Hysterosalpingo-contrast-sonography vs. magnetic resonance-hysterosalpingography for diagnosing fallopian tubal patency: A systematic review and meta-analysis

Effect of radiation on serum anti-Müllerian hormone during hysterosalpingography in female infertility

RESEARCH QUESTION

Does radiation exposure during hysterosalpingography (HSG) negatively affect serum anti-Müllerian hormone (AMH) levels in infertile women?

DESIGN

Prospective cohort study conducted at Songklanagarind Hospital, Thailand, between April 2021 and May 2023. Thirty-two infertile women and 34 control participants were enrolled. Serum AMH levels were assessed in the infertile group at baseline before the HSG procedure and at 1 and 3 months after the procedure. Control participants, who self-reported no medical conditions, underwent the same AMH level assessments. Changes in serum AMH levels were compared.

RESULTS

Infertile women had a mean age of 32.4 ± 3.8 years, body mass index of 21.2 ± 2.0 kg/m2 and baseline mean AMH level of 3.66 ng/ml (95% CI 3.00 to 4.32), which did not significantly differ from the control group. One month after HSG, mean AMH level significantly declined (0.33 ng/ml, 95% CI -0.65 to -0.01; P = 0.045) in the infertile group. The change in serum AMH levels between baseline and 1 month was significantly different in the HSG group compared with controls (-0.33 ng/ml, 95% CI -0.65 to -0.01 versus 0.36 ng/ml, 95% CI 0.06 to 0.67; P = 0.002). Changes in serum AMH levels from baseline to 3 months did not differ between the two groups.

CONCLUSIONS

One month after the HSG, infertile women experienced a significant decrease in serum AMH levels compared with controls. The change in serum AMH levels between baseline and 3 months after HSG did not significantly differ from that of the control group.

The definition of unexplained infertility: A systematic review

BACKGROUND

There is no consensus on tests required to either diagnose unexplained infertility or use for research inclusion criteria. This leads to heterogeneity and bias affecting meta-analysis and best practice advice.

OBJECTIVES

This systematic review analyses the variability of inclusion criteria applied to couples with unexplained infertility. We propose standardised criteria for use both in future research studies and clinical diagnosis.

SEARCH STRATEGY

CINAHL and MEDLINE online databases were searched up to November 2022 for all published studies recruiting couples with unexplained infertility, available in full text in the English language.

DATA COLLECTION AND ANALYSIS

Data were collected in an Excel spreadsheet. Results were analysed per category and methodology or reference range.

MAIN RESULTS

Of 375 relevant studies, only 258 defined their inclusion criteria. The most commonly applied inclusion criteria were semen analysis, tubal patency and assessment of ovulation in 220 (85%), 232 (90%), 205 (79.5%) respectively. Only 87/220 (39.5%) studies reporting semen analysis used the World Health Organization (WHO) limits. Tubal patency was accepted if bilateral in 145/232 (62.5%) and if unilateral in 24/232 (10.3%). Ovulation was assessed using mid-luteal serum progesterone in 115/205 (56.1%) and by a history of regular cycles in 87/205 (42.4%). Other criteria, including uterine cavity assessment and hormone profile, were applied in less than 50% of included studies.

CONCLUSIONS

This review highlights the heterogeneity among studied populations with unexplained infertility. Development and application of internationally accepted criteria will improve the quality of research and future clinical care.

Evaluation of tubal patency by hysterosalpingo-contrast Sonography (HyCoSy): Controversies, dilemmas and considerations

Evaluation of tubal patency is one of the vital steps in the process of female infertility management. Hysterosalpingo-contrast Sonography (HyCoSy) has become the first-line recommendation for evaluating tubal patency. However, there remain some controversies and dilemmas relevant to the evaluation of tubal patency by HyCosy, with no effective solution has been proposed or no consensus has been reached. Herein, combined with previous research and clinical experience, we conclude and analyze these controversies and dilemmas, aiming at offering our perspective on the opportunities and challenges which are faced by HyCosy.

