Transvaginal Sonohysterography (Tv-Sh), Versus Hysterosalpingography (Hsg) And Laparoscopy

July 5, 2011

The aim of this study was to evaluate the role of TV-SH in the assessment of tubal patency and to compare these results with those obtained using HSG and laparoscopy.

Abstract

Objective : The aim of this study was to evaluate the role of TV-SH in the assessment of tubal patency and to compare these results with those obtained using HSG and laparoscopy.

Study design : A prospective study was performed at Al-Azhar University Hospital, Cairo, Egypt and Hadi Hospital, a private Hospital in Kuwait. A total of 200 infertile patients (150 Egyptian and 50 Kuwaiti). All women underwent HSG, TV-SH, and Diagnostic Laparoscopy. Patients were classified into 2 groups:

Group 1:100 patients had primary infertility 

Group 2:100 patients had secondary infertility.

Results: The mean age was 27.6± 4.25 years for group 1 and 29.8±4.1 years for group 2.The mean duration of infertility was 4.6±2.1 years for group 1 and 5.2±1.9 years for group 2. On comparing the HSG findings with TV-SH and laparoscopic findings, there were no significant differences between the 3 methods of investigations. The total compatibility between the laparoscopic and HSG findings was 87%,and between the laparoscopic and TV-SH findings was 94.1%,the differences were statistically insignificant. According to the site of obstruction the sensitivity, specificity and diagnostic accuracy of TV-SH were insignificantly higher than that of HSG. TV-SH gave similar results as laparoscopy in diagnosing polycystic ovaries and did not detect the peritubal adhesions as HSG and laparoscopy. According to the site of obstruction and the presences or absences of hydrosalpingx, there was no significant difference between the sensitivity of TV-SH and HSG except in diagnosing corneal block (P<0.05).Also there were no significant differences between the specificity and diagnostic accuracy of the two methods.

Conclusion: TV-SH is a simple procedure, it does not involve radiation exposure, it could be added to the usual conventional procedures to assess tubal patency as a new, easy and safe method and can be performed as an outpatient procedure in the routine infertility clinic.

Key words:Transvaginal Sonohysterography, Hysterosalpingography, Laparoscopy

INTRODUCTION

 

Vaginal ultrasound has gained popularity with gynecologists and radiologists for evaluating many gynecologic problems(1). Sonohysterography, a term coined in 1993 to describe the infusion of sterile saline through the cervix and into the uterus during vaginal sonography, is a simple and elegant technique for visualizing the endometrium during a routine vaginal ultrasound examination(2). Sonohysterography may have many applications for infertility evaluation. It has been used to diagnose and locate endometrial polyps, intrauterine adhesions, and separated uteri, and has also been used to evaluate tubal patency(2)(3)(4)(5).Sonohysterography was as accurate as HSG in demonstrating tubal patency but less accurate in determining which tubes were patent(3).

The aim of this study was to evaluate the role of TV-SH in the assessment of tubal patency and to compare these results with those obtained using HSG and laparoscopy.

PATIENTS AND METHODS

 

We conducted a prospective study in two centers: Department of Obstetrics and Gynecology, AL- Azhar University Hospitals, Cairo, Egypt and Department of Obstetrics and Gynecology, Hadi Hospital, private hospital in Kuwait, during the period from October 1996 and October 1999 .The study included 200 infertile patients (150 Egyptians and 50 Kuwaiti). All women underwent HSG, TV-SH, and diagnostic laparoscopy. Their ages ranged from 20 to 35 years. Patients were classified into 2 groups. Group 1:100 patients had primary infertility and Group 2:100 patients had secondary infertility. The time period between the performance of the first and the last of the examinations was <2 months for each patient. Hysterosalpingography was conducted by the radiologists of the Hospitals. Laparoscopy, HSG, and TV-SH were conducted by specialized gynecologists of the departments of Gynecology of the Hospitals. The physicians performing the different examinations were blinded to the results of the other studies. Laparoscopy was considered the gold standard. The results of HSG, TV-SH were compared with those of laparoscopy.

Exclusion criteria were: ongoing or recent pelvic infection, late menses without confirmation of absence of pregnancy, and technical impairment in any of the examinations. The study was approved by the Ethics Committee of the Hospitals, and all patients gave informed consent.

