FERTILITY AND STERIUTY Copyright 1972 by The Williams & Wilkins Co. Vol. 2:3, ~o. 11, November 1972 Printed in U.S.A. HYSTEROSALPINGOGRAPHY IN THE DIAGNOSIS OF INFERTILITY (STATISTICAL ANALYSIS OF 337 CASES) GREGORY PONTIFEX, * M.D., DIMITRIOS TRICHOPOULOS, M.D., AND SAKELLARIOS KARPATHIOS, M.D. Department of Radiology, University of Athens Medical School, Aretaon Hospital, Athens, Greece Hysterosalpingography has been in use for over 50 years and its role in the diagnosis of infertility is well established. Most of the published studies, however, deal either with the advantages and disadvantages of the employed technics, or with the interpretation of the various findings. 1, 2 By contrast, the purpose of the present investigation is to evaluate the frequency and the etiologic significance of the hysterosalpingographic findings in patients with primary and secondary infertility. Several studies on this subject have already been published. 3. The present one, however, is based on a very large number of cases and, furthermore, has the advantage that all the hysterosalpingographies were performed by the same person (G.P.) or his staff under his supervision, and using the same technic. MATERIALS AND METHODS Between January 1, 1952 and December 31, 1962 some 18,800 hysterosalpingographies were performed in the Department of Radiology (division of diagnostic radiology) of the Maternity hospital "Alexandra." A short history was compiled for each patient before the examination. The present analysis is based on a randomly drawn 20% subsample of this material. Seventy-six out of 3773 hysterosalpingographies were excluded, either because of inadequate history, or because Received March 3, 1972, revised June 12, 1972. * Present address: Department of Radiology, UAMS, Aretaon Hospital. 76 Vas. Sophias avenue, Athens 611, Greece. 829 another hysterosalpingography had already been performed on the same patients. Of the remaining 3697 hysterosalpingographies, 281 concerned patients with primary infertility, 956 those with secondary infertility, 175 those with recurrent abortions, and the remaining 85 concerned patients with miscellaneous gynecologic problems. The findings in this paper refer to the two larger groups of patients, i.e., those with primary and secondary infertility. The technic of the hysterosalpingography has been simplified as follows: Two or 3 hr. before the examination, the patient was given an antispasmodic drug. Then she was placed on the fluoroscopic table and a preliminary X-ray film of the pelvis was taken. A radiolucent vaginal speculum was inserted, the vaginal vault cleansed with aqueous zephiran, and the anterior lip of the cervix was held horizontally with a simple tenaculum. The cannula, with the large or the small acorn 0.5-1 cm. from the tip, was placed into the cervical os and pressure was maintained to prevent leakage. The speculum was removed, the patient's legs were straightened, and she was moved upwards on the fluoroscopic table. Under fluoroscopic control with image intensifier and TV control, the opaque medium (preferably superfluid oily substances) was slowly injected into the uterine cavity. In most cases, only two X-ray films were taken; the first when the contrast medium opacifies at least one of the tubes and the
830 PONTIFEX ET AL. Vol. 23 second 2 hr. later in order to detect any possible spill of the contrast material into the peritoneal cavity. RESULTS Primary Infertility. The results from the analysis of the data concerning patients with primary infertility are summarized in Table 1. Congenital anomalies of the uterus were found in 99 out of 281 cases, i.e., in 20.1 %. The most common anomaly was hypoplastic uterus (201 cases) frequently associated with unilateral or bilateral tubal obstruction. Other common anomalies were congenital stenosis of the cervical os (132 cases), bicornuate uterus (73 cases), and arcuate uterus (62 cases). A number of other, relatively rare, anomalies (unicornis uterus, didelphus uterus, etc.) were also found (31 cases). Pelvic inflammatory (peritonitis, salpingitis, endometritis) were found in 18 patients with primary infertility (16.8%). The inflammation was probably due to TBC in 190 cases. Hysterosalpingography in cases of primary infertility associated with pelvic TBC showed particularly serious anomalies. Thus, bilateral tubal obstruction was found in 5.7% of them, as compared to 37.3% among women with primary infertility associated with other types of pelvic inflammatory, and 26.