Sonohysterography of the uterine cavity: preliminary investigations

Conservative surgical treatment of post-partum hemorrhage: Should we reconsider compression penetrating sutures?

OBJECTIVES

Evaluate the prevalence of uterine synechia after total uterine ligation (TUL) in comparison to TUL associated with compression-penetrating-sutures (CPS) in the conservative surgical management of severe postpartum hemorrhage (PPH).

METHODS

Prospective observational study of pregnant women that underwent conservative surgical management for PPH in a single French tertiary referral center. We compared the risk of uterine synechia with TUL, in comparison to performing TUL in addition to CPS. The synechia rate was calculated after uterine cavity assessment by 3D hysterosonography. Hysterectomies, women with placenta accreta spectrum and patients that received additional embolization treatment were excluded.

RESULTS

Over 6 years, 36 pregnant women underwent surgical treatment for PPH in 21,944 deliveries (1.64 per 1000). The median blood loss was 2700 [1570-3000] milliliters. Twenty-eight (77.7%) women underwent TUL, 8/36 (22.2%) underwent TUL in addition to CPS. Thirty-four (94,4%) cavity assessments were performed 2-to-6 months after delivery, since one woman of each group was lost to follow-up. When TUL was performed in addition to CPS, the prevalence of synechia was 42.9% (n = 3/7), versus 3.7% (n = 1/27) in TUL (p = 0.021; RR = 16.88, 95%CI [1.1-1051]). Synechia was absent in 30/34 (88.2%) women.

CONCLUSION

The prevalence of synechia was very low after TUL unlike CPS. Further studies should evaluate TUL in the conservative surgical management of PPH, to confirm the lower prevalence of synechiae in TUL and evaluate its impact on fertility.

Rational Use of TVS/Color and 3D in Evaluating Subfertile Women

Infertility is defined as the failure to conceive a desired pregnancy after 12 months of unprotected intercourse and affects approximately 10% of married couples. With recent technological development and proper use of medically assisted reproduction techniques, one half of these couples will become pregnant.

More than any other new method, ultrasound has made significant improvements in the modern management of female infertility. Transvaginal sonography provides the reproductive endocrinologists with a tool that cannot only evaluate normal and stimulated cycles but also assist in follicle aspiration and subsequent transfer of the embryo. The addition of color Doppler capabilities to transvaginal probes permits visualization of small intraovarian and endometrial vessels, allowing depiction of normal and abnormal physiologic changes in the ovary and uterus. This article reviews on the assessment of ovarian, uterine and tubal causes of infertility and on the current and future role of color Doppler and three-dimensional ultrasound in the field of reproductive endocrinology.

Comparison of diagnostic accuracy of saline infusion sonohysterography, transvaginal sonography and hysteroscopy in postmenopausal bleeding

OBJECTIVE

To compare the diagnostic accuracy of transvaginal sonography (TVS), saline infusion sonohysterography (SIS) and hysteroscopy (HS) with respect to pathological diagnosis in the detection of uterine cavity abnormalities associated with abnormal uterine bleeding among postmenopausal women.

METHODS

Being a prospective, investigator-blind trial, the present study was conducted on 137 postmenopausal women, with abnormal uterine bleeding, admitted to the Department of Obstetrics and Gynecology of Istanbul Bilim University, Florence Nightingale Hospital and Fertigyn Woman Health and IVF Center. After TVS, all patients underwent SIS using Cook Soft 500 IVF transfer catheter and HS, consecutively. Sensitivity, specificity, and positive and negative predictive values (PPV and NPV) were calculated to compare the diagnostic accuracy of TVS, SIS and HS.

RESULTS

Most commonly encountered endometrial lesions were polypoid lesion (38.0%) and hyperplasia (28.4%) among our study population consisting of 137 women (mean age 61.6 ± 9.6 years) in their postmenopausal stage. Overall sensitivity rates were 70.0% for TVS, 89.6% for SIS and 92.3% for HS, while the overall specificity rates were 50.0, 77.3 and 80.7%, respectively. HS had PPV of 96.2% and NPV of 65.3%, whereas PPV was determined to be 80.9 versus 95.3% and NPV was 35.4 versus 58.3% for TVS and SIS, respectively.

CONCLUSIONS

As an easy to perform, safe and well-tolerated procedure yielding high diagnostic accuracy, saline infusion SIS via this catheter seems to be superior to TVS and very close to HS. It may be used as the primary method for the detection of uterine abnormalities among postmenopausal women with abnormal uterine bleeding.

Diagnostic value of sonohysterography in the determination of fallopian tube patency as an initial step of routine infertility assessment

OBJECTIVES

Infertility is defined as the failure to conceive after 1 year of regular unprotected intercourse. It affects 10% to 15% of couples. Sonohysterography (SHG) is an accurate method for the assessment of fallopian tube patency, reflected in its high positive predictive value compared with hysterosalpingography (HSG) and laparoscopy with chromopertubation. In this study, our goal was to determine the diagnostic value of SHG for the diagnosis of bilateral tubal obstruction by comparison of SHG with HSG and laparoscopic results.

METHODS

This study was based on the evaluation of tubal patency by SHG and by the combination of HSG and laparoscopy in 40 patients. All patients underwent HSG as a routine infertility workup, and all patients with bilateral proximal tubal obstruction diagnosed by HSG subsequently underwent SHG.

RESULTS

Among 1024 infertile women referred to an infertility clinic, 117 (11.4%) had a diagnosis of a tubal factor as the cause of their infertility. Forty-two patients with HSG findings of bilateral proximal tubal obstruction were enrolled. Forty patients underwent SHG. In 32 patients (80%), at least 1 fallopian tube was patent, and 8 patients (20%) were reported to have bilateral tubal obstruction. Those 8 patients with SHG evidence of bilateral tubal obstruction underwent laparoscopy. Eventually, 6 of those were laparoscopically confirmed to have bilateral tubal obstruction.

CONCLUSIONS

Sonohysterography is an accurate method for the determination of fallopian tube patency. It is a simple, safe, and well-tolerated technique with a low risk of adverse effects and severe complications.

Management of uterine fibroids in the patient pursuing assisted reproductive technologies

Uterine leiomyomas are present in 30-70% of women of reproductive age. In addition to causing menstrual disorders and pain, uterine fibroids negatively affect fertility and pregnancy outcome for patients pursuing assisted reproduction. The two questions that have to be addressed are: which fibroids should be treated and how should they be treated? Submucosal fibroids are associated with a 70% reduction in delivery rate. Intramural fibroids had a lesser effect and reduced the delivery rate by approximately 30%. By contrast, studies have demonstrated that subserosal fibroids did not negatively impact fertility. Furthermore, both submucosal and intramural fibroids were associated with an increased risk of spontaneous miscarriage. Myomectomy is considered the treatment of choice to alleviate these detrimental effects. Further research is needed before alternative treatments can be recommended.

