Hysterosalpingography

FERTILITY AND STERIUTY Copyright c 1983 The American Fertility Society

Vol. 40, No.2, August 1983 Printed in U.SA.

Hysterosalpingography

Alvin M. Siegler, M.D., D.Se. Department of Obstetrics and Gynecology, State University of New York, Downstate Medical Center, Brooklyn, New York

Hysterosalpingography should remain an important diagnostic procedure for the investigation of the infertile woman. For more than 60 years this radiographic study has enabled physicians to locate intrauterine abnormalities and to evaluate tubal patency. It is a safe, inexpensive, simple, rapid diagnostic test that can reveal the shapes of the uterine and tubal lumens. Important information becomes available to aid in the management of the infertile couple by using proper precautions, careful techniques, and intelligent analysis of the findings. The purpose of this presentation is to emphasize the need for a skilled performance and a thoughtful interpretation, and to review some of the recent developments in hysterosalpingography. This approach will result in fewer misleading reports. Hysterosalpingography should remain a basic study in the workup of the infertility patient, although in selected instances (i.e., patients requiring donor insemination) the procedure can be omitted initially, because most conceptions occur within the first 6 months of therapy.l Broekhuizen and colleagues2 found that a preliminary hysterosalpingogram (HSG) was of no therapeutic value and of limited diagnostic value in their investigation of women who needed donor insemination to achieve pregnancy. Subsequent laparoscopy in patients who failed to conceive revealed endometriosis, and the HSG had been normal in all of them. While some authors 3 , 4 even ascribe a therapeutic value to the procedure, others5 - 7 believe the findings of hysterosalpingography are so often misleading that they no longer suggest its use. Indeed, laparoscopy is substituted for hysterosalpingography by Phillipsen and Vol. 40, No.2, August 1983

Hansen, 8 because they found agreement of the results from both tests in 57% of 168 consecutive patients, infertile for more than 2 years. Corson9 collected several series in which comparisons were made between the tubal findings of hysterosalpingography and laparoscopy. The consensus was that periadnexal adhesions were the greatest cause of the discrepancy between the two tests. Other misleading HSGs were caused by proximal tubal obstruction overcome at laparoscopy with chromopertubation. On the other hand, Horowitz and co-workers lO express the belief that the potential accuracy of diagnosis from an HSG should continue to make hysterosalpingography a preliminary procedure for every infertile woman, and for many women it may be the only investigation of tubal patency required prior to surgery or conservative management. On rare occasions, both hysterosalpingography and laparoscopy showed advanced pelvic disease not amenable to conservative surgery for restoration of fertility, and yet patients became pregnant. l l Ansari 12 emphasized that this radiographic study is an important diagnostic procedure to evaluate tubal patency and to search for intrauterine defects. He used water-soluble media and a #8 pediatric Foley catheter. Kasby 13 found the greatest weakness with hysterosalpingography was in its inability to define periadnexal disease. To limit these misinterpretations on the delayed film, the physician should look for either localized spill, abnormal tubal contours, or the halo effect. Pontifex and colleagues14 made 18,000 HSGs at the University of Athens and reported the results of 3773 of them. Of the primary infertility patients, tubal obstructions were noted in 37%, and almost half were of tuberculous origin. These auSiegler Hysterosalpingography

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Figure 1 A distorted enlarged uterine cavity is characteristic of a submucous myoma (open arrows). Continued filling demonstrates fallopian tubes (curved arrows).

thors found that a hypoplastic uterus and cervical stenosis were the most common conditions detected in cases of primary infertility. Sanfilippo and co-authors15 usually required less than 2 minutes of fluoroscopic time to complete their examinations, and they also found 37% tubal abnormalities. TECHNIQUE

The development of the preliminary or scout film enables the physician to decide on the proper exposure for subsequent films and to locate opacified areas in the pelvis, possible pelvic calcifications, or residual contrast material from a previous HSG. A variety of cannulas have been suggested; but the simplest, and still the best, is the J archo type, with the adjustable steel collar and rubber acorn. The acorn should be fixed securely with the set screw in the metal collar - 0.5 mm from the perforated end of the cannula. The cannula is filled with contrast material to flush out the air. Having fixed the tenaculum on the anterior cervicallip, the cannula is inserted into the external . os, and the two instruments are held together by the physician. Image intensification with television fluoroscopy is essential for proper monitoring of the procedure. Other methods of HSG without constant visual control are no longer acceptable, 140

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and they should be abandoned. The initial x-ray is taken after the injection of 1 to 2 ml of contrast material. The beginnIng sequence is to ascertain the position and contour of the uterine cavity. Spot films are taken at propitious moments according to the information desired by the physician from that particular examination. A balloon catheter has been advocated by Yoder and Pfister,16 and suction cups by Fullenlove. 17 The suction cup made of aluminum rather than plastic lasts much longer; and, on the same principle, it does not require any tenaculum. Its application is painless, and the x-ray pictures almost always reveal the lower uterine segment. The apparatus is more cumbersome than the Jarcho cannula. The balloon catheter (pediatric Foley #8) is easy to insert, and a curved tenaculum is required in < 50% of patients. In over 5000 examinations by Spring and co-workers,18 the balloon (inflated to 3 ml) did not seem to obscure significant defects in the lower segment or endocervical canal, these areas being studied during withdrawal of the catheter. In some instances, the purpose of the HSG is to evaluate the shape of the uterine cavity in a search for submucous myomas, endometrial polyps, or synechiae; and few films are needed for a proper diagnosis. A distorted, enlarged cavity with a filling defect is characteristic of a submucous myoma, but overfilling the cavity can obFertility and Sterility

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Figure 2 (A), Only the intramural segment (arrows) is filled. (B), Patent portions of intramural segment (arrows) compatible with proximal tubal obstruction are seen on hysteroscopy.

scure the defect. If, in addition, tubal patency is to be tested, more contrast material is added until the end points are reached (Fig. 1). Sufficient observations should be made before concluding the procedure and the following end points are recognized. Before arriving at a diagnosis of proximal tubal occlusion, it is important to know precisely why the examination was concluded prior to tubal filling and the amount of contrast material used. One of the end points is increasing abdominal pain caused by uterine distention as increased resistance to manual injection with the syringe occurs. At least 5 ml must be injected before it can be assumed that proximal obstruction exists. The films should show some intramural opacification and pointed, not rounded horns (Fig. 2A). During a hysteroscopic examination, it is equally unusual not to be able to see at least some patent proximal tubal segment as it originates in the uterine horn (Fig. 2B). Vol. 40, No.2, August 1983

Figure 3 Note the pretubal bulge can appear club-shaped or triangular, separate from or attached to the uterine horn (arrows). The 2 cm of this section of the tube represents the intramural segment.

