A Hysterosalpingogram or hsg is a diagnostic x-ray of the uterus and fallopian tubes. This test allows the gynecologist to observe the inside of the uterus and fallopian tubes for any problems such as blockage of fallopian tubes, endometrial polyps, fibroids, genital tuberculosis or abnormalities in the uterine cavity. Hysterosalpingogram is also done to find problems in the uterus, such as abnormal shape and structure, an injury, adhesions or a foreign body in the uterus. HSG is often used in cases where a sterilization reversal is sought.
A woman must inform the radiologist if she is allergic to iodine dye, suffer pelvic or sexually transmitted disease. Women with bleeding problems such as hemophilia or those on blood thinning medicines such as aspirin must keep the doctor appraised. The gynecologist or radiologist uses a cannula to fill the uterus with iodine. The dye will flow into the fallopian tubes as the uterus is hooked with these tubes, and the pictures are taken using high steady beam fluoroscopy, as the dye passes through. In case of injury or an abnormal structure, the picture can throw up the problems. The pictures are shown on a TV monitor during the test. If another view is needs, the examination table is tilted or the patient may be asked to change positions. A blockage can prevent sperm from moving into the fallopian tube and joining an egg for fertilization to occur.
A HSG can catch if there is any problem inside her uterus that possibly prevents a fertilized egg from implanting to the uterine wall. This helps in outlining the fallopian tubes so that any abnormalities in the tubes or uterine cavity is observed. In cases of infertility due to tubal blockage, HSG is used to evaluate the location and extent of blockage. The Hysterosalpingogram procedure takes a few minutes and can be moderately uncomfortable for the woman, with possibility of cramps. Women who have tubal disease may develop pelvic infection. In rare cases, the woman develops iodine allergy. Some women notice spotting for a couple of days after the HSG.
Risks of Hysterosalpingogram
In less than 1 in 100, there may be a chance of a pelvic infection after the test. The chances are higher in those who have had pelvic infections before. Antibiotics A negligible chance of damaging or puncturing the uterus or fallopian tubes during the test does exist during the test. There could be some allergic reaction to the iodine x ray dye. If oil based dye is used, the oil can leak into the blood. This can cause blockage of blood flow to a section of the lung. But most HSG tests are water based. A woman may feel some cramping similar to menstrual cramps during the procedure and the amount of pain may depend upon the problems that the doctor finds and treats during the test. There could be some vaginal bleeding for several days after the test.
The test result is considered normal if the injected dye spills freely out from the ends of the fallopian tube and the x ray shows normal uterine shape. However, if further tests do not reveal the cause of infertility or recurrent pregnancy loss, the doctor could order for a hysteroscopy. There are chances that while a HSG could show a normal uterine shape, a hysteroscopy show abnormalities.
Tubal Reconstructive Surgery
Tubal reconstructive surgery is performed to reconstruct the fallopian tubes which are obstructed or tied intentionally. This procedure helps in restoring the normal functioning of the fallopian tubes. Fallopian tubes play an important role in the reproduction process. The matured egg released by the ovary travels through the tube and converges with the sperm to facilitate fertilization. The fertilized egg gets implanted in the uterus to form the embryo. Sometimes the tubes may get blocked due to scar tissue caused by a pelvic infection, endometriosis, or pelvic surgery. When there is an obstruction, the egg cannot reach uterus nor can the sperm meet the egg causing infertility. Tubal reconstruction is a surgical method performed to repair the Fallopian tubes and thereby improving the chances of conception.
Tubal reconstructive surgery is also considered by those women who have undergone sterilization via tubal ligation earlier, but would want to reverse it now for personal reasons. Surgical techniques to reconstruct the fallopian tubes are aimed at achieving patency without harming the tubal anatomy. Hence microsurgical technique is the most preferred choice in conducting the tubal reconstructive surgery.
HSG (hysterosalpingogram) test is performed prior to surgery to evaluate the abnormalities inside the fallopian tubes. HSG Test will reveal the presence of blockage in the fallopian tubes.
Laparoscopic procedure is performed with micro instruments; it is minimally invasive, causes fewer traumas and relatively requires less hospital stay. Not all problems can be corrected using laparoscopy; few cases require an elaborate surgical procedure called laparotomy. Laparotomy is a procedure that involves making a large cut on the abdomen. Through Laparotomy, the surgeon can view the organs clearly, remove the blockage and join the healthy parts of the tubes. This procedure is usually adopted in case of reversal tubal ligation. The choice of the procedure depends upon various factors such as severity of the blockage, location of the obstruction and length of the Fallopian tubes.
