3. What are the characteristics of an optimal
imaging modality
• Diagnostically accurate
• Minimally invasive
• Cost effective
• Reliable
• Safe
NB: Depending on the disease process or the anatomic variation or
location, one imaging modality may be more suited than the other.
Also, more than one diagnostic test may be need.
4. PELVIC SONOGRAPHY
• Principle: Using a piezoelectric material on a probe, sounds are sent
to body structures which reflect the sounds differently. The reflected
sounds are then converted back to a unique electric signal that is
used to produce images
• Classification of pelvic sonography
• TVS or TAS
• According to Modes: B, M, or Doppler
• Dimensions: 2D, 3D or 4D
5. Indications of pelvic sonography
Other gynaecological reasons for pelvic
sonography
• Pelvic masses (management)
• Evaluation of ovarian torsion
• Abnormal uterine bleeding
• Uterine Fibroids
• Pelvic pain
• Recurrent pregnancy loss
• Foreign body in the uterus
• Suspected ectopic pregnancy
When evaluating for infertility, we do
pelvic sonography to:
• Monitoring follicle maturation
• Assessing Endometrial thickness
• Transvaginal oocyte aspiration
• USS guided embryo transfer
• Detection of hydrosalpinx
6. SALINE INFUSION SONOGRAPHY (SIS)
(Sonohysterography(SHG))
• During the SIS procedure, saline is introduced into the endometrial
cavity via an endocervical catheter as sonography is being done.
• SIS enables visualisation of lesions projecting into the uterine cavity
7. Technical issues to consider when doing SIS
• SIS is done at day 5-10 of the menstrual cycle to avoid confusion by
menstrual blood and ensure no occult pregnancy; this also gives us a
thin endometrial lining.
• A urine hCG may also be done to be sure there is no pregnancy
• It is good if a patient is taking COC and this can be used to time when
to do the procedure.
• NSAIDs can be given 30 minutes prior to the procedure to reduce on
the cramps that may follow the procedure
• Informed consent is needed, tell them the likely complications
8. Procedure of SIS
• An open speculum is put in the vaginal for visualisation of the cervix
• After the cervix is cleaned with an antiseptic, a cervical catheter is inserted,
this can be rigid SHG catheter, a 5 or 7 Fr- double lumen intrauterine HSG
catheter, or a latex-free urethrane H/S Elliptosphere catheter. A paediatric
catheter can also be used but it is difficult to use.
• The speculum is removed and Vaginal ultrasound (TVS) scan probe is put.
• Sterile Saline is then put in the endometrial cavity, this then separates the
posterior and anterior uterine walls; usually, there is no need to inflate the
catheter balloon.
• The uterus can the be scanned in the transverse and longitudinal planes
and 3D images are got.
• ACOG recommends doxycycline 100bd for 5/7 if a woman has PID or there
are dilated tubes seen on HSG.
9. Indications for SIS
SIS can detect intrauterine lesions such as:
1. Endometrial hyperplasia
2. Uterine polyps
3. Submucosal fibroid
SIS + 3D ultrasound scan can help in diagnosis/clarify of uterine
anomalies like septate & Bicornuate uterus by showing the outer
contour of the uterus.
10. Limitations of SIS
We don’t do SIS if there is:
• intrauterine gestation
• Pelvic infection
• Unexplained pelvic tenderness
• Hydrosalpinx; doing SIS would increase risk of post procedure infection
12. HYSTERO-SALPINGO CONTRAST SONOGRAPHY
(HyCoSY)
Procedure
• HyCoSy is done after SIS, so indications, planning, prerequisites, use of antibiotics, and
contraindications are same to as those of SIS.
• After evaluating the uterus, the uterine balloon is inflated to occlude the lower uterine
segment.
• After, a 20ml syringe is filled with saline and air and it is intermittently tilted to fill the
uterus with 1-3ml increments of saline followed by air.
• The mixture of saline and air can be seen as scintillations travelling from the proximal
interstitial part of the tube to the distal fimbria and ovary.
• If the tube fails to fill with the air/saline mixture, it is advantageous to roll the patient so
that we position that tube superiorly.
• Failure to visualize the scintillations in the tubes can mean cornual spasms or tubal
obstruction.
• After the procedure, the balloon is deflated and all instrument removed from the vagina
13. HYSTEROSALPINGOGRAM(HSG)
Indication for HSG
• To check tubal patency in cases of infertility
• To document tubal occlusion 3 months after a tubal occlusion device has been inserted
at laparoscopy to occlude the tubes as a means of contraception
Procedure
• In the HSG procedure, we instil contrast media via the cervix into the endometrial cavity
and uterine tubes and then take radiographs of the pelvis.
• HSG has a high sensitivity but low specificity for uterine cavity abnormalities; it therefore
is perfect as a screening test for these conditions.
• With HSG, it is difficult to differentiate between septate Uterus and Bicornuate uterus,
but using the PUSH-PULL technique, we can visualise the contour of the uterine fundus.
After we are sure of tubal patency, we hold the cervix with tenaculum, then push and pull the uterus, dispersing
contrast over the uterine fundus, radiographs taken after that can show external contour of the fundus.
