 and over to you. Yeah, good afternoon, everybody. And first of all, I would like to thank the Sonobas people for this amazing online discussions of, it's a feast for all the radiologists, so many workshops, so many lectures, so many eminent faculties talking about lots of topics. And I hope this topic is also useful to all of you. So without wasting much time, I will start my topic. It's imaging of fallopian tubes. Now, histosulfoemography is the first and foremost modality for imaging the tubes. It has become a commonly performed examination due to recent advances and improvements in as well as increasing popularity of reproductive medicine. HSC plays an important role in the evaluation of abnormalities related to the uterus and fallopian tubes. Uterine anomalies that can be detected at HSC include congenital anomalies, polyps, gliomyoma, surgical changes, cyanichi and adenomersis. Tubal abnormalities that can be detected include tubal occlusion, cyan, polyps, hydrosulfins, and peritubal adhesions. Now, HSC is the radiographic evaluation of uterus and fallopian tubes, you all know. And it is predominantly used in the evaluation of infertility. But apart from that, HSC is also used in the evaluation of women with a history of recurrent spontaneous abortions, postoperative evaluation of women who have undergone tubal lagation or reversal of tubal lagation that has been done in order to assess the patency. And even after myomectomy, prior and after the myomectomy, in order to know the size of the cavity. The primary role of HSC is in the evaluation of fallopian tubes. Ultrasonography is currently used for the evaluation of endometrium as beautifully told by Dr. Khurana Sir. And he has very beautifully elaborated the topic as such. And we can also use the ultrasound for the evaluation of abnormal uterine bleeding, polyps, pregnancy, whereas MRI is a modality which is used for the evaluation of uterine and myometrium. That is uterine contour, myomas, and other pathologies, as well as the ovaries. So in our practice with the increased demand for HSC, radiology should be familiar with the HSC techniques and interpretation of HSC images. Our tubes merely are piped. This is a question which we all need to know. Even if fallopian tubes are patent, this doesn't mean that they are normal. Most people think of fallopian tubes as simple tubes that allow eggs and sperm to meet and fertilize it to reach the uterus. However, in actuality, a fallopian tube is much more a dynamic organ. The effect of this negative pressure and sucking action plays its best when the femoral end expands and cover the ovulation site of the ovary well. So it is not only sufficient to know that tubes are patent, but we also need to know about the mobility of the fallopian tubes, the condition of the tubal lumen and the fimbria and the tubal ovarian relationship. So a functional test versus patency test. While a full testing of tubal function in patients with infertility is not possible, testing of tubal patency is important as tubal obstruction is a major cause of infertility. Now various tests for tubal patency that are available, first is the gold standard histero laparoscopy and then we cannot do histero laparoscopy in each and every patient. We need some screening techniques. So that is why we have other imaging studies for fallopian tubes, that is HSG, the histero sonogram, the selective histro sulfingogram, the magnetic resonance HSG, saline or contrast sonogram, histero sulfingocontrast sonography, 3D and 4D contrast ultrasonography and the traditional Rubens test. Now you all know that for 30 to 40% of the female factors are contributed by the tubal factors for infertility. And there is increasing trend of PID, ectopic, IUCDs and endometriosis, pelvic surgeries and sulfingitis which contribute to the putubal pathologies. Now what are the contraindications where we are not doing tubal patency test? These are women who are having their period, women who are pregnant and women who are having pelvic infections. So HSG not only opacifies the endometrial cavity, it also shows the anatomy of the fallopian tubes and it also shows the spill pattern if the tube is patent. So it is an advantage to study the endometrial cavity as well as to diagnose the mullerian abnormalities endometrial regions to assess the entire tube, the condition of the lumen and the spill pattern. So it is an outpatient procedure. It is relatively inexpensive. It does not require GA unless and until patient herself demands for that. It is associated with the therapeutic effect. There had been a lot of studies which say that many patients they conceive immediately after one or two cycles post HSG. It may be due to the positive pressure effect that is being imparted by the contrast on the fallopian tubes leading to wash out of the debris and thus leading to pregnancy. Now, what we need is to know that HSG needs to have an correct interpretation. Spilling of the dye, however, does not always indicate a normal fallopian tube. It takes an experienced expert to correctly interpret a normal tubal anatomy on HSG. Indeed, I would like to say the interpretation of HSG films is the most