JULY, 1974

HYSTEROSALPINGOGRAPHY IN INFERTILITY*
By HEUN Y. YUNE, M.D.,f EUGENE C. KLATTE, M.D.,t ROBERT E. CLEARY, M.D.,
and LOREN PETERSEN, M.D1
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INDIANAPOLIS, INDIANA

H YSTEROSALPINGOGRAPHY has also co-authors of this paper-R.E.C. and

proven to be an important diagnostic L.P.) have contributed 73 of the cases in
method in clinical gynecology for over o the past 2 years. Complete clinical and lab-
years. It is of particular value in the in- oratory records are available on each of
vestigation of the uterine and tubal factors these patients. Their up-to-date fertility
of female infertility.27”3”4 Until recently status is known. This group is the source of
the technique of the procedure has not the clinical analysis of the significance of
been significantly modified. A simpler and the hysterosalpingogeaphy information.
less painful technique utilizing a flexible
TECHNIQUE OF HYSTEROSALPIN000RAPHY
vacuum cervical adaptor is now avail-
A. THE CONVENTIONAL METHOD
able.”2 In spite of its advantage this
A detailed description of the conventional
technical modification has not gained the
technique is not warranted. It has been in
popular acceptance which it deserves.
use for the past half century and, even to-
The purpose of this paper is to report our
day, is utilized by the majority of clinicians.
experience with the newer modified tech-
nique for hysterosalpingography in the The significant differences of the conven-
study of patients with female infertility. tional technique in contrast to the newer
modifications are: (I) the use of a cervical
MATERIAL AND METHOD tenaculum to provide countertraction against
One hundred and forty-seven hysterosal- an intrauterine cannula; (2) use of a rigid

pingographies have been performed during intrauterine cannula (acorn rubber or

the past 3 years as a part of the diagnostic screw tip) ; (3) an oily contrast material;
work-up of infertile patients. During the (4) 2 roentgenograms following low ( to 4
first year, hysterosalpingographies were cc.) and high (io cc.) volume contrast
performed in a conventional manner utiliz- material injection, often obtained without
ing a cervical tenaculum, a rigid uterine fluoroscopic monitoring, and a third roent-
cannula (acorn or screw tip) and an oily genogram of the abdomen obtained 24

contrast material. Forty-one cases were hours later.

studied by this technique. During the past B. THE VACUUM CERVICAL ADAPTOR TECHNIQUE

2 years a vacuum cervical adaptor (MaIm- The essential items of equipment needed
strom or Semm) and an aqueous contrast are: (i) a vacuum cervical adaptor (Semm
material were used. There were io6 cases in or Malmstr#{246}m)* (Fig. I, a); (2) a cervical
this group. In 6 instances the vacuum adaptor application clamp (Fig. i, b); () a
cervical adaptor could not be utilized be- controlled pressure hand vacuum pump;
cause of the morphologic abnormality (i.e., () a removable vaginal speculum (Fig. i,
uterus didelphia). During the last i years c); (5) water soluble contrast material
the Semm adaptor has been used exclu- (Sinografin or Salpix) t (Fig. i, d); (6) an
sively (see Technique).
* Semm hydrotubation cup (portio-adaptor), WISAP,
Patients were referred to the Radiology 8 M#{252}nchen 71, Germany.
Malmstr#{246}m (AR vacuum extractor), Gotaborg, Sweden.
Department for hysterosalpingography by
t Sinografin (meglumine diatrizoate and meglumine iodipamide
several gynecologists; however, 2 (who are injection-38% iodine), E. R. 5quibb & Sons, Inc., Princeton,

* Presented at the Seventy-fourth Annual Meeting of the American Roentgen Ray Society, Montreal, P.Q., Canada, September
25-28, 1973.
From the Department of Radiology,t and the Department of Obstetrics and Gynecology4 Indiana University Hospital, Indianapolis,
Indiana.

