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Mohammad Ahmad Taymour MBBCh PROF. DR. Osama Abd El Aziz Al Shonoufy ASS. PROF. DR ... PDF

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COMPARATIVE STUDY BETWEEN HYSTEROSALPINGOGRAPHY, SALINE INFUSION SONOHYSTEROGRAPHY AND OFFICE HYSTEROSCOPY IN EVALUATION OF UTERINE FACTORS OF INFERTILITY THESIS SUBMITTED IN PARTIAL FULFILLMENT OF MASTER DEGREE IN OBSTETRICS AND GYNECOLOGY BY Mohammad Ahmad Taymour M.B.B.Ch Faculty of Medicine Cairo University SUPERVISED BY PROF. DR. Osama Abd El Aziz Al Shonoufy Professor of Obstetrics and Gynecology Faculty of Medicine - Cairo University ASS. PROF. DR. Akmal Nabil El Mazny Assistant Professor of Obstetrics and Gynecology Faculty of Medicine - Cairo University DR. Waleed Saber Abd El Gaber Lecturer of Obstetrics and Gynecology Faculty of Medicine - Cairo University Faculty of Medicine Cairo University 2012 ﻢﻴﺣﺮﻟا ﻦﲪﺮﻟا ﷲا ﻢﺴﺑ ﺎﻣَ ﻻﱠ إ ﺎﻧَ َﻟ مﻠْ ﻋِ ﻻَ كَ ﻧَ ﺎﺣَ ﺑْ ﺳُ اوُﻟﺎﻗَ ِ َ َ مﯾﻛِ ﺣَ ﻟْ ا مﯾِﻠﻌَ ﻟْ ا تَ ﻧْ أ كَ ﻧﱠ إ ﺎﻧَ ﺗَ ﻣْ ﻠﱠ ﻋَ ُ ُ ِ ﻢﻴﻈﻌﻟا ﷲا قﺪﺻ (٣٢ ﺔﻳآ) ةﺮﻘﺒﻟا ةرﻮﺳ Acknowledgment Firstly and lastly thanks to Allah the most merciful for his help. I would like to express my deepest gratitude and sincere appreciation to Prof. Dr. Osama Abd El-Aziz Alshonoufy, Professor of Obstetrics & Gynecology, Faculty of Medicine, Cairo University. I’m greatly thankful to him for his fatherly attitude, enthusiastic encouragement, his sincere advice, and supervision. He was very generous with his time and effort. My extreme thanks and gratefulness to Dr. Akmal Nabil El- Mazny, Ass. Prof. of Obstetrics & Gynecology, Faculty of Medicine, Cairo University. He was very generous with his time and advice, which helped to simplify my hard task of preparing this work. Also for his sincere supervision and the endless effort that he had offered throughout the period of making and revising this thesis. Also I would like to thank Dr. Waleed Saber Abd El-Gaber , Lecturer of Obstetrics and Gynecology, Faculty of Medicine , Cairo University for his keen interest, beneficial advice, constant support and scientific opinions during the conduction of the operative phase of this work. I’m grateful to all my professors, staff and colleagues of the Obstetrics & Gynecology department, Cairo University for their help and cooperation throughout this work. Many grateful thanks to my parents for their continuing love, care and strong support, to whom I'm indebted for what I am today. My sincere gratefulness and appreciation to my wife who stood by my side, her support provides me with aim and direction. Finally, I’m grateful to the patients for whom all our efforts are devoted. i Abstract Evaluation of the uterine cavity is mandatory when studying infertile patients. Likewise, assessment of the implantation site is an important step in the management of patients with diagnosed infertility, indeed uterine cavity pathologies such as fibroids, polyps and Müllerian anomalies can impair fertility and result in recurrent pregnancy loss and poor outcome of pregnancy. Thus, their detection and treatment are important in order to achieve therapeutic success. The direct view of the uterine cavity through hysteroscopy offers a significant advantage over other diagnostic methods which offer only a blind or indirect view of the cavity. Keywords: Infertility Hysterosalpingography Sonohysterography Office hysteroscopy ii List of contents Page Introduction............................................................................... 1 Aim of work.............................................................................. 3 Review of literature .................................................................. 4 Chapter (1): Infertility............................................................ 4 Chapter (2): Hysterosalpingography...................................... 26 Chapter (3): Saline infusion sonohysterography................... 51 Chapter (4):Hysteroscopy...................................................... 71 Patients and methods ................................................................ 112 Results....................................................................................... 118 Discussion................................................................................. 138 Summary and conclusions........................................................ 148 References................................................................................. 152 Arabic summary........................................................................ - iii List of abbreviations AAGL American Association of Gynecologic Laparoscopists ACOG American Congress of Obstetricians and Gynecologists ART Assisted Reproductive Technology AS Asherman's syndrome ASRM American Society of Reproductive Medicine AUB Abnormal uterine bleeding D&C Dilatation and Curettage DES Diethylstilbesterol DH Diagnostic hysteroscopy FDA Food and Drug Administration GnRH Gonadotropin-Releasing Hormone HSG Hysterosalpingography ICSI Intra cytoplasmic sperm injection IUAs Intrauterine adhesions IUI Intrauterine insemination IVF Invitro fertilization LR Lactated Ringer’s Solution MAC Monitored Anaesthesia Care MAP Mean Arterial Pressure NIC's Normal Infertile Couples NPV Negative Predictive Value NS Normal Saline NSAID Nonsteroidal anti-inflammatory drugs OD Outer Diameter OH / OHS Office Hysteroscopy PID Pelvic Inflammatory Disease PPV Positive Predictive Value SCHS Saline contrast hysterosonography SD Standard deviation SHG Sonohysterography SIN Salpingitis isthmica nodosa SIS Saline Infusion Sonohysterography TVS Transvaginal Sonography WL Working Length β-hCG β-human Chorionic Gonadotropin iv List of Tables Page Table (1): Causes of female factor infertility................................................... 