HYSTEROSALPINGOGRAPHY - It is the radiological procedure in which the contrast is injected into the uterus to study the uterine tube and fallopian tube

1. HYSTEROSALPINGOGRAPH
Y
SWAPNIL SHETTY
1st YEAR MSc.MIT
MCHP. MAHE. MANIPAL

2. Contents
2
Female Reproductive System
Indications & Contraindication,
Equipments, Procedure, Technique,
Aftercare & Complications
Basic anatomy and its blood supply
Falloposcopy & Sono Salpingography (Sion Test)
Other Procedures
1
2
3

3. 3
Anatomy
The female
reproductive organs
can be subdivided
into the internal and
external genitalia.

4. 4
External Organ
The external genitalia lie outside the
true pelvis. These include the
perineum, mons pubis, clitoris,
urethral (urinary) meatus, labia
majora and minora, vestibule, greater
vestibular (Bartholin) glands, Skene
glands, and periurethral area.

5. The internal genitalia are
those organs that are within
the true pelvis. These include
the vagina, uterus, cervix,
uterine tubes (oviducts or
fallopian tubes), and ovaries.
5
Internal Organ

6. Vagina:
● The vagina extends from the vulva externally to the uterine cervix internally. It is located within the
pelvis, anterior to the rectum and posterior to the urinary bladder. The vagina lies at a 90º angle in
relation to the uterus. The vagina is held in place by endopelvic fascia and ligaments.
● The vascular supply to the vagina is primarily from the vaginal artery, a branch of the anterior
division of the internal iliac artery.
Uterus
● The uterus is the inverted pear-shaped female reproductive organ that lies in the midline of the
body, within the pelvis between the bladder and the rectum.
● The uterus can be divided into 2 parts: the most inferior aspect is the cervix, and the bulk of the
organ is called the body of the uterus.
● The vasculature of the uterus is derived from the uterine arteries and veins. The uterine vessels
arise from the anterior division of the internal iliac, and branches of the uterine artery anastomose
with the ovarian artery along the uterine tube.
6

7. Cervix:
● The cervix is the inferior portion of the uterus, separating the body of the uterus from the
vagina.
● The cervix is cylindrical in shape, with an endocervical canal located in the midline, allowing
passage of semen into the uterus.
● The external opening into the vagina is termed the external os, and the internal opening into
the endometrial cavity is termed the internal os.
● The internal os is the portion of a female cervix that dilates to allow delivery of the fetus
during labor.
● The average length of the cervix is 3-5 cm.
● The vasculature is supplied by descending branches of the uterine artery.
7

8. Uterine tubes:
● The uterine tubes (also referred to as oviducts or fallopian tubes) are uterine appendages
located bilaterally at the superior portion of the cavity.
● Their primary function is to transport sperm toward the egg, which is released by the ovary,
and then to allow passage of the fertilized egg back to the uterus for implantation.
● Each tube is approximately 10 cm in length and 1 cm in diameter and is situated within a
portion of the broad ligament called the mesosalpinx.
● The uterine tube has 3 parts. The first segment, closest to the uterus, is called the isthmus.
The second segment is the ampulla. The final segment, furthest from the uterus, is the
infundibulum.
● The infundibulum gives rise to the fimbriae, fingerlike projections that are responsible for
catching the egg that is released by the ovary.
● The arterial supply to the uterine tubes is from branches of the uterine and ovarian arteries.
8

9. Ovaries:
● The ovaries are paired organs located on either side of the uterus.
● The ovaries are responsible for housing and releasing the ova, or eggs, necessary for
reproduction.
● The ovaries are small and oval-shaped, exhibit a grayish color, and have an uneven surface.
● the ovaries are approximately 3-5 cm in length during childbearing years and become much
smaller and atrophic once menopause occurs.
● Blood supply to the ovary is via the ovarian artery; both right and left ovarian arteries originate
directly from the descending aorta at the level of the L2 vertebra.
9

10. It is the radiological procedure
in which the contrast is injected
into the uterus to study the
uterine tube and fallopian tube
10
What is
Hysterosalpingography?

11. Menstruation
The mean duration of the MC
• Mean 28days(only in 15% of the females) ranging
from 21 to 35 yrs
Average duration : 3-8days
The normal estimated blood loss
• approximately 30ml .
The ovulation occurs
• Usually day 14.
The mean age
• Menarche-12.7
• Menopause-51.4

12. When can this procedure be performed?
12
28 days rule
Menstrual cycle varies, generally
28 days. If patient is to be
exposed to ionizing radiation for
diagnostic purposes and the
patient is of child-bearing age,
postpone exposure for 28 days
from first day of menstrual cycle to
next to rule out pregnancy.
10 days rule
If patient is to be exposed to ionizing
radiation for diagnostic purposes If
patient is to be exposed to ionizing
radiation for diagnostic purposes and the
patient is of child-bearing age, she
should be booked in the first 10 days of
the menstrual cycle, when conception is
unlikely to have occurred.

