- Email: [email protected]
Fertility after the demonstration of intravasation during hysterosalpingography
Int. J. Gvnaecol., 1986, 24: 431-433 International Federation of Gynaecology
431 & Obstetrics
FERTILITY AFTER THE DEMONSTRATION HYSTEROSALPINGOGRAPHY
M. RON, M. MENASHE, Department
I. AVIAD,
OF INTRAVASATION
DURING
Z. PALTI and P. MOGLE
of Obstetrics and Gynecology and the Radiology Department,
Hadassah University Hospital, Mount Scopus,
Jerusalem (Israel) (Received September 25th, 1985) (Revision received April 23rd, 1986) (Accepted April 28th, 1986)
Abstract
Introduction
Ron M, Menashe M, Aviad I, Palti Z, Mogle P (Department of Obstetrics and Gynecology and the Radiology Department, Hadassah University Hospital, Mount Scopus, Jerusalem, Israel). Fertility after the demonstration of intravasation during hysterosalpingography. In t J Gynaecol Obstet 24: 431-433, 1986 Intravasation of contrast medium was found in 28 women out of 450 women (6.25%) who underwent hysterosalpingography (HSG). Ten of these women had an otherwise normal uterine cavity and patent tubes. In six patients (66%) out of nine who underwent a repeated HSG within 2 months no intravasation was demonstrated. Seven of the 28 patients with intravasation (25%) of whom four were among the 10 patients with normal uterine cavity and patent tubes (40%) conceived and delivered later. It is concluded that in cases in which no other uterine pathology is demonstrated on HSG intravasation B not a persistent occurrence, and by itself does not affect the prognosis of fertility.
The occurrence of lymphatic or venous intravasation during the performance of hysterosalpingography (HSG) is less than 6% in various series’ [ 1,431. The etiology and therefore the significance of this phenomenon as related to the prognosis of fertility is not fully known. Among the etiologic factors mentioned in the literature are recent trauma to the uterine mucosa [ 71, deficient lining of the endometrium too early in the proliferative stage of the cycle [ 61, trauma during the procedure [4] and various intrauterine pathologies such as tuberculosis myomata and defects caused by infections which may also cause occluded tubes [ 61. Most of the reports on intravasation deal with the complications of this phenomenon. Except for the data of Drukman et al. [2] who reported the persistent recurrence of intravasation in the same patient on repeated HSG there is no information in the literature on whether this phenomenon is indeed persistent. No information was found by us as to whether the finding of intravasation as a sole pathological finding in HSG performed during a fertility workup has any prognostic significance for fertility. This work sums up our experience with
Keywords: Hysterosalpingography; tion; Fertility.
0020-7292/86/$03.50 0 1986 International Federation Published and Printed in Ireland
Intravasa-
Int J G?,naecol Obstet 24 of Gynaecology
& Obstetrics
432
Ron et al.
the phenomenon two questions. Patients
and tries to answer
these
and methods
During the years 1978- 1980 we performed 450 HSG. In 85% of the cases the indication for HSG was part of the workup of sterility. Most women underwent HSG during the proliferative phase of the cycle several days after cessation of menstrual bleeding. The procedure was performed under fluoroscopy and using a conventional uterine cannula. The contrast medium was Lipiodol (Sewage Laboratory, Houston, TX) and the amount injected did not exceed 10 ml. Whenever intravasation was seen on fluoroscopy, the injection of contrast media was immediately stopped. The injection pressures were not monitored but the injection was performed manually under fluoroscopy to ensure slow and gradual filling of the uterine cavity. Results In 28 patients out of 450 HSG performed (6.2%) during the years 1978-1980, there was some degree of lymphatic and/or venous intravasation. Of these 28 women, 10 had a normal uterus and patent tubes. Of the remaining 18 patients, six had one or both tubes occluded, nine had intrauterine adhesions (Ashermann syndrome) and three had submucosal myomas. Nine patients underwent more than one HSG. In only two patients did intravasation persist with an otherwise normal HSG and in one with occluded tubes. In six patients intravasation which was present on the first HSG was not demonstrated later. In one case intravasation disappeared after the removal of intrauterine adhesions by a D + C. In this series of 28 patients with intravasation, seven (25%) conceived after the demonstration of intravasation. Of those 10 patients whose HSG was normal (excluding intravasation) four (40%) conceived and delivered. Of the six patients in whom Int J Gymecol
Obstet
24
the intravasation disappeared, four had the second HSG in the luteal phase as compared with the proliferative phase of the cycle in the first HSG. In these four cases HSG was performed for this study in the luteal phase of the cycle, taking special care in avoiding intercourse before the performance of HSG, with a special informed consent of the patients.
