Hysterosalpingocontrast sonography (HyCoSy): evaluation of the pain perception, side effects and complications

Spontaneous Pregnancy after 4D-Hysterosalpingo-Sonography (HyCoSy) in the Same Menstrual Cycle: A Case Report and an Updating Review of the Current Literature regarding the Positive Impact of Tubal Flushing Effect on Fertility

Infertility is increasing worldwide, as well as in Italy, and fallopian tube pathology represents one of the most impacting causes of infertility for multiple women. Indeed, tubal patency assessment is a crucial step in medical evaluation for women attending an in vitro fertilization (IVF) center. Currently, different methods for tubal investigation are available, such as chromosalpingoscopy, hysterosalpingography (HSG), and hysterosalpingo-contrast sonography (HyCoSy). This diagnostic exam is performed by ultrasonography and an air-water-based contrast agent represented by air-water, or foam solution (HyFoSy). An additional side benefit of these assessment tests is a fertility-enhancing effect, thanks to a positive effect defined as "tubal flushing," which in current literature is more strongly associated with HyFoSy with respect to HyCoSy. In this report, we present a case of a 34-year-old woman presented to our attention at the Reproductive and Physiopathology Unit of Sandro Pertini Hospital, Rome, in 2023, with unexplained infertility for 3.1 years of free sexual intercourse with a partner who did not report sperm abnormalities. Subsequently, in this exam, the woman spontaneously conceived in the same menstrual cycle that the 4D-HyCoSy was performed, without any additional fertility enhancement interventions. In this case report, we also include an updating review of the current literature regarding the insurgence of spontaneous pregnancy after this technique in order to explore the physiopathological and etiopathogenetic mechanisms underlying the achievement of spontaneous pregnancy and to confront our case with other recent works published. According to our clinical experience and the current literature, 4D-HyCoSy is the easiest, safest, and cheapest diagnostic exam for investigating tubal patency, which can lead to medical success in some cases of "unexplained infertility" as the achievement of a spontaneous pregnancy.

Severe Pain and Postoperative Effects during Hysterosalpingography: A Meta-Analysis

Background

We aimed to evaluate the impact of pain on patients during Hysterosalpingography (HSG).

Methods

PubMed, PMC and other journals were searched for randomized controlled trials (RCTS) on HSG. Appropriate articles were selected for inclusion and reasonable exclusion according to keywords. Following a thorough review of the relevant literature, the process of literature screening was conducted in accordance with the aforementioned criteria. The methodological quality of the studies was assessed using the risk of bias assessment tool developed by the Cochrane Collaboration. Meta-analysis was conducted using RevMan 5.4.1 software.

Results

Twelve studies were included, including 1530 cases in the experimental group and 1545 cases in the control group. The literature summarizes the basic information of patients during HSG and makes statistics on the differences in visual analog scale (VAS) and pain perception. The findings from the HSG examination revealed a lack of significant association between patients' pain sensation and their age and BMI. However, the duration of pregnancy in patients decreased following HSG treatment (95%CI (-18.84 to -3.58), P=0.004).Compared with conventional testing, HSG could effectively reduce the pregnancy time of patients (95%CI (-18.84, -3.58), P=0.004), reduce the VAS of patients (95%CI (-4.73, -1.51), P=0.0001), and increase the number of patients without pain (95%CI (1.80, 10.43), P=0.001).

Conclusion

During the HSG examination, acceptable pain avoidance is generated and can be relieved over time. At present, there is no effective alternative method, so the patient should cooperate with the doctor to complete the examination, to relieve the pain.

Comparative Study Between Hysterosalpingo-Contrast Sonography and Hysterosalpingography in Evaluating Tubal Patency at Aminu Kano Teaching Hospital, Kano

Background

Tubal diseases contribute significantly to secondary infertility, affecting 25-35% of couples seeking infertility treatment. Traditional methods for assessing tubal patency, such as laparoscopy and dye tests, are invasive, costly, and require specialized expertise. Hysterosalpingography (HSG) is an alternative, but it involves pain and radiation exposure. This study aimed to compare the effectiveness of Hysterosalpingo-contrast Sonography (HyCoSy) using a saline and air mixture to HSG in assessing tubal patency in infertility patients at Aminu Kano Teaching Hospital.

Methodology

A cross-sectional study involved 50 consenting patients seeking fertility evaluation. The researchers used a semi-structured questionnaire to gather demographic information. HyCoSy with the saline and air mixture was performed between the 5th and 10th day of the menstrual cycle, followed by HSG within the next five days. The patency of each fallopian tube was assessed, and pain levels experienced during both procedures were recorded using a numerical rating scale.

