MRI for Diagnosing Intrauterine Adhesions

OBJECTIVES

To prospectively assess the diagnostic accuracy of MRI and transvaginal ultrasound (TVS) as well as the prognostic value of MRI for intrauterine adhesions (IUAs), using hysteroscopy as the reference standard.

DESIGN

Prospective observational study.

SETTING

Tertiary medical centre.

PATIENT(S)

Ninety-two women with amenorrhea, hypomenorrhea, subfertility, or recurrent pregnancy loss who underwent MRI and in whom Asherman's syndrome was suspected upon TVS.

INTERVENTION(S)

MRI and TVS were conducted approximately 1 week before hysteroscopy.

METHODS

Ninety-two patients suspected of having Asherman's syndrome were examined by MRI and TVS within 7 days of an upcoming hysteroscopy. All hysteroscopy procedures were performed during the early proliferative phase of the menstrual cycle. All hysteroscopic diagnoses were performed by an experienced expert. All MRIs were read by 2 experienced, blinded radiologists.

RESULTS

MRI was highly accurate (94.57%), sensitive (98.8%), and specific (42.9%) for diagnosing IUAs with a positive predictive value of 95.5% and a negative predictive value of 75%. The diagnostic values of MRI and TVS were significantly different according to McNemar tests. Junctional zone signal and junctional zone alterations correlated with the stage of IUAs.

CONCLUSION

MRI is markedly superior to TVS in terms of diagnostic accuracy for IUAs, with total agreement with hysteroscopic findings. However, the main advantage of MRI is that, unlike TVS and hysterosalpingography, it can be used to assess the risk of hysteroscopy and to predict postoperative recovery and future pregnancy based on the uterine junctional zone.

Endometrial thickness measurements among Asherman syndrome patients prior to embryo transfer

STUDY QUESTION

Is there an association between endometrial thickness (EMT) measurement and clinical pregnancy rate among Asherman syndrome (AS) patients utilizing IVF and embryo transfer (ET)?

SUMMARY ANSWER

EMT measurements may not be associated with successful clinical pregnancy among AS patients undergoing IVF.

WHAT IS KNOWN ALREADY

Clinical pregnancy rate after IVF is significantly lower in patients with a thin endometrium, defined as a maximum EMT of <7 mm. However, AS patients often have a thin EMT measurement due to intrauterine scarring, with a paucity of data and no guidance on what EMT cutoff is appropriate when planning an ET among these patients.

STUDY DESIGN, SIZE, DURATION

This is a retrospective cohort study of 45 AS patients treated at a specialized advanced hysteroscopic clinic from 1 January 2015, to 1 March 2019.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Review of EMT measurements prior to a total of 90 ETs, among 45 AS patients. The impact of the maximum EMT measurement prior to ET on clinical pregnancy rate was analyzed.

MAIN RESULTS AND THE ROLE OF CHANCE

A total of 25/45 (55.6%) AS patients ultimately went on to have ≥1 clinical pregnancy following a mean ± SD of 2.00 ± 1.26 ET attempts. There was a total of 90 ETs among the 45 AS patients, with 29/90 (32.2%) ETs resulting in a clinical pregnancy. Younger patient age (P = 0.05) and oocyte donation (P = 0.01) were the only variables identified to be significant predictors for a positive clinical pregnancy outcome on bivariate analysis. The mean EMT measurement prior to all ETs among AS patients was 7.5 ± 1.6 mm. EMT measurement prior to ET did not predict a positive clinical pregnancy on either bivariate (P = 0.84) or multivariable analysis (odds ratio 0.91, P = 0.60). 31.8% of EMT measurements measured <7.0 mm. In this small cohort, no difference in the clinical pregnancy rate was detected when comparing ETs with EMT measurements of <7.0 mm versus ≥7.0 mm (P = 0.83). The mean EMT measurement decreased with increasing AS disease severity; 8.0 ± 1.6 mm for mild disease, 7.0 ± 1.4 mm for moderate disease and 5.4 ± 0.1 mm for severe disease.

LIMITATIONS, REASONS FOR CAUTION

Our small sample size limits our ability to draw any definitive conclusions. In addition, patients utilized various infertility clinics. This limits our ability to evaluate the consistency of EMT measurements and the IVF care that was received.

WIDER IMPLICATIONS OF THE FINDINGS

EMT measurement cutoff values should be used with caution if canceling a scheduled ET in AS patients.

STUDY FUNDING/COMPETING INTEREST(S)

This study was not funded. K.I. reports personal fees from Karl Stroz and personal fees from Medtronics outside the submitted work. The other authors have no conflicts of interest.

TRIAL REGISTRATION NUMBER

N/A.

Hysterosalpingography versus hysterscopy in intrauterine pathology research of infertile patients

BACKGROUND

The objective of the present paper is to confirm the validity and reliability of hysterosalpingography (HSG) in intrauterine pathology research of infertile female patients by comparing the hysteroscopy (HC) findings to a "gold standard" test.

AIM

To analyze HSG and HC findings in infertility patients.

MATERIALS AND METHODS

The research was conducted as a prospective study at the Gynecological and Obstetrics Clinic "Narodni front" in Belgrade.

