|Year : 2020 | Volume
| Issue : 2 | Page : 400-404
Hysteroscopy versus transvaginal ultrasound in infertile women prior to intracytoplasmic sperm injection
Mohammed A Kandeel, Tarek M Sayyed, Ahmed M Tharwat, Amal S Hamed
Department of Obstetrics and Gynaecology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
|Date of Submission||02-Sep-2019|
|Date of Decision||23-Sep-2019|
|Date of Acceptance||29-Sep-2019|
|Date of Web Publication||27-Jun-2020|
Amal S Hamed
Source of Support: None, Conflict of Interest: None
The aim of this study was to compare the efficacy of transvaginal sonography (TVS) and hysteroscopy regarding the diagnosis of uterine cavity pathologies in a population of infertile women.
The presence of uterine pathology may negatively affect the chance of implantation.
Patients and methods
A cross-sectional study at the Department of Obstetrics and Gynaecology at Menoufia University Hospital between March 2018 and March 2019 on 60 women who underwent TVS in the early follicular phase for detection of any uterine cavity abnormalities, followed by diagnostic hysteroscopy for all cases.
The study included 60 women in the age range of 20–39 years. All cases were divided into two groups, women who were scheduled for first-time in-vitro fertilization (number 52) and women for recurrent in-vitro fertilization (number 8). The cases of primary infertility constituted 46.6% of all participants and 53.3% of cases were of secondary infertility. The abnormal uterine cavity was detected in about 25% of cases evaluated by TVS versus 45% of cases evaluated by hysteroscopy. Using hysteroscopy the most common uterine pathology was endometrial polyp which constituted 18.3% of all cases. TVS missed the diagnosis of 12 cases, three cases of polyps, two case of submucous fibroids, five cases of intrauterine septum, and two cases of intrauterine adhesions in comparison with diagnostic hysteroscopy.
Diagnostic hysteroscopy is superior to TVS in the diagnosis of intrauterine pathology. Office hysteroscopy takes little time comparable to TVS with little or no complications in experienced skilled hands. TVS has many screening parameters in the detection of polyps and submucous fibroids.
Keywords: hysteroscopy, intracytoplasmic sperm injection, transvaginal ultrasound
|How to cite this article:|
Kandeel MA, Sayyed TM, Tharwat AM, Hamed AS. Hysteroscopy versus transvaginal ultrasound in infertile women prior to intracytoplasmic sperm injection. Menoufia Med J 2020;33:400-4
|How to cite this URL:|
Kandeel MA, Sayyed TM, Tharwat AM, Hamed AS. Hysteroscopy versus transvaginal ultrasound in infertile women prior to intracytoplasmic sperm injection. Menoufia Med J [serial online] 2020 [cited 2020 Jul 15];33:400-4. Available from: http://www.mmj.eg.net/text.asp?2020/33/2/400/287770
| Introduction|| |
In-vitro fertilization (IVF) is an expensive treatment but results in a successful outcome in only a third of treatment cycles.
Implantation failure could be due to a variety of reasons, including embryo quality and uterine receptivity, but remains unexplained in many cases.
It represents a major cause of stress to both the clinician and the patient undergoing intracytoplasmic sperm injection (ICSI) cycle. Even minor uterine cavity abnormalities, such as endometrial polyps, small submucous myomas, adhesions, and septa are considered to have a negative impact on the chance to conceive. The presence of uterine pathology may negatively affect the chance of implantation. The prevalence of unsuspected uterine pathology in asymptomatic women with implantation failure has been reported to be as high as 50%.
The high prevalence of intrauterine pathologies in infertile women makes evaluation of the uterine cavity for fibroids, polyps, adhesions, and Mullerian abnormalities a reasonable decision. Therefore, one of the common investigations proposed for women undergoing IVF treatment is to evaluate the uterine cavity via hysteroscopy. Hysteroscopy is the gold standard test for assessing the uterine cavity.
It is generally performed as a definitive diagnostic tool to evaluate abnormal findings on hysterosalpingogram or saline hysterosonography performed during the course of investigation of subfertile women.
Hysteroscopy not only provides accurate visual assessment of the uterine cavity, but also provides a chance to treat any pathology detected during the examination. The availability of hysteroscopes with a smaller diameter has made the use of outpatient or office hysteroscopy feasible as a routine examination.
Currently, there is evidence that performing hysteroscopy before starting IVF treatment could increase the chance of pregnancy in the subsequent IVF cycle in women who had one or more failed IVF cycles.
