HYSTEROSALPINGOGRAPHY

WHEN TO SCHEDULE THE EXAMINATION? The first half of the menstrual cycle (proliferative phase). The best timing is day 7-10because:

- Blood has cleared from uterus.- Isthmus is most distensible.- Fallopian tubes are more readily filled.- Endometrium is not thick.

If patient has abnormal uterine bleeding, do not stick to optimal schedule but take care:

- Use water soluble cntrast media to avoid intravasation.- Blood clots may mimic intra uterine filling defects.

INDICATIONS: Infertility. Recurrent abortions. Abnormal uterine bleeding. After tubal ligations. Before artificial insemination.

CONTRAINDICATIONS: Immediately before and after menstruation. Pelvic infections. Sensitivity to contrast. Pregnancy.

COMPLICATIONS: Pelvic pain. Infection. Allergic reaction. Intravasation. Vasovagal attack. Bleeding.

IMPORTANT PSYCHOLOGICAL ASPECTS: The radiologist should be:

CALM, CARING, CONFIDENT

The patient should be informed about the whole procedure.

Patient should be allowed to watch the flouroscopic screen during examination.

She should be informed with the results during or immediately after examination.

PREPROCEDURE MEDICATIONS: ANTIBIOTICS:

- +ve history of PID and SBE- (Doxycycline 100 mg/twice daily two days before

procedure)- (200mg immediately after procedure followed by

100mg/twice daily for 5 days)

NSAID:- What the patient usually takes or Ibuprofen

400mg 30 minutes before procedure

CONTRAST MEDIA:

WATER SOLUBLE OIL SOLUBLE• Less density• Better fallopian tube

visualization• Immediate smear• Disappear within 1hr

(except tubal block)• Less complications

• No therapeutic effect

• More density• Better uterus visualization

• Delayed smear• Disappearance is delayed • More complications

(pulmonary embolism and granulomatous inflammation)

• Has a therapeutic effect

TECHNIQUE OF EXAMINATION:

Ask the patient to evacuate her bladder. Patient lies in lithotomy position and try to elevate

her buttocks. Lubricate speculum.

Insert it closed; then rotate; then open it. Sterilize vagina. Grasp anterior lip with vulsellum forceps (avoid

3&9 o’clock: highly vascular) Insert cannula inside the cervical canal. Inject contrast material.

RADIOLOGICAL ANATOMY: UTERUS:

- What we really see is the uterine cavity- The cavity is triangular in shape- Walls are regular and concave- Fundus may be convex- Length and intercorn. Dist. Are about 35mm

FALLOPIAN TUBES: - About 7-14 cm long- Devided into: Interstitial Isthmic Ampullary InfundibUlar Fimbrial

HOW DO WE COMMENT ON THE UTERUS SIZE: (LENGTH AND INTERCORN. DISTANCE= 35mm) SHAPE: (triangular with concave margins and flat

or convex fundus) INTRAUTERINE FILLING DEFECTS. IF UTERINE CAVITY IS DOUBLED:

- Intercornual angle (normal between 70-105).- External fundal indentation.

EMBRYOLOGY OF THE FEMALE GENITAL SYSTEM: Although genetic sex is determined at fertilization,

gender is not apparent until approximately the 12th week of embryonic life. By  the  6th week embryonic life, both male and female embryos start to develop the following structures on either side of the midline:

1. Genital ridge (proliferation of coelomic epithelium)

2. Mesonephric (Wolffian) duct (lateral to the genital ridge) 3. Paramesonephric (Mullerian) duct which consists of:

o Upper vertical part lateral to the Wolffian duct. o Middle horizontal part crosses in front of the

Wollfian duct o Lower vertical part fuses with the similar part of

the opposite side to form the utero-vaginal canal

Fallopian tubes have different cellular origins therefore not involved in Mullerian duct anomalies.

The ovaries arise from mesenchyme and epithelium of the gonadal ridge; also not involved

Urinary and genital systems arise from a common ridge of mesoderm. Renal agenesis, duplicated system and cystic kidneys are common.