frequently falsely interpreted test in medicine. We constantly see patients with diagnosis of normal tubes on HSG. But when we see those films very clearly or very closely, they turn how to have some or the other obvious tubal diseases. So our radiology colleagues need to focus on whether the tubes are open when they perform and interpret the readings. Question is whether the tubes are normal. Not only the tubes are patterned. So normal tubes, of course, have to be open, but open tubes may not be necessarily normal. That is a dictum to be followed while reporting. Now timing, the examination should be scheduled during seven to 12 days of the menstrual cycle. The endometrium is thin during this proliferative phase and that facilitates the image interpretation and that is also no pregnancy in this period. So if the patient has irregular menstrual cycles, go for a serum beta-HCG level and confirm it. We do not always require a prophylactic antibiotic treatment. Major equipment is a C-arm, a fluoroscopy room or even an X-ray table. And other is the H-SG tray, which consists of all the... Okay. So what is the exact interpretation? At H-SG, phallopentube should appear as thin, smooth lines. They should widen in the ampullary portion. The islamic portion is taken to a spaghetti in appearance. The phallopentubes, they vary in location within the pervix and they have vary in their tortuosity also. There should be free spillage of contrast material into the peritoneal cavity. Tuber abnormalities can be either due to congenital spasm, occlusion or an infection. So this is a normal histro-sulfingogram. These are the four parts of the tube. Cornu is thymus, ampulla and the fimbria. And this is the spillage pattern. The spills generally they outline the gut loops. So what are the points that are to be looked while reporting H-SG uterine cavity? The number, the size, shape, margin, lastly filling defects. Phallopentubes that extend the spillage of the dye into the peritoneal cavity or not. And the type of the spillage. If there is any block, the level of the block and any appearances of hydro-sulfings or any abnormalities such as tobacco pouch, beaded appearance, lymphatic venous intraversation of dye or not. So SiN is a disease of unknown origin and it is very occasionally seen in Indian patients and possibly due to a topic or any tubercular setting that we can see the findings of SiN on Phallopentubes. So these are the various findings. These are the diverticular pouches. Now coronal block, this is which we commonly occur is I should be evaluated whether it is true or pseudo. Coronal portion of the tube is encased by the smooth muscle of the uterus. So if there is any spasm of the muscle during H-SG1 or more tube may become not filled with the contrast and then we get a pseudo block. So in order to distinguish between pseudo and a true block, we have to administer a spasmolytic that is to be part of the pre-medication or we can continue administration of contrast which sometimes leads to opening of this spasm and a pacification of the distal tube. And again, we have a procedure known as selective Phallopentubes cannulation that is selective sulpingography, which also helps in knowing the pseudo and differentiating the tubal spasm and the tubal blocks. So tubal occlusion will have manifest as an abrupt cutoff of contrast medium with non-officification of the distal tube. It may be unilateral, bilateral, any part of the tube may be blocked. So hydro sulping, it is a tubular dilatation of the Phallopentubes mostly occurs in the ampullary and the femoral part. The blockages, I might be bilateral or unilateral. Unicornvite uterus is very well diagnosed on HSG in which the excess of the uterus is deviated to one side. There is a single cornoa which is seen at the top of the uterine cavity and a single Phallopentubes seen originating from it. Various mullerian abnormalities can also be diagnosed. There are criteria for distinguishing bicornvite and septic uterus. And there are various findings that are very peculiar. We've seen tuberculosis about Phallopentubes and uterus. Specifically, we have a big tube appearance, the girl club tube, the piped stem tube, the cobalt stem tube, leopard skin tube, and non-specifically, we can get hydro sulphings which we can also get in other PIDs, amucosal thickening and peritubal adagens. In uterus, we can see a proper T-shaped uterus due to Mark Sinakie and distortion of the endometrial cavity, a pseudo-unicornvite appearance, a trifoliate uterus, and non-specific findings are again, Sinakie, distortion of the contour, and there might be a venous and lymphatic intraversation of your contrast. So this is a tufted tube appearance. We can see it's tube in the form of a lot of tufts that are there, which is due to a pooling of contrast in the mucosal folds. Then this is a cotton woolly type of parents. Contrast has been accumulated in, again, again the mucosal folds leading to this pattern. The hydro sulphings on one side, multiple divertically on the other side. Then cotton woolly appearance of this contrast pooling. These are multiple strictures followed by dilatations leading to formation of