675
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:‘‘i
Review
Hysterosalpingography Isabel
C. Yoder1
and Deborah
in the 1990s
A. Hall
.
: y:
the procedure has been a primary tool in the evaluation of infertility, and given today’s increasing concern over infertility, it is a procedure that is likely to be more frequently performed. Fortunately. the technique and interpretation of hysterosalpingography have been refined, and the procedure is less painful and diagnostically more accurate than it once was. In this article, we discuss current techniques and use of contrast material in hysterosalpingography. We then review the impact of recent interventional developments, such as fallopian tube catheterization, on hysterosalpingography. Finally, we examme common tubal and uterine abnormalities in the context of the imaging techniques that have become available only in the last decade or so, for example, transvaginal sonography and MR imaging.
All
physicians involved in the evaluation and treatment of rely heavily on the information provided by hysterosalpingography. For many years this study has provided images of the lumina of the fallopian tubes that are not available by other diagnostic means, and it also gives the most accurate outline of the uterine cavity. Hysterosalpingography will therefore continue to be a valuable study in the upcoming decade, and it is important now to take account of the many advances in technology that impinge on the execution and interpretation of this study. In this article we first update the continuing debate about elements of the study itself, involving techniques and the choice of contrast material. We also consider surgical advances, such as the widespread use of microsurgical reconstruction of the fallopian tube, that Increase the demand for hysterosalpingography. Since radiologists are asked to evaluate the results of surgery, it is essential for them to be familiar with the postoperative appearances of the fallopian tube. Finally, we consider what must be by far the most Important development of the 1990s, the continuing integration of hysterosalpingography with new Interventional and imaging techniques. Fallopian tube catheterization expands the examination of the fallopian tube and offers new therapeutic applications. Transvaginal sonography and MR imaging have allowed noninvasive exploration of the female pelvis. Correlation of hysterosalpingography and MR imaging is particularly useful in the diagnosis of uterine myomas and congenital uterine duplication anomalies when surgery to preserve or enhance the reproductive capacity of the uterus Is indicated. Sonography and MR imaging should be correlated with hysterosalpingography to provide a more efficient diagnostic and therapeutic approach to the common mechanical causes of infertility. infertility
The
first
hysterosalpingogram
by using bismuth
Received March 13, 1991; Both authors: Department AJR 157:675-683,
was
paste as the contrast
obtained
medium.
80 years
574-06750
Technique
Hysterosalpingography is a procedure that falls within the domain of both radiology and gynecology. Today in the United States, 55% of hysterosalpingograms are obtained by the radiologist and gynecologist working together; only 27% are obtained by the radiologist alone [1]. These circumstances have led to the development of two major techniques. The balloon catheter technique is favored by radiologists [2], and the tenaculum-cannula technique is preferred by gynecologists working alone [3] or with radiologists [4, 5]. We favor the balloon catheter technique (Fig. 1) because it is simple to learn, is comfortable for patients, and facilitates diagnostic maneuvers such as turning patients to oblique and prone positions. Proponents of the cannula technique argue that the balloon may obscure uterine anatomy and may lead to dis-
ago
Since then,
accepted after revision May 21 1991. of Radiology, Massachusetts General
October 1991 0361 -803X/91/1
Article
Hospital,
Fruit St., Boston,
American
Roentgen
j
iI1
‘
v
Ray Society :
MA 02114.
Address
reprint
requests
to I. C. Yoder.
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676
YODER
AND
HALL
AJR:157,
October
1991
Fig. 1.-Normal balloon catheter hysterosalpingogram in a 36-year-old woman after 1 year of infertility. A, Anteflexed uterus, foreshortened on anteroposterior view. Foley balloon is inflated within lower cervical canal (arrow). B, After catheter is pulled gently, uterus is straightened and uterine cavity displayed beautifully. Because this maneuver may cause balloon (arrow) to pop out of cervical canal, it is usually reserved as final step after all necessary diagnostic films have been obtained. Fallopian tubes are normal in caliber, and free intrapentoneal spill is
ample.
A
B
comfort after the procedure [6]. In order not to interfere with clear visualization of the uterine cavity, the balloon catheter is inflated within the endocervical canal. This is especially important in the assessment of cervical incompetence, which requires an accurate measurement of the size of the internal cervical os. Regardless of personal preference, both balloon catheter and cannula techniques produce excellent diagnostic studies,
and physicians
should be well versed in both of them because
circumstances may dictate a specific need for one or the other. For example, balloon catheters allow simultaneous catheterization of a double cervix for better visualization of uterine duplication anomalies. The cannula technique is preferred in the presence of extensive uterine synechiae, because under those circumstances the balloon catheter will be
repeatedly
expulsed.
Physicians
also should
be aware
refinements in the instruments used for hysterosalpingography. A number of newly developed rigid balloon catheters
can be very useful
in cannulating
patients
with cervical
of [7]
ste
nosis, and a new plastic cannula can be used for the same purpose [8]. After catheter placement, routine spot films are obtained under fluoroscopic control. A normal study may require only five films: a preliminary view of the pelvis, followed by two anteroposterior views and an oblique view of each fallopian tube during instillation of contrast media. Usually, a total of 6-8 ml of contrast material is sufficient, but special circumstances such as an enlarged uterine cavity may warrant larger amounts. The initial anteropostenor spot film is an underfilled
view of the uterine cavity to show the presence endometnal lesions (Fig. 2A) that are easily obscured amounts of contrast media (Fig. 2B). After oblique the tubes
demonstrate
are obtained,
free
a final
dispersion
bowel loops. Peritoneal lead to the accumulation
anteroposterior
of contrast
adhesions surrounding of contrast material
view
material
of small by large views of should
around
the tubes may in a paratubal
collection. To aid the detection of paratubal collections, infusion of adequate amounts of contrast media and the use of
Fig. 2.-uterine polyps and postoperative peritoneal adhesions in a 38-year-old woman with a long history of infertility. Surgical abdominal myomectomy and uterine suspension were performed 5 years before. A, Eariy hysterosalpingogram shows multiple polyps as rounded and oval filling defects in uterine cavity (arrowheads) and a solitary air bubble (arrow). B, Further infusion of contrast material fills both fallopian tubes and obscures polyps. Ampullae, although not dilated, appear rigid and in an abnormally medial position. C, Drainage view shows loculated spill of contrast material (arrow), right peritubal halo (arrowhead), and some free spill into cul-de-sac (Cs). Multiple endometrial polyps were removed at hysteroscopy. Laparoscopy revealed multiple adhesions involving tubes, bowel, and pelvic side wall.
AJR:157,
October
drainage
HYSTEROSALPINGOGRAPHY
1991
films
are very helpful
(Fig. 2C). The drainage
film is
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obtained 5-1 0 mm after removal of the uterine catheter and after the patient has been allowed to move around or turn prone. Technical problems arise when the contrast material does not
flow
freely
into
one
or both
fallopian
tubes
and
there
appears to be interstitial tubal obstruction. This may represent a true obstruction or a transient lack of filling due to what is commonly referred to as tubal spasm. Several drugs, such as glucagon and terbutaline, have been used in an attempt to overcome muscular tubal spasm [9]. Our current approach is to try to overcome interstitial obstruction by turning the patient into a prone position and instilling additional contrast material [10]. The normal tube often will fill after this maneuver, and
the patient candidate
whose
tubes
for fallopian
Contrast
remain
tube
occluded
may become
a
catheterization.
Material
Debate continues between advocates of oil-soluble and those of water-soluble contrast media for hysterosalpingography. The arguments do not center on the diagnostic properties of the agents, because with few exceptions [1 1], everyone
agrees
that water-soluble
contrast
medium
provides
better uterine and ampullary mucosal detail, and therefore more accurate diagnostic studies [1 2]. The controversy concerns the therapeutic properties of each contrast medium. Some studies credit oil-soluble contrast medium for higher pregnancy
studies
rates
pregnancy
soluble that
after
[1 4] conclude
the
procedure
[1 3],
rates after hysterosalpingography
material.
oil-soluble
whereas
that there is no statistical
Recent
media
in
with oil or water-
animal studies
contrast
other
difference
[1 5, 1 6] have shown
result
in
granulomatous
changes and fibrosis on the peritoneal surfaces of the animals tested. Water-soluble contrast material produced either no peritoneal
reaction
or a mild transitory
inflammatory
reaction.
tube
677
catheterization.
Versed
(Roche
easily as other water-soluble Fallopian
Tube
agents
the peritoneum
longer periods than guidewire
do.
Catheterization
Obstruction at the interstitial or proximal portion of the fallopian tube precludes evaluation of the distal tube by hysterosalpingography and therefore may make laparoscopy necessary. Fallopian tube catheterization offers an alternative to laparoscopy.
It is a method
developed
by Thurmond
et al.
