Medical Journal of The Islamic Republic of Iran National Research Centre of Medical Sciences of I.R. IRAN ISSN: 1016-1430 Vol. 20, Num. 1, 2006, pp. 9-11

Medical Journal of the Islamic Republic of Iran , Vol. 20, No. 1, May, 2006, pp. 9-11

ROLE OF HYSTEROSALPINGOGRAPHY IN RECURRENT ABORTION FOR INVESTIGATION OF INTRAUTERINE PATHOLOGY

JALEH ZOLGHADRI, * SHAHRZAD GHOTBI^† , AND MAHMOOD BEHESHTI^‡

From the Dept. of Obstetrics and Gynecology, Shiraz University of Medical Sciences, Shiraz, I.R. Iran.

^* Assistant Professor, Department of Obstetrics and Gynecology, Shiraz University of Medical Sciences, Shiraz, Iran.
^{† †}Assistant Professor, Department of Obstetrics and Gynecology, Fasa Medical School, Fasa, Iran
^‡ Family Physician, Fasa Medical School, Fasa, Iran

Correspondence: Jaleh Zolghadri, M. D., Department of Obstetrics and Gynecology, Faghihi Hospital, Shiraz, Iran. Tel: +98(711)233-2365.

Code Number: mr06003

ABSTRACT

Background and Objective: To assess the diagnostic value of hys-terosalpingography (HSG) in the evaluation of the uterine cavity in recurrent aborters in comparison to hysteroscopy as the gold standard of diagnosis.
Results: The overall sensitivity and specificity of HSG was 18.75% and 82.2%, respectively. The false positive and false negative results of HSG were 17.8% and 81.25%, respectively, and the positive predictive value for HSG is, therefore, 37.5%.
Methods: 58 reproductive age women, all with habitual abortion (3 con-secutive abortions), were examined by both HSG and hysteroscopy.
Conclusion: Regarding very low sensitivity, specificity and high false-negative rates of HSG, it is concluded that it has low value in detection of uter-ine cavity abnormalities in habitual abortion and hysteroscopy should be used as the gold standard method for diagnosis in these patients.

Keywords: Hysterosalpingography; Hysteroscopy; Recurrent abortion.

Traditionally, habitual pregnancy loss has been de-fined as three or more clinically recognized pregnancy losses before 20 weeks gestational age. Using this defini-tion, it occurs in almost 1 in 300 pregnancies.¹ For pa-tients with a history of multiple pregnancy losses, the risk for subsequent pregnancy loss is estimated to be 24% after two clinically recognized losses, 30% after three losses and 40-50% after four losses.² Among the etiologies of spontaneous abortion such as genetic, endocrine, infec-tious, immunologic, thrombotic and anatomic factors, the last is the one in which surgical intervention for a septate uterus^{3, 4, 6} and intrauterine adhesions^{5, 6} significantly in-creases the rate of successful subsequent full term deliveries.

Due to the high incidence of uterine cavity pathologies and improvement of reproductive outcome after surgical correction, it is significant to evaluate the uterine cavity accurately in these patients.^{7, 8}

Among the diagnostic tools used to evaluate the uter-ine cavity, hysterosalpingography (HSG) has been used for many years to screen for anatomic abnormalities. Some studies recently have found that HSG will not pre-cisely evaluate the cavity and also the rate of false-positive findings may be as high as 30 to 38%.^{9, 10, 11, 12, 13}

As hysteroscopy is a route for direct visualization of the cavity, recently it has been known as a standard tool for diag-nosis of uterine cavity abnormalities. The present study was designed to compare hysterosalpingography and hys-teroscopy in diagnosing structural intrauterine abnormalities.

MATERIAL AND METHODS

Fifty-eight women of reproductive age with recurrent abortion referred to Shiraz University of Medical Sciences affiliated hospitals, Shiraz, Iran, from 1998 to 2002, were investigated with HSG and hysteroscopy. All patients were evaluated and other causes of abortion were ruled out first. Hysteroscopy was performed under general anes-thesia in the operating room using DW 5% as the medium. All hysteroscopies were performed by the first author, before reviewing the HSG. All HSGs were reported by the same radiologist. HSGs were performed using Urographin as the aqueous contrast medium. There were no complica-tions during or after hysteroscopy and HSG.

