A comparative study of conventional and magnetic resonance hysterosalpingography in assessing tubal patency at a tertiary care center

 

 

Abstract               Background: Infertility is defined as the inability to conceive after 12 months of regular unprotected sexual intercourse. Evaluation of uterotubal factors is an essential step in infertility management. Hysterosalpingography (HSG) is the most widely used method but this method is invasive and inconvenient to women. MRI-hysterosalpingography (MR-HSG) in addition to conventional MRI (with or without contrast) is effectively used in diagnosing the tubal and uterine cause of infertilities. Present study was aimed to compare conventional HSG and magnetic resonance hysterosalpingography in assessing tubal patency in patients with infertility. Material and Methods: Present study was prospective, observational study conducted in patients, referred for evaluation of tubal patency as a workup for infertility(primary or secondary) or for postoperative evaluation, following reversal of tubal ligation. Results: After applying inclusion and exclusion criteria total 48 patients were included in present study. 29 patients had primary infertility, while 19 patients had secondary infertility. Sensitivity, specificity, positive predictive value, negative predictive values of MR HSG in comparison with X‑ray HSG were 100%, 96.9% , 93.5%, 100% respectively. Conclusion: In evaluation of tubal patency MR-HSG is a simple, safe, sensitive tool, which also helps to assess uterus, ovaries and extra-uterine structures, important for evaluation of female infertility. Better assessment of this promising technique will be possible after wide-spread availability and use.

Key Words: female infertility, tubal patency, X-ray HSG, MR-HSG.

 

 

INTRODUCTION

Infertility is defined as the inability to conceive after 12 months of regular unprotected sexual intercourse. A variety of factors may affect normal fertility including patient age, anatomy, ovulatory status, and sperm quality. Potential causes of infertility can be divided into male and female causes and include endocrine, anatomic, genetic, and behavioural conditions. Approximately 15 % of couples have infertility¹. Some common causes of infertility are male factor (45 %), ovulation disorders (37 %) and tubal damage (18 %)². Tubal factors affect fertility in 18% to 81% of female infertile patients, depending on population³. Hence, evaluation of tubal patency is essential in investigation of female infertility. The prevalence of pelvic inflammatory disease, genital tract tuberculosis, and chronic infection is increasing and hence higher incidence of tubal factor is noted in infertile women ⁴.Evaluation of uterotubal factors is an essential step in infertility management. There are various invasive and noninvasive diagnostic procedures to evaluate uterine and/or tubal pathology. The noninvasive or minimally invasive modalities are ultrasonography, sonosalpingography and magnetic resonance imaging. The invasive modalities are hysterosalpingography (HSG), hysteroscopy and laparoscopy. Hysterosalpingography (HSG) is the most widely used method but this method is invasive and inconvenient to women. Many patients request anesthesia to perform HSG. Laparoscopy is also commonly used, requires proper anaesthesia. MRI-hysterosalpingography (MR-HSG) in addition to conventional MRI (with or without contrast) is effectively used in diagnosing the tubal and uterine cause of infertilities. Present study was aimed to compare conventional HSG and magnetic resonance hysterosalpingography in assessing tubal patency in patients with infertility.

 

MATERIAL AND METHODS

Present study was prospective, observational study conducted in Department of Radiodiagnosis, Oxford Medical college Hospital. Duration of study was 1 year (from September 2018 to August2019). Local institutional ethical committee clearance was taken for present study.

Inclusion criteria

Study was conducted in patients, were referred by the department of Obstetrics and Gynecology for

- evaluation of tubal patency as a workup for infertility(primary or secondary)

- for postoperative evaluation, following reversal of tubal ligation.

Exclusion criteria

• Uncooperative patients
• Patients with active pelvic inflammatory disease
• Patients with contraindications to MRI [pacemaker and cochlear implants]

After initial evaluation and written informed consent, patients were called on Day 7–Day 10 of the menstrual cycle. Tablet mefanamic acid was prescribed three times a day and a course of antibiotics [combination of ofloxacin and metronidazole] as premedication starting on the day before and continued two days post procedure. Under strict aseptic precautions, MRI‑compatible plastic HSG 5 - F microcatheter with inflatable bulb was inserted into the lower uterine cavity. The bulb was inflated with 3 cc of distilled water. Patient shifted to MRI scan. T2 W (TR: 7120 ms, TE: 90 ms, flip angle 900, slice thickness 5 mm, matrix 256 × 256) axial, sagittal, and coronal sequences were done. Dynamic T1 Cube Coronal 5 phases were taken. (TR: 3.8 ms, TE: 1.8 ms, TI: 7 ms, flip angle 120, slice thickness 3.4 mm, matrix 256 × 256). (PLZ CONFIRM IT) The first phase was imaged prior to saline infusion. Then, 10 ml of gadodiamide [1:100 dilution with 0.9% saline] was instilled and four successive phases were obtained. Corresponding subtracted images were generated automatically. The patients were immediately mobilized to the fluoroscopy room and 10 ml of iodinated contrast iohexol [Omnipaque; 350 mg/ml] was instilled through the same catheter. The spot film was taken after which the balloon was deflated and the catheter was removed. In patients with unilateral or bilateral tubal blocks, a diagnostic sos operative hystero-laparoscopy was planned in their next menstrual cycle as a part of routine subsequent evaluation and the findings were confirmed simultaneously. In patients with bilateral patent fallopian tube, who were either unable to conceive after 6 months or had some other factors also posted for diagnostic sos operative hystero-laparoscopy. The findings were confirmed during the procedure. All details (demographic, clinical, radiological and operative findings) were collected in a proforma in a Microsoft excel sheet. Statistical analysis was done using descriptive statistics.

 RESULTS

After applying inclusion and exclusion criteria total 48 patients were included in present study. 29 patients had primary infertility, while 19 patients had secondary infertility.

Age distribution of patients is shown in table 1.

 

Table 1: Age distribution of patients

Results of MR HSG and X‑ray HSG are shown in table 2. Whenever required and indicated diagnostic sos operative hystero-laparoscopy was performed and findings were confirmed. Results of tubal patency with MR HSG were identical to findings in diagnostic hystero-laparoscopy.

 

Table 2: comparison of MR HSG and X‑ray HSG

Total 96 tubes were evaluated during study for tubal patency. Results of MR HSG vs X‑ray HSG are compared in table 3.

Table 3: MR HSG vs X‑ray HSG – results for bilateral tubes

Sensitivity, specificity, positive predictive value, negative predictive values of MR HSG in comparison with X‑ray HSG were 100%, 96.9% , 93.5%, 100% respectively.

 

Table 4: Statistical analysis of MR HSG in comparison with X‑ray HSG