ISSN 1596-3519

Annals of African Medicine • Volume 13 • Issue 4 • October - December 2014

Volume 13 Number 4 December 2014

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Annals of African Medicine, Vol. 13, No. 4; 2014

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Original Article

Website: www.annalsafrmed.org DOI: 10.4103/1596-3519.142288 PMID: ******

Tubal abnormalities in patients with intrauterine adhesion: Evaluation using hysterosalpingography Balogun Babajide Olawale, Adegboyega Olukayode Ademola, Awosanya Gbolahan Olusegun Gbadebo Department of Radiology, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria

Correspondence to: Dr. Babajide O. Balogun, Department of Radiology, Lagos State University Teaching Hospital, Ikeja, Lagos, P.O. Box 17438, Ikeja, Nigeria. E‑mail: [email protected]

Abstract Background: Intrauterine adhesion (IUA) represents scar tissue inside the uterine cavity. Many patients may experience recurrent miscarriages, menstrual dysfunction, and may also be unable to achieve pregnancy. Tubal abnormalities are a significant cause of infertility in women. Hysterosalpingography (HSG) is a useful screening test for the evaluation of the uterine cavity and provides information relating to the assessment of tubal morphology and patency. Materials and Methods: The HSG radiographs of 92 patients with intrauterine adhesions, between November 2008 and October 2011, in the Lagos State University Teaching Hospital, were assessed and analyzed for tubal abnormality. Results: Out of the 92 patients studied, 12 (13.04%) were diagnosed with primary infertility, while the rest of the 80 (86.96%) were referred for secondary infertility. The age range of the patients was between 27 and 42 years, with a mean age of 34.58 ± SD years. The mean infertile period of all the study subjects was 5.78 ± SD years. The prevalence of tubal abnormalities demonstrated in the study was 67.39%. Sixty‑six (71.73%) patients presented with minor adhesions, while 26 (28.27%) patients presented with moderate adhesions. Conclusion: The prevalence of tubal abnormalities demonstrated in patients with intrauterine adhesion was 67.39%. Keywords: Hysterosalpingography, infertility, intrauterine adhesion, tubal pathology

Resume Contexte : Adhérence intra-utérin (IUA) représente les tissus cicatriciels à l'intérieur de la cavité utérine. Beaucoup de patients peut-être éprouver des fausses couches récurrentes, troubles menstruels et peut également être impossible d'obtenir une grossesse. Anomalies tubaires sont une cause importante de stérilité chez les femmes. Hystérosalpingographie (HSG) est un test de dépistage utile pour l'évaluation de la cavité utérine et fournit des informations relatives à l'évaluation de la morphologie tubaire et la perméabilité. Matériel et méthodes : Des radiographies de la HSG de 92 patients avec des adhérences intra-utérines, entre novembre 2008 et octobre 2011, dans le Lagos State University Teaching Hospital, ont été évaluées et analysées pour anomalie tubaire. Résultats : Out de 92 patients étudiés, 12 (13,04 %) ont été diagnostiqués avec l'infertilité primaire, tandis que le reste des années 80 (86.96 %) ont été désignés pour infertilité secondaire. La tranche d'âge des patients était de 27 à 42 ans, avec un âge moyen de 34,58 ± SD années. La période infertile moyenne de tous les sujets de l'étude était 5,78 ± SD années. La prévalence des anomalies tubaires, montré l'étude était 67,39 %. Soixante‑six (71.73 %) patients présentées des adhérences mineures, tandis que 26 patients (28.27 %) présentées des adhérences modérées. Conclusion : La prévalence des anomalies tubaires démontré chez les patients avec adhérence intra-utérine était 67,39 %. Mots-clés : Hystérosalpingographie, infertilité, adhérence intra-utérine, pathologie tubaire

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Olawale, et al.: Tubal abnormalities in intrauterine adhesion

Introduction

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Intrauterine adhesion (IUA) represents the scar tissue inside the uterine cavity, which is a complication of trauma or infection of uterine endometrium and may lead to destruction of the endometrial lining. This may occur following dilation and curettage performed for excessive uterine bleeding after childbirth, pregnancy termination or other gynecological conditions.[1] Prolonged use of an intrauterine device, endometritis, myomectomy, and Cesarean section may also lead to the development of IUA.[2] Women with IUA may have no obvious problems. Many patients, however, may experience menstrual dysfunction in the form of absent, light, or infrequent menstruation. They may also be unable to achieve pregnancy or experience recurrent miscarriages, and less commonly, pelvic pain or dysmenorrhea may be present.[3] Tubal abnormalities are a significant cause of infertility in women.[4] Hysterosalpingography (HSG) is a useful screening test for the evaluation of the uterine cavity and provides information relating to the assessment of tubal morphology and patency. This study is done to determine the prevalence of tubal abnormalities among patients with intrauterine adhesion, using HSG.

