Transvaginal salpingosonography for the assessment of tubal patency in infertile women: methodological and clinical experiences

Pregnancy outcomes of intrauterine insemination without ovarian stimulation in couples affected by unilateral tubal occlusion and male infertility

BACKGROUND

Information available to date regarding the pregnancy outcomes of intrauterine insemination (IUI) without ovarian stimulation (OS) in infertile patients with unilateral tubal occlusion remains scarce. The objectives of this study were to investigate for couples affected by unilateral tubal occlusion (diagnosed via hysterosalpingography (HSG)/transvaginal real-time three-dimensional hysterosalpingo-contrast sonography (TVS RT-3D-HyCoSy)) and male infertility: (1) whether significant differences exist in pregnancy outcomes between IUI with or without OS cycles, and (2) whether the pregnancy outcomes of IUI without OS in women with unilateral tubal occlusion were similar to those of women with bilateral patent tubes.

METHODS

258 couples affected by male infertility completed 399 IUI cycles. The cycles were divided into three groups: group A, IUI without OS in women with unilateral tubal occlusion; group B, IUI with OS in women with unilateral tubal occlusion; and group C, IUI without OS in women with bilateral patent tubes. The main outcome measures, including clinical pregnancy rate (CPR), live birth rate (LBR), and first trimester miscarriage rate, were compared between either groups A and B or groups A and C.

RESULTS

Although the number of dominant follicles > 16 mm were significantly higher in group B than that in group A (group B vs. group A: 1.6 ± 0.6 vs. 1.0 ± 0.2, P < 0.001), the CPR, LBR, and first trimester miscarriage rate were comparable between these two groups. When comparing group C to group A, the duration of infertility was significantly longer in group C than that in group A (group A vs. group C: 2.3 ± 1.2 (year) vs. 2.9 ± 2.1 (year), P = 0.017). Except for the first trimester miscarriage rate, which was significantly higher in group A (42.9%, 3/7) than that in group C (7.1%, 2/28) (P = 0.044), no significant differences were observed in the CPR and LBR in these two groups. After adjusting for female age, body mass index, and the duration of infertility, similar results were obtained between groups A and C.

CONCLUSIONS

In couples affected by unilateral tubal occlusion (diagnosed via HSG/TVS RT-3D-HyCoSy) and male infertility, IUI without OS might be an alternative treatment strategy. However, when compared to patients with bilateral patent tubes, the patients with unilateral tubal occlusion showed a higher first trimester miscarriage rate following IUI without OS cycles. Further studies are warranted to clarify this relationship.

OUP accepted manuscript

STUDY QUESTION

Does hysterosalpingo-foam sonography (HyFoSy) lead to similar pregnancy outcomes, compared with hysterosalpingography (HSG), as first-choice tubal patency test in infertile couples?

SUMMARY ANSWER

HyFoSy and HSG produce similar findings in a majority of patients and clinical management based on the results of either HyFoSy or HSG, leads to comparable pregnancy outcomes. HyFoSy is experienced as significantly less painful.

WHAT IS KNOWN ALREADY

Traditionally, tubal patency testing during fertility work-up is performed by HSG. HyFoSy is an alternative imaging technique lacking ionizing radiation and iodinated contrast medium exposure which is less expensive than HSG. Globally, there is a shift towards the use of office-based diagnostic methods, such as HyFoSy.

STUDY DESIGN, SIZE, DURATION

This multicentre, prospective, comparative study with a randomized design was conducted in 26 hospitals in The Netherlands. Participating women underwent both HyFoSy and HSG in randomized order. In case of discordant results, women were randomly allocated to either a management strategy based on HyFoSy or one based on HSG.

PARTICIPANTS/MATERIALS, SETTING, METHODS

We included infertile women between 18 and 41 years old who were scheduled for tubal patency testing during their fertility work-up. Women with anovulatory cycles not responding to ovulation induction, endometriosis, severe male infertility or a known iodine contrast allergy were excluded. The primary outcome for the comparison of the HyFoSy- and HSG-based strategies was ongoing pregnancy leading to live birth within 12 months after inclusion in an intention-to-treat analysis.

