|Year : 2017 | Volume
| Issue : 2 | Page : 47-50
Hysterosalpingographic findings in women with infertility in Awka, Anambra State, South-East Nigeria
Samuel Iloraah Udobi1, Michael Echeta Aronu2
1 Department of Radiology, Chukwuemeka Odumegwu Ojukwu University Teaching Hospital, Amaku, Awka, Nigeria
2 Department of Radiology, Nnamdi Azikiwe University Teaching Hospital, Nnewi, Nigeria
|Date of Web Publication||23-May-2019|
Dr. Michael Echeta Aronu
Department of Radiology, Nnamdi Azikiwe University Teaching Hospital, Nnewi
Source of Support: None, Conflict of Interest: None
Background: Infertility is a major concern among couples in our environment. Hysterosalpingography (HSG) is a radiological procedure used to investigate women with infertility. It can be used to assess the cervical canal, the uterine cavity, and the fallopian tubes in these women. So far, the pattern of HSG findings in Chukwuemeka Odumegwu Ojukwu University Teaching Hospital (COOUTH), Amaku, Awka, has not been documented despite a lot of these investigations already carried out here. Objective: The objective of the study was to review the HSG findings among women with infertility in Awka. Materials and Methods: A retrospective study of HSG of women with infertility was carried out simultaneously at COOUTH and Amen Specialist Diagnostic Clinic, both in Awka, Anambra State, South-East Nigeria, from April 2013 to May 2017. The Statistical Package for the Social Sciences (SPSS) version 21 was used for the analysis. Tests for central tendencies and dispersions as well as paired sample correlation tests were carried out.P ≤ 0.05 was considered statistically significant. Results: A total of 446 cases were analyzed. The age ranged from 19 to 53 years. The mean ± standard deviation was 32.33 ± 6.02 years. The most common age group that presented was 26–30 years (33.9%), while the least were those aged ≥51 years (0.2%). Majority (56.1%) of cases presented with primary infertility while 43.9% had secondary infertility. The HSG was normal in 120 (26.9%) cases and abnormal in 326 (73.1%). Intrauterine filling defects were seen in 120 (26.9%) cases. Tubal occlusion occurred in 178 patients (40%): 106 (23.8%) bilateral, 31 (7%) left unilateral, and 41 (9.2%) right unilateral. Hydrosalpinx occurred in 49 (11%) patients: bilateral in 19 (4.26%), left unilateral in 19 (4.26%), and right unilateral in 11 (2.47%). Loculated peritoneal spillage was seen in 58 (13%) cases. Conclusion: HSG plays a vital role in the diagnostic workup of females with infertility in our environment and is therefore encouraged as a frontline investigation in women with infertility.
Keywords: Hydrosalpinx, hysterosalpingography, infertility, tubal occlusion
|How to cite this article:|
Udobi SI, Aronu ME. Hysterosalpingographic findings in women with infertility in Awka, Anambra State, South-East Nigeria. Niger J Surg Sci 2017;27:47-50
|How to cite this URL:|
Udobi SI, Aronu ME. Hysterosalpingographic findings in women with infertility in Awka, Anambra State, South-East Nigeria. Niger J Surg Sci [serial online] 2017 [cited 2019 Jun 18];27:47-50. Available from: http://www.njssjournal.org/text.asp?2017/27/2/47/258803
| Introduction|| |
According to the WHO, infertility is a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse. Infertility can be due to male factors or female factors. The male is said to responsible in about 30%–40%, the female in about 40%–55%, and both are responsible in about 10% cases. In Nigeria, infertility is regarded as a social stigma. Women with infertility more readily seek solution than their male counterparts. Female infertility can be of primary or secondary cause and can be due to structural or functional abnormalities involving one or more of the following parts of their reproductive system: the cervix, uterus, Fallopian tube More Details, and ovary. For instance, pelvic inflammatory disease-related tubal adhesions have been estimated to be responsible for 30%–50% of all cases of female infertility.
Hysterosalpingography (HSG), though uses ionizing radiation, can be used to demonstrate the cervical canal, uterine cavity, and the lumen of the fallopian tubes. It is readily available and the cost is moderate. As a result, it is readily deployed in the investigation of female infertility. It remains the best modality to image the fallopian tubes. Its diagnostic usefulness includes detection of uterine fibroids, polyps, intrauterine adhesions, tubal occlusion, tubal tuberculosis, salpingitis isthmica nodosa, and peritubal adhesions.
