Technology assessment of saline contrast hysterosonography

Diagnostic value of saline infusion sonohysterography for detecting endometrial focal lesion

Introduction

Different diagnostic tools are available to evaluate endometrial focal lesion such as hysteroscopy, sonohystrography and transvaginal ultrasound. The present study aimed to determine the diagnostic value of saline infusion sonohystrography (SIS) in diagnosis of intrauterine lesions in women with Abnormal Uterine Bleeding (AUB).

Methods

This cross-sectional study recruited 100 married women with chief complain of AUB referred to gynecologic clinics at the Amir Al-Momenin hospital, Semnan, Iran from March 2014 to February 2016. All participants were in the reproductive age and post-menopausal period that showed abnormal endometrial thickness or endometrial focal lesions through transvaginal ultrasound. Participants underwent SIS, hysteroscopy plus focal lesion resection and endometrial biopsy in order. The gold standard was the histopathology of endometrial specimen reported by pathologist.

Results

Mean±SD age of women was 41.2±11.3 years. To diagnose the overall focal lesions, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the SIS were 79.6, 89.1, 89.6, and 78.8% respectively. These figures were 75.0, 87.5, 82.5 and 81.7%, respectively to diagnose polyps. The SIS sensitivity, specificity, PPV and NPV values to diagnose the myomas were 60.0, 97.8, 75.0, and 95.7% respectively.

Conclusion

Findings show that, SIS probably is a proper method for detecting endometrial focal lesion including polyps and myomas. Future studies may help to define further advantages of this procedure.

Structured imaging technique in the gynecologic office for the diagnosis of abnormal uterine bleeding

The aim in the diagnosis of abnormal uterine bleeding (AUB) is to identify the bleeding cause, which can be classified by the PALM-COEIN (Polyp, Adenomyosis, Leiomyoma, Malignancy (and hyperplasia), Coagulopathy, Ovulatory disorders, Endometrial, Iatrogenic and Not otherwise classified) classification system. In a gynecologic setting, the first step is most often to identify structural abnormalities (PALM causes). Common diagnostic options for the identification of the PALM include ultrasonography, endometrial sampling, and hysteroscopy. These options alone or in combination are sufficient for the diagnosis of most women with AUB. Contrast sonography with saline or gel infusion, three-dimensional ultrasonography, and magnetic resonance imaging may be included.

AIM

The aim of this article is to describe how a simple structured transvaginal ultrasound can be performed and implemented in the common gynecologic practice to simplify the diagnosis of AUB and determine when additional invasive investigations are required. Structured transvaginal ultrasound for the identification of the most common endometrial and myometrial abnormalities and the most common ultrasound features are described. Moreover, situations where magnetic resonance imaging may be included are described. This article proposes a diagnostic setup in premenopausal women for the classification of AUB according to the PALM-COEIN system. Moreover, a future diagnostic setup for fast-track identification of endometrial cancer in postmenopausal women based on a structured evaluation of the endometrium is described.

Pain experience during saline-contrast sonohysterography differs between premenopausal and postmenopausal women

PURPOSE

To evaluate whether the pain experienced during and after Saline-contrast sonohysterography (SCSH) differs between premenopausal and postmenopausal women.

METHODS

Sonohysterography was performed on 133 consecutive women because of suspected endometrial pathology. Of these, 34 women were excluded for the following reasons: they had cervical stenosis; they did not complete or return a questionnaire; or tenaculum or cervical dilatators were used during the procedure. All women were asked to fill out a questionnaire to characterize their pain and mark their pain experience on a 100-mm pain visual analog scale.

RESULTS

Data from the 99 patients included were used for statistical analysis. It showed that sonohysterography was well tolerated overall: 41% of the women did not feel any pain. Postmenopausal women experienced pain during SCSH more often than premenopausal women did: 71% (17/24) compared with 32% (24/75) experienced pain; p < 0.002; the median tolerance on the 100-mm visual analog scale was 43. The character of the pain differed between the two groups of women: postmenopausal women more often felt sharp pain (42%; 10/24), whereas premenopausal women more often felt gnawing and/or crampy pain (21%; 16/75) (p < 0.13).

CONCLUSIONS

Postmenopausal women were twice as likely to experience pain during SCSH as premenopausal women were. Therefore, postmenopausal women might benefit from analgesia induced prior to the procedure. © 2015 Wiley Periodicals, Inc. J Clin Ultrasound 44:267-271, 2016.

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.

A comparative study of the efficacy of sonosalpingography and hysterosalpingogram to test the tubal patency in all women with primary and secondary infertility

PURPOSE

This study was done to compare sonohysterography and correlate by hysterosalpingogram (HSG) for evaluation of utero tubal factor in female infertility.