CONGENITAL ANOMALIES OF THE UTERUS

MÜLLERIAN DUCT ANOMALIES ARE CATEGORIZED MOST COMMONLY INTO 7 CLASSES:

CLASS I (HYPOPLASIA/AGENESIS):

This class includes entities such as uterine/cervical agenesis or hypoplasia. The most common form is the Mayer-Rokitansky-Kuster-Hauser syndrome, which is combined agenesis of the uterus, cervix, and upper portion of the vagina. Patients have no reproductive potential aside from medical intervention in the form of in vitro fertilization of harvested ova and implantation in a host uterus. In uterine hypoplasia, the endometrial cavity is small, with a reduced intercornual distance (<2 cm). When uterine hypoplasia is associated with hormonal dysfunction (infantile uterus), not only is the uterus small, but the zonal anatomy is differentiated poorly on T2-weighted images.

CLASS II (UNICORNUATE UTERUS):

A unicornuate uterus is the result of complete, or almost complete, arrest of development of 1 müllerian duct . If the arrest is incomplete, as in 90% of patients, a rudimentary horn with or without functioning endometrium is present. If the rudimentary horn is obstructed, it may come to surgical attention when presenting as an enlarging pelvic mass. If the

contralateral healthy horn is almost fully developed, a full-term pregnancy is believed to be possible.

CLASS III (DIDELPHYS UTERUS):

This anomaly results from complete nonfusion of both müllerian ducts. The individual horns are fully developed and almost normal in size. Two cervices are inevitably present. A longitudinal or transverse vaginal septum may be noted as well. Didelphys uteri have the highest association with transverse vaginal septa but septa also may be observed in other anomalies. Consider metroplasty; however, since each horn is almost a fully developed uterus, patients have been known to carry pregnancies to full term.

CLASS IV (BICORNUATE UTERUS):

A bicornuate uterus results from partial nonfusion of the müllerian ducts. The central myometrium may extend to the level of the internal cervical os (bicornuate unicollis) or external cervical os (bicornuate bicollis). The latter is distinguished from didelphys uterus because it demonstrates some degree of fusion between the two horns, while in classic didelphys uterus, the two horns and cervices are separated completely. In addition, the horns of the bicornuate uteri are not fully developed; typically, they are smaller than those of didelphys uteri. Some patients are surgical candidates for metroplasty. The most important imaging finding is a concave fundus with a fundal cleft greater than 1 cm on us. On hysterosalpingography it can be diagnosed with confidence if the intercornual angle is above 105 and the intercornual distance is above 40mm.

CLASS V (SEPTATE UTERUS):

A septate uterus results from failure of resorption of the septum between the two uterine horns. The septum can be partial or complete, in which case it extends to the internal cervical os. Histologically, the septum may be composed of myometrium or fibrous tissue. The uterine fundus is typically convex but may be flat or slightly concave (<1-cm fundal cleft). Women with septate uterus have the highest incidence of reproductive complications. Differentiation between a septate and a bicornuate uterus is important because septate uteri are treated using transvaginal hysteroscopic resection of

the septum, while if surgery is possible and/or indicated for the bicornuate uterus, an abdominal approach is required to perform metroplasty. The outer fundal contour is convex, flattened, or mildly concave (fundal cleft <1 cm). A more reliable means for differentiating the two is to examine the fundal contour (see class IV).

CLASS VI (ARCUATE UTERUS):

An arcuate uterus has a single uterine cavity with a convex or flat uterine fundus, the endometrial cavity, which demonstrates a small fundal cleft or impression (>1.5 cm). The outer contour of the uterus is convex or flat . This form is often considered a normal variant since it is not significantly associated with the increased risks of pregnancy loss and the other complications found in other subtypes. It has been proposed that when a ratio of less than 10% between the height of the fundal indentation and the distance between the lateral apices of the horns is calculated on the basis of HSG findings, an adverse reproductive outcome is not anticipated

CLASS VII (DIETHYLSTILBESTROL-RELATED ANOMALY):

Several million women were treated with diethylstilbestrol (DES; an estrogen analog prescribed to prevent miscarriage) from 1945-1971. The drug was withdrawn once its teratogenic effects on the reproductive tracts of male and female fetuses were understood. The uterine anomaly is seen in the female offspring of as many as 15% of women exposed to DES during pregnancy. Female fetuses who are affected have a variety of abnormal findings that include uterine hypoplasia and a T-shaped uterine cavity. Patients also may have abnormal transverse ridges, hoods, stenoses of the cervix, and adenosis of the vagina with increased risk of vaginal clear cell carcinoma. Imaging findings are pathognomonic for this anomaly.

