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Chapter 5: Sonohysterography
(a)
(b)
Figure 5.1. Saline infusion sonohysterography, sagittal view, normal empty
uterine cavity. (a) SIS catheter advanced to the mid-body of the uterus.
(b) Balloon catheter pulled back to the level of the internal cervical os. The thin,
symmetric endometrium is easily seen and measured (calipers). A minute
amount of air in the balloon filled with saline is responsible for the obvious
linear shadow (arrow).
Figure 5.2. Longitudinal transvaginal SIS image of a blood clot (calipers). This
echodense pseudo-mass can be confused with true pathology within the uterus
and is characterized by shaggy and irregular borders, absence of vascular flow,
free-floating position, and tendency to break apart when touched with an
infusion catheter.
analgesia during the procedure is rare enough to warrant individualized treatment. In most practices, sonohysterography is
immediately preceded by high-frequency TVS. Exact menstrual
dating and latex allergy are documented first, and a negative
pregnancy test is obtained, along with a signed informed consent, when appropriate. The purpose of the baseline ultrasound
is to confirm all pelvic findings prior to the fluid enhancement
study. Awareness of any extreme anterior or posterior uterine
position can sometimes help facilitate placement of the infusion
catheter, and the unexpected finding of painless hydrosalpinges
is a reasonable indication for short-term postprocedure antibiotics, such as 200 mg doxycycline after the procedure and
then 100 mg/day for a total of 5 days [2].
Upon completion of the baseline ultrasound, the vaginal
probe is removed, set aside, and replaced with a speculum in the
vagina to visualize the cervix. The cervix is cleansed thoroughly
with a solution of either povidone iodine or chlorhexidine,
depending upon the patient’s allergy history. At this point, a
catheter that has been pre-filled with sterile saline from an
attached 10–12 ml syringe in order to avoid infusing air into
the cavity and completely obscuring visualization, is inserted
into the uterus. There are many catheter options available, such
as intrauterine insemination catheters, 5F or 7F balloon hysterosalpingography (HSG) catheters, pediatric feeding tubes,
small-gauge Foley catheters, in-vitro fertilization (IVF) embryo
transfer catheters, and others. The choice of catheter is entirely
up to the provider, and the selection depends upon cost, ease of
insertion, ability to distend the uterus, and patient comfort. It is
prudent, however, to have more than one catheter available for
use during the procedure because it is unreasonable to expect
one style to work best in all situations. If a balloon catheter is
used, the balloon is now filled also with saline and pulled back
with gentle traction to the level of the internal cervical os, so as to
prevent egress of fluid during the saline infusion. Dessole et al.
[3] compared six such catheters and found no statistical difference in their ability to correctly perform the SIS procedure.
After the catheter has been placed, the speculum is removed
from around the catheter, while being careful not to dislodge
it. The vaginal probe is inserted again into the vagina, and it
is more comfortable for the patient if the examiner uses the
fingers of a gloved free hand to open the labia and gently
depress the perineum to facilitate insertion, especially if a larger
three-dimensional ultrasound (3D) probe is used. Now imaging
is carried out by recording multiple views of the uterine body
and lower uterine segment in both sagittal and transverse planes
while saline is being infused to physically separate the walls. The
goal is to have a complete evaluation of the entire endometrial
cavity, and this typically requires multiple static images in both
planes. A typical study usually requires no more than 10–20 ml
of saline infused, but the total amount is variable and patientspecific. If the additional technology is available, a 3D volume
data set can be obtained in a matter of seconds, and this may
both shorten the procedure time and improve specificity of the
testing. Lastly, all instruments are removed from the uterus,
cervix, and vagina and appropriate documentation of the study
43
Section 1: Imaging techniques
is completed. The patient should be informed that short-term
spotting and pelvic cramping are not uncommon after this
procedure.
Optimizing performance
The following suggestions are offered to help maximize the
chance for procedural success and for troubleshooting, in
advance, of some of the more common difficulties that can be
encountered during SIS.
