Abstract
Introduction
Hysterosalpingography, along with laparoscoy, are the most requested examinations for tubal factor exploration for infertility, in developing countries.
Objective
To compare the results of hysperosalpingography and laparoscopy in patients assessed for infertility.
Patients & Methods:
This was a 5 years retrospective, descriptive study done at the Obstetrics and Gynecology Clinic of the HKM Centre, National University Hospital. All the patients admitted for infertility of tubal origin were included. These included 96 patients who had undergone hysterosalpingography followed by laparoscopy. The analysis was done with the SPSS version 12.0.1.
Result
The mean age of the patients was 33.3 years. Infertility was primary in 66.3% of cases and secondary in 33.7% of cases and the average duration was 48.9 months. Hysterosalpingography diagnosed 9.37% of proximal tubal obstruction while laparoscopy diagnosed same in 17.71%. Besides pelvic adhesive bands seen in 33.33% of cases, laparoscopy was able to visualize patent tubes with some pathology in 11.46%, and pelvic endometriosis in 6.25% of cases.
Conclusion
The results of HSG and those of laparoscopy are complementary in tubal infertility evaluation. While HSG seems to be reliable when the tubes are patent, laparoscopy helps to reveal false tubal obstructions observed with HSG, and also helps in the diagnosis of pelvic adhesive bands and endometriosis.
Keywords: Infertility, Hysterosalpingography, Laparoscopy, Pelvic pathologies
Introduction
Infertility is a real issue in developing countries, and a tragedy in Africa in particular. Evaluation of an infertile couple is a complex process made up of many steps which are anatomical and functional. Evaluating the female involves morphological and biological complementary examinations. Laparoscopy and hysterosalpingography are two procedures used in the fallopian tubes morphological exploration. Limited funds sometimes compel gynaecologists to prescribe only hysterosalpingography for their patients. MOL BWJ1 said for clinical practice, laparoscopy can be delayed after normal HSG for at least 10 months, since the probability that laparoscopy will show tubal occlusion after a normal HSG is very low. For the evaluation of peritubal adhesions HSG is not reliable2. Laparoscopy has become unavoidable for some diagnostic and surgical treatment causes of tubal obstruction. It can be recommended in cases with suspected bilateral tubal occlusion on HSG3.
This study is aimed at comparing results of hysterosalpingography and that of laparoscopy in patients being evaluated for tubal infertility in order to determine the degree of concordance between the two procedures.
Patients and Methods
We underwent a descriptive and retrospective study at the University Clinic of Gynecology and Obstetrics at the University Hospital National Center HKM, Cotonou, Benin Republic over a period of 5 years (January 2009 to December 2013). We included 96 patients explored for tubal infertility and who did a hysterosalpingography followed by laparoscopy. During Laparoscopy, tubal patency was verified in all cases by the methylene blue test. Exclusion criteria were infertility of less than two years. An interval of more than 3 months between the 2 procedures were observed. The data collected were analyzed using SPSS Version 12.0.1, Chi-square was used to determine the concordance between the outcome of hysterosalpingography and laparoscopy. The significance threshold was of 5%.
Results
The average age of the women evaluated was 33.3 years with a (range of 25 to 45 years). Primary infertility was found in 66.3%. The average duration of infertility was of 48.9 months with a range of 25 to 96 months. In this study7.8% patients had had myomectomy while 4% had had cesarean section. Obstetrics and gynecology history of intra-uterine manouvres (curetting) was found in 5.2%, while 3.7% had history of pelvic infection. No complications were recorded during the study period. The concordance of hysterosalpingography–laparoscopy in tubal obstruction was 46.84% as shown in Table 1. Hysterosalpingography showed proximal tubal obstruction in 9.37%. Of the 5.21% of tubes that were patent at hysterosalpingography were found occluded at laparoscopy. The concordance hysterosalpingography-laparoscopy showed 12.5% of proximal tubal obstruction for the two procedures as shown in Table 2. Hysterosalpingography showed 11.46% of distal tubal obstruction and 6.25% of tubes showing patency at hysterosalpingography were found to be occluded at laparoscopy as shown in table 3. About 5.4% of patients had unilateral proximal tubal obstruction with hysterosalpingography but laparoscopy confirmed same in 1.87% of cases. All bilateral proximal tubal obstructions were found to be soat laparoscopy. The unilateral distal tubal obstructions were identified in 9% of cases at hysterosalpingography while same was seen at laparoscopy in 8.5%. Laparoscopy revealed adhesive bands undetected with hysterosalpingography in 33.33% of cases, pelvic endometriosis undetected with hysterosalpingography in 6.25% of cases, and patenet tubes but with inflammatory features in 11.46% of cases.
