A Comparative Study of the Assessment of Tubal Patency in Female Infertility Between MR Hysterosalphingography and Conventional HSG with Diagnostic Laparoscopy as Gold Standard

“ A COMPARATIVE STUDY OF THE ASSESSMENT OF TUBAL

PATENCY IN FEMALE INFERTILITY BETWEEN MR HYSTEROSALPHINGOGRAPHY AND CONVENTIONAL

HYSTEROSALPHINGOGRAPHY WITH DIAGNOSTIC LAPAROSCOPY AS GOLD STANDARD”

Dissertation submitted to

THE TAMILNADU Dr.M.G.R. MEDICAL UNIVERSITY

In partial fulfillment of the requirements of

M.D. DEGREE EXAMINATION BRANCH – VIII– RADIODIAGNOSIS

KILPAUK MEDICAL COLLEGE CHENNAI– 600 010

THE TAMILNADU DR. M.G.R. MEDICAL UNIVERSITY CHENNAI – TAMILNADU, INDIA

APRIL 2017

BONAFIDE CERTIFICATE

This is to certify that the dissertation entitled “

A COMPARATIVE STUDY OF THE ASSESSMENT OF TUBAL PATENCY IN

FEMALE INFERTILITY BETWEEN MR

HYSTEROSALPHINGOGRAPHY AND CONVENTIONAL HYSTEROSALPHINGOGRAPHY WITH DIAGNOSTIC

LAPAROSCOPY AS GOLD STANDARD

” is a bonafide original work of Dr.M.S Fouzal Hithaya under the guidance of Dr.J.Devimeenal M.D., Professor of department of Radio diagnosis, Govt. Kilpauk Medical College & Hospital, Chennai -10 in partial fulfillment of the regulations for M.D RADIO DIAGNOSIS BRANCH VIII examination of the TamilNadu Dr. M.G.R Medical University to be held in april 2017.The period of postgraduate study and training is from 2014 to 2017.

PROF.J.DEVIMEENAL, DMRD., MD.,DNB Guide

Professor & Head of Department, Department of RadioDiagnosis,

Govt Kilpauk Medical college & Hospital, Kilpauk, Chennai - 600 010.

Prof. Dr.R.NARAYANA BABU,

M.D,DCH, Dean,

Govt Kilpauk Medical college &

Hospital,

Kilpauk,Chennai - 600 010.

DECLARATION

I Dr.M.S.Fouzal Hithaya , solemnly declare that this dissertation titled “A COMPARATIVE STUDY OF THE ASSESSMENT OF TUBAL PATENCY IN FEMALE INFERTILITY BETWEEN MR HYSTERSALPHINGOGRAPHY AND CONVENTIONAL HYSTEROSALPHINGOGRAPHY WITH DIAGNOSTIC LAPAROSCOPY AS GOLD STANDARD was prepared by me at the Govt Kilpauk Medical College & Hospital,Chennai - 10, under the guidance and supervision of Dr. J.Devimeenal,Professor, Govt Kilpauk Medical College &Hospital. This dissertation is submitted to The Tamil Nadu Dr. M.G.R Medical University, towards partial fulfillment of university regulations for the award of M.D branch VIII Radiodiagnosis.

Place: Chennai

Date: Dr.M.S Fouzal Hithaya

ACKNOWLEDGEMENT

I express my heartful gratitude to the Dean, Prof.Dr.R.NARAYANA BABU,M.D.,DCH Govt Kilpauk Medical

College & Hospital,Chennai-10 for permitting me to do this study.

I express my gratitude to Prof. Dr. J.DEVIMEENAL, D.M.R.D., M.D., DNB., Head of the Department, Govt Kilpauk medical college &Hospital, for her valuable guidance in doing the dissertation work.

I owe a lot to Prof. Dr. J.DEVIMEENAL, D.M.R.D., M.D., DNB., who is also my guide whose expert guidance, constant encouragement created an interest for me to pursue this study on MR hysterosalphingography. It is her constant supervision and support that made me possible to finish this study without much difficulty.

I am extremely thankful to my Professors,

Dr.P.CHIRTARARASAN, M.D., Dr. K.GOPINATHAN, M.D.,DNB.,

and Assistant professors Dr.R.KANAGASABAI, D.M.R.D., M.D.,

Dr.V.SUDHAKAR, M.D., Dr. G.USHA NANDHINI M.D.,DNB.,

DR.G.ARUN DILIP M.D., Dr.S.SUMEENA,DMRD., D.N.B,

Dr.D.PORKODI, DMRD., DR.S.SENTHILKUMAR DMRD., in the

Govt Kilpauk Medical College for their constant support,

encouragement and

advice during my study.

I am extremely thankful to Dr.T.K.SHANTHI GUNASINGH, M.D., DGO., Prof. and HOD Department of Obstetrics and Gynaecology, Kilpauk Medical College, for guiding and encouraging me throughout the study.

I also thank my fellow postgraduates DR.P.PRASANNA and DR. N.SUDHIR and junior postgraduates who helped me in carrying out my work and preparing this dissertation.

I thank all Radiology technicians including Mr.VIJAY and Mrs.GRACE MARY, Staff Nurses and all the Paramedical staff members and workers including Mrs.JEYA in Department of Radiology, for their co- operation in conducting the study.

I thank my husband Dr.BASHEER AHAMED, my parents Mrs.& Mr. SYED MOHAMED, my sister HAMZA, daughter RIFA SABURA for their understanding and co-operation in completion of this work.

Last but not the least; I owe my sincere gratitude to the patients

and their relatives who co-operated for this study, without whom the

study could not have been possible.

INDEX

Sl.No. CONTENTS PAGE

1 INTRODUCTION 1

2 AIMS AND OBJECTIVES 3

3 REVIEW OF LITERATURE 4

4 MATERIALS AND METHODS 36

5 CASES 42

6 STATISTICAL ANALYSIS AND RESULTS RRESRESULTS

52

7 DISCUSSION 77

8 CONCLUSION 84

9 BIBLIOGRAPHY

ANNEXURE:

ABBREVIATIONS

ETHICAL COMMITTEE APPROVAL PLAGIARISM

PROFORMA

CONSENT FORMS

MASTER CHART

INTRODUCTION

The World Health Organization defines infertility as “ A disease of the reproductive system defined by the failure to achieve a clinical pregnancy after twelve months or more of regular unprotected sexual intercourse”⁽¹⁾. ^. Secondary infertility is defined as the inability to become pregnant, or to carry a pregnancy to term, following a previous pregnancy or the birth of one or more biological children.

The global prevalence of primary infertility is about 2% and secondary infertility is 3 %^{( 2)}. The factors attributed to infertility are divided into male and female factors. The female factors are classified into ovarian, uterine, tubal causes. Tubal factors are the commonest factors contributing to 30 – 40% of the cases ⁽³⁾.

Hysterosalphingography is the radiographic technique used in the evaluation of uterus, fallopian tubes. It is used as the first line of investigation in the evaluation of tubal factors in infertility ⁽⁴⁾. Sonosalphingography is yet another technique used in the evaluation of tubal patency.

