Impact of oil-based contrast agents in hysterosalpingography on fertility outcomes in endometriosis: a retrospective cohort study

BACKGROUND

Previous studies have suggested that oil-based contrast agents used during hysterosalpingography (HSG) in infertile patients can enhance fertility. However, limited research has investigated the effect of oil-based contrast medium specifically in individuals with endometriosis-related infertility.

OBJECTIVE

This study aims to explore the impact of oil-based contrast medium on fertility outcomes in women with endometriosis-related infertility.

METHODS

Conducted at the First Affiliated Hospital of Guangxi Medical University (January 2020 to June 2022), the study included 512 patients undergoing HSG. Patients were categorized into oil-based and non-oil-based groups, and after propensity score matching, demographic characteristics were compared. Main outcomes included clinical pregnancy rates, live birth rates, early miscarriage rates, and ectopic pregnancy rates.

RESULTS

In our analysis, the Oil-based group showed significantly better outcomes compared to the Non-oil-based group. Specifically, the Oil-based group had higher clinical pregnancy rates (51.39% vs. 27.36%) and increased live birth rates (31.48% vs. 19.93%). This trend held true for expectant treatment, IUI, and IVF/ICSI, except for surgical treatment where no significant difference was observed. After adjusting for various factors using propensity score matching, the Non-oil-based group consistently exhibited lower clinical pregnancy rates compared to the Oil-based group. The Odds Ratio (OR) was 0.38 (95%CI: 0.27-0.55) without adjustment, 0.34 (0.22-0.51) in multivariable analysis, 0.39 (0.27-0.57) using inverse probability of treatment weighting (IPTW), and 0.22 (0.14-0.35) in propensity score matching.

CONCLUSION

Oil-based contrast medium used in HSG for women with endometriosis-related infertility is associated with higher clinical pregnancy rates and live birth rates compared to Non-oil-based contrast medium.

Outpatient hysteroscopy impact on subsequent assisted reproductive technology: a systematic review and meta-analysis in patients with normal transvaginal sonography or hysterosalpingography images

BACKGROUND

Standard management for intrauterine lesions typically involves initial imaging followed by operative hysteroscopy for suspicious findings. However, the efficacy of routine outpatient hysteroscopy in women undergoing assisted reproductive technology (ART) remains uncertain due to a lack of decisive high-quality evidence. This study aimed to determine whether outpatient hysteroscopy is beneficial for infertile women who have unremarkable imaging results prior to undergoing ART.

METHODS

A systematic review and meta-analysis were conducted following PRISMA guidelines, incorporating data up to May 31, 2023, from databases such as PubMed, Embase, and the Cochrane Library. The primary outcome assessed was the live birth rate, with secondary outcomes including chemical pregnancy, clinical pregnancy rates, and miscarriage rates. Statistical analysis involved calculating risk ratios with 95% confidence intervals and assessing heterogeneity with the I2 statistic.

RESULTS

The analysis included ten randomized control trials. Receiving outpatient hysteroscopy before undergoing ART was associated with increased live birth (RR 1.22, 95% CI 1.03-1.45, I2 61%) and clinical pregnancy rate (RR 1.27 95% CI 1.10-1.47, I2 53%). Miscarriage rates did not differ significantly (RR 1.25, CI 0.90-1.76, I2 50%). Subgroup analyses did not show a significant difference in clinical pregnancy rates when comparing normal versus abnormal hysteroscopic findings (RR 1.01, CI 0.78-1.32, I2 38%). We analyzed data using both intention-to-treat and per-protocol approaches, and our findings were consistent across both analytical methods.

CONCLUSIONS

Office hysteroscopy may enhance live birth and clinical pregnancy rates in infertile women undergoing ART, even when previous imaging studies show no apparent intrauterine lesions. Treating lesions not detected by imaging may improve ART outcomes. The most commonly missed lesions are endometrial polyps, submucosal fibroids and endometritis, which are all known to affect ART success rates. The findings suggested that hysteroscopy, given its diagnostic accuracy and patient tolerability, should be considered in the management of infertility.

DATABASE REGISTRATION

The study was registered in the International Prospective Register of Systemic Review database (CRD42023476403).

Hysterosalpingographic, ultrasonographic and clinical profile of infertile women in Butembo, Eastern Democratic Republic of Congo

Introduction

infertility is a reproductive health issue in modern society. In developing countries, ultrasonography and hysterosalpingography (HSG) are first-line exams investigating infertility in women. It is a highly reported issue in Africa and is linked to abnormalities diagnosed by medical imagery investigations. Our research aimed to evaluate ultrasonography and HSG usage in female infertility investigation in eastern DR Congo, and to point out the most frequent lesions in infertile women in this area.

Methods

it was a cross-sectional research. It included 1024 patients in four equipped hospitals with HSG and ultrasonography, who consulted from January 1st, 2019 up to December 31st, 2021. Data were collected from consultation dossiers and imagery protocols.

Results

of 1024 patients, the mean age was 30.85±5.05 years, 41.79 % (n=428) had primary infertility and 57.71% (n=591) had secondary infertility with parity ranges 1.28±1.25, abortion 1.17±1.33. HSG usage rate was 26.85% (n=275) whereas ultrasonography was 66.01%(n=749). The prevalent diagnosed lesions were uterine myomas 10.51 % (n=71), polycystic ovary syndrome (PCOS) 8.28%(n=56), endometrial dysplasia 7.99% (n=54), ovarian cysts 5.03% (n=34) at ultrasonography and tubal obstructions 53.45 %(n=147), hydrosalpinx 4.73% (n=13), cervical impotence 3.27% (n=9), uterine synechias 2.55%(n=7), müllerian abnomalies 2.55%(n=7), uterine retroversion 2.18% (n=6) at HSG. History of upper genital infection was a risk factor aOR= 3.71, 95%CI 1,55-8,88; p <0.001 for tubal obstruction to HSG.

Conclusion

regarding the high prevalence of tubal and uterine abnormalities in infertile women of eastern DR Congo, ultrasonography, and HSG should be more performed exams in clinical practice in low-income countries.

EMLA (lidocaine-prilocaine) cream for pain relief during hysterosalpingography: a systematic review and meta-analysis of randomised placebo-controlled trials

We systematically investigated the efficacy and safety of EMLA (5% lidocaine-prilocaine cream) versus placebo for pain relief among infertile patients undergoing hysterosalpingography (HSG). We screened four databases from inception until 25 November 2020. We included only randomised placebo-controlled trials (RCTs) and assessed their risk of bias. The main efficacy outcomes included safety and pain scores during the different stages of HSG. The pooled outcomes were summarised as mean difference (MD) with 95% confidence interval (CI). Three RCTs were included, comprising 258 patients (131 and 127 patients received EMLA and placebo, respectively). All RCTs revealed an overall low risk of bias. EMLA significantly reduced pain perception during cervical instrumentation of tenaculum and cannula (MD = -1.53, 95% CI [-2.59, -0.47], p = 0.005) and at 24 h after completion of HSG (MD = -1.30, 95% CI [-2.57, -0.03], p = 0.04). Despite EMLA decreased pain perception during the other procedural stages of HSG, the differences were not statistically significant compared with placebo. EMLA was safe and free of local and systemic adverse reactions. This meta-analysis advocates that topical application of 5% EMLA cream is safe and correlates with decreased pain perception during HSG, particularly during the cervical instrumentation step and at 24 h after HSG completion.

