factors associated with abnormal & inconclusive hysterosalpingograms (hsg… · 2017-05-25 ·...

Factors associated with abnormal & inconclusive

Hysterosalpingograms (HSG) for evaluation of

female infertility Faisal Karim Caroline Yap Sarah Aldugman Francesca Hanson Samuel Marcus

Queen Elizabeth Hospital Woolwich

London, UK

Declarations of Interest None

Introduction • Infertility affects 1/7 heterosexual couples in the UK

• The main causes of subfertility are:

• Male factors (30%) • Ovulatory disorders (25%) • Tubal damage (20%) • Uterine or peritoneal disorders (10%) • Unexplained (15%)

• 40% of cases have disorders in both sexes

HSG (1) • A hysterosalpinogram (HSG) is an X-ray procedure used to

assess uterine abnormalities and tubal patency

• A contrast dye is inserted in to the uterus via a catheter

• The uterine cavity will fill with dye , pass through the fallopian tubes and spill in to the abdominal cavity in a normal HSG

• NICE guidance recommends HSG or contrast sonography (HyCoSy) for women with subfertility who are not known to have co-morbidities such as endometriosis, pelvic inflammatory disease or previous ectopic pregnancy

HSG (2) • HSG & laparoscopy with dye test are the two most widely

used methods to assess tubal patency

• Laparoscopy and dye test is recommended when there is a history of co-morbidities and no contraindication to laparoscopy

• HSG is not a reliable indicator of tubal occlusion

• However, it is a reliable indicator of tubal patency

Aim of the audit • To ascertain the factors associated with abnormal and inconclusive HSGs

• To find out the outcome of those patients who had abnormal/ inconclusive HSG

Method (1) • Retrospective audit in a South London NHS Hospital

• 108 patient notes reviewed from a possible 159 during the

period from April 2015 – July 2016

• Review of medical notes, iCare (electronic noting system) & IMPAX (electronic system for all radiology images & reports) used to access HSG scan reports

• Data entered in to spreadsheet database and analysed

Method (2) • An abnormal HSG was defined as the presence of tubal

abnormalities (unilateral/bilateral obstruction, adhesions) and/or uterine abnormalities (intrauterine adhesions, uterine malformation or uterine filling defects)

• Statistical analysis was performed using Chi-squared test to compare variables with p < 0.05 considered statistically significant.

Results: Fertility History

• Mean duration of infertility: 33.6 months

• Mean age: 33.2 years

Chart1

Primary Subfertility

Secondary Subfertility

Age Range 21 - 42

0.56

0.44

Sheet1

Age Range 21 - 42

Primary Subfertility56%

Secondary Subfertility44%

To update the chart, enter data into this table. The data is automatically saved in the chart.

Results: Primary vs Secondary Subfertility

HSG Outcome Primary Subfertility Secondary Subfertility

Normal 21 (39%) 14 (33%)

Abnormal/Inconclusive 33 (61%) 29 (67%)

Total 54 43

Results: Duration of Infertility

HSG Outcome < 2 years ≥ 2 years

Normal 23 (40%) 12 (31%)

Abnormal/Inconclusive 34 (60%) 27 (69%)

Total 57 39

Results: Age < 30

p < 0.05

Chart1

Normal HSG

Abnormal/Inconclusive HSG

Age < 30

0.52

0.48

Sheet1

Age < 30

Normal HSG52%

Abnormal/Inconclusive HSG48%


Results: Age ≥ 30

p < 0.05

Chart1

Normal HSG


Age ≥ 30

0.31

0.69

Sheet1

Age ≥ 30

Normal HSG31%



Co-morbidities

• Raised BMI • Previous surgery including CS • Previous surgery and raised BMI • Previous Surgery, Adhesions, PID

Number of Co-morbidities (1)

0 1 ≥2

Abnormal/Inconclusive

18 (45%) 32 (65%) 12 (63%)

No report 0 2 (4%) 1 (5%)

Normal 20 (50%) 11 (23%) 4 (21%)

abandoned 2 (5%) 4 (8%) 2 (11%)

Total 40 49 19

HSG Outcome Number of Co-morbidities


p < 0.05

Chart1


No Report

Normal

Not Done

One Co-morbidity

0.65

0.04

0.23

0.08

Sheet1

One Co-morbidity


No Report4%

Normal23%

Not Done8%



p < 0.05

Chart1


No Report

Normal

Not Done

≥2 Co-morbidities

0.63

0.05

0.21

0.11

Sheet1

≥2 Co-morbidities


No Report5%

Normal21%

Not Done11%


Results: Raised BMI HSG Outcome BMI

Normal BMI Raised BMI

Abnormal/Inconclusive (n = 62)

41 (55%) 21 (62%)

No Report (n = 3)

2 (3%) 1 (3%)

Normal (n = 35)

27 (36%) 8 (24%)

abandoned (n = 8)