[18] to examine the distal tube when hysterosalpingography shows interstitial obstruction of one or both fallopian tubes. Fallopian tube catheterization is a natural extension of hysterosalpingography, but because the procedure is more painful and prolonged than hysterosalpingography, it requires separate scheduling. Patients are placed on oral antibiotics, usually doxycycline, for a few days before and after fallopian
of
selective
are
catheteriza-
cannulation
does. Because
the
balloon catheter used for dilatation has a much larger diameter than the interstitial segment of the tube, it probably breaks up adhesions within the cornu itself and not inside the tube. Furthermore, falloscopy shows that when a fibrotic stricture is present within the proximal tube, both the balloon catheter
and the guidewire are completely [23]. Another successful therapeutic pingography
gametes
has been
and embryos
procedure
as
doses
,
depends
[27].
not flood
small
NJ) and fentanyl
who perform selective salpingography have reported high rates of success, in the range of 86-98%, in catheterizing occluded tubes. More than half of the distal tubes visualized in this manner appear normal and show free intraperitoneal spill. The remainder show a variety of abnormalities, including pentubal adhesions, hydrosalpinx, salpingitis isthmica nodosa, and postsurgical isthmic stenosis. Endoscopic observation with falloscopy confirms [23] that the guidewire used for tubal cannulation breaks up intraluminal adhesions, and then contrast material flushes mucus plugs from the proximal tubes. Thus, fallopian tube catheterization enjoys both diagnostic and therapeutic properties. The subsequent pregnancy rate varies between 7% [21 ] and 31 % [20] overall, with a significant number of ectopic pregnancies. Tuboplasty, dilatation of the tube with a modified angioplasty balloon catheter as described by Confino et al. [24], does not improve the pregnancy rate (28%) but may prevent tubal reocclusion for
slightly
and does
Nutley,
tion of the ostium of the fallopian tube with an angiographic catheter. The technique was described recently in this journal [19]. Thurmond and Rosch [20] and other authors [21 22]
transvaginal the isthmus
viscous
the procedure,
given IV to treat pain as necessary. Fallopian tube catheterization entails
Clinical studies have shown no advantage to the use of lowosmolality contrast media over conventional contrast media [17]. Therefore, safety and diagnostic factors dictate the use of a conventional water-soluble contrast agent. The concentration of iodine does not need to exceed 30% to provide good detail. We use Sinografin (38% iodine, Squibb), which is more
During
Laboratories,
Radiologists
ineffective
in bypassing
application
of selective
its use for the direct
tubes
ability
be called
on to assist
of
[25].
The
to manipulate
catheter through the uterotubal under transvaginal sonographic may
sal-
introduction
into the fallopian
on the operator’s
it
a
ostium and into monitoring [26].
in these
fertilization
techniques as they become more popular. They require no anesthesia, and gamete intrafallopian transfer results in a 21 % live delivery rate, whereas in vitro fertilization with intrauterine
embryo
transfer
has
a 1 2%
rate
of live deliveries
In summary, fallopian tube catheterization improves on the diagnostic evaluation of the fallopian tube offered by hysterosalpingography, and may have diverse therapeutic applications. Complications of catheterization are similar to compli-
cations of hysterosalpingography, and include pain, radiation exposure, infection, and tubal perforation, which is unique to catheterization. Tubal perforation can occur when there is complete fibrotic obstruction of the tubal lumen, but it promptly seals over and has not produced any bleeding or other long-term problems. Prophylactic antibiotics have pre-
vented any septic complications Tubal The
length.
to date [28].
Abnormalities oviduct
is a muscular
It is divided
tube
measuring
into the intramural
10-14
(interstitial),
cm
isthmic,
in
678
YODER
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and ampullary portions. The normal mucosa consists of a single layer of columnar epithelium composed of secretory and ciliated cells [29]. The fallopian tube has a limited range of reactions to disease: obstruction and/or dilatation. Obstruction Obstruction of the interstitial segment is usually due to infection, such as salpingitis isthmica nodosa, or to endometriosis. Previous salpingectomy and tubal ligation are the most frequent causes of isthmic obstruction of the fallopian tube. Less often, infectious or endometriotic scarring in this portion of the tube may occur. The ampullary portion of the tube is
the most commonly
obstructed.
Hydrosalpinx Hydrosalpinx refers specifically to the dilatation of the ampullary segment of the tube that accompanies distal obstruction. The ampulla dilates preferentially because it has a thin muscular wall surrounding a relatively capacious lumen. Hydrosalpinx is usually the sequela of infection with agglutination
and fibrosis
of the fimbria.
It is associated
with
paratubal
adhesions. Gonococcal, chlamydial, and mixed bacterial salpingitis may result in hydrosalpinx. Endometriosis and pelvic surgery may also cause fimbrial adhesions, tubal occlusion, and hydrosalpinx (Fig. 3A). Endometriosis is increasingly a cause of infertility in the older patient who delayed childbearing. Transvaginal sonography provides a noninvasive view of the dilated fallopian tube but has proved disappointing in its ability to identify the normal tube [30]. A dilated fallopian tube is seen on transvaginal sonography as a tubular structure with a folded configuration and a well-defined echogenic wall [31] (Fig. 3B). Dilated fallopian tubes have to be differentiated from other cystic tubular structures in the pelvis such as bowel loops, which show peristaltic motion; dilated pelvic veins, which have blood flow within them; cystic adnexal masses; and appendicitis [32, 33]. Schlief and Deichert [34] infused SHU 454/Echovist (Schering, Berlin), a new echogenic contrast medium, into the uterus during transvaginal sonography and reliably showed patency of normal fallopian tubes.
The advantage
of this indirect
method
is that it spares
patient ionizing radiation. However, it is cumbersome requires uterine cannulation without giving the accurate tomic detail of the tube provided by hysterosalpingography.
the and ana-
AND
HALL
AJR:157,
Hysterosalpingography anatomy of the fallopian falloscopy. Falloscopy is that enables the surgeon the uterotubal ostium to hysteroscope [35].
Salpingitis
Isthmica
October
1991
offers the best view of the internal tube short of direct visualization by a new microendoscopic technique to explore the fallopian tube from the fimbria through a small flexible
Nodosa
The isthmic portion of the tube has a thick muscular wall, and luminal dilatation is very rare. More commonly, the hysterosalpingogram shows multiple small diverticula extending from the isthmic lumen into the wall (Fig. 4). This appearance is characteristic of salpingitis isthmica nodosa. It affects both tubes in 80% of cases [36] and often is associated with proximal obstruction or ampullary dilatation. Fallopian tube catheterization has increased our ability to diagnose salpingitis isthmica nodosa by its ability to fill the isthmic diverticula beyond the proximally occluded tube. These patients have a history of pelvic infection and exhibit a high rate of primary infertility (38%) and ectopic pregnancy (9.4%) [37]. lsthmic diverticulosis identical to salpingitis isthmica nodosa can sometimes be seen in tuberculosis of the fallopian tube. Unlike salpingitis isthmica nodosa, tuberculosis is accompanied by contraction of the ampulla and adnexal calcification.
Fallopian
Tube
Surgery
Microsurgical techniques allow the successful performance of tubotubal and tubouterine anastomoses. This surgery is commonly executed after diagnosis of an obstructive lesion by hysterosalpingography or for reversal of tubal ligation. Hysterosalpingography before reanastomosis after tubal Iigation is considered valuable by some authors [38] and unwarranted by others [39]. In our experience, currently few
requests
for salpingographic
evaluation
of tubes
are made
before reversal of sterilization. However, the demand is increasing for postoperative evaluation of tubes after all types of microsurgical reconstruction. Hysterosalpingography shows the patency of the tube, its length, the degree of narrowing at the site of the anastomosis (Fig. 5), the condition of the ampulla, and the development of paratubal adhesions. Measuring the length of the tube is important, as the viable pregnancy rate is reduced in women with oviducts shorter than 4 cm [40].
Fig. 3.-Left-sided hydrosalpinx in a 31-yearold woman with secondary infertility after normal delivery 41/2 years before. A, Hysterosalpingogram shows dilated and obstructed left fallopian tube (h). B, Transvaginal sonogram obtained 5 days later shows an anechoic tubular structure with linear echoes protruding into its lumen. This represents a dilated left fallopian tube (arrow) below an underfilled bladder (B). Laparotomy showed extensive pelvic endometriosis. Fulguration of endometriosis, lysis of adhesions, and left fimbrioplasty for a completely blocked tube were accomplished. Six months later, a pregnancy test was positive.
A
B
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AJR:157,
October
HYSTEROSALPINGOGRAPHY
1991
Fig. 4.-Salpingitis isthmica nodosa in a 28year-old woman with 7 years of infertility. Hysterosalpingogram shows bilateral isthmic diverticulosis (arrows), more pronounced on right side. Hydrosalpinx is bilateral. Ampullary mucosal pattern is better preserved on right side than on left. Patient had bilateral cuff salpingoplasties and lysis of adhesions. Nodularity of proximal tubes is consistent with salpingitis isthmica nodosa. Fig. 5.-Hysterosalpingogram after tubal reconstruction in a 33-year-old woman who had a tubotubal reanastomosis after a Pomeroy tubal ligation. One year after surgery, she had not conceived. Hysterosalpingogram shows a nondilated, freespilling left fallopian tube with marked circumferential narrowing at site of reanastomosis (white arrow) and a short and rigid left ampulla (A). Right fallopian tube shows complete isthmic obstruction (black arrow) at surgical site. cs = cul-de-sac.
4
The normal ciliated cells that line the fimbria and ampulla play a major role in ovum transport. These ciliated cells are destroyed with obstruction and hydrosalpinx. The hysterosalpingogram can be used to determine the success of surgical reconstruction. Increasing dilatation of the ampulla and effacement of its mucosal patterns as shown on hysterosalpingograms is directly correlated with significant decrease of both the percentage of ciliated cells and the pregnancy rate after microsurgical salpingostomy [41 ]. Donnez and CasanasRoux [41 ] report a 48% rate of pregnancy after repair of an occluded nondilated ampulla and a 22% rate of pregnancy in an occluded ampulla distended to a diameter greater than 2.5 cm. If pregnancy does not occur in a reasonable period and the postoperative hysterosalpingogram shows tubal abnormalities, the patient may then be a candidate for in vitro fertilization.