Although these techniques are feasible enough they are not without pitfalls which include limited evaluation of congenital abnormalities of uterus and extra uterine pathologies. Further more conventional hysterosalphingography carries an unavoidable risk of exposure of the female reproductive organs to radiation in young and potentially fertile women.

Most of the women undergoing conventional hystersalphingography further require transabdominal and transvaginal ultrasound for further anatomical details and identification of pathologies.

MRI of pelvis is the investigation of choice, because of its spatial and contrast resolution in defining the anatomy as well as the pathologies of the female reproductive tract as a whole. MRI well delineates the possible abnormalities in the reproductive organs including congenital abnormalities, myomas, endometriosis, ovarian cysts, polycystic ovaries etc.

MR hysterosalphingography ⁽⁵⁾ is a novel evolving technique that is aimed at evaluating the tubal patency. Having the inherent advantage of imaging the pelvis, MR hysterosalphingography is an innovative tool in female infertility evaluation.

MR hysterosalphingography may be used as a single stop investigation in detecting uterine, ovarian and tubal pathologies⁽⁶⁾. There is no risk of exposure of reproductive organs to radiation. MR hysterosalphingography as a single investigation avoids the young women from undergoing a series of varying investigations.

MR hysterosalphingography is a novel technique with very few pioneer studies conducted at national as well as international levels. This prospective study being done at Kilpauk Medical College is considered about the introduction of this novel technique, designing the methodology of doing it, and evaluating its diagnostic accuracy, thereby incorporating it in the infertility evaluation protocol in the near future.

This study’s chief objective is to assess the feasibility and efficacy of MR hysterosalphingography in identifying tubal patency in female infertility.

AIM

To assess tubal patency in female fertility using dynamic MR hysterosalphingography

OBJECTIVES

1. To assess the efficacy of dynamic MR hysterosalphingography in identifying tubal patency in female infertility.

2. To directly compare the results of dynamic MR

hysterosalphingography with conventional hysterosalphingography

with diagnostic laparoscopy as gold standard.

REVIEW OF LITERATURE

ANATOMY OF FEMALE REPRODUCTIVE SYSTEM

The female reproductive organs are divided into internal and external organs. The internal organs include uterus with a pair of fallopian tubes and a pair of ovaries ⁽⁷⁾.

The uterus is a hollow, firm, thick walled muscular organ. It is the child bearing organ. It is situated in the pelvis, anteriorly is the urinary bladder and posteriorly is the rectum. The adult uterus has the shape of an inverted pear. It measures approximately 7.5 cm (superoinferior), 5cm (transverse), 2.5 cm (antero posterior). It weighs about 30 – 40 grams.

PARTS OF THE UTERUS

The uterus has two parts: body and cervix. The body is the upper expanded portion and forms upper two thirds whereas the cervix is the lower

cylindrical portion which forms the lower one third of the organ. The constriction situated between the body and cervix is called the isthmus.

POSITION OF UTERUS

⁽⁸⁾

VERSION

Version is defined as the angle formed between the long axis of the uterine body with the long axis of the vagina in sagittal plane. Normally the uterus is anteverted and the angle of version is 90^o and open forwards. When the uterus is retroverted, the body of the uterus is tilted posteriorly.

FLEXION

Flexion is defined as the angle between the long axis of the uterus with the cervix. Normally the uterus is anteflexed. The angle of anteflexion is 125⁰. In retroflexed position, the uterus is flexed posteriorly. Normally the uterus is anteverted and anteflexed such that the long axis of uterus corresponds to the pelvic inlet and the long axis of vagina corresponds to the pelvic outlet.

Angle of anteversion Angle of anteflexion

BODY OF UTERUS:

^(9,10)

Body of the uterus has Fundus, anterior/ vesical surface, posterior/

intestinal surface and two lateral borders.

Fundus: Forms the convex dome of the uterus. It lies above the level of openings for fallopian tubes.

Anterior surface: Flat and is related to the urinary bladder. Forms posterior border of vesicouterine pouch.

Retroverted, Anteflexed Retroverted, Retroflexed

Anteverted, Anteflexed Anteverted, Retroflexed

Posterior surface: Is convex and related to the bowel loops. Forms anterior border of rectouterine pouch or Pouch of Douglas.

Lateral border: Rounded and convex. Gives attachment to the broad ligament which attaches it to the lateral pelvic wall.

Uterine cavity: Uterine cavity is slit like and is compressed anteroposteriorly. It is triangular in shape with base upwards and apex downwards. At the superolateral angles the cavity becomes continuous with the fallopian tubes on either sides through the cornua. At the apex the cavity becomes continuous with the cervical canal through the internal os.

Layers of uterus

1. Endometrium: The inner mucosal layer is specialized for menstrual and reproductive function

2. Myometrium: Muscular layer that forms the uterine volume. It is divided into outer myometrium and inner myometrium. The inner myometrium is called the junctional zone ⁽¹¹⁾ and normally measures < 8mm. It is made up of tightly packed compact smooth muscles with little amount of water content and extra cellular matrix.

3. Perimetrium: Outer serosal layer.

CERVIX

Cervix is the lower cylindrical part of uterus. It measures approximately 2.5 cm in length. The lower part of cervix projects into the vagina which divides the cervix into two parts:

1. Supravaginal part 2. Vaginal part

Supravaginal part: Anteriorly related to the urinary bladder, separated by parametrium made of fibrous tissue, posteriorly covered by the peritoneum which reflects over the rectum forming the recto uterine pouch containing small bowel loops, laterally extends the parametrium containing the ureters and uterine arteries^(12).

Vaginal part: The vaginal part projects anteriorly into the vagina.

Fornices are the spaces between the cervix and vaginal wall. There are anterior, posterior and two lateral fornices.

Cervical canal: The cervical canal is fusiform in shape. It communicates above with the uterine cavity through the internal os and below opens into the vagina through the external os. The external os is bounded by anterior and posterior lips. The walls have multiple mucosal folds called arbora vitae uterine because they arborise like branches of a tree. These mucosal folds interlock with each other so that the cavity is closed.

FALLOPIAN TUBES

Also called the uterine tubes. They are paired structures that extend laterally from the cornua and open into the peritoneal cavity via the fimbrial ends. The fallopian tube is 10 – 12 cm in length and 1 – 4 mm in diameter. It bridges between ovaries laterally and uterus medially.

PARTS

1. Interstitial / Intramural segment: situated within the myometrium.

2. Isthmus: lateral to it the isthmus which is the narrowest segment, about 2 – 3 cm in length.

3. Ampulla: widest part , about 4 mm in diameter, 6 – 7 cm in length

4. Infundibulum: funnel shaped lateral end of the tube which contains multiple finger like processes called fimbriae. Ovarian fimbria is the one which is the longest and is attached to the ovary.

OVARIES

A pair of female gonads, situated within ovarian fossa which lies in the posterior wall of true pelvis. Each ovary is ovoid in shape and measures approximately 1.5 x 3cm and weighs 2 – 8 grams. The central part is the medulla and outer is the cortex. Ovarian follicles are situated within the stroma of the ovarian cortex. The follicles are in varying stages of development and degeneration

.

BLOOD SUPPLY UTERINE ARTERY

Arises from the anterior division of the internal iliac artery. It crosses the ureter anteriorly and it traverses through the broad ligament and ends by anastamosing with the ovarian artery.

