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Hysterosalpingography
MODERN TRENDS Edward E. Wallach, M.D. Associate Editor
Hysterosalpingography Theodore A. Baramki, M.D. Department of Gynecology and Obstetrics, The Johns Hopkins University, Baltimore, Maryland
Objective: To demonstrate the value of the hysterosalpingogram in the evaluation of infertility. Conclusion(s): Hysterosalpingography, which should be done in the follicular phase of the cycle, evaluates the contour of the uterine cavity, cervical canal, and tubal lumina. Other than being diagnostic, it can prove to be therapeutic. The instrument used to introduce the radio-opaque medium should be chosen to give the least discomfort and to cause no leakage of dye from the cervix. Water-soluble medium is usually used rather than an oil-based medium. Fluoroscopy with image intensification gives the best results. Insufficient dye injection will give an incomplete study. Too much dye injection, especially under pressure, might cause extravasation of the dye into the vascular system or conceal the fimbrial ends of the tubes. (Fertil Steril威 2005;83:1595– 606. ©2005 by American Society for Reproductive Medicine.) Key Words: Synechiae, submucous myoma, adenomyosis, salpingitis isthmica nodosa, hydrosalpinx, endometrial hyperplasia, cervical incompetence, uterus didelphys
Hysterosalpingography is the radiographic evaluation of the cavity of the uterus and fallopian tubes after injection of a radio-opaque medium through the cervical canal. The study should be done during the follicular phase of the cycle so as not to interfere with a possible early pregnancy. The best results are obtained by fluoroscopy with image intensification. Although this procedure is considered diagnostic, it can prove to be therapeutic at times (1). A properly performed hysterosalpingogram (HSG) will give an idea as to the contour of the uterine cavity and the width of the cervical canal. Further injection will outline the cornua, isthmic, and ampullary portions of the tubes and evaluate the degree of spillage. If the uterine cavity shows no abnormality with a properly performed HSG, it is very unlikely that hysteroscopy would reveal an abnormality.
fort and prevents leakage of the dye. The instrument most commonly used to inject radio-opaque medium is the Jarcho cannula, which is a metal instrument that has a rubber “acorn” placed close to the tip so as to prevent leakage of the dye. The cannula is stabilized by hooking it to a single-tooth tenaculum applied to the anterior lip of the cervix. The HSG catheter (REDI-TECH, Atlanta, GA), which is becoming popular, is a plastic catheter with a balloon close to the tip. In most cases the catheter can be passed through the cervical canal without the use of a tenaculum. After insertion into the
FIGURE 1 Normal HSG with a Jarcho cannula.
Other than noting spillage of dye from the fimbrial ends of the tubes, the degree of free spillage is important. INSTRUMENTS The clinician should use the instrument that he/she feels comfortable with and that gives the patient the least discomReceived September 14, 2004; revised and accepted December 20, 2004. No reprints will be available. Correspondence to: Theodore A. Baramki, M.D., Johns Hopkins at Green Spring Station, Department of Gynecology and Obstetrics, 2330 W. Joppa Road, Suite 301, Lutherville, Maryland 21093 (FAX: 410-5832767; E-mail: [email protected]).
0015-0282/05/$30.00 doi:10.1016/j.fertnstert.2004.12.050
Baramki. Hysterosalpingography. Fertil Steril 2005.
Fertility and Sterility姞 Vol. 83, No. 6, June 2005 Copyright ©2005 American Society for Reproductive Medicine, Published by Elsevier Inc.
1595
FIGURE 2
FIGURE 3
Normal HSG with an HSG catheter with balloon.
Hysterosalpingogram catheter with inflated balloon at tip.
Baramki. Hysterosalpingography. Fertil Steril 2005.
Baramki. Hysterosalpingography. Fertil Steril 2005.
FIGURE 4 (A) Hysterosalpingogram with HSG catheter showing the balloon obstructing the lower uterine segment and cervical canal. (B) Same study as shown in A, except that the balloon was deflated during injection of more dye, showing a normal cervical canal.
Baramki. Hysterosalpingography. Fertil Steril 2005.
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Vol. 83, No. 6, June 2005
FIGURE 5
FIGURE 7
Hysterosalpingogram showing multiple filling defects due to endometrial polyps.
