|Year : 2014 | Volume
| Issue : 1 | Page : 19-23
Hysterosalphingographic findings in women with infertility in Sokoto North Western Nigeria
Mohammed Danfulani, Máaji Sadisu Mohammed, Saidu Sule Ahmed, Yunusa Garba Haruna
Department of Radiology, Usmanu Danfodiyo University Teaching Hospital, Sokoto State, Nigeria
|Date of Web Publication||25-Aug-2014|
Dr. Mohammed Danfulani
Department of Radiology, Usmanu Danfodiyo University Teaching Hospital, Sokoto State
Source of Support: None, Conflict of Interest: None
Background: Patients who presented with infertility could have a structural deformity that can be responsible for it. Hysterosalphingography (HSG) is a special contrast examination that is used to assess the structural integrity of the cervical canal, uterine cavity and fallopian tubes. This study reviewed the pattern of HSG findings in patients with infertility in Sokoto, Northwestern Nigeria. Materials and Methods: Descriptive retrospective study of patients who have been referred for HSG examination to our center. A total of 317 patients that had HSG examination done in our center from July 2009 to August 2012 were reviewed. The information retrieved from their records included biodata, indication for examination, summary of radiologist report. Data obtained were analyzed using Statistical Software SPSS version 18 for windows Results: A total of 317 patients were involved in the study, their ages ranged from 17 to 48 years. (mean 32.5 ± 5.5 years). The indications were primary infertility 143 (45.1%) and secondary 174 (54.9%) patients. Report showed that 139 (41.7%) patients had normal HSG findings and the remaining 178 (58.3%) had abnormalities in the cervical canal, uterine cavity or fallopian tubes. Tubal pathologies constituted the commonest finding 112 (33.6%) followed by uterine (25.5%) and cervical the least 45 (13.5%) patients. It was observed that majority of the lesions occurred in combination. Conclusion: HSG has a very high diagnostic yield in the management of infertility and should be routinely employed in patients being evaluated for infertility.
Keywords: Infertility, Hysterosalphingography, pattern
|How to cite this article:|
Danfulani M, Mohammed MS, Ahmed SS, Haruna YG. Hysterosalphingographic findings in women with infertility in Sokoto North Western Nigeria. Afr J Med Health Sci 2014;13:19-23
|How to cite this URL:|
Danfulani M, Mohammed MS, Ahmed SS, Haruna YG. Hysterosalphingographic findings in women with infertility in Sokoto North Western Nigeria. Afr J Med Health Sci [serial online] 2014 [cited 2020 Jul 14];13:19-23. Available from: http://www.ajmhs.org/text.asp?2014/13/1/19/139438
| Introduction|| |
Hysterosalphingography (HSG) is a special contrast examination that is used to assess the cervical canal, uterine cavity and both Fallopian tube More Detailss; usually an invasive procedure and is usually achieved by cannulating the cervical os and retrogradely injecting the contrast medium to outline the female reproductive tract, (cervix, Uterus and both tubes). ,, It is usually done under fluoroscopy with image intensification. 
HSG is a valuable technique in the evaluation of infertile patient.  It is of diagnostic value in the investigation of the cervical, uterine and tubal factors in female infertility and still remain the goal standard in terms of imaging perspective.  It is a cheap, safe and rapid diagnostic tool.  Despite the development of other diagnostic tools such as magnetic resonance imaging, hysteroscopy and laparoscopy, HSG remains the main examination for the fallopian tubes in the developing countries. 
HSG is very sensitive in identifying the uterine and tubal abnormalities hence an important diagnostic tool for uterine and tubal condition in our environment. 
Uterine abnormality is thought to be contributing factor in approximately 10% of infertile women and 50% of women with recurrent early pregnancy loss, while the prevalence of tubal abnormalities is approximately 20%. , Therefore assessment of uterine cavity and fallopian tubes is standard practice in the baseline investigations for infertility. 
