Can ultrasound-based investigations replace laparoscopy and hysteroscopy in infertility?

Two-dimensional hysterosalpingo-contrast-sonography compared to three/four-dimensional hysterosalpingo-contrast-sonography for the assessment of tubal occlusion in women with infertility/subfertility: a systematic review with meta-analysis

In this meta-analysis, we aimed to compare the diagnostic accuracy of 2D- and 3D/4D-HyCoSy for the assessment of tubal occlusion in women with infertility, using a laparoscopic tubal chromoperturbation dye test as the reference standard. Studies assessing 2D- and 3D/4D-HyCoSy for the assessment of tubal occlusion in women with infertility were searched from January 1990 to April 2019 using Medline and Web of Science databases by three of the authors, using the terms: 'hysterosalpingo-contrast-sonography', 'sonohysterosalpingography', 'HyCoSy', 'HyFoSy', 'three-dimensional', 'four-dimensional', 'ultrasound', 'tubal patency' and 'tubal occlusion'. Data quality was determined using the QUADAS-2 tool. Thirty articles were included; twenty-one studies used 2D-HyCoSy to assess tubal occlusion, six used 3D/4D-HyCoSy, one study used both techniques but in a different set of patients and two used both techniques in the same patients. The risk of bias for most studies was low as determined by QUADAS-2, except for the patient selection domain. Overall, pooled estimated sensitivity and specificity of 2D-HyCoSy were 86% (95% CI = 80%-91%) and 94% (95% CI = 90%-96%), respectively. The corresponding figures for 3D/4D HyCoSy were 95% (95% CI = 89%-98%) and 89% (95% CI = 82%-94%). High heterogeneity was found for both sensitivity and specificity. No statistically significant differences were found between the methods (p = 0.13). We concluded that 2D-HyCoSy has a similar diagnostic performance to 3D/4D-HyCoSy.

Comparison between findings of saline infusion sonohysterography and office hysteroscopy in patients with recurrent implantation failure

AIM:

This study aims to determine the accuracy of saline infusion sonohysterography (SIS) in the diagnosis of intrauterine pathologies in women with recurrent implantation failure (RIF).

SETTINGS AND DESIGN:

This is a prospective cross-over study which was carried out during the period between December 2013 and July 2014.

MATERIALS AND METHODS:

The study involved sixty subfertile women with a history of RIF. All cases underwent a transvaginal ultrasonography, SIS and then an office hysteroscopy (1 day after SIS) during early follicular phase. SIS was carried out by same sonographer, and then hysteroscopy was carried out by same gynecologist who was kept blind to findings at SIS.

STATISTICAL ANALYSIS:

Was done using IBM^© SPSS^© Statistics version 22. The sensitivity of SIS was calculated as it equals: True positive by SIS/all positive (true cases by hysteroscopy) and specificity was calculated as it equals: True negative by SIS/all negatives (normal by hysteroscopy).

RESULTS:

Overall uterine abnormalities were significantly less likely to be identified with SIS compared to hysteroscopy (P = 0.002), but analysis of each finding separately demonstrated a comparable difference between SIS and hysteroscopy (P > 0.05). We found that the sensitivity, specificity, positive predictive value, and negative predictive value of SIS to detect intrauterine pathology is 41.2%, 100%, 100%, and 81.1%, respectively.

CONCLUSION:

Our findings suggest a good role of SIS in the workup for RIF saving more invasive procedure for selected cases.

[Interest of laparoscopy in infertile couple with normal hysterosalpingography]

OBJECTIVES

The diagnostic laparoscopy has long been the key consideration in the export of female infertility. This place is being reconsidered, especially in the case of normal hysterosalpingogrophy (HSG), because of the advent of assisted reproductive technologies which are more efficient, and because of the improvement of medical imaging techniques which are more sensitive and specific. We wanted to clarify the place of the diagnostic laparoscopy in the balance of female infertility in normal HSG.