BRANCHES

Arcuate arteries to uterus: Arcuate arteries divide into radial arteries which in turn penetrate the myometrium. At the endometrial level they divide into basal and spiral arteries.

Tubal branch, Ovarian branch, Vaginal branch, Branch to round ligament are the other branches.

OVARIAN ARTERY

Anterolateral branch from the abdominal aorta inferior to the level of renal artery and superior to the level of inferior mesenteric artery. Supplies ovary, fallopian tube and ends by anastamosing with ovarian branch of uterine artery.

VENOUS DRAINAGE

Uterine veins drain into internal iliac veins.Right ovarian vein drains into inferior vena cava. Left ovarian vein drains into left renal vein.

NERVE SUPPLY

UTERUS: Supplied by branches from ovarian and hypogastric plexuses, third and fourth sacral nerves.

OVARY: Ovarian plexus is formed by branches from aortic, renal, superior hypogastric and inferior hypogastric plexuses.

SUPPORTS OF UTERUS

⁽¹³⁾

BROAD LIGAMENT

Formed by two layers of the peritoneum that drape over the uterus and extend to the lateral pelvic walls on either sides from the uterus.

Upper margin is formed by fallopian tubes medially and laterally is the suspensory ligament of ovary. Lower margin ends in the cardinal ligament.

Between the leaves of broad ligament is parametrium which is formed by extra peritoneal connective tissue and fat. Broad ligament encloses the round ligament, ovarian ligament, ovarian and uterine blood vessels, nerves and lymphatics.

ROUND LIGAMENT

Band of fibromuscular tissue extending from the anterolateral aspect of uterine fundus takes a curved course, runs in inguinal canal to end in labia majora.

CARDINAL/ TRANSVERSE CERVICAL/ MACKENRODT’S LIGAMENT

Extends from the cervix, upper vagina laterally to blend with fascia covering obturator internus muscle. Its is the major supporting structure.

UTEROSACRAL LIGAMENT

Extends posteriorly from the cervix and vagina at the level of internal os and curves towards the anterior body of sacrum at S2, 3 level.

OVARIAN LIGAMENT

Extends laterally from the uterus to the ovaries.

SUSPENSORY LIGAMENT OF OVARY

Extends from anterolateral aspect of ovary and blends with fascia covering psoas muscle.

Cross sectional image showing the relationship of uterine body, ovaries with broad, round ligaments

.

EMBRYOLOGY OF UROGENITAL SYSTEM

The urogenital system is derived from the intermediate mesoderm^(14,15) from which develop the kidneys, gonads, reproductive and urinary tract.

Mesonephric or Wolffian duct develops and the ureteric bud branches from the caudal end of Wolffian duct^(16).Adjacent to the mesonephric duct develops the paramesonephric duct or the Mullerian duct.

After sex determination the hormones – testosterone, anti mullerian hormone(AMH), Insulin-like 3 (Insl3)⁽¹⁷⁾ trigger the regression of Mullerian duct and stimulate the development of male genital tract. In female fetus the absence of these hormones stimulate the development of female reproductive system from the Mullerian duct and the regression of the Wolffian duct.

From 6^th to 11^th week of gestation fusion of the paired Mullerian ducts occur resulting in formation of uterus with cervix and also proximal 2/3^rd of the vagina. Bilateral fallopian tubes are formed from the unfused uppermost

part of the paired Mullerian ducts. The central uterovaginal septum gets absorbed by 9- 12 weeks, failure of which results in persistence of intrauterine septum.

The ovaries are developed from the primitive yolk sac and lower 1/3 rd of vagina is developed from the sinovaginal bulb which explains why these anomalies are not commonly associated with Mullerian duct anomalies.

Widespread classification of Mullerian duct anomalies is given by American Society of Reproductive Medicine (previously called as American Fertility Society AFS ) in 1998 ^(18).

The European Society of Human Reproduction and Embryology (ESHRE) ⁽¹⁹⁾ and European Society for Gynaecological Endoscopy improvised the classification system.

Advantages of the new ESHRE/ ESGE classification:

Anatomy as the primary basis and embryology as the secondary characteristic, user friendly, clear and accurate.

The prevalence of Mullerian duct anomalies is reported to be 0.16 – 10

% ⁽²⁰⁾

AMERICAN FERTILITY SOCIETY CLASSIFICATION

CLASS TYPE

I – MULLERIAN AGENESIS OR HYPOPLASIA

A- Vaginal B- Cervical C- Fundal D- Fallopian E- Combined II – UNICORNUATE

UTERUS

A – Communicating rudimentary horn with endometrial cavity

B – Noncommunicating rudimentary horn with endometrial cavity

C - Rudimentary horn without endometrial cavity

D - No rudimentary horn

III – UTERUS DIDELPHYS IV- BICORNUATE

UTERUS

A – Complete B - Partial V – SEPTATE UTERUS A – Complete

B - Partial VI – ARCUATE UTERUS

VII – DIETHYL

STILBESTEROL RELAED

ESHRE CLASSIFICATION

CLASS SUBCLASS

0 - NORMAL

I – DYSMORPHIC UTERUS a.T shaped b.Infantile II- SEPTATE UTERUS a.Partial

b.Complete III – DYSFUSED UTERUS a.Partial

b.Complete

IV- UNILATERALLY FORMED a.Rudimentary horn with cavity (Communicating/ Non communicating)

b.Rudimentary horn without cavity/ apalsia

V- APLASTIC/ DYSPALSTIC a.Rudimentary horn with cavity (unilateral/ bilateral) b. Rudimentary horn without cavity (unilateral/ bilateral)/

aplasia VI – UNCLASSIFIED

CO EXISTENT SUBCLASS CERVICAL/ VAGINAL ANOMALY Cervix:

C0 – Normal C1 – Septate

C2 – Double normal C3 – Unilateral aplasia/

Dysplasia

C4 – Aplasia/ Dyspalsia

Vagina:

V0 – Normal

V1 – Longitudinal nonobstructing septum V2 – Longitudinal obstructing septum

V4 – Transverse septum/ imperforate hymen V5 – Vaginal apalsia

INFERTILITY

Infertility is a major clinical problem affecting 10 – 15% of couples in the reproductive age group. The tubal factors contribute to about 30 – 40 % of the causes.

The tubal pathologies include blocked tubes, hydrosalphinx, tubo ovarian mass.⁽²¹⁾

The ovarian pathologies include polycystic ovaries, ovarian cysts.

Endometriosis is yet another important cause of infertility.

EVALUATION OF INFERTILITY

⁽²²⁾

Recommended guidelines for practice in evaluation of infertility:

1. Confirmation of ovulation by S.Progesterone on Day 21 in a cycle of 28 days or 7 days prior to the presumed day of onset of menstruation.

2. Hysterosalphingography to screen for uterine and tubal abnormalities after excluding active pelvic infections and endometriosis.

3. Women with body mass index > 30 kg/m² should be advised to loose weight as it may restore ovulation.

4. Ovulation induction/ intrauterine insemination not to be offered in women with unexplained infertility as it has not shown to increase pregnancy rates.

