The use of a new gel foam for the evaluation of tubal patency

Diagnostic accuracy of hysterosalpingo-foam sonography for assessment of fallopian tube patency in infertile women

RESEARCH QUESTION

What is the diagnostic accuracy of hysterosalpingo-foam sonography (HyFoSy), using two-dimensional ultrasound in tubal patency assessment in infertile women compared with laparoscopy with dye chromotubation?

DESIGN

This prospective study was conducted at My Duc Hospital, Vietnam. Infertile women aged 18 years or older, who were scheduled for laparoscopy, were included. Visual Analogue Scale (VAS) score for perception of pain during HyFoSy was used. Laparoscopy was carried out on the same day. Clinicians undertaking laparoscopy were blinded to HyFoSy results. Sensitivity, specificity, negative and positive predictive value, and 95% confidence intervals were calculated. A sample size of 455 women (n = 910 fallopian tubes) was needed to demonstrate a fluctuation hypothesis, not exceeding 6%, for sensitivity and specificity (power 0.80, two-sided alpha 5%, loss to follow-up 5%).

RESULTS

Between 2019 and 2022, 455 participants were recruited. Hysterosalpingo-foam sonography was unsuccessfully carried out in six participants. Two withdrew their consent. Data analysis was conducted on the remaining 447 participants (n = 868 fallopian tubes). The sensitivity and specificity of hysterosalpingo-foam sonography compared with laparoscopy were 0.75 (95% CI 0.71 to 0.79) and 0.70 (95% CI 0.65 to 0.74), respectively. Hysterosalpingo-foam sonography gave a positive predictive value of 0.76 (95% CI 0.73 to 0.80) and negative predictive value of 0.68 (95% CI 0.64 to 0.73). A total of 42.8% of women reported a VAS score of no pain. No adverse event was reported.

CONCLUSION

Compared with laparoscopy with dye chromotubation, two-dimensional HyFoSy is a well-tolerated, reliable technique for assessing tubal patency.

[Pregnancy after intrauterine insemination following hysterosalpingo-foam-sonography or hysterosalpingography]

OBJECTIVE

To compare clinical pregnancy rates following intrauterine insemination performed after hysterosalpingography (HSG) or hysterosalpingo-foam-sonography (HyFoSy).

MATERIAL AND METHODS

This is a retrospective study including 242 intrauterine insemination (IUI) performed between 2015 and 2020 at the fertility center of the Reunion Island. Among these inseminations, 121 with previous HSG and 121 with previous HyFoSy were matched. The main outcome of interest was clinical pregnancy rate. Secondary outcomes were birth rate and time to pregnancy after tubal patency test.

RESULTS

The pregnancy rate after insemination was 9.9% for the HSG group and 11.6% for the HyFoSy group, with no statistically significant difference between the groups (P=0.66). The live birth rate was similar in the two groups (7.4% for HSG and 10.7% for HyFoSy; P=0.37). Over half (57.1%) of the pregnancies occurred within 6 months after HyFoSy, whereas only 8.3% after HSG.

CONCLUSION

IUI results are not influenced by HyFoSy compared to HSG with regard to the pregnancy rates. Use of HyFoSy in infertility assessment allows global evaluation and more rapid adapted management. This approach could optimize management of patients undergoing IUI.

Diagnostic accuracy of hysterosalpingo-lidocaine-foam sonography combined with power Doppler (HyLiFoSy-PD) compared to laparoscopy and dye testing in tubal patency assessment in cases of infertility

Background

Tubal patency testing is an essential part of female subfertility evaluation. Hysterosalpingogram is less invasive and less expensive compared to laparoscopy and dye testing (LDT), i.e., laparoscopic chromopertubation. Hysterosalpingo-foam sonography (HyFoSy) uses commercial echogenic gel foam that is easily visible on ultrasound to assess the tubes. It offers a safer and less painful alternative to HSG, with no radiation exposure. Hysterosalpingo-lidocaine-foam sonography with power Doppler (HyLiFoSy-PD) uses lidocaine-made gel foam as a contrast medium. It was postulated to as to be less painful and easier to detect on ultrasound, compared with hysterosalpingo-foam sonography using other contrast media and that it can also be used whenever the commercial gel used with HyFoSy is not available or is relatively expensive.

Methodology

This prospective diagnostic accuracy study was carried out between February 2018 and 2020 at the Cairo Fetal Medicine Unit, Department of Obstetrics and Gynecology, Cairo University. One hundred twenty-two infertile patients, who were already scheduled for LDT as a part of their infertility work-up, were consecutively recruited for this study. The HyLiFoSy-PD (index test) was performed 1 week before the scheduled LDT for these patients. Using an intrauterine pediatric Folley’s balloon catheter, 20 ml of lidocaine-made gel foam was slowly infused intrauterine, while observing their flow in both fallopian tubes using a grayscale and power Doppler transvaginal two-dimensional ultrasound system. All patients then underwent LDT (reference test). The results of HyLiFoSy-PD were compared with those of LDT to determine the accuracy of HyLiFoSy-PD in tubal patency assessment. We also assessed the procedure duration, associated pain, and other complications.

