Structural findings of hysterosalpingography in infertile women in Enugu, southeast Nigeria

Ngozi R Njeze; Salome N Ezeofor

doi:10.4103/ijmh.IJMH_12_20

ORIGINAL ARTICLES

Year : 2020 | Volume : 25 | Issue : 2 | Page : 96-100

Structural findings of hysterosalpingography in infertile women in Enugu, southeast Nigeria

Ngozi R Njeze, Salome N Ezeofor
Department of Radiation Medicine, Faculty of Medical Sciences, College of Medicine, University of Nigeria, Nsukka, Nigeria

Date of Submission	11-Mar-2020
Date of Decision	26-Mar-2020
Date of Acceptance	24-May-2020
Date of Web Publication	29-Jul-2020

Correspondence Address:
Salome N Ezeofor
Department of Radiation Medicine, Faculty of Medical Sciences, College of Medicine, University of Nigeria, Nsukka.
Nigeria

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijmh.IJMH_12_20

Abstract

Background: In the Nigerian culture, barrenness is a near catastrophe for women. Hysterosalpingography (HSG), being a prime investigation for infertility, is widely used in developing countries because of its positive yield, accessibility, and cost-effectiveness. Aim: The aim of this study was to identify the pattern and the most common radiologic findings in the HSG of women with infertility in Enugu, southeast Nigeria. Materials and Methods: This was a cross-sectional study involving 160 female patients who presented at the gynecology clinic of a private hospital in Enugu, Nigeria with clinical impression of infertility. The women were in turn referred to the radiology center for HSG. Data were analyzed using RStudio. Results: A total of 254 radiologic features were obtained as some patients had more than one radiological findings. The age range of the participants was 20 - 46 years, and the most prevalent age group was 25 - 29 years (31.1%). The most common clinical type of infertility was secondary infertility.The most common abnormal cervical and uterine findings were synechia (80%) and fibroids (65%) respectively. Bilateral tubal blockage 29.4% was the most common finding in the fallopian tubes. Normal findings were seen in 5.44%. Conclusion: Synechia and fibroids were the most common abnormal radiologic findings in the cervix and uterus, respectively. HSG was found to be informative in infertility evaluation, hence should still be recommended as a first-line imaging modality in infertility.

Keywords: Enugu, fibroids, hysterosalpingography, infertility, Nigeria, synechia, tubal blockage

How to cite this article:
Njeze NR, Ezeofor SN. Structural findings of hysterosalpingography in infertile women in Enugu, southeast Nigeria. Int J Med Health Dev 2020;25:96-100

How to cite this URL:
Njeze NR, Ezeofor SN. Structural findings of hysterosalpingography in infertile women in Enugu, southeast Nigeria. Int J Med Health Dev [serial online] 2020 [cited 2021 Jan 28];25:96-100. Available from: https://www.ijmhdev.com/text.asp?2020/25/2/96/291054

Introduction

Hysterosalpingography (HSG) is a simple radiologic investigation. It is relatively safe and inexpensive. HSG is readily available, and is a rapid radiographic examination used for visualizing the cervical canal, uterine cavity, fallopian tubes, and the presence of adhesions for management of female infertility.^[1],[2] It is an invaluable diagnostic tool for demonstrating the cause and exact site of cervico-uterine and tubal structural abnormalities in infertile women.^[3]

In most African cultures, Nigeria inclusive, women are mostly blamed for problem of reproduction. As a result, they have frustration, stigmatization, and marital disharmony/divorce.^[4]

HSG was performed first by Rindfleisch^[5] using Bismuth solution in 1910 and was considered to be the first radiologic procedure.^[6] There has been an increased demand in recent years because of advances in infertility treatment that has resulted in success rate of in vitro fertilization.^[7] HSG has an increased level of specificity and sensitivity for the evaluation of structural anomalies of the cervix and uterus.^[8] Uterotubal anatomical anomalies are a major cause of primary infertility. Therefore, proper evaluation is critical for targeted therapy.^[9] Infertility bears a significant psychological, medical, and economic burden.^[10] It is described as the inability to conceive after 1 year of unprotected, regular, deep penetrating sexual intercourse among women aged 15–49 years.^[11] If a woman has never been pregnant, infertility is said to be primary. Secondary infertility is the inability to conceive after a past pregnancy, which may or may not have led to live birth.^[12],[13]

Infertility has become a public health problem in Africa. Individuals and nations as a whole are spending lots of funds in overcoming this challenge.^[14]

In the United States and United Kingdom, it is estimated that 10% and 6%, respectively, of couples are infertile.^[15] African couples however have a higher prevalence ranging from 20% to 60%,^[16] and this has been attributed to complications of unsafe abortions, increased rate of sexually transmitted diseases (STDs), and puerperal pelvic infections.^[17],[18] Apart from STDs, other causes of pelvic infections are tuberculosis, Herpes Simplex virus and HSV-2 seropositive.^[19],[20]

It is reported that at some point in a woman’s reproductive life, about 15% will experience primary or secondary infertility.^[21]

In most developing countries, HSG is still widely used for the investigation of the structural cause of infertility due to its ability in resolving female genital cavity, cost-effectiveness, and availability.

