DOI:10.2214/AJR.07.3957
AJR 2008; 191:1381-1385
© American Roentgen Ray Society
MR Hysterosalpingography with an Angiographic Time-Resolved 3D Pulse Sequence: Assessment of Tubal Patency
Elizabeth A. Sadowski1,
Jennifer E. Ochsner2,
Jody M. Riherd1,
Frank R. Korosec1,
Garima Agrawal1,
Elizabeth A. Pritts3 and
Mark A. Kliewer1
1 Department of Radiology, University of Wisconsin School of Medicine and Public
Health, 600 Highland Ave., Madison, WI 53792-3252.
2 Present address: Department of Radiology, University of Washington, Seattle,
WA.
3 Wisconsin Fertility Institute, Madison, WI.
Received March 7, 2008;
accepted after revision June 5, 2008.
Address correspondence to E. A. Sadowski
(esadowski{at}uwhealth.org).
Abstract
OBJECTIVE. The purpose of our study was to determine if tubal
patency can be assessed by MR hysterosalpingography (HSG) using a clinically
available MR angiographic sequence (3D time-resolved imaging of contrast
kinetics [TRICKS]). This capability would enhance the value of MRI in women
with infertility.
CONCLUSION. MR HSG effectively shows tubal patency and can be
considered when both conventional HSG and standard MRI are necessary for the
evaluation of women with infertility, such as in women with suspected uterine
anomalies or extrauterine disease.
Keywords: hysterosalpingography • infertility • MRI • tubal patency
Introduction
Women presenting with infertility undergo many laboratory tests and imaging
studies to exclude endocrine disturbances, congenital anomalies of the genital
tract, uterine abnormality, and occlusion of the fallopian tubes. Current
imaging techniques used to evaluate tubal patency include
hysterosalpingography (HSG) under fluoroscopy and contrast-enhanced
hysterosalpingosonography. However, these imaging examinations provide limited
evaluation of congenital uterine malformation and extrauterine disease
[1]. MRI, by contradistinction,
can offer a comprehensive anatomic survey and, potentially, can assess for
tubal patency
[2–4].
Because women with infertility may be referred to MR for diagnosis of
uterine or extrauterine abnormality, the ability to simultaneously assess
tubal patency would be beneficial. The purpose of this study was to determine
if MR HSG, using a clinically available MR angiographic sequence (3D
time-resolved imaging of contrast kinetics [TRICKS]), can be used to reliably
ascertain tubal patency.
Materials and Methods
Subjects
This nonrandomized, HIPAA-compliant study was approved by our institutional
review board, and written informed consent was obtained from all subjects.
Seventeen women with infertility were recruited between August 2005 and August
2006. All subjects underwent clinically indicated conventional HSG under
fluoroscopy before MR HSG. Average time between the MR HSG and conventional
HSG was 76 days. The conventional HSG was performed as part of routine
clinical care.
MRI Technique
MRI was performed on a 1.5-T system (Signa, GE Healthcare), using a
four-element phased-array surface coil. T1-weighted and T2-weighted images
using routine clinical parameters were obtained to assess for intra- and
extrauterine abnormalities. Then the patient was taken out of the MR scanner
and brought to a procedure room where an HSG catheter (Hystero-Salpingography
Catheter 5F, Medi cal Device Technologies) attached to IV tubing (Clearlink
System, 44-inch [111.8-cm] extension set, Baxter Healthcare), was placed by
the radiologist or referring gynecologist. After catheter placement, the
patient was returned to the MR scanner for the remainder of the
examination.
For all 17 subjects, approximately 20–40 mL of a 1:100 mixture of
gadodiamide (Omniscan, GE Healthcare) to normal saline (0.9%) was gently
hand-injected during a multiphase acquisition using a clinically available,
dynamic time-resolved T1-weighted angiographic sequence (3D TRICKS). The
optimal dilution was determined through our institutional clinical experience
with MR arthrography. An oblique axial plane through the pelvis to include the
uterus, ovaries, and cul-de-sac was prescribed using the following parameters:
TR/TE, 4.5/minimum; number of excitations, 0.7; matrix, 256 x 128; and
field of view, 26–28 cm.
