Hysterosalpingo-foam sonography: patient selection and perspectives

[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-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.

Is hysterosalpingo-foam sonography the new gold standard for assessing tubal patency? A systematic review and meta-analysis

The aim of this study was to compare hysterosalpingo-foam sonography (HyFosy) with other tubal patency tests to analyse its efficacy, safety and tolerance. A systematic review and meta-analysis were performed following the Cochrane Collaboration and PRISMA guidelines by searching PubMed and the Cochrane Library using the term 'HyFosy'. In total, 20 studies, published from 2012 to January 2023, were included in this review. Information about the identification of tubal patency, agreement with laparoscopy, pain intensity, procedure failure, occurrence of pregnancy, side effects and treatment modalities was extracted. In 94% of patients, HyFosy had the same result as laparoscopy. No difference was found between HyFosy and hysterosalpingography (HSG) in terms of identification of tubal patency [total risk ratio (TRR) 0.98, 95% CI 0.88-1.10] and procedure failure (TRR 0.47, 95% CI 0.07-3.05). The visual analogue scale pain score was in favour of HyFosy (TRR 1.09, 95% CI 1.00-1.17); 95% of patients scored <6. Only 1% of patients had procedure failure or side effects after undergoing HyFosy. HyFosy is at least as efficient as HSG. HyFosy should be fully integrated as a first-line tool for the assessment of tubal patency. New guidelines for the inclusion of HyFosy in the assessment of tubal patency and standardization of this new procedure are essential.

Sequential-contingent strategy for fallopian tube evaluation using hysterosalpingo foam sonography: a cost analysis

Background

Tubal pathology is the etiological factor in 20% of couples with female infertility. Historically, diagnostic evaluation of the fallopian tubes has been performed by means of hysterosalpingography (HSG). Hysterosonosalpingography with EXEM® foam is a recent technique with supposedly comparable effectiveness to HSG, but with better tolerability for patients.

Methods

Tubal patency was assessed in patients who were candidates for intrauterine insemination (IUI) between January 2020 and July 2021. (I) Hysterosonosalpingography with EXEM® foam. (II) If the patient had both tubes patent, IUI was proposed. In case of inconclusive or pathological results, HSG was performed. (III) If the HSG concludes tubal patency, IUI is proposed. On the other hand, if it results in tubal obstruction, in vitro fertilization (IVF) is proposed.

Results

Assessment of tubal patency by HSG showed concordance with previous Hysterosonosalpingography with EXEM® foam results in 45.5% (n=15) of cases of unilateral obstruction and 66.7% (n=6) of cases of bilateral obstruction. When we compare the total cost of HSG (€54,899.46) with the sum of patients who only required Hysterosonosalpingography with EXEM® foam together with those who underwent both tests (€45,575.96), it shows that the latter represents a cost benefit strategy (cost difference €9,323.50).

Conclusions

Our results suggest a benefit of €9,323.50 when performing the contingent sequential strategy, in case of pathological or inconclusive results, compared to performing a systematic HSG in all patients. Patients with an obstructive hysterosalpingogram with EXEM® and a patent hysterosalpingogram will be the subgroup that will benefit the most, as IUI can be proposed instead of IVF. In addition, there is a benefit in terms of optimizing the medical procedure, hospital visits and speeding up the time to start assisted reproductive technology (ART).

Is Hysterosalpingo-Contrast Sonography (HyCoSy) Using Sulfur Hexafluoride Microbubbles (SonoVue) Sufficient for the Assessment of Fallopian Tube Patency? A Systematic Review and Meta-Analysis

This study aimed to evaluate the diagnostic value of HyCoSy using sulfur hexafluoride microbubbles for fallopian tubal patency assessment in infertile females. Twenty-four studies, including 1358 females with 2661 detected fallopian tubes published from January 2003 to May 2019, were identified. The pooled sensitivity was 93% (95% CI: 90-95%), while the specificity was 90% (95% CI: 87-92%). The area under the receiver-operating characteristic curve was 0.96 (95% CI: 94-98%). The specificity of the four-dimensional HyCoSy subgroup was higher than the 2D/3D subgroup; an increased dose of contrast agent did not affect the specificity, with only a slightly reduced sensitivity.

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.

Undescended ovary without abnormal development of uterus and urinary system: a report of four cases

Background

Congenital anatomic abnormalities of fallopian tubes and ovaries are rarely reported. Herein, we describe four cases of undescended ovary during laparoscopic surgery with abnormal anatomy of fallopian tube, yet without abnormal uterine development and urinary system abnormalities, which are analyzed by their clinical features and effects on reproductive function.

Case presentation

For the patients with undescended ovary, the location of unilateral or bilateral upper poles of the ovaries were usually much higher than that of the bifurcation of the common iliac vessel, and the fallopian tubes at the same side opened in the para-colonic sulcus. Among these four patients, two patients had primary infertility, one patient had tubal pregnancy rupture and bleeding, and one patient had uterine leiomyoma. The development of uterus was normal in all cases, and there was no abnormal development of urinary system. During the infertility examination, the fact that fallopian tubes lifted up in hysterosalpingography (HSG) might be regarded as an indicator of possible undescended ovary. The pelvic ultrasonography examination was of limited use in diagnosing undescended ovary.

Conclusion

Laparoscopy is the gold standard for the diagnosis of undescended ovary. When there is periodic post-sacral spinal pain, MRI or HSG can be used for diagnosis of undescended ovary.

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.

