Modern assessment of the uterine cavity and fallopian tubes in the era of high-efficacy assisted reproductive technology

Abstract

The high efficacy of modern assisted reproductive technology (ART) and increase in the number of noninfertile patients who are using ART for family building in the United States call into question the relevance of the standard, one-size-fits-all infertility evaluation. Here, we explore whether all patients presenting for ART need uterine cavity and tubal assessment and what tests are most appropriate, efficient, and cost-effective in current times.

Keywords: Saline infusion sonohysterography (SIS); hydrosalpinx; hysterosalpingo-contrast sonography (HyCoSy); hysterosalpingography (HSG); hysteroscopy.

Figure 1:. Three-dimensional saline infusion sonohysterography (3D-SIS) coronal view of uteri.

3D-SIS allows accurate assessment of the whole uterus and uterine cavity, allowing more comprehensive assessment than traditional methods like hysteroscopy and HSG, which are limited only to uterine cavity.

1. Render modes: LEFT COLUMN: greyscale and Volume Contrast Imaging, CENTER COLUMN: HDlive, a.k.a. virtual hysteroscopy; RIGHT COLUMN: Automatic Volume Calculation software (SonoAVC)

2. Cases: TOP ROW (A): Normal uterus with normal uterine cavity shape and volume; MIDDLE ROW (B): Intrauterine synechiae and small uterine cavity volume due to presence of adhesions; BOTTOM ROW (C): Septate uterus with endometrial polyp in left part of uterine cavity.

Figure 2:. Three-dimensional saline infusion sonohysterography (3D-SIS) in assessment of submucosal myoma.

This method can determine suitability of submucosal myomas to hysteroscopic resection because it allows assessment of myoma penetration into myometrium, distance between myoma and uterine surface, and myoma size.

Figure 3:. Ultrasound tubal patency testing with foam (HyFoSy):

Doppler techniques objectively confirm the contrast flow and generate easy to interpret pictorial documentation of exam.

1. (A) 2D-HyFoSy in grey scale (LEFT) and tissue Doppler imaging (CENTER and RIGHT);

2. (B) 3D-HyFoSy in grey scale (LEFT), HDlive render mode (CENTER and RIGHT);

3. (C) 3D-HyFoSy and power Doppler. Power Doppler generates a highly useful sign called flaming tubes sign and makes diagnosis very easy to interpret for low and medium experienced users (53).