Ultrasound Obstet Gynecol 2013; 41: 328–335

Published online in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.11200

Automated three-dimensional coded contrast imaging

hysterosalpingo-contrast sonography: feasibility in office
tubal patency testing
C. EXACOUSTOS*, A. DI GIOVANNI*, B. SZABOLCS*, V. ROMEO*, M. E. ROMANINI*,
D. LUCIANO†, E. ZUPI* and D. ARDUINI*
*Department of Obstetrics and Gynecology, Università degli Studi di Roma ‘Tor Vergata’, Rome, Italy; †Department of Obstetrics and
Gynecology, Center for Fertility and Women’s Health University of Connecticut School of Medicine, New Britain, CT, USA

K E Y W O R D S: hysterosalpingography; three-dimensional ultrasound; transvaginal hysterosalpingo-contrast sonography;

ultrasound contrast medium; ultrasound imaging

ABSTRACT Conclusions HyCoSy with automated 3D-CCI technol-

ogy retains the advantages of conventional 2D HyCoSy
Objective To evaluate the feasibility of transvaginal
while overcoming the disadvantages. 2D HyCoSy is highly
hysterosalpingo-contrast sonography (HyCoSy) with new
observer-dependent and is only accurate in the hands of
automated three-dimensional coded contrast imaging
experienced investigators; by obtaining a volume of the
(3D-CCI) software in the evaluation of tubal patency
uterus and tubes, automated 3D volume acquisition per-
and visualization of tubal course.
mits visualization of the tubes in the coronal view and
Methods Patients undergoing HyCoSy with automated of the tubal course in 3D space, and should allow less
3D-CCI software were evaluated prospectively. First, to experienced operators to evaluate tubal patency status
evaluate the feasibility of 3D visualization of tubal course, relatively easily. Copyright  2012 ISUOG. Published
we performed consecutive volume acquisitions while by John Wiley & Sons, Ltd.
injecting SonoVue contrast agent. We then performed
conventional two-dimensional (2D) real-time HyCoSy to
INTRODUCTION
confirm tubal patency status by detection of saline and air
bubbles moving through the Fallopian tubes and around Evaluation of Fallopian tubal patency is one of the
the ovaries. We also evaluated visualization with CCI of initial steps in the diagnostic workup of infertile
the contrast agent around the ovaries, side effects and women. Hysterosalpingo-contrast sonography (HyCoSy)
pain during and after the procedure, by visual analog is currently performed as an office procedure to assess
scale (VAS) (ranging from 0 to 10, with 0 corresponding tubal patency by transvaginal sonography (TVS)1,2 .
to no pain and 10 corresponding to maximum pain). Because it can be performed in an outpatient setting,
it is a useful tool in one-stop infertility clinics3 .
Results A total of 126 patients (252 tubes) underwent
HyCoSy is based on the introduction into the uterine
3D-CCI HyCoSy followed by 2D real-time HyCoSy.
cavity and Fallopian tubes of a sonographic-enhancing
According to the final 2D real-time evaluation, bilateral
positive-contrast fluid that can be visualized by TVS. In
tubal patency was observed in 111 patients, bilateral tubal
a previous paper4 we showed that HyCoSy using saline
occlusion in four patients and unilateral tubal patency
solution mixed with air is an effective and inexpensive
in 11 patients. The concordance rate for tubal patency
screening tool with which to assess tubal patency
status between the first 3D volume acquisition and the
status, with high diagnostic accuracy when compared
final 2D real-time evaluation was 84% and that between
to hysterosalpingography (HSG) and laparoscopic dye
the second 3D volume acquisition and the final 2D real-
perturbation, which is the gold standard procedure in
time evaluation was 97%. A pain score >5 on VAS
tubal patency evaluation.
was recorded in 58% of patients during the procedure,
However, HyCoSy has limitations. It is highly observer-
but a pain score ≤ 5 was recorded in 85.7% of patients
dependent and it is only accurate in the hands of
immediately after the procedure.
experienced investigators4 – 7 , because the Fallopian tubal

Correspondence to: Dr C. Exacoustos, Obstetrics and Gynecology Department, Università degli Studi di Roma ‘Tor Vergata’, Ospedale
Generale S. Giovanni Calibita ‘Fatebenefratelli’, Isola Tiberina 1, 00186 Rome, Italy (e-mail: caterinaexacoustos@tiscali.it)
Accepted: 26 April 2012

