Sonohysterosalpingography: a suitable choice in infertility workup

Cost-effectiveness modelling of three different hysterosalpingography diagnostic strategies in addition to standard fertility management for couples with unexplained infertility in the United Kingdom

Previous studies have demonstrated hysterosalpingography (HSG) in general, and specifically with an oil-soluble contrast medium, directly increases pregnancy rates. Decision modelling was performed to compare fertility management using three HSG diagnostic strategies: (i) water-soluble contrast medium (WSCM)-HSG; (ii) Lipiodol® Ultra Fluid (LUF)-HSG; and (iii) No HSG, for women aged ≤39 years with unexplained infertility. Four reimbursement scenarios were modelled to reflect the various funding arrangements across the regions of the United Kingdom. Compared with WSCM-HSG, the live birth rates after 24 months increased by 3.4% with LUF-HSG and decreased by 2.7% with no HSG. From a patient perspective, fertility management with LUF-HSG is the most cost-effective strategy with cost-savings ranging from £299 to £857 per patient depending on the funding arrangement for IVF. From an NHS perspective, fertility management with LUF-HSG is cost-effective when 2 or more IVF cycles are NHS-funded. If none of the IVF cycles are NHS-funded, fertility management with LUF-HSG can be considered cost-effective if society is willing to pay £8,353 for an additional live birth. The findings from this analysis suggest that fertility management with WSCM-HSG is cost-effective compared to no HSG and LUF-HSG is the most cost-effective with increased live birth rates after 24 months.

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

STUDY OBJECTIVE

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

DESIGN

A single-center, retrospective cohort study.

SETTING

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

PATIENTS

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

INTERVENTIONS

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

MEASUREMENTS AND MAIN RESULTS

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

CONCLUSION

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

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.

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

Background

Tubal and uterine cavity diseases commonly compromise female fertility. At the present time, hysteroscopy, laparoscopy with chromopertubation and RX-Hysterosalpingography (RX-HSG) are widely accepted screening procedures enabling the effective assessment of both tubal patency and uterine cavity. Nevertheless, consistent evidence supports the reliability of Hysterosalpingocontrast sonography (HyCoSy) in uterine cavity and tubal patency investigation, as a part of the standard infertility work-up. This prospective study was aimed at evaluating the tolerability of the technique as well as the incidence of related side effects and complications in a large series of infertile patients.

Methods

Pain perception of 632 infertile women was measured by means of an 11-point numeric rating scale. Side effects and late complications were also recorded.

Results

The mean numeric rating scale was 2.15 ± 2.0 SD. Most of the patients (374/632, 59.17%) rated HyCoSy as a non-painful procedure, whereas 24.36% (154/632) women reported mild pelvic pain and 9.96% (63/632) classified the discomfort as “moderate”. Only 6.48% (41/632) of the patient population experienced severe pelvic pain. Fifteen (2.37%) patients required drug administration for pain relief. Twenty-six patients (4.11%) showed mild vaso-vagal reactions that resolved without atropine administration. No severe vaso-vagal reactions or late complications were observed.

Conclusions

HyCoSy is a well-tolerated examination and the associated vagal effects are unusual and generally mild. Consequently, we support its introduction as a first-line procedure for tubal patency and uterine cavity investigation in infertile women.