There were two sets of 1:100 gadodiamide and normal saline injections
during two separate 3D TRICKS acquisitions; one set was acquired with a slice
thickness of 4.4 mm and a temporal resolution of 2.2 seconds, and the second
set was acquired with a slice thickness of 5.4 mm and a temporal resolution of
1.8 seconds. A final axial T1-weighted, fat-suppressed 3D spoiled
gradient-echo series was obtained. After the study was complete, 20–40
mL of normal saline was used to flush the uterus. The entire MRI examination
lasted 60 minutes or less, which included the time required to place the HSG
catheter.
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Fig. 1A —27-year-old woman evaluated for infertility. Initial MR
angiography image (A) from series of 32 subtracted dynamic MR
angiographic sequence (time-resolved imaging of contrast kinetics [TRICKS])
shows small amount of dilute gadodiamide beginning to accumulate in
endometrial canal (arrow). Subsequent MR angiography images
(B–D) reveal more obvious accumulation of contrast material in
endometrial canal, filling of fallopian tubes (arrowheads, B),
and free bilateral spill (arrowheads, D). Conventional
hysterosalpingography (E) shows bilateral spill (arrows).
Axial T1-weighted 3D gradient-echo images (F–I) through pelvis
after dilute gadodiamide injection from inferior in pelvis (F) to
superior in pelvis (I) show contrast material posterior and inferior in
relation to uterus on left (arrow, F and G) from left
fallopian tube and anterior and superior to uterus on right (arrow,
I) from right fallopian tube.
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Fig. 1B —27-year-old woman evaluated for infertility. Initial MR
angiography image (A) from series of 32 subtracted dynamic MR
angiographic sequence (time-resolved imaging of contrast kinetics [TRICKS])
shows small amount of dilute gadodiamide beginning to accumulate in
endometrial canal (arrow). Subsequent MR angiography images
(B–D) reveal more obvious accumulation of contrast material in
endometrial canal, filling of fallopian tubes (arrowheads, B),
and free bilateral spill (arrowheads, D). Conventional
hysterosalpingography (E) shows bilateral spill (arrows).
Axial T1-weighted 3D gradient-echo images (F–I) through pelvis
after dilute gadodiamide injection from inferior in pelvis (F) to
superior in pelvis (I) show contrast material posterior and inferior in
relation to uterus on left (arrow, F and G) from left
fallopian tube and anterior and superior to uterus on right (arrow,
I) from right fallopian tube.
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Fig. 1C —27-year-old woman evaluated for infertility. Initial MR
angiography image (A) from series of 32 subtracted dynamic MR
angiographic sequence (time-resolved imaging of contrast kinetics [TRICKS])
shows small amount of dilute gadodiamide beginning to accumulate in
endometrial canal (arrow). Subsequent MR angiography images
(B–D) reveal more obvious accumulation of contrast material in
endometrial canal, filling of fallopian tubes (arrowheads, B),
and free bilateral spill (arrowheads, D). Conventional
hysterosalpingography (E) shows bilateral spill (arrows).
Axial T1-weighted 3D gradient-echo images (F–I) through pelvis
after dilute gadodiamide injection from inferior in pelvis (F) to
superior in pelvis (I) show contrast material posterior and inferior in
relation to uterus on left (arrow, F and G) from left
fallopian tube and anterior and superior to uterus on right (arrow,
I) from right fallopian tube.
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Fig. 1D —27-year-old woman evaluated for infertility. Initial MR
angiography image (A) from series of 32 subtracted dynamic MR
angiographic sequence (time-resolved imaging of contrast kinetics [TRICKS])
shows small amount of dilute gadodiamide beginning to accumulate in
endometrial canal (arrow). Subsequent MR angiography images
(B–D) reveal more obvious accumulation of contrast material in
endometrial canal, filling of fallopian tubes (arrowheads, B),
and free bilateral spill (arrowheads, D). Conventional
hysterosalpingography (E) shows bilateral spill (arrows).
Axial T1-weighted 3D gradient-echo images (F–I) through pelvis
after dilute gadodiamide injection from inferior in pelvis (F) to
superior in pelvis (I) show contrast material posterior and inferior in
relation to uterus on left (arrow, F and G) from left
fallopian tube and anterior and superior to uterus on right (arrow,
I) from right fallopian tube.
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Fig. 1E —27-year-old woman evaluated for infertility. Initial MR
angiography image (A) from series of 32 subtracted dynamic MR
angiographic sequence (time-resolved imaging of contrast kinetics [TRICKS])
shows small amount of dilute gadodiamide beginning to accumulate in
endometrial canal (arrow). Subsequent MR angiography images
(B–D) reveal more obvious accumulation of contrast material in
endometrial canal, filling of fallopian tubes (arrowheads, B),
and free bilateral spill (arrowheads, D). Conventional
hysterosalpingography (E) shows bilateral spill (arrows).
