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Chapter 3: Hysterosalpingography
dilatation in the diagnosis
and treatment of fallopian
tube occlusion. Am J
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735–40.
40. Thurmond AS, Rosch J.
Nonsurgical fallopian tube
recanalization for treatment
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174: 371–4.
41. Zagoria RJ.
Transcervical fallopian
tube recanalization.
Appl Radiol 1995;
24:34–9.
42. Dwivedi MK, Pal R, Jain M,
et al. Efficacy of fallopian tube
catheterization for treatment
of infertility. Indian J Radiol
Imaging 2005; 15:521–3.
33
Chapter
Fertiloscopy
4
Antoine Watrelot
Introduction
The management of unexplained infertility is problematic,
because in the absence of a clear diagnosis of the causes of
infertility, treatment decisions are in effect therapeutic trials. The
diagnosis of unexplained infertility is established classically when
no pathology is found concerning the sperm value, ovulation, and
the tubal patency. The problem is that the last is frequently only
the conclusion of hysterosalpingography (HSG) or ultrasonography (US), which have both proven to be inaccurate [1]. Broadly,
most patients with “unexplained” infertility are treated according
to one or the other of two intervention strategies:
1. Offering some cycles (often 3–6) of stimulated or
unstimulated intrauterine insemination (IUI) to see
whether pregnancy occurs; if it does not, IVF is offered. In
these cases, IUI has wasted both the patient’s time and the
payor’s resources (the payor may be the patient/the patient’s
family or a third party payor, such as an insurer or a
government).
2. Offering IVF immediately, because of the possibility that
IUI will not work, with the risks of overtreating the patients,
once again with a lack of cost-effectiveness.
A third alternative is abdominal laparoscopy. This is the
currently accepted “gold standard” for establishing causes of
infertility in the fallopian tubes and the peritoneal cavity surrounding the uterus [2,3]. However, laparoscopy is a nontrivial
surgical procedure with significant risks. It is often performed
without discovering any significant pathology, which, for the
woman concerned, means being exposed to a surgical procedure that offers no benefit. Complications occur in about 3 out
of every 1000 abdominal laparoscopies [4]. These complications include:
*
Those related to general anesthesia
*
Injury to blood vessels or organs that causes bleeding
*
Damage to ducts or other structures that allow body fluids
to leak out
The risks and trauma associated with laparoscopy, as well as
the likelihood that the procedure will prove with hindsight to
have been unnecessary (because the woman has no relevant
disease), make doctors and patients understandably cautious
about carrying out laparoscopy at an early stage. However, as
noted, the resulting failure to diagnose the cause of the patient’s
“unexplained” infertility may mean that unnecessary treatment
(for example, IVF which could have been avoided) or ineffective
treatments (for example, intrauterine insemination for a
woman with blocked fallopian tubes) are offered.
It was therefore of interest to find an alternative that was
safe, minimally invasive, and reproducible to a relatively low
cost: thus was developed the concept of fertiloscopy in 1998
after the pioneering work of Gordts on transvaginal hydrolaparoscopy (THL) (Figure 4.1)[5,6,7].
Fertiloscopy is the performance of a laparoscopy through
the vagina using saline solution instead of CO
medium [8,9].
Important advantages are:
*
It is safe, since no CO2or Trendelenburg position is required.
*
Complication rate is low and no serious complication are
anticipated.
*
A perfect evaluation is possible of the genital tract, observed
in a true physiological position without any need to
manipulate the structures, which is not the case in
laparoscopy.
*
The proce dure is minimally invasive and can be performed
as an office procedure with local anesthesia or with general
sedation in an ambulatory process.
as working
2
Technique [10]
It is essential to carry out a careful vaginal examination prior to
the procedure. This examination allows detection of pathology
of the pouch of Douglas, such as nodules of the rectovaginal
septum or fixed retroverted uterus. These situations are important contraindications for fertiloscopy because, when there is
posterior endometriosis, the rectum is attracted close to the
posterior vaginal vault and the risk of rectal injury is high
when inserting the trocar. In case of a fixed retroverted uterus
there is no space to penetrate the pouch of Douglas.