MAIN RESULTS AND THE ROLE OF CHANCE

Between May 2015 and January 2019, 1026 women underwent HyFoSy and HSG. HyFoSy was inconclusive in 97 of them (9.5%), HSG was inconclusive in 30 (2.9%) and both were inconclusive in 9 (0.9%). In 747 women (73%) conclusive tests results were concordant. Of the 143/1026 (14%) with discordant results, 105 were randomized to clinical management based on the results of either HyFoSy or HSG. In this group, 22 of the 54 women (41%) allocated to management based on HyFoSy and 25 of 51 women (49%) allocated to management based on HSG had an ongoing pregnancy leading to live birth (Difference −8%; 95% CI: −27% to 10%). In total, clinical management based on the results of HyFoSy was estimated to lead to a live birth in 474 of 1026 women (46%) versus 486 of 1026 (47%) for management based on HSG (Difference −1.2%; 95% CI: −3.4% to 1.5%). Given the pre-defined margin of −2%, statistically significant non-inferiority of HyFoSy relative to HSG could not be demonstrated (P = 0.27). The mean pain score for HyFoSy on the 1–10 Visual Analogue Scale (VAS) was 3.1 (SD 2.2) and the mean VAS pain score for HSG was 5.4 (SD 2.5; P for difference < 0.001).

LIMITATIONS, REASONS FOR CAUTION

Since all women underwent both tubal patency tests, no conclusions on a direct therapeutic effect of tubal flushing could be drawn.

WIDER IMPLICATIONS OF THE FINDINGS

HyFoSy or HSG produce similar tubal pathology findings in a majority of infertile couples and, where they differ, a difference in findings does not lead to substantial difference in pregnancy outcome, while HyFoSy is associated with significantly less pain.

STUDY FUNDING/COMPETING INTEREST(S)

The FOAM study was an investigator-initiated study funded by ZonMw, The Netherlands organization for Health Research and Development (project number 837001504). ZonMw funded the whole project. IQ Medical Ventures provided the ExEm-foam^® kits free of charge. The funders had no role in study design, collection, analysis and interpretation of the data. K.D. reports travel and speaker fees from Guerbet. F.J.M.B. reports personal fees as a member of the external advisory board for Merck Serono, The Netherlands, and a research support grant from Merck Serono, outside the submitted work. C.B.L. reports speakers’ fee from Ferring in the past, and his department receives research grants from Ferring, Merck and Guerbet. J.S. reports a research agreement with Takeda on MR of motility outside the submitted work. M.V.W. reports leading The Netherlands Satellite of the Cochrane Gynaecology and Fertility Group. B.W.J.M. is supported by an NHMRC Investigator grant (GNT1176437). B.W.J.M. reports consultancy for Guerbet and research funding from Merck and Guerbet. V.M. reports non-financial support from IQ medicals ventures, during the conduct of the study; grants and personal fees from Guerbet, outside the submitted work. The other authors do not report conflicts of interest.

TRIAL REGISTRATION NUMBER

NTR4746/NL4587 (https://www.trialregister.nl)

TRIAL REGISTRATION DATE

19 August 2014

DATE OF FIRST PATIENT’S ENROLMENT

7 May 2015

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.

Tubal Flushing Treatment for Unexplained Infertility

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

Two-dimensional hysterosalpingo-contrast-sonography compared to three/four-dimensional hysterosalpingo-contrast-sonography for the assessment of tubal occlusion in women with infertility/subfertility: a systematic review with meta-analysis

In this meta-analysis, we aimed to compare the diagnostic accuracy of 2D- and 3D/4D-HyCoSy for the assessment of tubal occlusion in women with infertility, using a laparoscopic tubal chromoperturbation dye test as the reference standard. Studies assessing 2D- and 3D/4D-HyCoSy for the assessment of tubal occlusion in women with infertility were searched from January 1990 to April 2019 using Medline and Web of Science databases by three of the authors, using the terms: 'hysterosalpingo-contrast-sonography', 'sonohysterosalpingography', 'HyCoSy', 'HyFoSy', 'three-dimensional', 'four-dimensional', 'ultrasound', 'tubal patency' and 'tubal occlusion'. Data quality was determined using the QUADAS-2 tool. Thirty articles were included; twenty-one studies used 2D-HyCoSy to assess tubal occlusion, six used 3D/4D-HyCoSy, one study used both techniques but in a different set of patients and two used both techniques in the same patients. The risk of bias for most studies was low as determined by QUADAS-2, except for the patient selection domain. Overall, pooled estimated sensitivity and specificity of 2D-HyCoSy were 86% (95% CI = 80%-91%) and 94% (95% CI = 90%-96%), respectively. The corresponding figures for 3D/4D HyCoSy were 95% (95% CI = 89%-98%) and 89% (95% CI = 82%-94%). High heterogeneity was found for both sensitivity and specificity. No statistically significant differences were found between the methods (p = 0.13). We concluded that 2D-HyCoSy has a similar diagnostic performance to 3D/4D-HyCoSy.

