Testing Fallopian tubes patency with use of hysterosalpingography method in infertility diagnostics

Own experience and current state of knowledge

Piotr Marianowski, MD, PhD, Iwona Szymusik, MD, PhD

WE SHOULD KNOW THIS

Infertility concerns about 15-20% of all couples. It is defined as the

inability to conceive a child within 12 months of regular sexual relations

without the use of contraceptives [1]. The most common causes

of infertility include male factor (45%), ovulation disorders (37%),

and disorders of the Fallopian tubes function (18%) [2, 3].

Diagnostic imaging in the diagnosis of female infertility

Imaging plays a key role in the female infertility di-agnostics [4-6]. Transvaginal ultrasound examina-tion (USG-TV) is in this case the standard procedure of first choice. The irregularities can be further evalu-ated by hysterosalpingo-contrast sonography Hy-CoSy. It has been found that it is highly sensitive, specific and accurate in identifying uterine abnor-malities, such as polyps. However, it has limited value in assessing the Fallopian tubes abnormalities. Magnetic resonance imaging - MRI can be used to evaluate various congenital anomalies of Müllerian ducts and internal endometriosis diagnostics, leio-myomata and endometriosis, but its role in evaluat-ing Fallopian tubes patency is currently limited [7, 8].

HSG (hysterosalpingography)

The primary diagnostic test allowing assessing Fal-lopian tubes and the uterus is hysterosalpingogra-phy (HSG), i.e. visualisation of these organs using X-rays after administration of contrast through the cervical canal. HSG is still the most widely used, im-portant, first-line diagnostic procedure to evaluate the uterine cavity and Fallopian tubes patency.

On the radiographic film Fallopian tubes should be visible as thin, smooth lines that extend to the ampullary section. Irregularities observed by HSG may be congenital or may result from contraction, occlusion or infection. Tubal occlusion is mani-fested by a sudden cut-off of contrast material, lack of translucency in the distal part of Fallopian tube. It may be unilateral or bilateral. Adhesions around the Fallopian tubes prevent from penetra-

tion of contrast material into the abdominal cavity and its free distribution [8, 9].

HSG can also be helpful in assessing abnormalities of the uterine cavity. It is believed that it has high sensitivity (60-98%) but low specificity (15-80%) in detecting abnormalities of the uterus, and there-fore hysteroscopy remains the method of choice in the final differentiation. The differential diagnosis of intrauterine filling defects by HSG includes pol-yps, submucosal fibroids, adhesions and intrauteral barriers. Such anomalies require further investiga-tion by hysteroscopy (or hysteroscopy combined with laparoscopy), supporting and providing an im-proved treatment of a given disease [1].

In 2008 the guidelines published by the European Society of Human Reproduction and Embryology (ESHRE) have recommended that prior to testing tubal patency the analysis of semen and ovulation should be carried. Laparoscopy should be offered first to women with high probability of pathology occurrence. Due to this approach there is also a therapeutic option in addition to diagnostic option in case of irregularities of Fallopian tube and pelvis.

The examination is carried out in the first phase of the menstrual cycle. Some authors successfully use hormonal contraceptives to optimize the pe-riod of test performance and to ensure security against possible exposure to X-rays in early preg-nancy. The contraindications for HSG, besides pregnancy, include: inflammations in pelvic organs and severe allergy to iodine-based contrast agents. Depending on anaesthesia method during the sur-gery, the patients should be informed about per-forming the procedure on an empty stomach.

Own experience

In our institution HSG is carried out with use of anal-gesics administered intravenously or in the form of suppositories. In many centres HSG is performed under sedation with propofol. Sedation is performed by the anaesthesiologist, and the patient is informed in advance about the theoretical threats, such as as-piration or an allergic reaction. Proponents of this method postulate that HSG procedure is then very well tolerated by the patients. Although the admin-istration of propofol is clearly more comfortable, in many other centres the procedure is performed without sedation. The benefits of this solution should be considered from the point of view of ad-ditional costs. It seems that using general anaesthe-sia for HSG is a bit exaggerated approach taking into account the recent reports of good pain tolerance by women subjected to this short, simple and mini-mally invasive diagnostic method. It should be reserved for a group of patients with very low pain threshold, having bad experiences from the past in connection with performance of procedure within the cervix. Moreover, many centres routinely use an antibiotic prophylaxis in the perioperative period.

The cervix is cannulated by a gynaecologist with a thin double-lumen balloon catheter for HSG (pro-duced by Balton) to seal the internal os. After proper location of the catheter in the uterine cavity and in-flating the balloon a water soluble iodine contrast (e.g. Guerbet hystero Telebrix ® AG, France) is admin-istered under fluoroscopic control. Contrast medium allows for visualisation of uterine cavity morphology and contours. Further injection of contrast agent al-lows for revealing the outlines of the uterine horns, the isthmic and ampullary parts of Fallopian tubes, the degree of contrast agent penetration into the abdominal cavity, and tubal patency. If it is impossi-ble to introduce the tip of single use catheter into the cervical canal, facilitation consists in fixing the cervix using the bullet forceps. It leads to a natural straightening of the cervical canal. In case of further difficulties it is recommended to carry out the ex-amination with use of metal Schultze camera.

