Accuracy of Tubal Patency Assessment in Diagnostic Hysteroscopy Compared with Laparoscopy in Infertile Women: A Retrospective Cohort Study

Magnetic Resonance Imaging Feature Analysis and Evaluation of Tubal Patency under Convolutional Neural Network in the Diagnosis of Infertility

To explore the diagnostic value of MRI image features based on convolutional neural network for tubal unobstructed infertility, 30 infertile female patients were first selected as the research objects, who admitted to the hospital from May 2018 to January 2020. They all underwent routine MRI examinations and CNN-based MR-hysteron-salpingography (HSG) examinations, in order to discuss the diagnostic accuracy of the two examinations. In the research, it was necessary to observe the patients' imaging results, calculate the diagnosis rate of the two examination results, and analyze the application effect of the CNN algorithm, thereby selecting the best reconstruction method. In this study, the analysis was conducted on the basis of no statistical difference in the baseline data of the included patients. The results of undersampling reconstruction at 2-fold, 4-fold, and 6-fold showed that CNN for data consistency layer (CNN_DC) had a better effect, and its peak signal-to-noise ratio (PSNR) was lower sharply than that of the other two reconstruction methods, while the normalized mean square error (NMSE) and structural similarity index measure (SSIM) were higher markedly than the values of the other two reconstruction methods. The diagnostic rate of routine MRI examination of the fallopian tube and other parts of the uterus was lower than or equal to that of MR-HSG examination by CNN. Routine MRI examinations of fallopian tube imaging artifacts were large, and the definition was reduced, which increased the difficulty of identification. However, MR-HSG examination by CNN indicated that the imaging artifacts were low, the clarity was high, and the influence of noise was small, which was conducive to clinical diagnosis and identification. For endometriosis, the accuracy of MR-HSG was 33.33% and the accuracy of MRI was 46.67%. CNN MR-HSG inspection method was significantly better than the conventional MRI inspection method (P < 0.05). Therefore, the results of this study revealed that MR-HSG examination by CNN had a clear imaging effect and obvious inhibition effect on background signals and rapid image generation without the need for reconstruction with the same spatial resolution, which improved the imaging quality and could provide a reference value for clinical diagnosis and subsequent related studies.

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

Background

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

Methods

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

Results

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

Conclusions

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

Assessment of Tubal Patency with Selective Chromopertubation at Office Hysteroscopy versus Modified Minilaparoscopy in Infertile Women

OBJECTIVES

Tubal factor is the leading cause of female infertility. Diagnostic hysterolaparoscopy with chromopertubation plays a pivotal role in its evaluation. Office hysteroscopy (OH) has gained popularity as the outpatient procedure for diagnostic purposes. OH being a less invasive approach, the current study was undertaken to compare the accuracy of assessment of tubal patency with chromopertubation at OH with modified minilaparoscopy in infertile patients.

MATERIALS AND METHODS

The present study was a pilot study conducted from March 2017 to August 2018. Eighty patients were recruited. OH was done without anesthesia. Diluted methylene blue dye was injected. The eddy current of blue dye, "Visualizable flow" at ostium, and disappearance of blue dye from the uterine cavity through ostium was documented as evidence of patent tubal ostium. In case of tubal occlusion, uterine cavity became blue due to backflow of dye. After OH, minilaparoscopy with chromopertubation was performed under general anesthesia. Both tubes were assessed separately for tubal patency.

RESULTS

All patients underwent OH followed by minilaparoscopy in the same sitting. OH was 87.5% sensitive with positive predictive value of 95.2%. Compared to minilaparoscopy, OH is 85.6% accurate in predicting tubal patency. The area under receiver operating curve was 0.96 (SE is 0.15 with 95% confidence interval of 0.93-0.99, P < 0.001). It implies that, OH should correctly identify all laparoscopic cases with probability of 0.96.

CONCLUSION

OH chromopertubation can be used as an alternative to laparoscopy for assessing tubal patency with added advantages of lack of requirement of anesthesia, minimal cost, and better patient acceptance. Moreover, the procedure is less time-consuming and less invasive with high sensitivity and moderate specificity.

Transvaginal Sonography Post-Office Hysteroscopy as a Screening Tool for Tubal Patency: A Reliable and Feasible Technique in an Outpatient Setting

OBJECTIVE

To determine feasibility and accuracy of post-hysteroscopic transvaginal ultrasonography (TVUS) measurement of pelvic fluid accumulation as a screening method for tubal patency (TP).

METHODS

We conducted a retrospective cohort study of 85 patients who underwent uterine cavity assessment by office hysteroscopy at our university-affiliated fertility centre from November 2019 to October 2020. During the study period, two-dimensional (2D) TVUS was performed pre- and post-hysteroscopy to evaluate TP. Patient records were reviewed for demographics, diagnosis, and prior/subsequent TP testing. Predictive values for TP were calculated.