Comparison of Hysterosalpingography and Laparoscopy as Diagnostic Tool for Tubal Infertility in Bangladesh

Background: Tubal evaluation is an integral part of the evaluation of female infertility. Hysterosalpingography (HSG) is the radiographic evaluation of the uterus and fallopian tubes, which has been used as a first-line test for tubal assessment since 1920s. Laparoscopy is considered to be the gold standard for the diagnosis and management of tubo-peritoneal pathology. The objective of this study is to evaluate and compare the diagnostic value of both HSG and laparoscopy for assessment of tubal occlusion.

Methods: This is a prospective cross-sectional study. Laparoscopic chromopertubation was conducted on 125 consecutive infertile women who attended the “Infertility Management Center” from October 2018 to September 2019. All patients had HSG performed in the radiology department of different hospitals. Laparoscopic findings were used as a reference standard to analyze the findings of HSG for tubal occlusion. Data were analyzed by SPSS software (version 16).

Results: Normal HSG findings were seen in 53 patients (42.4%). Unilateral tubal occlusion was present in 38 (30.7%), and bilateral occlusion in 34 (27.2%) patients. Laparoscopy showed normal findings in 85 (68.0%) patients. Unilateral tubal occlusion was demonstrated in laparoscopy in 27 (21.6%) and bilateral tubal occlusion in 13 (10.4%) patients. HSG findings for diagnosis of tubal occlusion was true positive in 30 (24%) cases, false positive in 42 (33.6%) cases, false negative in 10 (8%) cases, and true negative in 43 (34.4%) cases in comparison to laparoscopy findings. Sensitivity of HSG was found to be 75.0%, specificity 50.6%, and accuracy 58.4%. Positive predictive value and negative predictive value were 41.7% and 81.1%, respectively.

Conclusion: HSG is widely used for tubal assessment in Bangladesh as it is a relatively inexpensive, low-risk office procedure. But it has a low specificity and positive predictive value with a relatively high negative predictive value. Laparoscopy, on the other hand, is preferable when there is high suspicion of tubal pathology.

The history and current status of fallopian tube pressures - developing alternate methods for confirmation of tubal occlusion

Permanent contraception with hysteroscopic tubal ligation is an increasingly popular choice for women around the world. However, inconveniences associated with the required confirmation test for tubal occlusion can be prohibitive. As new methods of permanent contraception are being investigated, ways of making all aspects of the procedure more accessible and comfortable for women should be considered. Means of examining tubal patency in the infertility population, such as tubal perfusion pressures measured at the time of hysterosalpingogram (HSG), provide inspiration for alternative methods of tubal occlusion confirmation after contraception. Evaluation of intrauterine pressures measured by a manometer attached to an intrauterine balloon catheter could serve as a preliminary tool for verification of tubal occlusion; higher pressures would indicate tubal occlusion and lower pressures would indicate the need for confirmatory HSG. The development and validation of this technique is ongoing and could reduce overall costs and patient burdens associated with the current tubal occlusion confirmation procedure.

Imaging techniques for assessment of tubal status

Fallopian tubes make a vital portal for transfer of gametes and embryo. Tubal factor is responsible for infertility in 25-35% of cases. Hysterosalpingography (HSG) has been used to evaluate the uterine cavity and the tubal status since decades. It uses iodinated contrast and X-rays and is painful and inconvenient for patient. Laparoscopy is considered to be the gold standard for tubal evaluation, but is an operative procedure and needs anesthesia. Though ultrasound is a modality of choice for assessment of uterus and ovaries, it does not allow assessment of the fallopian tube unless there is any fluid surrounding it or inside the lumen. This fluid interface can be created artificially by introducing saline in the uterine cavity and fallopian tubes and scanning simultaneously. The procedure is named Saline infusion HSG. Saline infusion sonohysterosalpingography (SIS) can be done with B mode US and Doppler. SIS can demonstrate a patent tube but if blocked, the site of block cannot be demonstrated. Ultrasound contrast agents can be used for tubal assessment using contrast mode on the scanners. This procedure is known as hystero-contrast sonography (HyCoSy). This actually shows the passage of hyperechoic contrast agent through tubal lumen and delineates it and locates the site of block. Using the volume ultrasound may even make the demonstration of tubal status and fimbriae better. Results of HyCoSy have been found to correlate well with laparoscopic findings, which are a gold standard. It is recommended by National Institute for Health and Clinical Excellence as a primary investigation for tubal assessment in patients without any positive history of tubal damage and also can replace a second look laparoscopy.