Risk Factors of Contrast Agent Intravasation With Sulfur Hexafluoride Microbubble During Hysterosalpingo-Contrast Sonography

OBJECTIVES

To analyze the risk factors of sulfur hexafluoride microbubble contrast agent intravasation during hysterosalpingo-contrast sonography (HyCoSy), and to explore a simple prediction model by the obvious clinical history.

METHODS

This was a retrospective study included 299 infertility women who had undergone HyCoSy examination from July 1, 2018 to June 31, 2019. The factors were recorded, including age, endometrial thickness, balloon length, infertility type, history of intrauterine surgery, history of pelvic surgery, and tubal patency. The method of multivariate logistic regression analysis was adopted to analyze the risk factors affecting the contrast agent intravasation, and the receiver operating characteristic curves were plotted to test their efficacy.

RESULTS

Secondary infertility, a history of intrauterine surgery, thin endometrial thickness, and tubal obstruction were all risk factors of the occurrence of intravasation (P < .05). And the area under the receiver operating characteristic curves of the multifactor-combined prediction model of the intravasation was significantly larger than that of single-factor.

CONCLUSIONS

Sonographers and gynecologists should be familiar with the risk factors of intravasation and select the appropriate timing of HyCoSy toward reducing the occurrence of intravasation and other complications after thoroughly explaining and communicating with the patients.

The Diagnostic Value of Laparoscopy for the Evaluation of Patent but Abnormal Tubes on Hysterosalpingography

Objective: The diagnostic value of hysterosalpingography (HSG) findings suggestive of subtle tubal pathologies is controversial. The gold standard method to evaluate the fallopian tubes is laparoscopy. The aim of this study is to explore the laparoscopic findings of patients with abnormal findings but patent tubes detected on HSG. Methods: The study population included infertile women undergoing laparoscopy for further evaluation of abnormal tuba-related findings on HSG. The HSG views were evaluated for the presence of tubal patency and the convoluted tubes, loculation of the dye in the peritubal area, tubal ectasia, and fimbrial phimosis. The type and frequency of pelvic pathologies detected on laparoscopic examination and the predictive value of patent but abnormal fallopian tube finding on HSG were analyzed. Results: A total of 73 laparoscopy cases were eligible. Of these, 18 (25%) had normal laparoscopic findings. In 75% of the cases, there was at least one pelvic pathology detected during laparoscopy. The most common pelvic pathology detected was tubal adhesions. Tubal adhesions were detected in 21 cases (29%). Fimbrial phimosis was detected in 11 cases (13%). Paratubal cysts were detected in 7 cases (10%). Conclusion: While evaluating a HSG, focusing only on tubal patency may result in the failure of detecting subtle tubal pathologies. Clinicians should be familiar with abnormal HSG findings suggestive of tubal abnormalities. Careful examination of the HSG views regarding other tubal pathologies is warranted as these subtle conditions may impair fertility and laparoscopic correction of these pathologies has a positive impact on fertility.

Is Hysterosalpingo-Contrast Sonography (HyCoSy) Using Sulfur Hexafluoride Microbubbles (SonoVue) Sufficient for the Assessment of Fallopian Tube Patency? A Systematic Review and Meta-Analysis

This study aimed to evaluate the diagnostic value of HyCoSy using sulfur hexafluoride microbubbles for fallopian tubal patency assessment in infertile females. Twenty-four studies, including 1358 females with 2661 detected fallopian tubes published from January 2003 to May 2019, were identified. The pooled sensitivity was 93% (95% CI: 90-95%), while the specificity was 90% (95% CI: 87-92%). The area under the receiver-operating characteristic curve was 0.96 (95% CI: 94-98%). The specificity of the four-dimensional HyCoSy subgroup was higher than the 2D/3D subgroup; an increased dose of contrast agent did not affect the specificity, with only a slightly reduced sensitivity.

