Observer variability in the diagnosis and management of the hysterosalpingogram

Saline-Air Hysterosalpingo-Contrast Sonography Is Equivalent to the Modified Hysterosalpingogram Following Hysteroscopic Sterilization

PURPOSE

To estimate the diagnostic efficacy of saline-air hysterosalpingo-contrast sonography (SA-HyCoSy) compared with the modified hysterosalpingogram (mHSG) for confirmation of both coil location and tubal occlusion following hysteroscopic sterilization.

METHODS

This study included 19 women who underwent both SA-HyCoSy and mHSG where 1 test was followed by the other. Sensitivity, specificity, and positive and negative predictive values for tubal occlusion against the mHSG were calculated for each fallopian tube by 2 independent interpreters. Interrater reliability was assessed using Cohen κ statistic. Procedure time and pain level by 11-point numeric rating scale of SA-HyCoSy and mHSG were also compared.

RESULTS

Thirty-eight fallopian tubes were evaluated. Tubal occlusion was noted in 97.3% of tubes for both interpreters with the mHSG compared with 92.1% and 94.7% with SA-HyCoSy. The positive and negative predictive values for tubal occlusion were 100%/100% and 50%/33%, respectively, with an overall agreement of 97.4% and 95.7%, κ = 0.48, P < 0.01. Saline-air HyCoSy changed interpretation of coil insert location in 50% and 44.7% for each interpreter, being downgraded from optimal to satisfactory in 42.9% (9/21) and 36% (9/25) and upgraded to optimal in 58.8% (10/17) and 61.5% (8/13), respectively. There were no statistically significant differences in procedural time (7.5 vs 9.4 minutes, P > 0.05) or maximum pain scores (2.3 vs 3.1, P > 0.05) for the mHSG compared with SA-HyCoSy.

CONCLUSIONS

Our findings revealed a high degree of diagnostic accuracy with SA-HyCoSy for tubal occlusion, although coil location changed in nearly half of cases. Avoidance of radiation and patient convenience/compliance with SA-HyCoSy may outweigh the drawbacks.

The validity of HSG in infertility work up

Background

Our purpose was to evaluate the diagnostic accuracy of hysterosalpingography (HSG) in the diagnosis of the uterine cavity and tuboperitoneal abnormalities in infertile women. Reproducibility and consistency were also assessed. Two hundred infertile females underwent HSG, hysteroscopy, and/or laparoscopy as part of infertility workup. HSG examinations were retrospectively reviewed by three radiologists; we compared interobserver variability, and differences between the two results of reading the same examination after 3 months were compared to calculate intraobserver variability.

HSG sensitivity, specificity, PPV, NPV, and accuracy were calculated.

Results

The overall accuracy of HSG in diagnosing tubal, uterine cavity, and peritoneal abnormalities was 95.5%, 95%, and 89%, respectively (P value < 0.04).

HSG is reproducible in diagnosing normal versus abnormal examinations. Reproducibility in diagnosing uterine cavity, tubal, and peritoneal abnormalities was (ICC = 0.90), (ICC = 0.70), and (ICC = 0.31), respectively. Best agreement was seen in diagnosing luminal filling defect (sub mucous fibroid/polyp) (ICC = 0.90) (95% CI 0.86–0.98), whereas poorest agreement was found in diagnosing uterine adhesions (ICC = 0.13) (95% CI 0.10–0.13) and pelvic adhesions (ICC = 0.12) (95% CI 0.10–0.13) (P value < 0.03).

HSG consistency ranged from moderate to good (K = 0.49–0.79). It was highest in diagnosing normal versus abnormal examination (P value < 0.01); poorest in diagnosing pelvic adhesions.

Conclusion

HSG has high validity in negative results; it can minimize the use of invasive procedures. Laparoscopy is recommended in patients who had a pelvic disease or showing tubal obstruction on HSG.

The root of reduced fertility in aged women and possible therapentic options: current status and future perspects

It is well known that maternal ageing not only causes increased spontaneous abortion and reduced fertility, but it is also a high genetic disease risk. Although assisted reproductive technologies (ARTs) have been widely used to treat infertility, the overall success is still low. The main reasons for age-related changes include reduced follicle number, compromised oocyte quality especially aneuploidy, altered reproductive endocrinology, and increased reproductive tract defect. Various approaches for improving or treating infertility in aged women including controlled ovarian hyperstimulation with intrauterine insemination (IUI), IVF/ICSI-ET, ovarian reserve testing, preimplantation genetic diagnosis and screening (PGD/PGS), oocyte selection and donation, oocyte and ovary tissue cryopreservation before ageing, miscarriage prevention, and caloric restriction are summarized in this review. Future potential reproductive techniques for infertile older women including oocyte and zygote micromanipulations, derivation of oocytes from germ stem cells, ES cells, and iPS cells, as well as through bone marrow transplantation are discussed.