Could antispasmodic drug reduce pain during hysterosalpingo-contrast sonography (HyCoSy) in infertile patients? A randomized double-blind clinical trial

OBJECTIVE

To assess the effectiveness of an antispasmodic drug, hyoscine-N-butylbromide, in reducing pain during hysterosalpingo-contrast sonography (HyCoSy).

METHODS

Eight hundred and sixteen patients undergoing HyCoSy were randomized to receive 10 mg hyoscine-N-butylbromide (n = 408) or placebo (n = 408) per os, 30 min before the procedure, in a double-blind randomized controlled trial. Immediately after the procedure, the patient was asked to describe any pain experienced in comparison with pain usually suffered during the menstrual cycle, and the operator assigned a pain score between 0 and 4 as follows: 0 (no reaction or discomfort), 1 (slight pain, less than menstrual pain), 2 (moderate pain, exceeding menstrual cramps but no vasovagal reaction), 3 (vasovagal reaction or pain requiring observation in a hospital) and 4 (vasovagal reaction or pain requiring resuscitation). The primary aim was to estimate the difference in pain score, considered as a categorical value, between the active arm of the trial and the control group. The secondary aim was to evaluate if pain is related to tubal patency.

RESULTS

There was no difference in pain score between the hyoscine-N-butylbromide group and the placebo group (P = 0.807). There was a negative correlation between pain and tubal patency, regardless of treatment group (P < 0.0001).

CONCLUSIONS

Administration of 10 mg antispasmodic drug hyoscine-N-butylbromide does not reduce pain in patients undergoing HyCoSy.

The current place of tubal surgery in the management of subfertility

Treatment of tubal disease can be challenging and complex. It requires accurate assessment of the extent of disease and evaluation of all fertility parameters. Although traditionally treatment involved salpingectomy or IVF or a combination of the two, less invasive treatment options may prove beneficial. We evaluated the various diagnostic tools for disease assessment and the treatment options available.

Should a hysterosalpingogram be a first-line investigation to diagnose female tubal subfertility in the modern subfertility workup?

Tubal assessment is an integral part of female fertility evaluation. While diagnostic laparoscopy is gold standard, it is not suitable to be used as a screening test. Hysterosalpingogram (HSG) has been advocated as first-line investigation historically. With advances in diagnostics, more tests are available, such as hysterosalpingo contrast sonography (HyCoSy) and Chlamydia antibody titre (CAT) are available. The CAT test is much cheaper, less invasive and can be performed at any time during the cycle. The CAT test can also be used as a means of identifying which patients need further evaluation. HyCoSy has same diagnostic accuracy as HSG, without exposing women to radiation. We argue that HSG is out of date and has no place in a modern infertility evaluation. We also suggest a pathway (based on history, clinical and ultrasound evaluation) for investigations to screen for and diagnose tubal pathology.

Tolerability, side effects, and complications of hysterosalpingocontrast sonography (HyCoSy)

OBJECTIVE

To evaluate the tolerability, side effects and complications of hysterosalpingocontrast sonography (HyCoSy).

DESIGN

Prospective study.

SETTING

University hospital.

PATIENT(S)

669 infertile women.

INTERVENTION(S)

All patients were examined with HyCoSy and monitored for 30 minutes after the procedure. A telephone interview was subsequently carried out to record possible late side effects and postprocedural complications.

MAIN OUTCOME MEASURE(S)

Tolerability to the procedure was evaluated by means of an 11-point (0 to 10) numeric rating scale of the pain experienced. Postprocedural fever, pelvic infections, peritonitis, hemorrhage were recorded.

