Danielle E. Luciano

Can hysterosalpingo-contrast sonography replace hysterosalpingography in confirming tubal blockage after hysteroscopic sterilization and in the evaluation of the uterus and tubes in infertile patients?

OBJECTIVE The objective of the study was to assess the accuracy of hysterosalpingo-contrast sonography (HyCoSy) in establishing tubal patency or blockage and evaluating the uterine cavity by comparing it with hysteroscopy laparoscopy (HLC) or hysterosalpingography (HSG). STUDY DESIGN This study was a chart review evaluating infertility patients and patients who had undergone hysteroscopic sterilization who underwent both HyCoSy and HLC or HyCoSy and HSG at private offices associated with university hospitals. Sensitivity, specificity, positive predictive value, and negative predictive value of HyCoSy were calculated. RESULTS HyCoSy compared with HLC had a sensitivity of 97% and specificity of 82%, and HyCoSy compared with HSG was 100% concordant. Uterine cavities evaluated by sonohysterography and hysteroscopy were 100% concordant. CONCLUSION HyCoSy is accurate in determining tubal patency and evaluating the uterine cavity, suggesting it could supplant HSG not only as the first-line diagnostic test in an infertility workup but also in confirming tubal blockage after hysteroscopic sterilization.

Three-Dimensional Ultrasound in Diagnosis of Adenomyosis: Histologic Correlation With Ultrasound Targeted Biopsies of the Uterus

STUDY OBJECTIVE To evaluate the accuracy of 3-dimensional transvaginal sonography (3D TVS) in the diagnosis of adenomyosis by correlating adenomyosis-induced morphologic alterations in the myometrium and the junctional zone (JZ) with histopathologic features of targeted biopsy specimens of the uterus. DESIGN Prospective study (Canadian Task force classification II-2). SETTING Private practice associated with a university program. PATIENTS Symptomatic premenopausal women scheduled to undergo hysterectomy because of benign conditions. INTERVENTIONS Patients underwent preoperative 3D TVS of the uterus to evaluate alterations to the JZ, to measure the smallest (JZ(min)) and largest (JZ(max)) JZ thickness, and to assess for the presence of myometrial heterogeneous and cystic areas, hyperechoic striations, and asymmetry of the myometrial wall. Localization and position of the lesions in the myometrial wall were accurately recorded. Results of the sonographic features were correlated with the histopathologic findings of the ultrasound-based targeted biopsy specimens of the uterus. MEASUREMENTS AND MAIN RESULTS The study included 54 symptomatic premenopausal women with a mean age of 42.1 years. Of these, 12 had previously undergone endometrial ablation and 10 were receiving medical therapy, and these patients were considered separately for the statistical analysis. The prevalence of adenomyosis at histology was 66.6% (36/54). Of 32 patients who had received no previous treatment, 26 had adenomyosis on the targeted biopsy specimens of the myometrium. 3D TVS features of adenomyosis with the best specificity (83%) and positive predictive values were JZ(max) ≥8 mm, myometrial asymmetry, and hypoechoic striation. When we considered the presence of at least 2 of the described ultrasound features for the diagnosis of adenomyosis, accuracy was 90% (sensitivity, 92%; specificity, 83%; positive predictive value, 99%; and negative predictive value, 71%). Diagnostic accuracy was decreased to 50% in patients who had previously undergone endometrial ablation, and to 60% in patients receiving medical therapy. CONCLUSION 3D TVS demonstrates high diagnostic accuracy in detection of site and position of adenomyosis in the uterine walls. Endometrial ablation and medical therapy alter the appearance of the JZ, compromising the accuracy of 3D US in enabling the diagnosis of adenomyosis.

The uterine junctional zone: a 3-dimensional ultrasound study of patients with endometriosis

OBJECTIVE The uterine junctional zone (JZ) alterations are correlated with adenomyosis. An accurate evaluation of the JZ may be obtained by 3-dimensional transvaginal sonography (TVS). The aim of the present prospective study was to assess the value of detectable alterations by 3-dimensional TVS of the JZ in patients with pelvic endometriosis (diagnosed by laparoscopy and histologic condition) and to compare these findings with those of women without pelvic endometriosis. STUDY DESIGN Eighty-two patients who were scheduled for laparoscopy had undergone previous surgery and 2- and 3-dimensional TVS. Uterine multiplanar sections that were obtained by 3-dimensional TVS were used to evaluate JZ features. During laparoscopy, an accurate staging of pelvic endometriosis was performed. JZ thickness and JZ alterations were correlated with stage of endometriosis. RESULTS Of the 82 patients, 59 patients had endometriosis at laparoscopy and histology. The maximum thickness of JZ in patients with endometriosis was significantly greater than in patients without endometriosis (6.5 ± 1.9 mm vs 4.8 ± 1.0 mm; P < .001). The features of JZ appeared similar at different stages, whereas they are statistically different if correlated with patients without endometriosis. CONCLUSION JZ thickness and its alterations are different in patients with endometriosis compared with those women without endometriosis and are not correlated with American Society of Reproductive Medicine staging methods. Because these JZ ultrasound features are associated mostly with adenomyosis, a correlation between endometriosis and JZ hyperplasia and adenomyosis could be hypothesized. Noninvasive evaluation of the JZ may be useful in the identification of those women who are affected by endometriosis also in early stage of the disease when there are no other sonographic signs of pelvic endometriosis.

