Radiation exposure of ovaries during hysterosalpingography HAMID

HUSSAIN

MARVIN

A.

Louisville,

Kentucky

SHEIKH,

YUSSMAN,

M.D.* M.D.

Radiation exposure to an area alybroximating the location of the ovaries was measured in 29 patients undergoing hysterosalpingography. A thermoluminescent crystal technique was used for some patients; a pocket dosimeter placed into the upper uagina was used for additional patients. Radiation dosage varied from 75 to 550 millirads. The weight of the patient did not affect the amount of radiation delivered to the gonads. The duration of juroscopic time was th major factor increasing dosage. A discussion of hysterosalpingographic technigue and suggestions for decreasing gonadal irradiation during hysterosalpingography are included.

THOUGH CONTROVERSIAL, there is evidence to indicate that genetic mutation may be induced by less than a single roentgen of irradiation.ip4 Muller,s the Nobel prize geneticist, states in regard to irradiation of the gonads that there is “no dose so small as to give no mutations at all; each individual ionization and probably each activation of an atom carries its definite chance of producing a mutation.” On the average, each newly mutated gene, no matter how small the detriment it occasions, eventually takes its toll in the form of making a major contribution to the extinction of the line of descent. Schwartz’ found that the radiosensitivity of the recently fertilized ovum is greatest in the gastrula and morula stages and that it decreases gradually during fetal life. The evidence cited implies that prefertilization radiation or postfertilization exposure may have detrimental effects.‘, 8 Radiation damage to the germ cells is cumulative without regard to time. A mutation need not be a monstrosity, but it chances adding to the load of inherited human ills. High-level dosage, of course can result in sterility.’ With the advent of image-intensified fluoroscopy

From the Department of Obstetrics and Gynecology, University of Louisville School of Medicine. Received

for publication

Revised

February

Accepted

Februar)

November

18, 1974.

10, 1975. 24, 1975.

Reprint requests: Hamid Hussain She&h, M.D., Hunter Foundation for Health Care, 212 N. Upper St., Lexington, Kentucky 40507.

and cinematography, radiation exposure to the ovaries could have been decreased. Unfortunately, these techniques have been so used as to increase radiation exposure manyfold.9s lo The aim of the current investigation is to determine if radiation exposure to the ovaries can be decreased during hysterosalpingography. We have approached this question by measuring the ovarian radiation exposure during hysterosalpingography (HSG) with fluoroscopy.

Material and methods All the patients included in this study were undergoing either infertility investigation or hysterosalpingography following tubal sterilization (HSG followup of tubal sterilization is a separate study). A Foley catheter techniquell* l* was used for hysterosalpingography. Parekh and associates” recommended this method and we confirm its convenience as long as uterine manipulation is not required. In the latter event, a suction cannula is used rather than the Foley catheter.r3 After draping and insertion of a Graves speculum, the cervix and vagina were painted with an antiseptic solution. A No. 10 or 12 Foley catheter was introduced steadily into the uterus with the help of a ring or uterine forceps. The bulb of the Foley was distended with 2 to 4 ml. of air. Radiation exposure was measured with either of the following two devices applied as close to the ovaries as possible:

308

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and Yussman

Fig. 1. Devices used for measuring radiation exposure to ovaries. Left, pocket dosimeter in model vagina; right, diaphragm device.

Fig. 2. Hysterosalpingography Thermoluminescent crystals (TLD principle) carried by small containers at the ends of an arc made from the curvature of a contraceptive diaphragm.r4* l5 The device was inserted into the vagina so as to place the crystals in the lateral fornices, thus measuring the radiation exposure in the vicinity of each ovary (Fig. 1). We were unable to continue using this device because of nonavailability of the dose-reading instrument. An approximation of the irradiation exposure of the

with the dosimeter in the vagina. ovaries was obtained by a pocket dosimeter (Victoreen chamber principle).r5 The dosimeter was placed in an empty surgical glove and inserted into the vagina so that the chamber was deeply placed in the posterior fornix. A hysterosalpingogram was performed, using fluoroscopy intermittently with minimum exposure time. All the procedures were carried out by the same operator, using the same x-ray machine (Westinghouse), with KVP kept

Volume 124 Number3

Table

Radiation

I. Detailed

Fluoroscopic (sec. ) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29.

time 45 46 50 20 20 22 30 35 55 60 50 48 50 50 25 55 27 65 45 47 25 36 38 35 25 25 42 45 30

of ovaries

during

hysterosalpingography

309

data in 29 patients Tubeljilm distance (in.)