Transvaginal Ultrasonography and Saline Infusion Sonohysterography for the Detection of Intra-Uterine Lesions in Pre- and Post-Menopausal Women with Abnormal Uterine Bleeding

This prospective study investigated 79 pre- and 25 post-menopausal women with abnormal uterine bleeding who underwent conventional transvaginal ultrasonography (TVS) and saline infusion sonohysterography (SIS) and compared the results with histopathological findings obtained by dilatation and curettage, hysteroscopy or hysterectomy. Histological examination revealed normal endometrial histology in 28 patients, intracavitary polyps in 46 patients, submucosal fibroids in 18 patients, intramural fibroids in six patients and endometrial hyperplasia in six patients. The sensitivity and specificity of TVS in detecting endometrial polyps were 65.2% and 87.9%, respectively, compared with 91.3% and 93.1% for SIS. The sensitivity and specificity of TVS in detecting uterine fibroids were 95.8% and 95.0%, respectively, versus 91.6% and 98.7% for SIS. These results show that SIS is a satisfactory method of identifying lesions and that it is easy and cost-effective, and improves on the diagnostic utility of TVS. SIS is also a less invasive alternative to hysteroscopy, so should result in less morbidity in the evaluation of abnormal uterine bleeding in women.

Tolerability, side effects, and complications of hysterosalpingocontrast sonography (HyCoSy)

OBJECTIVE

To evaluate the tolerability, side effects and complications of hysterosalpingocontrast sonography (HyCoSy).

DESIGN

Prospective study.

SETTING

University hospital.

PATIENT(S)

669 infertile women.

INTERVENTION(S)

All patients were examined with HyCoSy and monitored for 30 minutes after the procedure. A telephone interview was subsequently carried out to record possible late side effects and postprocedural complications.

MAIN OUTCOME MEASURE(S)

Tolerability to the procedure was evaluated by means of an 11-point (0 to 10) numeric rating scale of the pain experienced. Postprocedural fever, pelvic infections, peritonitis, hemorrhage were recorded.

RESULT(S)

Of 660 patients who completed the examination, 483 (73.2%) completed the telephone follow-up after a period of 14.7 +/- 9.9 months from the procedure. The mean patient age was 34.5 +/- 4.3 years, and mean infertility duration was 28.1 +/- 23.2 months. The mean numeric rating scale was 2.7 +/- 2.5, and 10 patients (2.0%) required postprocedural drug treatment for pain relief. Mild vasovagal reactions were experienced in 20 cases (4.1%), and four patients (0.8%) had a severe vasovagal reaction. No late complications were reported. No patients required hospital admission after the procedure.

CONCLUSION(S)

In our series, HyCoSy was a well-tolerated examination with a very low rate of side effects and no late complications that required no atropine or anti-inflammatory drugs. These data support the safety of HyCoSy when performed as described, but further work is needed to estimate the rate of late complications and side effects in other settings.

Endometrial directed biopsy during sonohysterography using the NiGo device: prospective study in women with abnormal uterine bleeding

OBJECTIVE

To determine the accuracy of sonohysterography (SHG), combined with sonography-guided biopsies that are performed by using the NiGo device, in the diagnosis of endometrial pathologies in women with abnormal uterine bleeding (AUB).

DESIGN

Prospective study.

SETTING

Outpatient clinic.

PATIENT(S)

One hundred sixteen women with AUB (55 postmenopausal and 61 premenopausal).

INTERVENTION(S)

Patients underwent transvaginal sonography and SHG; when an endometrial condition needing a biopsy was diagnosed, the biopsy was performed both by using the NiGo device (ASL 1, Imperia, Italy) and by using Pipelle.

MAIN OUTCOME MEASURE(S)

Feasibility of SHG and endometrial biopsy by NiGo.

RESULT(S)

Sonohysterography was successfully performed by using the NiGo device in 87.4% of the cases (92.6% of premenopausal women and 81.5% of postmenopausal women). Seventy-eight (86.7%) women were judged to require endometrial biopsy; the NiGo device allowed obtaining an adequate biopsy for histological evaluation in 74 cases (94.9%). There was no statistically significant difference in efficacy between the NiGo and Pipelle in providing a specimen that was adequate for histological evaluation. Although no significant difference was observed in the histological diagnosis performed on the specimens obtained by the two techniques, NiGo allowed diagnosis of more focal lesions (simple hyperplasia, endometrial polyps, and myomas).

CONCLUSION(S)

The NiGo device allows an adequate biopsy for histological evaluation to be obtained during SHG in an outpatient setting.

A new technique to obtain endometrial directed biopsy during sonohysterography: the NiGo device

The primary goal of the clinical evaluation of abnormal uterine bleeding is to establish a specific diagnosis in the most efficient and least invasive manner possible. Hysteroscopy (HS) allows physicians to obtain directed biopsy in addition to direct visualization of the uterine cavity and lesions, but often requires ambulatory surgery centers and some anesthesia, or can potentially result in significant patient discomfort. Sonohysterography (SHG) is less invasive than HS but does not allow a histologic sample. A new technique, called the Nicoletti-Gorlero (NiGo) device, was developed and evaluated to obtain histologic results during SHG. This study is a prospective, observational evaluation between the NiGo device technique and standard HS to obtain endometrial samples. The NiGo device was used to obtain an endometrial sample during SHG in 18 women. In a subsequent session, HS was performed to verify the results. From January 2005 through November 2005 both procedures (SHG + biopsy and HS) were performed on 18 patients. The SHG procedures using the NiGo forcep were performed successfully on 15 out of 18 women, and the endometrial sample was obtained in 14 out of 15 patients. In one patient, the endometrial biopsy obtained provided too little tissue to accomplish histologic evaluation. All 13 pathologic results obtained with the NiGo device were identical with those subsequently obtained with HS. The office-based HS procedure was not successful in two women; in these women, an HS procedure performed in the operating room was necessary. The NiGo device technique allows the physician to obtain sonographic-guided biopsies of the entire endometrium during SHG. The technique is less invasive compared with HS. In our small series, there were no complications during the procedure.

Sonohysterography is superior to transvaginal sonography for the diagnostic approach of irregular uterine bleeding in women of reproductive age

PURPOSE

To evaluate and compare the accuracy of transvaginal sonography (TVS) and sonohysterography (SHG) in the investigation of women of reproductive age presenting with irregular uterine bleeding (IUB).

