AJR 2001; 177:131-135
© American Roentgen Ray Society
Hysterosalpingography
Spectrum of Normal Variants and Nonpathologic Findings
Belén Úbeda1,
Marta Paraira,
Enric Alert and
Ramón Angel Abuin
1
All authors: Department of Radiology, Institut Universitari Dexeus,
P0 Bonanova, 67 pl-2, 08017 Barcelona, Spain.
Received July 28, 2000;
accepted after revision December 4, 2000.
Address correspondence to B. Úbeda.
Introduction
Hysterosalpingography is a valuable technique in the evaluation of the
infertile patient. During the last decade, the number of women seeking
infertility evaluation has increased considerably. Hysterosalpingography is
considered a screening procedure for an infertility workup, and despite the
development of other diagnostic tools such as MR imaging, hysteroscopy, and
laparoscopy, hysterosalpingography remains the main examination for the study
of the fallopian tubes [1].
This technique provides useful, although indirect, information outlining the
uterine cavity and the fallopian tubes. Hysterosalpingography has been
reported to have a high sensitivity but a low specificity, especially in the
diagnosis of uterine cavity abnormalities
[2,
3]. The technical quality of
the hysterosalpingogram is important to limit factors leading to
misinterpretations. It is also essential for the radiologist to be familiar
with the normal and abnormal radiologic findings for the correct
interpretation of hysterosalpingograms.
This pictorial essay describes and illustrates the hysterosalpingographic
appearances of technical artifacts, normal variants, and findings with no
proven influence on fertility.
Technical Artifacts
Air Bubbles
During hysterosalpingography, air bubbles can incidentally be introduced
into the uterine cavity and may be mistaken for other filling defects such as
blood clots, polyps, submucosal myomas, or endometrial hyperplasia. An air
bubble appears as a round, well-defined filling defect; multiple air bubbles
are often seen, and they are usually identifiable by their mobility.
Introduction of air bubbles can be prevented by careful removal of air bubbles
trapped in the cannula. When present, air bubbles must be eliminated by
additional injection of contrast material, which flushes them out of the
uterine cavity through the fallopian tubes (Fig.
1A,1B).
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Fig. 1A. —Air bubbles in uterine horns of 29-year-old asymptomatic
woman. Hysterosalpingogram obtained with balloon-catheter shows multiple
rounded filling defects (arrows), which are mobile, at both uterine
horns.
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Fig. 1B. —Air bubbles in uterine horns of 29-year-old asymptomatic
woman. Hysterosalpingogram obtained with additional injection of contrast
material shows bubbles have been flushed out of uterine cavity through
fallopian tubes.
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Venous or Lymphatic Intravasation
Venous or lymphatic intravasation can occur in up to 6% of patients
undergoing hysterosalpingography
[4]. Although it can occur in
healthy patients, there are some predisposing factors such as recent uterine
surgery or increased intrauterine pressure because of tubal obstruction or
excessive injection pressure
[2,3,4].
The radiographic appearance of early intravasation is characterized by
filling of multiple thin beaded channels and an ascendant course (Figs.
2 and
3). When intravasation is
recognized, the injection should be stopped if an oil-soluble medium has been
used. Venous intravasation is innocuous as long as a water-soluble contrast
medium is used.
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Fig. 3. —Venous intravasation in healthy 36-year-old woman.
Hysterosalpingogram obtained in patient with right isthmic tubal occlusion
(short arrow) shows venous intravasation of contrast material into
myometrial vessels (long arrow).
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Controversy exists regarding the proper choice of contrast material for
hysterosalpingography. Some authors support the use of an oil-soluble contrast
medium, arguing that it provides greater contrast and sharpness of the image
and more information about the presence of peritubal adhesions
[5]. An increase in pregnancy
rates in infertile patients after hysterosalpingography with oil-soluble
medium has been suggested [6],
whereas another study [7] shows
no statistical difference between the use of oil- and water-soluble contrast
agents.
