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174
I. Tur-Kaspa and L.A. Stadtmauer
Fig. 13.7 3D SHG demonstrating a completely septated
uterus. The 3D reconstruction at the coronal plane leaves
no space for imagination, providing defi nite diagnosis and
Gel Instillation SHG
Gel SHG uses hydroxyethylcellulose gel instead
of saline as its medium. This is done in order to
try to simplify the technique of artifi cial uterine
cavity distension for SHG [ 49 ]. The gel provides
a more stable fi lling of the uterine cavity, allowing
a high-quality ultrasonographic visualization of
intrauterine pathology by 2D and 3D US [ 50 – 55 ].
Still, most centers will use saline for SHG.
No Pain with SHG
Tur-Kaspa [ 37 ] has recently summarized
data supporting that SHG, as well as HSG
and HysteroContrastSonography (HyCoSy),
should be considered pain-free procedures.
Hysterosalpingography (HSG) has a longstanding reputation of being a painful procedure.
The use of modern thin catheters and nonionic
assisting in planning the surgical treatment needed as well
as consulting with the patient
media that signifi cantly reduced pain during and
after HSG [ 56 – 60 ] was unable to affect signifi -
cantly HSG’s “reputation.” SHG and HyCoSy,
the modern ultrasound-based procedures that are
currently used instead of HSG for the evaluation
of the uterine cavity and/or the fallopian tubes,
“inherited” this high level of fear of pain. It is
possible that this stigma discourages patients and
makes them believe that the procedure should be
painful when it does not have to be. Several recent
randomized controlled trials (RCT) have failed to
demonstrate a signifi cant benefi t of various pharmacological strategies available to reduce pain
during these procedures, suggesting that the pain
is more psychological than physical [ 34 – 36 ]. It is
the author’s opinion, based on evidence data and
the experience of performing thousands of these
tests, that they can be pain free for women.
One of the primary ways to make SHG a painfree procedure is using gentle movements with a
thin fl exible catheter. Using a rigid catheter,
13 Sonohysterography in Reproductive Medicine
175
which requires grasping the cervix with a tenaculum, will promote pain. 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 ]. Warming the saline
solutions to body temperature before instillation
is another way of reducing patients’ discomfort.
It is crucial to introduce the saline solution slowly
into the cavity to prevent abrupt overdistention of
the uterus, which would induce immediate pain.
While women naturally may feel embarrassed,
stressed, and discomfort, as with any medical and
gynecological examinations, there should be no
more fear of pain from procedures such as SHG,
HyCoSy, and HSG [ 37 ].
Conclusions
SHG is a simple, cost-effective, safe, and
easy-to- perform procedure for the evaluation
of congenital and acquired uterine abnormalities. Published guidelines by AIUM and
ACOG are easy to implement in routine gynecological and reproductive medicine practice.
While using thin fl exible catheters, placing
them inside the cervix, and injecting the saline
slowly, this procedure can be pain free. SHG
can serve as a fi rst-line test for screening and
evaluation of the uterine cavity for the diagnosis of infertility and before ART.
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Evaluation of Tubal Patency (HyCoSy, Doppler)
Dimuthu Vinayagam and Kamal Ojha
1 4
Subfertility affects 1 in 10 couples worldwide.
Tubal pathology is thought to be a contributor in
up to 40 % [ 1 – 3 ] of cases of subfertility, making
tubal pathology the leading female cause.
Assessment of the fallopian tubes forms an
important and integral part of the fertility workup.
Tubal patency will determine subsequent treatment as well as assisted conception options. If
tubal assessment does reveal tubal blockage, then
the couple may be referred for in vitro fertilisation or tubal surgery. If the tubes are patent, then
alternative causes and consequent treatment
options will be investigated. The question of “are
the tubes patent” is one of the most important
clinical questions that must be answered when
performing a subfertility workup.
Any ideal modality of tubal assessment
will be sensitive, specifi c, safe, widely available, inexpensive and diagnostically accurate.