5 Table (2): Percentage of uterine malformations in hysterosalpingogram 40 Table (3): Statistical methods.......................................................................... 119 Table (4): Demographic features of the studied cases..................................... 120 Table (5): Type of infertility of the studied cases............................................ 120 Table (6): Description of Age among different findings of OHS of the studied cases..................................................................................................... 121 Table (7): Description of the type of infertility among the findings of OHS of the studied cases .......................................................................................... 122 Table (8): Description of the duration of infertility among the findings of OHS of the studied cases................................................................................. 123 Table (9): Distribution of findings of OHS among the studied cases.............. 124 Table (10): Comparison between positive and negative findings of OHS...... 124 Table (11): Distribution of the findings of HSG among the studied cases...... 125 Table (12) : Comparison between positive and negative findings of HSG..... 125 Table (13) : Distribution of the findings of SIS among the studied cases....... 126 Table (14) : Comparison between positive and negative findings of SIS 126 Table (15) : Findings of different used techniques among all the studied cases................................................................................................................. 127 Table (16) : Comparison between positive findings of HSG and OHS among the studied cases............................................................................................... 128 Table (17) : Comparison between positive findings of SIS and OHS among the studied cases............................................................................................... 128 Table (18): Sensitivity, specificity, PPV, NPV, and accuracy of different used techniques in the diseased cases compared to OHS................................ 129 Table (19): Sensitivity, specificity, PPV, NPV, and accuracy of HSG for different findings compared to OHS. 130 Table (20) : Sensitivity, specificity, PPV, NPV, and accuracy of SIS for different findings compared to OHS................................................................ 131 Table (21): Findings detected by different diagnostic techniques compared to OHS.............................................................................................................. 137 v List of Figures Page FIG (1). Unicornous uterus.............................................................................. 9 FIG (2). Didelphys uterus................................................................................ 9 FIG (3) Hysterosalpingogram showing uterus didelphys................................ 10 FIG (4). Bicornate uterus................................................................................. 10 FIG (5) Hysterosalpingogram showing a septate uterus.................................. 11 FIG (6). Arcuate uterus.................................................................................... 11 FIG (7) Hysterosalpingogram showing a T-shaped uterus due to diethylstilbestrol exposure in utero.................................................................. 12 FIG (8). Small size of the uterus cavity with normal length of the vagina..... 12 FIG (9) (A) Arcuate uterus: (B) Septate uterus: (C) Bicornuate uterus:......... 13 FIG (10) Normal hysterosalpingography......................................................... 35 FIG (11) Hysterosalpingogram showing a right unicornuate uterus............... 37 FIG (12) Hysterosalpingogram showing uterus didelphys.............................. 37 FIG (13) Hysterosalpingogram showing a bicornuate uterus.......................... 38 FIG (14) Hysterosalpingogram showing a septate uterus................................ 38 FIG (15) hysterosalpingography showing an arcuate uterus........................... 39 FIG (16) Hysterosalpingogram showing a T-shaped uterus............................ 39 FIG (17) Small size of the uterus cavity with normal length of the vagina.... 40 FIG (18) Hysterosalpingogram showing multiple filling defects due to endometrial polyps........................................................................................... 41 FIG (19). Nodosa isthmic salpingitis............................................................... 42 FIG (20) Hysterosalpingogram showing a normal uterine cavity and bilateral hydrosalpinx ...................................................................................... 43 FIG (21). Submucosa fibromyoma.................................................................. 44 FIG (22) Hysterosalpingogram showing large intramural myoma. ................ 44 FIG (23) Hysterosalpingogram showing a filling defect due to synechiae..... 45 FIG (24) Hysterosalpingogram showing adenomyosis................................... 46 FIG (25) Hysterosalpingogram showing an arcuate uterus............................. 47 FIG (26) Hysterosalpingogram showing tubal polyps bilaterally................... 