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Home , Hematosalpinx, Hysterosalpingography

Middle East Fertility Society Journal Vol. 10, No. 3, 2005 © Copyright Middle East Fertility Society

A prospective comparative study to assess the accuracy of MRI versus HSG in tubouterine causes of female

Khaled Abdel Malek, M.D.* Heba El-sawah, M.D. * Mohamed Hassan, M.D. * Amr Osama Azab, M.D.† Ahmed Soliman, M.D. *

Departments of Obstetrics and Gynecology, and Radiodiagnosis, Cairo University, Cairo, Egypt

Abstract

Objective: To evaluate the role of magnetic resonance imaging versus hysterosalpingography during investigating infertile women due to uterotubal causes of infertility Setting: kasr EL-Aini Hospital Materials and methods: All infertile women were subjected to both hysterosalpingography and MRI. was performed to confirm different findings, being considered the gold standard for diagnosis. Results: MRI was superior to HSG in diagnosing uterine anomalies (accuracy 100% vs. 96%), but failed to diagnose any case of intrauterine adhesions or peritubal adhesions. Conclusion: In infertile women with suspected uterine anomalies, magnetic resonance imaging is the study of choice because of its high accuracy and detailed elaboration of uterovaginal anatomy. Laparoscopy and are reserved for women in whom interventional is likely to be undertaken. Key words: hysterosalpingography, magnetic resonance imaging, laparoscopy, infertility

INTRODUCTION often required. On the other hand, Magnetic resonance imaging (MRI) produces images with Infertility is defined as one year of unprotected exquisite anatomical details that are clearer than intercourse that does not result in pregnancy (1). those obtained with ultrasonography or Uterine abnormalities were detected in 15-27% of , and -as far as we know- it is safe (4). infertile women (2). Hysterosalpingography (HSG) MRI has the potential to replace HSG / is the most widely used method of evaluating the laparoscopy in the diagnosis of abnormalities of and fallopian tubes, however, it is invasive the female genital tract, being non-invasive, with and inconvenient to women. Many patients request no hazard from ionizing radiation, improved soft anesthesia to perform HSG. It might even tissue contrast resolution and its capability of introduce as Chlamydia (3). When multidirectional imaging, simultaneous imaging of uterine abnormality is suspected, laparoscopy is multiple sections, along with its visualization (5,6).

*Department of Ob. Gyn., Cairo University, Cairo, Egypt Disorders of the Fallopian Tubes † Department of Radiodiagnosis, Cairo University, Cairo, Egypt Address for correspondence: Dr. Khaled Abdel Malek, Department of Ob. Gyn., Cairo University, Kasr El Eini MR imaging aids in noninvasive assessment of University Hospital Cairo, Egypt tubal dilatation and peritubal disease. Dilated

