Transvaginal sonographic tubal patency testing using air and saline solution as contrast media in a routine infertility clinic setting

Is hysterosalpingo-foam sonography (HyFoSy) more tolerable in terms of pain and anxiety than hysterosalpingography (HSG)? A prospective real-world setting multicentre study

BACKGROUND

In 60% of sterile couples a female factor is present, with these being tubal factors in 30-50% of cases. A tubal patency test is also required in women without a male partner undergoing fertility treatment. Thus, an accurate, safe and tolerable technique should be available. The aim of this study is to determine and to compare hysterosalpingo-foam sonography (HyFoSy) and hysterosalpingography (HSG) tolerability in terms of pain and anxiety.

METHODS

This is a prospective real-world setting multicentre study conducted in two tertiary hospitals in Madrid. 210 infertile women/women without a male partner looking to get pregnant were recruited; 111 for the HyFoSy group and 99 for the HSG group. Tolerability was measured in terms of anxiety by the State Trait Anxiety Inventory (STAI) and pain by the Visual Analogue Scale (VAS).

RESULTS

Median VAS score in HyFoSy group was 2 (P25; P75: 1; 3) versus 5 (4; 8) in HSG group, p < 0.001. The median State-STAI score in the HSG group was 18 points (10; 26) versus 10 (7; 16) in the HyFoSy group (p < 0.001); the median Trait-STAI score in the HSG group was 15 (11; 21) versus 13 (9; 17) in the HyFoSy group (p = 0.044).

CONCLUSIONS

HyFoSy shows higher tolerability to both: pain and anxiety. It is related to less pain and less post-test anxiety than HSG.

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.

Prospective Study of Concordance Between Hysterosalpingo-Contrast Sonography and Hysteroscopy for Evaluation of the Uterine Cavity in Patients Undergoing Infertility Studies

OBJECTIVES

The purpose of the study was to assess the accuracy of hysterosalpingo-contrast sonography (HyCoSy) for evaluation of the uterine cavity.

METHODS

Hysterosalpingo-contrast sonography was compared with hysteroscopy for assessment of the uterine cavity. This work was a descriptive prospective study to assess the concordance between pathologic intrauterine findings using the Cohen κ coefficient. Ninety infertile patients from Puerta de Hierro University Hospital were included in the study. They underwent HyCoSy between June 2016 and April 2017. Fifteen of them had pathologic findings in the uterine cavity during HyCoSy and therefore underwent hysteroscopy. Clinical and sonographic findings were compared in those 15 patients by to evaluate the agreement between both techniques.

RESULTS

In this study, intrauterine sonographic findings on HyCoSy and hysteroscopic features of the uterine cavity reached 100% concordance, with a κ coefficient of 1.000 and a 100% agreement rate.

CONCLUSIONS

Hysterosalpingo-contrast sonography permits a very accurate evaluation of the uterine cavity, which could be of interest for infertile patients who might be examined for tubal patency.

Hysterosalpingo-foam sonography: patient selection and perspectives

We present an overview of the common types of tubal patency tests, with a focus on hysterosalpingo-foam sonography (HyFoSy). Current evidence suggests that HyFoSy is an accurate alternative to X-ray hysterosalpingography (HSG) for outpatient tubal evaluation in women who are at low risk for tubal disease. It may be superior to saline hysterosalpingo-contrast sonography (HyCoSy) in excluding tubal occlusion. A hyperechogenic medium may enhance contrast visualization and enable clearer delineation of tubal anatomy. This may enhance confidence in the diagnosis of tubal patency, reduce false occlusion results, and improve the diagnostic yield of the test. It would be reasonable to deduce that HyFoSy would have similar performance characteristics as HyCoSy with other positive contrast agents. The available evidence supports the accuracy of HyFoSy compared to other forms of tubal investigation. We suggest a decision-making pathway based on the most current professional recommendations and available evidence. However, in this article, we do not provide a definitive exposition of the methods used for investigating tubal patency. Rather, we explore the contexts in which the various investigations are most and least suitable, and identify their strengths and limitations. Finally, we also discuss challenges encountered when performing tubal contrast sonography in clinical practice, including the problem of false occlusion results.

Hysterosalpingo-Contrast Sonography With a Saline-Air Device Is Equivalent to Hysterosalpingography Only in the Presence of Tubal Patency

OBJECTIVES

To compare hysterosalpingo-contrast sonography with a saline-air device to hysterosalpingography for evaluating tubal patency.

METHODS

Eighty women undergoing infertility evaluations were recruited for this prospective cohort study. All patients underwent both office-based hysterosalpingo-contrast sonography with a saline-air device and hysterosalpingography as the reference standard, and the fallopian tubes were individually assessed for tubal patency in each procedure. The Cohen κ coefficient was used to assess agreement between each procedure, and the Student t test and χ(2) test were used to compare differences in time, pain, and procedural preference.