TV-SH:

 

The sonographic examinations were carried out using Creds (Combison) 410 plus. with multifrequency convex transvaginal probe and a frequency range of 5 : 7.5 MHz transducer (for Egyptian patients) and Aloka Co., ltd SSD 1700 Dyna View II Tokyo-Japan (for Kuwaiti patients). Trained ultrasonographer performed the scans.

Scanned in longitudinal and transverse planes, and any de­tected abnormality was described and measured. The adnexa were also evaluated. Immediately after the performance of TVS, TV-SH was carried out, always in the first half of the menstrual cycle. A standard bivalve vaginal speculum was put in place, and the cervix was cleansed with povidone-iodine. The upper cervical lip was grasped with a tenaculum, and a polyethylene cannula of the type used for intrauterine inseminations (Unimar KDF-2.3 Intrauterine cannula: Prodimed, Neuily en Thelle, France) was introduced into the cervix. After that, the tenaculum and the speculum were removed, and the TVS probe was reinserted in the posterior vaginal vault. With concomitant ultrasonographic examination, 5-15 mL of physiologic sa­line solution was slowly infused to distend the endometrial cavity. During the distension and by the end of it, the cavity was evaluated, with attention to the contour, dimension, thickness, and regularity of the endometrium and presence of polypoid lesions (polyps or myomas) or adhesions. At the end of the examination, the balloon was emptied and the injector was removed. During each study; pre and post instillation scans were recorded on hard copy photos for patients record using Sony Graphic Video printer. Prophylactic antibiotics-200 mg of Doxycycline 20 min­utes before the procedure-were given to patients with a history of pelvic inflammatory disease and cardiac disorders(6). No analgesics or sedatives were used during the procedure. The patients were told to take an antispasmodic and an anti-inflammatory, agent 30 minutes before the procedure.

HSG:

 

All HSGs were conducted under the supervision of the same radiologist. They were performed between the 5th and the 14th day of the menstrual cycle by using fluoroscopy and using a non-ionic, monomeric, triiodinated, water soluble, , x-ray contrast medium {IOHEXOL (OMNIPAQUE)} Nycomed Ireland Ltd.

Laparoscopy:

 

This was done for each case, under general anaesthesia. Twenty ml of 0.5% methylene blue were injected using cervical cannula to test tubal patency by visualizing the bluish fluid staining the utenne cavity and tubes and coming out from the fimbrial end of both tubes.

The data obtained by transvaginal sonosalpingography, hystero­salpingography and laparoscopy for each case were recorded and tabulated for the comparative study.

STATISTICAL EVALUATION

 

For statistical analysis, Chi-square, the primary statistical test used for studying the relationship between variables, the sensitivity, specificity, and diagnostic accuracy of HSG and TV-SH were calculated by com­paring the results of each of the methods with those obtained by laparoscopy, the gold standard. The 95% CI for all parameters was also calculated.

RESULTS

 

This study comprised 200 infertile cases arranged in 2 groups. The mean age was 27.6± 4.25 years for group 1 and 29.8±4.1 years for group 2.The mean duration of infertility was 4.6±2.1 years for group 1 and 5.2±1.9 years for group 2.There were no significant differences between both groups and between the women of the two centers, regarding the means of ages and durations of infertility. 

Table 1 shows the HSG, TV-SH and laparoscopic findings in the studied cases. there was no significant difference between both groups. On comparing the HSG findings with TV-SH and laparoscopic findings, there were no significant differences between the 3 methods of investigations. The total compatibility between the laparoscopic and HSG findings was 87%,and between the laparoscopic and TV-SH findings was 94.1%,the differences were statistically insignificant. In cases with bilateral tubal block, compatibility was 87.1%,and incompatibility was 12.9% and in cases with unilateral tubal block,87.5% were compatible and 12.5% were incompatible, and the compatibility in bilateral tubal patency were 86.5% and incompatibility were 14.5%.

Table 2 represent the sensitivity, specificity and diagnostic accuracy of HSG and TV-SH according to the site of obstruction. The sensitivity, specificity and diagnostic accuracy of TV-SH were insignificantly higher than that of HSG.

Distribution of the 400 tubes studied according to the site of obstruction and to the presence or absence of hydrosalpingx , there were no significant differences between the 3 methods of investigations (Table 3).

