Hysterosalpingography in the 1990s

All physicians involved in the evaluation and treatment of infertility rely heavily on the information provided by hysterosalpingography. For many years this study has provided images of the lumina of the fallopian tubes that are not available by other diagnostic means, and it also gives the most accurate outline of the uterine cavity. Hysterosalpingography will therefore continue to be a valuable study in the upcoming decade, and it is important now to take account of the many advances in technology that impinge on the execution and interpretation of this study. In this article we first update the continuing debate about elements of the study itself, involving techniques and the choice of contrast material. We also consider surgical advances, such as the widespread use of microsurgical reconstruction of the fallopian tube, that increase the demand for hysterosalpingography. Since radiologists are asked to evaluate the results of surgery, it is essential for them to be familiar with the postoperative appearances of the fallopian tube. Finally, we consider what must be by far the most important development of the 1990s, the continuing integration of hysterosalpingography with new interventional and imaging techniques. Fallopian tube catheterization expands the examination of the fallopian tube and offers new therapeutic applications. Transvaginal sonography and MR imaging have allowed noninvasive exploration of the female pelvis. Correlation of hysterosalpingography and MR imaging is particularly useful in the diagnosis of uterine myomas and congenital uterine duplication anomalies when surgery to preserve or enhance the reproductive capacity of the uterus is indicated. Sonography and MR imaging should be correlated with hysterosalpingography to provide a more efficient diagnostic and therapeutic approach to the common mechanical causes of infertility.     

双腔球囊导管子宫输卵管碘水造影的临床应用

目的 探讨女性不孕症子宫腔输卵管碘水造影诊断的优越性.方法 应用双腔球囊导管插入子宫腔,注入2.5～3.5 ml生理盐水或空气充盈球囊,使球囊卡于子宫颈峡部,堵住子宫颈内口,用助推器注入碘海醇充盈子宫及输卵管,如遇输卵管阻塞时,可进一步增高宫腔内压力,使造影剂钝性分离,开通阻塞输卵管,整个过程在电视监视下进行,并选择实时摄片.结果 本组检查2 698例女性不孕患者,插管成功2 685例,成功率99.5%.诊断原发不孕806例,继发不孕1 868例,其他24例.子宫腔造影：正常2 198例（81.9%）,各种先天性畸形249例（9.3%）,各种后天性病变238例（8.9%）,输卵管阻塞3 082支.有98例曾在外院作过碘油造影,至今35例输卵管内仍有碘油潴留.输卵管重度积水117支（3.8%）.术中有轻度疼痛,无并发症及死亡.结论 该法简便快速,安全有效,图像质量优良,能获得比碘油造影更多的信息.克服了碘油造影不能加压和部分患者输卵管内长期碘油潴留的缺点,值得推广应用.     

MR hysterosalpingography: protocol development and refinement for simulating normal and abnormal fallopian tube patency--feasibility study with a phantom

PURPOSE: To develop and refine a pulse sequence and protocol for testing the feasibility of magnetic resonance (MR) hysterosalpingography in a phantom model. MATERIALS AND METHODS: A phantom simulating the uterus, fallopian tubes, and surrounding pelvic cavity was constructed. T2-weighted acquisition strategies-breath-hold fast spin-echo, rapid acquisition with relaxation enhancement (RARE), and haff-Fourier RARE-were refined to acquire sequential 70-mm coronal imaging volumes. Contrast agent was injected into the introducing catheter entering the os of the simulated uterus. Interacquisition interval, type of contrast agent (eg, sterile saline solution or water), and quantity of contrast agent (eg, 1-5 mL per acquisition) were varied. Digital image subtraction was used to enhance image quality. Images were qualitatively analyzed and rated good, fair, or poor for temporal resolution, spatial resolution, fallopian tube conspicuity, and free spill conspicuity. Once the technique was refine, the phantom was reconfigured to simulate unilateral and bilateral hydrosalpinx. RESULTS: The RARE sequence with an 8-second interacquisition interval and a 5-mL interacquisition of sterile water produced good images of the simulated fallopian tubes and free spill. Depiction of unilateral and bilateral hydrosalpinx was also reliably demonstrated. CONCLUSION: This study with a phantom model demonstrates the feasibility of MR hysterosalpingography to depict normal and diseased fallopian tubes.     