Axial T1-weighted 3D gradient-echo images (F–I) through pelvis
after dilute gadodiamide injection from inferior in pelvis (F) to
superior in pelvis (I) show contrast material posterior and inferior in
relation to uterus on left (arrow, F and G) from left
fallopian tube and anterior and superior to uterus on right (arrow,
I) from right fallopian tube.
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Fig. 1F —27-year-old woman evaluated for infertility. Initial MR
angiography image (A) from series of 32 subtracted dynamic MR
angiographic sequence (time-resolved imaging of contrast kinetics [TRICKS])
shows small amount of dilute gadodiamide beginning to accumulate in
endometrial canal (arrow). Subsequent MR angiography images
(B–D) reveal more obvious accumulation of contrast material in
endometrial canal, filling of fallopian tubes (arrowheads, B),
and free bilateral spill (arrowheads, D). Conventional
hysterosalpingography (E) shows bilateral spill (arrows).
Axial T1-weighted 3D gradient-echo images (F–I) through pelvis
after dilute gadodiamide injection from inferior in pelvis (F) to
superior in pelvis (I) show contrast material posterior and inferior in
relation to uterus on left (arrow, F and G) from left
fallopian tube and anterior and superior to uterus on right (arrow,
I) from right fallopian tube.
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Fig. 1G —27-year-old woman evaluated for infertility. Initial MR
angiography image (A) from series of 32 subtracted dynamic MR
angiographic sequence (time-resolved imaging of contrast kinetics [TRICKS])
shows small amount of dilute gadodiamide beginning to accumulate in
endometrial canal (arrow). Subsequent MR angiography images
(B–D) reveal more obvious accumulation of contrast material in
endometrial canal, filling of fallopian tubes (arrowheads, B),
and free bilateral spill (arrowheads, D). Conventional
hysterosalpingography (E) shows bilateral spill (arrows).
Axial T1-weighted 3D gradient-echo images (F–I) through pelvis
after dilute gadodiamide injection from inferior in pelvis (F) to
superior in pelvis (I) show contrast material posterior and inferior in
relation to uterus on left (arrow, F and G) from left
fallopian tube and anterior and superior to uterus on right (arrow,
I) from right fallopian tube.
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View larger version (142K):
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Fig. 1H —27-year-old woman evaluated for infertility. Initial MR
angiography image (A) from series of 32 subtracted dynamic MR
angiographic sequence (time-resolved imaging of contrast kinetics [TRICKS])
shows small amount of dilute gadodiamide beginning to accumulate in
endometrial canal (arrow). Subsequent MR angiography images
(B–D) reveal more obvious accumulation of contrast material in
endometrial canal, filling of fallopian tubes (arrowheads, B),
and free bilateral spill (arrowheads, D). Conventional
hysterosalpingography (E) shows bilateral spill (arrows).
Axial T1-weighted 3D gradient-echo images (F–I) through pelvis
after dilute gadodiamide injection from inferior in pelvis (F) to
superior in pelvis (I) show contrast material posterior and inferior in
relation to uterus on left (arrow, F and G) from left
fallopian tube and anterior and superior to uterus on right (arrow,
I) from right fallopian tube.
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Fig. 1I —27-year-old woman evaluated for infertility. Initial MR
angiography image (A) from series of 32 subtracted dynamic MR
angiographic sequence (time-resolved imaging of contrast kinetics [TRICKS])
shows small amount of dilute gadodiamide beginning to accumulate in
endometrial canal (arrow). Subsequent MR angiography images
(B–D) reveal more obvious accumulation of contrast material in
endometrial canal, filling of fallopian tubes (arrowheads, B),
and free bilateral spill (arrowheads, D). Conventional
hysterosalpingography (E) shows bilateral spill (arrows).
Axial T1-weighted 3D gradient-echo images (F–I) through pelvis
after dilute gadodiamide injection from inferior in pelvis (F) to
superior in pelvis (I) show contrast material posterior and inferior in
relation to uterus on left (arrow, F and G) from left
fallopian tube and anterior and superior to uterus on right (arrow,
I) from right fallopian tube.
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Data Analysis
A set of dynamic subtracted images was reconstructed with a slice thickness
of 2.2–2.7 mm and evaluated similar to an MR angiographic examination.
