HYSTEROSALPINGOGRAPHY – MEDICINAL UTERM AND TUBE FILM
Hysterosalpingography (HSG) is a frequently performed and increasingly important examination in the infertility department. HSG a X ray is the process; It helps to distinguish adhesions and formations within the uterus and Fallopian tubes and to determine the patency of the tubes. HSG plays a very important role in revealing any abnormality related to the uterus and tubes. Anomalies such as adhesions, polyps, fibroids, surgical changes, and adenomyosis in the uterus are uterine anomalies determined in HSG. Anomalies such as obstruction in the tubes, polyps, hydrosalpenx, adhesions around the tubal, salpingitis isthmica nodosum are also abnormal formations that can be seen in the tubes with HSG. While taking HSG, it is necessary to be careful against many possible complications such as bleeding and infection and to work meticulously in this regard.
In infertility cases, in the postoperative evaluation of those who had repeated miscarriages, in the postoperative evaluation of tubal ligation, when the tubes are requested to be reopened, in the evaluation of the uterus and tubes before some myomectomy cases. HSGhas a very important role.
The inner layer of the uterus is the most common in the evaluation of the endometrium and pregnancy. ultrasonography used. The role of ultrasound is important in the evaluation of the endometrium in polyps or abnormal uterine bleeding in the uterus. However, especially in cases where the uterine contour and the localization of myomas cannot be determined exactly by ultrasound. magnetic resonance (MR) review is very important. The value of HSG has been increasing in recent years. HSG film should be evaluated by experienced radiologists who interpret HSG images very well.
Pregnancy and absence of acute pelvic infection must be ruled out before performing an HSG. Since cramps may be felt in the uterus during the examination, it is recommended to take a pain reliever and cramp-relieving drug (non-steroidal anti-inflammatory drug) one hour before the HSG procedure.
Counting from the 1st day of the period of the HSG film, 6-8. It is the best timing to withdraw. Because the endometrium layer will be shed and thin after menstruation, the uterus is evaluated more clearly and the tubal opening (ostium) becomes more evident. Patients are advised not to have intercourse until the day of filming; Thus, the possibility of a pregnancy is also prevented. The suspicion of pregnancy should be eliminated by performing a beta HCG test in those with irregular menstruation and intermittent bleeding. To investigate acute pelvic infection, the erythrocyte sedimentation rate (ESR) should be measured. However, ESR may also increase in cases of infection such as collagen tissue diseases, sarcoidosis, and arthritis.
If there is no active infection at the time of HSG in patients with pre-existing pelvic infection (PID), the use of antibiotics is entirely up to the clinician.
The HSG procedure can usually be performed without any anesthesia in accordance with the pain threshold and tolerance level of the individuals, or it can be performed under sedoanalgesia. The patient is prepared in the lithotomy position. A metallic marker should be placed on one side of the pelvis to distinguish the patient’s right and left. In sterile conditions, the perineum, vagina and cervix are cleaned with povidone-iodine solution (Betadine). A speculum is inserted into the vagina. The cervix is wiped with the solution again. The HSG catheter is placed in the cervical canal, the balloon is inflated. Air bubbles must be removed from the syringe and cannula before drawing the HSG. Water-soluble contrast material is gradually infected; meanwhile, the uterus and tubes are observed fluoroscopically. The first film is taken following the early filling of the uterus; Filling defect or uterine inner mucosa contour abnormality is evaluated in this film. Small filling defects are best seen in this first film. After the uterus is fully filled, the second film is obtained; In this film, the full shape of the uterine cavity is revealed. When the uterus is too full, the surrounding filling defects disappear. Fallopian tubes are evaluated with the third film taken after some more contrast material is given. In the fourth film, intraperitoneal spread of the given contrast agent is observed. In order to evaluate the lower uterine segment, the balloon is deflated before the final films are taken and the pathological structures that may occur in this area are also evaluated. When taking an HSG, a single threaded tool is not usually used to hold the cervix. If the uterus is held back and traction is required, it can be gently pulled down by holding it in the HSG catheter.
There are many risks in the HSG procedure, such as pelvic infection, allergic reaction to the contrast agent used, intravasation of the contrast agent used, and embolization if an oily contrast agent is used.
In addition, the sudden leakage of air into the uterine cavity by the doctor who undergoes HSG may cause an iatrogenic filling defect, which may complicate the examination.
Bleeding may occur due to the irritation of the balloon of the catheter applied to the cervical canal for 2-4 days after the procedure. Minimal cramping may be felt due to the distortion of the contrast agent given during the procedure, but most patients tolerate this situation well. If the tubes are clogged, the cramp is felt more because the distension will be more.
Generally, lymphatic or vascular intravasation is clinically uncertain and not dangerous. Taking HSG within a few days after abortion, taking HSG during menstruation, direct contact with the endometrium during HSG, uterine anomalies such as uterine TB, carcinoma, myoma may cause intravasation. Perforation of the uterus during the HSG procedure is an extremely rare complication.