METHODS

This prospective study included 104 women presenting with IUB. All patients underwent TVS, SHG, and hysteroscopy, during which endometrial biopsies were obtained and any endometrial mass was treated with hysteroscopic surgery. Statistical analysis was performed by calculating the sensitivity, specificity, and positive and negative predictive values of TVS and SHG in diagnosing endometrial polyp, submucous myoma and all endometrial pathologies (polyp, submucous myoma, endometrial hyperplasia, and endometrial carcinoma) with the histopathological report of the tissues obtained by hysteroscopy serving as the end point for the analysis.

RESULTS

The sensitivity, specificity, and positive and negative predictive values, respectively of TVS were 61.2%, 90.9%, 85.7%, and 72.5% for diagnosing endometrial polyps; 75.0%, 92.0%, 63.1%, and 95.3% for diagnosing submucous myomas; and 75.0%, 80.6%, 87.9%, and 63.0% for diagnosing any kind of pathology. The corresponding diagnostic values of SHG were 83.7%, 96.4%, 95.3%, and 86.9% for polyps; 87.5%, 98.9%, 93.3%, and 97.8% for submucous myomas; and 88.2%, 91.7%, 95.2%, and 80.5% for any kind of pathology.

CONCLUSIONS

SHG showed superior sensitivity, specificity, and positive and negative predictive values compared with TVS in diagnosing intrauterine lesions in women of reproductive age with IUB.

Transvaginal sonohysterographic evaluation of uterine malformations

OBJECTIVE

The aim of this study was to assess the diagnostic value and the usefulness of sonohysterography (SHG) in the detection of uterine anomalies, compared with other diagnostic methods.

STUDY DESIGN

From January 2002 to December 2003, we collected 54 patients with a history of primary or secondary infertility or repeated spontaneous abortion and with a clinically or sonographically suspected abnormal uterus. All patients had previously undergone hysterosalpingography (ISG). All patients were examined by standard transvaginal ultrasound. Sonohysterography was then carried out by the intrauterine injection of an isotonic saline solution. Suspected uterine anomalies were also confirmed by hysteroscopy (HS) and/or laparoscopy.

RESULTS

Sonohysterography was able to detect all the anomalies. The sensitivity and specificity of sonohysterography were the same as for hysteroscopy. However, there was no significant difference between the diagnostic capabilities of the methods analyzed.

CONCLUSIONS

Transvaginal sonohysterography with saline solution is a low-cost, easy, and helpful examination method for uterine malformations. We propose that sonohysterography should be performed for the primary investigation of infertility and repeated miscarriages.

Advantages and disadvantages of hysterosonosalpingography in the assessment of the reproductive status of uterine cavity and fallopian tubes

BACKGROUND

Hysterosonosalpingography as a contrast ultrasound method is safer, cheaper and easier to perform than hysterosalpingography in the assessment of the uterine cavity and fallopian tubes. Is it feasible for all patients? Which is the main problem in the evaluation of target structures by ultrasound?

METHODS

In a prospective study, 68 patients in the initial stage of the infertility treatment were examined by hysterosonosalpingography using saline NaCl infundibile and Echovist as contrast media. Subsequently, further status of the tubes and uterine cavity was assessed by the "gold standards", laparoscopy and hysteroscopy.

RESULTS

Sensitivity and specificity of hysterosonosalpingography using NaCl infundibile for evaluation of the uterine cavity was 100 and 88.8%, respectively. Negative predictive value was 100% and positive predictive value 97%. Sensitivity and specificity of the method for the assessment of the tubal status was 100 and 66%, respectively, negative predictive value was 100% and positive predictive value was 61%. For the assessment of tubal patency using positive contrast Echovist the method has shown 100% sensibility and negative predictive value again but it reached a specificity of 77% and a positive predictive value of 70%. There were no evident complications during or after the procedure.

CONCLUSION

Hysterosonosalpingography is useful in making decisions regarding further procedures for the diagnosis and treatment of infertility. Uterine cavity evaluation using saline is the method of choice. Tubal patency can be assessed only under ideal sonographic conditions. The method is feasible for early assessment of the reproductive status of uterine cavity and fallopian tubes as a simple, safe and cheap outpatient method prior to any following invasive procedure or even histerosalpingography.

Saline contrast hysterosonography in abnormal uterine bleeding: a systematic review and meta-analysis

OBJECTIVE

To assess the diagnostic accuracy of saline contrast hysterosonography in the evaluation of the uterine cavity in women complaining of abnormal uterine bleeding.

DESIGN

A systematic review and meta-analysis of diagnostic studies that compared saline contrast hysterosonography to a gold standard diagnosis based on either hysteroscopy with or without histological sampling or to hysterectomy.

SETTING

University Hospital.

SAMPLE

Twenty-four studies (including 2278 procedures).

METHODS

Electronic databases were searched for relevant studies and references were cross checked. Validity was assessed and data were extracted independently by two authors. Heterogeneity was calculated, studies were plotted in an ROC area and data were pooled. Subgroup analysis was performed according to the validity area.

MAIN OUTCOME MEASURES

The success rate of saline contrast hysterosonography. The pooled sensitivity, specificity, likelihood ratio's and post-test probabilities of saline contrast hysterosonography on the prediction of uterine cavity abnormality.

RESULTS

The largest population of homogeneous data were the studies with complete verification. In these studies, the pooled sensitivity and pooled specificity of saline contrast hysterosonography in uterine cavity evaluation were respectively 0.95 (95% CI 0.93 to 0.97) and 0.88 (95% CI 0.85 to 0.92), the likelihood ratios were respectively 8.23 (95% CI 6.2 to 11) and 0.06 (95% CI 0.04 to 0.09) and the post-test probabilities were respectively 0.91 (95% CI 0.89 to 0.94) and 0.07 (95% CI 0.04 to 0.10). The overall success rate of saline contrast hysterosonography was 93% (95% CI 92% to 94%). The feasibility of saline contrast hysterosonography in postmenopausal women (success rate 86.5%, 95% CI 83.2 to 89.8) is significantly lower (P < 0.01) compared with premenopausal women (success rate 95%, 95% CI 94% to 96%).

CONCLUSION

Saline contrast hysterosonography is accurate in the evaluation of the uterine cavity in pre- and postmenopausal women suffering from abnormal uterine bleeding. The feasibility of saline contrast hysterosonography is high, although significantly better in premenopausal women compared with postmenopausal women. We conclude that saline contrast hysterosonography, in combination with an endometrium aspiration if necessary, can become the standard diagnostic procedure in women with abnormal uterine bleeding.

Sonohysterosalpingographic screening for infertile patients

OBJECTIVES

To compare the diagnostic accuracy of hysterosalpingography and sonohysterosalpingography in detecting tubal and uterine abnormalities.