Laparoscopy and dye testing is the accepted
gold standard for assessment of tubal pathology. However, this is an invasive and expensive
procedure. Hysterosalpingography (HSG) was
classically the fi rst-line investigation used in the
assessment of tubal pathology [ 4 ]. HSG involves
a radiological examination of the uterus and fallopian tubes using X-rays and contrast media.
D. Vinayagam , MB BS, BSc
K. Ojha , MRCOG (*)
Obstetrics and Gynecology , St. George’s Hospital,
Blackshaw Road , Tooting, London ,
SW17 OQT , UK
e-mail: dvinayagam@doctors.org.uk;
kamal.ohja@stgeorges.nhs.ui
Advances in ultrasonography have resulted in
the development of techniques using ultrasound
to diagnose tubal pathology. Hysterosalpingocontrast- sonography (HyCoSy) is the name
given to a technique that combines the use of
ultrasound and contrast media to delineate tubal
pathology. HyCoSy can be combined with 3D
imaging as well as advanced computer software
to enhance diagnostic imaging. Contrast media
employed include air, saline, albumin with micro
air bubbles and galactose with micro air bubbles.
The supplementary use of colour fl ow Doppler
has also been employed as a reliable and accurate
alternative modality.
In this chapter, we aim to provide an outline of
the currently employed methods used in the evaluation of tubal patency.
Laparoscopy and Dye Test (Chromopertubation)
Laparoscopy (+/− hysteroscopy) and dye testing
is the gold standard method for evaluation of
tubal patency. This is especially true of high-risk
women who have a history of endometriosis, previous pelvic infection or abdominal surgery.
Laparoscopy allows direct visualisation and concurrent treatment for various pelvic and tubal
pathologies such as endometriomas, pelvic endometriosis and peritubal adhesions. Methylene
blue dye is introduced via the cervix, and if tubal
patency is present, bilateral spill of dye can be
directly visualised from each fi mbrial end. This is
L.A. Stadtmauer, I. Tur-Kaspa (eds.), Ultrasound Imaging in Reproductive Medicine,
DOI 10.1007/978-1-4614-9182-8_14, © Springer Science+Business Media New York 2014
179
180
D. Vinayagam and K. Ojha
captured either on still photographs or on video.
Although laparoscopy is now a routine operation,
it is still associated with risks. These include
bleeding, infection, vascular damage as well as
visceral injuries to other organs (bowel and bladder). Should complications at laparoscopy occur,
then a laparotomy may be required. The use of a
general anaesthetic poses risks, and the possibility of subsequent venous thromboembolism must
not be overlooked. Facilities to perform laparoscopy may not be readily available in all fertility
clinic settings.
Laparoscopy is an expensive and invasive
procedure when used in this context, and appropriately trained clinical and auxiliary staff are
required to perform this.
Although this procedure is the gold standard
method for evaluating tubal patency, it shouldn’t
be the fi rst-line screening method employed on a
large scale. Patients should be appropriately
selected for this procedure. One possible way of
risk assessing women would be to perform the
inexpensive chlamydia antibody titre (CAT)
blood test, and if positive, these women should
be offered laparoscopy as the possibility of
encountering pelvic pathology is higher in this
group of patients [ 2 ]. This is already occurring in
some parts of Europe where CAT testing is used
as a fi rst-line test in subfertility workup, and
those above a fi xed cut-off level have postinfectious pelvic disease excluded by means of
laparoscopy and chromopertubation, rather than
having HSG [ 5 , 6 ]. In patients who are CAT posi-
tive, HSG should be omitted in order to avoid the
potential of infectious complications [ 7 ]. Patients
with a high-risk history (e.g. known endometriosis and previous pelvic surgery) should have their
pelvis assessed by means of a laparoscopy and
dye test [ 8 ].