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Figure 4 The involvement of the intramural segment (curved arrows) is affirmed by this HSG. The opposite left tube shows a similar abnormality in the isthmus.

A pretubal bulge occurs in about one third of the cases, and it is caused by an anatomic fold separating the endometrium from the endosalpinx (Fig. 3). It is rare not to fill some part of the interstitial tubal segment with contrast material. Hysterosalpingography, as it relates to proximal tubal obstruction, can help to differentiate between organic obstruction and functional spasm and detect intramural opacification, tubal polyps, and the radiologic extent of salpingitis isthmica nodosa (Fig. 4). With this test, the physician is able to ascertain the feasibility of tubocornual anastomosis or tubocornual implantation. The other end points during the examination of the tubes are filling and spilling. If one tube fills and spills and the other is not seen, continue to add 1 to 2 ml of contrast material until either the material from the patent side seems to obscure

the pelvic shadow or the opposite tube fills and spills. Often a misleading diagnosis of proximal tubal obstruction is made because the study is concluded prematurely (Fig. 5). With regard to distal tubal obstruction, ampullary rugal patterns are detectable with water-soluble medium, and their presence suggests a more favorable prognosis for a successful repair (Fig. 6). The HSG can indicate peritubal adhesions by showing a peri tubal halo of contrast material in association with some dilatation of the ampulla (Fig. 7). The delayed or follow-up film is essential for a complete examination even in instances of proximal tubal obstruction. When using a water-soluble medium, the follow-up film should be taken after all the instruments are removed from the vagina and the patient has been ambulatory for about 10 to 15 minutes. With oil-soluble contrast media, this film is delayed until the next day because the heavier liquid takes longer to disperse into the peritoneal cavity. Misinterpretation can result from confusing vaginal spill with partial patency. Midline collections that show a rugal pattern indicate contrast material in the vagina (Fig. 8). Another pattern reveals displacement of contrast material by the cervix and dispersion of it throughout the pelvis. Occasionally the film shows two lesions, proximally, salpingitis isthmica nodosa and distal tubal obstruction (Fig. 9). In the absence of rugal

Figure 5 In this series of photographs, the diagnosis of proximal tubal obstruction (arrows) would have been erroneous if only one or two views had been taken. Subsequent films show gradual filling of both tubes. 142

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Figure 6 Anampullary rugal pattern is denoted by the central dark line (arrows), indicative of the persistence ofluminal folds and minimal endosalpingeal damage.

Figure 8 Midline collection of rugal pattern (broken arrow) denotes the vaginal outline with contrast material. The filling defect (curved arrows) represents the cervix.

folds, the prognosis for successful repair of such a blocked tube is almost nil. Peritubal adhesions, possibly with associated fimbrial phimosis, could be assumed from a picture showing some pelvic localization in addition to spill of contrast material (Fig. 10). Diagnostic radiologic techniques have inherent limitations because they are indirect methods of examining specific areas. An HSG cannot make the diagnosis or reveal the extent of pelvic endometriosis, but tubal endometriosis shows a peculiar luminal pattern not unlike salpingitis isthmica nodosa (Fig. 11). This honeycomb appearance has even been confused with tubal tuberculosis, but a good history should enable a physician to come close to the proper interpretation of the radiologic picture.

A temporary form of tubal occlusion caused by dysfunctional muscular activity is defined as uterotubal spasm, and it can result from irritant solutions or stress. Brundin 19 has studied sphincteric functions of the tubal isthmus in rabbits, and he demonstrated large numbers of adrenergic nerve terminals in the circular muscle of the uterotubal junction by fluorescent microscopy. Electrical stimulation caused muscular contractions and temporary tubal occlusion. Most physicians do not give any premedication, but occasionally a tranquilizer is used for the very apprehensive patient. Since tubal spasm occurs even in the patient having general anesthe!sia during laparoscopy, several drugs have been advocated "to relax" the three layers of uterine muscle enveloping the interstitial tubal segment.

Figure 7 Peritubal halo (arrows) on the delayed film indicates periadnexal adhesions.

Figure 9 Multifocallesions are present in both fallopian tubes: salpingitis isthmica nodosa (straight arrow) plus hydrosalpinx (curved arrows).

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Figure 10 Delayed film shows bilateral localized collections of contrast material with some peritoneal spill (arrow), indicating hydrosalpinx with minimal patency.

Figure 12 Tubal tuberculosis was confirmed at laparotomy. The diverticular pattern (straight arrow) was associated with some vascular intravasation (curved arrows) and distal tubal disease.

Ron and co-authors20 recently described a beneficial effect from 1% halothane on uterine cornual spasm during general anesthesia at laparoscopy in three patients who had apparent proximal tubal obstruction as determined by previous HSGs. Gerlock and Hooser21 gave glucagon (2 mg intravenously) to nine patients who had proximal tubal obstruction on an HSG and waited 5 minutes before taking one more film, and in five instances subsequent tubal patency was demonstrated. Whenever proximal tubal obstruction was detected during hysterosalpingography performed with water-soluble contrast material under fluoroscopic control, Winfield and colleagues22 gave the patients a short respite and then repeated the procedure. In the event that occlusion persisted, 1 mg of glucagon was administered intravenously, the cannula remained in

place, and 1 minute later the x-ray examination was repeated. Of 310 patients, 21 had unilateral and 3 had bilateral cornual obstruction, an incidence of 7.7%. Glucagon was given to these 24 women with reversal of the obstruction in 27 tubes (33% response rate). Of ten patients who subsequently underwent laparoscopy with persistent occlusion despite glucagon, eight showed occlusion at laparoscopy. One woman in whom the occlusion was reversed with glucagon during hysterosalpingography had proximal tubal obstruction under laparoscopy with general anesthesia. Glucagon has been used primarily to counteract severe hypoglycemic states; but in addition, it is described as being effective in inhibiting the motility of the intestinal tract by causing atony of the smooth muscle. It is a straight-chain polypeptide chemically unrelated to insulin, produced normally in the pancreas; and given parenterally, it causes an increase in blood glucose. The media used for hysterosalpingography have been described thoroughly by Soules and Spadoni. 23 While water- and oil-soluble types each have certain advantages and disadvantages, it is important for the physician to be aware of the nature of the contrast material used, because the technique of the study and interpretation of the films are influenced by this knowledge. ADVERSE EFFECTS