642
 VOL. 121, No. 3 Hysterosalpingography in In fertility 643

soluble contrast material which has been

warmed to the body temperature. The hand
operated vacuum pump is connected to the
vacuum suction tube opening at the base
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of the cup of the cervical adaptor. The

cervical adaptor is placed in position over
the cervix and vacuum is applied (Fig. 2).

This eliminates the need for the cervical

tenaculum. The vaginal speculum is then
removed . Under fl uoroscopic monitoring,
small fractions of contrast material are
slowly injected. Overt pressure is not used.
Tightly coned down cervical-uterine canal
FIG. I. Instrument tray for hysterosa/pingograp/zy.
a. Vacuum cervical adaptor (Semm); b. cervical spot noentgenograms are obtained in the
adaptor application clamp; c. removable vaginal anteropostenion and oblique positions (. on
speculum; d. water soluble contrast material. A i film; Fig. 3, 11-D). The use of a small vol-
disposable, presterilized cervical adaptor has 2
ume (about 2 cc.) of a water soluble con-
tubes connected to its cup. One that opens to the
trast material makes it possible to demon-
central cone is for the contrast material injection.
The other tube is to be connected to a controlled strate small lesions often obscured by a
pressure vacuum pump. Application of this adap- larger quantity of oily contrast material.
tor does not require a cervical tenaculum or An additional 4 to cc. of contrast mate-
countertraction against an intrauterine cannula
rial is then fully distend
injected the to
which is needed for the conventional technique.
uterine cavity and the full length of the
fallopian tubes. The injection is performed
image intensified fluonoscopic table with a slowly and fluonoscopically monitored. This
small focal spot tube and a high ratio re- helps to prevent uterine or tubal spasms.
When the uterus and tubes are well opaci-
ciprocating grid.
The Semm cervical adaptor is favored fled, spot roentgenograms of the pelvis are
because of the flexibility of its connecting
obtained in the anteroposterior and oblique
tubes. This allows a wider range of move- projections (Fig. 3, E-G). Fluoroscopic
ment of the patient during the examination
such as turning to the prone Position. The
Malmstn#{246}m vacuum pump is employed be-
cause it has a glass bottle trap which pre-
vents the vacuum pump from becoming
clogged with tissue debris, mucus, etc.
The patient is placed in a lithotomy posi-
tion at the foot of the fluoroscopic exam in-
ing table. Usual penineal and vaginal prepa-
ration as for a sterile pelvic examination is
made. A removable speculum is vaginal
placed and the cervix is brought to full view
so its external os is identified. The vacuum
cervical adaptor is pnestenilized. The con-
FIG. 2. Cervical adaptor being applied. The transpar-
trast material injection tube in the center
ency of the cup of the cervical adaptor permits
of the cup is completely filled with water identification of the cervical os during its applica-
tion. i’he vaginal speculum is readily disassembled
and removed. Rotations and turning of the pa-
Salpix (sodium acetrizoate----53% iodine,) Ortho Pharmaceu- tient’s position during the examination are freely
tical Corporation, Raritan, New Jersey 08869. accomplished without discomfort.
 644 H. Y. Yune, E. C. Klatte, R. E. Cleary and L. Petersen JULY, 5974
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FIG. 3. Normal examination (full series).

I
(A-D) Composite of uterine body spot
roentgenograms with low volume of contrast agent (2-3 cc.) injected.

monitoring eliminates lack of filling or results were inconclusive in a number of

