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“A COMPARATIVE STUDY OF THE ASSESSMENT OF TUBAL
PATENCY IN FEMALE INFERTILITY BETWEEN
MR HYSTEROSALPHINGOGRAPHY AND CONVENTIONAL
HYSTEROSALPHINGOGRAPHY WITH DIAGNOSTIC
LAPAROSCOPY AS GOLD STANDARD”
Dissertation submitted to
THE TAMILNADU Dr.M.G.R. MEDICAL
UNIVERSITY
In partial fulfillment of the requirements
of
M.D. DEGREE EXAMINATION
BRANCH – VIII– RADIODIAGNOSIS
KILPAUK MEDICAL COLLEGE
CHENNAI– 600 010
THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY
CHENNAI – TAMILNADU, INDIA
APRIL 2017
BONAFIDE CERTIFICATE
This is to certify that the dissertation entitled “A COMPARATIVE
STUDY OF THE ASSESSMENT OF TUBAL PATENCY IN
FEMALE INFERTILITY BETWEEN MR
HYSTEROSALPHINGOGRAPHY AND CONVENTIONAL
HYSTEROSALPHINGOGRAPHY WITH DIAGNOSTIC
LAPAROSCOPY AS GOLD STANDARD” is a bonafide original work
of Dr.M.S Fouzal Hithaya under the guidance of Dr.J.Devimeenal M.D.,
Professor of department of Radio diagnosis, Govt. Kilpauk Medical
College & Hospital, Chennai -10 in partial fulfillment of the regulations
for M.D RADIO DIAGNOSIS BRANCH VIII examination of the
TamilNadu Dr. M.G.R Medical University to be held in april 2017.The period
of postgraduate study and training is from 2014 to 2017.
PROF.J.DEVIMEENAL,
DMRD., MD.,DNB
Guide
Professor & Head of Department,
Department of RadioDiagnosis,
Govt Kilpauk Medical college & Hospital,
Kilpauk, Chennai - 600 010.
Prof. Dr.R.NARAYANA BABU,
M.D,DCH,
Dean,
Govt Kilpauk Medical college &
Hospital,
Kilpauk,Chennai - 600 010.
DECLARATION
I Dr.M.S.Fouzal Hithaya, solemnly declare that this
dissertation titled “A COMPARATIVE STUDY OF THE
ASSESSMENT OF TUBAL PATENCY IN FEMALE
INFERTILITY BETWEEN MR HYSTERSALPHINGOGRAPHY
AND CONVENTIONAL HYSTEROSALPHINGOGRAPHY WITH
DIAGNOSTIC LAPAROSCOPY AS GOLD STANDARD was
prepared by me at the Govt Kilpauk Medical College & Hospital,Chennai -
10, under the guidance and supervision of Dr. J.Devimeenal,Professor, Govt
Kilpauk Medical College &Hospital. This dissertation is submitted to The
Tamil Nadu Dr. M.G.R Medical University, towards partial fulfillment of
university regulations for the award of M.D branch VIII Radiodiagnosis.
Place: Chennai
Date: Dr.M.S Fouzal Hithaya
ACKNOWLEDGEMENT
I express my heartful gratitude to the Dean,
Prof.Dr.R.NARAYANA BABU,M.D.,DCH Govt Kilpauk Medical
College & Hospital,Chennai-10 for permitting me to do this study.
I express my gratitude to Prof. Dr. J.DEVIMEENAL,
D.M.R.D., M.D., DNB., Head of the Department, Govt Kilpauk medical
college &Hospital, for her valuable guidance in doing the dissertation
work.
I owe a lot to Prof. Dr. J.DEVIMEENAL, D.M.R.D., M.D.,
DNB., who is also my guide whose expert guidance, constant
encouragement created an interest for me to pursue this study on MR
hysterosalphingography. It is her constant supervision and support that
made me possible to finish this study without much difficulty.
I am extremely thankful to my Professors,
Dr.P.CHIRTARARASAN, M.D., Dr. K.GOPINATHAN, M.D.,DNB.,
and Assistant professors Dr.R.KANAGASABAI, D.M.R.D., M.D.,
Dr.V.SUDHAKAR, M.D., Dr. G.USHA NANDHINI M.D.,DNB.,
DR.G.ARUN DILIP M.D., Dr.S.SUMEENA,DMRD., D.N.B,
Dr.D.PORKODI, DMRD., DR.S.SENTHILKUMAR DMRD., in the
Govt Kilpauk Medical College for their constant support,
encouragement and advice during my study.
I am extremely thankful to Dr.T.K.SHANTHI GUNASINGH,
M.D., DGO., Prof. and HOD Department of Obstetrics and
Gynaecology, Kilpauk Medical College, for guiding and encouraging
me throughout the study.
I also thank my fellow postgraduates DR.P.PRASANNA and
DR. N.SUDHIR and junior postgraduates who helped me in carrying
out my work and preparing this dissertation.
I thank all Radiology technicians including Mr.VIJAY and
Mrs.GRACE MARY, Staff Nurses and all the Paramedical staff
members and workers including Mrs.JEYA in Department of
Radiology, for their co- operation in conducting the study.
I thank my husband Dr.BASHEER AHAMED, my parents
Mrs.& Mr. SYED MOHAMED, my sister HAMZA, daughter RIFA
SABURA for their understanding and co-operation in completion of
this work.
Last but not the least; I owe my sincere gratitude to the patients
and their relatives who co-operated for this study, without whom the
study could not have been possible.
INDEX
Sl.No. CONTENTS PAGE
1 INTRODUCTION 1
2 AIMS AND OBJECTIVES 3
3 REVIEW OF LITERATURE 4
4 MATERIALS AND METHODS 36
5 CASES 42
6 STATISTICAL ANALYSIS AND RESULTS
RRESRESULTS
52
7 DISCUSSION 77
8 CONCLUSION 84
9 BIBLIOGRAPHY
ANNEXURE:
ABBREVIATIONS
ETHICAL COMMITTEE APPROVAL
PLAGIARISM
PROFORMA
CONSENT FORMS
MASTER CHART
INTRODUCTION
The World Health Organization defines infertility as “ A disease of the
reproductive system defined by the failure to achieve a clinical pregnancy after
twelve months or more of regular unprotected sexual intercourse”(1). .
Secondary infertility is defined as the inability to become pregnant, or to carry
a pregnancy to term, following a previous pregnancy or the birth of one or
more biological children.
The global prevalence of primary infertility is about 2% and secondary
infertility is 3 %( 2). The factors attributed to infertility are divided into male
and female factors. The female factors are classified into ovarian, uterine, tubal
causes. Tubal factors are the commonest factors contributing to 30 – 40% of
the cases (3).
Hysterosalphingography is the radiographic technique used in the
evaluation of uterus, fallopian tubes. It is used as the first line of investigation
in the evaluation of tubal factors in infertility (4). Sonosalphingography is yet
another technique used in the evaluation of tubal patency.
Although these techniques are feasible enough they are not without
pitfalls which include limited evaluation of congenital abnormalities of
uterus and extra uterine pathologies. Further more conventional
hysterosalphingography carries an unavoidable risk of exposure of the female
reproductive organs to radiation in young and potentially fertile women.
Most of the women undergoing conventional hystersalphingography
further require transabdominal and transvaginal ultrasound for further
anatomical details and identification of pathologies.
MRI of pelvis is the investigation of choice, because of its spatial and
contrast resolution in defining the anatomy as well as the pathologies of the
female reproductive tract as a whole. MRI well delineates the possible
abnormalities in the reproductive organs including congenital abnormalities,
myomas, endometriosis, ovarian cysts, polycystic ovaries etc.
MR hysterosalphingography (5) is a novel evolving technique that is
aimed at evaluating the tubal patency. Having the inherent advantage of
imaging the pelvis, MR hysterosalphingography is an innovative tool in female
infertility evaluation.
MR hysterosalphingography may be used as a single stop investigation
in detecting uterine, ovarian and tubal pathologies(6). There is no risk of
exposure of reproductive organs to radiation. MR hysterosalphingography as a
single investigation avoids the young women from undergoing a series of
varying investigations.
MR hysterosalphingography is a novel technique with very few pioneer
studies conducted at national as well as international levels. This prospective
study being done at Kilpauk Medical College is considered about the
introduction of this novel technique, designing the methodology of doing it,
and evaluating its diagnostic accuracy, thereby incorporating it in the infertility
evaluation protocol in the near future.
This study’s chief objective is to assess the feasibility and efficacy of
MR hysterosalphingography in identifying tubal patency in female infertility.
AIM
To assess tubal patency in female fertility using dynamic MR
hysterosalphingography
OBJECTIVES
1. To assess the efficacy of dynamic MR hysterosalphingography in
identifying tubal patency in female infertility.
2. To directly compare the results of dynamic MR
hysterosalphingography with conventional hysterosalphingography
with diagnostic laparoscopy as gold standard.
REVIEW OF LITERATURE
ANATOMY OF FEMALE REPRODUCTIVE SYSTEM
The female reproductive organs are divided into internal and external
organs. The internal organs include uterus with a pair of fallopian tubes and a
pair of ovaries (7).
The uterus is a hollow, firm, thick walled muscular organ. It is the child
bearing organ. It is situated in the pelvis, anteriorly is the urinary bladder and
posteriorly is the rectum. The adult uterus has the shape of an inverted pear. It
measures approximately 7.5 cm (superoinferior), 5cm (transverse), 2.5 cm
(antero posterior). It weighs about 30 – 40 grams.
PARTS OF THE UTERUS
The uterus has two parts: body and cervix. The body is the upper
expanded portion and forms upper two thirds whereas the cervix is the lower
cylindrical portion which forms the lower one third of the organ. The
constriction situated between the body and cervix is called the isthmus.