250 Abdel Malek et al. MRI vs. HSG in tubouterine infertility MEFSJ fallopian tubes manifest as fluid-filled ducts, which in cases of enlarged uterus, with a appear as retort-, sausage-, C-, or S-shaped cystic reported accuracy of 99% (16). In the latter, the masses at MR imaging. Thin, longitudinally abnormality is ill defined causing swelling of the oriented folds along the interior of the tube affected wall that shows punctuate foci of represent incompletely effaced mucosal or abnormal high T2 signal with thickening of the submucosal plicae (7). junctional zone (17). MR imaging can also be helpful in assessment The objective of this study is to assess the of pelvic inflammatory disease by showing tubo- accuracy of MRI compared to ovarian abscesses, dilated fluid-filled tubes, and hysterosalpingography (HSG), which used to be a free pelvic fluid (8). On T1-weighted images, a mainstay in the diagnosis of tubal and uterine high-signal-intensity rim in the innermost portion causes of . of a tuboovarian abscess has been reported. This rim shows marked enhancement on post contrast images and is believed to correspond to MATERIAL AND METHODS granulation tissue admixed with hemorrhage (9). Moreover, dilated fallopian tubes with high The present study included 94 women who signal intensity on T1-weighted images, which were admitted to the Department of Obstetric and correspond to , reportedly correlate Gynecology, Kasr El-Aini Hospital between June, with one of the effects of (7). 2002 and Dec., 2004. They were admitted Nevertheless, MR imaging is as yet of little use in complaining of inability to conceive for more than assessment of adhesions. one year. Each patient was asked about the duration of infertility whether 1ry or 2ndry. A Uterine Disorders detailed menstrual history and obstetric history were taken with emphasis on previous pregnancies, 1. Müllerian Duct Anomalies history of any abortions and gynecological history with emphasis on abnormal vaginal and Multiplanar MR imaging is useful for any D&C done. documenting uterine anomalies (10-13) Bicornuate Detailed general, abdominal and pelvic uterus appears in MR imaging as follows:(a) examinations with provisional clinical divergent uterine horns with an intercornual examinations were performed. A husband's semen distance exceeding 4 cm and (b) concavity of the analysis was a pre-requisite before admission. All fundal contour or an external fundal cleft more women underwent ultrasonography. When than 1 cm deep (14). While, Septate uterus is ultrasound showed or suspect abnormality, patient demonstrated as low signal intensity on T2- was recruited in the study. Laparoscopy was weighted images, whereas a septum composed of performed to confirm different findings, being abundant muscular tissue shows intermediate considered the gold standard for diagnosis. signal intensity. The external uterine contour is All hysterographies were performed during the normally convex, flat, or minimally indented by early follicular period of the menstrual cycle. The less than 1 cm (14), in contrast to that of a sterile instrument tray was inspected checking the . presence of a radiolucent vaginal speculum & a cervical plug to prevent reflux. Fractionated 2. Leiomyoma technique under fluoroscopic guidance using iodinated water-soluble contrast medium The diagnostic MR imaging finding for (Telebrix). The initial x-ray was taken after the leiomyoma is a sharply marginated mass that injection of 3-4 ml of contrast material. 2-3 serial typically has lower signal intensity than the films were taken. Another control film was taken on T2-weighted images (15). In 20 minutes later. addition, MR imaging is a highly accurate Magnetic resonance imaging (MRI) was modality for differentiating leiomyomas from performed with 1 or 1.5-T superconducting magnet

Vol. 10, No. 3, 2005 Abdel Malek et al. MRI vs. HSG in tubouterine infertility 251

a b

Figure 1. Mayer-Rokitansky-Küster-Hauser syndrome. (a) Sagittal T2WI: uterine agenesis and absent . (b) Axial T2WI: well developed (see arrows).

(Signa; GE Medical Systems, Milwaukee, Wis or of hysterosalpingography and MRI in correlation Philips, Gyroscan machine respectively). Oral with Laparoscopic findings as the gold standard. administration of water for bladder distention was not performed. Either the body coil (GE machine) or a synergy-body coil (Philips machine) was used. RESULTS First, fast spin echo T2-weighted images (WI) were performed in the axial, oblique coronal and The study population comprised 96 patients sagittal planes with a repetition time (TR) of complaining of infertility, with their age ranged 4,000-5,000 msec. and an echo time (TE) of 100- from 21-45 year with a mean age of 28 years and 7 110 msec, three signals acquired, an echo-train months. Seventy five patients complained of length of eight, and a 156x160 matrix. The section Primary infertility, 21 patients complained of thickness was 5-7 mm with a 1 mm intersection secondary infertility and 8 patients complained of gap and a 28 cm field of view. secondary infertility and repeated abortions. Then, spin echo T1-WI 600/15 msec (TR/TE) were Sixteen women were found to have congenital obtained in the axial plane with two acquisitions, anomalies of the genital tract, 23 patients suffered 192x256 matrix, 5-7 mm section thickness, and 1 mm from fibroids, 5 patients suffered from intrauterine interscan gap extending from the lower abdominal synechiae, 8 patients suffered from uni- or bilateral aorta down to the end of the pelvis. , and 26 had peritubal adhesions. Patients with congenital anomalies were as Statistical analysis follow: One patient suffered from complete failure of development of the Müllerian system (Meyer- Statistical analysis was performed to evaluate Rokitansky- Küster- Hauser syndrome) and the sensitivity, specificity and diagnostic accuracy complained of primary infertility for 1 year.

b a Figure 2. Subseptate uterus. (a) HSG: double simulating bicornuate uterus. (b) Axial T2 WI: smoothly convex uterine fundal contour with incomplete muscular septum.

252 Abdel Malek et al. MRI vs. HSG in tubouterine infertility MEFSJ

a b

Figure 3. Bicornuate uterus. (a) HSG: two separate divergent uterine cavities. (b) Oblique coronal T2 WI: typically shows the deep fundal cleft and additionally demonstrates fused pelvic kidneys (see arrow).

