[Hysterosalpingosonography by the vaginal route--a new method for assessing uterine tube patency]

BUT: Introducing a new sonographic method for evaluation the patency of fallopian tubes.

MATERIAL AND METHODS

Transvaginal hysterosalpingosonography (HSSG), using chlorocid as a contrast material was performed in 52 infertile women, 12 of with after ectopic pregnancy.

RESULTS

Transvaginal hysterosalpingosonography showed as patent 24 fallopian tubes and 68 obturated. LSC and/or HSG pointed 30 patent and 62 obturated. Compared to LSC and HSG, transvaginal HSSG showed 100% sensitivity and 88% specificity.

CONCLUSIONS

This investigation revealed the good diagnostic value of HSSG with chlorocid as an easy and not expensive method for the evaluation of the patency of fallopian tubes.

Transvaginal hysterosalpingo-contrast sonography (HyCoSy) compared with chromolaparoscopy

OBJECTIVE

To compare the efficacy and safety of HyCoSy with chromolaparoscopy for the diagnosis of tubal occlusion and uterine abnormalities.

METHODS

Sixty infertile women in whom the cause of infertility was thought to be tubal occlusion or uterine abnormalities and who satisfied the inclusion and exclusion criteria as specified in the study protocol were included. HyCoSy was performed during the first half of the menstrual cycle at least 24 hours prior to chromolaparoscopy. The results from both HyCoSy and chromolaparoscopy were compared in assessing tubal occlusion and uterine pathology.

RESULTS

For the evaluation of fallopian tubes, we found corresponding results between HyCoSy and chromolaparoscopy in 80.0%. The agreement between both procedures in assessing the uterine pathology was 80.4%. Twenty-two women experienced adverse events. The most common complaint was pelvic pain. Other events encountered were: nausea (3 women) and vaginal bleeding (2 women). All events were thought to be not related to the study drug.

CONCLUSION

HyCoSy showed good diagnostic performance in the evaluation of the fallopian tubes and uterus in infertile women. The adverse events reported in this study are minor and procedure-related (catheter insertion) rather than the trial substance.

HyCoSy--as good as claimed?

Hysterosalpingo contrast sonography (HyCoSy) has been compared favourably in the literature with hysterosalpingography (HSG). It does not require ionizing radiation and demonstrates the uterus and ovaries. HyCoSy is reported as being a safe, well tolerated, quick and easy investigation of Fallopian tube patency. Over a 1-year period HyCoSy was performed by two operators on 118 consecutive women who were thought likely to have patent Fallopian tubes. The examinations were graded using a local scale to assess discomfort and were correlated with tubal patency. HSG was performed on 116 patients by the same operators and discomfort recorded. 15 patients underwent both examinations. The degree of pain or reaction was graded 0 (no pain) to 4 (maximum) according to a locally devised scale. Costs of the two examinations were estimated. 89 patients examined by HyCoSy were graded 0-2. However, 23 had severe protracted pain and/or vasovagal reactions with bradycardia and hypotension. Of these, seven required resuscitation owing to prolonged symptoms, requiring treatment with atropine. 19 of the 23 had bilaterally patent Fallopian tubes. Where subsequent HSG was performed, tubal occlusion was confirmed in 8 of 15 women. Other pathologies were noted in 29 of the HyCoSy patients and there were six technical failures. During the same period no severe adverse reactions occurred in 116 patients having HSG performed by the same operators. Three of the HSG examinations were technically unsuccessful. Discomfort following HyCoSy was much greater than that reported previously. Possible mechanisms are discussed but it does not appear to be related to tubal occlusion. Diagnostic accuracy, costs and discomfort compare unfavourably with HSG.

Hysterosalpingo contrast sonography as a screening test for tubal patency in infertile women

The most informative method for assessing tubal patency in subfertile women is laparoscopy-and-dye. This investigation, however, puts a large burden on services and a screening test is needed that identifies a high likelihood of occlusion. In our infertility programme we introduced hysterosalpingo contrast sonography for this purpose, operated entirely by ultrasonographers. A series of audits indicated that this innovation speeded the process of investigation by several weeks and reduced the number of laparoscopy-and-dye procedures by 75%. The negative predictive value was 89% and the positive predictive value was 44%. The main limitation of the method was the long period required for training, in those without extensive experience of vaginal ultrasonography.