Tubal factor infertility: diagnosis and management in the era of assisted reproductive technology

Tubal factor infertility accounts for a large portion of female factor infertility. The most prevalent cause of tubal factor infertility is pelvic inflammatory disease and acute salpingitis. The diagnosis of tubal occlusion can be established by a combination of clinical suspicion based on patient history and diagnostic tests, such as hysterosalpingogram, sonohysterosalpingography, and laparoscopy with chromopertubation. Depending on several patient factors, tubal microsurgery or more commonly in vitro fertilization with its improving success rates are the recommended treatment options.

How members of the Society for Reproductive Endocrinology and Infertility and Society of Reproductive Surgeons evaluate, define, and manage hydrosalpinges

OBJECTIVE

To describe the management of hydrosalpinges among Society for Reproduction Endocrinology and Infertility (SREI)/Society of Reproductive Surgeons (SRS) members.

DESIGN

Cross-sectional survey of SREI/SRS members.

SETTING

Academic and private practice-based reproductive medicine physicians.

PARTICIPANT(S)

A total of 442 SREI and/or SRS members.

INTERVENTION(S)

Internet-based survey.

MAIN OUTCOME MEASURE(S)

To understand how respondents evaluate, define, and manage hydrosalpinges.

RESULT(S)

Of 1,070 SREI and SRS members surveyed, 442 responded to all items, for a 41% response rate. Respondents represented both academic and private practice settings, and differences existed in the evaluation and management of hydrosalpinges. More than one-half (57%) perform their own hysterosalpingograms (HSGs), and 54.5% involve radiologists in their interpretation of tubal disease. Most respondents thought that a clinically significant hydrosalpinx on HSG is one that is distally occluded (80.4%) or visible on ultrasound (60%). Approximately one in four respondents remove a unilateral hydrosalpinx before controlled ovarian hyperstimulation (COH)/intrauterine insemination (IUI) and clomiphene citrate (CC)/IUI (29.3% and 22.8%, respectively), and physicians in private practice were more likely to intervene (COH: risk ratio [RR] 1.81, 95% confidence interval [CI] 1.31-2.51; CC: RR 1.98, 95% CI 1.33-2.95). Although laparoscopic salpingectomy was the preferred method of surgical management, nearly one-half responded that hysteroscopic tubal occlusion should have a role as a primary method of intervention.

CONCLUSION(S)

SREI/SRS members define a "clinically significant hydrosalpinx" consistently, and actual practice among members reflects American Society for Reproductive Medicine/SRS recommendations, with variation attributed to individual patient needs. Additionally, one in four members intervene before other infertility treatments when there is a unilateral hydrosalpinx present.

Assessment of β-human chorionic gonadotropin level as a reliable predictor of tubal patency confirmed with transvaginal ultrasound-guided selective salpingography (TVSSG) following conservative treatment of tubal pregnancy

OBJECTIVE

To try putting the β-hCG level as a reliable predictor for tubal patency for women, who had previously undergone expectant treatment or who had received systemic methotrexate injection because of tubal pregnancy, and to simply check their tubal patency using a newly proposed procedure, a transvaginal ultrasound guided selective salpingography (TVSSG).

METHODS

One hundred and sixty patients were submitted to TVSSG after tubal pregnancy treatment. TVSSG was subsequently performed in the follicular phase of the menstrual cycle after the clinical treatment of tubal pregnancy. One hundred patients received expectant management and 60 were treated with single-dose methotrexate (50 mg/m(2) intramuscularly).

RESULTS

Of 160 patients (235 fallopian tubes examined), the affected tube was observed to be patent by TVSSG in 84 and 78%, respectively (P > 0.05). The contralateral tube was patent in 93%. Forty patients became pregnant and were thus not subsequently assessed with laparoscopy. Ten of these pregnancies ended in a miscarriage and five in a recurrent tubal pregnancy. The concordance of 86% for Fallopian tubes was achieved between the TVSSG and laparoscopy by the gold standard method. After the logistic regression was performed, it was observed that the levels of β-hCG > 5,000 mUI/ml were directly related to the tubal obstruction risk, odds ratio = 11.7 (95% CI = 2.27-61.32).

CONCLUSIONS

In the current study, the probability of ipsilateral tubal obstruction depends on the β-hCG levels. The increase in β-hCG levels is followed by an enhancement in tubal obstruction risk. Therefore, assessment of the β-hCG may be an effective tool for the prognosis of the reproductive future of these patients.

[Should a laparoscopy be necessary in case of infertility with normal tubes at hysterosalpingography?]