a beaded tube appearance, very classical of tuberculosis. This is, again, corkscrew tube, a vertically oriented tubes with tortuosity. Then there might be multiple adagens, Sinakie leading to distortion of uterine cavity. These are straight pipe-like tubes with tufted ends. This is pseudo-unicornvite, a distorted uterine contour. One cornu is not at all visualized. The other cornu is seen. There are multiple adagens leading to distortion of the endometal cavity. There might be, so we come to the sonohystero-sulfingography in which we use ultrasound to watch the movement of normal saline that is injected into the uterus. Sonohystero-sulfingography does not use x-ray. It does not use any iodine dye. So it is an outpatient procedure. It is associated with minimal patient discomfort and very low risk of infection is there. It is non-invasive. It is easy to perform in almost any medical setting. It does not require sedation or anesthesia. It does not have any adverse effects or any serious related complications. For this, we need an eight-french catheter, which is inserted just about to the level of the internal loss. We distend the balloon either by water or air and we introduce the probe into the vagina after removing the speculum and tineculum, but with the catheterin C2, we slowly inject some amount of saline by a 20 ml syringe and we concentrate on scanning the uterus and ovary in transverse section. We concentrate on one side at a time. We observe the fluid dribbling out through the ovary and we repeat the procedure on the other side. In case there is any doubt about patency of b-mode, we place a Doppler gate at the suspected site and a brief injection of saline is again met. There is a long-drawn noise that gradually decreases in intensity in a patent tube and the block will be seen as a steep Doppler shift followed by no noise. So similar procedure can be repeated if we use a color Doppler. There will be a sudden gush of contrast with filling of color in a patent tube. Now sono-historography or histroscopy is the diagnostic accuracy is comparable to the histroscopy. Although histroscopy enables visualization and evaluation of uterine cavity only, SHG allows evaluation of both uterus as well as adnexa. Results of SSG correlates positively with laparoscopy and SSG and HHG have been shown to have a 93% correlation. Now coming to another test that is histro-sono-sulfingography with contrast. We use here instead of the saline and eco-vist that is a specific ultrasonic contrast which enhances the visibility of endometrium as well as the fallopian tubes. So it is a very simple, well-tolerated OPD procedure again like sono-historosulfingography. Same procedure is applied instead of the saline we mix air and saline and insert it into the endometrial cavity. The bright echoes generated by the saline and air bubbles make the tubal visualization possible. The procedure is also known as sono-HSG. Coming to other modalities the MR-HSG in which again after injection of the MR contrast we take the patient inside the MR room and scan the uterus and ovaries. So this is also a very good procedure but it is very tedious and studies are still going on and not much use in India as such but it is giving promising results as equivalent to the X-ray-HSG. In addition it picks up uterine and extra uterine pathologies determining the management protocol in infertility. I haven't done any MR-HSG as such as for these are only studies that those are going on. It has been also said to add advantage of avoidance of a radiation exposure that is also there. And then again we are having a virtual HSG using CT scan. It's a multi-detector CT capacity of the CT is useful for depicting both the internal and external surfaces of the uterus, fallopian tubes and other pelvic organs providing high resolution data that are suitable for 2D, 3D. Again these are reconstructed images. Their temporal resolution is not as good as those of the HSG. So but only advantage is we can view the uterus adnexa as well as the fallopian tubes and we can evaluate the extra uterine factors as well as extra tubal factors in the same settings. So it's a non-invasive procedure for evaluating tubal pregnancy, it is painless. So take home messages, histro laparoscopy is the gold standard, but it is not useful as a screening test for each and every patient. We cannot do that for tubal assessment. So we have to use other screening methods which are more commonly the Sonoh-HSG, the HSG and the contrast enhanced HSG. So HSG remains the time-tested method but it requires expert interpretation. We already had a victim showing patent tubes are not always normal tubes, but normal tubes are always patent. All these three are comparable to each other in selective dose women who further need laparoscopy. Now coming to selective sulfinography, we are doing this lot of cases since 2000. And this is a very useful procedure and a lot of patients have been benefited with that. Patient do not undergo laparoscopy after this if they get a patent tube. In this, we insert a selective sulfinographic catheter up to the level of corneum via HSG catheter. It's a coaxial technique. And then we