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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5824_Библиотеки_им_академика_М_И_Перельмана.pdf
196
D.W. Stovall and M.W. Austin
the resection of larger hydrosalpinges (i.e.,
those that are visible by ultrasound). When the
removal of these larger hydrosalpinges were
specifi cally evaluated, a pregnancy rate hazards
ratio of 3.8 (95 % CI, 1.5–9.2) was found.
Therefore, it appears that the assessment of
hydrosalpinges by ultrasound may help clinicians to determine which patients may benefi t
the most from salpingectomy.
Other types of treatments for hydrosalpinges
prior to IVF include salpingostomy and antibiotic
therapy. Each of these therapies has specifi c
advantages. Salpingostomy allows one to drain
the hydrosalpinx fl uid and to preserve the fallopian tube. Therefore, this procedure may not only
improve pregnancy rates with IVF, but may also
improve fertility without the assistance of IVF.
Of course, fallopian tubes treated in this manner
may re-accumulate with fl uid making the procedure somewhat less desirable in patients who are
only planning to undergo IVF. Furthermore,
although one study has shown this procedure to
increase pregnancy rates with IVF to a similar
level as that seen after salpingectomy, more data
are needed to determine its true effectiveness
[ 26 ]. In addition, there are data to demonstrate
that the administration of doxycycline both
before and after oocyte retrieval may increase
pregnancy rates specifi cally in women with tubal
occlusion. However, these data are very preliminary, whether or not antibiotic therapy is truly
effi cacious for the improvement of pregnancy
with IVF in women with hydrosalpinges is not
known. In conclusion, it appears that either salpingectomy or proximal tubal occlusion yields
the best pregnancy rates with IVF in women with
hydrosalpinges and that the patients who may
benefi t most from this procedure are those whose
hydrosalpinges are large enough to be seen by
ultrasound. If a patient is not a surgical candidate,
it makes sense to use pre- and post-oocyte
retrieval doxycycline therapy as an alternative.
Hysteroscopic proximal tubal occlusion with a
sterilization device is another option, but further
study is needed before this procedure can be recommended prior to IVF.
Conclusions
The fallopian tubes serve several important
steps in the reproductive process including
oocyte pickup, gamete transportation, fertilization, and early embryonic development and
transfer. However, the fallopian tubes are vulnerable to damage from both infectious and
infl ammatory processes. When the distal end
of a fallopian tube is completely blocked and
the tube fi lls with fl uid, it is referred to as a
hydrosalpinx. Using specifi c criteria, hydrosalpinges can be readily diagnosed via ultrasound imaging. The presence of a
hydrosalpinx(s) has a signifi cant effect on
one’s chances for pregnancy. Bilateral hydrosalpinges result in sterility. In good prognostic
cases, surgical intervention can signifi cantly
improve the chances for successful intrauterine pregnancy. However, most individuals
with bilateral hydrosalpinges must undergo
IVF-ET to conceive. Furthermore, the presence of a hydrosalpinx(s) that is visible via
ultrasound clearly reduces the chances for
pregnancy from IVF. Treatment of a
hydrosalpinx(s) prior to IVF by either salpingectomy or proximal tubal occlusion has been
proven to increase the chance for pregnancy
with IVF.
References
1. Honore GM, Holden AE, Schenken RS.
Pathophysiology and management of proximal tubal
blockage. Fertil Steril. 1999;5:785–95.
2. CDC. Centers for disease control and prevention.
Sexually transmitted diseases (STDs). 2010 STD
treatment guidelines. 2011.
treatment/2010/default.htm
3. den Hartog JE, Morre SA, Land JA. Chlamydia
trachomatis- associated tubal factor subfertility:
immunogenetic aspects and serological screening.
Hum Reprod Update. 2006;12(6):719–30.
4. Beyler SA, James KP, Fritz MA, Meyer WR.
Hydrosalpingeal fl uid inhibits in-vitro embryonic
development in a murine model. Hum Reprod.
1997;12(12):2724–8.
5. Meyer WR, Castelbaum AJ, Somkuti S, Sagoskin
AW, Doyle M, Harris JE, Lessey BA. Hydrosalpinges
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adversely affect markers of endometrial receptivity.
