Gynecological Diagnosis (HSSG - SIS - HSG)- Interventional Radiology, Obstetrics and Gynecology

HSSG: It is performed during the follicular phase of the cycle. On the day of the procedure, largest follicle is identified by ultrasound. Its location (right or left ovary) is also determined along with its diameter. MBq 99m-Technetium-marked macroalbuminaggregates with a size of 5–20 mm, which imitates the size of sperms, is administered into the posterior vaginal fornix of a patient in lying position. Scans are taken at various time intervals. HSSG is a simple noninvasive method for functionally imaging and evaluating the patency of the female reproductive system pathways.

Hysterosalpingography or Hysterosalpingogram (HSG):

HSG is a radiographic evaluation of the uterus and fallopian tubes. It is mainly used in the evaluation of infertility. HSG is also used for the evaluation of women with a history of recurrent abortions as well as the postoperative evaluation of women who have undergone tubal ligation or reversal of tubal ligation.

Hysterosalpingoscintigraphy (HSSG):

HSSG is an ultrasound-based technique to assess tubal patency as an initial step of diagnosis in subfertile couples. It is a short and well-tolerated outpatient procedure. HSSG is a more sensitive and specific method to detect anomalies of the uterine cavity compare to HSG. It also permits simultaneous visualization of the myometrium and ovaries. HSSG has an advantage of avoiding ionizing radiation as well as the risks due to iodine allergy associated with HSG.

In past, HSSG was mainly used to examine the reliability of utero-tubal transport function in infertile women. The main outcome of the initial studies was that there was a rapid unilateral transport of immotile, sperm-like material through the female genital tract that led to the hypothesis of a ‘‘rapid sperm transport’’. The directed transport of sperm-like material, which can be documented by HSSG, is sustained by a constant upsurge of sub-endometrial cervico-fundal peristalsis from the early to the late follicular phase.

Saline Infusion Sonohysterography (SIS):

SIS is also known as saline ultrasound uterine scan. During this scan, small amount of saline (salt solution) is inserted into the uterus (or womb), which allows the lining of the uterus (endometrium) to be clearly seen on an ultrasound scan. SIS helps to see the presence of any thickening or small growths (polyps) of the endometrium of the uterus. SIS is also useful to evaluate the postmenopausal endometrium in females with postmenopausal bleeding.

How is HSG/HSSG/SIS is performed?

HSG and SIS scans are generally done as soon as the patient’s period finishes, around day 5–9 of the menstrual cycle where day 1 is considered the first day of menstrual bleeding.. Before the scan patient is asked to empty the bladder. Then patient is asked to lay down on a table under an X-ray imager called a fluoroscope. A speculum is inserted into your vagina to keep it open, and cervix is cleaned.

HSG: If the patient has irregular menstrual cycles or there is a likelihood of pregnancy, the health care provider would recommend undergoing blood tests for the serum – human chorionic gonadotropin levels. During the procedure, the patient is asked to lay down on supine position on the fluoroscopy table in the lithotomy or modified lithotomy position. After that the perineum is prepared with povidone-iodine solution and draped with sterile towels. Following this, the clinician/technician will insert a speculum into the vagina. After this, the cervix is localized and cleansed with povidone-iodine solution. While performing HSG, the doctor would insert a thin tube called cannula into cervix and slowly fill the uterus with a solution containing iodine. The iodine basically contrasts with uterus and fallopian tubes on the X-rays. Now, the balloon is inflated fully or to the extent that the patient can tolerate as this part of the procedure may cause cramping. Initial radiographic images are captured before contrast material is instilled. Next, water-soluble contrast material is then slowly injected and fluoroscopic images are taken intermittently to evaluate the uterus and fallopian tubes. Once necessary images of uterus and fallopian tubes are taken, the catheter is removed slowly. After the procedure, patient may have sticky vaginal discharge as well as light bleeding. The patient will be given a sanitary pad to avoid any stains on clothing. Patient may have symptoms such as dizziness, cramps, light vaginal bleeding etc. Patient may have spotting and/or cramps following the procedure. The reports are prepared right away. Generally patient is explained the result of the procedure right after the procedure. After the procedure the patient would be able to drive and resume normal activities.

Overall, HSG is minimally invasive and has very rare possibility of any complications. This examination provides very imperative information on gynecological problems regarding getting pregnant or carrying a fetus to term. Another benefit of this procedure is that it may probably open blocked fallopian tubes to allow the patient to become pregnant in the future. After this procedure, no radiation remains in the patient's body.

SIS: While performing SIS, the doctor would insert a small catheter into the uterus through the cervix. The speculum is then removed and the catheter still remains in the uterus. Now a transvaginal ultrasound transducer is inserted into the vagina. Doctor would place a protective sterile probe cover over the transducer and apply some lubricating gel for easy insertion. Now a small amount of saline (salt solution) is injected through the catheter into the uterine cavity. During and after the saline injection, the transducer is gently moved around to take the images of the inside of the uterus. The saline fluid in the uterus allows the clear visualization of lining of the uterus on the ultrasound screen and shows endometrial abnormality if any.

Following the procedure, small amount of fluid would leak from vagina. This fluid is basically saline solution that was injected through the catheter. Patient would also have some spotting and would be advised to use only sanitary pad and not tampons. This may continue for 24 hours. Generally there are not any major side effects after the procedure. Some patients may feel pelvic discomfort (like mild period cramps), but this kind of pain goes away within an hour or so. Many patients do not feel this pain at all. Very few patients may feel dizziness due to the cervix being slightly irritated because of the catheter. This generally passes within a few minutes and doe not lead to any serious side effects. After the procedure the patient would be able to drive and resume normal activities.

Overall, this procedure is very safe. One of the main risks is the possibility of developing an infection within uterus. However, it is very rare and can be treated with antibiotics if it occurs. The symptoms of this kind of infection includes continues pelvic pain and odorous vaginal discharge. If a patient develops this, it is advised to contact the clinic where the procedure was conducted.

HSSG: It is performed during the follicular phase of the cycle. On the day of the procedure, largest follicle is identified by ultrasound. Its location (right or left ovary) is also determined along with its diameter. MBq 99m-Technetium-marked macroalbuminaggregates with a size of 5–20 mm, which imitates the size of sperms, is administered into the posterior vaginal fornix of a patient in lying position. Scans are taken at various time intervals. HSSG is a simple noninvasive method for functionally imaging and evaluating the patency of the female reproductive system pathways.

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Sources:

• https://www.ncbi.nlm.nih.gov/pubmed/?term=16549607
• https://www.ncbi.nlm.nih.gov/pubmed/?term=24578476
• https://www.insideradiology.com.au/sis/
• https://www.webmd.com/infertility-and-reproduction/guide/blocked-fallopian-tubes-test#1
• https://www.acog.org/Patients/FAQs/Hysterosalpingography?IsMobileSet=false
• https://www.ncbi.nlm.nih.gov/pubmed/10027619
• https://www.ncbi.nlm.nih.gov/pubmed/?term=15063961
• https://www.sciencedirect.com/science/article/abs/pii/S000129988180027X

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