POSITION OF UTERUS(8)
VERSION
Version is defined as the angle formed between the long axis of the
uterine body with the long axis of the vagina in sagittal plane. Normally the
uterus is anteverted and the angle of version is 90o and open forwards. When
the uterus is retroverted, the body of the uterus is tilted posteriorly.
FLEXION
Flexion is defined as the angle between the long axis of the uterus with
the cervix. Normally the uterus is anteflexed. The angle of anteflexion is 1250.
In retroflexed position, the uterus is flexed posteriorly. Normally the uterus is
anteverted and anteflexed such that the long axis of uterus corresponds to the
pelvic inlet and the long axis of vagina corresponds to the pelvic outlet.
Angle of anteversion
Angle of anteflexion
BODY OF UTERUS: (9,10)
Body of the uterus has Fundus, anterior/ vesical surface, posterior/
intestinal surface and two lateral borders.
Fundus: Forms the convex dome of the uterus. It lies above the level of
openings for fallopian tubes.
Anterior surface: Flat and is related to the urinary bladder. Forms
posterior border of vesicouterine pouch.
Retroverted, Anteflexed
Retroverted, Retroflexed
Anteverted, Anteflexed
Anteverted, Retroflexed
Posterior surface: Is convex and related to the bowel loops. Forms
anterior border of rectouterine pouch or Pouch of Douglas.
Lateral border: Rounded and convex. Gives attachment to the broad
ligament which attaches it to the lateral pelvic wall.
Uterine cavity: Uterine cavity is slit like and is compressed
anteroposteriorly. It is triangular in shape with base upwards and apex
downwards. At the superolateral angles the cavity becomes continuous with the
fallopian tubes on either sides through the cornua. At the apex the cavity
becomes continuous with the cervical canal through the internal os.
Layers of uterus
1. Endometrium: The inner mucosal layer is specialized for menstrual and
reproductive function
2. Myometrium: Muscular layer that forms the uterine volume. It is divided
into outer myometrium and inner myometrium. The inner myometrium is
called the junctional zone (11) and normally measures < 8mm. It is made up of
tightly packed compact smooth muscles with little amount of water content and
extra cellular matrix.
3. Perimetrium: Outer serosal layer.
CERVIX
Cervix is the lower cylindrical part of uterus. It measures approximately
2.5 cm in length. The lower part of cervix projects into the vagina which
divides the cervix into two parts:
1. Supravaginal part
2. Vaginal part
Supravaginal part: Anteriorly related to the urinary bladder, separated
by parametrium made of fibrous tissue, posteriorly covered by the peritoneum
which reflects over the rectum forming the recto uterine pouch containing
small bowel loops, laterally extends the parametrium containing the ureters and
uterine arteries(12).
Vaginal part: The vaginal part projects anteriorly into the vagina.
Fornices are the spaces between the cervix and vaginal wall. There are anterior,
posterior and two lateral fornices.
Cervical canal: The cervical canal is fusiform in shape. It
communicates above with the uterine cavity through the internal os and below
opens into the vagina through the external os. The external os is bounded by
anterior and posterior lips. The walls have multiple mucosal folds called arbora
vitae uterine because they arborise like branches of a tree. These mucosal folds
interlock with each other so that the cavity is closed.
FALLOPIAN TUBES
Also called the uterine tubes. They are paired structures that extend
laterally from the cornua and open into the peritoneal cavity via the fimbrial
ends. The fallopian tube is 10 – 12 cm in length and 1 – 4 mm in diameter. It
bridges between ovaries laterally and uterus medially.
PARTS
1. Interstitial / Intramural segment: situated within the myometrium.
2. Isthmus: lateral to it the isthmus which is the narrowest segment, about
2 – 3 cm in length.
3. Ampulla: widest part , about 4 mm in diameter, 6 – 7 cm in length
4. Infundibulum: funnel shaped lateral end of the tube which contains
multiple finger like processes called fimbriae. Ovarian fimbria is the one
which is the longest and is attached to the ovary.
OVARIES
A pair of female gonads, situated within ovarian fossa which lies in the
posterior wall of true pelvis. Each ovary is ovoid in shape and measures
approximately 1.5 x 3cm and weighs 2 – 8 grams. The central part is the
medulla and outer is the cortex. Ovarian follicles are situated within the stroma
of the ovarian cortex. The follicles are in varying stages of development and
degeneration.
BLOOD SUPPLY
UTERINE ARTERY
Arises from the anterior division of the internal iliac artery. It crosses the
ureter anteriorly and it traverses through the broad ligament and ends by
anastamosing with the ovarian artery.
BRANCHES
Arcuate arteries to uterus: Arcuate arteries divide into radial arteries
which in turn penetrate the myometrium. At the endometrial level they divide
into basal and spiral arteries.
Tubal branch, Ovarian branch, Vaginal branch, Branch to round
ligament are the other branches.
OVARIAN ARTERY
Anterolateral branch from the abdominal aorta inferior to the level of
renal artery and superior to the level of inferior mesenteric artery. Supplies
ovary, fallopian tube and ends by anastamosing with ovarian branch of uterine
artery.
VENOUS DRAINAGE
Uterine veins drain into internal iliac veins.Right ovarian vein drains
into inferior vena cava. Left ovarian vein drains into left renal vein.
NERVE SUPPLY
UTERUS: Supplied by branches from ovarian and hypogastric plexuses,
third and fourth sacral nerves.
OVARY: Ovarian plexus is formed by branches from aortic, renal,
superior hypogastric and inferior hypogastric plexuses.
SUPPORTS OF UTERUS (13)
BROAD LIGAMENT
Formed by two layers of the peritoneum that drape over the uterus and
extend to the lateral pelvic walls on either sides from the uterus.
Upper margin is formed by fallopian tubes medially and laterally is the
suspensory ligament of ovary. Lower margin ends in the cardinal ligament.
Between the leaves of broad ligament is parametrium which is formed by extra
peritoneal connective tissue and fat. Broad ligament encloses the round
ligament, ovarian ligament, ovarian and uterine blood vessels, nerves and
lymphatics.
ROUND LIGAMENT
Band of fibromuscular tissue extending from the anterolateral aspect of
uterine fundus takes a curved course, runs in inguinal canal to end in labia
majora.
CARDINAL/ TRANSVERSE CERVICAL/ MACKENRODT’S
LIGAMENT
Extends from the cervix, upper vagina laterally to blend with fascia
covering obturator internus muscle. Its is the major supporting structure.
UTEROSACRAL LIGAMENT Extends posteriorly from the cervix and
vagina at the level of internal os and curves towards the anterior body of
sacrum at S2, 3 level.
OVARIAN LIGAMENT Extends laterally from the uterus to the ovaries.
SUSPENSORY LIGAMENT OF OVARY
Extends from anterolateral aspect of ovary and blends with fascia
covering psoas muscle.
Cross sectional image showing the relationship of uterine body, ovaries
with broad, round ligaments.
EMBRYOLOGY OF UROGENITAL SYSTEM
The urogenital system is derived from the intermediate mesoderm(14,15)
from which develop the kidneys, gonads, reproductive and urinary tract.
Mesonephric or Wolffian duct develops and the ureteric bud branches from the
caudal end of Wolffian duct(16).Adjacent to the mesonephric duct develops the
paramesonephric duct or the Mullerian duct.
After sex determination the hormones – testosterone, anti mullerian
hormone(AMH), Insulin-like 3 (Insl3)(17) trigger the regression of Mullerian
duct and stimulate the development of male genital tract. In female fetus the
absence of these hormones stimulate the development of female reproductive
system from the Mullerian duct and the regression of the Wolffian duct.
From 6th to 11th week of gestation fusion of the paired Mullerian ducts
occur resulting in formation of uterus with cervix and also proximal 2/3rd of
the vagina. Bilateral fallopian tubes are formed from the unfused uppermost
part of the paired Mullerian ducts. The central uterovaginal septum gets
absorbed by 9- 12 weeks, failure of which results in persistence of intrauterine
septum.
The ovaries are developed from the primitive yolk sac and lower 1/3 rd
of vagina is developed from the sinovaginal bulb which explains why these
anomalies are not commonly associated with Mullerian duct anomalies.
Widespread classification of Mullerian duct anomalies is given by
American Society of Reproductive Medicine (previously called as American
Fertility Society AFS ) in 1998 (18).
The European Society of Human Reproduction and Embryology
(ESHRE) (19) and European Society for Gynaecological Endoscopy improvised
the classification system.
Advantages of the new ESHRE/ ESGE classification:
Anatomy as the primary basis and embryology as the secondary
characteristic, user friendly, clear and accurate.
The prevalence of Mullerian duct anomalies is reported to be 0.16 – 10
% (20)
AMERICAN FERTILITY SOCIETY CLASSIFICATION
CLASS TYPE
I – MULLERIAN
AGENESIS OR
HYPOPLASIA
A- Vaginal
B- Cervical
C- Fundal
D- Fallopian
E- Combined
II – UNICORNUATE
UTERUS
A – Communicating rudimentary
horn with endometrial cavity
B – Noncommunicating rudimentary
horn with endometrial cavity
C - Rudimentary horn without
endometrial cavity
D - No rudimentary horn
III – UTERUS DIDELPHYS
IV- BICORNUATE
UTERUS
A – Complete
B - Partial
V – SEPTATE UTERUS A – Complete
B - Partial
VI – ARCUATE UTERUS
VII – DIETHYL
STILBESTEROL RELAED
ESHRE CLASSIFICATION
CLASS SUBCLASS
0 - NORMAL
I – DYSMORPHIC UTERUS a.T shaped
b.Infantile
II- SEPTATE UTERUS a.Partial
b.Complete
III – DYSFUSED UTERUS a.Partial
b.Complete
IV- UNILATERALLY FORMED a.Rudimentary horn with
cavity (Communicating/ Non
communicating)
b.Rudimentary horn without
cavity/ apalsia
V- APLASTIC/ DYSPALSTIC a.Rudimentary horn with
cavity (unilateral/ bilateral)
b. Rudimentary horn without
cavity (unilateral/ bilateral)/
aplasia
VI – UNCLASSIFIED
CO EXISTENT SUBCLASS CERVICAL/ VAGINAL ANOMALY
Cervix:
C0 – Normal
C1 – Septate
C2 – Double normal
C3 – Unilateral aplasia/
Dysplasia
C4 – Aplasia/ Dyspalsia
Vagina:
V0 – Normal
V1 – Longitudinal nonobstructing septum
V2 – Longitudinal obstructing septum
V4 – Transverse septum/ imperforate hymen
V5 – Vaginal apalsia
INFERTILITY
Infertility is a major clinical problem affecting 10 – 15% of couples in
the reproductive age group. The tubal factors contribute to about 30 – 40 % of
the causes.