Discussion There are many described causes leading to intravasation of contrast medium during the performance of HSG [ 21. These many etiologies make the significance of intravasation to the prognosis for fertility undetermined. In our series intravasation in the majority of cases was an additional finding of uterine pathology; mainly intrauterine adhesions as shown by its relatively high occurrence in this group, nine cases out of 28 (35%). In those cases with the existence of uterine pathology the prognosis for fertility is mainly determined by the nature of this pathology. In those cases in which intravasation was the only pathological finding, this pathology was not demonstrated in subsequent HSG in 80% of the cases. It is stressed that though in four cases in this study intravasation disappeared in the luteal phase of the cycle, there is no justification for exposing the patients to radiation during a possibly early conception when performing HSG during this phase of the cycle. The high occurrence of pregnancies - 25% in the whole group with intravasation and 40% in the group that did not show any other uterine pathology - is in agreement with the study of Gillespie [ 31 and his reported summary of the literature regarding fertility post HSG. This relatively good outcome in our series suggests that intravasation per se is not a bad prognostic sign as regards fertility.
Intravasation
References 1 Bateman BG, Nunley WC, Kitchin JD: Intravasation during hysterosalpingography using oil base contrast media, Fertil Steril34: 439, 1980. 2 Drukman A, Rozin S: Uterovenous and uterolymphatic intravasation in hysterosalpingography. J Obstet Gynecoi Brit Emp58: 73, 1951. 3 Gillespie H: The therapeutic aspect of hysterosalpingography. Brit J Radio1 38: 301, 1965. 4 Robbins SA, Shapira AA: Value of hysterosalpingography: study of 1000 cases. N Engl J Med 205: 380. 1931. 5 Roham graphy.
WE: Venous intravasation during Brit J Radio1 17: 13, 1944.
uterosalpingo-
during
hysterosalpingography
433
6 Walther 0: Zur I,rage der Embolie bei hysterosdlpingography mit Lipiodol. Acta Radio1 20: 457. 1939. 7 Witwer ER. Cushman HP, Leucutia T: Present status of hysterosalpingography with a review ot‘ the literature and report of 512 personal cases. Am J Roentgen01 23. 125. 1930. Address for reprints: M. Ron, M.D. Department of Obstetrics and Gynecology Hadassah University Hospital Mount Scopus Jerusalem, Israel
Int J Glwaecol
Obstet
24
431 & Obstetrics
FERTILITY AFTER THE DEMONSTRATION HYSTEROSALPINGOGRAPHY
M. RON, M. MENASHE, Department
I. AVIAD,
OF INTRAVASATION
DURING
Z. PALTI and P. MOGLE
of Obstetrics and Gynecology and the Radiology Department,
Hadassah University Hospital, Mount Scopus,
Jerusalem (Israel) (Received September 25th, 1985) (Revision received April 23rd, 1986) (Accepted April 28th, 1986)
Abstract
Introduction
Ron M, Menashe M, Aviad I, Palti Z, Mogle P (Department of Obstetrics and Gynecology and the Radiology Department, Hadassah University Hospital, Mount Scopus, Jerusalem, Israel). Fertility after the demonstration of intravasation during hysterosalpingography. In t J Gynaecol Obstet 24: 431-433, 1986 Intravasation of contrast medium was found in 28 women out of 450 women (6.25%) who underwent hysterosalpingography (HSG). Ten of these women had an otherwise normal uterine cavity and patent tubes. In six patients (66%) out of nine who underwent a repeated HSG within 2 months no intravasation was demonstrated. Seven of the 28 patients with intravasation (25%) of whom four were among the 10 patients with normal uterine cavity and patent tubes (40%) conceived and delivered later. It is concluded that in cases in which no other uterine pathology is demonstrated on HSG intravasation B not a persistent occurrence, and by itself does not affect the prognosis of fertility.
The occurrence of lymphatic or venous intravasation during the performance of hysterosalpingography (HSG) is less than 6% in various series’ [ 1,431. The etiology and therefore the significance of this phenomenon as related to the prognosis of fertility is not fully known. Among the etiologic factors mentioned in the literature are recent trauma to the uterine mucosa [ 71, deficient lining of the endometrium too early in the proliferative stage of the cycle [ 61, trauma during the procedure [4] and various intrauterine pathologies such as tuberculosis myomata and defects caused by infections which may also cause occluded tubes [ 61. Most of the reports on intravasation deal with the complications of this phenomenon. Except for the data of Drukman et al. [2] who reported the persistent recurrence of intravasation in the same patient on repeated HSG there is no information in the literature on whether this phenomenon is indeed persistent. No information was found by us as to whether the finding of intravasation as a sole pathological finding in HSG performed during a fertility workup has any prognostic significance for fertility. This work sums up our experience with
Keywords: Hysterosalpingography; tion; Fertility.