Hysterosalpingography (HSG)
HSG is an outpatient X-ray examination of the
uterine cavity and fallopian tubes using contrast media. This procedure is performed in
the follicular phase of the menstrual cycle so
as to not disrupt an early pregnancy. A cannula
(often metal) is inserted transcervically, and
a radio-opaque dye (e.g. Urografi n) is passed
through the cannula. X-ray images are then
obtained and patency is confi rmed by visualising the bilateral peritoneal spillage of the dye.
Following the procedure, patients should be
advised about pelvic pain, which will be similar
to dysmenorrhoea. Prophylactic antibiotics are
also usually prescribed.
In comparison to laparoscopy, HSG is more
cost-effective, can be performed in a lowresource setting and does not require as much
operator expertise. In addition, HSG can delineate uterine cavity abnormalities as well as tubal
blockage. The passage of dye through the tubes
can sometimes inadvertently cure the blockage
and therefore HSG can, on occasions, be therapeutic. A meta-analyses of over 4,000 subjects
concluded that HSG has a sensitivity of 53 % and
a specifi city of 87 % for any tubal pathology and
46 and 95 % for bilateral tubal pathology [ 6 , 9 ].
Both oil-soluble and water-soluble contrast
media have been employed in HSG. Oil-soluble
media are associated with risk of oil emboli as
well as inducing infl ammatory reactions within
the diseased fallopian tubes. The more commonly
used water-soluble agents have been shown to
result in increased bleeding post HSG; however,
they do produce superior radiographic images. A
randomised controlled trial did not show any statistically signifi cant difference in the live birth
rates following oil- or water-soluble contrast
media [ 10 ].
Disadvantages of HSG include the radiation
exposure to the pelvis. The mean dose-area product (DAP) for HSG is 2.05 Gy cm 2 versus 0.09 Gy
cm 2 for a chest X-ray [ 11 ]. The use of iodine-
based contrast media can result in hypersensitivity reactions and should be avoided in patients
known to be sensitive to iodine-containing compounds. HSG requires the services of the radiology department for interpretation of the images
produced. The procedure is associated with
patient discomfort during and after the procedure. The use of thinner, non-metal cervical catheters may reduce the discomfort experienced by
the patient. A study comparing HSG using a
rigid, metal cannula with a balloon catheter
14 Evaluation of Tubal Patency (HyCoSy, Doppler)
181
demonstrated less patient-reported pain, less
fl uoroscopic time, smaller amounts of contrast
medium and easier operation using the balloon
catheters [ 12 ].
Some operators advise patients to take simple
analgesia prior to attending for the procedure,
although there is a paucity of evidence that this
actually provides any signifi cant relief.
Hysterosalpingo-ContrastSonography (HyCoSy)
Hysterosalpingo-contrast-sonography is an outpatient transvaginal ultrasound procedure that
visualises the uterine cavity and observes spill
from the fi mbrial ends of the fallopian tubes.
The technique of HyCoSy was founded upon
two independent observations. The initial observation, published over 30 years ago, was that
saline could be injected into the uterine cavity to
delineate endometrial structures using a transvaginal ultrasound probe [ 13 ]. The same investi-
gators noted that saline would then be present in
the pouch of Douglas, indicating spill of saline
had occurred through patent fallopian tubes.
Normal fallopian tubes are rarely visualised on
ultrasound; however, diseased tubes (e.g. hydrosalpinx) are more readily apparent due to the
presence of fl uid. The notion that a fl uid-fi lled
intrauterine cavity/fallopian tubes could enhance
visual diagnosis leads to the idea that injecting
fl uid into the uterus could be used to detect both
intrauterine anomalies and tubal patency at ultrasound. Although saline was the fi rst fl uid agent to
be used, its use was reported with varying degrees
of success. There were limitations in observing
the fl ow through the entire tube as well as unpredictable and not easily reproducible results. Air
has also been described as a contrast agent that
can be used at HyCoSy. Although it has obvious
cost benefi ts, visualisation of the tubal course
may be more challenging. This, in part, may be
due to the similar echogenicities of air and the
surrounding structures (e.g. bowel gas) (Fig. 14.1 ).
