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Comparison between transvaginal sonography after diagnostic hysteroscopy and laparoscopic chromopertubation for the assessment of tubal patency in infertile women
Abstract
Diagnostic hysteroscopy has become a well-established modality for evaluating the uterine cavity, but provides no information regarding tubal patency. The aim of the present study was to investigate the diagnostic value of transvaginal sonography (TVS), performed directly after diagnostic hysteroscopy, for assessing tubal patency in infertile women, and to compare the findings with those obtained by means of laparoscopic chromopertubation.
A total of 56 infertile patients were referred to our endoscopic unit for laparoscopic chromopertubation in the period from September 2008 to January 2010. Diagnostic hysteroscopy, followed by TVS, was carried out prior to laparoscopic chromopertubation. The collection of free fluid in the pouch of Douglas was accepted as evidence of tubal patency. The findings of TVS and laparoscopic chromopertubation were compared. The data were analyzed for the sensitivity, specificity, accuracy, positive-predictivevalue, and negative-predictive value of the combination of hysteroscopy and TVS in detecting unilateral or bilateral tubal patency.
The presence of fluid in the pouch of Douglas was observed in 37 of the 56 cases. In 36 of these cases, unilateral or bilateral tubal patency was confirmed by laparoscopic chromopertubation. In 17 of the remaining 19 cases (without fluid in the pouch of Douglas during ultrasound), bilateral tubal occlusion was confirmed by laparoscopic chromopertubation. Diagnostic hysteroscopy followed by TVS showed a high sensitivity and specificity for the assessment of tubal patency.
TVS performed directly after diagnostic hysteroscopy in infertile patients provides additional nformation regarding tubal patency.
... There is increasing evidence that the possibility of performing hysteroscopy in an outpatient setting causes significantly less stress for patients as it is less invasive [4,5] and is lower in cost for the healthcare system [5]. Thus, outpatient "office" diagnostic hysteroscopy has gained more importance in the course of the diagnostic evaluation of infertility and has been claimed to be the gold standard for evaluation of uterine-dependent infertility, since the patient can be offered low-risk diagnostic and treatment procedures that include targeted biopsy sampling, polypectomy, removal of submucous leiomyomas, lysis of synechiae, removal of retained conception products, metroplasty, and retrieval of dislodged intrauterine devices or foreign bodies [6]. ...
... Inclusion criteria encompassed articles in the English language with the primary topic being diagnostic accuracy of hysteroscopic methods for evaluation of Fallopian tube patency. Four relevant articles were identified [4,5,7,8]. See ▶ Table 1 for an overview about reviewed studies. ...
... There was a significantly lower rate of cul de sac fluid accumulation during hysteroscopy for those patients who had bilateral occlusion in consecutive laparoscopy [8]. Noteworthy, it had already been reported previously, that transvaginal sonography performed directly after diagnostic hysteroscopy would provide additional information regarding tubal patency [4]. ...
The relevance of diagnostic hysteroscopy, especially when performed in an outpatient “office” setting, in the evaluation process of infertility has increased within the last few years. Notably, several articles on a possible role for diagnostic hysteroscopy in the assessment of Fallopian tube patency have been published recently. Three relevant articles were identified. Visualizing a “flow effect” or air bubbles dispersing through the ostia, sonographically assessed shifts in cul de sac volume, and selective Fallopian tubal cannulation are reportedly promising hysteroscopic techniques. In this review, an overview of hysteroscopy, details about diagnostic reliability, and considerations with regard to ease of use and difficulties are summarized. Based on these articles, hysteroscopic evaluation of tubal patency seems to be a promising, clinically relevant field for future clinical research.
... Fallopian tube anomalies account for more than 25% of all cases of infertility. [3][4][5] The assessment of the uterine cavity and tubal patency is an important step in the investigation of female infertility. Program for investigating infertile patient include a variety of test such as physical examination, laboratory testing, and most of the time, radiologic, and surgical studies. ...
... Contrast reaction and X-ray radiation exposure during HSG may induce abdominal pain and allergic reactions. [3,8,9] Moreover, to rule out the presence of endometriosis and peritubal adhesions, which could be missed with HSG, laparoscopy is a forced step after diagnosing tubal patency by HSG. [10] However, although diagnostic laparoscopy offers the possibility of surgical treatment, it expose the patient to operative and anesthesia risk. ...
... [11] Nevertheless, HSC does not help to examine fallopian tubal patency except when it is followed by ultrasonography. [9,[12][13][14] Although a number of studies [3,9] found that HSC had better diagnostic value in combination with TSV than other modalities, in this study, we aimed to compare the results of TVS after HSC with laparoscopy, as a gold standard, for assessing the fallopian tubal patency in infertile women referred to Shahid Beheshti Hospital affiliated with Isfahan University of Medical Sciences (IUMS). ...
Background
Infertility, as one of the most common gynecological disorders, affects many people worldwide. To choose the clinical treatment, correct assessment of tubal patency can provide an important clue; therefore, it is considered as one of the major steps in workup examinations of infertile women. In this study, we aimed to compare the results of transvaginal ultrasonography (TVS) after hysteroscopy (HSC) with laparoscopy, as a gold standard, for assessing the fallopian tubal patency in infertile women.
Materials and Methods
This is a cross-sectional study which included 49 infertile women referred to Shahid Beheshti Hospital affiliated with Isfahan University of Medical Sciences during the years 2015 and 2016. At first, patients who met the inclusion criteria were examined through HSC in by a specialist in gynecology and obstetrics in operating room because laparoscopy was performed after TVS with HSC, but HSC was performed without anesthesia. TVS was performed before and after of HSC to observe fluid in the pouch of Douglas. The findings of TVS with HSC and laparoscopy were compared.
Results
There was a strong agreement between TVS after HSC and laparoscopy (kappa coefficient = 0.935, 95% confidence interval [CI]: 0.81, 1.00). The sensitivity of TVS after HSC was 100% (95% CI: 66.37, 100) and specificity was 97.50% (95% CI: 86.84, 99.94) with a positive predictive value of 90% (95% CI: 55.50, 99.75) and negative predictive value of 100% (95% CI: 90.97, 100).
Conclusion
TVS after HSC is an accurate diagnostic tool for examination of fallopian tubal patency in infertile women.
... Laparoscopy (LPS) provides both a panoramic view of the pelvic reproductive anatomy and a magnified view of the uterine, ovarian, tubal, and peritoneal surfaces. Laparoscopic chromopertubation (LCT) (introducing methylene blue into the uterine cavity being injected through the cervical canal by a cannula during the procedure and then observation as it comes out of the ends of the tubes into the peritoneal cavity) is considered to be the gold standard for TP (5). However, LPS is an invasive surgical procedure, requires general anesthesia, provides no information regarding the uterine cavity and involves the usual risks of surgery (6). ...
... However, it is insufficient to investigate TP or tubal anatomy. It has been defined that HYS combined with ultrasonography can be used in the evaluation of TP with an additional ultrasonographic examination (5). In this method, detecting of the distension fluid in the cul-de-sac by USG was used as a test of TP. ...
