the
images. In patients with irregular menstrual cycles and suspicion of pregnancy,
beta hCG values are used in solving the mystery. Any risk of active pelvic
inflammatory disease is to be avoided by checking the erythrocyte
sedimentation rate (ESR).
The patient is made to lie supine in lithotomy or modified lithotomy
position. A 5 - F HSG catheter is placed in the cervical canal and the balloon
is inflated fully.
A scout radiograph is taken prior to the contrast administration. Water
soluble contrast material is administered into the uterine cavity. Fluoroscopic
images are taken intermittently to visualize the uterus and fallopian tubes.
Four spot radiographs are taken. The first radiograph is taken during
early filling of the endometrial cavity, to visualize any filling defects. The
second radiograph is taken when the uterine cavity is fully distended with
contrast. The third image corresponds to the fallopian tubes. The fourth image
is to be taken to look for intraperitoneal spill if any. Oblique views are taken to
avoid superimposition if any. Final image is taken after deflating the balloon so
as to look for the lower uterine segment.
Raymond et al (26) states that the high clinical value of
hysterosalphingography is due to the fact that it gives almost a perfect mold of
the cavities of cervix, uterus and lumen of fallopian tubes. Moreover it also
gives a permanent record. Such intricate details cannot be even given by
varying other modalities like bimanual examination, dilatation and curettage,
hysteroscopy and laparotomy. Many lesions not clinically suspected are
identified in hysterosalphingography.
a. Early filling, b. fully distended uterus, c. fallopian tubes showing interstitial,
isthmic, ampullary portions, d. intraperitoneal spill
Fallopian tubes in HSG
The fallopian tube appears as a 10 – 12cm long tubular structure
coursing along superior aspect of broad ligament. Radiographically three
segments are visible. The interstitial or cornual segment is short and traverses
the uterine musculature. The isthmic part is the longest and narrowest portion.
The ampullary part is the widest part near the ovary. The fimbriated portion is
the cone shaped end of fallopian tube and is not usually visualized in HSG.
The major advantages of hysterosalphingography are
(i) To diagnose intracavitory lesions
(ii) Fallopian tubal block and hydrosalphinx
(iii) Therapeutic effect of opening a blocked tube which is evidenced by
previously infertile women becoming pregnant after the procedure.
The major contraindications are:
(i) Active infection
(ii) Pregnancy
The major complications are:
(i) Minimal spotting lasting for less than 24 hours
(ii) Introduction of intrauterine infection. The risk of infection can be
prevented by the strict usage of sterile instruments and aseptic technique
(iii) Cramping pain. The pain is most severe during the time of inflation of
balloon in case of intrauterine catheter, and also when the uterine cavity
is distended with contrast material.The cramping pain is usually minimal
and transient and well tolerated by most of the patients
The other potential but rare complications include:
(i) Severe pain resulting in premature termination of the procedure due
to vasovagal reaction.
(ii) Systemic reaction to the contrast material if vascular intravasation
occurs, but lymphatic and vascular intravasation are supposed to be
clinically insignificant and not dangerous.
(iii) Perforation of uterus which is extremely rare and can be avoided by
skilled technique.
(iv) Risk of radiation exposure to the reproductive organs.
(v) Radiation exposure to an early unsuspected pregnancy, but it can be
avoided by proper timing of the examination and a negative
pregnancy test.
CONTRAST MEDIA
The use of oil based iodine solutions has multiple complications (27)
including edema of the fallopian tubes, and when spilled into the uterine cavity
cause adhesions with the adjacent organs. The use of oil based solutions has
become obsolete and now replaced by the use of water soluble contrast
media(28).
Boer et al (29) compared the pregnancy rate and quality of images in a
randomized control study in hysterosalphingography done using oil contrast
media and aqueous contrast media.
The oil contrast media used was Ethiodol, a mixture of fatty acids
obtained from poppy seeds. The aqueous contrast media used was a non ionic
low osmolar contrast media Iopamidol.
The oil contrast media provided a sharper image with more contrasting
image. The outline of uterine cavity was better delineated with oil contrast
media. However the ampullary folds were better defined using aqueous
contrast media. This is explained due to the lower iodine concentration in water
soluble media (30).
The water soluble media got dispersed in the peritoneal cavity within
10minutes which enables the control picture to be taken within 15 minutes. The
oil contrast media was reabsorbed from the peritoneal cavity only after two
hours which may persist even longer giving the chance of granuloma formation
and foreign body reaction within the peritoneal cavity.
There was no statistical difference in pregnancy rates following the two
procedures as against the increased pregnancy rate following oil based media in
studies conducted by Mackey et al and DeCherney et al (31, 32,33)
However Lindequist et al (34) and Rasmussen et al (35) reported that pain
during HSG after oil or water based media is the same but water based media
have increased rate of post procedure bleeding and infection.
Spring et al (36) in their prospective control study concluded no
significant difference in pregnancy rates following the use of varying contrast
media.
A well known complication of HSG is vascular or lymphatic
intravasation of contrast media. The incidence is reported to be about 6%. Use
of oil based contrast media can hence result in oil emboli ending up with
serious cardiovascular complications.
Notifying the risks and benefits water soluble contrast media is
considered preferable for HSG in day to day clinical practice.
CONTRAST INTRAVASATION
Intravasation (37) indicates the backward flow of the contrast media into
the adjoining veins. The contrast media passes from the endometrial cavity via
the myometrial veins into the draining pelvic veins, ovarian veins in particular.