Copyright  2012 ISUOG. Published by John Wiley & Sons, Ltd. ORIGINAL PAPER
3D-CCI HyCoSy and tubal patency testing
course is not linear and lies on different planes, so rapid
movements of the probe are needed to visualize the entire
tubal course and the passage of fluid through the tube
during infusion. Furthermore, HyCoSy is not as accurate
when tubes are occluded, possibly due to intermittent
tubal spasm and to difficulties in distinguishing saline and
air in the tubes from air moving in the bowels. Moreover,
HyCoSy with air/saline solution does not provide an
image of the entire tube and its course, as HSG does.
The use of ultrasound-enhancing contrast media has
been introduced to improve the evaluation of tubal
patency status8,9 . Recently, second-generation contrast
agents have been proposed to evaluate various gyneco-
logical lesions10 – 15 and for sonographic tubal patency
evaluation16 – 19 . These agents provide a substantial har-
monic response at low acoustic pressure and can be seen
more easily and endure longer than do the earlier con-
trast agents. Their safety for intravenous use has been
confirmed by the United States Food and Drug Adminis-
tration and by the European Commission.
Special ultrasound technologies have been
proposed15,17 – 19 for optimization of the use of
ultrasound contrast media by means of low acoustic
pressure. In coded contrast imaging (CCI)20 , the ultra-
sound machine emits a beam at a selected frequency and
receives a narrow band of harmonic signal, avoiding
overlap between the tissue and the contrast response.
The image displayed is based only on harmonic signals
produced by contrast-medium microspheres; broadband
ultrasonic signals from surrounding tissue are filtered out
completely.
In an attempt to overcome the limitations of conven-
tional two-dimensional (2D) HyCoSy, with its need for
an experienced sonographer to visualize the entire tubal
course, two ultrasound technologies have been combined:
CCI, to better evaluate the signals coming from the con-
trast medium, and three-dimensional (3D) sonography, to
acquire a volume of the Fallopian tubes20 .
Several studies4 – 9,16 – 20 have shown high accuracy
(85–95%) in determining tubal patency with different
ultrasound techniques and contrast media, including auto-
mated 3D-CCI HyCoSy21 . In this study, we investigated
further the feasibility of HyCoSy with the new automated
3D-CCI software in the evaluation of tubal patency and
visualization of the tubal course.
PATIENTS AND METHODS
Patients with primary and secondary infertility undergo-
ing evaluation of tubal patency were included in this study.
Infertile patients were defined as women who had been
actively trying to become pregnant for more than 1 year.
Before the HyCoSy procedure, all patients gave their
history and underwent clinical examination including 2D-
and 3D-TVS. During 2D TVS we described precisely
and recorded the presence of: fibroids; any intrauterine
pathology; any adnexal lesion; and retroperitoneal deep
infiltrating endometriosis (DIE). We excluded all patients
with ongoing pregnancy, reproductive tract cancer or
Copyright  2012 ISUOG. Published by John Wiley & Sons, Ltd.
329
with risk factors such as heart disease, especially heart
shunt hypertension and stroke. Exclusion criteria also
included presence of pelvic or vaginal infection and tubal
pathology that was detectable by TVS (hydrosalpinx,
acute salpingitis). Patients who met our criteria underwent
3D-CCI HyCoSy followed by 2D real-time HyCoSy
during the proliferative phase of their cycle (Days 5–12).
Our Institutional Review Board approved this study, and
written informed consent was obtained from each patient.
HyCoSy was performed, using a Voluson E8 ultrasound
machine (GE Healthcare, Zipf, Austria) with automated
3D-CCI HyCoSy software (GE Healthcare) and SonoVue
(Bracco International BV, Amsterdam, The Netherlands)
ultrasound contrast medium, according to the technique
described in our previous studies4,17,20 .
After inserting a speculum into the patient’s vagina,
a 5-Fr salpingographic balloon catheter (PBN Medicals,
Stenløse, Denmark) was placed in the uterine cavity and
filled with 1–2 mL air. This step ensured that the cervical
canal was closed, thus preventing leakage of fluid and
keeping the catheter in the correct position. The TVS
probe was positioned to visualize the transverse section
of the uterus and, if possible, both ovaries laterally. The
CCI mode was then started, causing the view of the pelvis
to become completely anechoic. Using CCI technology
during HyCoSy, the intrauterine injection of ultrasound
contrast medium in a completely anechoic pelvis was
visualized as hyperechoic fluid, seen first in the uterus,
then in the tube if it was proximally patent and, finally,
as it spilled into the abdominal cavity if the tube was
completely patent distally. 3D volume acquisition was
performed during injection, with the region of interest set
as wide as possible so that uterus and both ovaries could
be seen and allowing the whole length of the Fallopian
tube to be detected.
The sonographic volume acquisition technique was
standardized according to the following criteria: fre-
quency, 6–9 MHz; sweep angle, as wide as possible to
include the uterus in transverse section and both ovaries
laterally (maximum 120◦ ); sweep velocity, medium to
maximum quality; 3D box size, exceeding the uterus and
both ovaries by 1 cm on each side. The contrast medium
was highly echogenic and could be visualized for sev-
eral minutes, allowing the tubal course and shape to be
studied and more than one 3D volume acquisition to
be performed. For each patient, 3D volume acquisition
was performed consecutively twice, while injecting up
to 4 mL contrast media: 1.5 mL SonoVue diluted with
2.5 mL saline solution the first time and 2–4 mL saline
(which pushed the residual contrast agent through the
catheter into the tubes) the second time.
The multiplanar view of the uterus and tubes, obtained
during injection of the contrast medium (Figure 1), was
converted automatically, by dedicated software, to the
volume image. This resulted in a view of the uterine
cavity in coronal section, with both tubes laterally and
the contrast medium spilling around the ovaries if both
tubes were patent. The possibility to rotate this volume
showed the tubal course in 3D space (Figure 2 and
Ultrasound Obstet Gynecol 2013; 41: 328–335.
330 Exacoustos et al.

