Evaluation of cavity before ART: Saline Infusion Sonohysterography

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Evaluation of cavity before ART Saline Infusion
Sonohysterography
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IVF and IMPLANTATION

• Implantion rates are still low after IVF (10-
• 25(a)). Implantation failure is related to
• inadequate endometrial receptivity (2/3)
• embryo (1/3) (b)
• Increase in endometrial receptivity leads to
• Increase in pregnancy rates
• Decrease in early pregnancy losses
• Decrease in multipl pregnancies
• (a) de los Santos et al., 2003
• (b) Simon et al., 1998Ledee-Bataille et al., 2002

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• When implantation fails to occur despite the
  transfer of chromosomally normal good quality
  embryos, other factors that may impede
  implantation must be affecting implantation
• Endometritis,
• endocrine abnormalities,
• thrombophilias,
• immunologic factors
• congenital and acquired anatomic factors

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Methods to evaluate uterine cavity

• Hysterosalphingography (HSG)
• Transvaginal ultrasonography (TVU)
• Saline infusion sonohysterography (SIS)
• Office hysteroscopy (OHS)
• Diagnostic hysteroscopy

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Possible uterine factors associated with
implantation failure in IVF

• Uterine submucous fibroids
• Endometrial polyps
• Intrauterine adhesions
• Congenital uterine anomalies

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Saline Infusion Sonohysterography

• Use of SIS in general infertile population
• Use of SIS to evaluate cavity before ART

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Use of SIS in general infertile population
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Use of SIS in general infertile population
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Use of SIS in general infertile population
Histeroskopinin avantaji ayni anda tedavi imkani
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Endometrial polip Sens Spec PPV NPV Endometrial polip Sens Spec PPV NPV Endometrial polip Sens Spec PPV NPV Endometrial polip Sens Spec PPV NPV Myoma Uteri Sens Spec PPV NPV Myoma Uteri Sens Spec PPV NPV Myoma Uteri Sens Spec PPV NPV Myoma Uteri Sens Spec PPV NPV Intrauterine adhesion Sens Spec PPV NPV Intrauterine adhesion Sens Spec PPV NPV Intrauterine adhesion Sens Spec PPV NPV Intrauterine adhesion Sens Spec PPV NPV
Alborzi Int J Obstet Gynecol 2002 Int J Obstet Gynecol 2002 HSG vs SIS 31 100 97.6 98.2 55.6 84.2 93.8 100 0 93.3 0 100 0 100 0 99.4 70.6 76.5 99.4 100 92.3 97.1 100 97.7 92.3 97.1 100 97.7
Güven Int J Obstet Gynecol 2004 Int J Obstet Gynecol 2004 TVU Vs SIS Intracavitery pathology Sens Spec PPV NPV Intracavitery pathology Sens Spec PPV NPV Intracavitery pathology Sens Spec PPV NPV Intracavitery pathology Sens Spec PPV NPV
Güven Int J Obstet Gynecol 2004 Int J Obstet Gynecol 2004 TVU Vs SIS 78 38 61 59
Güven Int J Obstet Gynecol 2004 Int J Obstet Gynecol 2004 TVU Vs SIS 90 38 61 59
Alatas Hum Reprod 1997 Alatas Hum Reprod 1997 Alatas Hum Reprod 1997 TVU HSG SIS Intracavitery pathology Sens Spec PPV NPV Intracavitery pathology Sens Spec PPV NPV Intracavitery pathology Sens Spec PPV NPV Intracavitery pathology Sens Spec PPV NPV
Alatas Hum Reprod 1997 Alatas Hum Reprod 1997 Alatas Hum Reprod 1997 TVU HSG SIS 36.4 72.7 90.9 100 100 100 100 100 100 87.9 94.4 98.1
Soares Soares Fertil Steril 2000 HSG TVU SIS Endometrial polip Sens Spec PPV NPV Endometrial polip Sens Spec PPV NPV Endometrial polip Sens Spec PPV NPV Endometrial polip Sens Spec PPV NPV Intrauterine adhesion Sens Spec PPV NPV Intrauterine adhesion Sens Spec PPV NPV Intrauterine adhesion Sens Spec PPV NPV Intrauterine adhesion Sens Spec PPV NPV
Soares Soares Fertil Steril 2000 HSG TVU SIS 50 75 100 82.5 96.5 100 28.6 75 100 92.2 96.5 100 75 0 75 95.1 95.2 93.4 50 0 42.9 98.3 95.2 98.3
Hamilton Hamilton Hum Reprod 1998 TVU vs SIS The concordance rate of 52.6 and 65 for precontrast TVUS and SIS for intrauterine lesions (polyp and myoma) with H/S The concordance rate of 52.6 and 65 for precontrast TVUS and SIS for intrauterine lesions (polyp and myoma) with H/S The concordance rate of 52.6 and 65 for precontrast TVUS and SIS for intrauterine lesions (polyp and myoma) with H/S The concordance rate of 52.6 and 65 for precontrast TVUS and SIS for intrauterine lesions (polyp and myoma) with H/S The concordance rate of 52.6 and 65 for precontrast TVUS and SIS for intrauterine lesions (polyp and myoma) with H/S The concordance rate of 52.6 and 65 for precontrast TVUS and SIS for intrauterine lesions (polyp and myoma) with H/S The concordance rate of 52.6 and 65 for precontrast TVUS and SIS for intrauterine lesions (polyp and myoma) with H/S The concordance rate of 52.6 and 65 for precontrast TVUS and SIS for intrauterine lesions (polyp and myoma) with H/S The concordance rate of 52.6 and 65 for precontrast TVUS and SIS for intrauterine lesions (polyp and myoma) with H/S The concordance rate of 52.6 and 65 for precontrast TVUS and SIS for intrauterine lesions (polyp and myoma) with H/S The concordance rate of 52.6 and 65 for precontrast TVUS and SIS for intrauterine lesions (polyp and myoma) with H/S The concordance rate of 52.6 and 65 for precontrast TVUS and SIS for intrauterine lesions (polyp and myoma) with H/S
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Ultrasound Obstet Gynecol 2004 24 566571Which
infertile women should be indicated
forsonohysterography? ANDO H et al
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Which infertile women should be indicated
forsonohysterography?
Conclusions TV-SCSH should be performed on
selected patients following assessment of
endometrial images on transvaginal sonography in
order to diagnose intra- and pericavitary lesions
in infertile women
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Saline Infusion Sonohysterography