Materials and Methods The study materials consisted of the radiographs of 92 patients out of 1500 patients who had HSG done during a three‑year period, between November 2006 and November 2009, in the Radiology Department of the Lagos State University Teaching Hospital, Lagos, Nigeria. These patients were those whose radiographs showed intrauterine adhesions. The fallopian tubes were assessed for pathology as well as the duration of infertility. The patients were referred primarily for HSG investigation as a result of disordered menstrual flow and infertility. Each patient’s clinical information was extracted from the request cards and case notes. Approval for study was obtained from the Institution’s Ethics Committee, while written informed consent was obtained from the patients. Intrauterine adhesions were classified according to Schenker and Margolith’s classification[5] into minor (stage 1), moderate (stage 2), and severe adhesions (stage 3 – cicatrical scarring). Patients with severe intrauterine adhesions were excluded as the tubes may not have been assessable. Each HSG was performed by the radiologist during the early proliferative phase of the menstrual cycle and Vol. 13, October-December, 2014

interpreted by two radiologists. The patient was placed in the lithotomy position on the X‑ray table. A speculum and spot light were used to visualize the cervical os, which was then swabbed with antiseptic solution. An introducing cannula, such as the Leech Wilkinson cannula, was selected and placed in the external os. Slow injection of the contrast agent Ultravist (Iopromide ‑ by Bayer Schering), with gentle pressure, under fluoroscopic control, using a volume sufficient to fill, but not to overdistend the uterine cavity, was recommended, to minimize patient discomfort. Radiographs of the pelvis were obtained with the GE digital fluoroscopy machine (Precision RXi‑65) in the anteroposterior and both oblique projections during injection of the contrast. Delayed prone radiographs were also obtained after drainage of the contrast (after 15 minutes) to assess the degree of loculation of contrast.[6] All statistical tests were performed using the computer statistical software package SPSS, version 17 (SPSS Inc, Chicago IL).

Results Among the 92 patients recruited for the study, 12 (13.04%) were diagnosed with primary infertility, while the remaining 80 (86.96%) were referred for secondary infertility. The age range of the patients was between 27 and 42 years, with a mean of 34.58 years. The mean infertile period of all the study subjects was 5.78 years. The prevalence of tubal abnormalities demonstrated in the study was 67.39%, while that of IUA was 6.13%. Sixty‑six (71.73%) patients presented with minor adhesions, while 26 (28.27%) patients presented with moderate adhesions. The adhesions were also categorized based on their location in the uterine cavity. Fifty‑nine patients (64.13%) had adhesions in the cervical canal, 29 (31.52%) in the uterine cavity, and four (4.35%) in both the uterine cavity and cervical canal. Twenty‑eight (30.43%) cases had previous dilatation and curettage, 18 (19.56%), with a past history of myomectomy, 13 (14.13%) had Cesarean section surgery, 11 (11.95%) had a previous history of pelvic inflammatory disease, while the other 22 (23.93%) did not indicate having any relevant history [Table 1]. Bilateral or unilateral normal tubes, with free intraperitoneal spillage were present in 30 (32.69%) out of the 92 patients. Annals of African Medicine

Olawale, et al.: Tubal abnormalities in intrauterine adhesion

Hydrosalpinx, either bilateral or unilateral, was the most common tubal pathology. It was present in 26 (28.26%) of the patients studied [Table 2]. Fourteen (15.22%) out of the total number of patients had evidence of peritubal adhesion. Tubal blockage was seen in 18 (19.56%) patients, comprising of proximal obstruction in 12 (13.04%) and mid tubal in six (6.52%). Four (4.34%) patients presented with salpingitis isthmica nodosa.

canal and two (16.67%) of the patients had IUA in the uterine cavity. All the patients (six, 100.0%) with mid‑tubal obstruction had IUA in the cervical canal. Among the patients who had normal free peritoneal spillage, nine (30.0%) had IUA in the cervical canal, 20 (66.67%) of the patients had IUA in the uterine cavity, while one (3.33%) of

When the location of the IUA was compared to the tubal abnormality, patients with hydrosalpinx, 21 (80.77%), had IUA mainly in the cervical canal, three (11.54%) had IUA in the uterine cavity, while two (7.69%) had IUA in both the cervical canal and uterine cavity [Table 2] [Figure 1]. Among the patients who had a peritubal adhesion, 13 (92.86%) had IUA in the cervical canal alone [Figure 2]. None of the patients had IUA in the uterine cavity, while 7.14% of the patients had IUA in both the cervical canal and uterine cavity [Figure 3].