Figure 1 Automated three-dimensional coded contrast imaging hysterosalpingo-contrast sonography: multiplanar view showing contrast
medium in uterus and tubes and automated reconstruction of the volume.

Figure 2 Automated three-dimensional (3D) coded contrast imaging hysterosalpingo-contrast sonography. (a) Automated reconstructed
volume of contrast medium in uterus and patent tubes with spillage of contrast around the ovaries. (b,c) The possibility to rotate this volume
shows the tubal course in 3D space.

Videoclip S1). In addition, the software permitted the

sonographer to combine gray-scale imaging of the uterus
in coronal section, with automated reconstruction of the
contrast medium in the uterine cavity and patent tubes
superimposed in red (Figure 3 and Videoclip S2). In cases
of unilateral tubal occlusion, the tubal course was seen
on one side only (Figure 4b) and was not detectable if
both tubes were occluded (Figure 4c). Using 2D gray-
scale ultrasound of the ovary after contrast medium
injection in parallel with CCI permitted visualization of
the contrast agent around the ovaries as a hyperechoic
ring in anechoic tissue (Figure 5), thus confirming
tubal patency and spillage of the contrast fluid in the Figure 3 Automated three-dimensional coded contrast imaging
pelvis. hysterosalpingo-contrast sonography: gray-scale coronal section of
To determine final tubal patency status we then uterus, with automated reconstructed volume of contrast medium
performed real-time 2D HyCoSy, using at least one in uterine cavity and patent tubes superimposed in red.

Copyright  2012 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2013; 41: 328–335.
3D-CCI HyCoSy and tubal patency testing 331

Figure 4 Automated three-dimensional coded contrast imaging hysterosalpingo-contrast sonography: automated reconstructed volumes of
contrast medium in uterus and tubes in cases of bilateral tubal patency (a) and unilateral (b) and bilateral (c) tubal occlusion.