METHODS

In a prospective study for the evaluation of uterine and tubal pathologies, 186 patients with primary and secondary infertility rates (51.6% and 44%, respectively), as well as recurrent abortion rates (3.8%), underwent sonohysterosalpingography. The tubal pathologies, as well as intracavitary and/or structural uterine abnormalities, detected with this procedure were compared with preoperative hysterosalpingography and operative procedures.

RESULTS

With surgical findings as the gold standard, sonohysterosalpingography had a sensitivity of 78.2%, a specificity of 93.1%, a positive predictive value of 82.7%, and a negative predictive value of 91%. For total tubal and uterine pathologies, the findings for the same parameters using HSG were 76.3%, 81.8%, 90.9%, and 59.2%, respectively. Sonohysterosalpingography was more accurate than hysterosalpingography for detecting intrauterine adhesions and various forms of uterine anomalies.

CONCLUSIONS

Sonohysterosalpingography is a safe, easy, accurate, and promising procedure for the detection of female upper genital tract pathologies, especially because it can differentiate specific uterine anomalies.

Sonohysterography

Sonohysterography can distinguish focal from diffuse pathology reliably and has become a crucial imaging test in the triage of PMB and in premenopausal patients with dysfunctional uterine bleeding or infertility. Polyps and submucosal fibroids are the most common focal findings during SHG. In postmenopausal patients, detection and accurate localization of findings, rather than lesion characterization, are the primary goals of the procedure. Most, if not all, focal lesions in this patient population require tissue diagnosis, even when the imaging features suggest benign lesions.

Technology assessment of saline contrast hysterosonography

OBJECTIVE

The purpose of our study was to evaluate to which extent saline contrast hysterosonography (SCHS) is able to replace diagnostic hysteroscopy in uterine cavity evaluation in women suspected of intrauterine abnormalities.

STUDY DESIGN

In this prospective observational study we performed SCHS instead of diagnostic hysteroscopy. Diagnostic hysteroscopy was performed in case of failed or inconclusive SCHS. Univariate and multivariate analyses were used to assess subgroups for their risk of failure and inconclusiveness.

RESULTS

Two hundred fourteen women were included consecutively. SCHS was conclusive in 180 cases (84.1%), failed in 12 (5.6%), and inconclusive in 22 (10.3%). Uterine size above 600 cm(3) was the best predictor of failure and/or inconclusiveness (positive predictive value 0.42).

CONCLUSION

SCHS was able to replace 84% of the outpatient diagnostic hysteroscopies in uterine cavity evaluation in women suspected of intrauterine abnormalities. Our study showed that diagnostic hysteroscopy can be restricted to inconclusive or failed SCHS.

[Hysterosonography]

Hysterosonography, which consists in the injection of some cc of saline in the uterine cavity during sonography, allows an exploration of the uterine cavity and of the endometrium. Accuracy of hysterosonography is similar to that of office hysteroscopy. Hysterosonography distinguishes normal cavities from pathologic ones, endometrial atrophy from mucosal anomalies, polyps from myomas. Conversely, endometrial biopsy is still necessary for diagnosis of hyperplasia or cancer. Hysterosonography can also be proposed for first trimester bleedings, trophoblast retention or ectopic pregnancy. In the near future it could be applied to therapeutic goals such as sonographic section of polyps.

Ultrasonographic endometrial thickness for diagnosing endometrial pathology in women with postmenopausal bleeding: a meta-analysis

Our aim was to determine the diagnostic accuracy of endometrial thickness measurement by pelvic ultrasonography for predicting endometrial carcinoma and disease (hyperplasia and/or carcinoma) during an investigation of postmenopausal bleeding. We performed a systematic quantitative review of the available published literature, which consisted of online searching the MEDLINE and EMBASE databases (1966-2000) coupled with scanning of bibliography of known primary and review articles. The selection of studies, assessment of study quality, and extraction of data were performed in duplicate under masked conditions. Included in the analyses were 57 studies with 9031 patients. Accuracy data were summarized using likelihood ratios for various cut-off levels of abnormal endometrial thickness. The commonest cut-offs were 4 mm (9 studies) and 5 mm (21 studies), measuring both endometrial layers. None of the nine studies using the < or = 4 mm cut-off level were of good quality. Only four studies (out of the 21) used the < or = 5 mm cut-off level, which employed the best-quality criteria. Using the pooled estimates from these four studies only, a positive test result raised the probability of carcinoma from 14.0% (95% CI 13.3-14.7) to 31.3% (95% CI 26.1-36.3), while a negative test reduced it to 2.5% (95% CI 0.9-6.4). In conclusion, ultrasound measurement of endometrial thickness alone, using the best-quality studies cannot be used to accurately rule. However, a negative result at < or = 5 mm cut-off level measuring both endometrial layers in the presence of endometrial pathology rules out endometrial pathology with good certainty.

A comparison of outpatient hysteroscopy with saline infusion hysterosonography

OBJECTIVES

To establish the accuracy of saline infusion hysterosonography in diagnosing uterine pathology when compared with outpatient hysteroscopy.

DESIGN

Prospective, parallel, blinded comparative study.

SETTING

Outpatient hysteroscopy clinic in a large university teaching hospital.

POPULATION

All women referred for outpatient hysteroscopy in a 15-month period.

INTERVENTIONS

Women underwent saline infusion hysterosonography followed by flexible hysteroscopy. The ultrasonographer was blinded to the hysteroscopy result and the gynaecologist was blinded to the saline infusion hysterosonography result.

MAIN OUTCOME MEASURES

The relative success rates and pain scores for each procedure. The validity of saline infusion hysterosonography as a diagnostic test.

RESULTS

One hundred and seventeen women entered the study; 70 women were premenopausal and 47 postmenopausal. In 27 women, one or both procedures could not be performed. Saline infusion hysterosonography failed in 20 women, on one occasion hysteroscopy failed and both investigations failed in six women. Ninety cases remained for direct comparison, with 78 cases of agreement on the uterine findings in both investigations. Twelve cases disagreed; in one case, an adhesion was seen, two cases with polyps and five with fibroids seen on ultrasound but not seen on hysteroscopy. There were four cases where polyps were identified on hysteroscopy but not on saline infusion hysterosonography. The median pain scores were 1.6 for saline infusion hysterosonography and 3.2 for hysteroscopy.

CONCLUSIONS

Both saline infusion hysterosonography and hysteroscopy are well tolerated by women. Saline infusion hysterosonography has a high failure rate but has a lower pain score than hysteroscopy.

