Causes of misdiagnosis in assessing tubal patency by transvaginal real-time three-dimensional hysterosalpingo-contrast sonography

SUMMARY OBJECTIVE This study aims to investigate the causes of misdiagnosis in assessing tubal patency by transvaginal real-time three-dimensional hysterosalpingo-contrast sonography (TVS RT-3D-HyCoSy), in order to improve the diagnostic efficiency of TVS RT-3D-HyCoSy. METHODS A total of 162 oviducts of 83 infertility patients were examined by TVS RT-3D-HyCoSy. These results were compared with the gold standard for laparoscopic dye studies, and the misdiagnosed cases were analyzed. RESULTS TVS RT-3D-HyCoSy revealed that 68 oviducts were unobstructed and 94 obstructed. The results for the 144 oviducts were in line with the gold standard, while those for 18 oviducts were not. The accuracy rate of the TVS RT-3D-HyCoSy was 88.9%, and the misdiagnosis rate was 11.1%. The main causes of misdiagnosis included contrast medium countercurrent and diffusion, oviduct spasm, abnormal shape or position of the oviduct, pelvic adhesion, and poor imaging operation. CONCLUSION TVS RT-3D-HyCoSy can well-evaluate tubal patency, and understand and improve the cause of misdiagnosis. Furthermore, the diagnostic efficiency of TVS RT-3D-HyCoSy can still be further improved.

RESUMO OBJETIVO Este estudo tem como objetivo investigar as causas do diagnóstico equivocado na avaliação da patência tubária por meio da ultrassonografia de contraste histerosalpingo em tempo real transvaginal (TVS RT-3D-HyCoSy), a fim de melhorar a eficiência diagnóstica das TVS RT-3D-HyCoSy. MÉTODOS Um total de 162 ovidutos em 83 pacientes da infertilidade foi examinado por TVS RT-3D-HyCoSy. Esses resultados foram comparados com o padrão ouro para estudos de tintura laparoscópica, e os casos diagnosticados erroneamente foram analisados. RESULTADOS TVS RT-3D-HyCoSy revelaram que 68 ovidutos foram desobstruídos e 94 ovidutos foram obstruídos. Os resultados para os 144 ovidutos estavam em consonância com o padrão ouro, enquanto que aqueles para os 18 ovidutos, não. A taxa de acurácia do TVS RT-3D-HyCoSy foi de 88,9%, e a taxa de erro de diagnóstico foi de 11,1%. As principais causas de erro de diagnóstico incluíram contraponto e difusão do meio de contraste, espasmo do oviduto, forma ou posição anormal do oviduto, adesão pélvica e má operação de imagem. CONCLUSÃO TVS RT-3D-HyCoSy pode bem avaliar a patência tubária, e compreender e melhorar a causa do erro de diagnóstico. Além disso, a eficiência diagnóstica do TVS RT-3D-HyCoSy ainda pode ser melhorada.

Avaliação da reserva ovariana na predição do mau prognóstico reprodutivo: quando e como investigar / Ovarian reserve evaluation in the prediction of poor reproductive prognosis: when and how to investigate?

Muitas vezes, torna-se um grande desafio para o ginecologista a identificação daquelas com maior ou menor chance de concepção. Vários marcadores laboratoriais e ultrassonográficos, conhecidos conjuntamente como testes de avaliação da reserva ovariana, são estudados há décadas com a intenção de se buscar uma ferramenta para a predição do potencial reprodutivo. E, embora ainda se busquem os marcadores ideais para aplicação clínica, mais difícil do que os definir é definir quando eles estão indicados. Este artigo de atualização, assinado pela Comissão Nacional Especializada em Ginecologia Endócrina da Febrasgo, pretende oferecer ao leitor as ferramentas necessárias para o uso racional dos testes de avaliação da reserva ovariana no cotidiano.(AU)

Often, it becomes a great challenge for the gynecologist to identify women with a greater or lesser chance of conception. Several laboratory and ultrasound markers, known jointly as ovarian reserve evaluation tests, have been studied for decades with the intention of seeking a tool for the prediction of reproductive potential. And, while the ideal markers for clinical application are still sought, defining them is as harder as defining when they are indicated. This update article, signed by the National Specialized Committee on Gynecologic Endocrinology, Febrasgo, intends to offer the reader the necessary tools for the rational use of ovarian reserve evaluation tests in daily practice.(AU)

Functional magnetic resonance imaging for clinical evaluation of uterine contractility / Ressonância magnética funcional para avaliação clínica da contratilidade uterina

