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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 45  |  Issue : 3  |  Page : 155-159

Saline infusion sonography versus hysteroscopy in the evaluation of uterine cavity in women with unexplained infertility


Department of Obstetrics and Gynecology, Faculty of Medicine, Tanta University, Tanta, Egypt

Date of Submission09-Jun-2017
Date of Acceptance27-Jul-2017
Date of Web Publication29-Nov-2017

Correspondence Address:
Mohamed Helmy Draz
Department of Obstetrics and Gynecology, Faculty of Medicine, Tanta University, El-Refaae st, Tanta, El-Gharbia, 31111
Egypt
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DOI: 10.4103/tmj.tmj_49_17

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  Abstract 


Background Uterine abnormalities, congenital or acquired, are implicated as one of the causes of infertility. Embryo implantation depends on the quality of the ovum, the condition of the endometrium as well as the uterine cavity. Hence, it is recommended to diagnose and treat these abnormalities in patients with unexplained infertility.
Objective The aim of this study was to compare the diagnostic accuracy between saline infusion sonography (SIS) and hysteroscopy (HS) to evaluate uterine cavity pathologies among women with unexplained infertility.
Patients and methods This study was carried out on 50 women with unexplained infertility in the Department of Obstetrics and Gynecology at Tanta University Hospital, from March 2015 to December 2015. Patients were subjected to an ultrasound assessment of uterine cavity using saline as the contrast medium (SIS) and then followed by HS on a later date. Examination was performed after cessation of menstruation, but before the 10th day of the menstrual cycle (early-proliferative phase of the same menstrual cycle). The uterine cavity was inspected for irregularities such as synechiae, polyps, and submucous myomas, as well as uterine malformations. Sensitivity, specificity, accuracy, and positive and negative predictive values of SIS and diagnostic HS to detect intracavitary abnormalities were compared.
Results In this study, HS was more sensitive (100 vs. 85%), with the same specificity (100 vs. 100%), and more accurate (100 vs. 94%) than SIS. HS also had a higher predictive value (100 vs. 100% positive predictive value, 100 vs. 90% negative predictive value) than SIS during the evaluation of patients with unexplained infertility.
Conclusion Infertile women should be screened for possible uterine cavity abnormalities. HS is still considered the gold standard to diagnose intrauterine pathology as it is more sensitive and more accurate than SIS. However, SIS has the advantages of being a simple, well-tolerated, noninvasive, cheap, affordable, shorter duration, and accurate method for uterine cavity evaluation. Thus, SIS can be used as an alternative technique for the evaluation of uterine cavity abnormalities when HS is not available.

Keywords: assessment of uterine cavity unexplained infertility, hysteroscopy, saline infusion sonography


How to cite this article:
Draz MH, El-Sabaa TM, El Shorbagy SH. Saline infusion sonography versus hysteroscopy in the evaluation of uterine cavity in women with unexplained infertility. Tanta Med J 2017;45:155-9

How to cite this URL:
Draz MH, El-Sabaa TM, El Shorbagy SH. Saline infusion sonography versus hysteroscopy in the evaluation of uterine cavity in women with unexplained infertility. Tanta Med J [serial online] 2017 [cited 2018 Feb 25];45:155-9. Available from: http://www.tdj.eg.net/text.asp?2017/45/3/155/219442




  Introduction Top


Unexplained infertility usually refers to the absence of a definable cause for a couple’s failure to achieve pregnancy after 12 months of attempting conception. The couples had normal standard infertility investigations such as tests of ovulation, tubal patency, and semen analysis [1].

Evaluation of the uterine cavity is a basic step in the investigation of infertile women [2]. Both the conditions of the endometrium as well as the uterine cavity are considered to be important factors in determining receptivity for embryo implantation [3],[4],[5]. It has been suggested that unsuspected intrauterine abnormalities may negatively affect the uterine environment and thereby the likelihood of achieving an ongoing pregnancy [6]. Abnormal uterine findings have been found in 34–62% of infertile women [7]. Therefore, it is recommended to diagnose and treat these abnormalities to optimize the uterine conditions in patients with unexplained infertility [8].

Although hysteroscopy (HS) is known as the gold-standard procedure for uterine cavity assessment, it is a costly invasive procedure associated with its share of discomfort, risks, and is even unnecessary in 50% of patients who have normal uterine cavity [9]. The previous transvaginal sonography (TVS) has a positive predictive value as high as 85–95% for uterine abnormalities detected at HS in women with unexplained infertility [10], but it has a limitation in the form of a high false-negative rate for diagnosing focal intrauterine pathology [9]. It has been reported that the expansion of the uterine cavity with saline during TVS improves the delineation of uterine cavity abnormalities [11].