RESULT(S)

Of 660 patients who completed the examination, 483 (73.2%) completed the telephone follow-up after a period of 14.7 +/- 9.9 months from the procedure. The mean patient age was 34.5 +/- 4.3 years, and mean infertility duration was 28.1 +/- 23.2 months. The mean numeric rating scale was 2.7 +/- 2.5, and 10 patients (2.0%) required postprocedural drug treatment for pain relief. Mild vasovagal reactions were experienced in 20 cases (4.1%), and four patients (0.8%) had a severe vasovagal reaction. No late complications were reported. No patients required hospital admission after the procedure.

CONCLUSION(S)

In our series, HyCoSy was a well-tolerated examination with a very low rate of side effects and no late complications that required no atropine or anti-inflammatory drugs. These data support the safety of HyCoSy when performed as described, but further work is needed to estimate the rate of late complications and side effects in other settings.

2D and 3D hysterosalpingo-contrast-sonography in the assessment of uterine cavity and tubal patency

OBJECTIVE

To demonstrate the diagnostic efficacy of 2D B-mode, color and pulsed Doppler Hy-Co-Sy and 3D B-mode and power Doppler Hy-Co-Sy.

STUDY DESIGN AND METHODS

One hundred and fifty-two women were recruited into the 2D B-mode, color and pulsed Doppler Hy-Co-Sy study and 116 other women were recruited into the 3D B-mode and power Doppler Hy-Co-Sy study. We assessed the diagnostic performance (sensitivity, specificity, PPV and NPV) of 2D and 3D Hy-Co-Sy, compared to hysteroscopy, and laparoscopy and dye test in the assessment of uterine abnormalities and tubal patency, respectively.

RESULTS

The sensitivity, specificity, PPV and NPV of 2D hysterosonography compared to hysteroscopy were 93.6, 97.3, 98.2 and 97.3%, respectively. The sensitivity, specificity, PPV and NPV of 3D hysterosonography compared to hysteroscopy were 97.9, 100, 97.9 and 100%, respectively. Addition of color and pulsed Doppler to 2D Hy-Co-Sy and power Doppler to 3D Hy-Co-Sy contributed to diagnostic precision in detection of tubal patency. The sensitivity, specificity, PPV and NPV of 3D power Doppler Hy-Co-Sy in detection of tubal patency compared to laparoscopy and dye intubation were 100, 99.1, 99.2 and 100%, respectively.

CONCLUSION

2D and 3D Hy-Co-Sy are accurate methods for evaluation of uterine abnormalities and tubal patency in infertile patients.

The validity of air and saline hysterosalpingo-contrast sonography in tubal patency investigation before insemination treatment

OBJECTIVE

To compare the prognostic significance of tubal patency investigation by means of laparoscopy, hysterosalpingo-contrast sonography (HyCoSy) with air and saline as a contrast medium, and hysterosalpingography (HSG) in relation to the outcome of intrauterine insemination (IUI) treatment.

STUDY DESIGN

A retrospective study of 559 consecutive women attending the university hospital infertility clinic for infertility treatment in 1996-2003. Tubal patency was evaluated by laparoscopy in 261 women, by HyCoSy in 217 and by HSG in 81 women before insemination treatment. Altogether, 1240 insemination cycles were evaluated and the results were compared in the three study groups.

RESULTS

The clinical pregnancy rates per cycle were 14%, 18% and 18% in the laparoscopic, HyCoSy and HSG groups, with no statistically significant difference between the groups. The cumulative pregnancy rates (mean 2.3 cycles) were 30%, 41% and 38%, respectively, with a significant difference between the study groups. In cases of unilateral patency, cumulative pregnancy rates after two cycles were 18% (laparoscopy), 29% (HyCoSy) and 29% (HSG). The numbers of tubal pregnancies were similar in the subgroups.

CONCLUSIONS

Hysterosalpingo-contrast sonography with air and saline as a contrast medium is a very cost-effective tubal investigation method as regards selection of subjects for insemination.

Advantages and disadvantages of hysterosonosalpingography in the assessment of the reproductive status of uterine cavity and fallopian tubes

BACKGROUND

Hysterosonosalpingography as a contrast ultrasound method is safer, cheaper and easier to perform than hysterosalpingography in the assessment of the uterine cavity and fallopian tubes. Is it feasible for all patients? Which is the main problem in the evaluation of target structures by ultrasound?

