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12 Intrauterine Adhesions
163
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Sonohysterography in Reproductive Medicine
Ilan Tur-Kaspa and Laurel A. Stadtmauer
1 3
Introduction
The existing practice guidelines, indications, and
contraindications and the optimal technique for
Sonohysterography (SHG) are reviewed. This
will include a discussion on how to make the procedure pain free for women by using fl exible
catheters and gentle movements, infl ating the
balloon inside the cervix rather than inside the
uterine cavity, and injecting the saline slowly.
The main focus will be on diagnosis of intrauterine abnormalities through SHG rather than their
treatment thereafter. We conclude that SHG is a
safe, accurate, cost-effective, and easy-toperform procedure, for patients as well as for
physicians, to evaluate intrauterine pathology
and can be used as the primary diagnostic tool for
the evaluation of infertility and before ART.
I. Tur-Kaspa , MD (*)
Institute for Human Reproduction (IHR),
Department of Obstetrics and Gynecology ,
The University of Chicago , 409 W. Huron St. ,
Chicago , IL 60654 , USA
e-mail: drtk@infertilityihr.com
L. A. Stadtmauer , MD, PhD
Department of Obstetrics and Gynecology ,
Eastern Virginia Medical School, Jones Institute for
Reproductive Medicine , 601 Colley Avenue ,
Norfolk , VA 23507 , USA
e-mail: stadtmla@evms.edu
SHG vs. Hysteroscopy
Sonohysterography (SHG) was fi rst described in
1986 by Randolph et al. [ 1 ]. Randolph et al.
instilled saline into the uterus to provide contrast
during transabdominal US and compared the
SHG fi ndings in 61 women to hysterosalpingography (HSG) and laparoscopy/hysteroscopy.
They concluded that real-time US with fl uid
installation provides an accurate alternative to
HSG in screening for uterine abnormalities and
tubal patency. Syrop and Sahakian were the fi rst
to describe transvaginal SHG in 1992, followed
by Parsons and Lense in 1993 [ 2 , 3 ].
For a long time hysteroscopy with direct
visualization of the intrauterine cavity was considered the gold standard for diagnosing uterine
abnormalities [
cavitary abnormalities in women screened by
SHG or hysteroscopy for infertility range from
11 to 45 %, with polyps range between 6 and
25 % [
5 , 14 ]. In the last 15 years, accumulating
evidence-based data, including randomized control trials, systematic reviews, and meta-analyses,
has demonstrated that SHG has comparable sensitivity, specifi city, and accuracy in diagnosing
intrauterine abnormalities as hysteroscopy [ 7 – 13 ,
15 – 21 ]. Therefore, SHG and other ultrasonog-
raphy techniques may be used as effectively as
hysteroscopy for diagnosing intracavitary abnormalities [ 8 , 10 , 11 ]. Pre-IVF SHG was shown to
be effective at limiting cycle cancellations caused
by endometrial polyps [
be highly valuable as the fi rst line of offi ce-based
4 – 13 ]. The percentage of intra-
22 ], and it was shown to
L.A. Stadtmauer, I. Tur-Kaspa (eds.), Ultrasound Imaging in Reproductive Medicine,
DOI 10.1007/978-1-4614-9182-8_13, © Springer Science+Business Media New York 2014
167
168
I. Tur-Kaspa and L.A. Stadtmauer
diagnostic tool for patients with recurrent IVF
implantation failure [ 23 ]. These data may explain
why most of the high- performing IVF programs
in the US use SHG for the evaluation of uterine
cavity before ART [ 24 ].
In addition, cost analysis comparing SHG vs.
hysteroscopy screening prior to IVF showed that
using SHG is more cost-effective. While hysteroscopic screening is cost-effective [ 25 ], Kim and
Rone [ 26 ] have shown that SHG is more cost-
effective than hysteroscopy. They calculated the
average cost per patient ( n = 229) of SHG screening
and hysteroscopy in the subset of patients who had
signifi cant and/or correctable abnormalities ( n = 35,
15.3 %). The cost per patient using SHG screening
with additional hysteroscopy as needed was $645.
If hysteroscopy would have been used to screen the
same group of patients instead of SHG, the cost per
patient would have been $1281.