*
Sterile SIS tray. The instruments – which should be part of a
pre-set sterile tray, or wrapped separately and easily
available – for use with each SIS procedure include:
speculums of various sizes and widths, containers to hold
the antiseptic bactericidal solution of choice and saline, a
single-toothed tenaculum, cotton balls, ring forceps, small
graduated cervical dilators, lubricating jelly, at least two
options for intrauterine catheters – one containing a
balloon tip, sterile saline, povidone iodine and Hibiclens,
10- or 12-ml infusion syringes, local anesthetic, and needles.
*
Speculum. A single-hinged or open-sided speculum
facilitates removal from the vagina around the catheter,
especially if the attached syringe is a 20- or 30-ml size. If the
only speculum available is the more typical double-hinged
type, then, for the sake of patient comfort, do not attempt to
open it at its base to allow pull-through of the catheter and
syringe until it is completely outside of the introitus.
*
Uterine distension. There will be occasions where inherent
uterine pathology or laxity of the internal cervical os does
not allow for adequate distention of the cavity, and a balloon
catheter may help in this situation. The balloon should be
filled with 1–2 ml saline (not air), which is usually quite
adequate to allow it to be pulled back against the internal os
under mild tension and act as a stopper to prevent
retrograde leakage of fluid under pressure back out of the
uterus and cervix. As noted above, a single rapid 3D sweep
of insonation can also be beneficial w hen the uterus stays
distended only briefly. The volume data set obtained in this
manner can undergo postprocessing to create all the
necessary images in any plane and does not require refilling
of the syringe or the uterus.
*
Patient discomfort. Mild cramping during or after this
procedure does occasionally occur, so oral analgesic
medication may be started immediately prior to the
appointment or simply on an “as needed” basis. Significant
procedural pain can potentially be averted by avoiding
touching the uterine fundus with a firm catheter tip or by
inflating a balloon catheter in the cervix rather than in the
lower uterine segment prior to saline infusion [4]. It is
always best to begin the infusion slowly and continue slowly
while observing the patient’s subjective reaction. Very
rarely, even with only a minimal volume of saline instilled, a
patient will suffer with extreme pain, cramping, nausea
diaphoresis and faintness. Every office should be prepared
to address such a vasovagal reaction.
*
Cervical stenosis. Inability to adequately place a catheter is
one of the main causes of procedural failure. Sometimes, all
that is needed is a stronger, less-malleable catheter, such as
the Shepard insemination catheter (Cook Medical,
Bloomington, Indiana) that is equipped with a somewhat
rigid inner cannula. Other catheters that have been
proposed for this purpose include chorionic villus sampling
catheters and the Echosight catheter (Cook Medical) [2]. It
may be necessary to locate the cervical os or to serially dilate
the endocervical canal and internal os with small disposable
or metal dilators. This often requires use of a cervical
tenaculum, which, otherwise, is almost never necessary for
this procedure, in order to bring the uterus and cervix into
an aligned, horizontal plane. Use of either spray or
injectable local anesthesia on the cervical lip prior to
tenaculum placement is patient-centered, as is also
paracervical anesthetic block before any unusual or
prolonged efforts to dilate the canal. Finally, although it is not
an FDA-approved use, some physicians have also pretreated
their patients with oral or vaginal misoprostol in an effort to
successfully overcome severe cervical stenosis.
*
Sub-optimal visualization. A large, fibroid uterus and a
directly midplane uterus are two examples in which the
imaging may actually be improved by performing
transabdominal ultrasound with SIS, rather than TVS. Be
sure, then, always to have an abdominal probe available for
this express purpose, as well as to attempt imaging of
adnexal structures which are not seen vaginally.
*
Lower uterine segment evaluation. This area of the
endometrial cavity also requires examination. If a balloon
catheter is used, intracervical placement of the balloon
allows full and complete visualization. Sometimes,
however, a patulous or multiparous cervix simply will not
hold the balloon, and the only location it will work is above
the level of the internal cervical os. In this event, prior to
termination of the procedure, the balloon should be
deflated completely, and the lower uterine segment is
imaged while the catheter is being withdrawn and final
amounts of saline are infused simultaneously (Figure 5.3).
*
Endometrial sampling. If endometrial sampling is necessary,
SIS should be performed first so that disturbed or lifted
endometrial mucosa does not confuse image interpretation.