Hysterosalpingogram showing multiple filling defects due to submucous myomas.
Baramki. Hysterosalpingography. Fertil Steril 2005.
Baramki. Hysterosalpingography. Fertil Steril 2005.
FIGURE 6
FIGURE 8
Hysterosalpingogram showing a filling defect due to synechiae.
Hysterosalpingogram with an oblique view showing a submucous myoma that disappeared when more dye was injected (8).
Baramki. Hysterosalpingography. Fertil Steril 2005.
Baramki. Hysterosalpingography. Fertil Steril 2005.
Fertility and Sterility姞
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FIGURE 9
FIGURE 11
Hysterosalpingogram showing a filling defect in the left cornual area. It proved to be a superimposed gas bubble from the bowel over the uterine shadow.
Hysterosalpingogram showing irregular uterine cavity due to endometrial hyperplasia.
Baramki. Hysterosalpingography. Fertil Steril 2005.
Baramki. Hysterosalpingography. Fertil Steril 2005.
FIGURE 10 (A) Hysterosalpingogram showing a linear filling defect near the left cornu in a patient who had a secondtrimester miscarriage. (B) At exploration of the uterine cavity, the filling defect in A proved to be a piece of flat bone, as shown in this photomicrograph.
Baramki. Hysterosalpingography. Fertil Steril 2005.
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Vol. 83, No. 6, June 2005
FIGURE 12
FIGURE 14
Hysterosalpingogram showing irregular uterine cavity due to endometrial carcinoma in an anovulatory woman.
Hysterosalpingogram showing an arcuate uterus, absent left tube, and intravasation of dye in the uterine veins on the right obscuring the status of the right tube.
Baramki. Hysterosalpingography. Fertil Steril 2005.
Baramki. Hysterosalpingography. Fertil Steril 2005.
FIGURE 13 Hysterosalpingogram showing marked irregularity of the uterine cavity due to endometrial carcinoma.
FIGURE 15 Hysterosalpingogram showing marked distortion of the uterine cavity due to a large intramural myoma. Intravasation of dye is also noted.
Baramki. Hysterosalpingography. Fertil Steril 2005. Baramki. Hysterosalpingography. Fertil Steril 2005.
Fertility and Sterility姞
1599
FIGURE 16
FIGURE 18
Hysterosalpingogram showing a T-shaped uterus due to diethylstilbestrol exposure in utero (5).
Hysterosalpingogram showing a septate uterus. Note that the angle between the two horns is an acute one.
Baramki. Hysterosalpingography. Fertil Steril 2005.
FIGURE 17 Baramki. Hysterosalpingography. Fertil Steril 2005.
Hysterosalpingogram showing a right unicornuate uterus.
FIGURE 19 Hysterosalpingogram showing a bicornuate uterus with an obtuse angle between the two horns (6).
Baramki. Hysterosalpingography. Fertil Steril 2005.
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Baramki. Hysterosalpingography. Fertil Steril 2005.
Vol. 83, No. 6, June 2005
FIGURE 20
FIGURE 22
Hysterosalpingogram showing uterus didelphys. Two cannulas had to be used.
Hysterosalpingogram showing a septate uterus with extra dye in the lower uterine segment due to a previous cesarean section.
Baramki. Hysterosalpingography. Fertil Steril 2005. Baramki. Hysterosalpingography. Fertil Steril 2005.
FIGURE 21 (A) Hysterosalpingogram showing an irregular uterine cavity interpreted by the radiologist as showing multiple submucous myomas. (B) Repeat HSG of the same patient shown in A, with the cervix pulled down. It shows a septate uterus, not submucous myomas (7).
Baramki. Hysterosalpingography. Fertil Steril 2005.
Fertility and Sterility姞
1601
FIGURE 23
FIGURE 24
Hysterosalpingogram showing a dilated internal os due to an incompetent cervix. The patient had two mid-trimester pregnancy losses.
Hysterosalpingogram showing a mild form of adenomyosis.
Baramki. Hysterosalpingography. Fertil Steril 2005. Baramki. Hysterosalpingography. Fertil Steril 2005.
FIGURE 25 (A) Hysterosalpingogram showing adenomyosis. (B) Drainage film of patient shown in A, showing the dye in the glands of adenomyosis.