Effect of comfort theory-based nursing care on pain and comfort in women undergoing hysterosalpingography: a randomized controlled trial

OBJECTIVE

This study aims to examine the effect of comfort theory-based nursing care on pain and comfort in women undergoing hysterosalpingography.

METHODS

This randomized control trial was conducted on 126 women (42 in each intervention and control group). Virtual reality glasses group (n=42), mobile-assisted education group (n=42), and control group (n=42). The control group received only routine care. Comfort levels were evaluated at the beginning and end of the study using the General Comfort Scale and pain levels evaluated at the beginning and end of the study using the Visual Analog Scale.

RESULTS

The comfort theory-based nursing care (virtual reality glasses and mobile-assisted education group) was effective in increasing women's comfort with painful invasive procedures such as hysterosalpingography and reducing pain.

CONCLUSION

It is recommended that a nurse be present in the hysterosalpingography process, providing nursing care services continuously and introducing this program to working nurses.Clinical Trial Registration Number: NCT04676932.

Effect of interval time between hysterosalpingography and intrauterine insemination on the pregnancy outcome of infertile patients

Background

Hysterosalpingography (HSG) is the most commonly applied tubal patency test in clinical practice. Although some studies have found an increased pregnancy rate after HSG, no studies to date have specifically characterized the effect of interval time between HSG and IUI on pregnancy outcome.

Objectives

To investigate the effect of interval time between HSG and intrauterine insemination (IUI) on live birth rates of infertile patients.

Methods

Retrospective cohort study. The reproductive medical record system was used to identify patients who completed ≥1 IUI cycle between January 2017 and October 2021. According to the interval time between HSG and IUI, patients were divided into three groups: <6months interval group,6-12 months interval group and >12 months interval group. The generalized estimating equation with Poisson distribution was used to estimate the risk ratios (RRs) and 95% confidence intervals (CIs) of different groups.

Results

A total of 413 patients completed 701 IUI cycles during the study period, <6months interval group, 415 cycles; 6-12 months interval group, 138 cycles; >12 months interval group, 148 cycles. The live birth rate of <6 months group was higher than other two groups (17.35% vs. 12.32% vs. 8.11%, P=0.017); Similarly, the clinical pregnancy rate of <6 months group was also higher than other two groups (19.76% vs. 14.49% vs.11.49%, P=0.049). When adjusted separately for FSH, AMH, infertility type, duration of infertility, infertility diagnosis, total motile count (TMC) of sperm, medications, endometrium size and dominant follicle size, the live birth rate of >12 months group severally significantly decreased by 60% (adjusted RR = 0.40, 95% CI [0.19-1.40]). The cumulative clinical pregnancy and live birth rates of <6 months group were higher than other two groups (P<0.05), but the cumulative pregnancy rate among three groups were not statistically different (log rank test: P=0.06).

Conclusion

The interval time between hysterosalpingography and IUI is related to pregnancy outcome. The clinical pregnancy and live birth rates were the highest when the time interval was less than 6 months. Therefore, IUI should be recommend as soon as possible after HSG if the patient couple meets the IUI indication.

Cesarean scar disorder: Management and repair

Cesarean scar disorder (CSD) is an entity recently defined as uterine niche with at least one primary or 2 secondary symptoms. CSDs can be visualized by hysterosalpingography, transvaginal sonography, saline infusion sonohysterography, hysteroscopy, and magnetic resonance imaging, but diagnosis should be performed by exams able to measure the residual myometrial thickness (RMT). Although there is a limited number of studies evaluating fertility and reproductive outcomes after different types of surgery, the following consideration should be kept in mind. Asymptomatic women should not be operated with the hope of improving obstetrical outcomes. It is reasonable to consider hormone therapy for CSDs as a symptomatic treatment in women who no longer wish to conceive and have no contraindications. In case of failure of or contraindications to medical treatment, surgery should be offered according to the severity of symptoms, including infertility, the desire or otherwise to preserve the uterus, the size of the CSD, and RMT measurement. Hysteroscopy is considered to be more of a resection than a repair, so women who desire pregnancy should be excluded from this technique in case of RMT <3 mm. In this instance, repair is essential and can only be achieved by a laparoscopic or vaginal approach. The benefit of laparoscopic approach seems to persist after subsequent CS. Women with CSDs need to be given complete information, including available literature, before any treatment decision is made.

Evaluation and perspectives on hysterosalpingography (HSG) procedure in infertility: a comprehensive study

OBJECTIVE

Infertility continues to be a common medical problem with significant societal repercussions and psychological and economic effects on families' lives. Hysterosalpingography (HSG) is the preferred method in clinical practice for evaluating the uterine cavity and tubal patency. Our study aims to present a comprehensive perspective on the importance of the HSG procedure in the evaluation of infertile patients, starting with the recommendation of the HSG procedure to the patient, the application of the procedure, and the evaluation of the patient's post-procedure process.

PATIENTS AND METHODS

This is a prospective evaluation of 323 women who underwent HSG at Kafkas University between 2021-2022. The type and duration of infertility in patients, the source from which the patient received the recommendation for HSG, visual pain score for evaluating pain during the HSG procedure, HSG results, patients' perspectives on the procedure's contribution to the treatment processes, their immediate post-procedure pain, and their pregnancy status within 6 months after the procedure were evaluated.

RESULTS

72.1% of patients had primary, and 27.8% had secondary infertility. 82% of HSG results were reported as normal. Among primary infertility, uterine pathologies were detected in 62.5%. In secondary infertile patients, tubal pathology was detected in 88.4%. There is a statistically significant difference between the infertility types of patients with normal HSG results and those without (p=0.001). There was also a difference between the results of HSG and follow-up types (p<0.001). A statistical difference was also found between the HSG result and the patients' conception status within 6 months after the procedure (p<0.001).

CONCLUSIONS

When it comes to the cost of the HSG procedure for infertility, as well as potential pain, radiation exposure, and rare allergic reactions to the contrast material, it is important to choose the appropriate circumstances for this procedure. In order to avoid unnecessary interventional procedures, it would be beneficial to discuss the recommendation of HSG for primary infertile patients under 28.5 years of age. Further research is required in this regard. Since tubal factors are most common among secondary infertile women, this group of patients is more likely to benefit from HSG in the evaluation.

Value of ovarian positional assessment on 4D hysterosalpingo-contrast sonography

AIMS

To investigate the positional relationship between the ovary and Fallopian tube and the relationship between the ovarian position and tubal morphology.

MATERIAL AND METHODS

A total of 195 patients with 338 fallopian tubes were enrolled in this retrospective study. The ovarian and tubal positions were defined relative to the uterus in all directions. Tubal morphology was classified as smooth or tortuous.

RESULTS

The distribution of the Fallopian tubes corresponded to the positions of the ipsilateral ovaries in the superoinferior direction (χ2 =197.653, p<0.001), mediolateral direction (χ2 =237.447, p <0.001) and anteroposterior direction (χ2 =109.746, p<0.001). Tubal morphology differed according to ovarian position in the superoinferior (χ2 =21.804, p<0.001), mediolateral directions (χ2 =4.679, p=0.031) but not in the anteroposterior direction (χ2 =0.793, p=0.373).

