2.1.6\ Limitations of HSG

HSG should not be performed when there is active vaginal bleeding. This is to prevent the flushing of clots into the peritoneal cavity. HSG should also not be performed if there is active pelvic infection, because it could exacerbate the infection. The procedure should not be performed within 6 weeks of pregnancy, uterine surgery, tubal surgery, or uterine curettage because the defects in the endometrial or tubal lining predispose to venous intravasation of contrast material.

The major limitations of the procedure are the ability to characterize only patent canals and the inability to evaluate the external uterine contour adequately. HSG also entails exposure to ionizing radiation in these typically young women.

2.2\ Sonohysterography and

Sonohysterosalpingography

Sonography is frequently used to evaluate uterine pathology because of its excellent diagnostic accuracy, minimal patient discomfort, low cost, and widespread availability. With the addition of transvaginal sonography, color Doppler imaging, and sonohysterography, ultrasound has become a

sensitive technique for detecting endometrial and myometrial pathology.

Sonosalpingography (SSG) utilizes transvaginal sonography (TVS) during instillation of either saline or contrast medium into the uterine lumen to evaluate tubal patency and morphology. Tubal patency can be assessed by repeated injections of 3–5 mL of sterile saline in 75% of the patients. Injection of contrast media allows accurate assessment of tubal patency in up to 92% (Lindheim et al. 2006). Preliminary work suggests that three-­ dimensional and harmonic imaging greatly enhances sonographic depiction of the tube.

Before contrast or saline is introduced, it is recommended that the physician identifies the approximate location of the tube by identifying the ovary and endometrium that invaginates into the uterine cornua.

If there is a pain during injection, this may be a sign of tubal obstruction, either intrinsic or extrinsic from adhesions. Spasm may be present and may cause transitory lack of filling of the proximal portion of the tube (Lindheim et al. 2006).

Hydrosalpinges appear as fusiform cystic structures on TVS. If a hydrosalpinx is seen, patients may be given 200 mg doxycycline initially, and then 100 mg po twice a day for 5 days for prophylaxis of pelvic inflammatory disease (Lindheim et al. 2006).