Hysterosalpingography vs Hysteroscopy vs Hydrosonography

F.M. Severi, C. Bocchi, P. Florio, L. Cobellis, R. La Rosa, M.G. Ricci and F. Petraglia
Chair of Obstetrics and Gynecology, University of Siena, Siena, taly

Summary !he diagnosis of "terine and#or t"bal $athology as ca"ses of fe%ale infertility re$resents a f"nda%ental ste$ in the eval"ation of the infertile co"$le. &$art fro% the invasive diagnostic $roced"res, several others diagnostic techni'"es "sef"l to the clinical eval"ation of the "terine cavity and t"bal anato%y are( transvaginal sonogra$hy )!*S+, hysterosal$ingogra$hy ),SG+, hysterosco$y and hydrosonogra$hy ),-S+ and la$arosco$y. !he ai% of this st"dy .as to co%$are the diagnostic acc"racy of !*S, ,SG, hysterosco$y, ,-S and la$arosco$y in eval"ating "terine cavity and t"bal $atency in infertile .o%en. Introduction !he anato%ical#f"nctional eval"ation of fe%ale $elvic organs $lays a /ey role in the clinical assess%ent of infertility in infertile co"$les. !he clinical eval"ation of a great n"%ber of infertile#s"bfertile .o%en )01 234+ )215+ %ight be based on an eval"ation of the ris/s#benefits and costs#benefits ratio of diagnostic tools. !herefore, a lo. cost and ris/ %ethodological a$$roach sho"ld be addressed as a 6first choice7 investigation, later follo.ed by %ore co%$le8 or invasive $roced"res )9+. &%ong etiological factors of fe%ale infertility other reverse 6"terine7 factors are described. n fact, des$ite "terine %alfor%ations are detected only in :.234 of fertile .o%en, they have a %ean $revalence of 5.;4 in the infertile .o%en sho.ing a dee$ ca"sal relationshi$ ne8"s bet.een the t.o events. On the contrary, the relation bet.een leio%yo%as and infertility is less strong. !he %yo%as can alter fertility .ith %any %echanis%s s"ch as delaying s$er%ato<oa %oving "$ and $rogression, altering "terine, endo%etrial and t"bal contractility, co%$ressing or occl"ding sal$in8, hindering oocyte ca$t"re or, generically, altering endo%etri"% and conse'"ently its i%$lantation.

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F"rther%ore, intraliga%ento"s %yo%as can alter t"bal f"nction, .hile s"bsero"s fibroids do not. Conse'"ently, it is clear that the %yo%a location is %ore i%$ortant than %yo%a di%ension. t co%es that the "se of acc"rate diagnostic $roced"res are needed not only to detect the%, b"t $artic"larly to identify their to$ogra$hy. ,o.ever, altho"gh =;4 of .o%en s"ffer fro% "terine %yo%as )01>+, they are associated to infertility in only ;12:4 of cases and considered the %ain infertility ca"se only in =154 of cases )?+. S"b%"co"s and so%e intra%"ral fibroids, $oly$s, intra"terine synechiae and so%e chronic endo%etritis )chla%ydia+, can be res$onsible for %echanical and#or vasc"lar endo%etrial alterations that ca"se stro%al lesions )atro$hy, "lceration+. &deno%yosis can interfere .ith fertility as already described for %yo%as, b"t also by s$ecific %echanis%. @8tra"terine adhesions d"e to %yo%ecto%y )in $artic"lar .hen the $osterior "terine .all is involved+ or intra"terine adhesions deter%ined by s"rgical $roced"re are i%$ortant iatrogenic factors ca"sing "terine or t"bo1$eritoneal factor alterations. For all these reasons, to avoid these iatrogenic ris/s, the less invasive %ethodology %ight be chosen .hen a s"rgical $roced"re is needed. On the basis of these considerations, hydrosonogra$hy ),-S+ see%s to offer a good acc"racy in identifying the ca"ses of infertility, .ith the lo.er costs and ris/s for the $atient. n the eval"ation of "terine and t"bo1$eritoneal factors ca"sing infertility, al%ost all the $rotocols retain hysterosal$ingogra$hy ),SG+, hysterosco$y and la$arosco$y, first choice diagnostic tools. For a long ti%e ,SG .as the sole $roced"re $roviding i%$ortant details abo"t the $resence of intra"terine ano%alies and t"bal $atency. n the 2?0:As the introd"ction of the hysterosco$y allo.ed the direct vis"ali<ation of "terine cavity, b"t its val"e .as controversial for a long ti%e. Later, the clinical "se of "ltraso"nd, and $artic"larly of transvaginal sonogra$hy )!*S+, did not %odified the fe%ale infertility $rotocols, essentially based on ,SG, hysterosco$y and la$arosco$y. For the first ti%e in 2?>3 the instillation of sterile saline sol"tion into the "terine cavity .as described )2:+. n the $resent st"dy .e .ill eval"ate the effectiveness of ,-S, in the first ste$ eval"ation of fe%ale infertility, co%$aring its diagnostic acc"racy to that of ,SG, hysterosco$y and la$arosco$y. Materials and Methods !o deter%ine the acc"racy of ,-S vers"s ,SG, hysterosco$y and la$arosco$y one heterogeneo"s gro"$ of $atients .as enrolled.