CONCLUSIONS

Evaluating the ovarian position can provide preliminary information on the distribution and shapeof the Fallopian tube, helping the operator choose the appropriate initial plane and the necessary approaches for inspection.

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.

Pain Relief for Hysterosalpingography: A Randomized Controlled, Double Blinded Trial Comparing Suppository Diclofenac, Prilocaine/Lignocaine (EMLA) Cream And Placebo

BACKGROUND

Hysterosalpingography is dreaded by women due to pain. Pain intensity varies with different stages of the procedure and the search for an effective analgesia continues.

OBJECTIVE

To compare the effectiveness of suppository diclofenac (100mg), cervical lidocaine 25mg -prilocaine 25mg cream (5% EMLA) and placebo in pain relief for hysterosalpingography.

METHODOLOGY

This was a prospective, randomized, double-blinded, placebo-controlled study conducted at National Hospital Abuja, Nigeria, between November 2018 and March 2019. Participants were allocated to three groups (A, B, C). Group A received suppository diclofenac 100mg plus placebo cream, group B got EMLA cream plus placebo suppository while group C received placebo suppository and cream. Pain levels were assessed using Visual Analogue Scale (VAS) at baseline, during 4 different stages of the procedure, at 30 minutes and 24 hours after the procedure. Patients' satisfaction and side effects were also assessed. Data were analyzed using SPSS version 22 (SPSS Inc., Chicago, IL, USA). P value < 0.05 at 95% confidence interval was regarded as statistically significant.

RESULTS

The most painful step of the procedure was during uterine distension with contrast medium with mean VAS score of 6.33±1.539, 5.37±1.377, 7.03±1.245 in group A, B and C, respectively (p-value <0.05). Mean pain scores during 4 steps of the procedure were found to be significantly lower in EMLA group. Intervention groups were also more satisfied after the procedure.

CONCLUSION

EMLA 5% cream is a more effective analgesic for HSG compared to both diclofenac and placebo.

Live birth after additional tubal flushing with oil-based contrast versus no additional flushing: a randomised, multicentre, parallel-group pragmatic trial in infertile women with at least one patent tube at hysterosalpingo-foam sonography (HYFOIL study)

INTRODUCTION

Tubal patency testing is an essential part in the fertility workup of many subfertile women. Hysterosalpingography (HSG) has long been the test of choice in many clinics. There is evidence from a large randomised multicentre trial and from a recent meta-analysis that women who had HSG using oil soluble contrast medium (OSCM) had higher rates of ongoing pregnancy compared with women who underwent this procedure using water contrast. However, the field is moving away from HSG and nowadays hysterosalpingo-foam sonography (Hyfosy) using ultrasound guidance is considered as the first line office tubal patency test. Therefore, a large multicentre randomised clinical trial (RCT) will be initiated to evaluate if flushing the fallopian tubes with OSCM after a normal Hyfosy showing at least one patent fallopian tube will increase the live birth rate as compared with no flushing.

METHODS AND ANALYSIS

We plan a multicentre two arm, 1:1 randomised, open-label pragmatic comparative trial in 12 Belgian centres. After informed consent, we will randomise infertile women between 18 and 40 years of age, undergoing Hyfosy as part of the fertility workup to Hyfosy with additional tubal flushing with OSCM versus Hyfosy without additional flushing. Infertility is defined as lack of conception despite 12 months of unprotected intercourse, or three cycles of donor insemination without pregnancy or three ovulatory ovulation induction cycles without pregnancy, all three in combination with at least one patent tube on Hyfosy. Primary endpoint will be live birth with conception within 6 months after randomisation.

ETHICS AND DISSEMINATION

Approval on 11 May 2021 by the Ethics Committee from ZNA Hospital Antwerp who was the central Ethics Committee for the Clinical Trial Regulation Pilot (Pilot 412) in the 12 centres. The findings from this RCT will be disseminated in peer-reviewed publications and presentations at scientific international meetings.

TRIAL REGISTRATION NUMBERS

EudraCT number: 2020-002135-30 and NCT04379973.

Clinical Significance of Increasing Pressure Curve's Slope When Injecting Ultrasound Contrast Agent During Evaluation of Fallopian Tubal Patency

OBJECTIVE

To explore the association between Fallopian tubal patency and the slope of the increasing pressure curve for ultrasound contrast agent.

MATERIALS AND METHODS

A total of 136 patients underwent transvaginal 4-dimensional hysterosalpingo-contrast sonography (TVS 4D HyCoSy) between August 2015 and January 2016. We divided the patients into 3 groups according to different Fallopian tubal patency status: 71 patients (48.97%) in bilateral tubal patency group, 45 (31.03%) in unilateral tubal patency group, and 20 in bilateral tubal nonpatent group. The ultrasound contrast agent was injected and the pressure curve was recorded automatically in real time using a liquid-injecting machine that traces it as a pressure curve. The slopes of the different groups are compared through independent sample t test.

RESULTS

The slopes of the 3 groups were 1.242 ± 0.572, 1.472 ± 0.638, and 2.068 ± 1.236 kPa/s. A correlation was observed between the slope of the increasing pressure curve and tubal patency (R = 0.287, P < .05). The slopes differed significantly between the bilateral tubal patency group and bilateral tubal nonpatent group (P = .001) and between the unilateral tubal patency group and bilateral tubal nonpatent group (P = .012). However, the difference between the bilateral tubal patency and unilateral tubal patency groups was not significant (P = .266).

CONCLUSION

The increase of the injecting pressure curve's slope for contrast agent during 4D HyCoSy is associated with the nonpatent degree of the tube. This condition can be used as an objective index of tubal patency and can be a reference in diagnosis and treatment.

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.

Hysterosalpingography using Magnetic Resonance Imaging for infertility patients

OBJECTIVE

Some studies have shown that it is possible to evaluate tubal permeability through MRI. Our aim is to perform a prospective study and to perform a comprehensive review in the literature regarding HSG-MRI.

METHODS

We carried out a PUBMED search using the following keywords: hysterosalpingogram, hysterosalpingography, magnetic resonance imaging and MRI. As inclusion criteria, we included only papers published in English, and exams ran on humans. We also conducted a prospective inclusion of patients who had visited a human reproduction clinic between May/2017 and April/2019 for laboratory image diagnoses using HSG-MRI.

RESULTS

Following the inclusion and exclusion criteria, we included seven original papers. Review papers and those written in a language other than English, were excluded. Between the period of May/2017 and April/2019, we selected ten patients for our study. The average exam duration was 30 minutes. Cervical catheterization was possible in all cases. There were no major complications. We highlight that in 8/9 of patients, we could directly visualize uterine tubes with contrast (excluding one patient with bilateral tubal ligation).

CONCLUSIONS

Our initial experience with HSG-MRI shows promise. We demonstrated an optimized protocol for conducting an HSG-MRI (with excellent image quality). HSG-MRI had some advantages, such as not using ionized radiation, less pain and being able to analyze pelvic anatomy. Patients referred for a pelvic MRI as part of a more detailed investigation into infertility can also benefit from undergoing a simultaneous HSG using MRI.

