Hysterosalpingography in Infertility

Background: Infertility is a common medical problem. It can be due to problems in either partner, or both. Ovulatory dysfunction, tubal and peritoneal factors comprise the majority of female factor for infertility. Hysterosalpingography (HSG) plays an important role in the evaluation of abnormalities related to the uterus and fallopian tubes. Objective: The aim of this study was to evaluate the hysterosalpingographic findings of women with infertility in our setting. Materials and method: This cross sectional study was carried out in the infertility centre at BIRDEM, Dhaka, Bangladesh during the period of September 2002 to February 2003. Out of 100 infertile patients 50 infertile women of reproductive age (21-40 years) indicated for HSG were enrolled in this study. Results: Sixty percent patients had secondary infertility. Majority of the subjects of both primary and secondary infertility (55% and 60%) were in 26-30 years age group. On HSG any sort of uterine pathology was found in 10% cases and unilateral and bilateral tubal block were present in 24% and 20% cases respectively. Conclusion: Hysterosalpingography, a safe, less invasive procedure, has an important role in diagnosing uterine and tubal factors of infertility.


Introduction
The desire for reproduction is a basic human right.Though the population burden is the big problem in our country, on the other hand infertility is not an uncommon problem.The number of infertility visit has increased over the past decades. 1fertility is defined as the inability of a couple to conceive within one year with regular unprotected intercourse.Infertility is synonymous with sub fertility and implies a decrease in the ability to conceive.Primary infertility applies to those who have never conceived, whereas secondary infertility designates those who have conceived at sometime in the past. 1 The prevalence of women diagnosed with infertility is approximately 13%, with a range from 7-28%.It has remained stable over recent years. 1,2However the incidence of primary infertility has increased with a concurrent decrease in secondary infertility most likely as a result of social changes such as delayed child bearing.
Infertility can be due to problems in either partner, or both.The male is responsible in about 30-40%, the female in about 40-55% and both are responsible in about 10% cases.[5] Hysterosalpingography (HSG) is a fluoroscopic study performed by instilling radiopaque dye into the uterine cavity through a catheter to determine the contour of the uterine cavity and patency of the fallopian tubes. 1,34][5][6][7] It has been extensively employed in infertility investigations since its first application by Carey in 1914. 8 Hysterosalpingography can be obtained in an outpatient setting, with minimal analgesia consisting of premedication with a non steroidal anti-inflammatory drug (NSAID).The test is usually scheduled for the interval after menstrual bleeding and prior to ovulation.Either water or oil based dye may be selected.There is some evidence that the use of an oil based dye may have a fertility enhancing effect at least for the first few cycles.A HSG is contraindicated in the presence of an adnexal mass, pelvic inflammatory disease, with history of ectopic pregnancy or an allergy to iodine or radiocontrast dye.Uterine abnormalities that can be detected at HSG include congenital anomalies, intrauterine polyps, submucous leiomyomas, surgical changes and synechiae.10] The goal of this study was to evaluate the hysterosalpingographic findings of women with infertility in our setting.Out of 100 infertile patients 50 infertile women of reproductive age (21-40 years) indicated for hysterosalpingography (by history, clinical assessment and USG findings) were randomly selected in this study.Couple with male factor infertility and patients with any contraindication for HSG i.e. recent pelvic infection, allergy to oil based dye were excluded.HSG using oil based dye was done after menstrual flow has ceased but before the patient had ovulated i.e. by day 7 to day 10 of the menstrual cycle.The clinical assessment was done with a thorough history of both partners and was documented in preset data sheet.Female history included menstrual history, past obstetrical history and past medical or surgical history were also documented.Thorough physical examination was done to exclude any apparent anatomical abnormality.Collected data were compiled and expressed as proportion.

Results
Table I shows that 40% couple had primary infertility and 60% had secondary infertility.

Table I: Types of infertility (N=50)
Table II shows, majority of women (55% and 60%) were in age group 26-30 years for both primary and secondary infertility group.

Table II: Age distribution of the subjects (N=50)
Majority (46%) of the cases reported at the infertility centre within 2-5 years of unsuccessful attempt of pregnancy (Table III).

Discussion
In this study we found that most of the women undergoing hysterosalpingography had secondary infertility.Similarly secondary infertility was found to be commoner than primary in some other studies done abroad. 6,12e majority of both the primary and secondary infertility groups were in the age range of 26-30 years which is supported by studies done by Kiguli-Malwadde and Byanyima 6 and Haider et al. 13 In majority of cases duration of infertility was 2-5 years.In the studies done by Haider et al. 13 ,Santhalia et al. 5 , Abdalla14 and Kabala 12 mean duration of infertility at the time of presentation were >2 years, 3.9 years, 3-8 years and 5 years respectively.
In this study we found 70% subjects had normal menstrual cycle and 24% patients had irregular cycle.Similar findings were observed by Haider et al. 13 Regarding past illness, 18% had history of puerperal or post abortal infection.This differs from study done by Shayela 15 , where puerperal sepsis was present in 30% cases.Though both the studies were done in two tertiary care hospitals, the time interval is more than one decade which reflects a remarkable improvement in antenatal, intranatal, post natal and post abortal care.
On HSG, we found that most cases had normal uterine cavity, a minor proportion with irregular uterine cavity with a space occupying lesion and uterine anomaly was the least.These findings are in accordance with studies done by Santhalia et al. 5 , Kabala 12 , Mesbahi et al. 16 and Sakar et al. 17 On the other hand a good percentage (44%) of subjects had either bilateral or unilateral tubal block.[20][21] It is widely accepted that infertility is a common medical problem.There are several tools for detection of the causative factors of infertility which are widely available now a days.In a developing country like ours hysterosalpingography may still play an important role in diagnosing uterine and tubal factors of infertility and may avoid further expensive, invasive procedures and relieve the sufferers from the agonizing state of childlessness.

Table IV: Distribution of menstrual pattern (N=50)
Most of the women (60%) had no significant past history.Surgical interference was found in 12% cases followed by puerperal sepsis in 18% cases, diabetes mellitus in 8% cases and tuberculosis in 2% cases (Table V).
It was a cross sectional study carried out from September 2002 to February 2003, in Infertility Care Centre at Bangladesh Institute of Research & Rehabilitation in Diabetes, Endocrine and Metabolic disorders (BIRDEM), Dhaka, Bangladesh.