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Virtual hysterosalpingography: experiencewith over 1000 consecutive patients

Patricia Carrascosa,1 Carlos Capun ˜ ay,1 Javier Vallejos,1 Mariano Baronio,2

Jorge Carrascosa1

1Department of Computed Tomography, Diagnostico Maipu, Av. Maipu 1668, Vicente Lopez (B1602ABQ), Buenos Aires,

Argentina2CEGYR, Ciudad Auto ´ noma de Buenos Aires, Buenos Aires, Argentina

AbstractWith the advent of multidetector computed tomography

(MDCT), a whole new spectrum of diagnostic imaging

techniques and procedures appears. Virtual hysterosal-

pingography (VHSG) is a novel non-invasive modality

for assessing the uterus and female reproductive system

that combines hysterosalpingography technique with

MDCT technologies. Nowadays, 64-row VHSG offers

an excellent diagnostic performance, in concordance with

the development of new reproductive interventions and

the need of accurate diagnostic procedures. In this arti-

cle, we review the VHSG technique and describe normal

and pathologic findings.

Key words: Multidetector computed tomography—

Virtual studies—Virtual hysterosalpingography—

Infertility—Uterus—Fallopian tubes

The evaluation of the uterus and fallopian tubes with

diagnostic imaging procedures is classically carried out

using ultrasonography, X-ray hysterosalpingography

(HSG), and magnetic resonance imaging [1]. In the last

10 years, technical developments in computed tomogra-

phy (CT) and the emergence of the multidetector CT

scanners enable the evaluation of anatomic regions with

isotropic spatial and temporal resolution. These advances

allow a whole new spectrum of diagnostic imaging

techniques and procedures [2, 3].

Virtual hysterosalpingography (VHSG) is a novel,

non-invasive diagnostic modality that affords the unique

opportunity to assess the uterus and fallopian tubes

based on volumetric high-resolution CT data, improving

the visualization of the uterine cavity, the external mor-phology of the uterus and the morphology and patency

of the tubes, besides the assessment of the other pelvic

structures [4 – 7]. 64-row CT scanners are considered to-

day the state-of-the-art technology to perform VHSG

studies [4].

The purposes of this pictorial essay are to describe the

CT procedure and image processing techniques and to

characterize the normal and pathologic findings found in

our series of more than 1000 cases.

Materials and methods

PatientsWe retrospectively evaluated the CT data of 1500 pa-

tients (mean age 34.7 ± 4.6 years old; age range 22–

43 years) with the diagnosis of infertility. All patients

underwent the VHSG examination during the follicular

phase of the menstrual cycle. The CT image acquisitions

were carried out using a 64-row CT scanner (Brilliance

64; Philips Medical Systems, Highland Heights, OH).

The study protocol was approved by the Institutional

Review Board.

VHSG techniqueThe CT examination should be carried out between days

7–10 of the menstrual cycle. Patients were instructed to

abstain from sexual relations during the 48 h prior the

day of the CT scan. As a non-invasive technique, no

antibiotic prophylaxis is needed. In the CT room, the

patient is positioned supine on CT table in the lithotomic

position. The perineum is cleansed with povidone–iodine

solution and draped with sterile towels. A sterile specu-

lum is inserted into the vagina and the cervix is cleansed

with povidone–iodine solution. A 10/12-F dedicated

VHSG plastic cannula is positioned at the externalCorrespondence to: Patricia Carrascosa; email: [email protected]

ª Springer Science+Business Media, LLC 2010

AbdominalImaging

Abdom Imaging (2010)