Results

Comparing HyLiFoSy-PD with LDT in the 115 patients who completed the procedure, results showed 98.1% sensitivity, 90% specificity, 99% positive predictive value, 81.8% negative predictive value, 9.81 positive likelihood ratio, 0.02 negative likelihood ration, and 97.4% overall accuracy in the assessment of tubal patency (odds ratio = 463.5 with confidence interval = 79.39–2706; P-value: 0.687). The median procedure duration was 11 min. All patients experienced some degree of pain during the procedure with 91 patients (79%) reported mild pain and 24 patients (21%) reported moderate pain.

Conclusion

HyLiFoSy-PD was found to be an accurate tool in tubal patency assessment. It was also found to be safe and well-tolerated.

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.

Hysterosalpingo-Foam Sonography for the Diagnosis of Tubal Occlusion: A Systematic Review and Meta-analysis

This systematic review and meta-analysis evaluated the diagnostic accuracy of hysterosalpingo-foam sonography in suspected cases of tubal occlusion. The combined sensitivity and specificity estimates were 0.99 (95% confidence interval [CI], 0.89-0.99) and 0.91 (95% CI, 0.53-0.98), respectively, with positive and negative likelihood ratios of 11.5 (95% CI, 1.5-87.5) and 0.006 (95% CI, 0.0003-0.12), respectively. The diagnostic odds ratio was 1931.008 (95% CI, 69.7-53,460.8). These findings confirm hysterosalpingo-foam sonography as a highly accurate test for the diagnosis of tubal occlusion and show that it is on a par with standard tests.

Diagnostic Accuracy Study Comparing Hysterosalpingo-Foam Sonography and Hysterosalpingography for Fallopian Tube Patency Assessment

Introduction: Simplified ultrasound-based infertility protocols that appear to provide enough information to plan effective management have been described. Thus, the objective of this study is to compare the diagnostic accuracy of the hysterosalpingo-foam sonography (HyFoSy) in tubal patency testing with the traditional hysterosalpngography (HSG) for establishing a new diagnostic strategy in infertility. Material and Methods: Prospective observational diagnostic accuracy was performed in a private fertility clinic in which 106 women undergoing a preconceptionally visit were recruited. All of them had low risk for tubal disease, had performed an HSG and were negative for Chlamydia trachomatis antibody. Main outcome measures were tubal patency and pain grade. Results: Evaluation of tubal patency by HyFoSy showed a total concordance with the results of the previous HSG in 72.6% (n = 77), and a total discordance for 4.7% (n = 6), with the inter-test agreement Kappa equal to 0.57, which means moderate concordance. Among the patients, 59.1% did not report pain during the procedure, while the remaining 48.1% indicated pain in different degrees; patients usually report less pain and only 6.6% described more pain with HyFoSy than with HSG (OR 6.57 (CI 95% 3.11–13.89)). Clinical outcomes after performing HyFoSy were not affected. Conclusions: HyFoSy is in concordance with HSG regarding tubal patency results and it is a less painful technique than HSG. HyFoSy is more economical and can be performed in an exam room only equipped with an ultrasound scanner. Based on these results, HyFoSy could be the first-choice diagnostic option to assess tubal patency in patients with low risk of tubal disease.

Severe pain during hysterosalpingo-contrast sonography (HyCoSy): a systematic review and meta-analysis

PURPOSE

To assess the frequency of severe pain perception during hysterosalpingo-contrast sonography (HyCoSy) in infertile women and to assess whether there are differences in the frequency of associated pain according to the contrast used.

DESIGN

Systematic review and meta-analysis.

PATIENTS

Women undergoing HyCoSy due to infertility.

INTERVENTIONS

Searches were carried out in two databases (Pubmed and Web of Science). We included prospective or retrospective cohort observational studies that specified the type of contrast used during HyCoSy and reported data regarding the number of patients who perceived severe pain during the procedure and the scale used for pain perception score.

MAIN OUTCOME MEASURES

Pooled frequency of severe pain perception during HyCoSy and the pooled frequency of severe pain perception based on the contrast used.

RESULTS

Twenty-nine studies were included in this meta-analysis including a total of 7139 patients. In 10 studies, Saline solution with air was used as contrast EchoVist™ was used in ten studies, in five studies, SonoVue™ was used and in four studies, ExEm-Foam™ was used as contrast. Pooled estimated frequency of severe pain perception during HyCoSy was 6% (95% CI 4-9). No statistically significant differences have been described regarding frequency of severe pain perception in relation to the different contrasts used.

CONCLUSIONS

HyCoSy is a tolerable outpatient procedure. We did not find any evidence that one specific contrast was better tolerated than any other was.