Common disposable biopsy samplers can be used for this
purpose, or catheters that are specifically designed for the
dual purpose of fluid infusion and endometrial biopsy are
available, such as the Goldstein Sonobiopsy Catheter (Cook
Medical).
Complications
SIS is a minor office procedure that is usually very well tolerated by the vast majority of women, a lthough mild pelvic
cramping and spotting are not uncommon side-effects. There
are reports of occasional severe complications, and in a recent
prospective study of 1153 patients [5] the stated incidence
44
Chapter 5: Sonohysterography
(a)
Figure 5.3. Optimal visualization of the lower uterine segment. (a) With the catheter tip at the level of the internal cervical os, instillation of fluid is begun as the
catheter is completely withdrawn. (b) Distended lower uterine segment at the termination of the SIS procedure.
of peritonitis due to ascending pelvic infection was 0.95%.
Patients, of cou rse, should be apprised of this low-level risk
and encouraged to call or return for evaluation in the event of
postprocedural fever and progressive pelvic pain. In that same
study, surprisingly, 8.8% of the participants experienced moderate or severe pain, vasovagal symptoms, or nausea or vomiting during the procedure; however, mostly intrauterine
balloon catheters were used, and there is no mention of what
other techniques, if any, were employed to prevent or reduce
such reactions.
Failure of the procedure does also occur, unfortunately. de
Kroon [6], in a meta-analysis of 24 studies and 2278 procedures, describes an overall failure rate of 7% – a figure that
jumps to 13.5% in postmenopausal women, most likely due to
cervical stenosis. A 5–7% range for procedural failure or incomplete investigation has also been reported by several other
authors, with the larger fibroid uterus noted to be one of the
other statistical predictors for a suboptimal result.
Finally, there remains the valid concern about fluid contrast hysterography and possible intraperitoneal spread of
endometrial cancer. Two authors [7,8]havereportedsmall
prospective studies specifically designed to evaluate the risk
of sonohysterography in patients with uterine cancer. The
results differed substantially between the studies: the mean
volume amount of saline instilled necessary to complete an
adequate SIS examination varied from 8.5 to 33 ml, and the
occurrence of malignant or suspicious cells recovered from
tubal fluid s pill ranged from 6% to 25%. What seems clear is
that transtubal spill o f fluid and endometrial cells into the
peritoneal cavity does occur during SIS. Controversy still
exists, however, regarding the prognostic significance of peritoneal washings positive for cancer cells, whether they be
naturally occurring or artificially induced. Additionally,
even if some dissemination of malignant cells into the pelvis
does occur during a fluid contrast study and results in a small
risk of upstaging early endometrial cancer, there currently is
no definitive evidence that such an occurrence worsens long-
(b)
term prognosis [9]. More study is certainly needed in this
area. In the meantime, since high fluid volumes and pressures
during sonohysterography probably increase the rate of tubal
spill, every effort should be made to avoid both during the
procedure.
Diagnostic accuracy
Theliteratureisnowflush with multiple studies that document
how very well SIS compares with other uterine imaging modalities
in patients with AUB [10], infertility [11], and RPL [12]. Although
sonohysterography provides an indirect look inside the uterus, its
ability to accurately diagnose intracavitary filling defects, such as
myomas and polyps and adhesions and even malformations,
matches that of the “gold standard” hysteroscopy. Understandably,
SIS adds more information than TVS alone; in addition, its performance is consistently much more sensitive and specific than that
of hysterosalpingography, without exposing the patient to either
ionizing radiation or contrast allergy. An improvement over hysteroscopy for the clinician, this procedure images far more in the
female pelvis than simply the uterine cavity; yet, it is relatively
simple to learn and perform, and it can easily be provided by
those gynecology practices already offering TVS.
Specific imaging examples
Submucous myoma
Leiomyomas are hormone-dependent smooth-muscle tumors
of the myometrium. Reported to be present in 20–40% of
women during their reproductive years, they are the most
common tumor found in females. Sonohysterography is an
imaging technique with very high sensitivity for accurately
diagnosing submucosal myomas, which penetrate variably
into the endometrial cavity. The sonographic characteristics
of these benign masses include broad-based heterogeneous
echoes; isoechoic or hypoechoic appearance when compared
with surrounding myometrium; an intracavitary component
45
Section 1: Imaging techniques
that is sometimes also clearly lined with endometrium
(Figure 5.4); occasional poor sound transmission; distal shadowing when quite dense (Figure 5.5); hyperechoic foci if calcification is present; and a symmetrical and well-defined contour.
