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Infertility: Hysterosalpingography (162–164)
concentrations were consistent with an ovulatory cycle. PRL levels increased immediately after ovulation, and El levels followed a pattern similar to E2 levels but exceeded them especially in the luteal phase. As concentration increased in the follicular phase, T levels showed no consistent pattern. In one patient with primary oligomenorrhea (20 jJ.g LH-RH/pulse/90 minutes) ultrasonic observation revealed cyst formation in both ovaries. Treatment was discontinued on day 18; menses occurred on day 30. Immediately after initiation of therapy, LH concentration increased to 78 IUn on day 7 and fell gradually thereafter. E2 levels showed a peak (2000 pmoIn) on day 8, declined afterwards, and evoked a less-pronounced LH peak (27 IUm on day 13. El closely followed the pattern of E 2 • P concentration, low until day 14, increased to 66 nmol/l on day 21. 17-OHP levels ranged from 5 nmol/l to 10 nmolll; A concentration declined until day 11 and increased to 12 nmoIn on day 16. T levels ranged from 2 nmol/l to 3 nmoIn until day 12 and declined thereafter. In one patient with primary oligomenorrhea and secondary amenorrhea (12 years), no follicular development beyond the diameter of 0.8 cm was noted on ultrasonography. LH-RH therapy (5 jJ.g/ pulse/90 minutes) was discontinued on day 22, menses occurred on day 31. In premature ovarian failure (one patient), neither therapy with 5 jJ.g LH-RH/pulse/90 minutes nor with 20 jJ.g LH-RH/ pulse/90 minutes could induce follicular development. These results indicate: (1) in severe hypothalamic amenorrhea, previous ovarian hyperstimulation did not influence ovarian function; (2) luteal phase insufficiency may be treated with chronic pulsatile LH-RH before menotropin therapy is instituted; (3) caution is advised due to ovarian hyperstimulation in patients with endogenous LH-RH secretion; and (4) patients with gonadotropin resistance or premature ovarian failure are not candidates for ovulation induction with chronic pulsatile LH-RH.
INFERTILITY: HYSTEROSALPINGOGRAPHY (162-164)
162. Further Evidence for the Superiority of Oil-Soluble Contrast Media in Hysterosalpingogram. ALAN H. DeCHERNEY, AND MARY LAKE POLAN. Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, Yale University School of Medicine, New Haven, Connecticut. Vol. 41, No.2, February 1984
Hysterosalpingography utili.zing oil-soluble contrast media (OSCM) has previously been shown (Fertil Steril 33:407, 1980) to result in higher posthysterogram pregnancy rates (29%) when compared with procedures performed with water-soluble contrast media (WSCM) (13%). Higher pregnancy rates were found in both women with unexplained ~nfertility and those with infertility due to male factor. It was recommended that hysterograms be performed using WSCM and, if normal tubal architecture and function were demonstrated, 3 to 5 ml of OSCM be injected therapeutically. Subsequently, using this protocol, 145 additional hysterosalpingograms have been performed at the Yale-New Haven Hospital, and this report extends and confirms the previous observations. Thirty-one patients were eliminated from the study when overt tubal disease was documented, contraindicating use of OSCM. Thirty-three patients were eliminated because of superimposed ovulatory dysfunction. Of the remaining 81 patients, 4 were women with a normal evaluation prior to laparoscopy and 37 had male factor infertility. Patients were followed for the initial 6 months after hysterosalpingography to determine pregnancy rates. Of these women with unexplained infertility, 36.3% (16/44) conceived within 6 months. Women with male-related infertility had a 24.3% (9/37) pregnancy rate within 6 months. These pregnancy rates are significantly higher than the 13% posthysterogram pregnancy rate observed when WSCM alone was used. This study confirms the earlier results and strengthens the recommendation for initial use of WSCM and, if the hysterogram is normal, subsequent injection ofOSCM. 