Figure 1: Hysterogram showing unilateral hydrosalpinx with IUA in the uterine cavity and cervical canal

All the patients (four, 100.0%) who had salpingitis isthmica, had IUA in the uterine cavity. Among the patients who had obstruction‑proximal; a majority of 10 (83.33%) had IUA in the cervical Table 1: Frequency of women with relevant past medical history Numbers Percentage of cases Dilatation and curettage 28 30.43 Post‑myomectomy 18 19.56 Cesarean operation 13 14.13 Pelvic inflammatory disease 11 11.95 No relevant past medical history 22 23.93 Total 92 100 Figure 2: Hysterogram showing IUA in the cervical canal with left peritubal adhesion

Table 2: Relationship between tubal pathology and location of intrauterine adhesion Cervical canal Hydrosalpinx 21 80.8% Peritubal adhesion 13 92.9% Salpingitis ishmica 0 0.0% Obstruction-proximal 10 83.3% Obstruction-mid‑tubal 6 100.0% Free peritoneal spillage 9 30.0%

Uterine cavity 3 11.5% 0 0.0% 4 100.0% 2 16.7% 0 0.0% 20 66.7%

Both

Total

2 7.7% 1 7.1% 0 0.0% 0 0.0% 0 0.0% 1 3.3%

26 14 4 12 6 30

significant at P< 0.05 at 95% confidence level with Chi square test (χ2)

Annals of African Medicine

Figure 3: Hysterogram shows peritubal adhesion with hydrosalpinx. IUA is seen in both uterine cavity and cervical canal

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Olawale, et al.: Tubal abnormalities in intrauterine adhesion

the patients had IUA in both the cervical canal and uterine cavity. Hydrosalpinx, peritubal adhesion, obstruction, both proximal and mid‑tubal, were observed to be associated with IUA located in the cervical canal. Salpingitis Ishmica and normal free peritoneal spillage were found to be associated with IUA located in the uterine cavity. Page | 182

χ² (10) = 42.924, P = 0.000 (two‑tailed) With a P value of less than 0.05, the Pearson’s Chi Square test shows that these observations are statistically significant and cannot be attributed to chance variation. There is a statistically significant relationship between tubal pathology and location of IUA.

Discussion Hysterosalpingography remains the main examination for the fallopian tubes in developing countries, despite the development of other diagnostic tools, such as, Magnetic Resonance Imaging (MRI), Hysteroscopy, Laparoscopy, and Selective Ostial Salpingography. Most of these new diagnostic tools are not readily available within our environment.[7] HSG is a safe, simple procedure, with lower cost and less inconvenience to patients. Laparoscopy is considered the gold standard for the diagnosis of tubal pathology and other intraabdominal causes of infertility.[8] Laparoscopy also allows for direct visualization of some pathology, its nature, extent, and distribution; hence some authors have suggested laparoscopy after HSG for pelvic pathologies that could have been missed on HSG.[9] The true incidence of intrauterine synechiae is unknown and likely depends on the patient population examined, the criteria for evaluation, and methods used for making the diagnosis.[1,4,6] A prevalence of 6.13% was found in this study, whereas, 1.55% was found by Dmowski et al,[10] in women subjected to hysteroscopy, while the American Society for Reproductive Medicine (ASRM) estimates a frequency of 7% in cases of secondary amenorrhea.[11] The clinical presentation varies with the severity of the disease; a patient with mild scarring may be relatively asymptomatic. Hydrosalpinx is the most common tubal pathology reported in most studies,[12,13] including this survey, with an incidence of 28.26% [Figure 1]. This incidence, however, compares with similar studies Vol. 13, October-December, 2014

