Should a hysterosalpingogram be a first-line investigation to diagnose female tubal subfertility in the modern subfertility workup?

Chou Phay Lim 2 Zaid Hasafa 2 S. Bhattacharya 1 A. Maheshwari 0 0 Reproductive Medicine, Division of Applied Health Sciences, University of Aberdeen, Aberdeen Maternity Hospital , Aberdeen AB25 2ZL , UK 1 Division of Applied Health Sciences, School of Medicine, University of Aberdeen , Aberdeen AB25 2ZD , UK 2 Obstetrics and Gynaecology, Aberdeen Maternity Hospital , NHS Grampian, Aberdeen AB25 2ZL , UK Tubal assessment is an integral part of female fertility evaluation. While diagnostic laparoscopy is gold standard, it is not suitable to be used as a screening test. Hysterosalpingogram (HSG) has been advocated as first-line investigation historically. With advances in diagnostics, more tests are available, such as hysterosalpingo contrast sonography (HyCoSy) and Chlamydia antibody titre (CAT) are available. The CAT test is much cheaper, less invasive and can be performed at any time during the cycle. The CAT test can also be used as a means of identifying which patients need further evaluation. HyCoSy has same diagnostic accuracy as HSG, without exposing women to radiation. We argue that HSG is out of date and has no place in a modern infertility evaluation. We also suggest a pathway (based on history, clinical and ultrasound evaluation) for investigations to screen for and diagnose tubal pathology. Background Fallopian tube abnormalities account for up to 40% of female subfertility (Snick et al., 1997; Steinkeler et al., 2009). Assessment of tubal patency is one of the first steps in fertility investigations. Hysterosalpingography (HSG) is the most common first-line diagnostic test used for this purpose (Crosignani and Rubin, 2000; National Collaborating Centre for Womens and Childrens Health, 2004; Lanzani et al., 2009). In addition to assessing tubal patency, HSG also provides an image of the outline of the uterine cavity. It has also been suggested that HSG has a therapeutic role in enhancing subfertility (Mackey et al., 1971 ; DeCherney et al., 1980; Schwabe et al., 1983; Rasmussen et al., 1987; Yaegashi et al., 1987). As a relatively inexpensive outpatient procedure, HSG fulfils many attributes of a first-line test for tubal patency (Siegler, 1983; Nielsen et al., 1987; National Collaborating Centre for Womens and Childrens Health, 2004). Nevertheless HSG has certain limitations, which have prompted us to query its present role when newer modalities, such as the Chlamydia antibody titre (CAT) test and hysterosalpingo contrast sonography (HyCoSy), are readily available. Diagnostic accuracy Laparoscopy is commonly viewed as the gold standard in diagnosing tubal patency. It also provides an opportunity to diagnose and treat endometriosis and peritubal adhesions. However, it is an invasive and expensive procedure requiring general anaesthesia with a 0.13% risk of surgical complications (Chapron et al., 1998). Furthermore, facilities for surgery may not be readily available in every clinic. Hence, laparoscopy is unsuitable for routine use in subfertile women on a large-scale. Obtaining a reliable estimate of the risk of tubal pathology by another method, prior to proceeding with laparoscopy, would allow only high-risk patients to be selected for this procedure. Hence, HSG and CAT have been suggested for the initial investigation. HSG has been reported to have a sensitivity and specificity of 53 and 87%, respectively, for any tubal pathology and 46 and 95%, respectively, for bilateral tubal pathology when compared with laparoscopy (Broeze et al., 2010). The discriminatory capacity of CAT is comparable with that of HSG in the diagnosis of tubal occlusion (Mol et al., 1997), while HyCoSy is as accurate as HSG in terms of establishing tubal patency (Campbell et al., 1994; Heikkinen et al., 1995) (Table I) when compared with laparoscopy. HyCoSy has the additional advantage of allowing an ultrasound assessment of the pelvis at the same time and is superior in detection of intrauterine abnormalities (Alatas et al., 1997), such as endometrial polyps, submucosal fibroids, synechiae as well as hydrosalpinges and abnormal ovaries (Steinkeler et al., 2009). Hence, laparoscopy remains the gold standard for those who wish to have a definitive diagnosis. However, all three (CAT, HSG and HyCoSy) tests are proved to have similar accuracy in terms of identifying women who should have laparoscopy. Radiation exposure Women undergoing HSG are exposed to pelvic radiation. The mean dose-area product (DAP) for a complete HSG examination is 2.05 Gy cm2. In comparison, the mean DAP for a single posterior anterior chest X-ray examination is 0.09 Gy cm2 (Hart et al., 2009). In contrast, there is no exposure to radiation associated with HyCoSy and CAT. Use of contrast media HSG is performed by the passage of a radio-opaque dye from the cervical canal into the uterine cavity under fluoroscopic guidance (Bendick, 1947). HSG can be performed using water or oil-soluble contrast medium (OSCM). Although there are reports that the use of OSCM in HSG increases the chance of spontaneous pregnancy (Luttjeboer et al., 2007), they are associated, rarely, with oil embolism and granulomatous inflammation in the presence of obstructed or inflamed Fallopian tubes. Water-soluble contrast medium, which produces superior radiographic images, is currently seen as the preferred medium (Mackey et al., 1971; Soules and Spadoni, 1982; Schwabe et al., 1983). However, water-soluble contrast materials have been linked with an increased frequency and duration of bleeding after HSG (Lindequist et al., 1991) and higher post-HSG miscarriage rates (Rasmussen et al., 1991; Spring et al., 2000). It has been suggested that we should use water-soluble contrast media to demonstrate tubal patency followed by OSCM for its therapeutic advantage; however, this will increase the cost, time and discomfort associated with the procedure (DeCherney et al., 1980). Nevertheless, all types of media contain iodine, and hence are not suitable for use in women who are sensitive to iodine. HyCoSy does not require the use of iodine or involve exposure to radiation. HyCoSy has traditionally been performed using ultrasound contrast media; however, saline and air have been suggested as alternatives (Spalding et al., 1997; Boudghene et al., 2001). Organization of procedures HyCoSy can be carried out as an office procedure by specialists in reproductive medicine without the input from radiology services (as for HSG) (Schlief and Deichert., 1991; Deichert et al., 1992; Campbell et al., 1994), while CAT is a blood test that can be arranged from primary care. Both HyCoSy and HSG can only be performed at a certain time in the menstrual cycle. Alternatively, patients are advised to use contraception, which means that they loose at least raep llis ... 1 month in terms of trying for pregnancy. However, CAT determination from a blood test can be performed at any time during the cycle, without the need to avoid pregnancy. Cost CAT, being a blood (...truncated)