Comparison of hysterosalpingograms with laparoscopy in the diagnostic of tubal factor of female infertility at the Yaoundé General Hospital, Cameroon

Introduction The objectives were to assess the diagnostic value of hysterosalpingography (HSG) with laparoscopy as gold standard in the evaluation of tubal patency and pelvic adhesions in women suffering from infertility. Methods We conducted a comparative cross sectional study on 208 medical files of infertile women followed up at the Yaoundé General Hospital during a period of five years (December 2007 to December 2012). Tubal patency, hydrosalpinx and pelvic adhesions detected at HSG were compared with laparoscopic findings as the gold standard. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic accuracy of HSG were calculated with 95% confidence interval (CI). Results Mean age of the patients was 31.4± 6.45 years. Secondary infertility was the most frequent type of infertility (66.82%). HSG had a moderate sensitivity (51.0%; 95% IC. 37.5-64.4), high specificity (90.0%; 95% IC.74.4-96.5), high PPV (89.3%; 95% IC. 72.8-96.3) and a moderate NPV (52.9%; 95% IC. 39.5-65.9) in the diagnosis of bilateral proximal tubal occlusion. Concerning, distal tubal patency, HSG had a high sensitivity (86.8%; 95% IC. 76.7-92.9), low specificity (42.2%; 95% CI. 29.0-56.7), moderate PPV (69.4%; 95% IC. 58.9-78.2) and a moderate NPV (67.9%; 95% IC. 49.3-82.0) in the diagnosis of bilateral or unilateral distal tubal occlusion. However, HSG had a low diagnostic value (27.8%; 95%IC.18.8-39.0) in the pelvic adhesions. Conclusion HSG is of limited diagnostic value in tubal factor infertility and is of low diagnostic value for pelvic adhesions.


Introduction
One of the most common and underappreciated reproductive health problems in developing countries is the high rate of infertility and childlessness [1,2]. The inability to procreate is frequently considered a personal tragedy and a curse for the couple, impacting on the entire family and even the local community [3]. Tuboperitoneal factors are responsible for about 30-40% of cases of female infertility and hence evaluation of tubal patency represents a key step and a basic investigation in the assessment of infertile women [4,5]. Tubal occlusion is the most common underlying cause of infertility [6,7]. In Africa Tubal factor infertility ranges from 42 to 77% in the literature [8]. Hysterosalpingography (HSG), laparoscopy with chromopertubation or both can be used to evaluate tubal patency. Owing to its noninvasive nature and low cost, HSG is widely used as a first-line approach to assess tubal patency and uterine anomalies in routine fertility workup [9,10].
However, laparoscopy with chromopertubation has been the gold standard for investigating tubal patency [10]. The aim of this study was to compare hysterosalpingograms to laparoscopy as gold standard in the diagnosis of tubal factors of female infertility at the Yaoundé General Hospital in Cameroon, in order to determine their diagnostic value in our context.

Methods
This was a comparative cross-sectional study based on medical records of 208 women followed up for infertility at the Obstetrics and gynecology unit of the Yaoundé General Hospital (YGH) in Cameroon from December 2007 to December 2012.We included medical records of infertile women investigated by HSG and laparoscopy during the study period for assessment of tubal patency and pelvic adhesions. We had beforehand obtained approval from the medical committee of the YGH to conduct this study. All HSGs were performed at the radiology unit on an outpatient basis between the 7th to the 10th day of menstrual cycle. A water soluble contrast medium was used. X-Ray Photographs were taken at the instant. Images were taken at the instant when the uterine cavity and tubes were filled with opaque material and when an overflow was seen at both sides of the tubes or when maximal filling of the tubes was observed without any overflow. After 30 minutes, a late film was made to assess the contrast material diffusion. HSG findings were classified as having no tubal occlusions, one-sided or bilateral proximal or distal tubal occlusion. The presence of hydrosalpinx or pelvic adhesions were also noted. Additional abnormalities of the uterine cavity were recorded as well. A diagnostic and/or operative laparoscopy was performed in the operating theatre under general anesthesia, during the follicular phase of the menstrual cycle before the ovulatory period. During the laparoscopy, inspection of the pelvis (genital organs) and the liver was performed, followed by testing for tube patency using methylene blue injected through the cervix via a Novak cannula.
The presence of adhesions, structural abnormalities of the uterus, endometriosis and fallopian tube patency were sought for. Tubal patency assessed during laparoscopy was classified as no tubal occlusion, one-sided or two-sided proximal or distal tubal occlusion.
When it was necessary, operative laparoscopy was performed. Data

Results
Two hundred and eight women with a history of infertility who performed HSG and laparoscopy in their work up were included in this study. Table 1 shows the general characteristics of these patients. The mean age of the patients was 31.4± 6.4years (range from 19 to 44years). Secondary infertility was more frequent (66.82%) than primary infertility (28.36%), and married women were more represented (59.6%).  and interfering or preventing the normal capture and transport of the ovum [24]. In accordance with other authors [10,13,17,18,25]. We recorded a low sensitivity (24.6%) and specificity (45.4%) of HSG in diagnosing pelvic adhesions in this study. One of the limits of this study is that we didn't taken into consideration the possible variability of HSG interpretation among radiologists and the time interval between HSG and laparoscopy which could influenced the difference in the results of these two diagnostic tests. However, this study provided information on the diagnostic value of HSG in our setting.

Conclusion
The results of this study reveal that Hysterosalpingography is of limited diagnostic value in tubal factor infertility and of low diagnostic value for pelvic adhesions. Therefore, we believe that laparoscopy should be performed in cases of abnormal hysterosalpingograms and even in cases of normal hysterosalpingograms in the context of unexplained infertility.

Competing interests
The authors declare no competing interests.  Tables   Table 1: General patient characteristics