Gynecoradiology

Hysterosalpingogram

This is the standard, basic x-ray study of the uterus. It is designed to study the inside of a uterus (the uterine cavity) and give a crude assessment of whether the fallopian tubes are patent.

This basic procedure is offered by most hospital radiology departments and can be performed by a radiologist or a gynecologist.

The process is simple. A woman is brought in to a special room that has the x-ray equipment. She is asked to lie down and put her legs in stirrups, just as if she were going to have a PAP smear. A speculum is placed in the vagina and the opening to the uterus (called the cervix) is visualized by the doctor. After cleaning the cervix with an iodine solution, a long, narrow, flexible catheter is inserted through the opening of the cervix until the tip is inside the uterine cavity. A balloon on the end of the catheter is inflated to hold the catheter in place. The catheter is connected to some plastic tubing through which a special dye is passed into the uterus. This dye looks like water to the eye but it shows up on x-ray film because it blocks the passage of the x-rays leaving "unexposed film'. Therefore everywhere the dye flows looks white (or black if the image is reversed).

As the dye fills the uterus, x-rays are taken every few seconds, this reveals any abnormalities inside the uterus such as a split cavity, uterine fibroids or adhesions.

As more dye flows into the uterus, some will begin to fill the fallopian tubes. If the tubes are patent along their entire course, eventually the dye will "spill" out the other side.

This method for performing HSGs utilized an x-ray machine which snapped static pictures. Generally about three or four pictures were taken. At the CHR, digital images are created and stored in computer memory. These images can then be manipulated in a number of different ways using a computer to help a physician distinguish subtle abnormalities. Typically 50 to 60 images are generated from a basic HSG.

[ Back to top ]

Selective Hysterosalpingogram

Sometimes dye will not flow into the tube(s) because of an obstruction or "spasm" of the muscle around the opening of the tube. With an HSG alone, it is impossible to distinguish an obstruction (which is important) from spasm (which is of no importance). Furthermore, if a true obstruction exists, with an HSG alone, there is no way to bypass it.

With selective salpingography, a smaller diameter, flexible catheter can be run inside the HSG catheter and, with the help of the x-ray machine, can be directed right into the opening of the fallopian tube. Once this is done, dye can be introduced directly into the fallopian tube. In this way, it is possible to demonstrate a normal, patent, fallopian tube whose opening may be in spasm. Fallopian tubes with an actual obstruction can also be opened by the higher pressures which can be achieved with selective salpingography.

Note:
Selective Salpingography may not always be able to open an obstructed tube.

[ Back to top ]

Hysterosonograms

Hysterosonography is sort of a combination of a hysterosalpingogram and and an ultrasound. However, instead of using radio-opaque dye and x-rays to "see" the uterus, we use saline (salt water) and high resoltion ultrasound.

The result is a very sensitive method for visualizing abnormalities of the uterus. Hysterosograms are more "comfortable" than HSGs which can sometimes cause considerable cramping.

Hysterosonogram showing Intrauterine adhesions: This patient came to us having failed five IVF cycles at another program. The hysterosonogram revealed scar tissue (adhesions) inside the uterine cavity. Interestingly, an HSG performed previously did not demonstrate any adhesions.

Another hysterosonogram showing example of adhesions in the uterus.

Hysterosonogram demonstrating Intra-abdominal adhesions: Fluid which passed through the fallopian tubes allowed this view of pelvic adhesions from the fallopian tube to the uterus.

[ Back to top ]

High Resolution Ultrasound

Examples of early intra-uterine pregnancy using high resolution ultrasound.

This infertility patient conceived with the use of gonadotropins (injectable fertility medications). The amnion surrounding the embryo is clearly seen.

Using color flow doppler, blood flow is seen in the early embryo.

[ Back to top ]

Tubal Perfusion Pressure Measurements

Sometimes, even if a fallopian tube is patent, it does not work very well. Although most people, including some physicians, think of the fallopian tubes as a simple pipe that allows the egg into the uterus and the sperm to meet the egg, it is actually a dynamic organ. The tube is responsible for electrical and muscular contractions which are responsible for a large part of its function. Furthermore, a tube can be diseased (for example with endometriosis) so that it doesn't function very well even though it may not be "blocked" (non-patent).

With the use of specialized computer software, pressure transducers, and selective salpingography, we may now have the capability to more accurately measure the functioning of a fallopian tube. This is done by measuring the pressure it takes to move dye through a fallopian tube during selective salpingography. Tubes which are rigid and diseased need high pressures to move the dye through whereas normal tubes require only low pressures.

Does this matter? We believe so. Based on the study of Karande et al. 1995, done at the Center for Human Reproduction we have shown that women with high TPP measurements are more likely to have endometriosis than women with low pressures. More importantly, women with high TPP measurements take longer to become pregnant and DO NOT ACHIEVE PREGNANCY AS OFTEN as women with low TPP measurements.

In some cases, CHR physicians have used the information from SS/TPP measurements to recommend that a couple use another therapy such as IVF to attempt to achieve pregnancy.

[ Back to top ]

Wire Guide Cannulization

Occasionally, selective salpingography is insufficient to remove an obstruction. In that case, additional techniques are needed in order to attempt to achieve a patent fallopian tube. A thin, flexible, wire can be carefully threaded through a selective salpingography catheter and passed directly inside a fallopian tube. This technique (which is analogous to using a plumber's "snake" to open a blocked drain) is another technique CHR physician's can use to try open a blocked tube. Another use for this technique is to lower the TPP measurements in women with high levels. However, there is no convining data as yet that reducing TPP in this way will allow these women to acheive a pregnancy rate similar to those who have a low TPP. All of the procedures described are new procedures for the diagnosis and treatment of uterine and tubal disease. All of these methods can be performed in the office by appropriately trained and experienced physicians. They take little additional time over the basic HSG and provide clinically useful information. [ Back to top ]