Infertility affects approximately 10–15% of couples worldwide and is defined as the inability to conceive after one year of regular unprotected intercourse. Female factors contribute to nearly half of all infertility cases, with tubal and uterine pathologies being significant contributors. Among these, tubal blockage and uterine anomalies such as fibroids, polyps, adhesions, and congenital malformations can impair fertility by disrupting gamete transport, implantation, or embryo development.(1,2)

Hysterosalpingography (HSG) is a widely used, minimally invasive radiologic procedure that evaluates the morphology of the uterine cavity and patency of the fallopian tubes. It involves the introduction of a radio-opaque contrast medium into the uterine cavity followed by fluoroscopic imaging. HSG is typically performed in the follicular phase of the menstrual cycle, and it remains a first-line investigation in the infertility work-up due to its affordability, accessibility, and dual diagnostic and therapeutic potential.(3). In addition to its ability to detect tubal occlusion or hydrosalpinx, HSG can help identify intrauterine abnormalities like synechiae, fibroids, and uterine anomalies.(2,4)

Despite the advent of advanced imaging techniques such as saline infusion sonography and magnetic resonance imaging (MRI), HSG retains its relevance, particularly in low-resource settings.(3,5) Furthermore, studies have suggested a possible therapeutic benefit of HSG, particularly when oil-based contrast media are used, by flushing debris or mucus plugs from the fallopian tubes.(5)

This study aims to assess the diagnostic utility of HSG in evaluating tubal and uterine factors among infertile women and determine its role in guiding further management.

Source of Data: Study conducted at the Government General Hospitals Kadapa on patients coming to out-patient and in-patient department of the Obstetrics and Gynecology. Study Design:

Prospective study, Study Period: 18 months. Method of Sampling: purposive sampling Sample Size: 50. Study Duration: October 2022 to September 2023.Inclusion criteria: • Infertile women between 20-40 years • Day of cycle (between 6 and 11) • Not suffering from any other medical illness exclusion criteria: • Patients with vaginal discharge • Active or recently treated pelvic inflammatory disease • Suspected pregnancy • Recent intra-uterine instrumentation or tubal surgery • Active vaginal or uterine bleeding • Palpable adnexal mass or tenderness in bimanual examination. Methodology: • Patients were scheduled between 7th to 12th day of cycle • Pre ovulatory exam was performed to exclude early pregnancy. • Cervical os is identified as cannulated with water-soluble iodinated contrast. Statistical analysis: Data entered using the MS excel, Data analyzed using SPSS software 21, Frequency tables and percentages are calculated. Figures using bar diagrams and pie charts are demonstrated.

During the study period, 50 subjects were chosen for the study.

Table 1, shows the age distribution of a sample population. Most participants (64%) are aged 26 to 30. Smaller groups include those aged 21 to 25 and 31 to 35 (each 10%), 20 or younger (12%), and 36 and above (4%). The total sample size is 50, with a significant skew towards the 26-to-30 age group.

TABLE1 – Age distribution

The table displays the frequency and percentage of different types of infertility among a sample population. Primary infertility is the most prevalent, affecting 68% (34 individuals) of the participants. Secondary infertility accounts for the remaining 32% (16 individuals). The total sample size is 50, indicating this group's predominance of primary infertility cases.

TABLE - 2: Distribution of study participants according to type of infertility

The table presents the distribution of the duration of infertility (in years) among 50 individuals with primary and secondary infertility. For those with primary infertility, 17 individuals have experienced infertility for 0-5 years, 15 for 6-10 years, and 2 for 11 years or more. Among those with secondary infertility, 8 have experienced infertility for 0-5 years, 6 for 6-10 years, and 2 for 11 years or more. The p-value from the Chi-Square test is 0.702, indicating no statistically significant association between the type of infertility and the duration of infertility. This suggests that the duration of infertility does not significantly differ between individuals with primary and secondary infertility in this sample.]

TABLE – 3: Distribution of study participants according to duration and type of infertility

                                    Chi-Square test, p value is 0.702

The table presents the relationship between menstrual status and type of infertility (primary or secondary) among a sample of 50 individuals. For those with primary infertility, 22 individuals have normal menstrual status, 6 have dysmenorrhea, 4 have menorrhagia, and 2 have oligomenorrhea. Among those with secondary infertility, 9 individuals have normal menstrual status, 4 have dysmenorrhea, 1 has menorrhagia, and 2 have oligomenorrhea.

TABLE -4: Distribution of study participants according to menstrual symptoms and type of infertility

                                Chi-Square test, p value is 0.718.

The table examines the association between the type of infertility (primary or secondary) and uterine size among 50 individuals. Among those with primary infertility, 29 have a normal sized uterus, 4 have a small uterus, and 1 has a large uterus. For those with secondary infertility, 15 have a normal-sized uterus, none have a small uterus, and 1 has a large uterus.

