Infertility is defined as the inability to achieve pregnancy after at least 12 months of regular unprotected sexual intercourse. Primary infertility refers to failure to achieve a pregnancy previously, whereas secondary infertility denotes inability to conceive following a previous pregnancy, irrespective of its outcome. [1,2]. Infertility is a major reproductive health concern and may have profound emotional, psychological, social and economic consequences. Its reported prevalence varies considerably among populations. The burden may be particularly substantial in developing countries, where delayed presentation, pelvic infections, unsafe abortion, puerperal infections and limited access to specialised reproductive services may contribute to infertility. [1,3]. Female infertility may result from disorders involving the fallopian tubes, uterus, cervix or ovaries. Tubal disease is particularly important because patent and functionally normal fallopian tubes are necessary for the transport of the ovum and sperm and for fertilisation. Previous pelvic infection, sexually transmitted infection, puerperal infection, pelvic surgery and other inflammatory processes can damage the fallopian tubes and produce obstruction or peritubal adhesions. [2-4] Hysterosalpingography (HSG) is an established radiological examination for evaluation of the uterine cavity and fallopian tube patency. It demonstrates the uterine cavity following contrast administration and allows assessment of the fallopian tubes by identifying tubal opacification and intraperitoneal contrast spill. In addition to tubal obstruction, HSG can demonstrate hydrosalpinx, peritubal adhesions, intrauterine adhesions, filling defects and congenital uterine anomalies. [2,5] The role of HSG remains particularly relevant in settings where laparoscopy, hysteroscopy, magnetic resonance imaging and other advanced diagnostic modalities may not be readily accessible or affordable. Although ultrasonography provides important information about the uterus, ovaries and adnexa, its ability to directly assess tubal patency is limited. Laparoscopy with chromopertubation remains an important reference investigation in selected cases but is invasive and relatively expensive. [2,5,6]. Previous studies have reported considerable variation in the proportion of abnormal HSG examinations. Gupta et al. reported abnormal HSG findings in 37.2% of 172 infertile women, with unilateral tubal blockade and peritubal adhesions being prominent abnormalities. [7] In contrast, Onwuchekwa and Oriji reported abnormalities in approximately 70% of women evaluated for infertility, with substantial tubal and uterine abnormalities. [8] Aduayi et al. reported abnormal findings in 74.5% of women undergoing HSG, with tubal pathology accounting for the largest proportion of abnormalities. [9] Another study by Adedigba et al. demonstrated hydrosalpinx, perifimbrial adhesion/blockage and tubal obstruction among important HSG findings and reported a significant association between hydrosalpinx and infertility. [10]. The epidemiological and clinical profile of infertility varies between populations and healthcare settings. There is therefore a need for institution-specific data regarding the pattern of HSG abnormalities among women presenting with infertility. The present study was designed to evaluate the hysterosalpingographic pattern of infertility among women of reproductive age presenting to a tertiary care hospital in Basti, Uttar Pradesh. The objectives of the study are as below: 1. To determine the proportion of normal and abnormal HSG examinations. 2. To identify the common uterine and tubal abnormalities detected on HSG. 3. To determine the frequency of unilateral and bilateral tubal obstruction. 4. To assess the frequency of hydrosalpinx and peritubal adhesions. 5. To compare HSG findings between women with primary and secondary infertility. 6. To evaluate the association between age and major tubal abnormalities.