The tubal pathologies include blocked tubes, hydrosalphinx, tubo
ovarian mass.(21)
The ovarian pathologies include polycystic ovaries, ovarian cysts.
Endometriosis is yet another important cause of infertility.
EVALUATION OF INFERTILITY(22)
Recommended guidelines for practice in evaluation of infertility:
1. Confirmation of ovulation by S.Progesterone on Day 21 in a cycle of 28
days or 7 days prior to the presumed day of onset of menstruation.
2. Hysterosalphingography to screen for uterine and tubal abnormalities
after excluding active pelvic infections and endometriosis.
3. Women with body mass index > 30 kg/m2 should be advised to loose
weight as it may restore ovulation.
4. Ovulation induction/ intrauterine insemination not to be offered in
women with unexplained infertility as it has not shown to increase
pregnancy rates.
Hysterosalphingography is the first line of investigation offered to
women to rule out uterine and tubal pathologies. As opposed to invasive
procedures like laparoscopy , hysterosalphingography is a minimally invasive
procedure with therapeutic effects also, hence considered prior to other
procedures.
The varying methods to assess tubal patency are complementary to each
other and any single method is not mutually exclusive.(23)
TUBAL FACTOR
It is an established fact that when a dominant follicle in the ovary grows
to maturity, there occurs a surge of Luteinizing hormone (LH). The LH surge
results in rupture of the follicle and release of the ovum. The ovary is covered
by the fimbrial end of the fallopian tube similar to a ball held in the palm (24).
Stephan et al (24) reported that the fimbriae get distended and the fimbrial
vessels get engorged and sweep gently. The pulsatile movements of the
fimbriae are synchronous with the heart beat of the patient and slowly pull the
released ovum into the fallopian tube.
TECHNIQUES FOR ASSESSING TUBAL PATENCY
1. Conventional Hysterosalphingography
2. Sonohysterosalphingography
3. Magnetic Resonance Hysterosalphingography
4. Diagnostic laparoscopy
CONVENTIONAL HYSTEROSALPHINGOGRAPHY
Earlier called as Uterosalphingography, (25) was first introduced by
Heuser in 1924 in a paper titled, “The Clinical value of
Hysterosalphingography”. The paper was published in the third Pan American
Scientific Congress in Lima, Peru in December 1924. The contrast used at that
time was iodine in oil based solutions. In recent years the number of
hysterosalphingograms done have increased dramatically. This is attributed to
the advances made in assisted reproduction and advanced maternal age.(4)
TECHNIQUE (4)
No specific patient preparation is required prior to doing
hysterosalphingography. A nonsteroidal anti inflammatory drug is given one
hour prior to the procedure. The procedure is done between Day 7 – Day12 of
the menstrual cycle. The patient is advised to avoid sexual intercourse till the
day of procedure in the cycle. This is so as to avoid any minimal chance of
pregnancy. Moreover this is the period of proliferative phase during which the
endometrium is thinned out and this facilitates better interpretation of the
images. In patients with irregular menstrual cycles and suspicion of pregnancy,
beta hCG values are used in solving the mystery. Any risk of active pelvic
inflammatory disease is to be avoided by checking the erythrocyte
sedimentation rate (ESR).
The patient is made to lie supine in lithotomy or modified lithotomy
position. A 5 - F HSG catheter is placed in the cervical canal and the balloon
is inflated fully.
A scout radiograph is taken prior to the contrast administration. Water
soluble contrast material is administered into the uterine cavity. Fluoroscopic
images are taken intermittently to visualize the uterus and fallopian tubes.
Four spot radiographs are taken. The first radiograph is taken during
early filling of the endometrial cavity, to visualize any filling defects. The
second radiograph is taken when the uterine cavity is fully distended with
contrast. The third image corresponds to the fallopian tubes. The fourth image
is to be taken to look for intraperitoneal spill if any. Oblique views are taken to
avoid superimposition if any. Final image is taken after deflating the balloon so
as to look for the lower uterine segment.
Raymond et al (26) states that the high clinical value of
hysterosalphingography is due to the fact that it gives almost a perfect mold of
the cavities of cervix, uterus and lumen of fallopian tubes. Moreover it also
gives a permanent record. Such intricate details cannot be even given by
varying other modalities like bimanual examination, dilatation and curettage,
hysteroscopy and laparotomy. Many lesions not clinically suspected are
identified in hysterosalphingography.
a. Early filling, b. fully distended uterus, c. fallopian tubes showing interstitial,
isthmic, ampullary portions, d. intraperitoneal spill
Fallopian tubes in HSG
The fallopian tube appears as a 10 – 12cm long tubular structure
coursing along superior aspect of broad ligament. Radiographically three
segments are visible. The interstitial or cornual segment is short and traverses
the uterine musculature. The isthmic part is the longest and narrowest portion.
The ampullary part is the widest part near the ovary. The fimbriated portion is
the cone shaped end of fallopian tube and is not usually visualized in HSG.
The major advantages of hysterosalphingography are
(i) To diagnose intracavitory lesions
(ii) Fallopian tubal block and hydrosalphinx
(iii) Therapeutic effect of opening a blocked tube which is evidenced by
previously infertile women becoming pregnant after the procedure.
The major contraindications are:
(i) Active infection
(ii) Pregnancy
The major complications are:
(i) Minimal spotting lasting for less than 24 hours
(ii) Introduction of intrauterine infection. The risk of infection can be
prevented by the strict usage of sterile instruments and aseptic technique
(iii) Cramping pain. The pain is most severe during the time of inflation of
balloon in case of intrauterine catheter, and also when the uterine cavity
is distended with contrast material.The cramping pain is usually minimal
and transient and well tolerated by most of the patients
The other potential but rare complications include:
(i) Severe pain resulting in premature termination of the procedure due
to vasovagal reaction.
(ii) Systemic reaction to the contrast material if vascular intravasation
occurs, but lymphatic and vascular intravasation are supposed to be
clinically insignificant and not dangerous.
(iii) Perforation of uterus which is extremely rare and can be avoided by
skilled technique.
(iv) Risk of radiation exposure to the reproductive organs.
(v) Radiation exposure to an early unsuspected pregnancy, but it can be
avoided by proper timing of the examination and a negative
pregnancy test.
CONTRAST MEDIA
The use of oil based iodine solutions has multiple complications (27)
including edema of the fallopian tubes, and when spilled into the uterine cavity
cause adhesions with the adjacent organs. The use of oil based solutions has
become obsolete and now replaced by the use of water soluble contrast
media(28).
Boer et al (29) compared the pregnancy rate and quality of images in a
randomized control study in hysterosalphingography done using oil contrast
media and aqueous contrast media.
The oil contrast media used was Ethiodol, a mixture of fatty acids
obtained from poppy seeds. The aqueous contrast media used was a non ionic
low osmolar contrast media Iopamidol.
The oil contrast media provided a sharper image with more contrasting
image. The outline of uterine cavity was better delineated with oil contrast
media. However the ampullary folds were better defined using aqueous
contrast media. This is explained due to the lower iodine concentration in water
soluble media (30).
The water soluble media got dispersed in the peritoneal cavity within
10minutes which enables the control picture to be taken within 15 minutes. The
oil contrast media was reabsorbed from the peritoneal cavity only after two
hours which may persist even longer giving the chance of granuloma formation
and foreign body reaction within the peritoneal cavity.
There was no statistical difference in pregnancy rates following the two
procedures as against the increased pregnancy rate following oil based media in
studies conducted by Mackey et al and DeCherney et al (31, 32,33)
However Lindequist et al (34) and Rasmussen et al (35) reported that pain
during HSG after oil or water based media is the same but water based media
have increased rate of post procedure bleeding and infection.
Spring et al (36) in their prospective control study concluded no
significant difference in pregnancy rates following the use of varying contrast
media.
A well known complication of HSG is vascular or lymphatic
intravasation of contrast media. The incidence is reported to be about 6%. Use
of oil based contrast media can hence result in oil emboli ending up with
serious cardiovascular complications.
Notifying the risks and benefits water soluble contrast media is
considered preferable for HSG in day to day clinical practice.
CONTRAST INTRAVASATION
Intravasation (37) indicates the backward flow of the contrast media into
the adjoining veins. The contrast media passes from the endometrial cavity via
the myometrial veins into the draining pelvic veins, ovarian veins in particular.