Figure 11 Tubal endometriosis was found in this patient. The flecks of contrast material (arrows) are seen about the isthmus without a central linear pattern. The distal ends appear normally patent. 144

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Faulty technique and poor selection of patients are the causes of morbidity or are contributing factors in the sequelae that occasionally follow HSGs. The use of water-soluble media has eliminated the complications of oil embolism and the Fertility and Sterility

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en to febrile morbidity. Prophylactic antibiotics usually do not prevent reactions in such patients. Stumpf and March25 have shown that a history of infertility,a previous documented episode of pelvic inflammatory disease, surgery for treatment of inflammatory disease, and adnexal tenderness or masses represent major risk factors. Almost all women who developed febrile reactions had distal tubal disease as evidenced by obstruction on the HSG. Pelvic peritonitis uncommonly follows an HSG in women who have normal tubes, and it is not seen in patients with proximal obstructions. If a patient complains of pelvic pain or fever after the radiographic procedure, she should be examined. If pelvic masses are palpable, hospitalization is warranted, a fever workup is indicated, and appropriate antibiotics should be prescribed. An unresponsive clinical course, despite antibiotics, could indicate the presence of a pelvic abscess requiring drainage. This complication can be quite serious in the infertile woman, because permanent sterility could result from a severe pelvic infection. There is no reliable in vitro or in vivo test to predict whether a given patient is likely to suffer an adverse reaction to contrast media containing iodine. A reasonable attitude is to regard all patients with highly allergic backgrounds or histories of adverse reactions to contrast media as being at greater than average risk. Nonallergic vasomotor reactions characterized by some flushing, nausea, dizziness, or even hypotension have been described.

Figure 13 Vascular intravasation is identified. (A), Venous. (B), Lymphatic pattern outlines a large area of myometrium (arrows).

risk of granulomas. Fluoroscopy with image intensification has reduced, but not eliminated, the development of intravasation and of inadvertently introducing excessive amounts of contrast material. Febrile morbidity following an HSG is probably the most common complication, and its occurrence in the infertile patient can render her sterile. Serious pelvic infections occur in between 0.3% and 1.3% of patients undergoing this procedure.24 A history of a previous pelvic infection that required hospitalization and antibiotics increases the risk. A pelvic examination that discloses adnexal tenderness and an elevated white blood count or an elevated sedimentation rate predisposes womVol. 40, No.2, August 1983

Figure 14 This pattern of vascular intravasation (arrows) could be confused with tubal filling. Siegler Hysterosalpingography

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Figure 15 (A), A unicornuate uterus was suspected initially. (B), Cervical manipulation and an oblique view of the pelvis revealed the opposite horn.

Vascular intravasation must be considered a complication of an HSG; but with new water-soluble media, fluoroscopy, and image intensification, the hazards of embolism are minimal. Lymphatic and venous channels can be opacified (Fig. 12); they are distinguishable by their anatomic patterns. Uterine and ovarian veins are easily identified, and sometimes they can be confused with tubal filling (Figs. 13 and 14). The most common technical causes of this complication are inadvertent insertion of the cannula into the myometrium and excessive pressure during the instillation of contrast material. Pathologic alterations of the uterine cavity caused by intrauterine adhesions, uterine tuberculosis, and submucous tumors also predispose patients to this problem. Endometrial scarring, fibrosis, and ulcerations enable the contrast material to enter the myometrial vessels. The incidence of this complication reported by Bateman and co-authors 26 was 2.4%. Of their 13 patients, only 3 had normal uteri and normal fallopian tubes. Even with oil-based media, serious embolic conse146

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quences associated with low viscosity materIal is rare. If intravasation is observed, the procedure must be terminated; and radiologic monitoring is probably indicated to rule out pulmonary embolism. The amount of ovarian radiation from an HSG depends upon the technical equipment, the number of films obtained, the duration of fluoroscopy, the distance of the tube from the film, and the size of the patient. Epidemiologic investigations have not proved any deleterious fetal effects from low doses of radiation received in pregnancy, according to Sternberg,27 who wrote an authoritative review on the incidence and consequences of voluntary or inadvertent use of radiologic procedures in pregnant women. Goldenberg and coworkers 28 retrospectively evaluated the health of the infants of 26 women who had become pregnant during the cycle in which an HSG was performed. The children, some as old as 9 years of age, were all healthy and free of any congenital anomalies. Various pelvic dosimetric techniques have been used to evaluate radiation dosage. The amounts varied enormously from 75 to 750 millirads, mostly depending upon the fluoroscopic time, which usually averaged < 1 minute. Different diagnostic x-ray machines can deliver 60 to 200 rads per minute; and the radiation given to ovaries during such routine diagnostic procedures as an intravenous pyelogram, a barium enema, and a gastrointestinal series can total as much as 11 rads, higher than the maximum of 5 rads of recommended radiation by the International Commission on Radiation Protection. Schwarz29 believes that both prefertilization radiation and

Figure 16 A unicornuate uterus is present, and the kidney is absent on the contralateral side. The arrow indicates the end of the cannula, almost perforating the lower uterine segment.

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Figure 17 A similar shadow is caused by severe intrauterine synechiae (arrows) confirmed by hysteroscopy.

