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The Failed HSG

Today I will talk about why some women go in for an HSG and leave being told the test could not be done.

This is such a common problem, and it is usually all about the same thing. It’s about technique. The correct technique makes it easy, a different technique makes it unnecessarily difficult.

There are 2 ways to do a HSG. Remember the goal in performing a HSG is to get the dye in the uterus and then have it flow out of the tubes. To achieve this, many doctors slide a catheter through the cervix up into the uterus. This is the problem. If the cervical canal is narrow, whether naturally or as a result of some scarring after surgery, the catheter can’t get in easily. This results in pushing harder, and this causes pain, and pushing harder still may just jam the catheter against the side of the cervix. This leads to failure.

The second and easier way, for both the doctor and patient, is to put the dye in a syringe and put a soft cap on the end that snugs up against the cervix. We call this cap an acorn. The canal through the cap brings dye from the syringe to the cervical canal and up towards the uterine cavity.

Imagine trying to blow up a long skinny balloon by first shoving a straw half way in; it’s not so easy to get that straw through. But if you blow it up by just puffing into the hole (I know some of these balloons are hard to blow up but I’m just trying to illustrate the point) things go much easier.

Here are 2 pictures. Each has graphics that are a little different, but they are both drawings of HSGs, both represent a different way to do an HSG.


In the first, a catheter has been shoved through the cervical canal into the uterus. You can see the catheter inside with that little balloon at the tip. The balloon is designed to prevent the dye from backing up and coming out of the cervix. This makes sense, but there is a better way. In the second picture, the instrument is just pressed against the cervix, and that blocks the dye from coming out backwards. As you can see, nothing is shoved through the cervix. The dye finds its way into the uterus just from the pressure.

Even if the canal is very narrow, it does not matter, because the fluid dye will still have no problem following the path of the cervix. The same is true if the uterus is very ante-verted or retro-verted (tilted forward or backwards), both of which can make it very hard for the catheter to slide through the cervix and into the uterus. I’ll talk more about tilting soon in my upcoming blog about cervical stenosis.

I frequently see patients who some to see me having failed an hsg, meaning the test never got off the ground going because the catheter could not get into the uterus. The test was overly painful and there were no results to show for it.
All I do is repeat the test using the plug in the second picture and the test easily gets done. Occasionally I need to open the very end of the cervix in the place where the plug goes, but that’s much easier than needing to dilate the entire cervix to accommodate the full balloon catheter.

So if you had trouble with the HSG and live around NY, I would be happy to give it a go. Otherwise get the HSG done elsewhere, but ask first if they use the balloon. To be fair, even using my technique, rarely, rarely it still can’t be done and in that case I may need to dilate the cervix in the office or operating room.

Thanks for reading and please read the disclaimer from 5/17/06.

Dr. Licciardi

Sperm Morphology: New Guidelines Announced: 4% is Normal

Wow, what a relief to know that what we have been saying for years is now finally officially stated. Any sperm morphology over 3% is considered normal.

How did this change come about? The World Health Organization (WHO) determines the normal parameters for semen including volume, count, motility, forward progression and morphology. The WHO published their guidelines in 1987, with updates in 1992 and 1999. The original “normal” cutoffs were based on estimates from old data, some of it dating back to the 1950’s. There were inconsistencies in the way data was collected, ie the sperm studied was collected and analyzed in many centers, but there was little regulation of how the tests were being performed. Plus there was not clear data on the history of the men.

This time the semen tests were performed using similar protocols in all of the testing centers. Plus, some history was obtained from the men, mostly related to fertility status.

4500 men in 14 countries on 4 continents were tested. Australia, China, Denmark, Germany, Chile, Singapore, France, the UK, and the USA were some of the countries included.

Men were placed into one of 4 groups.
Fertile men. All men in this group had initiated a pregnancy sometime in the 12 months preceding testing. This was the most important group because the researchers could establish normal values based on men know to have fertile sperm.
There were 3 other groups evaluated. To save a little confusion, I’ll summarize and say 2 groups were a little more random in nature and the fertility status of the men was mostly unknown. The 4th group was also fertile, but the time since last pregnancy was unknown and may have been longer than 12 months.

The results.
The normal fertile men’s sperm had the following results.
Volume: The median (midway between the lowest and highest results) was 3.7 cc, but anything over 1.5 cc was considered normal
Concentration: the median was 73 million but anything over 15 million was considered normal
Motility: the median was 61%, anything over 40% being normal
Morphology: the median was 15%, anything over 3% was deemed normal.

Some important points.
You may have noticed that morphology is not the only parameter with a new normal value. Volume was at 2.0 cc, now it is at 1.5cc. A normal count was 20 million, this changed to 15 million. Motility was 50%, now it’s 40%. The normal morphology had the biggest change, as it went from 15% to 4%.

Keep in mind that in this group, all of these men were fertile, so even men with levels lower than the new definition of normal had working sperm. The normal values were established mathematically. If you were in the upper 95% of the fertile people you were deemed normal. The bottom 5% of the fertile people was deemed abnormal. This 95%/5% cutoff is the system used to define cut offs for other tests such as TSH, Prolactin and many others.

When comparing the different groups of men there were very slight differences in volume, count, etc, but hardly worth mentioning. Fertile men did have slightly higher volume and counts then men whose fertility status was unknown. Morphology was mostly similar in the different groups. Remember, there was no group of men who had established infertility, so in this study there is no way to compare normal fertile men to known infertile men.

And even though we have no details on the women, knowing that they became pregnant in the past year is probably all the information we need.

So now you know. Any morphology over 3% is considered normal. If your doctor tells you otherwise, ask him if he has seen the new WHO guidelines.

To take it one step farther, can there really be difference between 4% and 2%? I doubt that there is a difference between having 96% abnormally shaped sperm and 98% abnormally shaped sperm. So as I have said before, at our practice here at NYU, morphology is not considered with much respect, except in some rare cases where the sperm is unusually abnormal.

I hope this helps.

For those of you who want more details, here is the link.

www.who.int/reproductivehealth/topics/infertility/cooper_et_al_hru.pdf

Dr. Licciardi