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Hindawi Radiology Research and Practice Volume 2020, Article ID 6697653, 7 pages https://doi.org/10.1155/2020/6697653 Research Article Hysterosalpingography Findings and Jimah Ratio of the Uterine Cavity in Women with Infertility in Central Region, Ghana 1 1 2 Bashiru Babatunde Jimah , Philip Gorleku, and Anthony Baﬀour Appiah Department of Medical Imaging, School of Medical Sciences, University of Cape Coast, Cape Coast, Ghana Ghana Field Epidemiology and Laboratory Training Programme, University of Ghana, Accra, Ghana Correspondence should be addressed to Bashiru Babatunde Jimah; firstname.lastname@example.org Received 28 October 2020; Revised 15 November 2020; Accepted 1 December 2020; Published 14 December 2020 Academic Editor: Daniele La Forgia Copyright © 2020 Bashiru Babatunde Jimah et al. *is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Background. Infertility aﬀects from 1.3% to 25.7% of couples worldwide and, especially, from 14.5% to 16.4% in Africa. Hys- terosalpingography (HSG) is a diagnostic modality that is considered both common and eﬃcient. It is used to investigate abnormalities of the uterine cavity and fallopian tubes. *is study assessed the spectrum of ﬁndings on HSG among women with infertility in the Central Region (Ghana). Methods. We conducted a prospective cross-sectional study to examine 203 infertile women undergoing HSG work-up at the Cape Coast Teaching Hospital. *e exclusion criteria were acute infection of the vagina or cervix and active vaginal bleeding or pregnancy. Data were entered with Microsoft Excel and analyzed using SPSS version 21. Results. A total of 203 women were enrolled, and eighty-ﬁve (41.87%) of the women had at least one or more abnormalities. *e mean age was 32.9 years with majority of the women within 30–39 years (61.08%). More than half (50.74%) of the women presented with secondary infertility, while age of women (p � 0.004) and duration of infertility (0.034) were found to be in association with the type of infertility. Uterine ﬁndings were predominantly capacious uterine cavity (45.1%) and uterine ﬁbroids (33.3%), while fallopian tube ﬁndings included bilateral blockage (24.2%), right unilateral proximal blockage (17.7%), loculated spillage (16.1%), and left unilateral proximal blockage (16.1%). *e range of normal uterine cavity size, measured as ratio (Jimah ratio) of intercornual diameter to interiliac diameter was 0.2–0.45, with a mean of 0.36. Conclusion. Secondary infertility was the commonest indication for HSG in the study, and a signiﬁcant proportion of infertile women had abnormalities. Abnormalities were higher in the fallopian tubes than the uterus, while capacious uterine cavity, uterine ﬁbroid, and bilaterally blocked tubes were the top three abnormalities found. Infertility is a gynecological disorder with associated 1. Introduction medical, psychological, and economic problems, and it af- Infertility is a disease of the reproductive system deﬁned by fects 1.3% to 25.7% of couples worldwide [4, 5]. Infertility the failure to achieve a clinical pregnancy after 12 months or prevalence is highest in South Asia, sub-Saharan Africa, more of regular unprotected sexual intercourse [1, 2]. North Africa/Middle East, and Central/Eastern Europe and Generally, infertility can be primary or secondary. Primary Central Asia . Generally, the prevalence of secondary infertility is deﬁned as “the absence of pregnancy for a infertility is higher than primary infertility . In sub- couple who desire a child after 12 months or more of regular Saharan Africa, 14.5% to 16.4% of couples suﬀer from in- unprotected sexual intercourse, during which they have not fertility, mostly secondary representing 52% [6, 7]. *e used any contraceptives . Secondary infertility is deﬁned prevalence of infertility in Ghana is 11.8% . Wide range of as “the absence of a live birth for women who desire a child factors have been linked to infertility [2, 8, 9], but tubal and and have been in a union for at least ﬁve years since their last uterine abnormalities are the most common causes of female live birth, during which they did not use any contraceptives infertility [6, 9–11]. Identiﬁed factors may be social, physical, . and physiological, and these include but not limited