PATIENTS AND METHODS

It is a retrospective study on a series of 100 observations of infertile patients with a normal HSG and having a diagnostic laparoscopy in the department of Gynecology and Obstetrics at Farhat Hached hospital in Sousse (Tunisia) from 1st January 1993 to 1st March 2003.

RESULTS

The mean age was 32.3years; the mean duration of infertility was 70.47months. Laparoscopy revealed pelvic abnormalities in 45% of cases, dominated by disease tubo-adhesions (23%), endometriosis was found in 6% of cases. These anomalies are considered major in 23% of cases and minor in 22% of cases. Conducting a surgical procedure in the same operating time (adhesiolysis, tubal plastic surgery, electrocoagulation of endometriosis implants) could improve the prognosis of fertility. Only 20 patients were followed among the 45 with pelvic abnormalities, seven pregnancies have been completed (35% of cases).

DISCUSSION AND CONCLUSION

Laparoscopy has improved the prognosis for the fertility of our patients by treating abnormalities involved in infertility. It is estimated that the prognosis can be improved by selecting patients with risk factors for pelvic abnormalities.

[Should a laparoscopy be necessary in case of infertility with normal tubes at hysterosalpingography?]

The aetiological assessment of an infertile couple includes several complementary biological and morphological examinations. Initial exploration of the female genital tract requires the performance of pelvic ultrasound and hysterosalpingography. The value of systematic laparoscopy in infertility assessment is still subject to debate. The aim of the present review is to evaluate arguments against the systematic use of laparoscopy and to define the place of the other tests as Chlamydia Trachomatis serology, hysterosalpingosonography and MR-IRM. In our opinion, laparoscopy is of course indicated in infertility assessments not only when anomalies are revealed by hysterosalpingography but also in the following circumstances: past history of infection (especially a positive Chlamydia antibody blood test) and/or pelvic surgery (a significant risk of adhesions), unexplained secondary infertility, unexplained infertility after the age of 38 (when choosing between artificial insemination and direct enrolment in an IVF programme) and failure of 3 cycles of good-quality intra-uterine inseminations (with ovarian stimulation and a sufficient number of spermatozoids).

Infertility and the provision of infertility medical services in developing countries

BACKGROUND

Worldwide more than 70 million couples suffer from infertility, the majority being residents of developing countries. Negative consequences of childlessness are experienced to a greater degree in developing countries when compared with Western societies. Bilateral tubal occlusion due to sexually transmitted diseases and pregnancy-related infections is the most common cause of infertility in developing countries, a condition that is potentially treatable with assisted reproductive technologies (ART). New reproductive technologies are either unavailable or very costly in developing countries. This review provides a comprehensive survey of all important papers on the issue of infertility in developing countries.

METHODS

Medline, PubMed, Excerpta Medica and EMBASE searches identified relevant papers published between 1978 and 2007 and the keywords used were the combinations of 'affordable, assisted reproduction, ART, developing countries, health services, infertility, IVF, simplified methods, traditional health care'.

RESULTS

The exact prevalence of infertility in developing countries is unknown due to a lack of registration and well-performed studies. On the other hand, the implementation of appropriate infertility treatment is currently not a main goal for most international non-profit organizations. Keystones in the successful implementation of infertility care in low-resource settings include simplification of diagnostic and ART procedures, minimizing the complication rate of interventions, providing training-courses for health-care workers and incorporating infertility treatment into sexual and reproductive health-care programmes.

CONCLUSIONS

Although recognizing the importance of education and prevention, we believe that for the reasons of social justice, infertility treatment in developing countries requires greater attention at National and International levels.

The validity of air and saline hysterosalpingo-contrast sonography in tubal patency investigation before insemination treatment

OBJECTIVE

To compare the prognostic significance of tubal patency investigation by means of laparoscopy, hysterosalpingo-contrast sonography (HyCoSy) with air and saline as a contrast medium, and hysterosalpingography (HSG) in relation to the outcome of intrauterine insemination (IUI) treatment.

