Uterine.html
Uterine and tubal anatomical abnormalities in infertile women:
diagnosis with routine hysterosalpingography prior to selective
laparoscopy
M Heis, MD, FRCR, FFRRCSI, CST
Z Amarin, MD, FRCOG, FFPH
A Y Ibrahim, MD
N Obeidat, MD
B Obeidat, MD, FRCOG
M Omari, MD
Jordan University of Science and Technology, Irbid, Jordan
Corresponding author: Z Amarin (zoamarin@hotmail.com)
Abstract
Objective.
To assess the findings and usefulness of hysterosalpingography (HSG) as
a routine investigation in the fertility workup prior to selective
laparoscopy.
Design. Descriptive retrospective study.
Setting. A university hospital in the north of Jordan.
Subjects. All patients who underwent hysterosalpingography in the period 1 January - 31 December 2008.
Outcome measures. Detection of uterine and fallopian tube abnormalities and their correlation with laparoscopic findings.
Results.
During the study period, 281 infertile women underwent HSG with no
post-procedural complications. The mean (SD) age was 31.5 (5.9) years.
Mean (SD) duration of infertility was 4 (3.4) years. Infertility was
reported as primary and secondary in 119 (42.3%) and 162 (57.6%),
respectively. Altogether, 281 patients and 562 tubes were examined. Of
those, 402 were patent and 160 occluded. In only one woman were
peritubal adhesions diagnosed. Because of hysterosalpingographically
diagnosed tubal occlusion, 46 women (16.4%) were referred for
laparoscopy. Eight (17.3%) of them were treated with unilateral
salpingectomy, and 28 (60.8%) with bilateral salpingectomy.
Salpingolysis was performed on 7 (15.2%) women; 3 (6.7%) women had
untreatable adhesions. The concordance was 71.7%. The sensitivity of
HSG was 80%, the specificity 50%, the negative predictive value 61%,
and the positive predictive value 71%. Of the total of 281 women, 30
(10.7%) conceived within 1 - 11 months after HSG.
Conclusion.
The very high abnormal predictive value of HSG in the diagnosis of
tubal occlusion suggests that this procedure could be performed as a
screening examination.
Introduction
Infertility affects about 15% of the population,
with at least 1 in 6 couples needing specialist help at some time in
their lives because of infertility.1
After history taking, physical examination, semen analysis and
ovulation studies, assessment of tubal patency is the next standard
test. A universally agreed upon test for fallopian tube patency has not
been established. A variety of investigation modalities are available
that include hysterosalpingography (HSG), laparoscopic dye
hydrotubation, hysterosalpingo contrast sonography (HyCoSy), selective
salpingography, MR hysterosalpingography with an angiographic
time-resolved 3D pulse sequence, radiography/MRI, 2D HyCoSy with
contrast-tuned imaging, and falloposcopy.2
Traditionally, HSG and laparoscopy with dye have
been used in the diagnosis of tubal pathology. However, non-invasive
methods are associated with false-positive results where occlusion is
related to tubal spasm. Laparoscopy with dye is still considered to be
the gold standard if tubal pathology is suspected, but it requires
general anaesthesia and operating theatre facilities. Despite advanced
technology and experience, complications during laparoscopy remain a
major cause of significant morbidity and very seldom reveal any
pathological conditions.6
Furthermore, infertility healthcare costs are difficult to calculate.
There are few published data that determine the actual medical costs of
adding an infertility evaluation test.7
Without such data, it is difficult to determine if a certain
investigation would obviate the need to use other more invasive or more
financially onerous tests.
The aim of this study was to assess the findings
and define the role of HSG as a routine investigation in the fertility
workup, prior to selective laparoscopy, in a tertiary referral
institute in Jordan.
Materials and methods
Between 1 January and 31 December 2008, 281
pragmatic HSG studies were performed at the Jordan University of
Science and Technology to investigate anatomical causes for
subfertility on an outpatient basis during the proliferative phase of
the menstrual cycle, prior to selective laparoscopy. All procedures
were monitored fluoroscopically and interpreted by a radiologist. A
water-soluble contrast medium (Omnipaque 33) was used. One photograph
was taken when the cavity and fallopian tubes were filled, and one
after overflow into the peritoneal cavity or when there was maximal
filling without spillage. A late film was taken to detect contrast
depots. Findings of tubal pathology were classified as normal,
unilateral abnormality, bilateral abnormality, and findings suggestive
of peritubal adhesions on the basis of loculation of contrast medium
around the fallopian tube and restriction of flow away from the distal
end. Proximal tubal occlusion was diagnosed by the absence of contrast
medium beyond the isthmus, while the distal tubal occlusion was
diagnosed on the basis of contrast medium within the ampulla but not
passing through to the peritoneal cavity.
Results
The study population comprised 281 infertile women.
Overall, the mean age (SD) was 31.5 (5.9) years, with a range of 18 -
46 years. Mean (SD) duration of infertility was 4 (3.4) years, range 1
- 21 years. Infertility was reported as primary and secondary by 119
(42.3 %) and 162 (57.6 %), respectively.
Altogether, 281 patients and 562 tubes were
examined. None of the women had only one tube. Of the investigated
tubes, 402 were patent and 116 occluded. Table I shows tubal pathology,
and Tables II and III show the congenital uterine anomalies and uterine
pathology, respectively, as estimated by HSG. In all the 281 HSG
investigations in this study, the procedure was tolerated well, with no
post-procedural complications to warrant termination of the procedure,
and no febrile morbidity was noted.