The value of transvaginal 4-dimensional hysterosalpingo-contrast sonography in predicting the necessity of assisted reproductive technology for women with tubal factor infertility

Background

More than 50 million women suffer from infertility worldwide, among whom 30% have associated fallopian tube pathology. Fortunately, the diagnostic accuracy of tubal patency has been enhanced with the consistent development of ultrasound imaging technology, especially the invention of transvaginal 4-dimensional hysterosalpingo-contrast sonography (TV 4D HyCoSy). However, detailed imaging data for evaluating the tubal condition for spontaneous conception and assessing the necessity of assisted reproductive technology (ART) have yet to be amassed.

Methods

Patients with tubal factor infertility (TFI) who received TV 4D HyCoSy were recruited for this study. They were divided into two groups according to the method of conception: the natural pregnancy group (patients who naturally conceived within 3 months after TV 4D HyCoSy) and the assisted reproduction group (patients who failed to conceive naturally within the 3 months but successfully conceived through ART). Logistic regression analysis was performed to examine the data obtained from participants' medical history and TV 4D HyCoSy investigation.

Results

Of the initial 1,433 women, 348 were excluded due to exclusion criteria or lack of follow-up. A total of 1,085 TFI patients were finally included, with individuals in the natural pregnancy group accounting for 27.74% (n=301), and those in the ART group accounting for 37.33% (n=405). The age was younger and the duration of infertility was shorter in the group of women who conceive spontaneously after TV 4D HyCoSy (P<0.05). In terms of imaging data, their endometrial thickness was thinner, right fallopian tube wall was more intact, morphology of the right fallopian tube was smoother, and their ovarian motility (bilateral), fallopian tube visualization (bilateral) and overflow condition of the contrast agent from the fimbriae of fallopian tube (bilateral) were better. In addition, the resistance of the contrast agent injection was less likely to be persistent, reflux was less likely to happen and 0/1 dispersion of the contrast agent around the ovary (bilateral) were more likely to be annular (P<0.05).

Conclusions

The imaging data gathered from TV 4D HyCoSy in TFI patients were comprehensive, which suggested that TV 4D HyCoSy could have potential to be used to assess the necessity of post-HyCoSy ART intervention in patients with TFI. This could be of benefit in reducing the incidence of overtreatment and potential complications of ART.

Estimation of the Endometriosis Fertility Index prior to operative laparoscopy

STUDY QUESTION

Can the Endometriosis Fertility Index (EFI) be estimated accurately before surgery?

SUMMARY ANSWER

The EFI can be estimated accurately based on mere clinical/ultrasound information, with some improvement after adding data from diagnostic laparoscopy.

WHAT IS KNOWN ALREADY

The EFI is a validated clinical instrument predicting the probability of pregnancy after endometriosis surgery without the use of ART. Being an end-of-surgery-score, it implies the decision for operative laparoscopy to be made in advance-hence, its role in the pre-surgical decision-making process remains to be established.

STUDY DESIGN, SIZE, DURATION

Single-cohort prospective observational study in 82 patients undergoing complete endometriosis excision (between June and December 2016). Two methods were used to estimate the final EFI: type A based on non-surgical clinical/ultrasound findings only, and type B based on the combination of non-surgical clinical/ultrasound findings and diagnostic laparoscopy data. To calculate EFI type A, an algorithm was created to translate non-surgical clinical/imaging information into rASRM (revised American Society of Reproductive Medicine)-and EFI points. EFI type A and type B estimates were assessed for their clinical and numerical agreement with the final EFI score. Agreement was defined as clinical if EFI scores were within the same range (0-4, 5-6, 7-10), and numerical if their difference was ≤1.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All 82 patients underwent complete laparoscopic CO2-laser excision of any rASRM stage of endometriosis in the Leuven University Fertility Centre (LUFC) of University Hospitals Leuven, a tertiary referral centre for both endometriosis and infertility. An anonymized clinical research file was created. For each patient, three different data sets were created, in order to allow the estimation of the (surgical part) EFI and of the rASRM scores, defined as follows: 'Estimated type A' contained only non-surgical clinical/imaging data, 'Estimated type B' included type A information plus the information of the diagnostic laparoscopy and 'Final EFI' included information of type A, type B and all intra-operative information required to calculate the final EFI. To calculate EFI type A without surgical information, a set of rules was used to translate pre-surgical clinical/imaging information into (rASRM and EFI points). Scoring was done by one person (C.T.), with a time interval of 4 weeks between sessions for each EFI type. Next to the EFI, also rASRM score and stage were calculated.

MAIN RESULTS AND THE ROLE OF CHANCE

Agreement rate between estimated EFI type A and final EFI was high for both the clinical (0.915; 95% CI 0.832-0.965) and numerical definition (0.878; 95% CI 0.787-0.940). Agreement rates between estimated EFI type B and final EFI were even higher (clinical (0.988; 95% CI 0.934-1.000), numerical (0.963; 95% CI 0.897-0.992)).