[Update of Chlamydia trachomatis infection]

Chlamydia trachomatis (CT) is the most common sexually transmitted bacterial infection worldwide. It is asymptomatic in most cases and mainly affects young women, with potential long term sequelae (pelvic inflammatory disease, tubal infertility, obstetric complications). The impact on male fertility is controversial. Screening methods as well as antibiotics use have recently been reassessed due to resistance phenomena and the negative effect on the urogenital microbiota. Positive CT serology may be indicative of tuboperitoneal pathology, which may not be noticed on hysterosalpingography. New research on single-nucleotide polymorphisms (SNPs) aims to establish a patient profile at higher risk of infectious tubal damage due to CT. CT seropositivity is also associated with decreased spontaneous pregnancy rates and is a predictive factor for obstetrical complications.

Hysterosalpigography findings of female partners of infertile couple attending fertility clinic at Lagos University Teaching Hospital

Introduction

Hysterosalpingography (HSG) is an outpatient fluoroscopic method for the evaluation of the uterine cavity, fallopian tubes, and the surrounding peritoneal cavity. Female fertility depends greatly on normal female reproductive organs; hence tubal abnormalities may contribute significantly to female infertility. HSG is an invaluable screening tool in the evaluation of women with suspected tubal factor infertility. This study aims to review the HSG findings of women who sought fertility treatment at the Lagos University Teaching Hospital, Lagos (LUTH).

Methods

this was a retrospective study of the pattern of HSG findings among female partners of infertile couples seeking fertility treatment at the LUTH, over a 2-year period, from January 2018 to December 2019.

Results

a total of 266 medical records and HSG results were reviewed and included in the data analysis. The mean age (± standard deviation) was 38.4 (± 0.3) years with a range of 24 to 50 years. Most (80.5%) of the participants have secondary infertility and majority (65.4%) were nulliparous. Tubal pathology was the commonest abnormality detected on HSG in 54.9% of women. About one-third (30.8%) of women had bilateral tubal occlusion on HSG. With regards to the right fallopian tube, 43.2% of the participants had tubal occlusion, which differs from 41.7% on the left fallopian tube. Similarly, 10.2% of the women had hydrosalpinx on the left tube when compared with 9% on the right tube. Age (OR 1.055; 95% CI: 1.006, 1.106, p-value 0.028), and previous salpingectomy [OR 6.151; 95% CI: 1.335, 28.349] and myomectomy [OR 4.6; 95% CI: 1.814, 11.67] were identified as risk factors for tubal pathologies on HSG.

Conclusion

tubal abnormalities are common findings on HSG and the identifiable risk factors for tubal pathologies include age, salpingectomy, and myomectomy. HSG remains a vital screening tool in the evaluation of tubal-factor infertility in Nigeria.

Effects of oil-soluble versus water-soluble contrast media at hysterosalpingography on pregnancy outcomes in women with a low risk of tubal disease: study protocol for a randomised controlled trial

INTRODUCTION

In recent years, due to various factors, the rate of infertility in China has increased and now affects over 10% of women of reproductive age. Hysterosalpingography (HSG) is a common diagnostic procedure during fertility examinations. However, there is no consensus on the choice of contrast agents and their effects. As the largest multicentre, randomised controlled trial (H2Oil trial from the Netherlands) has shown that oil-soluble contrast at HSG can enhance fertility compared with water-soluble contrast, we propose this study to examine whether the use of oil-soluble contrast media results in increased rates of pregnancy in Chinese women undergoing HSG.

METHODS AND ANALYSIS

This study is a single-centre, randomised, controlled, parallel-group, superiority trial. Patients with low risk of tubal disease will be randomised to undergo HSG using iodinated oil injection (OSCM group, oil-soluble contrast media) or ioversol injection (WSCM group, water-soluble contrast media). To evaluate the potential superiority of the OSCM group, with 1:1 allocation ratio, 90% statistical power and a two-sided significance level of 5%, we have calculated a sample of 520 women per group to be enrolled, for a total of 1040 including 10% loss to follow-up or protocol variation. The primary outcome is the rate of ongoing pregnancy during 6 months after randomisation. The secondary outcomes will consist of thyroid function of patients and newborns, pain scores during HSG, rate of live birth, clinical pregnancies, miscarriages, ectopic pregnancy, time to ongoing pregnancy, time to live birth, cost calculations of the OSCM group/WSCM group, and assisted reproductive technology treatments between the two groups.

ETHICS AND DISSEMINATION

This protocol received authorisation from the Medical Research Ethics Committee of International Peace Maternity and Child Health Hospital on 18 January 2020 (approval no GKLW2020-02). The findings will be reported in peer-reviewed publications and presentations at international scientific meetings.

TRIAL REGISTRATION NUMBER

ChiCTR2000031612.

Green urine sign after laparoscopic chromopertubation as an effect of severe contrast intravasation: a report of three cases

Tubal diseases are responsible for 25% to 35% of female infertility. Laparoscopic chromopertubation is the gold standard for assessing tubal patency when female infertility is suspected. Intravasation is a complication of intrauterine procedures involving the passage of fluid filling the uterine cavity into the bloodstream through endometrial vessels (from the myometrial veins to the uterine venous plexuses). This complication has been described during hysterosalpingography and sonohysterosalpingography. We herein present a report of three cases in which severe intravasation occurred during laparoscopic chromopertubation using methylene blue as a contrast agent. The intravasation manifested as green urine (i.e., the "green urine sign"). The presence of methylene blue in the urine and blood was confirmed by laboratory tests. All three patients had risk factors for intravasation as described in the literature (unilateral or bilateral tubal obstruction, endometriosis, and previous intrauterine procedures for Mullerian duct anomalies and Asherman's syndrome). The green urine sign appeared a few hours after laparoscopic chromopertubation and spontaneously resolved after 24 hours. Cystoscopy was performed to rule out bladder injury. All three patients required only clinical observation.

A case report of ectopic pregnancy arising in a unicornuate uterus, accompanied by the undescended tube and ovary with double inferior vena cava

RATIONALE

The incidence of a unicornuate uterus is 0.2% to 0.3% of the whole population. A unicornuate uterus is closely associated with obstetrical complications such as early miscarriages, ectopic pregnancy, and malpresentation.

PATIENT CONCERNS

A 32-year-old patient developed a rare ectopic pregnancy arising at a distal, fimbriated end of the undescended fallopian tube.

DIAGNOSES

A transvaginal ultrasound scan revealed hemoperitoneum and no gestational sac in the uterine endometrium. A laparoscopic finding showed that high up in the right abdomen, just below the liver, an ectopic mass could be seen arising at a distal, fimbriated end of the fallopian tube, which was developed adjacent to the undescended right ectopic ovary.

INTERVENTIONS

After laparoscopic removal of the right salpinx, we removed it with a bag.

OUTCOMES

One day after the operation, she was discharged without problems. Postoperative hysterosalpingography showed the unicornuate uterus with patent left and some right salpinx. Magnetic resonance imaging revealed a unicornuate uterus, right ovary at the right inferior hepatic area, a bilateral normal kidney, and double inferior vena cava.

LESSONS

This is the first reported case of its type. It demonstrated that ectopic pregnancy may occur in the upper abdomen, not in the pelvic cavity, in uterine anomaly, and double inferior vena cava; hence, we must thoroughly check the whole abdominal cavity. Additional imaging tests are needed after treatment to see if there are any abnormalities.