Evaluation of the Uterus with HSG
Normal uterine cavity: The normal uterine cavity is triangular in HSG. The cervix, which is the lower part of the uterus, extends into the vagina. The uppermost part of the uterus is called the fundus. Fundus can be observed as concave, flat or convex in HSG. Tubes are attached to the fundus from the cornus.
Uterine folds:A filling defect, which is occasionally seen along the longitudinal axis of the uterus in the HSG film, is a normal finding.
Congenital uterine anomalies:Congenital uterine anomalies result from abnormal fusion of Müllerian ducts, which will form the uterus and fallopian tubes between 6-12 weeks of pregnancy.
– Unicornuate uterus:In HSG, it is observed as a single uterine horn with irregular contours.
– Bicornuate uterus:Two separate flat uterine horns are observed in HSG.
– Septate or arcuate uterus: In the septate uterus, an extension in the form of a curtain descending from the fundus is observed in the HSG film. In arcuate uterus, it is observed that the fundus part of the uterus is depressed (showing convexity) towards the cavity.
Luminal filling defects: Even with great care, air bubbles that can be seen occasionally while shooting HSG can be seen in the HSG film. These air bubbles are circumscribed, mobile, and displace as the contrast material is introduced. Fixed filling defects cannot be displaced.
Uterine synechia (adhesion):In the HSG film, uterine synechiae are observed as linear or oval filling defects, and these defects do not change according to the degree of filling of the contrast medium.
Abnormal uterine contour: Irregularities in the uterine contour are observed in cases such as submucosal fibroids, endometrial polyps, large fibroids pressing on the cavity, and diffuse adenomyosis. Cesarean section incision site can be observed as a transverse linear scar in the lower uterine segment.
Sonohysterogram: Uterine polyps and submucous fibroids are best detected with this method. A catheter is inserted into the uterine cavity and the cavity is filled by injecting sterile saline. Since the saline solution makes the endometrial polyp clearly visible, it can be easily observed by vaginal ultrasonic examination. Adenomyosis is clearly seen on USG and especially on MRI.
Evaluation of Fallopian Tubes with HSG
The best way to examine the fallopian tubes is to take an HSG. The tubes are 10-12 cm and extend over the broad ligament (broad ligament) from the ovary to the uterine horns.
HSG image of normal tubules:In the HSG image of normal tubes, each tube radiologically consists of three segments: Interstitial segment, isthmic segment, ampullary segment.
The interstitial (cornual) region of the tube, which is the part of the uterus that passes through the muscle layer, is the shortest segment. While the isthmic region is the longest and thinnest segment, the bulbous region is the widest part. The funnel-shaped fimbrial part at the end of the ampullary region is very rarely seen in the HSG film.
Tubal anomalies seen in HSG:The basis of tubal anomalies seen in HSG may be congenital (congenital) or may be due to spasm, obstruction or infection.
-Salpingitis isthmica nodosa:The formations called salpingitis isthmica nodosa, which are seen as small pockets and directicules in the isthmic part of the tube, are not known for certain, but they can also be seen in cases of pelvic infection, infertility, and ectopic pregnancy.
-Cornual spasm:In the case of cornual spasm, opaque material does not pass beyond the cornual part during the early filling period of the uterus in HSG, and amorphous (indeterminate) calcification can be observed behind.
-Tubal occlusion: Tubal occlusion is a condition seen in HSG, especially following tubal ligation. In HSG, it is observed that the radiopaque substance does not progress after the isthmic region of both tubules. Bulbous enlargement of the opaque substance is observed towards the point where the tuba is attached.
-Peritubal adhesion:In this case, it is observed that the contrast agent forms a large opaque clump in the parts adjacent to the tuba.
-Tubal polyps: Tubal polyps are observed in the interstitial part of the tube as filling defect in HSG. It usually does not cause tubal occlusion, it is asymptomatic. Tubal polyps are ectopic endometrial tissues. Tubal polyps are usually less than 1 cm in diameter and can be seen in one or both tubes.
-Hydrosalpenx: In the case of hyrosalpenx, the tuba bulbs area swells with opaque material and there is no spread in HSG. In order to differentiate tubal spasm and tubal occlusion (occlusion) on radiography, spasmolytic agents such as antispasmodic or glucagon should be used before the procedure. In particular, previous PID may cause scarring in the peritoneal cavity around the tubes, salpingitis isthmica nodosa, tubal occlusion, and infertility.
If the tubes are completely blocked on both sides in the HSG film, the tubes should be evaluated by laparoscopy after the next menstruation, the passage through the tubes should be monitored by giving methylene blue, if both tubes are clogged, if there is no dilation, then in vitro fertilization treatment should be recommended. If even one of the tubes is open and other factors do not prevent conception, a normal pregnancy chance can be given or insemination may be recommended.
Kiss. Dr. Kutlugul Yuksel
Gynecology and Obstetrics Specialist