The aim of our study was to evaluate the efficacy of both hysteroscopy and transvaginal sonography (TVS) for the evaluation of endometrial cavity in infertile women prior to ICSI.
| Patients and Methods|| |
This cross-sectional study was performed at the Department of Obstetrics and Gynaecology at Menoufia University Hospital between March 2018 and March 2019. Based on previous studies, the calculated sample size was 60 cases with two-sided confidence interval (95%) and a study power of 80% and alpha error of 0.05. The Institutional Review Board approved the study protocol and an informed consent was obtained from all participants to start the study. The study included all women with infertility planning to undergo ICSI who came to the outpatient gynecological clinic.
The inclusion criteria included primary or secondary infertility, age less than 40 years, BMI of less than 30, serum follicular-stimulating hormone of less than 10 IU/L, and regular menstrual cycle of 26–35 days.
The exclusion criteria included patients with gross pelvic pathology (ovarian swelling, huge fibroid, >10 cm), history of recurrent miscarriage, thyroid dysfunction, or elevated prolactin hormone and patients with intermenstrual blood loss.
TVS was performed to all women attending the Department of Obstetrics and Gynecology for infertility consultation before undergoing ICSI. The ultrasound assessment was performed by an experienced operator with an appropriate ultrasound machine (Sonata Plus, BMV TECHNOLOGY CO., LTD, Shenzhen 518010, China) with transvaginal probe 7.5 mHz transducer. Detection of uterine congenital anomalies, uterine fibroids, endometrial polyp, intrauterine septum, intrauterine adhesion, and other uterine or adnexal abnormalities was done.
Finally, hysteroscopy was performed in the operating theater, using the Hamou II microhysteroscope (Karl Storz, Germany).
Hysteroscopic examinations were done using rigid type with continuous irrigation and suction sheath (25 cm in length, 4 mm in diameter) with an outer sheath of 5.5 mm and 30° fore-oblique lens (Hamou II, Germany). The light source used was Xenon Nova 300 (Karl Storz).
Hysteroscopy was scheduled to be performed during the follicular phase of the menstrual cycle between days 5 and 10, usually immediately after cessation of menses, to afford a better view and easier detection of intrauterine abnormalities.
All patients were given 200 mg misoprostol vaginally at 12 h before the procedure for cervical ripening. The patient was put in lithotomy position. Bimanual examination of the uterus to detect its size and position was done. The vulva was cleansed with an appropriate antiseptic solution. The cervix was thoroughly cleaned with cotton soaked in nonfoaming antiseptic or physiological solution after insertion of self-retaining vaginal speculum. Cervical forceps (tenaculum) is then placed on the anterior lip of the cervix. The light source and the tube of irrigation solution were connected to the hysteroscope. Saline solution was used as a distension medium in this study. It was infused by a pneumatic cuff wrapped on the sterile solution plastic bottle suspended above the patient level. The speculum was removed after insertion into the cervical canal.
The principle of hysteroscopy was performed with a standard sequence, inspecting the endocervical canal, uterine cavity, endometrium, and tubal ostia.
Two types of statistics were done.
Quantitative data are shown as mean, SD, and range. Qualitative data are expressed as frequency and percent. Analytical statistics: χ2 test. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) and diagnostic accuracy were calculated. Mann–Whitney test.
P value was considered to be of statistical significance if it was less than 0.05.
| Results|| |
The study included 60 women in the age range of 20–39 years. All cases were divided into two groups, women who were scheduled for first-time IVF (number 52) and women who were scheduled for recurrent IVF (number 8). The cases of primary infertility constituted 46.6% of all participants and 53.3% of cases were secondary infertility as shown in [Table 1].
The abnormal uterine cavity is detected in about 25% of cases evaluated by TVS versus 45% of cases evaluated by hysteroscopy, with hysteroscopic examination. The most common uterine pathology was endometrial polyp which constituted 18.3% of all cases as shown in [Table 2]. No complication occurred during hysteroscopy in all participants (e.g. perforation, air embolism, anesthetic complication, or fluid overload).
|Table 2: Comparison of findings from both uterine evaluation techniques in infertile patients|
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TVS missed the diagnosis of 12 cases, three cases of polyps, two cases of submucous fibroids, five cases of intrauterine septum, and two cases of intrauterine adhesions as shown in [Table 3].
|Table 3: Hysteroscopic findings after normal transvaginal sonography in the study groups|
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The diagnostic performance of TVS for endometrial pathology with respect to hysteroscopic finding show the highest sensitivity for detection of submucous fibroid (81.4%) other than uterine pathologies as shown in [Table 4].