... HYS is the gold standard method for evaluation of intracavitary lesions; nevertheless, HYS is not a method to investigate TP (9). Several studies suggested that HYS could be used in evaluation of TP if combined with USG (5,17). In this method, the tube is considered patent when the turbulence of the contrast is visualized on the side or in the Douglas pouch. ...
p> Objective
The aim of this study was to evaluate the diagnostic accuracy of hysteroscopic chromopertubation (HCT) in the assessment of tubal patency by comparing its results with laparoscopic chromopertubation (LCT).
Study Design
The population of this prospective cohort study consisted of both fertile and infertile women. Sixty-four women were included to the study. HCT was assessed by the observation of the transport of highly concentrated methylene blue from uterine cavity to tubal ostia. The results of HCT were compared with the results of LCT as a gold standard. The accuracy of HCT, sensitivity, specificity, positive and negative predictive values in diagnosing tubal patency were calculated.
Results
The results of HCT and LCT were evaluated for right and left tubes, separately. One hundred and twenty-eight tubes were determined. Sensitivity, specificity, positive and negative predictive values for HCT were; 85.85%, 59.09%, 91% and 46.43%, respectively.
Conclusion
This study’s result showed that HCT had high sensitivity and moderate specificity values in the assessment of tubal patency. HCT during office hysteroscopy could give the chance to practitioners to assess tubal patency without subjecting the patient to multiple procedures. </p
... In this context, studies on hysteroscopic methods are concentrated because they can simultaneously provide treatment in case of detection of pathological conditions of the uterine cavity. Undoubtedly, the most important reasons are that they are less invasive and less cost-effective [9][10][11]. In this study, we aimed to compare the traditionally applied hysterosalpingography in the evaluation of infertile couples and office hysteroscopy, which we think may be superior in many ways. ...
... All hysterosalpingographic and hysteroscopic procedures were performed by the same physician. While planning the methodology of the study, a detailed literature search was conducted and an evaluation procedure suitable for our study was determined [10,12]. Both processes were performed during the late proliferative phase (10th day of menstruation). ...
Background: The main goal of this study was to prove that hysteroscopy is a superior method compared to hysterosalpingography in the evaluation of tubal passage and the uterine cavity in infertile women. Methods: The study was carried out on 30 volunteer women for whom evaluation of the uterine cavity and transit through the tubules was required due to infertility. In the evaluation of the hysteroscopic tubal passage, a 6Fr feeding cannula was advanced from the hysteroscope barrel, and firstly methylene blue and then an air bubble were applied to the fluid-filled uterine cavity through this flexible cannula. Results: When the reference method was taken as hysterosalpingography, the specificity of hysteroscopy was found to be 85.71% (95% CI (confidence interval): 42.13%–99.64%), sensitivity 94.74% (95% CI: 85.38–98.90%). The positive predictive value of hysteroscopy was calculated as 98.18% (95% CI: 89.78%–99.70%) and the negative predictive value was 66.67% (95% CI: 38.96%–86.24%). Observing the bubble and swirl effect together in the evaluation of the tube opening increases the diagnostic accuracy. And benefit of hysteroscopy in the evaluation of tubal passage was statistically significantly higher than hysterosalpingography. Conclusion: Considering the cellular damages that can be caused by hysterosalpingraphy and the real observation power provided by hysteroscopy, simultaneous evaluation and the comfort of making intervention possible, hysteroscopy will be a more useful and useful application.
... Various studies have found the role of diagnostic hysteroscopy in the assessment of tubal patency. Hysteroscopic tubal patency assessment can be done by various techniques such as determination of shift in culde sac volume pre hysteroscopy to posthysteroscopy by ultrasonography, [24,25] Parryscope method using air infusion at time of hysteroscopy which generates air bubbling effect confirming tubal patency, [25,26] selective tubal perturbation [27,28] and visualizable flow effect of hysteroscopic fluid at level of tubal ostia. [29] Torok and Major in 2012 showed that OH-guided selective chromopertubation is an effective highly reproducible technique compared to conventional laparoscopy. ...
... [29] Ott et al. compared the assessment of tubal patency at diagnostic hysteroscopy and laparoscopic chromopertubation and found that hysteroscopic flow through ostia is a reliable marker of tubal patency. Flow of air bubbles or saline toward ostium Table 5. [24][25][26][27][28][29][30][31] Direct observation of ostia and high intrauterine pressures during hysteroscopy minimizes the false-positive results secondary to spasm as compared to HSG. Promberger et al. also found that if tubes come into contact with cool saline, especially before laparoscopic chromopertubation, ostia may go into spasm leading to higher tubal occlusion rate during chromopertubation, and hence, a higher false-positive hysteroscopic flow rate. ...
Objectives: Tubal factor is the leading cause of female infertility. Diagnostic hysterolaparoscopy with chromopertubation plays a pivotal role in its evaluation. Office hysteroscopy (OH) has gained popularity as the outpatient procedure for diagnostic purposes. OH being a less invasive approach, the current study was undertaken to compare the accuracy of assessment of tubal patency with chromopertubation at OH with modified minilaparoscopy in infertile patients.
Materials and Methods: The present study was a pilot study conducted from March 2017 to August 2018. Eighty patients were recruited. OH was done without anesthesia. Diluted methylene blue dye was injected. The eddy current of blue dye, “Visualizable flow” at ostium, and disappearance of blue dye from the uterine cavity through ostium was documented as evidence of patent tubal ostium. In case of tubal occlusion, uterine cavity became blue due to backflow of dye. After OH, minilaparoscopy with chromopertubation was performed under general anesthesia. Both tubes were assessed separately for tubal patency.
Results: All patients underwent OH followed by minilaparoscopy in the same sitting. OH was 87.5% sensitive with positive predictive value of 95.2%. Compared to minilaparoscopy, OH is 85.6% accurate in predicting tubal patency. The area under receiver operating curve was 0.96 (SE is 0.15 with 95% confidence interval of 0.93–0.99, P < 0.001). It implies that, OH should correctly identify all laparoscopic cases with probability of 0.96.
Conclusion: OH chromopertubation can be used as an alternative to laparoscopy for assessing tubal patency with added advantages of lack of requirement of anesthesia, minimal cost, and better patient acceptance. Moreover, the procedure is less time-consuming and less invasive with high sensitivity and moderate specificity.
... Of these 59 patients, after successfully contacting 21 patients by phone, information regarding age at appendectomy was available in 54 cases. The median age at the time of surgery was 16 (IQR [11][12][13][14][15][16][17][18][19][20][21] years, and about two-thirds of the patients (34, 60.7%) were under the age Information on the type of appendicitis (simple/complex), operative technique, and complications was available from 20 patients. Perforated or complex appendicitis was noted in 8 (40%) of these patients. ...
