Tuboovarian Abscess after Saline Infusion Sonohysterography: An Unusual Complication

Case series of tubo-ovarian abscesses after saline infusion sonohysterography: reconsidering antibiotic prophylaxis

Saline infusion sonohysterography (SIS) is useful for evaluating intrauterine pathology, particularly for patients with abnormal uterine bleeding and during assessment of infertility. Infectious complications are relatively rare, and tubo-ovarian abscess (TOA) after SIS has only been reported once in the literature. We present two additional cases of TOA after SIS that presented to our institution. First, a 40-year-old female with known endometriosis and bilateral tubal occlusion, presented with ruptured TOA fifteen days after SIS during fertility evaluation. The second, a 45-year-old female with endometriomas and a hydrosalpinx identified on SIS, diagnosed with TOAs four days after SIS for abnormal uterine bleeding evaluation. While hysterosalpingogram has defined antibiotic prophylaxis criteria, and despite likely similar mechanisms for ascending infections, current guidelines do not recommend prophylaxis after SIS. These cases suggest infectious complications, such as TOA, after SIS may be more common than previously reported, and as demonstrated by these cases can have serious clinical consequences for patients. Furthermore, by comparing to a technically similar procedure as HSG, it may be reasonable to consider if certain patients at high risk of complication may benefit from antibiotic prophylaxis to prevent serious clinical infections.

Antibiotic Prophylaxis for Gynecologic Procedures prior to and during the Utilization of Assisted Reproductive Technologies: A Systematic Review

The use of assisted reproductive technologies (ART) has increased steadily. There has been a corresponding increase in the number of ART-related procedures such as hysterosalpingography (HSG), saline infusion sonography (SIS), hysteroscopy, laparoscopy, oocyte retrieval, and embryo transfer (ET). While performing these procedures, the abdomen, upper vagina, and endocervix are breached, leading to the possibility of seeding pelvic structures with microorganisms. Antibiotic prophylaxis is therefore important to prevent or treat any procedure-related infections. After careful review of the published literature, it is evident that routine antibiotic prophylaxis is generally not recommended for the majority of ART-related procedures. For transcervical procedures such as HSG, SIS, hysteroscopy, ET, and chromotubation, patients at risk for pelvic infections should be screened and treated prior to the procedure. Patients with a history of pelvic inflammatory disease (PID) or dilated fallopian tubes are at high risk for postprocedural infections and should be given antibiotic prophylaxis during procedures such as HSG, SIS, or chromotubation. Antibiotic prophylaxis is recommended prior to oocyte retrieval in patients with a history of endometriosis, PID, ruptured appendicitis, or multiple prior pelvic surgeries.

Surgical Management of Endometrial Polyps in Infertile Women: A Comprehensive Review

Endometrial polyps are benign localized lesions of the endometrium, which are commonly seen in women of reproductive age. Observational studies have suggested a detrimental effect of endometrial polyps on fertility. The natural course of endometrial polyps remains unclear. Expectant management of small and asymptomatic polyps is reasonable in many cases. However, surgical resection of endometrial polyps is recommended in infertile patients prior to treatment in order to increase natural conception or assisted reproductive pregnancy rates. There is mixed evidence regarding the resection of newly diagnosed endometrial polyps during ovarian stimulation to improve the outcomes of fresh in vitro fertilization cycles. Hysteroscopy polypectomy remains the gold standard for surgical treatment. Evidence regarding the cost and efficacy of different methods for hysteroscopic resection of endometrial polyps in the office and outpatient surgical settings has begun to emerge.

Saline instillation sonohysterography test after normal baseline transvaginal sonography results in infertility patients. Is it justified?

PURPOSE

To investigate whether there is additional value for saline instillation sonohysterography (SIS) as a routine screening tool when baseline transvaginal sonography (TVS) is normal.

METHODS

Two-hundred ninety four infertility patients underwent baseline TVS and were categorised according to the results. TVS findings were negative in study group (n = 124) and positive (any abnormalities) in control group (n = 170). All the patients were further investigated by SIS. Hysteroscopy was performed whenever SIS results were suspicious. Our main outcome measure was accuracy of SIS in detecting intracavitary lesions using pathology reports as gold standard.

RESULTS

In the study group, out of 124 SIS tests, 13 (10.4%) showed positive findings and were further investigated by hysteroscopy. Three out of the 13 (23.0%) had subsequent positive hysteroscopy findings, however, no (0.0%) abnormality was found on pathologic examination. In the control group, out of 170 SIS tests, 62 (36.4%) showed positive findings, and were further investigated by hysteroscopy. Forty-two cases out of the 62 (67.7%) had subsequent positive hysteroscopic findings. Pathological examination was positive in 35 out of the 42 (83.3%) positive hysteroscopies.

CONCLUSION

Routine SIS for patients with normal TVS did not contribute additional findings. However, in patients with any suspicious findings on TVS (including extracavitary lesions), SIS was beneficial.