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!he st"died gro"$ .as co%$osed by 25: infertile .o%en .ith a %ean age 55.= ;.2 )range =5190, inter'"artile =015;+ that "nder.ent ,-S )Sie%ens Sonoline SL= and Sie%ens @legra Milleni"% @dition, .ith ;10.; M,< transvaginal $robes+. Before or after transvaginal saline sol"tion inf"sion, they "nder.ent one or %ore different diagnostic#thera$e"tic $roced"re s"ch as ,SG, hysterosco$y, c"rettage and endo%etrial bio$sy, and la$arosco$y, all considered as reference. !he ,-S findings, recorded .itho"t /no.ing the res"lts of others investigations, .ere co%$ared .ith others %ethodology findings and .ith histology. Results n this gro"$ of infertile $atients it .as $ossible to deter%ine ,-S diagnostic acc"racy vers"s "terine %alfor%ations and "terine cavity $athology. &s concern t"bal $atency, in ;= .o%en ,SG .as co%$ared .ith ,-S, .hereas in 9> cases the la$arosco$ic chro%o$ert"bation .as co%$ared .ith both ,SG and ,-S. !he ,-S findings concerning the "terine cavity %or$hology .as correct in 2=3 cases. =: s"b%"co"s %yo%as )associated to $oly$s in 9 cases+, 2> cases of endo%etrial $oly$s, 23 "terine %alfor%ations, 9 intra"terine adhesions and 3> nor%al intra"terine findings .ith endo%etrial $attern synchrono"s .ith the %enstr"al cycle $hase, .ere correctly identified. !here .as discre$ancy in = cases( either ,-S and hysterosco$y de%onstrated the $resence of $oly$s, b"t the histologic e8a%ination identified only endo%etri"% in secretive $hase. !he co%$arison bet.een ,-S and hysterosco$y sho.ed an al%ost e'"al diagnostic ca$ability. Using as reference the histologic res"lts, ,-S sho.ed a sensitivity of 2::4, a s$ecificity of ?0.24, a PP* of ?3.>4 and a BP* of 2::4. &s concerned t"bal $atency the res"lts that derive fro% the co%$arison bet.een ,SG and ,-S agreed in 054 of cases )>;.94 of t"bes+, .ith an higher $revalence of t"bal occl"sions at ,SG e8a%ination. n 9> .o%en the co%$arison bet.een la$arosco$y and ,SG sho.ed an agree%ent in 0:.>4 of cases )>=.=4 of t"bes+, .hile bet.een la$arosco$y and hydrosonogra$hy in 0?.24 of cases )>>.>4 of t"bes+. &lso in this second gro"$ ,SG sho.ed an higher $revalence of false t"bal occl"sion. &ll bilateral t"bal occl"sions .ere correctly identified by ,-S. Conclusions Fro% the $resent res"lts so%e considerations .ere dra.n( ,-S %ade by s/illed o$erators allo.s an acc"rate eval"ation of "terine cavity