Radiation amount (m.R.)

Weight (lb.)

32 29 30 33 35 33 33 32 33 34% 33% 32% 30% 33 31 29 28 32 31 31 31 29 29% 30% 34 33% 33 33 35%

290 333 410 70 85 75 115 150 400 510 400 330 320 400 118 400 100 550 380 480 125 210 225 160 100 200 270 113 200

126 170 160 127 154 139 143 174 112 192 225 140 130 129 120 92 130 104 120 160 120 110 138 142 110 188 100 300 209

constant at 100. Fig. 2 is a hysterosalpingogram with the dosimeter in place. A No. 10 Foley catheter is in the uterine cavity. Fig. 3 is a hysterosalpingograph with two dosimeters in the vaginal canal. A second dosimeter with a finer scale was used to determine the accuracy of the original device.

Results Table I details the information noted for each patient. The total number of patients was 29; 26 were poststerilization procedures and three were indicated for diagnostic purposes. It will be noted that the weight of the patient was not related to the amount of radiation exposure. Radiation dosage increased with the number of Iluoroscopic views taken as well as the duration of fluoroscopic exposure. The tube/film distance remained as constant as possible. The radiation exposure of the gonads was identical for diagnostic and poststerilization hysterosalpingography. Table II summarizes the data derived from this study.

Comment Cooper radiation

exposure

and associates,i6r i’ measuring the amount delivered to the gonads by placing

of an

Exposures 2 2 3 2 2 2 2 2 3 3 3 3 3 3 2 2 1 2 2 2 t: 2 2 2 2 2 2 3

Fluoroscopic uiew 5 3 7 2 2 2 3 3 3 10 5 6 6 4 3 4 5 6 4 3 3 3 3 3 2 3 4 4 4

Indication Post tubal Post tubal Post tubal Post tubal Post tubal Post tubal Post tubal Post tubal Post tubal Post tubal Post tubal Post tubal Post tubal Post tubal Post tubal Post tubal Post tubal Post tubal Post tubal Post tubal Post tubal Post tubal Post tubal Post tubal Post tubal Post tubal Diagnostic Diagnostic Diagnostic

coagulation coagulation coagulation coagulation coagulation coagulation coagulation coagulation coagulation coagulation coagulation coagulation coagulation coagulation coagulation coagulation coagulation coagulation coagulation coagulation coagulation coagulation coagulation coagulation coagulation coagulation

ionizing chamber in a female cadaver close to the ovaries during HSG, found a mean value of 322 mrad. Martin’* found a value of 2,500 mrad. measured from the level of the skin. Berman and Sonnenblicklg used an intravaginal instrument to measure the radiation dose delivered to the gonads and found it to be 3.22 rads for six films. All the above series were carried out without the use of fluoroscopy. Figures as high as 27 roentgens for HSG are also reported.ls* *O Shirley,14 measuring the gonadal dosage with two plane film techniques, reported 130 mrad. With his careful use of fluoroscopy, the dosage was 1,000 to 1,500 mrad; Parekh and co-workers” found it to be 525 mrad. with three exposures, with fluoroscopy, 23 1.5 and 365.7 mrad., respectively. Thus, there is little difference between our findings and those of Parekh and Arronett, perhaps because the Foley catheter technique was used in both series. DeVeechi” has shown that during roentgen cinematography the ovaries receive about 2 rads per minute. Schwartz’ has shown that different diagnostic x-ray machines may deliver 60 to 200 rads per minute; with cobalt treatment the dose is of the order of 10 to 50 rads per minute and with radium it is approximately 0.1 to 0.2 rads per minute. Schwartz further measured the

310

Sheikh

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Table

II. Summary

Maximum

Maximum:

Radiation (m.R.)