Results

The results indicated that 68.8% of patients had bilateral patent tubes according to HyCoSy, while 60.4% were found to have patent tubes with HSG. A comparison of findings for individual tubes showed an 89.6% concordance rate between the two tests, with a Kappa index of 0.73, indicating substantial agreement. Importantly, patients reported significantly less pain during the HyCoSy procedure (mean NRS score of 4.1) compared to HSG (mean NRS score of 7.1).

Conclusion

This study demonstrated that HyCoSy using a saline and air mixture is highly comparable to HSG in assessing tubal patency. Notably, HyCoSy was preferred by patients due to its reduced pain and better tolerance, with minimal adverse effects. This suggests that HyCoSy may be a more patient-friendly and cost-effective alternative for tubal assessment in cases of infertility.

Hysterosalpingography Observations in Female Genital Tuberculosis with Infertility

Background

Hysterosalpingography (HSG) is radiographic evaluation of uterine cavity and tubal patency.

Aims

The aim of this study was to evaluate the safety and utilisation of HSG in female genital tuberculosis (FGTB) with infertility.

Settings and Design

The study was conducted in a tertiary referral centre of North India.

Materials and Methods

It was a prospective study on 87 cases of FGTB with infertility. Diagnosis of FGTB was made by composite reference standard using the presence of acid-fast bacilli on microscopy/culture or positive GeneXpert, positive polymerase chain reaction or epithelioid granuloma on endometrial biopsy or definitive or probable findings on laparoscopy or hysteroscopy.

Statistical Analysis Used

Suitable statistical methods were used with STATA software version 12.0.

Results

HSG findings were normal in 49 (56.32%) cases. There were filling defects in 14 (16.09%), short and shrunken cavity in 4 (4.49%), intrauterine synechiae in 14 (16.09%), T-shaped cavity in 3 (3.44%) and deformed uterine cavity in 5 (5.74%) cases. Fallopian tube findings were hydrosalpinx in 12 (13.79%) and 11 (12.64%) cases, beading of tube in 4 (4.59%) and 2 (2.29%) cases, pipestem appearance in 2 (2.29%) cases each and Maltese cross appearance in 3 (3.44%) and 2 (2.29%) cases, respectively. Tubal blockage was seen in 69 (79.31%) and 67 (77.01%) cases being cornual block in 28 (32.18%) and 26 (29.88%) cases, mid-tubal block in 16 (18.39%) and 15 (17.24%) cases, multiple blocks in 10 (11.49%) and 12 (13.79%) cases and fimbrial block in 15 (17.24%) and 14 (16.09%) cases. None of the cases had flare-up of the disease after HSG in the current study.

Conclusion

HSG is a useful modality in FGTB with infertility.

Is hysterosalpingo-foam sonography (HyFoSy) more tolerable in terms of pain and anxiety than hysterosalpingography (HSG)? A prospective real-world setting multicentre study

BACKGROUND

In 60% of sterile couples a female factor is present, with these being tubal factors in 30-50% of cases. A tubal patency test is also required in women without a male partner undergoing fertility treatment. Thus, an accurate, safe and tolerable technique should be available. The aim of this study is to determine and to compare hysterosalpingo-foam sonography (HyFoSy) and hysterosalpingography (HSG) tolerability in terms of pain and anxiety.

METHODS

This is a prospective real-world setting multicentre study conducted in two tertiary hospitals in Madrid. 210 infertile women/women without a male partner looking to get pregnant were recruited; 111 for the HyFoSy group and 99 for the HSG group. Tolerability was measured in terms of anxiety by the State Trait Anxiety Inventory (STAI) and pain by the Visual Analogue Scale (VAS).

RESULTS

Median VAS score in HyFoSy group was 2 (P25; P75: 1; 3) versus 5 (4; 8) in HSG group, p < 0.001. The median State-STAI score in the HSG group was 18 points (10; 26) versus 10 (7; 16) in the HyFoSy group (p < 0.001); the median Trait-STAI score in the HSG group was 15 (11; 21) versus 13 (9; 17) in the HyFoSy group (p = 0.044).

CONCLUSIONS

HyFoSy shows higher tolerability to both: pain and anxiety. It is related to less pain and less post-test anxiety than HSG.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Tubal Flushing Treatment for Unexplained Infertility

Tubal patency testing was initially introduced as a diagnostic test. However, it has been observed that some tubal patency tests also have a therapeutic effect. This therapeutic effect can be influenced by the contrast medium used during tubal flushing. In this review, we discuss current evidence associated with different methods for tubal flushing and their potential impact on reproductive outcomes in women with unexplained infertility. Furthermore, we discuss their diagnostic accuracy, safety, and cost-effectiveness.