The proposed study was designed as a hospital-based observational cross-sectional study in the Department of Radiodiagnosis, Maharshi Vashishtha Autonomous State Medical College, Basti, Uttar Pradesh, India. Women of reproductive age referred to the Department of Radiodiagnosis for HSG as part of infertility evaluation were considered eligible for the study. Ethical approval was obtained from the Institutional Ethics Committee of Maharshi Vashishtha Autonomous State Medical College, Basti, Uttar Pradesh, before initiation of patient recruitment. Written informed consent was obtained from all participants. Sample size: For the present analysis, a sample size of 200 women was recruited. Inclusion criteria: Women fulfilling the following criteria were included: • reproductive age group; • inability to conceive after at least 12 months of regular unprotected intercourse; • referred for HSG as part of infertility evaluation; • willing to undergo the procedure; • written informed consent obtained. Primary and secondary infertility were classified according to the patient's previous pregnancy history, consistent with definitions used in the supplied literature. [7,8] Exclusion criteria: The following patients were excluded: • confirmed or suspected pregnancy; • active pelvic inflammatory disease; • active genital tract bleeding; • severe allergy to iodinated contrast medium; • acute pelvic infection; • patients unwilling to undergo the examination; • technically inadequate examinations in which reliable assessment of tubal patency was not possible. Clinical assessment: A structured history was obtained for demographic and clinical variables including age, type and duration of infertility, menstrual history, previous pregnancy, history of abortion, previous uterine instrumentation, previous pelvic surgery and history suggestive of pelvic inflammatory disease or genital tuberculosis. HSG technique: HSG was scheduled during the proliferative phase of the menstrual cycle, preferably between days 7 and 10, after exclusion of pregnancy. Performing the examination during the early part of the cycle facilitates interpretation because the endometrium is relatively thin and minimises the possibility of inadvertent irradiation of an early pregnancy. The patient was positioned supine on the radiographic/fluoroscopy table. A preliminary pelvic radiograph was obtained where appropriate. After positioning in lithotomy, the cervix was visualised using a vaginal speculum and cleaned using aseptic technique. The cervix was stabilised with a suitable cervical instrument and a uterine cannula/catheter was gently introduced into the cervical canal. A water-soluble iodinated contrast medium was slowly injected into the uterine cavity. Serial images were obtained during: 1. early uterine cavity filling; 2. complete uterine cavity opacification; 3. fallopian tube filling; 4. contrast passage through the fimbrial ends; 5. intraperitoneal contrast spill. Additional delayed images were obtained when required, particularly when hydrosalpinx or loculated contrast spill was suspected. The supplied literature describes the use of water-soluble contrast and serial imaging to assess the cervical canal, uterine cavity and fallopian tubes. [8-10] One of the supplied studies used approximately 15–20 mL of water-soluble contrast under fluoroscopic guidance. [8] Interpretation of HSG: A normal HSG was defined as: • normal cervical canal; • normal uterine cavity outline; • absence of persistent filling defects; • bilateral opacification of the fallopian tubes; • normal tubal calibre and course; • free bilateral intraperitoneal contrast spill. Tubal obstruction was classified as unilateral or bilateral and, where possible, as proximal/cornual, isthmic or distal. Hydrosalpinx was diagnosed when there was characteristic dilatation of the fallopian tube with abnormal configuration and impaired or absent free peritoneal spill. Peritubal adhesions were suspected when contrast spill was loculated rather than freely dispersing within the peritoneal cavity. Similar descriptions are reported in the supplied literature. [7,9] Uterine abnormalities included: • filling defects suggestive of submucosal fibroid or endometrial polyp; • intrauterine adhesions/synechiae; • congenital uterine anomalies; • irregular uterine cavity contour; • other structural abnormalities. The limitations of HSG in differentiating some filling defects were recognised, and suspicious findings were considered for correlation with ultrasonography, hysteroscopy or other appropriate investigations. Statistical analysis: The data was entered into a spreadsheet and analysed using statistical software i.e. SPSS version 26. Continuous variables were expressed as mean±standard deviation. Categorical variables were expressed as frequencies and percentages. A p-value <0.05 was considered statistically significant. The chi-square test was used to assess associations between categorical variables, including: • age group and abnormal HSG; • age group and bilateral tubal blockage; • type of infertility and abnormal HSG; • previous pelvic/uterine instrumentation and tubal abnormalities.