Hysterosalphingography is the first line of investigation offered to women to rule out uterine and tubal pathologies. As opposed to invasive procedures like laparoscopy , hysterosalphingography is a minimally invasive procedure with therapeutic effects also, hence considered prior to other procedures.

The varying methods to assess tubal patency are complementary to each other and any single method is not mutually exclusive.⁽²³⁾

TUBAL FACTOR

It is an established fact that when a dominant follicle in the ovary grows to maturity, there occurs a surge of Luteinizing hormone (LH). The LH surge results in rupture of the follicle and release of the ovum. The ovary is covered by the fimbrial end of the fallopian tube similar to a ball held in the palm ⁽²⁴⁾.

Stephan et al ⁽²⁴⁾ reported that the fimbriae get distended and the fimbrial vessels get engorged and sweep gently. The pulsatile movements of the fimbriae are synchronous with the heart beat of the patient and slowly pull the released ovum into the fallopian tube.

TECHNIQUES FOR ASSESSING TUBAL PATENCY 1. Conventional Hysterosalphingography

2. Sonohysterosalphingography

3. Magnetic Resonance Hysterosalphingography 4. Diagnostic laparoscopy

CONVENTIONAL HYSTEROSALPHINGOGRAPHY

Earlier called as Uterosalphingography, ⁽²⁵⁾ was first introduced by Heuser in 1924 in a paper titled, “The Clinical value of Hysterosalphingography”. The paper was published in the third Pan American Scientific Congress in Lima, Peru in December 1924. The contrast used at that time was iodine in oil based solutions. In recent years the number of hysterosalphingograms done have increased dramatically. This is attributed to the advances made in assisted reproduction and advanced maternal age.⁽⁴⁾

TECHNIQUE

⁽⁴⁾

No specific patient preparation is required prior to doing hysterosalphingography. A nonsteroidal anti inflammatory drug is given one hour prior to the procedure. The procedure is done between Day 7 – Day12 of the menstrual cycle. The patient is advised to avoid sexual intercourse till the day of procedure in the cycle. This is so as to avoid any minimal chance of pregnancy. Moreover this is the period of proliferative phase during which the endometrium is thinned out and this facilitates better interpretation of the images. In patients with irregular menstrual cycles and suspicion of pregnancy, beta hCG values are used in solving the mystery. Any risk of active pelvic

inflammatory disease is to be avoided by checking the erythrocyte sedimentation rate (ESR).

The patient is made to lie supine in lithotomy or modified lithotomy position. A 5 - F HSG catheter is placed in the cervical canal and the balloon is inflated fully.

A scout radiograph is taken prior to the contrast administration. Water soluble contrast material is administered into the uterine cavity. Fluoroscopic images are taken intermittently to visualize the uterus and fallopian tubes.

Four spot radiographs are taken. The first radiograph is taken during early filling of the endometrial cavity, to visualize any filling defects. The second radiograph is taken when the uterine cavity is fully distended with contrast. The third image corresponds to the fallopian tubes. The fourth image is to be taken to look for intraperitoneal spill if any. Oblique views are taken to avoid superimposition if any. Final image is taken after deflating the balloon so as to look for the lower uterine segment.

Raymond et al ⁽²⁶⁾ states that the high clinical value of hysterosalphingography is due to the fact that it gives almost a perfect mold of the cavities of cervix, uterus and lumen of fallopian tubes. Moreover it also gives a permanent record. Such intricate details cannot be even given by varying other modalities like bimanual examination, dilatation and curettage, hysteroscopy and laparotomy. Many lesions not clinically suspected are identified in hysterosalphingography.

a

.

Early filling, b. fully distended uterus, c. fallopian tubes showing interstitial, isthmic, ampullary portions, d. intraperitoneal spill

Fallopian tubes in HSG

The fallopian tube appears as a 10 – 12cm long tubular structure coursing along superior aspect of broad ligament. Radiographically three segments are visible. The interstitial or cornual segment is short and traverses the uterine musculature. The isthmic part is the longest and narrowest portion.

The ampullary part is the widest part near the ovary. The fimbriated portion is the cone shaped end of fallopian tube and is not usually visualized in HSG.

The major advantages of hysterosalphingography are (i) To diagnose intracavitory lesions

(ii) Fallopian tubal block and hydrosalphinx

(iii) Therapeutic effect of opening a blocked tube which is evidenced by previously infertile women becoming pregnant after the procedure.

The major contraindications are:

(i) Active infection (ii) Pregnancy

The major complications are:

(i) Minimal spotting lasting for less than 24 hours

(ii) Introduction of intrauterine infection. The risk of infection can be prevented by the strict usage of sterile instruments and aseptic technique (iii) Cramping pain. The pain is most severe during the time of inflation of

balloon in case of intrauterine catheter, and also when the uterine cavity is distended with contrast material.The cramping pain is usually minimal and transient and well tolerated by most of the patients

The other potential but rare complications include:

(i) Severe pain resulting in premature termination of the procedure due to vasovagal reaction.

(ii) Systemic reaction to the contrast material if vascular intravasation occurs, but lymphatic and vascular intravasation are supposed to be clinically insignificant and not dangerous.

(iii) Perforation of uterus which is extremely rare and can be avoided by skilled technique.

(iv) Risk of radiation exposure to the reproductive organs.

(v) Radiation exposure to an early unsuspected pregnancy, but it can be avoided by proper timing of the examination and a negative pregnancy test.

CONTRAST MEDIA

The use of oil based iodine solutions has multiple complications ⁽²⁷⁾ including edema of the fallopian tubes, and when spilled into the uterine cavity cause adhesions with the adjacent organs. The use of oil based solutions has become obsolete and now replaced by the use of water soluble contrast media⁽²⁸⁾.

Boer et al ⁽²⁹⁾ compared the pregnancy rate and quality of images in a randomized control study in hysterosalphingography done using oil contrast media and aqueous contrast media.

The oil contrast media used was Ethiodol, a mixture of fatty acids obtained from poppy seeds. The aqueous contrast media used was a non ionic low osmolar contrast media Iopamidol.

The oil contrast media provided a sharper image with more contrasting image. The outline of uterine cavity was better delineated with oil contrast media. However the ampullary folds were better defined using aqueous contrast media. This is explained due to the lower iodine concentration in water soluble media ⁽³⁰⁾.

The water soluble media got dispersed in the peritoneal cavity within 10minutes which enables the control picture to be taken within 15 minutes. The oil contrast media was reabsorbed from the peritoneal cavity only after two hours which may persist even longer giving the chance of granuloma formation and foreign body reaction within the peritoneal cavity.

There was no statistical difference in pregnancy rates following the two procedures as against the increased pregnancy rate following oil based media in studies conducted by Mackey et al and DeCherney et al (31, 32,33)

However Lindequist et al ⁽³⁴⁾ and Rasmussen et al ⁽³⁵⁾ reported that pain during HSG after oil or water based media is the same but water based media have increased rate of post procedure bleeding and infection.

Spring et al ⁽³⁶⁾ in their prospective control study concluded no significant difference in pregnancy rates following the use of varying contrast media.

A well known complication of HSG is vascular or lymphatic intravasation of contrast media. The incidence is reported to be about 6%. Use of oil based contrast media can hence result in oil emboli ending up with serious cardiovascular complications.