Müllerian duct anomalies: MR imaging evaluation

Twenty-nine patients underwent magnetic resonance (MR) imaging for investigation of müllerian duct anomalies (MDAs). The anomalies evaluated were uterine agenesis (n = 2), uterine hypoplasia (n = 5), unicornuate uterus (n = 5), uterus didelphys (n = 5), bicornuate uterus (n = 10), and septate uterus (n = 2). The MR imaging interpretation was correlated with results of laparotomy (n = 18), hysterosalpingography (HSG) (n = 5), laparoscopy (n = 2), hysteroscopy (n = 1), HSG and laparotomy (n = 2), and HSG and laparoscopy (n = 1). MR imaging enabled correct classification of the anomaly in each patient and identification of coincidental gynecologic disease in 10 patients (34%). MR imaging results influenced clinical treatment in six (24%) of 25 patients referred prospectively. Of particular value was the ability to characterize septal tissue (myometrium versus fibrous tissue), identify the patients in whom the septum of bicornuate uteri had both fibrous and myometrial components, and establish that suspected adnexal lesions were actually components of obstructed MDAs.     

A scintigraphic method of examining the patency of oviducts using 133Xe

Described below is the radioisotope method of examining the patency of oviducts using a solution of ¹³³Xe. Scintigraphic pictures of the uterine cavity and oviducts were obtained with a Jumbo Toshiba gamma-camera; they were subsequently analysed by an Informatek SIMIS-3 data processing system. A total of 30 women aged between 20 and 36 with primary or secondary infertility were examined. The patency of oviducts and the shape of the uterine cavity was assessed on the basis of: the overall picture of the activity of ¹³³Xe in the uterine cavity and oviducts, the isocontours of the overall picture, curves of increasing and decreasing activity in the fallopian tubes, and the spatial picture of activity distribution in the uterus and fallopian tubes. The results of the examinations corresponded in all cases with the diagnosis made on the basis of hysterosalpingography. An advantage of the isotope method of examining the patency of fallopian tubes and the shape of the uterine cavity is the fact that it is an examination of a dynamic nature, completely safe for the patient and exposes the patients to a considerably lower dose of irradiation than during hysterosalpingography.     

Three-dimensional dynamic MR hysterosalpingography: a preliminary report

The aim of this study was to evaluate the feasibility of three-dimensional dynamic MR hysterosalpingography (3D MR HSG) for visualization of the cavum uteri and demonstration of bilateral fallopian tube patency as an alternative to conventional hysterosalpingography. Five infertile female patients underwent 3D dynamic MR HSG prior to conventional hysterosalpingography. The MR protocol consisted of axial T1-weighted spin-echo (SE), axial/coronal T2-weighted fast SE (FSE), and 3D MR angiography sequences before, during, and after injection of a diluted gadolinium solution into the cavum uteri via a balloon catheter. Positioning of the catheter was feasible in all patients. In one patient the catheter slipped out during MRI and in one patient the catheter was placed far in the cavum uteri. In three patients catheter position was optimal at the level of the cervical canal. Evaluation of pelvic anatomy, myometrium, and ovaries was possible in all patients on the basis of T1-weighted SE and T2-weighted FSE. Three-dimensional visualization of the dilated cavum uteri was possible in four patients. In these four patients 3D MR HSG also proved bilateral fallopian tube patency which was confirmed in each patient by conventional hysterosalpingography. Three-dimensional MR HSG is feasible and further research should be done to determine if this technique can evolve into an alternative technique to conventional hysterosalpingography with the advantages of no radiation and additional visualization of the uterus wall and ovaries.     

T-shaped uterus in diethylstilbestrol (DES) exposure.

Radiographic findings in four young women with small T-shaped uteri are reported. Three of the women had been exposed to diethylstilbestrol (DES) in utero. In the fourth, radiographic findings were typical of in utero diethylstilbestrol exposure.     