... Laparoscopic chromopertubation is generally considered the gold standard to evaluate for tubal patency against all other methods are compared. 11,12 We have been performing a standard technique for Ͼ2 decades on women with infertility with extremely low morbidity and excellent predictive value. Although more invasive than radiographic or sonographic hysterosalpingography, its advantages are that it requires no ionizing radiation and that, in selected cases, tubal patency can be reestablished intraoperatively. ...
Background and Objectives
The aim of the study was to investigate a potential association between previous childhood appendectomy, tube pathology, and female infertility.
Methods
We reviewed patients seeking care at the fertility clinic of our university medical center between 2006 and 2016. The history of previous appendectomy was extracted from hospital documentation and by telephone follow-up. Tubal patency was assessed by diagnostic laparoscopy and chromopertubation.
Results
In our study cohort (N = 237), 24.9% (n = 59) had a history of previous appendectomy. Previous appendectomy, therefore, was about 3-fold more prevalent in women seeking fertility treatment than in the general population. Patients with previous appendectomy had more intra-abdominal adhesions (P < .001) and patients with adhesions tended to have compromised tubal patency (P = .05). However, there was no direct correlation between a previous appendectomy and tube pathology (P = .727).
Conclusion
Because previous appendectomy was associated with intra-abdominal adhesions, and these were in turn associated with tube pathology, but appendectomy was not directly associated with compromised tubal patency, previous appendectomy may indirectly affect female fertility through mechanisms other than direct tubal obstruction. This is one of the largest study analyzing laparoscopic chromopertubation in association with previous childhood appendectomy.
... 9 Fallopian tube morphological abnormalities can be seen immediately during laparoscopy, which is considered the perfect standard for diagnosing tubal disease and other intra-abdominal reasons of infertility. 10 Diagnostic laparoscopic has emerged as the ideal technique in many clinics' infertility workups, functioning as the last step before recommending a partner for infertility treatment. 11 Surgical treatment is possible with diagnostic laparoscopic, but it also puts the patient at risk for operational and anaesthetic complications. ...
... e detection accuracy of MR-HSG was significantly higher than that of MRI. Compared with the routine examination of obstetrics and gynecology, MRI greatly reduces radiation damage [14] and can accurately display the internal organs and surrounding tissue structure of the pelvic cavity [15,16], thus showing significant advantages in the differential diagnosis of some reproductive system diseases. MR-HSG combines MRI technology with the gynecological examination, which greatly reduces radiation damage and greatly improves the accuracy of detection results [17]. ...
To explore the diagnostic value of MRI image features based on convolutional neural network for tubal unobstructed infertility, 30 infertile female patients were first selected as the research objects, who admitted to the hospital from May 2018 to January 2020. They all underwent routine MRI examinations and CNN-based MR-hysteron-salpingography (HSG) examinations, in order to discuss the diagnostic accuracy of the two examinations. In the research, it was necessary to observe the patients’ imaging results, calculate the diagnosis rate of the two examination results, and analyze the application effect of the CNN algorithm, thereby selecting the best reconstruction method. In this study, the analysis was conducted on the basis of no statistical difference in the baseline data of the included patients. The results of undersampling reconstruction at 2-fold, 4-fold, and 6-fold showed that CNN for data consistency layer (CNN_DC) had a better effect, and its peak signal-to-noise ratio (PSNR) was lower sharply than that of the other two reconstruction methods, while the normalized mean square error (NMSE) and structural similarity index measure (SSIM) were higher markedly than the values of the other two reconstruction methods. The diagnostic rate of routine MRI examination of the fallopian tube and other parts of the uterus was lower than or equal to that of MR-HSG examination by CNN. Routine MRI examinations of fallopian tube imaging artifacts were large, and the definition was reduced, which increased the difficulty of identification. However, MR-HSG examination by CNN indicated that the imaging artifacts were low, the clarity was high, and the influence of noise was small, which was conducive to clinical diagnosis and identification. For endometriosis, the accuracy of MR-HSG was 33.33% and the accuracy of MRI was 46.67%. CNN MR-HSG inspection method was significantly better than the conventional MRI inspection method P
... However, assessments of accuracy may have been hindered by the authors not using the gold standard of laparoscopy for a true determination of patency. When later reports compared sonographic fluid shifts to laparoscopic chromopertubation, a higher degree of sensitivity was observed in two reports with 94% (Habibaj et al.) [15] and 92% (Parry et al.) [9]. These findings are similar to our results, which also relied on laparoscopic controls. ...
Purpose
To determine whether an increase in cul de sac (CDS) fluid after hysteroscopy is predictive of tubal patency.
Methods
In a prospective clinical cohort study, 115 subfertile women undergoing laparoscopic and hysteroscopic surgery at the Medical University of Vienna were invited to participate. The primary outcome was determining whether an increase in fluid in the pouch of Douglas was reflective of unilateral or bilateral tubal patency. Vaginal sonography before and after hysteroscopy was performed to detect fluid in the pouch of Douglas, directly followed by laparoscopy with chromopertubation.
Results
Laparoscopic chromopertubation revealed bilateral Fallopian tube occlusion in 28 women (24.3%). Twenty-seven/40 patients (67.5%) with no fluid shift had bilateral occlusion during the consecutive laparoscopy ( p < 0.001). One/75 patients (1.3%) showing a fluid shift had bilateral occlusion (sensitivity of a present fluid shift for uni- or bilateral patency 85.1%, 95% CI: 81.7–99.9, specificity: 96.4%, 95% CI: 75.8–91.8). Intracavitary abnormalities (odds ratio, OR, 0.038; p = 0.030) and adhesions covering one or both tubes (OR 0.076; p = 0.041) increased the risk for a false abnormal result, i.e., uni- or bilateral tubal patency despite the lack of a fluid shift.
Conclusion
When CDS fluid does not change after hysteroscopy, this is a sensitive test for tubal occlusion and further testing may be warranted. However, if there is an increase in CDS fluid after hysteroscopy, particularly for a patient without fluid present prior, this is both sensitive and specific for unilateral or bilateral tubal patency.
... This additional information might be of high relevance because tubal factors have been estimated to account for about 14% of all cases of female subfertility [6]. Various methods for hysteroscopic tubal patency assessment have been reported including selective fallopian tube pertubation [3,7]; pre-to posthysteroscopy shifts in cul-de-sac volume detected by ultrasound [8,9]; the Parryscope technique, which uses air infusion during hysteroscopy to produce an air bubbling effect for confirmation of tubal patency [9,10]; and direct visualization of a "flow" effect of hysteroscopic fluid at the tubal ostia [11]. ...
Study objective:
To evaluate whether the presence of a visualizable "flow" effect in the fallopian tube ostia in hysteroscopy was predictive of tubal patency.
Design:
A prospective cohort study.
Setting:
In a prospective study, infertile women who underwent surgery because of infertility between March and November 2018 were included. The main outcome parameter was fallopian tube patency assessed by laparoscopic chromopertubation. The predictive parameter tested was the presence of hysteroscopic tube flow.
Patients:
Seventy-two infertile women.
Interventions:
Combined hysteroscopy and laparoscopy with chromopertubation.