Paratubal
Adhesions
Paratubal adhesions are difficult to evaluate by hysterosalpingography. They are the largest source of discrepancy between the results of hysterosalpingography and laparoscopy. Endometriosis, surgery, and pelvic infection are the common sources of adhesions. They cloak the peritoneal surfaces of the tubes and ovaries and disturb the tuboovarian relationship to such an extent that they interfere with ovum capture and transport by the fimbria. Laparoscopy provides direct visualization of adhesions, whereas hysterosalpingography gives only indirect evidence of their presence. The most suggestive salpingographic findings include a convoluted or vertical tube in association with loculated spill of contrast material and peritubal halo effect [42]. The detection of paratubal collections is improved by infusion of adequate amounts of contrast material and the use of drainage films.
Uterine
Abnormalities
The normal uterine cavity as shown on grams is triangular, with a smooth outline. within the uterine cavity may be due to air blood clots, adhesions, submucosal myomas, endometrial hyperplasia. Accurate diagnosis patient’s clinical and surgical history as well
hysterosalpingoFilling defects bubbles, polyps, carcinoma, and depends on the as correlation of
679
5
the hysterosalpingographic available imaging studies.
findings
with
findings
from
other
Leiomyomas
Uterine myomas are common benign tumors in young women. These tumors may produce symptoms associated with a pelvic mass, menorrhagia, and infertility. Transabdominal or hysteroscopic myomectomy is the surgery of choice to preserve the uterus and future reproductive capacity. Accurate localization of leiomyomas is a prerequisite for conservative surgery. The sonographic diagnosis of utcrine fibroids is easily available and inexpensive, but highly maccurate, with a prospective sensitivity on only 60% [43]. Difficulty in establishing the correct diagnosis is in part due to the variable patterns of echogenicity of fibroids and their frequent exophytic or pedunculated position, which can mimic other pelvic conditions [44]. Hysterosalpingography accurately shows the presence of submucous myomas as smooth filling defects in the uterine cavity (Figs. 6A and 6B) and often suggests the presence of intramural myomas by displacing or enlarging the uterine cavity. However, recent studies show that MR imaging far surpasses both sonography and hysterosRlpingography in its ability to identify, localize, and characteri7e leiomyomas before surgery [45-51]. On 12-weighted images, leiomyomas appear as discrete masses of lesser or greater intensity than the medium-intensity myometrium (Fig. 6C). Histologic analysis shows that on MR images, low-intensity leiomyomas consist of typical whorls of smooth muscle cells with various degrees of fibrosis, whereas high-intensity, inhomoqeneous leiomyomas contain various degrees of hyaline, mucinous, hemorrhagic, and myxomatous degeneration [46]. Sonography, hysterosalpingography, and MR imaging have all documented significant decreases in the volume of the uterine cavity and size of fibroids after 2-6 months of therapy with gonadotropin-releasing hormone agonist [52, 531. Reduction in tumor size is often associated with control of bleeding and normalization of RBC count and hemoglobin. Subsequent myomectomy, therefore, may be clinically safer and technically easier to perform. In summary, MR imaging is the diagnostic technique of
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680
YODER
choice before myomectomy. In order to keep the cost of diagnostic procedures within realistic limits, it is suggested that MR imaging replace all subsequent sonographic examinations in young patients once myomectomy has been chosen as the best form of therapy necessary to preserve reproductive capacity. Hysterosalpingography may be necessary to assess fallopian tube patency, but hysteroscopy may not be needed if MR imaging shows no evidence of submucous myoma.
Adenomyosis Adenomyosis refers to the presence of endometrium deep within the myometrial wall and hyperplasia of the myometrium around the implants [54]. The disease is more common in women older than 30 who have menorrhagia and dysmenorrhea. On sonograms, adenomyosis has been described as showing a nonspecific uterine enlargement with decreased echogenicity of the myometnum [55]. Rarely, adenomyosis
AND
HALL
AJR:157,
October
1991
can be diagnosed on hysterosalpingograms when contrast material extends from the uterine cavity into the glands within the myometrium. Characteristic short diverticular outpouchings are then seen along the body or fundus of the uterus (Fig. 7A). T2-weighted MR images of diffuse adenomyosis show thickening of the junctional zone and a poorly marginated low-signal-intensity mass [56] extending diffusely into the myometrium (Fig. 7B). This can usually be differentiated from leiomyomas, which on MR appear as well-circumscribed masses with variable signal intensity [57]. Adenomyosis is a nonresectable disease because it involves the myometrium diffusely and is usually treated by hysterectomy, whereas myomas are encapsulated and can usually be enucleated [58].
Congenital
Uterine
Anomalies
Congenital anomalies of the uterus are often incidentally diagnosed during an infertility workup but are not usually the
Fig. 6.-Uterine fibroid in a 40-year-old woman with an enlarged uterus and menorrhagia. A, Hysterosalpingogram shows an enlarged uterine cavity indented along its right wall by a very large, smooth submucosal mass (arrowheads). B, Further infusion of contrast material fills both fallopian tubes and shows mild right hydrosalpinx (h). Intravasation of contrast material into myometrial venous plexus is seen in fundal area (arrow) and should not be mistaken for adenomyosis. C, 12-weighted axial oblique MR image of pelvis shows an 8-cm rounded, hypointense mass with inhomogeneous areas of low intensity occupying entire right myometrial wall. This intramural fibroid (f) is partially submucosal because it disrupts junctional zone (j) and indents into right wall of endometrial cavity (e). Myomectomy yielded an 8-cm fibroid with central myxomatous degeneration. Uterine cavity was entered.
Fig. 7.-Adenomyosis in a 40-year-old infertile woman who had a myomectomy 1 year before. At that time, a uterine wall biopsy revealed adenomyosis. A, Hysterosalpingogram shows prominent diverticular outpouchings extending into left uterine wall (white arrow) and to a lesser extent into fundus (black arrow). Although this film suggests isthmic obstruction of right tube, subsequent film with patient prone showed filling of a normal right fallopian tube. B, Sagittal T2-weighted MR image of pelvis shows a retroflexed uterus. Normal medium-intensity myometrium (m) is replaced by diffuse, lobular, low-intensity adenomyosis (arrows) surrounding endometrial cavity. c = cervix, e = endometrium, B = bladder.
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AJR:1 57, October
HYSTEROSALPINGOGRAPHY
1991
cause of primary infertility. Diagnosis before or early in pregnancy allows the clinician to plan for surgical intervention if necessary and for the associated obstetric complications experienced by these patients, including multiple miscarnages, premature labor, and fetal malpresentations [59]. Current imaging techniques such as transvaginal sonography and MR imaging enable us to detect and characterize uterine abnormalities with great accuracy and without the use of ionizing radiation. Hysterosalpingography is still a simple and direct method of diagnosis, but eventually wider availability and decreased cost may make MR imaging the definitive diagnostic tool. Understanding and diagnosing congenital anomalies depends on knowledge of embryology. The fallopian tubes, uterus, and proximal vagina are embryologically derived from paired mUllerian or paramesonephric ducts [60]. The cephalad mUllerian ducts form the fallopian tubes and the caudal ducts fuse to form the uterus. Congenital anomalies of the fallopian tube are rare and seldom are demonstrable by hysterosalpingography. They include accessory ostia, multiple lumina, diverticula, duplications, and absence of portions of the tube. Uterine duplications result from variable lack of fusion of the caudal mUllerian ducts. Partial lack of external fusion is seen in the bicornuate uterus, and total failure of fusion is seen in the uterus didelphys, often associated with a vertical vaginal septum. In the septate or subseptate uterus, the caudal ducts have fused but there is total or partial lack of resorption of the medial septum. The unicornuate uterus is a rare anomaly resulting from development of only one m#{252}llerian duct and various degrees of atresia of the contralateral system. Up to 23% of women with a genital tract anomaly have a concomitant urinary tract deformity, commonly unilateral renal agenesis or renal ectopia [61].
Septate
and Bicornuate
Uteri
The hysterosalpingogram can help differentiate between the two most common congenital uterine anomalies, septate and bicornuate uteri. The hysterosalpingogram will show two separate and symmetric cavities in both septate and bicornuate uteri. However, if the angle between the cavities is acute, 75#{176} or less, it is most likely a septate uterus [62] (Fig. 8A). If the contrast-filled horns are widely divergent with an obtuse angle between them, a bicornuate uterus is the more likely diagnosis (Fig. 9A). The differentiation between these
Fig. 8.-Septate
woman who was
uterus in a 28-year-old Russian told in Russia that she had a
“double uterus.” A, Hysterosalpingogram shows a deeply soptated uterine cavity. Although uterine cavities deviate slightly, angle between them is 40#{176}. Later films showed that both tubes were patent. B, Coronal transvaglnal sonogram of uterus done during luteal phase of cycle shows a very thin septum (arrow) separating two distinct and prominent endometrial cavities (e). Patient plans to have hysteroscopic metroplasty before attempting pregnancy.