Figure 5 Visualization of the ovary with conventional two-dimensional gray-scale transvaginal sonography (a,c) and with coded contrast
imaging (CCI) mode (b,d), prior to (a,b) and following (c,d) injection of SonoVue contrast agent. Note the hyperechoic contrast around the
ovary on CCI after injection (d), confirming patency of the ipsilateral tube.

injection of 4–5 mL saline mixed with air and noting
the microbubbles’ movement throughout the tubes; if a
tube was patent on 3D-CCI HyCoSy and not initially
on 2D HyCoSy, which may occur due to tubal spasm,
we administered a further injection or waited a few
seconds and reassessed patency until the patency seen
on 3D imaging was confirmed. Determination of tubal
patency on 2D HyCoSy required all three of the following
criteria4,17,20 : passage of air and saline bubbles through
the interstitial part of the tube; detection of air bubbles
moving around the ovary (observation of flow around the
ovaries was possible even without visualization of passage
through the whole tubal course); detection of the solution
and air bubbles in the pouch of Douglas.
Immediately after the procedure, all patients received
antibiotic prophylaxis as a single 1-g dose of azithromycin,
administered orally.
Patients were asked to grade the discomfort experi-
enced with the aid of a 10-point visual analog scale (VAS),
with 0 corresponding to ‘no pain experienced’ and 10
corresponding to ‘maximum pain experienced’. The pain
score was evaluated during the procedure and 5–10 min
after. The need for analgesic drugs after the procedure
or symptoms of a vagal reaction (nausea, bradycardia,
sweating, hypotension) during the procedure were also
recorded.
To determine the feasibility of the method in the eval-
uation of tubal patency we therefore considered: visual-
ization of tubal patency during first and second injections
of SonoVue and 3D volume acquisition; visualization of
the contrast agent around the ovaries with CCI; detection
on 2D real-time HyCoSy of bubbles moving in the tube,
around the ovaries and in the pouch of Douglas; pain dur-
ing and after the procedure (using 0–10 VAS); and other
side effects (vagal reactions, need for analgesic drugs).

Copyright  2012 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2013; 41: 328–335.
332
3D-CCI HyCoSy
First injection
Bilateral tubal patency
(n = 79)
3D-CCI HyCoSy (n = 6)
Second injection
Bilateral tubal patency
(n = 104)
2D HyCoSy
real-time
(n = 7)
Bilateral tubal patency
(n = 111)
Figure 6 Flow chart of tubal patency status observed in 126 patients during hysterosalpingo-contrast sonography (HyCoSy) at first and
second SonoVue injections with three-dimensional coded contrast imaging (3D-CCI) volume acquisition, and after two-dimensional (2D)
real-time HyCoSy final evaluation. Numbers of patients who had incorrect classification of their tubal status at the first 3D evaluation and
needed further injections are given in the small dotted-line boxes.
Statistical analysis
Final tubal patency status was determined by considering
all results, after completion of the procedure (both 3D
and 2D evaluations and all injections), i.e. if passage
of fluid in the tube was observed by either 3D or 2D
HyCoSy, we considered the tube patent. This means
that we could have only false-positive occluded tubes
with no false-negative occlusions. For the purposes
of analysis, all 126 patients were considered to have
two tubes even if a previous salpingectomy had been
performed.
Statistical analysis was conducted to assess whether
tubes found to be patent or occluded at 3D-CCI HyCoSy
had the same status on 2D HyCoSy. This was done by
determining the concordance rate of tubal patency status
at first and at second 3D volume acquisitions with that
at final 2D real-time HyCoSy, by calculating accuracy
(percentage agreement) and Cohen’s kappa index for
each. The percentage of time that the contrast medium
was visualized around the ovaries was also calculated, as
was the mean degree of pain reported during and after
the procedure and the incidence of other side effects.
Descriptive analysis was achieved using proportions,
means and SD and statistical analysis was performed using
Student’s t-test for mean and SD. Patients with primary
infertility (defined when patients had never been pregnant)
or secondary infertility (defined when patients had had at
least one previous spontaneous pregnancy) were placed in
separate subgroups, and proportions were compared with
Copyright  2012 ISUOG. Published by John Wiley & Sons, Ltd.
Exacoustos et al.
126 infertile patients
Bilateral tubal occlusion Unilateral tubal occlusion
(n = 12) (n = 35)
(n = 19) (n = 1)
Bilateral tubal occlusion Unilateral tubal occlusion
(n = 5) (n = 17)
(n = 1)
Bilateral tubal occlusion Unilateral tubal occlusion
(n = 4) (n = 11)
chi-square or Fisher’s exact test, as appropriate. P < 0.05
was considered statistically significant.
RESULTS
From March 2009 to February 2010 we enrolled 131
patients into the study. Five patients were excluded
because of cervicovaginal infection (n = 4) or hydro-
salpinx (n = 1) detected at the time of preliminary
TVS. Thus, 126 patients, 83 with primary and 43
with secondary infertility, underwent 3D-CCI HyCoSy
followed by 2D real-time HyCoSy.
Population characteristics are summarized in Table 1.
Patients with primary infertility differed significantly from
those with secondary infertility in only a few studied
features, with a higher prevalence of endometriosis in
patients with primary infertility and, as might be expected,
the occurrence of miscarriages and ectopic pregnancies
only in the secondary infertility group.
At the end of the entire procedure (both 3D and
2D real-time HyCoSy) we observed 111 patients with
bilateral tubal patency, 11 patients with unilateral tubal
patency and four patients with bilateral tubal occlusion,
giving a total of 232 (92%) patent and 20 (8%)
occluded tubes (252 tubes in 126 patients). We considered
final tubal patency status results from primary and
secondary infertile patients together because they were not
statistically significantly different. Tubal patency status
results at the first and second injections of contrast agent
and 3D volume acquisition and the final result after 2D
Ultrasound Obstet Gynecol 2013; 41: 328–335.
3D-CCI HyCoSy and tubal patency testing 333