Results:
One-hundred forty-four fallopian tubes were evaluated, with 88 (61.1%) patent tubes at laparoscopic chromopertubation. A positive hysteroscopic flow effect was recorded for 94 (65.3%) ostia and was accurate in predicting patency (p < .001), with a sensitivity of 85.3% (95% confidence interval [CI], 76.1-91.9) and a specificity of 66.1% (95% CI, 52.2-78.2). A multivariate binary regression model revealed that the presence of a hydrosalpinx (odds ratio = 8.216; 95% CI, 1.062-63.574; p = .044) and peritubal adhesions (odds ratio = 3.439; 95% CI, 1.142-10.353; p = .028) were associated with a false-normal flow result. A hazy hysteroscopic picture was found in 15 of 21 (71.4%) and 5 of 51 (9.8%) cases with and without bilateral tubal occlusion, respectively (p < .001, sensitivity = 71.4% [95% CI, 47.8-88.7], specificity = 90.2% [95% CI, 78.6-96.7]).
Conclusions:
The presence of hysteroscopic tubal flow was a reliable indicator of tubal patency. A hydrosalpinx or peritubal adhesions increase the risk for a false-normal result. A hazy hysteroscopic picture suggests bilateral tubal occlusion. Using the hysteroscopic flow effect, one can provide additional information for the patient.
... Hysteroscopic examination and intervention-polypectomy are done during the first phase of the menstrual cycle (9). During hysteroscopy, the uterine cavity is viewed at a 30-degree angle, which allows for visualization of both mouths of the fallopian tube, fundus, anterior and posterior wall of the uterus as well as the lateral sides of the uterine cavity (10). At the height of the internal uterine mouth with the hysteroscope, a panoramic image of the uterine cavity is displayed, and the presence of any pathological findings, such as endometrial polyps (which are often observed), submucosal fibroids, septa, and adhesions, can be easily visualized. ...
Glycodelin (or placental protein 14) is a glycoprotein located in the glandular and thin epithelium of the endometrium. It is considered an important factor in the implantation process, and its traces can be found in elevated concentrations in the uterine flushing obtained at the time of implantation, while in the proliferative phase of the cycle, its levels are low. A certain concentration has been found to inhibit the binding of spermatozoids to the zona pellucida of the oocites therefore, it effects conception. It has a role in angiogenesis and is in high concentrations in the tissues of both benign and malignant gynaecological tumours.
The aim of this study is to analyse and display the glycodelin level changes before and after hysteroscopic polypectomy in infertile patients in the uterine flushing fluid and serum. This survey covers 80 infertile patients, who were divided into two groups. The first group, the experimental group, consisted of 50 infertile patients with endometrial polyps, and a control group of 30 infertile patients without endometrial polyps was also included.
The results primarily indicate the existence of changes in glycodelin levels preoperatively in the flushing and venous blood in infertile patients with endometrial polyps compared with the levels after surgery. In the control group of patients, no significant change in the glycodelin levels was detected in the flushing and venous blood. When comparing these two groups, statistically significant differences in the glycodelin levels in the flushing and venous blood were noted. We conclude that the presence of endometrial polyps in the cavum uteri affects the increase in the glycodelin concentration in the flushing fluid and in the plasma. Increased glycodelin concentrations complicate fertilization and implantation.
... In all 26 cases of unilateral or bilateral tubal patency confirmed by laparoscopy, fluid was observed in the pouch of Douglas after the procedure. Our experience suggests a two-step strategy, consisting of hysteroscopy plus ultrasound to increase chromopertubation sensitivity, followed by laparoscopy in the cases of hydrosalpinx caused by the procedure (Habibaj, Kosova, Bilali, Bilali, & Qama, 2012;Yildizhan, Dormusogluet, & Uygur, 2009). In addition, our results demonstrated excellent agreement with the gold standard (laparoscopy with dye) in 87.27% of the tubes, confirming the other studies in the literature (Szab o et al., 2010;T€ or€ ok & Major, 2012). ...
The aim of this study was to evaluate accuracy, tolerability and side effects of office hysteroscopic-guided chromoperturbations in infertile women without anaesthesia. Forty-nine infertile women underwent the procedure to evaluate tubal patency and the uterine cavity. Women with unilateral or bilateral tubal stenosis at hysteroscopy with chromoperturbation, and women with bilateral tubal patency who did not conceive during the period of six months, underwent laparoscopy with chromoperturbation. The results obtained from hysteroscopy and laparoscopy in the assessment of tubal patency were compared. Sensitivity, specificity, accuracy, positive-predictive value and negative-predictive value were used to describe diagnostic performance. Pain and tolerance were assessed during procedure using a visual analogue scale (VAS). Side effects or late complications and pregnancy rate were also recorded three and six months after the procedure. The specificity was 87.8% (95% CI: 73.80–95.90), sensitivity was 85.7% (95% CI 57.20–98.20), positive and negative predictive values were 70.6% (95% CI: 44.00–89) and 94.7% (95% CI: 82.30–99.40), respectively. Pregnancy rate (PR) within six months after performance of hysteroscopy with chromoperturbation was 27%. Office hysteroscopy-guided selective chromoperturbation in infertile patients is a valid technique to evaluate tubal patency and uterine cavity.
Aim: To report on the utilization of hysterosalpingo-foam sonography (HyFoSy) with hysteroscopic evaluation for selected patients undergoing Assisted Reproductive Technology Treatment (ART), whereby we aimed to assess the effectiveness of HyFoSy before hysteroscopy. Material and Method: This retrospective study included 36 infertile women referred to Baskent University’s Ankara Hospital Infertility Clinic in 2017-2019. HyFoSy was applied with hysteroscopy in one step for patients who had not previously been evaluated for tubal patency or who had to be re-evaluated. Results: Two patients were diagnosed with tubal obstruction by HyFoSy and were treated with hysteroscopic tubal catheterization, and tubal patency was obtained after this procedure. HyFoSy was applied in seven patients (19.49%) because their previous hysterosalpingography (HSG) reports were doubtful. Although previous HSG had shown tubal obstruction in three patients, the standard passage of the foam from the fallopian tubes to the abdominal cavity was observed when HyFoSy was applied. Conclusion: The one-step method that we apply in our clinic seems appropriate for both patients and clinicians because it speeds up the evaluation steps of the uterine cavity and fallopian tubes before the next ART attempt.
Objective
To determine feasibility and accuracy of post-hysteroscopic transvaginal ultrasonography (TVUS) measurement of pelvic fluid accumulation as a screening method for tubal patency (TP).
Methods
We conducted a retrospective cohort study of 85 patients who underwent uterine cavity assessment by office hysteroscopy at our university-affiliated fertility centre from November 2019 to October 2020. During the study period, two-dimensional (2D) TVUS was performed pre- and post-hysteroscopy to evaluate TP. Patient records were reviewed for demographics, diagnosis, and prior/subsequent TP testing. Predictive values for TP were calculated.