DOI: 10.1007/s00261-010-9616-6



cervical os. No cervical clamping is performed. A total

volume of 15 mL of a iodine contrast dilution [2.5 mL of

water-soluble iodine contrast (iobitridol; Xenetix 350,

Laboratorios Temis Lostalo, Buenos Aires, Argentina)

and 12.5 mL of saline solution] is instilled into the

uterine cavity using an automatic power injector at a

flow rate of 0.3 mL/s. CT examination includes an

anteroposterior localizer scan of the pelvis followed by

the volumetric acquisition of the axial images, approxi-

mately 45 s after initiation of the contrast solution

instillation. The VHSG examinations should be per-

formed with at least 64-row multidetector CT equip-

ments. Suitable technical scan parameters of data

acquisition are: 64 9 0.625 mm collimation, 0.6 mm

slice thickness, 0.3 mm reconstruction interval, 0.5 s

rotation time, pitch 0.64, 120 kV. Tube current modu-

lation is used to adapt mAs at the patient’s size, ranging

from 100 to 250 mAs. Scan time varies between 3 and 4 s

approximately.

Image post-processing

Using available CT image visualization and reprocessing

tools, two-dimensional and three-dimensional evalua-

tions are routinely performed during the image inter-

pretation and analysis.

1. Axial images: the first step in the analysis is the

evaluation of the original transverse CT images. They

give an integral evaluation of the pelvic structures. An

inter-median soft-tissue/bone window setting is re-

quired for the assessment of the internal and externalsurface of the cervix, uterus, and fallopian tubes.

2. Multiplanar reformats: these bi-dimensional images

are displayed in sagittal, coronal, and oblique views.

Curved multiplanar reconstructions are used for

unfolding the uterus in a single plane (Fig. 1). The

same window setting described earlier is utilized dur-

ing the analysis.

3. Maximum intensity projections: these three-dimen-

sional reconstructions offer detailed images of the

cervix, uterus and particularly the fallopian tubes

(Fig. 2).

4. Volume rendering: these three-dimensional recon-

structions show the entire pelvis anatomy and facili-

tate the identification of pathologic disorders (Fig. 2).

5. Virtual endoscopy: this advanced three-dimensional

display mode completes the image interpretation se-

quence. This algorithm creates endoluminal images

Fig. 1. A Sagittal multiplanar

reconstruction (MPR) used as

reference to depict the curved

MPR along the cervical canal and

uterine cavity. B Curved MPR

that unfolds the uterus in a single

plane.

Fig. 2. Normal uterus, cervix,

and fallopian tubes. A Maximum

intensity projection. B Volume

rendering reconstruction.

P. Carrascosa: CT virtual hysterosalpingography



similar to hysteroscopy, allowing an accurate delin-

eation of the lesion located in the cervical canal,

endometrial cavity, and the fallopian tubes when

dilated (Fig. 3).

Discussion

Indications and contraindications

The principal indication for VHSG is infertility; how-

ever, there are also others including repeated spontane-

ous abortions, preoperative and postsurgical assessment

in patients with history of leiomyomas, and character-ization of uterine malformations.

Contraindications of the procedure are pregnancy

and active pelvic infection.

Imaging findings

Normal anatomy. The uterus is a muscular organ whose

size varies depending on the patient’s age and parity. The

uterus has an inverted triangular shape, with the base

positioned cranially and the cervix placed in its inferior

side, extending into the vagina. The isthmus is the

transition between the cervix and the uterine body. The

fallopian tubes are usually 10–12 cm long and arise at the

cornua. Each fallopian tube can be divided into three

segments: interstitial, isthmic, and ampullary (Fig. 4).

Normal variants. In the cervical canal prominent cervical

glands can be found. They consist in tubular or sac-shape

structures protruding to the cervical wall at VHSG. Di-

lated cervical glands often appear as outpouchings

resembling diverticula and they are considered as normal

variation (Fig. 5). On occasion, prominent longitudinal

folds parallel to the cervical canal corresponding to

normal folds can be present at VHSG (Fig. 6). Linearcornual lucencies separating the cornual lumen from the

uterine cavity are secondary to localized muscular con-

traction and can be seen in some patients (Fig. 7).