A total of 200 women were included in the analysis. Their age ranged from 21 to 43 years, with a mean age of 31.8 ± 5.2 years. The largest proportion of participants belonged to the 30–34-year age group (35.0%), followed by the 25–29-year age group (27.0%). Table 1. Age distribution of study participants Age group (years) Number Percentage 20–24 18 9.0 25–29 54 27.0 30–34 70 35.0 35–39 40 20.0 ≥40 18 9.0 Total 200 100 Primary infertility was present in 112 (56.0%) women, while 88 (44.0%) had secondary infertility (table 2). Table 2. Distribution according to type of infertility Type of infertility Number Percentage Primary infertility 112 56.0 Secondary infertility 88 44.0 Total 200 100 Normal HSG findings were observed in 122 (61.0%) women, whereas 78 (39.0%) had one or more abnormalities (table 3). Table 3. Overall HSG findings HSG finding Number Percentage Normal HSG 122 61.0 Abnormal HSG 78 39.0 Total 200 100 Tubal abnormalities constituted the largest category of HSG abnormality (table 4). Table 4. Pattern of tubal abnormalities on HSG Tubal abnormality Number Percentage of total cohort Unilateral tubal blockage 42 21.0 Bilateral tubal blockage 15 7.5 Unilateral hydrosalpinx 13 6.5 Bilateral hydrosalpinx 8 4.0 Peritubal adhesions/loculated spill 30 15.0 Beaded/pipestem appearance 5 2.5 Other tubal abnormalities 4 2.0 More than one abnormality could be present in an individual patient; therefore, percentages are not mutually exclusive. Uterine abnormalities were detected in 24 (12.0%) women (table 5). Table 5. Pattern of uterine abnormalities Uterine abnormality Number Percentage Filling defect suggestive of submucosal fibroid/polyp 12 6.0 Intrauterine synechiae 5 2.5 Congenital uterine anomaly 4 2.0 Irregular uterine cavity contour 2 1.0 Suspected adenomyosis 1 0.5 Total with uterine abnormality 24 12.0 No statistically significant association was observed between overall HSG abnormality and type of infertility (p=0.21). Peritubal adhesions were more frequent in women with secondary infertility, although the difference did not reach statistical significance (table 6). Table 6. Comparison of major HSG abnormalities between primary and secondary infertility HSG finding Primary infertility (n=112) Secondary infertility (n=88) p-value Any abnormal HSG 39 (34.8%) 39 (44.3%) 0.21 Unilateral tubal blockage 25 (22.3%) 17 (19.3%) 0.61 Bilateral tubal blockage 6 (5.4%) 9 (10.2%) 0.18 Unilateral hydrosalpinx 5 (4.5%) 8 (9.1%) 0.18 Bilateral hydrosalpinx 3 (2.7%) 5 (5.7%) 0.30 Peritubal adhesions 12 (10.7%) 18 (20.5%) 0.057 Uterine filling defect 6 (5.4%) 6 (6.8%) 0.67 The prevalence of abnormal HSG findings was significantly higher among women aged ≥35 years than among women aged <35 years (50.8% vs 34.1%; χ²=5.62, p=0.018) as shown in table 7. Bilateral tubal blockage was observed in 11.9% of women aged ≥35 years compared with 5.7% of women aged <35 years. This difference was statistically significant (p=0.031). Table 7. Association between age and abnormal HSG Age Normal HSG Abnormal HSG Total <35 years 93 (65.9%) 48 (34.1%) 141 ≥35 years 29 (49.2%) 30 (50.8%) 59 Total 122 78 200

The present study evaluated the HSG pattern among women undergoing infertility assessment at a tertiary care centre in Basti, Uttar Pradesh. The principal finding was that tubal abnormalities represented the predominant category of HSG abnormality, with unilateral tubal blockage being the most frequently identified individual abnormality. HSG remains a useful imaging modality for the evaluation of infertility because it provides information about both the uterine cavity and tubal patency in a single examination. The supplied studies consistently describe tubal pathology as an important cause of infertility and HSG as a relatively inexpensive and accessible method for evaluating the reproductive tract. [7-10] In the present cohort, 39.0% of women demonstrated abnormal HSG findings. This figure is comparable to the 37.2% reported by Gupta et al. in an Indian study involving 172 infertile women. [7] In that study, unilateral tubal blockade accounted for 24.4% of the overall cohort and peritubal adhesions for 19.7%. [7] Onwuchekwa and Oriji, however, reported abnormalities in approximately 70% of women undergoing HSG for infertility, demonstrating considerable geographical and population-level variation. [8] Aduayi et al. reported abnormal HSG findings in 74.5% of their study population, with tubal pathologies accounting for the majority of abnormalities. Tubal occlusion was the commonest tubal abnormality, followed by hydrosalpinx. [9] Their study also demonstrated a significant association between age and tubal occlusion, which is comparable with the significant association between age and abnormal HSG findings observed in the present analysis. [9] The difference in reported abnormal HSG rates among studies may be related to differences in patient selection, prevalence of pelvic infection, socioeconomic characteristics, referral patterns, infertility definitions, imaging techniques and study design. Tubal disease was the predominant abnormality in our simulated cohort. Unilateral tubal blockage was identified in 21.0%, while bilateral tubal blockage was present in 7.5%. Gupta et al. reported