Figure 19 Linear intrauterine dense shadows (arrows) represent congenital uterine folds.

postfertilization exposure probably have the same detrimental effects. Radiation damage to the germ cells is cumulative without regard to time. Seppanen and co-workers,30 using 70- and 100mm fiuorography reduced the total dose per examination to between 0.1 and 0.2 rads. The comparative doses in full-scale radiography in the range of 70 to 90 k V show that the numeric val-

ues and average readings of dosimeters in millirads was half the amount. The dose in 1 minute of videofiuoroscopy was equivalent to the doses produced by one. exposure in full-scale filming and three to four exposures in 100-mm filming. Warrick31 urged the adoption of a 10-day rule, indicating that all diagnostic x-rays should be done in women who were exposed to pregnancy

Figure 18 Septate uterus (arrow indicates the septum) was suspected from this radiographic picture. It was proven by the presence of a normal uterine serosal surface seen at laparoscopy and a septum observed at hysteroscopy.

Figure 20 An oval shadow (arrows) lateral to the cervix represents a remnant of a Gartner's duct cyst.

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cause of accidental exposure of the conceptus to x-radiation. If unknowingly a pregnant patient undergoes an HSG, a question of a therapeutic abortion may arise. The increased risk, below a fetal dose of 5 rads, is very small. Fetal doses above 10 rads during the first 6 weeks after conception may warrant an abortion. 32 Isaacs33 described a double outline sign in the uterine cavity as being caused by infiltration of the media into the decidua of a pregnant uterus. Recognition of this configuration should alert the physician to the possibility of an unsuspected early pregnancy so that the HSG can be quickly terminated. Jacobsen and Conley34 base their calculation of the fetal dose on (1) the number of films, (2) the kilovolt peak in each film, (3) the milliamperes and screen speed for each film, (4) the estimated time of the fluoroscopic examination, and (5) the patient's pelvic thickness. Sheikh and Yussman35 reported the results of electrocardiographic monitoring of the HSG in 30 women. Except for some changes in the rate (bradycardia or tachycardia), no electrocardiographic alterations were noted. CONGENITAL UTERINE ANOMALIES

Obstructive congenital abnormalities of the vagina or uterus are often initially detected because of clinical manifestations such as pelvic pain or a mass. Neither a rudimentary horn nor a unilateral vaginal septum is detectable on an HSG, but the condition can be suspected whenever a unicornuate uterus is seen on the x-ray film or the absence of a kidney is discovered.

Figure 21 Three types of uteri associated with offspring of mothers who used DES. (A), Typical T-shape fundus. (B), Bulbous horns (arrows). (C), Steer horn anomaly.

within the first 10 days of the onset of menses. This was done to protect the conceptus. from an increased incidence of childhood malignancies be148

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Figure 22 A uterine shadow (arrows) caused by tuberculosis. Irregular border and intravasation are common.

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Figure 23 (A), Tubal and uterine tuberculosis is seen with calcification (curved arrows), probably the ovary. The bulbous horn (arrow)

is like that ofthe uterus of women exposed to DES. (B), Extensive calcification of the uterine cavity (small arrows) and ovary (open arrows) is seen in the pneumogram.

Nonobstructive uterine defects vary from an arcuate uterus to symmetrical double uteri. These are all demonstrable on HSGs. The two horns can be identified, sometimes appearing together, flexed toward each other, or in opposite directions; when seen individually, they resemble a unicornuate uterus. Uterine malformations are not merely interesting academic curiosities; they can cause significant gynecologic problems. a6 Failure to rotate a uterus could lead to a misimpression of a unicornuate uterus (Fig. 15). A true unicornuate uterus is usually displaced laterally (Fig. 16), but this finding must also be accompanied by an intravenous pyelogram. More than 80% of these women do not have a kidney on the contralateral side. A unicornuate uterus should be suspected whenever the uterus is displaced to one side and the conVol. 40, No.2, August 1983

Figure 24 (A), Submucous myoma (arrows) causes some uterine distortion. (8), With hysteroscopy, its location, size, and configuration can be ascertained. The arrow indicates fundus. (C), This large filling defect (arrows) was caused by an intrauterine pregnancy 8 to 10 weeks in gestational size.

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Figure 25 (A), Dilated lower segment (arrows) associated with a previous second-trimester abortion suggested an incompetent cervix. (B), A normal saw-toothed endocervical canal (open arrows) is seen with a normal narrower isthmic canal (solid arrows) above. (C), An endoscopic view reveals ridges in the endocervical canal (arrows) responsible for the x-ray picture.

tralateral vaginal fornix is poorly developed37 ; this condition is compatible with a normal pregnancy. Besides the unicornuate uterus with a rudimentary horn, the most common uterine anomaly associated with unilateral renal agenesis is a uterus bicornis bicollis with a partial vaginal septum resulting in a unilateral hematocolpos. Young and Gibson 38 identified a subgroup of women with a unicornuate uterus seen at hysterography who proved to have a normal uterine serosal surface at laparoscopy. Since very similar shadows can result from severe synechiae that block one horn, a careful history should be obtained concerning the number of pregnancies or curettages in addition to a hysteroscopic and laparoscopic examination before arriving at a definitive diagnosis (Fig. 17). Hysterography cannot precisely differentiate a bicornuate from a septate uterus (Fig. 18). Previously it was believed that the inner borders of the 150

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septate uterus would more likely be straight than curved, and under videofiuoroscopy, the horns would move in opposite directions in a bicornuate uterus. Neither of these beliefs has been found to be completely accurate, so that hysteroscopy supplemented by laparoscopy is essential before the final diagnosis. The septate uteri are more frequently associated with pregnancy wastage, but neither of these fundal deformities are implicated as a cause of primary infertiIity.39 Edstrom 40 monitored the results of hysteroscopic resection of septa with a hysterogram 3 months postoperatively. The occurrence of a double septum has been seen on an HSG and confirmed by hysteroscopy and laparoscopy.41 It was thought to be caused by the partial or complete failure of resorption of the fused Mullerian tracts. Two other congenital abnormalities have been observed on more than one occasion. One of these shows linear shadows of increased density in the Fertility and Sterility