681
two congenital abnormalities is critical, because the septate uterus can easily be corrected by hysteroscopic metroplasty [63]; patients with a bicornuate uterus may require a pregnancy trial before more major abdominal surgery such as a Strassman procedure [59]. Sonography in pregnant patients with uterine septa suggests that their very high rate of miscarriage may be due to implantation on the relatively avascular septum [64]. Sonographic characterization of uterine duplication anomalies in nonpregnant women shows that when abdominal sonography is performed in conjunction with hysterosalpingography, the correct diagnosis can be made in more than 90% of cases [62, 65]. Currently, transvaginal sonography offers an accurate view of the endometrial cavity and may enable a specific diagnosis of uterine duplication independently of the hysterosalpingogram. Careful coronal examination of the fundus during the luteal phase of the cycle will show two distinct endometrial cavity echoes with a thin echogenic septum between them in the septate uterus (Fig. 8B), whereas in the bicornuate uterus the two endometrial echoes will be widely separated by a double thickness of myometrium. More complex anomalies can be further clarified by MR imaging. MR imaging offers excellent evaluation of uterine anomalies by simultaneous demonstration of external and internal uterine contours [66-68]. On 12-weighted axial images perpendicular to the uterine cavity [69], the septum in a septate uterus is seen as a thin, low-intensity fibrous band separating high-signal endometrial cavities [66]. The intercornual distance is less than 4 cm [68]. In bicornuate and didelphys uteri, a deep external notch is present in the fundus and the uterine horns are more than 4 cm apart. Internally, a thick or double medium-intensity band of myometrium separates the two fundal endometnal cavities (Fig. 9B). Concurrent problems such as a septate vagina, hematocolpos and hematometra, incidental fibroids, and ovarian masses are well shown on MR imaging. A unicornuate uterus is well seen on hysterosalpingograms; however, MR imaging allows identification of the presence and degree of dilatation of noncommunicating rudimentary horns [68] before laparoscopy.
Diethyistilbestrol
(DES)
Exposure
in Utero
DES exposure in utero causes frequent uterine abnormalities that are well shown of hysterosalpingograms and consist
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682
YODER
AND
HALL
AJR:157,
October
1991
Fig. 9.-Bicornuate uterus in a 41-year-old infertile woman who had a first-trimester miscarriage 2 years before. A, Hysterosalpingogram shows a bicornuate uterus with widely divergent horns. Small concavity of distal left horn (straight arrow) suggests a small submucosal fibroid. B, Axial oblique 12-weighted MR image of pelvis confirms bicornuate configuration of uterus, and in addition shows an unsuspected 4-cm, low-intensity myoma (open arrow) within the myometrium separating the two horns and a 1-cm submucosal myoma within distal left horn (solid arrow).
Fig. 10.-32-year-old infertile woman with known diethylstilbestrol exposure in utero who had an irregular uterine cavity at hysteroscopy. Gynecologist questioned presence of submucosal fibroids. A, Hysterosalpingogram shows a 1-shaped irregular uterine cavity characteristic of in utero exposure to diethylstilbestrol. Fallopian tubes are normal. B, Sagittal 12-weighted MR image of uterus shows an anteflexed uterus (arrows). Overall size of uterus is smaller than normal, and low-intensity junctional zone (j) of myometrium is slightly thickened and irregular. Irregularities of uterine cavity seen at hysteroscopy and on hysterosalpingogram correlate exactly with irregular junctional zone shown on MR study. In addition, MR image definitely excludes presence of uterine fibroids. B = bladder.
of irregular constrictions and a 1-shaped uterine cavity (Fig. 1 OA). DES is a synthetic estrogen that was given to pregnant women during the 1 950s and 1 960s to prevent miscarriage. DES crosses the placenta and exerts a direct effect on the mUllerian system of the fetus. As a result, DES daughters, as they are called, show genital tract anomalies that are completely unrelated to fusion anomalies. Women who have vaginal and cervical changes due to DES are more likely to show uterine abnormalities on hysterosalpingography, and abnormal hysterosalpingograms are more often associated with a poor pregnancy outcome [70]. MR images (Fig. 1 OB) correlate well with the DES changes seen on hysterosalpingography and include hypoplasia of the uterus and cervix, 1-shaped cavities, and localized thickening of the junctional zone associated with indentations of the endometrial cavity [71].
REFERENCES 1. Levin DC, Matteucci BS. ‘Turf battles” over imaging and interventional procedures in community hospitals: survey results. Radiology 1990; 176:321-324 2. Yoder IC. Hysterosalpingography and pelvic ultrasound: imaging in infertility and gynecology. Boston: Little, Brown, 1988:1-35 3. Hunt RB, Siegler AM. Hysterosalpingography: techniques and interpretation. Chicago: Year Book Medical, 1990: 5-34 4. Winfield AC, Wentz AC. Diagnostic imaging of infertility. Baltimore: Williams & Wilkins, 1987:9-26
5. Karasick S. Karasick 0. Atlas of hysterosalpingography. Springfield, IL: Thomas, 1987 :3-30 6. Varpula M. Hysterosalpingography with a balloon catheter versus a cannula: evaluation of patient pain. Radiology 1989;172 :745-747 7. Sholkoft SD. Balloon hysterosalpingography catheter. AJR 1987;1 49: 995-996
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FR. A new cannula for hysterosalpingography. AJR 1988;151: 729-730 Thurmond AS, Novy M, Rosch J. Terbutaline in diagnosis of interstitial fallopian tube obstruction. Invest Radiol 1988;23 :209-210 Spring DB, Boll DA. Prone hysterosalpingography. Radiology 1980; 136: 235-236 Loy RA, Weinstein FG, Seibel MM. Hysterosalpingography in perspective: the predictive value of oil-soluble versus water soluble contrast media. Fertil Steril 1989;51 :170-172 Lindequist 5, Justesen P. Larsen C. Rasmussen F. Diagnostic quality and complications of hysterosalpingography: oil- versus water-soluble contrast media-a randomized prospective study. Radiology 1991;179:69-74 Rasmussen F, Lindequist 5, Larsen C. Justessen P. Therapeutic effect of hysterosalpingography: oil- versus water-soluble contrast media-a randomized prospective study. Radiology 1991;179:75-78 Alper MM, Garner PR, Spence JEH, Quarrington AM. Pregnancy rates after hysterosalpingography with oil- and-water-soluble contrast media. Obstet Gynecol 1986;68:6-9 Eisenberg AD, Winfield AC, Page DL, et al. Peritoneal reaction resulting from iodinated contrast material: comparative study. Radiology 1989;1 72:149-151 Moore DE, Segars JH, Winfield AC, et al. Effects of contrast agents on the fallopian tube in a rabbit model. Radiology 1990;1 76:721-724 Davies AC, Kirghley A, Borthwick-Clarke A, Walters HL. The use of lowosmolality contrast medium in hysterosalpingography: comparison with a
AJA:157,
October
1991
HYSTEROSALPINGOGRAPHY
conventional contrast medium. Clin Radiol 1985;36:533-536 Thurmond AS, Novy M, Uchida BT, Rosch J. Fallopian tube obstruction: selective salpingography and recanalization. Radiology 1987;1 63:511-514 1 9. Thurmond AS. Selective salpingography and fallopian tube recanalization. 18.
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AJR 1991;156:33-38 Thurmond AS, Rosch J. Nonsurgical fallopian tube recanalization for treatment of infertility. Radiology 1990:174:371-374 Lang EK, Dunaway HE, Roniger WE. Selective osteal salpingography and transvaginal catheter dilatation in the diagnosis and treatment of fallopian tube obstruction. AJR 1990;154:735-740 Kumpe DA. zwerdlinger SC, Rothbarth U, Durham JD, Albrecht BH. Proximal fallopian tube occlusion: diagnosis and treatment with transcervical fallopian tube catheterization. Radiology 1990;177: 183-1 87 Kenn J, Daykhovsky L, Grundfest W, Surrey E. Falloscopy: a microendoscopic transvaginal technique for diagnosing and treating endotubal disease incorporating guide wire cannulation and direct balloon tuboplasty. J Reprod Med 1990;35:606-61 2 Conflno E, Tur-Kaspa I, DeChemey A, et al. Transcervical balloon tubeplasty. A multicenter study. JAMA 1990:264:2079-2082 Hughes EG, Shekelton P, Leonie M, Leeton J. LJtrasound-guided fallopian tube catheterization per vaginum: a feasibility study with the use of laparoscopic control. Fertil Steril 1988;50:986-989 Fleischer AC, Herbert CM, Hill GA, Kepple DM. Transvaginal sonography: applications in infertility. Semin Ultrasound CT MR 1990;1 1:71-81 Medical Research International and the Society for Assisted Reproductive Technology. The American Fertility Society. In vitro-fertilization-embryo transfer in the United States: 1988 results from the IVF-ET registry. Fertil Steril 1990:53:13-20 Thurmond AS, Rosch J, Patton PE, Burry KA, Novy M. Fluoroscopic transcervical fallopian tube catheterization for diagnosis and treatment of female infertility caused by tubal obstruction. RadioGraphics 1988:8: 621-640 Netter FH. The Ciba Collection of medical illustrations, vol. 2. Reproductive system. West Caldwell, NJ: Ciba Pharmaceutical Co., 1984: 179-1 90 Timor-Tntsch lE, Rottem S. Transvaginal ultrasonographic study of the fallopian tube. Obstet Gynecol 1987:70:424-428 Tessler FN, Perella AR, Fleischer AC, Grant EG. Endovaginal sonographic diagnosis of dilated fallopian tubes. AJR 1989;153:523-525 Lande IM, Hill MC, Cosco FE, Kator NN. Adnexal and cul-de-sac abnermalities: transvaginal sonography. Radiology 1988:166:325-332 Terry J, Forrest T. Sonographic demonstration of salpingitis: potential confusion with appendicitis. J Ultrasound Med 1989;8:39-41 Schlief