The aetiological assessment of an infertile couple includes several complementary biological and morphological examinations. Initial exploration of the female genital tract requires the performance of pelvic ultrasound and hysterosalpingography. The value of systematic laparoscopy in infertility assessment is still subject to debate. The aim of the present review is to evaluate arguments against the systematic use of laparoscopy and to define the place of the other tests as Chlamydia Trachomatis serology, hysterosalpingosonography and MR-IRM. In our opinion, laparoscopy is of course indicated in infertility assessments not only when anomalies are revealed by hysterosalpingography but also in the following circumstances: past history of infection (especially a positive Chlamydia antibody blood test) and/or pelvic surgery (a significant risk of adhesions), unexplained secondary infertility, unexplained infertility after the age of 38 (when choosing between artificial insemination and direct enrolment in an IVF programme) and failure of 3 cycles of good-quality intra-uterine inseminations (with ovarian stimulation and a sufficient number of spermatozoids).

Clinical experience with contrast infusion sonography as an Essure confirmation test

OBJECTIVES

The purpose of this study was to assess the clinical experience, including the feasibility, safety, compliance, and efficacy, of contrast infusion sonography as an Essure (Conceptus Inc, Mountain View, CA) confirmation test.

METHODS

A retrospective chart review and telephone survey were conducted at an academic multispecialty group. The study participants were women with Essure intervention who underwent contrast infusion sonography, transvaginal sonography, and hysterosalpingography as Essure confirmation tests. The main outcome measures included the feasibility, safety, compliance, and efficacy of contrast infusion sonography as a first-line Essure confirmation test.

RESULTS

A total of 118 women had successful bilateral Essure placement. Of the 63 who consented to contrast infusion sonography, 53 (84.1%) had proper bilateral placement and tubal occlusion and were encouraged to rely on Essure. Four were suspected of having unilateral tubal patency; hysterosalpingography in 2 confirmed bilateral tubal occlusion, and 2 were noncompliant with second-line hysterosalpingography. Three patients suspected of having unsatisfactory or uncertain placement on initial transvaginal sonography were encouraged to undergo hysterosalpingography in lieu of contrast infusion sonography, which confirmed unsatisfactory placement in 2 and proper placement and occlusion in 1. Three contrast infusion sonographic procedures could not be completed because of technical issues; therefore, contrast infusion sonography was feasible in 95.2% of the patients (60 of 63). No notable adverse events occurred. Only 17 patients were noncompliant with any confirmation test, yielding an overall compliance rate of 86% (101 of 118). No pregnancies occurred during 669 woman-months of follow-up. The average reimbursement for contrast infusion sonography was US$251.78.

CONCLUSIONS

Preliminary clinical data suggest that contrast infusion sonography is a feasible, safe, and accurate Essure confirmation test, which is well accepted by patients.

[Anatomic evaluation of the female of the infertile couple]

One third of infertility cases are due to anatomical abnormalities of the female reproductive tract: endometrial polyps (33%), bilateral tubal blockage (12%), hydrosalpinx (7%), sub-mucosal fibroids (3%) and pelvic endometriosis. These may need surgical correction which could restore fertility. This review aim to determine which examinations should be performed first. Hysterosalpingography shows sensitivity of only 65% but it increases the achievement of spontaneous pregnancy by three times. Office hysteroscopy has an excellent sensitivity (>95%) for diagnosing intra-uterine lesions. Pelvic ultrasound, whose good sensitivity is improved by adding 3D imaging and hysterosonography, seems as efficient as office hysteroscopy in diagnosing uterine cavity abnormalities. Moreover, it also efficiently diagnoses pelvic diseases such as hydrosalpinx or endometrioma without laparoscopy. A first line laparoscopy is indicated in for woman suspected of endometriosis or tubal pathology (history of complicated appendicitis, previous pelvic surgery, pelvic inflammatory disease). For the others straight forward cases, the majority of patients, hysterosalpingography and pelvic ultrasound seem to be sufficient as primary diagnostic tool.

Benefit of diagnostic laparoscopy for patients with unexplained infertility and normal hysterosalpingography findings