Both the subtracted series and the anatomic images were reviewed on a PACS
system (Horizon Medical Imaging, version 11; McKesson Imaging Group) by a
single reader blinded to the conventional HSG results who recorded tubal
patency and any uterine abnormality visualized. The subtracted images were
viewed by scroll ing through the series manually on the PACS workstation and
were not viewed in cine mode. The diagnoses made on MR HSG were compared with
the final diagnoses rendered at the time of conventional HSG examination.
Results
We successfully evaluated tubal patency in 16 women using MR HSG (Fig.
1A,
1B,
1C,
1D,
1E,
1F,
1G,
1H,
1I). There was one failed MR
examination because of excessive patient motion.
Table 1 compares the results
from the MR HSG examinations to the results of conventional HSG. Of note, one
patient, in whom neither fallopian tube appeared patent on the conventional
HSG, did have patency of her left fallopian tube on MR HSG
(Table 1, subject 13). In
subject 11, on conventional HSG and the first injection of dilute gadodiamide
contrast medium at MR HSG, the left fallopian tube appeared occluded; however,
on the second injection of dilute gadodiamide contrast medium, there was free
spillage of contrast medium on the left (Fig.
2A,
2B,
2C). In four additional
patients, MR HSG showed free spill in fallopian tubes that appeared occluded
on conventional HSG (Table 1,
subjects 14–17). Despite visualizing obvious free spill of dilute
contrast on MR HSG, it was difficult to visualize the actual fallopian tubes
in their entirety in most patients.
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Fig. 2A —33-year-old woman evaluated for infertility. Conventional
hysterosalpingography (HSG) shows normal contour of uterine canal and free
spill of iodinated contrast material from right fallopian tube, with no spill
on left (arrow).
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Fig. 2B —33-year-old woman evaluated for infertility. Subtracted
dynamic 3D T1-weighted angiographic (time-resolved imaging of contrast
kinetics [TRICKS]) MR HSG image of first injection of dilute gadodiamide
contrast material, depicting normal endometrial canal contour, free spill of
contrast material from right fallopian tube (arrow), and no spill on
left.
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Fig. 2C —33-year-old woman evaluated for infertility. Subtracted
dynamic 3D T1-weighted angiographic (TRICKS) MR HSG image of second injection
of dilute gadodiamide contrast material with free spill from right and left
fallopian tubes (arrows).
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In the failed examination because of motion, the dynamic subtracted
angiographic images were nondiagnostic; however, free dilute contrast was
noted in the pelvis on the delayed fat-suppressed T1-weighted images. This
would imply at least one fallopian tube is patent.
There were five subjects with deformity of the uterine cavity contour on
conventional HSG. On MRI, the contour abnormalities were found to be large
leiomyomas (three cases), an arcuate configuration to the uterus (one case),
and a partial septate uterus (one case) (Fig.
3A,
3B,
3C,
3D,
3E,
3F). Furthermore, three women
were found to have abnormalities on MRI that were not suspected on
conventional HSG. These included a hydrosalpinx, an endometrioma, and an
atrophic ovary. There was no appreciable difference in the appearance of
images when comparing the dynamic subtracted sets of images with different
slice thicknesses.
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Fig. 3A —Images show uterine contour abnormalities on conventional and
MR hysterosalpingography (HSG) studies in two women. Image from subtracted
dynamic 3D T1-weighted angiographic series (time-resolved imaging of contrast
kinetics [TRICKS]) in 45-year-old woman shows bilateral spill of contrast
material and deformity of endometrial canal (arrow).
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Fig. 3B —Images show uterine contour abnormalities on conventional and
MR hysterosalpingography (HSG) studies in two women. Conventional HSG image
shows bilateral spill of contrast material and deformity of endometrial canal
(arrow).
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Fig. 3C —Images show uterine contour abnormalities on conventional and
MR hysterosalpingography (HSG) studies in two women. Axial T2-weighted fast
recovery fast spin-echo MR image shows leiomyoma (arrow) causing
deformity of endometrial canal seen on MR HSG and conventional HSG.
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Fig. 3D —Images show uterine contour abnormalities on conventional and
MR hysterosalpingography (HSG) studies in two women. In 31-year-old woman,
subtracted dynamic 3D T1-weighted angiographic (TRICKS) MR HSG image shows
indention of fundus (arrow).