Hum Reprod. 1997;12(7):1393–8.
6. Daftary GS, Kayisli U, Seli E, Bukulmez O, Arici A,
Taylor HS. Salpingectomy increases peri- implantation
endometrial HOXA10 expression in women with
hydrosalpinx. Fertil Steril. 2007;87(2):367–72.
7. Ng EH, Ajonuma LC, Lau EY, Yeung WS, Ho PC.
Adverse effects of hydrosalpinx fl uid on sperm motility and survival. Hum Reprod. 2000;15(4):772–7.
8. Baramki T. Hysterosalpingography. Fertil Steril.
2005;83:1595–606.
9. Frishman GN. The use of intrauterine lidocaine to
minimize pain during hysterosalpingography: a randomized trial. Obstet Gynecol. 2004;103:1261–6.
10. Swart P. The accuracy of hysterosalpingography in
the diagnosis of tubal pathology: a meta-analysis.
Fertil Steril. 1995;64(3):486–91.
11. Mol BWJ. Reproducibility of the interpretation of
hysterosalpingography in the diagnosis of tubal
pathology. Hum Reprod. 1996;11:1204–8.
12. Patel MD. Likelihood ratio of sonographic fi ndings in
discriminating hydrosalpinx from other adnexal
masses. AJR Am J Roentgenol. 2006;186:1033–8.
13. Guerriero S. Transvaginal ultrasonography associated
with color Doppler energy it the diagnosis of hydrosalpinx. Hum Reprod. 2000;15:1568–72.
14. Exacoustos C. Hysterosalpingo-contrast sonography compared with hysterosalpingography and
laparoscopic dye perturbation to evaluate tubal
patency. J Am Assoc Gynecol Laparosc. 2003;10(3):
367–72.
15. Strandell A. The assessment of endometrial pathology
and tubal patency: a comparison between the use of
ultrasonography and X-ray hysterosalpingography for
the investigation of infertility patients. Ultrasound
Obstet Gynecol. 1999;14:200–4.
16. Chan CC. Comparison of three-dimensional
hysterosalpingo- contrast-sonography and diagnostic
laparoscopy with chromopertubation in the assessment
of tubal patency for the investigation of subfertility.
Acta Obstet Gynecol Scand. 2005;84(9):909–13.
17. Timor-Tritsch IE. Three-dimensional ultrasound
inversion rendering technique facilitates the diagnosis
of hydrosalpinx. J Clin Ultrasound. 2010;38(7):
372–6.
18. American Fertility Society. The American Fertility
Society classifi cations of adnexal adhesions, distal
tubal occlusion, tubal occlusion secondary to tubal
ligation, tubal pregnancies, Mullerian anomalies and
intrauterine adhesions. Fertil Steril. 1988;49:944–55.
19. Schlaff WD, Hassiakos DK, Damewood MD, Rock
JA. Neosalpingostomy for distal tubal obstruction:
prognostic factors and impact of surgical technique.
Fertil Steril. 1990;54:984–90.
20. Rock JA, Katayama KP, Martin EJ, et al. Factors
infl uencing the success of salpingostomy techniques
for distal fi mbrial obstruction. Obstet Gynecol.
1978;52:591–6.
21. Zeyneloglu HB, Arici A, Olive DL. Adverse effects of
hydrosalpinx on pregnancy rates after in vitro fertilizationembryo transfer. Fertil Steril. 1998;70:492–9.
22. Camus E, Poncelet C, Aucouturier JS, et al.
Hydrosalpinx and fertilization in vitro-embryo transfer abstention or salpingectomy? Abstention, salpingectomy, or salpingostomy? Gynecol Obstet Fertil.
2000;29:466–73.
23. Johnson N, van Voorst S, Sowter MC, et al. Surgical
treatment for tubal disease in women due to undergo
in vitro fertilization. Cochrane Database Syst Rev.
2010;(3):CD002125.