Automated three-dimensional coded contrast imaging hysterosalpingo-contrast sonography: feasibility in office tubal patency testing.

To evaluate the feasibility of transvaginal hysterosalpingo‐contrast sonography (HyCoSy) with new automated three‐dimensional coded contrast imaging (3D‐CCI) software in the evaluation of tubal patency and visualization of tubal course.

Adhesion Reformation After Laparoscopic Adhesiolysis: Where, What Type, and in Whom They Are Most Likely to Recur

STUDY OBJECTIVE To assess if the severity or extent of adhesions, the organs involved, or presence of endometriosis predict recurrence or de novo adhesion formation. DESIGN Comparison of adhesion scores at initial operative laparoscopy and at second-look laparoscopy using the revised American Fertility Society adhesion classification system (Canadian Task Force classification I). SETTING A university-affiliated reproductive endocrinology and infertility center. PATIENTS In all, 38 women with moderate to severe adhesions who underwent laparoscopic adhesiolysis and second-look laparoscopy. INTERVENTIONS Adhesion scores were assessed at 6 sites in the peritoneal cavity before initial laparoscopic adhesiolysis and compared with adhesion scores at second-look laparoscopy. Adhesions were evaluated by extent, severity, organ involvement, and presence or absence of endometriosis to evaluate potential determinants of recurrence and de novo adhesion formation. All adhesions were totally removed at initial laparoscopy, all patients received 1000 mL of Ringers lactate solution intraperitoneally at the end of procedures, and the same surgeon treated all patients. MEASUREMENTS AND MAIN RESULTS Adhesion scores decreased in extent [23.3% (p = .005)] and severity [26.3% (p = .001)]. Dense adhesions decreased 31% (p < .000) and filmy adhesions decreased 35% (p = .048). Extent of adhesions assessed at less than one-third, one-third to two-thirds, and more than two-thirds decreased by 33% (p = .002), 42% (p = .000), and 31% (p < .000), respectively. Severity and extent of adhesions of abdominal wall decreased by 45% (p = .003) and 40% (p = .016); of bowel by 33% (p = .002) and 31% (p = .012); and of posterior cul-de-sac by 14% (p = .040) and 9.5% (p = .091), respectively. Severity and extent of adhesions involving both adnexa decreased by 12% to 15%, respectively, which was not statistically significant. Presence of endometriosis did not affect adhesion recurrence. De novo adhesions developed at 48 (21%) of 228 potential sites occurring in 22 of 38 patients, and were most frequent and severe on the adnexa and least on the abdominal wall. CONCLUSION Both extent and severity of adhesions are significantly reduced by laparoscopic adhesiolysis. Initial extent and severity of adhesions did not predict recurrence; however, the involved organ did, being most frequent on the adnexa and least frequent on the abdominal wall and bowel.

Contrast Ultrasonography for Tubal Patency

Evaluation of tubal patency is an essential part of a fertility workup. Laparoscopy with chromopertubation in conjunction with hysteroscopy is the gold standard in evaluation of tubal patency and the uterine cavity. In this review article we describe a newer method for evaluation of the uterus and fallopian tubes, that is, hysterosalpingo-contrast sonography (HyCoSy). Accuracy of HyCoSy for tubal patency has been shown to be comparable to that with hysterosalpingography (HSG) when compared with laparoscopic chromopertubation. Sensitivity ranges from 75% to 96%, and specificity from 67% to 100%. HyCoSy is also accurate when compared with HSG in determining tubal occlusion after hysteroscopic sterilization, with 88% of patients stating they would prefer to undergo the tubal occlusion test in their gynecologists office. Because HyCoSy also includes evaluation of the uterine cavity with saline solution-enhanced sonohysterography, accuracy in evaluating the uterine cavity is >90% when compared with hysteroscopy. HyCoSy enables the gynecologist to complete a fertility workup in the office in the most minimally invasive way. HyCoSy is well tolerated and has been suggested in the literature to replace HSG for evaluation of tubal disease in the subfertile population.

The impact of robotics on the mode of benign hysterectomy and clinical outcomes

The impact of robotics on benign hysterectomy surgical approach, clinical outcomes, and learning curve is still unclear.