ABSTRACT Uterine contractility out of the gestational phase, during the menstrual cycle and the habitual functional variations of the organ, this is one of the responsible mechanisms for reproduction and fertility, due to its direct action in the mechanisms conducting the spermatozoa to the ovule and in the decidual implantation. Pathologies such as uterine leiomyoma, endometriosis, adenomyosis, polycystic ovarian syndrome, as well as the use of intrauterine devices and oral contraceptives, may alter a functionality of uterine contractility. Thus, magnetic resonance imaging with ultrafast sequences provides a dynamic evaluation (cine-MRI) and thus the correlation of uterine contractility quality in patients with current infertility or pathologies.

RESUMO A contratilidade uterina fora da fase gestacional, durante o ciclo menstrual e as habituais variações funcionais do órgão, é um dos mecanismos responsáveis pela reprodução e fertilidade, devido sua ação direta nos mecanismos de condução dos espermatozoides até o óvulo e na implantação decidual. Patologias como leiomioma uterino, endometriose, adenomiose, síndrome dos ovários policísticos, bem como o uso de dispositivos intrauterinos e anticoncepcionais orais, podem alterar a funcionalidade da contratilidade uterina. Desta forma a ressonância magnética com sequências ultra-rápidas proporcionam uma avaliação dinâmica (cine-RM) e assim a correlação da qualidade da contratilidade uterina em pacientes com infertilidade ou patologias vigentes.

The salivary ferning test and ovulation in clomiphene citrate-stimulated cycles.

OBJECTIVE: To determine the day of ovulation by the salivary ferning test in clomiphene citrate-treated women. DESIGN: A descriptive study. SETTING: Department of Obstetrics and Gynecology, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand. SUBJECT: Seventy-five infertile women with regular menstrual cycles. MATERIAL AND METHOD: Infertile women were given 100 mg of clomiphene citrate for five days and collected their saliva samples daily until seven days after ovulation. Transvaginal ultrasound was performed daily to detect ovulation. The salivary ferning formation was examined by a normal light microscope and graded from 1-3, according to its extent and intensity. MAIN OUTCOME MEASURE: The salivary ferning score, the peak salivary ferning day, and the day of ovulation detected by ultrasound. RESULTS: The patients' age and cycle length (mean +/- SD) were 32.9 +/- 3.7 years and 28.4 +/- 1.3 days. The peak salivary ferning day corresponded with the ultrasound ovulation day in only 7.1%. There were two peaks of median salivary ferning scores; one was two days prior ovulation and the other was five days post ovulation. There was no correlation between the peak salivary ferning day and day of ovulation detected by ultrasound (r = 0.102, p > 0.05). CONCLUSION: In clomiphene citrate-stimulated cycles, the saliva ferning test does not seem to associate with ovulation.

[Fertility preservation in young women with endometrial carcinoma; report of three cases]

Although endometrial cancer is primarily a disease of the postmenopausal female, 25% of patients are premenopausal, with 3-5% in women 40 years old or younger. The younger group of women with endometrial carcinoma are frequently nulligravid with a history of infertility, and a strong desire to preserve fertility. This may pose a therapeutic dilemma for both patients and treating physician. We reported 3 young patients with atypical; complex hyperplasia or early stage endometrial cancer that treated with conservative hormonal therapy. Medical treatment of young patients with endometrial carcinoma and complex atypical hyperplasia who wish to preserve fertility is a reasonable and appealing option. A comprehensive evaluation prior to counseling the patient should include. A complete history and physical examination. A formal D and C with review of history with an experienced gyn-onc pathologist. Evaluation of the pelvic and abdomen preferably with contrast-enhanced MRI or transvaginal ultrasound. In patients found to have a clinical stage I grade I tumor and who want to preserve fertility, thorough counseling include risks and benefits, and explanation that the data is partial and incomplete due to the lack of appropriate controlled studies is mandatory. In patients considered for medical treatment, a high dose progestin regimen should be started with endometrial sampling every 3 months until complete regression of the tumor is documented. Although most responses are long standing, there is a small risk of progression during or after cessation of progestin therapy

value of transvaginal sonography performed before diagnostic hysteroscopy for the evaluation of uterine cavity in infertile women