Patients with unexplained infertility following standard infertility screening tests usually undergo timing therapy that coordinates the time of ovulation and coitus, controlled ovarian hyperstimulation, or intrauterine insemination. If the treatment is unsuccessful, diagnostic laparoscopy is performed. However, with recent improvements in the assisted reproductive technology (ART), there has been a growing tendency that bypasses diagnostic laparoscopy and proceeds directly to ART. Therefore, the value of diagnostic laparoscopy in current fertility practice is under debate. In the present study, we evaluated the usefulness of diagnostic laparoscopy for patients with unexplained infertility and normal hysterosalpingography (HSG) findings. Between January 1997 and December 2006, 57 infertile patients with normal HSG findings underwent diagnostic laparoscopy at Kinki University Hospital. In 46 (80.7%) of these patients, diagnostic laparoscopy revealed pathologic abnormalities. Specifically, endometriosis and peritubal and/or perifimbrial adhesions were found in 36 (63.2%) and 5 (8.8%) of the patients, respectively. In 8 patients (14.0%), the management plan was switched to ART because of severe tubal diseases. Among the 57 patients, 29 pregnancies (50.9%) were achieved, including 6 ART-mediated pregnancies. We conclude that diagnostic laparoscopy is beneficial for patients with unexplained infertility and normal HSG findings. Indeed, by diagnostic laparoscopy, we are able to detect the cause(s) of infertility in the pelvic cavity and to design a suitable management plan, which could lead to postoperative pregnancy. Therefore, because of the potential diagnostic and therapeutic benefits, patients with unexplained infertility and normal HSG findings should undergo diagnostic laparoscopy prior to ART.

Comparison of the effect of single-dose and multiple-dose methotrexate therapy on tubal patency

OBJECTIVE

To compare tubal patency by using hysterosalpingography (HSG) in women with unruptured ectopic tubal pregnancy who were treated with either single-dose or multiple-dose methotrexate (MTX) regimen.

DESIGN

A case series with a retrospective statistical analysis.

SETTING

Maternity and teaching hospital in Turkey.

PATIENT(S)

Sixty-one patients treated with MTX therapy for unruptured tubal ectopic pregnancy.

INTERVENTION(S)

Thirty-one patients received single-dose and 30 multiple-dose MTX treatment. The HSG was performed 4 to 6 months after treatment to assess tubal patency.

MAIN OUTCOME MEASURE(S)

Ipsilateral and contralateral tubal obstruction rates.

RESULT(S)

Free passage through the ipsilateral tube was observed in 17 of 30 cases (56.7%) after multiple-dose, and 26 of 31 cases (83.9%) after single-dose MTX therapy. Patency of the contralateral tube was higher after single-dose than multiple-dose MTX treatment, although the value was not statistically significant. Binary logistic regression analysis was used to evaluate the parameters of age, gravida, parity, initial titers of beta human chorionic gonadotropin, size of the adnexal mass, and MTX regimen and their correlation with the HSG results after the clinical treatment for unruptured ectopic pregnancy. Only the type of MTX regimen was found to be used as a predictor of ipsilateral tubal obstruction.

CONCLUSION(S)

In terms of ipsilateral tubal obstruction, multiple-dose MTX therapy appears to have a greater negative effect on tubal patency than single-dose therapy.

High incidence of tubal dysfunction is determined by laparoscopy in cases with positive Chlamydia trachomatis antibody despite negative finding in prior hysterosalpingography

Aim:  Hysterosalpingography (HSG) is one of the most commonly used methods in order to evaluate the condition of fallopian tubes in infertility clinics. In the present paper, we retrospectively compared the findings of HSG and laparoscopy to elucidate the relationship between tubal dysfunction and background factors, such as Chlamydia trachomatis infection, endometriosis and previous surgery. Methods:  We retrospectively reviewed clinical records of 314 patients who were examined by both HSG and laparoscopy between 1996 and 2001 in the Department of Obstetrics and Gynecology, University of Tokyo. Results:  When HSG findings were evaluated in reference to those of laparoscopy, sensitivity and specificity for tubal patency were 0.63 and 0.79, respectively, whereas those for peri-tubal adhesion were 0.65 and 0.61, respectively. We compared the percentage of existence of background factors between the patients who were diagnosed as normal by both HSG and laparoscopy (Group L[+]) and those whose fallopian tubes were observed as patent by HSG, but were not patent by chromopertubation under laparoscopy (Group L[-]). The percentage of patients with positive chlamydial antibodies in Group L(-) (42.9%, 15/35) was significantly higher than that of patients with positive chlamydial antibodies in Group L(+) (22.8%, 44/193, P < 0.05). Conclusions:  These finding suggested that even if HSG showed normally patent tubes in a patient with positive Chlamydia trachomatis antibodies, the possibility of tubal occulusion still remains high and further examination by laparoscopy is recommended. (Reprod Med Biol 2007; 6: 39-43).

Tubal patency following surgical and clinical treatment of ectopic pregnancy

CONTEXT AND OBJECTIVE

As there is little information about fertility outcomes among women following clinical treatment (methotrexate and expectant management) and surgery (salpingectomy) consequent to ectopic pregnancy, we evaluate the results from hysterosalpingography subsequent to treatment. The objective was to evaluate contralateral tubal patency using hysterosalpingography following surgery and clinical treatment of tubal pregnancy.

