Hysterosalpingography: a potential alternative to laparoscopy in the evaluation of tubal obstruction in infertile patients?

BACKGROUND: Evaluation of the fallopian tubes are important for infertile patients. The two most important diagnostic procedures used to evaluate tubal patency are hysterosalpingography and laparoscopy. OBJECTIVES: To asses the hysterosalpingography and laparoscopy results of patients diagnosed with infertility and investigate the diagnostic value of hysterosalpingography in patients with tubal factor infertility. METHODS: The hysterosalpingography and laparoscopy results of 208 patients who presented to the Obstetrics and Gynecology Clinic at Dicle University, Faculty of Medicine between January 2014- January 2018 were retrospectively evaluated. Hysterosalpingography and laparoscopy results were compared with regard to the investigation of the presence of tubal obstruction and of the pelvic structures that could cause tubal obstruction. The specificity, sensitivity, positive, and negative predictive values of hysterosalpingography were computed. RESULTS: The number of patients evaluated was 208. The ratio of primary infertile patients was 57.2% and 42.8% was secondary infertile. Hysterosalpingography was found to have a specificity of 64.6%, the sensitivity of 81.3%, the positive predictive value of 56.4%, and a negative predictive value of 86% in the determination of tubal obstruction. CONCLUSION: Patients with suspected tubal infertility can primarily be examined using hysterosalpingography in consideration of the invasive nature and the higher complication rate of laparoscopy.

The long-term costs and effects of tubal flushing with oil-based versus water-based contrast during hysterosalpingography.

RESEARCH QUESTION: What are the long-term costs and effects of oil- versus water-based contrast in infertile women undergoing hysterosalpingography (HSG)? DESIGN: This economic evaluation of a long-term follow-up of a multicentre randomized controlled trial involved 1119 infertile women randomized to HSG with oil- (n = 557) or water-based contrast (n = 562) in the Netherlands. RESULTS: In the oil-based contrast group, 39.8% of women needed no other treatment, 34.6% underwent intrauterine insemination (IUI) and 25.6% had IVF/intracytoplasmic sperm injection (ICSI) in the 5 years following HSG. In the water-based contrast group, 35.0% of women had no other treatment, 34.2% had IUI and 30.8% had IVF/ICSI in the 5 years following HSG (P = 0.113). After 5 years of follow-up, HSG using oil-based contrast resulted in equivalent costs (mean cost difference -€144; 95% confidence interval [CI] -€579 to +€290; P = 0.515) for a 5% increase in the cumulative ongoing pregnancy rate compared with HSG using water-based contrast (80% compared with 75%, Relative Risk (RR) 1.07; 95% CI 1.00-1.14). Similarly, HSG with oil-based contrast resulted in equivalent costs (mean cost difference -€50; 95% CI -€576 to +€475; P = 0.850) for a 7.5% increase in the cumulative live birth rate compared with HSG with water-based contrast (74.8% compared with 67.3%, RR 1.11; 95% CI 1.03-1.20), making it the dominant strategy. Scenario analyses suggest that the oil-based contrast medium is the dominant strategy up to a price difference of €300. CONCLUSION: Over a 5-year follow-up, HSG with an oil-based contrast was associated with a 5% increase in ongoing pregnancy rate, a 7.5% increase in live birth rate and similar costs to HSG with water-based contrast.

Hysterosalpingographic findings in primary and secondary infertility patients.

OBJECTIVES: To highlight and compare spectrum of hysterosalpingography (HSG) findings in primary and secondary infertility patients. Methods: This retrospective record-based cross-sectional study was performed in the Radiology Department, King Fahad Military Medical City, Dhahran, Kingdom of Saudi Arabia between August 2016 and 2018. All patients (N=303) who underwent successful HSGs were included, and grouped under primary and secondary infertility cases. Patients with failed, limited or incomplete studies were excluded. Imaging findings were documented as N (Normal) or Ab (Abnormal). Abnormal HSG findings were further categorized as: C=congenital malformation, I=infection or inflammation, S=surgery, T=tumor or tear. Abnormal findings were confirmed on further imaging or intervention. Chi-square test was used to determine any association of HSG findings with type of infertility, and p-value less than 0.05 was considered significant. Results: Of the 303 patients, 166 patients (54.8%) had primary infertility while the rest had secondary infertility. Abnormal studies were found in less than one-third of patients (n=93, 30.7%). Primary infertility patients exhibited more congenital (C) malformations, while surgery (S) was seen more in secondary infertility patients (p=0.01).  Conclusion: Congenital malformations are commonly found abnormalities on HSGs in primary infertility patients, while surgery related findings are seen in secondary infertility cases.