done.[4] The high prevalence of pelvic inflammatory disease in this group of patients can be inferred from the high number of patients with hydrosalpinx and peritubal adhesions. Pelvic infection most often produces inflammation of the uterine tubes and their adjacent structures. This is the most common cause of tubal obstruction leading to infertility.[14] Ascending infection from the lower genital tract is the most likely pathway of the spread to the uterine tubes and pelvic cavity. Vaginal or cervical infection or the presence of an intrauterine device can cause initial endometritis, which may then lead to salpingitis and its consequence.[15] Tubal obstruction, proximally, has an incidence of 13.33%. It may, however, be difficult to differentiate this from bilateral cornual spasm or underfilling from technical inadequacies.[12] The natural history of untreated adhesions is unknown; although spontaneous resolution and even successful pregnancies have been reported.[16] Other investigators claim that the adhesive process can be progressive. Hydrosalpinx, peritubal adhesion, and tubal obstruction both proximal and mid‑tubal were observed to be associated with IUA located in the cervical canal. Salpingitis Ishmica and normal free peritoneal spillage were found to be associated with IUA located in the uterine cavity. Tubal abnormalities are the significant cause of infertility in women. Tubal factors account for 15‑30% of infertility in all women in resource‑poor developing countries. These women usually have high rates of pelvic inflammatory disease (PID).[17] There is, however, poor correlation between organisms recovered from the endocervix and those collected from the tube or peritoneal cavity of patients with PID.[18] The role of infection, as a complication of IUA, has not been well‑established. Further studies to investigate the role of infection as a complication of IUA is advised, as this may help in bringing down, one of the most common causes of high incidence of infertility in Sub‑Saharan Africa.

Conclusion The prevalence of tubal abnormalities demonstrated in these patients with IUA was 67.39%. Annals of African Medicine

Olawale, et al.: Tubal abnormalities in intrauterine adhesion

References 1.

Besley MA. WHO report. Epidemiology of infertility. A review with particular reference to sub Saharan Africa. Bull World Health Organ 1976;54:319‑45. 2. March CM. Intrauterine adhesions. Obstet Gynecol Clin North Am 1995;22:491‑505. 3. Fayez JA. Uterine factors in infertility. Female Patient 1985;10:20‑32. 4. Bello TO. Pattern of tubal pathology in infertile women on hysterosalpingography in Ilorin, Nigeria. Ann Afr Med 2004;3:77‑9. 5. Schenker JG, Margalioth EJ. Intrauterine adhesions: An updated appraisal. Fertil Steril 1982;37:593‑610. 6. Karasick S, Goldfarb AF. Peritubal adhesion in infertile women: Diagnosis with Hysterosalpingography. AJR Am J Roentgenol 1989;152:777‑9. 7. Ubeda B, Paraira M, Alert E, Abuin RA. Hysterosal-pingography: Spectrum of normal variants and non‑pathological findings. AJR Am J Roentgenol 2001;177:131‑5. 8. Tanahatoe SJ, Hompes PG, Lambalk CB. Investigation of the infertile couple: Should diagnostic laparoscopy be performed in the infertility work up programme in patients undergoing intrauterine insemination? Hum Reprod 2003;18:8‑11. 9. Corson SL, Cheng A, Guttmann JN. Laparoscopy in the normal infertile patient: A question revisited. J Am Assoc Gynecol Laparosc 2000;7:317‑24. 10. Dmowski WP, Greenblatt RB. Asherman’s syndrome and risk of placenta accreta. Obstet Gynecol 1969;34:288‑99.

Annals of African Medicine

11. Practice Committee of the American Society for Reproductive Medicine. Current evaluation of amenorrhea. Fertil Steril 2006;86:S148‑55. 12. Horwitz RC, Morton PC, Shaft M, Hugo PA. Radiological approach to infertility – hysterosalpingography. Br J Radiol 1979;52:255‑62. 13. Sanfillipo JS, Yussman MA, Smith O. Hysterosalpingography in the evaluation of infertility. A six year review. Fertil Steril 1978;30:636‑43. 14. Sweet RL. Microbiology. In: Sweet RL, Wiesenfeld HC, editors. Pelvic inflammatory disease. London: Taylor and Francis; 2006. p. 19‑48. 15. Creasy JL, Clark RL, Cuttino JT, Groff JL. Salpingitis isthmica nodosa: Radiologic and clinical correlates. Radiology 1985;154:597‑600. 16. Glezerman M, Levine S, Berstein D. Asherman’s syndrome: A self‑limiting disease. Int J Gynaecol Obstet 1978;15:522‑5. 17. Hoffman L, Chan K, Smith B, Okolo S. The value of saline salpingography as a surrogate test of tubal patency in low‑resource setting. Int J Fertil Womens Med 2005;50:135‑9. 18. Jaiyeoba O, Soper DE. A Practical Approach to the Diagnosis of Pelvic inflammatory Disease.  Infect Dis Obstet Gynecol 2011;2011:753037. Cite this article as: Olawale BB, Ademola AO, Gbadebo AG. Tubal abnormalities in patients with intrauterine adhesion: Evaluation using hysterosalpingography. Ann Afr Med 2014;13:179-83. Source of Support: Nil, Conflict of Interest: None declared.

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