Baramki. Hysterosalpingography. Fertil Steril 2005.
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Vol. 83, No. 6, June 2005
FIGURE 26
FIGURE 28
Hysterosalpingogram showing a marked degree of adenomyosis.
(A) Hysterosalpingogram showing a normal uterine cavity with filling but no definite spillage from the tubes. (B) Hysterosalpingogram of the same patient shown in A after more dye was injected, showing bilateral hydrosalpinx.
Baramki. Hysterosalpingography. Fertil Steril 2005.
Baramki. Hysterosalpingography. Fertil Steril 2005.
FIGURE 27 (A) Hysterosalpingogram showing air bubbles in the uterine cavity and non-filling of the left tube. This is an incomplete study. (B) Hysterosalpingogram of the same patient shown in A after more dye was injected, showing a normal HSG.
Baramki. Hysterosalpingography. Fertil Steril 2005.
Fertility and Sterility姞
1603
FIGURE 29 (A) Hysterosalpingogram showing a normal uterine cavity but no filling of either tube. (B) Repeat HSG of patient shown in B, showing filling and patency of both tubes.
Baramki. Hysterosalpingography. Fertil Steril 2005.
FIGURE 30
FIGURE 31
Hysterosalpingogram showing tubal polyps bilaterally.
Hysterosalpingogram showing patent tubes after tubal implantation for bilateral cornual occlusion.
Baramki. Hysterosalpingography. Fertil Steril 2005. Baramki. Hysterosalpingography. Fertil Steril 2005.
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Vol. 83, No. 6, June 2005
FIGURE 32
FIGURE 33
Hysterosalpingogram showing salpingitis isthmica nodosa.
Hysterosalpingogram showing salpingitis isthmica nodosa with bilateral patency of the tubes.
Baramki. Hysterosalpingography. Fertil Steril 2005. Baramki. Hysterosalpingography. Fertil Steril 2005.
uterine cavity, the balloon is inflated with 1.5 mL of air to create a seal. Some centers use suction cups applied to the cervix to give an airtight application (2). MEDIA Different contrast media have been used in HSG since the procedure was initially described by Rindfleisch in 1910 (3). Oil-based medium (lipiodol), which was developed in 1921, was replaced by a water-soluble medium. The latter prevents oil embolism and granuloma formation. All types of media contain iodine. It is important to make sure that the patient is not allergic to iodine. If she is, it is advisable to premedicate her with glucocorticoids before the procedure.
FIGURE 34 Hysterosalpingogram showing a normal uterine cavity and bilateral hydrosalpinx.
TECHNIQUE It is advisable to ask the patient to take 600 mg ibuprofen orally 1 hour before the procedure to ease the cramps. The position of the uterus should be confirmed. After the patient lies on the x-ray table, sterile towels are applied to the perineum. A sterile speculum is inserted in the vagina for a proper visualization of the cervix. Betadine solution is used to sterilize the cervix. If a tenaculum is to be used, it should be applied gently. It should be explained to the patient what is being done, so as to gain her confidence. Before the cannula or catheter is inserted through the cervical canal, the dye should be passed through the instrument so as to expel the air and minimize or eliminate the air bubbles. After insertion of the instrument, the radio-opaque medium is injected slowly under fluoroscopy. The speculum is pulled out of the vagina before radiographs are taken so as not to obscure the cervical canal and lower uterine segment. It is advisable to take a radiograph after injection of 2 mL of medium to ensure that there are no filling defects like polyps or submucous myomas in the uterine cavity, which could be concealed by overdistending the uterus. If the uterus is retroverted, the tenaculum should be pulled to get a good view of the uterus. Further injection will outline the cornua, isthmic, and ampullary portions of the tubes and evaluate the degree of spillage. A healthy ampullary portion of the tube will show rugal folds. Collection of dye around the distal end of the tube might represent peritubal adhesions. Excessive injection of dye prevents proper interpretation of the study. Insufficient injection of dye will result in an incomplete study (4).
Baramki. Hysterosalpingography. Fertil Steril 2005.
