Hysterosalpingography in perspective: the predictive value of oil-soluble versus water-soluble contrast media

FERTILITY AND STERILITY

Vol. 51, No.1, January 1989

Copyright<> 1989 The American Fertility Society

Printed in U.S.A.

Hysterosalpingography in perspective: the predictive value of oil-soluble versus water-soluble contrast media

Randall A. Loy, M.D.* Frederick G. Weinstein, M.D. Machelle M. Seibel, M.D. Dana Biomedical Research Laboratories, Department of Obstetrics and Gynecology, Beth Israel Hospital and Harvard Medical School, Boston, Massachusetts

Hysterosalpingography (HSG) constitutes an integral component of the basic infertility evaluation. It provides an indirect visualization of endometrial contour and ideally should predict the likelihood of tubal patency and peritubal adhesions observed at laparoscopy. However, controversy still exists as to whether oil-soluble contrast media (OSCM) are diagnostically superior to water-soluble contrast media (WSCM). 1 This study was undertaken to compare the predictive values of OSCM with WSCM relative to laparoscopic diagnosis for the detection of pelvic pathology. 2 •3 MATERIALS AND METHODS

Seventy-seven consecutive patients with primary and secondary infertility were included in the study. The OSCM was used in 33 patients and WSCM was used in 44 patients. The choice of medium depended solely upon physician preference; one physician used OSCM exclusively, whereas the second physician used WSCM only. Both patient groups were comparable in age. All HSG were performed in the midproliferative phase of the menstrual cycle. With the patient in dorsolithotomy position, a bivalve speculum was placed into the vagina. The vagina and cervix were cleansed with a Betadine solution (Purdue FrederReceived June 13, 1988; revised and accepted August 29, 1988. *Reprint requests and present address: Randall Loy, M.D., Department of Obstetrics and Gynecology, Yale University School 'of Medicine, 339 Farnam Memorial Building, 333 Cedar Street, New Haven, CT 06510. 170

Loy et al.

Communications-in-brief

ick Co., Norwalk, CT) and a single-tooth tenaculum was applied to the anterior cervical lip for traction. Neither medication nor anesthesia was used. A rubber tip acorn cannula was placed into the cervical canal and attached to the tenaculum via a spring-loaded clip. The speculum was removed and the pelvis was initially scanned briefly with the image intensifier. Under fluoroscopic visualization between 5 and 10 ml of Ethiodol (E. R. Squibb and Sons, Princeton, NJ) (OSCM) and Sinografin (Squibb) (WSCM) were slowly injected into the uterus. The first anteroposterior roentgenogram was taken following instillation of 1 ml of contrast medium. The second film was obtained as the tubal lumina were outlined and the medium began to spill or accumulate. Lateral views were also obtained where indicated. A delayed anteroposterior plain film was obtained 10 minutes after WSCM or 24 hours after OSCM was instilled to evaluate whether the dispersement pattern of the contrast material suggested loculation and pelvic adhesions. The films were interpreted by an attending radiologist in conjunction with the performing physician. All patients subsequently underwent diagnostic laparoscopy. The mean interval between HSG and laparoscopy was 4.5 months for the OSCM group and 3.5 months for the WSCM group. At time of surgery a single-tooth tenaculum was again placed into the anterior cervical lip and a rubber tip acorn cannula inserted into the cervix. After carefullaparoscopic inspection of the internal genital organs, chromopertubation was performed injecting indigo carmine through the intracervical cannula. Diagnostic testing analysis was performed for each Fertility and Sterility

Table 1 Comparison of the Findings of Tubal Patency by HSG and Laparoscopy (Tubal Occlusion, Either Unilateral or Bilateral and Either Proximal or Distal)

HSG

Patent Occlusion Patent Occlusion

Laparoscopy

WSCM (n = 44)

OSCM (n = 33)

Combined (n = 77)

%

%

%

14 (42.5)

41 (53) 16 (21) 4 (5) 16 (21)

27 (61) 5 (11) 3 (7) 9 (21)

Patent Occlusion Occlusion Patent

11 (33.5)

1 (3) 7 (21)

method individually. The Z statistic for comparing two proportions was then employed, with alpha error designated as 0.05. RESULTS

Table 1 represents the data concerning tubal patency. Sensitivity was defined as the fraction of patients with an abnormal condition who had an abnormal HSG. Specificity was defined as the fraction of patients with a normal condition who had a normal HSG. Eleven of 12 patients with tubal occlusion were identified by HSG using OSCM (sensitivity = 92%) as compared with 5 of 8 patients (sensitivity= 63%) using WSCM (P < 0.01). The specificities were 67% and 75% for OSCM and WSCM, respectively (not significant). When the two methods were compared as to the predictive value of an abnormal test, i.e., the fraction of patients with an abnormal HSG demonstrating tubal occlusion who had an abnormal condition, the OSCM group (61%) was higher than the WSCM patient group (36%) (P < 0.05). The predictive value of a normal test was comparable with both media: 93% for OSCM and 90% for WSCM. The data for peritubal adhesions are represented in Table 2. The radiologic diagnosis of periadnexal disease was made in the presence of loculated or localized spill, abnormal tubal contours, or the halo effect. 3 Sensitivity rates for diagnosis of periadnexal adhesions were low, 35% and 33% for OSCM and WSCM respectively (not significant), whereas the specificity rates were considerably higher: 90% for OSCM and 92% for WSCM. With respect to adhesions, the predictive value of an abnormal HSG was 89% for OSCM and 67% for WSCM (P < 0.05). The predictive value of a normal HSG was 38% for OSCM and 63% for WSCM (P < 0.05). DISCUSSION