In the mid-1980s, an ultrasound contrast
agent named Echovist® was being trialled
for use in echocardiography. Due to its
Fig. 14.1 HyCoSy with water and air: this image
demonstrates air echogenic areas with a background of
echo-free areas. The air bubbles are seen to move through
the tube to demonstrate patency
Fig. 14.2 HyCoSy with SonoVue® dye showing dye in
the uterine cavity and the right tube
echogenic properties, Echovist® revolutionised
the visualisation of the fallopian tubes using
HyCoSy. Echovist® consists of galactose particles suspended in an aqueous galactase solution.
Echovist is no longer available, and SonoVue®, a
second-generation agent, is now commonly used.
The SonoVue® kit consists of a lyophilised powder which is mixed vigorously with normal saline
to form the injectable contrast media. SonoVue
consists of microbubbles of sulphur hexafl uoride. The interface between the sulphur hexafl uoride bubble and aqueous medium acts as a
refl ector of the ultrasound beam, thus enhancing
blood echogenicity and increasing contrast
between the blood and the surrounding tissues
(Fig. 14.2 ).
The contrast agent produces a hyperechoic
appearance on transvaginal ultrasonography. The
contrast media are detected fi rst in the uterine
cavity, proximal and then distal fallopian tubes
182
D. Vinayagam and K. Ojha
(if they are patent). Tubal patency is demonstrated by visualising intratubal fl ow for 5–10 s
using B-mode scanning and until peritoneal spill
is detected around the ovaries [ 14 ].
Below we outline a suggested technique for
performing the procedure. There are variations to
this technique, as well as inclusion and exclusion
of steps that may not be routinely performed by
other operators.
As HyCoSy is often performed as an outpatient procedure, it is imperative that clinicians performing this procedure remember
the basics of good bedside manner, effective
communication and making the patient feel at
ease. Most patients will be apprehensive about
the possible fi ndings but also the anticipated
discomfort. Operators performing HyCoSy
should be profi cient in transvaginal ultrasonography and placement of transcervical catheters and
possess the relevant clinical experience and skills
to perform this investigation.
It is good practice to issue patients with an
information leafl et (some time before the procedure) outlining the procedure so that they have
some idea of what to expect when they attend.
Leafl ets can also inform patients of what to do preprocedure and expect post-procedure and whom
to contact in the event of any complications.
Some operators will perform a urinary betaHCG test to exclude pregnancy prior to commencing the procedure, although as HyCoSy is
performed in the follicular phase of the cycle,
this isn’t done routinely.
The Technique
1. After gaining verbal consent and a brief
description of the procedure, the patient is
placed into the dorsal lithotomy position.
2. A warmed, sterile and well-lubricated
Cusco’s (bivalve) speculum (of the appropriate size for the patient) is then carefully and
slowly inserted into the vagina in order to
visualise the cervix. Occasionally, the cervix
may not be easily identifi ed, and gently
changing the angle of direction of the
speculum may help with this.
Fig. 14.3 HyCoSy catheter in cavity – ideally the catheter should be in the cervical canal. Occasionally, it is
placed in the cavity to prevent displacement during the
procedure
3. Once the cervix is identifi ed, it is cleaned
with an aseptic solution.
4. The authors recommend the use of a fl exible
balloon catheter and not the previously used
metal cannulae. Foleys catheters have also
been employed at this stage. The insertion
of the catheter does not routinely require the
use of a tenaculum; however, if tenaculum
use is required, then the authors suggest a
paracervical block with 1 % lignocaine
prior to grasping the cervix or only blocking
the anterior lip when the tenaculum is
applied.
5. If a balloon catheter is used, then the authors
recommend intracervical, as opposed to
intrauterine, balloon dilatation. It has been
demonstrated that this causes less pain, and
less contrast media are required in this way
too [ 15 ]. The balloon can be infl ated with air
or sterile water. This also allows visualisation of the lower end of the uterine catheter.