RESULTS

HSG indicated pathological findings in 72.5% of patients whereas HC revealed abnormalities of uterine cavity in 77.5%. In 12.5% of patients, HSG demonstrated a normal uterine cavity, and HC confirmed pathological findings, while in 7.5% of patients with filling defects and irregular shapes on HSG images, HC reported normal findings. In 22.5% of patients normal finding as well as endometrial polyps were reported; congenital malformations (anomalies) were found in 32.5%, submucosal myomas in 12.5% and Asherman's syndrome in 10%.

CONCLUSION

HC finding was crucial in final diagnosing.

Ultrasound is the optimal choice for guidance in difficult hysteroscopy

OBJECTIVES

To compare costs and complications associated with ultrasound-guided hysteroscopy vs laparoscopy-guided hysteroscopy vs hysteroscopy alone for the surgical repair of intrauterine septa and synechiae.

METHODS

This was a retrospective cohort study. Charts of all patients undergoing reparative surgery for intrauterine synechiae or uterine septa at our academic institution between 2000 and 2008 were reviewed. A total of 159 procedures were included in the study, categorized into concurrent laparoscopic guidance (n = 69), ultrasound guidance (n = 52) or no guidance (n = 38). Data regarding billing, surgical case logs and complications were collected for these procedures. Using these data, complication rates and inflation-adjusted charges were compared between the groups. Statistical analysis was performed using Fisher's exact test and Student's t-test, as appropriate.

RESULTS

A uterine perforation rate of 8.7% was observed with laparoscopic guidance vs 1.9% with ultrasound guidance (P = 0.12) and 5.3% with no guidance (P = 0.41). Analysis of billing data showed that average total costs were significantly less for ultrasound guidance than for laparoscopic guidance ($9124 vs $11 895, P < 0.001). Ultrasound guidance did not increase costs over hysteroscopy alone ($9124 vs $8242, P = 0.54).

CONCLUSION

Real-time transabdominal ultrasound guidance during the resection of intrauterine synechiae or septa resulted in a trend towards reduced uterine perforation. Moreover, ultrasound guidance is less costly than laparoscopic guidance and adds no additional cost over hysteroscopy alone. Taken together, transabdominal ultrasound guidance is the optimal means of intraoperative guidance for the resection of uterine synechiae and septa.

Placenta accreta: an association with fibroids and Asherman syndrome

OBJECTIVE

Placenta accreta is a life-threatening problem that is rising in incidence in the developed world. The increased risk of placenta accreta in women with placenta previa and 1 or more prior cesarean deliveries is well established and prompts careful sonographic evaluation. Our objective was to emphasize that accreta is also identified at sites other than cesarean scars.

METHODS

Two cases of placenta accreta without placenta previa seen in association with uterine scarring from myomectomy and uterine fibroids are described.

RESULTS

The sonographic and magnetic resonance imaging findings of accreta are reviewed in the classic setting of prior cesarean deliveries as well as myomectomy and uterine fibroids.

CONCLUSIONS

We suggest that when the placenta overlies any uterine abnormality, a careful search for invasive placentation is warranted.

Value of 3D ultrasound in the management of suspected Asherman's syndrome

OBJECTIVE

To assess the value of 3-dimensional (3D) ultrasound in the management of patients with suspected Asherman's syndrome.

STUDY DESIGN

A case series of 54 infertile patients who presented to a tertiary care center between 1998 and 2004 with suspected Asherman's syndrome underwent both hysterosalpingography and 3D ultrasound prior to hysteroscopy. Sensitivity and the ability to attain fertility postoperatively were calculated.

RESULTS

Intrauterine adhesions (IUAs) were demonstrated on 3D ultrasound and HSG in all cases and confirmed by hysteroscopy. However, 3D ultrasound had a sensitivity of 100% and HSG a sensitivity of 66.7% for correctly grading the extent of IUAs. In 61.1% of cases in which HSG results were inconsistent with hysteroscopy, lower uterine segment outflow obstruction was present, and HSG misclassified findings as severe Asherman's with complete cavity obstruction. Postoperatively, 90% of patients conceived.

CONCLUSION

3D ultrasound provides a more accurate depiction of adhesions and extent of cavity damage than HSG in patients with suspected Asherman's syndrome, particularly when differentiating severe IUAs from lower uterine segment outflow obstruction. Therefore, grading systems utilizing HSG to classify severity of disease should be revised to include 3D ultrasound findings.

Vaginal calculus secondary to vaginal outlet obstruction

Primary vaginal stones are extremely rare and are often mistaken for bladder calculi on plain radiography. However, intravenous pyelography and sonography can help differentiate between the two. We report a case of a large vaginal stone in a 21-year-old woman referred for apareunia and difficult micturation. The clinical findings of vaginal outlet obstruction and a hard mass anterior to the rectum made us suspect a bladder calculus; however, sonography of the pelvis indicated that the mass was in the vagina. Further examination using a probe to physically define the stone's location confirmed it to be a vaginal calculus. Surgery was performed to repair the outlet obstruction and remove the stone, which permitted the woman to urinate normally and engage in normal sexual relations.