|Table 4: Diagnostic performance of transvaginal sonography for endometrial pathology in respect to hysteroscopy (n=15)|
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The comparison was of two groups of participants who were scheduled for first-time IVF and who were scheduled for recurrent IVF according to TVS. A higher percentage of uterine cavity abnormality was found in the recurrent group (37.5% abnormal vs. 62.5% normal) than the first-time group (23% abnormal vs. 77% normal) as shown in [Table 5].
|Table 5: TV/US finding in women scheduled for both first-time and recurrent in-vitro fertilization|
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| Discussion|| |
Sixty consecutive women including 52 women who were undergoing IVF for the first time and eight with previous failed trial(s) of ICSI participated in the present study. Regarding infertility, 28 patients were nulligravdiae and 32 patients had secondary infertility. All patients involved in this study had TVS at early follicular phase before hysteroscopy. Hysteroscopic examination of these patients have shown that 45% had positive findings. This agrees with the previously published data that showed large ranges of abnormal finding rates from one study to another (47.2–64%). These differences could be explained by the hysteroscopic technique used, type of hysteroscopic distension medium, characteristics of the population including age of the population, ethnic factor, type of infertility (primary or secondary), and indications for hysteroscopy (infertility alone, hysterosalpingography abnormalities, prior to IVF).
Regarding the diagnosis of polyp 40.7% (number 11) of those with uterine pathology after hysteroscopic examination had uterine and cervical polyps and this represents 18.3% of all participants, but TVS diagnosed eight cases (13.3% of all participants) and missed three cases (5% of all cases) with sensitivity, specificity, PPV, and NPV of 73.3, 89.8, 70.3, 84.2%, respectively.
Our study is in agreement with Loverro et al., who hadreported that TVS had a sensitivity and specificity as high as 75% and 90%, respectively, for the detection of endometrial polyps. According to Niknejadi et al., TVS showed excellent specificity (91.2%), good sensitivity (88.2%), 81.4% PPV, and a 94.6% NPV in uterine polyp detection, while Fedele et al. reported that TVS had a misdiagnosis rate of 4.2% and was therefore less effective in distinguishing polyps than hysteroscopy.
In this study, about 11.6% (number 7) of patients had submucous fibroids that ranged in size from 1 to 3 cm. TVS diagnosed only five (8.3%) cases and missed two (3.3%) cases with sensitivity, specificity, PPV, NPV of 81.4, 94.3, 80, and 90%, respectively. The results of the present study are in accordance with those reported by Niknejadi et al., in which TVS had a sensitivity of 89.2% and a specificity of 99.6% for the identification of submucous fibroids. These findings correlate with the result of Loverro et al.with 90.9% sensitivity and a 100% specificity for the detection of endometrial fibroids.
TVS failed to distinguish adhesions in two (50%) out of four patients with sensitivity, specificity, PPV, and NPV of 50, 100, 100, 96.5%, respectively. According to Niknejadi et al., TVS failed to distinguish adhesions in 14 (67%) out of 21 patients, while Fedele et al.reported a high accuracy of TVS in diagnosing uterine adhesions. In our study two-dimensional TVS failed to detect any case of intrauterine septum. In the Niknejadi et al. study, TVS detected 30 cases with intrauterine septum out of 643 patients with a sensitivity of 67% and a specificity of 99.8%.
In the current study, there was one case of intrauterine abnormality missed by TVS in the failed IVF group (number 8) and this represents about 12.5% of this number compared with Bakas et al., which demonstrated that a significant percentage (42%) of intrauterine abnormalities remain undiagnosed even after TVS and hysterosalpingography in patients with a history of failed IVF/ICSI attempt. In our study, we had no complications for any case (0%). Hysteroscopy is generally considered to be the gold standard in the diagnosis of intrauterine pathology, including endometrial polyps, submucous myoma, intrauterine synechiae, and uterine septum. In our study although TVS consumed less money and time it missed 12 cases (20% of all cases) in which abnormal uterine findings were detected with hysteroscopy. In this study hysteroscopic examination showed 27 cases with intrauterine abnormalities, 11 (18.3%) cases of endometrial polyps, seven (11.6%) cases of submucous fibroids, four (6.6%) cases of intrauterine adhesions, and five (8.3%) cases of intrauterine septum. According to El-Toukhy et al. out of 323 patients who had outpatient hysteroscopy 15 (6%) had arcuate uterus, eight (2%) had endometrial polyp, five (2%) had partial uterine septum, and two (1%) patients had submucous fibroids. According to Mao et al. hysteroscopy improved the implantation rate and clinical pregnancy rates, but failed to improve livebirth rates and did not affect the miscarriage rate in women with repeated implantation failure (RIF) undergoing IVF. In our study no patients who had hysteroscopy followed up in their following ICSI trial to determine the clinical pregnancy rate. Saline infusion sonography (SIS) was not done to any of these cases. We compared the findings of traditional two-dimensional TVS for all patients with their hysteroscopic examination.