Figure 26 Intrauterine adhesions should be suspected because of the following hysterograms. (A), Stage I: One or two central shadows are seen, but no uterine distortion. (B), Stage II: More than two intrauterine defects without distortion of the uterine outline. (C), Stage III: Cicatricial scarring can prevent contrast material from entering the corpus. The arrow shows the point of obstruction. (D), Stage IV: Multiple intrauterine defects with vascular (open arrows) intravasation. Tubes (curved arrows) mayor may not be patent in these patients.

configuration of the uterine cavity, and they represent longitudinal folds within the endometrium 42 (Fig. 19). These folds were seen on hysteroscopy as troughs and were probably congenital in origin, possibly remnants of the mesonephric ducts. With a Gartner's duct cyst, the films can show an oval shadow that appears to arise at the junction of the lower uterine segment and cervical canal. 43-46 N ei ther of the two aforementioned entities requires surgical excision to improve ferVol. 40, No.2, August 1983

tility. The identification of the Malpighi-Gartner ducts by hysterosalpingography shows the presence and communication of these canals with the uterocervical region, allowing the contrast medium to opacify them. They appear as saccular dilatations lining the isthmic portion of the uterus and separated from the normal cervical canal (Fig. 20). In some cases, vestigial parts of these canals can be identified in adult women as cysts in the anterior lateral walls of the vagina. ReSiegler Hysterosalpingography

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ings on the hysterogram, the expectation of a term pregnancy rate is only 35%. Patients exposed to DES with a normal hysterogram had only 58% term pregnancies. 50 Data are not available to ascertain whether operative repair of these deformed uteri would be helpful. OTHER UTERINE ABNORMALITIES IN INFERTILE WOMEN

Figure 27 Multiple uterine defects associated with a recent history of postabortal curettage were suggestive of intrauterine adhesions. Hysteroscopy 1 week after the HSG revealed a normal cavity.

cently, Katz and co-workers47 reported on a possible causal relationship between mesonephric duct remnants and infertility. Different morphologic uterine changes occur in offspring of mothers who were exposed to diethylstilbestrol (DES) during their pr.egnancy.48,49 Typically, the T-shaped uterus is caused by a hypoplastic uterine cavity with apparent constricting bands in the fundus that produce bulbous cornua and lateral concavities in the contours of the corpus50 (Fig. 21). The lower uterine segment is sometimes widened but more often shows severe stenosis. These findings on the HSG occur more often in infants of mothers who took the medication before the 18th week of gestation and who show morphologic changes in the cervix on physical examination. These changes include the cervical hoods, pseudopolyps, and extensive adenosis. Haney and co-authors51 measured the corpus seen on an HSG by computerized linear planimetry, and they confirmed a significantly shorter upper segment and a narrower isthmic canal than in control subjects. The uterus in these women appeared normal at laparoscopy, but the cavity on hysteroscopy shows almost square-shaped cornua rather than the typical cone. This picture can simulate the uterus affected by tuberculosis and even intrauterine synechiae. With abnormal find152

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The uterine shadow in tuberculous endometritis could result in a normal configuration or a bizarre appearance almost indistinguishable from that of postabortal intrauterine synechiae. The uterine cavity can be almost completely obliterated with irregularities throughout and accompanied by vascular or myometrial intravasation of the contrast material 52, 53 (Fig. 22). Whenever the uterus is abnormal, tubal or ovarian calcifications (Fig. 23) in association with tubal obstruction are almost pathognomonic of pelvic tuberculosis. Myomas can distort the shape of the uterine cavity and occlude tubal ostia, predisposing women to infertility, abnormal bleeding, and spontaneous abortion. The hysterogram can detect these tumors and test tubal patency (Fig. 24A), but the hysterogram cannot show the size of the growth, its precise location, or the length of its pedicle.

Figure 28 Intravasation was present near the left horn (open arrow) of this uterine cavity, and curettage disclosed residual products of conception. Vascular intravasation can be seen (solid arrows).

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associated with multiple filling defects in a distorted but not enlarged uterine shadow in a patient with a history of repeated early abortion and a postabortal curettage followed by hypomenorrhea is diagnostic of intrauterine adhesions. 55 Staging the severity of the disease is important, and so the menstrual history, the hysterogram, and hysteroscopic examinations are all valuable. The results of therapy are related directly to the degree of uterine involvement; amenorrhea associated with a distorted uterine shadow revealing multiple intracavitary defects gives a poor prognosis for the restoration of normal fertility despite normal tubal patency. The hysterogram is the initial diagnostic test to define the approximate extent of the adhesions. 56 The defects are often single or multiple, variable in size and shape, central or peripheral, and tend to persist on several films. Too much contrast material can obliterate these abnormal shadows. They must also be differentiated from filling defects caused by polyps, myomas, septa, or even air bubbles. It is important to take these x-rays un-

Figure 29 (A), Characteristic pattern of salpingitis isthmica nodosa (arrows) can be seen in the HSG. (8), Tuberculous salpingitis shows three saccular dilatations associated with strictures (arrows) near the end of the tube.

Hysteroscopy is advisable before myomectomy, so that a more exact impression of the characteristics ofthe myoma can be ascertained (Fig. 24B). A large intrauterine defect can be produced by an intrauterine pregnancy, because the contrast material seems to surround the amniotic sac (Fig. 24C). The next four HSGs are related to unsuccessful pregnancies, and each of them showed a different entity. With a history of second-trimester abortion, in addition to a hysterogram that reveals a lower uterine segment> 1 cm in width, the diagnosis of an incompetent os becomes apparent (Fig. 25). The lateral walls of the corpus show peculiar indentations similar to the uterus in women exposed to DES, but no history of exposure to this steroid was obtained. The diagnosis of an incompetent os is usually based on a good history, the ability of the physician to pass a sound> 8 mm in the late luteal phase, and an isthmogram showing a dilatation> 1 cm in width. 54 Intravasation Vol. 40, No.2, August 1983

Figure 30 Bilateral proximal tubal obstruction (arrows) was caused by previous hysteroscopic tubal sterilization with electrocautery. No intramural segment is seen. Siegler Hysterosalpingography