The indications for HSG are as follows: evaluation of infertility, assisted reproduction, evaluation of women with spontaneous abortion, tubal sterilization efficiency, reversal of tubal surgery, evaluation of secondary amenorrhea, identification of congenital anomalies of the female genital tract, suspected uterovesical fistula, other uterine fistulae that may affect conception, abnormal uterine bleeding, and evaluation of uterine scar integrity after caesarian section.^[1],[22] The contraindications to HSG are pelvic inflammatory disease, risk of pregnancy, and hypersensitivity to contrast medium.

Some researchers have observed an increased incidence of conception after HSG investigation.^[1],[23]

It appears that there is increased demand due to recent advances in reproductive techniques. This study aimed to identify the current most common radiological abnormality to achieve the best possible diagnostic information and in future offer a solution to women with infertility in Enugu, southeast Nigeria.

Materials and Methods

This prospective cross-sectional study involved patients who were diagnosed with infertility and were referred to the radiology department of a private hospital in Enugu, southeast Nigeria to ascertain the cause of each patient’s infertility, between January 2018 and December 2018. Ethical clearance was obtained from the University of Nigeria Teaching Hospital, Enugu.

A total of 160 patients qualified for the study. HSG was carried out on each of the patients who met the “10-day rule” criterion and who ensured that they were not pregnant. This rule, which is part of the inclusion criteria, involves the investigation being done on the 10th day of the menstrual cycle. Calculation starts from the first day of the last menstrual period (LMP). This reduces the risk of irradiating a possible fetus and also minimizes the intravasation of the contrast medium into the uterine veins as this can obscure the visibility of possible lesions. Patients with pelvic inflammatory disease were excluded. Only patients with successful HSG examinations were recruited for the study. All the respondents were attending clinics in Enugu, southeast Nigeria. The investigation (HSG), which was carried out by radiologists, was preceded by obtaining informed consent from each patient after explanation of the procedure to them and psychotherapy. Then intravascular injection of 10 mg of Buscopan was administered. Conscious, open-mouth exercises were advised. A catheter was inserted through the cervical canal through which Urografin 76% (a contrast medium) was administered. Some sterile gauze padding was provided at the end of the procedure to avoid staining of the underwear.

All the radiographs were reported by the radiologists. The results were recorded, and data were analyzed using RStudio.

Results

A total number of 160 female patients aged between 20 and 46 years had HSG. A total of 148 were included in the study because 12 women did not meet the inclusion criteria. The most prevalent age range was 25–29 years (31.08%), whereas the least age range was 20–24 years (2.70%) as shown in [Table 1]. Most patients had a clinical history of secondary infertility. A total of 254 radiological findings were obtained because some patients had more than one findings. Synechia accounted for 80% of all radiological anomalies in the cervical canal [Figure 1], whereas fibroids (seen as intraluminal filling defect, narrowing or widening of the endometrial cavity, etc.) were the most common findings (65%) in the uterus [Table 2]. Bilateral tubal blockage is the most common anomaly in the fallopian tubes accounting for 29.4%, followed by left-sided tubal blockage (23.5%) [Figure 2]. In addition, hydrosalpinx is the most common on the right. Normal findings were seen in 5.44%.

Table 1: Age range from 20 to 46 years

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Figure 1: Changes in the cervix

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Table 2: Uterine radiologic findings

