New Nigerian Journal of Clinical Research

ORIGINAL ARTICLE
Year
: 2021  |  Volume : 10  |  Issue : 17  |  Page : 14--18

Evaluation of hysterosalpingographic findings of patients presenting with infertility in Kano, Northern Nigeria


Jamilu Tukur1, Safiya Usman Zahradeen2, Idris Usman Takai1, Mohammed Abba Suwaid3, Usman Muhammad Ibrahim4,  
1 Department of Obstetrics and Gynaecology, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria
2 Department of Obstetrics and Gynecology, Aminu Kano Teaching Hospital, Kano, Nigeria
3 Department of Radiology, Aminu Kano Teaching Hospital, Bayero University, Kano, Nigeria
4 Department of Community Medicine, Aminu Kano Teaching Hospital, Kano, Nigeria

Correspondence Address:
Dr. Idris Usman Takai
Department of Obstetrics and Gynecology, Aminu Kano Teaching Hospital, Bayero University, PMB 3452, Kano State
Nigeria

Abstract

Background: Hysterosalpingography (HSG) is a minimally invasive tool with reasonable specificity and sensitivity which is effective in diagnosing tubal factor infertility. Objective: This study determines the pattern of infertility, the risk factors for infertility in women presenting for HSG, and documented HSG findings among women with infertility at Aminu Kano Teaching Hospital (AKTH), Kano. Materials and Methods: This was a retrospective study of HSG findings among infertile women who presented for HSG between January 2016 and December 2018 in AKTH. The register for HSG was reviewed at the Radiology Department, and information obtained from the record included the age, file number, and the outcome of HSG. The corresponding files of the patients were then retrieved from the Central Medical Records Department. Information obtained from the case notes were age, parity, type of infertility, and risk factor for infertility. Results: During the study period, there were 400 cases of infertility who presented to the gynecological clinic, out of which 250 patients presented for HSG. One hundred and forty-four case notes were retrieved giving a retrieval rate of 57%. Majority of the women who had HSG during this study were aged between 26 and 30 years. Secondary infertility was predominant over primary infertility which occurred in 86 (59.7%) of the patients. Among the 144 patients who were examined, 71 (49.3%) of the women had an abnormal finding. Bilateral tubal blockage was the predominant abnormal finding on HSG, found in 27 (18.7%) patients. Right tubal blockage occurred more than left tubal blockage, which was seen in 15 (10.4%) and 13 (9.0%) patients, respectively. Regarding uterine pathology, uterine fibroid occurs most in the women accounting for 11 (7.6%) when compared to uterine adhesions which were found in only 4 (2.7%) women. Conclusion: Even though uterine adhesions were significant findings, bilateral tubal blockage and uterine fibroid were the main HSG findings in AKTH within the study period.



How to cite this article:
Tukur J, Zahradeen SU, Takai IU, Suwaid MA, Ibrahim UM. Evaluation of hysterosalpingographic findings of patients presenting with infertility in Kano, Northern Nigeria.N Niger J Clin Res 2021;10:14-18


How to cite this URL:
Tukur J, Zahradeen SU, Takai IU, Suwaid MA, Ibrahim UM. Evaluation of hysterosalpingographic findings of patients presenting with infertility in Kano, Northern Nigeria. N Niger J Clin Res [serial online] 2021 [cited 2021 Dec 5 ];10:14-18
Available from: https://www.mdcan-uath.org/text.asp?2021/10/17/14/314595


Full Text



 Introduction



Infertility is a disorder with notable medical, social, psychological, and economic problems, causing a lot of stress, unhappiness, and marital disharmony among couples. It is defined as the inability of a couple to conceive after 12 months of regular, unprotected sexual intercourse.[1] It can either be primary or secondary. In primary infertility, couples have never conceived in their lifetime, whereas secondary infertility is a failure to achieve pregnancy again after an earlier pregnancy which may or may not have led to live birth.[1]

The prevalence of infertility varies across regions of the world and is found to be in 8%–12% of couples worldwide.[2] It was found that 15% of all women will experience primary or secondary infertility at one point in their reproductive carrier.[3]