Notifying the risks and benefits water soluble contrast media is considered preferable for HSG in day to day clinical practice.

CONTRAST INTRAVASATION

Intravasation ⁽³⁷⁾ indicates the backward flow of the contrast media into the adjoining veins. The contrast media passes from the endometrial cavity via the myometrial veins into the draining pelvic veins, ovarian veins in particular.

The factors predominantly causing intravasation are the conditions increasing endometrial vascularity and permeability. Few clinical examples include menometorrhagia, endometriosis, urinary tract infections, and previous history of uterine surgery. It is also noted to be seen with increased intrauterine pressure because of tubal obstruction. Catheter cannulation and fixation causing pain and discomfort to the patient may induce spasm and trauma resulting in intravasation. The prevalence of intravasation is about 0.4 – 6.9%.Intravasation is classified into four levels ⁽³⁸⁾ as follows:

1. Level 0: No intravasation

2. Level I: Minimal intravasation limited to myometrium

3. Level II: Moderate but slow intravasation into parametrial, adnexal veins

4. Level III: Severe instant intravasation from myometrial, parametrial veins into paracaval veins

Level I – Intravasation showing myometrial enhancement (m)

Level II – Opacification of myometrial veins extending to iliac veins

Level III intravasation – Bilateral tubal spill with instant intravasation into pelvic veins

Intravasation is now of less clinical significance ⁽³⁹⁾ with the use of water soluble contrast media. Nevertheless the reporting radiologist must be confident enough to differentiate it from intraperitoneal spill in tubal blockage.

Eliminating the predisposing factors and proper timing of the procedure and technique can eliminate the intravasation.

CATHETER TYPE

There are multiple studies comparing the utility of balloon catheter vs metallic cannula in performing hysterosalphingography.

Tur – Kaspa et al ⁽⁴⁰⁾ in a prospective, blinded, randomised control study compared the utility of balloon catheter vs metallic cannula in terms of pain, time of the procedure.

The procedure using balloon catheter was statistically significant by using lesser contrast media, lesser procedure time, less pain and discomfort to the patient. However the quality of images were same with both the techniques.

The balloon catheter provides better seal at the level of internal os thereby preventing reflux of contrast, faster and better visualisation of uterine cavity, fallopian tubes. The increased intensity of pain with metallic cannula is explained due to the tension applied by it on the cervix.

Mello et al⁽⁴¹⁾ described in a prospective study that the intensity of pain using balloon catheter, metallic cannula with paracervical block was significantly less when compared to the traditional method of using metallic cannula without any anaesthesia.

Shlomo et al ⁽⁴²⁾ in a prospective study described that cervical vacuum cup cannula causes significantly less pain, lesser procedure time, smaller amount of contrast when compared with traditional metallic cannula.

Ubeda et al ⁽⁴³⁾ described that introduction of air bubbles incidentally may be mistaken for filling defects, polyps but identified by the fact that they are well defined, mobile and can be flushed out of the tubes by further injection of contrast. However introduction of air bubbles can be effectively prevented by removing the air trapped within the cannula.

Moro et al⁽⁴⁴⁾ in a randomised controlled double blinded study evaluated the effectiveness of antispasmodic drug hyoscine – N – butylbromide in contrast enhanced sonohysterosalphingography. There was no statistical difference in pain score between the hyoscine group and placebo group.

Aytekim et al ⁽⁴⁵⁾ evaluated the effect of preprocedure anxiety on post procedure pain scales and HSG outcomes. They identified that there was a statistical significance in increase in pain intensity in patients with increased preprocedure anxiety. But there was no statistical difference in tubal patency between the two groups with lower and higher anxiety levels.

Maryam et al⁽⁴⁶⁾ evaluated the effect of anti axiety drug valerium in a test group as against placebo group and identified significant reduction in post procedure anxiety score in the test group.

ANTIBIOTIC PROPHYLAXIS

The 31st Royal College of Obstetricians and Gynaecologists Study Group on the Prevention of Pelvic Infection recommended the use of following antibiotics⁽⁴⁷⁾ after an intrauterine instrumentation procedure like hysterosalphingography if not previously screened for Chlamydia.

Doxycycline 100 mg orally, twice daily for a week, Ofloxacin 400 mg orally twice daily with Clindamycin 450 mg orally four times daily or Metronidazole 500 mg orally twice daily, for a week.

DIAGNOSTIC ACCURACY OF HSG

According to Egle et al ⁽⁴⁸⁾ the sensitivity and specificity of HSG in identifying bilateral tubal occlusion is 89.5% and 90% respectively.

Adrian et al ⁽⁴⁹⁾ followed up HSG results with laparoscopy, hysteroscopy, fertility outcomes according to which HSG had false positivity of 39%, and negative predictive value of 100%.

Bukar et al ⁽⁵⁰⁾ in a retrospective study reviewed HSG images and identified tubal pathologies in about 72% of the cases.

Chou et al ⁽⁵¹⁾ questioned the utility of HSG as the first line investigation in female infertility stating the sensitivity and specificity as 53% and 85% and introduced a new technique of Chlamydial antibody detection with similar reliability as HSG and hence can replace it.

Vahdat et al ⁽⁵²⁾ in a study evaluated that HSG had a sensitivity of 95.6%, specificity of 60%, PPV of 84.62%, and NPV of 85.71% in diagnosing uterine malformations

.

MRI PELVIS IN INFERTILITY

Though HSG is the mainstay and the initial imaging modality in infertility evaluation, MRI is a useful adjunct since its introduction. MRI pelvis because of its excellent tissue contrast helps in delineating pelvic anatomy and pathologies as well in a detailed and descriptive way.

The commonly encountered pathologies in infertility⁽⁵³⁾ include (i) congenital uterine anomalies, (ii) acquired uterine abnormlaities like fibroids, (iii) extrauterine pathologies like adnexal cysts, endometriosis.

The sequences routinely used include ⁽⁵³⁾ coronal T1 (TR 400-500ms, TE 20ms, slice thickness 10mm, gap 2mm, one acquisition), axial, sagittal, oblique coronal T2 (TR 2000 – 2,500MS, TE 30 – 70ms, 3-5mm slice thickness, 0.5mm gap, FOV 28 -36CM, 256 pixels ) MRI depicts congenital uterine abnormalities in a detailed manner including the features about cavity, septum, external contour.

Uterus didelphys has widely separated uterine horns (intercornual distance > 4cm) and two separate endometrial cavities, cervices, upper vagina A fundal cleft > 1cm⁽⁵⁴⁾is reported to be 100% sensitive and specific in differentiating fusion anomalies (didelphys and bicornuate) from reabsorption anomalies (septate and arcuate).

When the apex of the fundal contour is below or less than 5 mm above a line drawn between the tubal ostia, the uterus is bicornuate. When the apex of the fundal contour is more than 5 mm above a line drawn between the tubal ostia, the uterus is septate.

The correct classification of Mullerian ductal anomalies is critical in deciding on further surgical management which is achieved by MRI as it gives better details about external uterine contour, endometrial, myometrial width which is not provided by HSG ⁽⁵⁵⁾.