24. Mijatovic V, Veersema S, Emanuel MH, et al. Essure
hysteroscopic tubal occlusion device for the treatment
of hydrosalpinx prior to in vitro fertilization-embryo
transfer in patients with a contraindication for laparoscopy. Fertil Steril. 2010;93:1338–42.
25. Galen DI, Khan N, Richter KS. Essure multicenter offlabel treatment for hydrosalpinx before in vitro fertilization. J Minim Invasive Gynecol. 2011;18:338–42.
26. Murray DL, Sagoskin AW, Widra EA, Levy MJ. The
adverse effect of hydrosalpinges on in vitro fertilization pregnancy rates and the benefi t of surgical correction. Fertil Steril. 1998;69:41–5.
Virtual Hysterosalpingography: A New Diagnostic Technique for the Study of the Female Reproductive Tract
Patricia Carrascosa and Carlos E. Sueldo
1 6
General Concepts
Virtual hysterosalpingography (VHSG) is a new
noninvasive diagnostic technique that evolved
from our prior experience with virtual colonoscopy studies [ 1 ]; it allows the evaluation of the
entire gynecologic tract in a single study, including the cervix, uterus [ 2 ], and fallopian tubes [ 3 ].
The use of MDCT allows the capture of an axial
volumetric acquisition in only a few seconds.
This can be post-processed in different planes
without loss of defi nition, permitting the evaluation of the anatomy or pathology in any plane
with similar quality. This concept is known as
isotropic images, where tridimensional and bidimensional images have the same resolution than
axial images.
The CT scanners should have at least 64 rows
of detectors [ 4 ] in order to acquire the images in
less than 5 s. The VHSG provides information
not only about the gynecologic tract but also of
the intrapelvic structures revealing associated
fi ndings.
The patient preparation for the study and
the timing in the menstrual cycle is similar
P. Carrascosa , MD
Maipu Diagnostics , Buenos Aires , Argentina
C. E. Sueldo , MD (*)
Department of Obstetrics and Gynecology (REI Division) ,
University of California San Francisco- Fresno ,
722 Medical Center Dr. East Suite 105 ,
Clovis , CA 93611 , USA
e-mail: drsueldo@hotmail.com
to a conventional HSG; also it has the same
contraindications (pregnancy, pelvic infections,
etc.). After exposing the ectocervix with a vaginal speculum and applying iodine to the cervix,
we place a plastic catheter size 10 F through the
ectocervix and instill 15 ml of a diluted iodine
solution (at 70 % in Physiosol) with a pump
running at 0.3 ml/s. The purpose of using the
pump is to achieve steady pressure and speed, to
diminish the patient’s discomfort, and to assure
an optimal uterine distention. The image acquisition begins 30 s after starting the instillation
and is completed after 5 s; MDCT with 256 or
320 rows of detectors complete the study in only
1.5 s, making VHSG a real-time study with easy
visualization of the contrast as it passes into the
peritoneum (Figs. 16.1 and 16.2 ).
Technical parameters in the CT equipment
with either 64 [ 5 ] or 256 rows are shown in
Table 16.1 .
Once the images are acquired, they are transferred to the workstation for different reconstructions: multiplanar reconstruction (MPR),
maximal intensity projection (MIP), volume rendering (VR), and endoscopic views.
Multiplanar reconstructions (coronal, sagittal,
and oblique) allow for the evaluation of the cervix, uterus, and fallopian tubes, as well as extrauterine structures, while the curved MPR
evaluates all the female structures in a single
plane (Fig.
Maximal intensity projection (MIP) images
provide excellent defi nition of the fallopian
tubes in a tridimensional format with grey tones,
16.3 ).
L.A. Stadtmauer, I. Tur-Kaspa (eds.), Ultrasound Imaging in Reproductive Medicine,
DOI 10.1007/978-1-4614-9182-8_16, © Springer Science+Business Media New York 2014
199
200
P. Carrascosa and C.E. Sueldo
Fig. 16.1 VHSG (volume rendering projection)
Table 16.1 Technical parameters in CT equipment with
64 vs 256 rows
Technical parameters
Slice thickness 0.9 0.625
Reconstruction interval 0.45 0.3
KV 100 80
mAs 100–150 100–150
Scan time acquisition 5 s 1.5 s
Radiation dose (mSv) 0.9 0.3
64 rows
256 rows
Fig. 16.2 VHSG (maximum intensity projection)
detecting the presence of hydrosalpinx and tubal
obstructions (Fig. 16.2 ).
