The use of repeat hysterosalpingographyTo the Editor:

Dessole and colleagues (1) have suggested replacing se-lective salpingography (SS) with a second hysterosalpingo-gram (HSG) a month after the first one showed proximaltubal obstruction (PTO). To support their strategy, the au-thors raised safety issues in terms of radiation exposure andrisk of tubal perforation and argue that SS is technicallydifficult and time consuming. We find it difficult to adopttheir suggestion.

The authors reported a 60% (24 out of 40 women) suc-cessful tubal opacification rate after the second HSG. In alarge study, Lang et al. (2) found that 82 out of 400 (20.5%)women had tubal patency demonstrated during a secondHSG, when the first one showed PTO. The discrepancy maybe due to differences in techniques, but the authors did notdiscuss this.

The technique of HSG employed by Dessole and col-leagues includes intravenous injections of muscle relaxants,high-pressure injection of contrast media in the uterus,stretching of the uterus by traction, and changing patientpositions during HSG. These measures are employed twice ifwomen have a repeat HSG. The discomfort and pain felt bythe women were not discussed.

The radiation exposure during SS has been shown to bewithin safety limits (3). After an initial short learning curve,the time required (and the radiation dose) is reduced, makingx-ray room time management more efficient (3). Our inci-dence of tubal perforation in 217 cases is 2.3%. These wereuncomplicated and did not require any further treatment.

Their comparison of pregnancy rates after HSG and afterSS was somewhat inappropriate. A paper published in 1980reporting on oil-based media HSGs was cited; these havegenerally gone out of favor, as water-based media arethought to be safer. On the other hand, a paper that reportedon women with multifactorial infertility was used as anindication of low pregnancy rates after SS (4). Interestingly,in the same paper the investigators calculated that, in thesubgroup of women with PTO as the only explanation oftheir infertility, the spontaneous conception rate was 46.1%.

The limitations of HSG and the relevant advantages of SShave been documented by Karande et al. (5). We feel thatSS, performed immediately after the diagnosis of PTO byHSG is more effective in the assessment and treatment ofthis condition. Performing a second HSG to confirm the

problem would not be the best use of both the patient’s andthe physician’s time.

Spyros Papaioannou, M.R.C.O.G.Masoud Afnan, F.R.C.O.G.Aravinthan Coomarasamy, M.D. Ch.B.Bolarinde Ola, M.R.C.O.G.Nahed Hammadieh, M.R.C.O.G.Khaldoon Sharif, M.R.C.O.G.The Assisted Reproduction UnitBirmingham Women’s HospitalBirmingham, United KingdomNovember 8, 2000

References1. Dessole S, Meloni GB, Capobianco G, Manzoni MA, Ambrosini G,

Canalis GC. A second hysterosalpingography reduces the use of selec-tive technique for treatment of a proximal tubal obstruction. Fertil Steril2000;73:1037–9.

2. Lang E, Dunaway HH. Recanalization of obstructed fallopian tube byselective salpingography and transvaginal bougie dilatation: outcomeand cost analysis. Fertil Steril 1996;66:210–5.

3. Karande CK, Pratt DE, Balin BS, Levrant SG, Morris RS, Gleicher NG.What is the radiation exposure to patients during a gynecoradiologicprocedure? Fertil Steril 1997;67:401–3.

4. Capitanio GL, Ferraiolo A, Croce S, Gazzo R, Anserini P, de Cecco L.Transcervical selective salpingography: a diagnostic and therapeuticapproach to cases of proximal tubal injection failure. Fertil Steril 1991;55:1045–50.

5. Karande VC, Pratt DE, Rabin DS, Gleicher N. The limited value ofhysterosalpingography in assessing tubal status and fertility potential.Fertil Steril 1995;63:1167–71.

PII S0015-0282(00)02074-X

Reply of the Authors:

We appreciate the interest of Papaioannou and colleaguesin our article (1) even if they do not agree with the conclu-sions.

Our study showed that the repetition of a second hystero-salpingography (HSG) after 1 month avoided unnecessaryselective salpingography (SS) in 60% of patients with prox-imal tubal obstruction (PTO).

Papaioannou and colleagues report to the contrary thatLang et al. (2) obtained tubal patency after a second HSG inonly 82 out of 400 (20.5%) women with PTO. After a moreaccurate reading of that study (2) it can be deduced that thedata cited by Papaioannou are not correct because the seriesconsidered in that paper regards all cases, both proximal anddistal, of tubal obstruction. On the other hand, our seriesregards only women with PTO.

During the performance of HSG, we used a differenttechnique. In the case of failed or partial opacification we

LETTERS TOTHE EDITOR

FERTILITY AND STERILITY�VOL. 76, NO. 4, OCTOBER 2001Copyright ©2001 American Society for Reproductive MedicinePublished by Elsevier Science Inc.Printed on acid-free paper in U.S.A.

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