163. A Review of the Utility and Reliability of Hysterosalpingography. MARK GIBSON, AND JESS mCKERSON. Department of Obstetrics and Gynecology, University of Vermont College of Medicine, Burlington, Vermont. This study examined the value of the hysterosalpingogram (HSG) in light of contemporary concepts regarding the pathophysiology of infertility. Of particular concern were: (1) the significance of unilateral abnormalities seen on HSGs; and (2) the information gained by laparoscopic examination subsequent to a normal HSG. Analysis of value of laparoscopy in the hysterosalpinAbstracts
698
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p
gographically normal patient focused on the frequency of laparoscopic findings that would lead to therapies of proven benefit to patients. Records and HSGs of 275 consecutive infertility patients seen at the University of Vermont were reviewed. Records pertinent to subsequent direct visualization of the pelvis either at laparotomy or laparoscopy were reviewed as well. There were 102 (37%) HSGs showing evidence of abnormalities of the adnexae. Among the HSGs showing evidence of adnexal abnormalities, 43 (43%) indicated abnormalities involving one side of the pelvis only. When correlated with subsequent direct visualization, hysterosalpingographic findings were found more often to be falsely positive in women exhibiting radiologic eviden~e of unilateral disease (10 of 25, or 40%) than m women with hysterosalpingographic evidence of bilateral abnormalities (5 of 39, or 13%). However, the unilateral abnormalities seen on HSG were confirmed at subsequent direct visualization in 15 ofthese women (60%); additional abnormalities involving the hysterosalpingographically normal adnexa were found in 9 patients (36%). Among the 173 women with normal HSGs, subsequent direct visualization of the pelvis was accomplished in 55 (32%). At subsequent direct visualization, abnormalities were discovered in 32 (58%) of these women. However, many of these women with normal HSGs and abnormal findings at subsequent laparoscopy or laparotomy harbored only unilateral or insignificant adhesions (6 of 8 with adhesions) or minimal pelvic endometriosis (20 of 24 with endometriosis). The utility of laparoscopy in the hysterosalpingographically normal patient was then reassessed to consider only the incidence of laparoscopic findings leading to therapy of known benefit to the patient. Following this approach, only 6 of 55 (11%) women with infertility and normal HSGs benefited from laparoscopy. We conclude that the HSG remains a useful tool in the evaluation of infertility and that the value of laparoscopy in the patient with a normal HSG may have been overemphasized. Laparoscopy is a necessary addition in the patient with unilateral hysterosalpingographic disease due to the greater inaccuracy of HSG in these patients.
164. The Ability of Hysterosalpingogram to Predict Findings at Diagnostic Laparoscopy: A Comparison of Oil-Soluble with Water-Sol70S
Abstracts
uble Contrast Media.
FREDERICK G. WEINSTEIN, MA-
CHELLE M. SEIBEL, MERLE BERGER, AND MELVIN TAYMOR.
Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia, and Beth Israel Hospital/Harvard Medical School, Boston, Massachusetts. Seventy-seven women of reproductive age undergoing infertility investigation had a hysterosalpingogram (HSG) and subsequent laparoscopy. In 33 instances, an oil-soluble medium was used, and in 44 cases, HSG was performed using a water-soluble medium. The mean interval between HSG and laparoscopy was 4 months. In those patients whose ~SG was done using an oil-soluble contrast medIUm, findings agreed in 13 of 33 instances. In ~ of these 13 cases, both procedures were normal, and in 8, both revealed pathology. However, in 20 of these 33 patients, there were disparate findings. In 14 of these 20 cases, abnormalities reported at laparoscopy were not recognized at HSG, and in 6 of these 20 cases, the HSG demonstrated abnormalities that were not found at laparoscopy. Among patients receiving water-soluble contrast medium, there was agreement on findings between HSG and laparoscopy in 20 of 44 in. stances and disagreement in 24 of 44 instances. Of these 24 patients, 13 had abnormalities at laparoscopy not recognized at HSG, and in 11 cases, the HSG demonstrated abnormalities not found at laparoscopy. . . Based on the findings in these 77 patients, It appears that there is no distinct advan~age of either contrast media in predicting findmgs at laparoscopy. Moreover, since disparate findin~s were recorded between HSG and laparoscopy m more than 50% of the cases, it underscores the fact that both procedures are necessary. Additionally, this study suggests that if pregnancy d?es not occur in the face of a normal HSG, a pentoneal factor has not been excluded and laparoscopy is indicated. INFERTILITY: SURGICAL (165-190)
165. Mullerian Duct Abnormalities and Associated Factors in Infertility. WILLIAM T. GRIFFIN AND JULIE LUBKER STRICKLAND. Department of Ob~tetrics and Gynecology, University of Missouri, Columbia, Missouri. Abnormalities of Mullerian malunion, although not common, traditionally have been asFertility and Sterility
INFERTILITY: HYSTEROSALPINGOGRAPHY (162-164)
162. Further Evidence for the Superiority of Oil-Soluble Contrast Media in Hysterosalpingogram. ALAN H. DeCHERNEY, AND MARY LAKE POLAN. Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology, Yale University School of Medicine, New Haven, Connecticut. Vol. 41, No.2, February 1984
Hysterosalpingography utili.zing oil-soluble contrast media (OSCM) has previously been shown (Fertil Steril 33:407, 1980) to result in higher posthysterogram pregnancy rates (29%) when compared with procedures performed with water-soluble contrast media (WSCM) (13%). Higher pregnancy rates were found in both women with unexplained ~nfertility and those with infertility due to male factor. It was recommended that hysterograms be performed using WSCM and, if normal tubal architecture and function were demonstrated, 3 to 5 ml of OSCM be injected therapeutically. Subsequently, using this protocol, 145 additional hysterosalpingograms have been performed at the Yale-New Haven Hospital, and this report extends and confirms the previous observations. Thirty-one patients were eliminated from the study when overt tubal disease was documented, contraindicating use of OSCM. Thirty-three patients were eliminated because of superimposed ovulatory dysfunction. Of the remaining 81 patients, 4 were women with a normal evaluation prior to laparoscopy and 37 had male factor infertility. Patients were followed for the initial 6 months after hysterosalpingography to determine pregnancy rates. Of these women with unexplained infertility, 36.3% (16/44) conceived within 6 months. Women with male-related infertility had a 24.3% (9/37) pregnancy rate within 6 months. These pregnancy rates are significantly higher than the 13% posthysterogram pregnancy rate observed when WSCM alone was used. This study confirms the earlier results and strengthens the recommendation for initial use of WSCM and, if the hysterogram is normal, subsequent injection ofOSCM. 163. A Review of the Utility and Reliability of Hysterosalpingography. MARK GIBSON, AND JESS mCKERSON. Department of Obstetrics and Gynecology, University of Vermont College of Medicine, Burlington, Vermont. This study examined the value of the hysterosalpingogram (HSG) in light of contemporary concepts regarding the pathophysiology of infertility. Of particular concern were: (1) the significance of unilateral abnormalities seen on HSGs; and (2) the information gained by laparoscopic examination subsequent to a normal HSG. Analysis of value of laparoscopy in the hysterosalpinAbstracts
698
i.