Comparison of Effectiveness as well as Advantages and Disadvantages of Different Dimensions of Hysterosalpingo-Contrast Sonography for Diagnosis of Lesions Associated with Female Infertility

Methods

Forty subjects who underwent routine two-dimensional (2D) vaginal ultrasound, three-dimensional HyCoSy (3D-HyCoSy), and four-dimensional HyCoSy (4D-HyCoSy) examinations from January 2021 to July 2022 at the ultrasound department of Pukou Branch of Jiangsu Province Hospital were enrolled to this study. Fallopian tubal recanalization by hydrotubation (FTRH) was used as the gold standard to compare the efficacy of 2D vaginal ultrasound, 3D-HyCoSy, and 4D-HyCoSy in assessing the subjects for the presence of polyps, myomas, and other occupants in the uterine cavity or uterine adhesions.

Results

A total of 18 cases of uterine cavity lesions, 11 of pelvic lesions, and 11 of ovarian lesions were identified by FTRH, while 80 fallopian tubes were found in 40 patients and 71 tubal obstructions were detected by FTRH. Vaginal ultrasound assessment of uterine cavity, pelvis, ovarian lesions, and tubal obstruction was moderately consistent with FTRH (Kappa = 0.616, 0.673, 0.654, and 0.640), 3D-HyCoSy was in good agreement with FTRH (Kappa = 0.812, 0.910, 0.906, and 0.894), and 4D-HyCoSy was in good agreement with FTRH (Kappa = 0.914, 0.903, 1.000, and 0.942), with 4D-HyCoSy being in good agreement with FTRH had the highest agreement.

Conclusion

4D-HyCoSy can be used as an effective tool for clinical diagnosis of female tubal obstruction infertility and provide a reference basis for the design of subsequent clinical treatment plans.

Comparation of magnetic resonance hysterosalpingography and hysterosalpingosonography for the assessment of fallopian tubal occlusion of female infertility: A protocol for systematic review and meta-analysis

OBJECTIVE

To evaluate the diagnostic performance of magnetic resonance hysterosalpingography (MR-HSG) for fallopian tubal occlusion in the context of female infertility when compared to the diagnostic performance of hysterosalpingosonography in evaluation of fallopian tubal occlusion of female infertility.

METHODS

We will search PubMed, Web of Science, Cochrane Library, and Chinese biomedical databases from their inceptions to the October 31, 2021, without language restrictions. Two authors will independently carry out searching literature records, scanning titles and abstracts, full texts, collecting data, and assessing risk of bias. Review Manager 5.2 and Stata14.0 software will be used for data analysis.

RESULTS

This systematic review will investigate whether MR-HSG has more diagnostic value than hysterosalpingosonography in evaluation of fallopian tubal occlusion of female infertility.

CONCLUSION

Our meta-analysis indicated MR-HSG may serve as an alternative for further evaluation of fallopian tubal occlusion of female infertility.

SYSTEMATIC REVIEW REGISTRATION

INPLASY2021110050.

The Performance of Transvaginal Two-Dimensional Fundamental Sonosalpingography Combined with Saline Infusion Pelvic Sonosalpingography for Assessing Fimbrial Part's Morphology and Function of the Fallopian Tubes

OBJECTIVES

The purpose of this study was to evaluate the diagnostic efficacy of transvaginal two-dimensional fundamental sonosalpingography (2D-FS) combined with saline infusion pelvic sonosalpingography (SIPS) for assessing fimbrial part's morphology and function of the fallopian tubes.

METHODS

One hundred and sixty-nine cases underwent 2D-FS combined with SIPS. Among them, 18 cases received laparoscopy and dye test (LDT) within 3 months after the examination and the results were regarded as reference standard.