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and %alfor%ations, $artic"larly in yo"ng .o%en, reaching a diagnostic acc"racy si%ilar to that of hysterosco$y, i%$roving the e8a%ination co%$liance and lo.ering both ris/s and side effects. &s first concl"sion ,-S co"ld avoid, at least at the first ste$, all the other diagnostic $roced"res, lo.ering costs and reaching a high diagnostic acc"racy .ith a non invasive, good co%$liance, %ethodology. !he eval"ation of t"bal $atency is traditionally considered f"nda%ental in the st"dy of ca"ses of infertility and it re$resents one third of the total cost in the %anage%ent of the infertile co"$le. -o"bting abo"t the real "tility of the investigations concerning infertility so%e researchers s"ggested to direct the available reso"rces to s"$$ort the assisted re$rod"ction techni'"es .itho"t dissi$ate the% in dangero"s, e8$ensive, and $erha$s "seless diagnostic investigations, necessary to access, after one or t.o years of infertility, in the *F1@! $rogra%. On the contrary, other researchers assert that there is still today a good reason to eval"ate t"bal factor, that alone re$resents abo"t 5:4 of the ca"ses of fe%ale infertility. n this debate ,-S co"ld re$resent a good co%$ro%ise. -o"bts abo"t the ,-S "tility in the st"dy of t"bal $atency are still e8isting no.. !he res"lts obtained sho. ho. the acc"racy of this %ethodology is at the sa%e level of ,SGAs, .hen the t.o techni'"es are co%$ared .ith la$arosco$ic chro%o$ert"bation. &ccordingly to the literat"re, the $resent st"dy confir%s that ,SG is a techni'"e that $resents a considerable n"%ber of false $ositive res"lts )that lead inevitably to la$arosco$y+ .hilst, on the contrary, ,-S has a lo.er false $ositive res"lts. Moreover, it is i%$ortant to notice that in the sa%$le analy<ed, ,-S never failed the $resence of a bilateral t"bal occl"sion. Generally this $athologic finding, is easily detectable also fro% a less e8$erienced sonologist by loo/ing the absence of fl"id in the -o"glas s$ace, al.ays $resent after fe. %in"tes fro% the saline inf"sion instillation. Mol )22+ doc"%ented ho. in a $o$"lation of infertile .o%en that "nder.ent ,SG, only the bilateral t"bal occl"sion .as strongly correlated .ith a lo. $ercentage of $regnancy ):.5:+, .hile the fec"ndity rate ratio bet.een .o%en .itho"t t"bal $athology and .o%en .ith %onolateral occl"sion .as al%ost e'"al )2 vs :.>2+. n according .ith o"r res"lts, a recent st"dy )2=+ stated that ,-S techni'"e can be considered the %ost acc"rate test in the eval"ation of "terine cavity diseases in infertile .o%en and in $artic"lar in case of $oly$oid lesions. n fact, "sing hysterosco$y as gold standard, ,-S sho.ed the sa%e diagnostic acc"racy of hysterosco$y in case of $oly$oid lesions and endo%etrial hy$er$lasia, a sensitivity of 00.>4 for "terine %alfor%ations

