Radiographic findings in Hysterosalpingography (HSG) of women attending infertility clinic at University of Uyo Teaching Hospital, Akwa-Ibom state

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1 Scholarly Journal of Medicine, Vol. 5(2) pp May, 2017 Available online at ISSN Scholarly-Journals Full Length Research Paper Radiographic findings in Hysterosalpingography (HSG) of women attending infertility clinic at University of Uyo Teaching Hospital, Akwa-Ibom state Moi, A.S.* 1, Etim, U. F. 2, Obotiba, A.D. 3, Abubakar, G.M. 4, Luntsi, G. 5, Nkubli, B.F. 6, Nwobi, I.C. 7 and Aniekop, U.P. 8 1,2,3,4,5,6,7,8 Department of Medical Radiography, University of Maiduguri, Borno State, Nigeria. Accepted 15 May, 2017: Infertility is considered a stigma and a major public health concern in Africa. In spite of improvements in medical services, the prevalence of infertility remains significant. Records from the radiology unit of University of Uyo teaching hospital indicates high incidence of HSG examination for women attending infertility clinic in the hospital. Hence, study was designed to establish the pattern of findings of HSG, and to correlate these findings with age of patients attending infertility clinic at the hospital. This institutional research ethics committee approved cross-sectional study involved review of 245 HSG reports performed between February, 2012 and February, Descriptive statistics was used to analyze the data collected using SPSS version The pattern of findings in HSG in the study area include; uterine fibroid, tubal blockage and adhesion. The commonest pathology responsible for infertility in the locality is uterine fibroid. The age group with the highest percentage of pathologies responsible for infertility is years. The common cause of infertility in the study locality is uterine fibroid followed by tubal blockage and adhesion. The pattern of HSG findings of the study are tubal blockage, adhesions, uterine fibroid, hydrosalpinx, isthmica nodosa, arcuate uterus and bicornuate uterus with the age group of years mostly affected. Key words: Computed Radiography, Conventional Radiography, Rationale. INTRODUCTION Infertility is defined as the inability to conceive after 12 months of unprotected coitus (Kiguli -Malwadde and Byanyima, 2004). It is divided into primary and secondary infertility. In primary infertility, couple is not able to become pregnant after at least one year of sexual intercourse, while in secondary infertility couple has been pregnant at least once and are not able to become pregnant again (Kiguli -Malwadde and Byanyima, 2004). Hysterosalpingography (HSG) is the radiographic technique for evaluation of uterine cavity and fallopian tubes. It remains the best procedure for assessment of fallopian tubes despite the advent of newer modalities, and it is used primarily for evaluation off female infertility. HSG is easy, relatively safe and a cost effective *Corresponding author moisolver@unimaid.edu.ng. procedure demonstrating a wide variety of uterine and tubal abnormities (Santhalia et al., 2013). The role of HSG in female infertility cannot be over emphasized (Acholonu et al., 2011). HSG is the commonest method of investigating the female genital tract with infertility being the most prominent indication for this examination (Kiguli-Malwadde and Byanyima, 2004). In addition to the diagnostic value, HSG may also be used for therapeutic purpose to unblock the blocked tubes (Salle et al., 1996). Fibroid, polyps, adhesion, women with history of recurrent abortion, bilateral tubal blockage and bicornuates uterus are the common examples of pathologies presented in HSG results (Acholonu et al., 2011). HSG is performed by injecting a. water soluble non-ionic contrast medium under fluoroscopic guidance into the uterus Uterine abnomalities are outlined by the opacity of the contrast medium into the uterine canal and fallopian tubal

