Diagnostic hysteroscopy and saline infusion sonography in the diagnosis of intrauterine abnormalities: an assessment of patient preference

Modern assessment of the uterine cavity and fallopian tubes in the era of high-efficacy assisted reproductive technology

The high efficacy of modern assisted reproductive technology (ART) and increase in the number of noninfertile patients who are using ART for family building in the United States call into question the relevance of the standard, one-size-fits-all infertility evaluation. Here, we explore whether all patients presenting for ART need uterine cavity and tubal assessment and what tests are most appropriate, efficient, and cost-effective in current times.

Patient and provider satisfaction with saline ultrasound versus office hysteroscopy for uterine cavity evaluation prior to in vitro fertilization: a randomized controlled trial

PURPOSE

To compare patient and provider satisfaction with saline ultrasound (SIS) versus office hysteroscopy for cavity evaluation prior to in vitro fertilization (IVF) and to assess the capability of hysteroscopy to manage pathology at time of diagnosis to reduce delays and supernumerary procedures.

METHODS

This was a randomized, controlled trial in a university fertility clinic. One hundred enrolled subjects undergoing routine uterine cavity evaluation prior to planned embryo transfer were randomized to SIS or office hysteroscopy without anesthesia. Subjects and providers completed surveys about their experience. Subjects with findings on SIS had a hysteroscopy performed or scheduled for further evaluation. Those with hysteroscopy findings had management attempted within the same procedure.

RESULTS

Overall patient satisfaction was high and did not differ between groups, while providers indicated that hysteroscopy provided a better cavity evaluation. There was no difference in time to complete procedures between groups. Pain score on a ten-scale was slightly higher in the hysteroscopy group compared to the SIS group (3.38 ± 1.85 vs. 2.44 ± 1.64, p < 0.01), but this did not impact satisfaction scores. Although pathology was found in a similar rate (22% vs. 36% for SIS and HSC groups, respectively), those in the SIS group all required secondary procedures, while only 1/17 did in the HSC group (p < 0.01).

CONCLUSION

Although the hysteroscopy group exhibited slightly higher pain scores, overall patient and provider satisfaction was high and similar between groups. There were significantly fewer secondary procedures and delays in the hysteroscopy group. Hysteroscopy is a reasonable first line screening tool for patients requiring cavity evaluation.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT04415489.

Three-dimensional saline infusion sonography compared to two-dimensional saline infusion sonography for the diagnosis of focal intracavitary lesions

BACKGROUND

Focal abnormalities most commonly acquired within the uterine cavity include endometrial polyps (arising from the endometrium) and submucous fibroids (arising from the myometrium). These benign abnormalities can cause several problems, including abnormal uterine bleeding (AUB) and subfertility. Two-dimensional saline infusion sonography (2D SIS) is a minimally invasive test that can be used to diagnose these pathologies, but it is less accurate than hysteroscopy, which is a more invasive procedure by which an endoscope allows direct visualisation of the uterine cavity. Three-dimensional (3D) SIS appears to enhance sonographic visualisation within the uterine cavity, thereby offering a potentially more accurate minimally invasive diagnostic test.

OBJECTIVES

Primary objectives • To evaluate the diagnostic accuracy of 3D SIS (index test 1) compared with 2D SIS for the diagnosis of focally growing lesions (presence or not) in women with AUB or subfertility, with hysteroscopy performed as the reference test. • To evaluate the diagnostic accuracy of 2D+3D SIS (index test 2) compared with 2D SIS for the diagnosis of focally growing lesions (presence or not) in women with AUB or subfertility, with hysteroscopy performed as the reference test. In this case, any abnormality on either modality was regarded as a positive result ('OR' approach). Secondary objectives • To evaluate the diagnostic accuracy of 3D SIS (index test 1) compared with 2D SIS according to type of abnormality and discrimination between uterine polyps and submucous fibroids in women with AUB or subfertility, with hysteroscopy and histology used as the reference.• To evaluate the diagnostic accuracy of 2D+3D SIS (index test 2) compared with 2D SIS according to type of abnormality and discrimination between uterine polyps and submucous fibroids in women with AUB or subfertility, with hysteroscopy and histology used as the reference.

SEARCH METHODS

We searched the following databases: Cochrane Central Register of Studies Online (CENTRAL CRSO), MEDLINE, Embase, PubMed, Cochrane Gynaecology and Fertility Group (CGF) Specialised Register and CGFG Diagnostic Test Accuracy (DTA) Specialised Register, clinicaltrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP). Screening reference lists of appropriate studies was also performed. We screened for eligibility all studies identified from inception until March 2016. We performed searches with no date or language restrictions.

