A RATHER DISTINCT PROGRESS in the choice of contrast preparation for hysterosalpingography

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1 Standard Radiographic Contrast Preparation (Urografin 60%) in Hysterosalpingography, with Special Regard to the Examination of the Fallopian Tubes PEKKA SOILA, M.D., and UNO WEGELIUS, M.D. A RATHER DISTINCT PROGRESS in the choice of contrast preparation for hysterosalpingography may be recognized throughout the history of this examination.2 4 Recently, the discussion has concentrated mainly on three types of contrast materials. 1 5 These are: ( 1) iodized oils, ( 2) "viscosized" watersoluble contrast materials, and ( ) pure water-soluble compounds of high concentration. The latter preparations usually contain three atoms of iodine in a molecule, and the viscosity of these preparations is guaranteed through a sufficiently high concentration. Definite agreement appears as yet not to have been attained as regards the relative advantages and disadvantages of these groups of preparations. In the course of a recent investigation concerning this problem, our attention was directed toward the possibility of using a standard contrast preparation for hysterosalpingography, without any consideration of the viscosity at all. 6 The compound in question is 60% n. N-diacetyl-, 5-diamino-2, 4, 6- tri-iodine-benzoic acid, marketed under the brand names Urografin and Renografin. t The reason to carry out an experimental series was the established favorable tolerance of the compound. Furthermore, it was reasoned that the low viscosity of the preparation would be helpful in an examination of the tubes, whereby less attention would be paid to exploration of the uterine cavity. MATERIAL AND METHOD Fifty consecutive patients referred to hysterosalpingography because of a primary or secondary sterility were examined with Urografin 60%. Four From the Department of Roentgenology, University Central Hospital, Turku, Finland. *Schering-Berlin, Germany. te. R. Squibb & Sons, New York, N.Y. 426

2 VoL. 14, No.4, 19~ MEDIUM FOR HYSTEROSALPINGOGRAPHY 427 TABLE 1. Distribution of Findings in Hysterosalpingography Normal findings Tubal occlusion dx. sin. Uterus unicollis bicornis Septum of the uterine cavity Uterine carcinoma Endometrial hyperplasia Cervicitis Sactosalpinx Closed Passage opened under pressure Tuberculosis Myoma Polypus Polyposis Genital hypoplasia Examination Repeated Not completed 10 Sph op dx Isthm. 4 sin. 4 Osti. 1 2 bilat. Bilat. 8 various types of cannulas were used alternatingly. Fifteen minutes prior to the examination the patients received one suppository of Buscopan. 0 All examinations were made by the radiologist alone, and fluoroscopic control was used throughout. After instrumentation the passage of the contrast material was followed under the screen, and the findings were registered with a sequence of radiographs. After removal of the instruments the patient was turned from the supine position into a prone position and an exposure was made to depict the cervical canal without the disturbing shadow of the instruments. RESULTS The results are summarized in Table 1. The distribution of the findings corresponds with what may be considered at the present time to be a characteristic distribution of the findings in hysterosalpingography. The selection of the patients for this examination, which involves a certain radiation hazard, is reflected in the comparatively low number of entirely normal findings, 10 cases, or 20% of the total number of examinations. A tubal closure *Boehringer Sohn, Ingelheim, W. Germany.

3 428 SOILA & WEGELIUS FERTILITY & STERILITY was detected in 29 instances (58%), of which 11, or 22%, were bilateral. The other findings, too, reflect a causal relation to the clinical complaint of the patients, primary or secondary sterility. As regards the contrast material Urografin 60%, experimentally used in this study, the following observations may be reported. The Instrumentation The selection of instruments, four various types in all, permits an evaluation of the rather low viscosity of Urografin 60%. Some difficulty was encountered in properly filling the cannula to avoid injection of air into the uterine cavity. Although considerable care was exercised in this respect, injection of air could not be completely avoided (Fig. 1). In spite of the fact that air insufflation has been widely used in the diagnosis and treatment of sterility cases, it was not considered appropriate to introduce air into the uterine cavity in connection with hysterosalpingography. Neither was the purpose of the study to use double-contrast method. Oil embolism as well as air embolism may. occur in spite of the early first-half of the menstrual cycle selected as the time of the examination. The occurrence of injection of air, 5 cases in all ( 10%), may be recorded as a drawback of the contrast agent examined. Otherwise no difficulty was encountered in the instrumentation. Technique of the Injection The difficulties in tightening up the external uterine orifice in hysterosalpingography are well known. With proper manipulation and, if necessary, with the use of two or even three forceps, a spill of the contrast material from the uterine orifice into the vagina may be rather effectively controlled. In 1 case the examination was considered to have been unsuccessful, owing to an insufficient attachment at a lacerated outer orifice. In another case no proper filling of the uterine cavity could be observed after an injection and during fluoroscopy. On the films a stricture of the internal orifice was suspected and a consequent dilatation of the internal orifice was performed (Fig. 2). Thereafter a hysterosalpingography was successfully carried out (Fig.S). The Findings The tips of the metallic instruments cast disturbing shadows upon the cervical canal. Films made with the instruments, but especially after their removal, showed the structures of the cervical canal in considerable detail Fig. 4-6). The freely moving Urografin appears to fill out very well the normal, as well as the pathologically changed, structures of the cervical canal.