RESULTS

Excluding proximal or middle segment obstructed tubes, the remaining fimbrial parts' display rate by using 2D-FS combined with SIPS was 75.1%. According to the ultrasonic appearance, the fimbrial parts were classified into 4 types: normal, abnormal, suspected abnormal, and unclassifiable. Normal fimbrial parts accounted for 73.8% when the tubes were patent; abnormal fimbrial parts accounted for 74.1% when the tubes were partial obstructed; all became abnormal when the tubes were distal complete obstructed. The fimbrial parts which had been classified by 2D-FS combined with SIPS were compared with LDT further. This combination's accuracy (ACC), sensitivity (SEN), specificity (SPE), positive predictive value (PPV), negative predictive value (NPV), and Youden's index (YI) were 86.4, 87.5, 85.7, 77.8, 92.3, and 0.73%, respectively. The result of consistency analysis showed the combination was essentially consistent with LDT result (Kappa = 0.713).

CONCLUSION

2D-FS combined with SIPS can be a preferred method for assessment of the fimbrial part's morphology and function, with its advantages of non-invasive, intuition, and accuracy. This combination could provide an objective imaging basis for choosing clinical treatment strategies and predicting prognosis.

Comparison between X-ray-hysterosalpingography and 3 Tesla magnetic resonance-hysterosalpingography in the assessment of the tubal patency in the cause of female infertility

OBJECTIVES

XR-hysterosalpingography currently represents the gold standard for tubal pathology evaluation. Magnetic resonance-HSG is an innovative technique. With our study, we aim to comprehend if and how MR-HSG, compared to traditional XR-HSG, could give us this additional information in the diagnostic/therapeutic process.

MATERIALS AND METHODS

This study included 19 patients between 30 and 42 years old (average age 37.7) affected by infertility. Patients underwent contextually both XR-HSG and MR-HSG, using a single catheterization. The dynamic MR-HSG exam consisted a MR sequence during contrast administration through the cervical catheter.

RESULTS

Both XR-HSG and MR-HSG documented that 15 of the 19 patients had bilateral tubal patency, while four patients had monolateral tubal patency. However, MR-HSG allowed us to diagnose additional findings: Two active endometriosis foci in adnexal localization and a condition of adenomyosis A unicornuate uterus malformation A submucous uterine myoma near the tubal ostium A decrease of the ovarian reserve in a patient So MR-HSG could potentially detect in 10/19 (52%) women the cause of their infertility, compared to 4/19 (21%) detected with XR-HSG and about 30% of women would have resulted as false negatives if we only used XR-HSG. Finally, with a questionnaire, we demonstrated that MR-HSG is less painful than XR-HSG.

CONCLUSIONS

These data thus confirm that XR-HSG and MR-HSG present the same diagnostic of assessing tubal patency. We also demonstrated that MR-HSG is able to detect further collateral findings that could likewise be a possible therapeutic target and it could possibly become the new gold standard in female infertility diagnostics.

Comparison of Hysterosalpingography With Laparoscopy in the Diagnosis of Tubal Factor of Female Infertility

Background: Laparoscopy is considered to be the gold standard in the evaluation of causes leading to infertility. Hysterosalpingography (HSG) permits indirect visualization of the cervical canal, uterine cavity, and tube patency, which is helpful for evaluating the causes of infertility.

Objective: This study aimed to detect tubal abnormalities in infertile women by HSG or laparoscopy and determine the value of HSG in diagnosing fallopian tube status.

Methods: The study group consisted of 1,276 patients. HSG was performed as a preliminary test for the evaluation of fallopian tube status. Women were subjected to laparoscopic examination on evidence of HSG abnormalities.