Fertility and Sterility姞
Hysterosalpingography is helpful in detecting the following uterine abnormalities: unicornuate uterus, double uterus, uterus didelphys, T-shaped uterus, adenomyosis, endometrial polyp, submucous myoma, synechiae, endometrial hy1605
perplasia/carcinoma, and cervical incompetence; and these tubal abnormalities: cornual occlusion, salpingitis isthmica nodosa, and hydrosalpinx. Figures 1–34 are photographs of HSGs in different conditions. Acknowledgment: The author thanks Mr. Zuhair Kareem, Senior Photographer at The Johns Hopkins Hospital, for his superb help in reproducing the photographs shown in this article.
REFERENCES 1. Schwabe MG, Shapiro SS, Haning RV Jr. Hysterosalpingography with oil contrast medium enhances fertility in patients with infertility of unknown etiology. Fertil Steril 1983;40:604 – 6.
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Hysterosalpingography
2. Malstrom T. A vacuum uterine cannula. Obstet Gynecol 1961;18:773. 3. Rindfleisch W. Darstellung des Cavum uteri. Klin Wochenschr 1910;4: 780. 4. Siegler A Hysterosalpingography. In: Wallach E, Zacur H, eds. Reproductive medicine and surgery. Baltimore: Mosby, 1986. 5. DeCherney AH, Cholst I, Naftolin F. Structure and function of the fallopian tubes following exposure to diethylstilbestrol (DES) during gestation. Fertil Steril 1981;36:741–5. 6. Troiano RN, McCarthy SM. Mullerian duct anomalies: imaging and clinical issues. Radiology 2004;233:19 –34. 7. Glatstein IZ, Sleeper LA, Lavy Y, Simon A, Adoni A. Palti Z, et al. Observer variability in the diagnosis and management of the hysterosalpingogram. Fertil Steril 1997;67:233–7. 8. Hurd WW, Wyckoff ET, Reynolds DB, Ameses LS, Gruber JS, Horowitz GM. Patient rotation and resolution of unilateral cornual obstruction during hysterosalpingography. Obstet Gynecol 2003;101:1275– 8.
Vol. 83, No. 6, June 2005
Hysterosalpingography Theodore A. Baramki, M.D. Department of Gynecology and Obstetrics, The Johns Hopkins University, Baltimore, Maryland
Objective: To demonstrate the value of the hysterosalpingogram in the evaluation of infertility. Conclusion(s): Hysterosalpingography, which should be done in the follicular phase of the cycle, evaluates the contour of the uterine cavity, cervical canal, and tubal lumina. Other than being diagnostic, it can prove to be therapeutic. The instrument used to introduce the radio-opaque medium should be chosen to give the least discomfort and to cause no leakage of dye from the cervix. Water-soluble medium is usually used rather than an oil-based medium. Fluoroscopy with image intensification gives the best results. Insufficient dye injection will give an incomplete study. Too much dye injection, especially under pressure, might cause extravasation of the dye into the vascular system or conceal the fimbrial ends of the tubes. (Fertil Steril威 2005;83:1595– 606. ©2005 by American Society for Reproductive Medicine.) Key Words: Synechiae, submucous myoma, adenomyosis, salpingitis isthmica nodosa, hydrosalpinx, endometrial hyperplasia, cervical incompetence, uterus didelphys
Hysterosalpingography is the radiographic evaluation of the cavity of the uterus and fallopian tubes after injection of a radio-opaque medium through the cervical canal. The study should be done during the follicular phase of the cycle so as not to interfere with a possible early pregnancy. The best results are obtained by fluoroscopy with image intensification. Although this procedure is considered diagnostic, it can prove to be therapeutic at times (1). A properly performed hysterosalpingogram (HSG) will give an idea as to the contour of the uterine cavity and the width of the cervical canal. Further injection will outline the cornua, isthmic, and ampullary portions of the tubes and evaluate the degree of spillage. If the uterine cavity shows no abnormality with a properly performed HSG, it is very unlikely that hysteroscopy would reveal an abnormality.
fort and prevents leakage of the dye. The instrument most commonly used to inject radio-opaque medium is the Jarcho cannula, which is a metal instrument that has a rubber “acorn” placed close to the tip so as to prevent leakage of the dye. The cannula is stabilized by hooking it to a single-tooth tenaculum applied to the anterior lip of the cervix. The HSG catheter (REDI-TECH, Atlanta, GA), which is becoming popular, is a plastic catheter with a balloon close to the tip. In most cases the catheter can be passed through the cervical canal without the use of a tenaculum. After insertion into the
FIGURE 1 Normal HSG with a Jarcho cannula.
