Educational presentation H: F Juan Pablo Dos Ramos Alferes, Alejandra de Salazar, Andrés Oyarzún Madrid, Germán Espil, Nebil Larrañaga, Shigeru Kozima. Abstract Resumen When studying infertility, hysterosalpingography (HSG) is a radio - En el estudio de la infertilidad, la Histerosalpingografía (HSG) es logic procedure that uses a contrast medium and that is very relevant un procedimiento de relevancia que consiste en un estudio radio - to evaluate both the Fallopian tubes and the uterine cavity. With this gráfico contrastado especial de gran importancia a la hora de eva - procedure we can evaluate the anatomy of those organs and, espe - luar las trompas de Falopio y la cavidad uterina, permitiendo cially, the Fallopian tubes permeability. evaluar su anatomía y fundamentalmente la permeabilidad de las When performing this study there are several alterations that can be trompas. found, but the filling defects are the most frequent findings according Son múltiples las alteraciones que pueden encontrarse al realizar to this study and they can represent different pathologies, such as este estudio, pero en nuestro medio las imágenes por defecto de re - polyps, fibromyomas, air bubbles, uterine folds and synechias. lleno son las de mayor prevalencia y pueden representar diferentes patologías, como: pólipos, miomas, burbujas de aire, pliegues ute - rinos y sinequias. Key words: Hysterosalpingography, filling defects, infertility, Palabras clave: Histerosalpingografía, defectos de relleno, in - polyps, fibromyomas, endometrial synechia. fertilidad, pólipos, miomas, sinequias. Introduction Currently, there has been a significant increase in findings will be correlated to the possible causal the requests for studies related to fertility, inclu - pathologies. ding hysterosalpingographies (HSG). This is pa - rallel to the implementation of the Law on Assisted Reproduction (14.208) (1) in Argentina, Objective its fundamental objective being the acknowledg - ment of human infertility as a disease. Make a revision of the pathologies that can be For the purpose of this paper, we will analyze presented as filling defects images in a HSG study several cases of patients referred from the Ferti - in patients undergoing examinations due to in - lity Departments of different institutions who fertility. came to the hospital for HSG that showed filling defects probably causing the infertility. The stu - dies above mentioned will be analyzed and the Contact information: Juan Pablo Dos Ramos Alferes. Received: March , / Accepted: October , Hosp. de Agudos Dr. Cosme Argerich – Ciudad Autónoma de Bs. As. Recibido: de marzo de / Aceptado: de octubre de E-mail: [email protected] Vol. / Nº - Diciembre Hysterosalpingography: Filling defect images and infertility Dos Ramos Alferes J. P. et al. Current importance sterile towels. The area is cleaned again with iodine solution and then a speculum is inserted into the When studying infertility, HSG is a radiologic pro - vagina previously lubricated with lidocaine gel. cedure that uses a contrast medium and that is very With a long Kocher clamp, the cervix is located and relevant to evaluate both the Fallopian tubes and after cleaning it with iodine solution it is sprayed the uterine cavity. With this procedure it is possible with lidocaine. The cervix of the uterus could be in to evaluate the anatomy of those organs and, espe - anteversion/anteflexion position (it is necessary to cially, the Fallopian tubes permeability. Although it clamp the anterior lip with a Pozzi forceps and re - is considered a procedure of diagnosis, in some tract it). It could also lie in retroversion/retroflexion cases it can have a therapeutic effect since it provi - position (it is necessary to clamp the posterior lip). des permeability in the Fallopian tubes with the A Rubinstein cannula with Hansen olive is connec - pressure of the contrast medium used during the ted to a syringe containing the contrast medium. study (2-5). The cannula must be purged to avoid air passage When performing this study there are several al - and then it is applied in the external cervical orifice terations that can be found, but from our expe - to inject the contrast medium. rience the filling defects are the most frequent findings, and they can represent different patholo - Image acquisition during the procedure gies in the uterus and the Fallopian tubes that will First image: It is obtained during the early filling of be analyzed next. the uterus and it is used to evaluate the presence of any filling defect or abnormality of the outline of the uterus. In this stage, there is a better evalua - Development tion of the filling defect images. Second image: It is obtained when the uterus is Study description completely distended and it provides a better eva - There is not a specific preparation required to per - luation of the shape of the uterus, even though the form this study. However, since during the exam small filling defects can be darkened. patients can feel a mild pain it is often recommen - Third image: It is obtained to show and evaluate the ded to make them take a