METHODS

Thirty women with primary or secondary infertility attending the outpatient department of the Department of Obstetrics & Gynaecology, Mahatma Gandhi Memorial Hospital, Kalamboli, from May 2010 to May 2011 underwent a sonosalpingography (SSG) on day 7 of the menstrual cycle and an HSG on day 9 of the same or next menstrual cycle. Sonosalpingography was used as the reference standard for HSG. All patients with any positive findings underwent hysterolaparoscopy.

RESULTS

For evaluation of tubal patency, SSG had sensitivity of 95.83% and specificity of 100% for evaluation of tubal patency. In contrast, in HSG for evaluation of tubal patency, the sensitivity is 91.67% and specificity is 100%.

CONCLUSIONS

Sonohysterosalpingography appears to be inexpensive, minimally invasive, quick, of no risk of ionizing radiation, and well-tolerable first-line diagnostic method for determining the tubal status and uterine cavity and can be performed at the time of conventional ultrasound scan in place of HSG and laparoscopy.

Prospective Study of Saline Infusion Sonography and Office Hysteroscopy

BACKGROUND

To evaluate the diagnostic potential of saline infusion sonography to pick up uterine cavity lesions and compare it with the gold standard office hysteroscopy.

METHODS

Study population consisted of women scheduled for office hysteroscopy for various indications. Uterine cavity of 208 women of the study group were evaluated first by saline infusion sonography and then by office hysteroscopy by two separate examiners. Findings were recorded separately for both procedures and compared. Pain rating was also noted after each procedure.

RESULT

In eight patients either or both the procedures could not be performed for various reasons, hence were excluded from the analysis. With saline infusion sonography, pathological findings were identified in 93 (46.5%) patients and hysteroscopy detected lesions in 88 (44%) patients. For all findings combined sensitivity of saline infusion sonography was 90.9%, specificity 88.3%, positive predictive value 86.0% and negative predictive value 92.5% as compared to hysteroscopy. Former was less painful and easier to perform than the latter.

CONCLUSION

The findings of saline infusion sonography and office hysteroscopy did not differ significantly. Thus saline infusion sonography is an excellent option for uterine cavity evaluation.

Saline sonohysterosalpingographic findings in infertile Nigerian women

This paper describes the findings in the first 100 women who underwent saline sonohysterosalpingography (SHG) at two privately owned health facilities in Enugu, South East Nigeria. This was a prospective study of the first 100 consecutive women presenting with infertility to the authors at Mbanefo Hospital and Hansa Clinics, both in Enugu, South-East geopolitical zone of Nigeria from 1 May 2005 to 20 January 2006. Saline sonohysterosalpingography was carried out in the standard way in these women. The findings were analysed using simple percentages and means +/- SD. The procedure was completed in 98 women, while in two others it was not possible to cannulate the uterine cavity. A total of 61 of the women had normal uterine musculature, 37 had interstitial fibroids and two had sonographic features of adenomyosis. Regarding the endometrial cavity, 93 women had a normal endometrium, four had a submucosal fibroid, one had intrauterine adhesions, while the endometrial cavity could not be assessed in two women who could not be cannulated. No case of submucosal polyp or uterine septa or other congenital uterine anomalies was seen. As assessed sonologically, 77 of the study subjects had bilateral patent tubes, while five had unilateral tubal patency. In one woman, there was uncertainty about tubal patency or blockage; in two women, the tubes could not be assessed because of non-cannulation of the uterine cavity and in 15 women, both tubes were blocked. A total of 74 women had normal ovaries; 15 had polycystic ovaries; five had atrophic ovaries consistent with ovarian failure and six women had ovarian cysts. In 18 women, the findings at sonosalpingography (SSG) were confirmed at laparoscopy in 11 women or laparotomy (two women) or by the fact that the patients became pregnant (five women). In 15 (83.3%) of these 18 women, the findings at SSG and laparotomy/laparoscopy or of the woman becoming pregnant were compatible. SSG is a useful screening test for assessing endometrial, tubal and ovarian factors in infertile Nigerian women, thereby obviating the need for laparoscopy and hysteroscopy in the majority of cases.

Saline infusion sonography in women with abnormal uterine bleeding: an update of recent findings

PURPOSE OF REVIEW

To inform about new developments concerning saline infusion sonography, especially in women suffering from abnormal uterine bleeding.

