|Year : 2022 | Volume
| Issue : 1 | Page : 15-19
Evaluation of radiological pattern of HSG in female patients with infertility in Katsina Northwestern Nigeria
Habiba B Saidu1, Mustapha Mohammed1, Naimatu A T. Abdullahi1, Mohammed A El habeeb1, Fatai A Salihu1, Habib Ibrahim1, Mohammad A Suwaid1, Mustapha S Hikima2, Abubakar S Sunusi3, Maikudi M Haruna3, Aliyu M Umar3, Mohammed A Hamza3, Abdullahi A Sani3, Murtala O Abdulwaheed3, S Abdulrasheed3, SM Abubakar3
1 Departments of Radiology and Obstetrics and Gynaecology, Federal Medical Centre Katsina, Nigeria
2 Department of Radiology, Faculty of Clinical Sciences, Bayero University, Kano/Aminu Kano Teaching Hospital, Kano, Nigeria
3 Department of Radiology, Muhammad Abdullahi Wase Teaching Hospital, Kano, Nigeria
|Date of Submission||15-Jul-2021|
|Date of Decision||07-Nov-2021|
|Date of Acceptance||18-Nov-2021|
|Date of Web Publication||12-Jul-2022|
Prof Mohammad A Suwaid
Department of Radiology, Faculty of Clinical Sciences, Bayero University, Kano/Aminu Kano Teaching Hospital, Kano
Source of Support: None, Conflict of Interest: None
Context: Hysterosalpingography (HSG), is the radiographic evaluation of the uterine cavity and fallopian tubes after the administration of a contrast medium through the cervical canal. Aims: To determine the pattern of infertility, the risk factors for infertility in women presenting for HSG, and the findings among women with infertility at Federal Medical Centre Katsina. Study Design: Cross-sectional, descriptive study design. Materials and Methods: This was a retrospective study of HSG findings done at the federal medical center Katsina over a 12-month period. Information on the patients was obtained from the Picture Archiving Communication System (PACS) system which includes the presenting clinical history, the age, and the outcome of HSG. Statistical Analysis: Data analysis was performed using SPSS version 23.0. Results: A total of one hundred and forty-four (144) women were examined. Their age ranged from 17 48 years with a mean of 31.2 ± 6.3 years. The most common indication for the procedure was infertility, accounting for 89.6% of all cases. The most common Radiological finding was tubal occlusion (factor), which was seen in 40 patients constituting 28% of the radiological findings. The right tubal occlusion was seen at 11.8% while the left tubal occlusion was seen at 6.9%. Bilateral tubal occlusion was seen in 9.0%. Conclusions: The frequent indication for HSG is infertility and the common finding on HSG was a tubal factor with hydrosalpinx being the frequent cause of infertility in our environment. The right tubal occlusion constitutes a higher percentage than the left. Secondary infertility was more common than primary infertility
Keywords: Hydrosalpinx, Hysterosalpingography (HSG), infertility, tubal factor
|How to cite this article:|
Saidu HB, Mohammed M, T. Abdullahi NA, El habeeb MA, Salihu FA, Ibrahim H, Suwaid MA, Hikima MS, Sunusi AS, Haruna MM, Umar AM, Hamza MA, Sani AA, Abdulwaheed MO, Abdulrasheed S, Abubakar S M. Evaluation of radiological pattern of HSG in female patients with infertility in Katsina Northwestern Nigeria. Niger J Basic Clin Sci 2022;19:15-9
|How to cite this URL:|
Saidu HB, Mohammed M, T. Abdullahi NA, El habeeb MA, Salihu FA, Ibrahim H, Suwaid MA, Hikima MS, Sunusi AS, Haruna MM, Umar AM, Hamza MA, Sani AA, Abdulwaheed MO, Abdulrasheed S, Abubakar S M. Evaluation of radiological pattern of HSG in female patients with infertility in Katsina Northwestern Nigeria. Niger J Basic Clin Sci [serial online] 2022 [cited 2022 Aug 10];19:15-9. Available from: https://www.njbcs.net/text.asp?2022/19/1/15/350716
| Introduction|| |
Hysterosalpingography (HSG) is the radiographic evaluation of the uterine cavity and fallopian tubes after the administration of a radio-opaque medium through the cervical canal.