4 VoL. 14, No. 4, 196 MEDIUM FOR HYSTEROSALPINGOGRAPHY 429 Fig. 1. a.. Enlargement of uterus due to myoma. b. Mter refilling of syringe, air bubble enters uterine cavity. Note distinct reproduction of tubes.

stricture. Fig.. Same case after dilatation.

5 40 SOILA & WEGELIUS FERTILITY & STERILITY Fig. 2. Stricture of cervical canal. Only a small amount of contrast material visible between, tip of cannula and stricture. Fig.. Same case after dilatation. Long and somewhat irregular cervical canal. Mucosal hyperplasia of uterine cavity. No passage on right side; left tube appears normal.

Note longitudinal folds. Small uterine cavity, bilateral tubal deformity with closure. Fig. 6.

6 VoL. 14, No.4, 196 MEDIUM FOR HYSTEROSALPINGOGRAPHY 41 Fig. 4. Cervical canal after removal of instruments. Normal appearance. Submucous myoma in left uterine horn. Fig, 5. Hyperplastic mucosa of cervical canal. Note longitudinal folds. Small uterine cavity, bilateral tubal deformity with closure. Fig. 6. Pronounced endocervicitis. Small uterine cavity. Right tube adherent and closed. Left tube well visualized, but there is no evidence of passage into peritoneal cavity. 6

7 42 SOILA & WEGELIUS FERTILITY & STERILITY a b Fig, 7. Large uterus of otherwise normal appearance. Intestinal shadows visible during initial injection (a), later hidden by increased amount of contrast material (b). The contrast shadow in the uterine cavity may be regarded as of being of two different types. Several observations support this impression. In a deliberate attempt to fill the uterine cavity only sparsely, to record the finding with an exposure and thereafter to increase the filling, revealed that the structures initially visible were later hidden out of sight by the increased amount of contrast material (Fig. 7 a and b). This observation may also be considered a disadvantage of Urografin 60%. However, the problem of a direct injection of rather dense contrast material into the various cavities of

Left tube appears also fixed, and there is an ampullary dilatation.

8 VoL. 14, No. 4, 196 MEDIUM FOR HYSTEROSALPINGOGRAPHY 4 Fig. 8. Normal finding. Note reproduction of tubes. Fig. 9. Right tube closed and fixed after partial resection. Left tube appears also fixed, and there is an ampullary dilatation. No evidence of passage. Fig. 10. Small mucosal fold in right uterine horn. Note detailed reproduction of both tubes.

the human body appears not yet to be definitely solved.

9 44 SOILA & WEGELIUS FERTILITY & STERILITY Fig. 11. Test injection with Urografin 45%. Unusually low contrast density in uterine cavity, where synechiae after previous curettage and a small air bubble are visible. Fair contrast in tubes and in peritoneal cavity. the human body appears not yet to be definitely solved. At any rate, the oily preparations used in hysterosalpingography certainly cast a denser shadow than any one of the water-soluble materials in use at the present time. Following a steady and continuous injection, the filling of the tubes could be recognized under the fluoroscope as soon as the contrast material had reached the ampullary segment. Also, the peritoneal spill could be immediately recognized. In the films, the tubes were seen reproduced in great detail (Fig. 8-10). The comparatively high concentration of Urografin 60% as well as its capacity quickly to fill out minute details of the tubes appears to be its greatest advantage. There was no appreciable risk of an unduly fast passage of the contrast through the tubes, as the tubes easily could be kept filled with a continued careful injection. As a rule, the peritoneal spill was not recognized as being too large to obscure structures of the uterine cavity or of the tubes. Side Effects There were no appreciable side effects attributable to the contrast substance. Urografin is generally known as a very-well-tolerated contrast rna-