Hysterosalpingography in endometriosis: performance and interpretation

Endometriosis is often seen and sometimes initially diagnosed on hysterosalpingography (HSG), an imaging exam routinely performed on patients with infertility. Here we discuss the role of HSG in the evaluation of patients with infertility with a focus on patients with endometriosis. The HSG technique, including patient preparation as well as potential risks and complications, is detailed. Imaging findings in patients with endometriosis are illustrated and a template for exam reporting is presented. Common imaging pitfalls are described with examples.

MRI of female genital tract congenital anomalies: European Society of Urogenital Radiology (ESUR) guidelines

Objective

To develop imaging guidelines for the MR work-up of female genital tract congenital anomalies (FGTCA).

Methods

These guidelines were prepared based on a questionnaire sent to all members of the European Society of Urogenital Radiology (ESUR) Female Pelvic Imaging Working Group (FPI-WG), critical review of the literature and expert consensus decision.

Results

The returned questionnaires from 17 different institutions have shown reasonable homogeneity of practice. Recommendations with focus on patient preparation and MR protocol are proposed, as these are key to optimised examinations. Details on MR sequences and planning of uterus-orientated sequences are provided.

Conclusions

The multiplanar capabilities and soft tissue resolution of MRI provide superb characterisation of the wide spectrum of findings in FGTCA. A standardised imaging protocol and method of reporting ensures that the salient features are recognised, contributing to a correct diagnosis and classification of FGTCA, associated anomalies and complications. These imaging guidelines are based on current practice among expert radiologists in the field and incorporate up to date information regarding MR protocols and essentials of recently published classification systems.

Key Points

• MRI allows comprehensive evaluation of female genital tract congenital anomalies, in a single examination.

• A dedicated MRI protocol comprises uterus-orientated sequences and vaginal and renal evaluation.

• Integration of classification systems and structured reporting helps in successful communication of the imaging findings.

Electronic supplementary material

The online version of this article (10.1007/s00330-020-06750-8) contains supplementary material, which is available to authorized users.

Intrauterine fluid instillation to confirm tubal occlusion after transcervical permanent contraception: A pilot study

OBJECTIVES

To determine if women with tubal patency experience more fluid loss compared to those with bilateral tubal occlusion following intrauterine instillation of fluid via a balloon catheter.

STUDY DESIGN

In this prospective cohort pilot study, we enrolled women with prior Essure® procedures and healthy controls from September 2016 to July 2017. We excluded women using an implant or intrauterine device, or with a prior cesarean delivery or permanent contraception procedures other than Essure®. An infusion pump delivered saline via balloon catheter under continuous pressure monitoring. After one minute, we withdrew the fluid and recorded volumes in and out. Subjects then underwent hysterosalpingogram for evaluation of tubal patency. We conducted crude analyses with t-tests and sensitivity analyses.

RESULTS

We recruited 23 participants; ten provided analyzable data in each group. Hysterosalpingogram confirmed patency in all control and occlusion in all post-Essure® subjects in the analysis group. We found the median volume of saline lost among control subjects [7.8 mL (7.4, 8.4)] larger than post-Essure® participants [2.2 mL (2.0, 3.8), p < 0.01]. While 50% of control subjects tolerated the full 10 mL of fluid instillation, none of the post-Essure® subjects tolerated this volume (p = 0.03). A combination of saline loss ≤4 mL and participant intolerance of the full 10 mL volume yielded sensitivity of 0.80 (95% CI: 0.57, 1.00) and specificity of 1.00 for bilateral tubal occlusion.

CONCLUSION

Instillation of a fixed volume into the uterus may discriminate between women with tubal patency and occlusion following permanent contraception procedures with high specificity and adequate sensitivity. These findings should be validated in larger, more diverse study populations.

IMPLICATIONS

Confirmation of tubal occlusion following permanent contraception with an office-based approach could improve acceptability of transcervical approaches. The recent removal of Essure® from the U.S. market increases the need for novel transcervical procedures and occlusion verification methods.

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.

Laparoscopic surgery: Any role in patients with unexplained infertility and failed in vitro fertilization cycles?

Patients who undergo several in-vitro fertilization (IVF) treatment cycles and fail to conceive present a frustrating problem to the clinician. When 1 cycle of IVF treatment fails, should we offer the couples to choose additional cycle of IVF instead of evaluation of the potential peritoneal factor? In cases of otherwise unexplained infertility, the investigation cannot be considered to be complete until laparoscopy has been performed. The aim of the study is to investigate the fertility outcome of laparoscopic treatment in infertile women with repeated IVF failures.This is a retrospective case-control study conducted in a tertiary care, academic teaching hospital from January 2012 to December 2015. Patients recruited in this study were classified into 2 groups. Study group (n = 45) were offered laparoscopy for evaluation of infertility, control group (n = 45) elected to proceed to IVF without laparoscopy. Diagnostic laparoscopy and subsequent excision of suspected endometriotic lesions, lysis of adhesion and treatment of tubal pathology were performed when indicated.Forty-four (97.8%) patients in study had pelvic pathologies and the treatment was performed at the same time. Twenty-four patients in study group conceived including 16 patients conceived spontaneously and 14 patients conceived with additional IVF following laparoscopy management. There was a significant difference in the ongoing pregnancy rates between patients conceived through IVF in study group and control group (41.9% vs 19.6%, P < .05).Laparoscopy in women with normal hysterosalpingography but recurrent IVF failures can detect unrecognized pelvic pathologies. Laparoscopy evaluation prior to additional cycle of IVF seems to improve the subsequent pregnancy rate.

Hysteroscopy as an investigation tool in recurrent implantation failure in vitro fertilization

OBJECTIVES

To evaluate the use of hysteroscopy in the assessment of uterine pathologies in infertile women with repeated implantation failure (RIF) after in vitro fertilization (IVF) and determine whether removal of such pathologies increased pregnancy rates in women with RIF.

METHODS

This prospective study was conducted at King Fahd Hospital of the University, Al-Khobar, Kingdom of Saudi Arabia, between January 2010 and December 2015. The inclusion criteria were women who underwent IVF treatment cycles and ended in more than 2 RIF, and women who underwent hysterosalpingography (HSG). Hysteroscopies were performed, findings were recorded, and the clinical pregnancy rates were compared and assessed in patients with and without uterine cavity abnormality. All hysteroscopic procedures were performed by a single consultant.

RESULTS

Hysteroscopies were performed on 266 women who  had at least 2 RIF. The average duration of infertility was 7.2±3.1 years. In 162 patients (60.9%), a hysteroscopy did not find any abnormality of the uterine cavity. In 104 patients (39.1%) there were one or more abnormal hysteroscopic findings. Hysterosalpingography was able to detect only 54 abnormalities (51.9%). The pregnancy rate was significantly higher in patients who were treated by a hysteroscopy for a detected uterine abnormality (39.4%).

CONCLUSION

A hysteroscopy was able to detect intrauterine pathologies which were missed by other investigative modalities. We believe patients with a history of RIF should undergo hysteroscopic examination before any further cycles are considered.