Infertility is defined as the inability of a couple to conceive after 12 months of regular, unprotected sexual intercourse. It can either be primary or secondary. In primary infertility, couples have never conceived in their lifetime, whereas secondary infertility is a failure to achieve pregnancy again after an earlier pregnancy which may or may not have led to live birth.
It is a disorder with notable medical, social, psychological, and economic problems, causing a lot of stress, unhappiness, and marital disharmony among couples.
It is estimated that 10–15% of couples globally experience infertility. In the United Kingdom and United States, it is estimated to be about 6 and 10%, respectively. In Africa, its prevalence is particularly high in the sub-Saharan region, ranging from 20 to 60% of couples. This has been attributed to the high rate of sexually transmitted diseases, complications of unsafe abortion and puerperal pelvic infections.
Community-based studies in some parts of Nigeria reported the rates of infertility to be as high as 45%. It is documented that 15% of all women experience primary or secondary infertility at one point in time in their reproductive life.
Different factors cause infertility including male factor, ovulation problems, and uterine and tubal pathologies. Tubal factors are attributed to both primary and secondary infertility with higher prevalence in secondary infertility making routine tubal investigation in secondary infertility a recommendation. Uterine factors causing infertility include polyps or fibroids, uterine wall irregularities, and congenital anomalies. Therefore, evaluation of the uterine cavity and Fallopian tubes is a standard practice in the baseline investigations for infertility.
HSG is used predominantly in the evaluation of infertility. Despite the arrival of newer imaging modalities, HSG still remains the best procedure to image the fallopian tubes. It can also be used in other cases, such as pain in the pelvis tract, congenital or anatomic abnormalities, anomalies of the menstrual cycle, recurrent spontaneous abortions and abnormal menses. Also, it is sometimes used as a preoperative control for women who are about to have uterine or tubal surgery.
HSG is a safe, relatively inexpensive, simple, and rapid diagnostic test. Some authorities are of the opinion that laparoscopy and hysteroscopy can replace HSG. However, the superiority of HSG in detecting uterine and intraluminal tubal pathology, its ready availability, and nonoperative technique still makes it the initial and standard procedure for evaluating female infertility in most developing countries like ours.,,,
HSG is associated with little disadvantages which involve patient discomfort, exposure to radiation to both patient and personnel, and scarcity of resources.
| Materials and Method|| |
The study was to check the pattern of HSG in female patients with infertility conducted at FMC Katsina, which is located in NorthWestern Nigeria.
FMC Katsina is about 500 bed tertiary health institution serving Katsina, Zamfara, Kebbi, Kano, Jigawa, and Sokoto states in Northwestern geopolitical zone of Nigeria. It also provides training facilities for postgraduate trainings. Women with infertility first present to Gynecological Clinic of the hospital during the daily clinics. The patient history is taken, followed by physical examination. HSG is one of the investigations requested in the evaluation of the patients with infertility and is carried out in the Radiology Department.
We conducted a retrospective secondary data analysis of the routine data of the HSG done for women presenting to the radiology department with infertility.
The study population comprised all women presenting to the gynecology clinic with any form of infertility between January 2020 to December 2020. All infertility cases with incomplete information about the HSG results from radiology records and clinic register were excluded.
Method of data collection
Record of the patients who went for HSG between January 2020 to December 2020 was obtained from the server of the Radiology Department. We extracted information on age, file number, history of patient and the outcome of HSG from the archive of the Radiology Department.
Data were collected from the PACS Server [Health Digital Information system (DIS) c 2112] All right reserved Federal Medical Centre, Katsina) and all analysis were performed using SPSS version 23.0 (IBM SPSS Statistics, Chicago, IL. USA).
The HSG examination was performed at the Radiology Department by trained radiologists who also interpreted the results thereafter. The patient normally comes to the department with a referral request form from the gynecologists. Verbal informed consent was obtained from the patient after due explanation of the procedure and possible complications with reassurance. The examination was performed during day 7–12 of the menstrual cycle. This was to prevent intravazation of contrast medium and to make sure that there was no existing pregnancy.
Contraindication for the procedure included pregnancy, active pelvic inflammatory disease, bleeding and severe allergy to iodine-based contrast agents were excluded.
