Comparison between hysterosalpingography and laparoscopy in assessment of tubal factor of infertility in case of postcesarean section delivery

Female infertility can be classified as a result of peritoneal factors, ovulation disorders, tubal obstruction, and uterine abnormalities. Cervical factors are rarely the sole cause []. Tubal patency can be assessed using hysterosalpingography (HSG), laparoscopy with chromopertubation, or both. Tubal patency and uterine anomalies are frequently evaluated using HSG as a primary method [,]. Nevertheless, the gold standard for evaluating tubal patency has been laparoscopy with chromopertubation []. This study aimed to compare HSG and laparoscopy in assessment of tubal patency in secondary infertility patients after previous caesarean section (CS). Patients and methods This comparative cross-sectional study was conducted on 85 women age between 20 and 40 years complaining from secondary infertility after CS delivery, recruited from Infertility Outpatient Clinic at the Gynaecology Department, Tanta University Hospitals during a period from December 2023 to November 2024. Informed written consent was obtained from the patients. The study was done after approval from the Ethics Committee of the Faculty of Medicine, Tanta University (approval code: 36264MS428/11/23). Exclusion criteria were associated male factor, associated cervical factor, associated uterine factor and associated ovarian factor of infertility, history of previous abdominal surgery myomectomy, ovarian cystectomy, and smoking. All patients were underwent sociodemographic characteristics and full history taking including (age, menstrual history, obstetric history especially number of children and sex, detailed history of previous deliveries and gynaecological procedures, and surgical history), general and abdominal examinations including (weight, BMI, height and blood pressure), routine laboratory investigation including (complete blood count, coagulation profile, blood group system, Rh typing, and virology) [hepatitis B virus, hepatitis C virus, and HIV], semen analysis and hormonal assessment including anti-Mullerian hormone (AMH), estradiol (E2), luteinizing hormone (LH), follicle-stimulating hormone (FSH), Prolactin, and thyroid stimulating hormone (TSH) and radiological investigations including (ultrasonography, HSG, and laparoscopy). Hysterosalpingography All HSGs were performed postmenstrual (between the sixth and tenth days of the menstrual cycle and at least 48 h after menstruation has ceased) to ensure that there was no pregnancy. Preventing unprotected intercourse during this time was recommended to the women. The procedure was conducted using a sterile aseptic technique at all stages of the HSG. Antibiotics were given one day prior and up to a few days after the procedure (vibramycin 100 mg/12 h for 1 week). The patient was asked to remain empty bladder. A lithotomy position was employed to situate the patient. A local antiseptic cleansing was conducted. Introduction of the posterior vaginal speculum. Allis tissue forceps were employed to secure the anterior lip of the cervix. HSG cannula was fitted with a syringe containing water soluble contrast medium (Urografin dye) and the passage of the dye was observed by using radiography intensifier and a video display unit. HSG criteria that were considered normal included a normal uterine cavity, no evidence of tubal occlusion, a normal fallopian tube contour, and unconstrained bilateral spillage of the contrast media into the peritoneal cavity. Abnormal HSG was defined as the presence of tubal obstruction, abnormal tubal contour, or contrast media loculation in the peritubal or peritoneal cavity, whether unilateral or bilateral. Suspicious lesions, such as air bubbles, were identified as having a more hypoechoic appearance and varying in shape, size, and displacement across successive films. Uterine adhesions were classified as irregular cavity contours or filling defects that were sufficiently pointed to angulate the contours []. Laparoscopy During the follicular phase of the menstrual cycle, laparoscopy was performed under general anaesthesia preceding the ovulatory period. Punctures were administered to the abdomen. To establish the pneumoperitoneum, the needle was connected to a tube that allowed CO2 to enter the body after the needle was properly