数字化子宫输卵管造影在不孕症诊断中的应用

目的 探讨子宫输卵管造影过程中,数字化成像对减小医生和患者所受X线辐射剂量的价值.方法 对234例不孕症采用数字透视作子宫输卵管造影检查,并连续记录3个月中病人每次检查所需的X线曝光时间.结果 子宫输卵管均正常者86例（36.7%）,单纯输卵管疾患112例（47.8%）,单纯子宫疾患17例（7.2%）,子宫粘连合并输卵管阻塞14例（6.0%）,子宫畸形合并输卵管阻塞3例（1.3%）.连续记录86例每次检查X线曝光时间为63 s～212 s,平均106 s.结论 数字化子宫输卵管造影配合造影方法上的改进,不仅可获得满意的诊断图像,并且可以大大减小医生和患者所受的X线辐射剂量.     

子宫输卵管碘油造影诊断价值分析

目的探讨子宫输卵管碘油造影的诊断价值。方法对120例资料较完整的子宫输卵管碘油造影的x线片进行分析。结果正常26例，宫腔异常5例，单侧输卵管不通39例，双侧输卵管不通27例，输卵管通而不畅23例，造影剂逆流14例。结论子宫输卵管碘滔造影是行之有效且简便实用的诊断方法。     

Septate or bicornuate uterus: Accuracy of three-dimensional trans-vaginal ultrasonography and pelvic magnetic resonance imaging

Objective

To estimate the accuracy of 3-dimensional transvaginal ultrasonography (3D-TVUS), hysterosalpingography (HSG) and pelvic magnetic resonance imaging (MRI) in the differentiation between septate and bicornuate uterus.

Patients and methods

Thirty-six patients with suspected septate or bicornuate uterus on 2D ultrasound or hysterosalpingography (HSG) underwent 3D-TVUS examination, MR imaging, diagnostic laparoscopy and hysteroscopy. HSG was performed only for those patients who did not undergo the procedure before (21 patients), we retrospectively revised the hysterosalpingography of 15 patients performed outside our hospital with acceptable quality.

Results

HSG showed sensitivity of 77.4%, specificity of 60% and overall accuracy of 75% in the differentiation between the septate and bicornuate uterus. MRI showed sensitivity of 93.5%, specificity of 80%, PPV of 96.6% and negative predicative value of 66.6%, with overall accuracy of 91.6%. The 3D ultrasound showed the highest diagnostic parameters, with sensitivity of 96.7%, specificity of 100%, PPV of 100% and negative predicative value of 83.3%, with overall accuracy of 97.2%.

Conclusions

Transvaginal 3-D ultrasonography is accurate for diagnosis and differentiation between septate uterus and bicornuate uterus. We recommend 3-D transvaginal ultrasonography as the first and only mandatory step in the assessment of the uterine cavity in patients with a suspected septate or bicornuate uterus, especially before planning surgery. MRI should be preserved for patients in whom 3D TVS is not possible like virgins.     

MR evaluation of uterine anomalies

The MR features of uterine anomalies were analyzed in eight women. Scans were done on a 1.5-T magnet with T1-weighted (TR 600 msec, TE 25 msec) and T2-weighted (TR 2000-2500 msec, TE 35-80 msec) spin-echo images obtained in several planes. The anomalies consisted of bicornuate uterus (three cases), septate uterus (one case), bicornuate uterus with septation (two cases), unicornuate uterus (one case), and uterus didelphys with vaginal septum (one case). These diagnoses were confirmed by hysterosalpingography with laparoscopy (five cases), dilation and curettage with laparoscopy (one case), or cesarean section (two cases). In six of the eight cases, MR correctly identified and accurately classified the type of anomaly. In the other two cases, the MR diagnosis was a bicornuate uterus with septation. One case proved to be a uterus didelphys with vaginal septum, and the other a bicornuate uterus without septation. The study shows that MR is a valuable tool for the diagnosis of uterine anomalies.     