opacify the corneum, inject the contrast and we opacify the tube. If the tube is blocked, we insert a guide wire via the corneal catheter and we assess the patency as well as we achieve the recanelization. So these are few videos I would like to play. So this is the catheter which is placed in the corneum. It's a J-shaped HSG catheter. We are pushing the guide wire. We are assessing the tubal motility also. You can very well see the tubes are moving normally. The guide wire is removed and we push in the contrast. See, this is the peritoneal spillage. The anatomy of the tube is also very well outlined. So it's a simple procedure for tubal obstruction. In patients with tubal obstruction. Other side we are also doing this. The guide wire is being inserted. See the motility of the fallopian tube. It is freely moving, followed by the injection of contrast media. This is trans servoical fluoroscopic guide wire mediated fallopian tube recanelization. So these are selective sulfingography and FTR is a safe and effective method. Fallopian tube recanelization is recommended as a first intervention in patients with proximal fallopian tube obstruction in experienced hands and with dedicated equipment and in an appropriate setting, the success rate is high and the treatment should be offered to every woman with PFTO before any other complex techniques are attempted. And these are the recommendations for by American College of Radiology. The HHG stands first, followed by the sonohistro sulfingography, followed by the transvaginal ultrasound and the role of MRI and these, they come after the transvaginal ultrasound which has got an edge above MRI also. Thank you. Thank you, Ma'am, for taking this really important topic and we might have just forgotten few important points because we usually learn these during our residency days and then do not have time to revise the technicalities. So thank you once again. So there are a few questions coming up. So regarding the size of the catheter, they wanted you to just kind of repeat. Which is, now routinely we have readymade catheters of eight French. Then we have specialized balloon catheters which have a single balloon or the double balloon. Double balloon catheters mostly I am using during recanelization procedures. And we can also you go for a six French folace catheter. Also traditionally we can use a leach-wikinson metallic canula or we can also use that vacuum cup hystrocath that I had used in my PG days. But now we are not using that vacuum cup because it is a bulky instrument. We are using going towards more sleeker type of canulas. Those are either single balloon or double balloon. Single balloon HSG canulas are very cheap. They can come around the rate of 700, 800 at disposable signal time. You don't need to sterilize them. You just use a single use and they are very easily available. Okay ma'am. Ma'am, if you can just summarize about the pre-medications for HSG like before we give the appointment. While we are giving the appointment to the patient on table before doing the procedure and after the procedure is done. See that time you need to counsel either by yourself. If you are too busy you just train your manager or somebody. You should be very clear about the LMP. You should be very clear about the regularity of the cycles. If the patient has regular cycles offer her an appointment between 7 to 10th day of the menstrual cycle. If the cycles are not regular get a beta HCG or a pregnancy test prior day and then ask for two prepare parts. And on that particular day there is no need of NPO. Just she had to take a light food just three hours prior to that. She can also take a painkiller with that. She should report an hour prior to the appointment. And we should give her injection atropine as well as any spasmolytic. I am using a buscopane in my setting. That should be half an hour prior to the table whenever we take the patient inside. Okay ma'am. And ma'am like do we need to give any antibiotic cover or anything after the procedure? We have no guidelines for prophylactic antibiotic treatment. Ideally if the patient is suffering from active PID we do not take the patient for HSG. We should first treat the episode of infection and then we should plan an HSG. For chronic PID there is no indication for any particular antibiotic. That is a domain of gynecologist to decide if the patient needs antibiotic prior or after. We routinely are not prescribing as radiologist. Okay ma'am. Thank you for that. Any specific instruction like we did for HSG proper for sonosalpingo-graphy? Sonosalpingo-graphy actually placement of your probe is very important. And you should be prior reporting. You should have seen lot of cases also. You should have be with some good mentor and then we should report. And you can take if you have a power Doppler or color Doppler setting that is really very useful for assessing the pregnancy instead of the normal 2D mode. So I think that has sorted out most of the queries. And we thank you once again for taking this important topic for us. Thank you so much people for giving me this opportunity and sorry there was some glitch in the wifi and that got disconnected.