Volume rendering reconstructions provide tri-
dimensional views of the reproductive tract, with
a window that recognizes the endoluminal contrast. These reconstructions detect a large spectrum of uterine and tubal pathology such as
cervical stenosis, polyps, and tubal disease
(Figs. 16.4 , 16.5 , and 16.6 ).
Virtual endoscopy algorithm of reprocessing
images confi rms the fi ndings encountered with
the previous methods and provides intraluminal
Fig. 16.3 VHSG (multiplanar reconstruction of an endocervical polyp)
Fig. 16.4 VHSG (volume rendering in tubal disease)
16 Virtual Hysterosalpingography: A New Diagnostic Technique for the Study of the Female
201
Fig. 16.5 VHSG (volume rendering in tubal disease)
Fig. 16.7 Normal uterine cavity (endoscopy view)
Fig. 16.6 Cervical stricture
information similar to a conventional hysteroscopy and falloposcopy (Figs. 16.7 and 16.8 ).
The rate of complications with VHSG in
our experience is extremely low; in over 7,000
VHSG studies performed since 2006, we did
not fi nd any cases of infection, bleeding, or
other signifi cant complications requiring hospitalization. In a few cases we observed intravascular passage of contrast, of which only
Fig. 16.8 Abnormal uterine cavity (endoscopy view)
one patient had an allergic reaction requiring
medical treatment that improved all symptoms
in a very short time.
In known cases of allergy to iodine, we use
gadolinium [ 6 ], a nonallergenic paramagnetic
contrast with a much higher cost (3×) than the
iodine contrast and therefore should not be
used routinely. We recently performed a comparative study between iodine and gadolinium
202
P. Carrascosa and C.E. Sueldo
( n = 50 patients, with 25 in each group) which
gave the following results: gadolinium was
slightly better tolerated than iodine in terms of
discomfort, the density of the intraluminal
images was not as intense with gadolinium,
and however the overall quality of the studies
was fairly similar. In addition, the amounts of
radiation exposure (0.9 mSv) for both contrasts
used in this particular study were also similar.
The VHSG study [ 7 , 8 ] is well tolerated by
our patients, and they all completed a questionnaire post-procedure to evaluate the degree of
discomfort experienced, categorized from grade
0 (no discomfort) to grade IV (very severe discomfort). Over 60 % of the patients had grade
0, 20 % grade I, 16 % grade II, 1.5 % grade III,
and 0.5 % grade IV. Interestingly, those patients
that previously had a conventional HSG revealed
much better acceptance of VHSG compared to
those patients that never had a conventional HSG.
Radiation During VHSG : The obvious com-
parison of the amount of radiation during a
VHSG study is with a conventional HSG, which
itself varies a great deal depending upon the
time of fl uoroscopy employed and the number
of fi lms taken per study. If, for example, an HSG
with 2 min of fl uoroscopy and 6 fi lms obtained
was performed, it would result in a radiation
exposure of 5 mSv. On the other hand, a VHSG
with a 256- row multidetector CT using our latest protocols and technical parameters will produce an exposure of only 0.3–0.4 mSv. It is
important to emphasize that this remarkable
drop in radiation exposure with the use of the
latest CT models is accomplished without compromising the quality of the studies performed.
Clinical Experience with Virtual Hysterosalpingography in Reproductive Medicine
Cervical Pathology in Infertility
The cervical anomalies may include different
types of pathology, like cervical stenosis, synechiae, wall irregularities, polypoid lesions, and
diverticula. The pathology present may alter
Fig. 16.9 Cervical synechiae
uterine access in infertile patients during certain
procedures such as uterine studies, intrauterine
inseminations, and embryo transfers, as well as
the possibility of causing cervical bleeding during those procedures, interfering with the optimization of results.