Common indications for these procedure include but not limited to evaluation of tubal patency, identification of congenital anomalies of genital tract, assessment of uterine cavity, efficiency of tubal sterilization, reversal of tubal surgery, assessment of pathologic secondary amenorrhoea among others.  Known contrast allergy is also an absolute contraindication. It is however contra-indicated in pelvic inflammatory infection (PID) and pregnancy.  Noted among its complications are pelvic infection, severe pain, Hemorrhage and vasovagal attacks. 
Reports have shown that tubal diseases constitute a major factor in infertility especially in Nigeria and other developing countries.  Where HSG is the main diagnostic tool for examination of the fallopian tubes hence the justification for undertaking this study. The aim of this study is to review the pattern of HSG findings in patients being referred to our clinic for infertility evaluation.
| Materials and Methods|| |
This is a retrospective review of 317 HSG investigations of infertile women referred to Nagarta Ultrasound and Radio-diagnostic Center-a private radiological center in Sokoto, Northwestern Nigeria. This study was conducted from July 2009 to August 2012. All the patients were referred from different neighboring hospitals and clinics within Sokoto and its environs.
A total of 317 HSG studies of women presented at the center during the course of this study were reviewed. Verbal consent was obtained after fully explaining the procedure to the study participants. The information retrieved from their records included bio data, indication for the examination and the summary of the radiologist reports/findings. Data obtained were entered into Microsoft Excel Spreadsheet and subjected to descriptive statistical analysis using Statistical Package for Social Sciences (SPSS) version 18 for windows.
The HSG examination was carried out by trained Radiologists who also interpreted the results afterwards. The procedure was performed as follows using standard procedures (Surton, ACOG).
The patient was asked to lie on her back with her feet placed as for a pelvic exam. A device called a speculum was inserted into the vagina. This is important so as to hold the walls of the vagina apart to allow the cervix to be viewed. The cervix was cleaned.
A vosellum was used to hold the anterior wall of the cervix and make steady. An instrument called a cannula was then inserted into the cervical os and the contrast was introduced into the uterine cavity to outline both the cervical canal, uterine cavity and the tubes.
X-ray films were taken as the contrast medium fills the uterus and tubes. Standard views taken include an Anterior-Posterior (AP) view of the pelvis, right and left lateral obliques and a delayed film after 30 min where necessary.
After the images were made, the cannula was removed. This procedure was applied to all the study participants (Surton and ACOG).
Also as part of precautionary measures taken during the conduct of this work, the ''Ten days rule'' was observed in the booking and the undertaking of HSG and is what was adhered to in our center; that procedure is best done within the first 10 days after the last menstrual cycle so as to avoid the possibility of accidentally irradiating the developing fetus. ,
Approval for this study was obtained from the Ethical Committee of the Study Center. Also both verbal and written consent were obtained from the participants.
| Results|| |
A total 317 patients were involved in this study. The minimum age was 17 years and the maximum age was 48 years with a mean and standard deviation value of 32.5 ± 5.5. A total of 202 (63.7%) of the sample size fall within the age range of 21-30 years, thus constituting the highest frequency of HSG in our study center. Out of 317 patients, 139 (41.7%) had normal findings while the remaining 178 (56.15%) patients revealed pathology in the cervix, uterus, fallopian tubes or in combination. [Table 1] shows the age distribution of the patients according to age ranges.
Secondary infertility constituted the commonest indication with 174 (54.9%) while primary infertility was responsible in the case of 143 (45.1%) patients. When the indication was further analyzed by age group; both primary and secondary infertility were common within the age range of 21-25 and 26-30 years as shown in [Table 2].
Cervical pathology was demonstrated in 45 patients which constituted 13.5%. Within the patient with cervical findings age group of 26-30 years had the highest (18 patients). The commonest cervical pathologies were cervicouterine-adhesions, cervicitis, cervical polyps, cervical diverticulum and cervical fibroids [Table 3].
As the age increases the frequency of cervical pathology findings decreases. No pathology was found in patients aged 46-50 years.