R, Deichert U. Hysterosalpingo-contrast sonography of the uterus and fallopian tubes: results of a clinical tnal of a new contrast medium in 120 patients. Radiology 1991;178:213-215 Kenn J, Daykhovsky L, Segalowitz J, et al. Falloscopy: a microendoscopic technique for visual exploration of the human fallopian tube from the utero tubal ostium to the fimbria using a transvaginal approach. Fertil Steril 1990;54:390-400 Karasick S, Karasick D, Schilling J. Salpingitis isthmica nodosa in female infertility. Can Assoc Radiol J 1985;35: 118-121 Creasy JL, Clark AL, Cuttino JT, Groff TA. Salpingitis isthmica nodosa: radiologic and clinical correlates. Radiology 1985;154:597-600 Karasick S, Ehrlich S. The value of hysterosalpingography before reversal of sterilization procedures involving the fallopian tubes. AJR 1989; 153: 1247-1 250 Groff TA, Edeistein JA, Schenken AS. Hysterosalpingography in the preoperative evaluation of tubal anastomosis candidates. Fertil Steril 1990;53:417-420 Rock JA, Guzick DS, Katz E, Zacur HA, King TM. Tubal anastomosis: pregnancy success following reversal of Falope ring or monopolar cautery sterilization. Fertil Steril 1987;48: 13-17 Donnez J, Casanas-Roux F. Prognostic factors of fimbrial microsurgery. Fertil Steril 1986:46:200-204 Karasick 5, Goldfarb AF. Pentubal adhesions in infertile women: diagnosis with hysterosalpingography. AJR 1989;1 52:777-779 Gross BH, Silver TM, Jaffe MH. Sonographic features of uterine leiomyomas: analysis of 41 proven cases. J Ultrasound Med 1983:2:401-406 Baltarowich OH, Kurtz AB, Pamell AG, Needleman L, Vilaro MM, Goldberg
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BB. Pitfalls in the sonographic diagnosis of uterine fibroids. AJR 1988;151 :725-728 Hamlin DJ, Pattersson H, Fitzsimmons J, Morgan L5. MR imaging of uterine leiornyomas and their complications. J Comput Assist Tomogr 1985;9(5):902-907 Hricak H, Tscholakoft D, Heinrichs L, et al. Uterine leiomyomas: correlation of MR, histopathologic findings, and symptoms. Radiology 1986;158: 385-391 Dudiak CM, Tumor DA, Patel 5K, Archie JT, Silver B, Norusis M. Uterine leiomyomas in the infertile patient: preoperative localization with MA imaging versus US and hysterosalpingography. Radiology 1988:167: 627-630 Zawin M, McCarthy S. Scoutt LM, Comite F. High-field MAI and US evaluation of the pelvis in women with leiomyomas. Magn Reson Imaging 1990;8:371 -376 Weinreb JC, Barkoft ND, Megibow A, Demopoulos A. The value of MA imaging in distinguishing leiomyomas from other solid pelvic masses when sonography is indeterminate. AJR 1990:154:295-299 Chang YCF, Arrive L, Hricak H. Gynecologic tumor in imaging. Semin Ultrasound CT MR 1989;10(1):29-42 Fishman-Javitt MC, Lorecchio JL, Stein HL. The uterus. In: Fishman-Javitt MC, Stein HL, Lovecchio JL, eds. Imaging of the pelvis: MRI with correlations to CT and ultrasound. Boston: Little, Brown, 1990:77-108 Donnez J, Sandow J, Schrurs B, Clerckx F, Gillerot S. Treatment of uterine fibroids with implants of gonadotropin-releasing hormone agonist: assessment by hysterography. Fertil Steril 1989;51(6):947-950 Zawin M, McCarthy 5, Scoutt L, et al. Monitoring therapy with a gonadotropin-releasing hormone analog: utility of MA imaging. Radiology 1990:175:503-506 McCarthy S. MR imaging of the uterus. Radiology 1989:171:321-322 Bohlman ME, Ensor RE, Sanders AC. Sonographic findings in adenomyosis of the uterus. AJR 1987;148:756-766 Mark AS, Hncak H, Heinnchs LAW, et al. Adenomyosis and leiomyoma: differential diagnosis with MA imaging. Radiology 1987:163:527-529 Togashi K, Ozasa H, Konishi I, et al. Enlarged uterus: differentiation between adenomyosis and leiomyoma with MA imaging. Radiology 1989:171 :531 -534 Clarke-Pearson DL, Dawood MY. Green’s gynecology: essentials of clinical practice, 4th ed. Boston: Little, Brown, 1990:357-372 Stein AL, March CM. Pregnancy outcome in women with mUllerian duct anomalies. J Reprod Med 1990:35:411-414 Golan A, Langer A, Bukovsky I, Caspi E. Congenital anomalies of the mUllenan system. Fertil Steril 1989:51 :747-755 Hamlin DJ, Pettersson H, Ramey SL, Moazam F. Magnetic resonance imaging of bicomuate uterus with unilateral hematometrosalpinx and ipsilateral renal agenesis. Urol Radiol 1986:8:52-55 Reuter KL, Daly DC, Cohen SM. Septate versus bicornuate uteri: errors in imaging diagnosis. Radiology 1989:172:749-752 Daly DC. Maier DB, Soto-Albors C. Hysteroscopic metroplasty, six year follow-up. Obstet Gynecol 1989:73:201-205 Fedele L, Dorta M, Bnoschi D, Giudici MN, Candiani GB. Pregnancies in septate uteri: outcome in relation to site of uterine implantation as determined by sonography. AJR 1989:152:781-784 Fedele L, Ferrazzi E, Dorta M, Vercillini P, Candiani GB. LJtrasonography in the differential diagnosis of double” uteri. Fertil Steril 1988:50:361-364 Mintz MC, Thickman Dl, Gussman D, Kressel HY. MR evaluation of uterine anomalies. AJR 1987:148:287-290 Fedele L, Dorta M, Brioschi D, Massari C, Candiani GB. Magnetic rosenance evaluation of double uteri. Obstet Gynecol 1989:74:844-847 Camngton BM, Hncak H, Nuruddin RN, et al. MUllerian duct anomalies: MA imaging evaluation. Radiology 1990:176:715-720 Baumgartner BR, Bemardino ME. MR imaging of the cervix: off-axis scan to improve visualization of zonal anatomy. AJR 1989:153:1001-1002 Kaufman RH, Noller K, Adam E, et al. Upper genital tract abnormalities and pregnancy outcome in diethylstilbestrol exposed progeny. Am J Obstet Gynecol 1984:148:973-984 Van Gils APG, Tjon A, Tham ATO, Falke THM, Peters AAW. Abnormalities of the uterus and cervix after diethylstilbestrol exposure: correlation findings on MR and hysterosalpingography. AJR 1989:153:1235-1238
of
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:‘‘i
Review
Hysterosalpingography Isabel
C. Yoder1
and Deborah
in the 1990s
A. Hall
.
: y:
the procedure has been a primary tool in the evaluation of infertility, and given today’s increasing concern over infertility, it is a procedure that is likely to be more frequently performed. Fortunately. the technique and interpretation of hysterosalpingography have been refined, and the procedure is less painful and diagnostically more accurate than it once was. In this article, we discuss current techniques and use of contrast material in hysterosalpingography. We then review the impact of recent interventional developments, such as fallopian tube catheterization, on hysterosalpingography. Finally, we examme common tubal and uterine abnormalities in the context of the imaging techniques that have become available only in the last decade or so, for example, transvaginal sonography and MR imaging.
All
physicians involved in the evaluation and treatment of rely heavily on the information provided by hysterosalpingography. For many years this study has provided images of the lumina of the fallopian tubes that are not available by other diagnostic means, and it also gives the most accurate outline of the uterine cavity. Hysterosalpingography will therefore continue to be a valuable study in the upcoming decade, and it is important now to take account of the many advances in technology that impinge on the execution and interpretation of this study. In this article we first update the continuing debate about elements of the study itself, involving techniques and the choice of contrast material. We also consider surgical advances, such as the widespread use of microsurgical reconstruction of the fallopian tube, that Increase the demand for hysterosalpingography. Since radiologists are asked to evaluate the results of surgery, it is essential for them to be familiar with the postoperative appearances of the fallopian tube. Finally, we consider what must be by far the most Important development of the 1990s, the continuing integration of hysterosalpingography with new Interventional and imaging techniques. Fallopian tube catheterization expands the examination of the fallopian tube and offers new therapeutic applications. Transvaginal sonography and MR imaging have allowed noninvasive exploration of the female pelvis. Correlation of hysterosalpingography and MR imaging is particularly useful in the diagnosis of uterine myomas and congenital uterine duplication anomalies when surgery to preserve or enhance the reproductive capacity of the uterus Is indicated. Sonography and MR imaging should be correlated with hysterosalpingography to provide a more efficient diagnostic and therapeutic approach to the common mechanical causes of infertility. infertility
The
first
hysterosalpingogram
by using bismuth
Received March 13, 1991; Both authors: Department AJR 157:675-683,
was
paste as the contrast
obtained
medium.
80 years
574-06750
Technique
Hysterosalpingography is a procedure that falls within the domain of both radiology and gynecology. Today in the United States, 55% of hysterosalpingograms are obtained by the radiologist and gynecologist working together; only 27% are obtained by the radiologist alone [1]. These circumstances have led to the development of two major techniques. The balloon catheter technique is favored by radiologists [2], and the tenaculum-cannula technique is preferred by gynecologists working alone [3] or with radiologists [4, 5]. We favor the balloon catheter technique (Fig. 1) because it is simple to learn, is comfortable for patients, and facilitates diagnostic maneuvers such as turning patients to oblique and prone positions. Proponents of the cannula technique argue that the balloon may obscure uterine anatomy and may lead to dis-
ago
Since then,
accepted after revision May 21 1991. of Radiology, Massachusetts General
October 1991 0361 -803X/91/1
Article
Hospital,
Fruit St., Boston,
American
Roentgen
j
iI1
‘
v
Ray Society :
MA 02114.
Address
reprint
requests
to I. C. Yoder.