Cervical abnormalities

Narrowing. In most cases, narrowing of the cervical canal

is a normal anatomic or menstrual cycle variant. How-

ever, it also can be related to postsurgical or instrumental

trauma, as well as the result of neoplastic stenosis (cervix

Fig. 3. Virtual endoscopy views of the cervical canal (A), isthmus (B), and uterine cavity (C).

Fig. 4. Normal anatomy. The

uterus has an inverted triangular

shape. The isthmus (arrowhead )

is the transition between the

cervix (white asterisk ) and the

uterine body (black asterisk ). The

fallopian tubes can be divided

into three segments: interstitial

(short arrow ), isthmic (long

arrow ), and ampullary (curved

arrow ). A Maximum intensity

projection. B Volume rendering

reconstruction.




leiomyoma). Narrowing of the cervix may be focal or

diffuse. It can be seen clearly with VHSG in different

angles without any cervical traction (Fig. 8).

Elevated lesions. Cervical polyps are rare. VHSG can de-

tect them easily by axial images and virtual endoscopy

views (Fig. 9). Other causes of elevated lesions include

synechiae, congenital remnants, and submucosal myo-

mas. Synechiae can generate irregular elevated lesions and

also stenosis of the canal (Fig. 10). In X-ray HSG as well

as in VHSG endoscopy views, air bubbles can be mistaken

with otherfilling defectssuch as polyps or blood clots. The

visualization of the bi-dimensional VHSG images can

identify them with high accuracy and avoid misdiagnosis.

Fig. 5. Dilated cervical gland (arrow head ). A Maximum intensity projection. B Volume rendering reconstruction. C Virtual

endoscopy view.

Fig. 6. Prominent longitudinal folds parallel to the cervical canal corresponding to normal thickened folds (arrowheads ). A Axial

CT image. B, C Virtual endoscopy views.

Fig. 7. Linear cornual lucencies (arrow heads ). Symmetrical linear defects in the cornual-tubal junction. A Maximum intensity

projection. B Coronal multiplanar reconstruction. C The linear corneal lucencies are not visible on the virtual endoscopy view.




Uterine abnormalities

Size anomalies. The size of the uterus has many varia-

tions and depends on the patient’s age and parity. A

small uterus can be found in young patients, nulliparous

women or in cases of extensive synechiae. A larger uterus

has also several etiologies but it is most frequently related

to multiparity and large leiomyomas.

Shape anomalies. Abnormalities of the uterine shape

have diverse causes. They include normal variants, con-

genital malformations and several acquired abnormali-

ties like myomas and previous surgeries.

Uterine malformations are due to abnormal fusion of

the Mu ¨ llerian ducts during the early gestational period

[8]. Infertility is usually not associated with these

abnormalities; nevertheless, an accurate diagnosis isimportant to decide a treatment. The most frequent

anomaly is arcuate uterus (Fig. 11). Other anomalies

include unicornuate uterus (Fig. 12), bicornuate uterus

(Fig. 13), septate uterus (Figs. 14, 15), and uterus didel-

phys (Fig. 16), being the septate uterus related to recur-

rent abortions [9]. In contrast to X-ray HSG, one of the

most important benefits of VHSG is the possibility to

visualize the external contour of the uterus [4, 10].

This facilitates the differentiation between a bicornuate

from a septate uterus, because a bicornuate uterus has a

bilobed, concave fundal appearance, whereas a septate

uterus has a normal, convex morphology. The angles

between the uterine horns can be also easily determined.

Elevated lesions. Endometrial polyps are focal over-

growths of the endometrium. On VHSG they consist in

elevated soft tissue density formations, variable in size,

sessile, or pedunculated (Fig. 17). High detailed, isotro-

pic images on VHSG permit the visualization of small

lesions on multiplanar reconstructions and virtual

endoscopic images. VHSG provides a complete charac-

terization of elevated lesions (morphology, density,

and size) [6]. As mentioned earlier, air bubbles can be

mistaken with other filling defects such as polyps, blood

clots, or submucosal myomas on VHSG endoscopy

views (Fig. 18).