Other useful modalities for investigation of female infertility include abdominopelvic ultrasound, sonohysterography, 3-dimensional ultrasound, hysteroscopy, laparoscopy, and magnetic resonance imaging (MRI). All these have their strong and weak points. For instance, ultrasound is good at detecting myometrial and ovarian lesions and does not use ionizing radiation. However, it is poor at demonstrating the fallopian tubes. Sonohysterography and hysteroscopy are good at detecting intracavitary uterine lesions, but not extracavitary ones. MRI can assess the uterus and the ovaries as well as other pelvic organs and the pelvic wall, but is costly and not readily available in our environment.
Chukwuemeka Odumegwu Ojukwu University Teaching Hospital (COOUTH) is a new teaching hospital, located in Awka, and serves Awka and its environs. HSGs have been carried out in the hospital for sometimes now. However, no study has so far been conducted here to ascertain the hysterosalpingographic findings.
This study which is a retrospective one is aimed at analyzing important findings on HSG at COOUTH and comparing the findings with those from other centers locally and internationally.
| Materials and Methods|| |
This retrospective and descriptive study was carried out simultaneously at COOUTH, Amaku, Awka, and Amen Specialist Diagnostic Clinic, Awka (a radiological center manned by consultant radiologists), Anambra State, Nigeria. COOUTH is a newly established state-owned teaching hospital located in the state capital Awka. Along with a federal teaching hospital located at Nnewi, it offers tertiary health-care services to residents of Anambra State and parts of the neighboring states such as Enugu, Imo, Kogi, and Delta.
The relevant information (biodata and clinical information) in the request forms of the patients referred for HSG from April 2013 to May 2017 were retrieved from the radiology department of COOUTH and Amen Specialist diagnostic clinic. The corresponding reports of the consultant radiologists were also retrieved from the department. The radiologists' comments on the cervical canals (site, sizes, and outlines), uterine cavities, fallopian tubes, and peritoneal spillage of contrasts were reviewed together with the corresponding patients' biodata and clinical information. A total of 446 cases were used. Cases with incomplete information (biodata, clinical information, and radiologists' report of HSG) were excluded.
The Statistical Package for the Social Sciences (SPSS) version 21.0 by IBM Corp. Armonk, New York, USA was used for the analysis. Quantitative variables such as ages of cases were analyzed with measures of central tendency as well as measures of dispersion. Paired sample correlation tests were carried out between the ages of the cases and the following variables: the presence of intrauterine adhesions (IUA), hydrosalpinges, and tubal occlusion. There was further test for correlation between the type of infertility and the presence of IUA and tubal occlusion. P ≤ 0.05 was considered statistically significant.
| Results|| |
A total of 446 cases were analyzed. The minimum age of the patients was 19 years while the maximum was 53 years. The mean age was 32.33 ± 6.02 years. The most common age group that presented was 26–30 years which accounted for 33.9%, followed by the 31–35 years' age grade (24.2%), whereas the least were those aged above 51 years and above (0.2%), followed by those aged 20 years and below which accounted for only 0.7% [Table 1].
Majority (56.1%) of patients presented with primary infertility whereas 43.9% presented with secondary infertility. Correlation test showed no statistically significant correlation between the age of the patients and the following: intrauterine adhesions, hydrosalpinges, and tubal occlusion. Similarly, there was no correlation between the type of infertility and intrauterine adhesions, hydrosalpinges, or tubal occlusion.
In 120 (26.9%) of the patients, the HSG findings appeared normal, while in 326 (73.1%), various abnormalities were seen [Table 2].
The cervical outlines were normal in 87.9%, irregular in 11.9%, and V shaped in 0.2% of cases, while the orientation of the cervical canal was central in 89.9%, leftward in 4.0%, and rightward in 6.9% of cases. In 422 (94.6%) cases, the diameter of the cervical canal was normal, while it was dilated in 2.5% and narrowed in 2.9% of cases. The length of the cervical canal was normal in 92.8%, elongated in 4.5%, and shortened in 2.7% of cases.
