HYSTEROSALPINGOGRAPHY

WHEN TO SCHEDULE THE EXAMINATION?

• The first half of the menstrual cycle (proliferative phase).
• The best timing is day 7-10because:
- Blood has cleared from uterus.
- Isthmus is most distensible.
- Fallopian tubes are more readily filled.
- Endometrium is not thick.
• If patient has abnormal uterine bleeding, do not stick to
optimal schedule but take care:
- Use water soluble cntrast media to avoid intravasation.
- Blood clots may mimic intra uterine filling defects.

INDICATIONS:
• Infertility.
• Recurrent abortions.
• Abnormal uterine bleeding.
• After tubal ligations.
• Before artificial insemination.

CONTRAINDICATIONS:
• Immediately before and after menstruation.
• Pelvic infections.
• Sensitivity to contrast.
• Pregnancy.

COMPLICATIONS:
• Pelvic pain.
• Infection.
• Allergic reaction.
• Intravasation.
• Vasovagal attack.
• Bleeding.
IMPORTANT PSYCHOLOGICAL ASPECTS:
• The radiologist should be:
CALM, CARING, CONFIDENT

• The patient should be informed about the whole procedure.

• Patient should be allowed to watch the flouroscopic screen

during examination.

• She should be informed with the results during or immediately

after examination.

PREPROCEDURE MEDICATIONS:
• ANTIBIOTICS:
- +ve history of PID and SBE
- (Doxycycline 100 mg/twice daily two days before
procedure)
- (200mg immediately after procedure followed by
100mg/twice daily for 5 days)

• NSAID:
- What the patient usually takes or Ibuprofen 400mg 30
minutes before procedure

CONTRAST MEDIA:

WATER SOLUBLE OIL SOLUBLE

• Less density
• Better fallopian tube
visualization
• Immediate smear
• Disappear within 1hr
(except tubal block)
• Less complications
• No therapeutic effect
• More density
• Better uterus visualization
• Delayed smear
• Disappearance is delayed
• More complications
(pulmonary embolism and
granulomatous inflammation)
• Has a therapeutic effect
TECHNIQUE OF EXAMINATION:

• Ask the patient to evacuate her bladder.

• Patient lies in lithotomy position and try to elevate her buttocks.
• Lubricate speculum.
• Insert it closed; then rotate; then open it.
• Sterilize vagina.
• Grasp anterior lip with vulsellum forceps (avoid 3&9 o’clock:
highly vascular)
• Insert cannula inside the cervical canal.
• Inject contrast material.

RADIOLOGICAL ANATOMY:
• UTERUS:
- What we really see is the uterine cavity
- The cavity is triangular in shape
- Walls are regular and concave
- Fundus may be convex
- Length and intercorn. Dist. Are about 35mm

• FALLOPIAN TUBES:
- About 7-14 cm long
- Devided into:
Interstitial
Isthmic
Ampullary
InfundibUlar
Fimbrial

HOW DO WE COMMENT ON THE UTERUS

• SIZE: (LENGTH AND INTERCORN. DISTANCE= 35mm)
• SHAPE: (triangular with concave margins and flat or
convex fundus)
• INTRAUTERINE FILLING DEFECTS.
• IF UTERINE CAVITY IS DOUBLED:
- Intercornual angle (normal between 70-105).
- External fundal indentation.
EMBRYOLOGY OF THE FEMALE GENITAL SYSTEM:
• Although genetic sex is determined at fertilization, gender is
not apparent until approximately the 12th week of embryonic
life. By the 6th week embryonic life, both male and female
embryos start to develop the following structures on either side
of the midline:

1. Genital ridge (proliferation of coelomic epithelium)

2. Mesonephric (Wolffian) duct (lateral to the genital
ridge)
3. Paramesonephric (Mullerian) duct which consists of:
o Upper vertical part lateral to the Wolffian duct.
o Middle horizontal part crosses in front of the
Wollfian duct
o Lower vertical part fuses with the similar part of
the opposite side to form the utero-vaginal canal

• Fallopian tubes have different cellular origins therefore not

involved in Mullerian duct anomalies.
• The ovaries arise from mesenchyme and epithelium of the
gonadal ridge; also not involved
• Urinary and genital systems arise from a common ridge of
mesoderm. Renal agenesis, duplicated system and cystic
kidneys are common.

