May 1, 2023

DR. PRADOSH KUMAR SARANGI

HYSTEROSALPINGOGRAPHY

UNDER GUIDANCE OFDR JAYASHREE MOHANTYDR SASMITA PARIDADR B M SWAINDR KALYANI PARIDA

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HYSTEROSALPINGOGRAPHY

Hysterosalpingography is the radiographic evaluation of uterus and fallopian tubes under fluoroscopic guidance.

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INDICATION

1. Infertility (main role)2. Recurrent spontaneous abortions3. Congenital anomalies of uterus 4. Postoperative evaluation following (a)tubal

ligation (b) reversal of tubal ligation5. Suspected case of genital tuberculosis6. To prove tubal occlusion after insertion of

transcervival sterilization microinsert (essure)HSG also has a potential therapeutic role in increasing the probability of pregnancy ( especially if oil soluble contrast –lipiodol is used)

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CONTRAINDICATION

• Suspected pregnancy• Acute pelvic infection• Active vaginal bleeding• Recent dilation and curettage• Immediate pre and post menstrual phase• Tubal or uterine surgery within last 6 wks• Contrast sensitivity

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PATIENT PREPARATION• Done in first half of menstrual cycle in proliferative

phase between 8th to 12th day• Patient to avoid unprotected sexual intercourse from

the date of her period until investigation is over to avoid possible risk of pregnancy

• If periods are irregular , do urine b- hcg test to rule out pregnancy

• Exclude active pelvic infection• Prophylactic antibiotics not routinely recommended

(considered in case of bacterial endocarditis)

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PROCEDURE• Informed consent is taken• Antispasmodic (im drotin) given before procedure.• Patient is asked to empty bladder immediately before

procedure• Scot film may be taken.• Patint is placed in lithotomy position• The perineum is cleaned with antiseptic solution (Betadine)and

draped with sterile towel. The cervix is localized and cleansed with povidone-iodine solution. A speculum is inserted into the vagina. Cervix is cannulated with any of available cannulas which is made air free before administration of contrast

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PROCEDURE ....• Tenaculm is used to hold anterior lip of cervix .• Speculum is removed & Patient is placed in slight

trendelenburg position and contrast is slowly given• 3 ml contrast to fill uterine cavity and another 3 ml to fill tube.

( up to 10 ml)• 4 spot films are taken• Additional oblique views may be taken for optimal

visualisation of pelvic pathology and tortuous fallopian tubes( to see retroverted or anteverted)

• After end of the procedure , antibiotic course is given and patient is informed about vaginal spotting for 1-2 days

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COMPLICATION

• Pain (because of dilatation of uterus , spillage into peritonium).

• Infection (pelvic).• Bleeding.• Vascular or lymphatic Intravasation• Vasovagal episode.• Pregnancy irradiation.• Allergic reaction (to iodinated contrast media).• Uterine perforation

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HISTORY OF HSG

• First report on HSG using oil soluble contrast (collargel) published by Carey in 1914.

• Collargel – significant tissue damage and painful

• Because of these serious adverse events, its use was abandoned and a tubal insufflation test was introduced by Rubin in 1920 (Rubin, 1920)

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HISTORY....

• Rubin insufflated oxygen (later carbon dioxide) under pressure through the cervical canal into the uterine cavity. Tubal patency was determined by presence of air under the diaphragm on X-ray, by auscultation of air flow into the abdomen or a drop in pressure during insufflation

• Heuser was the first to report on the use of lipiodol in HSGs (Heuser, 1925)

• Lipiodol- oil soluble, low viscosity, less toxic, became widely accepted

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• Lipiodol was gradually replaced by water soluble contrast media for several reasons

LIPIODOL is 40% iodine in poppy seed oil Manufactured by guerbert ,france

WHY WATER SOLUBLE CONTRAST MEDIA ARE PREFERRED ?

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CONTRAST MEDIALIPID SOLUBLE CONTRAST (lipiodol)

• Sharp image • Minimal pain• Delayed absorption • Risk of lipogranuloma

formatation in case of tubal block or hydrosalpinx

• Intravasation of contrast and possible risk of oil embolism

• Need of delayed film• Pregnancy rate doubled • Less often used

WATER SOLUBLE CONTRAST (iohexol-omnipaque,meglumine diatrizoate-urograffin

• Ampullary rugae clearly visualised

• Gets absorbed within hours, does not leave residue

• Granuloma formation rare• Pain persists after procedure• Prompt demonstration of

tubal patency, delayed film not needed.