Ultrasonography in Reproductive Medicine and Infertility, ed. Botros R. M. B. Rizk. Published by Cambridge University Press. © Cambridge
University Press 2010.
Fig. 4.2. The technique of fertiloscopy.
Chapter 4: Fertiloscopy
Fig 4.1. The principle of fertiloscopy.
Strict local anesthesia can be used, or general sedation may be
used. Strict local anesthesia is very useful in those countries
where office surgical procedures are allowed. In the other cases,
general sedation is normal; sometimes it is the choice of patients.
The advantage of general sedation is the possibility to practice
operative fertiloscopy at the same time when pathology is found.
Strict local anesthesia is carried out by first inserting an anesthetic swab (Emla gel) for 10 minutes, and then a classical paracervical block is performed using lidocaine. General sedation is
of the same kind as used for egg collection during IVF.
In all cases, fertiloscopy is performed as an ambulatory
technique. There are five steps in the procedure: (1) hydropelviscopy (Figure 4.2); (2) dye test; (3) salpingoscopy; (4) microsalpingoscopy; (5) hysteroscopy.
1. Hydropelviscopy is performed by first inserting a Verres
needle into the pouch of Douglas. This needle is inserted
1 cm below the cervix, and then saline solution is
instilled through a perfusion line using no other pressure
than gravity. When 150–200 ml has been instilled, the
Verres needle is removed and replaced by the fertiloscope
(FTO 1–40-Fertility Focus Ltd., UK). The sharp end of the
fertiloscope allows a direct insertion without any incision.
Also, the fertiloscope is fitted at its extremity with a balloon
that prevents it being inadvertently pulled out of the
peritoneal cavity (Figure 4.1). The optic is then introduced
via the fertiloscope, and observation can start (it is
important to use a 30° telescope of less than 4 mm outer
diameter). On first use of fertiloscopy, the view is
disconcerting to those accustomed to performing
conventional laparoscopy because the view is inverted
(Figure 4.1), but after a short learning period it becomes
easy to see all the reproductive structures. It is important to
have a systematic view of both ovaries, tubes (Figure 4.2),
fossae ovaricae, posterior part of the uterus, uterosacral
ligaments, and pelvic peritoneum.
Diameters
French
forceps
Fimbriae
Working method
Salpingoscopy
Fig 4.3. The technique of salpingoscopy.
Insertion:
sheath of
telescope
2.3 mm
diameter
telescope
2. When anatomy has been assessed, a dye test is performed
through the uterine fertiloscope (FH 1–29-Fertility Focus
Ltd., UK). Tubal patency is thus established.
3. Identification of tubal pathology such as intra-ampullary
adhesions or flattened mucosal folds (see Figures 4.6, 4.7,
4.8) is important because in these cases the only
valid therapeutic option is IVF. We therefore
systematically perform salpingoscopy (Figure 4.3). It
is straightforward to inspect the tubal ampulla
using the same scope, so salpingoscopy may be
practiced as a routine evaluation, which is not usually
the case during laparoscopy where a second optic, a
second cold light supply, and a separate irrigation are
needed [11].
35
Section 1: Imaging techniques
Fig 4.4. Normal microsalpingoscopy.
Fig 4.6. Minimal ovarian endometriosis.
Fig 4.5. Abnormal microsalpingoscopy with nuclei dye stained.
4. Microsalpingoscopy is a further step. The concept was
described by Marconi and Quintana [12] in1998, who
clearly demonstrated that after the dye test, the more the
nuclei are stained by the methylene blue dye, the more
pathological the tube is (Figures 4.4, 4.5). Every dye-stained
nucleus is a damaged cell (either inflammatory or in
apoptosis). To perform microsalpingoscopy a special optic
is used (Hamou II-K., Storz, Germany) that permits
magnification up to 100 times, thus achieving real “in vivo”
histology. Findings are classified as normal if none or few
dye-stained nuclei are seen, or pathological when many
nuclei are dye stained [13].
