Hysterosalpingography

Spectrum of Normal Variants and Nonpathologic Findings

1. 2. 3. 4. Beln beda1, Marta Paraira, Enric Alert and Ramn Angel Abuin + Author Affiliations 1. 1 All authors: Department of Radiology, Institut Universitari Dexeus, P 0 Bonanova, 67 pl-2, 08017 Barcelona, Spain.

Next Section Hysterosalpingography is a valuable technique in the evaluation of the infertile patient. During the last decade, the number of women seeking infertility evaluation has increased considerably. Hysterosalpingography is considered a screening procedure for an infertility workup, and despite the development of other diagnostic tools such as MR imaging, hysteroscopy, and laparoscopy, hysterosalpingography remains the main examination for the study of the fallopian tubes [1]. This technique provides useful, although indirect, information outlining the uterine cavity and the fallopian tubes. Hysterosalpingography has been reported to have a high sensitivity but a low specificity, especially in the diagnosis of uterine cavity abnormalities [2, 3]. The technical quality of the hysterosalpingogram is important to limit factors leading to misinterpretations. It is also essential for the radiologist to be familiar with the normal and abnormal radiologic findings for the correct interpretation of hysterosalpingograms. This pictorial essay describes and illustrates the hysterosalpingographic appearances of technical artifacts, normal variants, and findings with no proven influence on fertility. Previous SectionNext Section

Technical Artifacts
Air Bubbles During hysterosalpingography, air bubbles can incidentally be introduced into the uterine cavity and may be mistaken for other filling defects such as blood clots, polyps, submucosal myomas, or endometrial hyperplasia. An air bubble appears as a round, well-defined filling defect; multiple air bubbles are often seen, and they are usually identifiable by their mobility. Introduction of air bubbles can be prevented by careful removal of air bubbles trapped in the cannula. When present, air bubbles must be eliminated by additional injection of contrast material, which flushes them out of the uterine cavity through the fallopian tubes (Fig. 1A,1B).

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Fig. 1A. Air bubbles in uterine horns of 29-year-old asymptomatic woman. Hysterosalpingogram obtained with balloon-catheter shows multiple rounded filling defects (arrows), which are mobile, at both uterine horns.

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In a new window Download as PowerPoint Slide Fig. 1B. Air bubbles in uterine horns of 29-year-old asymptomatic woman. Hysterosalpingogram obtained with additional injection of contrast material shows bubbles have been flushed out of uterine cavity through fallopian tubes. Venous or Lymphatic Intravasation Venous or lymphatic intravasation can occur in up to 6% of patients undergoing hysterosalpingography [4]. Although it can occur in healthy patients, there are some predisposing factors such as recent uterine surgery or increased intrauterine pressure because of tubal obstruction or excessive injection pressure [2,3,4]. The radiographic appearance of early intravasation is characterized by filling of multiple thin beaded channels and an ascendant course (Figs. 2 and 3). When intravasation is recognized, the injection should be stopped if an oil-soluble medium has been used. Venous intravasation is innocuous as long as a water-soluble contrast medium is used.

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In a new window Download as PowerPoint Slide Fig. 2. Venous intravasation in healthy 28-year-old woman. Hysterosalpingogram shows network of thin vessels (arrow) can be opacified during hysterosalpingography in healthy patients.

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In a new window Download as PowerPoint Slide Fig. 3. Venous intravasation in healthy 36-year-old woman. Hysterosalpingogram obtained in patient with right isthmic tubal occlusion (short arrow) shows venous intravasation of contrast material into myometrial vessels (long arrow). Controversy exists regarding the proper choice of contrast material for hysterosalpingography. Some authors support the use of an oil-soluble contrast medium, arguing that it provides greater contrast and sharpness of the image and more information about the presence of peritubal adhesions [5]. An increase in pregnancy rates in infertile patients after hysterosalpingography with oil-soluble medium has been suggested [6], whereas another study [7] shows no statistical difference between the use of oil- and water-soluble contrast agents. Most authors advocate the use of a water-soluble contrast medium [2,3,4] because it provides better uterine and ampullary mucosal detail and has no serious secondary effects such as peritoneal inflammatory or granulomatous reaction and because it eliminates the risk of pulmonary and retinal oil emboli. In addition, venous intravasation of water-soluble contrast medium produces no adverse effects, entering the vascular system and being excreted by the kidneys. Therefore, both diagnostic and safety factors recommend the use of a water-soluble contrast medium. Previous SectionNext Section

Normal Variants
Myometrial Folds In a small percentage of patients, broad longitudinal folds parallel to the uterine cavity are seen on hysterosalpingograms with otherwise normal findings (Fig.4A,4B,4C). These folds are not associated with endometrial abnormalities. Although the exact etiology is unknown, the folds are considered as remnants of the mllerian duct fusion during fetal development [4].