LIMITATIONS, REASONS FOR CAUTION

Type A estimation is dependent on high-level gynaecological ultrasound expertise, which may not be available in all clinics. A small number of patients had no prior clinical, ultrasound (hard markers) or surgical confirmation of the diagnosis of endometriosis. When applying the estimated EFI type A in clinical practice, a priori assumptions of the presence or absence of endometriosis will need to be made in adjunct to the estimation of the estimated type A EFI when counselling patients on the potential benefit of an (at least diagnostic) laparoscopy. The level of agreement for type A or B should also be taken into account when counselling patients on the type of efforts undertaken to attempt to diagnose or rule out endometriosis.

WIDER IMPLICATIONS OF THE FINDINGS

As this study reports, the EFI can be estimated accurately based on clinical/ultrasound data only without the need for any surgical data. This means that the EFI could be used as an instrument to guide joint physician-patient decision-making between surgery, ART or other fertility management options for the individualized treatment of women with endometriosis-related infertility.

STUDY FUNDING/COMPETING INTEREST(S)

During this study period, C.T. was supported by FWO (Research Fund Flanders, Grant number 1700816N) and UZ Leuven KOF (University Hospitals Leuven, Klinisch Onderzoeksfonds).The LUFC received unrestricted research grants from Ferring Pharmaceuticals and Merck SA. Gedeon Richter and MSD sponsored travel to and attendance at scientific meetings. C.M. received consultancy fees from Lumenis (paid to KU Leuven, no private revenue). T.D. has been vice-president and head of global medical affairs infertility for the multinational pharmaceutical company Merck (Darmstadt, Germany) since 1 October 2015. He continues his academic appointment on a part-time basis as Professor of Reproductive Medicine at the University of Leuven (KU Leuven). T.D. has been vice-president and head of global medical affairs infertility for the multinational pharmaceutical company Merck (Darmstadt, Germany) since October 2015. He is also a Guest Professor in Reproductive Medicine and Biology at the Department of Development and Regeneration, Group Biomedical Sciences, KU Leuven (University of Leuven), Belgium, and an Adjunct Professor at the Department of Obstetrics and Gynecology in the University of Yale, New Haven, USA. This work was initiated before he joined Merck KGaA in October 2015, and completed during the subsequent years.

TRIAL REGISTRATION NUMBER

study registration number at UZ Leuven Clinical Trial Centre: S59221.

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.

Clinical Aspects of HyFoSy as Tubal Patency Test in Subfertility Workup

BACKGROUND

Tubal patency testing is an essential part of female subfertility evaluation. Traditionally, hysterosalpingography (HSG) was the first step to evaluate tubal patency. However, during the past decade Hysterosalpingo-Contrast Sonography (HyCoSy) was introduced in order to avoid radiation exposure and Hysterosalpingo-Foam Sonography (HyFoSy) has been developed as a safe and less painful alternative.

OBJECTIVES AND RATIONALE

The aim of this narrative review is to provide an overview of the currently available HyFoSy literature and related clinical aspects.

SEARCH METHODS

A literature search was conducted using PubMed and Embase from the introduction of HyFoSy to March 2019. Unfortunately, a meta-analysis was not possible due to a too small number of studies, being mutually incomparable for the various subjects of clinical aspects, even for the reliability as a test for tubal patency.

OUTCOMES

Nine small studies concluded that the accuracy and effectiveness as a test for tubal patency of 2D- and 3D-HyFoSy are comparable or even better than HSG or HyCoSy. With or without using Doppler techniques, 3D-HyFoSy does not seem to offer benefits above real-time 2D-HyFoSy. Five studies reported on pain and discomfort during HyFoSy, concluding that HyFoSy is a well-tolerated, less painful procedure compared to HSG, without a need for the use of analgesics. There are suggestions about an increased pregnancy rate in the first three cycles after the procedure but in no studies pregnancy outcome after HyFoSy was compared with other or no intervention.

WIDER IMPLICATIONS

HyFoSy is a promising and safe alternative for HSG with regard to accuracy and effectiveness. HyFoSy lacks radiation and iodine exposure and is a well-tolerated and less painful procedure than HSG, without the need for analgesics. However more research is needed to make clear statements regarding a therapeutic effect of HyFoSy.

Diagnostic value of three-dimensional saline infusion sonohysterography in the evaluation of the uterus and uterine cavity lesions

Purpose

The purpose of this review is to illustrate and discuss the seldom used technique of three-dimensional (3D) saline infusion sonohysterography (SIS) based on instillation of sterile saline through a catheter into the uterus under real-time vaginal transducer observation for assessment of the endometrial cavity.

Material and methods

The cases for this pictorial review were selected from the imaging material collected at the Ultrasound Unit, Clinical Imaging Department, Women’s Hospital of Hamad Medical Corporation during a seven-year period from 2011 to 2017. This was a retrospective collection of 216 consecutive cases that underwent two-dimensional (2D) and 3D SIS for evaluation of the uterine cavity, followed by verification of results with histopathology. An open-sided speculum is inserted into the vagina. An intrauterine catheter is then threaded into the endometrial cavity. After that, the speculum is removed carefully, and a vaginal transducer is inserted. Using a 60-ml syringe attached to the catheter, saline solution is instilled under direct real-time observation (2D SIS). Subsequently, reconstruction of the three-dimensional anatomy of the intrauterine cavity is performed.