RESULTS

In total, 75 patients with 148 fallopian tubes were evaluated. Tubal patency on hysterosalpingo-contrast sonography with the saline-air device was noted in 85.8% (n = 127) of tubes compared to 92.5% (n = 137) on hysterosalpingography, with a positive predictive value of 95.2%. Tubal occlusion was noted in 21 tubes (14.2%) on hysterosalpingo-contrast sonography compared to 11 (7.4%) on hysterosalpingography, with a negative predictive value of 23.8% (24 of 28). Overall, hysterosalpingo-contrast sonography agreed with hysterosalpingography in 126 of 148 fallopian tubes (85.1%; κ = 0.47; P < .001). The procedural time and pain scores were significantly greater for hysterosalpingo-contrast sonography compared to hysterosalpingography.

CONCLUSIONS

There was a significant degree of agreement between hysterosalpingo-contrast sonography with a saline-air device and hysterosalpingography when the fallopian tube was patent but not when it was occluded. In the absence of patency, further evaluations with hysterosalpingography may be indicated to avoid false-positive results. Although the procedure time and degree of pain appear to be greater, avoidance of radiation exposure by using hysterosalpingo-contrast sonography with a saline-air device may outweigh the drawbacks.

B-flow ultrasound facilitates visualization of contrast medium during hysterosalpingo-contrast sonography

OBJECTIVE

To assess if B-flow ultrasound improves visualization of flow of contrast medium in the Fallopian tubes during hysterosalpingo-contrast sonography (HyCoSy) compared with grayscale ultrasound.

METHODS

This prospective observational study included 160 women referred for HyCoSy as part of infertility work-up between January 2011 and September 2012. In each woman, at the same session, HyCoSy was performed first using saline with air and then using Sonovue®, and for each contrast medium, grayscale ultrasound was first used and then B-flow ultrasound was used. Flow of contrast was observed in three parts of each tube: intramural, middle and distal.

RESULTS

In 129 (81%) women, flow of Sonovue was observed in the intramural part of both tubes and in the pouch of Douglas when using grayscale ultrasound. In these women, flow of Sonovue was seen in the middle part of 70% of the 258 tubes when using grayscale ultrasound and in 93% when using B-flow ultrasound; and in the distal part in 81% when using grayscale ultrasound and in 98% when using B-flow ultrasound. When using air and saline, flow was seen in the intramural part of 90% and 93% of the tubes, in the middle part in 54% and 72%, and in the distal part in 66% and 90%, using grayscale ultrasound and B-flow ultrasound, respectively.

CONCLUSION

B-flow ultrasound facilitates detection of flow of contrast in the middle and distal parts of the tubes at HyCoSy, especially when a mixture of saline and air is used as contrast medium.

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

Background

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

Methods

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

Results

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

Conclusions

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

Automated three-dimensional coded contrast imaging hysterosalpingo-contrast sonography: feasibility in office tubal patency testing

OBJECTIVE

To evaluate the feasibility of transvaginal hysterosalpingo-contrast sonography (HyCoSy) with new automated three-dimensional coded contrast imaging (3D-CCI) software in the evaluation of tubal patency and visualization of tubal course.

METHODS

Patients undergoing HyCoSy with automated 3D-CCI software were evaluated prospectively. First, to evaluate the feasibility of 3D visualization of tubal course, we performed consecutive volume acquisitions while injecting SonoVue contrast agent. We then performed conventional two-dimensional (2D) real-time HyCoSy to confirm tubal patency status by detection of saline and air bubbles moving through the Fallopian tubes and around the ovaries. We also evaluated visualization with CCI of the contrast agent around the ovaries, side effects and pain during and after the procedure, by visual analog scale (VAS) (ranging from 0 to 10, with 0 corresponding to no pain and 10 corresponding to maximum pain).

RESULTS

A total of 126 patients (252 tubes) underwent 3D-CCI HyCoSy followed by 2D real-time HyCoSy. According to the final 2D real-time evaluation, bilateral tubal patency was observed in 111 patients, bilateral tubal occlusion in four patients and unilateral tubal patency in 11 patients. The concordance rate for tubal patency status between the first 3D volume acquisition and the final 2D real-time evaluation was 84% and that between the second 3D volume acquisition and the final 2D real-time evaluation was 97%. A pain score >5 on VAS was recorded in 58% of patients during the procedure, but a pain score ≤ 5 was recorded in 85.7% of patients immediately after the procedure.

CONCLUSIONS

HyCoSy with automated 3D-CCI technology retains the advantages of conventional 2D HyCoSy while overcoming the disadvantages. 2D HyCoSy is highly observer-dependent and is only accurate in the hands of experienced investigators; by obtaining a volume of the uterus and tubes, automated 3D volume acquisition permits visualization of the tubes in the coronal view and of the tubal course in 3D space, and should allow less experienced operators to evaluate tubal patency status relatively easily.

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.

Comparison of the pain experienced by infertile women undergoing hysterosalpingo contrast sonography or radiographic hysterosalpingography

OBJECTIVE

To evaluate the pain and cause of pain experienced by women undergoing hysterosalpingography (HSG) and contrast hysterosalpingo sonography (HyCoSy) with air in a saline solution for the assessment of uterine and tubal patency.

