Role of combined hysteroscopy and transvaginal ultrasound in evaluation of tubal patency in infertile women

INTRODUCTION

After one year of frequent unshielded sexual activity, infertility is described as the failure to adequately have a healthy child. Tubal dysfunction is considered to be the cause of around 30percent of all infertility cases. Examinations to establish whether or not the tubes are patent and unharmed are a crucial element of the infertility evaluation process. ¹

Hysterosalpingography can be used to assess the fallopian tube's patency, laparoscopy chromotubation, and salinsonohystrography, among other methods of testing (HyCoSy). Falloposcopy per vaginam and salpingoscopy done at laparoscopy were used to create the desired mucosal look.²

The use of hysteroscopy as part of a standard infertility evaluation has sparked controversy; yet HSG has been the most widely utilized diagnostic procedure for tubal patency testing for the past many years now. When comparing HSG with hysteroscopy (HSC), a lack of agreement occurred in 30% of the instances, according to the study.³

Using hysteroscopy to visualize the uterine chamber from all angles and take direct biopsies of lesions, doctors can make more precise and accurate diagnoses of intrauterine diseases.⁴

Hysteroscopy, on the other hand, is not a reliable means of determining tubal patency or anatomy. Hysteroscopy, on the other hand, can be useful in the examination of tubal patency when paired with ultrasonography.⁵

It has been recommended in recent years that sonosalpingography should be utilized as the initial step for determining tubal patency. ⁶

Tubal patency was assessed using both negative and positive contrasts. When the turbulence of the contrast may be seen on the side or in the Douglas pouch, the tube is deemed patent. ^{7, 8}

In 2009, Yildizhan et al. proposed that utilizing saline distension medium during hysteroscopic examination was useful for measuring accumulated fluid in the peritoneal cavity and confirming at least one patent tube.⁹

Fallopian tube morphological abnormalities can be seen immediately during laparoscopy, which is considered the perfect standard for diagnosing tubal disease and other intra-abdominal reasons of infertility.¹⁰

Diagnostic laparoscopic has emerged as the ideal technique in many clinics' infertility workups, functioning as the last step before recommending a partner for infertility treatment. ¹¹

Surgical treatment is possible with diagnostic laparoscopic, but it also puts the patient at risk for operational and anaesthetic complications.

In this study, we compared the findings obtained with laparoscopic chromopertubation to the diagnostic usefulness of TVS, which is performed shortly after diagnostic hysteroscopy to determine fallopian tubal patency in sexually active women.

PATIENTS AND METHODS

60 infertile ladies who came to our endoscopic department for laparoscopy chromopertubation had diagnostic hysteroscopy and TVS as part of their treatment plan between March 2018 and March 2019. The research group's average age was 27.4±5.1 years (range 20–35 years), with 40 women being nulligravida. Infertility lasted 4±1.6 years on average (range 1–12 years). All of the participants signed a written consent form, were of reproductive age, and had Ultrasonic folliculometry that indicated ovulation.

Exclusion criteria included suspicion of pregnancy, other causes of infertility (endocrinal cause and unexplained cause of fertile couples), symptoms suggestive of pelvic or lower genital tract infection, intractable cervical stenosis which would make insertion of hysteroscopy difficult and uncomfortable, patients with advanced or uncontrolled medical disease and patients with bad general condition, sever obesity and obvious organic pelvic pathology on clinical examination.

HSG was done in another day prior to the procedure using 2.5 ml of urographin dye injected in the cannula and HSG-1 film was taken, then another 2.5 ml of urographin dye was injected and HSG-2 film was taken, later film after 30 min was taken while the patient was in prone position for spill.

All patients received general anesthesia, in this study, an ultrasound instrument Madison Sono ACE R,( Medison, Seoul, South Korea)was used to perform a basic TVS evaluation of the female pelvis with 5.5 mhz trans-vaginal transducer to evaluate the uterus, identifying the visibility of the Fallopian tubes and evaluating the presence of fluid in the cul de sac and quantifying its amount if present

All hysteroscopic examinations were performed by means of vaginoscopic approach, the process is carried done without using a speculum or tenaculum. Hysteroscopic examination was conducted with a firm 30o hysteroscopy equipped with a 6mm lens and an 8-mm diameter diagnostic sheath that included an operating channel, (KARL STORZ GmbH & Co., Tuttlingen, Germany). Iv-tubing was linked to the inflow channel on the sheath with distilled water for uterine distension. At a fluid delivery system pressure of seventy to one hundred cm H2O, each hysteroscopic surgery used an average of 2 hundred ml of fluid. [It was possible to produce this pressure because the fluid bag was one m over the uterine cavity]. The uterine cavity was illuminated with a high-intensity cold light source and fibre optic wire. All of the procedures were videotaped.