TABLE - 5: Distribution of study participants according to uterus size and type of infertility

           Chi-Square test, p value = 0.322

The table presents the relationship between the type of infertility (primary or secondary) and the shape of the uterus among a sample of 50 individuals. The majority of individuals with both primary and secondary infertility have a standard uterus shape, with 31 individuals having primary infertility and 14 having secondary infertility. The bicornuate uterus shape is observed in 2 individuals with primary infertility and 1 with secondary infertility. The arcuate uterus shape is seen in 1 individual from each infertility group.

TABLE - 6: Distribution of study participants according to uterine shape and type of infertility

                                       p value = 0.854

The table presents the relationship between the type of infertility (primary or secondary) and the uterine surface characteristics among 50 individuals. Among those with primary infertility, 33 have a smooth uterine surface, and 1 has an irregular surface with a filling defect. For individuals with secondary infertility, 15 have a smooth uterine surface, and 1 has an irregular surface with a filling defect.

Table 7: Distribution of study participants according to uterus surface and type of infertility

                                     Chi-Square test, p value = 0.578

The table presents the association between types of infertility (primary and secondary) and tubal findings on hysterosalpingography (HSG) in a sample of 50 individuals. The most common finding for both primary and secondary infertility is regular tubes with bilateral spillage, observed in 28 individuals with primary infertility and 12 with secondary infertility. Other findings include bilaterally blocked tubes (2 primary, one secondary), bilateral hydrosalpinx with spillage (2 primary), bilateral hydrosalpinx with block (1 secondary), right block with left spillage (1 35 secondary), left block with right spillage (1 primary), and left hydrosalpinx with block (1 primary, 1 secondary).

Table 8: Distribution of study participants according to tubal findings on HSG and type of infertility

Pearson Chi-Square test, p value = 6.036

The current study consists of 50 patients. Age significantly impacts both primary and secondary infertility, affecting individuals' reproductive capabilities through biological, social, and psychological factors. As women age, the quality and quantity of their ovarian reserve decline, with a notable decrease in conception probability after 35 due to fewer healthy oocytes and increased chromosomal 38 abnormalities. Primary infertility is more prevalent in younger women seeking earlier medical advice, while secondary infertility is common among older women facing age-related reproductive conditions. Delayed childbearing for career or educational purposes also contributes to higher infertility rates in women over 30. Overall, timely reproductive planning and awareness are crucial to addressing the age-related decline in fertility.

Table 9: comparison of the age distribution among the various studies:

Both primary and secondary infertility are influenced by a variety of factors, including age, medical conditions, lifestyle, and environmental exposures, and both require medical evaluation and intervention to identify and address underlying causes.

Table 10: comparison the distribution of type of infertility among various studies

Overall, the findings from the current study, when compared with existing literature, emphasise the necessity of a multifaceted approach to infertility treatment and prevention. Tailored healthcare strategies that consider regional differences in infertility types and their underlying causes can lead to more effective management and better reproductive health outcomes for individuals worldwide.

The current study presents the relationship between menstrual symptoms and type of infertility (primary or secondary) among a sample of 50 individuals. For those with primary infertility, 22 individuals have normal menstrual status, 6 have dysmenorrhea, 4 have menorrhagia, and 2 have oligomenorrhea. Among those with secondary infertility, 9 individuals have normal menstrual status, 4 have dysmenorrhea, 1 has menorrhagia, and 2 have oligomenorrhea.

Table 11 a: Comparison of the distribution of menstrual symptoms among the various studies:

Table 11 b: Comparison of the distribution of menstrual symptoms among the various studies:

Characteristic     Primary infertility (Current study) Secondary infertility (Current study)    Primary infertility (Muni Kumari et al) (7)                Secondary infertility (Muni Kumari et al) (7) Uterine size

Table 12: Comparison of the uterine findings on HSG with previous studies:

The current study's findings on uterine size, shape, and surface characteristics of HSG are consistent with previous research, including studies by Bukar et al. (6), Muni Kumari et al. (7), and Ubeda et al. (8). Most individuals with infertility have a normal-sized uterus, a standard uterus shape, and a smooth uterine surface.

Primary infertility is more prevalent (68%) compared to secondary infertility (32%). Normal menstrual patterns are common in both types, though irregularities such as dysmenorrhea and menorrhagia are notable, particularly in primary infertility cases.  HSG findings reveal that most participants have a normal-sized, normally-shaped uterus with smooth surfaces, and regular tubes with bilateral spillage are the most common tubal finding. Despite various forms of tubal blockages and hydrosalpinx, the Chi-Square test shows no significant association between tubal findings and infertility type.

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