 Myself Dr. Sonali Pankatsoni, I am MD Radiology from GMC Nagpur. I am now settled in Amritsar and running the center by name Navya Diagnostic Center. I am a director and chief consultant there. My area of interest is vital medicine, female infertility and ultrasound. I am also specialized in trauma imaging and I have been consistently working on histero-sculptingography and fluoroscopic fallopian tube recanelization for proximal tubal obstruction since 2000 and I have done a number of cases of conventional histro-sculptingography as well as sonosculptingography and I hope you people will like this video on histro-sculptingography and various other modalities for checking tubal pregnancy. Thank you. Now you all know the incidence of tubal infertility. It is around 10 to 15 percent of the couples. They are seen to be sub-fertile. The main causes of infertility in women include anovulation and the tubal factors they contribute about 30 to 40 percent of all the female factors. Then there are other factors such as peritoneal, cervical and idiopathic. Now tubal pathologies we already discussed contribute to 30 to 40 percent. This is due to increasing trend of PID, ectopic pregnancies, use of intrauterine contraceptive devices, endometriosis, previous pelvic surgeries and sulfenitis. Now are fallopian tubes merely a pipe? No. They are a patent tube and they have a dynamic function of transporting ovum and that is why when we consider a fallopian tube we have to consider it as a dynamic organ. Now it is not sufficient to know just that fallopian tubes are patent. We need to know their function. It is very important to know the motility, the condition of tubal lumen, the condition of the fimbriae, the tubovarian relationship, how the ovary is being skirted by the tubes. Now in HSG we are just testing only the patency of the fallopian tube. It is not a test to assess the function. This should be very clear. Now what are the various tests for tubal patency? The gold standard is histero-laparoscopy. Other tubal tests are histero-sulfingography, the HSG, histero-sonogram, the selective histero-sulfingogram, the magnetic resonance HSG, saline or contrast sonogram, histero-sulfingo contrast sonography, 3D and 4D contrast USG and the traditional Rubens test. So the American College of Radiology has recommended following indications and contraindications for HSG to be conducted. Now what are the indications? Obviously infertility, then fallop of any sterilization procedure, any pelvic pain, irregular menstrual cycles, irregular vaginal bleeding, congenital abnormalities, prior or after tubal surgery, prior to assisted reproductive interventions, uterine fibroids, thickened or irregular endometrium and as equally to ectopic pregnancy. Now what are the contraindications? There are very few. We should be very sure that the patient is not pregnant. In case you are not very sure, get a pregnancy test done prior to the procedure. Any ongoing pelvic infection, if the patient has excessive discharge or bleeding PV, they should not be done. Any history of allergy to the contrast media, they should be avoided. Now histero-sulfingography had been widely used for assessment of tubal patency. It opacifies both the endometrial cavity as well as the fallopian tubes as well as it shows the spill of the patent tube. It is an advantage to study simultaneously the cavity as well as the tubes and we can very well assess the malaria abnormalities and endometrial legions with the help of this procedure. Now advantage of this procedure is an outpatient procedure. It is relatively inexpensive. It does not require any general anesthesia and is associated with therapeutic effect. What does that mean? Sometimes the patient comes to me with the history of primary infertility. We just do an HHG and it itself acts as a therapy because it flushes all the mucus plugs and may be causing hindrance to the tubal function and patient concives within one or two cycles why it is important to report a correct interpretation. Because spilling of the diet does not always mean that we are dealing with normal tubes. It takes an experienced expert to correctly interpret whether the tubal anatomy is normal on HHG or not. Indeed interpretation of HHG films is the most frequently falsely interpreted test in medicine. We constantly see patients with diagnosis of normal tubes on HHG who when we closely examine their X-ray films turn out to have obvious tubal disease. We should focus on the patency of tube when we perform and interpret HHG very minutely. For fertility specialist the fundamental question is only that whether the tubes are open or not. But one thing is very clear. Normal tubes of course have to be open and open tubes however are not necessarily always normal. So what is the patient