ovenfilling of important structures. The cases. The presence on absence of an organic
average total fluoroscopic time is 2 to 3 lesion cannot bewith non-
ascertained
minutes. Penitoneal spillage of the contrast visualization ofboth of the fallopian
one on
material is readily demonstrated and a de- tubes. During fluoroscopic observation it is
layed 24 hour roentgenogram has been un- frequently observed that one on both tubes
necessary. The length of time from prepara- are functionally obstructed to the flow of
tion to termination of the procedure is ap- contrast material. A few minutes nest and
proximately 20 to 30 minutes.
relaxation of the patient eliminates this
RES U LTS process. Had the examination been termi-
\Vith the conventional technique the nated prior to nest and repeated attempts,
 VOL. 121, No. 3 Hysterosalpingography in Infertility 645
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FIG. 3. (E) Medium volume. Cx-Internal cervical Os; c-cornua of the uterus; Rt and Lt-right and left
fallopian tubes; f-fimbriated portion; arrows-contrast spilling in peritoneal cavity. (F and G) Left
posterior oblique and right posterior oblique views. Oblique views are needed for a better appreciation of
the axis and the configuration of the uterine cavity. Note a generous intraperitoneal spilling of the con-
trast material. An air tight seal around the cervix by the vacuum cervical adaptor eliminates the intra-
vaginal loss of the contrast material. Unless the uterine cavity is very large, so cc. of contrast material is
usually quite sucient. The roentgenograms obtained are all fluorographic spot roentgenograms.

an organic obstructive lesion of the fallo- salpingognaphy. Seven cases became preg-
pian tubes would have been incorrectly nant within the first month following
thought to be present. hysterosalpi ngognaphy.
Utilizing the conventional technique with Abnormalities demonstrated by the ex-
a rigid cervical adaptor, the cervical os is amination were: (i) cases of unilateral
not as well sealed off from the vagina as tubal obstruction, i of these patients be-
with the vacuum cervical adaptor cup. came pregnant within I month after the
Spillage of contrast material back into the hystenosalpingography; (2) 5 cases of bi-
vagina was much more commonly seen. lateral tubal obstruction (Fig. , ii and B);
There were also cases in whom one or both (,) cases of unilateral
6 ovarian or adnexal
of the 2 roentgenograms obtained were not masses (Fig. 5, i and B), I of these pa-
properly positioned to cover all pertinent tients became pregnant 4 months after the
structures. Because of these technical dis- hysterosalpingography; (.) 3 cases of bi-
crepancies, clinical statistics would be lateral ovarian or adnexal 6, masses (Fig.
meaningless. The following statistics were 1 and B); () cases filling
of intrauterine
taken only from those 73 cases mentioned defects by a myoma on a polyp (Fig. 7, ii-
earlier whose records are complete and C), i became pregnant i month after
fertility status up-to-date. the hysterosalpingography; (6) i case of
Of the 73 cases (6o per cent) were nor- congenital deformity and dvsplasia of the
mal on hysterosalpingograph’. Eighteen of genitalia (Fig. 8, z1-D); () 3 cases had a
these cases (41 per cent) became pregnant combination of 2 or more abnormal findings
between I to 8 months after the hvstero- (Fig. 9, 4 and B); (8) 3 cases in which the
 646 H. Y. Yune, E. C. Klatte, R. E. Cleary and L. Petersen JULY, 5974

salpingography. It is much less painful than

the combined instrumentation and allows
excellent visualization of the cervical canal.
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Patients may note a slight cramping sensa-

tion when the vacuum cup is attached to
the cervix. This normally spontaneously re-
solves in a few minutes. We have not en-
countered a single case of peritoneal-irrita-
tion caused by the water soluble contrast
material spilling into the pelvic penitoneal
cavity (Sinografin was used exclusively for
these studies). In rare instances, pelvic
cramps lasted longer than a few minutes.
This was more frequent in nulliparous pa-

FIG. 4. Bilateral hydrosalpinx. (A) Moderate volume

filling fails to disclose the presence of a bilateral
hydrosalpinx. (B) Large, bulbous dilatation at the
end of each tube (arrows) without apparent pen-
toneal spilling of the contrast material is well
demonstrated later with a high volume filling.

diagnosis was uncertain because of a tech-

nically incomplete study (Table I).