METHODS

In a prospective study, 68 patients in the initial stage of the infertility treatment were examined by hysterosonosalpingography using saline NaCl infundibile and Echovist as contrast media. Subsequently, further status of the tubes and uterine cavity was assessed by the "gold standards", laparoscopy and hysteroscopy.

RESULTS

Sensitivity and specificity of hysterosonosalpingography using NaCl infundibile for evaluation of the uterine cavity was 100 and 88.8%, respectively. Negative predictive value was 100% and positive predictive value 97%. Sensitivity and specificity of the method for the assessment of the tubal status was 100 and 66%, respectively, negative predictive value was 100% and positive predictive value was 61%. For the assessment of tubal patency using positive contrast Echovist the method has shown 100% sensibility and negative predictive value again but it reached a specificity of 77% and a positive predictive value of 70%. There were no evident complications during or after the procedure.

CONCLUSION

Hysterosonosalpingography is useful in making decisions regarding further procedures for the diagnosis and treatment of infertility. Uterine cavity evaluation using saline is the method of choice. Tubal patency can be assessed only under ideal sonographic conditions. The method is feasible for early assessment of the reproductive status of uterine cavity and fallopian tubes as a simple, safe and cheap outpatient method prior to any following invasive procedure or even histerosalpingography.

An ultrasound-based approach to the assessment of infertility, including the evaluation of tubal patency

An optimal initial infertility investigation protocol would be a process that is diagnostically accurate, expeditious, cost-effective, reliable and as minimally invasive as possible. In addition, the investigation should provide the clinician with useful prognostic information regarding possible future treatment. At present, extensive use of invasive procedures such as diagnostic hysteroscopy and laparoscopy is the standard at many fertility centres. Recent advances in gynaecological ultrasonography have shown that ultrasound can replace routine invasive investigative procedures. An ultrasound-based approach would make the basic infertility investigation less time-consuming and less expensive, but at the same time more acceptable to the majority of patients. This chapter describes an ultrasound-based approach to the assessment of infertility. In addition, the role of ultrasonography for assessment of the pelvic organs as a basic part of the initial investigation of an infertile couple is discussed and compared to more traditional invasive methods.

Present concept of unexplained infertility

Despite improvements in both diagnostic assessment and treatment of infertile couples, many couples still have no explanation for their infertility. Unexplained infertility (the failure to conceive of a couple in whom no definitive cause for infertility can be found) has an incidence of 10-20% in all infertile couples. The incidence varies with the population studied and with the criteria used. Unexplained infertility is not an absolute condition but rather a relative inability to conceive, and many of these couples may conceive without treatment. The treatment options for unexplained infertility are several and the treatment results are promising. Expectant management can be recommended if the woman is under 28-30 years of age and the infertility duration is less than 2-3 years. In vitro fertilization (IVF) has revolutionized the treatment of infertile couples, as well as profoundly increasing the basic understanding of human reproduction. IVF can be used as both a diagnostic and a therapeutic tool in couples with unexplained infertility. The pregnancy rates with IVF are good, at 40% per treatment cycle. In addition, the outcome of pregnancies among women with unexplained infertility is generally comparable to that of spontaneous and other pregnancies using assisted reproductive technologies.

Hysterosalpingo-Contrast Sonography Compared with Hysterosalpingography and Laparoscopic Dye Pertubation to Evaluate Tubal Patency

STUDY OBJECTIVE

To evaluate the advantages and accuracy of hysterosalpingo-contrast sonography (HyCoSy) in assessing tubal patency compared with hysterosalpingogram (HSG) and laparoscopic dye pertubation.

DESIGN

Prospective study (Canadian Task Force classification II-2).

SETTING

Obstetrics and Gynecology Department, University of Rome Tor Vergata.

PATIENTS

Twenty-three women with at least 1 year of infertility, and 15 women with a history of chronic pelvic pain, suspected endometriosis, or pelvic inflammatory disease (PID), or with sonographic markers of adhesions.

INTERVENTIONS

HyCoSy, HSG, and laparoscopic dye pertubation.

MEASUREMENTS AND MAIN RESULTS

All patients underwent HyCoSy during the proliferative phase using air with saline as contrast medium, and HSG within 1 month of HyCoSy. Laparoscopy and dye pertubation were performed only in women with chronic pelvic pain, suspected endometriosis, PID, and sonographic markers of adhesions. In women undergoing all three procedures, HSG and HyCoSy had the same high concordance as laparoscopy, 86.7% and 86.7%, respectively. Three women in the infertility group became pregnant immediately after HyCoSy and dropped out of the study. In one woman, HyCoSy could not be performed because of cervical stenosis. Considering the total number of tubes (67), concordance between HyCoSy and HSG was 89.6%.