The etiology of stenotic cervices may be con-
genital, postsurgical, or postinfections; VHSG is
an ideal diagnostic instrument for cervical pathology as it does not require traction with a tenaculum, and it does not leave blind sectors after
image reconstruction; the MPR, MIP, and VR are
useful in diagnosing cervical stenosis allowing
one to navigate through the cervical lumen
clearly identifying the defects (Fig. 16.6 ).
Cervical synechiae are bands of fi brous tissue
localized inside the cervix, partially or completely occupying the lumen; the synechiae are
easily identifi ed by VHSG as elevated endocervical images showing soft tissue densities coming
from the wall toward the center of the cervix
(Fig. 16.9 ).
Cervical polyps are elevated lesions which
vary in size and number, although the majority of
patients have only a single polyp. They may
result from an abnormal response to the presence
of elevated estrogens, chronic infl ammation, etc.
and can present either asymptomatically or with
vaginal bleeding during intercourse or any other
cervical manipulation. They are rarely malignant, but after removal they should always be
sent to pathology. They are seen by VHSG as
16 Virtual Hysterosalpingography: A New Diagnostic Technique for the Study of the Female
203
Fig. 16.10 Endocervical polyp
partially or totally obstructing the lumen; the
MPRs show the soft tissue images and the virtual
endoscopy the endoluminal view of the polyp
(Fig. 16.10 ).
The cervical diverticula are herniations of the
cervical wall that can be seen by VHSG through
tridimensional and endoscopic views, where one
can clearly detect the neck of the diverticulum
inside the lumen. It is unclear if diverticula play a
role in human infertility.
Pathology of the Endometrial Cavity in Infertility
There are different pathologies that can affect the
endometrial cavity and also can be detected by
VHSG [ 9 ]. Most of them have tremendous
importance in reproductive medicine, as they can
compromise sperm transport, embryo implantation, or embryo growth, potentially increasing
the rate of spontaneous miscarriages. In one of
our VHSG studies, we evaluated in a prospective
manner the diagnostic accuracy and potential
clinical value in the detection of cervical and
uterine pathology in 69 patients, in comparison to
conventional diagnostic hysteroscopy (done by
clinicians blinded to the VHSG fi ndings). Virtual
HSG showed a diagnostic sensitivity of 96 %, a
specifi city of 86 %, a positive predictive value of
90 %, and a negative predictive value of 95.6 %.
Congenital anomalies of the Müllerian duct ,
such as septate or bicornuate uterus, can be diagnosed by VHSG [ 10 ]. An accurate diagnosis is
important in order to properly advise patients
about the best treatment to be implemented.
The MRI is considered the study of choice due
to its tissue resolution and its ability to outline
the outer margins of the uterine wall. Recently,
we demonstrated the value of VHSG in the differential diagnosis of these uterine anomalies,
as one can easily outline the external surface of
the uterine fundus. VHSG with volume rendering reconstruction allows the visualization of
the endometrial cavity plus the adjacent fl at or
minimally indented myometrium consistent with
a septated uterus. On the other hand, when the
indentation in the uterine fundus is deeper than
15 mm, creating the presence of two separate
horns, the diagnosis of bicornuate uterus is made
(Fig. 16.11a ); in uterine malformations, the endo-
scopic view is unable to differentiate between
septate and bicornuate uteri (Fig. 16.11b ).
Uterine synechiae consist of fi brous bands
that bind the uterine walls to one another; they
represent scars usually caused by trauma from an
aggressive curettage postabortion or postpartum;
their presence may be localized in a small sector
of the cavity or extensively spread out in a diffuse
manner, obliterating large sectors of the uterine
cavity. They can cause infertility or repeated
pregnancy losses. VHSG is an excellent diagnostic tool as MPR shows irregularly elevated lesions
with soft tissue density, while volume rendering
reconstructions show fi lling defects where the
synechiae are localized (Fig. 16.12 ).