The procedure was performed using fluoroscopy. The patient was placed in supine position on the fluoroscopy table, and a scout film of the pelvis was then taken to assess for proper positioning, technical factors and radiopaque pelvic lesions. Thereafter patient was placed in lithotomy position. Using aseptic technique, the cervix was then visualized with the aid of speculum and the anterior lip held with a Volsellum forceps. A matching size Leech–Wilkinson uterine cannula was inserted into the endocervical canal after sounding the uterus with a uterine sound. Maintaining a seal between the cannula and cervical canal and with a gentle traction on the Volsellum and pressure on the cannula, 15–20 ml of water-soluble contrast medium, urografin was injected slowly into the uterine cavity. The appearance of the uterine cavity and patency of the fallopian tubes was then assessed by fluoroscopy. Spot films during the phases of early uterine filling, tubal filling and peritoneal spill were also taken. A delayed film was then taken 30 minuites after to check for the clearance of the contrast from the pelvic cavity, especially if there was hydrosalpinx. For the detection of minor deformities of the uterine cavity, the radiographs of the uterus in the true anteroposterior projection were obtained. This was achieved by the cervical traction and oblique positioning of the patient where necessary. All HSG examinations were then interpreted by the direct visualization of the soft copy (digital image on PACS), checking for unilateral and bilateral spillage of contrast medium into the pelvic cavity and abnormalities in the outline of the cervix and uterine cavity which includes cervical stenosis, cervical adhesions, uterine fibroid, congenital abnormality of the uterus etc.
Data collected were entered into Excel spreadsheet, and analyzed using IBM SPSS version 23.0 (Armonk, New York, USA). Age of the clients were summarized using mean and standard deviation while frequencies and percentages were used to summarize reproductive characteristics, pattern of infertility, risk factors for infertility, and pattern of HSG findings.
The protocol for this study was submitted to the Health Research Ethics Committee of Federal medical center Katsina, Nigeria, for review, and approval was obtained before the commencement of data collection.
| Results|| |
A total of one hundred and forty four (144) women were examined in the study. The age of the subjects ranged from 17-48 years with a mean age of 31.2 ± 6.3 years. The highest age range for HSG request is 30-34 years, while the lowest request is 14-19 years.
The most common indication for HSG was infertility, accounting for 89.6% of all cases. Among the cases of infertility, secondary infertility was more common accounting for 46.5 cases, while primary infertility accounted for 43.1% of cases as shown in [Table 1 below. Other indications include Uterine fibroids with 4.9% and the least indications are adenomyosis, Ashermans and DUB with 0.7% each [Table 2] and [Figure 1].
|Figure 1: Showing the Radiological Findings of HSG. Key: NS = Normal study, UT FIB = Uterine fibroid, LTB = Left tubal blockage, RTB = Right tubal blockage, RHS = Right hydrosalphinx, LHS = Left hydrosalphinx, BHS = Bilateral hydrosalphinges, BCNT = Bicornuate uterus, Uterine Adhesions|
Click here to view
In eighty five subjects (59%), the examination revealed a normal result. The most common Radiological finding is tubal occlusion (tubal factor), which is seen in 40 patients constituting 28% of the radiological findings. The right tubal occlusion was seen in 11.8% while the left tubal occlusion was seen 6.9%. Bilateral tubal occlusion was seen in 9.0%. Among the tubal occlusion hydrosalphinges constitute the majority of the findings seen in 28 (19%) of the subjects. Right hydrosalpinx is higher than left hydrosalpix seen in 9.7%. Bilateral hydrosalpinges is seen in 4.1%. Other common findings include uterine fibroids, which was seen in 15 subjects (10.4%), and uterine adhesions seen in 3 cases (2.1%). Congenital uterine abnormality was seen in only 1 patient (0.69%). Fifteen case of uterine fibroid were seen making 10.41% [Table 3] and [Table 4]; [Figure 2].
|Figure 2: Showing the Proportions of Hydrosalphinges and Tubal Blockage by Side|
Click here to view
| Discussion|| |
We did HSG for a total of one hundred and forty four (144) women in the study. The age of the subjects ranged from 17-48 years with a mean age of 31.2 ± 6.3 years. This is almost the same as the study by Tukur et al. carried in Kano in which the mean was 30 +/-6.6 years with a range of 16-46 years. It is however higher than the finding of Lawan RO et al. in Zaria whose mean age was 27.37 ± 1.4. The study conducted by Danfulani et al. found the mean age of 32.5 ± 5.5. This was slightly higher than our study.