• Widely used and preferred

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INSTRUMENTS

tenaculum Hegar dilator

Speculum

leech wilkinson cannula

Sponge holder

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Different types of cannula used

1. leech wilkinson cannula 2. acorn tip metallic cannula 3.cervical vaccum cup 4. balloon catheter or pediatric foley’s catheter

6F

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WHICH ONE IS BETTER??

• Cervical vacuum cup vs metal cannula: Shorter length of time less fluoroscopic time small amount of contrast needed less pain ( no need to grasp cervix) Easier for physician to use Uterus cant be easily manipulated Need to reapply cannula Superior to metal cannula

Cervical vacuum cup

Cohen et al (British Journal of Obstetrics and GynaecologyOctober 2001, Vol. 108, pp. 1031–1035)

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BALLOON CATHETER VS METAL CANNULA

Less fluoroscopic timeSmall amount of contrastLess painEasier for physician to useGood seal at cervixSingle use/disposable(costly)Superior to metal cannula

BALLOON CATHETER

Tur-kaspa et al (Human Reproduction vol.13 no.1 pp.75–77, 1998)

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• Balloon catheter obscures lower uterine segment. Need to be deflated to visualise lower segment

• Balloon catheter better tolerated over cervical cup

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Cervical vacuum cup cannula

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Acorn tip metal cannula

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BALLOON CATHETER

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NORMAL HSG• The uterine cavity is shown

during HSG as a triangular contrast-filled structure, with its base on top and the apex caudally (inverted triangle) and the uterine fundus on top, which can be flattened, concave or slightly convex . -free spillage of the contrast to the peritoneum noted

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At least 4 spot films taken

4.Peritoneal spillage

2. Uterus fully distended

1.Early filling phase

3.Tubal filling phase

NORMAL HSG

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DETECTABLE PATHOLOGY

UTERINE1. Uterine anomaly2. Fibroid ( submucosal)3. Adenomyosis4. Endometrial polyp5. Intrauterine

adhesions/synaechiae6. Endometrial TB7. Cervical incompetence

TUBAL1. tubal block2. Tubal spasm3. Tubal polyp4. Hydrosalpinx5. Salpingitis isthmic

nodosum (SIN)6. Peritubal adhesions7. TB salpingitis

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NON PATHOLOGIC FINDINGS

• Air bubble- round, often multiple, welldefined mobile filling defect ,usually displaced to fallopian tubes if additional contrasts given

• Normal myometrial folds-longitudinal folds with parallel orientation to uterine cavity

• Prominent cervical glands-tubular structure with their origin in both cervical walls

• Previous caeserean section scar

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Luminal filling defects

• Common finding.• Includes : Air bubbles Uterine folds Synechiae endometrial polyp submucosal fibroid

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Spot radiograph shows air bubbles (arrow) in the left side of the uterus.

AIR BUBBLE

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Filling defects on consecutive images at the uterine fundus, that disappearprogressively after the administration of contrast, compatible with air bubbles.

DISAPPEARS

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HSG spot radiograph demonstrates uterine folds (arrows) as linear filling defects that parallel the longitudinal axis of the uterus. Uterine folds are normal findings that are occasionally seen at HSG.

UTERINE FOLDS

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PROMINENT CERVICAL GLANDS

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Spot radiograph shows the uterine incision from a cesarean section (arrows) in the typical location (i.e., oriented transverse in the lower uterine segment in the region of the isthmus). At HSG, a cesarean section scar can have a linear appearance (as in this case) or can occasionally manifest as a wedge-shaped outpouching or diverticulum.

CESAREAN SECTION SCAR

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UTERINE ANOMALIESclass anomalyi Partial / complete agenesisii Unicornuateiii Didelphysiv BicornuateV SeptateVi Arcuatevii DES-associated anomalies

AMERICAN SOCIETY OF REPRODUCTIVE MEDICINE

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Diagnosis: unicornuate uterus. Description: one cornua , one tube , one spillage.

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UNICORNUATE UTERUS

Single right uterine horn with single right fallopian tube. Right side spillage seen

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UTERUS DIDELPHYS 2 Uterine cavities, 2 cervical canals, 2 vagina..(nonfusion of the two Müllerian ducts.)