4 (5%) 4 (12%)

Total (n = 108)

74 34

Indications for HSG

Co-morbidity but declined laparoscopy

Co-morbidity but risk of

laparoscopy exceeds benefits

No co-morbidity

Unclear in notes


1 (50%) 28 (68%) 30 (51%) 3 (50%)

No report 0 (0%) 1 (2%) 1 (2%) 1 (17%)

Normal 1 (50%)

9 (22%) 24 (41%) 1 (17%)

abandoned 0 (0%)

3 (7%) 4 (7%) 1 (17%)

Total 2 41 59 6

HSG Outcome Indication for HSG

Tubal Patency

Chart1


Normal/Patent Tubes

Abandoned

No Report

Results

0.57

0.32

0.07

0.03

Sheet1

Results

Abnormal/Inconclusive57%

Normal/Patent Tubes32%

Abandoned7%

No Report3%


• No = 8 (7%)

• Cervical stenosis = 2 • Could not find cervix = 1 • Patient could not tolerate procedure = 1 • Technically difficult = 1 • Other = 3

Why was HSG not done/abandoned?

Abnormal/Inconclusive HSG & Subsequent Follow Up

• Referred for IVF or assisted conception – 25 (40%) • Underwent lap with dye test and proceed – 13 (21%)

• Awaiting lap with dye test and proceed • Advised weight loss • Initially became spontaneously pregnant but subsequently

miscarried • Patient and partner no longer a couple • No longer pursuing tubal patency tests due to male factor • Awaiting clinic review

Discussion (1) • Women ≥ 30 years of age are more likely to have

abnormal/inconclusive HSGs compared to those < 30 years of age.

• Similarly, women with co-morbidities are more likely to have abnormal/inconclusive HSGs compared to women with zero co-morbidities.

• The greater the age of the woman, the greater the chance of ≥ 1 co-morbidity.

• 21% of co-morbidities were in the < 30 category whereas 79% of co-morbidities were in the ≥ 30 category

Discussion(2) • Women without comorbidities should be offered HSG to

screen for tubal patency as per NICE/RCOG guidelines

• However, 44% of those undergoing HSGs suffered from co-morbidities

• The reasons were some women declined lap and dye and in others, the risks of performing lap and dye exceeded the benefit

Discussion (3) • There was no association between HSG results and the

following factors:

• Duration of infertility • Primary or secondary subfertility • BMI

Conclusion • The most important factors when discussing likely HSG

outcome with patients is age and number of co-morbidities

• Although BMI measured by itself did not have a significant effect on outcomes, it may have a synergistic effect when combined with other co-morbidities

References • Belisle S, Collins JA, Burrows EA, Willan AR. The value of laparoscopy among infertile

women with tubal patency. J Soc Obstet Gynaecol Can 1996;18:326–36. • Collins JA. Diagnostic Assessment of the Infertile Female Partner. Curr Probl Obstet

Gynecol Fertil 1988;11:6–42. • Marana R, Muzii L, Paielli FV, Lucci FM, Dell’Acquia S, Mancuso S. Proximal tubal

obstruction: are we overdiagnosing and overtreating? Gynaecol Endosc 1992;1:101. • Mol BW, Collins JA, Burrows EA, van der Veen F, Bossuyt PM. Comparison of

hysterosalpingography and laparoscopy in predicting fertility outcome. Hum Reprod 1999;14:1237– 42.

• Opsahl MS, Miller B, Klein TA. The predictive value of hysterosalpingography for tubal and peritoneal infertility factors. Fertil Steril 1993;60:444–8.

• Royal College of Obstetricians and Gynaecologists (2013) Fertility: assessment and treatment for people with fertility problems, NICE Clinical Guideline. 2nd Edition. London, RCOG.

• Swart P, Mol BW, van der Veen F, van Beurden M, Redekop WK, Bossuyt PM. The accuracy of hysterosalpingography in the diagnosis of tubal pathology: a meta-analysis. Fertil Steril 1995;64:486– 91.

Factors associated with �abnormal & inconclusive Hysterosalpingograms (HSG) for evaluation of female infertilityDeclarations of InterestIntroductionHSG (1)HSG (2)Aim of the auditMethod (1)Method (2)Results: Fertility HistoryResults: Primary vs Secondary SubfertilityResults: Duration of InfertilityResults: Age < 30Results: Age ≥ 30Co-morbidities �Number of Co-morbidities (1)Number of Co-morbidities (2)Number of Co-morbidities (3)Results: Raised BMIIndications for HSGTubal PatencyWhy was HSG not done/abandoned?Abnormal/Inconclusive HSG & Subsequent Follow UpDiscussion (1)Discussion(2)Discussion (3)ConclusionReferences

factors associated with abnormal & inconclusive hysterosalpingograms (hsg… · 2017-05-25 ·...

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