LIST OF TABLES
Table 1: Cross tabulation on findings on HSG
Table 2: Age and Findings Correlations
LIST OF FIGURES
Figure 1: Diagram of the female reproductive system
ABSTRACT
HSG is a commonly performed examination due to increasing popularity of reproductive medicine and infertility. It plays an important role in evaluation of abnormities related to uterus and fallopian tubes. This research work is a retrospective research study aimed at determining the common findings in hysterosalpingography at Federal Medical Centre Asaba, from May 2011 to April 2013. The patients that met the inclusive criteria were those that were diagnosed to be infertile.
The results show that the commonest finding is uterine fibroid 83(33.20%) and the type of findings occurring list is salpingitis isthmica nodosa 1(0.40%). The predominant ages were found to be between 30 – 34 years 101(40.40%). The earliest onset of these findings on HSG is 20 years and 30 – 34 years of group has the highest occurrence. There was also a strong negative correlation between the age of the patient and the findings on HSG.
This led to the conclusion that uterine fibroid is the major cause of infertility in women in this locality and is commonly seen among the mid-years. This if discovered on time and managed well will increase the chances of infertile women becoming fertile.
TABLE OF CONTENTS
Title page……………………………………………………..…….………. I
Approval Page…………………………………………………..………….… II
Certification……………………………………………………..………….III
Dedication……………………………………………………………….….. IV
Acknowledgement…………………………………………………..…….… V
List of tables ……………………………………………………………….. VI
List of figures…………………………………………………..………….. VII
Abstract ……………………………………………………..…………….. VIII
Table of Contents………………………………………………………….….I
CHAPTER ONE: INTRODUCTION
1.1 Background of study …………………………………………………………….……. 1
1.2 Statement of problem……………………………………………..…….. 2
1.3 Purpose of study………………………………………………..………….3
1.4 Significance of study ………………………………………..………… 3
1.5 Scope of study…………………………………………….……….. … 3
1.6 Literature review…………………………………………….………… 4
CHAPTER TWO: THEORETICAL BACKGROUND
2.1 The female reproductive system …………….……………………….10
2.2 Infertility…………………………………………………………… 19
2.2.1 Causes of Infertility………………………………………… 20
2.3 Hysterosalpingography………………………………………….….. 23
CHAPTER THREE: RESEARCH METHODOLOGY
3.1 Research Design………………………..………..………………… 25
3.2 Area of study……………………………………..…….…………… 25
3.3 Target Population…………….…………………..………………… 25
3.4 Inclusion Criteria…………………………………..………………. 25
3.5 Exclusion Criteria…………………………………..……………… 25
3.6 Procedure of Data Collection……………………………………….. 26
3.7 Method of Data Analysis……………………………..……………. 26
CHAPTER FOUR: PRESENTATION AND DATA ANALYSIS
4.1 Data Analysis…………………………………….………………… 28
CHAPTER FIVE: DISSCUSION, SUMMARY OF FINDINGS, CONCLUSION, RECOMMENDATION, AREA OF FURTHER RESEARCH AND LIMITATION.
5.1 Discussion…………………………………….…..…..……………. 30
5.2 Summary of Findings……………………………….………………. 31
5.3 Conclusion …………………………………………………….…… 32
5.4 Recommendation ………………………………………………….. 32
5.5 Area of Further Research …………………………………….……. 32
5.6 Limitations…………………………………………………………. 33
References………………………………………………………………. 34
Appendix……………………………………………………………….. 37
CHAPTER ONE
INTRODUCTION
- BACKGROUND OF STUDY
Hysterosalpingography (HSG) is the radiographic evaluation of the uterus and fallopian tubes 1. It can also be defined as the radiographic examination of endocervical canals, uterine cavity and fallopian tube with the use of a radiographic contrast medium 2. It is used predominantly in the evaluation of infertility. Other indications for HSG include the evaluation of women with a history of recurrent spontaneous abortions, the postoperative evaluation of women who have undergone tubal ligation or reversal of tubal ligation, and the assessment of patients prior to myomectomy . Hysterosalpingography (HSG) is the most commonly used technique in the evaluation of infertility. It has traditionally been considered the gold standard for assessment of the fallopian tubes, giving reliable information about their patency and morphology. It is also recommended for the study of the uterine cavity in the diagnosis of and treatment planning for other gynecologic problems such as intrauterine adhesions and congenital anomalies. HSG is an indirect means of showing the interior of the uterus and fallopian tubes. Endometrial lesions are shown as filling defects or uterine wall irregularities. HSG also enables visualization of the general configuration of the cavity.
Hysterosalpingography may show normal findings, which will show a healthy, normal shaped uterus and unblocked fallopian tubes. Intra uterine filling defects caused by intra-uterine adhesion, sub mucous fibroids, endometrial polyps. There may be a reduction in the size of the uterine cavity depending on the severity of the intra-uterine adhesion. Fibroids and endometrial polyps in addition to causing luminal filling defects, will also cause uterine cavity enlargement and sometimes deformities.