nonsteroidal anti-inflam - Fallopian tubes. In this case, it could be necessary matory drug one hour prior to the procedure. There to move the patient to an oblique position to ade - are only two contraindications: pregnancy and ac - quately extend the tubes and avoid the superposi - tive pelvic infection. tion of structures that may hinder image The exam must be scheduled between the 7th interpretation. and the 12th day of the menstrual cycle (day 1 Fourth image: It is obtained to show the peritoneal being the first day of menstrual bleeding) since du - effusion of the contrast medium (positive Cotte ring that period the endometrium is thin and it is test). possible to interpret images easily. Also, it constitu - Additional images: They are obtained to document tes an indirect way of making sure there is no preg - any anomaly observed during the procedure (6, 7). nancy, even though the patient needs to have a negative pregnancy test. Besides, the patient must Filling defect images in HSG submit the corresponding bacteriologic studies to Air bubbles make sure there is no pelvic inflammatory disease. One of the causes for contrast filling defect in ima - When it comes to antibiotic prophylaxis in patients ges in HSG is the presence of air bubbles inside the with antecedents of pelvic inflammatory disease uterine cavity, which are instilled with the contrast (PID), the decision to perform the procedure lies medium. Many times, the problem appears even in the hands of the referring physician. with an adequate purging of the instruments used. When performing the procedure, the patient has Therefore, an adequate preparation of the materials to be in a supine and lithotomy position on a fluo - to be used is essential before starting with the pro - roscopy table. First, the region of the perineum is cedure. The small air bubbles that can be instilled cleaned with iodine solution and then covered with during the procedure may simulate uterine patho - Revista Argentina de Diagnóstico por Imágenes Hysterosalpingography: Filling defect images and infertility Dos Ramos Alferes J. P. et al. logic images. However, there are certain characte - characteristic that may help is that when modifying ristics to differentiate them from true pathologic the pressure with which the contrast medium is ins - images. One of them is that the air generally accu - tilled, the bubbles may notably vary their position mulates in the non-dependent areas of the uterine and even migrate through the Fallopian tubes, per - cavity and it changes its position throughout the mitting the characterization of these radio-lucid study due to the movement of the contrast subs - images as air bubbles in the cavity (7, 8) (Fig. 1A- tance. Therefore, it is essential to evaluate the ima - B, 2A-C and 3A-B) . ges dynamically throughout the study. Another Fig. : A) Rounded radio-lucid defects in a-b uterine cavity next to the cervix in a partial contrast-filling image. B) The defect images were moved and they disappeared when com - pleting the total filling of the ute - rus due to air bubbles accidentally instilled with the contrast me - dium. Fig. : A and B) Multiple rounded fi - a b lling defect images in the ute - c rine cavity, modifying their position throughout the study. C) When completing the fi - lling of the uterine cavity with a contrast medium, filling de - fect images disappeared: air bubbles in the cavity. Vol. / Nº - Diciembre Hysterosalpingography: Filling defect images and infertility Dos Ramos Alferes J. P. et al. Fig. : Two small filling defect images in a-b the center of the cavity that when completing the filling were moved to the right uterine horn: air bub - bles. Uterine folds ding small polyps they may stay hidden by the con - When uterine folds are prominent they can be seen trast medium when it fills the uterine cavity. Also, it in HSG as filling defects in uterine cavity but they may not be possible to differentiate them from should not be confused with pathologic images, small submucosal myomas with this method. since they are normal variants. These folds are Hysterosonography has become that preferred thought to be caused by a refold of the internal face diagnostic imaging method for the identification of of the endometrium in a uterine cavity that is not endometrial polyps. Likewise, color Doppler US can completely distended. Therefore, an adequate dis - be used to identify the vascular pedicle of the polyp tention of the uterus during the study is essential under study, which will determine its dependence to reduce the folds or even eliminate them. to the endometrium (7, 8) (Fig. 7A-B and Fig. 8) . Imaging characteristics that let us differentiate normal uterine folds from pathologic images are the Myomas fact that the folds are in a longitudinal position, pa - Submucosal leiomyomas generally appear as filling rallel to the long axis of the uterus, they can even defect images, even large intramural myomas gene - extend to the uterine horns and generally, they are rating protrusion in the cavity can show this type more than one and parallel to each other (2, 8) (Fig.