positioned. The cannula and trocar were inserted at a 45º angle with the trocar directed towards the centre of the pelvis. Once the trocar was in the peritoneal cavity, it was extracted from the cannula. The trocar’s cannula was left in place, and the laparoscope was inserted through it. The Trendelenburg position was employed to examine the liver, abdominal cavity, and pelvis (genital organs) during the laparoscopy. The laparoscopy results were recorded after Methylene Blue was injected through the cervix using a corkscrew cannula to evaluate tubal patency. No tubal occlusion, one-sided or two-sided proximal or distal tubal occlusion, or both were the categories into which the tubal patency that was assessed during laparoscopy was classified. The absence of the aforementioned pathologies was used to define normal laparoscopy. Dense adhesions, endometriosis, or unilateral or bilateral tubal occlusion were considered abnormal findings. The presence of bilateral tubal occlusion, dense adhesions, and severe endometriosis was necessary to diagnose absolute mechanical infertility. Subsequently, patients were referred to antiretroviral therapy. Outcome measurements Primary outcome: Comparison between HSG and Laparoscopy in assessment of tubal patency in secondary infertility patients after previous caesarean section delivery. Secondary outcomes: Detection of sites of peritubal and peritoneal adhesions and performing Adhesiolysis, Diagnosis of endometriosis if present, and restoration of female fertility. Sample size The sample size and power analysis were calculated using Epi Info software statistical package created by WHO and center for Disease Control and Prevention, Atlanta, Georgia, USA version 2002. Sample size calculations were conducted according to the following set of criteria: A comparative cross-sectional study with a 95% confidence limit is employed. The estimated sensitivity of diagnosis of tubal fibrosis is at 70% with a margin of error of 10%. The sample size was determined to be 81 based on the aforementioned criteria. To address the absence of information and enhance the integrity of the study’s data, we increased the sample size to 85. Statistical analysis The collected data were initially collected in the master sheet with Microsoft Excel. SPSS version 26 (IBM Inc., Chicago, Illinois, USA) was employed to conduct the statistical analysis. Data were checked, coded, tabulated, and statistically analysed using SPSS. Mean and standard deviation (SD) were employed to represent quantitative variables. Frequency and percentage (%) were employed to represent qualitative variables. Evaluation of diagnostic performance by evaluation of diagnostic sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).

Table 1 shows the demographic data and hormonal analysis of the studied patients. The mean of FSH was 7.67 (±1.6) IU/l. The mean of LH was 14.88 ± 5.87 IU/l. The mean of TSH was 2.35 (±0.99) IU/l. The mean of E2 was 212.38 ± 97.49 pg/ml. The mean of Prolactin was 17.54 ± 4.16 µg/l. The mean of AMH was 1.99 (±0.49) ng/ml. Table 2 shows that there was a statistically significant difference between HSG and laparoscopy in bilateral proximal tubal blockage. Hydrosalpinx was higher by laparoscopy as mild early-stage hydrosalpinx with mild dilatation might not produce enough contrast to be identified as a hydrosalpinx by HSG. HSG was abnormal in 53 (62.35%) patients and normal in 32 (37.65%) patients, laparoscopy was abnormal in 74 (87.06%) of patients and normal in 11 (12.94%) of patients and laparoscopy can significantly detect tubal factor of infertility in case of post-CS delivery (P<0.001). Figures 1 and 2 shows the HSG and laparoscopic findings. Endometriosis was found in seven (8.24%) patients and cauterization of the endometriotic patches was done, adhesiolysis for the peritubal adhesions was done for 58 (68.24%) patients, tubal disconnection was done for six (7.06%) patients, unilateral tubal disconnection was done for four cases who had unilateral hydrosalpinx and bilateral tubal disconnection was done for two cases who had bilateral hydrosalpinx and three patients with unilateral hydrosalpinx were mild cases and tubal disconnection was not done (Table 3). Table 4 shows that HSG can detect tubal factor of infertility in case of post-CS with a good sensitivity 90%, specificity 19%, PPV 65%, NPV 55%, and accuracy 64%.