There are three types of tubal reconstructive surgical techniques followed by the doctors to repair the Fallopian tubes. The technique chosen depends upon the nature of the problem.
Tubal anastomosis: Tubal anastomosis is a surgical procedure that is normally performed to restore the function of fallopian tubes, which have been blocked by a previous sterilization operation. It is also called tubal ligation reversal or reanastomosis. Typically, sterilization procedure would have closed the mid portion of the tube that lies between the uterus and fimbrial end. Tubal anastomosis technique removes the blocked segment of the tube and joins the two remaining open segments to make it patent.
Tubal implantation: Tubal implantation is a surgical technique that is opted when the blockage is detected at the proximal end (where the Fallopian tube and uterus join). In such cases a new opening will be created in the uterus and a healthy portion of the tube will be inserted into the uterine cavity.
Salpingostomy: Salpingostomy is used in case of distal tubal occlusion, an obstruction near fimbrial end or near ovaries. Salpingostomy involves creating an opening into the Fallopian tube surgically. Salpingostomy is also effective for treatment of hydrosalpinges, a condition where fluid builds up in the tubes leading to an occlusion. Through salpingostomy, excess fluid can be drained and tubes can be cleared to allow normal functioning. Sometimes the problem may occur in the fimbrial region, an end portion of the Fallopian tube that is responsible for sweeping the egg into tube. In such cases fimbria is reconstructed through a surgery called fimbrioplasty.
Tubal reconstructive surgery success rates
The degree of success from surgery will depend upon the extent of tubal damage. Surgery works very well, if the adhesions are small and thin. However with dense adhesions the chances of pregnancy become remote. Age is an important factor that is taken into consideration before proceeding with surgery. Women below 35 years of age have fair chances of becoming pregnant within an year of tubal surgery.
Those who fail to conceive through tubal reconstructive surgery, or, are not right candidates for a surgery are advised to chose an alternative method called IVF or other assisted reproductive techniques.
Risks associated with tubal surgery
The biggest risk associated with tubal surgery is the possibility of developing ectopic pregnancy (tubal pregnancy). Tubal pregnancy is a serious issue and may prove fatal to the mother and hence should be removed as early as possible. Other risks include infection, bleeding, trauma to adjoining organs and also the risk associated with anaesthesia.
Levator Ani Syndrome
Levator ani syndrome also known as levator ani spasm, refers to pain and discomfort in the rectum caused by spasms in the levator muscles that surround the anus. Patients with Levator ani syndrome often complain of a pain associated with rectal pressure that gets worse on sitting or lying down. The pain is almost always dull and constant with a sensation of tightness and fullness in the rectal region. In few cases, the pain may not be constant, but recurrent at frequent intervals lasting up to 20 minutes. Prevalence of Levator ani syndrome is five times higher in women than men. Proctalgia fugax refers to the 'anal pain without known cause'. Here the episodes of pain are very brief and occur rather infrequently.
When the patient develops rectal pain, firstly the doctor would want to rule out any disease related to organs surrounding the anal canal and pelvic floor. Sometimes an endoscopy is done to investigate the cause of the pain. Patient with Levator Ani Syndrome experiences severe tenderness on palpation of the pubo-rectalis muscle and this forms the basis for diagnosing the levator ani syndrome. In case of Levator ani syndrome, the patient also undergoes posterior traction of the puborectalis muscle during rectal examination.
There is constant rectal, vaginal or perineum pressure. Defection becomes difficult. The symptoms are often aggravated by emotional stress. Muscular tension, injury or surgery can also lead to this condition. Childbirth injury, pelvic infection, lumbar disc surgery or sexually related injuries can lead to levator ani syndrome.
Treatment of Levator Ani Syndrome
Levator ani syndrome is usually resolved through the following steps:
1. Sitting on a doughnut shaped pillow to reduce the pressure.
2. Anti inflammatory drugs and muscle relaxants.
3. Application of perianal lidocaine jelly ointments.
4. Apart from medication and special tools, levator ani syndrome is also treated with physical therapy which includes digital massage of levator muscle, pelvic floor strengthening exercises , pelvic floor relaxation techniques.
5. Hot sitz bath also helps in alleviating the pain and anal pressure.
6. Levator ani syndrome is also treated using Electrogalvanic stimulation (EGS) and Biofeedback training. However recent studies reveal that Biofeedback is far more effective than EGS in treating Levator Ani Syndrome.
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Bibliography / Reference
Collection of Pages - Last revised Date: January 27, 2023