Results: The negative predictive value of HSG for detecting patency or occlusion for the right/left tube was 92.08 and 95.44%, respectively. The kappa values for the consistent diagnosis in the right/left tube were 0.470 and 0.574, respectively. In cases of low patency of the right/left tube, there was a greater than a 40% chance for the tube to be patent, and the remaining high probability was pelvic adhesion. The positive predictive value of HSG for detecting patency or occlusion for both tubes was 87.2%. The kappa value was 0.898 [95% CI (0.838, 0.937), p < 0.001], which meant that the diagnostic accuracy of HSG for both tube patency/occlusion was explicit. The kappa value for the diagnosis of hydrosalpinx (especially for bilateral tube hydrosalpinx) was 0.838 [95% CI (0.754, 0.922), p < 0.001], and the diagnostic accuracy for HSG was 79.8, 67.9, and 72.4%, respectively.

Conclusion: The current study concluded that HSG is a good diagnostic modality to detect tube abnormalities in infertile patients. HSG and laparoscopy are complementary to each other and whenever the patient is undertaken for diagnosis of infertility. Cost-effective HSG had good predictive value in identifying tubal factor infertility.

Clinical Significance of Increasing Pressure Curve's Slope When Injecting Ultrasound Contrast Agent During Evaluation of Fallopian Tubal Patency

OBJECTIVE

To explore the association between Fallopian tubal patency and the slope of the increasing pressure curve for ultrasound contrast agent.

MATERIALS AND METHODS

A total of 136 patients underwent transvaginal 4-dimensional hysterosalpingo-contrast sonography (TVS 4D HyCoSy) between August 2015 and January 2016. We divided the patients into 3 groups according to different Fallopian tubal patency status: 71 patients (48.97%) in bilateral tubal patency group, 45 (31.03%) in unilateral tubal patency group, and 20 in bilateral tubal nonpatent group. The ultrasound contrast agent was injected and the pressure curve was recorded automatically in real time using a liquid-injecting machine that traces it as a pressure curve. The slopes of the different groups are compared through independent sample t test.

RESULTS

The slopes of the 3 groups were 1.242 ± 0.572, 1.472 ± 0.638, and 2.068 ± 1.236 kPa/s. A correlation was observed between the slope of the increasing pressure curve and tubal patency (R = 0.287, P < .05). The slopes differed significantly between the bilateral tubal patency group and bilateral tubal nonpatent group (P = .001) and between the unilateral tubal patency group and bilateral tubal nonpatent group (P = .012). However, the difference between the bilateral tubal patency and unilateral tubal patency groups was not significant (P = .266).

CONCLUSION

The increase of the injecting pressure curve's slope for contrast agent during 4D HyCoSy is associated with the nonpatent degree of the tube. This condition can be used as an objective index of tubal patency and can be a reference in diagnosis and treatment.

Evaluating Fallopian Tube Patency: What the Radiologist Needs to Know

Impaired tubal patency accounts for up to 35% of cases of subfertility and infertility. Hysterosalpingography (HSG) or hysterosalpingo-contrast sonography (HyCoSy) represents a first-line test in evaluating fallopian tube patency. Despite the association of HSG with ionizing radiation, HSG is a reference standard in assessing fallopian tube patency and tubal conditions such as tubal occlusion, salpingitis isthmica nodosa, and hydrosalpinx. HSG is widely available and utilizes either a water-soluble contrast medium (WSCM) or an oil-soluble contrast medium (OSCM). Compared with WSCM, HSG with OSCM results in a higher incidence of non-in vitro fertilization pregnancies and, therefore, may be preferred in women younger than 38 years with unexplained subfertility. HSG may also be helpful in assessment after sterilization or before fallopian tube recanalization. US-based tubal tests are free of ionizing radiation and include HyCoSy, with either air-saline or microbubble US contrast material, and hysterosalpingo-foam sonography (HyFoSy), a tubal patency test that utilizes a gel foam. A comprehensive US infertility evaluation of the pelvis and fallopian tubes can be achieved in one setting by adding coronal three-dimensional imaging of the uterus, saline infusion sonohysterography, and HyCoSy or HyFoSy to routine pelvic US. MR HSG and virtual CT HSG also depict tubal patency and uterine and adnexal pathologic conditions and may be considered in select patients. While laparoscopic chromopertubation remains the standard for tubal patency evaluation, its disadvantages are its invasiveness and cost. Knowledge of the different fallopian tube tests and radiologic appearance of normal and abnormal fallopian tubes results in fewer pitfalls, accurate interpretation, and optimal patient care. Online supplemental material is available for this article. ^©RSNA, 2021.

