Hysterosalpingography in the workup of female infertility: indications, technique and diagnostic findings

Adrian C Schankath, Nikola Fasching, Cornelia Urech-Ruh, Michael K Hohl, Rahel A Kubik-Huch, Adrian C Schankath, Nikola Fasching, Cornelia Urech-Ruh, Michael K Hohl, Rahel A Kubik-Huch

Abstract

Objectives: To evaluate the spectrum of diagnostic findings in hysterosalpingography (HSG) examinations performed at our institution between 2006-2010 and their prognostic significance for treatment decisions and fertility outcomes.

Methods: Patients were filtered from our PACS. Pathological HSG studies were re-evaluated. Indications for referral, technical success and diagnostic findings were analysed. Pathological findings were correlated with further diagnostic workups, treatments and fertility outcomes.

Results: Of 411 HSG examinations, 226 (55 %) were normal, 94 (23 %) showed minor abnormalities and 5 (1.2 %) were not diagnostic. Eighty-six (21 %) examinations were pathological. Twenty-nine patients underwent subsequent laparoscopy, during which proximal tubal occlusion diagnosed at HSG was ruled out in 9/23 cases. Follow-up information was unavailable for 20 patients. Nineteen of 66 patients with follow-ups after pathological HSG had at least one subsequent successful pregnancy. Forty-one patients had no further treatment and no pregnancies.

Conclusions: The detection rate for pathologies at HSG was low (21 %). There was a high false-positive rate (39 %) for proximal tubal occlusion, most likely because of spasms, demonstrating the importance of delayed imaging after injection of antiperistaltic agents. HSG remains a valuable diagnostic tool. Our results, however, indicate that this technique should be more selectively indicated.

Main messages: • Good acceptance of HSG by the patients. No complications with antibiotic prophylaxis. • Low detection rate (21 % pathological exams) for pathologies in our study. • High false-positive rate for proximal tubal occlusion. • This demonstrates the importance of waiting longer after injection of buscopan. • High pregnancy rate in pathological cases: Indication too broad or even a therapeutic effect of HSG?

Figures

Fig. 1
Fig. 1
Scheme used for the characterisation of HSG findings, adapted from [6]
Fig. 2
Fig. 2
A 35-year-old patient: The irregular-shaped defect localised at the right side of the cervix was identified as a myoma using transvaginal sonography. No tubal pathology was performedShould this be: "No tubal pathology test was performed"? Please check.. No follow-up information was available for this external patient
Fig. 3
Fig. 3
A 36-year-old patient: Small and irregular bordered uterine cavity with multiple linear constrictions. LSC and HSC were performed, and the diagnoses of invasive endometriosis with multiple scars and a single submucosal myoma were established. The submucous myoma, which was not visible in HSG, was resected. Subsequently, the patient had two spontaneous pregnancies; the first resulted in a spontaneous abortion, and the second was successful
Fig. 4
Fig. 4
A 32-year-old patient: Symmetrically separated uterine cavity (uterus septus). Also, notice venous intravasation of the contrast medium (this can impede the image interpretation). LSC and HSC were performed, and the septum was resected. After this procedure, the patient was lost to follow-up
Fig. 5
Fig. 5
A 31-year-old patient: Suspected uterus unicornis unicollis at HSG (a) was identified as bicornis bicollis with MRI (b). MRI: T2-weighted, transversal oblique MRI of the pelvis demonstrates two uterine cavities separated by a muscular layer. Uterus didelphys was rated unlikely as no vaginal septum was visible with MRI. Laparascopy is planned
Fig. 6
Fig. 6
A 37-year-old patient: Dilated fallopian tubes without contrast spillage into the abdominal cavity (bilateral sactosalpinx). Following HSG, an LSC was performed including left-sided salpingectomy and right-sided adhesiolysis because of follicular salpingitis and peritubar adhesions, respectively. The HSC was normal. The patient had no recorded pregnancies to date
Fig. 7
Fig. 7
A 38-year-old patient. HSG: Irregular nodular configuration of the right tube (salpingitis isthmica nodosa). The left tube is proximally occluded. Because the patient had decided that she did not want more children, there was no further workup. The HSG was performed to assess the need for anticonception. History: Low anterior rectum resection. Reanastomosis of the right tube. Resection of the left tube. Right tube normal at laparascopy 3 years before HSG

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