Mohammad Ahmad Taymour MBBCh PROF. DR. Osama Abd El Aziz Al Shonoufy ASS. PROF. DR ...

20 Pages·2015·2.14 MB·English

COMPARATIVE STUDY BETWEEN
HYSTEROSALPINGOGRAPHY, SALINE INFUSION
SONOHYSTEROGRAPHY AND OFFICE HYSTEROSCOPY IN
EVALUATION OF UTERINE FACTORS OF INFERTILITY
THESIS
SUBMITTED IN PARTIAL FULFILLMENT OF MASTER DEGREE
IN
OBSTETRICS AND GYNECOLOGY
BY
Mohammad Ahmad Taymour
M.B.B.Ch
Faculty of Medicine
Cairo University
SUPERVISED BY
PROF. DR. Osama Abd El Aziz Al Shonoufy
Professor of Obstetrics and Gynecology
Faculty of Medicine - Cairo University
ASS. PROF. DR. Akmal Nabil El Mazny
Assistant Professor of Obstetrics and Gynecology
Faculty of Medicine - Cairo University
DR. Waleed Saber Abd El Gaber
Lecturer of Obstetrics and Gynecology
Faculty of Medicine - Cairo University
Faculty of Medicine
Cairo University
2012
ﻢﻴﺣﺮﻟا ﻦﲪﺮﻟا ﷲا ﻢﺴﺑ

ﺎﻣَ ﻻﱠ إ ﺎﻧَ َﻟ مﻠْ ﻋِ ﻻَ كَ ﻧَ ﺎﺣَ ﺑْ ﺳُ اوُﻟﺎﻗَ
ِ َ
َ
مﯾﻛِ ﺣَ ﻟْ ا مﯾِﻠﻌَ ﻟْ ا تَ ﻧْ أ كَ ﻧﱠ إ ﺎﻧَ ﺗَ ﻣْ ﻠﱠ ﻋَ
ُ ُ ِ

ﻢﻴﻈﻌﻟا ﷲا قﺪﺻ
(٣٢ ﺔﻳآ) ةﺮﻘﺒﻟا ةرﻮﺳ
Acknowledgment
Firstly and lastly thanks to Allah the most merciful for his help.
I would like to express my deepest gratitude and sincere
appreciation to Prof. Dr. Osama Abd El-Aziz Alshonoufy,
Professor of Obstetrics & Gynecology, Faculty of Medicine, Cairo
University. I’m greatly thankful to him for his fatherly attitude,
enthusiastic encouragement, his sincere advice, and supervision. He was
very generous with his time and effort.
My extreme thanks and gratefulness to Dr. Akmal Nabil El-
Mazny, Ass. Prof. of Obstetrics & Gynecology, Faculty of Medicine,
Cairo University. He was very generous with his time and advice, which
helped to simplify my hard task of preparing this work. Also for his
sincere supervision and the endless effort that he had offered throughout
the period of making and revising this thesis.
Also I would like to thank Dr. Waleed Saber Abd El-Gaber ,
Lecturer of Obstetrics and Gynecology, Faculty of Medicine , Cairo
University for his keen interest, beneficial advice, constant support and
scientific opinions during the conduction of the operative phase of this
work.
I’m grateful to all my professors, staff and colleagues of the
Obstetrics & Gynecology department, Cairo University for their help and
cooperation throughout this work.
Many grateful thanks to my parents for their continuing love, care
and strong support, to whom I'm indebted for what I am today. My
sincere gratefulness and appreciation to my wife who stood by my side,
her support provides me with aim and direction.
Finally, I’m grateful to the patients for whom all our efforts are
devoted.