Pain associated with endometriosis: therapeutic options

Defined as the presence of functional endometrial tissue outside the uterine cavity, endometriosis is a chronic and recurrent disease that affects 7–10% of reproductive-age women, causing pain, infertility or both, resulting in serious life disruption, emotional and physical suffering, and decreased productivity. The observation that endometriosis is more common in women with early ménarche, polymenorrhea, outflow genital tract obstruction or a family history of disease suggests that its development depends on the complex interaction of genetic, immunological, environmental and hormonal factors. Current therapies for the management of endometriosis are medical, surgical or both. Medical therapies induce a hypoestrogenic state to reduce menstrual flow and apoptosis of endometriotic lesions. They include androgenic or progestational compounds and gonadotropin-releasing hormone analogs, which are comparably effective but have very different adverse-effect profiles. Consequently, the choice of which medical treatment to prescribe may not be based on differences in efficacy but on differences in tolerability, safety and, when everything else is equal, cost. Although surgery to remove endometriosis is effective in relieving pain and restoring fertility, recurrence of symptoms is common and repeated medical and surgical interventions are often needed. The need for additional surgery may be reduced by the thorough excision of all lesions and disease at the initial surgery, followed by the postoperative administration of hormonal suppressive therapy with progestins to induce hypomenorrhea or amenorrhea. Definitive surgery with hysterectomy and removal of ovaries is frequently curative. Future therapies should be directed at identifying women at risk for the disease and implementing interventions that will prevent disease development altogether. Ultimately, the goal is to make endometriosis a disease of the past.

OP11.05: Three‐dimensional sonographic assement of tubal patency with gel foam: hysterosalpingo‐foam sonography (HyFoSy)

and higher serum estradiol (E), progesterone (P) and hCG levels and miscarriage rates would be inversely related to these parameters. Methods: Power calculations suggested a sample size of 100: 128 women were prospectively recruited. Blood was drawn for P, E and hCG levels and TV USS (Voluson E8) scan performed to acquire 3D power Doppler data of the uterus and pulsed wave Doppler studies of uterine arteries. VOCAL used to define endometrium and subendometrium and the values corrected for depth by standardising against iliac vessels (sVI, sFI, sVFI). This was repeated after 7 days (ET+7). Stats analysis using ANOVA, logistic regression and ROC analysis. Results: 106 women included. 60 (56.6%) women conceived; 15 (25%) miscarried in the first trimester. All parameters changed significantly from ET to ET+7. Whilst there was no significant difference in endometrial morphometry or standardised subendometrial vascular indices, mean uterine artery PSV and serum E, P and hCG levels were significantly higher in women who conceived at ET+7. All 3 serum markers were predictive of pregnancy with AUC of 0.84 (95% CI 0.73–0.92), 0.76 (95% CI 0.64–0.85) and 0.96 (95% CI 0.90–0.99) for E, P and hCG. The best threshold was hCG 5IU: sensitivity 71%, specificity 98% for pregnancy. No sig difference in any parameter between women who miscarried and those who had live birth (P > 0.05). Conclusions: Mean uterine artery PSV and serum estradiol, progesterone and hCG a week post ET are significantly higher in women who conceive after IVF. hCG levels were most predictive of conception. No serum or ultrasound marker could predict which of these ended in miscarriage.

OP16.04: Adenomyosis: three dimensional sonographic findings of the junctional zone in infertile patients

Objectives: The uterine junctional zone (JZ) seems to play an integral part in the implantation process. The coronal section of the uterus obtained by three dimensional (3D) transvaginal sonographic (TVS) permits an accurate evaluation of the JZ. An alteration in the JZ shows a high diagnostic accuracy for adenomyosis. The aim of this study is to assess the 3D TVS detectable morphological alterations of the JZ in infertile patients. Methods: We retrospectively evaluated JZ on the uterine coronal section obtained by 3D volume acquisition in infertile patients scheduled for HyCoSy. All patients underwent a HyCoSy, in the early proliferative phase, followed by a detailed TVS scan and 3D volume acquisition of the entire uterus. On the volume and multiplanar planes we evaluated: uterine diameters and volume, endometrial thickness, min JZ and max JZ thickness, alteration of the JZ, presence of myometrial cystic areas, asymmetry of myometrial wall, presence of myometrial hyperechoic areas and striations. A JZmax > 5 mm, or a JZmax-JZmin > 5, and presence of other TVS signs, were considered diagnostic for adenomyosis and were correlated with the cause of infertility when known. Results: Of the 123 infertile patients included in this study 81 had primary and 42 secondary infertility. 48 patients had a JZmax > 5 mm with a mean age of 37.8 ± 4.2 yrs significantly higher than those with JZmax ≤ 5 mm (35.6 ± 3.2 yrs). Patients with secondary infertility showed mean values of JZmax (6.4 ± 1.1 vs. 5.2 ± 1.2 mm) and JZmax-JZmin (3.8 ± 0.9 vs. 2.9 ± 1.2 mm) which was significantly greater than in patients with primary infertility. Other myometrial sonographic features of adenomyosis were found in 27 (56%) of 48 patients with JZ max > 5 mm and in only 3 of 75 (4%) with JZ max ≤ 5 mm. Conclusions: The coronal section of the uterus obtained by 3D TVS permits an accurate evaluation of the JZ on the coronal section. Non invasive assessment of JZ prior to conception may turn out to be useful in identifying those women affected by initial grade of adenomyosis.