CONGENITAL ANOMALIES OF THE

UTERUS
MÜLLERIAN DUCT ANOMALIES ARE CATEGORIZED MOST
COMMONLY INTO 7 CLASSES:

• CLASS I (HYPOPLASIA/AGENESIS):

This class includes entities such as uterine/cervical agenesis

or hypoplasia. The most common form is the Mayer-
Rokitansky-Kuster-Hauser syndrome, which is combined
agenesis of the uterus, cervix, and upper portion of the
vagina. Patients have no reproductive potential aside from
medical intervention in the form of in vitro fertilization of
harvested ova and implantation in a host uterus. In uterine
hypoplasia, the endometrial cavity is small, with a reduced
intercornual distance (<2 cm). When uterine hypoplasia is
 associated with hormonal dysfunction (infantile uterus), not
only is the uterus small, but the zonal anatomy is
differentiated poorly on T2-weighted images.

• CLASS II (UNICORNUATE UTERUS):

A unicornuate uterus is the result of complete, or almost

complete, arrest of development of 1 müllerian duct . If the
arrest is incomplete, as in 90% of patients, a rudimentary
horn with or without functioning endometrium is present. If
the rudimentary horn is obstructed, it may come to surgical
attention when presenting as an enlarging pelvic mass. If the
contralateral healthy horn is almost fully developed, a full-
term pregnancy is believed to be possible.

• CLASS III (DIDELPHYS UTERUS):

This anomaly results from complete nonfusion of both

müllerian ducts. The individual horns are fully developed and
almost normal in size. Two cervices are inevitably present. A
longitudinal or transverse vaginal septum may be noted as
well. Didelphys uteri have the highest association with
transverse vaginal septa but septa also may be observed in
other anomalies. Consider metroplasty; however, since each
horn is almost a fully developed uterus, patients have been
known to carry pregnancies to full term.

• CLASS IV (BICORNUATE UTERUS):

A bicornuate uterus results from partial nonfusion of the

müllerian ducts. The central myometrium may extend to the
level of the internal cervical os (bicornuate unicollis) or
external cervical os (bicornuate bicollis). The latter is
distinguished from didelphys uterus because it demonstrates
some degree of fusion between the two horns, while in classic
didelphys uterus, the two horns and cervices are separated
completely. In addition, the horns of the bicornuate uteri are
not fully developed; typically, they are smaller than those of
didelphys uteri. Some patients are surgical candidates for
metroplasty. The most important imaging finding is a concave
fundus with a fundal cleft greater than 1 cm on us. On
hysterosalpingography it can be diagnosed with confidence if
the intercornual angle is above 105 and the intercornual
distance is above 40mm.
• CLASS V (SEPTATE UTERUS):

A septate uterus results from failure of resorption of the

septum between the two uterine horns. The septum can be
partial or complete, in which case it extends to the internal
cervical os. Histologically, the septum may be composed of
myometrium or fibrous tissue. The uterine fundus is typically
convex but may be flat or slightly concave (<1-cm fundal
cleft). Women with septate uterus have the highest incidence
of reproductive complications. Differentiation between a
septate and a bicornuate uterus is important because septate
uteri are treated using transvaginal hysteroscopic resection of
the septum, while if surgery is possible and/or indicated for
the bicornuate uterus, an abdominal approach is required to
perform metroplasty. The outer fundal contour is convex,
flattened, or mildly concave (fundal cleft <1 cm). A more
reliable means for differentiating the two is to examine the
fundal contour (see class IV).

• CLASS VI (ARCUATE UTERUS):

An arcuate uterus has a single uterine cavity with a convex or

flat uterine fundus, the endometrial cavity, which
demonstrates a small fundal cleft or impression (>1.5 cm).
The outer contour of the uterus is convex or flat . This form is
often considered a normal variant since it is not significantly
associated with the increased risks of pregnancy loss and the
other complications found in other subtypes. It has been
proposed that when a ratio of less than 10% between the
height of the fundal indentation and the distance between the
lateral apices of the horns is calculated on the basis of HSG
findings, an adverse reproductive outcome is not anticipated

• CLASS VII (DIETHYLSTILBESTROL-RELATED

ANOMALY):

Several million women were treated with diethylstilbestrol

(DES; an estrogen analog prescribed to prevent miscarriage)
from 1945-1971. The drug was withdrawn once its teratogenic
effects on the reproductive tracts of male and female fetuses
were understood. The uterine anomaly is seen in the female
offspring of as many as 15% of women exposed to DES
during pregnancy. Female fetuses who are affected have a
 variety of abnormal findings that include uterine hypoplasia
and a T-shaped uterine cavity. Patients also may have
abnormal transverse ridges, hoods, stenoses of the cervix,
and adenosis of the vagina with increased risk of vaginal clear
cell carcinoma. Imaging findings are pathognomonic for this
anomaly.