Hysteroscopy have gained general acceptance as a method for the investigation of infertility. The main advantage of hysteroscopy is the capability of inspecting the uterine cavity. Transvaginal sonography [TVS] is a noninvasive modality that provide excellent imaging of the uterus and of endometrial abnormalities. The present study was designed to evaluate the use of TVS as the initial diagnostic procedure before hysteroscopy for detecting intrauterine disorders. Seventy-eight infertile women were examined by TVS and diagnostic hysteroscopy in the late follicular phase of the menstrual cycle and the results were compared. The uterine cavity abnormalities were present in 19.2% of the infertile females involved in the study. The Transvaginal scnography had 87.5% sensitivity, 100% specificity for detecting endometrial polyps while it had 100% sensitivity and 100% specificity for detecting other intrauterine cavity abnormalities including intrautcrine adhesions, uterine septae and submucosal myomas. Examination of the uterine cavity is an integral part of any thorough evaluation of an infertile woman. Tranavaginal sonography, when performed during the follicular phase, can detect most uterine cavity abnormalities. It was an accurate tool in the identification of intrauterine adhesions, uterine septae and submucosal fibroids

uterine biophysical profile scoring validity

To determine the applicability of uterine biophysical profile [UBP] scoring with chances of pregnancy in a spontaneous cycle in a cohort of females with unexplained infertility. Observational study. A secondary level private hospital, from June 2003 to June 2004. The study subjects included 26 infertile females in the third decade of life primarily referred for follicle maturation monitoring by ultrasound with patent tubes and normal utero-ovarian morphology. Male factor infertility was also excluded. The UBP was determined by applying the uterine scoring system for reproduction [USSR]. A score of 17 or above, out of a perfect score of 20, was hypothesized to be favorable for pregnancy. Frequency of pregnancy was correlated with the cumulative score as well as individual variable. Significance of correlation was taken at p<0.05. None of the patients showed a perfect score of 20. A score of 17 was noted in 06 patients out of whom 04 conceived [pregnancy rate=66.6%]. A score of 15 or less was observed in 20 patients, none of whom conceived [p=0.001]. No significant correlation was found with any of the individual variables including the endometrium and myometrium characteristics, as well as the uterine artery flow. Myometrium contraction was the most technically difficult parameter to be observed. In this small cohort of patients, an ultrasonographically assessed uterine score of 17 or above was significantly associated with chances of pregnancy in the similar spontaneous cycle

Comparison of hysterosonography and hysterosalpangiography in the diagnosis of intrauterine abnormalities in infertile women

Uterine abnormalities are found in approximately 34-62% of infertile women. Because of this relatively high prevalence of uterine abnormalities, evaluation of uterine cavity is performed in the primary evaluation of infertility. The purpose of this study was to compare the diagnostic accuracy of hysterosonography with that of hysterosalpangiography for the evaluation of abnormalities of uterine cavity of infertile women. Sixty six infertile women were prospectively evaluated with hysterosalpangiogram [HSG] and hysterosonogram [H/S] as a part of their infertility workup. The result of each examination was compared with what was obtained by hysteroscopy as a golden standard. The results of H/S agreed with hysteroscopy in 95.5% [K=0.86] while HSG agreed with hysteroscopy in 87.9% [K=0.64] of cases. Sensitivity of H/S was 85.7% and its specificity 98.1%, while sensitivity of HSG was 71.4% and its specificity 92.3%. Hysterosonography was in general more accurate test and appeared to be an acceptable first-line evaluation for intrauterine structure. We recommend use of hysterosonography as a noninvasive, easy, inexpensive, effective and well-tolerated method of investigating the intrauterine cavity in infertile women instead of hysterosalpangiography

Transvaginal sonography: comparative study of follicular monitoring between different ovarian stimulatory protocols in cases of oligomenorrhoea

The objective of this study was to compare the effects of different ovarian stimulatory protocols on ovulation in infertile women with oligomenorrhea. A total of 100 infertile women was examined by 2D intravaginal sonography and divided into five groups, each included 20 cases, according to the drug used in the induction of ovulation. An evaluation of follicular growing responses was done mainly by five parameters; the number of growing follicles in each ovary, pattern of follicular growth, rate of follicular development, day of maximum follicular growth and the maximum follicular diameter. Regarding the number of induced follicles, group III [clomiphene citrate + HMG] and group IV [HMG] had a significant higher mean number of follicles [6.1 +/- 3.2 and 4.6 +/- 2.9, respectively] compared with the other three groups. The pattern of follicular growth and rate of follicular development were symmetrical and synchronous, respectively, in group I and II and asymmetrical and asynchronous, respectively, in group III, IV and V