Pictorial review

The review presents the most common indication for SIS, like abnormal bleeding in pre- and postmenopausal patients. SIS allows us to distinguish between focal lesions and global endometrial thickening. SIS should be supported as a second-line diagnostic procedure for abnormal uterine bleeding, when findings from transvaginal ultrasound are inconclusive.

Conclusions

The addition of 3D techniques to SIS procedure helps in the distinction between endometrial and myometrial lesions, also it facilitates delineation of uterine anatomy, resulting in more precise and accurate diagnosis.

Use of Hysterosalpingo-Foam Sonography for Assessment of the Efficacy of Essure Hysteroscopic Sterilization

OBJECTIVES

Hysterosalpingo-foam sonography (HyFoSy) has been suggested to be a possible less invasive alternative to hysterosalpingography (HSG), which is the reference standard for confirmation of tubal occlusion after Essure (Bayer AG, Leverkusen, Germany) hysteroscopic sterilization. The purpose of our study was to evaluate the accuracy of HyFoSy compared to HSG for confirmation of tubal occlusion after Essure hysteroscopic sterilization.

METHODS

A prospective study included 90 patients who underwent Essure hysteroscopic sterilization. Twelve weeks after the sterilization, 2-dimensional transvaginal ultrasonography was performed to assess the microinsert position and was followed by HyFoSy and HSG for evaluation of tubal occlusion. Patients with patent fallopian tubes on HSG were scheduled for additional HSG procedures at 3-month intervals until tubal occlusion was documented.

RESULTS

Of 90 enrolled patients, 86 patients with 170 fallopian tubes underwent the complete imaging protocol. Tubal occlusion was evaluated by HyFoSy as an index test and HSG as a reference standard. The accuracy of HyFoSy was 97.1% (95% confidence interval [CI], 93%-99%). The sensitivity and specificity were 100% (95% CI, 97%-100%) and 54.6% (95% CI, 23%-83%), whereas the positive and negative predictive values were 97.0% (95% CI, 93%-99%) and 100% (95% CI, 42%-100%), respectively. No long-term complications were reported for HyFoSy or HSG.

CONCLUSIONS

Given that the concordance rate for tubal occlusion between HyFoSy and HSG was not 100%, an occluded fallopian tube on HyFoSy should be confirmed by HSG, which remains the reference standard for confirmation of tubal occlusion after Essure hysteroscopic sterilization.

The FOAM study: is Hysterosalpingo foam sonography (HyFoSy) a cost-effective alternative for hysterosalpingography (HSG) in assessing tubal patency in subfertile women? Study protocol for a randomized controlled trial

BACKGROUND

Tubal pathology is a causative factor in 20% of subfertile couples. Traditionally, tubal testing during fertility work-up is performed by hysterosalpingography (HSG). Hysterosalpingo-foam sonography (HyFoSy) is a new technique that is thought to have comparable accuracy as HSG, while it is less expensive and more patient friendly. HyFoSy would be an acceptable alternative for HSG, provided it has similar effectiveness in terms of patient outcomes.

METHODS/DESIGN

We aim to compare the effectiveness and costs of management guided by HyFoSy or by HSG. Consenting women will undergo tubal testing by both HyFoSy and HSG in a randomized order during fertility work-up. The study group will consist of 1163 subfertile women between 18 and 41 years old who are scheduled for tubal patency testing during their fertility work-up. Women with anovulatory cycles not responding to ovulation induction, endometriosis, severe male subfertility or a known contrast (iodine) allergy will be excluded. We anticipate that 7 % (N = 82) of the participants will have discordant test results for HyFoSy and HSG. These participants will be randomly allocated to either a management strategy based on HyFoSy or a management strategy based on HSG, resulting in either a diagnostic laparoscopy with chromopertubation or a strategy that assumes tubal patency (intrauterine insemination or expectant management). The primary outcome is ongoing pregnancy leading to live birth within 12 months after randomization. Secondary outcomes are patient pain scores, time to pregnancy, clinical pregnancy, miscarriage rate, multiple pregnancy rate, preterm birth rate and number of additional treatments. Costs will be estimated by counting resource use and calculating unit prices.

DISCUSSION

This trial will compare the effectiveness and costs of HyFoSy versus HSG in assessing tubal patency in subfertile women.

TRIAL REGISTRATION

Dutch Trial Register (NTR 4746, http://www.trialregister.nl ). Date of registration: 19 August 2014.