Submucosal myomas are benign neoplasms of thesmooth muscle of the uterus. They appear as round

masses with discrete lesser or higher density than normal

myometrium on VHSG and they are easily differentiated

from other elevated lesions [7, 11] (Figs. 19, 20).

Intrauterine synechiae refer to adhesions within

uterine cavity. They can be secondary to infection and

trauma, such as maneuvers of dilatation and curettage.

The infertility is attributed to an unfavorable endome-

trium for sperm migration and embryo implantation.

Adhesions manifest as linear, irregular, or serpinginous

filling defects within the uterine cavity (Figs. 21, 22).

Fig. 8. Narrowing of the

cervical canal (arrow head ). A, B

Coronal and sagittal maximum

intensity projections. C Volume

rendering reconstruction. D

Virtual endoscopy view.




Wall abnormalities. VHSG has the ability of evaluating

the uterine wall for the presence of uterine enlargement,

contour abnormalities, and focal masses.

Leiomyomas have a wide spectrum of shape, size, and

location and they can generate distortion of the uterus.

At VHSG, subserosal leimyomas appear as focal masses

deforming the external contour of uterus (Fig. 23), while

intramural myomas show as focal soft-tissue masses

within the normal myometrium.

Adenomyosis is characterized by the extension of the

endometrial glands into the myometrium. Adenomyosis

can be demonstrated on VHSG if there is a connection

between the endometrial glands extending deep into the

myometrium and the uterine cavity. VHSG of a focal

Fig. 9. Cervical polyp. There is

a small filling defect in the

cervical canal (arrow ). A Axial

image. B Maximum intensity

projection. C Volume rendering

reconstruction. D Virtual

endoscopy view.

Fig. 10. Cervical synechiae. There is an irregular, linear filling defect in the cervical canal (arrow ). A Axial CT image. B

Maximum intensity projection. C Virtual endoscopy view.




adenomyosis is nonspecific. It appears as small, isolated

diverticula projecting into the myometrium. Diffuse

adenomyosis manifest as irregular branching outpouch-

ings that are continuous with the uterine cavity (Fig. 24).

Hyperplasia of the myometrium and uterine wall

enlargement is almost always present around the

abnormal implants.

Postsurgical changes secondary to cesarean section

or myomectomy are frequently seen on VHSG exams.

C-section scar is usually seen at VHSG as a wedge-

shaped indentation near to the internal os (Fig. 25).

A small diverticulum-like outpouching can be seen

at the site of a submucosal myoma after surgical

resection.

Fig. 11. Arcuate uterus. There is a small, symmetric indentation in the fundus of the uterine cavity (arrow head ). The external

configuration of the uterus is normal. A Maximum intensity projection. B Volume rendering reconstruction.C Virtual endoscopy view.

Fig. 12. Unicornate uterus. A single uterine horn and a single fallopian tube are visualized. A Maximum intensity projection.

B Volume rendering reconstruction. C Virtual endoscopy view.

Fig. 13. Bicornuate uterus. The uterine horns are widelyseparated by myometrium. A Maximum intensity projection.

The heart-shape external appearance of the uterus is clearly

depicted (arrow head ). B Volume rendering reconstruction.C Virtual endoscopy view. Two polyps are present in the

endometrial cavity (asterisks ).




Fallopian tubes pathology. Conventional X-ray HSG is

suggested as the best appropriate examination for eval-

uating the fallopian tubes and determining tubal patency.

With recent advances in CT technologies, VHSG using

64-row MDCT allows an accurate tubal lumen and

tubal wall visualization, and it is possible a virtual

endoscopic intratubal navigation in dilated tubes [4]. At

VHSG, normal fallopian tubes are thin, smooth tubular

Fig. 14. Incomplete septate uterus. A Maximum intensity

projection. A normal external appearance of the uterus is

depicted (arrow heads ). An incomplete septum is present

(asterisk ). B Volume rendering reconstruction. There is an

acute angle between the two uterine horns. C Virtual endos-

copy view. The indentation of the septum in the uterine fundus

is visualized (asterisk ).