Results
Pelvic fluid accumulation post-hysteroscopy was found in 65.9% of patients (56). Accumulation of fluid was seen with the use of as little as 10–50 mL of saline. Using more fluid did not increase the likelihood of demonstrating TP (P = 0.17). A trend towards more false-negative results for TP was observed when less fluid was used (7.7% with 10–50 mL vs. 3.8% with 60–190 mL and 1.3% with 200–760 mL; P = 0.10). The positive predictive value (PPV) of TVUS post-hysteroscopy in comparison to known patency/occlusion was 100%; negative predictive value (NPV) was 33%; sensitivity was 82.8%; and specificity was 100%. Similar values were seen in a second analysis that included patients with highly suspected patent or occluded tubes (n = 60); presumed predictive values were: PPV 100%, NPV 42%, sensitivity 78.8%, and specificity 100%. The use of more fluid did not increase pain (P = 0.75). This finding remains after accounting for confounders (e.g., pre-medication, endometrial biopsy).
Conclusion
TVUS pre- and post-hysteroscopy is feasible in an outpatient setting, and can serve as a reliable screening tool for TP. When hysteroscopy is performed and TP is not known, TVUS can be added for screening, potentially omitting the need for more invasive examinations. With limited non-urgent ambulatory services, it is of upmost importance to maximize information from a single procedure.
Objective: The aim of this study was to investigate the diagnostic value of transvaginal sonography (TVS) performed after office hysteroscopy, for assessing tubal patency in subfertile women, and to compare the findings with those obtained with laparoscopic chromopertubation. Study design: This was a cross-sectional study. Patients and methods: TVS was first performed for 60 subfertile women to exclude the presence of free fluid in the pouch of Douglas. Office hysteroscopy was then performed in the outpatient clinic with saline distension medium using 80-100 mmHg pressure, followed by TVS again within 20 min to detect the presence of free fluid in the pouch of Douglas. Laparoscopy with tubal chromopertubation was performed within 1 week for all cases. The results of TVS and laparoscopic chromopertubation were compared. Results: The presence of free fluid in the pouch of Douglas after hysteroscopy was correlated to the presence of, at least, one patent tube through laparoscopic chromopertubation; there was a significant statistical difference (P<0.001). The test also revealed a sensitivity of 71.2%, a specificity of 100.0%, a positive predictive value of 100.0%, and a negative predictive value of 34.8%. Conclusion: The combination of hysteroscopy and TVS in detecting, at least, one patent tube is a good outpatient method for detecting tubal patency. Nevertheless, it cannot ensure bilateral tubal blockage in case of negative test; hence, another method of tubal patency assessment should be offered.
Background and Aim: In this article, we describe an easy and cost-efficient technique to improve the applicability of blue dye for chromopertubation using a pediatric transurethral catheter.
We evaluated our technique at a University Hospital with 21 patients aged between 19 and 39 years with primary and secondary infertility, undergoing laparoscopical chromopertubation of the fallopian tubes using a transurethral Foley catheter.
Our results show an easy and quick performance and distribution of a cost-efficient method.
Using a transurethral catheter is a time-efficient, easy-to-handle, cheap and effective method for chromopertubation.
Specialist infertility practice was studied in a group of 708 couples within a population of residents of a single health district in England. They represented an annual incidence of 1.2 couples for every 1000 of the population. At least one in six couples needed specialist help at some time in their lives because of an average of infertility of 21/2 years, 71% of whom were trying for their first baby. Those attending gynaecology clinics made up 10% of new and 22% of all attendances. Failure of ovulation (amenorrhoea or oligomenorrhoea) occurred in 21% of cases and was successfully treated (two year conception rates of 96% and 78%). Tubal damage (14%) had a poor outlook (19%) despite surgery. Endometriosis accounted for infertility in 6%, although seldom because of tubal damage, cervical mucus defects or dysfunction in 3%, and coital failure in up to 6%. Sperm defects or dysfunction were the commonest defined cause of infertility (24%) and led to a poor chance of pregnancy (0-27%) without donor insemination. Obstructive azoospermia or primary spermatogenic failure was uncommon (2%) and hormonal causes of male infertility rare. Infertility was unexplained in 28% and the chance of pregnancy (overall 72%) was mainly determined by duration of infertility. In vitro fertilisation could benefit 80% of cases of tubal damage and 25% of unexplained infertility--that is, 18% of all cases, representing up to 216 new cases each year per million of the total population.
Diagnostic laparoscopy is normally the standard procedure performed as the final test in the infertility work up before progressing
to infertility treatment. Recently, there has been a growing tendency to bypass diagnostic laparoscopy after a normal hysterosalpingogram
and instead to start direct infertility treatment [intrauterine insemination (IUI) or IVF] for indications such as unexplained
infertility, male subfertility and cervical hostility. In our clinic, laparoscopy revealed abnormalities that resulted in
changed treatment decisions in 25% of the patients who would normally have been scheduled for IUI if laparoscopy had not been
performed. The changed treatments mainly concerned surgery for minimal/mild endometriosis and periadnexal adhesions, both
performed during the diagnostic laparoscopy. Because the effect of such interventions on the success rate of IUI has never
been described, it still remains unclear whether laparoscopy is usefully performed in these cases. Therefore, further prospective
studies should be performed to assess whether delaying, or bypassing entirely, diagnostic laparoscopy is more cost effective
and if laparoscopic interventions for intra‐abdominal abnormalities are effective in terms of higher pregnancy rates after
treatment with IUI.
Diagnostic hysteroscopy is not widely performed in the office setting, one of the reasons being the discomfort produced by the procedure. This randomized controlled trial was performed to evaluate the effects of instrument diameter, patient parity and surgeon experience on the pain suffered and success rate of the procedure.
Patients were randomly assigned to undergo office diagnostic hysteroscopy either with 5.0 mm conventional instruments (n=240) or with 3.5 mm mini-instruments (n=240). Procedures were stratified according to patient parity and surgeon's previous experience. The pain experienced during the procedure (0-10), the quality of visualization of the uterine cavity (0-3) and the complications were recorded. The examination was considered successful when the pain score was <4, visualization score was >1 and no complication occurred.
Less pain, better visualization and higher success rates were observed with mini-hysteroscopy (P <0.0001, P <0.0001 and P <0.0001, respectively), in patients with vaginal deliveries (P <0.0001, P <0.0001 and P <0.0001, respectively) and in procedures performed by experienced surgeons (P=0.02, P=NS and P=NS, respectively). The effects of patient parity and surgeon experience were no longer important when mini-hysteroscopy was used.
Our data demonstrate the advantages of mini-hysteroscopy and the importance of patient parity and surgeon experience, suggesting that mini-hysteroscopy should always be used, especially for inexperienced surgeons and when difficult access to the uterine cavity is anticipated. They indicate that mini-hysteroscopy can be offered as a first line office diagnostic procedure.
The aim of the study was to evaluate if the diagnosis and treatment of uterine cavity abnormalities by hysteroscopy in patients undergoing IVF programme is of any value in improving clinical pregnancy outcome.