Distortion of the endometrial cavity may or may not be
associated with significant myometrial penetration, and the
European Society of Hysteroscopy has developed a classification system to describe the relevant anatomy. A Type 0, or T:0,
submucous fibroid has no intramural extension; T:1 has <50%
extension, and T:2 has >50% intramural involvement [13]. This
kind of classification allows authors around the world to speak in
similar terms, and it also is a tool that can assist surgeons with
preoperative planning. Hysteroscopic resection of T:0 and T:1
tumors can usually be accomplished completely (Figure 5.6),
whereas T:2 myoma resection may require more than one procedure to complete, should be performed by only the most
experienced hysteroscopists, and may be facilitated by the combined addition of either ultrasound or laparoscopic guidance.
Although the majority of women with myomas are asymptomatic, some patients with myomas may present with AUB in
the form of pre- or postmenstrual spotting, heavy or prolonged periods, or intermenstrual spotting. The exact association between fibroids and AUB has not been clearly defined,
but it has been theorized that excessive menorrhagia could be
due to venous congestion in the myometrium and endometriumfromtheobstructiveeffect of myomas on uterine vas-
culature. Surgery can be an appropriate option to address the
bleeding consequences of fibroids when conservative medical
management fails, and complete hysteroscopic resection of
submucous tumors has been shown by Corson and Brooks
[14] to dramatically improve menorrhagia rates.
Many authors agree that leiomyomas alone are probably
not a common cause of infertility [15], but the relationship of
fibroids to reproductive outcome is not well characterized.
Unfortunately, most of the studies that address this subject
are fraught with a paucity of prospective, randomized, controlled trials and a lack of statistical power. Tumors that distort
the endometrial cavity do appear to decrease fertility by 50–70%
in the patients undergoing IVF due to failure of implantation,
and their surgical correction can improve pregnancy rates
to baseline [16]. So, given either infertility or RPL, surgery to
remove submucosal myomas should be considered, but only
after a thorough evaluation of all other causes and potential
factors has been completed.
Figure 5.4. Coronal view of the uterus filled with saline. A Type 0 submucous
myoma is contained entirely within the cavity and arises from the right sidewall.
The mass is incompletely lined by endometrium and blood clot (arrow).
Figure 5.5. Sagittal view of a large Type I posterior submucous myoma
(calipers) with minimal myometrial penetration. This solid, mostly spherical mass
with mixed echoes and posterior acoustic shadowing has ultrasound
characteristics that are typical for a fibroid, and it would be amenable to
hysteroscopic resection.
Figure 5.6. This uterus as seen in horizontal cross-section contains a
submucous fibroid. Sonohysterography fluid contrast allows complete
delineation of the posterior tumor, its depth of myometrial and endometrial
extension (calipers), and its measured distance away from the exterior serosal
surface.
46
Chapter 5: Sonohysterography
Endometrial polyp
The most common filling defects identified by sonohysterography are polyps, which are growths of either mature or immature endometrium that are attached to a pedicle. Their
sonographic characteristics are that they have a sessile or
pedunculated base, usually an oval or fusiform shape, size
varying from millimeters to centimeters, slightly greater echogenicity than myometrium, typically isoechoic with endometrium, and mostly homogeneous echoes though they may
appear to have “microcysts” (Figure 5.7); they arise from
the endometrium, do not distort the endo-myometrial junction, and often reveal a “feeder vessel” (Figure 5.8) on color
Doppler evaluation. Patients with polyps may have no symptoms, may have fertility complaints, or may present with bleeding abnormalities similarly to women with fibroids. In fact, it is
not necessarily uncommon to find that some women with AUB
actually have coexisting submucous myomas and polyps
(Figures 5.9, 5.10).