[Intact unilateral twin pregnancy--sonographic diagnosis and laparoscopic treatment]

Ectopic twin pregnancy is rare. Most frequently it occurs as a heterotopic pregnancy located simultaneously in the the fallopian tube and in the uterus. An unusual case of an intact unilateral ectopic twin pregnancy in the 7th week of gestation was diagnosed at this early stage by TVS (transvaginal ultrasound). The patient was successfully treated by laparoscopic salpingectomy. A review of the current literature is discussed.

Screening sonohysterography in infertility

This prospective comparative study was carried out to assess the value of sonohysterography (SHG) in evaluating both the endometrial cavity and tubal patency in infertile patients and to compare its results with hysterosalpingography (HSG), diagnostic hysteroscopy and laparoscopic chromopertubation. It comprised 84 infertile women who were examined using SHG the day before combined diagnostic laparoscopy and hysteroscopy. Eighty-three patients had had HSG within 6 months. As regards the appearance of the endometrial cavity, the results of SHG agreed with hysteroscopy in 72.2% (k = 0.31) while HSG agreed with hysteroscopy in 75.6% (k = 0.39) of cases. The appearance of the right and left tubes using SHG agreed with laparoscopy in 72.4% (k = 0.16) and 60.5% (k = 0.13), respectively, while HSG agreed with laparoscopy in 94% (k = 0.52) and 90.4% (k = 0. 51), respectively. However, when the appearance of fluid in DP was considered as an indirect indicator of patency of at least one tube at SHG, the agreement with laparoscopy rised to 88.1% (k = 0.24) and 85.7% (k = 0.18) for both tubes respectively. In conclusion, SHG is similar to HSG as regards the appearance of the endometrial cavity but it is inferior to it for evaluating tubal factor. The implication of SHG in the infertility work-up as a simple and fast procedure can minimize costs and abuses of sophisticated techniques particularly in the developing countries with limited resources.

Virtual endoscopy using perspective volume-rendered three-dimensional sonographic data: technique and clinical applications

OBJECTIVE

We present a technique for obtaining three-dimensional external and virtual endoscopy views of organs using perspective volume-rendered gray-scale and Doppler sonographic data, and we explore potential clinical applications in the carotid artery, the female pelvis, and the bladder.

CONCLUSION

Using the proposed methods, radiologists will find it possible to create virtual endoscopy and external perspective views using sonographic data. The technique works well for revealing the interior of fluid-filled structures and cavities. However, expected improvements in computer performance and integration with existing sonographic equipment will be necessary for the technique to become practical in the clinical environment.

Laparoscopy-assisted intrapelvic sonography with a high-frequency, real-time miniature transducer for assessment of the Fallopian tube: a preliminary report

Our purpose was to visualize normal and abnormal Fallopian tubes using laparoscopy-assisted intrapelvic sonography with a specially developed 20 MHz flexible catheter-based high-resolution, real-time miniature (2.4 mm outer diameter) ultrasound transducer in infertile women. A total of 21 women (20 infertile, one with unilateral hydrosalpinx, and one tubal pregnancy) were studied with pelvic saline effusion under laparoscopy. Fimbriae were clearly depicted with a cockscomb-like form in 95% of patients. All ampullae were visualized, and mucosal layers were clearly distinguished from muscle layers in 70% of patients. Scanty intratubal effusion was noted in 50% of patients, and tubal spastic findings were found in 10% of patients. In all, 60% of isthmuses were detected, and mucosal layers were distinguished from muscle layers in 30%. In the subject with hydrosalpinx, the tubal wall was thinner, and it was not possible to distinguish between muscle and mucosal layers. In the subject with a tubal pregnancy, the amniotic membrane and decidua were depicted more clearly than by transvaginal sonography. In conclusion, laparoscopy-assisted intrapelvic sonography with a high-frequency, real-time miniature transducer may be useful in the assessment of tubal texture and function in tubal disorders, possibly in infertility practice.