The factors predominantly causing intravasation are the conditions
increasing endometrial vascularity and permeability. Few clinical examples
include menometorrhagia, endometriosis, urinary tract infections, and previous
history of uterine surgery. It is also noted to be seen with increased intrauterine
pressure because of tubal obstruction. Catheter cannulation and fixation
causing pain and discomfort to the patient may induce spasm and trauma
resulting in intravasation. The prevalence of intravasation is about 0.4 –
6.9%.Intravasation is classified into four levels (38) as follows:
1. Level 0: No intravasation
2. Level I: Minimal intravasation limited to myometrium
3. Level II: Moderate but slow intravasation into parametrial, adnexal
veins
4. Level III: Severe instant intravasation from myometrial, parametrial
veins into paracaval veins
Level I – Intravasation showing myometrial enhancement (m)
Level II – Opacification of myometrial veins extending to iliac veins
Level III intravasation – Bilateral tubal spill with instant intravasation
into pelvic veins
Intravasation is now of less clinical significance (39) with the use of
water soluble contrast media. Nevertheless the reporting radiologist must be
confident enough to differentiate it from intraperitoneal spill in tubal blockage.
Eliminating the predisposing factors and proper timing of the procedure and
technique can eliminate the intravasation.
CATHETER TYPE
There are multiple studies comparing the utility of balloon catheter vs
metallic cannula in performing hysterosalphingography.
Tur – Kaspa et al (40) in a prospective, blinded, randomised control study
compared the utility of balloon catheter vs metallic cannula in terms of pain,
time of the procedure.
The procedure using balloon catheter was statistically significant by
using lesser contrast media, lesser procedure time, less pain and discomfort to
the patient. However the quality of images were same with both the techniques.
The balloon catheter provides better seal at the level of internal os
thereby preventing reflux of contrast, faster and better visualisation of uterine
cavity, fallopian tubes. The increased intensity of pain with metallic cannula is
explained due to the tension applied by it on the cervix.
Mello et al(41) described in a prospective study that the intensity of pain
using balloon catheter, metallic cannula with paracervical block was
significantly less when compared to the traditional method of using metallic
cannula without any anaesthesia.
Shlomo et al (42) in a prospective study described that cervical vacuum
cup cannula causes significantly less pain, lesser procedure time, smaller
amount of contrast when compared with traditional metallic cannula.
Ubeda et al (43) described that introduction of air bubbles incidentally
may be mistaken for filling defects, polyps but identified by the fact that they
are well defined, mobile and can be flushed out of the tubes by further injection
of contrast. However introduction of air bubbles can be effectively prevented
by removing the air trapped within the cannula.
Moro et al(44) in a randomised controlled double blinded study evaluated
the effectiveness of antispasmodic drug hyoscine – N – butylbromide in
contrast enhanced sonohysterosalphingography. There was no statistical
difference in pain score between the hyoscine group and placebo group.
Aytekim et al (45) evaluated the effect of preprocedure anxiety on post
procedure pain scales and HSG outcomes. They identified that there was a
statistical significance in increase in pain intensity in patients with increased
preprocedure anxiety. But there was no statistical difference in tubal patency
between the two groups with lower and higher anxiety levels.
Maryam et al(46) evaluated the effect of anti axiety drug valerium in a
test group as against placebo group and identified significant reduction in post
procedure anxiety score in the test group.
ANTIBIOTIC PROPHYLAXIS
The 31st Royal College of Obstetricians and Gynaecologists Study
Group on the Prevention of Pelvic Infection recommended the use of following
antibiotics(47) after an intrauterine instrumentation procedure like
hysterosalphingography if not previously screened for Chlamydia.
Doxycycline 100 mg orally, twice daily for a week, Ofloxacin 400 mg
orally twice daily with Clindamycin 450 mg orally four times daily or
Metronidazole 500 mg orally twice daily, for a week.
DIAGNOSTIC ACCURACY OF HSG
According to Egle et al (48) the sensitivity and specificity of HSG in
identifying bilateral tubal occlusion is 89.5% and 90% respectively.
Adrian et al (49) followed up HSG results with laparoscopy,
hysteroscopy, fertility outcomes according to which HSG had false positivity
of 39%, and negative predictive value of 100%.
Bukar et al (50) in a retrospective study reviewed HSG images and
identified tubal pathologies in about 72% of the cases.
Chou et al (51) questioned the utility of HSG as the first line investigation
in female infertility stating the sensitivity and specificity as 53% and 85% and
introduced a new technique of Chlamydial antibody detection with similar
reliability as HSG and hence can replace it.
Vahdat et al (52) in a study evaluated that HSG had a sensitivity of
95.6%, specificity of 60%, PPV of 84.62%, and NPV of 85.71% in diagnosing
uterine malformations.
MRI PELVIS IN INFERTILITY
Though HSG is the mainstay and the initial imaging modality in
infertility evaluation, MRI is a useful adjunct since its introduction. MRI pelvis
because of its excellent tissue contrast helps in delineating pelvic anatomy and
pathologies as well in a detailed and descriptive way.
The commonly encountered pathologies in infertility(53) include (i)
congenital uterine anomalies, (ii) acquired uterine abnormlaities like fibroids,
(iii) extrauterine pathologies like adnexal cysts, endometriosis.
The sequences routinely used include (53) coronal T1 (TR 400-500ms, TE
20ms, slice thickness 10mm, gap 2mm, one acquisition), axial, sagittal, oblique
coronal T2 (TR 2000 – 2,500MS, TE 30 – 70ms, 3-5mm slice thickness,
0.5mm gap, FOV 28 -36CM, 256 pixels ) MRI depicts congenital uterine
abnormalities in a detailed manner including the features about cavity, septum,
external contour.
Uterus didelphys has widely separated uterine horns (intercornual
distance > 4cm) and two separate endometrial cavities, cervices, upper vagina
A fundal cleft > 1cm(54)is reported to be 100% sensitive and specific in
differentiating fusion anomalies (didelphys and bicornuate) from reabsorption
anomalies (septate and arcuate).
When the apex of the fundal contour is below or less than 5 mm above
a line drawn between the tubal ostia, the uterus is bicornuate. When the apex of
the fundal contour is more than 5 mm above a line drawn between the tubal
ostia, the uterus is septate.
The correct classification of Mullerian ductal anomalies is critical in
deciding on further surgical management which is achieved by MRI as it gives
better details about external uterine contour, endometrial, myometrial width
which is not provided by HSG (55).
Normal
Uterus didelphys
Bicornuate
Septate
MR HYSTEROSALPHINGOGRAPHY
The first MR hysterosalphingography trial dates back to 1996 when
Fred et al (56) evaluated its efficacy in 18 rabbit uterine horns. Five of the
fallopian tubes were ligated and 11 were left unaltered. 1 – 3ml of diluted
gadolinium contrast was injected via transvaginal catheter and T1 weighted
gradient images were taken before, during and after injection of contrast. It was
followed by conventional imaging with equal amount of iohexol and evaluation
was done by two radiologists blinded to the other study. Conventional HSG
correctly identified spill in all 11 cases and absence in all 5 cases. MRHSG
showed concurrent results in 14 of the 16 cases. Sensitivity and specificity of
MRHSG were 95.5% and 70% for tubal block. There was no statistical
difference between conventional HSG and MRHSG results.
Frye et al(57) in 2000 did a feasiblity study with a phantom simulating
uterus, fallopian tubes and surronding pelvic cavity. Container measuring 40 x
25 x 10cm was used to simulate uterus. The fallopian tube was 40cm long and
1mm inner diameter. The observations of the study were (i) the choice of
sequence was half Fourier RARE sequence which provide adequate temporal
resolution. (ii)The opitmal contrast agent was distilled water and (iii)quantity
was 5ml.
Weisner et al (58) in 2001 published a preliminary report on MRHSG
with a small sample size of 5. The sequences used were T1 SE, T2FSE and
angiographic sequences for 3D dynamic MRHSG. They concluded that
MRHSG is a feasible technique and further research is required to consider it
as an alternative technique to conventional HSG.
Sadowski et al (5) in 2008 did a prospective study on MRHSG using
dynamic time resolved T1weighted angiographic sequence - 3D TRICKS
using 2 sets of 1: 100 diluted gadodiamide in a sample size of 17 all of which
were preceeded by conventional HSG. The procedure could not be completed
in 1 patient. In 16 patients both MR and conventional HSG concurrently
showed bilateral block. Six tubes blocked on conventional HSG were patent on
MRHSG. Increased patency was thought to be due to the tubal block opened by
conventional HSG done prior to it. The increased sensitivity of MR to even
small amount of contrast was the other explanation given.
James (59) countered the Sadowsiki’s study in 2009 arguing that the
increased patency of MRHSG was not due to increased sensitivity of MRI but
rather due to the use plastic catheter instead of metallic cannula and its better
palcement yielded better tubal opacification.
Unterweger in 2002 (6) aimed at direct visualisation of fallopian tubes in
addition to patency by use of a specific higher viscosity contrast solution –
gadolinium mixed with polyvidone gel and compared the results with
conventional HSG in a sample size of 10. The direct visualisation of fallopian
tubes was possible in 5 cases. Eight out ot the 10 cases - six cases with bilateral
patency and 2 patients with unilateral block were concurrent with conventional
HSG results.
Winter et al (60) in 2010 tried a similar study in 37 patients using
Dotarem polyvidone in 1: 20 ratio. The procedure was abandoned in four of 37
patients due to dislodgement of catheter. 27 patients showed bilateral tubal
patency which was confirmed by laparoscopy.
De Feliche et al (61) considered MRHSG as a new promising tool in
infertility imaging and conducted a study with 16 patients to evaluate the
efficacy of MRHSG and to improvise the techniques. The average time period
was 25 – 30 minutes. 12/ 16 cases showed bilateral tubal patency .
Ma et al (62) conducted a MRHSG study with 20 infertile women and
compared it with previous HSG or laparoscopy results. Except for one case
with blocked tube in conventional HSG, MRHSG showed patency, the other
results were concurrent.
Cipolla et al (63) in 2016 did a study with 116 patients on 3T using time
resolved 3D sequence. Results were patency in 65%, unilateral block in 25%
and bilateral block in 9.8% and suggested MR with MRHSG as a single stop
shop investigation in infertility imaging.