Various authors4•8 have reported comparative studies of HSG and laparoscopy for the diagnosis Vol. 51, No.1, January 1989

of pelvic disease, and others have investigated pregnancy rates following HSG with OSCM and WSCM. 2 Little has been written, however, of the predictive value of OSCM versus WSCM in diagnosing tubal patency and peritubal adhesions. In this retrospective study comparing the diagnoses obtained following HSG (OSCM and WSCM) with those determined at laparoscopy combined with chromopertubation, OSCM was more sensitive (i.e., patients with an abnormal condition who had an abnormal HSG) than WSCM in the diagnosis of tubal patency (P < 0.01), but neither medium was highly sensitive in the diagnosis of peritubal adhesions. With respect to tubal patency, the predictive value of an abnormal test was greater using OSCM than WSCM (P < 0.05). The overall diagnostic reliability of HSG (OSCM and WSCM combined) relative to laparoscopy in this study was 66%. This value falls within the 56% to 89% range of complete agreement between the two procedures in previously published reports. 5 With respect to tubal patency, false-positive HSG (OSCM and WSCM) accounted for 28% of all HSG usually presenting as unilateral proximal tubal occlusion. Tubal spasm seems to be the most common cause of this phenomenon, 4•5 although technique, viscosity, or a large difference in tubal resistance may also be responsible. Falsenegative HSG (OSCM and WSCM) occurred frequently as well: 20% for tubal patency and 71% for peritubal adhesions. Periadnexal adhesions are the most commonly missed pathology3•4 ; endometriosis was also not diagnosable via HSG. 6 The greatest weakness of the HSG may be its inability to define periadnexal pathology. Although this could be due to the development of disease during the interim between HSG and laparoscopy, 5 errors in technique, or erroneous radiologic interpretation, it is more likely a limitation of the procedure itself. The advantages and disadvantages of OSCM and WSCM for HSG have been previously reviewed.1 Both types of contrast media may provide reliable information about uterotubal anatomy Table 2 Comparison of the Findings of Adhesions by HSG and Laparoscopy

HSG

Present Absent Absent Present

Laparoscopy

Present Absent Present Absent

Loy et al.

WSCM (n = 44)

OSCM (n = 33)

Combined (n = 77)

%

%

%

4 (9) 24 (55) 14 (32) 2 (4)

8 (24) 9 (27) 15 (46) 1 (3)

12 (15.5) 33 (43) 29 (37.5) 3 (4)

Communications-in-brief

171

with minimal side effects. This series demonstrates generally higher sensitivities and predictive values for OSCM in the diagnosis of pelvic disease in infertility patients. These results may, in part however, reflect subtle differences between HSG techniques and patient populations. This study concurs with other reports that HSG and laparoscopy with chromopertubation are complimentary procedures; HSG demonstrates the lumina and laparoscopy the surfaces of pelvic organs. HSG, although less reliable than laparoscopy, remains useful as a preliminary method for screening infertility patients. This is particularly true in this study for the diagnosis of tubal patency. OSCM may be diagnostically superior to WSCM; however, neither method is sufficient to diagnose endometriosis or pelvic adhesions. The diagnosis of these entities requires laparoscopic evaluation.

SUMMARY

This study of HSG in infertile patients compares the predictive values of OSCM with WSCM, relative to the laparoscopic diagnosis. The OSCM was found to have better sensitivity and higher predictive value for pelvic disease than the WSCM. HSG

172

Loy et al.

Communications-in-brief

and laparoscopy are adjunctive procedures, which are not mutually exclusive. REFERENCES 1. Soules MR, Spadoni LR: Oil versus aqueous media for hysterosalpingography: a continuing debate based on many opinions and few facts. Fertil Steril38:1, 1982 2. DeCherney AH, KortH, Barney JB, DeVore GR: Increase pregnancy rate with oil-soluble hysterosalpingography dye. Fertil Steril33:407, 1980 3. Siegler AM: Hysterosalpingography. Fertil Steril 40:139, 1983 4. Swolin K, Rosencrantz M: Laparoscopy vs. hysterosalpingography in sterility investigations. A comparative study. Fertil Steril 23:270, 1972 5. Maathuis JB, Horbach JGM, van Hall EV: A comparison of the results of hysterosalpingography and laparoscopy in the diagnosis of fallopian tube dysfunction. Fertil Steril 23: 428,1972 6. Gabos P: A comparison of hysterosalpingography and endoscopy in evaluation of tubal function in infertile women. Fertil Steril 27:238, 1976 7. Randolph JR, Ying YK, Maier DB, Schmidt CL, Riddick DH: Comparison of real-time ultrasonography, hysterosalpingography and laparoscopy/hysteroscopy in the evaluation of uterine abnormalities and tubal patency. Fertil Steril 46:828, 1986 8. World Health Organization: Comparative trial of tubal insufflation, hysterosalpingography and laparoscopy with dye hydrotubation for assessment of tubal patency. Fertil Steril 46:1101, 1986

Fertility and Sterility