Heterotopic pregnancy: discovery of ectopic pregnancy after elective abortion

We report a case of combined intrauterine and tubal pregnancy in a 23-year-old woman. The patient came to the emergency department complaining of lower abdominal pain after having had an elective abortion 2 weeks earlier. Her physician had done pelvic ultrasonography, noting an intrauterine pregnancy before the abortion. Our working diagnosis in the emergency department was retained products of conception versus postabortion endometritis. Pelvic ultrasonography in the emergency department revealed an ectopic pregnancy without evidence of retained products of conception, and the patient had a right salpingotomy with removal of the ectopic fetus without complications.

A case report: rare case of primary transitional cell carcinoma of the fallopian tube

Carcinomas other than adenocarcinomas are extremely rare in the fallopian tube. A 42-year-old woman with watery, intermittent vaginal discharge was found to have a left adnexal tumor. This case was diagnosed as primary carcinoma of the fallopian tube, FIGO Stage Ia. She underwent a total abdominal hysterectomy, a bilateral salpingo-oophorectomy, a pelvic and periaortic lymphoadenectomy, and an omentectomy, followed by cisplatin-based chemotherapy. Four years after the initial diagnosis of the disease, she remains in a disease-free state. Histologically, the tumor revealed a primary transitional cell carcinoma of the left fallopian tube. The findings on an immunohistochemical test for an epithelial membrane antigen, the CA125 antigen, were positive, whereas findings on a test for CEA were negative. We report a case of a malignant neoplasm of the fallopian tube with histological features of transitional cell carcinoma that arose from the tubal epithelium.

Arteriovenous malformation of mesosalpinx associated with a 'vanishing' ectopic pregnancy: diagnosis with three-dimensional color power angiography

We describe two cases of pelvic arteriovenous malformation diagnosed with the aid of three-dimensional color power angiography. In both cases, beta-human chorionic gonadotropin (beta-hCG) increased to significant levels (8413 and 1560 mIU/ml, respectively); however, neither an intrauterine nor an adnexal gestational sac could be found. In each case, we observed an adnexal mass with several tortuous areas exhibiting abundant turbulent flow. The diagnosis of arteriovenous malformation was made and further assessment by three-dimensional color power angiography and magnetic resonance imaging (MRI) was carried out. The complex vascular anatomy of arteriovenous malformation, including its feeding vessels and drainage, was clearly depicted by three-dimensional color power angiography and correlated well with magnetic resonance angiography. Levels of beta-hCG decreased in subsequent tests, and eventually became negative 2-3 months later without and intervention. We believe that an involutional ectopic pregnancy induced the rapid growth of the arteriovenous malformations within the mesosalpinx. Three-dimensional color power angiography can be performed quickly and easily, using existing ultrasound equipment. It improves our understanding of complicated vasculature, and thus is a useful adjunct to two-dimensional and color Doppler ultrasound in the diagnosis of arteriovenous malformation.

Methylene blue dyeing of cellular nuclei during salpingoscopy, a new in-vivo method to evaluate vitality of tubal epithelium

The Fallopian tube can be damaged by different noxious substances that may change cellular ultrastructure and function. Alteration of the cell membrane allows the passage of certain aniline dyes, which can stain the nucleus. A total of 310 Fallopian tubes from 163 patients who underwent a surgical or diagnostic laparoscopy during fertility studies was analysed by salpingoscopy. Cellular nuclei were stained by injection of 20 ml of a 10% solution of methylene blue in saline solution (NaCl 10%) through the cervical cannula prior to salpingoscopy. Evaluation of nuclear staining with methylene blue, adhesions, vascular alterations, and the flattening of folds in relation to pregnancy outcome was undertaken. Quantification of salpingoscopic findings was carried out according to a score. Flattening of folds and vascular alterations showed no difference in the pregnant and non-pregnant groups. On the other hand, adhesions and nuclear dyeing were significantly greater in the non-pregnant group (adhesions 13.6 versus 26.8%, P < 0.004, and nuclear dyeing: 25 versus 41.7%, P < 0.009, pregnant versus non-pregnant). Methylene blue dye is a new tool to evaluate in vivo cyto-histological tubal damage, and is a useful and simple method to provide a prognosis of salpingean function.

