Reproductive system

Methods of imaging the female reproductive system

• 1.

  Plain abdominal film

• 2.

  Hysterosalpingography

• 3.

  Ultrasound (US) – transabdominal/transvaginal

• 4.

  Computerized tomography (CT)

• 5.

  Magnetic resonance imaging (MRI)

• 6.

  Minimally invasive procedures including biopsies, cyst drainage, angiography, fibroid embolization

• 7.

  PET-CT.

Methods of imaging the male reproductive system (scrotum and testes)

• 1.

  US

• 2.

  MRI

• 3.

  Radionuclide imaging

• 4.

  Venography (including embolization of varices) and angiography.

Indications

• 1.

  Infertility

• 2.

  Recurrent miscarriages: investigation of suspected incompetent cervix, suspected congenital anomaly

• 3.

  Following tubal surgery, post sterilization to confirm obstruction and prior to reversal of sterilization

• 4.

  Assessment of the integrity of a caesarean uterine scar (rare).

Contraindications

• 1.

  During menstruation

• 2.

  Pregnancy or unprotected intercourse during the cycle

• 3.

  A purulent discharge on inspection of the vulva or cervix, or diagnosed pelvic inflammatory disease (PID) in the preceding 6 months

• 4.

  Contrast sensitivity (relative).

Contrast medium

High osmolar iodinated contrast material (HOCM) or low osmolar iodinated contrast material (LOCM) 270/300 mg I ml ^–1 10–20 ml.

Equipment

• 1.

  Fluoroscopy unit with spot film device

• 2.

  Vaginal speculum

• 3.

  Vulsellum forceps

• 4.

  Hysterosalpingography balloon catheter 5-F to 7-F. In patients with narrow cervix or stenosis of cervical os, Margolin HSG cannula may be used. It has a silicone tip and provides tight occlusion of the cervix for contrast injection.

Patient preparation

• 1.

  The patient should abstain from intercourse between booking the appointment and the time of the examination, unless she uses a reliable method of contraception and the appointment is made before day 21, or the examination can be booked between the 4th and 10th days in a patient with a regular 28-day cycle.

• 2.

  Apprehensive patients may need premedication.

• 3.

  Consent should be obtained. ¹

Technique

• 1.

  The patient lies supine on the table with knees flexed, legs abducted.

• 2.

  The vulva can be cleaned with chlorhexidine or saline. A disposable speculum is then placed using sterile jelly and the cervix is exposed.

• 3.

  The cervical os is identified using a bright light and the HSG catheter is inserted into the cervical canal. It is usually not necessary to use a Vulsellum forceps to hold the cervix with a forceps, but occasionally this may be necessary. The catheter should be left within the lower cervical canal if cervical incompetence is suspected.

• 4.

  Care must be taken to expel all air bubbles from the syringe and cannula, as these would otherwise cause confusion in interpretation. Contrast medium is injected slowly into the uterine cavity under intermittent fluoroscopic observation.

• 5.

  Spasm of the uterine cornu may be relieved by intravenous (i.v.) glucagon if there is no tubal spill bilaterally.

N.B. Opiates increase pain by stimulating smooth muscle contraction.

Images

The radiation dose should be kept as low as possible. Intermittent screening should be performed to the minimal requirement. Images should demonstrate:

• 1.

  Endometrial cavity, demonstrating or excluding congenital abnormalities or filling defects

• 2.

  Full view of the tubes demonstrating spill. If occluded, show the extent and level of block

• 3.

  If there is abnormal loculation of contrast, a delayed view may be useful.

Aftercare

• 1.

  It must be ensured that the patient is in no serious discomfort nor has significant bleeding before she leaves.

• 2.

  The patient must be advised that she may have spotting or occasionally bleeding per vagina for 1–2 days and pain which may persist for up to 2 weeks.

• 3.

  Prophylactic antibiotics are routinely given in several centres and is good practice.

Complications

Indications

• 1.

  Pelvic mass

• 2.

  Pregnancy – normal and suspected ectopic

• 3.

  Precocious puberty or delayed puberty

• 4.

  Pelvic pain

• 5.

  Assessment of tubal patency

• 6.

  In assisted fertilization techniques

• 7.

  Postmenopausal bleeding

• 8.

  Menstrual problems, location on IUD

• 9.

  Ovarian cancer screening.