Infertility is defined as the inability of a couple to achieve conception after 12 months of unprotected coitus of average frequency 3. The major causes of infertility are Failure to Ovulate, Poorly Functioning Fallopian Tubes disorders, endometriosis and other factors such asfibroid, polyps and adenomyosis which may lead to obstruction of the uterus and Fallopian tubes, behavioral factors, environmental and occupational factors. Tubal disease is among the most common cause of infertility cases from other studies. The major causes of infertility has not yet been documented in Asaba. This study was conducted in Federal M edical Center Asaba,Delta state.
1.2 STATEMENT OF PROBLEM
- Increase in infertility cases is becoming a major health concern among families in Asaba, Delta state Nigeria.
- Common pathologies seen among infertile women in Asaba, has not been documented.
1.3 PURPOSE OF STUDY
- To describe the common pathologies seen in HSG in patient with infertility in Asaba, Delta state.
- To describe the commonest pathologies responsible for primary and secondary infertility in Asaba, Delta state.
- To correlate the age of patient with the common findings on HSG.
1.4 SIGNIFICANCE OF STUDY
- This study will avail the clinician of the common pathologies associated with infertility in Delta state.
- It will define the pattern of utero-tubal abnormalities in infertile female patients.
- It will define if age is related to infertility.
1.5 SCOPE OF STUDY
This study will be carried out at Federal Medical Centre Asaba, Delta State, Nigeria.
1.6 LITERATURE REVIEW
In a study by Bukar et al 4, to review the Hysterosalpingography (HSG) in the investigation of infertile women carried out at the University of Maiduguri, Teaching Hospital, Maiduguri , 47.8% were investigated for primary infertility, (52.2%) were investigated for secondary infertility. The common pathology revealed among infertile woman were tubal peritoneal factor (72.1%), uterine Synechia (12.9%), bilateral tubal blockage (6.3%) and bicornuate uterus (1.8%).
In a research to evaluate the findings at HSG in patient presenting with infertility at Ebonyi State University Teaching Hospital, Abakaliki, by Ibekwe et al 5, the common age group encountered were between 25-34 years. 65% presented with secondary infertility while 35% presented with primary infertility. HSG findings were abnormal in 80% of patients (primary infertility 20% and secondary infertility 60%). Bilateral tubal blockage and bilateral fibrial adhesion were the commonest tubal factor abnormalities while intracavitary mass impression and cervical synechia were the commonest findings for uterine and cervical factor abnormalities.
In a study carried out by Bello 6 at the University of Ilorin Teaching Hospital, to evaluate tubal abnormalities at hysterosalpingography in primary and secondary infertility, HSG was done between day 7 and 10 of the menstrual cycle using standard procedure.He excluded that women of childbearing age with acute infection of vagina or cervix (because of the danger of dissemination of infection) and in active uterine or vaginal bleeding. Bilateral normal tubes characterized by normal size tubes with free interperitioneal spillage were present in 60% of the cases. Hydrosalpinxs either bilateral or unilateral was the most common tubal abnormality and was present in 23.3% of cases. While bilateral tubal is noted in 11.7% of cases, unilateral hydrosalpinx in either right or left tube was also noted in 11.7% of cases. However right unilateral hydrosalpinx was more frequent occurring in 7.5% bilateral tube blockage was observed in 7.5% unilateral tubal blockage occurring with either a normal or hydrosalpinx tube was observed in 13.33% of cases.
In a related work to determine structural findings at HSG in patient with infertility in Kampala, Uganda, by Elsie et al 7, bilateral tube blockage was seen in 32.9% while 6% had unilateral tubal blockage. Loculated spill was noted in 28% being bilateral in 24.4% fimbrial end adhesion were found in 17.3% of patients. Hydrosalphinx was seen in 12.8% while 30% had signs of pelvic peritoneal adhesions. Congenital abnormalities were found in 1.6% patients. In general tubal related factor were found in 72.9% of the patients, which is similar to what was reported in Kenya and in Tanzania. WHO reported that tubal occlusion and acquired tubal abnormalities accounted for 85% of infertility in Africa 8.
In a study to determine the Hysterosalpingographic Abnormalities in infertile women at the hospitals affiliated to Tabriz University of Medical Science, Iran by Mesbahi et al 2, 79% had primary inferility, while 21% had secondary infertility. Abnormal findings at hysterosalpingography were found in 42%. Abnormal uterine in 25%, abnormal fallopian tubes in 21% and abnormal uterine with the accompanying abnormal tubes in 4%.
Abnormal Radiological features related to uterus include;Uterus size: Normal (93%), greater than Normal (3%), less than Normal (4%). Uterus shape: Normal (90%), Acute (5%), Bicornuate (5%).Filling status: Normal (92%), Filling defect (8%).