One-step transvaginal three-dimensional hysterosalpingo-foam sonography (3D-HyFoSy) confirmation test for Essure® follow-up: a multicenter study

OBJECTIVE

To evaluate, in patients who underwent Fallopian-tube sterilization by hysteroscopic insertion of an Essure® device, the feasibility and accuracy of three-dimensional (3D) transvaginal sonography (TVS) to check the position of the device and 3D hysterosalpingo-foam sonography (3D-HyFoSy) using contrast-enhanced gel foam to assess consequent tubal occlusion.

METHODS

This was a prospective multicenter study conducted from June 2012 to July 2014 in four Italian centers, which included 50 women who underwent hysteroscopic Essure microinsert placement in a total of 95 Fallopian tubes. Placement of the microinserts was performed in an outpatient setting following standard procedure recommendations. All patients underwent transvaginal 3D-HyFoSy and hysterosalpingography (HSG) approximately 12-14 weeks after the procedure. The position of the devices was first checked on 3D-TVS and classified according to specific criteria (Positions A, B, C and D). Then, 3D-HyFoSy with ExEm® gel foam as the ultrasound contrast agent was performed to confirm tubal occlusion by the absence of contrast agent within the tubes and/or around the ovaries. To evaluate the feasibility of 3D-HyFoSy, consecutive volume acquisitions were performed while injecting the gel foam. After sonographic evaluation, women underwent HSG to assess the success of sterilization, as standard methodology. Side effects and pain evoked during and after 3D-HyFoSy and HSG were evaluated using a numeric pain rating scale.

RESULTS

On 3D-TVS, 10 devices (10.5%) were in Position A, two (2.1%) in Position B, 59 (62.1%) in Position C and 24 (25.3%) in Position D. During 3D-HyFoSy, tubal occlusion was observed in 89 of 95 tubes (93.7%). In the six cases in which the passage of the contrast was observed, one device (16.7%) was in Position B, one device (16.7%) in Position D and four devices (66.7%) were found to lie in Position C. Tubal patency was confirmed at HSG with a concordance rate of 100%. The mean pain score associated with 3D-HyFoSy was significantly lower than that on HSG.

CONCLUSIONS

3D-TVS with HyFoSy allows accurate assessment of the position of Essure microinserts and tubal occlusion. It can be considered a safe, reliable, non-invasive alternative to HSG. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

Hysterosalpingo-foam sonography (HyFoSy): Tolerability, safety and the occurrence of pregnancy post-procedure

BACKGROUND

Fallopian tube patency testing is an essential part of infertility evaluation. Hysterosalpingo-contrast sonography (HyCoSy) has been described as reliable, well tolerated and safe compared to other modalities such as laparoscopy and a dye test or hysterosalpingography. Limited availability of the previously used contrast has led to the introduction of a foam contrast agent as an alternative.

AIMS

To assess the tolerability, safety and occurrence of pregnancy post-procedure of hysterosalpingo-foam sonography (HyFoSy).

MATERIALS AND METHODS

A retrospective cohort study of women who had a HyFoSy at Queensland Ultrasound for Women from March 2013 to February 2015. A questionnaire was sent to their referring doctor to identify any complications or subsequent pregnancies with or without artificial reproductive technology (ART) within six months of the HyFoSy.

RESULTS

Of 200 women, four cases were abandoned due to difficulty introducing the intracervical catheter, severe discomfort or a vasovagal episode. Response from referring doctors for 155 women reported no post-procedural complication. One hundred and eleven women were followed up for at least six months. Twenty-four out of 59 women (40.7%) who had ART and 24 out of 52 women (46.2%) who did not have ART conceived. Fifty percent of women who were nulligravida at the time of investigation, found to have at least one patent fallopian tube, whose partner had a normal semen analysis, spontaneously conceived within the time of follow up.

CONCLUSIONS

HyFoSy is well tolerated and safe. A preponderance of pregnancies in the first month after HyFoSy suggests that a therapeutic effect may exist.

Sonohysterosalpingography: Comparison of foam and saline solution

PURPOSE

To compare sonohysterosalpingography (sono-HSG) with foam instillation (HyFoSy) versus saline solution (HyCoSy) in the evaluation of tubal patency.

METHODS

We prospectively enrolled 37 infertile women, scheduled for laparoscopy. The women were randomized into two groups: HyFoSy (group I) and HyCoSy (group II). The patients of both groups underwent laparoscopy with dye test. We assessed the diagnostic performance (sensitivity, specificity, and overall accuracy) of HyFoSy and HyCoSy, compared with laparoscopy and dye test, in the assessment of tubal patency.

RESULTS

Sono-HSG findings in tubal patency assessment obtained in the HyFoSy group were concordant with laparoscopic results in 94.4% of cases, with a sensitivity of 87.5% and a specificity of 100%, whereas in the HyCoSy group, concordance occurred in only 57.8% of examinations, with a sensitivity of 50% and a specificity of 66.6%.

CONCLUSIONS

HyFoSy allows a more accurate diagnosis of tubal patency compared with HyCoSy. © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 45:67-71, 2017.