% among women with primary infertility of any sort. Sixty-seven of the women whose hysterosalpingographies were within normal limits had histories of pelvic TBC. Other findings of etiologic importance in patients with primary infertility were: fibromyomas, 51 cases (2.1%); endometrial polyps, 88 cases (3.5%); cervicitis, hyperplasia of cervical endometrium, and cervical polyps, 107 cases (.3%). In 31 patients (1.2%) primary infertility was apparently the result of a previous pelvic. A small number of the patients with primary infertility (39 cases, i.e., 1.6%) had serious hormonal disorders. In most TABLE 1. Hysterosalpingographic Findings in Women with Primary Infertility Hysterosalpingographic findings Bilateral blockage and congenital anomalies Bilateral blockage and pelvic inflammatory Bilateral blockage and TBC pelvic inflammation Bilateral blockage and hormonal disorders Bilateral blockage and previous pelvic Bilateral blockage and endometrial polyp Bilateral blockage and anomalous position Bilateral blockage and other findings of the uterus Bilateral blockage Unilateral blockage and congenital anomalies Unilateral blockage and pelvic inflammatory Unilateral blockage and TBC pelvic inflammation Unilateral blockage and hormonal disorders Unilateral blockage and previous pelvic Unilateral blockage and endometrial polyp Unilateral blockage and anomalous position of the uterus Unilateral blockage Peritubal adhesions and congenital anomalies Peritubal adhesions and pelvic inflammatory Peritubal adhesions and TBC pelvic inflammation Peritubal adhesions and previous pelvic Peritubal adhesions and anomalous position of the uterus Peritubal adhesions Congenital anomalies Fibromyoma Endometrial polyp Cervical polyp, cervical hyperplasia, cervicitis Anomalous position (or inclination) of uterus Other hysterosalpingographic findings Normal hysterosalpingogram and pelvic inflammatory Normal hysterosalpingogram and TBC pelvic inflammation Normal hysterosalpingogram Total No. of cases 150 85 10 3 20 8 17 2 213 3 22 15 5 10 10 11 18 5 5 288 51 70 107 39 57 116 67 70 281
- November 1972 HYSTEROSALPINGOGRAPHY 831 of them, hysterosalpingography indicated bilateral tubal obstruction. In spite of the available radiologic and clinical information, it was not possible to determine the cause of bilateral obstruction in 213 cases, of unilateral obstruction in 11 cases, and of peritubal adhesions in 5 cases. Normal hysterosalpingographies were found in 35.8% of the patients with primary infertility examined. Secondary Infertility. The results from the 956 patients with secondary infertility are summarized in Table 2. In this table, our cases were classified according to the outcome of their last pregnancy and the hysterosalpingographic findings. It can be TABLE 2. Hysterosalpingographic Findings in Women with Secondary Infertility According to the }lp.ported Outcome of Their Last Pregnancy Hysterosalpingographic findings Reported outcome of the last pregnancy Induced Sponta- Normal Ectopic abortion neous abor- delivery tion Bilateral blockage and congenital anomalies 11 5 1 17 Bilateral blockage and pelvic inflammatory 8 10 3 21 Bilateral blockage and pelvic TBC inflammation 2 2 Bilateral blockage and previous pelvic or 6 3 3 12 Bilateral blockage and anomalous positlon of uterus 2 2 Bilateral blockage and other findings 1 1 2 Bilateral blockage 27 61 7 37 172 Unilateral blockage and congenital anomalies 2 2 8 Unilateral blockage and pelvic inflammatory 2 6 12 Unilateral blockage and pelvic TBC inflammation 3 2 5 Unilateral blockage and previous pelvic or 1 7 3 11 Unilateral blockage and anomalous position of 1 1 2 uterus Unilateral blockage and other findings Unilateral blockage 32 32 36 31 131 Peritubal adhesions and congenital anomalies 1 1 Peritubal adhesions and pelvic inflammatory 2 2 8 Peritubal adhesions and other findings Peritubal adhesions 1 16 16 6 39 Congenital anomalies 16 29 9 Endometrial adhesions 37 15 15 67 Fibromyoma 3 11 8 22 Endometrial polyp 10 2 16 Findings related with previous pelvic or 31 13 10 5 Anomalous position (or inclination) of uterus 1 8 5 3 17 Cervical hyperplasia, cervicitis 20 22 3 5 Other findings 11 13 1 25 Normal hysterosalpingogram and pelvic inflammatory 26 15 7 8 Normal hysterosalpingogram 61 87 20 168 Total 61 369 358 168 956 Total
832 PONTIFEX ET AL. Vol. 23 seen that the outcome of the last pregnancy was spontaneous abortion for 358 women, and tubal abortion or rupture (ectopic pregnancy) for 61 women. Among the remaining 537 women, 168 (17.6%) reported normal delivery and 369 artificial termination of their last pregnancy by dilatation and curettage. This last group of cases represents 38.6% of all patients with secondary infertility, or 68.7% of the infertile patients whose last pregnancy was not spontaneously interrupted. As far as the hysterosalpingographies are concerned, 228 cases (23.8%) had bilateral obstruction, 169 cases (17.7%) unilateral obstruction, and 8 cases (5.0%) peritubal adhesions. In 32 cases the causes of these anomalies were not radiologically identifiable. Pelvic (mostly tubal) inflammatory were clearly diagnosed in 96 cases (10.1 %). Among them, 2 were associated with a previous induced abortion, 29 with a previous spontaneous abortion, and 18 with a previous normal delivery. In only 7 cases the pelvic inflammation was of tuberculous nature. Secondary infertility was related to endometrial adhesions in 67 cases (7.0%), congenital anomalies of the uterus in 75 cases (7.9%), previous pelvic s or injuries in 77 cases (8.1%), endometrial polyps in 16 cases (1.7%), fibromyomas in 22 cases (2.3%), anomalous position or inclination of the uterus in 21 cases (2.2%), and to cervical disease in 5 cases (.7%). In 216 cases with secondary infertility (22.6%) the hysterosalpingography was