The factors predominantly causing intravasation are the conditions
increasing endometrial vascularity and permeability. Few clinical examples
include menometorrhagia, endometriosis, urinary tract infections, and previous
history of uterine surgery. It is also noted to be seen with increased intrauterine
pressure because of tubal obstruction. Catheter cannulation and fixation
causing pain and discomfort to the patient may induce spasm and trauma
resulting in intravasation. The prevalence of intravasation is about 0.4 –
6.9%.Intravasation is classified into four levels (38) as follows:
1. Level 0: No intravasation
2. Level I: Minimal intravasation limited to myometrium
3. Level II: Moderate but slow intravasation into parametrial, adnexal
veins
4. Level III: Severe instant intravasation from myometrial, parametrial
veins into paracaval veins
Level I – Intravasation showing myometrial enhancement (m)
Level II – Opacification of myometrial veins extending to iliac veins
Level III intravasation – Bilateral tubal spill with instant intravasation
into pelvic veins
Intravasation is now of less clinical significance (39) with the use of
water soluble contrast media. Nevertheless the reporting radiologist must be
confident enough to differentiate it from intraperitoneal spill in tubal blockage.
Eliminating the predisposing factors and proper timing of the procedure and
technique can eliminate the intravasation.
CATHETER TYPE
There are multiple studies comparing the utility of balloon catheter vs
metallic cannula in performing hysterosalphingography.
Tur – Kaspa et al (40) in a prospective, blinded, randomised control study
compared the utility of balloon catheter vs metallic cannula in terms of pain,
time of the procedure.
The procedure using balloon catheter was statistically significant by
using lesser contrast media, lesser procedure time, less pain and discomfort to
the patient. However the quality of images were same with both the techniques.
The balloon catheter provides better seal at the level of internal os
thereby preventing reflux of contrast, faster and better visualisation of uterine
cavity, fallopian tubes. The increased intensity of pain with metallic cannula is
explained due to the tension applied by it on the cervix.
Mello et al(41) described in a prospective study that the intensity of pain
using balloon catheter, metallic cannula with paracervical block was
significantly less when compared to the traditional method of using metallic
cannula without any anaesthesia.
Shlomo et al (42) in a prospective study described that cervical vacuum
cup cannula causes significantly less pain, lesser procedure time, smaller
amount of contrast when compared with traditional metallic cannula.
Ubeda et al (43) described that introduction of air bubbles incidentally
may be mistaken for filling defects, polyps but identified by the fact that they
are well defined, mobile and can be flushed out of the tubes by further injection
of contrast. However introduction of air bubbles can be effectively prevented
by removing the air trapped within the cannula.
Moro et al(44) in a randomised controlled double blinded study evaluated
the effectiveness of antispasmodic drug hyoscine – N – butylbromide in
contrast enhanced sonohysterosalphingography. There was no statistical
difference in pain score between the hyoscine group and placebo group.
Aytekim et al (45) evaluated the effect of preprocedure anxiety on post
procedure pain scales and HSG outcomes. They identified that there was a
statistical significance in increase in pain intensity in patients with increased
preprocedure anxiety. But there was no statistical difference in tubal patency
between the two groups with lower and higher anxiety levels.
Maryam et al(46) evaluated the effect of anti axiety drug valerium in a
test group as against placebo group and identified significant reduction in post
procedure anxiety score in the test group.
ANTIBIOTIC PROPHYLAXIS
The 31st Royal College of Obstetricians and Gynaecologists Study
Group on the Prevention of Pelvic Infection recommended the use of following
antibiotics(47) after an intrauterine instrumentation procedure like
hysterosalphingography if not previously screened for Chlamydia.
Doxycycline 100 mg orally, twice daily for a week, Ofloxacin 400 mg
orally twice daily with Clindamycin 450 mg orally four times daily or
Metronidazole 500 mg orally twice daily, for a week.
DIAGNOSTIC ACCURACY OF HSG
According to Egle et al (48) the sensitivity and specificity of HSG in
identifying bilateral tubal occlusion is 89.5% and 90% respectively.
Adrian et al (49) followed up HSG results with laparoscopy,
hysteroscopy, fertility outcomes according to which HSG had false positivity
of 39%, and negative predictive value of 100%.
Bukar et al (50) in a retrospective study reviewed HSG images and
identified tubal pathologies in about 72% of the cases.
Chou et al (51) questioned the utility of HSG as the first line investigation
in female infertility stating the sensitivity and specificity as 53% and 85% and
introduced a new technique of Chlamydial antibody detection with similar
reliability as HSG and hence can replace it.
Vahdat et al (52) in a study evaluated that HSG had a sensitivity of
95.6%, specificity of 60%, PPV of 84.62%, and NPV of 85.71% in diagnosing
uterine malformations.
MRI PELVIS IN INFERTILITY
Though HSG is the mainstay and the initial imaging modality in
infertility evaluation, MRI is a useful adjunct since its introduction. MRI pelvis
because of its excellent tissue contrast helps in delineating pelvic anatomy and
pathologies as well in a detailed and descriptive way.
The commonly encountered pathologies in infertility(53) include (i)
congenital uterine anomalies, (ii) acquired uterine abnormlaities like fibroids,
(iii) extrauterine pathologies like adnexal cysts, endometriosis.
The sequences routinely used include (53) coronal T1 (TR 400-500ms, TE
20ms, slice thickness 10mm, gap 2mm, one acquisition), axial, sagittal, oblique