Hysterosalpingo contrast sonography (HyCoSy) with SH U 454 (Echovist) for the assessment of tubal patency

A total of 88 Fallopian tubes from 44 patients was examined with hysterosalpingo contrast sonography (HyCoSy), hysterosalpingogram (HSG), and laparoscopic chromopertubation (LC) in order to assess their relative accuracy for measuring tubal patency. HyCoSy was done by transvaginal ultrasound and the contrast was SH U 454 (Echovist). The flow of multiple fractions of the contrast medium through each Fallopian tube was observed in real time in appropriate imaging planes by means of a transvaginal probe. Compared with laparoscopic results, we found a sensitivity of 85.2%, a specificity of 85.2%, a positive predictive value (PPV) of 71.9%, a negative predictive value (NPV) of 92.9% and concordance (HyCoSy/LC) of 85.2%, while the corresponding values for HSG were sensitivity = 85.2%, specificity = 83.6%, PPV = 69.7%, NPV = 92.7% and concordance (HSG/LC) of 84.1%. Compared with HSG results, HyCoSy obtained a co-positivity of 66.7%, a co-negativity of 81.8% and a concordance of 76.1%. In conclusion, HyCoSy with SH U 454 proved to be a reliable and safe modality for evaluating tubal patency; it is suitable as an outpatient diagnostic procedure to be used before more invasive procedures.

Vaginal sonosalpingography in the evaluation of tubal patency

BACKGROUND

During the past few years, sonosalpingography has been suggested as the first-line method to study tubal patency. This study was launched in order to study the applicability of this method at our institution.

METHODS

Thirty-two patients suffering from primary or secondary infertility were evaluated for tubal patency with sonosalpingography using a pediatric Foley urinary catheter and a combination of air and saline solution as a contrast medium. The uterine tubes were evaluated separately and the results were compared to the findings at laparoscopy and chromotubation performed independently. Four patients conceived before their scheduled laparoscopy and were excluded from the study. In addition, the patency of three Fallopian tubes could not be adequately evaluated, leaving altogether 53 uterine tubes that were evaluated by both methods.

RESULTS

The findings of both methods agreed in 47 out of 53 tubes (concordance, 88.7%). The sensitivity of sonosalpingography in diagnosing tubal patency was 90.2% and the specificity 83.3%. The positive predictive value for tubal patency by sonosalpingography was 94.9% and the negative predictive value 71.4%. Adverse events of sonosalpingography included moderate to severe abdominal pain in three patients, one vasovagal reaction, and one case of shoulder pain. No infectious complications were recorded.

CONCLUSIONS

The results confirm that sonosalpingography utilizing air and saline as a contrast medium is a reliable, simple and well-tolerated method to assess tubal patency in an outpatient setting. In addition, the procedure can be performed without prophylactic antibiotics using a regular pediatric Foley urinary catheter instead of an expensive hysterosalpingography catheter.

Assessing tubal patency with transvaginal salpingosonography after the reversal of tubal ligation for female sterilization

The objective of this study was to assess tubal patency using transvaginal salpingosonography (TSSG) among women treated by tubal ligation after sterilization and to compare these results with those obtained using X-ray hysterosalpingography (HSG). Twenty-one healthy women were recruited. Air was used as a contrast medium in TSSG and Omnipaque as a water-soluble contrast medium in the HSG examination. All women underwent at least one TSSG. If the woman did not become pregnant during the follow-up or had a miscarriage or tubal pregnancy, she was re-examined with a second TSSG and the results were compared with those of HSG undertaken during the same menstrual cycle. Because of the high pregnancy rate the final number of patients was reduced to 10. The observed agreement between the two TSSGs was 70%, which was low compared with our earlier results. The kappa coefficient was only 0.41. The sensitivity of TSSG for the detection of tubal occlusion was 54%. This can be explained by the fact that the mean time interval between the two TSSGs was long (5.5 months) and results were not therefore comparable or repeatable. We can conclude that the women with patent tubes became pregnant after the first TSSG while the women taking part in the second TSSG had impaired tubal function. There were more occluded tubes observed in the second TSSG than in the first. An analysis comparing the second TSSG with HSG produced better results. The observed agreement was 84%, kappa coefficient 0.67, demonstrating a good reproducibility of TSSG; the sensitivity of TSSG for the detection of tubal occlusion was 83%, specificity 85%, positive predictive value 91% and negative predictive value 75%. Thus, TSSG should be regarded as a reliable, rapid, safe and inexpensive method for testing tubal patency after reversal of tubal ligation for sterilization. It also allows simultaneous scanning of the uterine corpus, endometrium and ovaries and may have a clearing action on occluded tubes. TSSG can thus replace X-ray HSG in the primary evaluation of tubal status, even in this special group of patients.