Table 1 Population characteristics in 126 infertile patients who underwent hysterosalpingo-contrast sonography, according to level of
infertility

Characteristic Primary infertility (n = 83) Secondary infertility (n = 43) P* Total (n = 126)

Age (years) 34.8 ± 4.4 38.4 ± 4.3 < 0.0001 36.1 ± 4.7
Body mass index (kg/m2 ) 20.9 ± 2.9 22.2 ± 2.8 0.017 21.4 ± 2.8
Presence at initial TVS of:
Endometriosis 15 (18.1) 2 (4.6) 0.05 17 (13.5)
Myomas 10 (12.1) 6 (13.9) 0.78 16 (12.7)
History of:
Ectopic pregnancy 0 (0) 7 (16.3) 0.0004 7 (5.5)
Pelvic inflammatory disease 3 (3.6) 0 (0) 0.55 3 (2.4)
Recurrent miscarriage 0 (0) 9 (20.9) < 0.0001 9 (7.1)
Salpingectomy 1 (1.2) 5 (11.6) 0.017 6 (4.8)
Myomectomy 3 (3.6) 2 (4.6) 1.00 5 (3.9)
Metroplasty 1 (1.2) 1 (2.3) 1.00 2 (1.6)
Surgery for endometriosis 3 (3.6) 1 (2.3) 1.00 4 (3.2)

Data are given as mean ± SD or n (%). *Primary vs secondary infertility patients (Student’s t-test, chi-square test or Fisher’s exact test). TVS,
transvaginal sonography.