The feasibility, safety, and effectiveness of hysteroscopic sterilization compared with laparoscopic sterilization

BACKGROUND

In contrast to conventional laparoscopic sterilization, newer hysteroscopic approaches avoid the need for hospital admission, general anesthesia, and prolonged recovery. However, there are concerns that the feasibility, safety, and efficacy of hysteroscopic sterilization may be lower than established laparoscopic sterilization.

OBJECTIVE

We sought to evaluate the outcomes of hysteroscopic sterilization compared with laparoscopic sterilization in routine clinical practice in a comparative observational cohort study.

STUDY DESIGN

This study was carried out at University of Birmingham, United Kingdom, National Health Service teaching hospital, office hysteroscopy clinics, and day-case hospital unit. In all, 1085 women underwent hysteroscopic sterilization and 2412 had laparoscopic sterilization. Hysteroscopic sterilization was carried out using the tubal implant permanent birth control system in the office setting and laparoscopic sterilization using the tubal ligation system as a day-case under general anesthesia. Outcome data were collected regarding feasibility (technical completion of the sterilization procedure, satisfactory radiological confirmation at 3 months-hysterosalpingogram or transvaginal pelvic ultrasound scan), safety events within 30 days of procedures, reoperations, and unintended pregnancies within 1 year of procedures.

RESULTS

Hysteroscopic sterilization was successful in 992/1085 (91.4%; 95% confidence interval, 89.6-93.0%) at the first attempt. In comparison, bilateral tubal ligation was successfully performed in 2400/2412 (99.5%; 95% confidence interval, 99.2-99.8%) of patients who underwent laparoscopic sterilizations (odds ratio, 18.8; 95% confidence interval, 10.2-34.4). In all, 902/1085 (83.1%; 95% confidence interval, 80.8-85.2%) of successfully performed hysteroscopic procedures attended for radiological confirmation testing were considered satisfactory. The rate of adverse events within 30 days were similar: 2/1085 (0.2%) vs 3 (0.12%; 95% confidence interval, 0.04-0.36%). There were 3/1085 (0.3%; 95% confidence interval, 0.1-0.8%) unintended pregnancies after hysteroscopic sterilization compared with 5/2412 (0.2%; 95% confidence interval, 0.1-0.5%) laparoscopic sterilization (odds ratio, 1.3; 95% confidence interval, 0.3-5.6). Median length of follow-up for pregnancy outcome was 5 years. Hysteroscopic sterilization was associated with a higher risk of reoperation at 1 year compared to laparoscopic sterilization (odds ratio, 6.2; 95% confidence interval, 2.8-14.0) and the commonest reintervention was unilateral salpingectomy (12/22, 54.5%).

CONCLUSION

Hysteroscopic sterilization has been introduced as a more convenient, office-based method of permanent fertility control. However, while the small risk of unintended pregnancy is comparable to conventional laparoscopic sterilization, women should also be counselled regarding its lower success rate in successfully completing the procedure and its higher rate of failed reoperation.

An incidental finding of chronic salpingitis complications: Tubo-uterine fistula

Pelvic inflammatory disease (PID) is an infection of the upper genital tract in women that can include endometritis, parametritis, salpingitis, oophoritis, tubo-ovarian abscess, and peritonitis. The spectrum of the disease ranges from subclinical and asymptomatic infection to severe, lifethreatening illness; squealae include chronic pelvic pain, ectopic pregnancy, and infertility. In this case we report an uncommon complication of pelvic inflammatory disease, a tubo-uterian fistula. Our case was diagnosed by laparoscopy incidentally during assessment of infertility.

Impact of hysterosalpingography after operative treatment for ectopic pregnancy in Taiwan: A 16-year Nationwide Population-Based Analysis

By retrieving records from Taiwan's National Health Insurance (NHI) system's database, the current study aimed to investigate the impacts of hysterosalpingography (HSG) to patients after ectopic pregnancy (EP) operations in Taiwan.In this retrospective cohort study, insurance claims data from 1997 to 2013, derived from a cohort of 1 million people randomly sampled to represent all NHI beneficiaries, were analyzed. Patients after ectopic pregnancy (EP) operations were identified via the inclusion of the corresponding NHI procedure codes. We further divided the patients into 2 groups by whether received subsequent HSG, EP-HSG, and EP-no-HSG. Patients with history of previous pregnancies (PP) and subsequent HSG were grouped as PP-HSG. We sought to evaluate the following pregnancies (FP) rate, interval to FP in EP-HSG compared with that in EP-no-HSG, and PP-HSG.EP-HSG had significantly higher FP rate odds ratio than EP-no-HSG (OR, 1.64; 95% CI, 1.24-2.16, P < .001). EP-HSG had lower FP rate odds ratio than that in PP-HSG, but no significant difference (33.1% vs 34.6%, P  =  .654). The INTERVAL(HSG-FP) in EP-HSG was no significantly different from that in PP-HSG (843.34 ± 82 days vs 644.72 ± 24.30 days, P  =  .077). There was significant positive correlation between FP after EP and number of HSG (r  =  0.070, P < .001). There were significant negative correlation between FP and EP age (r  =  -0.270, P < .001), FP and INTERVAL(EP-HSG) (r  =  -0.212, P  =  .001). The multivariate analysis showed that INTERVAL(EP-HSG) less than 1 year is the predictor factor of INTERVAL(EP-FP) (hazard ratio: 1.422; 95% CI: 1.130-1.788; P = .003). It was evident that the longer the INTERVAL(EP-HSG), the lower the FP rate odds ratio; and the older the EP age, the lower the FP rate odds ratio. (OR, 95% CI; >1 year: 0.59, 0.41-0.86; >2 year: 0.42, 0.32-0.55; >25 years old: 0.47, 0.38-0.57; >30 years old: 0.29, 0.24-0.35; >35 years old: 0.12, 0.08-0.18, all P < .001).Receiving HSG after EP, short INTERVAL(EP-HSG), EP age less than 30 years old, had significant positive impacts on the FP. We encourage shortening the INTERVAL(EP-HSG), and the counseling of women on the most appropriate way to conceive thereafter.

Hysterosalpingography prior to the gonadotropin stimulated intrauterine insemination improves clinical pregnancy rates in women with unexplained infertility

PURPOSE OF INVESTIGATION

Gonadotropin stimulated intrauterine insemination (IUI) cycles performed following one month after hysterosalpingography (HSG) are associated with improvement in clinical pregnancy rates in unexplained infertile couples.

MATERIALS AND METHODS

A retrospective cohort study was performed between 2008 and 2014. A total of 92 unexplained infertile couples undergoing their first cycle IUI stimulated by gonadotropins were included in the analysis. Participants were classified into two groups according to IUI cycles performed one month (Group A, n = 25 cycles) or longer than one month (Group B, n = 67 cycles) after the HSG procedure.

RESULT

The overall clinical pregnancy rate was found as 25% (23 clinical pregnancies / 92 cycles). Clinical pregnancy rate was 44 % (11/25) for Group A and 17.9 % (12/67) for Group B. In Group A, there were significantly higher clinical pregnancy rates compared to Group B (OR: 3.6, 95% CI, 1.3-9.8; p = 0.012).

CONCLUSIONS

It has been demonstrated that fertility improving effect of HSG was most prominent in the first six months after procedure. Likewise, in gonadotropin stimulated IUI cycles performed following one month after HSG, there seems to be an improvement in pregnancy rates in unexplained couples. In unexplained cases, it may be a reasonable approach to plan IUI cycles in the first month after HSG in clinical practice.

