1 Institute of Diagnostic Radiology, Department of Radiology, University Hospital and 2 Division of Gynecological Endocrinology and Reproductive Medicine, University Women's Hospital, Basel, Switzerland
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Abstract |
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Key words: hysterosalpingography/infertility/magnetic resonance imaging
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Introduction |
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Materials and methods |
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As a first step uterine cannulation was performed by a gynaecologist using a balloon catheter (Charriere 8, Rüsch, Kernen, Germany) which was placed into the uterine cavity and blocked at its position. MR-imaging was performed in a 1.5 Tesla MR-unit (Symphony, Siemens, Erlagen). For imaging of the true pelvis standard axial and sagittal T1-w and T2-w sequences were acquired. For 3D dMR-HSG a fat-saturated 3D gradient-echo sequence was acquired with a phased array body coil (`FLASH 3D': TE/TR 3.6/1.4, Flip-angle 25, FOV 380mm, slice thickness 1.25mm, voxel size 1.4x0.7x1.3mm).
By using this three dimensional T1-weighted sequence, five consecutive data sets were acquired before, at the beginning, during early, during late, and after uterine injection of 20 ml of a strictly germ-free gadolinium-polyvidone gel solution which was formulated exclusively for this purpose.
The solution consisted of 18.6mmol/l Dotarem® (Acidum gadoteras DCI, Guerbet, Paris, France) mixed with polyvidone (140 mg PVP C30). Dotarem®, is a well known macrocyclic gadolinium-chelate complex used worldwide as a paramagnetic MR-contrast agent primarily for intravenous usage. However, since Dotarem® is an extracellular contrast agent it may also be used as a positive intestinal contrast agent for example for MR-colonographies or MR-enteroclyses and extravasation of Dotarem® into the peritoneal cavity is therefore harmless. Furthermore, Dotarem® is chemically very stable, does not bind to albumins or other proteins and does not undergo any metabolism. Therefore Dotarem® behaves intracorporally as other water-soluble and inert substances (such as mannitol or inulin) and is cleared by renal excretion within 24 hours. Polyvidone on the other hand is a viscosity increasing substance that is regularly used in conventional HSG contrast media such as Telebrix-Hystero (Guerbet, Paris France).
Viscosity of our slightly hyperosmolar contrast solution (600mOsm/kg H2O) could thus be increased up to 100 mPa·s. Each 3D acquisition took only 2025 s. All patients underwent X-ray-HSG as a gold-standard immediately following 3D dMR-HSG and both examinations were performed by the same gynaecologist and by the same radiologist. Finally all patients (who did not receive any anaesthesia or analgesia for HSG) were interrogated regarding their experiences during both procedures.
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Results |
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The use of 3D dMR-HSG allowed 3D visualization of a normal uterine cavity in eight patients and confirmation of bilateral Fallopian tube patency in six, which correlated with findings of conventional HSG (Figures 1 and 2). In two patients MR-HSG showed a one-sided occlusion of the Fallopian tubes which was confirmed by X-ray-HSG. Furthermore, due to the higher viscosity of our contrast solution, direct visualization of the Fallopian tubes was possible in five of seven patients (Figure 2
).
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Discussion |
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Proof of Fallopian tube patency may also be achieved by laparoscopy and by contrast enhanced sonography, but laparoscopy fails to provide visualization of the uterine cavity and contrast enhanced sonography has the disadvantage of being more observer dependent and, therefore, less reproducible (Philipsen, Hansen, 1981; Fayez et al., 1988; Reis et al., 1998
; Boudghene et al., 2001
). Furthermore, a variety of other possible causes for female infertility cannot be diagnosed accurately by conventional HSG and sonography and, therefore, many patients who are additionally referred for pelvic MRI finally have to undergo more than one of the aforementioned examinations.
Over the past years research activities on MR-HSG were intensified but 3D and dynamic visualization of the human uterine cavity and of Fallopian tube patency, together with direct visualization of Fallopian tubes has not yet been achieved (Lee et al., 1996; Frye et al., 2000
; Hagspiel et al., 2000
; Rouanet et al., 2000
; Wiesner et al., 2001
). Therefore, combined with standard pelvic MRI our method represents a possible one-step imaging approach to female infertility.
The fact that dislocation of the catheter occurred in three patients was a limitation and it is possible that this happened during the transfer to the MR system, where catheter repositioning was not possible anymore due to the narrow MR tube; however using open MR systems in which catheter positioning and repositioning could be done easily within the MR unit might solve this problem.
Further research and further technical optimization is needed as well as larger blinded comparative studies to evaluate the diagnostic accuracy of this method in regard to detection of various uterine and Fallopian pathologies compared with conventional HSG, laparoscopy and sonography.
However, one can state at the moment that the advantages of less pain during the examination, of more information about all organs of the true pelvis and especially of avoidance of exposure to ionizing radiation, do compensate for the longer examination time and for the expected higher costs of this new technique, which might evolve to a well-accepted alternative to conventional HSG and probably even replace this old method in the near future.
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Notes |
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References |
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Submitted on June 11, 2002; accepted on August 8, 2002.