Eleje GU et al. in Nnewi have a mean age of mean of 34.0 ± 6.3 years. The difference in age with those in the Northwestern Nigeria being slightly lower may be due to cultural differences influencing the age at marriage.
The age in which most women presented for HSG was 30-34 years. Tukur J et al. found age 20 and 29 years as the highest age range for HSG request. Danfulani M et al. in there study found age range of 21-30 years constitute the highest frequency of HSG in Sokoto North East Nigeria. All the 3 studies were carried out in Northwestern Nigeria thus the almost similar age range.
Infertility was the most common indication for HSG, accounting for 89.6% of all cases. Among the cases of infertility, secondary infertility was more common accounting for 46.5 cases, while primary infertility accounted for 43.1% of cases. This is in agreement with the study in Kano by Tukur et al. in which secondary infertility constituted 59.7% while the primary infertility constitutes 40.3%. It is also in agreement with previous studies.,, This higher rate of patients with secondary infertility compared to primary infertility may be explained by the frequent cases of PID, postabortal sepsis and puerperal sepsis in our setting., The study by Okafor CO in Nnewi South Eastern Nigeria, however shows primary infertility be commoner with 44.8% while the secondary infertility is 38.3%.
In eighty five subjects (59%), the examination revealed a normal result. This almost similar to the findings in Zaria by Lawan RO et al. in which the normal findings is 55%. It is also similar to findings by Bello in Ilorin. It is however different with the study in Lagos conducted by Baramki et al. This might be due to cultural differences influencing the age of marriage and also in which sexually transmitted disease and PID are less common in the Northwestern part of the country.
The most common Radiological finding is tubal factor (tubal blockage) which constitute about 28% of the radiological findings. This is slightly lower than the findings of Lawan RO in Zaria whose findings was 32.7%. The findings by Onwuchekwa R et al. is slightly higher than the index study. This can still be explained by the cultural difference between the Northern and Southern part of Nigeria where differences as par exposure to premarital and extra-marital sex and its sequelae such as sexually transmitted diseases and PID is present. The fact that Zaria had the first University in the North and is more cosmopolitan than Katsina at the initial stage with higher incidence of premarital sex and likely hood of PID may explain the slight difference.
Among the tubal factors, the most common finding was hydrosalphinges, seen in 28 (19%) of the subjects. This was higher than the study done in Zaria in which hydrosalpinx is seen in 10.5%. It is however similar to the study by Bello in Ilorin 23.3%. Hydrosalpinx is seen as a dilated convoluted tubular structure on HSG which gradually increases in size due to distal tubal occlusion. It is a result of fallopian tubes inflammation following infections such as gonococcal, chlamydial or tuberculosis of the genital tract. The fimbrial ends are eventually occluded due to adhesions leading to collection of the secretions in the lumen with gradual distension of the fallopian tube. The higher number of hydrosalpinges when compared to the findings in Zaria may be explain the by the fact that Zaria being expose to Western culture earlier than Katsina may take sanitary precautions that will likely reduce the onset of PID and its complications of hydrosalpinx. The hydrosalpinx is seen more on the right than the left side with 9.7 and 4.1% respectively. Which is dissimilar to the finding in Zaria but same with the findings from other studies.,, This supports the research which suggested that the presence of the appendix on the right side may predispose to increased PID on the right side with resultant hydrosalpinx.
The right tubal occlusion was seen in 11.8% while the left tubal occlusion was seen in 6.9%. Bilateral tubal occlusion was seen in 9.0%. The study by Tukur, Danfulani and Bukar however found bilateral tubal blockage as the commonest finding. The occurrence of higher right tubal blockage over left tubal blockage is similar to a study by Tukur et al. and Adetiloye.
Only one uterine anomaly was detected in this study which was bicornuate uterus, which is similar to the findings by Tukur et al. in Kano. The study by Bukar et al., however found five congenital uterine anomalies.
