525

Apparent Cornual Occlusionin Hysterosalpingography:Reversal by Glucagon

Alan C.WinfieldDonald Pittaway2

Wayne Maxson2James Daniell2

Anne Colston Wentz2

Received March 19, 1982; accepted May 20,1982.

Department of Radiology and Radiological Sc,-ences, Vanderbilt University Hospital, Nashville.TN 37232. Address reprint requests to A. C. Win-field.

Department of Obstetrics and Gynecology,Vanderbilt University Hospital, Nashville, TN37232.

AJR 139:525-527, September 19820361 -8o3x/82/1 393-0525 $00.00 American Roentgen Ray Society

In a series of 310 consecutive hysterosalpingograms, 24 patients were found withapparent cornual occlusion unrelated to prior tubal surgery. Intravenous glucagonadministration was effective in reversing the obstruction in nine (33%) Of the 27 tubes.Of the occluded tubes that did not respond to glucagon, 80% were shown to beoccluded at laparoscopy. Because cornual or isthmic spasm may be a cause ofapparent cornual occlusion at hysterosalpingography, administration of glucagon isrecommended before establishing the radiographic diagnosis of cornual occlusion.

Hysterosalpingography (HSG) in the evaluation of the infertile woman is usedprimarily to assess the uterine cavity and the patency of the fallopian tubes.Considerable data suggest that the technique is imperfect. Correlation of tubalpatency as determined by HSG and laparoscopy revealed discordant results in1 7% of the cases in a series of Gomel [1]. Tubal spasm during the radiographicprocedures may account for some of this inaccuracy. Siegler [2] showed suc-cessful pregnancies after radiographic evidence of tubal occlusion, and de-scnibed in detail what he referred to as uterotubal spasm. Whitehouse [3] similarlydiscussed the entity of cornual spasm and reviewed the historic use of numerouspharmacologic agents to overcome this problem. In the past, atropine, amylnitrate [4], dihydroergotamine [5], diazepam [3], and nitroglycerin L6] have allbeen used with varying degrees of success. More recently, Genlock and Hooser[7] reported using glucagon in nine patients with tubal occlusion, relieving theobstruction in five. Ansani and Shimoura [8] used glucagon in a very limited serieswith apparent success.

Because of our relatively frequent confrontation with the problem of cornualocclusion during HSG, we attempted to evaluate the use of parenteral glucagonduring the radiographic procedure. A prospective study was established to judgethe efficacy of glucagon in patients with apparent cornual occlusion.

Materials and Methods

The patient population consisted of outpatients referred either from the Center forFertility and Reproductive Research or the general Gynecology Clinic at Vanderbilt Univer-sity Hospital. Patients with obvious tubal pathology and previous salpingectomy wereomitted. Premedication was not used routinely. The usual technique consisted of theintroduction of aqueous contrast material (iothalamate methyl glucamine) via a Kiddecannula, although occasionally a pediatric Foley catheter was used. All examinations wereperformed under fluoroscopic control, using steady sustained pressure to introduce thecontrast material. If an occlusion at the cornua was encountered, repeat injection wasattempted after a short respite. In the event that the occlusion persisted, 1 mg of glucagonwas intravenously administered. The cannula or catheter remained in place during thisperiod. Injection was again attempted 30-60 sec after administration of glucagon.

A series of 310 patients who had undergone hysterosalpingography during a 1 yearperiod was reviewed. Of these, 24 demonstrated cornual occlusion and are included in this

Dow

nloa

ded

from

ww

w.a

jronli

ne.or

g by 1

11.22

3.252

.43 on

05/20

/13 fr

om IP

addre

ss 11

1.223

.252.4

3. Co

pyrig

ht AR

RS. F

or pe

rsona

l use

only;

all ri

ghts

reserv

ed

526 WINFIELD ET AL. AJR:139, September 1982

1 . Gomel V. Laparoscopy prior to reconstructive tubal surgery forinfertility. J Reprod Med 1977;18:251 -253

Fig. 1 .-Hysterosalpingograms. Ap-parent left cornual occlusion before (A)and patency after (B) glucagon admin-istration.

report. The effect of glucagon to achieve tubal patency is recorded.Where possible, data regarding tubal pathology and correlation withlaparoscopic results are included.

Results

Of the 310 patients, 21 had unilateral and three hadbilateral cornual occlusion as demonstrated on HSG. Thisyielded an overall incidence of 7.7%. Glucagon was admin-istered to these 24 patients with reversal of occlusion innine of the 27 tubes (33% response rate) and lowering theoverall incidence of connual occlusion to 1 8 (5.8%) of 310.The hysterosalpingognams shown in figure 1 illustrate anexample of apparent connual occlusion (before) that wassubsequently relieved with glucagon administration (after).The dilatation of the endocenvical canal and delineation ofthe endocervical glands indicate adequate injecting pres-sunes.

We then reviewed the charts of the patients who demon-strated connual occlusion by HSG and also underwent Ia-paroscopy. Thirteen patients (demonstrating 1 4 occludedtubes) were included in this series. Reversal of the cornualocclusion was achieved with glucagon in four (29%) of the1 4, comparable to the series as a whole. Of the 1 0 patientswith persistent cornual occlusion by HSG despite glucagonadministration, eight (80%) likewise demonstrated cornualocclusion at laparoscopy.