Selective and ambulatory salpingography

A new technique is here proposed to enhance, in a selective or direct way, the fallopian tubes. This new approach is suggested because hysterosalpingography (with the filling of the uterine cavity) is an indirect procedure, and therefore not completely reliable. Since intrauterine pressure cannot exceed 200 mmHg, and more pressure is needed to reach the tube ostia, false negatives are produced; up to 50% of the fallopian tubes not enhanced during hysterosalpingography are normal. Thurmond et al. were the first to introduce selective salpingography. They used a blind procedure with fluoroscopy passing through the uterine cavity, catheterized, with probes, and performed repeated fluoroscopic examinations of the uterine cavity. We suggest a different technique consisting in the use of hysteroscopy to visualize the ostium, and of a direct image to place the probe into the fallopian tube. The intubation is then repeated, if needed, in the other tube, which is then enhanced with the conventional means. X-ray pictures of both tubes will then be made. The technique is thus a simple and quick one, which can be carried out on an out-patient basis at the Radiology Department, without premedication, and with no need for previous preparation. Neither is it necessary to dilate the cervix nor to anesthesize the patient if the Karl-Storz chorionscope is used, which has proved the most useful instrument for this purpose. No complications were observed and the contraindications were similar to those of hysterosalpingography and hysteroscopy. To optimize the method, 16 direct fallopian tube intubations were carried out on a selected group of patients suffering from different kinds of infertility. The procedure lasted no longer than 20 minutes, was well tolerated, and allowed the patients to immediately resume their usual activities. We believe this practical technique to be the procedure of choice when one/both fallopian tubes are not enhanced during conventional hysterosalpingography.     

子宫输卵管造影对不孕症的诊断价值

目的 论证子宫输卵管造影在不孕症中的诊断价值。方法 对986例不孕症患者行子宫输卵管碘油造影，在造影时和24h后各摄盆腔正位片1张。结果 986例造影中，子宫输卵管正常98例（9.9%），输卵管炎症及积水254例（25.8%），慢性盆腔炎320例（32.5%），子宫输卵管结核160例（16.2%），子宫先天发育畸形154例（15.7%）。结论 子宫输卵管造影对女性不孕症的病因诊断有重要价值，可为临床治疗提供客观依据。     

MR hysterosalpingography in a rabbit model

Our objective was to evaluate the efficacy of MR imaging as compared with conventional hysterosalpingography (HSG) for the detection of fallopian tube patency after uterine injection of contrast material. Rabbit uterine horns (n = 18) were catheterized transvaginally. Five fallopian tubes were ligated and 11 were left unaltered. T1-weighted gradient-echo MR images were obtained before, during, and after injection of 1.0–3.0 mL of a dilute gadolinium-containing contrast agent. Corresponding conventional studies were performed with an equivalent volume of iohexol. Images were evaluated by two blinded readers. Observers agreed in all cases on the presence (n = 11) or absence (n = 5) of peritoneal spill with conventional HSG. Interpretation of MR HSG concurred with conventional HSG in 14 of 16 cases for each observer (P > .05). Reasons for misdiagnosis included small amounts of spill (n = 2), artifact (n = 1), and subtle spill between bowel loops (n = 1). Sensitivity and specificity for MR HSG were 95.5% and 70%, respectively, for the diagnosis of tubal patency/occlusions. No statistical difference was found between MR HSG and conventional HSG for the diagnosis of fallopian tube patency/obstruction. Potential advantages of MR HSG include no ionizing radiation, potentially diminished local contrast toxicity, superior visualization of uterine fibroids and endometriosis, and visualization of ovaries. We conclude that this technique warrants further study, including the use of a primate model to better simulate human anatomy.     

Radionuclide hysterosalpingography with technetium-99m-pertechnetate: application and radiation dose to the ovaries.

Although radionuclide hysterosalpingography (RNHSG) has been suggested as an efficient procedure for assessing function of fallopian tubes, the radiation dose to the ovaries was addressed as an important issue to be taken into consideration. We describe a modified method of RNHSG, calculating the radiation dose to the ovaries. A small dose of approximately 18.5 MBq (0.5 mCi) of [99mTc]pertechnetate was administered directly into the uterine cavity without overpressure. The accuracy of the method was 84.5% as compared with the contrast hysterosalpingography. The estimated average dose to the ovaries was 0.057 mGy/MBq (0.21 rad/mCi) or 1.08 mGy (108 mrad) per study. RNHSG is an accurate method for functional study of fallopian tube patency with low radiation dose.     