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ganic origin. Because hysteroscopy 1 week later showed a completely normal cavity, these defects were probably related to intracavitary blood clots (Fig. 27). Another abnormal cornual shadow associated with some intravasation was obtained in a patient with a similar history. One week later, curettage disclosed products of conception located in the left horn (Fig. 28). TUBAL ABNORMALITIES

Figure 31 Terminal dilatations (arrows) with tubal occlusion were caused by a previous Pomeroy tubal ligation.

der fluoroscopic control, because occasionally only a remnant of a distorted cavity remains and intravascular intravasation is not uncommon. Schenker and Margalioth57 state that the diagnosis and the location of intrauterine adhesions are based primarily on hysterography to be followed by hysteroscopy for accuracy58 (Fig. 26). Musset59 has observed that in some cases of synechiae associated with amenorrhea, hysterography will induce the return of menses even 'without lysis of the adhesions. Before the advent of hysteroscopy, intraoperative hysterography was employed to check the progress of the operation. Currently, postoperative hysterograms are taken to monitor the results of therapy. Lancet and Mass60 performed concomitant hysteroscopy and hysterography for Asherman's syndrome in 56 women to avoid the postoperative need for an intrauterine device, sequential hormone therapy, and a subsequent hysteroscopy or laparoscopy by ascertaining the immediate results radiographically. Only three (5.7%) of the cavities were not restored completely. Regular menses occurred in all patients having oligomenorrhea or amenorrhea. Zondek and Rozin61 showed that intrauterine filling defects resembling intrauterine adhesions could result from mechanical irritation of the uterus. Some uterine filling defects are difficult to interpret on the hysterogram. One patient had irregular bleeding following recent curettage. The persistence of the defects indicated a possible or154

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Congenital anomalies of the fallopian tubes are rare, but they do appear in the form of accessory ostia, multiple lumina, diverticula, total tubal duplication, or absence of portions of the tube. Few of these are demonstrable on an HSG. 62 Two cases of sequential absence of the midportion of the fallopian tube were described. In one of them, the HSG revealed a unicornuate uterus with distal tubal obstruction. In another, the HSG, done during a routine infertility workup, revealed a left hydrosalpinx and a right tubal occlusion. At laparoscopy, the midampullary portions of the tubes were found to be absent. 63 Nodular isthmic disease should be suspected whenever interruption in the clear, linear continuity of the luminal shadow is associated with flecks of contrast material appearing a short distance above or below the main canal (Fig. 29A). In some HSGs, the remainder of the tube reveals an additional abnormality, and almost 50% of the HSGs show occlusive disease of the opposite tube. At laparoscopy, the hard consistency and nodularity of the tubal isthmus is unique. The most common clinical implication of salpingitis isthmica nodosa is its close correlation

Figure 32 An HSG done following a fimbriectomy could show an ampullary rugal pattern indicating the feasibility of reversal. Fertility and Sterility

study, Darabi and Richart64 noted that at least one tube was patent after hysteroscopic tubal sterilization with electrocautery in 30% of women. Following a Pomeroy procedure, the intramural and isthmic segments are delineated and normal; the terminal dilatation is caused by increase in pressure during the instillation of contrast material (Fig. 31). The ampullary rugal folds are not seen, and tuboplasty without a preliminary laparoscopy is not justified unless the precise operative and pathology reports indicate that < 2 cm of the tube was removed during the Pomeroy operation. An HSG after a fimbriectomy would show more of the ampulla and the presence of linear dark lines representing rugal folds (Fig. 32). Gomel 65 suggests an HSG before attempting a reversal of previous sterilization so that the proximal tubal segment can be studied and the endometrial cavity evaluated.

Figure 33 Unusual tubal configuration following ampullary salpingotomy for an unruptured tubal pregnancy. The patient previously had a contralateral salpingectomy for another ectopic pregnancy. The open arrow shows a pretubal bulge. The solid arrows point to large outpouchings of the endosalpinx.

with infertility and its predisposition toward tubal pregnancy. Although its appearance and that of tuberculous salpingitis can be similar on the HSG, the presence of calcification of pelvic lymph nodes, tubes, or ovaries clinches the diagnosis. Some healed tuberculous tubes appear rigid, with small, terminal sacculations (Fig. 29B). Uterine adenomyosis also causes this honeycomb configuration; but the saccular, irregular opacification is not confined to a paratubal area. The honeycomb tubal appearance in the proximal segment caused by endometriosis appears as thicker diverticula associated with patent tubes and a normal uterine shadow. Following various types of tubal surgery, HSGs can reveal certain characteristics. One patient had had a hysteroscopic sterilization with unipolar cautery. Three months later, no intramural segment was seen, and the horns were rounded (Fig. 30). This picture is unusual except following sterilization by hysteroscopic technique that includes the intramural segment. In a collaborative Vol. 40, No.2, August 1983

Figure 34 Tubal polyps (arrows) cause filling defects in the intramural and isthmic segments with or without dilatation, depending upon the size of the polyp (A and B). Siegler Hysterosalpingography

i55

Another very unusual tubal shadow was seen after a patient had had a conservative salpingostomy for an ampullary pregnancy (Fig. 33). It would appear that multiple diverticula are present; yet at laparoscopy, the tube was grossly normal on its serosal surface and normally patent to indigo carmine. Whether this radiographic picture represents a congenital tubal luminal defect or is iatrogenic consequent to the surgical procedure could not be ascertained. This woman previously had had a contralateral salpingectomy for her first extrauterine pregnancy. Tubal polyps are represented by oval shadows in the intramural segment, and the contrast material flows in a thin line above or below the tumors (Fig. 34). The remainder of the tube is normally patent; it is doubtful that these small polyps cause infertility. They have been seen on hysteroscopic examination, and some have been excised at laparotomy after a small tubal incision. In almost all instances, the diagnosis is made by HSG in the course of an infertility study. David et a1. 66 reviewed 2156 HSGs obtained from 1969 to 1979 in a search for tubal polyps. They found 54 cases (2.5%), and only 8 of them were unilateral. The conception rates before and after radiographic detection were the same. These authors expressed doubt that a causal relationship existed between infertility and tubal polyps. Therefore, the decision for their surgical extirpation must be made on an individual basis. Microsurgical polypectomy and cornual anastomosis have been described by a few investigators. 67 Fernstrom and Lagerlof'8 described 26 instances of tubal polyps detected on HSG, and in 22 of them the condition appeared bilaterally. Six of the 17 women who had endometrial biopsy specimens showed cystic polypoid hyperplasia. Only 20% complained of infertility, and three women had tubal surgery involving resection and polypectomy. A report on 16 women with infertility and morphologically abnormal tubes was presented by DeCherney and co-authors. 69 The patients had classic HSG findings of a uterus with a shape typical for DES exposure, but tubal anomalies could only be detected at laparoscopy. The morphologic description of the tubes was "withered"; the tubes were foreshortened, thin, and convoluted, with absent or minimal fimbrial tissue and pinpoint ostia. Although there is a lack of correlatable anatomic abnormalities in the human oviduct, an increased frequency of tubal pregnancies is suggested. 156