Endometrial polyps are usually surgically excised in symptomatic patients, although the exact association of polyps with
AUB is not yet completely known. In a recent retrospective
study of a mix ed population of 300 women with polyps, 24.3%
of whom were asymptomatic, the underlying rate of malignancy and complex hyperplasia with atypia was 1.6%. All of
the cancer cases were in peri- or postmenopausal patients
symptomatic with AUB [17]. Thus, the authors reaffirmed
the need for symptomatic polyps to be removed. Although
cancerous polyps have been found in asymptomatic women,
there is currently no evidence-based standard that guides management decisions when the diagnosis of an endometrial polyp
is completely incidental.
If there is a decisive relationship between infertility and
the presence of polyps, that, too, needs further study. The
mechanisms that regulate and impact implantation are
mostly unexplained, but there is still concern that structural
abnormalities in the uterine cavity may play a role in
subfertility, implantation failure, and miscarriage. Reports
about polyps, and whether or not their removal results in
improved pregnancy rates, are conflicting [18,19]; however,
it is still common clinical practice to screen the uterine
cavity for abnormalities such as polyps in infertility
patients, especially prior to IVF or after IVF failures, and
SIS is an ideal way to accomplish this.
Postmenopausal women undergoing tamoxifen therapy
are at increased risk for precancerous or cancerous change of
the endometrium, but screening for these conditions in
asymptomatic women using tamoxifen is not recommended.
The presence of endometrial polyps in this group of patients
prior to therapy, however, may increase the defined risk from
this medication. Conseque ntly, pretreatment sonohysterography to specifically investigate for polyps is a reasonable
consideration.
Figure 5.8. Color-flow image of an anterior endometrial polyp with a sessile
base and a central “feeder vessel.”
Figure 5.7. Saline sonohysterography of a retroverted uterus with two polyps
that are isoechoic with endometrium. The larger mass protruding from the
anterior wall has a microcystic appearance.
Figure 5.9. True coronal view of the uterus. Intracavitary fluid outlines two
distinct masses: (1) a Type 0 submucous myoma (calipers) positioned near the
left cornu and outlined with endometrium; (2) a central, brightly echogenic
polyp.
47
Section 1: Imaging techniques
Blood clot
It is necessary to appreciate fully the ultrasound characteristics of a blood clot due to its tendency to be confused
Figure 5.10. Combined findings of an anterior Type II submucous myoma
(arrow), which is seen deviating the contour of the endometrial cavity, and an
endometrial polyp (arrowhead).
with either adhesions or polyps when not free-floating.
Most commonly, the surface contour of such a pseudofilling defect is irregular. It is understandably avascular,
may appear to move during active saline infusion, and is
variably echodense depending upon its age (Figure 5.2).
The diagnosis of a blood clot can sometimes be confirmed
with the use of a firm catheter during SIS, which can be
advanced into such an apparent mass and intentionally
used to actively disrupt and scatter it.
Endometrial malignancy
Ahistologicalbiopsyisrequiredtomakeafirm diagnosis of
either endometrial hyperplasia or cancer. When the disease is
diffuse, endometrial sampling, even when performed in the
office, is highly reliable. It is when the abnormality is found
focally within the uterine cavity that false-negative results can
and do occur. Clinical examples of where sonohysterography
might be useful include histo-pathological results that denote
inadequate sampling, such as “ tissue insufficient for diagnosis” (Figure 5.11); a biopsy diagnosis that does not match the
transvaginal ultrasound finding, such as “endometrial atrophy” in a postmenopausal woman whose endometrial stripe
(a)
(b)
(d)(c)
48
Figure 5.11. (a) Abnormal endometrial thickness measured (calipers) in a postmenopausal patient with bleeding. Office biopsy reported tissue insufficient for
diagnosis. (b) Application of color-flow reveals a central “feeder vessel” (arrow). (c) Saline surrounds a homogeneously echodense filling defect (calipers), suggestive of
polyp. The endometrium lining the cavity is very thin and symmetric, explaining the biopsy results. (d) Benign polyp confirmed on hysteroscopy.