CONCLUSION

Transvaginal HyCoSy using a combination of air and saline appears to be an inexpensive, fast, and well-tolerated method of determining tubal patency. One of the most important advantages of this technique is, in our opinion, the possibility of obtaining information on tubal status and the uterine cavity at the same time as conventional ultrasound scan is performed.

Intrauterine insemination results are not affected if Hysterosalpingo Contrast Sonography is used as the sole test of tubal patency

OBJECTIVE

To assess whether women can be assigned to intrauterine insemination (IUI) treatment on the basis of fallopian tubal patency, diagnosed by Hysterosalpingo Contrast Sonography (Hy Co Sy).

DESIGN

Case controlled, clinical study.

SETTING

Tertiary referral center.

PATIENT(S)

The cases were consecutive, infertile women who underwent Hy Co Sy and IUI. The control group was women who had IUI over the same period but whose tubal patency was assessed by hysterosalpingogram (HSG) or laparoscopy and dye (lap and dye).

INTERVENTION(S)

Women with bilateral patency at Hy Co Sy and with unexplained, anovulatory, or male factor infertility underwent IUI using the partner's (IUI-H) or donor's (IUI-D) semen. Their outcome was compared with that of cohorts of women who had been examined using HSG or lap and dye.

MAIN OUTCOME MEASUREMENT(S)

Clinical pregnancy rate per cycle and cumulative pregnancy rates at IUI-H or IUI-D.

RESULT(S)

The clinical pregnancy rates per cycle at IUI-H or IUI-D did not differ among the three groups. The cumulative pregnancy rates after three cycles of IUI-H were 0.17, 0.15, and 0.17 in the Hy Co Sy, HSG, and lap and dye cohorts, respectively, and 0.69, 0.77, and 0.54 in the same groups after six cycles of IUI-D. There were no differences in the clinical characteristics or stimulation regimes used.

CONCLUSION(S)

Women screened as "normal" by Hy Co Sy may be allocated to treatments that rely on accurate assessment of tubal patency without compromising their chance of conception.

Can ultrasound-based investigations replace laparoscopy and hysteroscopy in infertility?

OBJECTIVES

To compare the use a simplified ultrasound based infertility investigation of the infertile couple with the current use of laparoscopy and hysteroscopy.

STUDY DESIGN

Thirty-three infertile couples underwent transvaginal ultrasound and hystero-salpingo-contrast-sonography. A diagnosis was formulated based on the results of the ultrasound investigations, a semen analysis and endocrine parameters. The following day, all subjects underwent a laparoscopic chromotubation and hysteroscopy by a surgeon unaware of the ultrasound findings. A diagnosis based on the findings at laparoscopy and hysteroscopy, the same semen analysis and endocrine parameters, was then made. The two diagnoses were compared.

RESULTS

A 90.9% agreement was found between the diagnoses made from the two methods used. When considering laparoscopic diagnosis the Gold Standard of tubal patency, the sensitivity to diagnose occluded tubes using hystero-contrast-sonography was 92.8%. The corresponding figures for specificity, PPV and NPV were 96.2%, 92.8% and 98.1%, respectively.

CONCLUSIONS

A simple, ultrasound based approach to investigate the infertile couple, can be used effectively as an initial examination modality during the couple's work-up. However, there is a need for a larger study to confirm these results.

A simplified ultrasound based infertility investigation protocol and its implications for patient management

PURPOSE

To evaluate whether a simplified infertility investigation protocol, focusing on the use of hysterocontrast sonography (HyCoSy), one blood test, and a semen analysis, would be sufficient as an initial screening test to select couples for specific treatment.

METHODS

The infertile couples underwent gynaecological examination, cervical sampling for cytology and Chlamydia trachomatis culture, B-mode transvaginal ultrasonography and basic hormonal analyses followed by a HyCoSy, and a semen analysis. A preliminary diagnosis was made for all patients. A management plan for treatment was suggested when possible; otherwise further examinations were recommended. The data were stored for later analysis and the routine investigation protocol was then adhered to and a final diagnosis and treatment were decided upon.