DIAGNOSTIC LAPARSCOPY
Tshabu et al (64) did a comparative study of HSG with laparoscopy. The
concardance between the two in tubal block was about 47%. Only 5.2% of the
tubes patent at HSG were blocked in laparoscopy. The conclusions of the study
were that HSG is complementary to laparoscopy in infertility evaluation. HSG
has better reliability in diagnosing tubal patency than detecting tubal block.
Laparoscopy reveals out falsely blocked tubes at HSG and in addition picks up
endometriosis and pelvic adhesions.
Fatemeh et al (65) did a comparative prospective study on HSG followed
by laparoscopy as gold standard after an interval of 3 months. The sensitivity,
specificity, positive, negative predictive values, accuracy were 92.1%, 85.7%,
97.2%, 66.7%, 99.1% respectively.
Tsuji et al (66)evaluated the utility of diagnostic laparoscopy in patients
with normal hysterosalphingography findings. The study consisted of 54
patients. Laparscopy revealed pathologic findings in nearly 80% of the patients.
So the study concluded that diagnostic laparscopy is mandatory in all infertile
patients with normal hysterosalphingography prior to artificial reprouctive
techniques because of its proven diagnostic and therapeutic benefits.
MATERIALS AND METHODS
At our institution female patients presenting with infertility are
evaluated in Department of Obstetrics and Gynecology and then referred
to Department of Radio diagnosis for radiological evaluation.
Forty patients between age 20 – 40 yrs with primary or secondary
infertility were referred for evaluation of tubal patency. The patients were
first subjected to dynamic MR hysterosalphingography and subsequently
to conventional hysterosalphingography. Those with tubal block were
subjected to diagnostic laparoscopy as a part of further evaluation and to
confirm the tubal block.
The study was conducted after obtaining proper informed consent
from the patient. As this was a prospective controlled study, ethical
committee approval from Institutional Ethics Committee, Kilpauk
Medical College, was obtained.
INCLUSION CRITERIA
1. Age group : 20 – 40 yrs
2. Patients with primary infertility with failure to achieve a clinical
pregnancy after 12 months of unprotected sexual intercourse.
3. Patients with secondary infertility with failure to achieve a clinical
pregnancy after 12 months of unprotected sexual intercourse.
4. Postoperative evaluation of patients following reversal of tubal
ligation.
5. Recurrent spontaneous abortions
6. Day 7 – Day 12 of menstrual cycle (4)
EXCLUSION CRITERIA:
1. Menstruating females
2. Beyond Day 12 of menstrual cycle.(4)
3. Non consenting and unco-operative patients
4. Patients with active pelvic inflammatory disease
5. Patients with contraindications to MRI - pacemaker and cochlear
implants
STUDY DESIGN:
All the patients were advised to abstain from sexual intercourse
during the days after menstruation till the day of procedure so as to avoid
any chance of pregnancy during the procedure.
The procedure was commenced after obtaining informed consent
from the patient with detailed explanation of the procedure to be
undertaken. The patient was given oral mefanamic acid (65) three times a
day and a course of antibiotics (combination of ofloxacin and
metronidazole) as premedication starting on the day before and
continued two days post procedure.
The patient was asked to empty the bladder and made to lie in
lithotomy or modified lithotomy position in the lithotomy table. The
external genitalia was painted with povidone – iodine solution and draped
with sterile towels. Per vaginal examination was done to assess the
version, size of uterus.
Sim’s speculum was inserted into the vagina. The cervix was
cleansed with povidone – iodine gauze. The anterior lip of cervix was
held gently with a valsellum forceps. Uterine sound was inserted into the
uterine cavity to assess the length of the uterine cavity.
MRI compatible plastic Hysterosalphingogram 5 - F micro catheter
with inflatable bulb was inserted into the lower uterine cavity. The bulb
was inflated with 3 cc of distilled water. The guide wire was removed and
an empty 3ml syringe attached to the catheter. The speculum and
valsellum forceps were removed.
The patient was then shifted to MRI scan. 1.5 Tesla (GE) machine
was used. The following sequences were used:
1. T2 W Axial
TR: 7120 ms,
TE: 90 ms,
Flip angle 900
Slice thickness 5mm,
Matrix 256 x 256
2. T2W Coronal
3. T2 W Sagittal
4. T1 W Axial
TR: 740 ms,
TE: 13 ms,
Flip angle 900
Slice thickness 5mm,
Matrix 256 x 256
5. T1 Cube Coronal – 5 phases each phase scanning for 15 seconds..
TR: 3.8 ms,
TE: 1.8 ms,
TI: 7ms,
Flip angle 120
Slice thickness 3.4 mm,
Matrix 256 x 256
The first phase was imaged prior to saline infusion. 10 ml of 1 in
100 dilution of Gadodiamide (Omniscan GE Healthcare 0.5mmol/ml) in
0.9% saline was instilled and the successive phases were obtained.
4 successive phases were obtained demonstrating the endometrial
cavity, tubal patency/ block, peritoneal spill if any. Corresponding
subtracted images were generated automatically.
The patient was immediately mobilized to the Xray room. 10 ml of
iodinated contrast iohexol (Omnipaque GE Healthcare 350mg/ml)
instilled through the same catheter. Spot film was taken to look for
endometrial cavity, fallopian tubes, peritoneal spill if any. The balloon
was deflated and the catheter removed.
The patients with unilateral or bilateral tubal block were subjected
to diagnostic laparoscopy in their next cycle as a part of routine
subsequent evaluation and the findings were confirmed at the same time.
The patients with bilateral tubal patency were followed up after 3
months and if failed to conceive were subjected to diagnostic laparoscopy
as a part of further evaluation at department of Obstetrics and
Gynecology, KMC and the findings were confirmed during the
procedure.
Diagnostic laparoscopy was done in the Department of Obstetrics
and Gynecology by gynecologist. Methylene blue dye was used for
assessing the tubal patency. Direct visualization of spill into the
peritoneal cavity was done with laparoscope.
The results were tabulated. Statistical analysis was made
comparing the results of MRHSG, conventional HSG with diagnostic
laparoscopy as gold standard.
CASE : 1
30yrs old, P2L1, tubectomy done 5years back, post tubal reanastamosis status
Coronal T2W with balloon
catheter placed in situ just
beyond the level of internal
os
Coronal T1 CUBE Phase 1
image prior to the
instillation of 1: 100
gadodiamide in saline
Coronal T1CUBE Phase 2
image showing contrast
within the endometrial
cavity, absence of peritoneal
spill on both sides, reflux of
contrast in the vagina
Conventional HSG showing
uterine cavity, bilateral tubal
block
Subtracted images reformatted
showing contrast within
endometrial cavity and absence
of peritoneal spill, reflux of
contrast in the vagina
CASE: 2
31 years nullipara with previous history of two spontaneous first trimester
abortions
Axial and Sagittal T2W images showing balloon catheter
within the endometrial cavity
Coronal T1 CUBE Phase 2
image showing contrast
within uterine cavity and
bilateral fallopian tubes
Coronal T1 CUBE Phase 3
image showing contrast
within uterine cavity and
bilateral peritoneal spill
Subtracted images
reformatted showing
contrast within endometrial
cavity and bilateral
peritoneal spill
Conventional HSG showing
uterine cavity, bilateral
peritoneal spill
CASE : 3
24 years old, nullipara with previous history of two spontaneous first trimester
abortions
Axial T2 W images showing two uterine horns uniting at the level of internal
os with a single cervix. The external uterine contour is convex without
indentation – partial septate uterus. The cervix is deflected to the left.
Longitudinal vaginal septum
pulled out for better
visualisation
TI CUBE Phase 3 image
showing absence of
peritoneal spill on both
sides.