Contrast-enhanced ultrasound using SonoVue mixed with oral gastrointestinal contrast agent to evaluate esophageal hiatal hernia: Report of three cases and a literature review

BACKGROUND

Due to a thicker abdominal wall in some patients, ultrasound artifacts from gastrointestinal gas and surrounding tissues can interfere with routine ultrasound examination, precluding its ability to display or clearly show the structure of a hernial sac (HS) and thereby diminishing diagnostic performance for esophageal hiatal hernia (EHH). Contrast-enhanced ultrasound (CEUS) imaging using an oral agent mixture allows for clear and intuitive identification of an EHH sac and dynamic observation of esophageal reflux.

CASE SUMMARY

In this case series, we report three patients with clinically-suspected EHH, including two females and one male with an average age of 67.3 ± 16.4 years. CEUS was administered with an oral agent mixture (microbubble-based SonoVue and gastrointestinal contrast agent) and identified a direct sign of supradiaphragmatic HS (containing the hyperechoic agent) and indirect signs [e.g., widening of esophageal hiatus, hyperechoic mixture agent continuously or intermittently reflux flowing back and forth from the stomach into the supradiaphragmatic HS, and esophagus-gastric echo ring (i.e., the “EG” ring) seen above the diaphragm]. All three cases received a definitive diagnosis of EHH by esophageal manometry and gastroscopy. Two lesions resolved upon drug treatment and one required surgery. The recurrence rate in follow-up was 0%. The data from these cases suggest that the new non-invasive examination method may greatly improve the diagnosis of EHH.

CONCLUSION

CEUS with the oral agent mixture can facilitate clear and intuitive identification of HS and dynamic observation of esophageal reflux.

Evaluation of hysterosalpingographic findings among patients presenting with infertility

Background

Infertility is a global health issue and hysterosalpingography (HSG) is a valuable radiological tool in infertility workup and remains a main modality for investigating female infertility. However, the HSG findings of infertility are not the same worldwide.

This study aimed at evaluating the incidence of HSG findings in patients investigated for primary and secondary infertility, correlating these findings with their clinical data that reflect the infertility causes and comparing the findings with previous international studies.

Methods

A prospective descriptive study of 75 female patients referred, as cases of infertility, for HSG examination in Elrebat Hospital and Khartoum Advanced Diagnostic Center. HSG was performed in the first half of the cycle. The procedure and its complications, were explained to the patients and informed consents were obtained. Patients with active pelvic infection and active uterine or vaginal bleeding were excluded from the study. Using aseptic technique and with proper patient’s positioning, iodinated contrast was introduced into the cervix under fluoroscopic monitoring, to demonstrate the uterine cavity, fallopian tubes and free spillage into the peritoneal cavity. Personal data, clinical data and HSG findings were analyzed using SPSS version 23.

Results

The commonest age group seen was 26–36 years. Close incidences of primary and secondary infertility were detected. 52.7% had abnormal findings in HSG. Tubal pathology (42.7%) being the most common abnormality, followed by uterine and combined abnormalities. There was strong association between past medical history suggesting pelvic inflammatory disease (PID) or past history suggesting tubal blockage secondary to abdominopelvic surgery and tubal abnormalities.

Conclusion

HSG examinations revealed that the most common abnormality was tubal blockage possibly complicating PID and abdominopelvic surgeries. This reflects the HSG diagnostic and therapeutic role in the assessment of female infertility and the further needs for more preventive measures targeting the reduction of tubal pathologies in developing countries.