Different factors cause infertility including male factor, ovulation problems, and uterine and tubal pathologies. Tubal factors are attributed to both primary and secondary infertility with higher prevalence in secondary infertility making routine tubal investigation in secondary infertility a recommendation.[4] Uterine factors causing infertility include polyps or fibroids, uterine wall irregularities, and congenital anomalies.[4] Therefore, evaluation of the uterine cavity and fallopian tubes is a standard practice in the baseline investigations for infertility.[5] Hysterosalpingography (HSG) has largely replaced Rubin's test for the evaluation of tubal patency in infertile women.[3] HSG is a safe, relatively inexpensive, simple, and rapid diagnostic test. Some authorities are of the opinion that laparoscopy and hysteroscopy can replace HSG. However, the superiority of HSG in detecting uterine and intraluminal tubal pathology, its ready availability, and nonoperative technique still makes it the initial and standard procedure for evaluating female infertility in most developing countries like ours.[6],[7],[8] Although HSG is still a vital and undisputed method for the evaluation of infertile women, recent studies revealed that sonohysterography is superior to HSG for evaluating intrauterine and tubal abnormalities, as it is free of ionizing radiation, cheaper, and more tolerable.[5] HSG is associated with little disadvantages which involve patient discomfort, exposure to radiation to both patient and personnel, and scarcity of resources.[6] HSG is a specialized radiologic (fluoroscopically guided) investigation of the uterus and fallopian tubes following the injection of 10–20 mL of a water-soluble contrast medium through the cervix,[7],[9] to visualize the uterine cavity and to determine patency of the fallopian tubes most commonly.[7] Common indications for this procedure include but not limited to evaluation of tubal patency, identification of congenital anomalies of the genital tract, assessment of uterine cavity, efficiency of tubal sterilization, reversal of tubal surgery, and assessment of pathologic secondary amenorrhea among others. Known contrast allergy is an absolute contraindication to HSG. It is also contraindicated in pelvic inflammatory disease (PID) infection and pregnancy. Some of its complications include pelvic infection, severe pain, hemorrhage, and vasovagal attacks due to the pain.[5] HSG may show normal findings. Abnormal findings include tubal blockage, multiple uterine fibroids, uterine adhesions, cervical adhesions, cervicouterine adhesions, and hydrosalpinx.[8]

Tubal infertility is a major cause of infertility in our environment with HSG been the first-line diagnostic tool used in assessing it. HSG has been found to be minimally invasive, cheap with high sensitivity and specificity; however, the acceptability of HSG in recent time is declining since laparoscopy became available in some centers despite both being complementary to each other. This study aimed to determine the pattern of infertility among women presenting for HSG, identify the risk factors, and document the HSG findings among infertile women attending infertility clinic Aminu Kano Teaching Hospital (AKTH). Findings from this study may prompt the decision-makers at various levels for favorable policies aimed at reducing the infertility burden in Nigeria and could serve as a foundation for future research.

 Materials and Methods



Study area

The study was conducted at AKTH, Kano. Kano State is located in Northern Nigeria and lies between latitude 12000 North and longitude 14031 East. According to the 2006 census, the population of Kano city is 2,282,861 and for the state is 9.6 million.[10] The United Nations population projections put the current metro area population of Kano in the year 2020 at 3,999,000, which translate to a 2.38% increase from 2019.

AKTH is about 720-bed tertiary health institution serving Kano, Jigawa, Katsina, Zamfara, Kebbi, Kaduna, and Sokoto states in northwestern geopolitical zone of Nigeria. It also provides training facilities for medical students, nurses, laboratory technologists, and postgraduate trainings. Women with infertility first present to Gynecological Clinic of Obstetrics and Gynecology Department of AKTH. During the daily clinics, detailed history is taken followed by thorough physical examination. HSG is one of the investigations requested in the evaluation of the patients with infertility and is carried out in the Radiology Department.

Study design

We conducted a retrospective secondary data analysis of the routine data for women presenting to the gynecology clinic with infertility and conducted HSG investigation in AKTH, Kano.

Study population

The study population comprised all women presenting to the gynecology clinic with any form of infertility between January 2016 and December 2018 in AKTH. These included those coming directly to AKTH as well as those referred from outside facilities for infertility management. All infertility cases with incomplete information about the HSG results from radiology records and clinic register and patients referred from other hospitals for other reasons for HSG beside infertility were excluded.

Method of data collection

Record of the patients who went for HSG between January 2016 and December 2018 was obtained from the archive of the Radiology Department (excluding those referred from other hospitals). A datasheet was used to extract data from the Radiology Department and Medical Records of AKTH, Kano. We extracted information on age, file number, and the outcome of HSG from the archive of the Radiology Department. The corresponding files of the patients (using the file number) were retrieved from the central medical records. The information obtained from the case notes were age, parity, last childbirth, type of infertility, and risk factors for infertility.