Chapter 5: Sonohysterography
(a) (b)
Figure 5.12. Two views of endometrial cancer. (a) Diffuse adenocarcinoma. Endometrium (calipers) is mostly homogeneous and very thick. (b) Focal carcinosarcoma
appears irregular and echogenic. This is not an SIS image; rather, the fluid seen in this complex endometrial cavity is blood. Office biopsy can miss this diagnosis,
especially given the thin, symmetric endometrium seen anteriorally.
is uncharacteristically thickened; or any patient with AUB
whose endometrium on TVS is indistinct or not visible in
its entirety, despite the biopsy results. Any focal findings on
SIS deserve hysteroscopy and selective biopsy under direct
visualization, and focal cancers tend to have irregular borders, may disrupt the endo-myometrial junction or reveal
obvious myometrial invasion, and can be highly vascular
(Figure 5.12). Finally of note is the fact that endometrial
cancers may cause poor distensibility of the cavity during
saline infusion [20].
Effects of tamoxifen
Mostwomenundergoingadjuvanttherapyforbreastcancer
with tamoxifen have no pathological endometrial changes.
However, the estrogen-agonist effect of tamoxifen can be
associated with endometrial polyps, hyperplasia, metaplasia,
and cancer, so postmenopausal patients, especially, with
any signs of bleeding, should be thoroughly evaluated.
Unfortunately, the most common abnormal TVS finding in
this situation is a nonspecific thickened endometrial stripe
with scattered cystic changes (Figure 5 .13). Because there are
many diagnostic options, which include subepithelial stromal
hypertrophy and subendometrial cysts, SIS can be used to help
delineate true endometrial abnormalities when abnormal
symptoms arise.
Intrauterine synechia
Intrauterine adhesions almost never occur de novo or spontaneously; rather, they are a recognized complication of
uterine curettage necessitated by postpartum or postabortion retained products of conception or septic abortion.
Patients with this condition may be entirely asymptomatic
and present with unexplained infertility or RPL, or they may
seek relief for menstrual complaints of amenorrhea, hypomenorrhea, or dysmenorrhea. An interrupted endometrial
Figure 5.13. A previous breast cancer patient on tamoxifen presented with
abnormal uterine bleeding. The thick endometrium (calipers) of this retroverted
uterus on sagittal view appears heterogeneous and cystic. After endometrial
sampling excluded hyperplasia and malignancy, sonohysterography revealed a
large polyp whose final pathology was benign.
stripe seen on transvaginal ultrasound may suggest the possibility of synechia (Figure 5.14). SIS, however, is a simple
and sensitive imaging method that can confirm the diagnosis, which manifests as thick, thin, firm,orundulatingechogenic bridging bands extending from anterior to posterior
uterine walls (Figure 5.15). The lateral walls and fundus of
the uterus also may be involved, and true coronal plane
views can help elucidate the extent of disease. Not surprisingly, distension of the cavity may be difficult and require
increased injection pressures (Figure 5.16), or the most
49
Section 1: Imaging techniques
(a) (b)
Figure 5.14. (a) Transverse view of the uterus. A thin endometrial stripe appears discontinuous and interrupted by a longitudinal linear structure (arrow)
whose echodensity is similar to that of myometrium. (b) Sonohysterography confirms a thick adhesion to the right of midline bridging between anterior
and posterior uterine walls.
severe cases of Asherman syndrome may result in a failed
study altogether because adherent endometrial walls simply
do not separate. Valle and Sciarra [21]showedmanyyears
ago that making the diagnosis of intrauterine adhesions is
critical because hysteroscopic treatment can dramatically
improve both menstrual disturbances and reproductive outcome in affected women.
Congenital uterine anomaly
In most studies to date, the prevalence of congenital uterine
anomalies (CUA; also known as congenital uterine abnormalities) is similar in both infertile and fertile women at around
4–7%. In women with a diagnosis of RPL, however, the
prevalence of this condition rises to nearly 17% [22]. Of the
many known possible uterine malformations, complete or
partial septate uterus is the most com mon major anomaly
with a mean incidence of 35%, when present is associated
with the poorest reproductive outcome, and is the most easily
amenable to surgical treatment [23]. Uterine anomalies can
result in impaired pregnancy outcomes, and obstetric complications are more frequent. The goal of hysteroscopic septum resection is to restore a normal uterine cavity, and
successful treatment gives in near-normal pregnancy results
with a term delivery rate of 75% and a live birth rate of
85% [24].