Conventional HSG
showing two uterine
horns, right fallopian tube
and right peritoneal spill
CASE : 4
24years nulligravida, married for 2 years
Axial T1, Coronal T2 W images showing balloon catheter within the
endometrial cavity with left ovarian cyst with areas of T1, T2
hyperintensities suggestive of haemorrhagic cysts
Subtracted reformatted image
showing bilateral tubal block
where as conventional HSG shows
right tubal spill and Type III
intravasation of contrast
CASE :5
35 yrs P1L1, last child birth 10years back for secondary infertility evaluation
Axial and Sagittal T2W images showing T2 hyperintense oblong
cystic lesion in right adnexa with few internal septations
mimicking right hydrosalphinx
Coronal T1 CUBE images Phase 2 showing left tube and
Phase 3 showing right tube and absence of peritoneal spill
Subtracted reformatted
images showing bilateral
tubes and distal block and no
peritoneal spill, refluxed
contrast in the vagina
Conventional HSG showing
bilateral fimbrial block and
no peritoneal spill
CASE :6
25 years P2L1, post tubal reanastamosis status
Coronal T2 W image with
balloon catheter in situ
Subtracted reformatted
image showing uterine
cavity
Subtracted reformatted image showing left tubal spill,
corresponding conventional image showing left tubal spill
STATISTICAL ANALYSIS AND RESULTS
TYPE OF INFERTILITY
TYPE OF INFERTILITY NO. OF CASES
PRIMARY 22
SECONDARY 18
TYPE OF SECONDARY INFERTILITY
CAUSES OF SECONDARY INFERTILITY NO. OF CASES
RECURRENT ABORTIONS 4
POST TUBAL REANASTAMOSIS 9
UNEXPLAINED 5
TYPE OF
OCCLUSION
NO. OF CASES
PROXIMAL 14
DISTAL 2
TOTAL 16
TYPE OF
INFERTILITY
MR HSG BLOCK
PATENT
TOTAL UNILATERAL BILATERAL
PRIMARY
0
5
17
22
SECONDARY
3
8
7
18
TOTAL
3
13
24
40
PRIMARY56%
SECONDARY -ABORTIONS
10%
SECONDARY -PTRA22%
SECONDARY -UNEXPLAINED
12%
INFERTILITY
TYPE OF
INFERTILITY
CONVENTIONAL HSG
BLOCK
PATENT
TOTAL
UNILATERAL BILATERAL
PRIMARY
1
4
17
22
SECONDARY
3
8
7
18
TOTAL
4
12
24
40
TYPE OF HSG
BLOCK
PATENT
TOTAL UNILATERAL BILATERAL
MR HSG
3
13
24
40
CONVENTIONAL
HSG
4
12
24
40
TYPE OF
HSG
BLOCK PATENT TOTAL
UNILATERAL BILATERAL
MR HSG
3
13
24
40
DL
7
9
24
40
TYPE OF HSG TUBES
BLOCKED
TUBES
PATENT
TOTAL
MRHSG 29 51 80
CONVENTIONAL HSG 28 52 80
DIAGNOSTIC
LAPAROSCOPY
25 55 80
NON TUBAL PATHOLOGIES NUMBER
UTERINE ANOMALIES 4
MYOMA UTERUS 2
POLYCYSTIC OVARIES 6
OVARIAN CYSTS 3
ENDOCERVICAL POLYP 1
POST TUBAL REANASTAMOSIS TUBAL STATUS
PATENT
U/L BLOCK
B/L BLOCK
0
1
2
3
4
5
6
7
8
PRIMARY INFERTILITY
SECONDARY INFERTILITY
PATENT
U/L BLOCK
B/L BLOCK
B/LBLOCK56%U/L BLOCK
22%
PATENT22%
0%
RIGHT TUBE: MR HSG - AGE GROUP
Crosstab
MR HSG RIGHT
PATENT BLOCK Total
AGE
GROUP
21-25 YEARS Count 11 4 15
% within MR HSG
RIGHT
42.3% 28.6% 37.5%
% of Total 27.5% 10.0% 37.5%
26-30 YEARS Count 7 5 12
% within MR HSG
RIGHT
26.9% 35.7% 30.0%
% of Total 17.5% 12.5% 30.0%
31 YEARS &
ABOVE
Count 8 5 13
% within MR HSG
RIGHT
30.8% 35.7% 32.5%
% of Total 20.0% 12.5% 32.5%
Total Count 26 14 40
% within MR HSG
RIGHT
100.0% 100.0% 100.0
%
% of Total 65.0% 35.0% 100.0
%
LEFT TUBE MRHSG AGE GROUP Crosstab
MR HSG LEFT
PRESENT BLOCK Total
AGE GROUP 21-25 YEARS Count 10 5 15
% within MR HSG LEFT 40.0% 33.3% 37.5%
% of Total 25.0% 12.5% 37.5%
26-30 YEARS Count 8 4 12
% within MR HSG LEFT 32.0% 26.7% 30.0%
% of Total 20.0% 10.0% 30.0%
31 YEARS & ABOVE Count 7 6 13
% within MR HSG LEFT 28.0% 40.0% 32.5%
% of Total 17.5% 15.0% 32.5%
Total Count 25 15 40
% within MR HSG LEFT 100.0% 100.0% 100.0%
% of Total 62.5% 37.5% 100.0%
RIGHT TUBE: MR HSG – YEARS AFTER MARRIAGE
Crosstab
MR HSG
RIGHT
PATE
NT
BLOC
K Total
MARITAL
HISTORY
GROUP
0-5
YEARS
Count 18 5 23
% within MR HSG
RIGHT
69.2% 35.7% 57.5%
% of Total 45.0% 12.5% 57.5%
6-10
YEARS
Count 4 6 10
% within MR HSG
RIGHT
15.4% 42.9% 25.0%
% of Total 10.0% 15.0% 25.0%
11-15
YEARS
Count 4 3 7
% within MR HSG
RIGHT
15.4% 21.4% 17.5%
% of Total 10.0% 7.5% 17.5%
Total Count 26 14 40
% within MR HSG
RIGHT
100.0% 100.0% 100.0%
% of Total 65.0% 35.0% 100.0%
LEFT TUBE: MR HSG – YEARS AFTER MARRIAGE
Crosstab
MR HSG LEFT
PATEN
T
BLOC
K Total
MARITAL
HISTORY GROUP
0-5
YEARS
Count 18 5 23
% within MR
HSG LEFT
72.0% 33.3% 57.5%
% of Total 45.0% 12.5% 57.5%
6-10
YEARS
Count 4 6 10
% within MR
HSG LEFT
16.0% 40.0% 25.0%
% of Total 10.0% 15.0% 25.0%
11-15
YEARS
Count 3 4 7
% within MR
HSG LEFT
12.0% 26.7% 17.5%
% of Total 7.5% 10.0% 17.5%
Total Count 25 15 40
% within MR
HSG LEFT
100.0% 100.0% 100.0%
% of Total 62.5% 37.5% 100.0%
RIGHT TUBE: MR HSG - POST TUBAL REANASTAMOSIS
Crosstab
MR HSG RIGHT
PATENT BLOCK Total
PTRA NO Count 23 8 31
% within MR HSG
RIGHT
88.5% 57.1% 77.5%
% of Total 57.5% 20.0% 77.5%
YES Count 3 6 9
% within MR HSG
RIGHT
11.5% 42.9% 22.5%
% of Total 7.5% 15.0% 22.5%
Total Count 26 14 40
% within MR HSG
RIGHT
100.0% 100.0% 100.0%
% of Total 65.0% 35.0% 100.0%
LEFT TUBE: MR HSG - POST TUBAL REANASTAMOSIS
Crosstab
MR HSG LEFT
PATENT BLOCK Total
PTRA NO Count 22 9 31
% within MR HSG
LEFT
88.0% 60.0% 77.5%
% of Total 55.0% 22.5% 77.5%
YES Count 3 6 9
% within MR HSG
LEFT
12.0% 40.0% 22.5%
% of Total 7.5% 15.0% 22.5%
Total Count 25 15 40
% within MR HSG
LEFT
100.0% 100.0% 100.0%
% of Total 62.5% 37.5% 100.0%
Right Tube: MRHSG Vs Xray HSG
MRHSG
XrayHSG
Positive
Negative
Total
Positive
13 1 14
Negative
0 26 26
Total
13 27 40
Parameter
Estimate (95% CI –
Wilson score)
Sensitivity
100%
Specificity
96.3%
PPV
92.86%
NPV
100%
Diagnostic
accuracy
97.5%
Left Tube: MRHSG Vs Xray HSG
Statistical test Value right Value left
McNemar 1.0 1.0
Kappa agreement 0.94 1.0
XrayHSG
MRHSG Positive Negative Total
Positive 15 0 15
Negative 0 25 25
Total 15 25 40
Parameter Estimate (95% CI – Wilson
score)
Sensitivity 100%
Specificity 100%
PPV 100%
NPV 100%
Diagnostic accuracy 100%
Right tube: MRHSG Vs DL
MRHSG
DL
Positive Negative Total
Positive
12 2 14
Negative
0 26 26
Total
12 28 40
Parameter
Estimate (95% CI – Wilson score)
Sensitivity
100%
Specificity
92.86%
PPV
85.71%
NPV
100%
Diagnostic accuracy
95%
Left tube: MRHSG Vs DL
MRHSG
DL
Positive Negative Total
Positive
13 2 15
Negative
0 25 25
Total
13 27 40
Parameter Estimate (95% CI – Wilson score)
Sensitivity 100%
Specificity 92.59%
PPV 86.67%
NPV 100%
Diagnostic accuracy 95%
Statistical test Value right Value left
McNemar 0.5 0.5
Kappa agreement 0.88 0.88
Right tube: XrayHSG Vs DL
XrayHSG
DL
Positive Negative Total
Positive
12 1 13
Negative
0 27 27
Total
12 28 40
Parameter
Estimate (95% CI – Wilson score)
Sensitivity
100%
Specificity
96.43%
PPV
92.31%
NPV
100%
Diagnostic accuracy
97.5%
Left tube: X-rayHSG Vs DL
XrayHSG
DL
Positive Negative Total
Positive
13 2 15
Negative
0 25 25
Total
13 27 40
Parameter Estimate (95% CI – Wilson score)
Sensitivity 100%
Specificity 92.59%
PPV 86.67%
NPV 100%
Diagnostic accuracy 95%
Statistical test Value right Value left
McNemar 1.0 0.5
Kappa agreement 0.94 0.89
Bilateral tubes: MRHSG Vs XrayHSG
MRHSG
XrayHSG
Positive Negative Total
Positive
28 1 29
Negative
0 51 51
Total
28 52 80
Parameter
Estimate (95% CI – Wilson score)
Sensitivity
100%
Specificity
98.08%
PPV
96.55%
NPV
100%
Diagnostic accuracy
98.7.5%
Bilateral tubes: MRHSG Vs DL
MRHSG
DL
Positive Negative Total
Positive
25 4 29
Negative
0 51 51
Total
25 55 80
Parameter Estimate (95% CI – Wilson score)
Sensitivity 100%
Specificity 92.73%
PPV 86.21%
NPV 100%
Diagnostic accuracy 95%
DISCUSSION
The study comprised of 40 patients with either primary or secondary
infertility referred from the department of Obstetrics and Gynecology for
hysterosalphingography. The study included women from 20 – 40 years. The
mean age of the patients was 24.8 years.
The study was completed in all 40 patients with good patient compliance
as against the previous studies in which it was abandoned in 1 out of 17
patients in study conducted by Sadowski et al(5) 4 out of 37 patients in study
conducted by Winter et al (60)
The patients with primary infertility were 22 in number constituting
56% of the sample size. The patients with secondary infertility were 18 in
number constituting 44% of the sample size. According to Tshabu et al (64), in
their study primary infertility was 66.3% and secondary infertility was 33.7%
of cases.