 A common finding is separation of the uterine cavity

into right and left compartments. A divided uterine
cavity can result from septate, bicornuate, or
didelphys uterus. Certain criteria are used to
increase confidence in diagnosing 1 of the 3 entities.

• Intercornual distance: If the distance between the distal ends

of the horns (ends that are continuous with fallopian tubes) is
less than 2 cm, the likelihood of septate uterus is increased. If
the distance is greater than 4 cm, the likelihood of didelphys
and bicornuate uterus is increased. Measurements of 2-4 cm
(typical distance in a normal uterus) were indeterminate in an
abnormal cavity configuration.
• Intercornual angle: This is the angle formed by the most
medial aspects of the two uterine hemicavities. The diagnostic
accuracy of HSG alone is only 55% for differentiation of
septate from bicornuate uteri. An angle of less than 75°
between the uterine horns is suggestive of a septate uterus,
and an angle of more than 105° is more consistent with
bicornuate uteri. Unfortunately, the majority of angles of
divergence between the horns fall within this range, and
considerable overlap between the two anomalies is noted. In
addition, the presence of leiomyomas or adenomyosis within
the septum may cause secondary distortion and widening of
the angles of divergence of the uterine horns. It has been
reported that when US is used in conjunction with HSG, the
correct diagnosis can be made in 90% of cases.

Degree of Confidence:

• A large overlap exists between the subtypes when

comparing uterine cavitary configuration,
intercornual distance, and intercornual angle. In
several studies, HSG had significantly less accuracy
for diagnostic precision compared to MRI or US. In
the studies, much of the final pathology was based
on laparoscopic or surgical findings, primarily of the
appearance of the uterine fundus, which HSG was
not able to assess.
 • Since HSG techniques did not provide diagnoses
with high degrees of confidence, US and MRI soon
began to play a larger role in assessment and
treatment of patients. Currently, anomalies
incidentally discovered on HSG are referred for
further evaluation using MRI or US.
• The only anomaly in which HSG plays a significant
role in diagnosis is DES uterus (AFS class VII). The
abnormal uterine cavity can be depicted clearly on
HSG but often is visualized as only uterine
hypoplasia on US or MRI.
• Additional findings on MRI and U/S include:

- External fundal contour:

External uterine contour must demonstrate a convex,

flat, or mildly concave

- External fundal indentation:

If the fundal indentation of the external uterine contour

is below the interostial line or less than 5 mm above the
line, the uterus is considered to be bicornuate or
didelphic. The septate uterus is defined by a fundal
indentation of more than 5 mm above the interostial line

- Degree of cervical communication.

INTRAUTERINE FILLING DEFECTS

1.ASHERMAN'S SYNDROME:

It is also called "uterine synechiae". It presents a condition

characterized by the presence of scars within the uterine cavity.
The cavity of the uterus is lined by the endometrium. This lining
can be traumatized, typically after a dilation and curettage (D&C)
done after a miscarriage, abortion, or delivery, and then
develops intrauterine scars which can obliterate the cavity to a
 varying degree. In the extreme, the whole cavity has been
scarred and occluded. Even with relatively few scars, the
endometrium may fail to respond to estrogens and rests. The
patient experiences secondary amenorrhea and becomes
infertile. An artificial form of Asherman's syndrome can be
surgically induced by uterine ablation in women with uterine
bleeding problems in lieu of hysterectomy. Ultrasound is not a
reliable method of diagnosing Asherman's Syndrome. Options
include HSG (hysterosalpingography) or SHG
(sonohysterography). Hysteroscopy is the most reliable.

2. UTERINE FIBROIDS:

Fibroids are very common - they are benign (noncancerous)

tumors of the uterine muscle. The size and location of the fibroid
are important. The large majority of them are very small or
located in an area of the uterus such that they will not have any
impact on reproductive function.

There are 3 general locations for fibroids:

1. Subserosal - on the outside surface of the uterus

2. Intramural - within the muscular wall of the uterus
3. Submucous - bulging in to the uterine cavity

The only type that will have any impact on reproductive function
(unless it is very large) is the submucous type that pushes in to
the uterine cavity. These are much less common than the other 2
types of fibroids. Because of their location inside the uterine
cavity, submucous fibroids can cause infertility or miscarriages.