14. Procedure of HSG
• Informed consent
• Insert a speculum
• Clean the cervix with antiseptic
• Apply local anaesthesia using gel or spray of lidocaine.
• The cervix is then held and stabilized with a tenaculum. It also aids when
we want to apply traction to the uterus in the “push-pull procedure”.
• A Rigid or standard HSG cannula is inserted in the cervix. The catheter must
be flashed before insertion to avoid introduction air in the uterus. The air
bubbles can be confused for uterine pathology
• If there is failure to dilate the cervix or there is cervical stenosis, we can use
400µg of misoprostol 12hrs before the procedure.
15. Technical issues to consider when doing HSG
• Do the HSG in follicular phase of the menstrual cycle.
• A urine pregnancy test may be done to rule out occult pregnancy.
• An NSAID may be given to treat the cramping the commonly follows the
procedure.
Contrast media issues:
We can use water soluble contrast media like iothalamate meglumine 30-
60%. This results in better imaging. Soluble contrast media don’t obscure the
fine details of the structure imaged, and dissipate quickly, rendering delayed
images unnecessary.
Oil soluble contrast media like Ethiodol can obscure fine details, can cause oil
embolism, and lead to granuloma formation. However, higher pregnancy
rates have been reported with use oil soluble contrast
16. Procedure of HSG
• The HSG procedure is combined with fluoroscopy to ensure correct
positions of pelvic structure before injection of contrast media.
• If contrast returns to the cervix, the balloon is inflated to seal the
catheter. There may be tubal obstruction due to spasms of the
Fallopian tubes during the procedure. This can occur, and 60% of
repeat HSG showed tubal patency. Some times, rolling the patient so
that the side with corneal occlusion is down can help resolve this
obstruction in 50% of cases.
• If the patient has hydrosalpinx or recent history of PID, a course of
appropriate antibiotics is recommended; ACOG recommends
doxycycline 100mg bd for 5 days.
17. •Other/Modified HSG techniques
• CT-VHSG
• MRI-VHSG
Contraindication of HSG
• Pelvic infection
• Allergy to iodine
• Active uterine bleeding
• Suspected or confirmed endometrial cancer for fear of disseminating the cancer
• Pregnancy
NB: use of prednisone + antihistamine 1hr before the procedure can be
tried if the client has iodine allergy. Also, use Gadolinium or non ionic
contrast like iohexol & iopidol can reduce the incidence of allergic
reactions
18. Complications of HSG procedure
• Oil embolism
• Granuloma formation
• Vasovagal reaction(pallor, light-headedness, bradycardia, hypotension and sweating)
• Spasm/cramping
• Pelvic infections
• Uterine perforation
The risk factor for PID after HSG include, past infertility, previous pelvic
surgery for infection, history of PID, adnexal tenderness at time of the
procedure, and Adnexal mass. Laparoscopy may be better for such
patients
19. MAGNETIC RESONANCE IMAGING
• Principles: MRI technology applies external magnetic fields to align
small magnetic fields of water protons. Radiofrequency
electromagnetic pulses are then applied to cause realignment of
those protons. Radiofrequency energy is emitted by protons as they
resume their previous state of alignment.
• Different types of tissues will recover their different original
alignment at different rates with different time constants.
The Images of MRI can be:
• T1-weighted: water is darker than Fat which appear as white
• T2-Weighted: Fat and Fluid appear dark. Some T2 images are done with fat suppression
techniques which makes fat dark and liquid dark in colour.
20. Indication of MRI
• Leiomyoma: it can help in location, size, and number
• Congenital anomalies of the reproductive tract
• Unicornuate Uterus
• Bicornuate Uterus
• Arcuate Uterus
• Uterine agenesis
• Uterus Didelphys
• Differentiate Bicornuate from septate Uterus
• May help in diagnosis of adenomyosis
• MRI can be superior to other tests of similar accuracy if the patient is
obese,
21. Magnetic Resonance Imaging (MRI)
How to prepare a patient for MRI
• Fast 4 to 6 hours to reduce peristalsis
• Patient voids before the procedure
• Better be done in proliferative phase when we are sure she is not pregnant and
menstrual blood won’t appear as artifacts
Limitation of MRI
• Pace makers
• Indwelling metals
• Claustrophobia & patient discomfort
• Not for the pregnant, especially in first trimester(NOT TERATOGENIC THOUGH)
• MRI contrast crosses the placenta
• Gadolinium hypersensitivity, and it not used in pregnancy and renal failure
22. Advantages of MRI
• It gives multiplanar images
• Less operator dependent relative to sonography
• No exposure to ionizing radiation
• Image quality is not affected by uterine size or patient size/obesity
23. Imaging modalities used when assessing male
reproduction
• Scrotal ultrasonography (Doppler for blood flow to testis, e.t.c)
• MRI of the genital tract for obstructive lesions
• Brain MRI
• CT scan can show stones that are causing obstructive azoospermia
• Vasography: rarely used nowadays, it can help in diagnosing cause of
azoospermia if a patient has normal sperm levels and shape seen at
testicular biopsy.
24. References
• Falcone, T. & Hurd, W. W. (2017). Clinical reproductive medicine and
Surgery: A practical guide. 3rd edition. Cham, Springer.