p
gographically normal patient focused on the frequency of laparoscopic findings that would lead to therapies of proven benefit to patients. Records and HSGs of 275 consecutive infertility patients seen at the University of Vermont were reviewed. Records pertinent to subsequent direct visualization of the pelvis either at laparotomy or laparoscopy were reviewed as well. There were 102 (37%) HSGs showing evidence of abnormalities of the adnexae. Among the HSGs showing evidence of adnexal abnormalities, 43 (43%) indicated abnormalities involving one side of the pelvis only. When correlated with subsequent direct visualization, hysterosalpingographic findings were found more often to be falsely positive in women exhibiting radiologic eviden~e of unilateral disease (10 of 25, or 40%) than m women with hysterosalpingographic evidence of bilateral abnormalities (5 of 39, or 13%). However, the unilateral abnormalities seen on HSG were confirmed at subsequent direct visualization in 15 ofthese women (60%); additional abnormalities involving the hysterosalpingographically normal adnexa were found in 9 patients (36%). Among the 173 women with normal HSGs, subsequent direct visualization of the pelvis was accomplished in 55 (32%). At subsequent direct visualization, abnormalities were discovered in 32 (58%) of these women. However, many of these women with normal HSGs and abnormal findings at subsequent laparoscopy or laparotomy harbored only unilateral or insignificant adhesions (6 of 8 with adhesions) or minimal pelvic endometriosis (20 of 24 with endometriosis). The utility of laparoscopy in the hysterosalpingographically normal patient was then reassessed to consider only the incidence of laparoscopic findings leading to therapy of known benefit to the patient. Following this approach, only 6 of 55 (11%) women with infertility and normal HSGs benefited from laparoscopy. We conclude that the HSG remains a useful tool in the evaluation of infertility and that the value of laparoscopy in the patient with a normal HSG may have been overemphasized. Laparoscopy is a necessary addition in the patient with unilateral hysterosalpingographic disease due to the greater inaccuracy of HSG in these patients.
164. The Ability of Hysterosalpingogram to Predict Findings at Diagnostic Laparoscopy: A Comparison of Oil-Soluble with Water-Sol70S
Abstracts
uble Contrast Media.
FREDERICK G. WEINSTEIN, MA-
CHELLE M. SEIBEL, MERLE BERGER, AND MELVIN TAYMOR.
Department of Obstetrics and Gynecology, Eastern Virginia Medical School, Norfolk, Virginia, and Beth Israel Hospital/Harvard Medical School, Boston, Massachusetts. Seventy-seven women of reproductive age undergoing infertility investigation had a hysterosalpingogram (HSG) and subsequent laparoscopy. In 33 instances, an oil-soluble medium was used, and in 44 cases, HSG was performed using a water-soluble medium. The mean interval between HSG and laparoscopy was 4 months. In those patients whose ~SG was done using an oil-soluble contrast medIUm, findings agreed in 13 of 33 instances. In ~ of these 13 cases, both procedures were normal, and in 8, both revealed pathology. However, in 20 of these 33 patients, there were disparate findings. In 14 of these 20 cases, abnormalities reported at laparoscopy were not recognized at HSG, and in 6 of these 20 cases, the HSG demonstrated abnormalities that were not found at laparoscopy. Among patients receiving water-soluble contrast medium, there was agreement on findings between HSG and laparoscopy in 20 of 44 in. stances and disagreement in 24 of 44 instances. Of these 24 patients, 13 had abnormalities at laparoscopy not recognized at HSG, and in 11 cases, the HSG demonstrated abnormalities not found at laparoscopy. . . Based on the findings in these 77 patients, It appears that there is no distinct advan~age of either contrast media in predicting findmgs at laparoscopy. Moreover, since disparate findin~s were recorded between HSG and laparoscopy m more than 50% of the cases, it underscores the fact that both procedures are necessary. Additionally, this study suggests that if pregnancy d?es not occur in the face of a normal HSG, a pentoneal factor has not been excluded and laparoscopy is indicated. INFERTILITY: SURGICAL (165-190)
165. Mullerian Duct Abnormalities and Associated Factors in Infertility. WILLIAM T. GRIFFIN AND JULIE LUBKER STRICKLAND. Department of Ob~tetrics and Gynecology, University of Missouri, Columbia, Missouri. Abnormalities of Mullerian malunion, although not common, traditionally have been asFertility and Sterility