Table 4 shows the findings of HSG, Laparoscopy and TV-SH in the diagnosis of peritubal adhesions and polycystic ovaries (PCO). TV-SH gave similar results as laparoscopy in diagnosing PCO and did not detect the peritubal adhesions as HSG and laparoscopy.

Table 5 shows the sensitivity, specificity, and diagnostic accuracy of HSG and TV-SH according to the site of obstruction and the presences or absences of hydrosalpingx. There was no significant difference between the sensitivity of two methods except in diagnosing cornual block (P<0.05).Also there were no significant differences between the specificity and diagnostic accuracy of the two methods.

Discussion

Ultrasonic evaluation of the fallopian tubes presents one of the greatest challenges for the sonographer.(7) Hysterosalpingography is still an important diagnostic procedure to evaluate fallopian tube patency(8). Hysterosalpingography allows documentation of tubal patency, enables detection of several tubal lesions and permits assessments of the fine intratubal architectural details, especially when an aqueous contrast medium is used(6)(7)(9). In the present study the HSG findings showed that the incidence of tubal block in primary infertility was 50% and in secondary infertility was 60%.These results were in agreement with the previous studies(9)(10),(11) Okonofua et al, in (1989)(11) reported that HSG and laparoscopy were compatible in diagnosis of intratubal and distal tubal occlusion. The present study was in agreement with the previous studies(11)(12)(13)(14)(15), regarding, the HSG findings confirmed by laparoscopy and revealed that the compatibility was found in 87% of cases while incompatibility was found in 13% of cases studied. On the other hand low figures for compatibility between the HSG and laparoscopy were reported by other investigators(16)(17).

In the present study the comparison between TV-SH results and the laparoscopic results show no significant difference between the two procedures. The compatibility of TV-SH for diagnosis of tubal patency or block was 94.1% when compared with laparoscopy.

The present study was in agreement with the results of previous studies by Allahbadia 1992 and 1993(17)(18), who reported more than 90% compatibility between TV-SH and laparoscopy. But Volpi et al, (1994)(19) reported 87.3%,Heikkinen et al 1995 (20) reported 85% and Inki et al 1998 (21) reported that 88.7% of the cases of TV-SH were compatible when compared with that of laparoscopy. However Mitri et al in (1 991)(22) reported only 72% compatibility. The present study was disagreement with the previous study due to the difference in technique and amount of injected saline. In the present study, the sensitivity, specificity and the diagnostic accuracy of TV-SH were insignificantly higher than that of HSG when both methods were compared. These results were in agreement with the previous studies(3)(23)(24). Regarding the site of tubal obstruction and the presence or absence of hydrosalpingx, the 400 tubes were distributed in 5 groups: cornual block, midsegment block, fimbrial block, hydrosalpingx or patent tubes (table 3). Comparing the results of TV-SH or HSG with that of laparoscopy revealed insignificant differences. TV-SH gave similar results with laparoscopy in diagnosing PCO and did not detect the peritubal adhesions as HSG and laparoscopy. these findings was in agreement with the result of previous study reported by Allahbadia (1992)(17).Mitri et al (1991)(22) and Tufekii et al (1992)(25) reported in their studies similar conclusion regarding the accuracy of TV-SH in diagnosing the site of tubal obstruction. Mitri et al (1991)(22) concluded that TV-SH is a simple technique and should replace the use of HSG. The disadvantage of the procedure is that it cannot demonstrate with accuracy the proximal part of the tube especially the cornual area. However Balen et al (1993)(26) reported that TV-SH compared with HSG was insufficiently accurate in determining tubal pathology and it could not replace conventional HSG.

In conclusion: TV-SH is a simple procedure, it does not involve radiation exposure, it could be added to the usual conventional procedures to assess tubal patency as a new, easy and safe method and can be performed as an outpatient procedure in the routine infertility clinic.