If the catheter is found to be placed in the
uterine cavity under ultrasound guidance,
this can be withdrawn into the cervical canal.
Figure 14.3 shows the balloon in the uterine
cavity – this is occasionally done if the catheter does not appear to be well fi xated in the
cervical canal (and therefore prevents it from
falling out).
6. Once the catheter is in situ and secure, the
speculum (and tenaculum if applied) can be
14 Evaluation of Tubal Patency (HyCoSy, Doppler)
183
gently removed, ensuring the catheter is not
dislodged. The patient is then forewarned
that the transvaginal ultrasound probe will be
inserted.
7. At this stage, the authors perform a conventional B-mode transvaginal scan to assess
the uterus, ovaries and pouch of Douglas.
The correct placement of the catheter balloon can also be checked at this point.
Alternatively, a conventional scan can be
performed after step 1(before the catheter is
introduced).
8. After warning the patient, the contrast
medium can be injected slowly and steadily.
It is important to remember that the uterus is
pressure sensitive, and as such, excessive
rates and/or volumes of injecting will result
in unnecessary patient discomfort. Beware
that blocked fallopian tubes may increase the
pain experienced by the patient. The authors
suggest using no more than 10 ml of contrast
media. If the balloon has been infl ated correctly, there should be no leakage, and evaluation of the uterus and both tubes should be
possible using less than 10 ml. In the author’s
experience, 2–5 ml is suffi cient for demonstrating tubal patency.
9. Tubal patency is assessed by demonstrating
fl ow along the entire length of the tube or by
streaming at the cornual end for at least 10 s
with spill into the pouch of Douglas [ 16 ].
10. A detailed examination of the uterus is
performed by scanning slowly and systematically from the cervix to fundus. Any relevant lesions (e.g. submucous leiomyoma)
can be closely analysed and relevant images
produced.
11. Each tube is followed, in turn, until spill is
visualised adjacent to the ovary.
12. Strict criteria must be adhered to in order to
ensure that the fallopian tube is followed in
its entirety, before it is considered to be patent. Any delay in tubal fi ll and/or spill must
be appropriately documented. Any apparent
distortion of the tubal diameter or tubal
course must also be documented and preferable supplemented with the use of images/
videography.
13. This could be followed by assessment of the
uterine cavity with normal saline to exclude
endometrial polyp or submucous fi broids.
HyCoSy (and HSG) has the signifi cant advantage over laparoscopy of being outpatient-based
(offi ce) investigations without a need for general
anaesthesia. There is no risk of visceral or vascular injuries. Patients do not need to be fasted for
either procedure, and both the patient and her
partner can be present whilst the investigation is
being performed.
Unlike HSG, HyCoSy does not involve the
use of ionising radiation and iodine-based contrast media or the use of radiology services – it
can be performed by a gynaecologist/specialist in
reproductive medicine, obviating the need for a
radiologist. As an ultrasound-based investigation, other pelvic structures can be assessed
simultaneously. HSG may preclude the need for
laparoscopy in some cases, thereby improving
patient satisfaction and preventing the need for
invasive investigations.
HyCoSy has been shown to be at least as
effective as hysterosalpingography at detecting
tubal blockage. When compared with the gold
standard of laparoscopy and dye testing, reported
rates for sensitivity and specifi city are 80 and
84 %, respectively [ 17 ]. The use of HyCoSy is
superior to hysterosalpingography in detecting
intrauterine anomalies such as leiomyoma, polyps, septae and hydrosalpinx.
Two-dimensional transvaginal HyCoSy as
described above, although in many ways superior
to HSG, does have its limitations. Due to the tortuous course of the fallopian tubes, the entire tube
will not be visualised in one scanning plane.
Visualisation of the tubal course can be further
limited by tubal spasms. As a result, the falsepositive rate for tubal occlusion is 5–10 % [ 18 ].