STUDY DESIGN

A retrospective study of 559 consecutive women attending the university hospital infertility clinic for infertility treatment in 1996-2003. Tubal patency was evaluated by laparoscopy in 261 women, by HyCoSy in 217 and by HSG in 81 women before insemination treatment. Altogether, 1240 insemination cycles were evaluated and the results were compared in the three study groups.

RESULTS

The clinical pregnancy rates per cycle were 14%, 18% and 18% in the laparoscopic, HyCoSy and HSG groups, with no statistically significant difference between the groups. The cumulative pregnancy rates (mean 2.3 cycles) were 30%, 41% and 38%, respectively, with a significant difference between the study groups. In cases of unilateral patency, cumulative pregnancy rates after two cycles were 18% (laparoscopy), 29% (HyCoSy) and 29% (HSG). The numbers of tubal pregnancies were similar in the subgroups.

CONCLUSIONS

Hysterosalpingo-contrast sonography with air and saline as a contrast medium is a very cost-effective tubal investigation method as regards selection of subjects for insemination.

Affordable IVF for developing countries

Worldwide, more than 80 million couples suffer from infertility; the majority are residents of developing countries. Residents of developing countries encounter a lack of facilities at all levels of health care, but especially infertility diagnosis and treatment. Infertility defined as a disease has a much stronger negative consequence in developing countries compared with Western societies. Social isolation, economic deprivation and violence are commonly observed. Tubal infertility due to sexually transmitted diseases, unsafe abortion and post-partum pelvic infections are the main causes of infertility in developing countries. Very often those conditions are only treatable by assisted reproductive technologies. Although preventative measures are undoubtedly the most cost-effective approach, not offering assisted reproduction is not an alternative. This study proposes a specially designed infertility care programme leading to cost-effective simplified assisted reproduction as a valid treatment protocol in developing countries when prevention or alternative methods have failed. Special attention should be given to avoid adverse outcomes such as ovarian hyperstimulation and multiple embryo pregnancy.

ECHOVIST-200 enhanced hystero-sonography

Tubal occlusion is one of the most common causes of infertility. Therefore, examination of tubal patency is a very important diagnostic tool. Our aim was to determine whether hysterosalpingo-contrast sonography is able to show tubal patency, whether it has any side effects and what role this technique may have in the future. Echovist-200 hysterosalpingo-contrast sonographic examinations have been used in our service in 195 cases since 1998. We found tubal patency in 157 cases (84.4%), and unilateral or bilateral occlusions in 34 instances (12.5%). In four cases we could not visualize the tubes because they were too long. In the last mentioned cases we performed a laparascopy-dye test for the control of our results. The most common side effect during the check-up procedure was abdominal pain. This the patients tolerated well. We did not experience any other serious side effect. Comparing our results with those reported from abroad, we found them similar to the latter. According to our experience, the HyCoSy method for the evaluation of infertility is quick and well tolerated.

The cost of out-patient culdoscopy compared to in-patient laparoscopy in women with infertility

Diagnostic laparoscopy is a common procedure performed in many hospitals worldwide to investigate infertile women. However, morbidity and cost prevent it being considered a first-line diagnostic tool. If out-patient culdoscopy could replace in-patient laparoscopy then a major component of the cost of investigations could be avoided. We studied ten consecutive infertile patients who had laparoscopy under general anaesthesia and another ten patients who had culdoscopy under local anaesthesia in The One Stop Fertility Clinic (OSFC) in The Royal Free Hospital in London. The costs for each patient from both groups was calculated and compared. We found that out-patient investigation in an OSFC produced a saving of over 350 pounds sterling per case or 28% to the hospital compared with in-patient investigation. Although there were other factors which may influence the costs of out-patient culdoscopy, it did provide noticeable savings to the healthcare system.