Spontaneous conception outcome in infertile women after four-dimensional hysterosalpingo-contrast-sonography

BACKGROUND

Four-dimensional hysterosalpingo-contrast sonography (4D-HyCoSy) is the preferred way for evaluating fallopian tubal patency and it associated with higher rate of spontaneous conception. However, Few studies have evaluated the influencing factors of spontaneous conception in 4D-HyCoSy and suggested ways to choose treatment options after 4D-HyCoSy. The study was to evaluate the correlation between spontaneous conception outcome and the patients' clinical characteristics as well as tubal patency in infertile women to provide reference on ways to manage the patient after 4D-HyCoSy.

METHODS

This was a retrospective study and analysis of two hundred and eighty three (283) infertile patients who underwent a 4D-HyCoSy between December 2014 and October 2017 in our center. Eligible patients were those whose partners semen parameters were normal when based on World Health Organization (WHO) criteria, and had spontaneous conception without clinical interventions after 4D-HyCoSy.

RESULT(S)

One hundred and sixteen patients (40.9%) conceived spontaneously and the mean conception time was (8.8 ± 0.3) months. Within a year after 4D-HyCoSy, the spontaneous conception rate was highest in type VI(62.5%), followed by type IV (46.2%), type III (44.4%), type V (39.4%), type II (33.9%) and type I (14.8%). With Cox regression analysis, two factors associated with spontaneous conception outcome appeared to increase spontaneous conception rate: patients with type IV or type VI tubes and duration of infertility less than 2 years. The age, type of infertility, multiparas, history of pelvic surgery, history of uterine cavity operation, uterine fibromyomata and polycystic ovary were unrelated to spontaneous conception outcome after 4D-HyCoSy.

CONCLUSION(S)

This study showed that some infertile women could succeed in spontaneous conception after 4D-HyCoSy. Hence, We recommend the usage of 4D-HyCoSy as first line for tubal patency test and infertile patients should be advised to accept 4D-HyCoSy examination as soon as possible. Expectant treatment of about 8-9 months is reported to be feasible for infertile women whose 4D-HyCoSy findings showed one tube patency or poor patency. Alternatively, an immediate clinical intervention is recommended for those with bilateral obstructed tubes .

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.

Assessment of the Influence on Spontaneous Pregnancy of Hysterosalpingo-Contrast Sonography

Objective

Our objective was to explore whether the pregnancy rate (PR) was higher than usual after hysterosalpingo-contrast sonography (HyCoSy).

Methods

We conducted a prospective observational study of 1,008 infertility patients, all of whom were examined by HyCoSy. The expected time for spontaneous pregnancy was at least 180 days after the HyCoSy exams. There were three types of HyCoSy results: type I, defined as both fallopian tubes patent; type II, defined as one fallopian tube patent with obstruction in the other; and type III, defined as both fallopian tubes obstructed. During the HyCoSy examinations, we recorded the mobility of the ovaries, injective resistance, and contrast agent venous intravasation. Before the examinations, we recorded each patient's medical history, including maternal age, infertility type, median duration of menstrual cycle, dysmenorrhea, and parity number.

Results

The PR was 19.44% within 180 days after HyCoSy and it was significantly higher in the first 30 days (6.35%) (P <.01). The PR of type I was highest, with a rate of 32.01%, followed by the PR of type II (25.51%) and type III (15.04%) (P <.01). Univariate analysis showed that younger age, patency of both fallopian tubes, good ovarian mobility, and absence of injective resistance were positively related to the initiation of pregnancy (P <.01). Infertility type, median duration of menstrual cycle, dysmenorrhea, parity number, contrast agent venous intravasation, and identity of the sonographer were unrelated to pregnancy (P >.05). However, multivariate analysis showed that patency of both fallopian tubes and the absence of injective resistance were independently associated with pregnancy.

Conclusion

Some infertility patients conceived successfully and naturally not long after HyCoSy, most often in the first month after the examination. Multivariate analysis showed that patency of both fallopian tubes and the absence of injective resistance were independently factors associated with the ability to conceive after HyCoSy examination.

Oil-based versus water-based contrast for hysterosalpingography in infertile women: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

To determine the effect of the using oil-soluble contrast material (OSCM) vs. water-soluble contrast material (WSCM) for hysterosalpingography on pregnancy rates in infertile women.

DESIGN

Systematic review and meta-analysis.

SETTING

Not applicable.

PATIENT(S)

Infertile women.

INTERVENTION(S)

We included randomized controlled trials comparing pregnancy outcomes in women with infertility undergoing hysterosalpingography using OSCM and WSCM. Paired reviewers independently screened citations, assessed risk of bias of included studies, and extracted data. A random-effects model was used to report all outcomes. The Grading of Recommendations Assessment, Development, Evaluation（GRADE） system was used to quantify absolute effects and quality of evidence.

MAIN OUTCOME MEASURE(S)

The primary outcome was ongoing pregnancy per randomized women.

RESULT(S)

Six trials with a total of 2,562 patients were selected. Our meta-analysis showed OSCM was associated with significantly higher rates of ongoing pregnancy compared with WSCM (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.12-1.93; I² = 44%, moderate-quality evidence). Three trials reported live birth, but they were not pooled owing to extreme statistical heterogeneity (I² = 86%). There was no difference in incidence of miscarriage (OR 0.83, 95% CI 0.56-1.24) or ectopic pregnancy (OR 0.65, 95% CI 0.18-2.36) between OSCM and WSCM groups. Three trials were rated as low risk of bias, whereas three were considered unclear.

CONCLUSION(S)

Women who previously underwent hysterosalpingography using oil contrast had higher rates of ongoing pregnancy compared with women who underwent this procedure using water contrast. There is not enough evidence to either support or oppose the difference between groups concerning miscarriage and ectopic pregnancy.