Due to the echogenicity of bowel, distal spill from
the tubes may be diffi cult to distinguish from surrounding bowel and therefore relies on a certain
level of operator expertise. Interpretation can
therefore be slightly more challenging as compared to hysterosalpingography. As the procedure
does rely on the technical ability of the clinician
performing the procedure, there can be considerable inter- and intra-observer variability.
184
D. Vinayagam and K. Ojha
Three-Dimensional Coded Contrast Imaging (3D CCI) During HyCoSy
Coded contrast imaging (CCI) comprises of dedicated computer software, designed to enhance
the view of the fallopian tubes whilst fi ltering out
signals from other tissues. The image which is
produced is based on ultrasound signals produced
by the contrast media and not by surrounding
tissues.
Coded contrast imaging enhances the use of
contrast media by means of low acoustic pressure, thereby enhancing visualisation of the
fallopian tube by enabling the clinician to differentiate between the harmonic response of the
contrast medium and signals from other surrounding organs such as bowel [ 18 ]. The soft-
ware is able to fi lter out ultrasound signals
produced by the organs and thereby display an
image which is solely based on harmonic signals
produced by the contrast media.
This technology has been applied in other
fi elds including studying the microvasculature of
the liver, breast lesions as well has myocardial
perfusion function.
In order to further enhance the technology,
second-generation contrast media are used. The
fi rst-generation contrast media (Echovist®) contain microbubbles that have rigid membranes and
are therefore unable to respond with harmonic
signals at low acoustic pressures. However,
second- generation agents, such as SonoVue®,
provide a substantial harmonic response at low
acoustic pressure. The use of a second-generation
contrast medium with CCI technology enables
the operator to view the hyperechoic fl uid fi rstly
in the uterus and then the proximal tube and lastly
spill into the abdominal cavity. Due to the detectable differences between the harmonic response
between the contrast media and that of the surrounding tissue, there is a clear distinction
between the contrast media and the surrounding
structures.
The use of 3D imaging (without CCI) using
saline-air contrast has been reported; however,
the resulting image may not necessarily be clear
enough to make a conclusion regarding tubal
patency. However, when 3-dimensional imaging
is combined with CCI, the tubal course and
structure can be studied in much greater detail.
Software packages that provide the volume
acquisition images are available, and when this is
combined with 3D CCI, then a 3D image with the
uterus and tubes, showing the tubal course in its
entirety and tubal spill (if patent), is seen as a
hyperechoic image in a completely anechoic
pelvis (i.e. no other structures are seen).
Volume acquisition performed during
HyCoSy is a static procedure and as such requires
less challenging probe movements and therefore
requires less operator experience and expertise as
compared to conventional 2D TVS HyCoSy [ 18 ].
As 3D CCI visualises both fallopian tubes, less
contrast media are required – this is benefi cial
both to the patient and also from a cost perspective. Another advantage of 3D CCI at HyCoSy is
that the images can be stored (similar to Doppler
imaging and HSG) and viewed by clinical colleagues, unlike conventional 2D HyCoSy which
is a dynamic procedure that only the operator
can interpret. However, 3D imaging requires
greater funding and therefore is not accessible in
resource poor settings. A recent study [ 19 ] com-
paring 3D HyCoSy in 150 tubes to laparoscopy
and dye testing demonstrated a sensitivity and
specifi city of 93.5 and 86.3 %, respectively. The
authors reported a positive predictive value of
87.8 % and negative predictive value of 92.6 %.
These values compare favourably with previously reported sensitivities and specifi cities of
2D HyCoSy.
Although more work is required to assess the
diagnostic accuracy and feasibility of 3D CCI
HyCoSy, it appears that this novel method of
evaluating tubal patency will become widespread
in the future and an integral part of the subfertility workup (Fig. 14.4 ).
Blood-Flow and Doppler Imaging
Blood fl ow and Doppler are additional modalities
that can be employed in conjunction with
HyCoSy.
Blood fl ow is a relatively new technique
which has been employed in other medical