 

Table 1: HSG, Laparoscopic and TV-SH Findings. NO(%)

 Bilateral Tubal BlockUnilateral Tubal BlockBilateral Tubal patency

Primary

28 (28 %)22 (22 %)50 (50 %)

34 (34 %)

26 (26 %)40 (40 %)
P-ValueN.S.N.S.N.S.
Total62 (31 %)48 (24 %)90 (45 %)
LaparoscopyPrimary24 (24 %)16 (16 %)60 (60 %)
Secondary30 (30 %)26 (26 %)44 (44 %)
P-ValueN.S.N.S.N.S.
Total54 (27 %)42 (21 %)104 (52 %)
TV-SHPrimary26 (26 %)18 (18 %)56 (56 %)
Secondary32 (32 %)26 (26 %)42 (42 %)
P-ValueN.S.N.S.N.S.
Total58 (29 %)44 (22 %)98 (49 %)

 

Table 2: Sensitivity, Specificity & Diagnostic accuracy according to site of obstruction

 Bilateral Tubal BlockUnilateral Tubal BlockBilateral Tubal patency

TV-SH

93.1 %95.4 %94.5 %

87.0 %

87.5 %88.1 %
P-ValueN.S.N.S.N.S.
SpecificityTV-SH97.3 %98.75 %94.1 %
HSG94.8 %96.3 %87.2 %
P-ValueN.S.N.S.N.S.
Diagnostic AccuracyTV-SH96 %98 %95 %
HSG92 %94 %87 %
P-ValueN.S.N.S.N.S.

 

Table 3: Distribution of cases according to sites of tubal obstruction. (NO(%)

Site of ObstructionTV-SHHSGLaparoscopyP-Value
Cornual block30 (7.5 %)38 (9.5 %)26 (6.5 %)N.S.
Mid segment block32 (8.0 %)28 (7.0 %)28 (9.5 %)N.S.
Fimbrial block76 (19 %)90 (22.5 %)64 (16 %)N.S.
Hydrosalpingx22 (5.5 %)16 (4.0 %)22 (5.5 %)N.S.
Patent tubes240 (60 %)228 (57 %)250 (62.5 %)N.S.
Total400 (100 %)400 (100 %)400 (100 %)N.S.

 

Table 4: Diagnosis of peritubal adhesions and PCO (Polycystic Ovary)

 HSGLaparoscopyTV-SH
Peritubal adhesions28440

N.S.

P<0.001

Polycystic Ovary-1212

P<0.05

N.S.

 

Table 5: Parameters according to site of obstruction

 SensitivitySpecificityDiagnostic Accuracy
 TV-SHHSGP-ValueTV-SHHSGP-ValueTV-SHHSGP-Value
Cornual block86.6 %68.4 %<0.0598.4 %96.8 %N.S.98 %94 %N.S.
Mid segment block86.3 %79.1 %N.S.98.3 %97.3 %N.S.97 %95 %N.S.
Fimbrial block84.2 %71.1 %N.S.90.5 %92.8 %N.S.94 %88 %N.S.
Hydrosalpingx100 %72.7 %N.S.100 %98.4 %N.S.100 %97 %N.S.
Patent Tubes96.1 %92.5 %N.S.96.1 %88.2 %N.S.45 %90 %N.S.

References:

REFERENCES

1. Ashley Hill D: Sonohysterography in the office: instruments and technique. Contemporary OB/GYN Archive 1997;15.

2. Parsons AK, Lense JJ: Sonohysterography for endometrial abnormalities: Preliminary results. J Clin Ultrasound 1993;21:87.

3. Randolph JR, Ying YK, Maier DB et al: Comparison of real-time ultrasonography, hysterosalpingography, and laparoscopy/hysteroscopy in the evaluation of uterine abnormalities and tubal patency. Fertil Steril 1986;46:828.

4. Van Roessel J, Wamsteker K, Exalto N: Sonographic investigation of the uterus during artificial uterine cavity distention. J Clin Ultrasound 1998;15:439.

5. Syrop CH, Sahakian V: Transvaginal sonographic detection of endometrial polyps with fluid contrast augmentation. Obstet Gynecol 1992;79:1041. Timor Tritsch 1991 .

6. Siegler AM: Endoscopy in infertility, In: Progress in infertility, Eds Behrman SJ, Kistner RW, Patton GW.3 rd edition. Little Brown and Company,Boston,Tornto.1988,p 71.