Diagnostic accuracy of Saline Infusion sonohystero-salpingography (SIS) as compared to Hystero-salpingography (HSG) in the assessment of sub-fertile women.

OBJECTIVE: To compare the sensitivity and specificity of saline infusion sonohysterography with hysterosalpingography as a diagnostic tool in the assessment of infertile women.. METHODS: The comparative cross-sectional study was carried out at a private infertility clinic in Karachi, and comprised women who registered for assessment of infertility from June 2011 to May 2013. Uterine and tubal pathology was assessed as a possible cause of infertility by using saline infusion sonohysterography as an index test and hystero-salpingography as the standard reference. The diagnostic accuracy of the two tests was compared. Sub-fertile patients were followed up for 2 weeks after the tests for any possible adverse effects of the procedures. Data was analysed using SPSS 19. RESULTS: Of the 256 subjects, 184 (72%) presented with primary and 72 (28%) with secondary infertility. Overall mean age of the sample was 28}8 years. The mean BMI was 29.8}4.1 in primary infertile compared to 28.2}.5 in women with secondary sub-fertility. The sensitivity of saline infusion sonohysterography for detecting patency of the tubes was 100% and the specificity was 91% whereas positive predictive value was 69.8% and negative predictive value was 100% (Kappa: 0.61). For large uterine polyps, sensitivity and specificity was 100% and for small polyps sono-hystero-salpingography showed 14% false positive results (Kappa: 0.21). CONCLUSIONS: Saline infusion sono-hysterography was found to be a more reliable method of diagnosing tubal or uterine pathologies compared to hystero-salpingography for cases of infertility.

Hysterosalpingosonography Is Not as Effective as Hysterosalpingography to Increase Chances of Pregnancy.

OBJECTIVE: This study sought to examine whether hysterosalpingosonography (sono-HSG) is as effective as hysterosalpingography (HSG) in facilitating conception by comparing pregnancy rates in the 6 months following the procedures. METHODS: This retrospective noninferiority study (Canadian Task Force classification II-2) was conducted at a tertiary university centre. The investigators studied 440 consecutive eligible infertile women. Bilateral tubal occlusion, severe male infertility, and having undergone both procedures were exclusion criteria. Tubal testing, as part of the infertility workup, was performed by either sono-HSG or HSG. The primary outcome was pregnancy, defined as a positive fetal heartbeat on ultrasonographic examination, in the 6 months following the procedure. RESULTS: A total of 57 pregnancies (26%) were observed in the HSG group and 33 (15%) in the sono-HSG group. Adjusted and non-adjusted relative risks of pregnancy in the 6 months following sono-HSG compared with HSG were 0.61 (95% CI 0.42-0.89) and 0.58 (95% CI 0.39-0.85). Adverse events were infrequent with both procedures (sono-HSG, 1%; HSG, 4%; P = 0.16). CONCLUSION: This study suggests that uterine flushing as performed during sono-HSG is not as effective as when performed during HSG to increase the chances of pregnancy, but further studies will be required because of bias related to the retrospective study design.

Hysterosalpingography in infertility investigation protocol: is it still useful?

PURPOSE OF INVESTIGATION: to assess the radiological findings of women undergoing hysterosalpingography (HSG) as initial infertility investigation protocol. MATERIALS AND METHODS: A retrospective study on infertile women who underwent HSG at Institute of Radiology of Sassari University, Italy. RESULTS: The present case series included 2,845 HSG, performed from January 1997 to March 2014. The age of the patients ranged from 20 to 48 years. The negative exams (tubal patency) were 2,039 out of 2,845 (71.67%). CONCLUSION: A technique of diagnostic imaging for the evaluation of infertility should be non-invasive, not expensive, rapid, of simple execution, and also be able to provide information on tubal patency and pelvic diseases. For these reasons, HSG today remains a useful diagnostic investigation tool in the diagnostic work-up of infertile patients.