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In a new window Download as PowerPoint Slide Fig. 4A. Myometrial folds in 34-year-old woman. Hysterosalpingogram shows broad longitudinal folds (arrows) parallel to uterine cavity that must be identified at early underfilled view of uterus.

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In a new window Download as PowerPoint Slide Fig. 4B. Myometrial folds in 34-year-old woman. Delayed radiographs obtained with larger volumes of contrast material show that contrast material progressively obliterates view of folds.

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In a new window Download as PowerPoint Slide Fig. 4C. Myometrial folds in 34-year-old woman. Delayed radiographs obtained with larger volumes of contrast material show that contrast material progressively obliterates view of folds. Double Uterine Contour Hysterosalpingography should be performed during the follicular phase of the menstrual cycle before ovulation. In the few patients in whom hysterosalpingography is performed during the late secretory phase of the menstrual cyclefor example, in the evaluation for cervical incompetencea double contour can be seen as a thin line of contrast medium surrounding the uterine cavity (Fig. 5). The contrast medium does not penetrate into the myometrial vessels, and therefore there is no filling of the myometrial, uterine, or ovarian veins. A double contour representing contrast material underneath the decidual reaction of the endometrium can also be observed in an early pregnancy [4] (Fig. 6).

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In a new window Download as PowerPoint Slide Fig. 5. Double uterine contour (asterisk and arrows) in 30-year-old woman. Hysterosalpingogram obtained during late secretory phase of menstrual cycle shows double uterine contour.

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In a new window Download as PowerPoint Slide Fig. 6. Double uterine contour in 34-year-old pregnant woman. Hysterosalpingogram was inadvertently obtained in this patient who had vaginal bleeding resembling menses 1 month before study. Hysterosalpingogram shows mildly enlarged uterine cavity with double contour. No gestational sac is evidenced. Prominent Cervical Glands The normal cervical canal is delineated by the internal and external cervical os and can have variable appearances depending on the patient and the time in her cycle. The cervical canal is usually narrower at the external and internal os and wider in the midportion. The walls may be smooth or serrated with longitudinal ridges representing the plicae palmatae. Sometimes, filling of normal endocervical glands may be observed as multiple tubular structures that originate from both cervical walls (Fig. 7).

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In a new window Download as PowerPoint Slide Fig. 7. Prominent cervical glands in 27-year-old woman. Hysterosalpingogram with normal findings shows tubular-shaped structures (arrows) originating from cervical walls that correspond to filling of normal or dilated cervical glands. Previous SectionNext Section

Findings with No Proven Influence on Fertility

Arcuate Uterus The arcuate uterus is usually an incidental finding during hysterosalpingography, and it appears as a mild smooth concavity in the uterine fundus instead of the more common straight or convex normal fundal contour (Fig. 8). According to the American Fertility Society's classification, an arcuate uterus is considered a class VI mllerian anomaly [8]. Nevertheless, an arcuate uterus is such a minor uterine malformation that it is considered a normal variant and is not associated with infertility or obstetric complications [4, 8]. It must be differentiated from the V-shaped fundus of the subseptate uterus and from an extrinsic compression caused by an intramural myoma.

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In a new window Download as PowerPoint Slide Fig. 8. Arcuate uterus in 30-year-old woman. Hysterosalpingogram with normal findings shows smooth concave indentation of uterine fundus (arrow). Gartner's Duct Cyst Gartner's duct is a remnant of the caudal portion of the mesonephric or wolffian duct that fails to resorb normally in the female. Gartner's ducts can be single or multiple and are usually located parallel to the anterior

lateral wall of the proximal third of the vagina [4]. Secretion by persistent glandular tissue may allow cysts to form in its course. Gartner's duct cysts may be visualized during hysterosalpingography if they communicate with the uterine lumen. These cysts are usually incidental findings with no clinical significance. They appear as tubular structures that run parallel to the uterine cavity or vagina, sometimes with cystic or saccular dilatations (Figs. 9and 10).

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In a new window Download as PowerPoint Slide Fig. 9. Gartner's duct cyst in 25-year-old asymptomatic woman. Hysterosalpingogram shows tubular structure, running parallel to uterine cavity (arrows), that represents Gartner's duct communicating with uterine lumen.