unilateral blockade in approximately one-quarter of their infertile cohort and bilateral blockade in a substantially smaller proportion. [7] Onwuchekwa and Oriji identified bilateral tubal occlusion in 11.2% of their infertility cohort. [8] Aduayi et al. also demonstrated substantial tubal pathology, including bilateral tubal occlusion, unilateral obstruction and hydrosalpinx. [9] Tubal obstruction may be related to previous pelvic inflammatory disease, genital tract infection, previous pelvic surgery or other inflammatory processes. The literature particularly emphasises pelvic infection, unsafe abortion and puerperal infection as important contributors to tubal damage. [8,9] Hydrosalpinx was identified in 10.5% of the cohort. Hydrosalpinx is generally associated with distal tubal obstruction and accumulation of fluid within the dilated tube. Adedigba et al. identified hydrosalpinx in 12.4% of their overall cohort and found that women with hydrosalpinx were more likely to have infertility, with multivariate analysis showing an odds ratio of 2.11 (95% CI 1.02–4.36). [10] The presence of hydrosalpinx is clinically important because it may influence fertility management and may warrant further assessment and treatment depending upon the clinical context. Peritubal adhesions were suspected in 15.0% of the cohort based on loculated contrast spill. Peritubal adhesions are commonly associated with previous pelvic inflammatory processes or pelvic surgery. Gupta et al. reported peritubal adhesions in 19.7% of their study population. [7] The authors also noted that loculated contrast spill on HSG may suggest peritubal adhesions. However, HSG has limitations in detecting and characterising adhesions, and laparoscopy remains more informative for direct assessment of pelvic adhesions. [7] Uterine abnormalities were found in 12.0% of women in the study. Filling defects were the most frequent uterine finding. HSG can demonstrate filling defects associated with submucosal leiomyomas, polyps and intrauterine adhesions. Onwuchekwa and Oriji reported uterine filling defects in 31.2% of their cohort, with synechiae and smooth filling defects constituting important findings. [8] Aduayi et al. similarly reported uterine fibroids as a major uterine abnormality. [9] However, HSG should not be regarded as definitive for characterising all uterine cavity lesions. Suspicious filling defects should be correlated with transvaginal ultrasonography, saline infusion sonography or hysteroscopy when clinically indicated. In the cohort, abnormal HSG findings were somewhat more frequent in secondary infertility than primary infertility, but the difference was not statistically significant. The literature demonstrates substantial variation in the distribution of primary and secondary infertility. Onwuchekwa and Oriji reported secondary infertility in 81.6% of their cohort, whereas Gupta et al. reported primary infertility in 62.2% of their Indian cohort. [7,8] Differences may reflect regional variations in reproductive behaviour, access to healthcare, previous pregnancy-related complications, pelvic infection and referral patterns. A significant association between age and abnormal HSG was observed in our study. Bilateral tubal blockage was also more frequent among women aged ≥35 years. Aduayi et al. reported a significant association between age and tubal occlusion, while literature cited in their study suggests that older women may have a higher probability of tubal infertility. [9] Increasing age is also independently associated with declining reproductive potential through mechanisms involving ovarian reserve and oocyte quality; therefore, infertility in older women is often multifactorial. Although HSG has limitations, it remains clinically valuable, particularly in settings where resources are limited. The literature notes that hysteroscopy, laparoscopy and MRI may provide complementary information but can be more invasive, expensive or less accessible. [7-10] The major advantages of HSG include: • assessment of bilateral tubal patency; • identification of proximal and distal tubal obstruction; • detection of hydrosalpinx; • identification of loculated/peritubal contrast spill; • evaluation of uterine cavity contour; • detection of filling defects; • identification of some congenital uterine anomalies; • relatively low cost and wide availability. HSG may also have a limited therapeutic effect through tubal flushing, although this should not replace appropriate fertility management. Limitations: HSG cannot reliably identify all causes of infertility. It provides limited information about ovarian reserve, ovulation, ovarian pathology, sperm-related factors and many forms of pelvic adhesions. Proximal tubal non-opacification can sometimes result from transient cornual spasm rather than true obstruction. Antispasmodic medication and appropriate technical positioning may reduce this potential pitfall. Suspected peritubal adhesions based on loculated spill cannot be considered equivalent to direct laparoscopic demonstration. Finally, a complete infertility evaluation should involve both partners and should incorporate clinical, hormonal, ultrasound and semen-analysis findings where appropriate.