preparation? It is done in the first half of menstrual cycle in the proliferative phase between 8 to 12 days. Patient is asked to avoid any unprotected intercourse from the date of a period until the investigation in order to avoid the possible risk of pregnancy. If periods are regular do urine beta HHG test to rule out pregnancy, exclude active pelvic infection and prophylactic antibiotics. These are not routinely given but can be given in patients of bacterial endocarditis. So what is the procedure? Take an informed consent. Give pre-medication in the form of antispasmodic injection bascopal and injection atropine to elevate any vasovagal syncope or attack. Patient is asked to empty bladder immediately prior to the procedure. A plain radiograph of pelvis is taken for any evidence of any calcification, IOCDs or tabectomy rings. Patient is placed in lithotomy position. The perinem is prepared, draped. Speculum is inserted followed by holding of cervix with inoculum. Dilatation of cervix by sound followed by cannulation of cervix with HHG cannula of your choice. Mostly I am using leach- Wilkinson's cannula and or a single balloon HHG cannula which is nowadays very much in use. Now cannula should be free of air. This is a very important tip because it helps to eliminate any bubble artifacts in the uterus after injection. After cannulation we remove the speculum, position the patient and catheter or the area of fluoroscopy and adjust our factors. We talk to her regarding any discomfort, explain about the pushing of injection and then inject. Initially we inject only 3 to 5 ml. We take the spot film one which generally depicts the uterus size, shape and endometrial cavity. It is followed by gradual injection of another 5 cc to delineate the fallopian tubes. Another 3 to 5 ml if you don't see the spillage in previous films or on the fluoroscopy monitor is given. So in all we are taking 3 to 4 spot films. Sometimes some oblique views are also taken when there is gross anti-version or retroversion and at the end patient is advised to take antibiotics and she is guided about some vaginal spotting for the coming days. So what are the complication pain because of the dilatation of uterus spillage into peritoneum, pelvic infection sometimes may occur due to improper septic precautions and bleeding, vascular or lymphatic intraversation, vasovigal syncope. This is very common that is why I stress the importance of pre-medication. Here comes the role of atropine. Pregnancy radiation. So there is lot of theories about how much is the radiation received by the ovaries. It is only 1 millisievert my friends and this is very negligible when it comes to reproduction. It is equivalent to 10 chest x-rays. Allergic reaction to iodinated contrast media. This is also very commonly seen. You should be ready with the emergency in order to tackle any emergency situation. Neutron perforation if it is in the hands of any inexperienced radiologist or gynecologist. Now what are the contrast media? We are using the water-cellulose non-ionic contrast media in the form of Omnifac or IOhexol. We can very clearly see the tubal anatomy. It gets absorbed within hours and does not live residue. There is no granulom formation. Very rarely it occurs. Pain sometimes persists with this contrast. And there is prompt demonstration of tubal potency. Delayed film not needed. These are the metallic and this is the balloon catheter. This has got a side-damp for injection of the balloon. Now instrumentation, this is the trolley settings. We need the speculum, telneculum, sounds and the HHG cannulas. Now balloon catheter versus methyl catheter. Less fluoroscopic tin in balloon catheter. Small amount of contrast. Less pen. It is easier for the physician to use. It provides a good seal at the cervix. And it is mostly expensive because it is disposable, single-time use. And hence a balloon catheter obviously is superior to a metallic cannula. So these are the spot films. First of all, we take only 3 mL of contrast and we see the uterine cavity. This is followed by another injection of 5cc. You can very well see the fallopian tubes and then the another two films for the spillage and the pattern of the spillage. So what reporting format should include the name, age, date and time, the last menstrual period of the patient, informed consent, under pre-op medications, shape and size of the endometrial cavity should be mentioned. The shape of the uterus, whether it is arcoate, subcepted, septate, bicoornate if you are very sure otherwise you can just mention the findings and unicornoid or T-shaped. Regular irregular margins, any synechia, air bubbles, artifacts, tubal course outline, any blocks, type of spill, focal peritoneal free, any peritubal adhesions, any strictures, hydrosulfins, any