Fig. 15. Complete septate uterus. A Maximum intensity projection. A normal external appearance of the uterus is depicted. The

uterine septum extends into the cervical canal (arrow heads ). B Volume rendering reconstruction. C Virtual endoscopy view.

Fig. 16. Uterus didelphys.

Presence of two separate uterine

and cervical cavities. The clinicalexamination showed two vaginal

cavities separated by a septum.A Maximum intensity projection.B Volume rendering

reconstruction.




structures that widen in the ampullary portion. In ab-

sence of pathology, there should be free spillage of

contrast material into peritoneal cavity.

Tubal occlusion secondary to inflammation or pre-

vious surgery manifests as non-opacification or abrupt

interruption of the fallopian tube with no intra-perito-

neal contrast spillage. Occlusion can be unilateral

(Fig. 26) or bilateral, and can affect the proximal,

middle, and distal segment of the tube. If blockage is

distal, a hydrosalpinx can be developed.

Hydrosalpinx defines the dilatation of the ampullary

portion of the tube (Fig. 27). It is commonly secondary

to post-infection scarring, endometriosis, and surgery.

Although ultrasound provides a non-invasive view of the

dilated tube, VHSG offers a better view of the inside of

the dilated tube with a direct visualization by virtual

Fig. 17. Endometrial polyp.

There is a filling defect at the left

lateral wall of uterine cavity

(arrow head ). A Maximum

intensity projection. B Volume

rendering reconstruction. C, D

Virtual endoscopy views.

Fig. 18. Air bubble. A Virtual

endoscopy view. There is a small

filling defect at the fundus of the

uterine cavity (arrow ). B Coronal

thin slab maximum intensity

projection showing a small, round

shape, low attenuated structurethat corresponds to air (arrow ).




falloscopy (Fig. 28). Intratubal adhesions can be seen in

those cases.

Grade of discomfort

Based in our experience and data analysis, VHSG is a

well-tolerated examination, with the majority of the

patients (86%) referring absence or only mild discom-

fort during the procedure. The use of a plastic cannula

positioned in the external cervical os without cervical

clamping reduces pain. The instillation of a dilution of

water soluble contrast media using an automatic

power injector at a slow rate assures less peritoneal

irritation. Besides, it is not necessary to turn or change

the patient’s position on the CT table during the

exam.

Fig. 19. Submucosal myoma.A, B Coronal and axial maximum

intensity projections. Presence of

a large filling defect in the right

antero-lateral wall of the uterus

(asterisks ). C Volume rendering

reconstruction. D Virtual

endoscopy view.

Fig. 20. Submucosal myomas.

There are two large filling defects

that protrude into the uterine

cavity. A Coronal multiplanarreconstruction. B Virtual

endoscopy view.




Radiation

Concern for radiation exposure is particularly important

when relatively young patients and the gonadal region

are involved. One of the most important subjects of

discussion regarding multidetector CT is the association

with potentially high radiation dose risks. Knowledge

about multidetector technology principles, the modifi-

cation of the acquisition parameters according to the

weight and size of the patient, the correct election of the

best pitch and rotation time and implementation of dose

modulation techniques, ensure to scan with the minimum

radiation dose while maintaining a diagnostic imagequality, using a dose as low as reasonably achievable

(ALARA).

Radiation dose reported for a routinely X-ray HSG

by committees from the American College of Radiology

(ACR) and the Radiological Society of North America

(RSNA) is about 1 mSv [12]. In our daily practice, the

radiation dose of this examination ranges between 1 and

4 mSv. Radiation dose estimations for VHSG are low. In

our initial series of 1000 cases, the mean effective radi-

ation dose was 2.58 ± 0.75 mSv [6]. Modifications and

readjustments in the acquisitions parameters, especially

in the scan length and tube current (mA), allow us to

significantly reduce the mean radiation dose. In our last

500 cases, the mean effective radiation dose was

0.93 ± 0.08 mSv, resulting in a mean difference of 1.65

P < 0.0001 (95% CI 1.60–1.70).