real-time HyCoSy are shown in Figure 6 and Table 2. Bilateral tubal occlusion was confirmed by laparoscopy
The first and second 3D volume acquisitions in relation to in all four patients with bilateral occlusion on 2D HyCoSy.
final tubal patency status on 2D evaluation had accuracy Among the 11 patients with unilateral tubal occlusion we
(concordance rate) of 84% and 97%, respectively, and had no laparoscopic confirmation of tubal patency status;
Cohen’s kappa index of 27% and 68%. Bilateral tubal however, five of these patients had a previous unilateral
patency was observed in 79 (62.7%) patients at first salpingectomy for ectopic pregnancy or endometriosis and
injection and 3D volume acquisition, in 104 patients in one patient HSG confirmed unilateral tubal occlusion.
(82.5%) at second injection and 3D volume acquisition, In one case of previous salpingectomy for ectopic
and finally was confirmed in 111 patients (88%) at 2D pregnancy we detected contrast media and fluid passage;
real-time evaluation. In only eight patients were further this was in fact likely through the residual proximal tube.
injections and 2D real time examination necessary to Contrast agent around the ovaries was observed in 121
achieve the correct final tubal patency status (Figure 6); out of 126 patients (96%) (Figure 5). It was detected
the concordance rate to the final TVS tubal patency status bilaterally in all cases of bilateral tubal patency except
for tubal status following the second injection and 3D one (spillage of contrast medium in the peritoneal cavity
volume acquisition was 94% (Table 2). was observed but it did not surround both ovaries clearly,
possibly due to the presence of adhesions). In four of
the 11 patients with unilateral tubal occlusion it was
detected bilaterally, even around the ovary ipsilateral to
Table 2 Tubal patency status results in 126 infertile patients (252 the occluded tube (perhaps because of diffusion of fluid in
Fallopian tubes) after first and second SonoVue contrast medium
injection with three-dimensional coded contrast imaging (3D-CCI) the pelvis). Contrast agent spillage around the ovaries was
evaluation, and after two-dimensional (2D) real-time absent in the four patients with bilateral tubal occlusion.
hysterosalpingo-contrast sonography (HyCoSy) final evaluation A pain score >5 (on 0–10 VAS) was recorded in 57.9%
of patients during the procedure, but a pain score ≤ 5
HyCoSy modality was recorded in 85.7% of patients immediately after the
3D-CCI volume procedure (Table 3), with only 11% of patients (n = 14)
acquisition
2D real-time
requiring analgesic drugs and only 5.6% (n = 7) with
Tubal patency status First Second final evaluation vagal reactions. All seven of the latter patients responded
well to atropine administration. In no case was hospital
Patients (n = 126)
admission required.
Bilaterally patent 79 (62.7) 104 (82.5) 111 (88.1)
Bilaterally occluded 12 (9.5) 5 (4.0) 4 (3.2)
Unilaterally occluded 35 (27.8) 17 (13.5) 11 (8.7)
Concordance rate to 94 (74.6) 119 (94.4) 126 (100)
DISCUSSION
final results*
Tubes (n = 252)
Several studies4 – 9,17 – 21 attest to the high accuracy
Patent tube 193 (76.6) 225 (89.3) 233 (92.5) of transvaginal HyCoSy in the assessment of tubal
Occluded tube 59 (23.4) 27 (10.7) 19 (7.5) patency compared with laparoscopic chromopertuba-
Concordance rate to 212 (84.1) 244 (96.8) 252 (100) tion and HSG. However, 2D HyCoSy, even when per-
final results* formed with ultrasound-enhancing contrast media, is
Data are given as n (%) of patients or tubes. *Concordance rate a highly operator-dependent technique. An experienced
between each 3D volume acquisition and final 2D real-time sonographer is necessary to manipulate the TVS probe
evaluation. efficiently in order to detect the contrast medium echoes

