Page 22 - WALS Journal

Hysterosalpingography, Laparoscopy or Both in the Diagnosis of Tubal Disease in Infertility
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Of the 67 patients with normal HSG findings, 12 were found misinterpretation as distal occlusions. In our study we found
to have adnexial adhesions, 3 were diagnosed with pelvic 6 false- positive cases.
endometriosis and 3 patients had ovarian cysts. Of the twelve Both HSG and laparoscopy have advantages and
cases of bilaterally occluded tubes detected by HSG, only 3 disadvantages. HSG is quite accurate in defining the uterine
(25%) were confirmed to have bilateral occlusion during cavity. Laparoscopy on the other hand, although not able to
laparoscopy. give information on the uterine cavity, is superior to
histerosalpingography in the assessment of tubal patency and
Discussion allows detection and, most importantly, treatment of
intraabdominal pathologies as endometriosis and peritubal
Histerosalpingography (HSG) is a frequently utilized diagnostic adhesions. The disadvantages of histerosalpingography are
method in the assessment of tubal status and detection of the possibility of allergic reactions to iodine, pelvic infections,
intrauterine anatomical defects in the infertility diagnostic endometriosis secondary to carriage of endometrial tissue onto
workup. However, the inadequacy of HSG in determining the extrauterine sites, and tubal rupture due to contrast material
state of tubal patency, emphasizes the need for laparoscopy. given under pressure in patients with hydrosalphinges. Also
Laparoscopy provides both a panoramic view of the pelvic the ovaries are said to be exposed to 500-1000 mRads of radiation
reproductive anatomy and a magnified view of pelvic organs during HSG. The disadvantages of laparoscopy are its
and peritoneal surfaces. It is generally accepted that, diagnostic invasiveness, cost, and related risks of surgical complications. 17
laparoscopy is the gold standard in diagnosing tubal pathology During our HSGs, a water soluble contrast medium was used,
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and other intraabdominal causes of infertility. Compared with and no complications were encountered. During laparoscopy,
laparoscopy, HSG has only moderate sensitivity but relatively the only complication encountered was hemorrhage from the
high specificity. If an occlusion is detected in HSG, there is a 5 mm trocar insertion site that was managed by cauterization.
60% possibility of the tubes to be actually patent, however, A diagnosis of unexplained infertility is usually made only
when patency is demonstrated in HSG, there is little chance the after it has been demonstrated that the female partner ovulates
tube to be actually occluded. 9,10 In our study, the likelihood regularly, has patent fallopian tubes, shows no evidence of
ratio of HSG for tube patency was found to be 3.21, and the peritubal adhesions, fibroids or endometriosis and has a partner
likelihood ratio for tubal occlusion was 0.26. Consequently, with normal sperm production and function. Fatum et al
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similar to the studies mentioned previously, we concluded that suggested that couples with unexplained infertility should be
HSG is more accurate in detecting patent tubes rather than treated by 3-6 cycles of combined gonadotrophins and IUI
occluded ones. Both false negative and false positive results without preceding diagnostic laparoscopy, and if unsuccessful,
can be seen with HSG. In accordance with literature, the false- they should be referred directly to IVF. In their opinion, this
negative results were much more common than the false- approach would prove to be the most cost effective and efficient
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positive results in our study. Injection of contrast material treatment protocol. In Drake et al’s series of 24 cases with
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during HSG can lead to the misdiagnosis of tubal occlusion unexplained infertility, 18 were found to have abnormal findings
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following cornual spasm. In HSG, while one tube can be in laparoscopy. It was proposed that the usage of laparoscopy
observed to be patent, the other one can be occluded. Whereas as a standard test of tubal function would reduce the apparent
this observation may indicate an actual one sided proximal tubal incidence of unexplained infertility. They concluded that
occlusion, most commonly it is due to the tendency of the laparoscopy is an essential final step in an otherwise negative
contrast material to enter the tube with the least resistance. work-up for infertility. Laparoscopy has been shown to reveal
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Therefore, the occluded appearing tube is in fact most likely to abnormal findings in 21-68 % of infertile patients with a normal
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be normal. Another scenario resulting in false-negative hysterosalpingogram. 4,8,19 Hening et al have detected adnexial
diagnosis of tubal occlusion is when inadequate wedging of adhesions and pelvic endometriosis during surgery in 21% of
the cervical cannula allows leakage of contrast material into the patients with normal HSG findings. The superiority of
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vagina, thus interfering with generation of sufficient laparoscopy over HSG in assessing extratubuler pathology is
intracavitary pressure and often leading to the misdiagnosis of shown in our study as has been demonstrated in other studies. 6
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tubal occlusion. In our study, we found 15 false negative Tanahatoe et al stated that laparoscopy revealed abnormalities
cases. Although often venous and lymphatic channels can be that resulted in altered treatment decisions in 25% of the patients
identified by their anatomy, contrast intravasation into uterine who would normally have been scheduled for IUI if laparoscopy
and ovarian veins can sometimes be mistaken for tubal filling. 15 had not been performed. The altered treatments mainly
False- positive HSG results may be due to the contrast material concerned surgery for minimal/mild endometriosis and
entering through the dilated tube with hydrosalphinx. In the periadnexial adhesions, both performed during diagnostic
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presence of peritubal adhesions, even though the tubes may laparoscopy. In our study, 27 % of cases with normal HSGs
actually be patent, focal contrast deposits can lead to the were found to have adnexial adhesions, ovarian cysts and pelvic

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