Sonohysterographic findings of endometrial and subendometrial conditions

Sonohysterography has become the standard test in the evaluation of dysfunctional uterine and postmenopausal bleeding because it allows reliable differentiation between focal and diffuse endometrial and subendometrial lesions, with the most common being polyps and submucosal fibroids. An endometrial polyp usually appears as a well-defined, homogeneous, polypoid lesion that is isoechoic to the endometrium with preservation of the endometrial-myometrial interface. Atypical polyps have cystic components, multiplicity, a broad base, and hypoechogenicity or heterogeneity. Submucosal fibroids are usually broad-based, hypoechoic, well-defined, solid masses with shadowing and an overlying layer of echogenic endometrium that distorts the endometrial-myometrial interface. Atypical fibroids are pedunculated or have a multilobulated surface. The major advantage of sonohysterography is that it can accurately depict the percentage of the fibroid that projects into the endometrial cavity. Endometrial hyperplasia usually appears as diffuse thickening of the echogenic endometrial stripe without focal abnormality, but occasionally focal hyperplasia can be seen. Endometrial cancer is typically a diffuse process, but early cases can appear as a polypoid mass. Adhesions usually appear as mobile, thin, echogenic bands that bridge a normally distensible endometrial cavity, but occasionally thick, broad-based bands or complete obliteration of the endometrial cavity is seen. Although endometrial lesions have characteristic features, a wide range of appearances is possible, with significant overlap between entities. Radiologists should be familiar with the broad spectrum of findings that may be seen at sonohysterography in both benign and malignant processes to raise the appropriate level of concern and to direct the clinician toward the appropriate means of diagnostic biopsy or surgery.

Postmenopausal bleeding: value of imaging

Endovaginal sonography in combination with HSG is an effective screening tool in evaluating patients with postmenopausal bleeding. Endovaginal sonography is highly sensitive for detecting endometrial carcinoma and can identify patients at low risk for endometrial disease obviating the need for endometrial sampling in this subgroup of patients. In patients with abnormal findings at sonography, a detailed morphologic analysis can be used to determine which patients can undergo blind endometrial sampling successfully versus those who would benefit from hysteroscopic guidance. In patients in whom endovaginal sonography and HSG are inadequate, MRI may provide additional information on the appearance of the endometrium, particularly in patients in whom endometrial sampling is difficult (eg, patients with cervical stenosis).

Sonohysterography: a prospective survey of results and complications in 81 patients

PURPOSE

To evaluate the sonohysterography (SHG) for the diagnosis of intrauterine abnormalities and describe complications and failure rate.

STUDY DESIGN

A prospective survey on 81 patients, (44 patients with menometrorrhagia, 30 with postmenopausal bleeding and 7 with infertility) was conducted. Histopathology and clinical survey, if sonohysterography was normal, were the gold standards.

RESULTS

Pathology has been performed in 55 cases. There were four failures (cervical stenosis), one severe complication (endometritis), one pelvic pain. Sensitivity and specificity of sonography were 56 and 83%; for sonohysterography 88 and 98%; and for hysteroscopy 78 and 97%. Sonohysterography was accurate for the diagnosis of the submucous myoma component.

CONCLUSION

Sonohysterography is available in uterine pathology, easy, safe and cheap, but sonographists and patients should be informed of the little risks of such examination technique.

Ultrasonographic assessment of endometrial thickness: a review

Measurement of endometrial thickness with ultrasonography is a modality commonly used today. Its clinical importance and applications extend throughout the phases of the reproductive lives of women. In premenopausal women, endometrial thickness is used to monitor infertility treatment, while in postmenopausal women with abnormal uterine bleeding it is useful as an initial investigation for endometrial hyperplasia or cancer. Moreover, endometrial thickness can vary with the menstrual cycle and with the use of hormone replacement therapy or selective estrogen receptor modulators. In this review, the use of ultrasound to measure both the premenopausal and postmenopausal endometrium is discussed.

Transvaginal sonography, saline contrast sonohysterography and hysteroscopy for the investigation of women with postmenopausal bleeding and endometrium > 5 mm

OBJECTIVES

To determine the ability of transvaginal ultrasound, with or without saline infusion, to detect focally growing lesions in the uterine cavity in women with postmenopausal bleeding and endometrium > 5 mm, and to determine the accuracy of conventional ultrasound, saline contrast sonohysterography and diagnostic hysteroscopy under general anesthesia to diagnose endometrial polyps, submucous myomas and uterine malignancy.

DESIGN

In a prospective study, 105 women with postmenopausal bleeding and endometrium > 5 mm underwent conventional ultrasound examination and saline contrast sonohysterography. Diagnostic and operative hysteroscopy under general anesthesia was then performed. The presence of focally growing lesions and the type of lesion (endometrial polyp, submucous myoma, malignancy or unclear focal lesion) were noted at ultrasound examination and at hysteroscopy.

RESULTS

There was almost perfect agreement (96%) between saline contrast sonohysterography and hysteroscopy in the diagnosis of focally growing lesions. Saline contrast sonohysterography and hysteroscopy both had a sensitivity of approximately 80% with regard to diagnosing endometrial polyps (false-positive rates of 24% and 6%, respectively), whereas conventional ultrasound missed half of the polyps (sensitivity, 49%; false-positive rate, 19%). Hysteroscopy was superior to both saline contrast sonohysterography and conventional ultrasound with regard to discriminating between benign and malignant lesions (sensitivity, 84%, 44%, and 60%; false-positive rate, 15%, 6% and 10%, respectively). The risk of malignancy was increased seven-fold (odds ratio, 7.3; 95% confidence interval, 1.9-27.8) in women with distension difficulties at saline contrast sonohysterography, and two thirds of the women with a poorly distensible uterine cavity had a malignant diagnosis.

CONCLUSION

Saline contrast sonohysterography is as good as hysteroscopy at detecting focally growing lesions in the uterine cavity in women with postmenopausal bleeding. However, neither hysteroscopy nor saline contrast sonohysterography can reliably discriminate between benign and malignant focal lesions. Distension difficulties at saline contrast sonohysterography should raise a suspicion of malignancy.

