Continuing Education Activity

Hysterosalpingogram is an imaging procedure performed to assess the causes of infertility in females. Hysterosalpingogram utilizes radiopaque dye injected into the uterus and is visualized with an x-ray. Infertility in females is a complex workup assessed from a hormonal, structural, and partner-based approach. Disorders of the fallopian tube can account can for up to 60% of the reasons for infertility. This imaging procedure is commonly the second step in the diagnostic approach for female patients presenting with infertility. Pelvic ultrasound is generally the first. This activity explains the interprofessional team's role in evaluating and diagnosing some causes of infertility in females using this modality.

Objectives:

• Describe the indications for a hysterosalpingogram.
• Describe the contraindications for a hysterosalpingogram.
• Summarize the technique and potential findings for a hysterosalpingogram.
• Outline some interprofessional strategies to improve patient care when using hysterosalpingogram.

Introduction

Hysterosalpingogram is a test imaging procedure commonly the second step in the diagnostic approach for female patients presenting with infertility. Pelvic ultrasound is generally the first.

Infertility in females is a complex workup assessed from a hormonal, structural, and partner-based approach. Disorders of the fallopian tube can account for up to 60% of the reasons for infertility, depending on the population.[1]

One of the easily diagnosable causes of infertility is structural and developmental abnormalities. The primary role of hysterosalpingography is to assess the patency of the fallopian tubes and the structure of the endometrial cavity. The fallopian tubes generally carry the oocytes, which are released from the ovaries. The fallopian tubes are the patent structures that attach to the uterus at the interstitial space. The fallopian tube structures start with the fimbria at the ovarian end, infundibulum, ampulla, and isthmus. Hysteroscopially, the connection of the fallopian tube to the cavity is referred to as the ostia.

During the procedure, a radioopaque media fills the uterine cavity, continues into the fallopian tubes, and eventually reaches fimbriated ends next to the ovaries. Typically 1 to 3 mL of media is introduced into the uterine cavity. During the filling process, multiple pelvic X-rays are taken to visualize the spread of the media.

The exact number of the images is institution-dependent. The filling is continued until media are flowing from both the fallopian tubes. The hysterosalpingogram has limited visualization to areas that have patency to the cavity for which the contrast medial is deposited. In the setting where at least one fallopian tube is not showing contrast spillage, intravenous anticholinergic medication can be given to rule out the possibility of fallopian tube smooth muscle spasms. The contrast media appears hyper-dense on imaging, thus allowing for visualizing the media’s pathway.[2]

Guidelines include HSG as part of a standard fertility evaluation. Laparoscopy and dye are more appropriate in women with a history of pelvic inflammatory disease (PID), previous ectopic pregnancy, or endometriosis. This allows assessment of both tubal and other pelvic pathology.[3] 

Anatomy and Physiology

A hysterosalpingogram procedure assesses the female genital tract anatomy with a focus on the fallopian tubes and uterus. The female internal genitalia typically is comprised of a uterus with two fallopian tubes. During organogenesis, it is possible to have many different congenital malformations affecting the reproductive system. The endometrial cavity can have defects, which can be from Mullerian duct anomalies. These defects are from a failed resorption of the uterovaginal septum that can range from an arcuate uterus to a septate uterus. Additionally, defects result from the incomplete fusion of the Mullerian ducts, which can lead to a bicornuate uterus presentation.

There are currently seven classifications for Mullerian abnormalities: agenesis, unicornuate, didelphys, bicornuate, septate, arcuate, and Diesthystilbestrol-related anomalies. Imaging databases house different variations of abnormalities, useful for anatomical presentations that fall into a mixture of classifications.[4] Mullerian abnormalities are found in around 5% of all hysterosalpingograms.[5] The most common type of Mullerian abnormality is type V, the septate uterus. The septum is formed during organogenesis and is a fibromuscular band. The band is a remnant of the fusion of the paramesonephric ducts and usually undergoes physiologic resorption.

