Aetiological Diagnosis of Infertility at Conakry University Hospital: Role of Hysterosalpingography and Pelvic Ultrasound

Objective: The objective of this study was to investigate the etiologies of infertility and to determine the contribution of hysterosalpingography coupled with ultrasound in the exploration of female infertility at Donka University Hospital. Methodology: This was a prospective descriptive cross-sectional study carried out in the Radiology Department of Donka National Hospital over a period of ten (10) months. It involved 78 women who came to the department for hysterosalpingography and/or pelvic ultrasound examinations, as part of the exploration of infertility. Data collection involved the use of pre-established survey forms to gather information on the parameters studied. Sociodemographic parameters, ultrasound and hysterosalpingography results were studied. A correlation was made between age at marriage and infertility to determine whether early marriage has an impact on primary infertility, with a statically significant result for p value greater than 0.05. Results: The mean age of our patients was 33.7 ± 5.6 years, with extremes of 18 and 35 years. The 18-35 age group was the most represented, with a frequency of 80.7%. The 34% of our patients were married before the age of 18, with a marriage duration ranging from 6 months to 15 years. The indication for investigations was dominated by secondary infertility, with a frequency of 65%, followed by primary infertility (35%). All our women underwent ultrasound-hysterosalpingography, i.e. 100%, in search of the cause of infertility. Ultrasound was pathological in 35.8%. The most common ultrasound lesions were myomas and ovarian dystrophies, with 12.8% each. However, hysterosalpingography was pathological in 35%. Tubal obstructions affected almost a third of our women (29.5%), followed by phimosis and tubo-peritoneal adhesions. Conclusion: Diagnostic evaluation of infertility requires a multidisciplinary approach, including collaboration between infertility gynecologists, radiologists and other infertility specialists. Medical imaging remains indispensable in the evaluation of female infertility.

Comparative Analysis of Saline Sonohysterosalpingography to Hysterosalpingography in the Diagnosis of Utero-Tubal Pathology amongst Infertile Women at the University of Port Harcourt Teaching Hospital

Background: The evaluation of the uterus and its tubes cannot be overemphasized in the management of infertile women. Transvaginal saline sonohysterosalpingography (SHG) is another novel method with certain advantages for uterine and tubal assessment in women. Objective: To determine the accuracy of saline SHG findings by comparing it with conventional Hysterosalpingography (HSG) findings in infertile women. Result: The concordance between saline sonohysterosalpingography and hysterosalpingography for the diagnosis of submucous fibroids, uterine adhesions and tubal patency in this study was over 94%. The saline SHG had sensitivity and specificity of 93.8% and 94.1% respectively for diagnosis of uterine fibroids (submucous) and a sensitivity and specificity of 62.5% and 98.9% in the diagnosis of intrauterine adhesions. It also had a sensitivity and specificity of 98.9% and 78.6% respectively in the detection of patent fallopian tubes. Conclusion: The ability of saline SHG to diagnose uterine pathology and tubal patency was comparable to that of conventional HSG. Saline SHG has the potential to replace HSG as the first-line test for the evaluation of uterine or tubal disease in infertile women.

Findings of Hysterosalpingography in Women Who Underwent Gynaecologic Imaging in a Tertiary Hospital in Douala, Cameroon

Background: Hysterosalpingography (HSG) is the first-line investigation among infertile women in Cameroon. There is a dearth of studies on the use of HSG in Cameroon. The aim of this study was threefold: 1) to describe the indications;2) findings of hysterosalpingography and 3) factors associated with abnormal findings on HSG at the Douala General Hospital, Cameroon. Methods: We conducted a retrospective descriptive study of 242 files of patients who underwent hysterosalpingography at the Radiology Department of the Douala General Hospital from January 2012 to December 2016. We collected data on the sociodemographic, obstetric variables and indications of HSG using a pretested data collection form. We also interpreted HSG films during the study period. Data analysis was with EPI-INFO version 7. Results: The age range was 19 - 46 years with a mean age of 33.16 ± 5.45 years. Majority 138/242 (57.1%) were in the age group 30 - 40 years. The main indication of HSG was infertility 87.2% (211/242). Most of the cases 95.87% (232/242) had abnormal findings at HSG. Tubal and uterine abnormal findings made up 133/232 (57.3%), and 97/232 (41.81%) of cases, respectively. Tubal occlusion and hydrosalpinges were found in 99/232 (42.67%) and 19/232 (8.19%) while uterine fibroids and uterine synechiae were found in 57/232 (24.97%) and 30/232 (12.93%), respectively. The factors independently associated with abnormal findings at HSG were: a history of recurrent pregnancy loss (AOR 2.95;95% CI: 1.19 - 7.32, p = 0.02) and infertility (AOR 0.24;95% CI: 0.06 - 0.92, p = 0.038). Conclusions: Infertility constituted the main indication, with tubal occlusion resurging as the most common abnormal finding on hysterosalpingography in this study. A history of recurrent pregnancy loss and infertility were factors independently associated with abnormal findings on hysterosalpingography. Therefore, HSG should be associated with hysteroscopy for uterine pathology and laparoscopy or selective salpingography to decrease the false-positive results of tubal patency in infertile women in Cameroon.