FIG. . Pelvic kidney. (A) Moderate volume contrast

DISCUSSION material filling and (B) postevacuation roentgeno-
grams demonstrate patent right tube, a left pelvic
An ideal special nadiologic procedure
mass (arrows) with the right side deviation of the
should be accurate, technically simple and uterine axis and nonvisualization of the left tube.
have a minimum of patient morbidity. The The left tube was found to be hypoplastic. The
vacuum cup technique of hystenosalpingog- patient had multiple other urogenital anomalies.
raphy approaches this ideal. The same size mass in the pelvis, if intraperitoneal,
will have a better chance of having more of its sur-
The vacuum cervical adaptor better
faces delineated by the intraperitoneal contrast
serves the combined functions of the cervi- material. Small intraperitoneal “masses” such as
cal tenaculum and the intrauterine cannula small-bowel loops frequently mimic a normal
which are still widely utilized for hysteno- ovary (see Fig. 6, A and B).
 VOL. 121, No. 3 Hystenosalpingography in Infertility 647

tients (primary in fertility). These patients’ It has long been debated whether or not
symptoms subsided shortly after the re- hystenosalpingography has any therapeutic
moval of the vacuum cervical adaptor. The effect on certain conditions of female infer-
intensity of discomfort is much less than tility.8’#{176}”6 This series is too small to be
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the combination of a tenaculum and intra- conclusive; however, in this small patient
uterine cannulation. Of io6 cases studied sample the conversion to fertility from an
with the vacuum cup method, only 3 re- infertile status was noted in a number of
quired an analgesic agent or tranquilizer. patients whose hystenosalpingograms were
There were individuals of low pain thresh- normal.
old who had marked symptoms even during Hysterosalpingography does not con-
preparation of the perineum and vagina sistently visualize the ovaries; however, an
prior to the examination. abnormally enlarged ovary is frequently
outlined when a generous quantity of con-
trast material has freely spilled into the
pelvic penitoneal cavity. A mass outlined
in the region of the ovary may have mul-
tiple etiologies. The combination of hys-
terosalpingography and pelvic pneumog-
raphy or laparoscopy is necessary if in-
vestigation of the status of the ovaries is to
be made.’3”5
On 3 occasions the combination of an
ovarian or adnexal mass, partial loculation
of the contrast material in the vicinity of
the mass and elsewhere in the Douglas
pouch, and ipsilateral tubal obstruction or
penitubal adhesions was present (Fig. 9,
LI and B). These patients had never had a
clinical episode of pelvic inflammatory dis-
ease on pelvic operation. Extrauterine en-
dometniosis was strongly suspected and
subsequently proven by laparoscopy or
lapanotomy. However, on 3 other occasions,
a normal hysterosalpingogram was present
with subsequently proven extrauterine en-
dometniosis.

SUMMARY

FIG. 6. Simple ovarian cysts. (A) Left posterior i. A detailed description of hystero-
oblique and (B) right posterior oblique views with salpingography utilizing a vacuum cervical
high volume contrast material filling demonstrate
adaptor is given.
a 74XI04 cm., nonlobulated, smooth surfaced
cystic left ovary (arrows) and a smaller, incom- 2. The authors’ experience with this
pletely delineated right ovarian mass (B). These technique is briefly stated.
were exogenous hormone-induced simple cysts. 3. The vacuum cervical adaptor modi-
Note that the tubes are entirely patent. When
fication of the hystenosalpingognaphic tech-
more than half of a circumference of a pelvic mass
nique is a significant improvement and
comes into contact with the contrast material
which has spilled into the peritoneal cavity, the merits widen acceptance because of its
over-all size and shape of the mass become obvious. technical simplicity, assurance of thorough-
 648 H. Y. Yune, E. C. Klatte, R. E. Cleary and L. Petersen JULY, 1974
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F:

11G. 7. Polvps. (A and B) Low volume contrast material filling of the uterine cavity outlines a solitary
polypoid lesion on the right side fundus portion which is less than i cm. in its longer dimension. (C) A small
polypoid lesion is present in the supracervical region of the uterine cavity. Subsequent high volume filling
with contrast material has obscured these lesions completely. Without preliminary low volume filling
under fluoroscopic control, especially using a less diffusable contrast agent, a small polypoid lesion can be
easily missed.
 VOL. 121, No. 3 Hystenosalpingography in Infertility 649
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Lc