The uterine cavity was centrally located in 392 (87.9%) cases, deviated leftward in 6.1%, deviated rightward in 3.8%, and elevated in 1.1%. The uterine outline appeared irregular in 20.6% of cases. The size of the uterine cavity was normal in 397 (89.0%) cases, enlarged in 1.1%, and small in 3.6%. One hundred and twenty (26.9%) cases showed filling defect in the uterine cavity, 47 (10.5%) were intraluminal, and 73 (16.4%) were marginal.
A total of 168 (39.9%) patients had tubal occlusion, 106 (23.8%) were bilateral, 31 (7%) were left sided, and 41 (9.2%) were right sided.
Hydrosalpinx was present in 49 (11.00%) cases. This was bilateral in 19 (4.26%) cases, left sided in 19 (4.26%), and right sided in 11 (2.47%). Fifty-eight cases (13%) showed loculated peritoneal spillage.
| Discussion|| |
The minimum age of the cases in this study is 19 years. This compares favorably with 18 years reported in Zaria, but is greater than that obtained in Maiduguri and lower than that obtained in Ado Ekiti. The maximum age in this study, which is 53 years, compares favorably with 55 years in the study by Eduwem et al. in Calabar and differs from 40 years documented by Ibinaiye et al. and 45 years reported by Bukar et al.
In this study, primary infertility (56.1%) was higher than the secondary type (43.9%). This finding is in agreement with a research done in Ethiopia and another done in Nnewi, South-East Nigeria. On the contrary, Botwe et al. in Ghana and Bukar et al. in Maiduguri, as well as Eze et al. in Benin, Nigeria, all reported higher incidences of the secondary type. It is likely that cultural and religious background played a role in this case as areas with less extramarital restraint will likely record more secondary infertility.
The cervical outlines appear abnormal in 12.1% of the cases in our study. This value is lower than 14.8% obtained by Okafor et al., but higher than 4.5% reported by Ibinaiye et al.
The cervix has irregular outline in 11.9% of our study population, and this value is higher than that reported by Okafor et al. The cervix was dilated in 2.5% and narrowed in 2.9% of the cases. On the other hand, Ibinaiye et al. reported dilated cervix in 0.9% of cases, while Bukar et al. and Eduwem et al. reported cervical stenosis in 0.4% and 1.95% of cases, respectively.
On HSG of the uterus, myomas, polyps, intrauterine adhesions, and even gas bubbles (iatrogenic) may appear as filling defects with various features. In this study, intrauterine filling defects were seen in 26.9% of the patients. However, some studies in other centers found these causes of filling defects to be within the 35.6%–56% range.,,, A study by Abubakar et al. pointed to a lower percentage.
The most common tubal lesion in this study was tubal occlusion (39.9%), with 23.8% being bilateral, 7% left unilateral, and 9.2% right unilateral. Abasiattai et al. similarly reported tubal block as the most common tubal lesion and bilateral involvement to be higher than unilateral. However, some researchers reported unilateral block to be higher.,,
This study showed no significant correlation between age and tubal occlusion (total, bilateral, or unilateral). On the contrary, Aduayi et al. reported a positive association between age and occlusion. The reason for the disparity between these two studies is not clear and coupled with the relative scarcity of this type of correlation tests in the reviewed literature; there is a need for more researches along this line.
In this study, hydrosalpinx accounted for 11% (bilateral in 4.26%, left sided in 4.26%, and right sided in 2.47%). While some researchers reported a higher percentage of this pathology,, others reported lower.,
The preponderance of unilateral hydrosalpinges over bilateral type seen in this study is in agreement with the findings in most of the reviewed literature.,,, On the other hand, while some researchers reported the left-sided lesion to be higher than the right sided type, as seen in this study, others noted the contrary.,
Fifty-eight (13%) of the patients in our study showed loculated peritoneal spillage, which is an evidence of pelvic adhesions. While this is close to that reported by Eze et al. (12%), it is higher than those obtained by Eduwem et al. and Danfulani et al. On the other hand, Aduayi et al. reported pelvic adhesions in 17.9% of cases while Abasiattai et al. noted peritoneal adhesions in 30.7%, and these values are higher than that obtained in this study.
| Conclusion|| |
With HSG as a single modality, 39.9% of the cases were diagnosed of tubal block and 23.8% were bilaterally, while 11% were diagnosed of hydrosalpinx and 4.26% were bilaterally so. Because both conditions are notable causes of infertility, this study has shown that HSG plays vital roles in the management of female infertility in our environment. Coupled with the nonavailability and/or nonaffordability of more modern modalities to a vast majority of women with infertility in our environment, HSG is still advised as a frontline investigation in female infertility workup.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Zegers-Hochschild F, Adamson GD, de Mouzon J, Ishihara O, Mansour R, Nygren K, et al.