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676
YODER
AND
HALL
AJR:157,
October
1991
Fig. 1.-Normal balloon catheter hysterosalpingogram in a 36-year-old woman after 1 year of infertility. A, Anteflexed uterus, foreshortened on anteroposterior view. Foley balloon is inflated within lower cervical canal (arrow). B, After catheter is pulled gently, uterus is straightened and uterine cavity displayed beautifully. Because this maneuver may cause balloon (arrow) to pop out of cervical canal, it is usually reserved as final step after all necessary diagnostic films have been obtained. Fallopian tubes are normal in caliber, and free intrapentoneal spill is
ample.
A
B
comfort after the procedure [6]. In order not to interfere with clear visualization of the uterine cavity, the balloon catheter is inflated within the endocervical canal. This is especially important in the assessment of cervical incompetence, which requires an accurate measurement of the size of the internal cervical os. Regardless of personal preference, both balloon catheter and cannula techniques produce excellent diagnostic studies,
and physicians
should be well versed in both of them because
circumstances may dictate a specific need for one or the other. For example, balloon catheters allow simultaneous catheterization of a double cervix for better visualization of uterine duplication anomalies. The cannula technique is preferred in the presence of extensive uterine synechiae, because under those circumstances the balloon catheter will be
repeatedly
expulsed.
Physicians
also should
be aware
refinements in the instruments used for hysterosalpingography. A number of newly developed rigid balloon catheters
can be very useful
in cannulating
patients
with cervical
of [7]
ste
nosis, and a new plastic cannula can be used for the same purpose [8]. After catheter placement, routine spot films are obtained under fluoroscopic control. A normal study may require only five films: a preliminary view of the pelvis, followed by two anteroposterior views and an oblique view of each fallopian tube during instillation of contrast media. Usually, a total of 6-8 ml of contrast material is sufficient, but special circumstances such as an enlarged uterine cavity may warrant larger amounts. The initial anteropostenor spot film is an underfilled
view of the uterine cavity to show the presence endometnal lesions (Fig. 2A) that are easily obscured amounts of contrast media (Fig. 2B). After oblique the tubes
demonstrate
are obtained,
free
a final
dispersion
bowel loops. Peritoneal lead to the accumulation
anteroposterior
of contrast
adhesions surrounding of contrast material
view
material
of small by large views of should
around
the tubes may in a paratubal
collection. To aid the detection of paratubal collections, infusion of adequate amounts of contrast media and the use of
Fig. 2.-uterine polyps and postoperative peritoneal adhesions in a 38-year-old woman with a long history of infertility. Surgical abdominal myomectomy and uterine suspension were performed 5 years before. A, Eariy hysterosalpingogram shows multiple polyps as rounded and oval filling defects in uterine cavity (arrowheads) and a solitary air bubble (arrow). B, Further infusion of contrast material fills both fallopian tubes and obscures polyps. Ampullae, although not dilated, appear rigid and in an abnormally medial position. C, Drainage view shows loculated spill of contrast material (arrow), right peritubal halo (arrowhead), and some free spill into cul-de-sac (Cs). Multiple endometrial polyps were removed at hysteroscopy. Laparoscopy revealed multiple adhesions involving tubes, bowel, and pelvic side wall.
AJR:157,
October
drainage
HYSTEROSALPINGOGRAPHY
1991
films
are very helpful
(Fig. 2C). The drainage
film is
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obtained 5-1 0 mm after removal of the uterine catheter and after the patient has been allowed to move around or turn prone. Technical problems arise when the contrast material does not
flow
freely
into
one
or both
fallopian
tubes
and
there
appears to be interstitial tubal obstruction. This may represent a true obstruction or a transient lack of filling due to what is commonly referred to as tubal spasm. Several drugs, such as glucagon and terbutaline, have been used in an attempt to overcome muscular tubal spasm [9]. Our current approach is to try to overcome interstitial obstruction by turning the patient into a prone position and instilling additional contrast material [10]. The normal tube often will fill after this maneuver, and
the patient candidate
whose
tubes
for fallopian
Contrast
remain
tube
occluded
may become
a
catheterization.
Material
Debate continues between advocates of oil-soluble and those of water-soluble contrast media for hysterosalpingography. The arguments do not center on the diagnostic properties of the agents, because with few exceptions [1 1], everyone
agrees
that water-soluble
contrast
medium
provides
better uterine and ampullary mucosal detail, and therefore more accurate diagnostic studies [1 2]. The controversy concerns the therapeutic properties of each contrast medium. Some studies credit oil-soluble contrast medium for higher pregnancy
studies
rates
pregnancy
soluble that
after
[1 4] conclude
the
procedure
[1 3],
rates after hysterosalpingography
material.
oil-soluble
whereas
that there is no statistical
Recent
media
in
with oil or water-
animal studies
contrast
other
difference
[1 5, 1 6] have shown
result
in
granulomatous
changes and fibrosis on the peritoneal surfaces of the animals tested. Water-soluble contrast material produced either no peritoneal
reaction
or a mild transitory
inflammatory
reaction.
tube
677
catheterization.
Versed
(Roche
easily as other water-soluble Fallopian
Tube
agents
the peritoneum
longer periods than guidewire
do.
Catheterization
Obstruction at the interstitial or proximal portion of the fallopian tube precludes evaluation of the distal tube by hysterosalpingography and therefore may make laparoscopy necessary. Fallopian tube catheterization offers an alternative to laparoscopy.
It is a method
developed
by Thurmond
et al.
[18] to examine the distal tube when hysterosalpingography shows interstitial obstruction of one or both fallopian tubes. Fallopian tube catheterization is a natural extension of hysterosalpingography, but because the procedure is more painful and prolonged than hysterosalpingography, it requires separate scheduling. Patients are placed on oral antibiotics, usually doxycycline, for a few days before and after fallopian
of
selective
are
catheteriza-
cannulation
does. Because
the
balloon catheter used for dilatation has a much larger diameter than the interstitial segment of the tube, it probably breaks up adhesions within the cornu itself and not inside the tube. Furthermore, falloscopy shows that when a fibrotic stricture is present within the proximal tube, both the balloon catheter
and the guidewire are completely [23]. Another successful therapeutic pingography
gametes
has been
and embryos
procedure
as
doses
,
depends
[27].
not flood
small
NJ) and fentanyl
who perform selective salpingography have reported high rates of success, in the range of 86-98%, in catheterizing occluded tubes. More than half of the distal tubes visualized in this manner appear normal and show free intraperitoneal spill. The remainder show a variety of abnormalities, including pentubal adhesions, hydrosalpinx, salpingitis isthmica nodosa, and postsurgical isthmic stenosis. Endoscopic observation with falloscopy confirms [23] that the guidewire used for tubal cannulation breaks up intraluminal adhesions, and then contrast material flushes mucus plugs from the proximal tubes. Thus, fallopian tube catheterization enjoys both diagnostic and therapeutic properties. The subsequent pregnancy rate varies between 7% [21 ] and 31 % [20] overall, with a significant number of ectopic pregnancies. Tuboplasty, dilatation of the tube with a modified angioplasty balloon catheter as described by Confino et al. [24], does not improve the pregnancy rate (28%) but may prevent tubal reocclusion for
slightly
and does
Nutley,
tion of the ostium of the fallopian tube with an angiographic catheter. The technique was described recently in this journal [19]. Thurmond and Rosch [20] and other authors [21 22]
transvaginal the isthmus
viscous
the procedure,
given IV to treat pain as necessary. Fallopian tube catheterization entails
Clinical studies have shown no advantage to the use of lowosmolality contrast media over conventional contrast media [17]. Therefore, safety and diagnostic factors dictate the use of a conventional water-soluble contrast agent. The concentration of iodine does not need to exceed 30% to provide good detail. We use Sinografin (38% iodine, Squibb), which is more
During
Laboratories,
Radiologists
ineffective
in bypassing
application
of selective
its use for the direct
tubes
ability
be called
on to assist
of
[25].
The
to manipulate
catheter through the uterotubal under transvaginal sonographic may
sal-
introduction
into the fallopian
on the operator’s
it
a
ostium and into monitoring [26].
in these
fertilization
techniques as they become more popular. They require no anesthesia, and gamete intrafallopian transfer results in a 21 % live delivery rate, whereas in vitro fertilization with intrauterine
embryo
transfer
has
a 1 2%
rate
of live deliveries
In summary, fallopian tube catheterization improves on the diagnostic evaluation of the fallopian tube offered by hysterosalpingography, and may have diverse therapeutic applications. Complications of catheterization are similar to compli-
cations of hysterosalpingography, and include pain, radiation exposure, infection, and tubal perforation, which is unique to catheterization. Tubal perforation can occur when there is complete fibrotic obstruction of the tubal lumen, but it promptly seals over and has not produced any bleeding or other long-term problems. Prophylactic antibiotics have pre-
vented any septic complications Tubal The
length.
to date [28].
Abnormalities oviduct
is a muscular
It is divided
tube
measuring
into the intramural
10-14
(interstitial),
cm
isthmic,
in
678
YODER
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and ampullary portions. The normal mucosa consists of a single layer of columnar epithelium composed of secretory and ciliated cells [29]. The fallopian tube has a limited range of reactions to disease: obstruction and/or dilatation. Obstruction Obstruction of the interstitial segment is usually due to infection, such as salpingitis isthmica nodosa, or to endometriosis. Previous salpingectomy and tubal ligation are the most frequent causes of isthmic obstruction of the fallopian tube. Less often, infectious or endometriotic scarring in this portion of the tube may occur. The ampullary portion of the tube is
the most commonly
obstructed.