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),SG 99.94+ and of 0;4 )PP* 9=.?4+ in the detection of intra"terine adhesions ),SG 0;4 PP* ;:4+. Moreover Goldberg )25+ fo"nd that in the eval"ation of $atients .ith infertility or rec"rrent $regnancy loss and "terine abnor%alities on ,SG, ,-S .as %ore acc"rate than ,SG and $rovided additional infor%ation abo"t "terine abnor%alities $artic"larly on the relative $ro$ortion of the intracavitary and intra%yo%etrial co%$onents of s"b%"c"s %yo%as, as .ell as e8tracavitary %yo%as and the adne8ae. Later, concerning the a$$earance of "terine cavity, -ar.ish)29+ confir%ed that ,-S agreed .ith hysterosco$y in 0=.=4 of cases, .hile the a$$earance of t"bes obtained "sing ,-S agreed .ith la$arosco$y in 0=.94 of cases )right t"be+ and 3:.;4 )left t"be+. Using as direct indicator of t"bal $atency the a$$earance of fl"id in -o"glas s$ace the agree%ent bet.een ,-S and la$arosco$y rised to >>.24 )one t"be+ and to >;.04 )both+. &lso in the eval"ation of abnor%al "terine bleeding ,-S see%s to have an i%$ortant role )2;+. !herefore, the "se of ,-S as first a$$roach $roced"re in the $rotocols for the eval"ation of fe%ale infertility, allo. either a significant red"ction of the invasive $roced"res ris/s and of related costs .itho"t losing acc"racy. n concl"sion, ,-S re$resents today the gold standard $roced"re in the infertile co"$le diagnostic a$$roach. References 2. !e%$leton &. nfertility and the establish%ent of $regnancy11 overvie.. Br Med B"ll ;3(;001>0, =:::. =. B"c/ett C, Bentic/ B. !he e$ide%iology of infertility in a r"ral $o$"lation. &cta Obstet Gynecol Scand 03(=5510, 2??0. 5. Miller D,, Ceinberg RE, Canino BL, Elein B&, So"les MR. !he $attern of infertility diagnoses in .o%en of advanced re$rod"ctive age. &% D Obstet Gynecol 2>2(?;=10, 2???. 9. Griffin M, Pana/ CF. !he econo%ic cost of infertility1related services( an e8a%ination of the Massach"setts infertility ins"rance %andate. Fertil Steril 0:(==1?, 2??>. ;. Bah"% GG. Uterine ano%alies. ,o. co%%on are they, and .hat is their distrib"tion a%ong s"bty$esF D Re$rod Med 95(>001>0, 2??>. 3. Raga F, Ba"set C, Re%ohi D, Bonilla1M"soles F, Si%on C, Pellicer &. Re$rod"ctive i%$act of congenital M"llerian ano%alies. ,"% Re$rod 2=( ==001>2, 2??0. 0. Lo$es P. n an infertile .o%an, does the $resence of one or several %yo%as of less than three c% in dia%eter G"stify a %yo%ecto%yF Contrace$t Fertil Se8 =;( 5;:12, 2??0.

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>. Para<<ini F, Begri @, La *ecchia C, Chateno"d L, Ricci @, G"arnerio P. Re$rod"ctive factors and ris/ of "terine fibroids. @$ide%iology 0(99:1=, 2??3. ?. B"ttra% *C, Reiter RC. Uterine leio%yo%ata( etiology, sy%$to%atology, and %anage%ent. Fertil SterilH 53)9+( 95519;, 2?>2. 2:. Randol$h DR, Uing IE, Maier -B, Sch%idt CL, Riddic/ -,. Co%$arison of real ti%e "ltrasonogra$hy, hysterosal$ingogra$hy, and la$arosco$y#hysterosco$y in the eval"ation of "terine abnor%alities and t"bal $atency. Fertil Steril 93(>=>15=, 2?>3. 22. Mol BC, S.art P, Boss"yt PM, van der *een F. s hysterosal$ingogra$hy an i%$ortant tool in $redicting fertility o"tco%eF Fertil Steril 30( 3351?, 2??0. 2=. Soares SR, Barbosa dos reis MM, Ca%argos &F. -iagnostic acc"racy of sonohysterogra$hy, transvaginal sonogra$hy and ,ysterosal$ingogra$hy in $atients .ith "terine cavity diseases. Fertil Steril 05(9:3122, =:::. 25. Goldberg DM, Falcone !, &ttaran M. Sonohysterogra$hic eval"ation of "terine abnor%alities noted on hysterosal$ingogra$hy. ,"% Re$rod 25(5=>=15, 2??0. 29. -ar.ish &M, Io"ssef &&. Screening sonohysterogra$hy in infertility. Gynecol Obstet nvest 9>(9510, 2???. 2;. -escarg"es G, Le%ercier @, -avid c, Genevois &, Le%oine DP, Mar$ea" L. Chich initial tests sho"ld be $erfor%ed to eval"ate %eno1 %etrorrhagiasF & co%$arison of hysterogra$hy, transvaginal sonohysterogra$hy and hysterosco$y. D Gynecol Obstet Biol Re$rod 5:(;?139, =::2.

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