Practice Guidelines for SHG
The American Institute of Ultrasound in Medicine
(AIUM) has published in March 2008 [ 27 ] a prac-
tice guideline for ultrasonography in reproductive
medicine. In the same year, the American College
of Obstetrics and Gynecology (ACOG) published a
technology assessment on SHG, in collaboration
with AIUM; the Society for Reproductive
Endocrinology and Infertility (SREI), an affi liate
of the American Society for Reproductive Medicine
(ASRM); and the American College of Radiology
(updated in 2012) [ 28 ]. The reader is highly encour-
aged to review these guidelines. They describe the
technique, the indications and contraindications,
and the qualifi cations and responsibilities of the
physician performing the SHG. The authors of this
chapter have found it easy to adhere and to comply
with the above guidelines in their practices and
have incorporated them into this review.
Indication and Contraindication
The AIUM and ACOG guidelines [ 27 , 28 ] describe
the indications and contraindications for SHG.
The most common indication for SHG is pre- and
postmenopausal abnormal uterine bleeding [ 29 ,
30 ]. Screening of the uterine cavity prior to ART
and for the evaluation of infertility and habitual
abortions is the second most common indication.
SHG may be performed for the evaluation of congenital or acquired (fi broids, polyps, and synechiae) uterine anomalies and preoperative and
postoperative evaluations of the uterine cavities.
SHG may also be performed for further diagnosis
of any suboptimal imaging of the endometrium
and when focal or diffuse endometrial thickening
or abnormalities are seen on a regular TVUS.
The two main contraindications for SHG is
pregnancy and pelvic infection or unexplained
pelvic tenderness. Abnormal uterine bleeding
(AUB) is not a contraindication, though it may
make the interpretation of the fi ndings more challenging [ 20 ]. Tur-Kaspa et al. [ 14 ] have prospec-
tively analyzed SHG of 409 consecutive patients
with AUB and have found 37.2 % of intracavitary
abnormalities, mainly polyps and submucosal
fi broids. Goldstein [ 30 ] has suggested “ultrasound
fi rst” as an approach to women with postmenopausal bleeding. SHG may be used for triage by
identifying patients with no disease vs. those with
focal or global abnormalities. Furthermore,
patient acceptability and diagnostic capability of
SHG is high, and it reduces demand for hysteroscopy [ 29 ]. SHG- guided endometrial biopsy pro-
vided an accurate pathological diagnosis in 89 %
of patients compared to 52 % with blind endometrial sampling [ 29 , 31 ].
SHG Procedure [ 14 , 27 , 28 , 32 ]
Menstrual dating should be documented and
pregnancy should be ruled out before performing
SHG. The best timing for performing SHG is
after the menstrual fl ow and prior to ovulation, in
cycle days 5–10. This is when the endometrial
lining is most symmetrical and precludes the
chance for an early pregnancy. During the luteal
phase, the lining is thickened and more echogenic and may be associated with a higher falsepositive rate of polyps. Using birth control pills
may assist in scheduling this test at any day of the
menstrual cycle.
13 Sonohysterography in Reproductive Medicine
169
Patients should be informed of alternative
procedures and the possible risks and complications of SHG (mainly discomfort, low risk of
infection, and bleeding) and then sign a consent
form. Pretreatment antibiotic is not recommended routinely unless the patient has a history
of gynecological infections or tubal factor infertility [ 33 ]. Several RCTs, using different analge-
sics, have failed to demonstrate benefi ts of using
any drug to signifi cantly reduce pain during or
after SHG [ 34 – 36 ]. Unless indicated, no analge-
sics or sedatives are routinely needed before, during, or after SHG, since it may be considered as a
pain-free procedure [ 14 , 37 ].
Prior to SHG, TVUS is performed with routine evaluation and measurement of the uterus,
endometrium, and ovaries. The presence of fl uid
in the cul-de-sac should be noted, and any pelvic
abnormal fi ndings such as hydrosalpinges should
be documented. If a patient had a baseline TVUS
on day 3 of her period and returns for SHG a few
days later, then a quick scan for the evaluation of
the uterine cavity and of fl uid in the cul-de-sac
may be performed after the insertion of the catheter before the injection of the saline.
A speculum is placed in the vagina to visualize
the cervix. After cleansing the external os with
betadine or equivalent solution, the SHG catheter
is inserted into the cervical canal. The SHG catheter should be prefi lled with saline in order to
avoid infusing air bubbles into the uterine cavity.