2 Moi et al., 22 obstruction is noted by the absence of free spillage of contrast medium into the peritoneal cavity. Radiographic image receptors are used to obtain the image of the uterus, tubal anatomy and peritoneal spillage. First film visualizes the uterine cavity and the second film is obtained during early tubal filling while the third, after peritoneal spillage (Santhalia et al., 2013). Several studies have been done to assess pattern of HSG findings in patients with infertility. Hydrosalpinges was found to be the highest cause of abnormality with rare cases of congenital abnormality (Nwankwo and Akani, 2005). This find was not in agreement with a similar study conducted in Ghana which shows that tubal blockage was the commonest finding (Botwe et al., 2015). The disparity may be due to the fact that various studies were performed in different locations. To the best of the researcher s knowledge there is dearth of literature on the subject matter in the study locality. Hence, study was designed to establish the pattern of findings of HSG, and to correlate these findings with age of patients attending infertility clinic at the hospital MATERIALS AND METHODS A retrospective cross-sectional design was carried out, reviewing 245 radiological reports on patients that had HSG examination at the Radiology Department of University of Uyo Teaching Hospital, from February 2012 to February Data were collected using data capture sheet with columns for age, indications and findings. Descriptive statistics (frequency and percentages) was used to analyze the data collected using Statistical package for Social Sciences (SPSS) version PROCEDURE Indications Indications for hystersalpingography include: - Female infertility aimed at assessing tubal and uterine factors - Confirmation of tubal patency or monitoring of tubal patency or occlusion after surgical procedure. - Demonstration of congenital abnormalities or other lesion in patient with recurrent abortion. - Assessment of proximal tubal segment before tubal ligation reversal. - Amenorrhea unresponsive to hormonal stimulation - Evaluation of tubal patency after tubal surgery Contraindications HSG should not be performed during menstruation and pregnancy. Other contraindication include: pelvic sepsis, recent dilatation and curettage, severe cardiac or renal disease, uterine malignancy, endometrial carcinoma and on women who are sensitivity to contrast medium. Contrast Medium High Osmolar Contrast Medium (HOCM) or Low Osmolar Contrast Medium (LOCM). Volume ml. LOCM have no advantage with regard to image quality or sideeffects but the nonionic dimer, Iotrolan, is associated with a lower incidence and decreased severity of delayed pain (Chapman and Nakielny, 2001). Equipment - Vaginal speculum - Cotton wool - Sterile gauze - Vulsellus/sponge holding forceps - 10ml syringe - Antiseptic solution - Uterine cannula, Leech Wikinson s cannula Patient Preparation The procedure is performed in the first half of the menstrual cycle following cessation of bleeding i.e. 7 th to 10 th day of the menstrual cycle. This is because endometrium is thin during this proliferative phase and this facilitates better image interpretation and ensuring that there is no pregnancy (Kiguli -Malwadde and Byanyima, 2004). The patient is asked to refrain from unprotected sexual intercourse from the date of her period until after the investigation to be certain that there is no risk of fetal irradiation. Examination in the second half of the cycle is avoided because the thickened endothelium in the secretory phase increases the risk of venous intravasation and may cause a false positive diagnosis of corneal occlusion. The patient should be asked to empty the bladder prior to the procedure to ease discomfort from insertion of the speculum. Details of the procedure should also be explained to the patient (Kiguli- Malwadde and Byanyima, 2004). Premedication Steroid (prednisolone) premedication is prescribed in asthmatics when intravenous contrast is used; therefore it

3 Scholarly J. Med. 23 Table 1: Age distribution of participants. Age (Years) Frequency Percentage (%) is reasonable to do the same for HSG because intravasation is also possible from this procedure. Apprehensive patients may need premedication such as diazepam. Spasm of the uterine cornus may be relieved by glucagon given intravenously. Technique The patient lies supine on the table with knees flexed, legs abducted and heels together i.e. in lithotomy position (Chapman and Nakielny, 2001). The genitalia is cleansed from the external to the internal, using antiseptic solution. The vagina is dilated using a speculum; the cervix is localized and a uterine sound is then used to ascertain the depth and direction (anteverted or retroverted) of the uterus to aid manipulation of the contrast agent into the uterine cavity. Afterwards, the cannula is inserted into the cervical canal. If a Foley catheter is used; there is usually no need to grab the cervix with the vulsellum forceps. The catheter should just be inserted and inflated with air or normal saline. Subsequently, the contrast medium is injected slowly into the cervix, the uterine cavity and fallopian tubes via the cannula/catheter using 20ml syringe. This is done under intermittent fluoroscopic control. Care must be taken to expel air bubbles from the syringe and cannula/catheter prior to the injection, as these would otherwise cause confusion in interpretation (Chapman and Nakielny, 2001). Also the vagina speculum should be removed after catheterization before the contrast injection so that its image should not obscure the cervical area on the resultant images taken during the filling of the uterine cavity and again during the filling of the fallopian tubes. Finally, after the removal of the cannula and the forceps, additional film is taken to check the presence of contrast medium in the peritoneal cavity. Aftercare i. Efforts should be made to ensure that the patient is in no serious discomfort or has significant bleeding before leaving the department. ii. The patient should be informed on the possibility of bleeding per vagina for 1-2 days and pain may persist for up to 2 weeks. Complications a.complication due to the contrast medium b.complication due to the technique Other Techniques Ultrasound, Sonohysterosalpingography, Laparoscopy, Magnetic resonance imaging RESULTS Table 1 above and 2.3 below is use to explain the results. Projections One conventional radiograph (control/prelim radiograph) of the pelvis (on a 24 x 30cm film) is necessary before the contrast medium is administered into the uterine cavity. This is to check possible masses or calcifications which could otherwise make interpretation of the images difficult. Also, it helps to check adequacy of the technical factors such as exposure factors, evidence of good centering and inclusion of the target area. A metallic marker is placed over one side of the pelvis to indicate the right or left side of the patient. The contrast films are DISCUSSION The result of this research shows that common pathologies seen in HSG patients at University of Uyo Teaching Hospital were uterine fibroid (36.0%), tubal blockage (18.0%) and adhesion (18.0%).This is in line with the study conducted by Bukar et al., (2011) whose findings showed common pathology in HSG to be adhesion (12.9%) and tubal blockage (6.3%). The finding of this study also corresponds with the findings of Kiguli- Malwadde and Byanyima (2004), Botwe et al., (2015) who found that tubal blockage was the most common