A common finding is separation of the uterine cavity into right and left compartments. A divided uterine cavity can result from septate, bicornuate, or didelphys uterus. Certain criteria are used to increase confidence in diagnosing 1 of the 3 entities.

Intercornual distance: If the distance between the distal ends of the horns (ends that are continuous with fallopian tubes) is less than 2 cm, the likelihood of septate uterus is increased. If the distance is greater than 4 cm, the likelihood of didelphys and bicornuate uterus is increased. Measurements of 2-4 cm

(typical distance in a normal uterus) were indeterminate in an abnormal cavity configuration.

Intercornual angle: This is the angle formed by the most medial aspects of the two uterine hemicavities. The diagnostic accuracy of HSG alone is only 55% for differentiation of septate from bicornuate uteri. An angle of less than 75° between the uterine horns is suggestive of a septate uterus, and an angle of more than 105° is more consistent with bicornuate uteri. Unfortunately, the majority of angles of divergence between the horns fall within this range, and considerable overlap between the two anomalies is noted. In addition, the presence of leiomyomas or adenomyosis within the septum may cause secondary distortion and widening of the angles of divergence of the uterine horns. It has been reported that when US is used in conjunction with HSG, the correct diagnosis can be made in 90% of cases.

Degree of Confidence:

A large overlap exists between the subtypes when comparing uterine cavitary configuration, intercornual distance, and intercornual angle. In several studies, HSG had significantly less accuracy for diagnostic precision compared to MRI or US. In the studies, much of the final pathology was based on laparoscopic or surgical findings, primarily of the appearance of the uterine fundus, which HSG was not able to assess.

Since HSG techniques did not provide diagnoses with high degrees of confidence, US and MRI soon began to play a larger role in assessment and treatment of patients. Currently, anomalies incidentally discovered on HSG are referred for further evaluation using MRI or US.

The only anomaly in which HSG plays a significant role in diagnosis is DES uterus (AFS class VII). The abnormal uterine cavity can be depicted clearly on HSG but often is visualized as only uterine hypoplasia on US or MRI.

Additional findings on MRI and U/S include:

- External fundal contour:

External uterine contour must demonstrate a convex, flat, or mildly concave

- External fundal indentation:

If the fundal indentation of the external uterine contour is below the interostial line or less than 5 mm above the

line, the uterus is considered to be bicornuate or didelphic. The septate uterus is defined by a fundal indentation of more than 5 mm above the interostial line

- Degree of cervical communication.

INTRAUTERINE FILLING DEFECTS

1.ASHERMAN'S SYNDROME:

It is also called "uterine synechiae". It presents a condition characterized by the presence of scars within the uterine cavity. The cavity of the uterus is lined by the endometrium. This lining can be traumatized, typically after a dilation and curettage (D&C) done after a miscarriage, abortion, or delivery, and then develops intrauterine scars which can obliterate the cavity to a varying degree. In the extreme, the whole cavity has been scarred and occluded. Even with relatively few scars, the endometrium may fail to respond to estrogens and rests. The patient experiences secondary amenorrhea and becomes infertile. An artificial form of Asherman's syndrome can be surgically induced by uterine ablation in women with uterine bleeding problems in lieu of hysterectomy. Ultrasound is not a reliable method of diagnosing Asherman's Syndrome. Options include HSG (hysterosalpingography) or SHG (sonohysterography). Hysteroscopy is the most reliable.

2. UTERINE FIBROIDS:

Fibroids are very common - they are benign (noncancerous) tumors of the uterine muscle. The size and location of the fibroid are important. The large majority of them are very small or located in an area of the uterus such that they will not have any impact on reproductive function. 

There are 3 general locations for fibroids:

1. Subserosal - on the outside surface of the uterus2. Intramural - within the muscular wall of the uterus3. Submucous - bulging in to the uterine cavity

The only type that will have any impact on reproductive function (unless it is very large) is the submucous type that pushes in to the uterine cavity. These are much less common than the other 2 types of fibroids. Because of their location inside the uterine cavity, submucous fibroids can cause infertility or miscarriages.