to 2 Radiology Research and Practice obesity, abuse of alcohol and tobacco, infections, history of 2.3. Sampling Technique. We employed a consecutive either sexually transmitted diseases (STDs), or pregnancy sampling to enroll women attending the Department of complications, while orders are unexplained [2, 7–9, 12, 13]. Medical Imaging. Over the decades, the world has innovated lots of simple but eﬀective diagnostic tools and techniques to identify the 2.3.1. Inclusion Criteria. *e inclusion criteria were as potential causes of infertility among couples. Ultrasonog- follows: raphy (USG), computed tomography (CT), magnetic res- onance imaging (MRI), hysteroscopy, laparoscopy, and Diagnosis of infertility hysterosalpingography (HSG) are widely used . Hys- terosalpingography is often the ﬁrst investigation employed 2.3.2. Exclusion Criteria. *e exclusion criteria were as in female infertility. *e technique uses a contrast medium follows: to visualize the uterine cavity and fallopian tubes, hence able to infer tubal and uterine pathologies [2, 5, 15, 16]. (1) Women with acute infection of the vagina or cervix Previous studies on HSG diagnostic outcome reported (2) Women with active vaginal bleeding varied ﬁndings [4, 10, 11, 13, 17–22]. About 38% of Nigerian (3) Pregnant women women subpopulation had tubal and uterine abnormalities, and these included tubal blockage (11.38%), uterine ﬁbroid (5.52%), multiple myomata (1.72%), bilateral tubal adhe- 2.4. Data Collection Procedure. HSG was performed in the sions (2.07%), uterine adhesions (8.28%), cervical adhesions preovulatory phase of the menstrual cycle as an outpatient (2.07%), cervicouterine adhesion (2.41%), hydrosalpinx with th procedure between the 5 and 10 day of the menstrual cycle. spillage (3.45%), and rotated uterus (0.69%) . *e suppository diclofenac (100 mg) was administered 30 Another study in Nigeria revealed that 75% with tubal and minutes prior to the procedure. *e patients were placed in uterine abnormalities, tubal occlusions (bilateral (14.0%), the lithotomy position and cleaned, and vaginal speculum was right (6.0%), and left (7.0%)), uterine ﬁbroids (17.0%), and passed to visualize the cervix. A cervical cannula was inserted pelvic adhesion (12.0%) were the most common diagnosis after air bubbles have been expelled. Approximately 10–20 ml . A study in Iran also reported tubal abnormalities in of a water-soluble contrast medium (iopamirol) was injected women with primary and secondary infertility: hydrosalpinx manually through the cannula under ﬂuoroscopic guidance. (2.6% and 2.8%, respectively), tubal occlusion (4.7% and 9.8%, Two supine hysterograms were taken. *e ﬁrst image was respectively), and limited passage of contrast media (2.8% and obtained during the early ﬁlling of the uterus and used to 3.6%, respectively) . *e only study in Ghana found evaluate any ﬁlling defects or uterine contour abnormality. 60.03% of women with various abnormalities, which includes *e second image was taken with the uterus and fallopian tubal blockage (43.7%) (bilateral (20.5%), left (12.5%), and tubes fully distended and free intraperitoneal spillage of right (10.6%)) and ﬁbroids (25.4%) . contrast material seen. An oblique hysterogram was taken in *e limited studies on HSG in Ghana indicate an urgent uncertain cases, and no delayed images were taken. need to improve on data nationwide. *is study assessed the spectrum of ﬁndings on hysterosalpingography (HSG) in women with infertility in the Central Region and proposed a 2.4.1. Data Analysis and Interpretation of HSG. Data were method for estimating the size of the uterine cavity. *e study entered and analyzed using Statistical Package for Social will provide preliminary data to inform the practice of cli- Sciences (IBM SPSS version 21). We described the data in nicians, radiologists, and other medical practitioners; add to frequencies, proportions, and mean with standard deviation. knowledge of infertility among women in Ghana; and inform Test of statistical association was done using the chi-square further research on infertility in women in the country. test and one-way analysis of variance (ANOVA). All sta- tistical associations were considered signiﬁcant at p val- ue≤ 0.05. HSG is considered normal when both tubes were 2. Materials and Methods well outlined by the free ﬂow of contrast medium, without 2.1. Study Design. *is cross-sectional study was conducted loculation in the peritoneal cavity and normal uterine at the Department of Imaging of the Cape Coast Teaching outline. HSG was considered abnormal when there was Hospital within 8 months period (April to November 2017). evidence of either unilateral or bilateral tubal obstruction or Data were collected using semistructured questionnaires. uterine cavity abnormality. HSG was performed by two radiologists. 