Comparison between X-ray-hysterosalpingography and 3 Tesla magnetic resonance-hysterosalpingography in the assessment of the tubal patency in the cause of female infertility

The first MR-HSG studies were carried out in 1996 on animal models [12] with very good results and hoping for possible and promising outcomes also in humans. The first report on women done by Wiesner et al. in 2001 [13] outlined the first fundamental innovations of MR-HSG compared to the traditional technique, that are the absence of ionizing radiation and the possibility of visualizing the entirety of uterus and ovaries. In the study of Sadowski et al. [14] published in 2008 by the American Journal of Roentgenology, which assessed tubal patency through MR-HSG using 3D time-resolved images of contrast kinetics, there was a higher number of tubal patency identified by MR-HSG rather than XR-HSG. However, this may be due to different catheterization procedures and the use of inflatable balloon in MR-HSG only, as hypnotized by J.E.Silberzweig in the 2009 letter [15], differently from our study where we used the same catheter for both techniques. Therefore, the higher sensibility in tubal patency diagnosis may have been overestimated in the said study and it could explain the comparable results of the two techniques in our analysis. Other studies on MR-HSG follow [10, 16,17,18], that delineate the first protocols, however, they do not compare it with other techniques. In 2019, Volondat et al. [11] confirm the diagnostic accuracy of MR-HSG and the possibility of better diagnosing intra-uterine malformation, as happened in our study with one case of communicant unicornuate uterus (Fig. 5). Volondat’s research also pointed out the better tolerability for the patients of this technique, compared to the traditional one.

These are the procedural risks in order of frequency reported in the literature [16,17,18]:

Pain due to catheterization, to contrast injection in the uterine cavity or to the need of higher pressure when trying to unblock the tube (pain can persist in the following hours, so that resting and oral analgesics are recommended)

Vasovagal reflex

Post-procedural infections

Metrorrhagia

Allergic reaction to contrast

Uterine or tubal perforation

Contrast transfer to venous or lymphatic system.

None of the adverse effects above were seen in our study, except for pain. Jagganatan et al. in 2019 [19] confirmed how sensibility, specificity, positive and negative predictive value and diagnostic accuracy in tubal patency were absolutely comparable between the two techniques and that there were no statistically significant differences. This is in accordance with our study because our results are completely overlapping in the assessment of unilateral and bilateral tubal patency. The thing that makes MR-HSG superior to XR-HSG is the ability to consider further fundamental findings to determine the cause of infertility, in particular in our study we found out:

(1)

The presence of active endometriosis foci in annexes and adenomyosis (Fig. 6), that may address the clinician towards an effective pharmacological treatment;

(2)

The 3D documentation of uterine malformations such as unicornuate uterus (Fig. 5) and a retroversed-anteflexed uterus, badly assessable in XR-HSG;

(3)

The presence of a submucous myoma in the tubal ostium that could represent an obstacle for the correct sperm migration and/or of the ovum, the surgical resection of which could resolve the infertility;

(4)

The ovarian reserve decrease, which could also be approached form a therapeutic, hormonal or assisted fecundation point of view;

(5)

In two patients, we found out that the cause of the lack of tubal patency was high-grade bilateral sactosalpinx, more evident on one side (Fig. 4), for which both techniques gave the same results regarding the tubal patency, however, MR-HSG allowed us to understand the cause behind it.

Fig. 6figure 6

Focal iperintensity in T1 without contrast sequence in the right annex (a) and left annex (b) to be referred to endometriosis foci. Myometrial inhomogeneity demonstrable in axial T2 sequence to be referred to adenomyosis (c)

Since we studied a little number of cases and using descriptive data rather than numerical ones, we can establish that, even with completely comparable results regarding tubal patency, the two techniques have some differences in diagnostic ability for female infertility causes. Among the 15 patients which were negative to the dynamic test, MR-HSG allowed us to diagnose three cases of endometriosis, one submucous myoma, one uterine malformation (communicant unicornuate uterus) and one ovarian reserve decrease. If we consider the sensibility in diagnosing female infertility causes (and not just tubal diseases) we can say that of the 15/19 patients who resulted as negatives with the two techniques, actually 6/15 had another extra-tubal pathology which could possibly be cause or a contributing factor to infertility and that could only be detectable with MR-HSG. So, if we add up these six patients with extra-tubal pathologies with the four patients with known tubal pathology, potentially 10/19 (52%) women could have a cause of infertility detectable with MR-HSG, compared to 4/19 (21%) found with XR-HSG. Our results show that about 30% (52–21%) of women that would have been studied with XR-HSG only, could have resulted as false negatives for infertility determining pathologies (Tables 4 and 5).

Table 4 Extra-tubal diagnostic capacity of MR-HSGTable 5 Reproductive system pathology diagnostic capacity comparison between XR-HSG and MR-HSG

Also regarding the therapeutic part of the examination, through the administration of higher pressured contrast in the endocervical catheter to unblock the tube, showed comparable results between the two techniques (Table 2). Both did not succeed, with the only difference that the iodine-based contrast in XR-HSG resulted as more painful for the patients, probably because of its higher density (Table 3).

The growing interest in the last years over MR-HSG and its use [16, 20,21,22], also in comparison with XR-HSG [23], demonstrates its high potential and that it could possibly become the main technique in clinical practice and not only in scientific research. There are also some emerging studies over virtual hysterosalpingography using CT [24], which, however, uses ionizing radiation that, even if in small dose, should be avoided in women of childbearing age, especially if there is a valid and safe alternative such as MR-HSG.

The limits of ISG-MRI consist in the impossibility to subject the patients to such an examination in the presence of absolute contraindications and/or relative to MRI, in particular, the high field (3 T) used in our study and with regard to ISG-RX is the presence of a well-known allergy to non-ionic iodine contrast, statistically more frequent than the allergy to paramagnetic contrast. The limitations of this study are the small number of cases under investigation, partly due to the SARS-Cov2 pandemic.

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