Treatment of Infertile Women with Unilateral Tubal Occlusion Diagnosed by Hysterosalpingography:The Role of Intrauterine Insemination

Summary:The optimal assisted reproductive treatment strategy for infertile women with unilateral tubal obstruction remains uncertain.To investigate the role of intrauterine insemination(IUI)in the treatment of infertile women with unilateral tubal occlusion,the data of 148 couples were retrospectively collected and analyzed.Seventy-eight infertile women with unilateral occlusion diagnosed by hysterosalpingography(HSG)were categorized as the study group and 70 others with unexplained infertility as the control group.The study group was divided into a proximal occlusion subgroup and a mid-distal occlusion subgroup for further analysis.The main outcomes,namely the clinical pregnancy rate(CPR),ongoing pregnancy rate(OPR),and live birth rate(LBR)per cycle,were analyzed.Our results showed a tendency of lower CPR,OPR,and LBR in the study group than in the control group,without statistical significance.Further investigations revealed that the unilateral proximal occlusion subgroup had similar CPR,OPR,and LBR as the control group,while the unilateral mid-distal occlusion subgroup had significantly lower CPR(5.1%vs.20.0%,P=0.035),OPR(5.1%vs.20.0%,P=0.035),and LBR(5.1%vs.20.0%,P=0.035)than the control group.In conclusion,the clinical outcomes of IUI were worse in patients with unilateral tubal occlusion than in those with unexplained infertility.This might be primarily caused by the worse outcome of patients with unilateral mid-distal tubal occlusion instead of proximal occlusion.

Hysterosalpingography Profile of Utero-Tubal Lesions in Female Infertility in Mopti (Mali, West Africa)

Introduction: Infertility is the inability to achieve pregnancy after 12 months of regular, unprotected sexual intercourse by a couple of childbearing age. It is a real public health problem because of its high prevalence in both developed and developing countries. Female infertility occupies a prominent place in reproductive health in Africa such as in our country Mali. The objective of this work was to determine the hysterosalpingography profile of utero-tubal lesions in the etiological research of female infertility in Mopti. Materials and Method: This was a cross-sectional descriptive study covering a period of one year from January 2019 to December 2019 in the radiology department of Sominé Dolo Hospital in Mopti. The variables analyzed were patient age and hysterosalpingography results. The hysterosalpingography examination was performed 3 or 4 days after menstruation on a remote-controlled table under fluoroscopic control. Data analysis was done with the aid of SPSS version 22 and Excel 2016 software. Results: During the study period, 9012 patients were seen in the imaging department, including 115 patients, or 1.3% for infertility assessment. The 25 - 29 age group was the most represented with 34 patients or 29.6%. The mean was 30.39 ± 6.96 years with extremes of 17 and 46 years. Tubal abnormalities represented 45 cases or 39.1%. Hydrosalpinx was the most prevalent with 26 cases or 36.6%. Conclusion: Tubal lesions were the most observed, especially hydrosalpinx following. Hysterosalpingography remains the first choice in the radiological assessment of female infertility in our context.

An Impact of Suspected Peritubal Adhesions by Hysterosalpingography on Outcomes of Intrauterine Insemination

Objective To assess the fertility prospect of women with suspected peritubal adhesions diagnosed by hysterosalpingography （HSG） treated with intrauterine insemination （IUI）. Methods The study group consisted of 93 patients diagnosed as bilateral suspected peritubal adhesions by HSG, and 175 patients with no tubal pathology were classified as control group. A total of 496 cycles of lUI were finished in 268 infertile women. Results There were no differences in basic clinical parameters between the two groups. Cumulative pregnancy rates after two cycles of lUI were 19.4%for the study group, and 34.3%for the control. Cumulative pregnancy rate in the women with abnormal contrast media loculation was significantly lower than that in women of the control （7.4% vs 34.3%, P=0.037）. The cumulative pregnancy rates were similar between the women with abnormal tubal contour and the normal ones （36. 7% vs 34.3%, P=0.800）. Conclusion Suspected peritubal adhesions in HSG were worthy more attention, since the outcome of lUI in women with loculation of contrast material, combined with or without abnormal tubal contour resulted in a significantly lower pregnancy rate than the normal ones. IUI should be delayed before tubal patency was confirmed during these patients.