Other than noting spillage of dye from the fimbrial ends of the tubes, the degree of free spillage is important. INSTRUMENTS The clinician should use the instrument that he/she feels comfortable with and that gives the patient the least discomReceived September 14, 2004; revised and accepted December 20, 2004. No reprints will be available. Correspondence to: Theodore A. Baramki, M.D., Johns Hopkins at Green Spring Station, Department of Gynecology and Obstetrics, 2330 W. Joppa Road, Suite 301, Lutherville, Maryland 21093 (FAX: 410-5832767; E-mail: [email protected]).
0015-0282/05/$30.00 doi:10.1016/j.fertnstert.2004.12.050
Baramki. Hysterosalpingography. Fertil Steril 2005.
Fertility and Sterility姞 Vol. 83, No. 6, June 2005 Copyright ©2005 American Society for Reproductive Medicine, Published by Elsevier Inc.
1595
FIGURE 2
FIGURE 3
Normal HSG with an HSG catheter with balloon.
Hysterosalpingogram catheter with inflated balloon at tip.
Baramki. Hysterosalpingography. Fertil Steril 2005.
Baramki. Hysterosalpingography. Fertil Steril 2005.
FIGURE 4 (A) Hysterosalpingogram with HSG catheter showing the balloon obstructing the lower uterine segment and cervical canal. (B) Same study as shown in A, except that the balloon was deflated during injection of more dye, showing a normal cervical canal.
Baramki. Hysterosalpingography. Fertil Steril 2005.
1596
Baramki
Hysterosalpingography
Vol. 83, No. 6, June 2005
FIGURE 5
FIGURE 7
Hysterosalpingogram showing multiple filling defects due to endometrial polyps.
Hysterosalpingogram showing multiple filling defects due to submucous myomas.
Baramki. Hysterosalpingography. Fertil Steril 2005.
Baramki. Hysterosalpingography. Fertil Steril 2005.
FIGURE 6
FIGURE 8
Hysterosalpingogram showing a filling defect due to synechiae.
Hysterosalpingogram with an oblique view showing a submucous myoma that disappeared when more dye was injected (8).
Baramki. Hysterosalpingography. Fertil Steril 2005.
Baramki. Hysterosalpingography. Fertil Steril 2005.
Fertility and Sterility姞
1597
FIGURE 9
FIGURE 11
Hysterosalpingogram showing a filling defect in the left cornual area. It proved to be a superimposed gas bubble from the bowel over the uterine shadow.
Hysterosalpingogram showing irregular uterine cavity due to endometrial hyperplasia.
Baramki. Hysterosalpingography. Fertil Steril 2005.
Baramki. Hysterosalpingography. Fertil Steril 2005.
FIGURE 10 (A) Hysterosalpingogram showing a linear filling defect near the left cornu in a patient who had a secondtrimester miscarriage. (B) At exploration of the uterine cavity, the filling defect in A proved to be a piece of flat bone, as shown in this photomicrograph.
Baramki. Hysterosalpingography. Fertil Steril 2005.
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Baramki
Hysterosalpingography
Vol. 83, No. 6, June 2005
FIGURE 12
FIGURE 14
Hysterosalpingogram showing irregular uterine cavity due to endometrial carcinoma in an anovulatory woman.
Hysterosalpingogram showing an arcuate uterus, absent left tube, and intravasation of dye in the uterine veins on the right obscuring the status of the right tube.
Baramki. Hysterosalpingography. Fertil Steril 2005.
Baramki. Hysterosalpingography. Fertil Steril 2005.
FIGURE 13 Hysterosalpingogram showing marked irregularity of the uterine cavity due to endometrial carcinoma.
FIGURE 15 Hysterosalpingogram showing marked distortion of the uterine cavity due to a large intramural myoma. Intravasation of dye is also noted.
Baramki. Hysterosalpingography. Fertil Steril 2005. Baramki. Hysterosalpingography. Fertil Steril 2005.
