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ysterosalpingography is a valuabletechnique in the evaluation of the in-fertile patient. During the last de-

cade, the number of women seeking infertilityevaluation has increased considerably. Hystero-salpingography is considered a screening proce-dure for an infertility workup, and despite thedevelopment of other diagnostic tools such asMR imaging, hysteroscopy, and laparoscopy,hysterosalpingography remains the main exami-nation for the study of the fallopian tubes [1].This technique provides useful, although indi-rect, information outlining the uterine cavity andthe fallopian tubes. Hysterosalpingography hasbeen reported to have a high sensitivity but a lowspecificity, especially in the diagnosis of uterinecavity abnormalities [2, 3]. The technical qualityof the hysterosalpingogram is important to limitfactors leading to misinterpretations. It is also es-

sential for the radiologist to be familiar with thenormal and abnormal radiologic findings for thecorrect interpretation of hysterosalpingograms.

This pictorial essay describes and illustratesthe hysterosalpingographic appearances oftechnical artifacts, normal variants, and find-ings with no proven influence on fertility.

Technical Artifacts

Air Bubbles

During hysterosalpingography, air bubblescan incidentally be introduced into the uterinecavity and may be mistaken for other filling de-fects such as blood clots, polyps, submucosalmyomas, or endometrial hyperplasia. An airbubble appears as a round, well-defined fillingdefect; multiple air bubbles are often seen, andthey are usually identifiable by their mobility.

Introduction of air bubbles can be prevented bycareful removal of air bubbles trapped in thecannula. When present, air bubbles must beeliminated by additional injection of contrastmaterial, which flushes them out of the uterinecavity through the fallopian tubes (Fig. 1).

Venous or Lymphatic Intravasation

Venous or lymphatic intravasation can occurin up to 6% of patients undergoing hysterosal-pingography [4]. Although it can occur inhealthy patients, there are some predisposingfactors such as recent uterine surgery or in-creased intrauterine pressure because of tubalobstruction or excessive injection pressure [24].

The radiographic appearance of early in-travasation is characterized by filling of mul-tiple thin beaded channels and an ascendantcourse (Figs. 2 and 3). When intravasation is

Hysterosalpingography:

Spectrum of Normal Variants andNonpathologic Findings

Beln beda

1

, Marta Paraira, Enric Alert, Ramn Angel Abuin

Received July 28, 2000; accepted after revision December 4, 2000.

1

All authors: Department of Radiology, Institut Universitari Dexeus, P Bonanova, 67 pl2, 08017 Barcelona, Spain. Address correspondence to B. beda.

AJR

2001;177:131135 0361803X/01/1771131 American Roentgen Ray Society

Pictorial Essay

H

Fig. 1.Air bubbles in uterine horns of29-year-old asymptomatic woman.A, Hysterosalpingogram obtained withballoon-catheter shows multiplerounded filling defects (arrows), whichare mobile, at both uterine horns.B, Hysterosalpingogram obtainedwith additional injection of contrastmaterial shows bubbles have beenflushed out of uterine cavity throughfallopian tubes.

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Fig. 2.Venous intravasation in healthy 28-year-old woman. Hysterosalpingogramshows network of thin vessels (arrow) can be opacified during hysterosalpingogra-phy in healthy patients.

Fig. 3.Venous intravasation in healthy 36-year-old woman. Hysterosalpingogramobtained in patient with right isthmic tubal occlusion (short arrow) shows venousintravasation of contrast material into myometrial vessels (long arrow).

C

Fig. 4.Myometrial folds in 34-year-old woman. A, Hysterosalpingogram shows broad longitudinal folds (arrows) parallel to uterine cavity that must be identified at early underfilled view of uterus.B and C, Delayed radiographs obtained with larger volumes of contrast material show that contrast material progressively obliterates view of folds.

BA

Fig. 5.Double uterine contour (as-terisk and arrows) in 30-year-oldwoman. Hysterosalpingogram ob-tained during late secretory phaseof menstrual cycle shows doubleuterine contour.

Fig. 6.Double uterine contour in34-year-old pregnant woman. Hys-terosalpingogram was inadvertentlyobtained in this patient who hadvaginal bleeding resembling menses1 month before study. Hysterosal-pingogram shows mildly enlargeduterine cavity with double contour.No gestational sac is evidenced.

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recognized, the injection should be stoppedif an oil-soluble medium has been used.Venous intravasation is innocuous as long asa water-soluble contrast medium is used.