One patient who was seen to reverse the cornual occlu-sion by glucagon during HSG demonstrated apparent occlu-sion during lapanoscopy despite general anesthesia.

Discussion

Tubal patency is probably the most important informationto be derived from HSG. If there is lack of correlation withother methods in determining the patency of the fallopiantubes, it would seem obvious that the examination demon-strating occlusion would be the one likely to be in error.Inconstant muscle spasm would seem the likely explanationfor this phenomenon.

Anatomically, the fallopian tubes contain two layers ofinvoluntary muscle. The more peripheral is thin and longi-tudinally arranged; the inner layer is circular in orientation,somewhat thickest adjacent to the uterus [9]. The interstitialsegment of the tube at the connua is surrounded by myo-

metnium. Brundin [1 0] studied the sphinctenic activity of thefallopian tubes in rabbits and demonstrated a large numberof adrenergic nerve fibers in the circular muscles at theuterotubal junction. It may well be that cornual spasm isactually due to contracting myometnium rather than tubalmuscle itself [3].

Cornual occlusion, due either to spasm or mechanicalobstruction, is not rare. Siegler [2] evaluated 1 000 salpin-gograms and showed an incidence of 2O.5#{176}/ofor cornualocclusion. Our data showed a lesser incidence of 7.7%,nonetheless a significant frequency. The difference in theincidence may be due to differences in the patient popula-tion, technique, and contrast material.

It seems appropriate to look for a pharmacologic adjunctto relieve muscle spasm at this critical junction. Glucagonhas been demonstrated on numerous occasions to be aneffective, safe, smooth muscle relaxant in the gastrointes-tinal tract [7, 1 1 , 1 2]. The contraindications are few, al-though glucagon has been reported to initiate adverse no-actions in patients with pheochnomocytoma and insulinoma.Occasionally mild nausea may accompany the administra-tion of glucagon, although this was not observed in ourseries.

Our results suggest that uterotubal (connual) spasm maybe a causative factor in pseudo-obstruction of the fallopiantubes and demonstrates the efficacy of glucagon duringHSG when cornual occlusion is encountered. We haveshown that about one-third of cases with cornual occlusionare reversible with this pharmacologic aid and are the resultof spasm rather than mechanical occlusion. Indeed, gluca-gon may have a reasonable role in laparoscopy if initialattempts to demonstrate tubal patency are unsuccessful.We believe that, at this time, glucagon is a safe and effectivepharmacologic adjunct in the evaluation of the patency ofthe fallopian tubes.

ACKNOWLEDGMENTS

We thank Angela Sullivan and Carolyn Cooper for help in manu-script preparation.

REFERENCES

Dow

nloa

ded

from

ww

w.a

jronli

ne.or

g by 1

11.22

3.252

.43 on

05/20

/13 fr

om IP

addre

ss 11

1.223

.252.4

3. Co

pyrig

ht AR

RS. F

or pe

rsona

l use

only;

all ri

ghts

reserv

ed

CORNUAL OCCLUSION IN HYSTEROSALPINGOGRAPHY 527AJR: 139, September 1982

2. Siegler AM. Hysterosalpingography, 2d ed. New York: Med-com, 1974:125-136

3. Whitehouse GH. Gynaecological radiology. Oxford: BlackwellScientific, 1981 :28

4. Stallworth J. Facts and fancy in the study of female infertility.Br J Obstet Gynaecol 1948;55: 171-180

5. Siebert E. Relaxant effect of dihydroergotamine and hyderginein hysterosalpingography. Gynecol Obstet Invest 1953;135:172-176

6. Whitelaw MJ. Use of nitroglycerin in hysterosalpingography.Fertil Steril 1977;28:327-328

7, Gerlock AJ, Hooser CW. Oviduct response to glucagon duringhysterosalpingography. Radiology 1976; 119:727-728

8. Ansari AH, Shimoura H. Hypotonic hysterosalpingography with

glucagon. Fertil Steril 1978;30:476-4779, Brash JC, Jameson EB. Cunninghams textbook of anatomy.

Edinburgh: Oxford University, 1973;741-7421 0. Brundin J. Distribution and function of adrenergic nerves in the

rabbit fallopian tube. Acta PhysiolScand[Suppl] 1965;259: 1-57

1 1 . Moss AA, Kressel HY, Korobkin M, Goldberg HI, Rohling BM,Brash AC. Effect of gastrografin and glucagon on CT scanningof the pancreas. Radiology 1978;126:71 1-714

1 2. Miller RE, Chernish SM, Brunelle AL, Rosenak BD. Double-blind radiographic study of dose response to intravenous glu-cagon for hypotonic duodenography. Radiology 1978;127: 55-59

Dow

nloa

ded

from

ww

w.a

jronli

ne.or

g by 1

11.22

3.252

.43 on

05/20

/13 fr

om IP

addre

ss 11

1.223

.252.4

3. Co

pyrig

ht AR

RS. F

or pe

rsona

l use

only;

all ri

ghts

reserv

ed