13. Indications
13
Infertility
Infertility means not being
able to become pregnant
after a year of trying.
Recurrent abortion
Recurrent pregnancy loss, defined
as 3 consecutive pregnancy
losses prior to 20 weeks from the
last menstrual period.
Following tubal surgery
During tubal ligation, the
fallopian tubes are cut, tied or
blocked to permanently prevent
pregnancy.
Uterine and tubal
lesions
tuberculosis, sub mucous
fibroids, polyps etc.
Migrated IUCD
Migration of the IUD to the
pelvic and abdominal cavity or
adjacent organs may be seen
following perforation of the
uterus.
Congenital or acquired
uterine anomalies
including septa and
adhesions or synechiae, as
in Asherman’s syndrome

14. Contraindications
Active pelvic
sepsis
Sensitive to
contrast
media
Severe renal
or cardiac
disease
The week prior
to and the week
following onset
of menstruation
Pregnancy
14
Cervicitis/purule
nt vaginal
discharge

15. Equipments
15
1. Fluoroscopy
2. Sims speculum
3. Uterine sound and dilator
4. 20cc syringe
5. Foley’s catheter

16. Contrast Media
Water soluble
Urograffin 60%, Conray 280, trivideo
280, angiografin.
Volume:
• Average volume 5-6 ml.
• In nulliparous women 3-4 ml, if
there is hydrosalphyx >10 ml
16

17. Preparation &
premedications
17
Ideal time of
procedure: between
8th and 10th day of
menstrual cycle.
• patient should be advised to
abstain from intercourse
between booking the
appointment and the time of
examination
• 4 hours of fasting prior to the
procedure.
• Ask the patient to void the
urine before procedure
• If patient is anxious – 5 to 10 mg of I.V diazepam
30 min before the procedure
• 0.6mg atropine sulphate in 1ml ampoule can
given I.V 10 - 15 min before starting the
procedure

18. Techniques
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1. Using Cannula 2. Using Foleys catheter
1. Leech Wilkinson canula
2. Jercho type
3. Spackman

19. 19
Cannula method
• The patient is placed in lithotomy position at the edge of the x-ray table.
• A speculum is introduced into the vagina and the anterior lip of the cervix is
held with tenaculum and gentle traction is applied.

20. 20
Cannula method
• The canula is inserted into the cervical canal under direct vision.
• The speculum is then removed, and patient is carefully moved to
supine position
• Under fluoroscopic control,
2ml of the contrast media
is injected to outline
uterine cavity.
• To prevent the leak from
cervix, a downward
traction should be kept on
the tenaculum while
keeping an upward
pressure to the canula.
cannula

21. 21
Cannula method
Disadvantage: Causes cervical trauma and bleeding

22. 22

23. 23
Foley’s catheter method
• 8F Foley’s catheter is used.
• The cervix is exposed with a
vaginal speculum and swabbed
with an antiseptic solution.
• The lumen of the catheter is filled
with contrast to prevent air
bubbles.

24. 24
Foley’s catheter method
The catheter is inserted through the
cervical os using a cervical forceps to
guide it when the ballon lies within
uterine cavity ,it is gently inflated with
water (2-3ml)
Before injection of contrast, the
ballon is pulled downwards against
the internal os.
The speculum is withdrawn, and
catheter is attached to syringe and
contrast is injected

25. 25

26. Filming
26
As the tube begin to fill When peritoneal spill
has occurred
Maximum x-ray
screening time must
not exceed 30 sec.
Only 3-4 spot
exposures are
permitted in order to
minimize radiation to
gonads

27. b.Tubal Filling
Phase
a.Early Filling
Phase
c.Uterus Fully
Distended
d.Peritoneal
Spillage

28. Aftercare
28
It must be ensured that
patient is in no serious
discomfort before she
leaves.
She must be cautioned
that there may be mild
bleeding for 1-2 days

29. 1.Pain may occur
• Using the vulsellum forceps.
• During insertion of canula.
• With tubal distension and distension of uterus.
• Generalized lower abdominal pain due to
peritoneal irritation by the contrast media
2.Trauma to the uterus due to
canula causing perforation.
3.Exacerbation of pelvic infection
(0.25-3% infection rate after
procedure)
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Complication

30. 30
Normal &
Abnormal
findings

31. 31
Falloposcopy
• Falloposcopy is a recent development, pioneered by Dr. Kerin of USA.
• In this method, a very fine flexible fiberoptic tube is guided through the
cervix and uterus into each fallopian tube, thus allowing the
visualization of the inner lining of the entire length of the fallopian tube.
• This can provide useful information about the extent of tubal damage,
and the possibility for successful repair.

32. 32
Sonosalpingography (Sion test)
• Foley's catheter (SF) is introduced into uterine cavity with the patient
in supine position. The bulb of the catheter is inflated with 2 ml of
normal saline.
• Transvaginal sonography of uterus with catheter insitu is performed in
sagittal and coronal planes.
• After scanning the uterus and ovaries, the area between the cornua of
uterus and the ovary on one side is focused upon.
• A mixture of normal saline and air is pushed with moderate force into
uterine cavity using a 20 cc syringe fixed to the metallic adaptor.
• be seen distending in case of tubal block.