RESULTS

Pelvic fluid accumulation post-hysteroscopy was found in 65.9% of patients (56). Accumulation of fluid was seen with the use of as little as 10-50 mL of saline. Using more fluid did not increase the likelihood of demonstrating TP (P = 0.17). A trend towards more false-negative results for TP was observed when less fluid was used (7.7% with 10-50 mL vs. 3.8% with 60-190 mL and 1.3% with 200-760 mL; P = 0.10). The positive predictive value (PPV) of TVUS post-hysteroscopy in comparison to known patency/occlusion was 100%; negative predictive value (NPV) was 33%; sensitivity was 82.8%; and specificity was 100%. Similar values were seen in a second analysis that included patients with highly suspected patent or occluded tubes (n = 60); presumed predictive values were: PPV 100%, NPV 42%, sensitivity 78.8%, and specificity 100%. The use of more fluid did not increase pain (P = 0.75). This finding remains after accounting for confounders (e.g., pre-medication, endometrial biopsy).

CONCLUSION

TVUS pre- and post-hysteroscopy is feasible in an outpatient setting, and can serve as a reliable screening tool for TP. When hysteroscopy is performed and TP is not known, TVUS can be added for screening, potentially omitting the need for more invasive examinations. With limited non-urgent ambulatory services, it is of upmost importance to maximize information from a single procedure.

Hysteroscopy for Assessing Fallopian Tubal Obstruction: A Systematic Review and Diagnostic Test Accuracy Meta-analysis

OBJECTIVE

To assess the diagnostic accuracy of hysteroscopy compared with that of laparoscopic chromopertubation for the detection of fallopian tubal obstruction.

DATA SOURCES

An electronic search from inception to March 31, 2020, was performed in Medline, Scopus, EMBASE, and the Cochrane Central Register of Controlled Trials.

METHODS OF STUDY SELECTION

This diagnostic accuracy meta-analysis was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses and Synthesizing Evidence from Diagnostic Accuracy Tests recommendations. A combination of the following Medical Subject Headings terms and keywords was included in the search strategy: "hysteroscopy[MeSH]," "tubal obstruction," "tubal patency," "tubal dysfunction," and "tubal blockage." Quality assessment of the included studies was conducted using the Quality Assessment Tool for Diagnostic Accuracy Studies-2 (University of Bristol, Bristol, United Kingdom). Publication bias was evaluated by means of the Deek funnel plot asymmetry test. The following outcomes were analyzed: diagnostic odds ratio, area under hierarchical summary receiver operating characteristic and area under receiver operating characteristic curve, sensitivity, specificity, and positive and negative likelihood ratios.

TABULATION, INTEGRATION, AND RESULTS

Six studies comparing hysteroscopy with laparoscopic chromopertubation were included in the meta-analysis. After pooling all the studies, the diagnostic odds ratio was 43. The evaluated area under receiver operating characteristic curve was 0.93, correlating with high diagnostic accuracy for the index test. Sensitivity and specificity were 88% and 85%, respectively. In addition, the positive and negative likelihood ratios were 5.88 and 0.16, respectively.

CONCLUSION

Hysteroscopic techniques are highly accurate and sensitive for detecting fallopian tubal obstruction. Interventional assessment enhances diagnostic accuracy compared with observational assessment, as does the office setting compared with the operating room. Additional studies, along with a refinement of the techniques, could facilitate the widespread use of hysteroscopic techniques for the detection of fallopian tube occlusion.

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 .

Hysteroscopic Assessment of Tubal Patency: A Randomized Comparison between the Flow and Parryscope Techniques

STUDY OBJECTIVE

To evaluate the accuracy of the "Parryscope" and "flow" techniques for hysteroscopic assessment of tubal patency.

DESIGN

Prospective randomized clinical trial.

SETTING

From May to October 2019, women with subfertility undergoing laparoscopic and hysteroscopic surgery at the Medical University of Vienna were invited to participate in the study. The primary outcome was accuracy of Fallopian tube patency relative to the gold standard of laparoscopic chromopertubation.

PATIENTS

Sixty women with subfertility.

INTERVENTIONS

Hysteroscopy with either the "Parryscope" or the "flow" techniques for tubal assessment, directly followed by laparoscopy with chromopertubation.

MEASUREMENTS AND MAIN RESULTS

Hysteroscopic prediction of fallopian tube patency was possible in a statistically significant manner in both study groups (p <0.05). The Parryscope technique achieved higher sensitivity (90.6%, 95% CI: 61.7-98.4) and specificity (100%, 95% CI: 90.0-100.0) than the flow technique (sensitivity: 73.7%, 95% CI: 48.8-90.9 and specificity: 70.7%, 95% CI: 54.5-83.9).

CONCLUSION

Using the Parryscope technique to determine if air bubbles traverse the ostia can provide valuable additional information during hysteroscopy and is more accurate in predicting fallopian tubal occlusion than the flow method.

The Role of Diagnostic Hysteroscopy in the Evaluation of Fallopian Tube Patency: a Short Review

The relevance of diagnostic hysteroscopy, especially when performed in an outpatient “office” setting, in the evaluation process of infertility has increased within the last few years. Notably, several articles on a possible role for diagnostic hysteroscopy in the assessment of Fallopian tube patency have been published recently. Three relevant articles were identified. Visualizing a “flow effect” or air bubbles dispersing through the ostia, sonographically assessed shifts in cul de sac volume, and selective Fallopian tubal cannulation are reportedly promising hysteroscopic techniques. In this review, an overview of hysteroscopy, details about diagnostic reliability, and considerations with regard to ease of use and difficulties are summarized. Based on these articles, hysteroscopic evaluation of tubal patency seems to be a promising, clinically relevant field for future clinical research.

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.