Fertility and Sterility姞
1599
FIGURE 16
FIGURE 18
Hysterosalpingogram showing a T-shaped uterus due to diethylstilbestrol exposure in utero (5).
Hysterosalpingogram showing a septate uterus. Note that the angle between the two horns is an acute one.
Baramki. Hysterosalpingography. Fertil Steril 2005.
FIGURE 17 Baramki. Hysterosalpingography. Fertil Steril 2005.
Hysterosalpingogram showing a right unicornuate uterus.
FIGURE 19 Hysterosalpingogram showing a bicornuate uterus with an obtuse angle between the two horns (6).
Baramki. Hysterosalpingography. Fertil Steril 2005.
1600
Baramki
Hysterosalpingography
Baramki. Hysterosalpingography. Fertil Steril 2005.
Vol. 83, No. 6, June 2005
FIGURE 20
FIGURE 22
Hysterosalpingogram showing uterus didelphys. Two cannulas had to be used.
Hysterosalpingogram showing a septate uterus with extra dye in the lower uterine segment due to a previous cesarean section.
Baramki. Hysterosalpingography. Fertil Steril 2005. Baramki. Hysterosalpingography. Fertil Steril 2005.
FIGURE 21 (A) Hysterosalpingogram showing an irregular uterine cavity interpreted by the radiologist as showing multiple submucous myomas. (B) Repeat HSG of the same patient shown in A, with the cervix pulled down. It shows a septate uterus, not submucous myomas (7).
Baramki. Hysterosalpingography. Fertil Steril 2005.
Fertility and Sterility姞
1601
FIGURE 23
FIGURE 24
Hysterosalpingogram showing a dilated internal os due to an incompetent cervix. The patient had two mid-trimester pregnancy losses.
Hysterosalpingogram showing a mild form of adenomyosis.
Baramki. Hysterosalpingography. Fertil Steril 2005. Baramki. Hysterosalpingography. Fertil Steril 2005.
FIGURE 25 (A) Hysterosalpingogram showing adenomyosis. (B) Drainage film of patient shown in A, showing the dye in the glands of adenomyosis.
Baramki. Hysterosalpingography. Fertil Steril 2005.
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Baramki
Hysterosalpingography
Vol. 83, No. 6, June 2005
FIGURE 26
FIGURE 28
Hysterosalpingogram showing a marked degree of adenomyosis.
(A) Hysterosalpingogram showing a normal uterine cavity with filling but no definite spillage from the tubes. (B) Hysterosalpingogram of the same patient shown in A after more dye was injected, showing bilateral hydrosalpinx.
Baramki. Hysterosalpingography. Fertil Steril 2005.
Baramki. Hysterosalpingography. Fertil Steril 2005.
FIGURE 27 (A) Hysterosalpingogram showing air bubbles in the uterine cavity and non-filling of the left tube. This is an incomplete study. (B) Hysterosalpingogram of the same patient shown in A after more dye was injected, showing a normal HSG.
Baramki. Hysterosalpingography. Fertil Steril 2005.
Fertility and Sterility姞
1603
FIGURE 29 (A) Hysterosalpingogram showing a normal uterine cavity but no filling of either tube. (B) Repeat HSG of patient shown in B, showing filling and patency of both tubes.
Baramki. Hysterosalpingography. Fertil Steril 2005.
FIGURE 30
FIGURE 31
Hysterosalpingogram showing tubal polyps bilaterally.
Hysterosalpingogram showing patent tubes after tubal implantation for bilateral cornual occlusion.
Baramki. Hysterosalpingography. Fertil Steril 2005. Baramki. Hysterosalpingography. Fertil Steril 2005.
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Baramki
Hysterosalpingography
Vol. 83, No. 6, June 2005
FIGURE 32
FIGURE 33
Hysterosalpingogram showing salpingitis isthmica nodosa.
Hysterosalpingogram showing salpingitis isthmica nodosa with bilateral patency of the tubes.