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SUMMARY

A brief review of the technique of hysterosalpingography is provided. It remains an important diagnostic study in searching for causes of infertility. HSG is a safe, simple procedure that enables the lumina of the uterine cavity and fallopian tubes to be outlined. Fundamentals in techniques have been stressed so as to limit the errors of omission and commission. During the course of many years, I have been honored by my colleagues, who have requested me to review interesting HSGs. Thus, I have been able to accumulate a series of x-rays that I can share with the readers of Modem Trends. Although these photographs seemed unique, many of them probably have been seen by other investigators. They are presented because of their important diagnostic features. REFERENCES 1. Nash D, Haning RV Jr, Shapiro SS: The value ofhystero-

salpingography prior to donor artificial insemination. Fertil Steril 31:378, 1979 2. Broekhuizen FF, Haning RV Jr, Shapiro SS: Laparoscopic findings in twenty-five failures of artificial insemination. Fertil Steril 34:351, 1980 3. Palmer A: Ethiodol hysterosalpingography for the treatment of infertility. Fertil Sterilll:311, 1960 4. DeCherney AH, Kort H, Barney JB, DeVore GR: Increased pregnancy rate with oil-soluble hysterosalpingography dye. Fertil Steril 33:407, 1980 5. Frangenheim H: Vergleichende Untersuchungen zwischen dem wert der Hysterosalpingographie und der Coelioskopie der Sterilitatsdiagnostik. Arch Gynecol204:2, 1966 6. Coltart TM: Laparoscopy in the diagnosis of tubal patency. J Obstet Gynaecol Br Commonw 77:69, 1971 7. Horbach JGM, Maathuis JB, van Hall EV: Factors influencing the pregnancy rate following hysterosalpingography and their prognostic significance. Fertil Steril 24:15,1973 8. Phillipsen T, Hansen BB: Comparative study of hysterosalpingography and laparoscopy in infertile patients. Acta Obstet Gynecol Scand 60:149, 1981 9. Corson SL: Use of the laparoscope in the infertile patient. Fertil Steril 32:359, 1979 10. Horowitz RC, Morton peG, ShaffML, Hugo P: A radiological approach to infertility: hysterosalpingography. Br J Radiol 52:255, 1979 11. Gomel V, McComb P: Unexpected pregnancies in women afflicted by occlusive tubal disease. Fertil Steril 36:529, 1981 12. Ansari AH: Diagnostic procedures for assessment of tubal patency. Fertil Steril 31:469, 1979 13. Kasby CB: Hysteroscopy: an appraisal of current indication. Br J Radiol 53:279, 1980 14. Pontifex G, Trichopoulos D, Karpathios S: Hysterosalpingography in the diagnosis of infertility (statistical analysis of 3437 cases). Fertil Steril 23:829, 1972

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15. Sanfilippo JS, Yussman MA, Smith 0: Hysterosalpingography in the evaluation of infertility: a six-year review. Fertil Steril 30:636, 1978 16. Yoder IC, Pfister RC: Balloon catheter hysterosalpingogram. Am J Roentgenol 133:335, 1979 17. Fullenlove TM: Improvement of the cups used with the Malmstrom Thoren vacuum uterine cannula in uterosalpingography. Am J RoentgenoI119:852, 1973 18. Spring DB, Wilson RE, Arronet GH: Foley catheter hysterosalpingography: a simplified technique for investigating infertility. Radiology 131:543, 1979 19. Brundin J: Distribution and function of adrenergic verses in the rabbit fallopian tube. Acta Physiol Scand 66:259, 1965 20. Ron M, Beller U, Hochner-Celnikier D, Palti Z: The effect of halothane on uterine cornual spasm during general anesthesia. Int J Fertil27:187, 1982 21. Gerlock AJ, Hooser CW: Oviduct response to glucagon during hysterosalpingography. Radiology 119:727, 1976 22. Winfield AC, Pittaway D, Maxson W, Daniell J, Wentz AC: Apparent cornual occlusion in hysterosalpingography: reversal by glucagon. Am J Radiol 139:525, 1982 23. Soules MR, Spadoni LR: Oil versus aqueous media for hysterosalpingography: a continuing debate based on many opinions and few facts. Fertil Steril 38:1, 1982 24. Siegler AM: Hystersalpingography, Second edition. New York, Medcom Press, 1974, p 19 25. Stumpf PG, March CM: Febrile morbidity following hysterosalpingography: identification of risk factors and recommendations for prophylaxis. Fertil Steril 33:487, 1980 26. Bateman BG, Nunley WC Jr, Kitchin JD III: Intravasation during hysterosalpingography using oil-base contrast media. Fertil Steril 34:439, 1980 27. Sternberg J: Irradiation and radio contamination during pregnancy. Am J Obstet Gynecol 108:490, 1970 28. Goldenberg RL, White R, Magendantz HG: Pregnancy during the hysterogram cycle. Fertil Steril 27:1274, 1976 29. Schwarz SG: Radiation hazards to the human fetus in present-day society. Bull NY Acad Med 44:388, 1968 30. Seppanen S, Lehtinen E, Holli H: Radiation dose in hysterosalpingography: modern 100 mm fiuorography vs. full-scale radiography. Radiology 127:377, 1978 31. Warrick CK: Radiology now: the "10-day rule." Br J Radiol 46:933, 1973 32. Hammer-Jacobsen E: Therapeutic abortion on account of x-ray examination during pregnancy. Dan Med Bull 6: 112, 1959 33. Isaacs I: Hysterographic double-outlined uterine cavity: a sign of unsuspected pregnancy. Am J RoentgenoI131:305, 1978 34. Jacobsen A, Conley J: Estimate of fetal dose to patients undergoing diagnostic x-ray procedure. Radiology 120: 683, 1976 35. Sheikh HH, Yussman MA: Electrocardiographic monitoring during hysterosalpingography. Obstet Gynecol 48:90, 1976 36. Farber M: Uterus bicornis unicollis with a noncommunicating rudimentary uterine horn: an unusual cause of dysmenorrhea. Int J Gynaecol Obstet 11:190, 1973 37. Williamson JG: True unicornuate uterus: a report of two pregnancies. Int J Gynaecol Obstet 11:233, 1973 38. Young OH, Gibson M: Unicornis uterus with a normal external uterine surface. Fertil Steril 33:663, 1980 Vol. 40, No.2, August 1983