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Figure 2: Tubal blockage

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Discussion

HSG is a gold standard in the investigation of infertility.^[24],[25] Incidence of infertility varies in different parts of the world. This study shows that the incidence of secondary infertility is higher than that of primary, and this is in agreement with previous Nigerian studies conducted in Port Harcourt, Sokoto, Ado-Ekiti, and Calabar.^{[10],[22],[26],[27]} On the contrary, some other reports such as that from Nnewi, Nigeria and India, showed a higher incidence of primary infertility.^[25],[28] Infertility caused by tubal factor as the most common abnormal finding has been reported in many studies carried out in Nigeria, South Africa, and Egypt.^{[1],[3],[29],[30]} This study reports the highest abnormal finding to be uterine pathology and comprised roundish filling defects due to leiomyomas/fibroids and polyps (which may impair implantation of embryo). This is supported by other studies in Nigeria.^[10],[28] Factors attributed to the rising incidence of uterine fibroids are as follows: decreasing number of pregnancies, increased age of first pregnancy, increased age during reproductive years, genetics, hormonal changes (estrogen, progesterone, etc.), deficiency of micro nutrients (example, iron, vitamin D, etc.), and stress.^[31] Furthermore, a study in Ghana also showed increased incidence of uterine fibroid in obese patients and patients who are much older at the time of last delivery.^[32]

The highest number of patients that presented at the clinic were in the age range of 25–29 years, and this is in agreement with other reports.^{[1],[22],[27]} This is not surprising because in modern times, most females get married after completing their higher education in this age range (25–29 years). In the past, in our environment, females had minimal or no education and therefore married at a much younger age. Presentation for infertility at older age has been reported by various studies.^{[3],[26],[28],[33]}

The tubal blockage may result from previous pelvic infections arising from puerperal, postabortal sepsis, poor personal hygiene, and minimal education. Other possible causes of the tubal blockage are STDs, endometriosis, previous abdominal/pelvic surgery, previous ruptured appendix, hydrosalpinx, and so on. This decline in tubal abnormality as a result of infection may well be due to improved female education resulting in better health awareness. There could be a further decline in the incidence of pelvic infections but because single parenting is not popular in this part of the country, females with unwanted pregnancies still hide and seek initial treatment in unconventional medical centers. Of all the tubal abnormalities obtained from this work, bilateral tubal blockage is the most common. It also has a higher incidence than unilateral blockage. This finding has similarity with some reports.^{[24],[26],[27],[34]} It is however contrary to other studies where unilateral tubal blockage was noted to be more common.^{[10],[22],[33]} Although some researchers showed that right tubal blockage is more common than the left,^[22],[33] ours showed left blockage to be more common. The tubal blockage hinders the egg and the sperm from undergoing successful fertilization, although pregnancy may be achieved with one patent fallopian tube.

In this study, a higher incidence of right unilateral hydrosalpinx predominates. This is in concordance with a study by Poonam^[25] but contrary to that by Vasiljević et al.,^[35] in which bilateral hydrosalpinges is more common. The reason for the predilection on either side is unclear.

Synechia is also common in our environment as it was 80% of cervical anomalies and this is supported by a previous report.^[22] This may also be as a result of previous pelvic infections, past unconventional termination of pregnancy, treatments by “quack” medical personnel, and so on.

Lower incidence of a normal finding of 5.44% was documented from this report when compared with higher figures of 41.7% and 77.8% in other studies in India.^[2],[22] The explanation for this is unknown. These cases with normal findings rule out structural abnormalities as the cause of the infertility. Therefore, other investigations such as transvaginal ultrasound and hormonal assays ought to be explored.

There were only two cases (1.35%) of congenital anomalies both hypoplasia in this report, which shows it is uncommon in this environment. Malformation makes the uterus grossly inadequate in housing a growing zygote. This is close to a study in Uganda,^[24] which reports 1.6% in the studied population. An earlier study has reported congenital anomalies as high as 20%; highest being also uterine hypoplasia.^[25] It can be said that the incidence of congenital uterine anomaly appears geographical.

Some patients in this study, as in an earlier study,^[1] had multiple abnormalities.

Some gynecologists reported that their patients benefited from the finding/advise regarding treatment offered by the radiologist. Ten of 148 (6.76%) of the patients became pregnant within months after the procedure. This establishes the fact supporting the somewhat “amazing” therapeutic effect of HSG.^[36]

Conclusion

The most common abnormal finding with HSG in the cervix is synechia, whereas the most common in the uterus is fibroids. Accurate interpretation of HSG images is crucial for initial workup of patients with infertility and subsequent avoidance of unnecessary and sometimes more aggressive procedures.

Recommendations

Future research is recommended to elucidate the cause of the increased incidence of uterine fibroids in this environment.

Health policies/national health insurance scheme provided for hysterosalpingogram is advised. This will help alleviate the burden of payment as every woman desires to have her own offspring in view of the cultural influence.

Acknowledgement

We are grateful to Engr Ngozi Menkiti who assisted in the data analysis.

Financial support and sponsorship

This study was self-funded.

Conflicts of interest

There are no conflicts of interest.

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