Transvaginal four-dimensional hysterosalpingo-contrast sonography: Pain perception and factors influencing pain severity

AIM

The purpose is to investigate pain perception during transvaginal four-dimensional hysterosalpingo-contrast sonography (TV 4D-HyCoSy) and factors influencing pain severity.

METHODS

This was a retrospective study included 340 women who underwent TV 4D-HyCoSy examination from January 2016 to October 2017. The factors were recorded, including age, childbearing history, infertility type, history of pelvic inflammation, pelvic surgery, history of uterine manipulation, history of ectopic pregnancy, atropine delivery mode, uterine position, uterine malformation, uterine lesion, fibroid, intrauterine adhesion, polycystic ovary, endometrial implantation cyst, dysmenorrhea score, the degree of patency of fallopian tube and contrast agents dosage. Pain was evaluated during and after TV 4D-HyCoSy. The time point of peak pain was evaluated and the influencing factors of moderate/severe pain were analyzed.

RESULTS

The highest pain occurred at contrast instillation. The independent influencing factors of moderate/severe pain were age (P = 0.021), dysmenorrhea score (P = 0.003) and tubal patency (P < 0.001). Further analysis showed that age affected the pain score when TV 4D-HyCoSy started and the peak pain occurred. Dysmenorrhea score and tubal patency affect the pain score at most time points.

CONCLUSION

Age, dysmenorrhea score and tubal patency are factors influencing the severity of pain during TV 4D-HyCoSy.

SonoPODography: A new diagnostic technique for visualizing superficial endometriosis

OBJECTIVE

To perform a pilot diagnostic accuracy study of a novel transvaginal ultrasonography procedure called saline-infusion sonoPODography to predict superficial endometriosis in patients with suspected endometriosis.

STUDY DESIGN

A prospective single-center diagnostic accuracy study was performed from September 2019-November 2019. The index test sonoPODography was performed and the results were documented in a standardized fashion. SonoPODography was performed by installing saline into the pouch of Douglas (POD) via an intrauterine balloon catheter to create an acoustic window between the ultrasound probe and surrounding structures. The pelvis was then assessed for the presence or absence of superficial endometriosis using pre-defined features. Direct visualization at laparoscopy and histological assessment of excised endometriosis confirmed the outcome. The diagnostic performance of sonoPODography was evaluated.

RESULTS

42 consecutive participants underwent sonoPODography. Superficial endometriosis was identified by sonoPODography in 24/42 (57.1 %) and in 37/42 (88.1 %) participants by direct visualization at laparoscopy. The overall diagnostic performance of sonoPODography was: accuracy 69.1 %, sensitivity 64.9 %, specificity 100.0 %, positive predictive value 100.0 %, negative predictive value 27.8 %. Amongst those without deep endometriosis/endometriomas/pouch of Douglas obliteration, the diagnostic performance was: accuracy 80.0 %, sensitivity 77.7 %, specificity 100.0 %, positive predictive value 100.0 %, negative predictive value 33.3 %. The pouch of Douglas peritoneum was the most common site of superficial endometriosis.

CONCLUSIONS

SonoPODography is a novel ultrasound-based procedure that permits the direct visualization of superficial with respectable diagnostic accuracy. The findings of this pilot study are promising and justify the initiation of a larger outpatient study. SonoPODography may establish new avenues for the non-invasive diagnosis and investigation of endometriosis.

Pain Perception and Side Effects During Saline Infusion Sonohysterography With a Balloon Catheter: A Randomized Comparative Study of Cervical Versus Intrauterine Catheter Placement

OBJECTIVES

This study aimed to evaluate whether the site of the balloon placement into either the uterine cavity or cervical canal can affect the intensity of pain during sonohysterography.

METHODS

In this randomized clinical trial, women who underwent saline infusion sonohysterography (SIS) were randomized to intracervical or intrauterine balloon placement between May 2012 and May 2014. The examination was scheduled at the early follicular phase of the menstrual cycle. The primary outcome measures included the degree of pain after inflation and then after deflation of the balloon catheter. Data were analyzed on the basis of the intention-to-treat principle for each woman who underwent SIS.

RESULTS

A total of 300 infertile women were assigned to the treatment groups. There were no significant differences in inflation and deflation pain and the total procedure time between the 2 groups. The total volume of required saline for adequate distention of the cavity was significantly lower in the cervical group than the intrauterine group (p = .015). Nulliparous women had insignificantly more pain after the initial inflation of the balloon compared with multiparous women (p = .069). The pain score was not associated with patients' age, the volume of the saline infused, the presence of intrauterine abnormality, and the procedure time.