2.5. Ethical Considerations. Ethical approval for this study 2.2. Sample Size. A total of 300 women were estimated to was obtained from the Ethical Review Committee of the attend the Department of Medical Imaging within the 8- Cape Coast Teaching Hospital. Written informed consent month period. Sample size calculation was done using was obtained after the nature of the study was adequately RAOSOFT sample size calculator, assuming minimum explained to the clients. Clients were assured of data security sample size for the study taking into consideration the and conﬁdentiality. *ey were also informed about the holidays. We estimated 207 patients after including 5% beneﬁt of the research ﬁndings and how it will inﬂuence the nonrespondent rate. way the procedure is done locally and internationally. Radiology Research and Practice 3 Participation was purely voluntary, and they had the option 4. Discussion to terminate after been enrolled in the study. Hysterosalpingography (HSG) is a common radiographic procedure used in the investigation of female infertility . 3. Results It is eﬃcient in the detection of fallopian tube and uterine cavity pathologies including tubal occlusion and congenital 3.1. Demographic and Clinical Presentation of Women. A uterine anomalies [2, 5, 15, 16]. total of 203 women aged between 19 and 47 years and the In this study, two hundred and three (203) women with mean age of 32.9 years with history of infertility were en- infertility were enrolled, and some had complimentary ul- rolled. Most of the women were within 30–39 years (61.19%). trasound scan (USG). Most of the women presented with Secondary infertility (50.74%) was the most common form secondary infertility (50.74%) which is similar to the ﬁndings of infertility, and 58.62% of them have no history of live reported by previous studies in Nigeria [8, 17, 18, 24] and birth. *e commonest duration of infertility (56.16%) was 1 Ghana . On the contrary, studies from diﬀerent conti- to 4 years. Based on the association between age, duration of nents reported the predominance of primary infertility in infertility, ﬁndings on HSG, and indication of HSG, their study subjects: China , Iran , and India . women’s age (p � 0.004) and duration of infertility Our ﬁndings are consistent with the assertion that there is a (p � 0.034) were found to be signiﬁcantly associated with higher prevalence of secondary infertility in women in the indication of HSG (Table 1). developing countries compared to primary infertility in developed countries [5, 7, 20]. Previous ﬁndings also suggest 3.2. Findings on Hysterosalpingography. Out of the 203 that the prevalence of risk factors such as sexually trans- women studied, eighty-ﬁve (41.29%) of them were diag- mitted infections, poor reproductive health behavior, iat- nosed with at least one abnormality on HSG (Table 1). rogenic health care infections, and medical neglect of Forty-four (51.3%) of the women had only fallopian tube precursor conditions of secondary infertility is higher in abnormalities. *e common tubal abnormalities were developing countries [4, 8, 16, 20]. bilateral blockage (24.2%), right unilateral proximal A greater proportion of the women presented with 1 to 4 blockage (17.7%), loculated spillage (16.1%), and left years duration of infertility, comparable to 4 years as re- unilateral proximal blockage (16.1%) (Figure 1). As shown ported by Heis et al. , but less than the mean years (6.7 in Figure 1, 27 (31.8%) women were diagnosed with only years) as reported by Al-Jaroudi et al. . In this study, age uterine abnormality. Capacious uterine cavity (45.1%) and of women (p � 0.004) and duration of infertility (p � 0.034) ﬁlling defects/ﬁbroids (33.3%) were the common uterine were found to be in association with the forms of