Among the patients with secondary infertility 4 patients (10%) had
previous history of recurrent abortions. 9 patients (22%) had history of
tubectomy and surgery done for reversal of tubal ligation. 5 of the patients
(10%) had infertility for unidentified causes.
MR HYSTEROSALPHINGOGRAPHY
Out of the 40 patients, 16 patients had tubal block either unilateral or
bilateral. 24 patients had bilateral patency. Of the 16 patients, 13 patients had
bilateral block and 3 patients had unilateral block. Considering the total number
of tubes studied in 40 patients 29 tubes were found to be blocked and 51 tubes
were patent.
In our study 60% of the patients had bilateral patency and 40% had
bilateral block which is similar to the study by Cipolla et al (63) in which 65%
had patent tubes, 35% had unilateral or bilateral block..
In the primary infertility group 17 of the 22 patients had bilateral tubal
patency. 5 patients had tubal block and all 5 were bilateral block.
In the secondary infertility group 7 of the 18 patients had patent tubes. 11
patients had tubal block of which 3 had unilateral block and 8 had bilateral
block.
Evaluating the right sided tubes with MR hysterosalphingography, 26
tubes (65%) were patent and 14(35%) were blocked. When classified according
to the age there were 15 patients in the age group of 20 -25 years, of which 11
tubes were patent and 4 were blocked. In the age group of 26 -30 years, there
were 12 patients of which 7 tubes were patent and 5 were blocked. In the age
group of 31 – 40 years, there were 13 patients of which 8 tubes were patent and
5 were blocked. Of the 35% of blocked right sided tubes 10% were in 20 – 25
years, 12.5% were in 26- 30years and 12.5% in 31- 40 years. There was no
statistically significant difference in tubal patency (p = 0.68) according to the
various age groups.
Evaluating the left sided tubes with MR hysterosalphingography 25
tubes (62.5%) were patent and 15(37.5%) were blocked. When classified
according to the age out of 15 patients in the age group of 20 -25 years, of
which 10 tubes were patent and 5 were blocked. In the age group of 26 -30
years, out of 12 patients 8 tubes were patent and 4 were blocked. In the age
group of 31 – 40 years, out of 13 patients 7 tubes were patent and 6 were
blocked. Of the 37.5% of blocked right sided tubes 12.5% were in 20 – 25
years, 10% were in 26- 30years and 15% in 31- 40 years. There was no
statistically significant difference in tubal patency (p = 0.73) according to the
various age groups.
When classified according to the years after marriage as three groups
from 1 – 5years, 6 -10 years, 11 – 15 years there were 23 patients in 1- 5 years
group, 10 patients in 6 – 10 years group and 7 patients in 11 – 15 years group.
Evaluating the right sided tubes with MR hysterosalphingography, out
of the 23 patients in 1- 5 years group 18 tubes were patent and 5 were blocked.
Out of the 10 patients in 6 – 10 years group 4 tubes were patent and 6 were
blocked. Out of the 7 patients in 11 – 15 years group 4 tubes were patent and 3
were blocked. There was no significant difference in tubal patency (p = 0.09)
considering age after marriage.
Evaluating the left sided tubes with MR hysterosalphingography, out of
the 23 patients in 1- 5 years group 18 tubes were patent and 5 were blocked.
Out of the 10 patients in 6 – 10 years group 4 tubes were patent and 6 were
blocked. Out of the 7 patients in 11 – 15 years group 3 tubes were patent and 4
were blocked. There was no significant difference in tubal patency (p = 0.05)
considering age after marriage.
There were 9 patients with post tubal reanastamosis status and 31
patients without such history. Evaluating the right sided tubes with MR
hysterosalphingography out of the 9 tubes, 3 tubes were patent and 6 were
blocked. Where as in the remaining 31 patients 23 tubes were patent and 8
were blocked. There was statistical difference in tubal patency (p = 0.02) after
reversal of tubal ligation.
Evaluating the left sided tubes with MR Hysterosalphingography out of
the 9 tubes, 3 tubes were patent and 6 were blocked. Of the remaining 31
patients 22 were patent and 9 were blocked. There was statistical significance
in tubal patency (p = 0.04) after reversal of tubal ligation in left sided tubes
also.
CONVENTIONAL HYSTEROSLAPHINGOGRAPHY
In conventional HSG group also there were 16 cases of tubal block
either unilateral or bilateral and 24 cases of tubal patency. But a case of
primary infertility which showed bilateral block in MR
Hysterosalphingography was found to have unilateral block in the conventional
method. It was the only case in which there was discordance between MR and
conventional methods. Whereas in all other cases the results were concordant
between MR and conventional hysterosalphingography.
Sadowski et al (5) in their study identified 6 tubes which were blocked in
conventional method were actually patent in MR hysterosalphingography due
to better resolution of MRI, but it was not accepted by James (59) stating that
the increased patency was only due to the plastic catheter instead of metallic
cannula. It was not a confounding factor in our study as the same catheter was
used in both MR and conventional HSG except in one case where the balloon
catheter was dislodged after MR hysterosalphingography and thus proceeded
conventional HSG with a metallic cannula.
Our results are also supported with the study conducted by Unterwerger
et al(6) in which 8 out of the 10 cases showed concordant results in both MR and
conventional HSG
DIAGNOSTIC LAPAROSCOPY
In diagnostic laparoscopy all patients with bilateral patency in MR and
conventional hysterosalphingography were found to be patent. Among the
patients with tubal block 7 had unilateral block and 9 had bilateral block.
6 patients with bilateral block in MR hysterosalphingography were
found to have unilateral block in diagnostic laparoscopy.5 patients with
bilateral block in conventional hysterosalphingography were found to have
unilateral block in diagnostic laparoscopy. The increased patency in diagnostic
laparoscopy might be attributed to the fact that the tubes were opened during
the previous two procedures as stated by Sadowski et al(5)
Our results are comparable with the study done by Winter et al(60) in
which 27 out of 33 patients had bilateral tubal patency and 1 out of 6 patients
with bilateral block was confirmed at laparoscopy. In the study by Winter et al
tubal cathetrisation was done in two patients and in three out of the remaining 6
patients with bilateral tubal block neither conventional HSG nor laparoscopy
could be done.
Considering individual tubes in 40 patients, the total number of tubes is
80.
In MR hysterosalphingography out of the 80 tubes, 51 tubes were patent
and 29 tubes were blocked.In conventional hysterosalphingography out of the
80 tubes 52 tubes were patent and 28 tubes were blocked.In diagnostic
laparoscopy out of the 80 tubes 55 tubes were patent and 25 tubes were
blocked.
The Kappa agreement between MR hysterosalphingography and
conventional hysterosalphingography was 0.94 for right sided tubes and there
was no statistical difference between the two procedures with McNemar test
value of 1. (Significant if value < 0.05). The Kappa agreement between MR
hysterosalphingography and conventional hysterosalphingography was 1.0 for
left sided tubes, and there was no statistical difference between the two
procedures (Mcnemar test value - 1.0). These statistical tests prove the high
degree of concordance between MR and conventional hysterosalphingography.
The Kappa agreement between MR hysterosalphingography and
diagnostic laparoscopy was 0.88, compared to the agreement between
conventional hysterosalphingography and diagnostic laparoscopy which was
0.94 for right sided tubes.The Kappa agreement between MR
hysterosalphingography and diagnostic laparoscopy was 0.88 compared to the
agreement between conventional hysterosalphingography and diagnostic
laparoscopy which was 0.89 for left sided tubes.
The sensitivity, specificity, positive predictive value (PPV), negative
predictive value (NPV), diagnostic accuracy of MR hysterosalphingography in
comparison to conventional hysterosalphingography were 100%, 98.08%,
100%, 96.5%, 98.75% respectively.
The sensitivity, specificity, positive predictive value (PPV), negative
predictive value (NPV), diagnostic accuracy of MR hysterosalphingography in
comparison to diagnostic laparoscopy were 100%, 92.73%, 86.21%, 1005,
95% respectively.
Fatemeh et al (65) in their study stated the sensitivity and specificity of
HSG in detecting bilateral tubal patency or tubal block is 92.1%, 85.7%
respectively. The positive predictive value, negative predictive value,
diagnostic accuracy were 97.2%, 66.7% and 91.1%.
The extra tubal factors identified in our study were 4 cases of congenital
uterine anomalies (1 bicornuate, 3 septate), 2 cases of myoma, 3 cases of
complex ovarian cysts,6 cases of polycystic ovaries and 1 case of endocervical
polyp. Sadowski et al (5) identified 3 cases of myomas, 2 cases of uterine
anomalies (1 arcuate, 1 partial septate), 1 hydrosalphinx, 1 endometrioma and 1
atrophic ovary.
CONCLUSION
MR hysterosalphingography is a novel upcoming investigation with
very few pioneering studies at both national and international levels. The study
is one of its kind exploring the utility and feasilbilty of HSG being done using
MRI.
MRHSG gives promising results as good as the age old investigation of
Xray HSG. In addition it picks up uterine and extra uterine pathologies
determining the management protocol in infertility. It also has the added
advantage of avoidance of radiation exposure to the potential reproductive
organs and use of highly diluted contrast.
MR hysterosalphingography incorporated in MRI of pelvis in infertility
protocol has a great way in the future.
