A history of pelvic inflammatory disease, septic abortion, ruptured appendix,
tubal surgery, or ectopic pregnancy alerts the physician to the possibility of tubal damage. PID is the major contributor to tubal infertility and ectopic pregnancies.

Laparoscopically confirmed PID indicates that the incidence of subsequent tubal infertility is approximately 12% after one episode of pelvic infection, 23% after two episodes, and 54% after three episodes. The risk of ectopic pregnancy is increased 6-7 fold after pelvic infection.

Almost one-half of patients who are eventually found to have tubal damage and/or pelvic adhesions, however, have no history of antecedent disease.

Tubal disease is diagnosed by HSG and by laparoscopy. The HSG is performed 2 to 5 days after cessation of a menstrual flow.

If there is a hx of PID, a sedimentation rate is obtained prior to HSG and, if
elevated, antibiotic therapy is given. The procedure is then postponed for a
month when a repeat sed-rate is obtained.

If there is a documented history of PID, the risk of a serious re-infection following HSG is high, and it should be replaced by laparoscopy. If an HSG is
performed in a patient who is at questionable risk for infection, a water-soluble rather than an oil dye should be used because it can be reabsorbed in the event of a hydrosalpinx, and will not become trapped in fallopian tube.

The overall risk of infection with HSG is probably less than 1%, although in a
high-risk population serious infection can occur in approximately 3% of cases.

Doxycycline, 200mg after the procedure, can be administered if the tubes are
dilated, followed by 100mg bid for 5 days. Many clinicians routinely administer
prophylactic antibiotics (doxy 100mg bid for 5 days, beginning 2 days before the procedure).

HSG should be performed under image intensification fluoroscopy, and a minimal number of films taken. Only 3 films are usually required -- a preliminary before dye injection, a film showing spill of dye from one or both tubes, and a delayed film to show spread of dye through the peritoneal cavity.

The dye can be injected either using a classic Jarcho cannula with a single-tooth tenaculum, or a suction apparatus appended to the cervix with dye injected through a contained cannula. A third technique involves threading a pediatric Foley catheter through the cervix into the uterus.

Use of a prostaglandin synthesis inhibitor which can be purchased over the
counter and taken 30 min prior to the procedure can decrease the pain which
many women experience with HSG.

The dye should be injected slowly so that abnormalities of the uterine cavity are not missed. This is of special importance in DES exposed daughters, many of whom have abnormalities of uterine contour. Usually no more than 3-6ml of dye are required to fill the uterus and tubes.

If the patient complains of cramping, the injection of dye should be stopped for a few minutes and fluoroscopy temporarily discontinued.

If the tubes fill but dye droplets do not spill from the ends of the tubes, the uterus should be pushed up in the abdomen by means of the tenaculum or suction cup. This puts the tubes on stretch and may help to release dye from the fimbriated ends.

If dye does not pass into the tubes, changing the woman to a prone position will sometimes facilitate passage of dye.

If the dye goes through one tube rapidly and fails to enter the other tube, it
usually means that the dye-containing tube presents the path of least resistance. In this situation, the nonfilling tube is usually normal. When both tubes were patent on x-ray, the pregnancy rate is only slightly higher (58%) than when there is unilateral patency and nonfilling of the other tube (50%).

A conception rate of 41% within 1 year of an HSG with oil media has been
reported, whereas the rate was only 27% when water-soluble agents were
employed.

A review of the question of oil versus aqueous dye noted that in every
retrospective study in which increased pregnancy rates were noted after HSG, an oil dye was used.

In a randomized, prospective study of close to 400 women, the pregnancy and live birth rates were increased in women who had their HSG performed with oil dye. Within 9 owlation cycles following an HSG, the pregnancy rate was 33% in the oil dye group and 17% in the water dye group.

HSG with Ehiodol is a very useful therapeutic as well as diagnostic tool in women with infertility.

How does the oil dye increase fertility?

1) It may effect a mechanical lavage of the tubes, dislodging mucus plugs.
2) It may straighten the tubes and thus break down peritoneal adhesions.
3) It may provide a stimulatory effect for the cilia of the tube.
4) It may improve cervical mucus.
5) The iodine may exert a bacteriostatic effect on the mucous membranes .
6) Ethiodol decreases in vitro phagocytosis by peritoneal macrophages. If the same effect occurs in vive it could decrease macrophage activity and thus aid fertility by inhibiting the release of cytokines and decreasing phagocytosis of sperm.

The use of an oil medium has been criticized on grounds that it is only slowly
absorbed and may cause granuloma formation. Granulomas are found very
infrequently, and they also may follow the use of water dyes.

An additional fear with oil dye is embolization -- this is rare.

REFERENCE
Speroff L., Glass RH, Kase NG: Clinical Gynecologic Endocrinology and Infertility,
Williams and Wilkins 1994.