Department of Obstetrics and Gynecology, Wright State University, Boonshoft School of Medicine, Dayton, OH, USAUnited States
Department of Radiology, University of Utah, Salt Lake City, UT, USA The evaluation of the fallopian tubes is an essential part of the infertility workup, with abnormalities related to the fallopian tubes accounting for up to 40% of female subfertility.
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The evaluation of the fallopian tubes is an essential part of the infertility workup, with abnormalities related to the fallopian tubes accounting for up to 40% of female subfertility. Laparoscopy is still considered the gold standard in the diagnostic evaluation of fallopian tubes, though the hysterosalpingogram (HSG) has long been recognized as complementary to laparoscopy, since tubal anatomy can be distinctly be seen.2 That said, previous investigations using laparoscopy as the gold standard demonstrate HSG has a sensitivity and specificity of 53% and 87%, respectively, for any tubal pathology and 46% and 95%, respectively, for bilateral tubal pathology.
Short Changing the Algorithm in the Evaluation Communication of Pelvic Anatomy in the Infertile Patient: * *Corresponding author Is Hysterosalpingo Contrast Sonography Steven R. Lindheim, MD, MMM Professor of Obstetrics and Gynecology Director With Saline-Air Device the Appropriate Division of Reproductive Endocrinology and Infertility Miami Valley Hospital Test for Everyone?
128 Apple Street Suite 3800 Weber CHE Dayton OH 45409, USA 1 2 1 Kathryn Coyne, MS ; Thomas C. Winter III, MD ; Rose Maxwell, PhD ; Steven R. Tel. (937) 208-2301 1* Lindheim, MD, MMM Fax: (937)222-7255 E-mail: steven.lindheim@wright.edu 1Department of Obstetrics and Gynecology, Wright State University, Boonshoft School of Medicine, Dayton, OH, USA Volume 2 : Issue 5 2 Department of Radiology, University of Utah, Salt Lake City, UT, USA Article Ref. #: 1000GOROJ2126 Article History th The evaluation of the fallopian tubes is an essential part of the infertility workup, with Received: March 12 , 2016 th abnormalities related to the fallopian tubes accounting for up to 40% of female subfertility. Accepted: April 19 , 2016 th Laparoscopy is still considered the gold standard in the diagnostic evaluation of fallopian tubes, Published: April 25 , 2016 though the hysterosalpingogram (HSG) has long been recognized as complementary to laparos- copy, since tubal anatomy can be distinctly be seen.2 That said, previous investigations using Citation laparoscopy as the gold standard demonstrate HSG has a sensitivity and specificity of 53% and Coyne K, Winter III TC, Maxwell 87%, respectively, for any tubal pathology and 46% and 95%, respectively, for bilateral tubal R, Lindheim SR. Changing the al- 3 pathology.
gorithm in the evaluation of pelvic anatomy in the infertile patient: is In last few years, there has been a move away from these methods and towards the hysterosalpingo contrast sonography with saline-air device the appropriate use of Hysterosalpingo Contrast Sonography (HyCoSy). Laparoscopy mandates regional or test for everyone? Gynecol Obstet general anesthesia and incurs significant operative costs and risks.4 In contrast, while HSG ob- Res Open J. 2016; 2(5): 126-128. viates the need for hysteroscopy and/or laparoscopy, it is associated with exposure to ionizing doi: 10.17140/GOROJ-2-126 5-8 radiation and the need for iodinated contrast material. While HyCoSy has been advocated as an alternative to the HSG since the 1980s, its use in evaluating tubal patency has been limited as the normal fallopian tube is a poor sonic reflector, devoid of the defined interfaces that produce 9-11 clear organ outlines.9-11 Various agents to enhance transvaginal ultrasound visualization of the fallopian tubes have been described; however, given storage issues, expense, and lack of FDA approval, it has obviated their routine use in the office setting. Others have substituted a mixture of saline and/or air for more elaborate distending media: some vigorously shake a syringe of saline and air creating air bubbles immediately before infusion, while others have described fill- ing a syringe with both air and saline and tilting the syringe with the intermittent infusion of air 12-14 followed by saline in increments of 1-3 mL. Recently, the FDA approved saline-air devices, which create and deliver a constant alternating pattern of saline and air as a continuous stream in a controlled fashion allowing for fallopian tube evaluation under ultrasound guidance.15 The allure of the HyCoSy-saline-air device (HyCoSy-SAD) is that: 1) it is a relatively quick and non-invasive procedure that can be done in the office setting and does not require exposure to ionizing radiation; 2) a number of studies, including a meta-analysis, have demon- strated concordance rates of 83% to 100% and a diagnostic accuracy of 65% to 85% between Copyright HyCoSy-SAD, laparoscopy, and HSG in establishing tubal patency when detecting tubal pa- ©2016 Lindheim SR. This is an 2,8-19 thology ; and 3) the low cost of air and saline solutions makes this particular HyCoSy pro- open access article distributed un- der the Creative Commons Attribu- cedure attractive to determine tubal patency (price points range from USD 10-40 for the SIS tion 4.0 International License (CC catheter and USD 90-150 for the saline-air device). BY 4.0), which permits unrestricted use, distribution, and reproduction However, caution needs to heeded when embracing new technology and discarding in any medium, provided the origi- nal work is properly cited. gold standards. Work by our research team concurs with reports from other investigators that
Risk factors Associated with Indeterminate- Inconclusive HyCoSy-SAD • Dysmenorrhea • Cervical Stenosis • Uterine Fibroids • Low Antral Follicle Counts
indicate a high degree of concordance with HSG when using fibroids, which make identification of the uterine cornua and a HyCoSy-SAD to detect tubal patency; however, the converse ovaries challenging (Figure 2). While the HyCoSy-SAD allows is not true with respect to tubal occlusion.20 Indeterminate or for the simple delivery of saline and air as a continuous stream inconclusive studies using the HyCoSy-SAD tend to be asso- in a controlled fashion, further refinement with proper patient ciated with patients with cervical stenosis, as air bubbles are selection may advance this procedure as a useful first-line mo- less likely to traverse the cervix and ascend upwards towards dality in the evaluation of tubal patency and reduce the false the fallopian tubes, and with diminished ovarian reserve, where positives and negative studies.
smaller ovaries may make it harder to track the air-bubbles. In our experience, there is nearly a two times greater likelihood ConFLICTS oF InTEREST: None.
of incorrectly reading a fallopian tube as occluded on HyCoSy- SAD, and between 5-10% of seemingly normal HyCoSy-SAD