RECENT FINDINGS

The diagnostic accuracy of saline infusion sonography has been established before the period of this review; however, recent papers support the high diagnostic accuracy and conclude saline infusion sonography is able to replace diagnostic hysteroscopy in the evaluation of the uterine cavity. The use of gel instead of saline as distension medium and the introduction of new three-dimensional inversion rendering techniques enhances the visualization of the endometrium which may improve the diagnostic accuracy of saline infusion sonography. A simple, feasible and seemingly cost-effective method of saline infusion sonography-based guided endometrial biopsy has been developed. The technique may allow saline infusion sonography based polypectomy. A classification of submucous fibroids has been proposed in order to allow more accurate, saline infusion sonography-based, preoperative selection of fibroids suitable for hysteroscopic resection.

SUMMARY

The development of saline infusion sonography-based guided biopsies allows saline infusion sonography to compete with vaginoscopic operative hysteroscopy. Additional comparative trials are needed in order to finalize the decision about the proper method of the assessment of the uterine cavity.

Reproducibility of the measurement of submucous fibroid protrusion into the uterine cavity using three-dimensional saline contrast sonohysterography

OBJECTIVE

To determine the intraobserver and interobserver reproducibility of measurement of the percentage of protrusion of submucous fibroids into the uterine cavity using three-dimensional saline contrast sonohysterography (3D-SCSH).

METHODS

Women diagnosed with submucous uterine fibroids on B-mode two-dimensional (2D) ultrasound scan were invited to join the study and 3D-SCSH was carried out. 3D volume datasets were stored digitally and were examined later using the technique of planar reformatted sections. The reproducibilities of the measurement of fibroid diameter and protrusion ratio into the uterine cavity (ratio of the size of the segment of the fibroid protruding into the cavity to the total diameter of the fibroid) were examined by two independent observers who were unaware of the initial 2D scan findings. Interobserver reproducibility was assessed by calculating the difference between measurements taken by the two operators (limits of agreement) and interclass correlation coefficient. Intraobserver repeatability was assessed by calculating the difference between two measurements for each variable (limits of agreement) and further expressed as an intraclass correlation coefficient.

RESULTS

Thirty-three 3D ultrasound volumes were examined. There was a good agreement between the observers in classifying the fibroids as greater or less than 50% confined to the myometrium (Cohen's kappa 0.81). There was no bias in measurements for both variables either between observers or with repeated measurements by each observer. For fibroid diameter and protrusion ratio the inter- and intraclass correlation coefficients were high (0.984-0.995), with narrow limits of agreement.

CONCLUSION

3D-SCSH is a reproducible method for the quantification of the percentage of a submucous fibroid protruding into the uterine cavity.

Diagnostic hysteroscopy and saline infusion sonography: prediction of intrauterine polyps and myomas

STUDY OBJECTIVE

To compare the positive predictive value (PPV) of diagnostic hysteroscopy (DH) and saline infusion sonography (SIS) for the detection of myomas and polyps in patients with abnormal uterine bleeding.

DESIGN

All consecutive women referred to our University Hospital diagnosed with an intrauterine polyp or myoma by office DH or SIS were included in the study. Patients referred to our clinic from 1993 through 2000 underwent DH. From 2001 through 2004 SIS was performed. After hysteroscopic removal in an inpatient setting, histopathologic results were used as a gold standard to calculate PPV of SIS and DH. (Canadian Task Force classification II-3)

SETTING

Tertiary referral center.

INTERVENTION

Diagnostic hysteroscopy and saline infusion sonography.

PATIENTS

Women in whom an intrauterine polyp or myoma was diagnosed either by DH or SIS MEASUREMENTS AND MAIN RESULTS: The PPVs of SIS and DH in the evaluation of intrauterine polyps and fibroids did not significantly differ. However, p = 0.3 is the significant difference for the PPV of SIS in premenopausal women comparing the PPV of SIS for fibroids (0.95) with the PPV of SIS for polyps (0.81).

CONCLUSIONS

Diagnostic hysteroscopy and saline infusion sonography are equivalent diagnostic tools for the detection of intrauterine myomas and polyps.

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.

Effect of myomectomy on the outcome of assisted reproductive technologies

OBJECTIVE

To evaluate the impact of myomectomy on in vitro fertilization-embryo transfer (IVF-ET) and oocyte donation cycle outcome.

DESIGN

Retrospective case-controlled study of consecutive fresh IVF-ET and oocyte donation patients during a 2-year interval.

SETTING

Private assisted reproductive technology (ART) center.

PATIENT(S)

Patients with submucosal leiomyomata resected hysteroscopically (group A: 15 oocyte donor recipients; group 1 = 31 IVF-ET patients) and those with intramural components or strictly intramural leiomyomata that distorted or impinged upon the endometrial cavity resected at laparotomy (group B = 26 oocyte donor recipients; group 2 = 29 IVF-ET patients).