Sperm transport in the human female genital tract and its modulation by oxytocin as assessed by hysterosalpingoscintigraphy, hysterotonography, electrohysterography and Doppler sonography

The transport function of the uterus and oviducts and its modulation by oxytocin has been examined using hysterosalpingoscintigraphy, recording of intrauterine pressure, electrohysterography and Doppler sonography of the Fallopian tubes. After application to the posterior vaginal fornix, a rapid (within minutes) uptake of the labelled particles into the uterus was observed during the follicular and during the luteal phase of the cycle in all patients. Transport into the oviducts, however, could only be demonstrated during the follicular phase. Transport was directed predominantly into the tube ipsilateral to the ovary bearing the dominant follicle; the contralateral oviduct appeared to be functionally closed. The proportion of patients exhibiting ipsilateral transport did increase concomitant with the increase of the diameter of the dominant follicle. That ipsilateral transport has biological significance is suggested by the observation that the pregnancy rate following spontaneous intercourse or insemination was significantly higher in those women in whom ipsilateral transport could be demonstrated than in those who failed to exhibit lateralization. Oxytocin administration was followed by a dramatic increase in the amount of material transported to the ipsilateral tube, as demonstrated by radionuclide imaging and by Doppler sonography following instillation of ultrasound contrast medium. Continuous recording of intrauterine pressure before and after oxytocin administration did show an increase in basal tonus and amplitude of contractions and a reversal of the pressure gradient from a fundo-cervical to a cervico-fundal direction. These actions of oxytocin were accompanied by an increase in amplitude of potentials recorded by electrohysterography. These data support the view that uterus and Fallopian tubes represent a functional unit that is acting as a peristaltic pump and that the increasing activity of this pump during the follicular phase of the menstrual cycle is reflected by an increased transport into the oviduct ipsilateral to the ovary bearing the dominant follicle. In addition, they strongly suggest a critical role of oxytocin in this process. Failure of this mechanism appears to be a cause of subfertility or infertility, as indicated by the low pregnancy rate following intrauterine insemination or normal intercourse in the presence of patent Fallopian tubes. It may be regarded as a new nosological entity for which we propose the term tubal transport disorder (TTD). Since pregnancy rate of such patients is normal when treated with in-vitro fertilization (IVF), hysterosalpingoscintigraphy seems to be useful for the choice of treatment modalities in patients with patent Fallopian tubes suffering from infertility.

Torsion of the fallopian tube: progression of sonographic features

Isolated torsion of the fallopian tube is a rare gynecologic condition that is difficult to diagnose preoperatively. We present the sonographic and CT findings over a 48-hour period in a case of isolated torsion of the fallopian tube. The radiologic features of isolated torsion have been described previously; however, to our knowledge, the progressive findings have not been previously reported.

Transvaginal sonographic markers of tubal inflammatory disease

OBJECTIVES

Since the introduction of transvaginal sonography (TVS), clear pictures of the female reproductive tract have been obtained. These images enable the accurate description of Fallopian tube pathology. However, the current literature on the ultrasound diagnosis of pelvic inflammatory disease (PID) is confusing and contradictory. The goal of our study was to identify sonographic markers of inflammatory disease of the pelvis and to place these in a clinical context.

PATIENTS AND METHODS

Seventy-seven patients were scanned by TVS. They were divided into two groups, according to their clinical picture, the first group with acute PID and the second with a history of chronic PID or no history at all. The sonographic markers studied were shape, wall structure and wall thickness of the Fallopian tube. Ovarian involvement and the presence of pelvic fluid were also evaluated.