Post-CS tubal factor infertility is a complex condition influenced by surgical techniques, patient-specific factors, and postoperative care. Understanding its etiology and risk factors is critical for developing effective preventive and management strategies [,]. HSG and laparoscopy are the two routine procedures that are most frequently employed in the evaluation of mechanical infertility []. The present study revealed that according to demographic data in the studied patients, the mean of age was 27.5 ± 5.89 years. The mean of weight was 77.3 ± 11.16 kg. The mean of height was 27.24 (±3.05) kg/m2. Parity was once in 43 (50.59%) patients, twice in 39 (45.88%) patients, and three times in three (3.53%) patients. Additionally, in accordance with the current study findings, Hamed et al. [] reported that the age ranged from 23 to 38 years with a mean value (±SD) of 28.6 (±5.6) years. The mean of BMI was 24.1 ± 4.4 kg/m2. Parity in secondary type only (n=20) was once in four (20%) patients, twice and three times in three (13.3%) patients. Regarding hormonal analysis, the present study reported that the mean of FSH was 7.67 ± 1.6 IU/l. The mean of LH was 14.88 ± 5.87 IU/l. The mean of TSH was 2.35 ± 0.99 IU/l. The mean of E2 was 212.38 ± 97.49 pg/ml. The mean of prolactin was 17.54 ± 4.16 µg/l. The mean of AMH was 1.99 ± 0.49 ng/ml. Regarding HSG findings, this study revealed that proximal tubal blockage (nonvisualized tubes) was unilateral in two (2.35%) patients and bilateral in six (7.06%) patients, distal tubal blockage with no peritoneal spillage nor hydrosalpinx (obstruction near or at fimbrial end) was unilateral in two (2.35%) patients and bilateral in one (1.18%) patient, distal tubal blockage with hydrosalpinx was unilateral in four (4.71%) patients and bilateral in two (2.35%) patients, patent tubes with peritubal adhesions and tubal elevation was unilateral in 24 (28.24%) patients and bilateral in 12 (14.12%) patients, HSG was normal in 32 (37.65%) patients. In agreement with the present study, the HSG results of the cases were evaluated by Yildirim et al. [], who revealed that 45.3% (n=48) were normal. Only 27.4% (n=29) of the cases were attributable to the tubal factor. 23 of the 29 tubal pathologies were unilateral, while six were bilateral tubal obstructions. Also demonstrated that upon the evaluation of the HSG results, six cases were classified as bilateral hydrosalpinx. In agreement with the present study, Dutta et al. [] reported that regarding HSG findings, right proximal tubal blockage presented in 28 (56%) patients, right distal tubal blockage was in 20 (40%) patients, left proximal tubal blockage was present in 16 (32%) patients, and left distal tubal blockage was present in 28 (56%) patients, Also, in line with the current study findings, bilateral hydrosalpinx was observed in two (3.33%) patients and unilateral hydrosalpinx in three (5%) cases, according to Singhvi et al. []. Also found that peritubal adhesions were present in 11 (18.34%) cases, and in 10 (16.67%) cases, they were associated with bilateral tubal block. In one (1.67%) case, bilateral patency was present. Regarding laparoscopic findings, this study revealed that proximal tubal blockage with no chromopertubation was unilateral in two (2.35%) patients and bilateral in one (1.18%) patient. Distal tubal blockage (fimbrial phimosis-scarred fimbrial end) with no chromopertubation nor hydrosalpinx was unilateral in three (3.53%) patients and bilateral in one (1.18%) patient, distal tubal blockage with hydrosalpinx was unilateral was in seven (8.24%) patients and bilateral in two (2.35%) patients. Patent tubes (positive chromopertubation) with peritubal adhesions, tubal elevation was unilateral in 39 (45.88%) patients and bilateral in 19 (22.35%) patients, Laparoscopy was normal in 11 (12.94%) patients. Also, in accordance with the current study findings, Gharekhanloo et al. [] who showed that as regard laparoscopy, unilateral proximal tubal occlusion was reported in 8.7%, unilateral distal tubal occlusion was reported in 3.5%, bilateral proximal tubal occlusion was reported in 7%, bilateral distal tubal occlusion was reported in 3.5%. Also, Hydrosalpinges was reported in 9.6% and peritubal adhesion was reported in 17.4%. In agreement with the present study, Yildirim et al. [] adhesions were detected laparoscopically in 33% (n=35) of the cases. Two of the three bilateral obstructions and sixof the twenty unilateral blocks were accompanied by adnexal adhesions. The present study demonstrated that endometriosis was found in seven (8.24%) patients and Cauterization of the endometriotic patches was done. Adhesiolysis for the peritubal adhesions was done for 58 (68.24%) patients. Tubal disconnection was done for six (7.06%) patients, unilateral tubal disconnection was done for four cases who had unilateral hydrosalpinx and bilateral tubal disconnection was done for two cases who had bilateral hydrosalpinx. Three patients with unilateral hydrosalpinx were mild cases and tubal disconnection was not done. In contrast with this study, Tripathy et al. [] showed that in 45% of the patients, pelvic endometriosis was identified through laparoscopy. This difference may be attributed to different sample sizes, and they included patients with primary and secondary infertility while we included patients with secondary infertility post-CS delivery. The present study showed that there was significant difference between HSG