International committee for monitoring assisted reproductive technology (ICMART) and the World Health Organization (WHO) revised glossary of ART terminology, 2009. Fertil Steril 2009;92:1520-4.
Ibinaiye PO, Lawan RO, Polite O, Hamidu HU, Igashi B. Evaluation of pattern of uterine and cervical abnormalities potentially responsible for infertility in Zaria, Nigeria: Hysterosalpingographic assessment. Boi Med J 2015;12:1-8.
Masuda IK, Suha J, Jesmin J, Shahana S, Chowdhury TA. Hysterosalpingography in Infertility. Delta Med Coll J 2014;2:9-12.
Bello TO. Pattern of tubal pathology in infertile women on hysterosalpingography in Ilorin, Nigeria. Ann Afr Med 2004;3:77-9.
Eng CW, Tang PH, Ong CL. Hysterosalpingography: Current applications. Singapore Med J 2007;48:368-73.
Bukar M, Mustapha Z, Takai UI, Tahir A. Hysterosalpingographic findings in infertile women: A seven year review. Niger J Clin Pract 2011;14:168-70.
] [Full text]
Aduayi OS, Akanbi GO, Akintayo AA, Aduayi VA. Hysterosalpingography findings among women presenting for gynaecological imaging in Ado-Ekiti, South Western Nigeria. Int J Reprod Contracept Obstet Gynecol 2016;5:1906-11.
Eduwem DU, Akintomide AO, Bassey DE, Ekott MI. Hysterosalpingographic patterns and relevance in the management of infertility in a Nigerian tertiary health institution. Asia J Med Sci 2016;7:70-4.
Admassie D, Negatuy Y. Evaluation of the fallopian tube in infertile women by hysterosalpingography in Tikur Anbessa hospital, Addis Ababa, Ethiopia. Int J Nurs Midwifery 2011;3:178-81.
Okafor CO, Okafor CI, Okpala OC, Umeh E. The pattern of hysterosalpingo – Graphic findings in women being investigated for infertility in Nnewi, Nigeria. Niger J Clin Med 2010;13:264-7.
Botwe BO, Bamfo-Quaicoe K, Hunu E, Anim-Sampong S. Hysterosalpingographic findings among Ghanaian women undergoing infertility work-up: A study at the Korle-Bu teaching hospital. Fertil Res Pract 2015;1:9.
Eze CU, Ohagwu CC, Abonyi LC, Njoku J, Irurhe N, Igbinedion FO. A spectrum of hysterosalpingographic findings in infertile women in Benin city Nigeria. J Reprod Infertil 2013;4:13-8.
Abubakar A, Ali YM, Nwobi IC, Nkubli BF, Miftaudeen MN, Njiti MM, et al
. Common hysterosalpingography protocols and findings among infertile women in a tertiary healthcare institution in Northeast, Nigeria. IOSR J Dent Med Sci 2016;15:124-7. Available from: http://www.iosrjournals.org
. [Last accessed on 2017 Jul 02].
Nwankwo NC, Akani CI. Pattern of hysterosalpingographic findings in infertility in Port Harcourt. West Afr J Radiol 2005;12:15-9.
Abasiattai AM, Edemkong II, Bassey EA. Hysterosalpingographic findings among infertile women in Uyo, South-Eastern Nigeria. West Afr J Radiol 2007;14:24-8.
Phillips CH, Benson CB, Ginsburg ES, Frates MC. Comparison of uterine and tubal pathology identified by transvaginal sonography, hysterosalpingography, and hysteroscopy in female patients with infertility. Fertil Res Pract 2015;1:20.
Danfulani M, Mohammed MS, Ahmed SS, Haruna YG. Hysterosalphingographic findings in women with infertility in Sokoto, North Western Nigeria. Afr J Med Health Sci 2014;6:19-23.
[Table 1], [Table 2]