7. Bacevac J, Ganovic R: Diagnostic value of hysterosalpingography in examination of Fallopian tubes in infertile women (abstract). Srp Arh Celok Lek 2001,129(1-2):18-21

8. Standell A, Bourne T, Bergh C: The assessment of endometrial pathology and tubal patency: A comparison between the use of ultrasonography and x-ray hysterosalpingography for the investigation of infertility patients. Ultrasound Obstet Gynecol 1999;14:200-204.

9. Serour GI, Abdalla AT, Hamed AF, Salah AA, Bahgat H: Microsurgical correction of lateral end block of the fallopian tube for infertile patients. Population Sciences, Journal of International Islamic Centre For Population Studies and Research,1987;7:115.

10. Khera KR, Dhaliwal LK, Gupra I. Hysterosalpingography in secondary infertility. Asia Oceania J Obstet Gynecol 1988;14(2):177.

11. Okonofua FE, Essen UI, Nimaluragi T. Hysterosalpingography versus laparoscopy in tubal infertility: comparison based on findings at laparatomy. Int J Gynaecol Obstet. 1989;28(2):143-7.

12. Spalding H, Martikainen H, Tekay A, Jouppila P. A randomized study comparing air to Echovist as a contrast medium in the assessment of tubal patency in infertile women using transvaginal salpingosonography. Hum Reprod. 1997;12(11):2461-4.

13. Spalding H, Perala J, Martikainen H, Tekay A, Jouppila P. Assessing tubal patency with transvaginal salpingosonography after the reversal of tubal ligation for female sterilization. Hum Reprod.1998;13(1O):2819-22.

14. de Almeida I, Souza C, Reginatto F, Cunha Filho JS, Facin A, Freitas F, Lavic Y, Passos EP. Hysterosonosalpingography and hysterosalpingography in the diagnosis of tubal patency in infertility patients. Rev Assoc Med Bras. 2000;46(4):342-5.

15. Inki P, Palo P, Anttila L. Vaginal sonosalpingography in the evaluation of tubal patency. Acta Obstet Gynecol Scand. 1998;77(10):978-82.

16. Dhaliwal LK, Khera KR, Gupta I, Gupta AN. Comparison of hysterosalpingography and laparoscopy in the evaluation of tubal factor.Asia Oceania J Obstet Gynaecol. 1987 Mar;13(1):65-7.

17. Allahbadia GN. Fallopian tubes and ultrasonography: the Sion experience. Fertil Steril. 1992;58(5):901-7.

18. Allahbadia GN. Fallopian tube patency using color Doppler. Int J Gynaecol Obstet. 1993;40(3):241-4.

19. Volpi E, De Grandis T, Rustichelli S, Zuccaro G, Patriarca A, Sismondi P. A new technique to test tubal patency under transvaginal sonographic control. Acta Obstet Gynecol Scand. 1994 Nov;73(10):797-801.

20. Heikkinen H, Tekay A, Volpi E, Martikainen H, Jouppila P. Transvaginal salpingosonography for the assessment of tubal patency in infertile women: methodological and clinical experiences. Fertil Steril. 1995 Aug;64(2):293-8.

21. Inki P, Palo P, Anttila L. Vaginal sonosalpingography in the evaluation of tubal patency. Acta Obstet Gynecol Scand. 1998;77(10):978-82.

22. Mitri FF, Andronikou AD, Perpinyal S, Hofmeyr GJ, Sonnendecker EW. A clinical comparison of sonographic hydrotubation and hysterosalpingography. Br J Obstet Gynaecol. 1991;98(10):1031-6.

23. Zuo W, Wang P. Comparative study on assessment of tubal patency among tubal insufflation, hydrotubation, hysterosalpingography and chromotubation under laparoscopy. Zhonghua Fu Chan Ke Za Zhi. 1996 Jan;31(1):29-31(abstract).

24. Omigbodun AO, Fatukasi JI, Abudu T. Ultrasonography as an adjunct to hydrotubation in the management of female infertility. Cent Afr J Med. 1992 Aug;38(8):345-50.

25. Tufekii EL, Durmusoghi F, Girit S, Yalli S, Bayirli E. Evaluation of tubal patency by transvaginal sonosalpingography. Fertil Steril 1992;87(2):336.

26. Balen FG, Allen CM, Siddle NC, Lees WR. Ultrasound contrast hysterosalpingography--evaluation as an outpatient procedure. Br J Radiol. 1993 Jul;66(787):592-9.