3. UTERINE POLYPS:

Uterine polyps are quite common. They're soft red fleshy

tumours of the endometrium (the lining of the uterus or womb).
They vary in size from 1cm (0.4in) - when they contain only
endometrial tissue (womb lining) - to 5cm (2in). Larger polyps
often contain not just endometrial cells, but also muscular and
fibrous tissue from deeper in the wall of the womb. Polyps are
prone to bleeding and bleeding between periods is often the first
clue to their existence.

Polyps may either lie flat against the inside of the womb or be
pedunculated, which means they form on the end of a 'stalk' of
flesh. Pedunculated polyps sometimes hang down through the
cervix, where they may become trapped, cutting off the blood
 supply to the tumour (known as strangulation of the polyp). In
this case they may bleed profusely and may be painful.

HYDROSALPINX
WHAT IS A HYDROSALPINX?
• A hydrosalpinx is a blocked, dilated, fluid-filled fallopian tube
usually caused by a previous tubal infection. The pelvic
infections that lead to hydrosalpinx formation are usually
caused by sexually transmitted diseases. Diagnosis of
hydrosalpinx is usually made by a hysterosalpingogram. If the
tubes are open, the liquid will spill out the ends of the tubes. If
the tubes are blocked, the liquid is trapped.
• If the fallopian tubes are completely blocked, conception will
not occur without medical intervention. In milder cases, fertility
may be restored by opening the tubes surgically. However, if
the lining of the tubes is badly damaged, in vitro fertilization
(IVF), which bypasses the tubes, is the treatment of choice.
• At hysterosalpingography, the complete depiction of fallopian
tubes from the uterine to the abdominal ostium should always
be pursued, because tubal morphology might be of the utmost
importance for the final diagnosis.
• The careful evaluation of the ampullary lumen by means of
hysterosalpingography can provide useful information about
tubal mucosal abnormalities. Therefore, we stress that
hysterosalpingography should be considered not only for
diagnosis of tubal patency but also for its capacity, which might
be improved, to depict mucosal damage.
• The morphology of the ampullary tract of the fallopian tubes is
of paramount importance for the final diagnosis, and a precise
hysterosalpingographic result can greatly help the gynecologist
in the care of patients. The cobblestone pattern is an effective
radiographic sign of intraluminal adhesions in hydrosalpinges,
which, if preliminarily diagnosed, might bring into question the
need for a surgical approach. On the contrary, a normal
hysterosalpingogram cannot be used to conclude the infertility
work-up in cases of continuing infertility, because a patent and
 radiographically normal tube might not be a normally
functioning tube.
• Tuberculous salpingitis is characterized by:
- Thick mucosal folds
- Tubal calcification
- Tubal occlusion/patency
- Beaded/rosary appearance
- Sometimes..rigid tubes
‘pipe stem appearance’
- Ragged saw tooth endometrial cavity
- Endometrial hyperplasia
- Polypoidal filling defects

SALPINGITIS ISTHMICA NODOSA

• Salpingitis isthmica nodosa is also referred to as
tubal diverticulosis. HSG demonstrates multiple
small diverticular collections of contrast protruding
from the lumen into the wall of the isthmic portion
of the fallopian tubes. Histologically, the up to 2
mm sized diverticula represent hypertrophied tubal
mucosa that penetrates the myosalpinx (i.e.
muscular wall of the tube). There is secondary
hyperplasia and hypertrophy of the surrounding
myosalpinx, and hence at laparoscopy, localized
nodular thickening or swelling of the isthmus is
identified.
• The etiology of salpingitis isthmica nodosa is
unknown, however it may be a postinfectious
reaction. Patients have histologic evidence of
previous salpingitis and may have high serum
chlamydial antibody titers. Salpingitis isthmica
nodosa predisposes to a higher rate of primary
infertility by interfering with upward sperm
migration and ectopic pregnancy by trapping the
fertilized ovum within the tube. Hence the diagnosis
of salpingitis isthmica nodosa by HSG is important
in the management of the infertile patient.
• A HSG of the nodular area with severe SIN shows
several pockets containing the X-ray dye. Of
specific note is the observation that no dominant
channel is seen as the dye flows through the
tube. This means there appears to be no direct
 pathway for sperm to travel. This increases the
chance of a tubal pregnancy.

SIGNS OF PELVIC ADHESIONS

• Fixed uterine condition on probing.
• Vertical tube orientation.
• Loculation of the contrast