DESIGN AND SETTING

This was a prospective study at the Department of Obstetrics of Universidade Federal de São Paulo, a tertiary center.

METHOD

Among 115 patients who underwent hysterosalpingography following surgery and clinical treatment of tubal pregnancy between April 1994 and February 2002, 30 were treated with a single intramuscular dose of methotrexate (50 mg/m(2)), 50 were followed up expectantly and 35 underwent salpingectomy.

RESULTS

The patency of the ipsilateral tube was 84% after methotrexate treatment and 78% after expectant management. In addition, contralateral tubal patency was 97% after methotrexate treatment, 92% after expectant management and 83% after salpingectomy. There were no statistically significant differences between the clinical treatment and surgery groups.

CONCLUSIONS

The findings from this study suggest similar contralateral tubal patency rates following salpingectomy, methotrexate treatment and expectant management.

Comparison of hysterosalpingography, hysterosonography and hysteroscopy in evaluation of the uterine cavity in patients with recurrent pregnancy losses

AIM

To evaluate the accuracy and acceptability of hysterosonography (HS) in the diagnosis of uterine anomalies in patients with recurrent pregnancy loss.

METHOD

Sixty non-pregnant patients with a history of at least three previous recurrent miscarriages were submitted to the HS, HSG and hysteroscopy (HTC) exams. The findings fall into three categories: synechiae, polypoid lesions and abnormal uterine cavity shape. The HTC exam was used as the gold standard. The findings of the HS and the HSG were compared to the HTC's and the agreement was evaluated using the Kappa coefficient. Significance was established at < 0.05. Sensitivity, specificity, positive and negative predictive values were determined for each method.

RESULT

Uterine anomalies were present in 38.3% (23) of the patients: 16 (26.7%) with synechiae, 3 (5.0%) with polypoid lesions and 8 (13.3%) with abnormal uterine cavity shape. Accuracy of the HS and the HSG was 90.9 and 85.2%. General sensitivity of the HS was superior to the HSG (90.5 vs. 75.0%). It also had a higher degree of agreement with the HTC (Kappa = 0.81 vs. 0.68). The HS caused significantly less pain than the other two methods.

CONCLUSIONS

The HS had higher diagnostic accuracy in the detection of uterine cavity anomalies and it was better tolerated by the patients when compared to hysterosalpingography and hysteroscopy.

Unexplained infertility: does it really exist?

Recent medical literature has quite extensively addressed the use of various terminologies within the field of reproductive medicine. This discussion has, however, so far overlooked the fact that one of the most frequently made diagnosis, so-called unexplained infertility (UI), not only didactically but, even more importantly, clinically, appears unsustainable as an independent diagnosis. The arguments in support of such a contention are manifold. The diagnosis of UI is highly subjective. It is dependent on which diagnostic tests have been performed (or have been omitted) and at what level of quality. Paradoxically, a diagnosis of UI will, therefore, be more often reached if the diagnostic workup is incomplete or of poor quality. Supported by evidence from the literature, the argument is made that the conditions, most frequently misdiagnosed as UI, are endometriosis, tubal infertility (especially distal and peritubal disease), premature ovarian ageing and immunological infertility. Because of the obvious unreliability of a diagnosis of UI and the widely reported unevenness in diagnostic criteria, we recommend the abandonment of UI as a formal infertility diagnosis. Better efforts to reach infertility diagnoses more accurately should improve the diagnostic accuracy of hitherto frequently missed diagnoses, which often falsely have led to a diagnosis of UI.

Routine use of hysterosalpingography prior to laparoscopy in the fertility workup: a multicentre randomized controlled trial

BACKGROUND

A multicentre randomized controlled trial with or without hysterosalpingography (HSG) was conducted to assess the usefulness of HSG as a routine investigation in the fertility workup prior to laparoscopy and dye.

METHODS

From 1 April 1997 to 1 April 2002, subfertile women were allocated by a computer-based 1 : 1 ratio randomization procedure, either for an HSG followed by laparoscopy and dye (the intervention group) of for laparoscopy and dye only (the control group) as a part of their fertility workup. Cumulative pregnancy rate (CPR) within 18 months after randomization was the primary outcome of interest.

RESULTS

344 women were randomized to the intervention group (n = 169) and the control group (n = 175). There was no significant difference in CPR at 18 months in the intervention group (49.1%) [95% confidence interval (CI) 41.6 to 56.6] and the control group (50.3%) (95% CI 42.8 to 57.8), a difference of -1.2% (95% CI -11.8% to 9.5%).

CONCLUSION

The routine use of HSG at an early stage in the fertility workup prior to laparoscopy and dye does not influence CPR, compared with the routine use of laparoscopy and dye without HSG.