Most authors advocate the use of a water-soluble contrast medium
[2,3,4]
because it provides better uterine and ampullary mucosal detail and has no
serious secondary effects such as peritoneal inflammatory or granulomatous
reaction and because it eliminates the risk of pulmonary and retinal oil
emboli. In addition, venous intravasation of water-soluble contrast medium
produces no adverse effects, entering the vascular system and being excreted
by the kidneys. Therefore, both diagnostic and safety factors recommend the
use of a water-soluble contrast medium.
Normal Variants
Myometrial Folds
In a small percentage of patients, broad longitudinal folds parallel to the
uterine cavity are seen on hysterosalpingograms with otherwise normal findings
(Fig.
4A,4B,4C).
These folds are not associated with endometrial abnormalities. Although the
exact etiology is unknown, the folds are considered as remnants of the
müllerian duct fusion during fetal development
[4].
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Fig. 4A. —Myometrial folds in 34-year-old woman. Hysterosalpingogram
shows broad longitudinal folds (arrows) parallel to uterine cavity
that must be identified at early underfilled view of uterus.
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Double Uterine Contour
Hysterosalpingography should be performed during the follicular phase of
the menstrual cycle before ovulation. In the few patients in whom
hysterosalpingography is performed during the late secretory phase of the
menstrual cycle—for example, in the evaluation for cervical
incompetence—a double contour can be seen as a thin line of contrast
medium surrounding the uterine cavity (Fig.
5). The contrast medium does not penetrate into the myometrial
vessels, and therefore there is no filling of the myometrial, uterine, or
ovarian veins. A double contour representing contrast material underneath the
decidual reaction of the endometrium can also be observed in an early
pregnancy [4]
(Fig. 6).
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Fig. 6. —Double uterine contour in 34-year-old pregnant woman.
Hysterosalpingogram was inadvertently obtained in this patient who had vaginal
bleeding resembling menses 1 month before study. Hysterosalpingogram shows
mildly enlarged uterine cavity with double contour. No gestational sac is
evidenced.
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Prominent Cervical Glands
The normal cervical canal is delineated by the internal and external
cervical os and can have variable appearances depending on the patient and the
time in her cycle. The cervical canal is usually narrower at the external and
internal os and wider in the midportion. The walls may be smooth or serrated
with longitudinal ridges representing the plicae palmatae. Sometimes, filling
of normal endocervical glands may be observed as multiple tubular structures
that originate from both cervical walls
(Fig. 7).
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Fig. 7. —Prominent cervical glands in 27-year-old woman.
Hysterosalpingogram with normal findings shows tubular-shaped structures
(arrows) originating from cervical walls that correspond to filling
of normal or dilated cervical glands.
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Findings with No Proven Influence on Fertility
Arcuate Uterus
The arcuate uterus is usually an incidental finding during
hysterosalpingography, and it appears as a mild smooth concavity in the
uterine fundus instead of the more common straight or convex normal fundal
contour (Fig. 8). According to
the American Fertility Society's classification, an arcuate uterus is
considered a class VI müllerian anomaly
[8]. Nevertheless, an arcuate
uterus is such a minor uterine malformation that it is considered a normal
variant and is not associated with infertility or obstetric complications
[4,
8]. It must be differentiated
from the V-shaped fundus of the subseptate uterus and from an extrinsic
compression caused by an intramural myoma.
Gartner's Duct Cyst
Gartner's duct is a remnant of the caudal portion of the mesonephric or
wolffian duct that fails to resorb normally in the female. Gartner's ducts can
be single or multiple and are usually located parallel to the anterior lateral
wall of the proximal third of the vagina
[4]. Secretion by persistent
glandular tissue may allow cysts to form in its course.
Gartner's duct cysts may be visualized during hysterosalpingography if they
communicate with the uterine lumen. These cysts are usually incidental
findings with no clinical significance. They appear as tubular structures that
run parallel to the uterine cavity or vagina, sometimes with cystic or
saccular dilatations (Figs. 9
and 10).