Saline infusion sonography (SIS) is a diagnostic technique with many advantages. It is performed in a comparatively shorter duration of time, is more cost effective, and is less painful for patients than HS [7],[12], but reports on its diagnostic accuracy are conflicting. Some authors consider a negative saline contrast hysterosonography as proof of a normal uterine cavity [13], whereas others report insufficient diagnostic accuracy to rely on in clinical practice [14].

Therefore, this study was designed to compare the accuracy of SIS versus HS in the assessment of uterine cavity abnormalities in women with unexplained infertility.


  Patients and methods Top


This observational study was carried out on 50 patients at the Department of Obstetrics and Gynecology at Tanta University Hospital from March 2015 to December 2015. An informed consent was obtained from all participants in this research with the approval of the Ethical Committee of Tanta University hospital.

Patients underwent an ultrasound assessment of the uterine cavity with saline as the contrast medium (SIS), and then a HS was performed for uterine cavity assessment. Both SIS and HS procedures were scheduled after the menstrual period in the early-midfollicular phase of a cycle of the same menstrual cycle.

Patients included in this study were between 20 and 35 years old with a BMI ranging from 18 to less than 25 kg/m2. They had normal gynecological ultrasonography, normal ovulatory tests, normal hysterosalpingography with tubal patency, and normal semen analysis according to the WHO criteria for husbands. Patients with any systemic or local disease were excluded. All patients were subjected to a full assessment of history, and general and local clinical examination to exclude general diseases and local causes of infertility.

SIS was performed after the menstrual cycle, during the proliferative phase of the menstrual cycle, no later than day 10 using a 6.5-MHz transvaginal transducer (H60; Samsung, Seoul, Korea). The patient was placed in the lithotomy position. A sterile speculum was placed into the vagina and the cervix was brought into view. The cervix was then cleansed with a povidone–iodine solution. The pediatric Foley’s catheter and stiffener were placed at the external cervical os and the catheter was advanced through the stiffener into the endometrial canal; the balloon was inflated with 2 ml saline so that the catheter did not become dislodged. The speculum was removed carefully and the endovaginal probe was reinserted beside the catheter. Under direct sonographic visualization, the balloon was gently retracted to occlude the internal cervical os. Again, under sonographic guidance, ∼5–20 ml of warm sterile saline was injected, sonographic evaluation of the endometrial cavity was performed in both the coronal and the sagittal planes, the balloon was then deflated, and evaluation of the lower uterine segment and the endocervical region was performed.

Diagnostic HS is generally a short procedure with minimal blood loss. Normal sterile, isotonic saline solution was used for distention of the uterine cavity. As the HS was introduced into the external cervical os and advanced into the endocervical canal, the video monitor was observed. The distal tip of the HS was then gently advanced through the length of the cervix, taking care to keep the endocervical canal central within the viewing field. The intrauterine space was then ready for systematic inspection. The first evaluation was a panoramic view of the intrauterine cavity. Next, careful inspection using Bettocchi HS was performed with a 30° direction of view (Karl Storz Endoscopy, Utrecht, the Netherlands) of the lateral uterine walls, uterine fundus, and anterior and posterior uterine walls.

During assessment of the uterine cavity, any abnormal findings were treated by operative HS under general anesthesia and specimens were sent for histopathology examinations. The data for each patient were collected and analyzed. The sensitivity, specificity, accuracy, and the predictive values of the SIS and HS were calculated and compared using the following formulas:
  1. Sensitivity: probability that the test results will be positive when the disease is present (true positive rate, expressed as a %);
  2. Specificity: probability that the test results will be negative when the disease is present (true negative rate, expressed as a %);
  3. Positive predictive value (PPV: probability that the disease is present when the test is positive);
  4. Negative predictive value (NPV: probability that the disease is present when the test is negative); and accuracy is the ratio of the true positive and true negative in all patients.


A result was considered significant at a P value of less than 0.05 and highly significant at a P value of less than 0.01.


  Results Top


The present study included 50 women with unexplained infertility in the age range 20–34 years, with a mean age of 26.88±3.42 years and a BMI range between 20 and 24 kg/m2, with mean BMI of 22.6±1.53 kg/m2 as shown in [Table 1].
Table 1 Age and BMI of the patients with unexplained infertility

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SIS evaluation of the uterine cavity of the studied cases indicated a normal uterine cavity in 33 (66%) cases and uterine cavity abnormalities in 17 (34%) cases [six (12%) endometrial polyps, five (10%) submucous fibroid, three (6%) uterine septum, one (2%) uterine adhesions, and two (4%) increased endometrial thickness]. The majority of patients with normal uterine findings were younger than 30 years of age. Three cases were diagnosed falsely with normal uterine cavity, but were diagnosed with abnormal uterine cavity by HS (two cases of an endometrial polyp and one case of Asherman syndrome were false negative).