Another patient had ovarian dysgenesis, hysteroscopy, and hysterosalpingography are the hypoplastic uterus and breasts and hirsutism. She most effective techniques currently used to evaluate complained of primary and primary female pelvic disorders related to infertility. Magnetic infertility for 2 years. The patient received resonance (MR) imaging has also been used for over replacement therapy after marriage. Four patients had 10 years to evaluate problems associated with female bicornuate uterus: One of them had bicornuate uterus, infertility. MR imaging is well known to provide left hydrosalpinx and left peritubal adhesions. accurate information for differentiation of congenital One patient had bicornuate uterus and fused uterine anomalies and detection and localization of pelvic kidneys. Another one had a uterine leiomyomas. and tubal block. She complained of primary One of the main advantages of hystero- infertility. Five Patients had septate uterus: two of salpingography is that it provides documented films patients had septate uterus & peritubal adhesions in for the findings whether normal or abnormal. On the addition and complained of primary infertility. One other hand, this technique has several inherent patient had PTA & fundal myoma and complained of disadvantages including exposure to ionizing primary infertility. Four patients had subseptate radiation, exposure to material and uterus: They complained of secondary infertility and limitation of the investigation to include only the repeated abortions inner contour of the upper genital tract (3). Although HSG is accepted as a first diagnostic modality in infertility, it is performed without any DISCUSSION sedation or anesthesia and, therefore, the patient is not relaxed (18). Hence, the rate of tubal spasm at the In recent years, demand for infertility services and cornua and, therefore, false positive tubal blockage, is treatment of infertility have increased. Laparoscopy, said to be higher than usual.

a b

Figure 4. Uterus Didelphus. Axial T2 WI: (a) shows two separate uterine cavities & (b) at a lower level shows two separate cervices.

Vol. 10, No. 3, 2005 Abdel Malek et al. MRI vs. HSG in tubouterine infertility 253

a b

Figure 5. Subserous myoma. (a) HSG: normal uterus and tubes with smooth splaying of the peritoneal spill. (b) Sagittal T2WI: well circumscribed 6x5 cm mass of homogenous low signal bulging on the anterior mall of anteverted uterus indenting the bladder dome.

Laparoscopy is usually indicated when an metallic objects. abnormality is detected. The aim of this study was to assess the On the contrary, the major advantage of MR sensitivity and specificity of MRI as a relatively imaging is the nonuse of ionizing radiation, which non invasive modality in the detection and is an important consideration in women of differentiation of tubal and uterine causes of reproductive age. Another advantage is that MR female infertility used to be detected with imaging is less invasive and less observer hysterosalpingography. dependent than the classic imaging techniques. In the present study, out of 94 patients Furthermore, recent advances in MR imaging examined, 16 patients had congenital anomalies of with the phased-array coil have created further the FGT and only one patient showed complete imaging possibilities, resulting in excellent spatial failure of the Müllerian duct development or the and tissue contrast resolution, multiplanar Meyer- Rokitansky- Küster- Hauser syndrome capability, and fast techniques. This rendered MRI (Figure 1). Also, a single patient had unicornuate a safe non invasive imaging modality and its use as uterus. Unicornuate uteri are caused by the an alternative diagnostic tool is an attractive unilateral failure of Müllerian migration and option. account for approximately 10% of Müllerian The disadvantages of MR imaging are limited developmental anomalies (19). In this study the to its relatively high cost and long examination unicornuate uterus was definitely diagnosed by time; it is contraindicated in patients with HSG. MRI was only suggestive. pacemakers, cochlear implants, and certain

Figure 6. Interstitial myoma. (a) HSG: normal uterus and tubes. (b) Sagittal T2WI shows with intramural 3.5 cm myoma of non homogenous low signal with hyperintense rim denoting early degenerative changes.

254 Abdel Malek et al. MRI vs. HSG in tubouterine infertility MEFSJ Table 1. Accuracy of MRI vs. HSG regarding different findings

Accuracy Sensitivity Specificity PPV NPV

Congenital anomalies HSG 96.3% 100% 95.6% 88.9% 100% MRI 100% 100% 100% 100% 100% Intra-uterine synechia HSG 98.1% 100% 100% 100% 98.1% MRI 0 0 0 0 0 Fibroid HSG 0% 0% 0% 0% 0% MRI 93.5% 75.0% 100% 100% 97.5% Peritubal HSG 95.3% 78.9% 98.9% 93.8% 95.6% MRI 0% 0% 0% 0% 0%

