An Italian study in the November issue of Radiology found that hysterosalpingography can provide useful information about tubal mucosal abnormalities. According to researchers from the departments of radiology, obstetrics and gynecology, and surgery at Università Cattolica del Sacro Cuore in Rome, the cobblestone pattern is an effective radiographic sign of intraluminal adhesions in hydrosalpinges.
The study also suggested that intraluminal disease in patent tubes might not always be excluded on normal hysterosalpingograms.
The authors’ objective was to compare the radiographic findings in the tubal ampullary tract and the direct view of the ampullary lumen to verify if, and by what signs, hysterosalpingography can be used to predict mucosal damage. Forty-one consecutive patients, ages 25-42 years, who were candidates for diagnostic or surgical laparoscopy for infertility, underwent hysterosalpingography and preoperative salpingoscopy.
The researchers performed hysterosalpingography in the proliferative phase of the cycle. They obtained one frontal radiograph and two radiographs in both the right- and the left-anterior oblique projections with fluoroscopic guidance during the injection of contrast medium. The images were evaluated by two radiologists.
"Thin longitudinal radiolucent bands in the ampullary tract were considered clear evidence of normal mucosa. The presence of rounded filling defects (cobblestone pattern) or the absence of radiolucent bands in the ampullary tract were considered abnormal," they wrote (Radiology, November 2000, Vol.217:2, pp.521-525).
The authors then performed laparoscopic salpingoscopy on the patients in the same phase of the cycle, within three to six months after hysterosalpingography. They performed a chromopertubation test by transcervically injecting 100 mg of methylene blue dye through a uterine manipulator. Tubal patency was diagnosed when the dye spilling from the abdominal ostium was observed.
They assessed the ampullary mucosa during salpingoscopy, by following the Brosens and Puttemans classification of fold patterns: classes I and II were considered normal; classes III-V, abnormal.
"A different surgeon, blinded to the diagnoses of the first surgeon and radiologists, repeated the evaluation by reviewing [each exam registered on S-VHS video]," they wrote.
The team then evaluated hysterosalpingography as to its usefulness in correctly identifying tubal mucosal damage at salpingoscopy. Abnormal tubal mucosa was identified in 18 of 74 cases, for an accuracy rate of 24%. Salpingoscopic results were used to confirm an abnormal pattern in 16 of the 18 abnormal hysterosalpingographic cases, with an accuracy rate of 89%.
The sensitivity of hysterosalpingography in detecting mucosal abnormalities at salpingoscopy was 73% and the specificity was 96%, they reported.
The cobblestone pattern was observed in 12 of 18 cases. The authors found all tubes showing the cobblestone pattern at hysterosalpingography had an abnormal mucosal pattern at salpingoscopy (classes III and IV), and that the cobblestone pattern was found only in hydrosalpinges and never in patent tubes.
"When this pattern was observed [in 12 cases], abnormal mucosa (class III or IV) was always diagnosed at salpingoscopy. A preoperative hysterosalpingographic diagnosis of an abnormal pattern in a hydrosalpinx is useful," they concluded.
They also reported considerable variability in interpreting radiographic findings when clinicians were not assisted by an attending radiologist who reviewed hysterosalpingograms.
They noted that a radiographically normal patent tube might not be a normally functioning tube, as six of 43 tubes diagnosed as normal and patent at hysterosalpingography showed intraluminal adhesions (class III or IV) at corresponding salpingoscopy.
According to the researchers, "the cobblestone pattern is an effective radiographic sign of intraluminal adhesions in hydrosalpinges, which, if preliminarily diagnosed, might bring into question the need for [salpingoscopy]," they said.
The study supports findings that "a normal hysterosalpingogram cannot be used to conclude the infertility work-up in cases of continuing infertility, because a patent and radiographically normal tube might not be a normally functioning tube," they wrote.
Dr. Anna Lia Valentini and her co-authors will present a pictorial version of this study as Educational Exhibit 0128OB-e at the upcoming RSNA conference.
By Jonathan S. BatchelorAuntMinnie.com staff writer
November 16, 2000
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