To determine accuracy of HyCoSy utilizing microbubble ultrasound (US) contrast in diagnosing fallopian tube (FT) patency in patients undergoing a complete infertility (US) evaluation.
Materials and Methods:
This single-center retrospective institutional review board (IRB)-approved study reviewed 28 consecutive women (mean age 32 years, ± 5.8 years) from 12/2018 to 4/2020, who underwent HyCoSy as a part of a complete infertility evaluation with transvaginal US (TVUS) and saline infusion sonohysterography (SIS). Dilute US contrast agent (sulfur hexafluoride lipid type A microspheres) was injected after SIS with cines obtained in dual grayscale/contrast mode. US images were retrospectively reviewed and a final diagnosis of tubal occlusion or patency was made by assessing the following signs: (1) surge of bright contrast adjacent to ovary; (2) visualization of contrast progressing through entire FT; (3) a rim of contrast surrounding ipsilateral ovary; (4) free contrast in adnexa. Hysterosalpingogram (HSG) performed within 4 weeks of HyCoSy served as a reference standard. Seven patients with difficult imaging findings due to position of the uterus or adnexa, tubal abnormalities, or initial grayscale abnormalities, underwent both HyCoSy and HSG exams and were included in statistical analysis. Sensitivity (SENS)/Specificity (SPEC)/positive predictive value (PPV)/negative predicitive value (NPV) were calculated based on 13 fallopian tubes (n=1 had prior unilateral salpingectomy), with SENS defined as ability to identify tubal occlusion. HSG was not obtained in 21 patients, of which 17 showed normal HyCoSy exams and 34 patent FT.
Visualization of contrast progressing through entire FT, ovarian rim sign, and free contrast in adnexa were the most reliable signs of tubal patency. 9/13 FT were occluded, with 1 false positive (FP) and 3 true negative. SENS/SPEC/PPV/NPV of HyCoSy for tubal occlusion = 100%/75%/100%/90%. A single FP HyCoSy study showed hydrosalpinx without free spill and HSG showed a hydrosalpinx with loculated spill due to adhesions. TVUS showed adenomyosis (n=8), deep endometriosis (n=2), hydrosalpinx (n=6), endometrial polyp or synechiae (n=4), polycystic ovarian disease (n=3), myoma (n=9), and loculated peritoneal fluid (n=2). Limitations include small sample size, small number of HSG, and lack of evaluation of interobserver variability.
HyCoSy with microbubble contrast shows promise as an addition to the complete infertility US exam and may obviate need for HSG in uncomplicated cases. A complete infertility US exam with HyCoSy examines intra- and extrauterine pathologies and tubal patency in one setting without ionizing radiation.