Baramki. Hysterosalpingography. Fertil Steril 2005. Baramki. Hysterosalpingography. Fertil Steril 2005.
uterine cavity, the balloon is inflated with 1.5 mL of air to create a seal. Some centers use suction cups applied to the cervix to give an airtight application (2). MEDIA Different contrast media have been used in HSG since the procedure was initially described by Rindfleisch in 1910 (3). Oil-based medium (lipiodol), which was developed in 1921, was replaced by a water-soluble medium. The latter prevents oil embolism and granuloma formation. All types of media contain iodine. It is important to make sure that the patient is not allergic to iodine. If she is, it is advisable to premedicate her with glucocorticoids before the procedure.
FIGURE 34 Hysterosalpingogram showing a normal uterine cavity and bilateral hydrosalpinx.
TECHNIQUE It is advisable to ask the patient to take 600 mg ibuprofen orally 1 hour before the procedure to ease the cramps. The position of the uterus should be confirmed. After the patient lies on the x-ray table, sterile towels are applied to the perineum. A sterile speculum is inserted in the vagina for a proper visualization of the cervix. Betadine solution is used to sterilize the cervix. If a tenaculum is to be used, it should be applied gently. It should be explained to the patient what is being done, so as to gain her confidence. Before the cannula or catheter is inserted through the cervical canal, the dye should be passed through the instrument so as to expel the air and minimize or eliminate the air bubbles. After insertion of the instrument, the radio-opaque medium is injected slowly under fluoroscopy. The speculum is pulled out of the vagina before radiographs are taken so as not to obscure the cervical canal and lower uterine segment. It is advisable to take a radiograph after injection of 2 mL of medium to ensure that there are no filling defects like polyps or submucous myomas in the uterine cavity, which could be concealed by overdistending the uterus. If the uterus is retroverted, the tenaculum should be pulled to get a good view of the uterus. Further injection will outline the cornua, isthmic, and ampullary portions of the tubes and evaluate the degree of spillage. A healthy ampullary portion of the tube will show rugal folds. Collection of dye around the distal end of the tube might represent peritubal adhesions. Excessive injection of dye prevents proper interpretation of the study. Insufficient injection of dye will result in an incomplete study (4).
Baramki. Hysterosalpingography. Fertil Steril 2005.
Fertility and Sterility姞
Hysterosalpingography is helpful in detecting the following uterine abnormalities: unicornuate uterus, double uterus, uterus didelphys, T-shaped uterus, adenomyosis, endometrial polyp, submucous myoma, synechiae, endometrial hy1605
perplasia/carcinoma, and cervical incompetence; and these tubal abnormalities: cornual occlusion, salpingitis isthmica nodosa, and hydrosalpinx. Figures 1–34 are photographs of HSGs in different conditions. Acknowledgment: The author thanks Mr. Zuhair Kareem, Senior Photographer at The Johns Hopkins Hospital, for his superb help in reproducing the photographs shown in this article.
REFERENCES 1. Schwabe MG, Shapiro SS, Haning RV Jr. Hysterosalpingography with oil contrast medium enhances fertility in patients with infertility of unknown etiology. Fertil Steril 1983;40:604 – 6.
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Baramki
Hysterosalpingography
2. Malstrom T. A vacuum uterine cannula. Obstet Gynecol 1961;18:773. 3. Rindfleisch W. Darstellung des Cavum uteri. Klin Wochenschr 1910;4: 780. 4. Siegler A Hysterosalpingography. In: Wallach E, Zacur H, eds. Reproductive medicine and surgery. Baltimore: Mosby, 1986. 5. DeCherney AH, Cholst I, Naftolin F. Structure and function of the fallopian tubes following exposure to diethylstilbestrol (DES) during gestation. Fertil Steril 1981;36:741–5. 6. Troiano RN, McCarthy SM. Mullerian duct anomalies: imaging and clinical issues. Radiology 2004;233:19 –34. 7. Glatstein IZ, Sleeper LA, Lavy Y, Simon A, Adoni A. Palti Z, et al. Observer variability in the diagnosis and management of the hysterosalpingogram. Fertil Steril 1997;67:233–7. 8. Hurd WW, Wyckoff ET, Reynolds DB, Ameses LS, Gruber JS, Horowitz GM. Patient rotation and resolution of unilateral cornual obstruction during hysterosalpingography. Obstet Gynecol 2003;101:1275– 8.
Vol. 83, No. 6, June 2005