In a study done to evaluate the fallopian tubes in infertile women by hysterosalpingography in Tikar Aubessa Hospital, Addis Ababa, Ethiopia by
Daniel and Yewebdar 9, of the 331 patients, 70 (21.2%) of the women had normal bilateral fallopian tubes and the remaining 261 (78.9%) had abnormal tubal findings. Out of the 261 abnormal findings, 167 (50.5%) revealed proximal tubal blockage, of which 91 (27.5%) were bilateral and 76 (22.98 %) unilateral blockage. From among the 94 (28.3%) women who belong to the abnormal cluster, 12 (3.6%) exhibit distal tubal blockage with or without hydrosalpinges due to fimbrial blockage. The rest 82 (24.8%) women of the 94 displayed both proximal and distal tubal blockage with or without hydrosalpinges. Bilateral hydrosalpinges are found to be double the unilateral hydrosalpinges. Young women of ≤32 years of age exhibit an exceeding primary infertility. However, over 32 years of age secondary infertility outweigh primary infertility. The highest percentage (17.2%) of proximal tubal blockage was witnessed in women of age range 28 to 32 years and remained high throughout the age ranges. Those women in the age range of 28 to 32 years showed high percentage of distal tubal blockage with or without hydrosalpinges.
In a related work to assess infertility in women by Hysterosalpingographic assessment of the fallopian tubes in Lagos, Nigeria by Akinola et al 10, it was found out that of the 220 patient examined, 185 (84%) had secondary infertility while 35(16%) had primary infertility. Age range of the patient was between 23 and 38 years with a mean of 28 years and 4 months. Of the 220 patients, 84 (38.2%) had normal uterine cavities and the fallopian tubes were outlined with normal caliber and free peritoneal spill. The fallopian tubes were classified bilaterally blocked in 22(10%) patients and only the left tube was blocked in 32 (2.7%, right hydrosalpix in 6(2.7%) and left in 8 (3.6%) patients.
In a research work done to evaluate Hysterosalpingography in the workup of female infertility by Adrian C. et al 11, of the 411 HSG examinations, 226 (55%) were normal. In 15 of the examinations that were assessed as normal, administration of Buscopan was required to differentiate spastic tubal occlusion from true tubal occlusion. There were minor abnormalities observed in 94 examinations (23 %). Five examinations (1.2 %) were not diagnostic (early termination of the exam due to venous filling of the uterine plexus). In 86 (21 %) of the examinations, at least one pathology was described that was probably or possibly relevant to female infertility. The detailed analysis of our study was based on this subpopulation. There was a statistically significant age difference between patients with normal (mean 31.8 years) and pathological (mean 34.1 years) HSG examinations (P-value00.0001). Of these 86 patients, 30 solely uterine pathologies were identified. The most common uterine pathologies were filling defects and Müllerian duct anomalies, including arcuate uterus, hypoplastic uterus, uterus septus and uterus bicornis bicollis. A few patients had minor abnormalities of the uterine cavity that were described as likely originating from mucosal irregularities. In 47 of the 86 examinations, tubal pathologies were present, and one-sided tubal occlusion was the most common finding. Five of these patients had a history of salpingectomy. Further findings included bilateral tubal occlusion, postinfectious tube abnormalities, including salpingitis, isthmica nodosa, and peritubal adhesions. One patient had several pathological findings.
In a related work done by Ramadhan 12, at Muhimbili University of Health and allied sciences, to assess the imaging findings in infertile female patients which underwent hysterosalpingograhic investigation at Muhmbili National Hospital, it was found out that the participant mean age was 30 years and mean duration of infertility of 5 years secondary infertility was slightly common. 70% of patients were between 16-30years. Abnormal findings at HSG were found in 60% of the patients, most of these abnormal findings were found in patient with older age between 31 and 45 years and those with long duration of infertility for more than 5 years. He commonest findings has tubal blockage (41%) and the least was uterine congenital abnormality (3.8%).Uterine fibroid was the commonest uterine pathology accounting for 10% of all cases.
In a research work carried out by Poonam 13 to evaluate the role of HSG in cases of sub-fertility, normal tubal findings were present in 56 out of 105 cases which accounts for 53.33% of cases. Amongst the different tubal abnormalities, tubal occlusions reigned supreme with the incidence of 34.28%. There was preponderance of proximal tubal blockage (88.88%). However no significant difference was found between the right or left side. Tubal pathology with tubal blockage due to PID was one of the most frequent causes of infertility in women. 5.71% of the cases have either unilateral or bilateral hydrosalpinx. This appeared as a localized collection of contrast medium which gradually increases in size. 2.85% of the cases had beaded and wiry appearance of the tubes which is a characteristic finding in late stages of genital tuberculosis involving the tubes.
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