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ABBREVIATIONS
1. HSG - Hysterosalphingography
2. MR HSG - Magnetic Resonance Hysterosalphingography
3. DL - Diagnostic Laparoscopy
4. T1W - T1 weighted
5. T2W - T2 weighted
6. TR - Time to repeat
7. TE - Time to Echo
8. A - Abortion
9. P1 - Para1
10. P2 - Para2
11. L - Live children
12. Nulli - Nullipara
13. RT - Right
14. LT - Left
15. P - Patent
16. B - Block
PROFORMA
STUDY TITLE:
“COMPARATIVE STUDY OF ASSESSMENT OF TUBAL
PATENCY IN FEMALE INFERTILITY BETWEEN MR
HYSTEROSALPHINGOGRAPHY AND CONVENTIONAL
HYSTEROSALPHINGOGRAPHY WITH DIAGNOSTIC
LAPARSCOPY AS GOLD STANDARD”
Sl.No:
Name :
Age/Sex :
Occupation :
Address :
Menstrual History:
Marital History:
Sexual history:
Obstetric history:
Surgical history:
FINDINGS:
MR HYSTEROSALPHINGOGRAPHY:
PATENCY RIGHT TUBE:
PATENCY LEFT TUBE:
OTHER FINDINGS:
CONVENTIONAL HYSTEROSALPHINGOGRAPHY:
PATENCY RIGHT TUBE:
PATENCY LEFT TUBE:
DIAGNOSTIC LAPAROSCOPY:
PATENCY RIGHT TUBE:
PATENCY LEFT TUBE:
Signature of Investigator Signature of the Participant
Witness:
INFORMED CONSENT FORM
Title of the study:” COMPARATIVE STUDY OF ASSESSMENT OF TUBAL
PATENCY BY MR HSG AND CONVENTIONAL HSG WITH DIAGNOSTIC
LAPAROSCOPY AS GOLD STANDARD”
Name of the Participant:
Name of the Principal (Co-Investigator):
Name of the Institution:
Name and address of the sponsor / agency (ies) (if any):
Documentation of the informed consent
I have read the information in this form (or it has been
read to me). I was free to ask any questions and they have been answered. I am over 18
years of age and, exercising my free power of choice, hereby give my consent
to be included as a participant in the study.
1. I have read and understood this consent form and the information
provided to me.
2. I have had the consent document
explained to me.
3. I have been explained about the
nature of the study.
4. I have been explained about my rights and responsibilities by
the investigator.
5. I have been informed the investigator of all the treatments I am taking or have
taken in the past months including any native (alternative) treatment.
6. I have been advised about the risks associated with my participation
in this study.*
7. I agree to cooperate with the investigator and I will inform him/her
immediately if I suffer unusual symptoms. *
8. I have not participated in any research study within the past
month(s). *
9. I have not donated blood within the past months(Add if the study
involves extensive blood sampling). *
10. I am aware of the fact that I can opt out of the study at any time without having to
give any reason and this will not affect my future treatment in this hospital. *
11. I am also aware that the investigator may terminate my participation in the study at
any time, for any reason, without my consent. *
12. I hereby give permission to the investigators to release the information obtained
from me as result of participation in this study to the sponsors, regulatory
authorities, Govt. agencies, and IEC. I understand that they are publicly presented.
13. I have understand that my Identity will be kept confidential if my data are
publicly presented
14. I have had my questions answered to
my satisfaction.
15. I have decided to be in the
research study.
I am aware that if I have any question during this study, I should contact the
investigator. By signing this consent form I attest that the information given in this
document has been clearly explained to me and understood by me, I will be given a
copy of this consent document
For adult participants:
Name and signature / thumb impression of the participant (or legal representative if
participant incompetent)
PATIENT INFORMATION SHEET
Investigator (principal and at least one Co-investigator):DR.M.S Fouzal Hithaya
Name of Participant:
Title: Comparative study of assessment of tubal patency in female infertility between MR
Hysterosalphingography and conventional hysterosalphingography with diagnostic
laparoscopy as gold standard.
You are invited to take part in this research/ study /procedures. The information in this
document is meant to help you decide whether or not to take part. Please feel free to ask
if you have any queries or concerns.
You are being asked to participate in this study being conducted in Kilpauk Medical
Medical College,Chennai-10.
Hysterosalphingography is one of the several tests done in patients coming for infertility
evaluation. Its chief aim to identify whether the fallopian tubes are patent. If there is
block in fallopian tubes there will be difficulty in conception and that leads to infertility.
There are several methods to do hysterosalphingography (HSG). It can be done using X
ray, ultrasound.
MRI of pelvis has become an invaluable tool in evaluation of infertility in the present
scenario. It depicts all kinds of uterine and extra uterine factors that may lead to
infertility. Doing hysterosalphingography by MRI is a new technique that is recently
developing. No previous studies have been conducted in its regard so far in the
department. By doing MR HSG we can combine the benefits of MRI with
hysterosalphingography. So this study aims at developing the method of doing it so that it
can be incorporated in infertility evaluation in near future in our hospital. If done
successfully it will be of great help to the patients coming for infertility evaluation.
Study Procedures
First you will be placed in lithotomy position so that the HSG catheter can be placed in
situ within the uterine cavity for the purpose of doing the procedure. It will be done under
strict aseptic conditions. After doing so you will be shifted to 1.5 T MRI scanner. Routine
sequences will be initially obtained. Then 10 ml of saline with few drops of MRI contrast
will be injected through the catheter placed in the uterine cavity. Subsequent sequences
are obtained so as to look for tubal patency which will be shown by the spill of the
contrast in the peritoneal cavity.
Then you will be subsequently shifted to the Xray room safely in a stretcher. Again 10 ml
of X ray contrast will be injected through the same catheter and tubal patency will be
looked for by taking a spot film. The catheter will be removed safely. You will be given
adequate pain killers and antibiotics as required.
If you are found to have tubal block you will be asked to undergo diagnostic laparsocopy
subsequently in department of Obstetrics and Gynaecology at Kilpauk Medical College.
If you are found to have patent tubes, you will be asked to review after a period of 3
months. If you fail to conceive you will have to undergo diagnostic laparoscopy.
Possible Risks to you
Risks of this procedure is rare and includes
Cramping pain: You may have cramping pain during the procedure but it
will be minimised by pain killers.
Bleeding: You may have minimal spotting/ bleeding per vaginum after the
procedure but it will be self limiting.
Infections: Most of these are minor; however it can be prevented by
adequate antibiotics.
Possible benefits to other people
The result of the research may provide benefits to the society in terms of advancement of
medical knowledge and/or therapeutic benefits to future patients
Confidentiality of the information obtained from you
You have the right to confidentiality regarding the privacy of your medical information
(personal details, results of physical examinations, investigations, and your medical
history). By signing this document, you will be allowing the research team investigators,
other study personnel, sponsors, IEC and any person or agency required by law like the
Drug Controller General of India to view your data, if required.
The information from this study, if published in scientific journals or presented at
scientific meetings, will not reveal your identity.
How will your decision to not participate in the study affect you?
Your decisions to not participate in this research study will not affect your medical care
or your relationship with investigator or the institution. Your doctor will still take care of
you and you will not loose any benefits to which you are entitled.
Can you decide to stop participating in the study once you start?
The participation in this research is purely voluntary and you have the right to withdraw
from this study at any time during course of the study without giving any reasons.
However, it advisable that you talk to the research team prior to stopping the treatment.
S.
N
O
NAME AGE MARRIED
FOR
OBSTETRIC
HISTORY
MR HSG CONVENTIONAL
HSG
DL
RT
TUBE
LT
TUBE
RT
TUBE
LT
TUBE
R
T
LT
1. KAVITHA 32 14YRS NULLI P P P P P P
2. MALAR 22 4YRS NULLI P P P P P P
3. MEENATCHI 31 8YRS P1L1 P P P P P P
4. JEEVITHA 25 4YRS A2 P P P P P P
5. PRIYA 27 3YRS NULLI P P P P P P
6. EZHILARASI 31 5YRS A2 P P P P P P
7. KALA 29 3YRS NULLI P P P P P P
8. NITHYA 20 2YRS NULLI P P P P P P
9. PADMAVATHY 25 2YRS NULLI P P P P P P
10. RANI UE 31 7YRS P1L1 P P P P P P
11. ARUNA 24 2YRS NULLI P P P P P P
12. KASTHURI 39 12YRS P2L1 P P P P P P
13. GEETHAPRIYA 27 2YRS NULLI P P P P P P
14. UMA 29 7YRS NULLI P P P P P P
15. SUDHA 21 2YRS NULLI P P P P P P
16. DURGADEVI 24 2YRS A2 P B P B P B
17. BHAVANI 30 9YRS P2L2 B B B B B B
18. ZEENATH 35 12YRS P2L1 P B P B P B
19. SHENBAGAM 25 2YRS NULLI P P P P P P
20. REVATHI 24 2YRS NULLI P P P P P P
21. KALPANA 26 3YRS NULLI P P P P P P
22. KANNAGI 30 6YRS P2L1 B B B B B B
23. PALLAVISELVI 32 5YRS A2 P P P P P P
24. MAHALAKSHMI 37 12YRS P2L1 P P P P P P
25. TAMILSELVI 32 8YRS P2L1 B B B B B B
26. NALINI 35 13YRS P1LI B B B B B B
27. MANJULA 25 4YRS P2L2 B B B B B B
28. JYOTI 32 6YRS NULLI B B B B P B
29. GEETHA 24 2YRS NULLI B B P B P B
30. AYESHA 25 2YRS NULLI P P P P P P
31. NOORJAHAN 25 3YRS NULLI P P P P P P
32. SEVATHA 26 4YRS NULLI B B B B B P
33, MAHALAKSHMI 39 14YRS P2L1 B B B B B B
34. DHANALAKSHMI 28 4YRS NULLI P P P P P P
35. SUHASHINI UE 29 8YRS P1L1 B B B B B B
36. DHILARA UE 38 15YRS P2L2 B B B B B P
37. MANGALAKSHMI 23 2YRS NULLI B B B B B B
38. THIRUMATHI 28 4YRS P2L1 B P B P B P
39. DHANALAKSHMI 25 6YRS NULLI B B B B
B B
40 PARAMESHWARI 28 6YRS NULLI P P P P P P
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