Controversy exists regarding the properchoice of contrast material for hysterosalpin-gography. Some authors support the use of anoil-soluble contrast medium, arguing that it pro-vides greater contrast and sharpness of the im-age and more information about the presence ofperitubal adhesions [5]. An increase in preg-nancy rates in infertile patients after hystero-salpingography with oil-soluble medium hasbeen suggested [6], whereas another study [7]shows no statistical difference between the useof oil- and water-soluble contrast agents.

Most authors advocate the use of a water-soluble contrast medium [24] because it pro-vides better uterine and ampullary mucosaldetail and has no serious secondary effectssuch as peritoneal inflammatory or granuloma-tous reaction and because it eliminates the riskof pulmonary and retinal oil emboli. In addi-tion, venous intravasation of water-solublecontrast medium produces no adverse effects,entering the vascular system and being ex-creted by the kidneys. Therefore, both diag-nostic and safety factors recommend the use ofa water-soluble contrast medium.

Normal Variants

Myometrial Folds

In a small percentage of patients, broadlongitudinal folds parallel to the uterine cav-ity are seen on hysterosalpingograms withotherwise normal findings (Fig. 4). Thesefolds are not associated with endometrial ab-normalities. Although the exact etiology isunknown, the folds are considered as rem-nants of the mllerian duct fusion during fe-tal development [4].

Double Uterine Contour

Hysterosalpingography should be performedduring the follicular phase of the menstrual cyclebefore ovulation. In the few patients in whomhysterosalpingography is performed during thelate secretory phase of the menstrual cycleforexample, in the evaluation for cervical incompe-tencea double contour can be seen as a thinline of contrast medium surrounding the uterinecavity (Fig. 5). The contrast medium does notpenetrate into the myometrial vessels, and there-fore there is no filling of the myometrial, uterine,or ovarian veins. A double contour representingcontrast material underneath the decidual reac-tion of the endometrium can also be observed inan early pregnancy [4] (Fig. 6).

Prominent Cervical Glands

The normal cervical canal is delineated by theinternal and external cervical os and can havevariable appearances depending on the patientand the time in her cycle. The cervical canal isusually narrower at the external and internal osand wider in the midportion. The walls may besmooth or serrated with longitudinal ridges rep-resenting the plicae palmatae. Sometimes, fillingof normal endocervical glands may be observedas multiple tubular structures that originate fromboth cervical walls (Fig. 7).

Findings with No Proven Influence on Fertility

Arcuate Uterus

The arcuate uterus is usually an incidentalfinding during hysterosalpingography, and itappears as a mild smooth concavity in theuterine fundus instead of the more commonstraight or convex normal fundal contour (Fig.8). According to the American Fertility Soci-etys classification, an arcuate uterus is consid-ered a class VI mllerian anomaly [8].Nevertheless, an arcuate uterus is such a minoruterine malformation that it is considered a

normal variant and is not associated with infer-tility or obstetric complications [4, 8]. It mustbe differentiated from the

V

-shaped fundus ofthe subseptate uterus and from an extrinsiccompression caused by an intramural myoma.

Gartners Duct Cyst

Gartners duct is a remnant of the caudal por-tion of the mesonephric or wolffian duct thatfails to resorb normally in the female. Gartnersducts can be single or multiple and are usuallylocated parallel to the anterior lateral wall of theproximal third of the vagina [4]. Secretion bypersistent glandular tissue may allow cysts toform in its course.

Gartners duct cysts may be visualized duringhysterosalpingography if they communicate withthe uterine lumen. These cysts are usually inci-dental findings with no clinical significance.They appear as tubular structures that run parallelto the uterine cavity or vagina, sometimes withcystic or saccular dilatations (Figs. 9 and 10).

Infantile Uterus

The normal adult uterus can have variableappearances, with a triangular-shaped uter-ine cavity and smooth margins. The uterine

Fig. 7.Prominent cervical glandsin 27-year-old woman. Hysterosal-pingogram with normal findingsshows tubular-shaped structures(arrows) originating from cervicalwalls that correspond to filling ofnormal or dilated cervical glands.

Fig. 8.Arcuate uterus in 30-year-old woman. Hys-terosalpingogram with normal findings shows smoothconcave indentation of uterine fundus (arrow).