INTERVENTION(S)

Precycle hysteroscopic or abdominal myomectomy and subsequent fresh IVF-ET or oocyte donation.

MAIN OUTCOME MEASURE(S)

Results of controlled ovarian hyperstimulation as well as ongoing pregnancy and implantation rates were evaluated in comparison with contemporaneous patient groups without such lesions (group C = 552 oocyte donor recipients; group 3: 896 IVF-ET patients).

RESULT(S)

As would be expected, the mean number and size of leiomyomata were significantly larger in patients who underwent abdominal myomectomy. However, neither ongoing pregnancy nor implantation rates were significantly different in comparison with controls among either oocyte donor recipients (group A: 86.7%, 57.8%; group B: 84.6%, 55.2%; group C 77%, 49.1%). The findings were similar for those undergoing IVF-ET in comparison with controls (group 1: 61%, 24%; group 2: 52%, 26%; group 3: 53%, 23%).

CONCLUSION(S)

Precycle resection of appropriately selected clinically significant leiomyomata results in IVF-ET or oocyte donation cycle outcomes that are similar to controls.

A comparative study of three-dimensional saline infusion sonohysterography and diagnostic hysteroscopy for the classification of submucous fibroids

BACKGROUND

The purpose of this study was to compare three-dimensional saline infusion sonohysterography (3D SIS) and diagnostic hysteroscopy for the diagnosis and classification of submucous uterine fibroids.

METHODS

This was a prospective double-blind study of 49 women who presented with a history of menorrhagia, diagnosed on non-enhanced two-dimensional ultrasonography with submucous fibroids. Fibroids were classified on 3D SIS according to the proportion of fibroid contained within the endometrial cavity, using the European Society of Hysteroscopy Classification of Submucous Fibroids. These results were then compared with the findings at diagnostic hysteroscopy.

RESULTS

A total of 61 submucous fibroids was identified in 49 symptomatic women. Diagnostic hysteroscopy confirmed these findings in all cases. There was agreement between the two methods in 11/12 cases of Type 0 fibroids (92%), 34/37 (92%) of Type I fibroids and 9/12 (75%) of Type II fibroids. The overall level of agreement was good with a kappa value of 0.80.

CONCLUSIONS

There is a good overall agreement between 3D SIS and diagnostic hysteroscopy in classification of submucous fibroids. Agreement is better in cases where a greater proportion of the fibroid is contained within the uterine cavity.

The clinical value of 3-dimensional saline infusion sonography in addition to 2-dimensional saline infusion sonography in women with abnormal uterine bleeding: work in progress

OBJECTIVE

To evaluate the clinical relevance of 3-dimensional saline infusion sonography (3D-SIS) in addition to conventional SIS in women with abnormal uterine bleeding suspected of having intrauterine abnormalities.

METHODS

All women suspected of having intrauterine abnormalities were eligible. Before 3D-SIS, conventional SIS was performed. The results of these techniques were compared with the "combined method reference standard" (hysteroscopy, endometrial sampling, and clinical follow-up in cases with normal SIS findings). Diagnostic characteristics (with 95% confidence intervals [CIs]) of 3D-SIS and SIS were calculated as well as their respective accuracy in evaluating the histologic nature, the intrauterine extension, and the location of intrauterine abnormalities. Moreover, the reliability (kappa value) and clinical relevance of 3D-SIS were assessed.

RESULTS

A total of 49 women were included, and 4 women were excluded. The positive predictive values of 3D-SIS and SIS were, respectively, 1.00 and 0.86 (95% CI, 0.72-0.99; P = .15), and the diagnostic accuracy values were 0.98 (95% CI, 0.94-1.0) and 0.91 (95% CI, 0.83-0.99; P = .08). Saline infusion sonography and 3D-SIS were equally accurate in evaluating the histologic nature, intrauterine extent, and location of intrauterine abnormalities (respective kappa values: 0.85 versus 0.93; P = .88; 0.83 versus 0.83; and 0.77 versus 0.80; P = .81). The reliability of 3D-SIS was good: intraobserver and interobserver agreement (kappa) were 0.78 and 0.72. Three women (6.7%) had the benefit of additional 3D-SIS: in these women, SIS wrongly led to a diagnosis of intrauterine abnormalities (P = .08).

CONCLUSIONS

Three-dimensional saline infusion sonography is valid and reliable in women suspected of having intrauterine abnormalities and may indeed have relevant clinical value in addition to conventional SIS.