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In a new window Download as PowerPoint Slide Fig. 10. Gartner's duct cyst in 32-year-old woman. Hysterosalpingogram reveals course of Gartner's duct cyst running along vaginal wall. Saccular dilatations (large arrow) can be present. Note left hydrosalpinx with severe ampullary dilatation and no free intraperitoneal spill (small arrows). Infantile Uterus The normal adult uterus can have variable appearances, with a triangular-shaped uterine cavity and smooth margins. The uterine body comprises two thirds of the entire uterine length, and the remaining third corresponds to the endocervical canal. In patients taking oral contraceptives for long periods of time, a small T-shaped uterus can be observed characterized by a 1:1 ratio between the uterine body and the cervix, which are the normal proportions of a premenarchal uterus (Fig. 11). This appearance can also be observed in adult women with severe estrogen deficiencies in which the uterus fails to attain postpuberal proportions because of the absence of normal estrogen stimulus [4].

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In a new window Download as PowerPoint Slide Fig. 11. Infantile uterus in 30-year-old woman. Hysterosalpingogram shows small, T-shaped uterus with cervix and uterine body of similar size. Patient had been taking oral contraceptives for several years. Tubal Polyps Tubal polyps are small foci of ectopic endometrial tissue located at the intramural portion of the fallopian tubes. They can be unilateral or bilateral, and they measure less than 1 cm in diameter. Radiologically, tubal polyps appear as smooth, round or oval filling defects, not associated to tubal dilatation or obstruction, with free flow of contrast medium to the peritoneal cavity (Fig. 12). Patients with tubal polyps are asymptomatic, and polyps are usually an incidental finding at hysterosalpingography; of hysterosalpingograms obtained for infertility investigation, the reported incidence is 1-2.5% [9].

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In a new window Download as PowerPoint Slide Fig. 12. Tubal polyps in 37-year-old woman. Normal hysterosalpingogram shows incidental unilateral filling defect at interstitial portion of right Fallopian tube (arrow). The role of tubal polyps in infertility has been long questioned, but an absolute causal relationship between tubal polyps and infertility has not been definitely established [9, 10]. The consensus is that other causes of infertility should be sought before treatment of polyps is considered. Hormonal and surgical treatments have so far been unsuccessful. Cesarean Delivery Scar Cesarean delivery requires a transverse incision at the uterine isthmus and can be seen at hysterosalpingography as a wedge-shaped out-pouching at the level of the internal os (Fig. 13). This finding has no clinical significance and is not a diagnostic problem if it is correlated with the clinical history of the patient.

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In a new window Download as PowerPoint Slide Fig. 13. Cesarean section scar in 37-year-old woman who had cesarean delivery several years earlier. Hysterosalpingogram shows wedge-shaped outpouching at level of internal cervical os representing site of cesarean scar (arrow). Postmyomectomy Diverticulum Myomectomy is being performed increasingly for the treatment of menorrhagia and infertility. After the resection of a submucous fibroid, small diverticulagenerally less than 1 cm in diametercan be found in some patients at the site of resection [11] (Fig. 14). The significance of this finding has not yet, to our knowledge, been documented, but diverticula seem to have no clinical importance when they are small and not associated with major distortion of the uterine cavity.

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In a new window Download as PowerPoint Slide Fig. 14. Diverticulum in 33-year-old woman who underwent resection of submucous fibroid. Hysterosalpingogram obtained after patient underwent myomectomy shows small diverticulum at site of resection with no distortion of uterine cavity (arrow). Previous SectionNext Section

Summary
The number of hysterosalpingographic examinations has increased during the last decade because of the greater concern regarding infertility. Hysterosalpingography plays an extremely important role in the diagnostic assessment and treatment of infertility in the female patient. An accurate interpretation of the hysterosalpingogram is necessary for the infertility workup, considering the nonpathologic findings that are seen at otherwise normal examinations. Knowledge of these entities is important to avoid the practice of unnecessary and sometimes more aggressive procedures. Previous SectionNext Section

Footnotes
Address correspondence to B. beda. Received July 28, 2000.

Accepted December 4, 2000. American Roentgen Ray Society Previous Section

References
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Krysiewicz S. Infertility in women: diagnostic evaluation with hysterosalpingography and other imaging techniques. AJR 1992;159: 253 -261

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Yoder IC, Hall DA. Hysterosalpingography in the 1990s. AJR 1991;157:675 -683

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Thurmond AS. Hysterosalpingography: imaging and interventionRSNA categorical course in genitourinary radiology. Chicago: Radiological Society of North America, 1994: 221-228 4.

Yoder IC. Hysterosalpingography and pelvic ultrasound: imaging in infertility and gynecology. Boston: Little, Brown, 1988: 23-28, 133-193