Tubal Pregnancy Treated with Trichosanthin and Followed up by Hysterosalpingography

Twenty cases of unruptured tubal pregnancy were treated with trichosanthin intramuscularly.Only two cases were eventoally operated, so the effective rate was 90% . Hysterosalpingography was takenin 14 of 18 cases who was willing to accept the procedure at 0. 5- 1.5 year after the conservative treatment.Both tubes were patent in 10 of 14 cases, the rate of patency was 71.4% .

The Interest of Endoscopy in the Diagnosis of Fallopian Tubes Diseases at the Yaoundé Gyneco-Obstetric and Pediatric Hospital (Ygoph)

Introduction: Fallopian diseases are often implicated in female infertility. Several radiological and surgical explorations have been proposed in order to evaluate the severity of lesions found in utero-adnexal pathology. Among tools that are used to investigate such pathologies, we have ultrasound, hysterosalpingography and endoscopy. But, in many developing countries like Cameroon, the usage of endoscopy in gynecology is not yet known by many practicians. The objective of our study was to show the interest of endoscopy in the diagnosis of fallopian tube pathologies. Methodology: We conducted a cross-sectional and descriptive study from March 1st, 2017 to May 31st, 2017 at the Gyneco-Obstetrics and Pediatric department of our Hospital. We included all women who presented infertility and underwent ultrasound, hysterosalpingography (HSG) and endoscopy at the Yaoundé Gyneco-obstetrics Hospital. We analyzed epidemiological parameters, clinics, ultrasound, hysterosalpingography and endoscopic finding. We used Cohen’s Kappa test to determine the correlation between HSG/endoscopy and ultrasound/endoscopy in the diagnosis of fallopian tube pathologies. The threshold was significant for a K-value > 0.20. Results: We got a sample of 156 women;the mean age was 32.6 ± 4.5 years. The Secondary infertility dominated in 66.7% of cases;31.1% of women presented a past medical history of sexually transmitted infections and 41.7% did abortions before. Endoscopic lesions were dominated by a fallopian obstruction in 54.5% of cases, 8.3% of adhesions, 33.9% of women presented uterine myomas, 37.8% of ovarian cysts and 1.3% of pelvic endometriosis. The K-values between HSG and endoscopy for distal and proximal tube obstructions were significant with respective thresholds of 0.25 and 0.30. The K-value between ultrasound and endoscopy was not significant with a threshold of 0.015 for the tubal hydrosalpinx. Conclusion: Endoscopy assessment appears as the most efficient tool to investigate fallopian tube diseases.

Is Laparoscopy Still Necessary in the Management of Tubal Infertility?

Objectives: To compare between hysterosalpingography (HSG) and laparoscopic findings in patients tested for infertility and thereby to determine the significance of the latter examination. Methods: This was a descriptive study performed in two Gynecology departments in the Dakar (Senegal). Included were 84 patients with suspicious tubal-infertility who underwent HSG followed by laparoscopy. The Kappa (K) statistics was used to clarify the concordance between HSG vs. laparoscopy findings. Results: Kappa concordance between HSG and laparoscopy showed the followings: 0.08 for proximal tubal obstructions (poor agreement), 0.40 for distal tubal obstructions (moderate agreement), and -0.08 for peritoneal adhesions (no agreement). Laparoscopy revealed pelvic adhesions in 84% of cases, pelvic endometriosis in 12% of cases, and apparently normal tubes in 12%. According to the distal tubal operability score, 16.6% of the lesions were classified as stage 4 and 23.8% at stage 1. Conclusion: HSG and laparoscopy findings did not agree in patients with tubal infertility, and thus, laparoscopy should be employed, especially when HSG showed abnormal findings. HSG has a low diagnostic value in adhesions.