VAGINAL SEPTUM

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UTERUS DIDELPHYS

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BICORNUATE UNICOLLIS

2 uterine cavities, 1 cervical canalIncomplete fusion of the cephalad extent of the uterovaginal horns with resorption of the uterovaginal septum.

1 CERVIX

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BICORNUATE UNICOLLIS UTERUS

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BICORNUATE BICOLLIS

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Spot radiograph shows two markedly splayed uterine horns. BICORNUATE UTERUS

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BICORNUATE UNICOLLIS

> 100 degree

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UTERUS DIDELPHYS2 uterus2 cervix2 vagina

UTERUS BICORNIS BICOLLIS2 uterus2 cervix1 vagina

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DES-related uterine anomaly. Hysterosalpingogram demonstrates a hypoplastic T-shaped uterus. The patient had been exposed to DES while in utero.

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ARCUATE UTERUS

Depression of uterine fundus

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SEPTATE UTERUS: PARTIAL AND COMPLETE

There is incomplete resorption of the final fibrous septum between the two uterine horns.

SEPTUM

PARTIAL COMPLETE

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SEPTATE UTERUS

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slight separation (forming acute angle). SEPTATE UTERUS

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Bicornuate and Septate Uteri• Bicornuate:– Fundus indented– Cavities widely

separated( > 100 degree)– Partial fusion of

mullerian ducts

• Septate:– Normal external surface– Cavities are close

together– Defect in canalization or

resorption of midline septum between mullerian ducts.

HSG cant differentiate these two. Definite diagnosis by MRIIntervening cleft > 1 cm & intercornual distance > 5cm in bicornuate uterus

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ADENOMYOSIS

Irregular outline, multiple diverticulum (arrows)

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FIBROID UTERUS

Multiple filling defects

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RIGHT SUBMUCOSAL MYOMA

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SALPINGITIS ISTHMICA NODOSA

• Out pouchings of isthmus• Unilateral or bilateral• Unknown cause• Associated with infertility, PID and ectopic

pregnancy

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SALPINGITIS ISTHMIC NODOSUM (SIN)

small outpouchings or diverticula from the isthmic portion of the fallopian tubes. SIN can be either unilateral or (as in this case) bilateral.

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LEFT SALPINGITIS ISTHIMICA NODOSUM

Multiple outpouchings from isthmus ( arrow)

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RIGHT HYDROSALPINXSteep right oblique spot radiograph shows dilatation of the ampullary portion of the right fallopian tube (arrow). The left fallopian tube is normal in caliber. Mucosal folds are visible in the ampullary portions of both fallopian tubes, a finding that helps confirm the presence of contrast material within the tubes

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BILATERAL HYDROSALPINX

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TUBAL POLYP

small filling defect (arrow) in the proximal left fallopian tube, a finding that typically represents a tubal polyp

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TUBAL POLYP . (FILLING DEFECT)

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Dilatation of the ampullary portion of the left fallopian tube, a finding that is consistent with a hydrosalpinx. No contrast material spillage is seen on the left side. The right fallopian tube is abruptly cut off, a finding that is consistent with previous tubal ligation.

LEFT HYDROSALPINX ,RIGHT TUBAL LIGATION

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Cutoff of contrast material in the isthmic portions of both fallopian tubes, with bulbous dilatation of the distal aspects of the opacified portions. These findings can be seen with postsurgical occlusion (eg, following tubal ligation).

TUBAL LIGATION

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A round collection of contrast material adjacent to the left fallopian tube, a finding that suggests peritubal adhesions. Note the free contrast material spillage on the right side.

LEFT PERITUBAL ADHESION

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SYNECHIAE

• Intra uterine adhesions• Post curettage and infection• Linear filling defect • Arising from one of the uterine walls• Multiple+infertility= Asherman syndrome

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Central oval filling defect within the uterus SYNECHIAE

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SYNECHIAEMultiple irregular filling defects in uterine cavity

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Right fallopian tube does not opacify beyond the cornual portion (arrow), whereas the left fallopian tube opacifies to the ampullary portion. Arrowheads indicate amorphous calcifications on the right side of the pelvis. These calcifications were also present on the scout image

CORNUAL SPASM

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LEFT CORNUAL SPASM

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B/L FALLOPIAN TUBE LIGATION

No peritoneal spillage of contrast

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VASCULAR INTRAVASATION

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Irreversible tubal occlusion with a microinsert. Scout radiograph obtained prior to the instillation of contrast material shows a microinsert that has been placed hysteroscopically into the proximal fallopian tube.

