Infertility was defined by the World Health Organization in 1993 as a common gynecological condition in which couples live normally for one year without contraception and do not conceive. The prevalence of infertility is reported to be about 5-8% in developed countries and up to 30% in some areas of developing countries, with tubal disease accounting for about 25-50% of infertility. Hysterosalpingography is an important method to diagnose tubal infertility. The traditional iodinated oil imaging method is prone to allergy and is time-consuming, poorly tolerated by patients, slow to be absorbed in the abdominal cavity, and produces irritation to nearby tissues, which limits its use in patients. In order to explore a safe and convenient method to examine the patency of fallopian tubes, our hospital performed hysterosalpingography using Onepak in 69 infertility patients from June 2002 to July 2004, which is summarized as follows: Xiaoping Pan, Interventional Vascular Surgery Department, Wuhai People’s Hospital
I. Clinical data
The subjects were patients with tubal infertility voluntarily examined by using Onepak in our gynecology outpatient clinic, aged 24–35 years, with infertility duration of 2–10 years and average 4.8 years. There were 32 patients with primary infertility and 37 patients with secondary infertility, and 26 cases with 30% positive pancytopenia test.
II. Instruments and methods
Equipment and instruments: The surveillance equipment was OEC 9800 C-arm from GE, USA, and the instruments were conventional instruments for hysterosalpingography.
2. Contrast agent: 300mgI/ml of Onepac, containing 647mg of lohexol per ml of sterilized aqueous solution, was used. 20ml and 50ml were used.
3. Preparation before contrast: 2 – 7 days after menstruation, half an hour before contrast 30% pantethine glucosamine one ml drop into the conjunctiva and observe for 15 minutes. If there is tearing, conjunctival redness, swelling and pain, the test is positive for iodine allergy. In this case, dexamethasone 10mg is given 30 minutes before the procedure and then the imaging is performed.
4.Contrast procedure: The patient lies supine on the examination bed, routinely disinfects and spreads the towel, observes the pelvic cavity, then places the hysterosalpingography catheter and slowly injects the contrast agent Onepac under fluoroscopy. Generally, when 5-7 ml is injected, the uterine tube fills up; when the injection continues to 10-15 ml, the contrast agent can be seen overflowing from the umbilical end of the fallopian tube to the pelvic cavity, appearing as a cloud or irregular patchy shadow. If there is no diffuse shadow of contrast agent in the pelvic cavity, it can be decided whether to continue to inject contrast agent according to the resistance of contrast agent injection. If the resistance is low, the injection can be continued until the contrast diffusion appears in the pelvis. If the resistance is high and there is no diffuse shadow in the pelvic cavity, the contrast injection can be stopped and the contrast catheter can be left in place for 5 – 15 minutes of observation. Surveillance equipment will be used to capture images of the whole contrast process.
Judgment method
1.Patency of the fallopian tubes: the uterus is filled in an inverted triangle, and the fallopian tubes on both sides are bent like worms on both sides of the uterus. The contrast agent first fills the isthmus of the proximal part of the fallopian tubes, and then fills the distal pot belly rapidly, and then diffuses from the umbilical end to the pelvis. The image acquisition mainly shows the travel of the uterus and fallopian tubes and scattered cloudy shadows in the pelvis, or the contrast agent accumulates around the uterus at the bottom of the pelvis, forming irregular shadows.
2. Fallopian tube obstruction: The fallopian tube does not show shadow at all, or no longer shows shadow after showing one end, and the contrast agent is injected to a certain dose with high resistance and cannot be injected further. There is no diffuse shadow of contrast agent in the pelvis.
3. The fallopian tube is patent, there is resistance to push injection of contrast agent, contrast agent enters the pelvic cavity slowly, and after stopping contrast agent injection for 5 – 15 minutes, diffusion of contrast agent in the pelvic cavity is seen.
4. Hydrocele: The contrast agent accumulates in the fallopian tube, and the fallopian tube is abnormally dilated in a cystic or salami shape, which is obvious at the distal end, with no contrast agent dispersion in the pelvic cavity.
IV. Results
1. Tubal patency: 39 cases of bilateral tubal patency, 10 cases of bilateral tubal obstruction, 12 cases of unilateral tubal obstruction, 5 cases of tubal patency, and 3 cases of hydronephrosis.
2. Allergic reactions: 69 patients, including 26 patients with positive allergy test for contrast agent, none of them had allergic reactions during the procedure with preoperative medication.
3. abdominal pain, nausea and vomiting: most patients had only mild discomfort in the lower abdomen, especially in patients with good tubal patency. 2 patients complained of significant abdominal pain and 1 patient had nausea and vomiting.
V. Discussion
Hysterosalpingography, is a common diagnostic method for tubal infertility. It provides contrast imaging and can definitely evaluate the patency of the fallopian tubes. It also shows the contour of the endometrial cavity, the tension of the myometrium, the site of tubal atresia and changes in the mucosa of the fallopian tubes. It has its irreplaceable role in the diagnosis of tubal infertility. Even some infertile patients with patent fallopian tubes become pregnant a few months after hysterosalpingography is performed.
The traditional contrast method using iodinated oil as a contrast material may not only result in oil embolism, but sometimes chemical peritonitis or foreign body granulomatous reaction in the fallopian tubes. In addition, allergic reactions, rash, shock and even death can occur. Thus limiting its use in some patients. With the continuous updating of diagnostic X-ray equipment and the continuous improvement of the quality of water-soluble contrast agents in recent years, more and more hysterosalpingograms have started to use water-soluble contrast agents. Onepac is the most widely used water-soluble, low osmolarity, non-ionic contrast agent in the world. Clinical studies have confirmed that Onepac is extremely safe and has excellent imaging effects. It has the advantages of high contrast, good patient tolerance, no local irritation, low incidence of allergic reactions, and minimal side effects. None of the 69 patients who underwent hysterosalpingography with Onepac had allergic reactions, and most of them had no significant discomfort. The diagnosis was made within half an hour in all patients, saving time and trouble. It shows that this method is safe, convenient and has the value of promotion.
In terms of technical operation, our hospital uses interventional equipment with image intensifier, which can collect images in real time while fluoroscopy. This not only avoids the absorption of a large amount of X-rays by the ovaries during the imaging process, but also enables timely detection of reversal of blood vessels and backflow of contrast into the vagina, thus controlling the amount of contrast agent, diagnosing polyps or other minor lesions that are not easily detected, and correcting the direction and depth of the hysterosalpingogram catheter placement site.