TVS was re-performed immediately after finishing the hysteroscopy to detect free fluid in cul de sac and measure its volume by taking 3 dimensions in 2 different planes if present as shown in fig.1. The presence of liquid in the Douglas pouch was taken as a sign of unilateral or bilateral tubal patency.

Chromopertubation is then done through laparoscopy in the same sitting, using a verus needle to create pneumoperitoneum

3 port laparoscopy was used, primary trocher through the sub umbilical incision, two secondary 5mm trochers, through which an instruments are inserted, then navigation through the abdomen and pelvis to assess the uterus, ovaries and search for other lesion that may be significant like peri-hepatic filmy adhesion (Fitz-Hugh-Curtis syndrome) which donates PID, therapeutic reproductive surgery, like coagulation of stage I or II endometriosis, adhesiolysis, or cystectomy, was done during laparoscopy when necessary, followed by a methylene blue test to determine tubal patency, and the incisions were fixed with vicryl suture.

TVS results were compared to laparoscopic chromopertubation and HSG results the sensitivity, specificity, accuracy, and positive, negative predictive values of diagnostic hysteroscopy accompanied by TVS were calculated to assess tubal patency. Fig. 1

Fig. 1:  Showing free fluid in the Douglas pouch and its three-dimension measurement

RESULTS

The study comprised 60 female with a mean age of 27.4 yrs ± 5.1(20-35) and the mean was BMI (kg/m2) 26.3±3.7(20.4-34.9) with 40 patients (66.7%) with 1^ry infertility and 20 patients (33.3%) with 2^ry infertility

In 44 (73.3 percent) of the 60 instances, hysteroscopy was normal. The most prevalent finding (7 instances) among women with aberrant findings was an endometrial polyp, as indicated in table 1. Sub mucous myoma (4 instances) and intra-uterine adhesions were also discovered (3 cases), tubal ostial abnormalities (4 cases), and unicornuate uterus (2 cases) Cervical stenosis (2 cases). the overall count of discovered abnormalities surpasses the real number of patients with such abnormalities since several lesions were found in various individuals; hence, the total number of detected abnormalities above the real percentage of participants with these abnormalities (16 patients).

When comparing HSG to hysteroscopy in uterine assessment, HSG showed normal cavity in 49 case. In 44 of these cases, normal cavity was confirmed by hysteroscopy. Of the 11 cases with abnormal cavity, intra-uterine lesion was confirmed in all 11 cases, giving the HSG a positive-predictive value of 87.5%, a negative-predictive value of 71.4%, an accuracy of 73.4%, a sensitivity of 92.8%, and a specificity of 97.1%.

In 49 cases, an ultrasound reported the existence of fluid in the Douglas pouch. In all 49 of these cases, tubal patency was established by laparoscopic chromopertubation. Laparoscopic chromopertubation verified bilateral tubal blockage in 8 of the 11 negative instances (no fluid in the Douglas pouch). In three of the negative instances, patent tubes were verified laparoscopically, providing diagnostic hysteroscopy supported by TVS a positive predictive value of 100%, a negative predictive value of 72.7 percent, an accuracy of 96 percent, a sensitivity of 94.9 percent, and a specificity of 94.4 percent.

The study showed that the best cut off point of the fluid volume in Douglas pouch after hysteroscopy at which 1 or 2 tubes are patent is six ml with sensitivity of 91.9% and specificity of 66.7percent. The area under the curve is 0.86

In 49 patients, HSG revealed one or two patent tubes. Tubal patency was established in 46 of these instances by laparoscopic chromopertubation. Of the 11 negative cases (with bilateral tubal block), laparoscopic chromopertubation verified bilateral tubal blockage in 5 instances. Patent tubes were verified by laparoscopic chromopertubation in 6 of the negative instances, giving the HSG a positive-predictive value of 92.8%, a negative-predictive value of 50%, an accuracy of 87.5%, a sensitivity of 92.8%, and a specificity of 50%.

Table 1: Hysteroscopically detected intrauterine abnormalities

Table 2: Comparison between the tubal patency results of laparoscopy and the hysteroscopy fluid.

Table 3: Comparison between the results of HSG and laparoscopy regarding tubal patency