SELECTION CRITERIA

The population of interest consisted of premenopausal women with AUB or subfertility and postmenopausal women with AUB. Diagnostic test accuracy studies, randomised controlled trials (RCTs) and prospective cohort studies were eligible for inclusion if they evaluated the accuracy of both 2D SIS and 3D SIS for the diagnosis of acquired intracavitary abnormalities with hysteroscopy used as the reference standard. In light of the lack of data for 3D SIS, we also included studies that evaluated the accuracy of 3D SIS alone.

DATA COLLECTION AND ANALYSIS

Two review authors read all potentially eligible references after performing a first screening by title and abstract (LLN and FJRH). They independently extracted data to construct 2×2 tables from eligible studies and assessed studies for methodological quality using the QUADAS-2 tool (revised tool for quality assessment of diagnostic accuracy studies). To describe and visually present results, we produced in RevMan forest plots showing pairs of sensitivity and specificity together with 95% confidence intervals from each study, as well as raw receiver operating characteristic (ROC) plots. We displayed paired analyses in an ROC plot by linking sensitivity-specificity pairs from each study by using a dashed line. To compare 3D SIS versus 2D SIS, we restricted analyses to studies that provided 2×2 tables for both tests and used the bivariate meta-analysis of sensitivity and specificity.

MAIN RESULTS

Thirteen studies (1053 women) reported the accuracy of 3D SIS for focal uterine abnormalities; 11 of these (846 women) were suitable for meta-analysis, and eight reported accuracy according to the type of focal abnormality. The design of the included studies seems applicable. The main problem involving the quality of included studies is insufficient reporting of study methods, resulting in unclear risk of bias for several of the quality domains assessed. Therefore, we considered the overall quality of the evidence as low. The summary estimate (11 studies reporting absence or presence of abnormality at 3D SIS) for sensitivity was 94.5% (95% confidence interval (CI) 90.6% to 96.9%) and for specificity 99.4% (95% CI 96.2% to 99.9%). Meta-analysis of the eight studies (N = 716) directly comparing 2D SIS versus 3D SIS showed summary sensitivity of 96.9% (95% CI 91.9% to 98.8%) and summary specificity of 99.5% (95% CI 96.1% to 100%) for 3D SIS. For 2D SIS, summary sensitivity was 90.9% (95% CI 81.2% to 95.8%) and summary specificity was 96.3% (95% CI 86.1% to 99.1%). The difference in accuracy between 2D SIS and 3D SIS was non-significant (P values of 0.07 for sensitivity and 0.10 for specificity).

AUTHORS' CONCLUSIONS

Low-quality evidence suggests that 3D SIS may be very accurate in detecting intracavitary abnormalities. Meta-analysis revealed no statistically significant differences between 2D SIS and 3D SIS. Summary sensitivity and summary specificity are higher for 3D SIS, but margins of improvement are limited because 2D SIS is already very accurate. When the technology and appropriate expertise are available, 3D SIS offers an alternative to 2D SIS. Both 2D SIS and 3D SIS should be considered alternatives to diagnostic hysteroscopy when intracavitary pathology is suspected in subfertile women and in those with abnormal uterine bleeding.

CONSUMER PREFERENCES FOR SCANNING MODALITY TO DIAGNOSE FOCAL LIVER LESIONS

OBJECTIVES

Differences in the process of using liver imaging technologies might be important to patients. This study aimed to investigate preferences for scanning modalities used in diagnosing focal liver lesions.

METHODS

A discrete choice experiment was administered to 504 adults aged 25 ≥years. Respondents made repeated choices between two hypothetical scans, described according to waiting time for scan and results, procedure type, the chance of minor side-effects, and whether further scanning procedures were likely to be required. Choice data were analyzed using mixed-logit models with respondent characteristics used to explain preference heterogeneity.

RESULTS

Respondents preferred shorter waiting times, the procedure to be undertaken with a handheld scanner on a couch instead of within a body scanner, no side-effects, and no follow–up scans (p≤.01). The average respondent was willing to wait an additional 2 weeks for the scan if it resulted in avoiding side-effects, 1.5 weeks to avoid further procedures or to be told the results immediately, and 1 week to have the scan performed on a couch with a handheld scanner. However, substantial heterogeneity was observed in the strength of preference for desirable imaging characteristics.