However, hysteroscopic evaluation of the uterine cavity of the studied cases showed no false-negative cases as 30 (60%) cases were diagnosed with normal uterine cavity and uterine cavity abnormalities were diagnosed in 20 (40%) cases in this study: eight (16%) endometrial polyps, five (10%) submucous fibroid, three (6%) uterine septum, two (4%) uterine adhesions, and two (4%) increased endometrial thickness, as shown in [Table 2].
Table 2 Saline infusion sonography and hysteroscopy findings in the population studied

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In this study, the HS was more sensitive (100 vs. 85%), had the same specificity (100 vs. 100%), and was more accurate (100 vs. 94%) than SIS, and the HS also had higher predictive values (100 vs. 100% PPV; 100 vs. 90% NPV) than SIS during the evaluation of patients with unexplained infertility as shown in [Table 3].
Table 3 Diagnostic potential of saline infusion sonography compared with hysteroscopy (n=50)

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  Discussion Top


The acquired and congenital uterine anomalies are important causes of female infertility; hence, investigation of the uterine cavity is obligatory practice in the assessment of infertile women, particularly in patients with unexplained infertility [14].

Many tools are used in the diagnosis of intrauterine pathology, the most frequently used being TVS, SIS, diagnostic HS, and sampling, individually or in combination. The choice of the best test will depend primarily on its diagnostic accuracy [15].

Although it has been reported that instillation of saline during ultrasound (SIS) enhances and augments the image of the endometrial cavity [16], diagnostic HS is still generally accepted as the gold standard for the evaluation of the uterine cavity. It is an invasive procedure, which is associated with discomfort for the patients and sometimes vasovagal attack [17].

In our study, 50 women with unexplained infertility agreed to undergo SIS in addition to the HS for uterine cavity assessment. The most frequent uterine pathology detected in both SIS and HS was an endometrial polyp, followed by submucous fibroids and other uterine cavity abnormalities.

Our findings were similar to those of Kasius et al. [18], who found that the most frequent abnormalities during the evaluation of uterine cavities were endometrial polyps, followed by other uterine pathology. Also, Fatemi et al. [19] found that in a total of 678 asymptomatic infertile women before in-vitro fertilization/intracytoplasmic sperm injection, the overall prevalence of unsuspected intrauterine abnormalities was endometrial polyps and submucous myomas. The impact of endometrial polyps on fertility is uncertain, but some studies have shown improved pregnancy rates following their removal [20].

SIS yielded a false-negative diagnosis of three cases: two cases of endometrial polyps and one case of Asherman syndrome that was diagnosed by HS. In this study, the HS was more sensitive (100 vs. 85%), had the same specificity (100 vs. 100%), and was more accurate (100 vs. 94%) than SIS, and also had higher predictive values (100 vs. 100% PPV; 100 vs. 90% NPV) than SIS during the evaluation of patients with unexplained infertility.

The findings of the present research were almost comparable with the findings of Khan et al. [21], who reported 100% sensitivity, 67% specificity, 98% PPV, and 100% NPV for SIS in their study in the detection of endometrial cavity abnormalities. Our results were also similar to Cepni and colleagues, who found that SIS and hysteroscopy were equally accurate in the diagnosis of endometrial polyps and submucous fibroids in premenopausal patients, whereas HS was the most accurate tool for the diagnosis of polypoid lesions in the postmenopausal group. They also concluded that performing TVS, SIS, and dilatation and curettage could reduce the number of diagnostic HS performed for the evaluation of uterine cavity abnormalities [22].Widrich and colleagues also found a greater correlation between SIS and hyperplasia compared with HS, with no statistically significant difference between SIS and HS in detecting various other intrauterine lesions. The diagnostic accuracy of SIS in comparison with HS in terms of both sensitivity and specificity were 90.9 and 88.3%, respectively, in their study [23].

Gunes and colleagues studied the accuracy of SIS in 83 women with suspected endometrial cavity abnormalities using SIS for the diagnosis of endometrial cavity abnormalities in patients with abnormal uterine bleeding. They concluded that SIS was a reliable and accurate method for the detection of uterine cavity abnormalities and it can be a good alternative technique for the evaluation of uterine cavity abnormalities where office HS is not available [24].

Grimbizis et al. [25] considered HS as only a complementary procedure in case of abnormal findings detected by other methods (primarily hysterosalpingography and ultrasound) [26],[27].


  Conclusion Top


Women with unexplained infertility should be screened for possible uterine cavity abnormalities. SIS is a simple and well-tolerated procedure that can be used as an alternative technique for the evaluation of uterine cavity abnormalities when HS is not available. However, HS is still considered the gold standard to diagnose intrauterine pathology as it is more sensitive and more accurate than SIS.

Acknowledgements

All authors played an equal role in design, work, statistical analysis, and manuscript writing.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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