Sonohysterography is better able than HSG and TVS to
differentiate a septate from a complete bicornuate uterus, and
a precise diagnosis in this situation is of paramount importanc e
to the gynecologic surgeon because the respective operations
necessary to correct these two conditions are completely different from one another. The normal uterus has an endometrial
cavity that is entirely empty and has a conelike appearance on
sagittal view (Figure 5.1). The septate uterus has a convex, flat,
or slightly indented fundal contour, while the cavity is divided
Figure 5.15. A balloon catheter is seen to the right of a fine, irregular, shaggy
adhesion which stretches from the anterior to the posterior uterine wall.
either partially (subseptate) or completely (septate) by a midline
longitudinal band of varying length and width with an echotexture similar to that of myome trium (Figure 5.17). The thickness of the septum and the relationship of the septum to the
fundal myometrium are important data points when planning
hysteroscopic metroplasty. Three-dimensional ultrasound
technology, with the addition of its reconstructed coronal
plane image, allows accurate measurement of dimensions and
volume.
Additional studies
Although beyond the scope of this chapter, there are several
other extrapolations of saline infusion ultrasound of the pelvis
that deserve mention.
50
Chapter 5: Sonohysterography
(a) (b)
Figure 5.16. This patient presented with very light, short menses beginning after uterine curettage for spontaneous miscarriage. Both the sagittal view (a) and coronal
view (b) show a thick adhesive band (calipers) that partially obliterates the uterine cavity.
Figure 5.17. A subseptate uterus is seen in this coronal SIS image. The diagnosis
is confirmed by visualizing a partial septum (arrow) in combination with a normal
surface uterine contour (broken curved line). Endometrial polyps (arrowheads)
are an incidental finding.
3D SIS
The ability to rapidly acquire and store a set of volume
data about the entire uterus has some potential advantages:
( 1 ) t he vo lu me da ta ca n b e e v a lu a te d i n a n y pl a ne d e s ir e d ,
retrospectively, possibly reducing the usual amount of time
necessary during two-dimensional SIS for uterine distension and m ultiple still images; (2 ) the true “ C-plane ,” or
coronal view, of the uterus maximizes the information
about the endometrial cavity, the myometrium, and the
fundal contour (Figure 5.18,andseeFigures 5.16, 5.4,
5.9) to potentially improve diagnostic accuracy in the set-
ting of CUA (Figure 5.17).
Sonosalpingography or hysterosalpingo-contrast
sonography (HyCoSy)
This procedure uses a technique similar to SIS to evaluate tubal
obstruction in infertility patients. Ultrasound-positive contrast
media can distend the uterus and reveal the tubes, but an
alternative is to use an agitated mixture of air and saline to
observe for patency. Exacoustos et al. showed HyCoSy to be as
effective as HSG in diagnosing tubal patency, and the detection
rate for tubal obstruction was 80% [25].
Operative SIS
If there is a drawback to SIS alone, it is that, unlike office hysteroscopy, it does not allow guided biopsy at the time of diagnosis.
There have been promising studies to evaluate the feasibility of
using SIS guidance for both directed biopsy and polyp resection,
but further randomized research is needed in this area.
Sonovaginography
Combining TVS with vaginal saline infusion may improve the
ability to image structures surrounding the vagina, such as the
rectovaginal septum for endometriosis.
Key points in clinical practice
1. SIS is a simple, minimally invasive, cost-effective imaging
option that is applicable to many gynecolo gic conditions.
2. For evaluation of the endometrial cavity, the degree of
accuracy for this office test approximates that of
hysteroscopy and exceeds that of both HSG and TVS.
3. Sonohysterography is well tolerated by the patient, nearly
risk-free, and can be learned easily by those physicians
already experienced in transvaginal ultrasound.
51
Section 1: Imaging techniques
(a) (b)
(c)
Figure 5.18. 3D SIS, multiplanar views: (a) transverse, (b) sagittal; (c) coronal. The ability to see all three orthogonal planes simultaneously helps to locate exactly
the size and position of both a posterior submucous myoma (arrow) and a left lateral endometrial polyp (arrowhead).
References
1. Breitkopf D Goldstein SR,
Seeds JW; ACOG Committee
on Gynecologic Practice.
ACOG technology assessment
in obstetrics and gynecology.
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