Technique for hysterosalpingography procedure

The appropriate time to perform HSG is at the end of the 1st week (preferably on day 10) following the menstrual period at which time the isthmus is at its most distensible point and the fallopian tubes are most readily filled by contrast medium.[11] HSG is not done in the second half of the cycle because of the risk of inadvertently irradiating an unidentified ongoing pregnancy and because the thickened secretory endometrium heightened the risk of venous intravasation which could lead to false-positive result of cornual occlusion.[12]

HSG examination is done by our trained radiologists who also interpreted the results afterward. Before the procedure, a patient is given a gown to dress into and she is given analgesic and antispasmodic in the form of intravenous pentazocine and buscopan to relieve pain and prevent spasm of the tubes, respectively. The patient is asked to lie in dorsal position as for a pelvic examination. A speculum is inserted into the vagina so as to expose the cervix.

A vulsellum is used to hold the anterior wall of the cervix for good grasp and to align the cervical canal with the uterine cavity. Leech Wilkinson's cannula is then inserted into the external cervical os and screwed so as to fix well into the cervix to prevent the spillage of the contrast material. Contrast is introduced into the uterine cavity to outline the cervical canal, uterine cavity, and the tubes.

X-ray films are taken in real time as the contrast medium passes through and fills the uterus and tubes with the first film taken immediately after injecting the contrast. The views taken include an anterior-posterior view of the pelvis, with a delayed film after 30 min where necessary so as to demonstrate pelvic adhesions when the contrast is not visualized in the peritoneal cavity. After the images are made, the cannula is removed and the patient is sat up and redressed.

Statistical analysis

Data collected were cleaned, entered into Excel spreadsheet, and analyzed using IBM SPSS version 21.0 (Armonk, New York, USA). Age of the clients was summarized using mean and standard deviation while frequencies and percentages were used to summarize reproductive characteristics, pattern of infertility, risk factors for infertility, and pattern of HSG findings.

Ethical consideration

The protocol for this study was submitted to the Health Research Ethics Committee of AKTH, Kano, Nigeria, for review, and approval was obtained before the commencement of data collection.

 Results



During the study period, there were 400 cases of infertility who presented to the gynecological clinic, in which 250 patients presented for HSG. One hundred and forty-four case notes were retrieved giving a retrieval rate of 57%. The age range was between 16 years and 46 years with a mean age of 30 ± 6.6 years.

Age and parity distributions of women who had hysterosalpingography

[Table 1] shows the age distribution and reproductive characteristics of women who had HSG. The women between 20 and 29 years of age constituted the highest number who had HSG 75 (52.9%), followed by 30–39 years which constituted 55 (38.2%) of the women. The least number of women (4, 2.8%) who presented for HSG were <19 years. More than half of the women 93 (64.6%) were nulliparous and only 1 (0.7%) woman was grand multipara.{Table 1}

Indications for hysterosalpingography

[Table 2] presents the indication for HSG. More than half of the women (86, 59.7%) had secondary infertility, whereas 58 (40.3%) had HSG because of primary infertility.{Table 2}

Risk factors (previous medical or surgical exposure) in the women presenting for hysterosalpingography

[Table 3] shows the risk factors (previous medical or surgical exposure) in the women presenting for HSG. Majority of the women (115, 79.9%) had no exposure either medically or surgically, whereas 17 (11.8%) had previous history of manual vacuum aspiration, 6 (4.2%) had previous history of sexually transmitted infections (STIs), 4 (2.7%) had previous cesarean section, and only 2 (1.3%) of them had previous ectopic pregnancy with salpingectomy.{Table 3}

Hysterosalpingography findings

[Table 4] illustrates the HSG findings among the 144 patients who were examined. More than half of the women (73) had a normal study. Bilateral tubal blockage was the predominant abnormal finding on HSG constituting 18.7%. Pelvic adhesion occurred in a significant number of the patients 13 (9%), whereas cervical adhesions occurred in only 5 (3.4%) patients while uterine adhesions were found in 4 (2.7%) of the patients.{Table 4}