infertility. abnormalities. Fourteen (16.5%) women had both fallopian Our ﬁndings could not assign any possible reasons for this tube and uterine abnormalities. association. However, aging is likely to inﬂuence the oc- On tubal abnormalities, hydrosalpinx and left tubal currence of secondary infertility likely due to the prolonged patency are reported in Figure 2. exposure to the risk factors of infertility. We also reported HSG image to demonstrate the bi- As seen in this study, eighty-ﬁve (41.87%) of the lateral tubal patency and capacious uterine cavity in a women were diagnosed with at least one or more ab- participant (Figure 3). normalities. *is is comparable to a study in Switzerland  and Nigeria  which reported 44% and 37.6%, respectively. Our ﬁndings at the Cape Coast Teaching 3.3. Complimentary Ultrasonography Findings. Forty-nine Hospital, Ghana, vary from those of Botwe et al. from the women with abnormality on HSG had complimentary ul- Korle-Bu Teaching Hospital of Ghana, who found that trasound examination, and 51.1% showed abnormalities 60.03% of their women had abnormalities on HSG . such as ﬁbroids (78.3%), adenomyosis (4.3%), and 17.4% Many other studies have reported much higher propor- hydrosalpinx. tions: 98.19% in China , 92% in India , and 85.8% and 75% in Nigeria [11, 27]. *e possible explanation to the disparity in ﬁndings is likely due to exposure to in- 3.4. Uterine Cavity Size as a Ratio (Jimah Ratio) to the Corno- fections such as sexually transmitted disease (STD) and Iliac Diameter. Intercornual diameter (the diameter be- pelvic inﬂammatory disease (PID). tween the cornua of the uterus) and interiliac diameter (the A signiﬁcant proportion (71.6%) of women who had diameter between lower ends of the right and left iliac bones HSG abnormalities were diagnosed with tubal pathologies. at the level of the sacroiliac joint) were measured, and ratio Similar proportions were reported by Aduayi et al. (66.4%) (Jimah ratio) between intercornual diameter to interiliac in Nigeria , Bhatt et al. (68.4%) in India , and Hong diameter was determined. *e HSG measurement of the et al. (80%) in China . On the contrary, our proportion is normal uterine cavity size as a ratio (Jimah ratio) of the much higher than that reported by Niknezhady et al. (11.9%) corno-iliac diameter is illustrated in Figure 4. in Iran , Eze et al. (21%) in Nigeria , and Schankath *ere was signiﬁcant diﬀerence in the mean of intercornual et al. (54.7%) in Switzerland . *e discrepancies between diameter (p< 0.001), interiliac diameter (p< 0.001), and our ﬁnding and previous studies may be due to cultural intercornual diameter to interiliac diameter ratio (p< 0.001) disparities which predeﬁne the exposure to premarital and for all patients with normal uterine cavities (Table 2). 4 Radiology Research and Practice Table 1: Association between age, duration of infertility, ﬁndings on HSG, and type of infertility. Indication Statistical indices Variable Primary Secondary Total X (df) p value N � 98 100% N � 103 100% N � 201 100% Age 10.86 (2) 0.004 <30 36 36.73 22 21.36 58 28.86 30–39 58 59.18 65 63.11 123 61.19 40+ 4 4.08 16 15.53 20 9.95 Duration of infertility 8.67 (3) 0.034 <1 2 2.04 5 4.85 7 3.48 1_4 62 63.27 52 50.49 114 56.72 5_10 33 33.67 37 35.92 70 34.83 >10 1 1.02 9 8.74 10 4.98 Findings on HSG 0.18 (1) 0.674 Normal 59 60.2 59 57.28 118 58.71 Abnormal 39 39.8 44 42.72 83 41.29 HSG, hysterosalpingography; X , chi-square test df-degree of freedom; signiﬁcant level at p ≤ 0.05. 50.0 45.1 45.0 40.0 33.3 35.0 30.0 24.2 25.0 17.7 20.0 16.1 16.1 14.5 13.7 15.0 8.1 10.0 3.9 3.2 2.0 2.0 5.0 0.0 Type of uterine abnormality (n = 41) Types of fallopian tube abnormality (n = 58) HSG ﬁndings Figure 1: Hysterosalpingography ﬁndings in infertile women. extramarital sex and its sequelae such as sexually transmitted On HSG, hydrosalpinx is seen as a dilated convoluted diseases and PID [16, 17, 24]. tubular structure . *e fallopian tube inﬂammation is *e common tubal abnormalities found were tubal aggravated by STDs such as chlamydial or tuberculosis of the blockage which included bilateral blockage (24.2%) and right genital tract [24, 28]. Our proportion for hydrosalpinx unilateral proximal blockage (17.7%), and 16.1% each had (14.5%) among women diagnosed with tubal abnormalities loculated