Hydrosalpinx Hydrosalpinx refers specifically to the dilatation of the ampullary segment of the tube that accompanies distal obstruction. The ampulla dilates preferentially because it has a thin muscular wall surrounding a relatively capacious lumen. Hydrosalpinx is usually the sequela of infection with agglutination
and fibrosis
of the fimbria.
It is associated
with
paratubal
adhesions. Gonococcal, chlamydial, and mixed bacterial salpingitis may result in hydrosalpinx. Endometriosis and pelvic surgery may also cause fimbrial adhesions, tubal occlusion, and hydrosalpinx (Fig. 3A). Endometriosis is increasingly a cause of infertility in the older patient who delayed childbearing. Transvaginal sonography provides a noninvasive view of the dilated fallopian tube but has proved disappointing in its ability to identify the normal tube [30]. A dilated fallopian tube is seen on transvaginal sonography as a tubular structure with a folded configuration and a well-defined echogenic wall [31] (Fig. 3B). Dilated fallopian tubes have to be differentiated from other cystic tubular structures in the pelvis such as bowel loops, which show peristaltic motion; dilated pelvic veins, which have blood flow within them; cystic adnexal masses; and appendicitis [32, 33]. Schlief and Deichert [34] infused SHU 454/Echovist (Schering, Berlin), a new echogenic contrast medium, into the uterus during transvaginal sonography and reliably showed patency of normal fallopian tubes.
The advantage
of this indirect
method
is that it spares
patient ionizing radiation. However, it is cumbersome requires uterine cannulation without giving the accurate tomic detail of the tube provided by hysterosalpingography.
the and ana-
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AJR:157,
Hysterosalpingography anatomy of the fallopian falloscopy. Falloscopy is that enables the surgeon the uterotubal ostium to hysteroscope [35].
Salpingitis
Isthmica
October
1991
offers the best view of the internal tube short of direct visualization by a new microendoscopic technique to explore the fallopian tube from the fimbria through a small flexible
Nodosa
The isthmic portion of the tube has a thick muscular wall, and luminal dilatation is very rare. More commonly, the hysterosalpingogram shows multiple small diverticula extending from the isthmic lumen into the wall (Fig. 4). This appearance is characteristic of salpingitis isthmica nodosa. It affects both tubes in 80% of cases [36] and often is associated with proximal obstruction or ampullary dilatation. Fallopian tube catheterization has increased our ability to diagnose salpingitis isthmica nodosa by its ability to fill the isthmic diverticula beyond the proximally occluded tube. These patients have a history of pelvic infection and exhibit a high rate of primary infertility (38%) and ectopic pregnancy (9.4%) [37]. lsthmic diverticulosis identical to salpingitis isthmica nodosa can sometimes be seen in tuberculosis of the fallopian tube. Unlike salpingitis isthmica nodosa, tuberculosis is accompanied by contraction of the ampulla and adnexal calcification.
Fallopian
Tube
Surgery
Microsurgical techniques allow the successful performance of tubotubal and tubouterine anastomoses. This surgery is commonly executed after diagnosis of an obstructive lesion by hysterosalpingography or for reversal of tubal ligation. Hysterosalpingography before reanastomosis after tubal Iigation is considered valuable by some authors [38] and unwarranted by others [39]. In our experience, currently few
requests
for salpingographic
evaluation
of tubes
are made
before reversal of sterilization. However, the demand is increasing for postoperative evaluation of tubes after all types of microsurgical reconstruction. Hysterosalpingography shows the patency of the tube, its length, the degree of narrowing at the site of the anastomosis (Fig. 5), the condition of the ampulla, and the development of paratubal adhesions. Measuring the length of the tube is important, as the viable pregnancy rate is reduced in women with oviducts shorter than 4 cm [40].
Fig. 3.-Left-sided hydrosalpinx in a 31-yearold woman with secondary infertility after normal delivery 41/2 years before. A, Hysterosalpingogram shows dilated and obstructed left fallopian tube (h). B, Transvaginal sonogram obtained 5 days later shows an anechoic tubular structure with linear echoes protruding into its lumen. This represents a dilated left fallopian tube (arrow) below an underfilled bladder (B). Laparotomy showed extensive pelvic endometriosis. Fulguration of endometriosis, lysis of adhesions, and left fimbrioplasty for a completely blocked tube were accomplished. Six months later, a pregnancy test was positive.
A
B
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AJR:157,
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HYSTEROSALPINGOGRAPHY
1991
Fig. 4.-Salpingitis isthmica nodosa in a 28year-old woman with 7 years of infertility. Hysterosalpingogram shows bilateral isthmic diverticulosis (arrows), more pronounced on right side. Hydrosalpinx is bilateral. Ampullary mucosal pattern is better preserved on right side than on left. Patient had bilateral cuff salpingoplasties and lysis of adhesions. Nodularity of proximal tubes is consistent with salpingitis isthmica nodosa. Fig. 5.-Hysterosalpingogram after tubal reconstruction in a 33-year-old woman who had a tubotubal reanastomosis after a Pomeroy tubal ligation. One year after surgery, she had not conceived. Hysterosalpingogram shows a nondilated, freespilling left fallopian tube with marked circumferential narrowing at site of reanastomosis (white arrow) and a short and rigid left ampulla (A). Right fallopian tube shows complete isthmic obstruction (black arrow) at surgical site. cs = cul-de-sac.
4
The normal ciliated cells that line the fimbria and ampulla play a major role in ovum transport. These ciliated cells are destroyed with obstruction and hydrosalpinx. The hysterosalpingogram can be used to determine the success of surgical reconstruction. Increasing dilatation of the ampulla and effacement of its mucosal patterns as shown on hysterosalpingograms is directly correlated with significant decrease of both the percentage of ciliated cells and the pregnancy rate after microsurgical salpingostomy [41 ]. Donnez and CasanasRoux [41 ] report a 48% rate of pregnancy after repair of an occluded nondilated ampulla and a 22% rate of pregnancy in an occluded ampulla distended to a diameter greater than 2.5 cm. If pregnancy does not occur in a reasonable period and the postoperative hysterosalpingogram shows tubal abnormalities, the patient may then be a candidate for in vitro fertilization.
Paratubal
Adhesions
Paratubal adhesions are difficult to evaluate by hysterosalpingography. They are the largest source of discrepancy between the results of hysterosalpingography and laparoscopy. Endometriosis, surgery, and pelvic infection are the common sources of adhesions. They cloak the peritoneal surfaces of the tubes and ovaries and disturb the tuboovarian relationship to such an extent that they interfere with ovum capture and transport by the fimbria. Laparoscopy provides direct visualization of adhesions, whereas hysterosalpingography gives only indirect evidence of their presence. The most suggestive salpingographic findings include a convoluted or vertical tube in association with loculated spill of contrast material and peritubal halo effect [42]. The detection of paratubal collections is improved by infusion of adequate amounts of contrast material and the use of drainage films.
Uterine
Abnormalities
The normal uterine cavity as shown on grams is triangular, with a smooth outline. within the uterine cavity may be due to air blood clots, adhesions, submucosal myomas, endometrial hyperplasia. Accurate diagnosis patient’s clinical and surgical history as well
hysterosalpingoFilling defects bubbles, polyps, carcinoma, and depends on the as correlation of
679
5
the hysterosalpingographic available imaging studies.
findings
with
findings
from
other
Leiomyomas
Uterine myomas are common benign tumors in young women. These tumors may produce symptoms associated with a pelvic mass, menorrhagia, and infertility. Transabdominal or hysteroscopic myomectomy is the surgery of choice to preserve the uterus and future reproductive capacity. Accurate localization of leiomyomas is a prerequisite for conservative surgery. The sonographic diagnosis of utcrine fibroids is easily available and inexpensive, but highly maccurate, with a prospective sensitivity on only 60% [43]. Difficulty in establishing the correct diagnosis is in part due to the variable patterns of echogenicity of fibroids and their frequent exophytic or pedunculated position, which can mimic other pelvic conditions [44]. Hysterosalpingography accurately shows the presence of submucous myomas as smooth filling defects in the uterine cavity (Figs. 6A and 6B) and often suggests the presence of intramural myomas by displacing or enlarging the uterine cavity. However, recent studies show that MR imaging far surpasses both sonography and hysterosRlpingography in its ability to identify, localize, and characteri7e leiomyomas before surgery [45-51]. On 12-weighted images, leiomyomas appear as discrete masses of lesser or greater intensity than the medium-intensity myometrium (Fig. 6C). Histologic analysis shows that on MR images, low-intensity leiomyomas consist of typical whorls of smooth muscle cells with various degrees of fibrosis, whereas high-intensity, inhomoqeneous leiomyomas contain various degrees of hyaline, mucinous, hemorrhagic, and myxomatous degeneration [46]. Sonography, hysterosalpingography, and MR imaging have all documented significant decreases in the volume of the uterine cavity and size of fibroids after 2-6 months of therapy with gonadotropin-releasing hormone agonist [52, 531. Reduction in tumor size is often associated with control of bleeding and normalization of RBC count and hemoglobin. Subsequent myomectomy, therefore, may be clinically safer and technically easier to perform. In summary, MR imaging is the diagnostic technique of
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680
YODER
choice before myomectomy. In order to keep the cost of diagnostic procedures within realistic limits, it is suggested that MR imaging replace all subsequent sonographic examinations in young patients once myomectomy has been chosen as the best form of therapy necessary to preserve reproductive capacity. Hysterosalpingography may be necessary to assess fallopian tube patency, but hysteroscopy may not be needed if MR imaging shows no evidence of submucous myoma.