There are many catheter options, including HSG/
SHG curved catheters, intrauterine insemination
catheters, and balloon SHG/HSG catheters. Any
rigid catheter, which requires grasping the cervix
with a tenaculum, may induce signifi cant pain for
the patient. If a balloon catheter is used, it is preferred to infl ate the balloon intracervically rather
than intrauterine, and the appropriate position of
the catheter may be confi rmed by pulling it
slightly. An RCT recently showed a signifi cantly
less fl uid used for SHG and signifi cantly less pain
felt by patients when the balloon was infl ated
inside the cervix rather than in the lower uterine
segment [ 38 ]. Furthermore, by infl ating the bal-
loon intracervically, one may avoid balloon
hyperinfl ation inside the uterine cavity, which
may displace and obscure a pathological fi nding,
such as endometrial polyp. Next, the speculum is
removed and the TVUS probe is inserted into the
vagina. Physiological saline solution is then
slowly injected to distend the endometrial lumen
under direct real-time visualization. Injecting the
fl uid slowly is mandatory to avoid abrupt uterine
distension and pain. Documentation should
include images of the endometrial cavity, including the lower segment and the upper cervical
canal in at least two planes, longitudinal and
transverse (Fig. 13.1 ). The reader is encouraged to
read the offi cial guidelines set by ACOG and
AIUM [ 27 , 28 ].
SHG for Congenital Uterine Anomalies
SHG is a cost-effective method available in an
outpatient setting which is highly accurate in
identifying uterine anomalies, especially septate
and bicornuate uterus [ 44 ]. Mullerian anomalies
are congenital defects in the development of the
uterus and the upper vagina. The ability of 2D
US to distinguish between different types of
uterine anomalies is limited and operator dependent. The fi nding of a uterine anomaly may
affect the management of the infertile and/or
pregnant woman and the pregnancy outcome. In
a recent meta-analysis [ 39 ], including 94 obser-
vational studies comprising 89,861 women, the
prevalence of uterine anomalies diagnosed by
optimal tests was 5.5 % (95 % CI, 3.5–8.5) in
unselected population, 8.0 % (95% CI, 5.3–12)
in infertile women, 13.3 % (95 % CI, 8.9–20.0)
in women with a history of miscarriage, and
24.5 % (95 % CI, 18.3–32.8) in women with
miscarriage and infertility.
Congenital uterine anomalies are associated
with poor reproductive outcome [ 40 ]. All uterine
anomalies are associated with an increase incidence of fetal malpresentations at delivery.
Unifi cation defects do not reduce fertility but
some defect, in particular bicornuate uteri, are
associated with aberrant outcomes throughout the
course of pregnancy. Canalization defects appear
to reduce the chance of clinical pregnancy and to
increase risk of preterm delivery. These are more
170
Fig. 13.1 2D longitudinal
( upper image ) and transverse
( lower image ) images of the
uterus showing adequate
distention of the endometrial
canal with saline during SHG
I. Tur-Kaspa and L.A. Stadtmauer
profound in cases of septate uteri. Arcuate uteri,
while previously considered to have no reproductive sequelae, are specifi cally associated with
poor outcomes in late pregnancy, i.e., second-trimester miscarriage and malpresentation [ 40 ].
Uterine anomalies are defi ned by the criteria outlined by the American Society of
Reproductive Medicine [ 41 ]. The visualiza-
tion of the uterine fundus at the coronal plane
is necessary for classifying uterine shape. SHG
has been shown to have superior diagnostic ability with compared with HSG and 2D US for the
evaluation of uterine malformation. Tur-Kaspa
et al. [ 14 ] studied prospectively the prevalence
of uterine anomalies diagnosed by SHG in 600
consecutive infertile patients compared to 409
patients with AUB. While the prevalence of
septate uterus was 3 % in each group, arcuate
uterus was signifi cantly more common among
the infertile patients (15 % vs. 6 %, respectively). All other anomalies had <1 % frequency
in either group. Tur-Kaspa et al. [ 14 ], as well as
others [ 7 – 11 ], concluded that SHG is an excel-
lent method for the evaluation of congenital uterine anomalies. 3D SHG may be needed in some
cases to assist in the fi nal diagnosis.