Additional pathologies aside from Mullerian abnormalities include uterine cancer, polyps, fibroids, and adhesions. There are other superior ways to detect these findings, but the findings can still be present with a hysterosalpingogram.

Additional pathologies that can be diagnosed from hysterosalpingogram focus on the patency of the fallopian tubes. Tubal occlusions are present in 12 to 33% of patients undergoing an infertility workup.[6] The primary cause of tubal occlusions is sexually transmitted infections. Gonorrhea has been suggested to be associated with 90% of cases of infertility.[7] A recent systematic review demonstrated a positive correlation between Chlamydia trachomatis infection and female infertility in greater than 75% of studies.[8]

Indications

A hysterosalpingogram is an imaging technique in the pathway for diagnosing causes of infertility in females. The initial imaging technique is mainly ultrasonography, but a hysterosalpingogram is used to visualize the intrauterine space and the fallopian tubes' patency. The initial ultrasonography is usually done through a transvaginal route that can be used to detect gross structures like fibroids and polyps. Hysterosalpingography is more sensitive to identifying the abnormalities within the fallopian tubes. After the initial ultrasound imaging, providers can offer a hysterosalpingogram or a hysterosalpingosonogram. Recent research has suggested that a hysterosalpingogram is superior when the primary outcome is pregnancy.[9]

A randomized control trial of 1119 women compared hysterosalpingography with oil or water contrast. Pregnancy and live births were improved in the oil contrast group. Other authors agree but have asked for trials comparing modalities such as ultrasound and laparoscopy.[10]

Contraindications

There are two contraindications for HSG: pregnancy and an active pelvic infection. Ideally, performing HSG during the early follicular phase is an effective measure to avoid this issue. Additionally, the endometrial lining is thin, and this can aid image interpretation.

Additionally, a contraindication to the procedure can be associated with the media contrast used. Allergies to iodine need to be addressed with the patient. Furthermore, if the patient has a history of thyroid disease, the procedure should be discussed with her endocrinologist. Using iodine can lead to a Wolff-Chaikoff effect (presumed reduction in thyroid hormone levels) or exacerbate thyrotoxicosis in patients with a known history of Grave’s disease.[11] Glucocorticoid premedication has been suggested before the procedure; however, radiologists have found data lacking to support the use. Non-iodine contrast should be used in patients with iodine allergies.

A history of pelvic inflammatory disease is not a direct contraindication for a hysterosalpingogram. Postprocedure infection may occur in 1.4% to 3.4% of cases. Antibiotics may reduce this risk. If dilated fallopian tubes are discovered during the procedure (risk of up to 11%), an appropriate antibiotic such as doxycycline 100 mg twice daily for five days is commonly recommended in this setting.

Patients with a history of pelvic infection can also be started on doxycycline before the procedure and continued if dilated fallopian tubes are noted. Otherwise, in patients with no history of pelvic infection and without evidence of dilated fallopian tubes, antibiotics are not required, per ACOG Practice Bulletin 131.

Equipment

• Speculum
• Fluoroscopic table 
• Tenaculum is generally used and a
• Metal cannula with a rubber acorn tip 

Alternatives:

• Plastic catheter with an inflatable balloon 
• Thin catheter and shallow acorn 

Preparation

HSG does not generally require sedation.  

There is no evidence that prophylactic nonsteroidal anti-inflammatory drugs reduce pain during HSG.[12] Recent data suggest that premedication with the antispasmodic, anticholinergic drug hyoscine-N-butylbromide can reduce pain during and after HSG and may also decrease proximal tubal spasm causing a picture of false occlusion.[13] 

Technique or Treatment

Patients should be scheduled for the imaging procedure during the early follicular phase for the patient. This phase is early in the patient's menstrual cycle and is superior to the luteal phase because the endometrial lining is thinner, which increases patency.

A speculum is placed in the vagina, and the cervix is visualized and cleansed in the usual manner. Patient setup: On a fluoroscopic table in the dorsal lithotomy position, the patient should have her arms laterally or behind her head. There should be no metal in the field of examination. Speculum examination and cleansing to visualize the cervix are then performed. 