Copyright  2012 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2013; 41: 328–335.
334
Table 3 Pain evaluation by visual analog scale (VAS) in 126
infertile patients during and after hysterosalpingo-contrast
sonography (HyCoSy)
Score ≤ 5 Score >5 VAS score
(n (%)) (n (%)) (mean ± SD)
Pain during HyCoSy 53 (42.1) 73 (57.9) 5.31 ± 2.8
Pain after HyCoSy 108 (85.7) 18 (14.3) 2.41 ± 2.7
Pain during and after 55 (43.6) 13 (10.3) 3.86 ± 2.0
HyCoSy
Vagal reactions 2 (1.6) 5 (4.0)
Analgesic drugs 2 (1.6) 12 (9.5)
administered
VAS score ranges from 0 to 10, with 0 corresponding to ‘no pain
experienced’ and 10 corresponding to ‘maximum pain experienced’.
and visualize the different parts of the tubes, as only
rarely can the entire tube be visualized during fluid injec-
tion. 3D acquisition starting from a transverse section of
the uterus is static, does not require probe movement and
automatically generates the multiplanar image and the
reconstruction of the entire uterine cavity and bilateral
tubal course in case of patency.
Combination of a second-generation contrast medium
with CCI, which discriminates the harmonic response
of contrast microbubbles from ultrasound echoes of
surrounding tissues, is very helpful for clearer visualiza-
tion of the fluid passage throughout the tubes. Recently,
high accuracy (90%) of automated 3D-CCI HyCoSy in
detecting tubal patency has been reported21 , but the pro-
cedure seems difficult to perform for many sonographers.
With this feasibility study, therefore, we wanted to
assess first how simple it is to perform automated 3D-CCI
HyCoSy and second if it is as accurate as the more diffi-
cult 2D HyCoSy. Concordance with final tubal patency
status of 97% was obtained at the second 3D volume
acquisition, demonstrating that when tubal patency by
3D ultrasound is observed, no further evaluation is
needed. With previous studies we have demonstrated that
HyCoSy has a high concordance rate to laparoscopy4 ,
which is still considered the gold standard for evaluation
of tubal patency status.
If tubal occlusion is detected during 3D ultrasound,
further injections are required, especially in cases of
unilateral tubal occlusion. In many of these cases, the
fluid passage is better in one tube whereas the other tube
seems to be occluded, possibly due to spasm. After waiting
some minutes and repeating the injection, often the tube
is seen to be patent. However, on repeated injections,
3D volume acquisition cannot show accurately the tubal
course, because spillage of fluid in the peritoneal cavity
provides a diffuse image of contrast medium around the
pelvic organs and not just in the tube.
Moreover, with 2D real-time HyCoSy, for each tube one
injection and often more than one is needed to visualize the
passage of fluid in the tubes bilaterally. Because both tubes
are visualized simultaneously during 3D HyCoSy volume
acquisition with only one or two injections, less contrast
agent and fluid is required in comparison to 2D real-time
HyCoSy. In our experience, and in accordance with other
Copyright  2012 ISUOG. Published by John Wiley & Sons, Ltd.
Exacoustos et al.
studies6,22 , the greater the volume of fluid injected, the
more pain is felt by the patient; however, there is no
association with the incidence of vagal reactions. While
more than 50% of our patients reported pain during
the procedure, it disappeared in most cases immediately
afterwards. This was probably because the cramping and
discomfort was due not only to the injections but also to
the balloon catheter inside the uterine cavity.
Another major advantage of HyCoSy with automated
3D-CCI is the possibility to obtain images of the uterus
and tubal course that are similar to those obtained by
HSG, with the advantage that the volume can be moved
and rotated in 3D space. They can also be shared easily
with other clinicians, whereas 2D HyCoSy is a dynamic
real-time exam in which the passage of fluid is seen only
by the ultrasound examiner and images are very difficult
to interpret. Moreover, the acquired volumes can be
stored and analyzed later, reducing the examination time
for patients.
A disadvantage of this new technique compared with
2D HyCoSy is the cost, of both a 3D machine and the
contrast medium. Another limitation is the fact that
most ultrasound contrast media are approved in many
countries only for intravenous injection, and not for
injection into the uterus and tubes.
In conclusion, HyCoSy with automated 3D-CCI
technology retains the advantages of conventional 2D
HyCoSy while at the same time overcoming the disadvan-
tages. This technology permits visualization of the tubal
course, creating images of the tubes in the coronal view
and obtaining a volume so that the tubal course in 3D
space can be evaluated. It provides imaging of the entire
tube and its course, similar to HSG, with the advantages
of: requiring no exposure to radiation; the possibility of
repeating injections if needed; and the possibility of being
performed in an outpatient setting. The clarity with which
spillage is seen and the ease of automated 3D volume
acquisition without any difficult probe movements makes
this diagnostic method straightforward even for an inex-
perienced sonographer. With this study we have shown
that this 3D-CCI HyCoSy method has high diagnostic
feasibility, and can be performed easily in the office. It pro-
vides the possibility of infertile patients having only one
scan in the proliferative phase of the cycle, while obtain-
ing information about uterine and adnexal morphology,
as well as tubal patency (One-stop Infertility Clinic). We
are confident that 3D-CCI HyCoSy will find a place in
the early outpatient investigation of infertile women.
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SUPPORTING INFORMATION ON THE INTERNET
The following supporting information may be found in the online version of this article:
Videoclip S1 Video showing rotation of uterine and tubal volume obtained by three-dimensional (3D) coded
contrast imaging hysterosalpingo-contrast sonography and how tubal course in 3D space can be better
evaluated.
Videoclip S2 Video showing automated reconstructed uterine volume in gray scale, with overlapping red
contrast media in Fallopian tubes.
Copyright  2012 ISUOG. Published by John Wiley & Sons, Ltd.
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