Gender and Sexual Health: Infertility

Infertility is common in the United States, with up to 15% of heterosexual couples experiencing difficulty in achieving conception. Family physicians often are the first physicians to evaluate couples attempting to conceive. Evaluation begins with assessment of ovulation, evaluation of anatomic abnormalities, and semen analysis. Many etiologies of anovulation can be managed by family physicians, and clinicians can offer counseling on timing of intercourse and assist patients with lifestyle changes to promote fertility. Ovulation induction for women with polycystic ovary syndrome and treatment of hypothyroidism also can be managed in the family physician's office. For couples who are referred to a reproductive endocrinology subspecialist, clinicians can provide emotional support, screen for depression and anxiety, and provide education about procedures and behaviors that can affect success rates.

The analysis of factors influencing the success of diagnosing salpingemphraxis by x-ray hysterosalpingography

OBJECTIVE

The factors influencing the diagnosing of salpingemphraxis by X-ray hysterosalpingography (HSG) are identified and summarized, to provide a reference for improving the precision of the diagnosis procedure.

PATIENTS AND METHODS

In order to analyze the collected data, the methods of stratified sampling and retrospective analysis were adopted. Two county-level medical units, two medical units in prefecture-level cities and two provincial medical units in our province were chosen. Patients were selected from a group of women diagnosed with infertility and probable salpingemphraxis who were admitted to a hospital for further studies between February 2010 and January 2015. From those, 3 individual cases were selected in each month summing up to a total of 1,080 cases. Surgical processes and results were analyzed to identify the determining factors that lead to a precise diagnosis.

RESULTS

The success rate of the surgical procedures had nothing to do with the trauma level of hospitals, instead it is positively correlated with the period of sampling (p < 0.05). The precision of surgeries correlates with the age group of the patients, the selection time bracket of samples, the types of contrast agents used, the location of the salpinx, whether anticholinergic agents are used before operations, the depth of catheter with double-cavity saccule, and the procedures for injecting contrast agents (p < 0.05). On the other hand, the precision of the surgeries has nothing to do with the level of hospitals, the types of X-ray machines used or the types of salpingemphraxis. Through multi-factor regression analysis, it can be seen that the selection time period of samples, the location of the salpinx, whether anticholinergic agents are used before operations, the depth of catheter with double-cavity saccule and the procedures for injecting contrast agents are independent risk factors that determine the precision of the procedure (p < 0.05).

CONCLUSIONS

Clinical factors that seem to influence the precision of HSG are proposed based on analysis of a large sample in a small area using a stratified sampling method.

[Prevalence of infections (Chlamydia, Ureaplasma and Mycoplasma) in patients with altered tuboperitoneal factor]

OBJECTIVE

To determine the prevalence of Chlamydia, Ureaplasma and Mycoplasma in patients with peritoneal tubal factor infertility and altered.

MATERIAL AND METHODS

A descriptive, observational, retrospec- tive, transversal, infertility patients Juarez Hospital of Mexico 2013 to 2015. Study included patients with infertility diagnosis and detection of antibodies (IgG) by ELISA for Chlamydia and vaginal cultures for Mycoplasma and Ureaplasma, hysterosalpingography and histerolapa- roscopia with chromotubation

RESULTS

46 patients with a mean age of 32.5 years. It was found that 36% were positive for these infections (n = 17): Chlamydia in 8.7% (n = 4), Ureaplasma in 21.7% (n = 10) and Mycoplasma in 6.5% (n = 3). Chlamydia patients and bilateral tubal occlusion (OTB) in 5.8% (n = 1), Ureaplasma and OTB (n = 5) were identified in 29.4% of them with pelvic inflammatory disease (PID) and tubal obstruction Ureaplasma right (OTD) in 5.8% (n = 1), Ureaplasma and tubal patency but with loose adhesions in 5.8% (n = 1) and Mycoplasma with OTB in 11.1% (n = 2), p = 0.425. Hysterosalpingography showed a sensitivity of 59% and specificity of 79%.

CONCLUSIONS

Although there was no association of variables, Ureaplasma infection was more common in patients with infertility and tubal damage.

An Exceptional Case of Complete Septate Uterus With Unilateral Cervical Aplasia (Class U2bC3V0/ESHRE/ESGE Classification) and Isolated Mullerian Remnants: Combined Hysteroscopic and Laparoscopic Treatment

STUDY OBJECTIVE

To report the combined hysteroscopic and laparoscopic treatment of a complete septate uterus with unilateral cervical aplasia (class U2bC3V0/ESHRE/ESGE classification) and isolated mullerian remnants.

DESIGN

Step-by-step presentation of the surgical treatment (Canadian Task Force classification 4).

SETTING

Complete septate uterus with unilateral cervical aplasia (formally Robert's uterus) is characterized by the presence of a uterine septum completely dividing the endometrial cavity into an obstructed hemicavity and a contralateral nonobstructing hemicavity connected normally to the existing cervix. It has always been described as isolated without any associated anomaly.

PATIENT

A 30-year-old woman was referred to our department for dysmenorrhea and primary infertility. Hysterosalpingography showed the presence of a right (RT) hemiuterus with a patent fallopian tube; further evaluation with 2- and 3-dimensional ultrasound and magnetic resonance imaging showed an externally normal-appearing uterus, a right normal hemicavity connected normally with the existed cervix and, a left hemicavity fully divided from the right one by a complete septum and not connected with the cervix. Interestingly, a peculiar complex mass with cystic areas, attached posterolaterally from the left side to the uterine wall at the level of the isthmus and the upper cervix, was also diagnosed.

INTERVENTIONS

The study protocol was approved by our local institutional review board. During outpatient hysteroscopy, a right uterine hemicavity with a single ostium was identified without any communication with the left hemicavity. The patient was then scheduled for combined laparoscopic and hysteroscopic treatment. During laparoscopy, a normal uterine body with multiple myomas and a pseudocystic lesion attached posteriorly and left laterally to the uterus at the level of the isthmus and the upper cervix were shown; no communication between the cystic part of that lesion and the isthmus or the cervicovaginal canal was observed. During hysteroscopy, a longitudinal incision of the septum with a 5F bipolar electrode was performed; the left hemicavity was opened, and the corresponding tubal ostium was identified. The pseudocystic lesion was then excised after opening and sent for pathological analysis; the defect was closed with interrupted intracorporeal knots.

MEASUREMENTS AND MAIN RESULTS

A single normal endometrial cavity with both tubal ostia was obtained, thus restoring obstruction by unification of the uterine cavity. A histologic report of the removed pseudocystic lesion was compatible with the diagnosis of mullerian remnants. A follow-up hysteroscopy 3 months after showed a normal uterine cavity without postsurgical adhesions.

CONCLUSION

The use of 3-dimensional ultrasound and magnetic resonance imaging in combination with the new ESHRE/ESGE classification system gives the opportunity to obtain a precise representation of the female genital anatomy even in the presence of complex anomalies. Although a septate uterus with unilateral cervical aplasia has been already described, the presence of mullerian remnants is a rare entity associated with cyclic pelvic pain, thus needing adequate recognition and treatment. The combined hysteroscopic and laparoscopic approach offers a unique opportunity for the treatment of complex anomalies.