Hysterosalpingocontrast sonography (HyCoSy): evaluation of the pain perception, side effects and complications.

BACKGROUND: Tubal and uterine cavity diseases commonly compromise female fertility. At the present time, hysteroscopy, laparoscopy with chromopertubation and RX-Hysterosalpingography (RX-HSG) are widely accepted screening procedures enabling the effective assessment of both tubal patency and uterine cavity. Nevertheless, consistent evidence supports the reliability of Hysterosalpingocontrast sonography (HyCoSy) in uterine cavity and tubal patency investigation, as a part of the standard infertility work-up. This prospective study was aimed at evaluating the tolerability of the technique as well as the incidence of related side effects and complications in a large series of infertile patients. METHODS: Pain perception of 632 infertile women was measured by means of an 11-point numeric rating scale. Side effects and late complications were also recorded. RESULTS: The mean numeric rating scale was 2.15 ± 2.0 SD. Most of the patients (374/632, 59.17%) rated HyCoSy as a non-painful procedure, whereas 24.36% (154/632) women reported mild pelvic pain and 9.96% (63/632) classified the discomfort as "moderate". Only 6.48% (41/632) of the patient population experienced severe pelvic pain. Fifteen (2.37%) patients required drug administration for pain relief. Twenty-six patients (4.11%) showed mild vaso-vagal reactions that resolved without atropine administration. No severe vaso-vagal reactions or late complications were observed. CONCLUSIONS: HyCoSy is a well-tolerated examination and the associated vagal effects are unusual and generally mild. Consequently, we support its introduction as a first-line procedure for tubal patency and uterine cavity investigation in infertile women.

Rate of detection of unsuspected pregnancies after implementation of mandatory point-of-care urine pregnancy testing prior to hysterosalpingography.

PURPOSE: The aim of this study was to determine the rate of detection of unsuspected pregnancies after the implementation of mandatory point-of-care urine pregnancy testing before hysterosalpingography (HSG). METHODS: At the authors' institution, HSGs are scheduled to occur during days 8 to 12 of the menstrual cycle. Upon arrival in the radiology department, all women undergo point-of-care urine pregnancy testing before HSG (at a cost of $1.25 per test). Urine pregnancy test results were retrospectively reviewed. RESULTS: Four hundred ten women (mean age, 25.9 years; range, 22-50 years) underwent point-of-care urine pregnancy testing before HSG between October 2010 and July 2012. Study indications were infertility evaluation (90.7% [372 of 410]) and tubal patency assessment after placement of tubal occlusive devices (9.3% [38 of 410]). Two positive urine pregnancy test results (0.5%) were recorded. One positive result was deemed a false-positive because the patient had received an intramuscular injection of ß-human chorionic gonadotropin before the scheduled HSG, and follow-up laboratory testing showed declining ß-human chorionic gonadotropin levels. The second positive result was a true-positive, and the patient was determined to be 4.5 weeks pregnant on the date of the scheduled HSG. CONCLUSIONS: One of 410 women presenting for HSG was found to have an unsuspected early pregnancy, which was detected with a point-of-care urine pregnancy test. Consideration should be given to routine pregnancy testing of women before HSG because scheduling on the basis of menstrual cycle dates can be unreliable.

CT appearance of the pelvis after Cesarean delivery--what is considered normal?

OBJECTIVE: To describe the normal computed tomography (CT) appearance of the pelvis after uncomplicated Cesarean section (C-section). PATIENTS AND METHODS: Pelvic CT examinations of 31 patients after uncomplicated C-section were reviewed. RESULTS: Higher postoperative day (POD) correlated well with decreases in the uterine long axis and endometrial width but did not correlate to scar width. Full thickness defect of the uterine wall was revealed in 48% of patients. Small volumes of intrauterine gas presented in half of patients at POD 1-26. Free pelvic fluid appeared in 74%. Pelvic collections were rare and small. CONCLUSION: There is wide variability in pelvic CT appearance following uncomplicated C-section.