Adenomyosis Adenomyosis refers to the presence of endometrium deep within the myometrial wall and hyperplasia of the myometrium around the implants [54]. The disease is more common in women older than 30 who have menorrhagia and dysmenorrhea. On sonograms, adenomyosis has been described as showing a nonspecific uterine enlargement with decreased echogenicity of the myometnum [55]. Rarely, adenomyosis
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1991
can be diagnosed on hysterosalpingograms when contrast material extends from the uterine cavity into the glands within the myometrium. Characteristic short diverticular outpouchings are then seen along the body or fundus of the uterus (Fig. 7A). T2-weighted MR images of diffuse adenomyosis show thickening of the junctional zone and a poorly marginated low-signal-intensity mass [56] extending diffusely into the myometrium (Fig. 7B). This can usually be differentiated from leiomyomas, which on MR appear as well-circumscribed masses with variable signal intensity [57]. Adenomyosis is a nonresectable disease because it involves the myometrium diffusely and is usually treated by hysterectomy, whereas myomas are encapsulated and can usually be enucleated [58].
Congenital
Uterine
Anomalies
Congenital anomalies of the uterus are often incidentally diagnosed during an infertility workup but are not usually the
Fig. 6.-Uterine fibroid in a 40-year-old woman with an enlarged uterus and menorrhagia. A, Hysterosalpingogram shows an enlarged uterine cavity indented along its right wall by a very large, smooth submucosal mass (arrowheads). B, Further infusion of contrast material fills both fallopian tubes and shows mild right hydrosalpinx (h). Intravasation of contrast material into myometrial venous plexus is seen in fundal area (arrow) and should not be mistaken for adenomyosis. C, 12-weighted axial oblique MR image of pelvis shows an 8-cm rounded, hypointense mass with inhomogeneous areas of low intensity occupying entire right myometrial wall. This intramural fibroid (f) is partially submucosal because it disrupts junctional zone (j) and indents into right wall of endometrial cavity (e). Myomectomy yielded an 8-cm fibroid with central myxomatous degeneration. Uterine cavity was entered.
Fig. 7.-Adenomyosis in a 40-year-old infertile woman who had a myomectomy 1 year before. At that time, a uterine wall biopsy revealed adenomyosis. A, Hysterosalpingogram shows prominent diverticular outpouchings extending into left uterine wall (white arrow) and to a lesser extent into fundus (black arrow). Although this film suggests isthmic obstruction of right tube, subsequent film with patient prone showed filling of a normal right fallopian tube. B, Sagittal T2-weighted MR image of pelvis shows a retroflexed uterus. Normal medium-intensity myometrium (m) is replaced by diffuse, lobular, low-intensity adenomyosis (arrows) surrounding endometrial cavity. c = cervix, e = endometrium, B = bladder.
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AJR:1 57, October
HYSTEROSALPINGOGRAPHY
1991
cause of primary infertility. Diagnosis before or early in pregnancy allows the clinician to plan for surgical intervention if necessary and for the associated obstetric complications experienced by these patients, including multiple miscarnages, premature labor, and fetal malpresentations [59]. Current imaging techniques such as transvaginal sonography and MR imaging enable us to detect and characterize uterine abnormalities with great accuracy and without the use of ionizing radiation. Hysterosalpingography is still a simple and direct method of diagnosis, but eventually wider availability and decreased cost may make MR imaging the definitive diagnostic tool. Understanding and diagnosing congenital anomalies depends on knowledge of embryology. The fallopian tubes, uterus, and proximal vagina are embryologically derived from paired mUllerian or paramesonephric ducts [60]. The cephalad mUllerian ducts form the fallopian tubes and the caudal ducts fuse to form the uterus. Congenital anomalies of the fallopian tube are rare and seldom are demonstrable by hysterosalpingography. They include accessory ostia, multiple lumina, diverticula, duplications, and absence of portions of the tube. Uterine duplications result from variable lack of fusion of the caudal mUllerian ducts. Partial lack of external fusion is seen in the bicornuate uterus, and total failure of fusion is seen in the uterus didelphys, often associated with a vertical vaginal septum. In the septate or subseptate uterus, the caudal ducts have fused but there is total or partial lack of resorption of the medial septum. The unicornuate uterus is a rare anomaly resulting from development of only one m#{252}llerian duct and various degrees of atresia of the contralateral system. Up to 23% of women with a genital tract anomaly have a concomitant urinary tract deformity, commonly unilateral renal agenesis or renal ectopia [61].
Septate
and Bicornuate
Uteri
The hysterosalpingogram can help differentiate between the two most common congenital uterine anomalies, septate and bicornuate uteri. The hysterosalpingogram will show two separate and symmetric cavities in both septate and bicornuate uteri. However, if the angle between the cavities is acute, 75#{176} or less, it is most likely a septate uterus [62] (Fig. 8A). If the contrast-filled horns are widely divergent with an obtuse angle between them, a bicornuate uterus is the more likely diagnosis (Fig. 9A). The differentiation between these
Fig. 8.-Septate
woman who was
uterus in a 28-year-old Russian told in Russia that she had a
“double uterus.” A, Hysterosalpingogram shows a deeply soptated uterine cavity. Although uterine cavities deviate slightly, angle between them is 40#{176}. Later films showed that both tubes were patent. B, Coronal transvaglnal sonogram of uterus done during luteal phase of cycle shows a very thin septum (arrow) separating two distinct and prominent endometrial cavities (e). Patient plans to have hysteroscopic metroplasty before attempting pregnancy.
681
two congenital abnormalities is critical, because the septate uterus can easily be corrected by hysteroscopic metroplasty [63]; patients with a bicornuate uterus may require a pregnancy trial before more major abdominal surgery such as a Strassman procedure [59]. Sonography in pregnant patients with uterine septa suggests that their very high rate of miscarriage may be due to implantation on the relatively avascular septum [64]. Sonographic characterization of uterine duplication anomalies in nonpregnant women shows that when abdominal sonography is performed in conjunction with hysterosalpingography, the correct diagnosis can be made in more than 90% of cases [62, 65]. Currently, transvaginal sonography offers an accurate view of the endometrial cavity and may enable a specific diagnosis of uterine duplication independently of the hysterosalpingogram. Careful coronal examination of the fundus during the luteal phase of the cycle will show two distinct endometrial cavity echoes with a thin echogenic septum between them in the septate uterus (Fig. 8B), whereas in the bicornuate uterus the two endometrial echoes will be widely separated by a double thickness of myometrium. More complex anomalies can be further clarified by MR imaging. MR imaging offers excellent evaluation of uterine anomalies by simultaneous demonstration of external and internal uterine contours [66-68]. On 12-weighted axial images perpendicular to the uterine cavity [69], the septum in a septate uterus is seen as a thin, low-intensity fibrous band separating high-signal endometrial cavities [66]. The intercornual distance is less than 4 cm [68]. In bicornuate and didelphys uteri, a deep external notch is present in the fundus and the uterine horns are more than 4 cm apart. Internally, a thick or double medium-intensity band of myometrium separates the two fundal endometnal cavities (Fig. 9B). Concurrent problems such as a septate vagina, hematocolpos and hematometra, incidental fibroids, and ovarian masses are well shown on MR imaging. A unicornuate uterus is well seen on hysterosalpingograms; however, MR imaging allows identification of the presence and degree of dilatation of noncommunicating rudimentary horns [68] before laparoscopy.
Diethyistilbestrol
(DES)
Exposure
in Utero
DES exposure in utero causes frequent uterine abnormalities that are well shown of hysterosalpingograms and consist
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682
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AJR:157,
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1991
Fig. 9.-Bicornuate uterus in a 41-year-old infertile woman who had a first-trimester miscarriage 2 years before. A, Hysterosalpingogram shows a bicornuate uterus with widely divergent horns. Small concavity of distal left horn (straight arrow) suggests a small submucosal fibroid. B, Axial oblique 12-weighted MR image of pelvis confirms bicornuate configuration of uterus, and in addition shows an unsuspected 4-cm, low-intensity myoma (open arrow) within the myometrium separating the two horns and a 1-cm submucosal myoma within distal left horn (solid arrow).
Fig. 10.-32-year-old infertile woman with known diethylstilbestrol exposure in utero who had an irregular uterine cavity at hysteroscopy. Gynecologist questioned presence of submucosal fibroids. A, Hysterosalpingogram shows a 1-shaped irregular uterine cavity characteristic of in utero exposure to diethylstilbestrol. Fallopian tubes are normal. B, Sagittal 12-weighted MR image of uterus shows an anteflexed uterus (arrows). Overall size of uterus is smaller than normal, and low-intensity junctional zone (j) of myometrium is slightly thickened and irregular. Irregularities of uterine cavity seen at hysteroscopy and on hysterosalpingogram correlate exactly with irregular junctional zone shown on MR study. In addition, MR image definitely excludes presence of uterine fibroids. B = bladder.
of irregular constrictions and a 1-shaped uterine cavity (Fig. 1 OA). DES is a synthetic estrogen that was given to pregnant women during the 1 950s and 1 960s to prevent miscarriage. DES crosses the placenta and exerts a direct effect on the mUllerian system of the fetus. As a result, DES daughters, as they are called, show genital tract anomalies that are completely unrelated to fusion anomalies. Women who have vaginal and cervical changes due to DES are more likely to show uterine abnormalities on hysterosalpingography, and abnormal hysterosalpingograms are more often associated with a poor pregnancy outcome [70]. MR images (Fig. 1 OB) correlate well with the DES changes seen on hysterosalpingography and include hypoplasia of the uterus and cervix, 1-shaped cavities, and localized thickening of the junctional zone associated with indentations of the endometrial cavity [71].
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