CONCLUSIONS

An average individual belonging to a general population sub–group most likely to require imaging to characterize focal liver lesions in the United Kingdom would prefer contrast–enhanced ultrasound over magnetic resonance imaging or computed tomography. Insights into the patient perspective around differential characteristics of imaging modalities have the potential to be used to guide recommendations around the use of these technologie

A randomised controlled trial of Outpatient versus inpatient Polyp Treatment (OPT) for abnormal uterine bleeding

BACKGROUND

Uterine polyps cause abnormal bleeding in women and conventional practice is to remove them in hospital under general anaesthetic. Advances in technology make it possible to perform polypectomy in an outpatient setting, yet evidence of effectiveness is limited.

OBJECTIVES

To test the hypothesis that in women with abnormal uterine bleeding (AUB) associated with benign uterine polyp(s), outpatient polyp treatment achieved as good, or no more than 25% worse, alleviation of bleeding symptoms at 6 months compared with standard inpatient treatment. The hypothesis that response to uterine polyp treatment differed according to the pattern of AUB, menopausal status and longer-term follow-up was tested. The cost-effectiveness and acceptability of outpatient polypectomy was examined.

DESIGN

A multicentre, non-inferiority, randomised controlled trial, incorporating a cost-effectiveness analysis and supplemented by a parallel patient preference study. Patient acceptability was evaluated by interview in a qualitative study.

SETTING

Outpatient hysteroscopy clinics and inpatient gynaecology departments within UK NHS hospitals.

PARTICIPANTS

Women with AUB - defined as heavy menstrual bleeding (formerly known as menorrhagia) (HMB), intermenstrual bleeding or postmenopausal bleeding - and hysteroscopically diagnosed uterine polyps.

INTERVENTIONS

We randomly assigned 507 women, using a minimisation algorithm, to outpatient polypectomy compared with conventional inpatient polypectomy as a day case in hospital under general anaesthesia.

MAIN OUTCOME MEASURES

The primary outcome was successful treatment at 6 months, determined by the woman's assessment of her bleeding. Secondary outcomes included quality of life, procedure feasibility, acceptability and cost per quality-adjusted life-year (QALY) gained.

RESULTS

At 6 months, 73% (166/228) of women who underwent outpatient polypectomy were successfully treated compared with 80% (168/211) following inpatient polypectomy [relative risk (RR) 0.91, 95% confidence interval (CI) 0.82 to 1.02]. The lower end of the CIs showed that outpatient polypectomy was at most 18% worse, in relative terms, than inpatient treatment, within the 25% margin of non-inferiority set at the outset of the study. By 1 and 2 years the corresponding proportions were similar producing RRs close to unity. There was no evidence that the treatment effect differed according to any of the predefined subgroups when treatments by variable interaction parameters were examined. Failure to completely remove polyps was higher (19% vs. 7%; RR 2.5, 95% CI 1.5 to 4.1) with outpatient polypectomy. Procedure acceptability was reduced with outpatient compared with inpatient polyp treatment (83% vs. 92%; RR 0.90, 95% CI 0.84 to 0.97). There were no significant differences in quality of life. The incremental cost-effectiveness ratios at 6 and 12 months for inpatient treatment were £1,099,167 and £668,800 per additional QALY, respectively.

CONCLUSIONS

When treating women with AUB associated with uterine polyps, outpatient polypectomy was non-inferior to inpatient polypectomy at 6 and 12 months, and relatively cost-effective. However, patients need to be aware that failure to remove a polyp is more likely with outpatient polypectomy and procedure acceptability lower.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN 65868569.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 61. See the NIHR Journals Library website for further project information.

Cost-effectiveness of office hysteroscopy for abnormal uterine bleeding

Background and Objectives:

Office diagnostic hysteroscopy allows physicians to directly view the endometrial cavity, tubal ostia, and endocervical canal without taking the patient to the operating room (OR). We sought to determine whether office hysteroscopy performed to evaluate abnormal uterine bleeding decreases the need for hysteroscopy performed in the OR and the associated financial and risk implications.

Methods:

One hundred thirty patients who underwent office diagnostic hysteroscopy between January 2009 and March 2012 at 2 outpatient clinics in an academic university setting were identified. Records were reviewed from paper charts and electronic medical records. Hospital charts for patients who required hysteroscopy in the OR were reviewed as well. Charge estimates were obtained from our billing department. These results were analyzed for review of the data.

Results:

Seventy-five of the 130 women who underwent diagnostic office hysteroscopy for abnormal bleeding did not need to undergo hysteroscopy in the OR. This represents estimated savings of $1498 per patient (95% confidence interval, $1051–$1923) in procedure charges. Among the 55 women who underwent OR hysteroscopy, there was 71% agreement between findings on hysteroscopy in the office and in the OR.