Fifteen cases of Uterine fibroids were seen 10.41%. This is similar to the studies carried out by Onwuchekwa CR et al. in which 27 cases were seen (10.8%) with uterine leiomyoma on the HSG.
| Conclusion|| |
The highest indication for HSG is infertility and the highest finding on HSG is tubal factor with hydrosapinx being the highest cause of infertility in our environment. The right tubal occlusion constitutes a higher percentage than the left. Secondary infertility is more commoner than primary infertility.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Baramki TA. Hysterosalpingography. Fertil Steril 2005;83:1595-606.
Onwuchekwa CR, Oriji VK. Hysterosalpingographic (HSG) pattern of infertility in women of reproductive age. J Hum Reprod Sci 2017;10:178-84.
] [Full text]
Evers JL, Collins JA. Assessment of efficacy of varicocele repair for male subfertility: A systemic review. Lancet 2003;361:1849–52.
Okonofua FE. Infertility in Sub-Saharan Africa. In: Okonofua F, Odunsi K, editors. Contemporary Obstetrics and Gynaecology for Developing Countries. Benin City, Nigeria: WHARC; 2003. p. 28–56.
Ogunniyi SO, Makinde OO, Dare FO. Abortion related deaths in Ile-Ife, Nigeria. Afr J Med Med Sci 1999;19:271–4.
Danfulani M, Mohammed MS, Ahmed SS, Haruna YG. Hysterosalphingographic findings in women with infertility in Sokoto North Western Nigeria. Afr J Med Health Sci 2014;13:19-23. [Full text]
Aziz MU, Anwar S, Mahmood S. Hysterosalpingographic evaluation of primary and secondary infertility. Pak J Med Sci 2015;31:1188-91.
Idrisa A. Infertility. In: Kwawukume EY, Emuveyan EE, editors. Comprehensive Gynaecology in the Tropics. Accra Graphics Packaging; 2005. p. 333–43.
Bukar M, Mustapha Z, Takai UI, Tahir A. Hysterosalpingographic findings in infertile women: A seven year review. Niger J Clin Pract 2011;14:168-70.
] [Full text]
Tukur J, Zahradeen SU, Takai IU, Suwaid MA, Ibrahim UM. Evaluation of hysterosalpingographic findings of patients presenting with infertility in Kano, Northern Nigeria. N Niger J Clin Res 2021;10:14-8. [Full text]
Kurama MB, Kamale DC, Mustapha Z, Bello LH, Abubakar A, Shettima AB, et al
. A review of 375 consecutive hysterosalpingograms at University of Maiduguri Teaching Hospital Radiology Department. IOOSR J Nurs Health Sci 2016;5:44-7.
Case AM, PiersonRA. Clinical use of sonohysterography in the evaluation of infertility. J Obstet Gynaecol Can 2003;25:641-8.
Lawan RO, Ibinaiye PO, Onwuhafua P, Hamidu A. Evaluation of pattern of tubo-peritoneal abnormalities potentially responsible for infertility in Zaria, Nigeria: Hysterosalpingographic assessment. Sub-Saharan Afr J Med 2015;2:110-6. [Full text]
Eleje GU, Okaforcha EI, Umeononihu OS, Udegbunam OI, Etoniru IS, Okwuosa AO Hysterosalpingographic findings among infertile women: Review at a tertiary health care institution in Nnewi, South-east Nigeria. Afrimedic J 2012;3:20-3.
Bello TO. Tubal abnormalities on hysterosalpingography in primary and secondary infertility. West Afr J Med 2006;25:130-3.
Kiguli-Malwadde E, Byanyima RK. Structural findings at hysterosalpingography in patients with infertility at two private clinics in Kampala, Uganda. Afr Health Sci 2004;4:178-81.
Bhatla N. Infection as they infect individual organs. In: Jeffcoates Principles of Gynaecology. 7th
ed. Michigan, USA: Butterworths; 2015. p. 355-74.
Mesbazri S, Pourissa M, Refahi S, Tabarraei Y, Dehgha MH. Hysterosalpingographic abnormalities in infertile women. Res J Biol Sci 2009;4:430-2.
Adetiloye VA. Hysterosalpingography in investigation of infertility: Experience with 248 patients. West Afr J Med 1993;12:191-6.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4]