spillage and left unilateral proximal blockage. A was consistent with previous studies in Ghana  and similar observation was made by Lawan et al. in Nigeria . Nigeria . *ese proportions though low are a major Percentage (%) Unicornuate uterus Bicornuate uterus Irregular uterine cavity Filling defects/ﬁbroids Capacious uterine cavity Enterouterine ﬁstula Right unilateral proximal blockage Right unilateral distal blockage Le unilateral proximal blockage Le unilateral proximal blockage Bilateral blockage Loculated spillage Hydrosalpinx Radiology Research and Practice 5 Figure 2: HSG image of right hydrosalpinx and left tubal patency. Figure 3: HSG image of bilateral tubal patency and capacious uterine cavity. Table 2: Mean and standard deviation of intercornual diameter, interiliac diameter, and ratio of intercornual diameter to interiliac diameter. Intercornual to Intercornual Interiliac diameter interiliac ratio diameter (n � 186) (n � 186) (Jimah ratio) HSG ﬁndings (n � 99) Mean SD Mean SD Mean SD Normal 29.13 4.68 80.65 10.37 0.36 0.06 Abnormal HSG without uterine abnormality 30.33 7.14 80.73 6.64 0.36 0.12 ANOVA <0.001 <0.001 <0.001 HSG, hysterosalpingography; SD, standard deviation; ANOVA, one-way analysis of variance; signiﬁcant level at p ≤ 0.05. Figure 4: HSG image of Jimah ratio (uterine ratio) � intercornual diameter (red line)/interiliac diameter (black line). 6 Radiology Research and Practice reproductive health problem in women as PID remains a better assess the spectrum of HSG abnormalities in both burden to developing countries [4, 8, 16, 17, 24]. normal and infertile women in the country. Uterine factors remain the second leading cause of in- fertility among women [5–7, 11, 14, 17, 21, 23]. Our study Data Availability indicates that almost 50% of women with HSG abnormalities *e data used to support the ﬁndings of this study are in- had various forms of uterine pathologies. Individual studies cluded within the article. have reported diﬀerent proportions of uterine abnormalities in Nigeria (33.4%  and 56.10%) , Switzerland (34.9%) Conflicts of Interest , and India (56.4%) . Most of the uterine anomalies consist of capacious *e authors declare that there are no conﬂicts of interest. uterine cavity (45.1%) and ﬁbroids (33.3%). A similar study in Ghana  reported slightly lower proportion (25.4%) of Authors’ Contributions uterine ﬁbroids. On the contrary, much lower proportions were reported by Eze et al. (17.0%) and Abubakar et al. BJJ conceptualized the topic, designed the protocol, per- (5.5%) in Nigeria [11, 17]. Complimentary ultrasound formed most of the HSG procedures, interpreted the HSG (USG) was done for 49 women with uterine abnormality on ﬁndings, and drafted and edited the manuscript. PG drafted, HSG, and it was observed that 51% had abnormalities such reviewed, and edited the manuscript. ABA performed data as uterine ﬁbroids (78.3%) analysis and interpretation and drafted, reviewed, and edited In this study, the mean of intercornual diameter, interiliac the manuscript. All authors read and approved the ﬁnal diameter (the diameter between lower ends of the right and left version of the manuscript. iliac bones), and ratio of intercornual diameter to interiliac diameter was taken. *is was done for all those with normal Acknowledgments uterine ﬁndings on HSG, irrespective of the fallopian tube disease. Our ﬁndings showed that there was statistically sig- *e authors wish to acknowledge the contributions of Priscilla Laryea, Isaac Dapaah, Dr. Mohammed Owusu niﬁcant diﬀerence in the mean of intercornual diameter (p< 0.001), intercornual diameter (p< 0.001), and the mean Ansah, Althea Mannah, and Anudjo Messiah Kwame and ratio of intercornual diameter to interiliac diameter (p< 0.001) Kortor Setor Nicholas and Mr. Oduro for their participation between those with normal HSG ﬁndings and those with only in the performance of the HSG procedures. tubal pathologies. *e range of intercornual diameter to References interiliac diameter ratio (otherwise known as Jimah ratio) is 0.2–0.45, for all women with a mean of 0.36 irrespective of  F. Zegers-Hochschild, G. D. Adamson, J. D. 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Radiology Research and Practice – Hindawi Publishing Corporation
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