Comparison of uterine and tubal pathology identified by transvaginal sonography, hysterosalpingography, and hysteroscopy in female patients with infertility

Abstract

Background: The causes of female infertility are multifactorial and necessitate comprehensive evaluation including physical examination, hormonal testing, and imaging. Given the associated psychological and financial stress that imaging can cause, infertility patients benefit from a structured and streamlined evaluation. The goal of such a work up is to evaluate the uterus, endometrium, and fallopian tubes for anomalies or abnormalities potentially preventing normal conception. To date, the standard method for assessing these structures typically involves some combination of transvaginal sonography (TVS), hysterosalpingography (HSG), and hysteroscopy (HSC). The goal of this review is to compare the diagnostic accuracy of TVS, HSG, and HSC for diagnosing abnormalities in infertility patients to determine if all studies are necessary for pre-treatment evaluation.

Results: We identified infertility patients prior to initiation of assisted reproductive technology who had baseline TVS, HSG, and HSC within 180 days of each other. From medical record review, we compared frequencies of each finding between modalities. Of the 1274 patients who received a baseline TVS over 2 years, 327 had TVS and HSG within 180 days and 55 patients had TVS, HSG and HSC. Of the 327, TVS detected fibroids more often than HSG (74 vs. 5, p < .0001), and adenomyosis more often than HSG (7 vs. 2, p = .02). HSG detected tubal obstruction more often than TVS (56 vs. 8, p = .002). Four (1.2 %) patients had endometrial polyps on both HSG and TVS. In the 55 patients with HSG, TVS, and HSC, HSC identified endometrial polyps more often than TVS (10 vs. 1, p = .0001) and HSG (10 vs. 2, p = .0007). TVS detected more fibroids than HSC (17 vs. 5, p < .0001). Tubal obstruction was identified more often by HSG than HSC (19 vs. 5, p < .0001).

Conclusions: TVS is superior for evaluation of myometrial pathology. HSG is superior for evaluation of tubal pathologies. Endometrial pathologies are best identified with HSC.

Keywords: Hysterosalpingography; Infertility; Transvaginal sonography.

Fig. 1

a 38-year-old G1P1 female with a history of infertility presenting for baseline assessment prior to initiation of ART. Coronal transvaginal sonographic image through the uterus demonstrates a 6.0 × 4.2 × 3.9 cm left sided mass with heterogenous echotexture and an echogenic rim, consistent with a large calcified intramural fibroid. b HSG demonstrates a normal endometrial cavity without filling defects to suggest fibroids as seen on TVS. The fallopian tubes are normal in caliber and demonstrate free intraperitoneal spill of contrast bilaterally

Fig. 2

36 year-old G2P1A1 female with a history of infertility × 3 years, presenting for baseline assessment of tubal patency prior to initiation of ART. HSG demonstrates normal contour of the endometrial cavity. The left fallopian tube opacifies normally and demonstrates free intraperitoneal spill. The right fallopian tube fills with contrast, but terminates abruptly near its terminus (arrowhead). No right sided contrast spill is identified, diagnostic of distal tubal obstruction. This tubal obstruction was not appreciated on TVS or HSC

Fig. 3

a 38-year-old G2P2 female with history of male factor infertility presenting for baseline assessment prior to initiating ART. Transvaginal grey-scale image of the left adnexa demonstrates an anechoic tubular structure (calipers), measuring 43 × 31 × 19 mm, separate from the left ovary (not shown) and consistent with hydrosalpinx. b HSG demonstrates contrast pooling within a dilated, blind ending fallopian tube (arrows), confirming the presence of a left sided hydrosalpinx. The right fallopian tube is normal in caliber and demonstrates free intraperitoneal spill of contrast, indicating tubal patency

Fig. 4

a 44 year-old G0P0 female with inability to conceive for 4 years presents for baseline assessment prior to IVF. TVS demonstrates an 11 × 11 × 10 mm echogenic lesion within the left aspect of the endometrial cavity (calipers). Flow was demonstrated within the lesion with color Doppler, raising the possibility of endometrial polyp. b Corresponding HSG demonstrates a depended rounded filling defect within the left aspect of the endometrial cavity, which persisted on multiple projections, suggestive of a polyp. The fallopian tubes are normal in caliber and patent. The patient went on to HSC, where the lesion proved to be a submucosal fibroid