Hysterosalpingographic Findings among Patients Undergoing Infertility Work-Up in Kisangani, Democratic Republic of the Congo

Introduction: Hysterosalpingography is an important tool in the investigation of the causes of female infertility. In developing countries such as the Democratic Republic of Congo, the HSG is the basic tool for performing first-line anatomical (pelvic) assessment. The aim of this study is to determine the prevalence of the different lesions observed in hysterosalpingography carried out during the assessment of infertile women monitored in Kisangani. The study set also out to look for differences in these lesions according to the type of infertility. Methods: This cross-sectional study was conducted in Kisangani from June 2016 to December 2018. The 130 cases of hysterosalpingography performed for female infertility assessment during the study period were included, of which 33.07% for primary infertility and 66.93% for secondary infertility. Results: The mean age of the patients was 33.52 ± 6.01 years;the history of pelvic inflammatory disease was noted with a predominance for secondary infertility (11% vs. 4.65%). Using hysterosalpingography, 7 (5.38%) patients had a normal result;94 (72.31%) had tubal obstruction;25 (19.23%) had hydrosalpinx;11 (8.46%) had uterine fibroids;pelvic adhesions were suspected in 12.64% of cases. There was no obvious association between all these lesions and the type of infertility. Conclusion: We found that tubal obstructions were the most prevalent lesions in this study, regardless of the type of infertility. These lesions would reflect the high prevalence of septic abortions and sexually transmitted infections in developing countries such as the Democratic Republic of the Congo.

Laparoscopy in the Diagnosis and the Treatment of Infertility（Analysis of 340 consecutive cases）

Three hundred and jorty patients suffering from primary and secondary infertility were investigated by laparoscopy with the following results. 1. The substantial and most common causes of infertility were related to chronic pelvic inflammatory disease and pelvic endometriosis. 2. Comparison of the result of chromopertubation under direct vision during loparoscy with the preoperative results with hysterosalpingography and phenolphthaline tubal instillation test showed significant difference (P<0.01). In the tubal patent group the compatibility of the results was 90.2% and 79% respectively whereas in the obstructed tubal group the discrepancy between the results was 50.5% and 59% respectively. 3. With the aid of laparoscopic investigation, the underlying cause of infertility could be verified in 97.6% of the patients. In 53.2% of the cases 14 different kinds of operations were performed directly under the laparoscope, while 12.9% of the cases required loparotomy. In 58.5% of the patients laparoscopy was performed in combination with hysteroscopy and 26 operations,consisting of uterine septum resection and intrauterine adhesiolysis were completed undder the monitoring of the loparoscope.

The role of 3-dimensional ultrasound for the diagnosis of congenital uterine anomalies

Objectives: To demonstrate the value of 3-dimensional (3-D) ultrasound (US) in the diagnosis of congenital uterine anomalies. Methods: Fifty one infertile patients referred to our US unit during 12 years period, with suspected diagnosis of congenital uterine anomalies by previous HSG or 2D US examinations, were evaluated by transvaginal 3-D US. The 3-D US diagnoses were compared to the initial HSG diagnosis, and to hysteroscopic evaluation when performed. Results: 3-D scan confirmed the initial HSG diagnosis in 27 out of 51 (52.9%) women. The concordancy rates between the initial diagnosis by HSG and 3-D US results were 30.4% for bicornuate uterus;75% for arcuate uterus;83% for septate uterus;and 80% for unicornuate uterus. Of the 13 cases with normal HSG and suspicious 2-D US, 30.8% were found to be normal by 3D sonography. In cases where hysteroscopy was done, the results were 100% in concordance with the 3-D US evaluations. Conclusions: 3-D US is an accurate test for the assessment of uterine congenital anomalies. Its ability to concomitantly visualized, the external uterine contour with the uterine cavity on the same coronal plan, makes this noninvasive, easy to perform test the procedure of choice for the diagnosis of uterine anomalies.

An evaluation of methods for the test of tubal patency in female infertility

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Continued Diagnostic Difficulties in Preoperatively Differentiating Lipiodized Oil and Residual Metallic Material: A Case Report

Retained foreign objects in the abdomen and pelvis are serious clinical problems yet the imaging required can present difficulties. Prolonged retention of lipiodized oil used for hysterosalpingography over years is very rare. However, lipiodized oil had previously been misdiagnosed as residual metallic material. We are reporting a case in which the latest computed tomography (CT) equipment seemed inadequate for obtaining a clear pre-operative diagnosis. Here, we describe the case of a 33-year-old Japanese female whose pelvis had contained retained lipiodized oil that had been suspected as residual metallic material. The preoperative diagnosis was very difficult and included three-dimensional computed tomography (3D-CT) of unclear results despite expectations of resolution. By laparoscopic surgery, we removed a cyst of approximately 2 cm containing a yellowish oily fluid. Postoperatively, we demonstrated that the fluid was lipiodized oil. A postoperative experiment to attempt distinguishing lipiodized oil from metal through gemstone spectral CT imaging did not offer clarity either. Distinguishing between retained lipiodized oil and metallic material in the abdominal cavity may still present unexpected difficulties even with the latest medical equipments.