CONCLUSIONS

Intracervical catheter placement did not reduce pain during or after SIS. However, intracervical balloon insertion requires a less-significant volume of saline compared with intrauterine placement, leading to a reduced risk of intrauterine infection and the spread of malignant endometrial cells into the peritoneal cavity at the time of the procedure.

Comparison of Virtual Ultrasonographic Hysteroscopy with Conventional Hysteroscopy in the Workup of Patients Who Are Infertile

STUDY OBJECTIVE

To compare the tolerability and diagnostic accuracy of virtual ultrasonographic hysteroscopy (VUH) with that of conventional diagnostic outpatient hysteroscopy in the workup of patients who are infertile.

DESIGN

A single-center, retrospective cohort study.

SETTING

Department of Obstetrics and Gynecology, Gynecologic Oncology, and Minimally Invasive Pelvic Surgery Unit of Sacred Heart Hospital Don Calabria in Negrar, Italy.

PATIENTS

A total of 120 consecutive women who underwent hysterosalpingosonography and subsequent VUH and conventional hysteroscopy for infertility evaluation were included. The inclusion criterion was infertility for at least 1 year, with evaluation in the early or intermediate follicular phase of the menstrual cycle.

INTERVENTIONS

After the placement of an intracervical catheter, a Ringer Lactate solution was injected into the uterine cavity and fallopian tubes, and a 3D volume was obtained. The ultrasound volume acquired was successively elaborated offline, and a VUH was performed. Subsequently, a variable amount of air was introduced into the uterine cavity, and the patency of the salpinges was evaluated.

MEASUREMENTS AND MAIN RESULTS

The VUH findings were compared with those of conventional hysteroscopy performed in the subsequent month. For the detection of endometrial pathology in the overall pool, the sensitivity and specificity of VUH in comparison with conventional hysteroscopy were 100% (95% confidence interval [CI], 84.6%-100%) and 100% (95% CI, 96.3%-100%), respectively. For the detection of uterine cavity pathology and uterine malformations in the overall pool, the sensitivities of VUH were 80% (95% CI, 28.4%-99.5%) and 100% (95% CI, 75.3%-100%), respectively, with specificities of 100% (95% CI, 96.8%-100%) and 100% (95% CI, 96.6%-100%), respectively, when compared with conventional hysteroscopy. The positive predictive values for endometrial pathology, uterine cavity alterations, and uterine malformations were 100% (95% CI, 84.6%-100%), 100% (95% CI, 39.8%-100%), and 100% (95% CI, 75.3%-100%), respectively, with a receiver operating characteristic area of 100%, 90% (95% CI, 70%-100%), and 100%, respectively. There were no cases of severe vasovagal reactions or other complications. Most patients (67%, 81 of 120 women) described the examination as "less painful than expected," 25% (30 of 120 women) "just as expected," and only 7% (9 of 120 women) as "more painful than expected."

CONCLUSION

VUH was well tolerated and showed a high accuracy (100%) in the study of the uterine cavity when compared with conventional hysteroscopy.

Causes of misdiagnosis in assessing tubal patency by transvaginal real-time three-dimensional hysterosalpingo-contrast sonography

OBJECTIVE

This study aims to investigate the causes of misdiagnosis in assessing tubal patency by transvaginal real-time three-dimensional hysterosalpingo-contrast sonography (TVS RT-3D-HyCoSy), in order to improve the diagnostic efficiency of TVS RT-3D-HyCoSy.

METHODS

A total of 162 oviducts of 83 infertility patients were examined by TVS RT-3D-HyCoSy. These results were compared with the gold standard for laparoscopic dye studies, and the misdiagnosed cases were analyzed.

RESULTS

TVS RT-3D-HyCoSy revealed that 68 oviducts were unobstructed and 94 obstructed. The results for the 144 oviducts were in line with the gold standard, while those for 18 oviducts were not. The accuracy rate of the TVS RT-3D-HyCoSy was 88.9%, and the misdiagnosis rate was 11.1%. The main causes of misdiagnosis included contrast medium countercurrent and diffusion, oviduct spasm, abnormal shape or position of the oviduct, pelvic adhesion, and poor imaging operation.

CONCLUSION

TVS RT-3D-HyCoSy can well-evaluate tubal patency, and understand and improve the cause of misdiagnosis. Furthermore, the diagnostic efficiency of TVS RT-3D-HyCoSy can still be further improved.