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Fig. 3E —Images show uterine contour abnormalities on conventional and
MR hysterosalpingography (HSG) studies in two women. Conventional HSG shows
endometrial contour abnormality (arrow) that could represent either
bicornuate or partial septate uterine malformation.
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Fig. 3F —Images show uterine contour abnormalities on conventional and
MR hysterosalpingography (HSG) studies in two women. Coronal T2-weighted image
through uterus shows normal contour along serosal surface of fundus with
indentation of myometrium and endometrium into uterine canal, indicating
partial septate uterus (arrow).
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Discussion
The current trend for couples to defer childbirth to later ages has
resulted in an increasing number of couples presenting with infertility
problems. Fallopian tube occlusion is a common cause of infertility, found in
up to 40% of women being evaluated for the inability to conceive
[5]. Conventional HSG under
fluoroscopy remains the most commonly used procedure to diagnose fallopian
tube patency in women [6].
However, conventional HSG exposes the reproductive organs of a potentially
fertile woman to ionizing radiation. Furthermore, conventional HSG provides a
limited evaluation of other causes of infertility, such as congenital uterine
malformation, myometrial abnormalities (adenomyosis, leiomyomas), and
extrauterine diseases (endometriosis, adhesions, pelvic infection, adnexal
disease).
MRI is valuable in defining uterine disease and anomalies and in
identifying extrauterine causes of infertility
[2–4].
This study demonstrates the ability of MR HSG to assess tubal patency using a
clinically available MR angiographic sequence (TRICKS). All fallopian tubes
appearing to be patent by conventional HSG were shown as patent on MR HSG. MR
HSG also demonstrated free peritoneal spill in more than half of the fallopian
tubes thought to be occluded on the conventional HSG study. Notably, one
patient who appeared to have bilateral occlusion of the fallopian tubes on
conventional HSG revealed a patent left fallopian tube on MR HSG during
injection of dilute 1:100 gadodiamide and saline.
An unexpected finding from the study was the increased number of patent
fallopian tubes evident using MR HSG compared with conventional HSG. Possibly,
opening of the fallopian tubes from contrast injection during conventional HSG
accounts for this. However, MRI may be more sensitive to spillage of small
amounts of contrast material because MRI has inherently superior contrast
resolution compared with conventional radiography
[7]. Further investigation in a
randomized, blinded study would need to be performed to accurately determine
the cause of this finding.
Previous attempts to assess tubal patency in women have been performed
using T1-weighted and T2-weighted sequences with a maximum temporal resolution
of 20 seconds per phase
[8–10].
These previous investigators did adequately depict tubal patency in most (but
not all) subjects on MRI. In the current study, we used the 3D TRICKS MR
angiography sequence with dilute 1:100 gadodiamide and saline and successfully
visualized contrast spillage from the fallopian tubes in all but one of our
subjects (Table 1; subject 6).
In this subject, patient motion during the injection rendered the subtracted
angiographic images nondiagnostic. However, on the delayed axial
fat-suppressed T1-weighted images, contrast material was seen in the pelvis,
indicating free spill and patency of at least one fallopian tube in this
subject.
Evaluating tubal patency with the 3D TRICKS MR angiography sequence using
dilute 1:100 gadodiamide and saline has several advantages over other
techniques. First, the 3D TRICKS angiography sequence is clinically available
without specific requirements for vendor or physicist support. The parameters
chosen provide adequate spatial resolution for visualization of fallopian tube
contrast spillage, with superior temporal resolution of approximately 2
seconds per phase. This temporal resolution allowed documentation of
progressive spillage from left and right tubes and, therefore, discrimination
of contrast spill from the separate tubes. Patient motion is a potential
problem, but the speed of the dynamic TRICK sequence allowed near-real-time
resolution of the contrast spillage from the fallopian tubes in nearly all
subjects.
Gadolinium-based contrast agents have been safely used for more than 15
years on millions of subjects with normal renal function in concentrations
much higher than we have used. In women with normally functioning kidneys, the
contrast material should be excreted in the urine, under the assumption that
all the contrast material is resorbed from the peritoneum, uterus, and
fallopian tubes [11].
This study shows that tubal patency can be effectively assessed with a
clinically available MR angiographic sequence (3D TRICKS). This capability
enhances the already established value of MRI for the evaluation of uterine
and extrauterine abnormalities. MR HSG can be considered as a single
comprehensive examination when both conventional HSG and standard MRI are
necessary in the work-up of women with infertility.
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Abstract
Introduction