What are the factors predictive of hysterosalpingogram compliance after female sterilization by the Essure procedure in a publicly insured population?

To determine what factors are predictive of post-Essure hysterosalpingogram (HSG) compliance. We conducted a retrospective chart review of all patients who underwent the Essure procedure at the two campuses of the Truman Medical Center, Kansas City, Missouri, from January 1, 2005 through December 31, 2010. Our study population consisted primarily of women who were publicly insured (89.0 %) and unmarried (76.7 %). Of 132 patients referred for HSG, 70 (53.0 %) complied. In adjusted analyses women 35 years and older had an almost fourfold higher odds of HSG compliance (OR = 3.72, 95 % CI 1.35-10.23) and women with 3 or more living children had a 64 % lower odds of HSG compliance (OR = 0.36, 95 % CI 0.16-0.82). Women younger than 35 who had 3 or more children had the lowest compliance rate (36.4 %) suggesting an interaction between age and parity. Women undergoing the Essure procedure at the campus with a dedicated protocol to ensure compliance had an almost fourfold higher odds of HSG compliance (OR = 3.67, 95 % CI 1.01-13.40). In a population consisting largely of publicly insured, unmarried women, several factors are predictive of post-Essure HSG compliance. These include age, parity and the presence or absence of an institutional protocol to keep track of patients after their Essure procedure.

The significance of laparoscopy in determining the optimal management plan for infertile patients with suspected tubal pathology revealed by hysterosalpingography.

The fallopian tube has numerous functions, including ovum pick-up, the place of fertilization of the ovum and cleavage of the embryo, and transfer of the embryo to the uterus. Tubal pathology impairs functions of the fallopian tube and reduces fertility. The degree of tubal pathology determines the possibility for fertility. The evaluation of the fallopian tube is necessary to determine the management plan of infertility. Hysterosalpingography (HSG) is often performed as a first line approach to assess tubal patency and the presence of adhesions; however, HSG has limitations in detecting tubal pathology. In the current study, we evaluated the significance of laparoscopy in determining the optimal management plan for infertile patients with suspected tubal pathology revealed by HSG. Between 1997 and 2009, 127 patients with suspected tubal pathology as demonstrated by HSG underwent laparoscopy at Kinki University Hospital, and a retrospective analysis was performed. Of 87 patients with unilateral tubal pathology revealed by HSG, 20 patients (23.0%) were given an indication for assisted reproductive technology (ART), based on the laparoscopic findings. Of 40 patients with bilateral tubal pathology revealed by HSG, 33 patients (82.5%) with bilateral tubal pathology detected by laparoscopy were given a high indication for ART. Laparoscopy enables exact evaluation of the fallopian tube and selection of the optimal management plan in infertile patients with suspected tubal pathology revealed by HSG. Therefore, laparoscopy should be performed in infertile patients with suspected tubal pathology revealed by HSG, as it is of diagnostic importance.

[Exploration of infertility: correlation hysterography hysteroscopy]. / Exploration de l'infertilité: Corrélation hystérographie hystéroscopie.

BACKGROUND: In literature, a uterine lesion in found in half of the infertile women. AIM: To compare the results of the hysteroscopy and the hysterosalpingography in the study of the uterine cavity as exploration of feminine infertility. METHODS: Retrospective study, over a period of four years from 1 January 2005 to 31 December 2008 however, on 140 cases of infertile patients explored in the gynecology obstetrics department in Mahmoud El Matri hospital. RESULTS: Compared with hysteroscopy, hysterography had an overall sensitivity of 76.56%, a specificity of 77.63%, a PPV of 74.24%, an NPV of 79.72% and a very strong correlation with coefficient of 0.83. Best correlations between the two examinations were found with polyps, fibroids and synechia. CONCLUSION: Hysterosalpingography remains the first line examination in the exploration of feminine infertility. However, hysteroscopy must be realized as a second examination in case of lesions found at the hysterography or at once in certain cases.

How to deal with double partial verification when evaluating two index tests in relation to a reference test?