Use of atropine in four-dimensional hysterosalpingo-contrast sonography: Does it suppress pain during infertility examination?

This study aimed to ascertain if atropine is useful for suppressing the pain suffered during four-dimensional hysterosalpingo-contrast sonography (4D-HyCoSy) when assessing infertility in women. A total of 252 patients were divided into 2 groups to receive or not receive atropine (0.5 mg) injection 30 minutes before 4D-HyCoSy. Pain was evaluated using a numerical rating scale (NRS): during 4D-HyCoSy; upon 2-dimensional transvaginal sonography; before catheter insertion; upon insertion and fixation of the catheter into the uterine cavity; 30 minutes after 4D-HyCoSy. According to the degree of patency of Fallopian tubes, the 6 patterns observed were integrated further into 3 patient groups: all-negative (both Fallopian tubes were negative), positive-and-negative (one Fallopian tube showed patency and the other showed stenosis or non-patency), and all-positive (both Fallopian tubes showed stenosis or non-patency). We compared the NRS scores and prevalence of side-effects other than pain between the atropine-injection and non-atropine-injection groups within the three groups mentioned above. The NRS score showed no significant differences among the groups at any time point (all P > .05). The different prevalence of side-effects other than pain was significant between the atropine-injection and atropine-non-injection groups (P = .012). These data suggest that atropine does not reduce pain in patients during 4D-HyCoSy. However, atropine may reduce the prevalence of other side-effects during 4D-HyCoSy, which needs a further, large, prospective, multi-cohort study to verify.

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.

Current management of tubal infertility: from hysterosalpingography to ultrasonography and surgery

RATIONALE

The development of IVF techniques has diminished the importance of tubal infertility but recent discoveries shed a new light on reproductive tubal surgery prior to any IVF cycle.

OBJECTIVE

To adapt current state of the art recommendations concerning tubal factor infertility to actual possibilities in Romanian healthcare system and to grow the awareness of fellow fertility specialists and general practitioners to the improved outcomes of novel management and treatment modalities.

METHODS AND RESULTS

67 free full text articles centered on the subject of management in tubal infertility were identified in international databases. Four articles described general diagnosis using data from medical history, 21 works approached the diagnosis through hysterosalpingography, 14 papers introduced the use of different sonographic procedures, 8 files analyzed the importance of exploratory laparoscopy and 20 articles reviewed different treatment modalities.

DISCUSSIONS

Current data show that active implementation of the large scale use of tubal surgery prior to any IVF cycle will reduce up to 30% the costs associated with obtaining a viable pregnancy in cases with tubal factor sterility.

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.

Clinical case presentation: life threatening Group A sepsis secondary to HyCoSy

Hysterosalpingo contrast sonography (HyCoSy) is a commonly performed procedure in the investigation of infertility. Infection is an uncommon complication of this procedure. Should it occur, it is generally mild and amenable to outpatient treatment with oral antibiotics. We present a case of an immunosuppressed woman who underwent HyCoSy for investigation of secondary infertility and developed life‐threatening sepsis with Group A streptococcus.

B-flow ultrasound facilitates visualization of contrast medium during hysterosalpingo-contrast sonography

OBJECTIVE

To assess if B-flow ultrasound improves visualization of flow of contrast medium in the Fallopian tubes during hysterosalpingo-contrast sonography (HyCoSy) compared with grayscale ultrasound.

METHODS

This prospective observational study included 160 women referred for HyCoSy as part of infertility work-up between January 2011 and September 2012. In each woman, at the same session, HyCoSy was performed first using saline with air and then using Sonovue®, and for each contrast medium, grayscale ultrasound was first used and then B-flow ultrasound was used. Flow of contrast was observed in three parts of each tube: intramural, middle and distal.

RESULTS

In 129 (81%) women, flow of Sonovue was observed in the intramural part of both tubes and in the pouch of Douglas when using grayscale ultrasound. In these women, flow of Sonovue was seen in the middle part of 70% of the 258 tubes when using grayscale ultrasound and in 93% when using B-flow ultrasound; and in the distal part in 81% when using grayscale ultrasound and in 98% when using B-flow ultrasound. When using air and saline, flow was seen in the intramural part of 90% and 93% of the tubes, in the middle part in 54% and 72%, and in the distal part in 66% and 90%, using grayscale ultrasound and B-flow ultrasound, respectively.

CONCLUSION

B-flow ultrasound facilitates detection of flow of contrast in the middle and distal parts of the tubes at HyCoSy, especially when a mixture of saline and air is used as contrast medium.