33. 33
Sonosalpingography (Sion test)
• A slight traction is given to the catheter while injecting to occlude
internal os with the bulb. If the fallopian tube is patent the flow can be
seen as a gush of fluid cascading past the 'surprised' ovary and this
phenomenon is called the 'Waterfall Sign’.
• Then the same procedure is repeated with the other side focused.
• When the tubes are blocked, the patient complains of acute pain in the
suprapubic region and , the reflux of fluid and air is seen in the stem of
the catheter.
• Also uterine cavity can be seen distending in case of tubal block.

34. 34
Sonosalpingography (Sion test)
Advantages:
• Can demonstrate the tubal block, its site and extent with higher
accuracy and reliability.
• No radiation exposure.
Disadvantages:
• Individual tube evaluation sometimes become difficult.

35. Abnormal findings in HSG
UTERINE
1. Uterine anomalies : Unicornuate, Didelphys, Bicornuate, Septate, Arcuate
2. Fibroid ( submucosal)
3. Adenomyosis
4. Endometrial polyp
5. Intrauterine adhesions/synechiae
6. Endometrial TB
7. Cervical incompetence
8. Uterine myoma
TUBAL
1. Tubal block
2. Tubal spasm
3. Tubal polyp
4. Hydrosalpinx
5. Salpingitis isthmic nodosum (SIN)
6. Peritubular adhesions
7. TB salpingitis

36. 36
Unicornuate Uterus
Unicornuate uterus is a rare
genetic condition in which only
one half of a girl's uterus forms.

37. 37
Uterus didelphys
Uterus didelphys represents
a uterine malformation where
the uterus is present as a paired
organ when the embryogenetic
fusion of the Müllerian ducts fails to
occur.

38. 38
Bicornuate uterus
A bicornuate uterus is a type of
congenital uterine malformation or
müllerian duct anomaly in which
the uterus appears to be heart-
shaped.

39. 39
Septate Uterus
A septate uterus is a deformity of
the uterus, which happens during
fetal development before birth. A
membrane called the septum
divides the inner portion of uterus,
at its middle.

40. 40
Arcuate Uterus
An arcuate uterus is a mildly
variant shape of the uterus. It is
technically one of the Müllerian
duct anomalies but is often
classified as a normal variant.

41. 41
Uterine Fibroid
Uterine fibroids are
noncancerous growths of
the uterus that often appear
during childbearing years.

42. 42
Adenomyosis
Adenomyosis is a condition in
which the inner lining of the uterus
(the endometrium) breaks through
the muscle wall of the uterus (the
myometrium). Adenomyosis can
cause menstrual cramps, lower
abdominal pressure, and bloating
before menstrual periods and can
result in heavy periods.

43. 43
Endometrial Polyps
Overgrowth of cells in the lining of
the uterus (endometrium) leads to
the formation of uterine polyps,
also known as endometrial polyps.

44. 44
Intrauterine synechiae
Intrauterine synechiae, also known as
Asherman syndrome, is a condition
characterized by the formation of
intrauterine adhesions, which are
usually sequela from injury to the
endometrium, and is often associated
with infertility.

45. 45
Endometrial TB
Endometrial tuberculosis is a rare
diagnosis in the postmenopausal
period, and it can mimic a
carcinoma.

46. 46
Cervical insufficiency
Cervical insufficiency is the inability of
the cervix to retain fetus, in the
absence of uterine contractions or
labor (painless cervical dilatation),
owing to a functional or structural
defect.

47. 47
Uterine myoma
Myomas are tumors of the smooth
muscle found in the wall of the
uterus. Myomas range in size and
might not grow or grow slowly.

48. 48
Tubal Block
Fallopian tube obstruction is a
major cause of female infertility.
Blocked fallopian tubes are unable
to let the ovum and the sperm
converge, thus making fertilization
impossible.

49. 49
Tubal Spasm
Fallopian tube spasm is a
transient functional anomaly
that can mimic a true
mechanical tubal occlusion

50. 50
Tubal Polyp
A Fallopian tube polyp refers to a
small focal lesion of ectopic
endometrial tissue located at the
intramural portion of the fallopian
tube.

51. 51
Hydrosalpinx
Hydrosalpinx refers to a fallopian
tube that's blocked with a watery
fluid. This condition is typically
caused by a previous pelvic or
sexually transmitted infection, a
condition like endometriosis, or
previous surgery.

52. 52
Salpingitis isthmic
nodosum (SIN)
Salpingitis isthmica nodosa (SIN),
sometimes also referred to as
diverticulosis of the fallopian tube,
refers to nodular scarring of the
fallopian tubes.

53. 53
Peritubular Adhesion
Adhesions, also called scar tissue,
can block or distort the fallopian
tubes. Anything that leads to an
inflammatory response can start
adhesion formation.

54. 54
TB salpingitis
Tuberculous salpingitis is an
infection in human's body, which
develops hematogenously from
the primary lesions (lung and
intestine) to the reproductive
system.

55. Does anyone have a any questions?
55
Thanks!