i
Abstract
Evaluation of the uterine cavity is mandatory when studying
infertile patients. Likewise, assessment of the implantation site is an
important step in the management of patients with diagnosed infertility,
indeed uterine cavity pathologies such as fibroids, polyps and Müllerian
anomalies can impair fertility and result in recurrent pregnancy loss and
poor outcome of pregnancy. Thus, their detection and treatment are
important in order to achieve therapeutic success.
The direct view of the uterine cavity through hysteroscopy offers a
significant advantage over other diagnostic methods which offer only a
blind or indirect view of the cavity.
Keywords:
Infertility
Hysterosalpingography
Sonohysterography
Office hysteroscopy
ii
List of contents
Page
Introduction............................................................................... 1
Aim of work.............................................................................. 3
Review of literature .................................................................. 4
Chapter (1): Infertility............................................................ 4
Chapter (2): Hysterosalpingography...................................... 26
Chapter (3): Saline infusion sonohysterography................... 51
Chapter (4):Hysteroscopy...................................................... 71
Patients and methods ................................................................ 112
Results....................................................................................... 118
Discussion................................................................................. 138
Summary and conclusions........................................................ 148
References................................................................................. 152
Arabic summary........................................................................ -
iii
List of abbreviations
AAGL American Association of Gynecologic Laparoscopists
ACOG American Congress of Obstetricians and Gynecologists
ART Assisted Reproductive Technology
AS Asherman's syndrome
ASRM American Society of Reproductive Medicine
AUB Abnormal uterine bleeding
D&C Dilatation and Curettage
DES Diethylstilbesterol
DH Diagnostic hysteroscopy
FDA Food and Drug Administration
GnRH Gonadotropin-Releasing Hormone
HSG Hysterosalpingography
ICSI Intra cytoplasmic sperm injection
IUAs Intrauterine adhesions
IUI Intrauterine insemination
IVF Invitro fertilization
LR Lactated Ringer’s Solution
MAC Monitored Anaesthesia Care
MAP Mean Arterial Pressure
NIC's Normal Infertile Couples
NPV Negative Predictive Value
NS Normal Saline
NSAID Nonsteroidal anti-inflammatory drugs
OD Outer Diameter
OH / OHS Office Hysteroscopy
PID Pelvic Inflammatory Disease
PPV Positive Predictive Value
SCHS Saline contrast hysterosonography
SD Standard deviation
SHG Sonohysterography
SIN Salpingitis isthmica nodosa
SIS Saline Infusion Sonohysterography
TVS Transvaginal Sonography
WL Working Length
β-hCG β-human Chorionic Gonadotropin
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List of Tables
Page
Table (1): Causes of female factor infertility................................................... 5
Table (2): Percentage of uterine malformations in hysterosalpingogram 40
Table (3): Statistical methods.......................................................................... 119
Table (4): Demographic features of the studied cases..................................... 120
Table (5): Type of infertility of the studied cases............................................ 120
Table (6): Description of Age among different findings of OHS of the
studied cases..................................................................................................... 121
Table (7): Description of the type of infertility among the findings of OHS
of the studied cases .......................................................................................... 122
Table (8): Description of the duration of infertility among the findings of
OHS of the studied cases................................................................................. 123
Table (9): Distribution of findings of OHS among the studied cases.............. 124
Table (10): Comparison between positive and negative findings of OHS...... 124
Table (11): Distribution of the findings of HSG among the studied cases...... 125
Table (12) : Comparison between positive and negative findings of HSG..... 125
Table (13) : Distribution of the findings of SIS among the studied cases....... 126
Table (14) : Comparison between positive and negative findings of SIS 126
Table (15) : Findings of different used techniques among all the studied
cases................................................................................................................. 127
Table (16) : Comparison between positive findings of HSG and OHS among
the studied cases............................................................................................... 128
Table (17) : Comparison between positive findings of SIS and OHS among
the studied cases............................................................................................... 128
Table (18): Sensitivity, specificity, PPV, NPV, and accuracy of different
used techniques in the diseased cases compared to OHS................................ 129
Table (19): Sensitivity, specificity, PPV, NPV, and accuracy of HSG for
different findings compared to OHS. 130
Table (20) : Sensitivity, specificity, PPV, NPV, and accuracy of SIS for
different findings compared to OHS................................................................ 131
Table (21): Findings detected by different diagnostic techniques compared
to OHS.............................................................................................................. 137
v
List of Figures
Page
FIG (1). Unicornous uterus.............................................................................. 9
FIG (2). Didelphys uterus................................................................................ 9
FIG (3) Hysterosalpingogram showing uterus didelphys................................ 10
FIG (4). Bicornate uterus................................................................................. 10
FIG (5) Hysterosalpingogram showing a septate uterus.................................. 11
FIG (6). Arcuate uterus.................................................................................... 11
FIG (7) Hysterosalpingogram showing a T-shaped uterus due to
diethylstilbestrol exposure in utero.................................................................. 12
FIG (8). Small size of the uterus cavity with normal length of the vagina..... 12
FIG (9) (A) Arcuate uterus: (B) Septate uterus: (C) Bicornuate uterus:......... 13
FIG (10) Normal hysterosalpingography......................................................... 35