apparently normal. DISCUSSION Three points should be taken into account before the findings of this study can be correctly interpreted. First, although hysterosalpingography has been a more or less standard procedure for all women with infertility admitted to the "Alexandra" hospital, it is nevertheless possible that some selective factors may have been operating, so that our material may not be strictly representative. Thus, it is conceivable that some patients, investigated with a Rubin test, become pregnant and are excluded, so that the study is weighted towards pathologic studies. It is also conceivable that women with infertility and hormonal disorders are successfully treated before a hysterosalpingography is performed. Second, the diagnostic criteria for some anomalies of the uterus (e.g., "hypoplastic uterus") are neither well established nor sufficiently objective. Third, the relative importance of the various causes of primary and secondary infertility may not be the same in different places and during different periods of time. Congenital anomalies of the uterus are apparently responsible for a large proportion of cases with primary infertility (20.1%) and for a smaller proportion of cases with secondary infertility. Many women with secondary infertility related to congenital anomalies of the uterus also reported previous habitual abortions (Table 2). Pelvic inflammatory are a common-cause of both primary and secondary infertility. Furthermore, it is likely that a large number of cases with secondary infertility and bilateral or unilateral tubal obstruction or peritubal or endometrial adhesions of unknown etiology belong, in fact, to that group. TBC pelvic inflammation is frequently related to primary, but only rarely to secondary, infertility. Pelvic inflammatory among women with this latter condition are usually postabortive. As might be expected, patients with secondary infertility reported induced or spontaneous abortions as the outcome of their last pregnancy more frequently than women of the general population. It has been found in a number of studies of the general population 5 that the proportion
November 1972 HYSTEROSALPrNGOGRAPHY 833 of Greek women with a history of either induced or spontaneous abortion, at a previous pregnancy of any particular order, does not exceed 36% and 25%, respectively. Therefore, our results confirm the existence of a positive relationship between secondary infertility and both spontaneous and induced abortions and support the findings of Pigeaud and Pellisier,6 who have noted a relatively high proportion of pathologic hysterosalpingographies among women with previous spontaneous or induced abortion. The importance of ectopic pregnancy as a cause of secondary infertility, already suggested by many authors,7 was also confirmed in the present study. SUMMARY Three thousand six hundred ninetyseven hysterosalpingograms over an 11- year period have been reviewed. The indications for these examinations were as follows: primary infertility, 281 cases; secondary infertility, 956 cases; recurrent abortions, 175 cases; and miscellaneous gynecologic disorders, 85 cases. The hysterosalpingographic findings in the groups of primary and secondary infertility have been tabulated and correlated with data from obstetric and gynecologic histories. Congenital anomalies of the uterus (mainly hypoplastic uterus and congenital stenosis of cervical os) form the main group of conditions related to primary infertility (20.1% of the cases). Pelvic inflammatory are also very frequent (16.8%). Almost one-half of them are of tuberculous nature and these are frequently combined with bilateral tubal blockage. In about 36% of the cases with primary infertility the hysterosalpingograms were apparently normal. Among cases with secondary infertility, bilateral tubal blockage is the most common finding (23.8%), followed by unilateral blockage (17.7%). In a large proportion of women with secondary infertility, the reported outcome of the last pregnancy was either spontaneous (37.%) or induced abortion (38.6%). REFERENCES 1. FODA, M. S., YOUSSEF, A. F., SHAFEEK, M. A., AND KASSEM, K. A. Hysterography in diagnosis of abnormalities of the uterus. I, II, and III. Brit J Radiol 35:115, 783, 836, 1962 a, b, and c. 2. FULLENLOVE, T. M. Experience with over 2000 uterosalpingographies. Amer J Roentgen 106:63, 1969. 3. ALTEMUS, R., CHARLES, D., AND VODER, V. E. Conventional hysterosalpingography used in the evaluation of sterility problems. A critical analysis. Fertil Steril 18:713, 1967.. GEARY, W. L., HOLLAND, J. B., WEED, J. C., AND WEED, J. C., JR. Uterosalpingography. Amer J Obstet Gynec 10:687, 1968. 5. VALAORAS, V., POLYCHRONOPOULOU, A., AND TRICHO POULOS, D. "Abortion in Greece." In Proceedings of the Sixth Conference of the International Planned Parenthood Federation. Europe and Near East Region. Budapest, September 1969, p. 31. 6. PIGEAUD, H. AND PELLISSIER, B. Hystero-salpingographies systematiques dans les suites d'avortements. Bull Fed Gynec Obstet Franc 20:79, 1968. 7. SKUW, V. Significance of tubal pregnancy in the reproductive life of women. Amer J Obstet Gynec 80:278, 1960.