0020-7292/86/$03.50 0 1986 International Federation Published and Printed in Ireland
Intravasa-
Int J G?,naecol Obstet 24 of Gynaecology
& Obstetrics
432
Ron et al.
the phenomenon two questions. Patients
and tries to answer
these
and methods
During the years 1978- 1980 we performed 450 HSG. In 85% of the cases the indication for HSG was part of the workup of sterility. Most women underwent HSG during the proliferative phase of the cycle several days after cessation of menstrual bleeding. The procedure was performed under fluoroscopy and using a conventional uterine cannula. The contrast medium was Lipiodol (Sewage Laboratory, Houston, TX) and the amount injected did not exceed 10 ml. Whenever intravasation was seen on fluoroscopy, the injection of contrast media was immediately stopped. The injection pressures were not monitored but the injection was performed manually under fluoroscopy to ensure slow and gradual filling of the uterine cavity. Results In 28 patients out of 450 HSG performed (6.2%) during the years 1978-1980, there was some degree of lymphatic and/or venous intravasation. Of these 28 women, 10 had a normal uterus and patent tubes. Of the remaining 18 patients, six had one or both tubes occluded, nine had intrauterine adhesions (Ashermann syndrome) and three had submucosal myomas. Nine patients underwent more than one HSG. In only two patients did intravasation persist with an otherwise normal HSG and in one with occluded tubes. In six patients intravasation which was present on the first HSG was not demonstrated later. In one case intravasation disappeared after the removal of intrauterine adhesions by a D + C. In this series of 28 patients with intravasation, seven (25%) conceived after the demonstration of intravasation. Of those 10 patients whose HSG was normal (excluding intravasation) four (40%) conceived and delivered. Of the six patients in whom Int J Gymecol
Obstet
24
the intravasation disappeared, four had the second HSG in the luteal phase as compared with the proliferative phase of the cycle in the first HSG. In these four cases HSG was performed for this study in the luteal phase of the cycle, taking special care in avoiding intercourse before the performance of HSG, with a special informed consent of the patients.
Discussion There are many described causes leading to intravasation of contrast medium during the performance of HSG [ 21. These many etiologies make the significance of intravasation to the prognosis for fertility undetermined. In our series intravasation in the majority of cases was an additional finding of uterine pathology; mainly intrauterine adhesions as shown by its relatively high occurrence in this group, nine cases out of 28 (35%). In those cases with the existence of uterine pathology the prognosis for fertility is mainly determined by the nature of this pathology. In those cases in which intravasation was the only pathological finding, this pathology was not demonstrated in subsequent HSG in 80% of the cases. It is stressed that though in four cases in this study intravasation disappeared in the luteal phase of the cycle, there is no justification for exposing the patients to radiation during a possibly early conception when performing HSG during this phase of the cycle. The high occurrence of pregnancies - 25% in the whole group with intravasation and 40% in the group that did not show any other uterine pathology - is in agreement with the study of Gillespie [ 31 and his reported summary of the literature regarding fertility post HSG. This relatively good outcome in our series suggests that intravasation per se is not a bad prognostic sign as regards fertility.
Intravasation
References 1 Bateman BG, Nunley WC, Kitchin JD: Intravasation during hysterosalpingography using oil base contrast media, Fertil Steril34: 439, 1980. 2 Drukman A, Rozin S: Uterovenous and uterolymphatic intravasation in hysterosalpingography. J Obstet Gynecoi Brit Emp58: 73, 1951. 3 Gillespie H: The therapeutic aspect of hysterosalpingography. Brit J Radio1 38: 301, 1965. 4 Robbins SA, Shapira AA: Value of hysterosalpingography: study of 1000 cases. N Engl J Med 205: 380. 1931. 5 Roham graphy.
WE: Venous intravasation during Brit J Radio1 17: 13, 1944.
uterosalpingo-
during
hysterosalpingography
433
6 Walther 0: Zur I,rage der Embolie bei hysterosdlpingography mit Lipiodol. Acta Radio1 20: 457. 1939. 7 Witwer ER. Cushman HP, Leucutia T: Present status of hysterosalpingography with a review ot‘ the literature and report of 512 personal cases. Am J Roentgen01 23. 125. 1930. Address for reprints: M. Ron, M.D. Department of Obstetrics and Gynecology Hadassah University Hospital Mount Scopus Jerusalem, Israel
Int J Glwaecol
Obstet
24