5. A standard hysteroscopy (through the same optic) is then
performed in order to have a complete evaluation of the
reproductive system.
At the end of the procedure, the scar is so small that it is not
necessary to close the vaginal puncture site and we do not give
any antibiotics.
Imaging
Introduction of a Verres needle and then of the fertiloscope in
the pouch of Douglas sometimes raises fear of rectal injury.
Even if it has been demonstrated that such an injury is avoidable and not of serious consequence, one may prefer to introduce the instrumentation with a visual control. The technique
of ultrasound-guided entry has been proposed.
Operative fertiloscopy
In the beginning, fertiloscopy was purely diagnostic. But thanks to
the operative channel provided on the fertiloscope, several forms
of treatment have rapidly been developed and performed. We can
now routinely practice adhesiolysis, treatment of minimal and
sometimes mild endometriosis, and ovarian drilling [14].
In order for it to become generally accepted, it needed to be
shown that operative fertiloscopy was as effective as the same
procedure practiced during laparoscopy, and this requirement
places some limitations on the procedures [15]. These are
described below.
The operative channel is unique and small (5F, 1.5 mm
diameter) and because of this only relatively limited adhesiolysis can be performed (especially when adhesions are found
between the distal part of the tubes, ovaries, and fossa ovarica)
(Figure 4.5). Similarly, endometriotic lesions can be treated
only when minimal or moderate (Figures 4.3 , 4.4).
Another requirement is to avoid any bleeding during operative fertiloscopy, since only a few drops of blood will obscure
the field of vision. For this reason, very careful hemostasis is
necessary and a bipolar probe should obviously be used to work
in the liquid environment. Several such probes exist and we
36
Fig 4.7. Ovarian drilling.
Chapter 4: Fertiloscopy
mostly use the disposable Versapoint (Gynecare, USA). For all
these reasons, it is evident that operative fertiloscopy does not
compete with operative laparoscopy: it is only an additional tool
that may in some cases avoid unnecessary laparoscopy.
Justification of fertiloscopy
The fundamental question was to know at an early stage whether
fertiloscopy was as accurate as laparoscopy, which was considered at that time the “ gold standard” in infertility investigation.
To be able to answer this question, we designed a special
study: the FLY study (acronym for fertiloscopy versus laparoscopy) [16]. This was a multicenter prospective randomized study
in which first fertiloscopy and then laparoscopy were performed
on the same infertile patient by two surgeons A and B randomized
for the procedure. Every procedure was video recorded, the
files being seen by two independent reviewers. This trial was
approved by the French ethical committee under the Huriet law.
Fourteen teaching hospitals centers were enrolled (12 in France,
1inBelgium,and1inTunisia),and92patientswerestudied.
Calculation of sensitivity and specificity was performed as
well as concordance test using kappa score on the results from
six sites (both ovaries, tubes, peritoneum, and ovaries), the total
number of sites for analysis being 552 (92 × 6). The kappa score
between sites varied from 0.75 to 0.91.
A correlation between two diagnostic tools is considered as
excellent when the kappa score reaches 0.75 or more. Thus the
conclusion of the FLY study was that “fertiloscopy should replace
laparoscopy in infertile women with no obvious pathology.”
Can fertiloscopy be used as a first-line
infertility test?
For many years we have been looking for a simple, reproducible,
safe, minimally invasive, and relatively cheap method to diagnose
pelvic abnormalities in infertile patients. Many noninvasive tools
such as hysterosalpingography (HSG) and hysterosonography
(USG) or invasive as laparoscopy are available.
Their ability to assess the four important parameters
to consider (i.e., tubal patency, tuboperitoneal environment,
tubal mucosa, and uterine cavity) is variable. They are summarized in Figures 4.8, 4.9, 4.10, which demonstrate that fertiloscopy seems to be the most suitable exploration.