The spectrum of imaging appearances of müllerian duct anomalies: focus on MR imaging

Müllerian duct anomalies (MDAs) are the result of incomplete development, vertical or lateral fusion, or absorption of the müllerian ducts. The range of anomalies includes uterovaginal agenesis or hypoplasia, unicornuate uterus, uterus didelphys, bicornuate uterus, septate uterus, and arcuate uterus. Correct diagnosis and classification of these anomalies are essential because pregnancy outcomes and treatment options vary between the types of anomaly. Furthermore, early identification of MDAs helps to avoid prolonged symptomatic periods and the complications that may subsequently arise, such as infertility, endometriosis, and neoplasm. Although many of these abnormalities are initially diagnosed by ultrasound or hysterosalpingography, MR imaging is the most accurate noninvasive modality available for classification of the various anomalies because of its better anatomic assessment compared with other diagnostic modalities. Familiarity with the wide variety of MDA presentations can help in the planning of appropriate treatment.     

子宫输卵管通液测压诊疗仪的临床应用价值

目的:探讨子宫输卵管通液测压诊疗仪(简称遥控造影仪)的临床应用价值.方法:应用遥控造影仪对149例不孕症患者行子宫输卵管造影术(HSG),并观察宫腔及输卵管情况.结果:输卵管完全梗阻85条(29.5%),其中积水23条;不完全梗阻37条(12.8%),积水9条;完全通畅166条(57.7%).子宫畸形13例(8.7%);宫腔粘连16例(10.7%);子宫内膜炎31例(20.8%);子宫正常者89例(59.7%).所有病例中出现各类对比剂逆流12例(8.1%).结论:使用遥控造影仪进行子宫输卵管造影是一种安全可靠的造影方法,但子宫造影管需要进一步改进.     

子宫显著屈曲患者的输卵管再通术

目的：探讨利用自制装置对子宫显著屈曲合并输卵管梗阻的不孕患者进行输卵管再通术的插管方法并分析其疗效。方法：经子宫输卵管造影证实子宫显著屈曲伴单侧或双侧输卵管阻塞患者48例,共66争输卵管阻塞,应用自制装置,配合使用各种手术器械,施行选择性输卵管造影及再通术。采用复通率及妊娠率（随访2年）评价输卵管再通术的治疗效果,并将其与子宫位置正常患者进行比较。结果：48例患者均插管成功,施行再通术后,有56条输卵管复通,复通率为84．8％,随访2年后9例妊娠,妊娠率18．8％,妊娠率低于子宫位置正常患者,而复通率与子宫位置正常患者相近。结论：使用自制装置能够较方便完成显著屈曲子宫的输卵管再通术,各种手术器械的配合使用有利于成功插管。     

Magnetic resonance hysterography and hysterosalpingography using hyperpolarized (3)He: demonstration of feasibility in an animal model

Assessment of the uterine cavity and patency of the fallopian tubes remains a difficult goal with magnetic resonance imaging (MRI). The purpose of this paper is to describe the development of a new magnetic resonance hysterography (MR-HG) and hysterosalpingography (MR-HSG) technique employing hyperpolarized (3)He. Two-dimensional (2D) and 3D gradient-echo imaging sequences were developed and optimized using a phantom. An optimized sequence was then applied in swine cadavers. J. Magn. Reson. Imaging 2000;12:1009-1013.     

Imaging of female infertility

Normal reproduction requires healthy female anatomy. Cervical, uterine, tubal, ovarian, and peritoneal factors can coexist and cause female infertility. Ultrasound, hysterosalpingography, MR imaging, and fallopian tube catheterization are the radiologists' armamentarium for diagnosis. This article illustrates important findings in the infertile woman. An understanding of these entities helps i n accurateand sympathetic treatment.