13 Sonohysterography in Reproductive Medicine
Fig. 13.2 2D longitudinal
image of SHG demonstrating
intrauterine adhesion at the
lower uterine segment,
connecting the anterior and
the posterior walls of the
uterus
Fig. 13.3 2D longitudinal
image of SHG demonstrating
two polyps protruding into
the uterine cavity
171
SHG for Acquired Uterine Abnormalities
SHG can serve as a fi rst-line test for the evaluation of acquired intrauterine abnormalities such
as adhesions (Fig. 13.2 ), polyps (Fig. 13.3 ), and
fi broids. Tur-Kaspa et al. [ 14 ] have documented
that intracavitary abnormalities are signifi cantly
more frequent among patients with AUB than
with infertility. Polyps were the most common
abnormal fi nding among patients with AUB or
infertile women (30 and 13 %, respectively) [ 14 ].
Submucosal fi broids were found in 9 % of the
AUB group and 3 % among infertile women [ 14 ].
Submucosal fi broids have been shown by metaanalysis to signifi cantly lower pregnancy rates in
ART and should be removed by operative hysteroscopy [ 4 , 6 ]. Besides infertility, the submucosal
fi broids may cause bleeding and miscarriages. The
European Society of Hysteroscopy has developed
172
I. Tur-Kaspa and L.A. Stadtmauer
Fig. 13.4 3D SHG images of a uterine polyp. They are able to show the size and location of the stalk of the polyp more
accurately in preparation for operative hysteroscopy and for consulting the patient
a classifi cation system for fi broids which can also
assist in the surgical approach. A Type 0 submucosal fi broid has no myometrial invasion, while
a T1 has <50 % extension and T2 has more than
50 % extension into the myometrium. The TO and
T1 are appropriate for the hysteroscopic approach,
while the T2 may require more than one procedure
or be removed laparoscopically.
the evaluation of postmenopausal bleeding, 2D
and 3D SHG have similar diagnostic accuracy
as hysteroscopy with higher patient acceptability of SHG [ 45 , 46 ].
A 3D US, in comparison to a 2D US, allows
for the visualization of the entire uterine cavity in
the coronal view; it can detect the exact placement of uterine fi broids, polyps, and synechiae in
the cavity, as well as the mean diameter of different tissues. A 3D US examination comprises
2D vs. 3D SHG
approximately four steps: (1) data acquisition, (2)
volume calculation, (3) image animation, and (4)
When the option of having a 3D SHG scan is
available, it may shorten the procedure and the
volume of the saline used [ 42 ]. 3D SHG vs. 2D
SHG is more accurate for diagnosing congenital uterine anomalies. For acquired uterine
anomalies, in experienced hands, 3D will not
improve the accuracy, but may assist it for better imaging (Figs. 13.4 and 13.5 ) [ 43 , 44 ]. For
data storage and transfer. The scans can be
obtained either by freehand, by manual movement through the region of interest (ROI), or,
automatically, by sweeping through the ROI. 3D
US needs post-processing of the received data.
Data can be stored and visualized in various
displays such as multiplanar with navigation
through the planes or surface rendering mode.
13 Sonohysterography in Reproductive Medicine
173
Fig. 13.5 3D SHG image of a corneal uterine polyp providing excellent information for the practitioner and
patient on the size and location of the polyp
For more details on 3D US technique, the reader
may refer to Chap. 2 .
A saline infusion enhances the contrast in a
3D US and can facilitate the accurate diagnosis
of congenital uterine anomalies, especially the
arcuate uterus (Fig. 13.6 ) compared with the
septate uterus (Fig. 13.7 ) and the bicornuate
uterus. The serosal edge and the fundal indentation can be clearly seen. Through TUI tomographic imaging, a series of images can
visualize the leiomyomata protruding into the
uterine cavity vs. deviating the endometrial
cavity.
3D adds value to 2D SHG by improving
with visualization of the uterine fundus [ 47 ].
Others suggest that when the SHG is performed
by an experienced examiner, 3D does not add
additional value to the 2D SHG [ 48 ]. It is the
opinion of the authors that adding a 3D US to a
2D SHG will allow the exam to be completed
faster with the same or better accuracy. Still in
most cases, 2D SHG is adequate for diagnosing abnormal intracavitary fi nding.
Fig. 13.6 3D SHG demonstrating an arcuate uterus. The visualization of the fundal area at the coronal plane and the
ability to measure the depth of the anomaly can easily defi ne arcuate uterus and rule out a septum