RESULTS

Agreement between the diagnosis based on HyCoSy and our routine protocol was present in 74% of cases (N = 73). In 13% (N = 13) there was partial agreement. In 36% the HyCoSy based protocol was considered sufficient to suggest treatment.

CONCLUSIONS

A simplified approach may lead to a significant reduction in both the time and cost of investigating an infertile couple.

The significance of hydrosalpinx in in vitro fertilization

OBJECTIVE

To review the effects of hydrosalpinx on IVF/ET and the role of salpingectomy.

DESIGN

The literature on hydrosalpinx, IVF/ET, embryotoxicity, and salpingectomy for hydrosalpinx was identified through MEDLINE searches and reviewed.

RESULT(S)

Hydrosalpinx has been associated with poor fertility prognosis. IVF/ET is a better alternative to tubal surgery for those patients with severe distal tubal disease, and it is also more cost effective. However, the presence of hydrosalpinx has a negative effect on IVF/ET by decreasing the pregnancy rates and implantation rates compared with patients undergoing IVF/ET for tubal disease but without hydrosalpinx. The hydrosalpingeal fluid has been demonstrated to be embryotoxic to developing embryos, thus leading to increased early pregnancy losses. Poor endometrial receptivity has also been demonstrated in the presence of hydrosalpinges. Removal of the hydrosalpinges leads to improved IVF/ET rates comparable to those patients without hydrosalpinx. Therefore, salpingectomy has been recommended for patients with hydrosalpinx who will be undergoing IVF/ET.

CONCLUSION(S)

The presence of hydrosalpinx has a negative effect on IVF/ET because of the suspected embryotoxicity of the hydrosalpingeal fluid. Surgical removal of the hydrosalpinx has been shown to improve IVF/ET rates.

Tubal patency and fertility outcome after expectant management of ectopic pregnancy

OBJECTIVE

To study tubal patency and fertility outcome of patients with expectantly managed ectopic pregnancy (EP).

DESIGN

A prospective study.

SETTING

Department of Obstetrics and Gynecology, Turku University Central Hospital, Turku, Finland.

PATIENT(S)

Thirty patients who wanted to become pregnant again were treated successfully by expectant management of EP.

INTERVENTION(S)

Patients were examined with posttreatment hysterosalpingography, and they filled out a questionnaire about their subsequent pregnancies.

MAIN OUTCOME MEASURE(S)

Free passage through open lumen showing tubal patency; number of full-term pregnancies and EPs revealing relative rate of subsequent fertility.

RESULT(S)

A free passage through the diseased tube was seen in 93% of the cases (28 of 30). Two of the 24 patients (8.4%) who wanted to become pregnant had an obstruction in the diseased tube. One (4.2%) of them had a normal opposite tube and later had a normal pregnancy. The other (4.2%) had an obstruction in both tubes and subsequently had a repeat EP. One of the 6 patients had an EP (this patient did not want to become pregnant and did not use contraception). However, her posttreatment hysterosalpingography was normal. In total, the subsequent pregnancy rate was 88% (21 of 24), and the rate of repeat EP was 4.2% (1 of 24).

CONCLUSION(S)

Patients who are treated with expectant management have a good long-term fertility outcome. Spontaneous regression of EP does not lead to increased harm or damage to the tube, i.e., the risk for repeat EP is low.

Sonographic hydrotubation using agitated saline: a new technique for improving fallopian tube visualization

Vaginal sonographic hydrotubation (SHT) was assessed in the evaluation of uterine configuration and tubal patency in 71 women undergoing investigation for infertility. In addition, a new technique using "agitated" saline during transvaginal sonography was evaluated in 50 of the patients. Ultrasound was more sensitive in detecting uterine abnormalities (89% compared with 6% for hysterosalpingography (HSG). Of 142 individual fallopian tubes studied, the diagnosis on SHT and HSG were the same in 120 (85%). Laparoscopic results were available on 15 patients. The findings on all 19 tubes in which the SHT and HSG diagnosis had concurred were confirmed. Of 11 tubes in which the diagnoses had differed, the laparoscopic finding agreed with the diagnosis made with SHT in seven, HSG in three, and neither in one. As shown in previous studies, sonographic hydrotubation is a simple technique with a high degree of accuracy. The use of "agitated" saline improved the ease with which the fallopian tubes were visualized.