Normal

Uterus didelphys

Bicornuate Septate

MR HYSTEROSALPHINGOGRAPHY

The first MR hysterosalphingography trial dates back to 1996 when Fred et al ⁽⁵⁶⁾ evaluated its efficacy in 18 rabbit uterine horns. Five of the

fallopian tubes were ligated and 11 were left unaltered. 1 – 3ml of diluted gadolinium contrast was injected via transvaginal catheter and T1 weighted gradient images were taken before, during and after injection of contrast. It was followed by conventional imaging with equal amount of iohexol and evaluation was done by two radiologists blinded to the other study. Conventional HSG correctly identified spill in all 11 cases and absence in all 5 cases. MRHSG showed concurrent results in 14 of the 16 cases. Sensitivity and specificity of MRHSG were 95.5% and 70% for tubal block. There was no statistical difference between conventional HSG and MRHSG results.

Frye et al⁽⁵⁷⁾ in 2000 did a feasiblity study with a phantom simulating uterus, fallopian tubes and surronding pelvic cavity. Container measuring 40 x 25 x 10cm was used to simulate uterus. The fallopian tube was 40cm long and 1mm inner diameter. The observations of the study were (i) the choice of sequence was half Fourier RARE sequence which provide adequate temporal resolution. (ii)The opitmal contrast agent was distilled water and (iii)quantity was 5ml.

Weisner et al ⁽⁵⁸⁾ in 2001 published a preliminary report on MRHSG with a small sample size of 5. The sequences used were T1 SE, T2FSE and angiographic sequences for 3D dynamic MRHSG. They concluded that

MRHSG is a feasible technique and further research is required to consider it as an alternative technique to conventional HSG.

Sadowski et al ⁽⁵⁾ in 2008 did a prospective study on MRHSG using dynamic time resolved T1weighted angiographic sequence - 3D TRICKS using 2 sets of 1: 100 diluted gadodiamide in a sample size of 17 all of which were preceeded by conventional HSG. The procedure could not be completed in 1 patient. In 16 patients both MR and conventional HSG concurrently showed bilateral block. Six tubes blocked on conventional HSG were patent on MRHSG. Increased patency was thought to be due to the tubal block opened by conventional HSG done prior to it. The increased sensitivity of MR to even small amount of contrast was the other explanation given.

James ⁽⁵⁹⁾ countered the Sadowsiki’s study in 2009 arguing that the increased patency of MRHSG was not due to increased sensitivity of MRI but rather due to the use plastic catheter instead of metallic cannula and its better palcement yielded better tubal opacification.

Unterweger in 2002 ⁽⁶⁾ aimed at direct visualisation of fallopian tubes in addition to patency by use of a specific higher viscosity contrast solution – gadolinium mixed with polyvidone gel and compared the results with conventional HSG in a sample size of 10. The direct visualisation of fallopian tubes was possible in 5 cases. Eight out ot the 10 cases - six cases with bilateral patency and 2 patients with unilateral block were concurrent with conventional HSG results.

Winter et al ⁽⁶⁰⁾ in 2010 tried a similar study in 37 patients using Dotarem polyvidone in 1: 20 ratio. The procedure was abandoned in four of 37

patients due to dislodgement of catheter. 27 patients showed bilateral tubal patency which was confirmed by laparoscopy.

De Feliche et al ⁽⁶¹⁾ considered MRHSG as a new promising tool in infertility imaging and conducted a study with 16 patients to evaluate the efficacy of MRHSG and to improvise the techniques. The average time period was 25 – 30 minutes. 12/ 16 cases showed bilateral tubal patency .

Ma et al ⁽⁶²⁾ conducted a MRHSG study with 20 infertile women and compared it with previous HSG or laparoscopy results. Except for one case with blocked tube in conventional HSG, MRHSG showed patency, the other results were concurrent.

Cipolla et al ⁽⁶³⁾ in 2016 did a study with 116 patients on 3T using time resolved 3D sequence. Results were patency in 65%, unilateral block in 25%

and bilateral block in 9.8% and suggested MR with MRHSG as a single stop shop investigation in infertility imaging.

DIAGNOSTIC LAPARSCOPY

Tshabu et al ⁽⁶⁴⁾ did a comparative study of HSG with laparoscopy. The concardance between the two in tubal block was about 47%. Only 5.2% of the tubes patent at HSG were blocked in laparoscopy. The conclusions of the study were that HSG is complementary to laparoscopy in infertility evaluation. HSG has better reliability in diagnosing tubal patency than detecting tubal block.

Laparoscopy reveals out falsely blocked tubes at HSG and in addition picks up endometriosis and pelvic adhesions.

Fatemeh et al ⁽⁶⁵⁾ did a comparative prospective study on HSG followed by laparoscopy as gold standard after an interval of 3 months. The sensitivity, specificity, positive, negative predictive values, accuracy were 92.1%, 85.7%, 97.2%, 66.7%, 99.1% respectively.

Tsuji et al ⁽⁶⁶⁾evaluated the utility of diagnostic laparoscopy in patients with normal hysterosalphingography findings. The study consisted of 54 patients. Laparscopy revealed pathologic findings in nearly 80% of the patients.

So the study concluded that diagnostic laparscopy is mandatory in all infertile patients with normal hysterosalphingography prior to artificial reprouctive techniques because of its proven diagnostic and therapeutic benefits.

MATERIALS AND METHODS At our institution female patients presenting with infertility are

evaluated in Department of Obstetrics and Gynecology and then referred to Department of Radio diagnosis for radiological evaluation.

Forty patients between age 20 – 40 yrs with primary or secondary infertility were referred for evaluation of tubal patency. The patients were first subjected to dynamic MR hysterosalphingography and subsequently to conventional hysterosalphingography. Those with tubal block were subjected to diagnostic laparoscopy as a part of further evaluation and to confirm the tubal block.

The study was conducted after obtaining proper informed consent from the patient. As this was a prospective controlled study, ethical committee approval from Institutional Ethics Committee, Kilpauk Medical College, was obtained.

INCLUSION CRITERIA 1. Age group : 20 – 40 yrs

2. Patients with primary infertility with failure to achieve a clinical pregnancy after 12 months of unprotected sexual intercourse.

3. Patients with secondary infertility with failure to achieve a clinical pregnancy after 12 months of unprotected sexual intercourse.

4. Postoperative evaluation of patients following reversal of tubal

ligation.

5. Recurrent spontaneous abortions 6. Day 7 – Day 12 of menstrual cycle

⁽⁴⁾

EXCLUSION CRITERIA:

1. Menstruating females

2. Beyond Day 12 of menstrual cycle.

⁽⁴⁾

3. Non consenting and unco-operative patients 4. Patients with active pelvic inflammatory disease

5. Patients with contraindications to MRI - pacemaker and cochlear implants

STUDY DESIGN:

All the patients were advised to abstain from sexual intercourse during the days after menstruation till the day of procedure so as to avoid any chance of pregnancy during the procedure.

The procedure was commenced after obtaining informed consent

from the patient with detailed explanation of the procedure to be

undertaken. The patient was given oral mefanamic acid

⁽⁶⁵⁾

three times a

day and a course of antibiotics (combination of ofloxacin and

metronidazole) as premedication starting on the day before and

continued two days post procedure.