Values of beta-human chorionic gonadotropin as a risk factor for tubal obstruction after tubal pregnancy

AIM

The hysterosalpingography (HSG) was evaluated after the clinical treatment of tubal pregnancy and the possible risk of tubal obstruction through the following parameters: beta-human chorionic gonadotropin (beta-hCG) levels, size of the adnexal mass, aspects of the image at ultrasound, and color Doppler.

METHODS

Eighty patients were submitted to HSG after tubal pregnancy treatment from April 1994 to February 2002. Fifty received expectant management and 30 were treated with single-dose methotrexate (MTX) (50 mg/m(2) intramuscularly).

RESULTS

The patency of the ipsilateral tube was 84% and 78% after the MTX and expectant treatments, respectively (P > 0.05). After the logistic regression was performed, it was observed that levels of beta-hCG >5000 mUI/ml were directly related to the tubal obstruction risk, odds ratio = 11.79 (95% CI = 2.27-61.32). Other variables were not directly related to the tubal obstruction risk.

CONCLUSIONS

In this study, the probability of ipsilateral tubal obstruction depends on the beta-hCG levels. The increase in beta-hCG levels is followed by an enhancement in tubal obstruction risk. Therefore, the beta-hCG may be effective for the prognostic of the reproductive future of these patients.

Transvaginal laparoscopy

Transvaginal laparoscopy (TvL) offers an alternative to standard diagnostic laparoscopy in subfertile patients without obvious pelvic pathology. With a specially developed needle-trocar system, access to the pouch of Douglas is gained through a needle puncture of the posterior fornix. Performed under local anaesthesia or sedation with the patient in a dorsal decubitus position and using prewarmed Ringer lactate as a distension medium, TvL allows complete exploration of the tubo-ovarian structures without supplementary manipulation. The combination of transvaginal sonography and transvaginal endoscopy, including minihysteroscopy, TvL, salpingoscopy and chromopertubation test, permits the most complete exploration of the reproductive tract and can be used as a first-line investigation of female fertility in a one-stop infertility clinic. As the transvaginal route offers easy access to the tubes, ovaries and fossa ovarica, some operative procedures are possible. However, in the absence of a panoramic view, these will be limited to minor interventions.

Hysterosalpingography

OBJECTIVE

To demonstrate the value of the hysterosalpingogram in the evaluation of infertility.

CONCLUSION(S)

Hysterosalpingography, which should be done in the follicular phase of the cycle, evaluates the contour of the uterine cavity, cervical canal, and tubal lumina. Other than being diagnostic, it can prove to be therapeutic. The instrument used to introduce the radio-opaque medium should be chosen to give the least discomfort and to cause no leakage of dye from the cervix. Water-soluble medium is usually used rather than an oil-based medium. Fluoroscopy with image intensification gives the best results. Insufficient dye injection will give an incomplete study. Too much dye injection, especially under pressure, might cause extravasation of the dye into the vascular system or conceal the fimbrial ends of the tubes.

Tubal patency after clinical treatment of unruptured ectopic pregnancy

OBJECTIVE

To evaluate tubal patency using hysterosalpingography after clinical treatment of tubal pregnancy.

METHOD

Of 80 patients who underwent hysterosalpingography after clinical treatment of tubal pregnancy from April 1994 to February 2002, 30 were treated with a single 50 mg/m(2) dose of methotrexate intramuscularly (n=30) and 50 were followed up expectantly.

RESULTS

Patency of the ipsilateral tube was 84% after methotrexate treatment and 78% after expectant management. In addition, contralateral tubal patency was 97% after methotrexate treatment and 92% after expectant management. There were no statistically significant differences between the groups.

CONCLUSION

Findings from this study suggest similar tubal patency rates after methotrexate treatment and expectant management.

Minimally invasive exploration of the female reproductive tract in infertility

Classically, invasive and non-invasive tests are performed to evaluate the causes of infertility. Transvaginal hydrolaparoscopy (THL) allows the exploration of the pelvic structures with a mini-endoscope, using a vaginal needle-guided trocar introduction technique and saline as a distension medium. A first study on 349 patients demonstrated the feasibility of the procedure and gave a high patient satisfaction. Access to the pouch of Douglas was achieved in 330 patients (94.5%) under local anaesthesia and in an ambulatory environment. The mean pain score measured on a visual analogue scale of 10 was 2.7, comparable to the score of mini-hysteroscopy only and significantly lower than the scores of hysterosalpingography with either metal cannula or balloon catheter. A total of 96% of the patients agreed to repeat the procedure under the same circumstances if required. The diagnostic accuracy of the technique was demonstrated in a prospective study, in which two independent endoscopists explored 10 patients with both THL and standard laparoscopy. The inter-observer agreement for ovarian adhesions was 75% for standard laparoscopy and 90% for THL. In addition, in patients with mild endometriosis, more peri-ovarian adhesions were detected with THL than with standard laparoscopy. A multinational survey to evaluate the risk and outcome of bowel injury during THL registered 24 (0.65%) cases in 3667 procedures. In all cases, the diagnosis was made immediately and the treatment was conservative without complications.