METHOD

In this prospective study, 121 infertile women undergoing these 2 procedures measured the pain incurred using a digital/analog scale (1-10). We looked for correlations between pain level and variables pertaining to the procedures. Vagal effects and their persistence were also recorded.

RESULTS

The pain was less during HSG (median, 5) than during HyCoSy (median, 7). It was greater than menstrual pain for 38.8% of participants during HSG and for 70.5% of participants during HyCoSy. There was no correlation between pain and difficult catheter passage, degree of tubal obstruction, volume of contrast medium injected, or presence of IgG antibodies to Chlamydia when these variables were studied for HyCoSy alone. However, the strong correlation between pain score and volume of contrast medium injected during each procedure seems to explain the significantly higher pain levels during HyCoSy (P<0.001). In 65.3% and 57.8% of participants, respectively, the pain disappeared immediately after the HSG or HyCoSy. Only mild vagal effects were recorded following both procedures, in 0.8% of participants after HSG and 2.5% of participants after HyCoSy.

CONCLUSION

Hysterosalpingo contrast sonography is similar to HSG regarding rapidity of pain disappearance, and infrequency and moderation of vagal effects, but the level of pain is slightly higher, probably due to the greater volume of medium injected.

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.

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.

Clinical use of sonohysterography in the evaluation of infertility

Assessment of tubal patency and evaluation of the uterine cavity should be part of all infertility investigations. Sonohysterography (SHSG), also referred to as saline-enhanced ultrasonography, is being used with increasing frequency for investigation of infertility and other gynaecological indications. Sonohysterography is similar to hysterosalpingography (HSG) in its effectiveness for evaluating tubal patency, and superior to HSG for assessing intrauterine abnormalities. Advantages of SHSG over HSG include the ability to assess extrauterine structures, lack of ionizing radiation, and often better tolerability by the woman being examined. Sonohysterography can offer detailed assessment of the female pelvis, and has the potential to replace HSG as a routine, first-line infertility investigation. This paper discusses the technique and indications for SHSG, and reviews its use in infertility investigation, in particular in the assessment of the uterine cavity and tubal patency.

MR hysterosalpingography: protocol development and refinement for simulating normal and abnormal fallopian tube patency--feasibility study with a phantom

PURPOSE

To develop and refine a pulse sequence and protocol for testing the feasibility of magnetic resonance (MR) hysterosalpingography in a phantom model.

MATERIALS AND METHODS

A phantom simulating the uterus, fallopian tubes, and surrounding pelvic cavity was constructed. T2-weighted acquisition strategies-breath-hold fast spin-echo, rapid acquisition with relaxation enhancement (RARE), and haff-Fourier RARE-were refined to acquire sequential 70-mm coronal imaging volumes. Contrast agent was injected into the introducing catheter entering the os of the simulated uterus. Interacquisition interval, type of contrast agent (eg, sterile saline solution or water), and quantity of contrast agent (eg, 1-5 mL per acquisition) were varied. Digital image subtraction was used to enhance image quality. Images were qualitatively analyzed and rated good, fair, or poor for temporal resolution, spatial resolution, fallopian tube conspicuity, and free spill conspicuity. Once the technique was refine, the phantom was reconfigured to simulate unilateral and bilateral hydrosalpinx.

RESULTS

The RARE sequence with an 8-second interacquisition interval and a 5-mL interacquisition of sterile water produced good images of the simulated fallopian tubes and free spill. Depiction of unilateral and bilateral hydrosalpinx was also reliably demonstrated.

CONCLUSION

This study with a phantom model demonstrates the feasibility of MR hysterosalpingography to depict normal and diseased fallopian tubes.

Saline infusion sonohysterosalpingography, an underutilized technique

Saline infusion sonohysterography (SIS) is an important gynaecological diagnostic tool which is little used in Australia. We herein report the findings in 60 women referred for SIS, the procedure being uneventfully performed in 55. Forty-nine of the 60 referrals were for investigation of abnormal uterine bleeding. The technique described allows examination of the uterine cavity and the Fallopian tubes. In 26 of the patients information was obtained which improved or altered the diagnosis made on B mode and colour Doppler ultrasound. Unlike hysteroscopy, SIS is always performed as an outpatient procedure, appropriate disinfection procedures are relatively simple to implement (1), and vasovagal reactions are rare. Hysteroscopy was avoided in 11 patients, there were other benefits in 4 patients, and in only 1 of 16 patients did the hysteroscopy findings differ with SIS. If diagnostic pitfalls are avoided by careful attention to detail, SIS offers a powerful new gynaecological investigative tool in the investigation of bleeding disorders (including menorrhagia, intermenstrual and postmenopausal bleeding), uncertain endometrial findings on vaginal ultrasound, infertility, and in the investigation of congenital and acquired uterine abnormalities.