Hysterosalpingogram

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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. This activity explains the interprofessional team's role in evaluating and diagnosing some causes of infertility in females.

Objectives:

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

Introduction

The imaging procedure is commonly the second step in the diagnostic approach for female patients presenting with infertility. Infertility in females is a complex workup assessed from a hormonal, structural, and partner-based approach. 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 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. The media fills the uterine cavity and continually fills 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 there are media flowing from all 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 that 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 and thus allows for the visualization of the media’s pathway.

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 near the fundus, 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 are sourced from the incomplete fusion of the Mullerian ducts, which can lead to a bicornuate uterus presentation.

Currently, there are seven different 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.[1] Mullerian abnormalities are suggested to be found in around 5% of all hysterosalpingograms.[2] 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 suggested to be present in 12 to 33% of patients undergoing an infertility workup.[3] The major cause of tubal occlusions is sexually transmitted infections. Gonorrhea has been suggested to be associated with 90% of the cases of infertility.[4]

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, however, has suggested that hysterosalpingogram is more superior when the primary outcome is pregnancy.[5]

Contraindications

The primary contraindication to the procedure is 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. The use of iodine can lead to a Wolff-Chaikoff effect or exacerbate thyrotoxicosis in patients with a known history of Grave’s disease. Glucocorticoid cover may be indicated before the procedure.

Pelvic inflammatory disease is not a direct contraindication for a hysterosalpingogram, but if a patient has a diagnosis, the patient should be started on antibiotics. Specific guidelines are addressed through literature provided by the American College of Obstetrics and Gynecology.[6] A single retrospective study suggests a finding of dilated fallopian tubes results in a high probability of having a post-hysterosalpingogram pelvic inflammatory disease diagnosis. The recommended regimen is doxycycline 100mg twice daily for five days.[7]

Equipment

An acorn cannula or a balloon tip catheter are the two main devices used to inject media into the intrauterine space. Since entry into the endocervix is required, a tenaculum (single-tooth, double-tooth) and cervical dilators (Hank, Haeger, or Pratt) are used. Depending on provider preference, local agents such as lidocaine with epinephrine can be injected into the paracervical space or cervical stroma to minimize traumatic bleeding and pain.   

Media generally used is the radio-opaque dye is injected with a cannula through the endocervix. All media contain iodine with a current preference toward water-soluble. Historically, oil-based media was used since it was thought that the ability to return to conception-capable was quicker. This has been unfounded. Oil-based media increases the risk of granuloma formation.[8]

Preparation

The patient is put under sedation during the procedure with the assistance of anesthesiologists. The anesthetic agent chosen is important because it must act quickly, reduce fallopian tube spasms, and reduce the pain of the procedure during uterine manipulation. A double-blinded randomized control trial demonstrated that midazolam was superior to dexmedetomidine in reducing pain while also being non-inferior for fallopian tube spasm frequency.[9]

Technique

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 as is superior to the luteal phase because the endometrial lining is thinner, which increases patency. Before the procedure, the patient can take analgesic medication for pain prophylaxis. The patient is placed into lithotomy positive with legs in stirrups. The vaginal and cervix are prepared with antiseptic. A speculum is placed in the vagina to allow for visualization of the cervix. Typically, the anterior lip is grasped with a single-tooth tenaculum. The cervix is sequentially dilated with dilators until the HSG cannula can be placed into the endometrial cavity. The media fills the cavity and eventually flows out of the fallopian tubes. Once the media is filled, an X-ray is taken. X-rays can be continually taken until there is a confirmation of media flow. Three standard views are obtained: frontal and two obliques. Once the procedure is completed, the patient can be sent home. It is advised that the patient can take pain medication to reduce pain symptoms after the procedure.

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. If a patient has a history of pelvic inflammatory disease or a known abnormal architecture for a prior laparoscopic procedure, then antibiotic prophylaxis is indicated.

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.[10]

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. Furthermore, since this imaging technique uses X-rays, there is an increased risk of developing pelvic cancers. There is a new development of magnetic resonance imagining technique for a hysterosalpingogram. 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.[11]

Clinical Significance

When using a hysterosalpingogram as an imaging modality for infertility regarding tubal blockage, sensitivity and specificity are 53% and 87%, respectively.[12] Regarding endometrial cavity abnormalities, sensitivity and specificity are not as good but still are an important part of the final workup for infertility.[13] 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.[14] 

The efficacy of hysterosalpingograms is limited to only being able to visualized patent cavities. While this can detect several anomalies, this imaging technique is limited because it is unable to comment on the endometrial surface as a possible reason for infertility.

Enhancing Healthcare Team Outcomes

Like most health care procedures, it is essential for interprofessional team members to exercise consistent interpersonal communication. Gynecologists, anesthesiologists, radiology technicians, nurses, and additional health care teams all play an important role in patient care. Research has shown that failure to collaborate between teams increases medical errors. This interprofessional communication will drive improved diagnosis leading to improved and targeted treatment. [Level 5]


Article Details

Article Author

Christopher Mayer

Article Editor:

Preeti Deedwania

Updated:

6/20/2021 3:54:57 PM

PubMed Link:

Hysterosalpingogram

References

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[8]

Miyazaki Y,Yamamoto T,Hyakudomi R,Taniura T,Hirayama T,Takai K,Hirahara N,Tajima Y, Case of inflammatory granuloma in inguinal hernia sac after hysterosalpingography with oily contrast medium. International journal of surgery case reports. 2020;     [PubMed PMID: 32544832]

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[11]

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