Strategy for fertiloscopy
According to the specific health system and the legislation concerning office procedure, two different strategies are available:
1. When office procedure is available and permitted,
fertiloscopy may be practiced early in the infertile work-up
(i.e., after one year of infertility). In this case fertiloscopy is
performed under strict local anesthesia. If no abnormalities
are detected then it is logical to practice expectant
management up to two years of infertility since the chances
of pregnancy per cycle are still 12% during the second year
of infertility. After two years of infertility, the spontaneous
pregnancy rate falls around 5% and it is then consistent
to propose IUI. If pathology is detected, the patient is
treated accordingly, which means further surgery in cases of
endometriosis or pelvic adhesions or IVF if the tubes appear
to be damaged beyond the possibility of surgical repair.
This is often the case when tubal mucosa is involved.
2. When surgical office procedures are not available or not
permitted, fertiloscopy is performed under general
anesthesia in the operating room prior to beginning IUI or
IVF (this means after 2 years of infertility except in patients
aged over 38, when only one year of infertility is required,
or over 40 years, when fertiloscopy is carried out directly).
When fertiloscopy is normal, patients are referred for
artificial reproductive technologies (ART) or treated
according to the lesions encountered.
Advantages of local anesthesia are obvious; also it is a low-cost
option. General anesthesia, on the other hand, allows for
37
Section 1: Imaging techniques
Fig 4.8. Strategy for fertiloscopy.
n = 1164
Fertiloscopy = normal
Salpingoscopy = normal
n = 572
IUI
Fertiloscopy = normal
Salpingoscopy = abnormal
n = 202
Fertiloscopy = abnormal
Salpingoscopy = normal
n = 261
Fertiloscopy = abnormal
Salpingoscopy = abnormal
n = 129
IVF
operative fertiloscopy or further laparoscopy when required at
the same time. Indeed, the patient may choose between the two
options, but the earlier the fertiloscopy is practiced the more
likely it is that any pathology can be treated in order to obtain
pregnancy in the shortest time.
Complications
Complications are rare if clinicians respect firstly the learning
curve – which has been evaluated at 5 to 10 procedures according to the surgeon’s skill – and secondly the contra-indications,
which are pathology of the pouch of Douglas such as recto-
Fig 4.9. Results of fertiloscopy.
Surgery
vaginal endometriosis or fixed retroverted uterus. These pathologies are detected by vaginal examination prior to the procedure. Any doubt should lead to cancellation of the fertiloscopy
and to proposal of the necessary laparoscopy.
The only real complication is represented by rectal injury.
However, such injury may be always treated conservatively with
antibiotics without the need for further surgical intervention [17].
Case studies [18]
Between July 1997 and January 2008, 1589 patients presenting
with infertility lasting more than one year were potentially
38
Chapter 4: Fertiloscopy
Scoring of diagnostic tools
0 = no value, 5 = very good value
Tub
o-
peritoneal
environment
1
1
HSG
[1]
USG
[2]
Laparoscopy
[3]
Laparoscopy
+ hysteroscopy
Fertiloscopy
[16]
Tubal
patency
4
4
50 5 1
55 5 1
55 5 5
Uterine
cavity
4
4
enrolled for fertiloscopy. In all these patients, the sperm evaluation in the husband showed either a normal value or a value
allowing the use of IUI. Also, every patient considered as
normal or doubtful underwent HSG.
Out of 1589 candidate patients, ninety-one (5.7%) were
excluded during the selection process due to abnormalities
discovered during the preoperative clinical examination (as
previously described, mainly endometriosis of the rectovaginal space or fixed retroverted uterus). These cases, being
contraindicated for the technique, were referred to operative
laparoscopy.
Thus, 1498 patients underwent fertiloscopy. Written consent was required for each patient. The mean age was 32 years
(range 22–41); mean duration of infertility was 3.2 years (range
1–9). Primary infertility affected 1018 patients (68.0%).