The patient was asked to empty the bladder and made to lie in lithotomy or modified lithotomy position in the lithotomy table. The external genitalia was painted with povidone – iodine solution and draped with sterile towels. Per vaginal examination was done to assess the version, size of uterus.

Sim’s speculum was inserted into the vagina. The cervix was cleansed with povidone – iodine gauze. The anterior lip of cervix was held gently with a valsellum forceps. Uterine sound was inserted into the uterine cavity to assess the length of the uterine cavity.

MRI compatible plastic Hysterosalphingogram 5 - F micro catheter

with inflatable bulb was inserted into the lower uterine cavity. The bulb

was inflated with 3 cc of distilled water. The guide wire was removed and an empty 3ml syringe attached to the catheter. The speculum and valsellum forceps were removed.

The patient was then shifted to MRI scan. 1.5 Tesla (GE) machine was used. The following sequences were used:

1. T2 W Axial TR: 7120 ms, TE: 90 ms, Flip angle 90

⁰

Slice thickness 5mm, Matrix 256 x 256 2. T2W Coronal 3. T2 W Sagittal 4. T1 W Axial

TR: 740 ms, TE: 13 ms, Flip angle 90

⁰

Slice thickness 5mm, Matrix 256 x 256

5. T1 Cube Coronal – 5 phases each phase scanning for 15 seconds..

TR: 3.8 ms,

TE: 1.8 ms,

TI: 7ms,

Flip angle 12

⁰

Slice thickness 3.4 mm, Matrix 256 x 256

The first phase was imaged prior to saline infusion. 10 ml of 1 in 100 dilution of Gadodiamide (Omniscan GE Healthcare 0.5mmol/ml) in 0.9% saline was instilled and the successive phases were obtained.

4 successive phases were obtained demonstrating the endometrial cavity, tubal patency/ block, peritoneal spill if any. Corresponding subtracted images were generated automatically.

The patient was immediately mobilized to the Xray room. 10 ml of iodinated contrast iohexol (Omnipaque GE Healthcare 350mg/ml) instilled through the same catheter. Spot film was taken to look for endometrial cavity, fallopian tubes, peritoneal spill if any. The balloon was deflated and the catheter removed.

The patients with unilateral or bilateral tubal block were subjected to diagnostic laparoscopy in their next cycle as a part of routine subsequent evaluation and the findings were confirmed at the same time.

The patients with bilateral tubal patency were followed up after 3

months and if failed to conceive were subjected to diagnostic laparoscopy

as a part of further evaluation at department of Obstetrics and

Gynecology, KMC and the findings were confirmed during the

procedure.

Diagnostic laparoscopy was done in the Department of Obstetrics and Gynecology by gynecologist. Methylene blue dye was used for assessing the tubal patency. Direct visualization of spill into the peritoneal cavity was done with laparoscope.

The results were tabulated. Statistical analysis was made

comparing the results of MRHSG, conventional HSG with diagnostic

laparoscopy as gold standard.

CASE : 1

30yrs old, P2L1, tubectomy done 5years back, post tubal reanastamosis status

Coronal T2W with balloon catheter placed in situ just beyond the level of internal os

Coronal T1 CUBE Phase 1 image prior to the

instillation of 1: 100 gadodiamide in saline

Coronal T1CUBE Phase 2 image showing contrast within the endometrial cavity, absence of peritoneal spill on both sides, reflux of contrast in the vagina

Conventional HSG showing uterine cavity, bilateral tubal block

Subtracted images reformatted showing contrast within

endometrial cavity and absence of peritoneal spill, reflux of contrast in the vagina

CASE: 2

31 years nullipara with previous history of two spontaneous first trimester abortions

Axial and Sagittal T2W images showing balloon catheter within the endometrial cavity

Coronal T1 CUBE Phase 2 image showing contrast within uterine cavity and bilateral fallopian tubes

Coronal T1 CUBE Phase 3 image showing contrast within uterine cavity and bilateral peritoneal spill

Subtracted images reformatted showing

contrast within endometrial cavity and bilateral

peritoneal spill

Conventional HSG showing uterine cavity, bilateral peritoneal spill

CASE : 3

24 years old, nullipara with previous history of two spontaneous first trimester abortions

Axial T2 W images showing two uterine horns uniting at the level of internal os with a single cervix. The external uterine contour is convex without

indentation – partial septate uterus. The cervix is deflected to the left.

Longitudinal vaginal septum pulled out for better

visualisation

TI CUBE Phase 3 image showing absence of peritoneal spill on both sides.

Conventional HSG showing two uterine horns, right fallopian tube and right peritoneal spill

CASE : 4

24years nulligravida, married for 2 years

Axial T1, Coronal T2 W images showing balloon catheter within the endometrial cavity with left ovarian cyst with areas of T1, T2

hyperintensities suggestive of haemorrhagic cysts

Subtracted reformatted image showing bilateral tubal block where as conventional HSG shows right tubal spill and Type III intravasation of contrast

CASE :5

35 yrs P1L1, last child birth 10years back for secondary infertility evaluation

Axial and Sagittal T2W images showing T2 hyperintense oblong cystic lesion in right adnexa with few internal septations

mimicking right hydrosalphinx

Coronal T1 CUBE images Phase 2 showing left tube and Phase 3 showing right tube and absence of peritoneal spill

Subtracted reformatted images showing bilateral tubes and distal block and no peritoneal spill, refluxed contrast in the vagina

Conventional HSG showing bilateral fimbrial block and no peritoneal spill

CASE :6

25 years P2L1, post tubal reanastamosis status

Coronal T2 W image with balloon catheter in situ

Subtracted reformatted image showing uterine cavity

Subtracted reformatted image showing left tubal spill, corresponding conventional image showing left tubal spill