Fibroids and infertility: a systematic review of the evidence

A systematic literature review was performed to determine whether leiomyomata are associated with decreased fertility rates, and whether surgical removal increases fertility rates postoperatively. Meta-analysis was conducted when multiple studies addressed a single issue and were sufficiently homogeneous. Data were analyzed for effect of any fibroid upon fertility, as well as specific fibroid location. Results of studies comparing women with infertility and fibroids versus infertile controls showed widely disparate results. Subgroup analysis failed to indicate any effect on fertility of fibroids that did not have a submucous component. Conversely, women with submucous myomas demonstrated lower pregnancy rates (RR 0.30; 95% confidence interval [CI] 0.13--0.70) and implantation rates (RR 0.28; 95% CI 0.10--0.72) than infertile controls. Results of surgical intervention were similar. When all fibroid locations were considered together, myomectomy results were again widely disparate. However, when women with submucous myomas were considered separately, pregnancy was increased after myomectomy compared with infertile controls (RR 1.72; 95% CI 1.13--2.58) and delivery rates were now equivalent to infertile women without fibroids (RR 0.98; 95% CI 0.45--2.41). The current data suggest that only those fibroids with a submucosal or an intracavitary component are associated with decreased reproductive outcomes, and that hysteroscopic myomectomy may be of benefit.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians

LEARNING OBJECTIVES

After completion of this article, the reader will be able to summarize the data on the role of fibroids and infertility, describe the effect of myomectomy on fertility, and list the methods used to evaluate intracavitary fibroids.

Transvaginal sonography combined with saline contrast sonohysterography in evaluating the uterine cavity in premenopausal patients with abnormal uterine bleeding

OBJECTIVES

To evaluate whether saline contrast sonohysterography (SCSH) adds additional information to that obtained by transvaginal sonography (TVS) for predicting endometrial abnormality in premenopausal patients with abnormal uterine bleeding.

PATIENTS AND METHODS

This was a two-center prospective study at a university clinic and a central hospital in Denmark. The uterine cavity was evaluated with TVS and SCSH in 470 premenopausal patients with abnormal uterine bleeding. One hundred and eighty-nine of the patients had operative hysteroscopy or hysterectomy within 4 months which provided a detailed description of the uterine cavity and was used as the true value for exclusion of polyps and submucous myomas.

RESULTS

Based on normal endometrial morphology alone, the results for detection of an abnormal uterine cavity were as follows: sensitivities of TVS 0.92, SCSH 0.99; specificities of TVS 0.62, SCSH 0.72; positive predictive values of TVS 0.80, SCSH 0.85; negative predictive values of TVS 0.82, SCSH 0.98. Transvaginal sonography combined with SCSH was superior to TVS for detection of intracavitary abnormalities (McNemar test, P = 0.008). The post-test probability of there being an abnormal cavity after normal findings on TVS alone was 0.18 (0.10-0.32) and after TVS and SCSH it was 0.02 (0.01-0.11). When normal endometrial morphology was combined with an endometrial thickness of < 12 mm for evaluation of all abnormalities including hyperplasia, the diagnostic potential of TVS or SCSH was almost unchanged except for specificities, which were markedly lower (TVS 0.54; SCSH 0.57). In all the patients referred, TVS had a negative predictive value of 0.94 for identification of polyps and myomas when findings at subsequent SCSH were accepted as the true value. Transvaginal sonography reduced the pretest probability of polyps or submucous myomas from 0.35 to a post-test probability of 0.06, but missed 21% of the polyps.

CONCLUSIONS

Sonohysterography was a sensitive tool and was superior to TVS used alone for evaluation of the uterine cavity in patients who underwent operative surgery for abnormal uterine bleeding. All abnormalities except one were found at SCSH, while TVS alone missed polyps and had almost one in four equivocal findings. The use of TVS, without saline contrast, left one in five of the polyps undiagnosed in referred patients with abnormal bleeding.

Pressure lavage under ultrasound guidance: a new approach for outpatient treatment of intrauterine adhesions

OBJECTIVE

To present pressure lavage under ultrasound guidance (PLUG) as a new therapeutic procedure for selected cases of intrauterine adhesions (IUA).

DESIGN

An open clinical investigation with no control group.

SETTING

Teaching hospital.

PATIENT(S)

Seven consecutive patients referred to our department for secondary amenorrhea due to IUA.

INTERVENTION(S)

A newly developed technique based on sonohysterography was used to monitor the effects of intrauterine injections of saline solution on the continuous accumulation of saline in the uterine cavity for the mechanical disruption of IUA.

MAIN OUTCOME MEASURE(S)

Lysis of intrauterine adhesions, restoration of menses, and increased pregnancy rate in infertile patients.

RESULT(S)

Five patients with mild IUA obtained satisfactory lysis of adhesions by the use of the PLUG technique. A second-look hysteroscopy after 1 month showed that filmy adhesions persisted in two patients with moderate IUA. These adhesions were removed successfully during hysteroscopy. Restoration of menses was obtained and has continued in all patients. Two of the three infertile patients became pregnant.

CONCLUSION(S)

This technique is safe and ideal as an in-office procedure. PLUG allows complete lysis in mild IUA cases, and the need for therapeutic, and possibly follow-up hysteroscopy, can be avoided. In moderate IUA cases, the procedure may represent a useful initial step in reducing the need for operative hysteroscopy.

Ultrasound assessment of the endometrium in healthy, asymptomatic early post-menopausal women: saline infusion sonohysterography versus transvaginal ultrasound

OBJECTIVE

To exclude pre-existing endometrial pathology in asymptomatic early post-menopausal women before starting hormone replacement therapy by transvaginal ultrasound (TVS) and saline infusion sonohysterography (SIS).

METHODS

In a cross-sectional study, 148 healthy women (mean age, 51.1 years; range, 46-59 years) underwent ultrasound evaluation of the endometrium before participation in a clinical trial. TVS was used to measure double-layer endometrial thickness. SIS was performed at the same visit to measure anterior and posterior single-layer endometrial thickness, and to identify endometrial abnormalities when present. Ultrasound results were defined as informative if the endometrium could be adequately visualized. Findings on TVSs were defined as abnormal if a double-layer endometrial measurement > 5.0 mm was obtained. Findings on SIS were defined as abnormal if one or both single layers of the endometrium measured > 2.5 mm, or if focal endometrial thickening or a polyp was present.

RESULTS

Of the 148 eligible women, informative TVS results were obtained from 134 women, SIS results from 133 women and both procedures combined from 119 women. TVS scans gave abnormal results in 8.2% of women (11 of 134) and SIS gave abnormal results in 36.8% of women (49 of 133). Of the 14 women with a non-informative TVS, eight had abnormal SIS results. Of the 15 women with a non-informative SIS, three had abnormal TVS results. In the 119 women with both informative TVS and SIS, abnormal TVS scans were found in 6.7% of women (eight of 119) and abnormal SIS in 34.5% of women (41 of 119). All eight women with abnormal TVS had an abnormal SIS, whereas 29.7% (33 of 111) of the women with a normal TVS had an abnormal SIS.

CONCLUSIONS

Ultrasound evaluation demonstrated endometrial abnormalities in 34.5% (41 of 119) of asymptomatic post-menopausal women. SIS is more accurate than TVS in the detection of endometrial abnormalities.