Evaluation of Cases of Secondary Infertility by Hysterosalpingography and Hysteroscopy

Hysterosalpingography (HSG) and hysteroscopy, two investigative modalities were performed on a group of 50 patients of secondary infertility and the results analysed. In this study, the infertile women were evaluated with HSG followed by hysteroscopy to evaluate the causes of secondary infertility and attempt a correlation between these investigative modalities. The complete agreement between HSG and hysteroscopy was established in 43 (86%) cases. HSG showed a false positive rate of 23% and false negative rate of 6%. The sensitivity of HSG was 77% and specificity 93% in diagnosing uterine conditions. The conditions missed were likely due to the overfilling of the uterus. HSG showed a good correlation with hysteroscopy and being a safe and simple procedure, it should be the preliminary Investigation in infertile patients. Thus, the two investigative modalities were found to be complementary to each other rather than being mutually exclusive.

Reliability of clinicians versus radiologists for detecting abnormalities on hysterosalpingogram films

OBJECTIVE

To evaluate the consistency of the identification of abnormal findings on hysterosalpingogram (HSG) and compare the reliability of clinicians to that of radiologists.

DESIGN

Evaluation of reliability of diagnostic test.

PATIENT(S)

Women undergoing evaluation for infertility.INTEVENTION(S): Retrospective review of 50 HSG films by three reproductive endocrinologists and three radiologists. Each film was reread 30 days later in a blinded fashion.

MAIN OUTCOME MEASURE(S)

The consistency of each individual reader, the reliability of detecting specific abnormalities, and the consistency of clinicians compared with radiologists was evaluated with a kappa (K) statistic and interclass correlation coefficient (ICC).

RESULT(S)

Average intrareader reliability was high for the detection of normal uterus, normal tubes, and tubal obstruction and low for the detection of hydrosalpinx, uterine adhesions, and pelvic adhesions. Inter-reader reliability was high in the detection of normal uterine contour, normal tubal patency, and uterine filling defect and lower for the detection of a hydrosalpinx. The reliability of detecting pelvic adhesion or salpingitis isthmica nodosa was poor.

CONCLUSION(S)

Intrareader reliability was generally good, especially for the detection of normal findings. Agreement among different readers is lower in detecting rare outcomes such as hydrosalpinx and pelvic adhesion and salpingitis isthmica nodosa. Clinicians more reliably diagnose hydrosalpinx and tubal obstruction, while radiologists more reliably detect the more subtle findings of salpingitis isthmica nodosa or uterine adhesions.

Transvaginal hydrolaparoscopy

Transvaginal hydrolaparoscopy (THL) correlates well with standard laparoscopy for evaluation of the cul-de-sac in women with unexplained infertility. Office THL, chromopertubation, and hysteroscopy appear well tolerated, safe, and suitable for most patients, and may be more cost effective than hysterosalpingogram in the infertility work-up. Gynecologic and operative THLs are applicable for selected indications.

Interrater agreement on tympanometry in infants

Two-hundred and forty-two tympanograms of infants were interpreted according to a standard operating procedure independently by an audiologist and ten study doctors from the Finnish Otitis Media Vaccine Trial. The interrater agreement among the study doctors according to Kappa index was excellent (kappa = 0.80). The agreement was significantly better on curves taken during pre-scheduled healthy visits than during sick visits due to respiratory infection (p < 0.001). In addition concurrent knowledge of the clinical ear status significantly improved the agreement on abnormal curves (flat B-curves and failed F-curves, p < 0.001). The clinical differences between the groups were minor. The age of the infant had no effect on interpretation. The agreement between the audiologist and the study doctors was also excellent (kappa = 0.77). Excellent agreement can be achieved in infant tympanometry through adequate instruction and training.

Evaluation of outpatient hysteroscopy, saline infusion hysterosonography, and hysterosalpingography in infertile women: a prospective, randomized study

OBJECTIVE

To compare the diagnostic accuracy, pain scores, and procedure length of outpatient hysteroscopy (OHS), hysterosalpingography (HSG), and saline infusion hysterosonography (SIS) for evaluation of the uterine cavity of infertile women.

DESIGN

Prospective, randomized, investigator-blind study.

SETTING

Tertiary infertility clinic.