STATISTICAL ANALYSIS AND RESULTS

TYPE OF INFERTILITY

TYPE OF INFERTILITY NO. OF CASES

PRIMARY 22

SECONDARY 18

TYPE OF SECONDARY INFERTILITY

CAUSES OF SECONDARY INFERTILITY NO. OF CASES

RECURRENT ABORTIONS 4

POST TUBAL REANASTAMOSIS 9

UNEXPLAINED 5

TYPE OF OCCLUSION

NO. OF CASES

PROXIMAL 14

DISTAL 2

TOTAL 16

TYPE OF INFERTILITY

MR HSG BLOCK

PATENT

TOTAL UNILATERAL BILATERAL

PRIMARY 0 5 17 22

SECONDARY 3 8 7 18

TOTAL 3 13 24 40

PRIMARY 56%

SECONDARY - ABORTIONS

10%

SECONDARY - PTRA

22%

SECONDARY - UNEXPLAINED

12%

INFERTILITY

TYPE OF INFERTILITY

CONVENTIONAL HSG

BLOCK PATENT TOTAL

UNILATERAL BILATERAL

PRIMARY 1 4 17 22

SECONDARY 3 8 7 18

TOTAL 4 12 24 40

TYPE OF HSG

BLOCK

PATENT

TOTAL UNILATERAL BILATERAL

MR HSG 3 13 24 40

CONVENTIONAL HSG

4 12 24 40

TYPE OF HSG

BLOCK PATENT TOTAL

UNILATERAL BILATERAL

MR HSG 3 13 24 40

DL 7 9 24 40

TYPE OF HSG TUBES

BLOCKED

TUBES PATENT

TOTAL

MRHSG 29 51 80

CONVENTIONAL HSG 28 52 80

DIAGNOSTIC LAPAROSCOPY

25 55 80

NON TUBAL PATHOLOGIES NUMBER

UTERINE ANOMALIES 4

MYOMA UTERUS 2

POLYCYSTIC OVARIES 6

OVARIAN CYSTS 3

ENDOCERVICAL POLYP 1

POST TUBAL REANASTAMOSIS TUBAL STATUS

PATENT U/L BLOCK

B/L BLOCK 0

1 2 3 4 5 6 7 8

PRIMARY INFERTILITY

SECONDARY INFERTILITY

PATENT U/L BLOCK B/L BLOCK

B/LBLOCK U/L BLOCK 56%

22%

PATENT 22%

0%

RIGHT TUBE: MR HSG - AGE GROUP

Crosstab

MR HSG RIGHT PATENT BLOCK Total AGE

GROUP

21-25 YEARS Count 11 4 15

% within MR HSG RIGHT

42.3% 28.6% 37.5%

% of Total 27.5% 10.0% 37.5%

26-30 YEARS Count 7 5 12

% within MR HSG RIGHT

26.9% 35.7% 30.0%

% of Total 17.5% 12.5% 30.0%

31 YEARS &

ABOVE

Count 8 5 13

% within MR HSG RIGHT

30.8% 35.7% 32.5%

% of Total 20.0% 12.5% 32.5%

Total Count 26 14 40

% within MR HSG RIGHT

100.0% 100.0% 100.0

%

% of Total 65.0% 35.0% 100.0

%

LEFT TUBE MRHSG AGE GROUP Crosstab

MR HSG LEFT

PRESENT BLOCK Total

AGE GROUP 21-25 YEARS Count 10 5 15

% within MR HSG LEFT 40.0% 33.3% 37.5%

% of Total 25.0% 12.5% 37.5%

26-30 YEARS Count 8 4 12

% within MR HSG LEFT 32.0% 26.7% 30.0%

% of Total 20.0% 10.0% 30.0%

31 YEARS & ABOVE Count 7 6 13

% within MR HSG LEFT 28.0% 40.0% 32.5%

% of Total 17.5% 15.0% 32.5%

Total Count 25 15 40

% within MR HSG LEFT 100.0% 100.0% 100.0%

% of Total 62.5% 37.5% 100.0%

RIGHT TUBE: MR HSG – YEARS AFTER MARRIAGE Crosstab

MR HSG

RIGHT PATE NT

BLOC

K Total

MARITAL HISTORY GROUP

0-5 YEARS

Count 18 5 23

% within MR HSG RIGHT

69.2% 35.7% 57.5%

% of Total 45.0% 12.5% 57.5%

6-10 YEARS

Count 4 6 10

% within MR HSG RIGHT

15.4% 42.9% 25.0%

% of Total 10.0% 15.0% 25.0%

11-15 YEARS

Count 4 3 7

% within MR HSG RIGHT

15.4% 21.4% 17.5%

% of Total 10.0% 7.5% 17.5%

Total Count 26 14 40

% within MR HSG RIGHT

100.0% 100.0% 100.0%

% of Total 65.0% 35.0% 100.0%

LEFT TUBE: MR HSG – YEARS AFTER MARRIAGE Crosstab

MR HSG LEFT PATEN

T

BLOC

K Total

MARITAL

HISTORY GROUP 0-5 YEARS

Count 18 5 23

% within MR HSG LEFT

72.0% 33.3% 57.5%

% of Total 45.0% 12.5% 57.5%

6-10 YEARS

Count 4 6 10

% within MR HSG LEFT

16.0% 40.0% 25.0%

% of Total 10.0% 15.0% 25.0%

11-15 YEARS

Count 3 4 7

% within MR HSG LEFT

12.0% 26.7% 17.5%

% of Total 7.5% 10.0% 17.5%

Total Count 25 15 40

% within MR HSG LEFT

100.0% 100.0% 100.0%

% of Total 62.5% 37.5% 100.0%

RIGHT TUBE: MR HSG - POST TUBAL REANASTAMOSIS

Crosstab

MR HSG RIGHT

PATENT BLOCK Total

PTRA NO Count 23 8 31

% within MR HSG RIGHT

88.5% 57.1% 77.5%

% of Total 57.5% 20.0% 77.5%

YES Count 3 6 9

% within MR HSG RIGHT

11.5% 42.9% 22.5%

% of Total 7.5% 15.0% 22.5%

Total Count 26 14 40

% within MR HSG RIGHT

100.0% 100.0% 100.0%

% of Total 65.0% 35.0% 100.0%

LEFT TUBE: MR HSG - POST TUBAL REANASTAMOSIS Crosstab

MR HSG LEFT

PATENT BLOCK Total

PTRA NO Count 22 9 31

% within MR HSG LEFT

88.0% 60.0% 77.5%

% of Total 55.0% 22.5% 77.5%

YES Count 3 6 9

% within MR HSG LEFT

12.0% 40.0% 22.5%

% of Total 7.5% 15.0% 22.5%

Total Count 25 15 40

% within MR HSG LEFT

100.0% 100.0% 100.0%

% of Total 62.5% 37.5% 100.0%

Right Tube: MRHSG Vs Xray HSG

MRHSG XrayHSG

Positive Negative Total

Positive

13 1 14

Negative

0 26 26

Total

13 27 40

Parameter

Estimate (95% CI – Wilson score)

Sensitivity

100%

Specificity

96.3%

PPV 92.86%

NPV 100%

Diagnostic

accuracy 97.5%

Left Tube: MRHSG Vs Xray HSG

Statistical test Value right Value left

McNemar 1.0 1.0

Kappa agreement 0.94 1.0

XrayHSG

MRHSG Positive Negative Total

Positive 15 0 15

Negative 0 25 25

Total 15 25 40

Parameter Estimate (95% CI – Wilson score)

Sensitivity 100%

Specificity 100%

PPV 100%

NPV 100%

Diagnostic accuracy 100%

Right tube: MRHSG Vs DL

MRHSG DL

Positive Negative Total

Positive

12 2 14

Negative

0 26 26

Total

12 28 40

Parameter

Estimate (95% CI – Wilson score)

Sensitivity

100%

Specificity

92.86%

PPV 85.71%

NPV 100%

Diagnostic accuracy

95%

Left tube: MRHSG Vs DL

MRHSG DL

Positive Negative Total

Positive

13 2 15

Negative

0 25 25

Total

13 27 40

Parameter Estimate (95% CI – Wilson score)

Sensitivity

100%

Specificity

92.59%

PPV 86.67%

NPV

100%

Diagnostic accuracy

95%

Statistical test Value right Value left

McNemar 0.5 0.5

Kappa agreement 0.88 0.88

Right tube: XrayHSG Vs DL

XrayHSG DL

Positive Negative Total

Positive

12 1 13

Negative

0 27 27

Total

12 28 40

Parameter

Estimate (95% CI – Wilson score)

Sensitivity

100%

Specificity

96.43%

PPV 92.31%

NPV 100%

Diagnostic accuracy

97.5%