An ultrasound-based approach to the assessment of infertility, including the evaluation of tubal patency

An optimal initial infertility investigation protocol would be a process that is diagnostically accurate, expeditious, cost-effective, reliable and as minimally invasive as possible. In addition, the investigation should provide the clinician with useful prognostic information regarding possible future treatment. At present, extensive use of invasive procedures such as diagnostic hysteroscopy and laparoscopy is the standard at many fertility centres. Recent advances in gynaecological ultrasonography have shown that ultrasound can replace routine invasive investigative procedures. An ultrasound-based approach would make the basic infertility investigation less time-consuming and less expensive, but at the same time more acceptable to the majority of patients. This chapter describes an ultrasound-based approach to the assessment of infertility. In addition, the role of ultrasonography for assessment of the pelvic organs as a basic part of the initial investigation of an infertile couple is discussed and compared to more traditional invasive methods.

Intrauterine insemination results are not affected if Hysterosalpingo Contrast Sonography is used as the sole test of tubal patency

OBJECTIVE

To assess whether women can be assigned to intrauterine insemination (IUI) treatment on the basis of fallopian tubal patency, diagnosed by Hysterosalpingo Contrast Sonography (Hy Co Sy).

DESIGN

Case controlled, clinical study.

SETTING

Tertiary referral center.

PATIENT(S)

The cases were consecutive, infertile women who underwent Hy Co Sy and IUI. The control group was women who had IUI over the same period but whose tubal patency was assessed by hysterosalpingogram (HSG) or laparoscopy and dye (lap and dye).

INTERVENTION(S)

Women with bilateral patency at Hy Co Sy and with unexplained, anovulatory, or male factor infertility underwent IUI using the partner's (IUI-H) or donor's (IUI-D) semen. Their outcome was compared with that of cohorts of women who had been examined using HSG or lap and dye.

MAIN OUTCOME MEASUREMENT(S)

Clinical pregnancy rate per cycle and cumulative pregnancy rates at IUI-H or IUI-D.

RESULT(S)

The clinical pregnancy rates per cycle at IUI-H or IUI-D did not differ among the three groups. The cumulative pregnancy rates after three cycles of IUI-H were 0.17, 0.15, and 0.17 in the Hy Co Sy, HSG, and lap and dye cohorts, respectively, and 0.69, 0.77, and 0.54 in the same groups after six cycles of IUI-D. There were no differences in the clinical characteristics or stimulation regimes used.

CONCLUSION(S)

Women screened as "normal" by Hy Co Sy may be allocated to treatments that rely on accurate assessment of tubal patency without compromising their chance of conception.

Advances in the assessment of the uterus and fallopian tube function

Hysterosalpingo-contrast-sonography (HyCoSy) using saline and Echovist is a well tolerated outpatient technique that provides a significant amount of information of relevance to the infertile woman that is not obtainable at hysterosalpingogram (HSG) whilst avoiding exposure to X-ray irradiation. When performed by experienced operators, it serves as a valuable, first-line screening test for the more invasive procedures of laparoscopy and dye chromopertubation and hysteroscopy. If detailed diagnostic information is required in women in whom there is no clinical or ultrasound evidence of pelvic pathology, the surgical technique of fertiloscopy can be considered to be appropriate. This technique permits confirmation that the ovum pick-up mechanism is normal, the tubes are patent and the uterine cavity is normal, while salpingoscopy and microsalpingoscopy permit the assessment of the tubal lumen.

Investigation of the infertile couple: a one-stop ultrasound-based approach

The appropriateness of many investigations for subfertility will continue to be of debate for some time yet. Of most benefit to the concerned couple would be a process that is diagnostically accurate, expeditious and reliable. It should be performed with a minimum of invasion and provide both patient and clinician with useful prognostic information regarding possible future treatment. This article is intended to illustrate the advantages of an ultrasound-based process of subfertility investigation. Discussed is the role of ultrasound compared with more invasive investigative methods such as laparoscopy and hysteroscopy. In addition, the potential capacity of newer advanced ultrasound technologies is reviewed.