Discussion
The main finding(s) of this study are the concordance of hysterosalpingography–laparoscopy in tubal obstruction was 46.84% .The concordance hysterosalpingography-laparoscopy showed 12.5% of proximal tubal obstruction for the two procedures. About 5.4% of patients had unilateral proximal tubal obstruction with hysterosalpingography but laparoscopy confirmed same in 1.87% of cases.
Tubal exploration in infertility assessment is essential. Hysterosalpingography is most often performed first in order to evaluate uterine anatomy and tubal patency especially in developing countries. Laparoscopy helps to directly visualize the tubes, the uterus and the pelvis. It is both diagnostic and therapeutic. Most authors consider it as the “gold standard” before pelvic exploration in cases of infertility. Laparoscopy is considered to be the reference exam in tubal evaluation in cases of infertility1, 2 .The main issue in this study was to know the degree of correlation between hysterosalpingography results and those of laparoscopy. This study shows that in more than one third of cases (35.38%), tubes patency at hysterosalpingography were occluded at laparoscopy. These results are comparable to those of Swart2 who made the same observation in 35% of cases. We also recorded 18% of tubal obstruction with laparoscopy despite a normal hysterosalpingography. In a case of a permeable tube with hysterosalpingography with a bilateral proximal tubal obstruction with laparoscopy, anesthesia should be before further injection of methylene blue dye. This helps to stop tubal spasms. In fact hysterosalpingography reliability would make laparoscopy useless and would therefore justify a selective laparoscopy3. Some proximal obstructions with hysterosalpingography HSG) can be explained by tubal spasm, as this procedure is done without analgesia. Our study is in favor of a moderate correlation between hysterosalpingography and laparoscopy in the detection of proximal obstructions. Mol and al4, on proximal tubal obstruction with hysterosalpingography found 40% of them patent at laparoscopy. The possibility of a false proximal tubal occlusion due to spasm at HSG justifies the performance of laparoscopy in order to confirm the diagnosis. The presence of false positives with HSG in this case can be explained by spasms induced by pain5. Some measures help to reduce the rate of false positives with HSG include the use of pain killers, counseling, a gentle pull on the cervix, and an expert reading of the HSG. Distal tubal obstructions are accessible to surgical therapeutic maneuvers5. This diagnosis justifies therapeutic laparoscopy improves spontaneous fertility in some patients6. In this study, the two procedures showed agreement on distal tubal patency with a moderate correlation. The difficulty is usually on how to differienciate on HSG a bilateral tubal patency from unilateral distal obstruction. The visibility of a tube injected with dye filling up to its distal part could be associated with mixing of the dye with peritoneal fluid from the patent tube. This will cover the obstruction of the other tube. Pelvic adhesive bands are associated with female infertility 10 - 23% of cases7. Laparoscopy is still the most reliable in diagnosing adhesive bands8. Laparoscopy gives a direct vision of the pelvis, and can be considered the reference examination for pelvic adhesive band diagnosis. Endometriosis is better diagnosed with laparoscopy and the rate in infertile women is estimated to be between 20 - 68.0% 9. Capelo and al10 found in 50% of cases a pelvic endometriosis during laparoscopy in patients evaluated for unexplained endometriosis. In our series, pelvic endometriosis was recorded in 6.25% of cases which were not diagnosed with HSG. HSG alone seems insufficient to diagnose pelvic pathologies associated with tubal obstruction.
Conclusions
The results of HSG and those of laparoscopy are complementary in tubal infertility evaluation. While HSG seems to be reliable when the tubes are patent, laparoscopy helps to reveal false tubal obstructions observed with HSG, and also helps in the diagnosis of pelvic adhesive bands and endometriosis.
Table 1 . concordance based on tubal patency.
| HSG | Laparoscopy | ||
| Tubal obstruction | Tubal patency | Total | |
| Tubal obstruction | 45 (46,84%) | 11(11,46%) | 56(58,33%) |
| Tubal patency | 20 (20,83%) | 20(20,83%) | 40(41,66%) |
| Total | 65 (67,70%) | 31(32,29%) | 96(100%) |
Table 2 . concordance base on proximal tubal obstruction.
| HSG | Laparoscopy | ||
| Tubal obstruction | Tubal patency | Total | |
| Tubal obstruction | 70(72,91%) | 5(5,21%) | 75(78,12%) |
| Tubal patency | 9(9,37%) | 12(12,50%) | 21(21,87%) |
| Total | 79(82,9%) | 17(17,71%) | 96(100%) |
Table 3 . Concordance based on distal tubal obstruction.
| HSG | Laparoscopy | ||
| Tubal obstruction | Tubal patency | Total | |
| Tubal obstruction | 65(67,70%) | 6(6,25%) | 71(73,95%) |
| Tubal patency | 11(11,46%) | 14(14,58%) | 25(26,04%) |
| Total | 76(79,16%) | 20(20,83%) | 96(100%) |
Footnotes
Competing Interests: The authors have declared that no competing interests exist.
Grant support: None
References
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