Conclusion:

Office hysteroscopy is a useful diagnostic tool that can help decrease the rate of diagnostic hysteroscopy in the OR under anesthesia when used in a select patient population.

The evolving role of saline infusion sonography (SIS) in infertility

Saline infusion sonography (SIS) has become a valuable diagnostic modality in gynaecology over the last three decades. SIS is now commonly employed for detailed evaluation of the uterine cavity as part of pre-treatment assessment in infertile women. The objective of this paper is review the scientific literature on SIS in infertility. Medline, Ovid and Cochrane databases were searched for relevant articles. The indications, technical aspects and the potential advantages of SIS are discussed. The efficacy and sensitivity of SIS are compared to hysteroscopy in the evaluation of uterine polyps, fibroids, intrauterine adhesions and uterine anomalies. Increasing evidence suggests the use of SIS prior to an in-vitro fertilization (IVF) cycle as it has increased sensitivity in the detection of intrauterine pathology. SIS is cost-effective and results in better patient satisfaction scores than hysteroscopy.

Evaluation of sonohysterography in detecting endometrial polyps - 241 cases followed with office hysteroscopies combined with histopathological examination

Introduction

Hysteroscopy is considered the ‘gold standard’ procedure in assessing uterine pathology however it is more expensive and invasive method than ultrasonography. An alternative to the diagnostic hysteroscopy is sonohysterography.

Aim

To evaluate the usefulness of sonohysterography in detecting endometrial polyps in female patients diagnosed with infertility.

Material and methods

We compared the results of sonohysterographic examinations with hysteroscopy combined with histopathological findings.

Results

All the 241 sonohysterography examinations were performed successfully. No complications were observed. Forty-three hysteroscopies (17.8%) and six sonohysterography examinations (2.5%) were performed in short total intravenous anesthesia because of a low pain threshold of the patients. After hysteroscopic resection polyps were diagnosed in 74 (30.7%) patients. In 72 cases both saline infusion sonography (sonohysterography, SIS) examination and hysteroscopy confirmed the occurrence of an endometrial polyp. In 7 examinations (4.2%) the diagnosed polyp was not confirmed in sonohysterography (false-positive results). Two SIS procedures (2.7%) did not confirm the occurrence of the polyp (false-negative results). Sensitivity, specificity accuracy and error of sonohysterography in detecting endometrial polyps were 97.3%, 95.8% 96.2% and 3.7%, respectively. Positive and negative predictive values were 91.1% (PPV) and 98.7% (NPV). The agreement between SIS and hysteroscopy combined with histopathological examination was very high (K = 0.91).

Conclusions

Sonohysterography is a safe and highly sensitive and specific method used in diagnostics of endometrial polyps. Its results closely correspond to those obtained in a hysteroscopic examination and histopathological analysis.

A new diagnostic test for endometrial cancer?: Cytology analysis of sonohysterography distention media

OBJECTIVE

During saline-infused sonohysterography (SIS), the distension fluid is typically discarded. If cytology analysis could identify those patients with endometrial cancer, many women would be spared from further procedures.

METHODS

Thirty consecutive patients with clinical stage I or II endometrial adenocarcinoma were prospectively recruited preoperatively. Saline-infused sonohysterography was performed by instilling 5 mL of saline, withdrawing and sending for analysis. Saline was reinfused until complete SIS images were obtained and sent separately for cytology.

RESULTS

Of the 30 women enrolled, SIS was technically successful in 29. Demographics included mean age (60.5 ± 6.99 years), body mass index (35.55 ± 8.18 kg/m), endometrioid histology (76%), and grade (grade 1, 67%). Prestudy diagnostic method included biopsy (70%), dilatation and curettage (17%), and hysteroscopy (10%). Adequate cytology specimens were obtained in 66% of the 5 mL flushes and 72% of the complete SIS collections. Of adequate specimens, the sensitivities to detect endometrial cancer for the 5-mL, complete, and combined fluid samples were 26% (95% confidence interval, 9%-51%), 36% (17%-59%), and 42% (22%-63%). Sensitivity based on the whole study sample (N = 30) was 33% (17%-53%). Statistical significance was not found in the association between a positive test and age, body mass index, grade, diagnostic method, or volume instilled or aspirated.

CONCLUSIONS

Most patients with early endometrial cancer can undergo SIS procedures with adequate cytology specimens obtained from distention media. However, the sensitivity is low, and refinements are necessary before utilizing as a diagnostic test. In cases with positive results, the patient may be able to avoid other costly and painful procedures.