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body comprises two thirds of the entire uter-ine length, and the remaining third corre-sponds to the endocervical canal. In patientstaking oral contraceptives for long periods oftime, a small

T

-shaped uterus can be ob-served characterized by a 1:1 ratio betweenthe uterine body and the cervix, which arethe normal proportions of a premenarchaluterus (Fig. 11). This appearance can also beobserved in adult women with severe estro-gen deficiencies in which the uterus fails toattain postpuberal proportions because of theabsence of normal estrogen stimulus [4].

Tubal Polyps

Tubal polyps are small foci of ectopic en-dometrial tissue located at the intramural portionof the fallopian tubes. They can be unilateral orbilateral, and they measure less than 1 cm in di-ameter. Radiologically, tubal polyps appear assmooth, round or oval filling defects, not associ-

ated to tubal dilatation or obstruction, with freeflow of contrast medium to the peritoneal cavity(Fig. 12). Patients with tubal polyps are asymp-tomatic, and polyps are usually an incidentalfinding at hysterosalpingography; of hysterosal-pingograms obtained for infertility investigation,the reported incidence is 12.5% [9].

The role of tubal polyps in infertility hasbeen long questioned, but an absolute causalrelationship between tubal polyps and infer-tility has not been definitely established [9,10]. The consensus is that other causes of in-fertility should be sought before treatment ofpolyps is considered. Hormonal and surgicaltreatments have so far been unsuccessful.

Cesarean Delivery Scar

Cesarean delivery requires a transverse inci-sion at the uterine isthmus and can be seen athysterosalpingography as a wedge-shaped out-pouching at the level of the internal os (Fig. 13).

This finding has no clinical significance and isnot a diagnostic problem if it is correlated withthe clinical history of the patient.

Postmyomectomy Diverticulum

Myomectomy is being performed increas-ingly for the treatment of menorrhagia and in-fertility. After the resection of a submucousfibroid, small diverticulagenerally less than1 cm in diametercan be found in some pa-tients at the site of resection [11] (Fig. 14). Thesignificance of this finding has not yet, to ourknowledge, been documented, but diverticulaseem to have no clinical importance when theyare small and not associated with major distor-tion of the uterine cavity.

Summary

The number of hysterosalpingographic ex-aminations has increased during the last de-cade because of the greater concern

Fig. 11.Infantile uterus in 30-year-old woman. Hysterosalpingogram shows small,T-shaped uterus with cervix and uterine body of similar size. Patient had been tak-ing oral contraceptives for several years.

Fig. 12.Tubal polyps in 37-year-old woman. Normal hysterosalpingogram shows in-cidental unilateral filling defect at interstitial portion of right Fallopian tube (arrow).

Fig. 9.Gartners duct cyst in 25-year-old asymptomatic woman.Hysterosalpingogram shows tubularstructure, running parallel to uterinecavity (arrows), that representsGartners duct communicating withuterine lumen.

Fig. 10.Gartners duct cyst in 32-year-old woman. Hysterosalpingo-gram reveals course of Gartnersduct cyst running along vaginal wall.Saccular dilatations (large arrow)can be present. Note left hydrosal-pinx with severe ampullary dilata-tion and no free intraperitoneal spill(small arrows).

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regarding infertility. Hysterosalpingographyplays an extremely important role in the di-agnostic assessment and treatment of infer-tility in the female patient. An accurateinterpretation of the hysterosalpingogram isnecessary for the infertility workup, consid-ering the nonpathologic findings that areseen at otherwise normal examinations.Knowledge of these entities is important toavoid the practice of unnecessary and some-times more aggressive procedures.

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Fig. 13.Cesarean section scar in 37-year-old woman who had cesareandelivery several years earlier. Hys-terosalpingogram shows wedge-shaped outpouching at level of internalcervical os representing site of cesar-ean scar (arrow).

Fig. 14.Diverticulum in 33-year-oldwoman who underwent resection ofsubmucous fibroid. Hysterosalpingo-gram obtained after patient under-went myomectomy shows smalldiverticulum at site of resection withno distortion of uterine cavity (arrow).

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This article has been cited by:

1. Krishna Surapaneni, James E. Silberzweig. 2008. Cesarean Section Scar Diverticulum: Appearance on Hysterosalpingography.American Journal of Roentgenology 190:4, 870-874. [Abstract] [Full Text] [PDF] [PDF Plus] [Supplemental Material]

2. Thomas M. Dykes, Cary Siegel, William Dodson. 2007. Imaging of Congenital Uterine Anomalies: Review and Self-AssessmentModule. American Journal of Roentgenology 189:3_supplement, S1-S10. [Abstract] [Full Text] [PDF] [PDF Plus] [SupplementalMaterial]

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