SCOUT FILM

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Radiograph obtained after instillation shows no contrast material filling of the fallopian tube beyond the microinsert, a finding that helps document tubal occlusion.

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HSG FINDINDS IN GENITAL TUBERCULOSIS

FALLOPIAN TUBES UTERUS SPECIFICBeaded tubeGolf club tubePipestem tubeCobblestone tubeLeopard skin tube NON SPECIFICHydrosalpinxMucosal thickeningPeritubal adhesion

SPECIFICT shaped uterusPseudounicornuate uterusTrifoliate uterusNONSPECIFICendometritisSyneciaedistortion of uterine

contourVenous, lymphatic

intravasation71

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TUFTED TUBE Multiple small diverticular like appearance surrounding the ampulla produced by caseous ulceration gives the tubal outline a Rosette-like appearance

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TB SIN-likePenetration of contrast medium between the mucosal folds produces small diverticular-like outpouchings with a bizarre pattern. Entire of both tube involved (arrows).

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cotton-wool plug appearanceDistribution of contrast medium in a reticular pattern producing a " cotton-wool plug" appearance [arrow]

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BEADED TUBE

Multiple constrictions along the fallopian tube giving rise to a " beaded" appearance [arrows]

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GOLF CLUB TUBE

Sacculation of both tubes in distal portion with an associated hydrosalpinx giving a Golf club-like appearance (arrows).

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PIPE STEM APPEARANCE

Absence of normal tortuosity and a curved or straight pipe like appearance show fibrotic stage of tuberculous salpingitis. Irregular contour of the uterine cavity with diminished capacity in the fundual portion resembling a septate uterus.

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FLORAL APPEARANCE

Twisted hydrosalpinx resembles a floral appearance of left side tube (arrow).

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LEOPARD SKIN APPEARANCEMultiple rounded filling defects following intraluminal granuloma formations within the hydrosalpinx, resembling a " leopard skin" appearance [arrows]

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COBBLE STONE APPEARANCE

Intraluminal scarring of the tube gives rises a cobblestone like appearance which is an effective radiographic sign of intraluminal adhesions

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CORK SCREW APPREANCE

Vertically fixed tubes secondary to dense peritubal adhesions. Dense connective tissue causes the lack of tubal mobility. The hyperconvulated right tube and manifests a " cork screw" like appearance [arrows]

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PERITUBAL HALO

Thickening of the tubal walls due to peritubal adhesions (arrows) represents a cloudy sign on hysterosalpingograms. This finding is a non-specific feature of tubal tuberculosis.

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TOBACCO POUCH APPREANCE

Terminal hydrosalpinx with the conical narrowing is seen in the right tube (arrow). Eversion of the fimbria secondary to adhesions, with a patent orifice produces the tobacco pouch appearance in the left terminal.

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A.Uterine cavity is normal in shape and size. Terminal sacculation are seenin both tubes. B. Irregularity, multiple filling defects and obliteration of right ostium secondary to extensive synechiae formation in this site. Obstruction of left tube is also seen.

A B

INTRAUTERINE ADHESION AND DISTORTION

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A. Pseudo-unicornuate uterus. Unilateral scarring of the cavity makes an asymmetric intrauterine obliteration, resembling a unicornuate uterus. the irregular contour and vertical orientation of long axis. B. True unicornuate uterus. the smooth contour, more horizontal orientation of long axis and normal ipsilateral fallopian tube.

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T –SHAPED TB UTERUS DES RELATED T SHAPED UTERUS

T-shaped configuration in two different patients. A. " T-shaped" tuberculosis uterus. Irregular contour of the uterine cavity with diminished capacity resembling a T-shaped uterus. Both tubes are obstructed from isthmic portion.B. T-shaped uterus due to DES exposure. Narrow endocervical canal and small uterine cavity. Note both tubes are normal.

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TRIFOLIATE SHAPED UTERUS

Synechiae formation at the uterine borders and partial obliteration in the fundus produce a trifoliate like appearance. Both tubes are obstructed in the isthmic portion

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DIAGNOSTIC ACCURACY(Hsg vs laparoscopy)

• Hsg-minimally invasive -superior to laparoscopy for detecting intrinsic

tubal and uterine pathology. - false negative rate due to undected

peritubal adhesion,incomplete filling of a dilated hydrosalpinx

- false positive rate due to tubal spasm, inadequate contrast injection

both are complementary methods in evaluation of infertility

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Thank

You