Because of hysterosalpingographically diagnosed
tubal occlusion, 46 women (16.4%) were referred for laparoscopy.
Laparoscopy confirmed the findings shown on HSG. Eight (17.3%) subjects
underwent unilateral salpingectomy and 27 (58.6%) bilateral
salpingectomy. Salpingolysis was performed on 7 (15.2%) women;4 (8.6%)
women had untreatable adhesions. The concordance was 71.7%. The
sensitivity of HSG was 80%, specificity 50%, negative predictive value
61%, and positive predictive value 71% (see Table IV). The remaining 34
women were either lost to follow-up or were referred for in vitro fertilisation. Of the total of 281 women, 30 (10.7%) conceived within 1 - 11 months after HSG.
Discussion
The issue of a gold standard is important.
Laparoscopy and dye test is commonly used in most clinical studies on
tubal factor subfertility as the reference standard. Some studies
questioned the choice of laparoscopy and dye test as a gold standard
procedure. Meta-analyses comparing results of HSG and laparoscopy and
dye test for the diagnosis of tubal pathology demonstrated that over
one-third of the tubes found to be occluded at laparoscopy and dye test
showed patency at HSG.8
Therefore, it could be said that the diagnosis of tubal occlusion can
not be made with absolute certainty unless it is checked and probably
confirmed by HSG, unless it is argued that the actual procedure of one
or the other procedure was instrumental in affecting tubal patency,
owing to the actual hydrostatic pressure exerted on the tubes during
the procedure. In the current study, all 46 women (16.4%) with
hysterosalpingographically diagnosed tubal occlusion were confirmed by
laparoscopy, confirming the value of HSG for intra-tubal pathology. In
contrast, laparoscopy and dye test as a primary procedure has not
proved to be a gold standard test, as some patients diagnosed with
bilateral tubal occlusion by this technique were reported to have a
3-year cumulative pregnancy of 2%.9
Fertiloscopy has been recently advocated as the procedure of choice for
evaluation of tubal status, but further evaluation of its merits is
necessary.10
The routine use of HSG in the fertility workup
should be undertaken against the background of the possibility of
faulty technique and artifacts. Hofmann et al.11
found that 17% of the films were technically inadequate. Artifacts
include faulty insertion of the cannula, vaginal reflux, different
tubal muscle tone and cornual spasm.12
,
13
Although HSG has traditionally been used as a
first-line technique for the diagnosis of tubal pathology, it is
associated with false-positive results related to tubal spasm. In
addition, the diagnostic accuracy of HSG could be influenced by lack of
reproducibility. The interpretation of HSG results could be biased
owing to variability within and between observers, especially regarding
the interpretation of the possibility of adhesions.14
Furthermore, it has been estimated that clinicians were more reliable
in diagnosing hydrosalpinx and tubal obstruction, while radiologists
were more reliable in the detection of salpingitis isthmica nodosa and
uterine adhesions.15
Some studies advocate a 3- to 6-month interval to
allow for the so-called positive perturbation effect after normal HSG.
Only patients who did not conceive during this interval were referred
for laparoscopy with dye.16
,
17 In our study, of the total of 281 women, 30 (10.7%) conceived within 1 - 11 months after HSG.
We conclude that the very high abnormal predictive
value of HSG in the diagnosis of tubal pathology suggests that this
procedure could be performed as a screening examination, whereas
diagnostic laparoscopy could be used as a second-line technique.
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Table I. Tubal pathology identified by
hysterosalpingography
Bilateral hydrosalpinx
27
Unilateral hydrosalpinx
19
Bilateral distal occlusion
5
Unilateral distal occlusion
27
Bilateral proximal occlusion
11
Unilateral proximal occlusion
16
Bilateral combined proximal/distal occlusion
6
Unilateral combined proximal/distal occlusion
5
Periadnexal adhesions
1
Table II. Congenital uterine anomalies identified
by hysterosalpingography
Attribute
Frequency
%
No congenital anomalies
258
91.8
Bicornuate unicollis uterus
9
3.2
Arcuate uterus
11
3.9
Uterine septum
1
0.4
Hypoplastic uterine cavity
2
0.7
Total
281
100
Table III. Uterine pathology identified by
hysterosalpingography
Attribute
Frequency
%
Normal opacification
216
76.8
Congenital uterine anomalies
23
8.1
Retroverted uterus with normal opacification
14
5,.0
Uterine fibroid
15
5.3
Poor opacification with irregular outline
4
1.4
Caesarean section scar
4
1.4
Adhesions
1
0.4
Irregular outline of uterine cavity
4
1.4
Total
281
100
Table IV. Tubal pathology identified by hysterosalpingography and findings at laparoscopy
Tubal pathology identified by hysterosalpingography
Findings at laparoscopy
Type of pathology
N
Normal
One-sided
tubal occlusion
Two-sided
tubal occlusion
Peri-adnexal adhesions
Bilateral hydrosalpinx
12
1
1
9
1
Unilateral hydrosalpinx
8
0
6
0
2
Bilateral distal occlusion
2
0
0
2
0
Unilateral distal occlusion
9
1
6
0
2
Bilateral proximal occlusion
3
0
0
3
0
Unilateral proximal occlusion
6
4
2
0
0
Bilateral combined proximal/distal occlusion
2
0
0
2
0
Unilateral combined proximal/distal occlusion
3
0
2
0
1
Periadnexal adhesions
1
0
0
0
1
Total
46
6
17
16
7