PATIENT(S)

Forty-six consecutive infertile women.

INTERVENTION(S)

Outpatient HSG, OHS, and SIS, followed by operative hysteroscopy (HS).

MAIN OUTCOME MEASURE(S)

Uterine abnormalities, procedure length, and subjective pain.

RESULT(S)

Fifty-nine percent of infertile subjects were found to have an abnormality on at least one of three outpatient uterine evaluations. When compared with the case of definitive operative HS, 60% of abnormalities were correctly classified by HSG, 72% by OHS, and 52% by SIS (P: NS). When comparing all combinations of 2 outpatient screening tests to operative hysteroscopy, 68% were correctly classified by HSG/OHS, 58% by HSG/SIS, and 64% by OHS/SIS (P: NS). The average time length for the OHS was 9.1 min., which was significantly greater than for both HSG (average, 5.3 min) and SIS (average, 6.1 min.) (P<.0001 for both). HSG and SIS were not statistically different regarding procedure time length. The average pain score (0-10) for SIS was 2.7, compared with 5.8 and 5.3 for HSG and OHS, respectively. Both HSG and OHS mean pain scores were significantly greater than the SIS mean.

CONCLUSION(S)

OHS, SIS, and HSG were statistically equivalent regarding evaluation of uterine cavity pathology in infertile women.

Fallopian tube disease: the cobblestone pattern as a radiographic sign

PURPOSE

To identify radiographic signs of mucosal damage by comparing hysterosalpingography with salpingoscopy in a prospective study.

MATERIALS AND METHODS

Forty-one candidates for laparoscopy underwent hysterosalpingography and peroperative salpingoscopy; at both, tubal patency was noted. Radiographic criteria for mucosal abnormality were rounded filling defects (ie, the cobblestone pattern) and the absence of longitudinal radiolucent bands in the ampullary tract. At salpingoscopy, tubal mucosa was categorized by means of inspection into five classes of fold pattern: classes I and II, normal; classes III-V, abnormal. Hysterosalpingographic and salpingoscopic results were compared by means of a two-by-two table and kappa statistics.

RESULTS

Seventy-four tubes were evaluated. At hysterosalpingography, 31 tubes were distally nonpatent. Of these, 26 showed a distal obstruction at salpingoscopy. None of the patent tubes at hysterosalpingography showed obstruction at salpingoscopy. The agreement between hysterosalpingography and salpingoscopy in detecting abnormal mucosal pattern was 89.2% (kappa, 0.73; P: <.001). The cobblestone pattern always corresponded to intraluminal adhesions at salpingoscopy. The absence of radiolucent bands corresponded to abnormal mucosa at salpingoscopy in four of six cases. The cobblestone pattern was found only in hydrosalpinges and never in patent tubes. Six normal patent tubes at hysterosalpingography showed intraluminal adhesions at salpingoscopy.

CONCLUSION

Results indicate that the cobblestone pattern is an effective radiographic sign of intraluminal adhesions in hydrosalpinges and suggest that intraluminal disease in patent tubes might not always be excluded on normal hysterosalpingograms.

Laparoscopy in the "normal" infertile patient: a question revisited

STUDY OBJECTIVE

To determine the prevalence of reproductive pathology in a group of infertile women thought to be at low risk for altered pelvic anatomy.

DESIGN

Retrospective chart review and follow-up (Canadian Task Force classification II-2).

SETTING

Academic-affiliated, private reproductive endocrinology practice.

PATIENTS

One hundred infertile women.

INTERVENTION

Diagnostic and/or therapeutic laparoscopy.

MEASUREMENTS AND MAIN RESULTS

Of 100 patients with a negative reproductive work-up up to the point of laparoscopy, 68 had pathology of reproductive significance: intrinsic tubal disease 24, peritubal adhesive disease 34, and endometriosis 43, some in combination. Laparoscopy was especially helpful in establishing treatment protocols for older women, who were referred for assisted reproductive techniques earlier than otherwise might have been the case. Women conceived after hormone therapy and after operative intervention. Although the hysterosalpingogram was read as normal in all women, tubal disease was diagnosed laparoscopically, independent of endometriosis, in 27 patients, with 2 having complete obstruction. Endometriosis stage I-II was found in 22 patients, stage III in 13, and stage IV in 6.

CONCLUSION

Even in women thought to be at low risk for significant pelvic pathology affecting reproduction, the yield was high. Although some pregnancies were achieved after operative intervention, frequently laparoscopy was helpful in making a decision to go to assisted reproductive technology, particularly when infertility had been of long duration and in older women. Frequently the degree of pathology was such that a full operating suite was necessary to provide adequate instrumentation and anesthesia for operative intervention, which would not have been the case with office laparoscopy.