Evaluation of tubal microinserts position using 3D ultrasound and pelvic X-ray

PURPOSE

To retrospectively compare three-dimensional ultrasonography (3D-US) and pelvic X-rays to assess the position of tubal sterilization microinserts.

MATERIAL AND METHODS

Forty-four patients who underwent tubal sterilization with Essure(®) microinserts in our institution were included. The microinserts'position was evaluated three months after the procedure using 3D-US and pelvic X-rays. Placement on 3D-US was binary categorized as correct or incorrect and the distance between the two devices was reported. The orientation and symmetric deployment of the microinserts and the distance between the proximal parts of the two devices was assessed on pelvic X-rays. Performance of 3D-US and pelvic X-ray were compared using Mac Nemar test. Comparison of the distance between the two devices measured on pelvic X-rays and 3D-US was made with the paired Student t test.

RESULTS

3D-US images showed microinserts in 93% (41/44). Eighty-six percent (38/44) were correctly positioned on 3D-US and 82% (36/44) on pelvic X-rays. No significant differences between the performances of the two imaging techniques were found. No significant differences for the distance between the two devices measured on pelvic X-ray and 3D-US was found.

CONCLUSION

3D-US is a simple, non-ionizing technique, which appears as a promising alternate technique to pelvic X-rays to assess the correct position of Essure(®) microinserts.

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.

[Definitive contraception with Essure device: Single institutional experience on 517 procedures]

OBJECTIVES

To analyse the outcomes of patients undergoing Essure sterilization in a single institution, interns of complications and technique failure.

PATIENTS AND METHODS

Retrospective descriptive study of 517 patients underwent definitive contraception with Essure device in outpatient hysteroscopy office without anesthesia and controlled at 3 months with abdominal radiography, ultrasonography and hysterosalpingography in selected cases.

RESULTS

The success rates of the insertion of Essure was 96.8%, similar to data reported in the literature with 3.7% of vagal reactions, as most prevalent complication. 7 (1.35%) unintended pregnancies were observed.

CONCLUSIONS

Essure is a permanent birth control device, with high rate of successful insertion and a low rate of complications. Unintended pregnancies in our study are high and we must change the protocols of placement and monitoring, considering hysterosalpingography as a routine control test.

A practical approach to diagnosing and treating infertility by the generalist in obstetrics and gynecology

PURPOSE

To present a diagnostic and treatment paradigm for infertility designed for the obstetrician gynecologist generalist.

MATERIALS AND METHODS

Simple methods of tubal evaluation, e.g., the hysterosalpingogram (HSG) and post-coital test to evaluate both male and cervical factor are discussed. Treating paradigms will be discussed for ovulatory disorders and luteal phase defects. The role of the OB/GYN generalist on performing surgery in the modem era will be mentioned.

RESULTS

If an HSG shows a unilateral hydrosalpinx the generalist should consider performing the unilateral salpingectomy since the advent of in vitro fertilization-embryo transfer (IVF-ET) with a de-emphasis on surgery has made the reproductive endocrinologist/infertility specialist (REI) less skillful in laparoscopic surgery. The REI rarely performs tuboplasty today. Not only does the exclusive treatment in the luteal phase with progesterone save the women money and side effects (including multiple births), but may actually improve pregnancy rates compared to the usual technique of follicle stimulating drugs plus intrauterine insemination.

CONCLUSIONS

Because the generalist will not be tempted to suggest therapies, e.g., IVF-ET because this effective therapy is the best option for the financial success of the REI, but at the expense of financial depletion of the patient, there is plenty of room for generalists taking over as the first line physicians for infertility rather than just a referral service. Reproductive endocrinologists/infertility will almost invariably perform IUI each month even if not doing IVF which is also profitable to the REI, but costly in time and money to the patient. In contrast, the generalist, aimed with the knowledge that IUI does not improve pregnancy rates if the post-coital test is normal, will save the patient and/or the insurance money if the woman conceives. Obviously certain circumstances, e.g., bilateral blocked fallopian tubes or very severe oligoasthenozoospermia (but not teratozoospermia) will prompt an immediate referral to an REI.

Hysterosalpingography versus hysterscopy in intrauterine pathology research of infertile patients

BACKGROUND

The objective of the present paper is to confirm the validity and reliability of hysterosalpingography (HSG) in intrauterine pathology research of infertile female patients by comparing the hysteroscopy (HC) findings to a "gold standard" test.

AIM

To analyze HSG and HC findings in infertility patients.

MATERIALS AND METHODS

The research was conducted as a prospective study at the Gynecological and Obstetrics Clinic "Narodni front" in Belgrade.

RESULTS

HSG indicated pathological findings in 72.5% of patients whereas HC revealed abnormalities of uterine cavity in 77.5%. In 12.5% of patients, HSG demonstrated a normal uterine cavity, and HC confirmed pathological findings, while in 7.5% of patients with filling defects and irregular shapes on HSG images, HC reported normal findings. In 22.5% of patients normal finding as well as endometrial polyps were reported; congenital malformations (anomalies) were found in 32.5%, submucosal myomas in 12.5% and Asherman's syndrome in 10%.

CONCLUSION

HC finding was crucial in final diagnosing.

Hysterosalpingography: an imaging Atlas with cross-sectional correlation

Hysterosalpingography (HSG) provides a unique combination of both fallopian tube and uterine cavity evaluation. A comprehensive understanding of both HSG and correlative cross-sectional imaging findings are essential radiologic skills. This article will review the spectrum of technical artifacts, anatomic variants, congenital uterine anomalies, uterine and tubal pathology, and postsurgical findings as they appear on HSG. Additionally, correlation with MR and ultrasound images is provided. This review article serves as a reference for residents new to HSG as well as staff who perform and interpret HSG infrequently.

Fallopian tube torsion in the pediatric age group: radiologic evaluation

Fallopian tube torsion is a rare but important cause of acute pelvic pain in young adolescent girls. It is a surgical emergency treated with either detorsion or salpingectomy. The imaging findings can be nonspecific and challenging. However, an accurate early diagnosis is essential for prompt surgical treatment. Our objective was to review whether imaging findings can be specific enough to suggest the diagnosis of tubal torsion prospectively in the appropriate clinical setting. An Institutional Review Board-approved retrospective review of our imaging database from 2005 to 2012 revealed 10 surgically proven cases of fallopian tube torsion. All cases had sonography performed; 5 cases had additional multidetector computed tomography. All 10 patients (9-17 years) presented with acute pelvic pain. Sonographic findings included dilated tubular structures in 6 of 10 cases: adjacent to a normal ipsilateral ovary in 5 of 6 and adjacent to a benign ovarian teratoma in 1. In 4 cases, no dilated tube was identified; 3 of 4 had a cystic mass separate from the ovaries, and 1 had the imaging appearance of a multicystic ovary. Computed tomographic findings in the 5 cases that underwent multidetector computed tomography included a dilated tubular structure in 3 of 5; 2 of 5 had a cystic adnexal mass identified. Although rare, tubal torsion should be considered in female adolescents with acute pelvic pain. Sonography should be the first imaging choice. When a tubular structure or a midline cystic mass associated with a normal ipsilateral ovary is noted, tubal torsion should be considered in the differential diagnosis.