Procedures
In 1490 patients (99.5%), fertiloscopy was performed as an
ambulatory procedure; 288 patients (19.2%) were treated
under strict local anesthesia; the remaining 1202 (80.8%) were
treated under general sedation, which allowed operative fertiloscopy at the same time when necessary.
Findings of diagnostic fertiloscopy
Global results were a s follows. Patients’ macroscopic findings
appeared to be normal in 1006 (67.1%) . We included in this
category patients with subtle lesions such as paratubal cyst,
nonconnective adhesions, very minimally endometriotic
lesions, and minor tubal alterations such as sacculation or
accessory tube.
Pathology was found in the other 492 (32.8%).
Endometriosis was found in 112 patients (7.5%); in 79 (5.3%)
cases the endometriosis was considered mild and in 33 cases
Fig 4.10. Comparison of diagnostic
tools
To tal
Tubal
mucosa
2
0
11
9
11
16
20
(2.2%) was severe. The frequency of endometriosis thus appears
quite low. This is due firstly to the exclusion policy for patients
with endometriosis of the rectovaginal septum and secondly to
patients with minimal endometriosis being considered as having subtle lesions and classified as normal or having minimal
impact on fertility. We should therefore add 72 cases of rectovaginal endometriosis and 139 cases of minimal endometriosis.
Thus, 323 patients (21.6%) presented end ometriosis at various
stages or locations, which is consistent with findings in an
infertile population.
Pelvic adhesions and tubal path ology were the second main
pathologies, encountered in 380 patients (25.4%). We distinguished minimal adhesions with normal tubes in 114 patients
(7.6%); 208 patients (13.9%) had mild adhesions associated with
either a phimosis or hydrosalpinx, and 58 patients (3.9%) had a
severe adhesion status associated with tubal lesions (phimosis,
hydrosalpinx, or proximal tubal blockage). The group of
patients with severe adhesions is rather small because very
often lesions were seen on HSG and in these cases patients
were directly referred to operative laparoscopy as mentioned
above.
Initially fertiloscopy was exclusively diagnostic; then in
1999 we added the routine practice of microsalpingoscopy
following the work of Marconi [12]. In the earlier period
(prior to January 1999) 266 fertiloscopies were performed;
1232 have been performed since that time. We have shown
that salpingoscopy and microsalpingoscopy are feasible
routinelyinagreatnumberofcases.Inourseriesitwaspossible
to carry out both techniques in at least one tube in 1164 cases
(94.3%).
From 1999 the results of microsalpingoscopy were taken
into account, making it possible to distinguish four situations
according to the tubal mucosa score (Figure 4.9): group 1,
normal fertiloscopic findings and normal tubal mucosa; group
2, normal fertiloscopic findings but abnormal tubal mucosa;
39
Section 1: Imaging techniques
group 3, abnormal fertiloscopic findings but with normal tubal
mucosa; group 4, abnormal fertiloscopic findings and abnormal tubal mucosa. We had 572 patients in group 1, 202 in group
2, 261 in group 3, and 129 in group 4.
Patients of groups 2 and 4 (i.e., with abnormal tubal
mucosa, were directly referred to IVF. Patients of group 1
were considered eligible for IUI, and patients of group 3 have
had subsequent surgical treatment. Thus, 331 patients were
referred for IVF (28.4%), 572 were referred for IUI (49.1%),
and 261 were referred for surgery (22.4%).
Out of the 261 patients for whom surgery was decided, in
139 (53.3%) treatment was achieved through operative laparoscopy, 105 (40.2%) were treated by operative fertiloscopy, and
only 17 (6.5%) were treated by microsurgical proximal anasto mosis. When operative fertiloscopy was performed it involved
distal ovarosalpingolysis in 78 cases and treatment of ovarian
superficial lesions in 27 cases.
We were able to achieve a complete follow-up for only 6
months because of the varying geographic origins of the
patients. Among the 572 patients referred for IUI, 118
(20.6%) became pregnant in the following 6 months and
after 1–3 IUI attempts. Among the 331 patients referred for
IVF, 121 (35.6%) became pregnant after 1 or 2 attempts.