Research into the diagnostic accuracy of clinical tests is often hampered by single or double partial verification mechanisms, that is, not all patients have their disease status verified by a reference test, neither do all patients receive all tests under evaluation (index tests). We show methods that reduce verification bias introduced when omitting data from partially tested patients. Adjustment techniques are well established when there are no missing index tests and when the reference test is 'missing at random'. However, in practice, index tests tend to be omitted, and the choice of applying a reference test may depend on unobserved variables related to disease status, that is, verification may be missing not at random (MNAR). We study double partial verification in a clinical example from reproductive medicine in which we analyse the diagnostic values of the chlamydia antibody test and the hysterosalpingography in relation to a diagnostic laparoscopy. First, we plot all possible combinations of sensitivity and specificity of both index tests in two test ignorance regions. Then, we construct models in which we impose different assumptions for the verification process. We allow for missing index tests, study the influence of patient characteristics and study the accuracy estimates if an MNAR mechanism would operate. It is shown that data on tests used in the diagnostic process of the same population are preferably studied jointly and that the influence of an MNAR verification process was limited in a clinical study where more than half of the patients did not have the reference test.

[Contribution of transvaginal ultrasound to hysterosalpingography in the etiological research on female infertility in Abidjan]. / Apport de l'echographie transvaginale associée a l'hystérosalpingographie dans la recherche etiologique de l'infertilité féminine a Abidjan (Côte d'Ivoire).

We performed hysterosalpingography (HSG) and transvaginal ultrasound (TVU) in 124 Ivorian women as part of an infertility evaluation. The aim was to investigate the causes of infertility and show the advantages of combining HSG and TVU as part of a comprehensive evaluation of infertility in African woman. TVU and HSG were normal in 35.5% of cases, while in 64.5% of cases, at least one disease was demonstrated. This included uterine pathology in 50.3%, tubal disease in 25.2%, ovarian pathology in 7.5% and peritoneal pathology in 7% of cases. Of all the diseases identified by the association HSG and TVU, 71.3% were found by TVU, while 61.5% were confirmed by HSG. TVU was more efficient in identifying uterine and ovarian pathologies while HSG excelled in tubal pathology. HSG and TUV had identical performances on the peritoneal pathology. The association HSG-ETV should be systematic in the full assessment of female infertility in sub-Saharan Africa.

Virtual hysterosalpingography: experience with over 1000 consecutive patients.

With the advent of multidetector computed tomography (MDCT), a whole new spectrum of diagnostic imaging techniques and procedures appears. Virtual hysterosalpingography (VHSG) is a novel non-invasive modality for assessing the uterus and female reproductive system that combines hysterosalpingography technique with MDCT technologies. Nowadays, 64-row VHSG offers an excellent diagnostic performance, in concordance with the development of new reproductive interventions and the need of accurate diagnostic procedures. In this article, we review the VHSG technique and describe normal and pathologic findings.

Sonohysterography: time to step up its use in gynaecologic imaging in West Africa.

Sonohysterography is a simple, safe and convenient technique that is easily and rapidly performed in the ultrasound room; yet the technique seems to be underutilized in West Africa. We present two cases that were successfully carried out in our centre followed by detailed description, uses and challenges of the technique, with the hope of encouraging clinicians and sonographers in the sub-region to step up its use. Two women were referred for evaluation of their endometrial cavities on account of increasingly heavy menstrual bleeding. Sonohysterography revealed intracavity uterine masses with hyper-echoic focal thickening highly suggestive of endometrial polyps; histology confirmed the diagnosis of endometrial polyps. Sonohysterography is an affordable and feasible diagnostic modality for evaluating the endometrial cavity. Where equipment and skill permit, the technique should be used more often in the West African sub-region. Sonohysterography, Tansvaginal sonography, Gnaecologic imaging, West Africa.

Hysterosalpingography in the evaluation of infertility: a five years review. (FGAE, 2001 -5).