10 VoL. 14, No.4, 196 MEDIUM FOR HYSTEROSALPINGOGRAPHY 45!erial in a great variety of radiologic examinations. Even after considerable peritoneal spill no serious side effects developed. One patient experienced pain in her right lower abdomen during the injection. This was explained on the basis of a closure of the tube, which was seen to open as a result of a somewhat increased pressure. ~ DISCUSSION The relative advantages and disadvantages of Urografin 60% in hysterosalpingography are quite apparent. The observations made on the basis of the present series revealed features which are deductible from the physicochemical qualities of this concentration of the compound. The main feature of Urografin 60% is a high concentration of iodine, which gives a rather dense contrast shadow. This is definitely advantageous as regards the examination of the fallopian tubes. Some advantage also may be gained in examination of the cervical canal. The examination of the uterine cavity should be carried out with a small amount of this preparation, as finer details of the anatomy may be suppressed, if the uterine cavity is overfilled with it. This observation caused us to pedorm a test injection with U rografin 45% (Fig. 11). A small bubble of air entered the uterine cavity with the low-viscosity fluid, but the structures of the uterine cavity became rather adequately visualized. Urografin 60% has a low viscosity too, and it fills minor cavities and irregular details of the structures rather well. Peritoneal spill was not found to cause any appreciable irritation, but it might constitute a disturbing effect by way of covering some parts of the structures to be examined. Instrumentation and the filling of the instruments require care in handling the contrast fluid, if injection of air is to be avoided. Though Urografin 60% and analogous preparations have not yet solved all the problems of contrast media, they might be favorably considered for hysterosalpingography.7 This is especially true in cases of sterility, where there is reason to direct the inquiry toward the condition of the tubes. While the search for an ideal contrast material might continue for some time, steady progress and even a certain differentiation with regard to the clinical and radiologic problem may be recognized through the advent of the three iodinecontaining contrast compounds. SUMMARY 1. Urografin 60% has been tried in an experimental series of 50 cases of primary or secondary sterility examined by hysterosalpingography. 2. The chief characteristics of Urografin 60% are low viscosity and a high

11 46 SOILA & WEGELIUS FERTILITY & STERILITY degree of density. Hence, an investigation of the fallopian tubes may especially profit from the use of Urografin 60%.. Painful irritation or other side effects were negligible. The low viscosity of Urografin 60% constitutes a disadvantage in so far as the instrumentation and injection should be made with due regard to this quality. Small amounts and visual control of the injection are recommended. 4. The diagnostic results correspond fully with what may be expected to be a characteristic distribution of findings in hysterosalpingography at the present time. REFERENCES Kivela Hospital Helsinki, Finland I. FELDMAN, H. J. Hysterosalpingography for therapy with infertility (Ethiodol). Intemat. /. Fertil. 5:289, ( 1960). 2. KJELLBERG, S. R. Hystero-salpingo-pelvigraphie. Acta radial. Suppl. 4, MAcGREGOR, W. G., and SHEACH, J. R. Biligrafin for hysterosalpingography. Letter to the Editor. Lancet 271:682, NORMAN, 0. In Rontgendiagnostik. Ergebnisse , edited by Schinz-Glauner Uehlinger. Thieme, Stuttgart, RUBIN, J. C., MYLLER, E., and HARTMANN, C. 0. Salpix: A new approach to the ideal radiopaque medium for hysterosalpingography. Fertil. & Steril. 4:57, SoiLA, P., GRi:iNRoos, M., KAuPPILA, 0., and PYYKi:iNEN, L. Wasserli:isliche, viskosierte Wasserli:isliche und jodolige Kontrastmittel in der Hysterosalpingographie. Acta radial. Suppl. 218, YoUNGSTROM, K. A. Salpingography: Study of use of diatrizoate sodium (Hypaque). /. Kansas M. Soc. 59:08, 1958.

Incidence of Residual Intraperitoneal lodochlorol after Hysterosalpingography

Incidence of Residual Intraperitoneal lodochlorol after Hysterosalpingography A Radiologic Study of I 00 Infertile Women Who Subsequently Became Pregnant Abner I. Weisman, M.D. STUDIES by Brown, Jennings,