E. Bertonotti

OC059: Recurrent miscarriage: Three dimensional power Doppler evaluation of endometrial and subendometrial volume and vascularity and correlation to uterine arteries blood flow

Objectives: To evaluate the relationship between uterine arteries blood flow and endometrial and subendometrial volume and vascularity using three-dimensional (3D) power Doppler untrasonography in patients with recurrent miscarriage (RM). Methods: 40 women with unexplained RM were included in the study. All patients underwent an accurate screening in order to exclude all the etiological RM factors. Three-D ultrasound examination with power Doppler was performed in all cases in the midluteal phase of the cycle by Voluson 730 pro GE machine. Twenty patients showed increased resistance to uterine arteries blood flow whereas in 20 cases normal resistances were found. Endometrial and subendometrial volume, vascularization index (VI), flow index (VI) and vascularization flow index (VFI) were calculated using the VOCAL (Virtual Organ Computer-aided AnaLysis) software. Results: Endometrial and subendometrial volume and VI were found significantly lower in patients with increased resistance to uterine arteries blood flow. No statistically significant correlations between uterine arteries PI, endometrial and subendometrial FI and VFI were observed. Nonetheless, patients with increased resistances to uterine arteries blood flow showed lower 3D vascularization indices. Conclusions: 3D power Doppler ultrasonography study of uterine perfusion seems to reflect the actual blood flow to the subendometrium and endometrium. This technique represents a unique tool to examine the blood supply towards the endometrial and subendometrial regions providing the opportunity to identify women with RM in which appropriate therapeutic protocols may effectively improve the possibility for successfully pregnancy.

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.

OC11.04: Three dimensional evaluation of adenomyosis: correlation of sonographic findings to histology

Methods: Observational cohort study of 804 patients. Two consecutive cohorts of 402 women undergoing SIS or GIS at the department Bleeding Clinic were included. Patients characteristics, ultrasound features, technical failure rates and final diagnosis (based on endometrial sampling, hysteroscopy and/or surgery) were compared. Pathology was defined as hyperplasia, polyps, intracavity myomas and carcinoma. Results: Mean age was 50.7 years (SD 12) and 50.2 years (SD 11.6) in the SIS and GIS group (NS). In the SIS group 12.7% were nulliparous and 53% premenopausal versus 17.4% and 57.2% in the GIS group (NS). Technical failure rate was 5.0% for SIS versus 1.9% for GIS (difference between proportions 0.03; CI [0.0054-0.0588]). Failure due to inadequate distension was 1.5% versus 0.3% for SIS and GIS (difference between proportions 0.01; CI [−0.02 0.03]). Pathology was diagnosed in 180 (49%) patients of the SIS group versus 147 (40.2%) of the GIS group (difference between proportions 0.09; CI [0.02-0.16]). The LR+ and LR− of a lesion during contrast sonography was 4.03 and 0.28 for SIS and 3.9 and 0.19 for GIS, respectively (NS). The sensitivity was 77.8% and 85.0%, respectively (NS). The negative predictive value was 79.1% for SIS and 88.6% for GIS (difference between proportions 0.095; CI [0.02-0.17]). Conclusions: The technical failure rate, partly due to unstable filling of the uterine cavity and transcervical backflow, was less for GIS. The diagnostic accuracy of GIS was comparable with SIS. We conclude that GIS is a feasible and accurate alternative for SIS in the evaluation of periand postmenopausal women with abnormal bleeding.

OP11.07: Transvaginal sonographic mapping of pelvic adhesions in women with chronic pelvic pain

Objectives: To compare the efficacy of multi-step hysterosalpingo contrast sonographic (HyCoSy)-based triage for the assessment of tubal patency with X-ray hysterosalpingography (HSG) and laparoscopy (LPS) in an outpatient office infertility program. Methods: Infertile patients are routinely examined by HyCoSy during the proliferative phase to asses tubal patency. The first step was based on a 2D-HyCoSy using saline mixed with air. If tubal patency was doubtful, patients underwent a 2D-HyCoSy using Sonovue (Bracco Diagnostics, Inc.) as contrast media and Contrast-Tuned Imaging. In doubtful cases this second procedure was performed during the same examination with the same catheter (8Fr–Nelaton). These cases underwent as confirmative test either HSG or LPS. Sensitivity and specificity of this multi-step HyCoSy compared to HSG and LPS was calculated by statistical analysis. Results: In 68 patients tubal patency was assessed at saline–air HyCoSy (69%). We report the results of this multi-step HyCoSy in the remaining 30 doubtful cases (59 tubes) compared to HSG (34 tubes)–LPS (25 tubes) (Table). The six discordant occluded tubes proved patent at LPS, similarly the one discordant patent at HyCoSy was found occluded at LPS. Therefore sensitivity and specificity of contrast-HyCoSy when compared to HSG were both 100%. Sensitivity and specificity at LPS were 87% and 60%, respectively.