520 patients participated in this prospective randomized study and were classified into two groups. Group I (n = 265) without office hysteroscopy. Group II (n = 255) had office hysteroscopy and was sub classified into Group II a and Group II b. Group II a (n = 160) had normal hysteroscopic findings whereas Group II b (n = 95) had abnormal office hysteroscopy findings, which were corrected at the same time.
There was no difference in the mean number of oocytes retrieved, fertilization rate, and number of embryos transferred among the patients in different groups. Statistically significant difference was observed in terms of clinical pregnancy rates between Group I and Group II a (26.2 and 44.44%, P < 0.05), and Group I and Group II b (26.2 and 39.55%, P < 0.05), respectively.
Patients with recurrent IVF embryo transfer failures after normal hysterosalpingography findings should also be reevaluated using hysteroscopy prior to further commencing IVF-embryo transfer cycles in order to enhance the clinical pregnancy rates.
A randomized, controlled study was performed to compare vaginoscopic versus traditional (speculum with or without tenaculum) hysteroscopy in terms of pain score and procedure time.
Three hundred patients were randomized in two groups: Group A, diagnostic hysteroscopy with vaginoscopic approach (150 patients) and Group B, diagnostic hysteroscopy with traditional approach (150 patients). All procedures were performed using a semi-rigid 3.5-mm minihysteroscope with a 0 degrees grade optic. Patients of each group were divided into three subgroups according to their reproductive status: fertile nulliparous (FN), fertile multiparous (FM) and post-menopausal (MEN) women. Women were asked to rate their degree of pain during four phases of the procedure: introduction of hysteroscope (Group A) or speculum (Group B) into the vagina (Phase I) and progression through cervical canal up to internal uterine orifice (IUO) (Phase II), inspection of uterine cavity (Phase III) and performing of endometrial biopsy (Phase IV). A total pain score was calculated for each group. For each patient, the duration of hysteroscopy was recorded from the introduction to the extraction of the scope (Group A) or of the speculum (Group B).
Although the median total pain scores were 2 in each group, the 95% confidence interval for vaginoscopic hysteroscopy (1.86-2.01) was significantly (P < 0.05) lower than that for traditional hysteroscopy (2.10-2.26). Comparison between the corresponding phases of the procedure showed the only significant difference during Phase I of the procedure [Group A: 1 (95% CI 1.0-1.18) versus Group B: 2 (95% CI 2.3-2.8); P < 0.05]. No significant differences in terms of duration of the procedure were observed between the two approaches.
When surgeons using vaginoscopic hysteroscopy with a semi-rigid minihysteroscope were compared with those using traditional approach and the same instrumentation, the operating times and the patients' pain scores were similar.
Diagnostic hysteroscopy has not yet been generally accepted as a well-tolerated office procedure. The aim of our study was to verify compliance, side-effects and haemodynamic variations when a mini-hysteroscope is used.
A prospective randomized trial on office hysteroscopy was performed by comparing the use of a traditional 5 mm hysteroscope (group A) and of a 3.3 mm mini-hysteroscope (group B). Two patient groups (A and B), each comprising 100 cases, were formed on the basis of a randomized computer-generated list.
A marked reduction in the mean (+/- SD) pelvic pain score during office hysteroscopy was seen in group B (2.3 +/- 2.1) as compared with group A (4.6 +/- 2.2) (P < 0.0001, Mann-Whitney test). This result was also confirmed when using an alternative approach: four classes of pelvic pain at the visual analogue score (VAS). A significant reduction was observed in the incidence of moderate and severe pelvic pain in group B at the end of the examination (P = 0.001) and 5-10 min later (P < 0.05).
The use of mini-hysteroscopes (3.3 mm with diagnostic sheath) lowers considerably the level of pelvic pain the patients feel: it is halved in comparison with traditional calibre hysteroscopes (2.3 +/- 2.1, on a 0-10 VAS). Furthermore the outpatient hysteroscopy failure rate is less than half (2%) with the mini-hysteroscope compared with the traditional 5 mm hysteroscope (5%). As for side-effects and haemodynamic parameters, no differences were observed except for an increase (P < 0.05) in bradycardia in group B. The advantage of this technique is self-evident, if the patients' compliance is taken into account: in many cases the introduction or withdrawal of the vaginal speculum was reported as the greatest discomfort.
Office hysteroscopy is an excellent method of identifying and treating intracavitary uterine lesions. It has become easy to learn and perform; as an aid of modern technological applications, it is safe, accurate, provides immediate results under direct visualisation, and offers the additional benefit of histological confirmation and the discomfort of patients is minimal. We applied an extended literature search to explore the special features and details of the technique itself, as it evolved since it first appeared 30 years back. Our initial goal was to examine potential changes/improvements of the modality, in terms of the instrumentation used and the technique itself, the indications of use, its incorporation in daily practice, and patients' and clinicians' acceptability.
To evaluate the effectiveness of hysteroscopy as a method for the diagnosis of tubal patency using saline distention media.
In this prospective study, 62 women between 21 and 38 years with a history of at least 1 year of infertility who underwent hysteroscopy and hysterosalpingography (HSG) on two consecutive cycles were studied. Transvaginal ultrasonography carried out before and after hysteroscopy in order to measure the abdominal fluid (in ml) in the peritoneal cavity of the cul-de-sac. The difference between the two results was calculated. A next cycle HSG was performed and patients were divided into three groups according to whether there was no tubal occlusion (group 1), a unilateral occlusion (group 2) or a bilateral occlusion (group 3): Peritoneal fluid measurements were compared among the three groups. Finally, pain and discomfort were recorded at the end of the process.
According to the HSG, 34 women were in group 1, 13 in group 2 and 9 in group 3. Peritoneal fluid measurements were 6.88 +/- 2.7 ml in group 1, 4.21 +/- 0.9 ml in group 2 and 1.08 +/- 0.7 ml in group 3. Statistical differences were found between groups 1 and 3 and between groups 2 and 3 (P < 0.05). All of the patients reported significantly less pain during hysteroscopy in response to HSG.
Using saline distension media during hysteroscopic evaluation was effective to allow measurement of the accumulating fluid in the peritoneal cavity and to confirm at least one patent tube with minimal pain.
To assess the value of hysterosalpingography (HSG) in diagnosing tubal patency and peritubal adhesions using laparoscopy with chromopertubation as the gold standard.
Meta-analysis of 20 studies comparing HSG and laparoscopy for tubal patency and peritubal adhesions.
Four thousand one hundred seventy-nine patients with infertility in 20 studies.
Hysterosalpingography and diagnostic laparoscopy as part of infertility workup.
Tubal patency and peritubal adhesions.
For tubal patency the reported sensitivity and specificity differed between studies. In a subset of studies that evaluated HSG and laparoscopy independently, a point estimate of 0.65 for sensitivity and 0.83 for specificity was calculated. For peritubal adhesions a summary receiver operating characteristic curve could be estimated.
Although HSG is of limited use for detecting tubal patency because of its low sensitivity, its high specificity makes it a useful test for ruling in tubal obstruction. For the evaluation of peritubal adhesions HSG is not reliable.