The most common causes of inability to perform the test using a thin catheter is a state after cervical

procedures, strong, fixed retroverted uterus and lack of experience of the practitioner.

In our institution after administration of contrast four X-ray images are taken of each patient, includ-ing the image before and after filling the uterus cavity, after imaging tubal contours and contrast agent penetration to abdominal cavity. In selected cases it is also possible to make additional imaging, e.g. after administration of the agents inhibiting the peristalsis, but these are rather rare cases. During the examination the radiologist and the gynaecol-ogist evaluate the images and determine the diag-nosis. Radiological report and images, as well as the scopy record are made available to the patients for possible further consultations on digital carrier (CD-ROM, USB).

Hysterosalpingography is relatively simple for per-formance and now it is commonly carried out in out-patients clinics.

According to the guidelines of ESHRE and NICE (National Institute for Health and Clinical Excel-lence) 2012 [11] the Fallopian tubes patency examination should be recommended by HSG or HyCoSy method after exclusion of male infertility factor. In case of suspicion or detection of any Fallopian tube or uterus organs pathology, the laparoscopy, hysteroscopy should be made with use of USG-TV.

In recent years the important role of research in the direction of Chlamydia is postulated as an impor-tant screening test in case of deciding about the test methods of tubal patency, [10]. Hysterosalpin-gosonography with contrast has become an im-portant tool in the diagnosis of uterus and Fallopian tube pathology [12, 13]. It is more challenging for the investigator than HSG and has a longer learn-ing curve. HyCoSy advantages are that it costs less, causes less pain and that it does not bring any exposure to radiation.

HSG is a safe, cheap and – in case of applying the sedation with propofol - a very well-tolerated procedure for evaluation of the Fallopian tube, which should be applied in infertility examina-tion protocol.

Literature

1. Pundir J, El Toukhy T. Uterine cavity assessment prior to IVF. Womens Health (Lond Engl) 2010, 6 (6): 841-8.

2. Farhi J, Ben-Haroush A. Distribution of Causes of infer-tility in patients attending primary fertility clinics in Israel. Isr Med Assoc J 2011, 13 (1): 51-4.

3. Marianowski P, Kaminski P, Wielgos M, Szymusik i Lu-dwikowski G. Comparison of tubal patency asses-sment during microlaparoscopy and laparoscopy, and its compatibility with previous hysteresisrosalpingo-graphy results. Neuro Endocrinol Lett 2007, 28 (2): 149

4. Akande V, Turner C, Horner P, Horne A, Pacey A, Bri-tish Fertility Society. Impact of Chlamydia trachomatis in the reproductive setting: British Fertility Society Guidelines for practice. Hum Fertil (Camb) 2010, 13 (3): 115-25.

5. Brown SE, Coddington CC, Schnorr J, Toner JP, Gib-bons W, OEH-Ninger S. Evaluation of outpatient hy-steroscopy, saline infusion hysterosonography, and hysterosalpingography in infertile men: a prospective, randomized study. Fertil Steril 2000, 74 (5): From 1029 to 1034.

6. Steinkeler I, Woodfield CA, Lazarus S, Hillstrom MM. Female in fertility: a systematic approach to radiologic imaging and diagnosticsis. Radiographics 2009, 29 (5): 1353-1370.

7. Imaoka I, Wada A, Matsuo M, Yoshida M, Kitagaki H, Sugimura K. MR imaging of disorders associated with female infertility: use in diagnosis, treatment, and ma-nagement. Radiographics 2003; 23 (6): 1401-1421.

8. Simpson WL Jr, Beitia LG, Mester J. Hysterosalpingo-graphy: a reemerging study. Radiographics 2006, 26 (2): 419-31.

9. Mol BW, Collins JA, Burrows EA, van der Veen F, Bos-suyt PM. Comparison of hysterosalpingography and laparoscopy in predicting fertility outcome. Hum Re-prod 1999, 14 (5): 1237-1242.

10. Den Hartog JE, Lardenoije CM, Severense JL, Land JA, Evers JL, Kessels AG. Screening strategies for tubal factor subfertility. The reaction Hum produc-tion 2008, 23 (8): 1840-8.

11. Good clinical treatment in assisted reproduction. An ESHRE position paper. Eur Soc Hum Reprod Embryol 2008 12th Lim CP, Hasafa Z, Bhattacharya S, Mahesh-wari A. Should a hysterosalpingogram be a first-line investigation to diagnose female tubal subfertility in the modern subfertility workup? Hum Reprod 2011, 26 (5): 967-71.

12. Broeze KA, Opmeer BC, Van Geloven N, Coppus SF, Collins JA, Den Hartog JE, Van der Linden PJ, Maria-nowski P, Ng EH, Van der Ste- JW eg, Steures P, Strandell A, Van der Veen F, Mol BW. Are patient cha-racteristics associated with the accuracy of hystero-salpingography in diagnosing tubal pathology? An individual patient data meta-analysis. Hum Reprod Update 2011, 17 (3): 293-300.

MD Piotr Marianowski, MD Iwona SzymusikDepartment of Obstetrics and Gynaecology, Medical University of Warsaw, Pl. Starynkiewicza 1/3, Warsaw

• Double-lumen catheter visible under X-ray

• Balloon blocking outflow of contrasting agent during

the examination

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inflation and deflation

Catheter forhysterosalpingography

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