and Laparoscopy in bilateral proximal tubal blockage due to false positive results of HSG which may be due to: technical issues during the procedure as in adequate injection pressure or insufficient volume of the contrast medium, debris or mucus plugs near the proximal tubal ostia that may temporarily block the tubes or tubal spasm that occurred during the procedure. These false positive results were found to be normal patent tubes by laparoscopic chromopertubation. Hydrosalpinx was higher by laparoscopy as mild early-stage hydrosalpinx with mild dilatation might not produce enough contrast to be identified as a hydrosalpinx by HSG. This study was consistent with the findings of Tripathy et al. [] who demonstrated that bilateral block occurred in 22 patients during laparoscopy. In 25 patients who underwent HSG bilateral block. The statistical significance of the association between bilateral tubal block in HSG and bilateral tubal block in laparoscopy was significant (P<0.0001). The significant statistical association validates HSG as a useful diagnostic tool for bilateral tubal blockages, but the slight differences highlight the need for laparoscopy to confirm findings. Additionally, this study came in accordance with Tan et al. [] who reported that the diagnostic value of bilateral tubal occlusion was relatively low when the bilateral tubes were diagnosed with occlusion by HSG, with a probability of 58.8%. In contrast with this study, Gharekhanloo et al. [] showed that the comparison between HSG and LS showed no significant differences in diagnosis of bilateral proximal tubal occlusion (P=0.28). The present study showed that HSG was abnormal in 53 (62.35%) patients and normal in 32 (37.65%) patients. Laparoscopy was abnormal in 74 (87.06%) of patients and normal in 11 (12.94%) of patients. Laparoscopy can significantly detect tubal factor of infertility in case of post-CS delivery (P<0.001). In agreement with the present study, Singhvi et al. [] reported that laparoscopy was more effective than HSG in evaluating tubal patency during infertility investigations due to the number of false positives that HSG produced. Tubal block was diagnosed in 35 (58.3%) cases by both HSG and laparoscopy. HSG determined that eight (13.3%) cases were false positives, as they were revealed to be patent during laparoscopy. Laparoscopy is superior to HSG in assessing tubal patency because it provides definitive, direct visualization and avoids false positives caused by functional obstructions or technical issues. Also, in line with the present study findings, Banotra et al. [] demonstrated that HSG was positive in 21 (30.8%) patients and negative in two (2.9%) patients. Laparoscopy was positive in 23 (33.8%) of patients. Additionally, Hegab et al. [] stated that diagnostic laparoscopy was more precise in evaluating tubal patency than HSG, which is consistent with the results of the current study. In the present study, HSG can detect tubal factor of infertility in case of post-CS with a good sensitivity 90%, specificity 19%, PPV 65%, NPV 55%, and accuracy 64%. This study was consistent with the findings of Dhaliwal et al. [] who determined that the sensitivity of HSG findings was 69.01% and the specificity was 46.15%. The PPV of HSG was 77.78%, while the NPV was 35.29%. The diagnostic accuracy of HSG was 62.89%. Khetmalas et al. [] revealed that the sensitivity of HSG in detecting tubal factors of infertility was 63.64%, while the specificity was 82.86%, in contrast to this study. The negative predictive value of HSG was 78.38%, while the positive predictive value was 70%. The study’s strength lies in its focus on patients with secondary infertility following caesarean section delivery and its tertiary center setting. The current study’s limitations included the comparatively small sample size and the inability to provide long-term follow-up service for our patients.

Despite the relative simplicity compared with laparoscopy, HSG may lead to incorrect interpretation either false positive result or false negative.it has a high sensitivity in diagnosis of tubal blockage but low in value in detecting tubal adhesions that may lead to infertility in case of post-CS delivery. Laparoscopy is the preferred method for the examination of the external part of the fallopian tubes, fimbriae, tubo-ovarian relationship, postoperative adhesions visualisation, and other pelvic abnormalities that may be the cause of infertility and cannot be detected by HSG, such as endometriosis and adhesions, as well as their surgical management. While HSG serves as a valuable initial screening tool. Laparoscopy with chromopertubation is superior and crucial for comprehensive evaluation and treatment planning in infertility cases. Laparoscopy can be an alternative to HSG in diagnosing tubal factor of infertility in case of post-CS delivery. Therefore, present study recommend laparoscopy as an effective tool to assess tubal patency in secondary infertility patients after a previous CS. In order to verify the current findings, additional prospective multicenter studies with larger sample sizes are required. Author’s contributions The manuscript has been read and approved by all the authors, that the requirements for authorship have been met, and that each author believes that the manuscript represents honest work should be included. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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