Observer variability in the diagnosis and management of the hysterosalpingogram

Objective: To determine the reproducibility of hysterosalpingogram (HSG) inter Design: Fifty HSG films were distributed to five fertility practitioners with a mean of 20 years clinical experience. Each observer evaluated components of uterine and tubal status and provided clinical recommendations for hysteroscopy and laparoscopy. Setting: University hospital-affiliated reproductive endocrine practice. Intervention(s): None Main Outcome Measure(s): The level of agreement among observers for each uterine and tubal category as determined by the kappa (kappa) statistic. Determinants of clinical recommendation for further diagnostic studies were assessed. Result(s): The level of agreement between observers as determined by kappa ranged from 0.645 in the hydrosalpinx category, indicating fair reliability, to 0.111 for pelvic adhesions, indicating poor reliability. The composite kappa for uterine status was 0.345 whereas the composite kappa for tubal status was 0.430. Agreement among observers concerning management showed marginal reproducibility with a kappa of 0.261. Overall, more than one abnormality of either the cavity or the fallopian tubes led to a diagnostic recommendation for further workup in greater than or equal to 90% of cases. Conclusion(s): In a group of five experienced clinicians, there was considerable variability in the interpretation as well as the clinical management of the HSG. Physicians caring for infertile couples should be aware of this discrepancy and should, if possible, review carefully both the original films as well as the report of the attending radiologist in formulating their diagnostic evaluation and management plan.