Comparison of transvaginal sonography, saline infusion sonography, and hysteroscopy in premenopausal women with abnormal uterine bleeding

PURPOSE

Saline infusion sonography (SIS) is a relatively new technique in the evaluation of abnormal uterine bleeding. We compared the diagnostic accuracy of SIS with that of transvaginal sonography (TVS) in the detection of intracavitary abnormalities in premenopausal women with abnormal uterine bleeding.

METHODS

In this prospective study, consecutive premenopausal women who underwent a hysteroscopy for abnormal uterine bleeding also underwent TVS and SIS. The findings at TVS and SIS were compared with the hysteroscopic and histologic findings. Sensitivity, specificity, and likelihood ratios were calculated. Receiver operating characteristic curves were constructed to assess the performance of endometrial thickness measured using TVS.

RESULTS

Sixty-two patients were included in the study. TVS demonstrated 60% sensitivity in directly visualizing intracavitary abnormalities and 93% specificity. The likelihood ratio of the presence of an intracavitary abnormality was 8, and the likelihood ratio of the absence of an intracavitary abnormality was 0.43. Defining an abnormality at TVS as direct visualization of an intracavitary abnormality or an endometrial thickness greater than 5 mm, TVS had an 85% sensitivity and a 21% specificity, with corresponding likelihood ratios of 1.1 and 0.71, respectively. For SIS, the sensitivity, specificity, and likelihood ratios of the presence and absence of intracavitary abnormalities were 88%, 95%, 10, and 0.13, respectively.

CONCLUSIONS

SIS is more accurate in the diagnosis of intracavitary abnormalities in premenopausal women than is TVS. An approach using endometrial thickness measurement by TVS and reserving SIS for patients who have an endometrial thickness greater than 5 mm or an intracavitary abnormality visualized by TVS would be the most effective method to reduce the number of hysteroscopies.

Radiographic imaging techniques for the diagnosis of abnormal uterine bleeding

The introduction of SIS has been a significant advance in TVUS evaluation of the endometrial cavity in the 1990s. SIS provides an unparalleled, clear, enhanced view of the endomyometrial complex that cannot be obtained with TVUS alone. Focal and global endometrial pathology can be differentiated with SIS. Saline infusion improves the sensitivity for the detection of endometrial abnormalities. The continuing challenge for gynecologists is to provide patients with cost-effective, minimally invasive evaluation and directed therapy for menstrual dysfunction. SIS targets patients needing biopsy, directs the surgical approach, and minimizes office diagnostic hysteroscopy--all with a quick office procedure. For patients, the benefits include minimal and brief discomfort and a better understanding of intrauterine pathology through viewing the ultrasound monitor. Patients also appreciate the ease of scheduling, the minimal time away from work, and that no escort is needed after the procedure. SIS provides an extension of the pelvic gynecologic examination. SIS is the most important imaging modality for evaluating endometrial pathology. Although there is no perfect test to evaluate the endometrium, overall, SIS is superior to other imaging and diagnostic procedures. It is less expensive than D&C or hysteroscopy. It is a safe, efficient, convenient, and well-tolerated procedure. In some instances, however, neither TVUS nor SIS is definitive in determining the location of fibroids or able to discern adenomyosis. In these instances, MR imaging triage is helpful. MR imaging is gaining widespread acceptance and, in many instances, is a cost-effective tool in the evaluation of abnormal uterine bleeding. It is noninvasive, differentiates uterine anatomy in response to exogenous hormones or the normal menstrual cycle, and reliably localizes pelvic pathology and size of lesions. When uterine conservation is desired in women with fibroids and TVUS or SIS is indeterminate in localizing depth of myometrial involvement of a fibroid, MR imaging should be considered as a part of the clinical algorithm. The precision of MR imaging localization of submucosal fibroids can obviate the need for hysterectomy and permit a skilled surgeon to hysteroscopically resect the fibroids. If the clinical examination is suspicious for adenomyosis and the US is nondiagnostic, the clinician should consider MR imaging strongly. When the results of the imaging study would influence surgical route and planning, MR imaging should be considered in the preoperative evaluation.

Diagnostic accuracy of sonohysterography, transvaginal sonography, and hysterosalpingography in patients with uterine cavity diseases

OBJECTIVE

To evaluate the diagnostic accuracy of sonohysterography (SHG) in uterine cavity diseases in infertile patients, comparing its results with those of hysterosalpingography (HSG) and transvaginal sonography (TVS). Hysteroscopy was the gold standard.

DESIGN

Descriptive, prospective study.

SETTING

A tertiary university referral center.

PATIENT(S)

Sixty-five infertile women 19 to 43 years of age.

INTERVENTION(S)

Patients underwent SHG, conventional TVS, HSG, and hysteroscopy.

MAIN OUTCOME MEASURE(S)

The results of each examination were compared with those obtained by the gold standard. The following diagnoses were considered separately: polypoid lesions, uterine malformations, intrauterine adhesions, and endometrial hyperplasia (EH). Sensitivity, specificity, positive and negative predictive values (PPV and NPV, respectively), and 95% confidence intervals were calculated.

RESULT(S)

Sonohysterography had the same diagnostic accuracy as the gold standard for polypoid lesions and EH, with no equivocal diagnosis. Hysterosalpingography showed a sensitivity of 50% and a PPV of 28.6% for polypoid lesions and a sensitivity of 0% for EH. Transvaginal sonography had both sensitivity and PPV of 75% for polypoid lesions and EH. For uterine malformations, SHG had a sensitivity of 77.8%, whereas TVS and HSG both had a sensitivity of 44.4%. Sonohysterography and HSG had a sensitivity of 75% in the detection of intrauterine adhesions and respective PPVs of 42.9% and 50%. Transvaginal sonography showed sensitivity and PPV of 0% for this diagnosis.

CONCLUSION(S)

Sonohysterography was in general the most accurate test. Its diagnostic accuracy was markedly superior for polypoid lesions and EH, with total agreement with the gold standard. In diagnosis of intrauterine adhesions, SHG had limited accuracy, similar to that obtained by HSG, with a high false-positive diagnosis rate.