other findings related to adhesions, cervix, polyps and calcification. Now most common artifact we can see is the air bubble artifact. This is the air bubble. Now how does it differ from any other filling defect? It will subsequently disappear in the subsequent films after injection of further contrast. Now cervical ferning pattern. The cervical pattern looks like that. Now, histosulfongography of septate uterus can again demonstrate a variety of cervical septation including complete septation or septation at the level of internal loss or including septation till the two separate cervical canals. Now bicoornate uterus with various degrees of duplication of cervix in different patient it might include two symmetric uterine cavities with communication at the isthomas there the inter-conval angle is 105 that is more than 100 that is the criteria. Single cervix and vagina are present. Intervening cleft sometimes extends to the endoservical canal also till the level of os. Now this is the ESHRE and ESG classification. You all very well, you are all very well versed with that. If you would like to stress ESG cannot differentiate this the various types of malaria abnormalities definitely the diagnosis is by MRI only. Few of the points are there too for differentiating bicoornate septate such as in bicoornate we get fundus indentation the angle between the cavities is wide more than 100 and there is partial fusion of malaria duct. Inceptate the external surface is always normal the cavities are much closer there is defect in canalization or resorption of the midline septum but definite diagnosis is only by MRI. Now few of the abnormalities I would like to point these are the hydro-sulfur these are the dilated tubal structures which appear like sometimes like balloon these are obstructed hydro-sulfur they lead to further lead to pyosulfur and chances of increased ectopic pregnancies tubal ligation this is very commonly seen we get large amount of patients in Indian settings after tubal ligation and generally tube is seen till the isthemic part there is tubal ligation at the junction of proximal one third and distal 2 by 3 in the isthemic part we can very well see the tubes till the isthemic part. Sineke now these are your definitive uterine defects which can be of any shape and size and they are causing defects in the endometrial cavity these can be single multiple or they can even give a distorted appearance to the entire cavity. Cornuol spasm now this is very important entity because whenever you are doing a good HHG you don't need this type of film this type of film indicates that there was no proper pre-medication given patient must have been in pain followed by a cornuol spasm leading to pseudo blockage at the level of cornuol as an apple sign proper medication we can reduce these cornuol spasms with the help of injection antispasmodic such as bascopal now tuberculosis in Indian setting is very common we get variety of tubal patterns in case of involvement by tuberculosis such as pipe like appearance stretched out tube instead of going down in the pelvis stretched up due to peritubal adhesion now there are multiple strictures here there is balloon like dilatation tubal obstruction multiple strictures sometimes there are peritubal adhesions and cotton wool appearance now the one uterus that had been talked about very much in the previous text is the T-shaped configuration in patient who had received the diethylstilbosterol therapy these are nowadays not commonly seen instead we are getting these T-shaped configurations small uterus in patient with fulminant genitourinary reproductive system cox I have seen such type of uterus with cox we no more see such type of uterus associated with any drug medication now disadvantage which is very important the iodinated contrast reactions are already discussed these can cause any amount of reaction right to anaphylaxis and you should be all ready for that nowadays with replacement by non ionic water soluble contrast media we are getting very fewer reactions then exposure to radiation as already told it is less than 1 millisievert and majority of the radiation is actually distributed it is sometimes fainful no doubt and we can very well alliate the symptoms of the patient by giving proper sedation sometimes some patients can be offered short GIF they are highly apprehensive about the procedure so a proper counseling session should be there prior to the procedure with the referring physician also the radiologist should have a small chat regarding how is the type of patient and whether she will cooperate for sedation or she will need a short G and we need a good radiological setup sometimes you need a good image intensifier or even a small extraneous instrument table can also give good results