A tenaculum is generally used, and a metal cannula with a rubber acorn tip allows a cervical seal. The protruding metal tip is placed through the cervix, and a cannula is fixed to the tenaculum. This can be used to manipulate the uterus to ensure complete visualization due to radiographs. A plastic catheter with an inflatable balloon is an additional technique, and a thin catheter and shallow acorn can be used.[14]

Prior to placement, contrast should be injected through the device to avoid air in the cavity which can interfere with images.

A scout radiograph of the pelvis is obtained before the contrast medium is instilled after the instruments have been placed. Slow injection of contrast can decrease patient discomfort.

Generally, at least four radiographs are obtained:

1. Early filling of the uterus to detect defects.
2. After complete filling of the uterus to detect shape.
3. Evaluate the fallopian tubes
4. Free peritoneal spill.

Other films may be necessary.

The media used is a radio-opaque dye that has changed over the years. By reducing osmolality, water-soluble contrast agents have improved safety and tolerance for HSG. Initial agents were hyperosmolar (> 1000 mOsmol/kg) and ionic. Plasma has an osmolarity of between 275 to 290 mOsm/kg. Subsequently, nonionic agents with 2 to 3 times the osmolality of plasma have been developed. Nonionic iso-osmolar contrast agents such as iodixanol and iotrolan are available (see reference).[15] While there is a wide variety of available agents, there is no consensus on which is preferable.[10]

Transient discomfort is common and usually described as crampy in nature, and if it occurs, its intensity may vary from mild to severe. 

Physiological reactions, such as nausea, vomiting, flushing, chills, and vasovagal reactions, may occur. [ACR Committee on Drugs and Contrast Media. ACR Manual on Contrast Media American College of Radiology; 2021.]

Complications

The procedure is considered a clean-contaminated procedure because the cannula and or catheter breaches the endocervix. Antibiotics are typically not indicated for HSG since the procedure is considered clean-contaminated. Antibiotic prophylaxis is indicated if a patient has a history of pelvic inflammatory disease or a known abnormal architecture from a prior laparoscopic procedure.

In rare situations, it has been reported that a hysterosalpingogram finding of prior retained products of conception with associated intravasation of contrast media can be associated with future volume overload in future hysteroscopic procedures.[16]

As with many gynecologic procedures requiring access through the cervix, abdominal cramping and vaginal bleeding are expected in the days after the imaging procedure is complete. The magnetic resonance imagining technique for a hysterosalpingogram is a new development. This method would eliminate the potential complications that are associated with radiation. This new imaging technique was determined to be non-inferior to X-ray hysterosalpingograms in a study based in France.[17]

Clinical Significance

When using a hysterosalpingogram as an imaging modality for infertility regarding tubal blockage, sensitivity and specificity are 53% and 87%, respectively.[18] Regarding endometrial cavity abnormalities, sensitivity and specificity are not as good but still are an essential part of the final workup for infertility.[19] A study comparing the sensitivity and specificity of a hysterosalpingogram and a sonohystogram showed that sonohysterogram was superior to a hysterosalpingogram for identifying intrauterine defects.[20] 

The efficacy of hysterosalpingograms is limited to only being able to visualize patent cavities. While this can detect several anomalies, this imaging technique is limited because it cannot comment on the endometrial surface as a possible reason for infertility.

Enhancing Healthcare Team Outcomes

Like most healthcare procedures, interprofessional healthcare team members need to exercise consistent interpersonal communication. Gynecologists, anesthesiologists, radiology technicians, nurses, and additional health care teams all play an essential role in patient care. Research has shown that failure to collaborate between teams increases medical errors. Meticulous documentation and communication with other team members are required for optimal patient care and the ability of the team to react to status changes, including the results of diagnostic testing such as hysterosalpingogram. This interprofessional communication will drive improved diagnosis leading to improved and targeted treatment. [Level 5]