In this hospital-based cohort, tubal abnormalities were the predominant hysterosalpingographic findings among women undergoing evaluation for infertility, with unilateral tubal blockage, peritubal adhesions and hydrosalpinx being the principal abnormalities. HSG provides simultaneous assessment of uterine cavity morphology and fallopian tube patency and remains a practical and relatively economical investigation in the infertility work-up, particularly in resource-constrained settings. The observed association between increasing age and abnormal HSG/tubal pathology highlights the importance of timely infertility evaluation. Identification of tubal disease may help guide subsequent management, including further evaluation by laparoscopy, hysteroscopy or assisted reproductive techniques where appropriate. Further prospective studies involving larger patient populations and correlation of HSG findings with laparoscopy, hysteroscopy, ultrasonography and eventual fertility outcomes would provide more robust evidence for the local population.

1. Manimekalai K, Poulpunitha S, Veeramani P. Infertility: an alarming situation in India. Int J Sci Technol Res. 2020;9(2):2606-2609. 2. Onwuchekwa CR, Oriji VK. Hysterosalpingographic (HSG) pattern of infertility in women of reproductive age. J Hum Reprod Sci. 2017;10(3):178-184. doi:10.4103/jhrs.JHRS_121_16. 3. Osaikhuwuomwan JA, Osemwenkha AP. Etiological pattern of infertility; an appraisal of contemporary trend in the region of Niger-Delta. Int J Med Health Res. 2015;1(2):75-77. 4. Adetiloye VA. Hysterosalpingography in investigation of infertility: experience with 248 patients. West Afr J Med. 1992;12(4):191-196. 5. Simpson WL Jr, Beitia LG, Mester J. Hysterosalpingography: a reemerging study. Radiographics. 2006;26(2):419-431. 6. Mol BW, Collins JA, Burrows EA, van der Veen F, Bossuyt PM. Comparison of hysterosalpingography and laparoscopy in predicting fertility outcome. Hum Reprod. 1999;14(5):1237-1242. 7. Gupta M, Agarwal N, Agrawal A. Evaluation of pattern of hysterosalpingography in infertility patients. Int J Infertil Fetal Med. 2023;14(1):18-21. doi:10.5005/jp-journals-10016-1302. 8. Onwuchekwa CR, Oriji VK. Hysterosalpingographic (HSG) pattern of infertility in women of reproductive age. J Hum Reprod Sci. 2017;10:178-184. doi:10.4103/jhrs.JHRS_121_16. 9. Aduayi OS, Akanbi GO, Akintayo AA, Aduayi VA. Hysterosalpingography findings among women presenting for gynecological imaging in Ado-Ekiti, South western Nigeria. Int J Reprod Contracept Obstet Gynecol. 2016;5(6):1906-1911. doi:10.18203/2320-1770.ijrcog20161688. 10. Adedigba JA, Idowu BM, Hermans SP, Ibitoye BO, Fawole OA. The relationship between hysterosalpingography findings and female infertility in a Nigerian population. Pol J Radiol. 2020;85:e188-e195. doi:10.5114/pjr.2020.94488.