3. UTERINE POLYPS:

Uterine polyps are quite common. They're soft red fleshy tumours of the endometrium (the lining of the uterus or womb). They vary in size from 1cm (0.4in) - when they contain only endometrial tissue (womb lining) - to 5cm (2in). Larger polyps often contain not just endometrial cells, but also muscular and fibrous tissue from deeper in the wall of the womb. Polyps are prone to bleeding and bleeding between periods is often the first clue to their existence.

Polyps may either lie flat against the inside of the womb or be pedunculated, which means they form on the end of a 'stalk' of flesh. Pedunculated polyps sometimes hang down through the cervix, where they may become trapped, cutting off the blood supply to the tumour (known as strangulation of the polyp). In this case they may bleed profusely and may be painful.

HYDROSALPINX

WHAT IS A HYDROSALPINX? A hydrosalpinx is a blocked, dilated, fluid-filled fallopian

tube usually caused by a previous tubal infection. The pelvic infections that lead to hydrosalpinx formation are usually caused by sexually transmitted diseases. Diagnosis of hydrosalpinx is usually made by a hysterosalpingogram. If the tubes are open, the liquid will spill out the ends of the tubes. If the tubes are blocked, the liquid is trapped.

If the fallopian tubes are completely blocked, conception will not occur without medical intervention. In milder cases, fertility may be restored by opening the tubes surgically. However, if the lining of the tubes is badly damaged, in vitro fertilization (IVF), which bypasses the tubes, is the treatment of choice.

At hysterosalpingography, the complete depiction of fallopian tubes from the uterine to the abdominal ostium should always be pursued, because tubal morphology might be of the utmost importance for the final diagnosis.

The careful evaluation of the ampullary lumen by means of hysterosalpingography can provide useful information about tubal mucosal abnormalities. Therefore, we stress that hysterosalpingography should be considered not only for diagnosis of tubal patency but also for its capacity, which might be improved, to depict mucosal damage.

The morphology of the ampullary tract of the fallopian tubes is of paramount importance for the final diagnosis, and a precise hysterosalpingographic result can greatly help the gynecologist in the care of patients. The cobblestone pattern is an effective radiographic sign of intraluminal adhesions in hydrosalpinges, which, if preliminarily diagnosed, might bring into question the need for a surgical approach. On the contrary, a normal hysterosalpingogram cannot be used to conclude the infertility work-up in cases of continuing infertility, because a patent and radiographically normal tube might not be a normally functioning tube.

Tuberculous salpingitis is characterized by:- Thick mucosal folds- Tubal calcification- Tubal occlusion/patency- Beaded/rosary appearance- Sometimes..rigid tubes ‘pipe stem appearance’- Ragged saw tooth endometrial cavity- Endometrial hyperplasia- Polypoidal filling defects

SALPINGITIS ISTHMICA NODOSA

Salpingitis isthmica nodosa is also referred to as tubal diverticulosis. HSG demonstrates multiple small diverticular collections of contrast protruding from the lumen into the wall of the isthmic portion of the fallopian tubes. Histologically, the up to 2 mm sized diverticula represent hypertrophied tubal mucosa that penetrates the myosalpinx (i.e. muscular wall of the tube). There is secondary hyperplasia and hypertrophy of the surrounding myosalpinx, and hence at laparoscopy, localized nodular thickening or swelling of the isthmus is identified.

The etiology of salpingitis isthmica nodosa is unknown, however it may be a postinfectious reaction. Patients have histologic evidence of previous salpingitis and may have high

serum chlamydial antibody titers. Salpingitis isthmica nodosa predisposes to a higher rate of primary infertility by interfering with upward sperm migration and ectopic pregnancy by trapping the fertilized ovum within the tube. Hence the diagnosis of salpingitis isthmica nodosa by HSG is important in the management of the infertile patient.

A HSG of the nodular area with severe SIN shows several pockets containing the X-ray dye.  Of specific note is the observation that no dominant channel is seen as the dye flows through the tube.  This means there appears to be no direct pathway for sperm to travel.  This increases the chance of a tubal pregnancy.

SIGNS OF PELVIC ADHESIONS Fixed uterine condition on probing. Vertical tube orientation. Loculation of the contrast