Uterine cavity assessment in infertile women: sensitivity and specificity of three-dimensional hysterosonography versus hysteroscopy

Assessment of uterine abnormalities is a core part in infertility evaluation. The aim of this study was to evaluate the sensitivity and specificity of three-dimensional hysterosonography [3-DHS] in the diagnosis of uterine abnormalities in infertile women. The infertile women who visited Royan Institute and referred to 3-DHS consecutively, prior to in vitro fertilization, from 2010-2011 included in this cross-sectional study. For patients who underwent hysteroscopy in addition to 3-DHS [214/977], the verification bias adjusted sensitivity and specificity of 3-DHS which were calculated by global sensitivity analysis method. Hysteroscopy was used as the gold standard for diagnosis of uterine abnormalities. Histological diagnosis of resected endometrial tissues by hysteroscopy was assessed and the adjusted sensitivity and specificity of 3-DHS and hysteroscopy in detection of polyp or hyperplasia were determined. Histopathologic results were considered as the gold standard for diagnosis of polyp or hyperplasia. The overall sensitivity and specificity for 3-DHS in diagnosis of uterine anomalies considering hysteroscopy as the gold standard were 68.4% and 96.3% respectively. Sensitivity and specificity of hysteroscopy in diagnose of polyp or hyperplasia was calculated at 91.3% and 81.4% respectively. Sensitivity and specificity of 3-DHS in diagnosis polyps or hyperplasia was calculated at 91.4% and 80.2% respectively. The results of present study proved that, compared to hysteroscopy; 3-DHS has a reliable specificity for diagnosis of uterine abnormalities. Sensitivity and specificity of 3-DHS and hysteroscopy in detecting polyp or hyperplasia regarding histopathology as the gold standard was the same

True unicornuate uterus- Pseudounicornuate uterus

A 27 year old patient presented with primary infertility of 3 years' duration and also a history of myomectomy [5 years ago] was referred to our infertility clinic for investigation of infertility. The latest Hysterosalpingography [HSG] revealed an obstructed left fallopian tube with apparently a unicornuate uterus with luminal contour irregularity and normal left fallopian tube [Figure 1]. Significant information in her past medical history revealed that she had another HSG two years before and her first hysterosalpingography [HSG] showed a apparently unicornuate uterus. Additional significant information in comparison with second HSG revealed that both fallopian tubes were opacified [Figure 2]. In this case medical history also included hysteroscopic diagnosis of adhesion following open myomectomy at the age of 22. Comparison of previous graphies and hysteroscpic findings lead to a suggestion of pseudounicornuate uterus. Intrauterine adhesions develop after trauma to the basal layer of the endometrium. Unilateral excessive scarring of the uterus may lead to an obliteration of the uterine lumen resulting in an image that can mimic a unicornuate uterus [pseudounicornuate uterus] [1]. A true unicornuate uterus should be excluded from pseudounicornuate uterus by a] horizontally oriented in its long axis due to deficient development of mullerian ducts b] smooth or regular contour c] with one tube. While pseudounicornuate uterus look like acquired lesion and cicatrisation leads to a usually irregular contour and uterus is more vertical in its long axis [2]. Obtaining an accurate history, comparison of previous sonographic or laparoscopic findings, and awareness about this image of synechiae are the critical steps in differentiating a pseudounicornuate uterus from true unicornuate uterus

Application of 3D ultrasonography in detection of uterine abnormalities

Structural pathologies in the uterine cavity such as m_llerian duct anomalies [MDAs] and intrauterine lesions [fibroids, polyps, synechiae] may have important roles in subinfertility, implantation failure and pregnancy outcome. Various imaging modalities such as hysterosalpingography [HSG], sonography, laparoscopy and hysteroscopy are used in the evaluation of MDAs and intrauterine lesions. Recently, three-dimensional ultrasound [3DUS] has been introduced as a non-invasive, outpatient diagnostic modality. With increased spatial awareness, it is superior to other techniques used for the same purpose