RESULTS

The best marker of tubal inflammatory disease, either acute or chronic, was the presence of an incomplete septum of the tubal wall, which was present in 92% of the total cases. A thick wall and the 'cogwheel' sign were sensitive markers of acute disease, whereas a thin wall and 'beads-on-a-string' sign were indicators of chronic disease. Palpable findings and surgical history were not discriminatory, but were present in three-quarters and one-third of the study population, respectively. Three false-positive cases are presented: an ovarian cystadenoma, an appendiceal mucocele and one case with periovarian fluid accumulation.

CONCLUSIONS

The tubo-ovarian complex and the tubo-ovarian abscess should be considered separate entities that differ in their clinical implications. TVS allows one to distinguish between them. Distinguishing characteristics of acute and chronic salpingitis are presented.

Intraluminal ultrasound imaging of the fallopian tube wall: results of standardized in vitro investigations of pig and human tubal specimens

OBJECTIVE

To investigate to what extent anatomic structures of the tubal wall can be identified reproducibly and whether altered areas can be detected and delimited by intraluminal ultrasound.

DESIGN

Standardized in vitro experiment with descriptive evaluation of findings, comparative analysis of apparative and morphologic data, and determination of interobserver variability (video documentation, blinded reviewer).

SETTING

Department of Gynecology and Obstetrics, University of Heidelberg, Germany. SPECIMEN(S): Seventy-two human and pig fallopian tubes.

INTERVENTION(S)

Catheterization with a 2.9F or 3.2F ultrasound catheter and sonographic depiction of the fallopian tube, with either simultaneous manual and sonographic wall-thickness measurement or coagulation of the tubal wall.

MAIN OUTCOME MEASURE(S)

A correlation coefficient of r = 0.76 for manual and sonographic tubal wall measurements and K = 0.88 (with 95% confidence interval of 0.74-1.0) for interobserver variability in recognizing coagulated areas.

RESULT(S)

Tubal wall anatomy and artificially altered (coagulated) areas were displayed reproducibly with intraluminal ultrasound, thus giving a characteristic, recognizable pattern of the tubal wall.

CONCLUSION(S)

These in vitro experiments provide evidence that intraluminal ultrasound may expand the current diagnostic possibilities in cases of tubal pathology, providing nonsurgical access to the tubal wall.

Two- and three-dimensional high-resolution imaging of the human oviduct with optical coherence tomography

OBJECTIVE

To evaluate the feasibility of optical coherence tomography, a new method of micron-scale imaging, for high-resolution assessment of the oviduct. Optical coherence tomography is analogous to ultrasound except that it measures the backreflection of infrared light rather than acoustical waves.

DESIGN

The ampulla of a human fallopian tube was imaged in vitro using optical coherence tomography. Images were generated in 2 and 3 dimensions.

SETTING

University.

PATIENT(S)

Samples were obtained from women who had undergone hysterectomy for leiomyomatosis.

INTERVENTION(S)

None

MAIN OUTCOME MEASURE(S)

The ability to perform imaging on a micron scale, which is a level of resolution higher than that of any currently available clinical technology.

RESULT(S)

Two- and three-dimensional data sets of the reflectance of a human fallopian tube were acquired. A volume of 5 x 5 x 2.5 mm (length x width x depth) was scanned. The axial resolution was 11 microm, and the lateral resolution at the focus was 20 microm. The data sets showed detailed structures of the fallopian tube.

CONCLUSION(S)

Our ability to obtain micron-scale two- and three-dimensional images of an in vitro oviduct suggests that it may be possible to identify and surgically treat tubal causes of infertility.