Endometrial polyps constitute focal elevations
of the endometrium and contain glands, fi brous
stroma, and blood vessels; they are fairly common (11–24 %) among infertile patients. Their
role in causing infertility is controversial, but
there is some consensus that those polyps larger
than 1 cm should be removed, especially when
present in IVF candidates. VHSG has various
modalities of image reconstruction (bidimensional, tridimensional, and endoscopic) that
allow the visualization and identifi cation of the
204
a
P. Carrascosa and C.E. Sueldo
b
Fig. 16.12 Endometrial synechiae
Fig. 16.11 Uterine malformation: ( a ) volume rendering
and ( b ) endoscopic views
intrauterine lesions; the MPRs show the polyps
as elevated lesions from the wall that move
toward the cavity with a soft tissue density. The
virtual endoscopic images show the polyps with
endoluminal views, allowing the assessment of
polyp size and shape (Fig. 16.13 ).
Submucous myomas are generally benign
tumors from the smooth muscle, single or multiple, with a variable size, number, and location.
They may be a cause of infertility when they are
Fig. 16.13 Endometrial polyp
submucous in location, as they may interfere
with sperm transport and/or embryo implantation
and they may also cause repeated miscarriages.
The identifi cation of the tumors is important as it
can help plan the best surgical approach for their
16 Virtual Hysterosalpingography: A New Diagnostic Technique for the Study of the Female
ab
Fig. 16.14 Submucous myoma seen by ( a ) endoscopic and ( b ) volume rendering views
205
removal and the possible success of the procedure. The use of VHSG permits the identifi cation
of submucous myomas and determines the size
and at times the percentage of intramural extension. We determined that the sensitivity and specifi city of VHSG for the detection of submucous
myomas are 91.7 and 100 %, respectively. The
volume rendering and endoscopic views clearly
distinguish the endometrial-myometrial line and
localize the myoma and its relation with the
endometrial cavity (Fig. 16.14a, b ).
Evaluation of the Fallopian Tubes
Hysterosalpingography (HSG) has been the traditional method of evaluation of the fallopian
tubes for the last several decades; tubal patency
is clearly established as the dye injected passes
through the fi mbriated ends and disperses around
the peritoneal cavity near the adnexa. The diagnosis of tubal obstruction when a hydrosalpinx is
present is fairly certain; on the other hand the
lack of passage of dye into the fallopian tube may
represent a cornual spasm, a mucus plug, or
insuffi cient amount (or pressure) of the contrast
injected transcervically to complete the study.
Recently, the introduction of VHSG, as a new
diagnostic modality based on computer tomography, appears to be a step forward in the diagnosis
of fallopian tube pathology. Initially in our experience with this technique, using older CT equipment, we were not able to clearly visualize the
fallopian tubes. More recently, the use of 256row MDCT allows the study to be completed in
only 1.5 s, capturing the images in real time
while the fi lling material is still present in the
tubes or as it escapes through the fi mbriated
ends. Through the fi lling of the fallopian tubes,
one is able to obtain volumetric images of high
resolution, which allows high image quality and
virtual endoscopic navigation, similar to the
visualization of the inner tubal lumen as
described by conventional falloposcopy. Also,
the projection of volume rendering (VR) provides excellent defi nition of the fallopian tubes,
detecting the presence of hydrosalpinx
(Fig. 16.15 ), tubal obstructions (Fig. 16.5 ), etc.
making VHSG a valuable diagnostic tool for the
assessment of tubal pathology.
206
P. Carrascosa and C.E. Sueldo
Fig. 16.15 Bilateral hydrosalpinges
Conclusions
VHSG should be considered a new and
improved diagnostic technique for the evalua-
tion of the female reproductive tract over other
existing diagnostic modalities, as it provides
high-quality images of the cervix, uterine cav-
ity, and fallopian tubes. The versatility of the
image reconstructions allows for accurate
visualization and diagnosis of diverse patho-
logic processes in the female reproductive
tract, many of them of high signifi cance in
infertility. The study is completed in a short
amount of time, well tolerated, and with mini-
mal radiation exposure as compared to con-
ventional HSG. The cost-benefi t ratio, which
varies from country to country, is an important
consideration that should be determined on an
individual basis; yet we are confi dent that
VHSG has a bright future given its many diagnostic advantages.
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