Uterine findings were observed in 85 (25.5%) patients as shown in [Table 4]. Again the age group 26-30 years had the highest (10.8%) patients involvement. The uterine pathology findings decreased as the age advances and none was found in patients aged between 46-50 years. The commonest uterine pathology noted were; uterine adhesions, congenital uterine anomaly (biconuate and arcuate uterus) uterine fibroids, Asherman's syndrome, cervicouterine adhesion, uterine-hypoplasia among others [Table 5]. Most of the pathologies occurred in combination.
|Table 5: Distribution of HSG fi ndings among women investigated for infertility|
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A total of 112 (33.6%) patients had tubal pathology, hence the commonest. As seen in [Table 6], more than half of patients with tubal pathology again are below the age of 30 years. Thereafter, tubal pathology findings decreased as the age advances as it were the findings for both cervical and uterine lesions.
This descriptive retrospective study was carried out to document the pattern of HSG findings of infertile women in this environment.
More than 50% of the patients being evaluated in this study revealed abnormality in cervical canal, uterine cavity, fallopian tubes or in combination. This is in agreement with a study done in Maiduguri, North Eastern region of Nigeria sub-Saharan Africa presumably due to same cultural beliefs and practices.  Although HSG is still vital and undisputed in the evaluation of infertile women, recent studies reveal that sonohysterography is superior to HSG for assessing intrauterine abnormalities; as it is free of ionizing radiation, cheaper and more tolerable.  The demonstration of pathologies in 54.7% of patients in this study is comparable to that reported from Maiduguri,  Enugu and Ile-Ife. ,
Tubal pathology was the largest abnormality observed in this present study. Of the 317 patients seen, 112 (33.6%) showed positive finding in the fallopian tubes. Right tubal blockage was more preponderant in this study over the left tubal block. This finding agrees with what was reported by Adetiloye  but is in contrast to findings elsewhere where bilateral tubal block constituted the most common findings. , While [Figure 1] and [Figure 2] demonstrates the commonest tubal findings in this study, [Figure 3] shows a typical normal HSG.
|Figure 1: Shows HSG image of patient with left sided hydrosalphinx with a right blocked tube|
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Infection is the commonest single most important cause of infertility in our environment as it is demonstrated by the high incidence of tubal pathologies as seen in this and many previous studies. ,,,
Consequently primary prevention and prompt treatment of this infection are of paramount importance and should be encouraged in the reduction of high incidence of tubal infertility in our environment.
Hydrosalphinges was the next common tubal pathology noted in this study. Bilateral was commoner 12 (3.6%) this is similar to the study in Port Harcourt where the incidence was (5%)  followed by left sided Hydrosalphinx which occurred in 10 (3%) patients.
Congenital uterine abnormalities encountered here constituted only about 3 (0.9%) of the abnormalities detected on HSG in our study, this is lower than Maiduguri studies  but almost similar to 1.4% and 1.5% by sanfilippo and Nickerson, respectively. , Uterine pathology uterine adhesions constituted 35(14.7%) and is the commonest uterine abnormality then followed by uterine fibroid. This is similar to studies done by Bukar et al. but is contrast with Mgbor who found uterine fibroid as the commonest uterine abnormality.  Our finding is also similar to the findings of Asaleye et al. in Ile-Ife. The high incidence of uterine adhesions may probably be due to infection and post-instrumentation (Dilatation and Curettage) of an unwanted recent pregnancy. The aggressive and prompt use of antibiotics to treat infection would significantly lower the contribution of uterine adhesion as a cause of infertility.
In conclusion hysterosalphingography (HSG) has proved to be of very high diagnostic yield as it is demonstrated by its high detection of uterine and tubal abnormalities in the management and evaluation of patients with infertility and remains an important tool in the work-up for infertility.