BACKGROUND: Internal genital occlusion, mainly the fallopian tubes, secondary to pelvic inflammatory disease, is the most common causes of female infertility in sub-Saharan Africa and hysterosalpingography is a common diagnostic modality. OBJECTIVE: This was to discuss the findings of HSG and compare among primary and secondary infertility. PATIENTS AND METHODS: All infertility clinical records of five years (2001-2005) at FGAE central clinic were retrieved and those women who had undergone HSG procedure selected. The type and duration of infertility, socio-demographic factors and the recorded results of HSG were analyzed. RESULTS: Among the total of 8582 attendants of the infertility clinic, 96% were women and 4% males. HSG was undertaken on 1716 (21%) women. Secondary and primary infertility were 894 (53%) and 804 (47%) respectively. Addis Ababa residents were 84%; married 93%; house wives 61% and office workers were 25%. About 39% (n = 662) of the women came to the clinic for investigation after 30 years of age and 42% (n = 714) after five years duration of infertility. There were 55% (n = 934) with secondary and above level of education while 10% had no formal school. Normal HSG was 604 (36%); significantly more in primary than secondary (p = 0.0002). The uterine cavity was normal in 1253 (73%) of which 21% had bilateral tubal blockage while among the abnormal, 44% showed bilateral block (P = 0.0000000). Tubal abnormalities were significantly associated with the acquired uterine defects than that of the 2.8% congenital uterine abnormalities. Of the 847 (49%) bilateral tubal patency, 14% had luminal defects. Unilaterally patent tubes were demonstrated in 324 (19%) women: more in secondary type (p = 0.0001) without significant difference between the right and the left. Bilateral tubal obstructions were noted in 527 (31%) of which 25% were symmetrical and 6% asymmetrical. Of the blocked tubes, the sites were 60% terminal and 37% proximal. CONCLUSION: The review showed that most of the HSG were abnormal commonly tubal blockage: significantly more in secondary than primary infertility. End block was the commonest site and is associated with hydrosalpinx. The association of acquired uterine and tubal defects and secondary infertility is indicative of damage of internal genital tract following the previous pregnancies. Though applicable also to the primary infertility group, other infections (STI, TB) may contribute to the damage.

Filshie clip closure: determination of closure through the analysis of X-rays.

The Filshie method is a tubal occlusion method commonly used to prevent pregnancy. In medical negligence cases where it is suspected that closure of a Filshie clip may be faulty, lawyers may call on expert surgeons to assess whether or not a clip is closed on the basis of visual examination of the X-rays. However, it is not uncommon for experts to disagree. The aim of this work was to reduce the uncertainty in determining whether or not Filshie clips had been correctly closed. An estimate of the error in the estimate of the clip height was made by propagating measurement errors through a mathematical model. The effects of angle of presentation of the clip, digitisation of the image and resolution of the measurements were studied and the method was applied to two cases. The analysis indicated that measurement errors were least when the digitisation of the image was at 600dpi, angle of presentation of the clip was less than 40 degrees and the measurements could be made to an accuracy of +/-1pixel. Under these conditions it was possible to determine clip closure height with an error of less than +/-0.2mm.

Post-Essure hysterosalpingography compliance in a clinic population.

STUDY OBJECTIVE: To determine the follow-up rate for post-Essure hysterosalpingography (HSG) in a non-study, general clinic population in an urban environment. DESIGN: Retrospective chart review (Canadian Task Force classification II-2). SETTING: University teaching hospital. PATIENTS: Eighty-three University Health Center (UHC) patients who underwent attempted placement of the Essure permanent birth control device at the ambulatory surgery center at Hutzel Women's Hospital from January 2003 through June 2007. INTERVENTION: Hysteroscopic placement of the Essure permanent birth control device. MEASUREMENTS AND MAIN RESULTS: Placement of the Essure permanent birth control device was attempted in 83 patients, of which 79 were successfully completed (95.2%). Of the 79 patients, 10 underwent post-Essure HSG (12.7%). HSG was performed 3 to 6 months after placement of the Essure device. Bilateral tubal occlusion was documented in all 10 patients. CONCLUSION: Despite preoperative and postoperative counseling, the follow-up rate for post-Essure HSG for this clinic population was only 12.7%. For those in whom HSG was performed, bilateral tubal occlusion was confirmed in all. Steps or approaches to promote compliance with postprocedural confirmation of tubal occlusion should be utilized to improve future follow-up rates.