4 Moi et al., 24 Table 1: Age distribution of participants. Age (Years) Frequency Percentage (%) Table 2: Distribution of HSG finding HSG Finding Frequency Percentage (%) Tubal Fallopian tube Adhesions Uterine fibroid Hydrosalpinx Isthmica Nodosa Arcuate uterus Bicornuate uterus Table 3: Correlation of Age and HSG findings. Age category Tubal Fallopian Tubes Adhesions Uterine fibroid Hydrosalpinx Isthmica Nodosa Arcuate uterus Bicornuate uterus TOTAL PERCENTAG E (%) years years years years years years TOTAL PERCENTAGE(%) pathology responsible for infertility. This study found uterine fibroid as the most prevalent pathology as demonstrated in HSG examination. The most affected age group were participants within the age range of years (41.2%) and years (29.8%). These findings are in line with that of Botwe et al., (2015) who revealed that common pathologies in HSG were found between age group of years and years, but contrary to that of Kiguli-Malwadde and Byanyima (2004) and Bukar et al., (2011) who found participants within the age group of years as most affected. This could be due to delayed conception, as nature abhors vacuum, and considering the fact that study was carried out in different locations CONCLUSION In conclusion, the study revealed pattern of HSG findings to include tubal blockage, adhesions, uterine fibroid, hydrosalpinx, isthmica nodosa, arcuate uterus and bicornuate uterus with the age group of years mostly affected. Uterine fibroid was found as the commonest pathology responsible for infertility in the locality. This was followed by tubal blockage and adhesion. REFERENCES Botwe BO, Bamfo-Quaicoe K, Hunu E, and Anim-Sampong. (2015).

5 Scholarly J. Med. 25 Hysterosalpingography findings among Ghanaian women undergoing infertility work-up: a study at the Korle-Bu Teaching Hospital. Fertility Research and Practice. DOI: /s Bukar M. (2011). Hysterosalpingographic findings in infertile women: a seven year review, Nigerian journal of clinical practice. 14 (2). pp Chapman S and Nakielny R (eds.) (2001). A guide to radiological procedure 4 th ed. Edinburgh: Elsevier limited. Elsie K. and Rosemary B. (2004).Structural finding at HSG in patients with infertility, African Health Sciences. 3 (4) Nwankwo NC and Akani CI. Pattern of hysterosalpingography findings in infertility in Port Harcourt. West African Journal of Radiology. 2005; 12(1):Pp Salle, B, Sergeant, P, Gaucherand, P, Guimont, I., Hilaire, P.S. and Rudigoz, R.C. (1996).Transvaginal Hysterosonographic Evaluation of Septate Uteri: A Preliminary Report. Human Reproduction. 11(5): Santhalia, P.K., Gupta, M.K., Uprety, D., Ahmad, K., Agrawal, N., and Rauniyar, R.K. (2013). The Role of Radiographic Hysterosalpingography in Infertility in Eastern Nepal. Nepalese J. Radiolo. 3(4).59-66

RADIOLOGICAL ASSESSMENT OF THE UTERUS AND FALLOPIAN TUBES IN INFERTILE WOMEN AT ABAKALIKI, NIGERIA.

Nigerian Journal of Clinical Practice Sept 2008 Vol 11(3) :211-21 RADIOLOGICAL ASSESSMENT OF THE UTERUS AND FALLOPIAN TUBES IN INFERTILE WOMEN AT ABAKALIKI, NIGERIA. *A.O.C Imo, **I. Sunday-Adeoye *Department