FIG (11) Hysterosalpingogram showing a right unicornuate uterus............... 37
FIG (12) Hysterosalpingogram showing uterus didelphys.............................. 37
FIG (13) Hysterosalpingogram showing a bicornuate uterus.......................... 38
FIG (14) Hysterosalpingogram showing a septate uterus................................ 38
FIG (15) hysterosalpingography showing an arcuate uterus........................... 39
FIG (16) Hysterosalpingogram showing a T-shaped uterus............................ 39
FIG (17) Small size of the uterus cavity with normal length of the vagina.... 40
FIG (18) Hysterosalpingogram showing multiple filling defects due to
endometrial polyps........................................................................................... 41
FIG (19). Nodosa isthmic salpingitis............................................................... 42
FIG (20) Hysterosalpingogram showing a normal uterine cavity and
bilateral hydrosalpinx ...................................................................................... 43
FIG (21). Submucosa fibromyoma.................................................................. 44
FIG (22) Hysterosalpingogram showing large intramural myoma. ................ 44
FIG (23) Hysterosalpingogram showing a filling defect due to synechiae..... 45
FIG (24) Hysterosalpingogram showing adenomyosis................................... 46
FIG (25) Hysterosalpingogram showing an arcuate uterus............................. 47
FIG (26) Hysterosalpingogram showing tubal polyps bilaterally................... 48
FIG (27) The appearance of well-shaped endometrial polyp which is
detected by hydrosonography.......................................................................... 60
FIG (28) Endometrial polyp by 2D sonohysterography.................................. 60
FIG (29) Endometrial polyp by SIS................................................................. 61
FIG (30) Endometrial polyp by SIS................................................................. 61
FIG (31) Hydrosonographic appearance of a submucous myoma.................. 63
FIG (32) Hydrosonographic appearance of a submucous myoma.................. 63
FIG (33) Intrauterine synechiae 2D sonohysterography ................................ 65
FIG (34) 5 mm Rigid hysteroscope................................................................. 82
FIG (35) Flexible diagnostic hysteroscope...................................................... 82
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Page
FIG (36) Normal panoramic view of the uterine cavity.................................. 90
FIG (37) Intrauterine adhesions....................................................................... 96
FIG (38) Uterine septum.................................................................................. 97
FIG (39): Uterine septum and an endometrial polyp....................................... 98
FIG (40): Submucous myoma.......................................................................... 100
FIG (41): Endometrial polyp........................................................................... 100
Fig (42): Type of infertility of the studied patients......................................... 120
Fig (43): Description of Age among different findings of OHS of the studied
cases................................................................................................................. 121
Fig (44): Description of the type of infertility among the findings of OHS of
the studied cases............................................................................................... 122
Fig (45) : Description of the duration of infertility among the findings of
OHS of the studied cases................................................................................. 123
Fig (46): Distribution of findings of OHS among the studied cases............... 124
Fig. (47) : Distribution of the findings of HSG among the studied cases....... 125
Fig. (48) : Distribution of the findings of SIS among the studied cases.......... 126
Fig. (49) : Findings of different used techniques among all the studied cases 127
Fig. (50) : Sensitivity, specificity, PPV, NPV, and accuracy of different used
techniques for all the studied cases compared to OHS.................................... 129
Fig. (51) : Sensitivity, specificity, PPV, NPV, and accuracy of different
techniques for diagnosis of intrauterine synechia. 132
Fig. (52) : Sensitivity, specificity, PPV, NPV, and accuracy of different
techniques for diagnosis of septate uterus....................................................... 133
Fig. (53) : Sensitivity, specificity, PPV, NPV, and accuracy of different
techniques for diagnosis of polyps .................................................................. 134
Fig. (54) Sensitivity, specificity, PPV, NPV, and accuracy of different
techniques for diagnosis of myoma................................................................. 135
Fig. (55): Sensitivity, specificity, PPV, NPV, and accuracy of different
techniques in diagnosis of cases free of pathological findings........................ 136
Fig. (56) : Findings detected by different diagnostic techniques compared to
OHS.................................................................................................................. 137
vii
INTRODUCTION
One of the basic steps of an infertility workup is to evaluate the
shape and regularity of the uterine cavity. Acquired uterine lesions, such
as uterine fibroids, endometrial polyps, intrauterine adhesions, or all of
these, may cause infertility by interfering with proper embryo
implantation and growth. (Brown et. al, 2000)
In fact, infertility related to uterine cavity abnormalities has been
estimated to be the causal factor in as many as 10% to 15% of couples
seeking treatment. Moreover, abnormal uterine findings have been found
in 34% to 62% of infertile women. (Pansky et. al, 2006).
Traditionally hysterosalpingography (HSG) has been the most
commonly used technique in the evaluation of infertility. It gives reliable
information about the patency and morphology of the fallopian tubes. It is
also helpful in evaluating uterine cavity abnormalities. (Roma et. al,
2004).
Sonohysterography (SHG) is considered a simple, effective and
well tolerated technique for enhanced transvaginal sonographic imaging
of the endometrial cavity. The instillation of sterile saline into the uterine
cavity via a fine catheter provides both a contrast medium and an
expanding agent. So, Saline infusion sonohysterography can help to
triage patients to (1) no anatomic pathology, (2) globally thickened
anatomic pathology that may be evaluated with blind endometrial
sampling, or (3) focal abnormalities that must be evaluated under direct
vision (Goldstein, 2006).
1