Focal intracavitary masses recognized with the hyperechoic line sign at endovaginal US and characterized with hysterosonography

In 42 women, endovaginal ultrasonography (US) was performed because of an abnormal central endometrial complex. Retrospective review of the endovaginal US scans and subsequently obtained hysterosonograms with histopathologic correlation showed a hyperechoic line surrounding the central endometrial complex in 25 patients, all of whom had focal intracavitary processes. Cystic spaces within the central endometrial complex in 17 of these patients reflected polyps; this finding was associated with a hyperechoic line in 15. At hysterosonography, all polyps (n = 29) had a narrow attachment to the endometrium. All five fibroids were broadly attached and had a rim of overlying endometrium. These focal abnormalities were easily distinguished from global endometrial processes amenable to a blind biopsy procedure. This initial experience showed that a hyperechoic line circumscribing the central endometrial complex at endovaginal US allows prediction of focal intracavitary disease, particularly when the line is associated with cystic spaces within the central endometrial complex. The presence of a hyperechoic line can be used to direct the patient to a visually guided hysteroscopic procedure rather than a potentially unsuccessful blind biopsy procedure. Alternatively, absence of a hyperechoic line can prompt management appropriately directed by hysterosonographic characterization of the uterine contents as focal or diffuse.

Transvaginal sonohysterographic evaluation of intrauterine adhesions

PURPOSE

We assessed the role of preoperative sonohysterography in the diagnosis of intrauterine synechiae.

METHODS

Nineteen patients with a suspected diagnosis of intrauterine adhesion underwent hysterosalpingography, transvaginal sonography, and sonohysterography performed in the consultation room. The patients were then treated by hysteroscopy under laparoscopic or ultrasound guidance.

RESULTS

Transvaginal sonography showed an abnormal uterine cavity in only 10 cases. The sensitivities of sonohysterography and hysterosalpingography in the diagnosis of intrauterine adhesions were both 100%. Sonohysterography showed complete correlation with hysterosalpingography.

CONCLUSIONS

We recommend routine sonohysterography after transvaginal sonography in cases of suspected intrauterine synechiae.

Comparative study of transvaginal hysterosonography and biopsy for the evaluation of post-menopausal bleeding

BACKGROUND

The aim of this prospective study was to evaluate transvaginal hysterosonography (TVHS) in post-menopausal bleeding (PMB) as an alternative to endometrial biopsy. The study was conducted at the Zarka Military Hospital, Amman, Jordan, over a one-year period from 1996 to 1997.

PATIENTS AND METHODS

The study comprised 98 women presenting with post-menopausal bleeding who had been listed for diagnostic dilatation and curettage. Transvaginal sonography (TVS) and transvaginal hysterosonography were performed one week before operation. The mean age of the women was 57 years, and all of them had had their menopause for at least six months.

RESULTS

Sixty-one women (62%) demonstrated endometrial thickness of more than 5 mm by transvaginal sonography. All the women had transvaginal hysterosonography, except seven on whom hysterosonography could not be performed for technical reasons and who had to be excluded from the study, leaving a total of 54 women. TVS confirmed the presence of endoluminal mass in 30 of 54 women (60%). Twenty-two of the 30 endoluminal mass cases were pedunculated while eight were sessile. Sixteen of the pedunculated cases were endometrial polyps while the remaining six were fibroid polyps. Five of the sessile cases were fibroid, two were endometrial hyperplasia, and the last one endometrial carcinoma. The other 44 out of the 98 patients also underwent transvaginal hysterosonography. No pathology could be detected in these patients, but they were noted to have atrophic endometrium after dilatation and curettage.

CONCLUSION

The combination of transvaginal sonography and transvaginal hysterosonography is both sensitive and specific with regard to detecting and excluding endoluminal masses as the cause of post-menopausal bleeding. Diagnostic dilatation and curettage fails to detect a large percentage of some lesions, so TVS in combination with TVHS should be considered as the initial examination in the evaluation of all women with post-menopausal bleeding.

A prospective study of transvaginal hydrosonography in the evaluation of abnormal uterine bleeding

OBJECTIVE

The purpose of this study was to determine whether the intrauterine instillation of saline solution during transvaginal ultrasonographic imaging (hydrosonography) improves the diagnostic accuracy in detecting intrauterine abnormalities determined by direct visualization of the intrauterine cavity with either hysteroscopy or after hysterectomy.

STUDY DESIGN

This study was a prospective, blinded study of 39 women referred with the diagnosis of abnormal uterine bleeding after failing medical management. A routine vaginal probe ultrasonographic examination was followed by a blinded transvaginal hydrosonography in patients proceeding to either hysteroscopy or hysterectomy.

RESULTS

Twelve of the 39 patients had masses that impinged on the intrauterine cavity at hysteroscopy or hysterectomy. In 4 of the 12 patients with confirmed masses, an intrauterine lesion was detected by hydrosonography that was not seen on routine vaginal probe ultrasonography. In no case was an intrauterine mass detected by the hysteroscopy or after hysterectomy when hydrosonography indicated a normal intrauterine cavity. In 4 cases hydrosonography suggested that masses were present that were not confirmed at direct visualization. Although hydrosonography always recognized when intracavitary pathologic conditions existed in a patient, hydrosonography sometimes underestimated the number of intracavitary lesions present.

CONCLUSIONS

Hydrosonography is a simple, minimally invasive, and effective tool to use in the evaluation of patients with abnormal uterine bleeding who have not responded to medical treatment. In no case did hydrosonography fail to indicate when pathologic conditions existed in a given patient, and a normal hydrosonography always indicated a normal intrauterine cavity at hysteroscopy or after hysterectomy. For these reasons hydrosonography is a sensitive tool to triage women with abnormal uterine bleeding to operative or conservative management.

Sonohysterographic screening before in vitro fertilization

OBJECTIVE

To evaluate the use of sonohysterography for uterine screening before IVF.

DESIGN

Prospective screening with sonohysterography and comparison with available hysterosalpingographic and hysteroscopic evaluations.

SETTING

Private practice.

PATIENT(S)

Seventy-two women undergoing IVF-ET using their own or donor eggs.

INTERVENTION(S)

Sonohysterography was performed by instilling saline into the uterine cavity through an intracervical balloon catheter; there was concurrent vaginal sonographic visualization in all cases.

MAIN OUTCOME MEASURE(S)

Sonohysterographic findings and pregnancy rates.

RESULT(S)

Cavitary lesions were detected in 8 (11.1%) of 72 sonohysterographic examinations. Six of 8 cases were confirmed and treated by hysteroscopy. After sonohysterographic evaluation, 35 (48.6%) of 72 patients conceived, resulting in 25 ongoing or delivered pregnancies, 5 chemical pregnancies, and 5 spontaneous abortions. No statistically significant difference was observed in the pregnancy outcome for patients undergoing IVF who had sonohysterography compared with that for patients undergoing IVF during the same period who previously had a uterine evaluation by a different method. The estimated cost savings per patient undergoing sonohysterography instead of in-office hysteroscopy was $275.

CONCLUSION(S)

Sonohysterography offers advantages over in-office hysteroscopy and hysterosalpingography for evaluation of the uterus before IVF.