We developed a new approach to diagnostic hysteroscopy that reduces patient discomfort and increases the possible applications of hysteroscopy. Between February 1992 and March 1996, 1200 hysteroscopies were performed at our institution. Of these, the last 680 were done using the vaginoscopic approach without preselection. Discomfort was reduced in all patients, including those with moderate stenosis of the internal cervical os. Vaginoscopy is easy to perform and incurs no additional cost for the patient. It is ideal for office hysteroscopy and in patients who otherwise might require general anesthesia, such as virgins and older women with somewhat stenotic vaginas.
To verify the reliability of transvaginal ultrasonography in diagnosing intrauterine disease and in evaluating the operability of submucous myomas and to determine the feasibility, acceptability and validity of hysteroscopy for menorrhagia, we performed a prospective 5 year study on 793 women of mean age +/- SD of 41.5 +/- 7.8 years. All the patients referred for excessive menstrual bleeding with uterine volume <12 week pregnancy who underwent complete physical examination, transvaginal ultrasonography and outpatient hysteroscopy with endometrial biopsy were included in the study. Outpatient hysteroscopy was not completed due to intolerance or was unsatisfactory due to excessive bleeding in 23 cases (2.9%). Only 28 women (3.5%) declared they would have refused the procedure had they imagined the pain involved. One case of pelvic infection was observed. Compared with hysteroscopy, transvaginal ultrasonography had 96% sensitivity, 86% specificity, 91% positive predictive value and 94% negative predictive value in the diagnosis of intrauterine abnormality. The sensitivity, specificity, positive and negative predictive values of ultrasonography in identifying submucous myomas operable hysteroscopically (intramural extension <50%) were respectively 80, 69, 83 and 65% with a k index of agreement between ultrasonography and hysteroscopy of 0.48. Thus, considering the good specificity and high negative predictive value, transvaginal ultrasonography may be suggested as the initial investigation in menorrhagic patients, limiting hysteroscopy to cases with positive or doubtful sonographic findings.
In patients with endometrial carcinoma, the use of hysteroscopy may result in malignant peritoneal cytology. The significance of these mechanically disseminated malignant cells is uncertain.
Disseminated endometrial carcinoma occurred in a 39-year-old patient with endometrial carcinoma which had been hysteroscopically resected and treated conservatively. Hysteroscopic dissemination was strongly suggested based on the limited extent of carcinoma in the uterus, the exophytic nature of the pelvic tumor implant, and the lack of associated endometriosis.
Hysteroscopy should be reserved for patients in whom prior endometrial sampling fails to demonstrate malignancy.
To determine the prevalence of reproductive pathology in a group of infertile women thought to be at low risk for altered pelvic anatomy.
Retrospective chart review and follow-up (Canadian Task Force classification II-2).
Academic-affiliated, private reproductive endocrinology practice.
One hundred infertile women.
Diagnostic and/or therapeutic laparoscopy.
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.
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.
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.
Prospective, randomized, investigator-blind study.
Tertiary infertility clinic.
Forty-six consecutive infertile women.
Outpatient HSG, OHS, and SIS, followed by operative hysteroscopy (HS).
Uterine abnormalities, procedure length, and subjective pain.
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.
OHS, SIS, and HSG were statistically equivalent regarding evaluation of uterine cavity pathology in infertile women.
At present, several of the elements in widespread use in basic infertility testing are in dispute, marked variability exists
in the work-up among specialists, and practice patterns are influenced both by modern assisted reproductive technologies (ART)
and the increasing age of couples seeking help for infertility. This article is intended to stimulate the debate on a possible
(lack of) usefulness of conventional methods of infertility evaluation in relation to both the modern techniques of assisted
reproduction and the woman's age.
To compare the acceptance and tolerability of the mini-pan-endoscopic approach (transvaginal hydrolaparoscopy [THL] combined with minihysteroscopy) versus hysterosalpingography (HSG) for evaluating tubal patency and the uterine cavity in an outpatient infertility investigation.
Randomized controlled study.
University hospital.
Twenty-three infertile patients without obvious pelvic pathology.
Women were randomly divided into two groups. One group underwent minihysteroscopy and THL with tube chromoperturbation as first investigation and HSG within the following 7 days, while in the other group the investigation sequence was inverted. Women reported pain experienced before and at the end of procedures.
Mean duration of procedures, level of pain experienced, diagnostic agreement about tubal patency and uterine cavity normality.
THL and minihysteroscopy took significantly more time but was significantly less painful than HSG. Regarding tubal patency, in 95.5% of cases THL agreed with HSG. In one case, HSG diagnosed a bilateral obstruction of tubes, whereas at THL a bilateral spreading of methylene blue was seen. Agreement on intrauterine pathologies between minihysteroscopy and HSG was poor (43%); the number of intrauterine abnormalities found at hysteroscopy was significantly greater than at HSG.
THL in association with minihysteroscopy provided more information and was better tolerated than HSG in an outpatient infertility investigation.
The investigation for potential tubal disease is an essential step in the work-up of infertility. This review article provides an evidence-based overview of the diagnosis and management of tubal factor infertility.
While laparoscopic chromopertubation remains the gold standard in the diagnosis of tubal disease and hysterosalpingography is still widely used, newer modalities offer some advantages. Sonohysterography with the use of contrast medium is superior to hysterosalpingography and comparable to laparoscopic chromotubation in diagnosing tubal blockage. Chlamydia serology is the most cost-effective and least invasive diagnostic test for tubal disease, and it is comparable to, if not better than, hysterosalpingography. Depending on the nature and degree of tubal dysfunction as well as the age and ovarian reserve of the patient, various treatments for tubal infertility are available. For proximal tubal obstruction, transcervical tubal cannulation with tubal flushing is a reasonable first approach. Surgical techniques for tubal repair, such as salpingostomy or fimbrioplasty for distal tubal obstruction, can provide good results. Still, tubal factor remains a major indication for in-vitro fertilization and embryo transfer, which bypasses the tubal problem altogether. In certain situations, such as the presence of hydrosalpinx, prophylactic surgery can be used in conjunction with in-vitro fertilization and embryo transfer.
As with infertility in general, the diagnosis and management of tubal infertility should be tailored to the individual patient. Future studies should help to further clarify the role of the various diagnostic tests and therapeutic approaches for tubal infertility.
The purpose of this study was to evaluate the diagnostic accuracy of hysterosalpingography (HSG) in comparison with hysteroscopy in the detection of intrauterine abnormality in infertile patients.
Seventy-eight patients being investigated for infertility and undergoing HSG and hysteroscopy were studied retrospectively. Radiologic findings on HSG, including single or multiple filling defects and uterine wall irregularities, were evaluated and compared with hysteroscopic findings, which were considered the reference standard.
HSG showed a sensitivity of 81.2% compared with that of hysteroscopy and a specificity of 80.4%, with a positive predictive value of 63.4% and a negative predictive value of 83.7%. HSG also had a false-negative rate of 90% and a false-positive rate of 21.8%. Overall agreement between the two procedures was 73%.