___

Ru
it Lu

0$,
FIG. 8. Complete duplication of genitalia. (A-D) A sagittal septum divides the vagina to the left and the right
halves, each leading to a separate cervical os (solid arrows in B and D). A Foley catheter was placed in the
left vagina and the contrast material was injected. Re and Lc-- right and left cornu; Ru and Lu-right
and left uterine cavity; Rv and Lv-right and left vaginal cavity; open arrows in A and B-air in fallopian
tubes; open arrows in C-communication between Ru and Lu; open arrow in 0-right vaginal fornix.
 650 H. Y. Yune, E. C. Klatte, R. E. Cleary and L. Petersen JULY, 1974

FIG. 9. Peritubal-pelvic adhesions andpelvic masses.

(A and B) ‘I’he right fallopian tube is patent and
the contrast material spills freely into the pen-
toneal cavity from this side. ‘I’he left tube is ob-
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structed or very severely strictured at its fimbni-

ated end resulting in a “sausage-link” like marked
dilatation and elongation of the entire length of the
tube (open arrows). A smooth surfaced, oval mass
in the left adnexal region (solid arrows) sponta-
neously disappeared in 2 weeks after cessation of
the ovulation-inducing agent (Clomid) medication.
‘I’his enlargement was most probably a functional
corpus luteum cyst. Subsequently a laparotomy
was performed which disclosed pelvic and ovarian
endometriosis. ‘Fhe combination of a strictured
tube or peritubal adhesions and pelvic or ovarian
masses very strongly suggests endornetriosis.

ness and significant reduction of pain and

discom font.
4. Hysterosalpingography remains a prin-
cipal method in the study of female infer-
tili ty.

Heun Y. Yune, M.D.

Department of Radiology
School of Medicine
Indiana University Hospital
Indianapolis, Indiana 96207

REFERENCES

TABLE I I. AARO, L. A., and STEWART, J. R. Hysterosal-

pingography with image-intensified fluoros-
RESULTS OF HYSTEROSALPINGOGRAPHY
IN 73 INFERTILE FEMALES
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I 528.
2. AVNET, N. L., and ELKIN, M. Hysterosalpin-
No. of Became
gography. Radiol. Clin. North America, 1967,
Patients Pregnant
5, 105-120.
3. BARWIN, B. N. Hysterosalpingography in infer-
Normal 44 18
tility. Ulster M. 7., 1971, 4!, 6i-6g.
Unilateral tubal obstruction. 4 I
4. BEHRMAN, S. J., and POPPY, J. H. Hysterosal-
Bilateral tubal obstruction. . o
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Unilateral adnexal or ovarian
943.
mass 6 I
. BUXTON, L., and SOUTHAM, A. Critical survey of
Bilateral adnexal or ovarian
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mass 3 0
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70, 741-752.
Congenital dysplasia of inter-
6. CRON, R. S. Hysterosalpingography and infer-
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Combination of more than 2
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Gynec., 1965, 5, 12-17.
minor abnormalities 3 0
Inconclusive study 3 0
7. GEARY, W. L., HOLLAND,J. B., WEED, J. C., and
WEED, J. Uterosalpingography.
C., JR. Am. 7.
Total 73 21 Obst. & Gynec., 1969, /04, 687-692.
8. GILLESPIE, H. W. Therapeutic aspect of hys-
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305-302. Gynec., 1970,36, 940-943.
9. MACKEY, R. A., GLASS, R. H., OLSON, L. E., and 13. PAREKH, M. C., MURTHY, Y. S., KOSASA, T., and
VAIDYA, R. Pregnancy following hysterosal- ARRONET, G. H. Validity of hysterosalpingog-
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