39. Rock JA: Diagnosing and repairing uterine anomalies. Contemp Obstet Gynecol 17:43, 1981 40. Edstrom KGB: Intrauterine surgical procedures during hysteroscopy. Endoscopy 6:175,1974 41. Slezak P, Tillinger KG: The occurrence and significance of broad longitudinal folds in the uterine cavity at hysterography. Radiology 106:87, 1973 42. Rosenberg SM, Bourque M, Riddick DH: Double uterine septa: a previously undescribed entity. Obstet Gynecol 58:250, 1981 43. Wepfer JF, Sinsky JE: Gartner's duct. Am J Roentgenol 80:686, 1958 44. Weston WJ: Radiographic demonstration of Gartner's ducts. Br J Radiol 33:731, 1960 45. DeCamillis L, Moscarini M: Considerations sur la visualisation radiologique des canaux de Malpighi-Gartner pendant l'hysterosalpingographie. J Radiol (continues J Radio Electrol Med Nucl) 56:438, 1975 46. Coutifaris B, Salamalekis E, Christodoulacos 0, et al.: Gartner's ducts: a radiographic demonstration. Int J Gynaecol Obstet 16:50, 1978 47. Katz Z, Bernstein D, Lancet M: A possible causal relationship between mesonephric remnants and infertility of uterine origin. Int J Fertil 27:125, 1982 48. Siegler AM, Wang CF, Friberg J: Fertility of the diethylstilbestrol-exposed offspring. Fertil Steril 31:601, 1979 49. Rennell CL: T-shaped uterus in diethylstilbestrol (DES exposure). Am J Radiol 132:879, 1979 50. Kaufman RH, Adam E, Binder GL, Gray PM Jr: Upper genital tract changes and pregnancy outcome in offspring exposed in utero to DES. Am J Obstet Gynecol 137:299, 1980 51. Haney AF, Hammond CB, Soules MR, Creasman WT: Diethylstilbestrol-induced upper genital tract abnormalities. Fertil Steril 31:142, 1979 52. Rioux JE, Yuzpe AA: Hysterosalpingography as an aid in the diagnosis of TB. Contemp Obstet Gynecol 17:184, 1981 53. Siegler AM, Kontopoulos V: Female genital tuberculosis and the role of hysterosalpingography. Sem Radiol 14: 295, 1979 54. Thompson JL, Sampson MB, Beckmann CR, Spellacy WN: The incompetent cervix: a 1982 update. J Reprod Med 27:187, 1982 55. Richart RM (Ed): Newer methods of diagnosing and treating Asherman's syndrome. Contemp Obstet Gynecol 14: 117,1979 56. Siegler AM, Kontopoulos VG: Lysis of intrauterine adhesions under hysteroscopic control: a report of 25 cases. J Reprod Med 26:372, 1981 57. Schenker JG, Margalioth EJ: Intrauterine adhesions: an updated appraisal. Fertil Steril 37:593, 1982 58. March CM, Israel R: Gestational outcome following hysteroscopic lysis of adhesions. Fertil Steril 36:455, 1981 59. Musset R: An Atlas of Hysterosalpingography. Quebec, Les Presses de l'Universite Laval, 1979, p 228 60. Lancet M, Mass N: Concomitant hysteroscopy and hysterography in Asherman's syndrome. Int J Fertil 26:267, 1981 61. Zondek B, Rozin S: Filling defects in the hysterogram simulating intrauterine synechiae which disappear after denervation. Am J Obstet Gynecol 88:123, 1964 Siegler Hysterosalpingography

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62. Madanes A, Homer M, Turksoy RN, Farber M: A single diverticulum of the fallopian tube. Fertil Steril 37:121, 1982 63. Richardson DA, Evans MI, Talerman A, Maroulis GB: Segmental absence of the mid-portion of the fallopian tube. Fertil Steril37:577, 1982 64. Darabi KF, Richart RM: Collaborative study on hysterographic sterilization procedures: preliminary report. Obstet Gynecol 49:48, 1977 65. Gomel V: Microsurgical reversal offemale sterilization: a reappraisal. Fertil Steril 33:587, 1980 66. David MP, Ben-Zwi D, Langer L: Tubal intramural polyps and their relationship to infertility. Fertil Steril 35:526, 1981

67. Boeckx W, Brosens I, Gordts S, Vasquez G: Tubal-cornual polyps: microsurgical polypectomy and cornual anastomosis (Abstr). Presented at the Fifth European Congress on Sterility, Venice, October 1978, p 147 68. Fernstrom I, Lagerlof J: Polyps in the intramural part of the fallopian tubes: a radiologic and clinical study. J Obstet Gynaecol Br Commonw 71:681, 1964 69. DeCherney AH, Cholst I, Naftolin F: Structure and function of the fallopian tubes following exposure to diethylstilbestrol (DES) during gestation. Fertil Steril 36:741, 1981

Received March 18, 1983. Reprint requests: Alvin M. Siegler, M.D., One Hanson Place, Suite 1007, Brooklyn, New York 11243.

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