Radiation 550

Minimum:

of radiation

data

Fluoroscopic view

10

Fluorosco#~ic timp

6.5

Radiation 70

2

20

Average radiation with two exposures and fluoroscopy, 231.5 m.R. Average radiation with three exposures and fluoroscopy, 365.7 m.R. Average fluoroscopy time, 39.1 sec. Average tube/film distance, 31.9 in. Average fluoroscopic views, 4 (approximately). Mean radiation for diagnostic HSG, 194 m.R.

with two dosimeters in the

before the decision is made to undertake a procedure on a fertile patient. We feel that the current study confirms that (1) radiation exposure during hysterosalpingography can be decreased while retaining the efficacy of the procedure, and (2) hysterosalpingography can be simplified by the use of a Foley catheter technique. Radiologic procedures involving gonad exposure, when indicated, should be done in the proliferative phase of the menstrual cycle, and radiologic exposure should be kept to a minimum.

radiation given to the ovaries during such routine diagnostic procedures as intravenous pyelography, barium enema, and gastrointestinal series, at a total of 11 rads, higher than the maximum of 5 rads recommended radiation by the International Commission on Radiation Protection.3 These figures represent quite high radiation exposures, and should be kept in mind

We wish to thank Douglas M. Haynes. M.D., Professor of Obstetrics and Gynecology, and Curtis P. Sigdestad, M.D., Chief of Radiation Biology, for their critical review of the paper. We are indebted to John T. Queenan, M.D., Professor and Chairman, Department of Obstetrics and Gynecology, University of Louisville, for his encouragement in this project, Our appreciation to Mr. Ahren Jacobson, Radiation Physicist, for his technical advice and to the X-ray Department personnel for their cooperation in carrying out this study.

Fig. 3. Hysterosalpingography vaginal cavity.

REFERENCES

1. Rugh, R.: J. Obstet. Gynecol. Br. Commonw. 62: 461, 1955. 2. Israel, S. L.: AM. J. OBSTET. GYNECOL. 64: 971, 1952. 3. Kaplan, I.: J. Obstet. Gynecol. Br. Commonw. 60: 872, 1953. 4. Rubin, I. C.: AM. J. OBSTET. GYNECOL. 59: 259, 1950. 5. Muller, H. J.: AM. J. OBSTET. GYNECOL. 67: 463, 1954. 6. Schwartz, S. G.: Bull. N. Y. Acad. Med. 44: 388, 1968. 7. MacMahon, B.: J. Natl. Cancer Inst. 28: 1173, 1962. 8. Stewart, A.: Lancet 1: 751, 1971. 9. Aaro, L. A., and Stewart, J. R.: AM. J. OBSTET. GYNECOL. 105: 1124, 1972. 10. DeVeechi, A.: Electra. Med. 41: 29, 1973. 11. Parekh, M. C., Mahendar, C., and Arronett, G. H.: Clin. Obstet. Gynecol. 15: 1, 1972.

12. Ansari, A. H., and Arronett, G. H.: Fertil. Steril. 17: 442, 1966. 13. Parekh, M. C., Murthy, Y. S., and Arronett, G. H.: Obstet. Gynecol. 36: 940, 1970. 14. Shirley, R. L.: Fertii. Steril. 22: 83, 1971. 15. Jacobson, A.: Health Physics Press 25: 76, 1973. 16. Cooper, G., and Cooper, J. B.: Clin. Obstet. Gynecol. 9: 11, 1966. 17. Cooper, G., and William, K.: J. A. M. A. 177: 766, 1959. 18. Martin, J. M.: Med. J. Aust. 2: 806, 1955. 19. Berman, R., and Sonnenblick, B. P.: AM. J. OBSTET. GYNECOL. 74: 1, 1957. 20. Standford, R. W., and Vance, J.: Br. J. Radiol. 28: 266, 1955.