HSG is still a useful screening test for the evaluation of the uterine cavity in the study of primary or secondary infertility. In addition, HSG provides information concerning the assessment of tubal morphology and patency. We believe that these two procedures are complementary in the evaluation of the uterine cavity.
To evaluate and compare the diagnostic value of hysterosalpingography (HSG) and laparoscopic chromopertubation (LCP), in the diagnosis of fallopian tube patency.
A comparative prospective study.
The infertility clinic of the Department of Obstetrics and Gynaecology, Ga-Rankuwa hospital (Medical University of Southern Africa), Pretoria, South Africa.
Fifty patients were initially diagnosed with either unilateral or bilateral tubal block using HSG. Six to eight weeks later the same women were subjected to LCP to assess tubal patency.
Diagnostic accuracy of HSG to establish tubal patency, site of occlusion and the presence of other pathologies was compared with results obtained after laparoscopic chromopertubation (LCP).
Hysterosalpingography diagnosed bilateral proximal, bilateral distal and mixed (i.e. one side proximal and the other distal) tubal occlusion in 15(40.5%); 13(35.1%) and five (13.5%) cases respectively. Diagnostic laparoscopy confirmed the above sites of occlusion in nine (24.3%), 71(45.9%) and three (8.1%) cases. Laparoscopy detected bilateral tubal patience in three (8.1%) patients, in whom HSG had diagnosed tubal occlusion. USG was able to detect peritubal Adhesion in only four (10.8%) patients as compared with 11 patients when LCP procedure was used. In comparison with HCP, hysterosalpingography demonstrated 70% specificity for accurately diagnosing proximal tubal occlusion.
On a comparative scale, HSG demonstrated reduced positive predictive value especially for bilateral proximal tubal occlusion. However, in spite of its relatively limited value for accurately identifying tubal patency, HSG should still serve as a useful primary investigation.
Hysterolaparoscopy is the gold-standard procedure for mechanical evaluation of the female pelvic organs. However, it is invasive and potentially life-threatening. The purpose of the present study was to assess the value of an alternative, minimally invasive technique.
All consenting women who reached the stage of mechanical evaluation in their infertility work-up were invited to participate in the study. All underwent diagnostic hysteroscopy followed by hysterosalpingo contrast sonography (HyCoSy) performed in a single session on an outpatient basis. Patient clinical data were collected prospectively.
Twenty women participated in the study, 6 with primary infertility and 14 with secondary infertility. All procedures yielded satisfactory evaluation of the uterine cavity and uterine and ovarian structures, fallopian tube patency, and relationship between the fallopian tube fimbrial edges and the ovaries. All patients were discharged within 2 h; there were no complications during or after the procedure.
The combination of hysteroscopy and hysterosalpingo contrast sonography (HyCoSy) can provide a comprehensive, functional and relatively non-invasive evaluation of the female pelvic organs.
1) To investigate the relationship between operator experience and the success of outpatient hysteroscopy; and 2) to determine if the introduction of normal saline and the use of narrow-caliber hysteroscopes and vaginoscopic approach are associated with a lower failure rate.
Retrospective study.
Teaching-hospital based outpatient hysteroscopy clinic.
Five thousand consecutive women undergoing outpatient hysteroscopy between October 1988 and June 2003.
The hysteroscopies were carried out both by experienced operators and by trainees. Procedures were performed using 4-mm and 2.9-mm telescopes with 5-mm and 3.5-mm diagnostic sheaths, respectively. Between October 1988 and 1996, the uterine cavity was distended with CO(2) (CO(2) period), whereas normal saline was preferred after 1997 (1997-2003: saline period). Traditional technique of hysteroscope insertion and vaginoscopic approach were used depending on operator preference and experience and patient characteristics.
Success, failure, and complication rates.
The hysteroscopies were successfully performed in nearly 95% of cases by 362 operators (mean 13.8 hysteroscopies per operator) with different levels of expertise. Failure and complication rates were 5.2% and 5.4%, respectively, without any significant difference between CO(2) and saline periods. Vasovagal attacks and shoulder pain were significantly higher during the CO(2) period. The success of outpatient hysteroscopy was negatively affected by postmenopausal status, nulliparity, need for cervical dilatation or local anaesthesia, traditional technique of hysteroscope insertion, and use of a 5-mm hysteroscope.
A high level of expertise is not a prerequisite to performing hysteroscopy on an outpatient basis. Recent advances in technique and instrumentation facilitate this approach and might encourage greater adoption by the wider gynecology community.
This study was conducted to assess the accuracy and feasibility of diagnostic hysteroscopy in the evaluation of intrauterine abnormalities in women with abnormal uterine bleeding.
Electronic databases were searched from 1 January 1965 to 1 January 2006 without language selection. The medical subject heading (MeSH) and textwords for the following terms were used: hysteroscopy, diagnosis, histology, histopathology, hysterectomy, biopsy, sensitivity and specificity.
University Hospital.
The inclusion criteria were report on accuracy of diagnostic hysteroscopy in women with abnormal uterine bleeding compared to histology collected with guided biopsy during hysteroscopy, operative hysteroscopy or hysterectomy.
Electronic databases were searched for relevant studies and references were cross-checked. Validity was assessed and data were extracted independently by two authors. Heterogeneity was calculated and data were pooled. Subgroup analysis was performed according to validity criteria, study quality, menopausal state, time, setting and performance of the procedure. The pooled sensitivity, specificity, likelihood ratios, post-test probabilities and feasibility of diagnostic hysteroscopy on the prediction of uterine cavity abnormalities. Post-test probabilities were derived from the likelihood ratios and prevalence of intrauterine abnormalities among included studies. Feasibility included technical success rate and complication rate.
One population of homogeneous data could be identified, consisting of patients with postmenopausal bleeding. In this subgroup the positive and negative likelihood ratios were 7.9 (95% CI 4.79-13.10) and 0.04 (95% CI 0.02-0.09), raising the pre-test probability from 0.61 to a post-test probability of 0.93 (95% CI 0.88-0.95) for positive results and reducing it to 0.06 (95% CI 0.03-0.13) for negative results. The pooled likelihood ratios of all studies included, calculated with the random effects model, were 6.5 (95% CI 4.1-10.4) and 0.08 (95% CI 0.07-0.10), changing the pre-test probability of 0.46 to post-test probabilities of 0.85 (95% CI 0.78-0.90) and 0.07 (0.06-0.08) for positive and negative results respectively. Subgroup analyses gave similar results. The overall success rate of diagnostic hysteroscopy was estimated at 96.9% (SD 5.2%, range 83-100%).
This systematic review and meta-analysis shows that diagnostic hysteroscopy is both accurate and feasible in the diagnosis of intrauterine abnormalities.
Investi-gation of the infertile couple: should diagnostic
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Tanahatoe SJ, Hompes PG, Lambalk CB. Investi-gation of the infertile couple: should diagnostic