Among the 261 patients treatedsurgically,weobtained92
(35.2%) pregnanc ies.
One hundred and five patients (40.2%) were treated through
operative fertiloscopy and 29 pregnancies were achieved
(27.6%). One hundred and thirty-nine patients (53.2%) had
an operative laparoscopy and 53 pregnancies were obtained
(38.1%). In the remaining 17 patients we performed a microsurgical anastomosis for proximal tubal obstruction and 10
pregnancies were obtained (58.8%). There was no significant
difference between patients who had IVF and patients who
underwent a surgical approach.
In all, 331 patients out of 1164 (28.4%) became pregnant in
the following 6 months.
*
As in all surgical procedures, complications may occur.
*
We had three rectal injuries, all treated conservatively
(i.e., antibiotics for 5 days without any further surgery).
*
Only one infection (0.09%) occurred despite the fact that no
antibiotics are routinely given.
*
We also had two abnormal vaginal bleedings (0.17%); in
such cases a stitch on the vaginal wall was required, which is
not commonly the case.
*
Lastly, we had 11 cases of false route (0.95%). That signifies
that the fertiloscope was inserted between the peritoneum
and the vaginal wall. This complication was the result of
poor technique (essentially linked with a slow insertion of
the needle in the pouch of Douglas instead of its insertion
with a firm movement).
*
There were no complications in patients who had operative
fertiloscopy.
Conclusion
Our series demonstrates that fertiloscopy is useful for diagnosis
of tubal diseases that are not openly visible after noninvasive
exploration like HSG.
Results of the FLY study have shown that fertiloscopy is at
least as accurate as laparoscopy and dye. However, fertiloscopy is less invasive and less risky than “lap-and-dye.”
Moreover, fertiloscopy allows a careful evaluation of the
tubal mucosa. In this respect, fertiloscopy shows superiority
in comparison with lap-and-dy e. Indeed salpingoscopy allows
us to explore only the distal part of the tube. The proximal
portion is too narrow to be explored except by falloposcopy,
which is still experimental because of the poor quality of
imaging obtained. This disadvantage is counterbalanced by
the fact that the distal part of the tube is not only the more
common location of tubal lesions but is also the most important part of the tube where everything happens: oocyte
retrieval and fertilization.
Microsalpingoscopy seems to have a good prognostic value
but will require more studies before it is completely validated.
Nevertheless, for the first time an “in-vivo histological” appreciation of the tubal mucosa is available
Therefore, patients who have been elected for tubal surgery
have a pregnancy rate after 6 months that is not statistically
different from the IVF group (35.2% and 35.6%, respectively).
Tubal surgery remains a valid option after proper selection.
Also, when tubal pathology is discovered we may in some
circumstances propose treatment by operative fertiloscopy (in
our series 105 patients [40.2%]).
Fertiloscopy also appears to be a relatively easy technique
but it has to be learned by experience. In our experience we
consider that the practice of 10 fertiloscopies is necessary for a
“new” laparoscopic surgeon to be able to include fertiloscopy in
his or her strategy.
At this stage we believe that fertiloscopy should be widely
adopted as a precise minimally invasive tool as already demonstrated by several teams. Sharma et al. [3] considered fertiloscopy a safer method than laparoscopy and one that in addition
allows salpingoscopy, Tanos et al. [19] performed 78 fertiloscopies and showed that the learning curve was short and the
results were very accurate. More recently Nohuz et al. [20]
performed fertiloscopy in 229 infertile women and discovered
a pathology in 28.6% of cases. These results are similar to those
observed in our study.
Fertiloscopy is an attractive alternative to lap-and-dye
when tubal pathology is suspected. Accuracy of fertiloscopic
findings has been demonstrated and allows a good selection
for patients with tubal or peritubal pathology. When this is
done, pregnancy rate after tubal surgery is the same as after
IVF. A spontaneous pregnancy obtained after surgery has
many advantages: it is cheaper, it is more physiological, and
when the disease is tre ated several pregnancies can be achieved
without further treatment.