As hysteroscopy is a route for direct visualization of the cavity, recently it has been known as a standard tool for diag-nosis of uterine cavity abnormalities. The present study was designed to compare hysterosalpingography and hys-teroscopy in diagnosing structural intrauterine abnormalities.

RESULTS

From 58 women, 48 (81%) had early, 3(5.2%) late and 8(13.8%) early and late abortions (early and late abor-tions are defined as less than 12 weeks and equal to or more than 12 weeks, respectively). The mean age was 29 (19 -39), gravidity 4.3 (3-15), parity 0.36 (0-2), abortion 3.9 (3-15).

In HSG, there were 8 (13.8%) abnormal reports in-cluding 3 endometrial polyps, 1 Asherman syndrome, 2 submucosal myomas, 2 septate uteri and 50 cases were normal. There were 16 (27.6%) abnormal hysteroscopic examinations, three of which were similar to the HSG findings. Abnormal hysteroscopy results were 3 endo-metrial polyps, 3 Asherman syndromes, 4 submucosal myomas, 2 septate uteri, 4 endometritis cases, and 42 cases were normal (Table I). Of three common diagnoses, two were submucous myomas and one Asherman syn-drome. Five abnormal HSGs had normal hysteroscopic findings. On the other hand, all of the abnormal cases de-tected by hysteroscopy had normal HSG findings except for three cases (Table II). Hence, the sensitivity of HSG was 18.75% and the specificity was 82.2% in detecting intrauter-ine pathologies. The false-positive rate was 17.8% and the false-negative rate 81.25% (Table III). The positive predic-tive value was 37.5% and the rate of similar findings 18.7%.

DISCUSSION

Congenital or acquired uterine defects remain an important consideration in the investigation of recurrent pregnancy loss. When repeated first or second trimester losses, preterm delivery or abnormal fetal presentation are documented, the suspicion of a structural uterine abnor-mality should be high. The optimal way of diagnosis for uterine pathology is still a matter of considerable contro-versy.⁶ Hysterosalpingography (HSG) was exclusively used for years in the investigation of the uterine cavity. Recently, in parallel to huge developments and advances in endoscopy in various disciplines of medicine, diagnos-tic hysteroscopy seems to be emerging as a possible main tool for the diagnosis of uterine cavity abnormalities. This is of particular importance in habitual aborters when the consistent ability to carry the pregnancy may be directly related to such uterine pathologies.

In our study, the sensitivity of HSG was 18.75% and specificity was 82.2%. The false positive and false nega-tive results by HSG were 17.8% and 81.25%, respectively, and positive predictive value for HSG was 37.3%.

A false positive of 38.3% and 33% was reported by Arieh et al.⁹ and Ragni et al,⁸ respectively. An extremely high false negative proportion of HSG (81.25%) in our study was higher than that reported by others (28.3% and 44%).^{5, 6}

Overall, the positive predictive value for HSG was 37.5% which is similar to other reports (44% and 31%).^{7, 8} In our series a similarity of 18.7% between HSG and hys-teroscopy findings in a group of 58 patients was obtained, but reports by Kessler and Arieh showed 54.3% and 31%, respectively.^{4, 9}

It seems that with such low sensitivity and high false negative and low positive predictive value for HSG, the use of HSG as a good tool for the diagnosis of intrauterine pathology in habitual abortion should be questioned.

Hysterosalpingography findings may be misleading, and poor technique in performing HSG can be responsible for the errors in interpretation of the radiography films. Air bubbles, mucus and debris can mimic filling defects and poor placement of the canula can cause intravasation. An excessive amount of contrast medium in the uterus can obliterate shadows caused by intrauterine adhesions.

In accordance with other findings, we believe that al-though HSG could be a screening method in the diagnosis of intrauterine pathology, hysteroscopy must be used as an adjunct for the definitive diagnosis of this abnormality, be-cause it usually gives a more accurate picture. Both proce- dures should be complementary to each other. The use of them together increases their diagnostic value and gives a more correct estimate of uterine and tubal status.^{14, 15, 16, 17}

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