| Conclusion|| |
From this study, it is concluded that diagnostic hysteroscopy especially in an outpatient clinic setting with no anesthesia is superior to two-dimensional TVS in the diagnosis of intrauterine pathology. Office hysteroscopy takes little time with little or no complications in experienced skilled hands. Diagnostic hysteroscopy has a reasonable cost when compared with other radiological examination like three-dimensional TVS or MRI and gives more information than traditional two-dimensional TVS ultrasound.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bouwmans CA, Lintsen BM, Eijkemans MJ, Habbema JD, Braat DD, Hakkaart L. A detailed cost analysis of in vitro
fertilization and intracytoplasmic sperm injection treatment. Fertil Steril 2008; 89
Margalioth EJ, Ben Chetrit A, Gal M, Eldar-Geva T. Investigation and treatment of repeated Implantation failure following IVF-ET. Hum Reprod 2006; 21
Cenksoy P, Ficicioglu C, Yildirim G, Yesiladali M. Hysteroscopic findings in women with recurrent IVF failures and the effect of correction of hysteroscopic findings on subsequent pregnancy rates. Arch Gynecol Obstet 2013; 287
Pundir J, El Toukhy T. Uterine cavity assessment prior to IVF. Womens Health (Lond Engl) 2010; 6
Roma Dalfo' A, Ubeda B, Ubeda A, Monzo'n M, Rotger R, Ramos R,et al
. Diagnostic value of hysterosalpingography in the detection of intrauterine abnormalities: a comparison with hysteroscopy. Am J Roentgenol 2004; 183
De Placido G, Clarizia R, Cadente C, Castaldo G, Romano C, Mollo A,et al
. Compliance and diagnostic efficacy of mini-hysteroscopy versus traditional hysteroscopy in infertility investigation. Eur J Obstet Gynecol Reprod Biol 2007; 135
Bosteels J, Weyers S, Putteraans P, Panayotidis C, Van Herendael B, Gomel V,et al
. The effectiveness of hysteroscopy in improving pregnancy rates in subfertile women without other gynaecological symptoms: a systematic review. Hum Reprod Update 2010; 16
Richilin SS, Ramachadian S, Schanti A. Glycodelin level in uterine flushing and in plasma of patients with leiomyomas and polyps: implications and implantation. Hum Reprod 2002; 17
Loverro G, Nappi L, Vicino M, Carriero C, Vimercati A, Selvaggi L. Uterine cavity assessment in infertile women: comparison of transvaginal sonography and hysteroscopy. Eur J Obstet Gynecol Reprod Biol 2001; 100
Niknejadi M, Haghighi H, Ahmadi F, Niknejad F, Chehrazi M, Vosough A,et al
. Diagnostic accuracy of transvaginal sonography in the detection of uterine abnormalities in infertile women. Iran J Radiol 2012; 9
Fedele L, Bianchi S, Dorta M, Vignali M. Intrauterine adhesions: detection with transvaginal US. Radiology 1996; 199
Bakas P, Hassiakos D, Grigoriadis C, Vlahos N, Liapis A, Gregoriou O. Role of hysteroscopy prior to assisted reproduction techniques. J Minim Invre Gynecol 2014; 21
Polisseni F, Bambirra EA, Camargos AF. Detection of chronic endometritis by diagnostic hysteroscopy in asymptomatic infertile patients. Gynecol Obstet Invest 2003; 55
El-Toukhy T, Campo R, Khalaf Y, Tabanelli C, Gianaroli L, Jordts S, Mestdagh G. Hysteroscopy in recurrent in-vitro
fertilisation failure (TROPHY): a multicentre, randomised controlled trial. Lancet 2016; 387
Mao X, Wu L, Chen Q, Kuang Y, Zhang S. Effect of hysteroscopy before starting in_vitro fertilization for women with recurrent implantation failure. A meta–analysis and systematic review. Medicine (Baltimore) 2019; 98
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]