PPV = Positive Predictive value NPV = Negative Predictive value

Bicornuate uterus was found in 4 patients in can be differentiated by the deep (> 1 cm) fundal this study; the investigations were carried out using cleft present in the bicornuate uterus on coronal HSG and MRI and confirmed by laparoscopy. oblique images of the uterus and widened The incidence of septate uterus varies between intercornual distance > 4 cm. The septate uterus 20% and 80% of Müllerian developmental had a convex, flat or minimally indented (< 1 cm) anomalies, depending on the series (20-22). The outer fundal contour on coronal oblique images of large variation in the reported incidence is most the uterus (Figure 2). likely related to the difficulty in distinguishing Homer et al ;(2000) reported that the most bicornuate and septate uteri before the advent of common major uterine anomaly in women with MR imaging. Although it is noted that the cornu of recurrent pregnancy loss is subseptate uterus (24). the septate uterus frequently create a more acute The results of Salim et al; are similar, showing that angle than seen with a bicornuate uterus, the the subseptate uterus was the most common major degree of overlap on a HSG is uncertain (23). uterine anomaly, accounting for 77% of cases On MRI, the bicornuate & septate uterus suffering from repeated abortions (25). The present appeared as a uterus with 2 cavities. However, they study included 5 patients with septate uterus.

a b

Figure 7. Left hydrosalpinx. (a) HSG: dilated tortuous left showing no spill. (b) Coronal T2 WI: corresponding left adnexal multilocular cystic lesion.

Vol. 10, No. 3, 2005 Abdel Malek et al. MRI vs. HSG in tubouterine infertility 255

Figure 8. Left peritubal adhesions. (a) HSG (control film): persistent loculation of the peritoneal spill on the left side. (b) Sagittal T2 WI: septated (multilocular) fluid in Douglas’ pouch.

HSG and MRI were performed and the end Douglas pouch (Figure 8). result was confirmed by laparoscopy. In this study one patient with bicornuate uterus had fused pelvic kidneys (Figure 3, 4) and another patient with CONCLUSION subseptate uterus had a left pelvic kidney. MRI failed to diagnose all the five patients with MR imaging is a useful noninvasive modality intrauterine synechiae that were detected on as an adjunct for routine infertility work-ups. In hysterosalpingography. infertile women with suspected uterine anomalies, Twenty three women suffered from fibroids, 5 magnetic resonance imaging is the study of choice patients had a fibroid ≥ 5cm and the remaining because of its high accuracy and detailed myomas ranged 1-3.5 cm. MRI missed two elaboration of uterovaginal anatomy. Moreover, submucous myoma (1cm). According to Murase et MRI has the advantage of extending the diagnostic al, magnetic resonance (MR) imaging is an information to detect the frequently associated accurate imaging technique for detection and anomalies of the urinary tract. Laparoscopy and localization of leiomyomas (26). On T2-weighted hysteroscopy are reserved for women in whom images, non-degenerated leiomyomas appear as interventional therapy is likely to be undertaken well circumscribed masses of decreased signal intensity (Figure 5); however, cellular leiomyomas can have relatively higher signal intensity on T2- REFERENCES weighted images and demonstrated enhancement on contrast material-enhanced images. 1. Hornstein MD, Schust D. Infertility. In: Berek JS, Adashi Degenerated leiomyomas have variable EY, Hillard PA, eds. Novak's gynecology. 12th ed. Baltimore, Md: Williams & Wilkins, 1996; 915-962. 14. appearances on T2-weighted images according to 2. Jones HW and Rock J. The infertile couple. N. Engl. the type and extent of degeneration (Figure 6). J.Med. 1993; 329, 1710-1715. Regarding tubal pathology, MRI had an 3. De-Cherney AH. Hysterosalpingography. Fertil Steril accuracy of 99.1%, sensitivity of 87.5%, 1986; 45, 582. 4. Schultz WW, van Andel P, Sabelis I, Mooyaart E. specificity and PPV of 100% and NPV of 99% in Magnetic resonance imaging of male and female genitals diagnosing hydrosalpinx (Figure 7). This study during coitus and female sexual arousal. BMJ. 1999 Dec included 13 patients with peritubal adhesions and 18; 319(7225): 1596-1600. HSG had an accuracy of 95.3%, while MRI failed 5. Smith RC, Reinhold C, Lauge RC, McCauley TR, Kier R to show these adhesions. In only one of these and McCarthy S. Fast spin echo MR, imaging of the female pelvis. Radiol. 1992; 184, 665-669. cases, MRI showed fine septation within fluid in 6. Kunz G, Beil D, Huppert P and Leyendecker G.

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