Transvaginal hysterosalpingo-contrast sonography (HyCoSy) compared with chromolaparoscopy: a preliminary report

Fifteen infertile women who required tubal passage evaluation by chromolaparoscopy were recruited. Those who had lower genital tract infection or abnormal uterine bleeding were excluded from the study. Transvaginal HyCoSy was performed during the first half of the menstrual cycle at least 24 hours prior to chromolaparoscopy. The results from both transvaginal HyCoSy and chromolaparoscopy were compared in assessing tubal patency and uterine pathology. A high correlation was noted regarding uterine examination using transvaginal HyCoSy compared with chromolaparoscopy (sensitivity, specificity, PPV and NPV were 91.7%, 33.3%, 84.6% and 50%, respectively). The correlation of the outcome between the two procedures in assessing tubal patency, when combining both tubes, was also high (sensitivity, specificity, PPV and NPV were 100%, 55.6%, 80% and 100%, respectively). The most common adverse event was only mild pelvic pain which did not necessitate any treatment. These preliminary results reveal the potential value of transvaginal HyCoSy as an alternative in infertility investigations. It seems to be as effective but less invasive than conventional chromolaparoscopy. The adverse events reported in this study relate more to the procedure (catheter insertion) rather than the trial substance.

Heterotopic triplet pregnancy. Report of a case with successful twin intrauterine gestation

BACKGROUND

Reports of coexisting multiple intrauterine pregnancies and ectopic pregnancy are extremely rare. We present one case with early sonographic diagnosis of heterotopic pregnancy, successful laparoscopic treatment and a subsequent normal pregnancy course and outcome of the intrauterine twin gestation.

CASE

A 29-year-old woman, gravida 1, para 0, presented for her first prenatal visit at 5 weeks of gestation with pelvic pain. She had conceived with 75 IU leutinizing hormone and follicle-stimulating hormone and homologous intrauterine insemination. The sonogram confirmed a dichorionic twin intrauterine pregnancy and left tubal pregnancy at 7 weeks of gestation. The patient underwent a laparoscopic left salpingostomy and removal of the ectopic pregnancy. Level II sonogram showed a grossly unremarkable twin gestation at 20 weeks. Labor was induced at 37 weeks of gestation due to mild preeclampsia and underwent vaginal delivery without difficulties. The first twin was a girl, weighing 2,722 g, with Apgar scores of 9/9. The second twin, a boy, was delivered 10 minutes later, weighing 2,863 g, with Apgar scores of 9/9.

CONCLUSION

Early sonography is essential for the diagnosis of heterotopic pregnancy, and timely surgical intervention can save the intrauterine twin gestation, with a subsequent normal pregnancy course and outcome.

Radionuclide hysterosalpingography is not predictive in the diagnosis of infertility

OBJECTIVE

To investigate whether radionuclide hysterosalpingography (radionuclide HSG), which has been suggested as a more functional approach to the diagnosis of tubal infertility than conventional patency tests, is predictive in the diagnosis of infertility.

DESIGN

A retrospective analysis of data from an inquiry form containing questions about pregnancy outcome after radionuclide HSG.

SETTING

University hospital-based, tertiary care infertility clinic.

PATIENT(S)

Two hundred sixteen women had an infertility work-up including radionuclide HSG performed between April 1986 and April 1993. Forty-one (18.9%) women were excluded from the study; 9 had moved to unknown addresses, 16 did not answer the inquiry, and 16 gave answers that were not interpretable. There were 175 (81.1%) women in the final study group.

INTERVENTION(S)

An inquiry form containing questions regarding pregnancy was sent to 207 women who undergone radionuclide HSG as a routine procedure in their infertility workup.

MAIN OUTCOME MEASURE(S)

Occurrence of pregnancy related to outcome of radionuclide HSG and its test properties calculated.

RESULT(S)

Bilateral or unilateral tubal transport was demonstrated by radionuclide HSG in 129 women, of whom 66 (51%) later became pregnant. Of the pregnant women, 36 (55%) had successful infertility treatment, whereas 30 (45%) reported spontaneous pregnancy. Forty-six women showed no transport at radionuclide HSG. Twenty-five (54%) of these women became pregnant, 14 (56%) with infertility treatment and 11 (44%) without infertility treatment. The predictive values of transport and no transport radionuclide HSG were 0.51 and 0.46, respectively. The sensitivity of radionuclide HSG was 0.25, and the sensitivity was 0.73. Likelihood ratios for pregnancy when radionuclide HSG showed transport and no transport were 1.03 and 0.93, respectively.

CONCLUSION(S)

Our data strongly indicate that a single radionuclide HSG investigation is not able to predict fertility potential.