Hysterosalpingo-foam sonography: patient selection and perspectives

We present an overview of the common types of tubal patency tests, with a focus on hysterosalpingo-foam sonography (HyFoSy). Current evidence suggests that HyFoSy is an accurate alternative to X-ray hysterosalpingography (HSG) for outpatient tubal evaluation in women who are at low risk for tubal disease. It may be superior to saline hysterosalpingo-contrast sonography (HyCoSy) in excluding tubal occlusion. A hyperechogenic medium may enhance contrast visualization and enable clearer delineation of tubal anatomy. This may enhance confidence in the diagnosis of tubal patency, reduce false occlusion results, and improve the diagnostic yield of the test. It would be reasonable to deduce that HyFoSy would have similar performance characteristics as HyCoSy with other positive contrast agents. The available evidence supports the accuracy of HyFoSy compared to other forms of tubal investigation. We suggest a decision-making pathway based on the most current professional recommendations and available evidence. However, in this article, we do not provide a definitive exposition of the methods used for investigating tubal patency. Rather, we explore the contexts in which the various investigations are most and least suitable, and identify their strengths and limitations. Finally, we also discuss challenges encountered when performing tubal contrast sonography in clinical practice, including the problem of false occlusion results.

Sperm Chromatin Dispersion Test before Sperm Preparation Is Predictive of Clinical Pregnancy in Cases of Unexplained Infertility Treated with Intrauterine Insemination and Induction with Clomiphene Citrate

Background/aims

A large proportion of men with normal sperm results as analyzed using conventional techniques have fragmented DNA in their spermatozoa. We performed a prospective study to examine the incidence of DNA fragmentation in sperm in cases of couples with previously unexplained infertility and treated with intrauterine insemination. We evaluated whether there was any predictive value of DNA fragmentation for pregnancy outcome in such couples.

Methods

The percentage of DNA fragmentation and all classical variables to evaluate sperm before and after sperm treatment were determined. We studied the probable association between these results and pregnancy outcome in terms of clinical and ongoing pregnancy rate per started first cycle. We also assessed the optimal threshold level to diagnose DNA fragmentation in our center.

Results

When using threshold levels of 20, 25, and 30%, the occurrence of DNA fragmentation was 42.9, 33.3, and 28.6%, respectively. Receiver operating characteristic (ROC) analysis of all cases revealed an area under the curve of 80% to predict the clinical pregnancy rate per cycle from testing the sperm motility (a + b) before treatment. We failed to generate an ROC curve to estimate pregnancy outcome from the amount of DNA fragmentation before treatment. However, when selecting only those men with a pretreatment DNA fragmentation of at least 20%, the pretreatment result was statistically different between couples who achieved a clinical pregnancy and those who did not.

Conclusion

DNA fragmentation is often diagnosed in couples with unexplained infertility. Each center should evaluate the type of test it uses to detect DNA fragmentation in sperm and determine its own threshold values.

Power Doppler flow mapping and four-dimensional ultrasound for evaluating tubal patency compared with laparoscopy

OBJECTIVES

To study the accuracy of four-dimensional (4D) ultrasound and power Doppler flow mapping in detecting tubal patency in women with sub-/infertility, and compare it with laparoscopy and chromopertubation.

STUDY DESIGN

A prospective study. The study was performed in the outpatient clinic and infertility unit of a university hospital. The sonographic team and laparoscopic team were blinded to the results of each other. Women aged younger than 43 years seeking medical advice due to primary or secondary infertility and who planned to have a diagnostic laparoscopy performed, were recruited to the study after signing an informed consent. All of the recruited patients had power Doppler flow mapping and 4D hysterosalpingo-sonography by injecting sterile saline into the fallopian tubes 1 day before surgery. Registering Doppler signals, while using power Doppler, both at the tubal ostia and fimbrial end and the ability to demonstrate the course of the tube especially the isthmus and fimbrial end, while using 4D mode, was considered a patent tube.

RESULTS

Out of 50 recruited patients, 33 women had bilateral patent tubes and five had unilateral patent tubes as shown by chromopertubation during diagnostic laparoscopy. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy for two-dimensional power Doppler hysterosalpingography were 94.4%, 100%, 100%, 89.2%, and 96.2%, respectively and for 4D ultrasound were 70.4%, 100%, 100%, 70.4%, and 82.6%, respectively.

CONCLUSIONS

Four-dimensional saline hysterosalpingography has acceptable accuracy in detecting tubal patency, but is surpassed by power Doppler saline hysterosalpingography. Power Doppler saline hysterosalpingography could be incorporated into the routine sub-/infertility workup.

Pain during Fallopian-tube patency testing by hysterosalpingo-foam sonography

OBJECTIVES

To evaluate perception of pain during Fallopian-tube patency testing by hysterosalpingo-foam sonography (HyFoSy).

METHODS

In this cross-sectional study, 216 consecutive women presenting at a university fertility clinic for HyFoSy examination were included. Patients were instructed to take ibuprofen 1 hour before the procedure. Immediately after the procedure, patients filled in a questionnaire concerning discomfort or pain experienced during the process, including a visual analog scale (VAS) score for perception of pain.