Complications

Complications are extremely rare. The non-invasive and

painless nature of the procedure significantly reduced the

risk of bleeding, infection, and vasovagal reactions.

Allergic-like reactions to the contrast media are also

infrequent due to the use of a diluted low osmolar non-

ionic iodinated agent. Alternatively, a gadolinium dilu-

tion can be used in patients with documented iodine

allergy history [13].

Advantages

Advantages of the procedure are: (i) the non-invasive,

painless, well-tolerated nature of the procedure; (ii)

the extremely low risk of complications; (iii) the

Fig. 21. Uterine synechiae. There is a large, irregular linear filling defect in the uterine cavity (arrow ). A Maximum intensity

projection. B Volume rendering reconstruction. C Virtual endoscopy view.

Fig. 22. Asherman Syndrome. Large uterine synechiae. The uterus is small and irregular in shape. A Maximum intensity

projection. B Volume rendering reconstruction. C Virtual endoscopy view.




high-resolution isotropic images that provide detailed

information of the uterus and fallopian tubes; (iv) the

possibility to have a non-invasive endoluminal view of the

cervical canal and endometrial cavity; (v) the evaluation of

extra uterine pathology (adnexal pathology, bowel

abnormalities, pelvic processes, and skeletal abnormali-

ties); and (vi) a low radiation dose.

Disadvantages

Relative disadvantages of the procedure include: (i) the

cost, twofolds the cost of X-ray HSG; (ii) the availability

of the examination; and (iii) the inability to perform an

immediate tubal cannulation in case of proximal tubal

occlusion.

Fig. 23. Large subserosal

myoma. A, B Coronal and

sagittal maximum intensity

projections. There is enlargement

of the uterus secondary to thepresence of a large leiomyoma in

the posterior wall (asterisks ).C Virtual endoscopy view of the

inside of the uterus. The

endometrial cavity is normal.

D Virtual endoscopy view of the

external surface of the uterus.

There is a large subserosal

myoma (asterisk ).

Fig. 24. Diffuse adenomyosis. Multiple variable-sized outpouchings projecting off the uterine fundus wall (arrow heads ).A Maximum intensity projection. B Volume rendering reconstruction. C Virtual endoscopy view.




Conclusions

Sixty-four-row VHSG is a new high-resolution modality

that provides a reliable, non-invasive diagnostic proce-

dure useful in the evaluation of the female reproductive

system. Uterine and tubal anatomy and pathology can be

accurately evaluated with this examination. The combi-

nation of bi-dimensional, three-dimensional, and endo-

luminal views give well-appointed anatomic information

and a detailed characterization of the different patho-

logic processes. It provides a more precise information in

comparison with X-ray HSG. Based on all the concepts

exposed, we conclude that 64-row VHSG may play a

valuable role in the infertility diagnosis.

Fig. 25. C-section scar. Diverticulum-like deformity of the isthmic region due to C-section (arrow head ). A, B Coronal and

sagittal maximum intensity projections. C Virtual endoscopy view.

Fig. 26. Unilateral right fallopian tube

occlusion. A Maximum intensity

projection. B Volume renderingreconstruction.

Fig. 27. Slight right tube

ampullary dilation (arrow head )

with large left tube hydrosalpinx

(asterisk ) without peritoneal

spillage. A Maximum intensityprojection. B Volume rendering

reconstruction.




Acknowledgment. We would like to thank Dr. Graciela FernandezAlonso for her assistance in editing this manuscript.

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Fig. 28. Unilateral right tube

hydrosalpinx (arrow ) without

peritoneal spillage. Normal left

fallopian tube with peritoneal

spillage. A Maximum intensity

projection. B Virtual endoscopy

view of the dilated right tube.


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