40
Chapter 4: Fertiloscopy
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41
Chapter
Sonohysterography
5
William W. Brown, III
Introduction
Saline infusion sonohysterography (SIS) is a minimally invasive
office technique designed to maximize investigation of the
female genital tract. Transvaginal sonography (TVS) is performed while sterile saline is simultaneously infused into the
uterus to distend the endometrial cavity. The fluid contrast
enhances ultrasound visualization by outlining intracavitary
defects or growths. The result is a simple screening method
for pelvic abnormalities with major advantages over other
imaging modalities and without the invasive risks or expense
of surgical evaluation.
Procedural method
Indications
Clinical applications for this diagnostic test include the following: abnormal uterine bleeding (AUB), infertility, recurrent
pregnancy loss (RPL), postmenopausal bleeding, abnormal
TVS finding, postoperative assessment, possible intrauterine
adhesions, tamoxifen pretreatment evaluation, indistinct endometrium, and retained products of conception.
Contradictions
A very satisfying fact about this simple office procedure is that
there are only two absolute contraindications: pregnancy or
possible pregnancy, and active pelvic infection. If a history of
chronic pelvic inflammatory disease is elicited, if painful dilated
fallopian tubes are discovered during baseline TVS, if the pelvis
is inexplicably tender on bimanual examination or with vaginal
ultrasound probe palpation [1], or if a mucopurulent cervical
discharge is noted on speculum examination, then SIS can be
delayed and prophylactic antibiotic treatment offered. Active
vaginal bleeding is only a relative contraindication to SIS,
primarily because blood and clot can inhibit optimal imaging
and confound interpretation.
Timing
Ideally, in a patient who is ovulating and menstruating regularly, this procedure should be performed sometime between
cycle days 6 and 10; that is, after the end of the menstrual flow
and prior to ovulation. Thi s timing precludes the chance of
interfering with a very early pregnancy, and the expected thin,
symmetric follicular-phase endometrium will optimize the ability to visualize any uterine filling defects, if present (Figure 5.1).
The more echodense luteal-phase endometrium, which thickens as the cycle advances and measures up to 14–16 mm immediately prior to menstruation, may obscure small intracavitary
echogenic masses. Not only that, late secretory endometrium
can look irregular and polypoid, thereby increasing the possibility of a false-positive diagnosis. As might be expected, careful
timing for SIS is less of a consideration in those patients who are
on hormonal contraception because pregnancy risk should be
obviated and the suppressed endometrial growth enhances
visualization. Lastly, although bleeding is not a contraindication, it is best to avoid this test when a patient is bleeding very
heavily. Blood clots, especially, may hinder the validity of the
results by masquerading as filling defects themselves and potentially obscuring true nearby lesions (Figure 5.2).
Practically speaking, however, it is not always possible to
schedule this examination when it is best for both patient and
physician. Menstrual histories are not always known or predictable, and ovulatory status can be uncertain. Pregnancy testing is
always advised when appropriate in premenopausal women, but
such testing can be falsely negative early in the luteal phase.
Sexually active patients practicing unprotected intercourse can
be given the option to return after their next menses or sign a
written consent that acknowledges the potential risks of sonohysterography to an undiagnosed pregnancy.
Technique
Antibiotic treatment prior to sonohysterography is not routinely recommended; however, it is important to consider its
use if the patient has already been noted to have certain particular gynecologic indications as described above. The American
Heart Association 2007 guidelines for the prevention of infective endocarditis no longer consider any genitourinary procedures as high-risk and do not recommend routine use of
prophylactic antibiotics, even in patients with the highest-risk
cardiac conditions. Additionally, the need for any nonsteroidal
Ultrasonography in Reproductive Medicine and Infertility, ed. Botros R. M. B. Rizk. Published by Cambridge University Press. © Cambridge
University Press 2010.