48 FIG (27) The appearance of well-shaped endometrial polyp which is detected by hydrosonography.......................................................................... 60 FIG (28) Endometrial polyp by 2D sonohysterography.................................. 60 FIG (29) Endometrial polyp by SIS................................................................. 61 FIG (30) Endometrial polyp by SIS................................................................. 61 FIG (31) Hydrosonographic appearance of a submucous myoma.................. 63 FIG (32) Hydrosonographic appearance of a submucous myoma.................. 63 FIG (33) Intrauterine synechiae 2D sonohysterography ................................ 65 FIG (34) 5 mm Rigid hysteroscope................................................................. 82 FIG (35) Flexible diagnostic hysteroscope...................................................... 82 vi Page FIG (36) Normal panoramic view of the uterine cavity.................................. 90 FIG (37) Intrauterine adhesions....................................................................... 96 FIG (38) Uterine septum.................................................................................. 97 FIG (39): Uterine septum and an endometrial polyp....................................... 98 FIG (40): Submucous myoma.......................................................................... 100 FIG (41): Endometrial polyp........................................................................... 100 Fig (42): Type of infertility of the studied patients......................................... 120 Fig (43): Description of Age among different findings of OHS of the studied cases................................................................................................................. 121 Fig (44): Description of the type of infertility among the findings of OHS of the studied cases............................................................................................... 122 Fig (45) : Description of the duration of infertility among the findings of OHS of the studied cases................................................................................. 123 Fig (46): Distribution of findings of OHS among the studied cases............... 124 Fig. (47) : Distribution of the findings of HSG among the studied cases....... 125 Fig. (48) : Distribution of the findings of SIS among the studied cases.......... 126 Fig. (49) : Findings of different used techniques among all the studied cases 127 Fig. (50) : Sensitivity, specificity, PPV, NPV, and accuracy of different used techniques for all the studied cases compared to OHS.................................... 129 Fig. (51) : Sensitivity, specificity, PPV, NPV, and accuracy of different techniques for diagnosis of intrauterine synechia. 132 Fig. (52) : Sensitivity, specificity, PPV, NPV, and accuracy of different techniques for diagnosis of septate uterus....................................................... 133 Fig. (53) : Sensitivity, specificity, PPV, NPV, and accuracy of different techniques for diagnosis of polyps .................................................................. 134 Fig. (54) Sensitivity, specificity, PPV, NPV, and accuracy of different techniques for diagnosis of myoma................................................................. 135 Fig. (55): Sensitivity, specificity, PPV, NPV, and accuracy of different techniques in diagnosis of cases free of pathological findings........................ 136 Fig. (56) : Findings detected by different diagnostic techniques compared to OHS.................................................................................................................. 137 vii INTRODUCTION One of the basic steps of an infertility workup is to evaluate the shape and regularity of the uterine cavity. Acquired uterine lesions, such as uterine fibroids, endometrial polyps, intrauterine adhesions, or all of these, may cause infertility by interfering with proper embryo implantation and growth. (Brown et. al, 2000) In fact, infertility related to uterine cavity abnormalities has been estimated to be the causal factor in as many as 10% to 15% of couples seeking treatment. Moreover, abnormal uterine findings have been found in 34% to 62% of infertile women. (Pansky et. al, 2006). Traditionally hysterosalpingography (HSG) has been the most commonly used technique in the evaluation of infertility. It gives reliable information about the patency and morphology of the fallopian tubes. It is also helpful in evaluating uterine cavity abnormalities. (Roma et. al, 2004). Sonohysterography (SHG) is considered a simple, effective and well tolerated technique for enhanced transvaginal sonographic imaging of the endometrial cavity. The instillation of sterile saline into the uterine cavity via a fine catheter provides both a contrast medium and an expanding agent. So, Saline infusion sonohysterography can help to triage patients to (1) no anatomic pathology, (2) globally thickened anatomic pathology that may be evaluated with blind endometrial sampling, or (3) focal abnormalities that must be evaluated under direct vision (Goldstein, 2006). 1

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I would like to express my deepest gratitude and sincere appreciation to Prof. University. I'm greatly thankful to him for his fatherly attitude, important step in the management of patients with diagnosed infertility, indeed uterine cavity pathologies such as fibroids, polyps and Müllerian anom
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