| References|| |
|1.||Cron RS. Hysterosalphyngography and Infertility. Aust NZJ Obstet Gynaecol 1965;5:12-7. |
|2.||Heasler DC Jr, Brant WE. Obstetrics and Gynaecological Imaging, Radiology Recall. 2 nd ed. India: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2008. p. 580. |
|3.||Theodore A, Baranki MD. Modern trends in hysterosalphingography. Fertil Steril 2005;83:1595-606. |
|4.||Oguntoyinbo AE, Amole AO, Komolafe OF. Sonographic Assessment of tubal patency in the investigation of female infertility in Ilorin, Nigeria. Afr J Reprod Health 2001;5:100-5. |
|5.||Ubeda B, Martha P, Enric A, Ramonm AA. Pictorial Essay: Hysterosalpingography: Spectrum of normal variants and pathological findings. Am J Roentgenol 2001;177:133-5. |
|6.||Sanfillippo JS, Tadsman MA, Smitti O. Hysterosalphingraphy in the evaluation of infertility. A six year review. Fertil Steril 1978;30:636-43. |
|7.||Nickerson C. Infertility and uterine contour. Am J Obstet Gynaecol 1977;129:268-71. |
|8.||Kodaman PH, Arici A, Seli E. Evidence based diagnosis and management of tubal factor infertility. Curr Opin Obstet Gynecol 2004;16:221-9. |
|9.||Ronald GG. The female reproductive systems. In: Grainger RG, Allison DJ, Editors. Diagnostic Radiology. Vol. 3, Philadelphia: Churchill Livingstone; 1993. p.1809-69. |
|10.||Kaishima JA, Dani PA, Ekedigwe JE. Hysterosalphingographic evaluation of 998 consecutive infertile women in Jos, Nigeria. Int J Gynaecol Obstet 2010;108:255-7. |
|11.||Okafor CO, Okafor CI, Okpala OC, Umeh E. The pattern of hysterosalphingographic findings in women being investigated for infertility in Nnewi, Nigeria. Niger J Clin Pract 2010;13:264-7. |
|12.||Akinola RA, Akinola OI, Fabamwo AO. Infertility in women: Hysterosalpingographic assessment of fallopian tubes in Lagos, Nigeria. Educ Res Rev 2009;4:86-9. |
|13.||David S. Textbook of Radiology and Imaging, 7 th ed. London: Churchill Livingstone; 2002. p. 1085-90. |
|14.||American College of Obstetricians and Gynecologists (ACOG). Available from: http://www.acog.org/~/media/For%20Patients/faq143.pdf?dmc=1andts=20140212T1438496440. [Last accessed on 2014 Feb 11]. |
|15.||Bukar M, Mustapha Z, Takai UI, Tahir A. Hysterosalphingographic findings in infertile women: A seven year review. Niger J Clin Pract 2011;14:168-70. |
|16.||Case AM, Pierson RA. Clinical use of sonohysterography in the evaluation of infertility. J Obstet Gynaecol Can 2003;25:641-8. |
|17.||Mgbor SO. Pattern of hysterosalphingographic findings in gynaecological patients in Enugu. Niger Med J 2006;47:14-6. |
|18.||Asaleye CM, Adetiloye VA, Oyinlola TO. Review of Hysterosalphingographic reports done for infertility over a 10 year period. Niger J Health Sci 2004;4:36-9. |
|19.||Adetiloye VA. Hysterosalphingography in the investigation of infertility: Experience with 248 patients. West Afr J Med 1993;12:191-6. |
|20.||Adinma JB, Adinma E, Okpala OC. Hysterosalphingography in management of infertility. Bilatera tubal occlusion. West Afr J Radiol 1995;3:29-33. |
|21.||Idrisa A, Ojiyi E, Hamidu AU. Hysterosalphingography versus laparoscopy in the evaluation of female infertility in Maiduguri, Nigeria. Trop J Obstet Gynaecol 2003;20:20-3. |
|22.||Brow SE, Codding CC, Schnorr J, Toner JP, Gibbons W, Oehminger S. Evaluation of outpatient hysteroscopy, saline infusion hysterosonography and hysterosalphingography in infertile women; a prospective, randomized study. Fertil Steril 2007;74:1029-34. |
|23.||Bruncham RC, Maclean IW, Binns B, Peeling RW. Chlamydia trachomatis: Its role in tubal infertility. J Infect Dis 1985;152:1275-82. |
|24.||Horwitz RC, Norton PC, Shaff MI. A radiological approach to infertility. Hysterosalphingography. Br J Radiol 1971;52:255-62. |
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]