• Use of SIS in general infertile population
• Use of SIS to evaluate cavity before ART

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Use of SIS to evaluate cavity before ART
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Uterine cavity assessment prior to IVF

• No statistically significant difference was
  observed in the pregnancy outcome for patients
  undergoing IVF who had sonohysterography compared
  with that for patients undergoing IVF during the
  same period who previously had a uterine
  evaluation by a different method.
• Conclusion(s) Sonohysterography offers
  advantages over in-office hysteroscopy and
  hysterosalpingography for evaluation of the
  uterus before IVF.
• Kim et al. Fertil Steril 1998

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Uterine cavity assessment prior to IVF

• Conclusions
• SCHS in comparison with H/S
• 87.5 sensitivity, 100 specificity, 100 PPV,
  91.6 NPV.
• TVUS in comparison with H/S
• 81 sensitivity, 95 specificity, 93 PPV, 86
  NPV.
• However unlike SCHS, TVUS
• (1) could not could not diagnose submucosal
  fibroids in the presence of multiple fibroid
  uterus
• (2) distinguish between a hyperplastic
  endometrium and a large polyp or
• (3) differentiate between an arcuate and a
  septate uterus
• Ayida G et al. Ultrasound Obstet Gynecol 1997

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Uterine cavity assessment prior to IVF

• SIS was performed in 80 patients before ICSI and
  compared with 240 cycles in patients with normal
  HSG
• A subsequent hysteroscopy was undertaken in
  patients with intracavitary lesions
• Clinical pregnancy rates were comparable between
  groups (40.2 vs 42.5)
• SIS appears to be a simple, inexpensive and safe
  alternative to HSG for the evaluation of uterine
  cavity before IVF/ICSI
• Alatas et al Hum Reprod 1998

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Role of saline infusion sonography in
uterineevaluation before frozen embryo transfer
cycleGera et al Fertil Steril 2008
group A positive SIS findings and treated group
B positive SIS findings and not treated group
C negative SIS findings
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In an IVF program, SHG as an outpatient
diagnostic method is easy, sensitive, and well
tolerated.
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Conclusions

• compared with hysteroscopy, SHG seems to offer
  similar diagnostic capabilities in at least some
  studies in assessing uterine cavity. It is also
  less invasive and costly.
• In comparison with HSG, SHG has been found
  superior for evaluation of the uterus. It has a
  higher sensitivity, better tolerated, does not
  require the use of radiation, and provides better
  diagnostic accuracy.
• larger, prospective, randomized studies has to be
  designed to draw a definite conclusion regarding
  the efficiency of SHG before ART