 Discussion



A total of 144 HSG films were studied and 49.3% detected abnormalities, whereas 50.6% showed no abnormality. The finding of HSG that showed no abnormality. In this study, the finding of HSG that showed no abnormality is lower than a study carried out in Zaria[13] which showed 55% of the patients with no abnormality but higher than the finding of Eleje et al. in Nnewi[3] which showed normal findings in only 21.9% of the patients. The difference in the abnormal finding of HSG in this study and that of Nnewi[3] could be associated to higher rates of history of STIs and induced abortions which predispose patients to pelvic infections, repeated dilatation and curettage, and the sequelae of uterine adhesions and tubal blockage. Our study revealed a mean age of 30.24 years, which is in contrast to a study in Zaria[13] that showed a mean age of 27.37 years. The majority of the women in our study who presented for HSG fell between the ages of 20 and 29 years, which is similar to a study by Danfulani et al.[5] It is, however, lower than the findings of Eleje et al.[3] and Onwuchekwa and Oriji,[1] which showed that the majority of the women in their studies were between the ages of 35–39 years and 30–34 years, respectively. This difference may be due to the fact that there is predominant early marriage in Northern part of Nigeria compared to other regions.

In this study, secondary infertility is more prevalent than primary infertility which is similar to the findings seen in previous studies.[5],[6],[14],[15] The study done in Ethiopia, however, showed primary infertility as more prevalent when compared to secondary infertility.[16] This may be due to PID which has been reported in many literature to be prevalent in our subregion and also major causes of secondary infertility.[1]

Tubal pathology was the most common finding, with bilateral tubal blockage being the highest. This is similar to a study by Danfulani et al.[5] and Bukar et al.[6] The high rate of tubal related abnormalities could be due to postabortal sepsis and/or puerperal sepsis as a result of lack or inaccessibility to safe medical facilities so that majority of the women give birth under poor sanitary conditions or have unsafe abortions and poorly treated spontaneous abortions.[17]

The occurrence of higher right tubal blockage over left tubal blockage is similar to a study by Adetiloye.[18] Although false positive and/or negative may be a possible confounder in this study, false-positive result could be explained as a result of spasm of uterine muscles during the procedure of HSG following the injection of the contrast product, which may constrict or occlude one or both fallopian tubes. Small plugs of material, usually like mucus or protein debris, can also occlude the proximal tube(s) in situations of very narrow tube within the uterus. Another scenario resulting in the false-positive diagnosis of proximal tubal occlusion is when inadequate wedging of the cervical cannula allows leakage of contrast material into the vagina, thus interfering with generation of sufficient intracavitary pressure and often leading to the misdiagnosis of tubal occlusion. The false-negative result can occur in situations, whereby there is contrast intravasation into the uterine and ovarian veins during HSG.[19] In this study, right hydrosalpinx and left hydrosalpinx were found to be 2% and 5.5%, respectively, which is lower than the finding of 6.4% and 44.8%, respectively, by Onwuchekwa and Oriji.[1]

Only one uterine anomaly was detected in this study which was hypoplastic uterus, whereas in a study by Bukar et al.,[6] three hypoplastic uterus were detected alongside with other congenital anomalies of bicornuate and arcuate uterus.

Uterine fibroid was the most common uterine pathology detected, followed by uterine synechiae; this was similar to a study done in Enugu[20] but contrasting the finding of Bukar et al.[6] which showed synechiae as the main occurrence followed by fibroids. The high incidence of this uterine adhesions as in Sokoto[5] may probably be due to infection and postinstrumentation (dilatation and curettage) of an unwanted recent pregnancy. The aggressive and prompt use of antibiotics to treat infection would significantly lower the contribution of uterine adhesion as a cause of infertility.[5] STI and miscarriage were seen in 4.2% and 11.8% of the patients, which was much lower than the finding of Eleje et al. in Nnewi[3] as 42.6% and 25.1%, respectively. About 79.9% showed no exposure in this study which was in contrast to a study,[3] which showed only 9.8% with no exposure. This is so because the prevalence of STI, pelvic inflammatory disease, and induced abortion occurs less common in our society probably due to early marriage when compared to other parts of the country.[3]

 Conclusion



Secondary infertility is more common than primary infertility in this study. Secondary infertility is more common than primary infertility in this study and tubal factor infertility remains the major contributing pathology in female presenting with infertility at AKTH.

Limitation

The study is retrospective in nature where data storage and retrieval was relatively difficult and poor. Therefore, only record with complete clients' information was retrieved and analyzed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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