RESULTS

The median VAS score for perception of pain during transvaginal ultrasound examination and during HyFoSy examination was 1.5 (95% CI, 1.2-1.7) and 3.6 (95% CI, 3.0-4.0), respectively. One-third of women reported that the level of discomfort or pain during HyFoSy examination was similar to that during the preceding transvaginal ultrasound examination and 48% of women considered HyFoSy examination to be neutral/unpleasant, but not painful. There was an inverse association between both patients' age and parity and the pain experienced.

CONCLUSIONS

HyFoSy examination is tolerated well and allows for reliable tubal patency testing without exposing the patient to ionizing radiation in an outpatient setting with a low technical failure rate.

Evaluation of pain during hysterosalpingography with the use of balloon catheter vs metal cannula

Our aim was to investigate the use of a balloon catheter device in comparison with metal cannula for hysterosalpingography (HSG) in terms of patient comfort. A total of 168 patients were randomised for HSG either with a balloon catheter (n = 83) or metal cannula (n = 85). Scores of pelvic pain during insertion of the devices, injection of the contrast medium and 1 h after the procedure were evaluated using the Wong Baker Faces Pain Rating Scale; complications and reinsertion rates were also noted. The pain scores were significantly lower in the balloon catheter group (p < 0.001). The reinsertion rate of metal cannula was higher (8.2% vs 2.4%) as well as the incidence of nausea being the most common short-term adverse effect (14.1% vs 1.2%) in the metal cannula group (p = 0.002). Performing HSG with a balloon catheter is advantageous for decreasing the pain and side-effects related to the procedure, when compared with the use of a metal cannula.

Safety aspects and side-effects of ExEm-gel and foam for uterine cavity distension and tubal patency testing

A state-of-the-art overview of the safety and side-effects of ExEm-gel for uterine cavity distension and ExEm-foam for tubal patency testing is presented. A literature search was carried out using PubMed, textbooks, pharmaceutical databases and reports of toxicity tests. Information on clinical use in humans and experiments in animal models was collected and grouped according to the following components: glycerol, hydroxyethyl cellulose and purified water; subjects included toxicity test, influence on sperm cells, oocytes, blastocyst development, uterine cavity distension, tubal patency testing, pain and obstetric applications. No unknown side-effects of gel or foam, or unexpected concerns about safety, were reported. More information than expected was available on the absence of effects of the components on various human tissues. Although it is difficult to prove that the search is complete, and it is possible that side-effects remain unreported, the combination of glycerol, hydroxyethyl cellulose and purified water is considered to be safe for intrauterine application and tubal patency testing, indicating an optimal risk-benefit ratio in clinical use. The safest strategy, however, is to restrict clinical examinations with gel and foam to the pre-ovulatory phase of the menstrual cycle.

Pelvic inflammatory disease: a retrospective clinical analysis of 1,922 cases in North China

PURPOSE

To identify the cause of pelvic inflammatory disease (PID) in Shanxi, North China.

METHODS

Retrospective analysis of 1,922 women with PID who underwent laparoscopy for infertility.

RESULTS

1,922 cases (42.3%) of PID were detected in 4,540 cases of infertility, wherein the incidence rates of nonspecific PID and female genital tuberculosis (FGTB) were 57.9 and 42.1%, respectively. From 1985 to 1995, FGTB (25.1%) was the first reason for infertility, while from 1996 to 2006, nonspecific PID (33.9%) emerged as the most common cause of infertility. Further, FGTB (74.7%) was the major factor causing occluded fallopian tubes, followed by nonspecific PID (61.1%), and the damage of the former was more serious than the latter.

CONCLUSIONS

PID is the main cause of tubal infertility, but the etiology of PID has changed from FGTB to nonspecific PID in the last 10 years in Shanxi.

What is the societal burden of endometriosis-associated symptoms? a prospective Belgian study

Endometriosis is a complex disease that affects a large number of women of reproductive age and imposes a significant burden on patients and society. The aim of this study was to evaluate diagnosis, comorbidities, healthcare resource use, treatment patterns, costs and quality of life of women with endometriosis seen in a Belgian tertiary care centre. A total of 134 patients were included in a prospective questionnaire-based cost-of-illness study. Patients were diagnosed after a median delay of 2 years after onset of symptoms. Almost all patients reported having at least one comorbidity. Total annual costs per patient were €9872 (95% confidence interval €7930–11,870), with costs of productivity loss representing 75% of total costs. Hospitalizations, surgeries, infertility treatments, pain and anxiety increased total costs significantly (P 0.001). Patients generated an average of 0.82 QaLY over a 1-year time horizon. This study showed that direct and indirect costs attributable to endometriosis-associated symptoms are substantial. Earlier diagnosis and cost-effective treatment of endometriosis may decrease productivity loss, quality of life impairment and healthcare consumption and consequently reduce total costs to patients and society.