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Fig. 9. —Gartner's duct cyst in 25-year-old asymptomatic woman.
Hysterosalpingogram shows tubular structure, running parallel to uterine
cavity (arrows), that represents Gartner's duct communicating with
uterine lumen.
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Fig. 10. —Gartner's duct cyst in 32-year-old woman. Hysterosalpingogram
reveals course of Gartner's duct cyst running along vaginal wall. Saccular
dilatations (large arrow) can be present. Note left hydrosalpinx with
severe ampullary dilatation and no free intraperitoneal spill (small
arrows).
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Infantile Uterus
The normal adult uterus can have variable appearances, with a
triangular-shaped uterine cavity and smooth margins. The uterine body
comprises two thirds of the entire uterine length, and the remaining third
corresponds to the endocervical canal. In patients taking oral contraceptives
for long periods of time, a small T-shaped uterus can be observed
characterized by a 1:1 ratio between the uterine body and the cervix, which
are the normal proportions of a premenarchal uterus
(Fig. 11). This appearance can
also be observed in adult women with severe estrogen deficiencies in which the
uterus fails to attain postpuberal proportions because of the absence of
normal estrogen stimulus
[4].
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Fig. 11. —Infantile uterus in 30-year-old woman. Hysterosalpingogram
shows small, T-shaped uterus with cervix and uterine body of similar size.
Patient had been taking oral contraceptives for several years.
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Tubal Polyps
Tubal polyps are small foci of ectopic endometrial tissue located at the
intramural portion of the fallopian tubes. They can be unilateral or
bilateral, and they measure less than 1 cm in diameter. Radiologically, tubal
polyps appear as smooth, round or oval filling defects, not associated to
tubal dilatation or obstruction, with free flow of contrast medium to the
peritoneal cavity (Fig. 12).
Patients with tubal polyps are asymptomatic, and polyps are usually an
incidental finding at hysterosalpingography; of hysterosalpingograms obtained
for infertility investigation, the reported incidence is 1-2.5%
[9].
The role of tubal polyps in infertility has been long questioned, but an
absolute causal relationship between tubal polyps and infertility has not been
definitely established [9,
10]. The consensus is that
other causes of infertility should be sought before treatment of polyps is
considered. Hormonal and surgical treatments have so far been
unsuccessful.
Cesarean Delivery Scar
Cesarean delivery requires a transverse incision at the uterine isthmus and
can be seen at hysterosalpingography as a wedge-shaped out-pouching at the
level of the internal os (Fig.
13). This finding has no clinical significance and is not a
diagnostic problem if it is correlated with the clinical history of the
patient.
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Fig. 13. —Cesarean section scar in 37-year-old woman who had cesarean
delivery several years earlier. Hysterosalpingogram shows wedge-shaped
outpouching at level of internal cervical os representing site of cesarean
scar (arrow).
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Postmyomectomy Diverticulum
Myomectomy is being performed increasingly for the treatment of menorrhagia
and infertility. After the resection of a submucous fibroid, small
diverticula—generally less than 1 cm in diameter—can be found in
some patients at the site of resection
[11]
(Fig. 14). The significance of
this finding has not yet, to our knowledge, been documented, but diverticula
seem to have no clinical importance when they are small and not associated
with major distortion of the uterine cavity.
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Fig. 14. —Diverticulum in 33-year-old woman who underwent resection of
submucous fibroid. Hysterosalpingogram obtained after patient underwent
myomectomy shows small diverticulum at site of resection with no distortion of
uterine cavity (arrow).
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Summary
The number of hysterosalpingographic examinations has increased during the
last decade because of the greater concern regarding infertility.
Hysterosalpingography plays an extremely important role in the diagnostic
assessment and treatment of infertility in the female patient. An accurate
interpretation of the hysterosalpingogram is necessary for the infertility
workup, considering the nonpathologic findings that are seen at otherwise
normal examinations. Knowledge of these entities is important to avoid the
practice of unnecessary and sometimes more aggressive procedures.
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Introduction
Technical Artifacts
