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1 Department of Radiology, Institut Universitari Dexeus, P0 Bonanova,
67 pl -2, Barcelona 08017, Spain.
2 Department of Gynecology and Obstetrics, Institut Universitari Dexeus,
Barcelona 08017, Spain.
Received November 24, 2003;
accepted after revision February 2, 2004.
Address correspondence to A. Roma Dalfó
(dpi{at}idexeus.es).
Abstract
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MATERIALS AND METHODS. Seventy-eight patients being investigated for infertility and undergoing HSG and hysteroscopy were studied retrospectively. Radiologic findings on HSG, including single or multiple filling defects and uterine wall irregularities, were evaluated and compared with hysteroscopic findings, which were considered the reference standard.
RESULTS. HSG showed a sensitivity of 81.2% compared with that of hysteroscopy and a specificity of 80.4%, with a positive predictive value of 63.4% and a negative predictive value of 83.7%. HSG also had a false-negative rate of 90% and a false-positive rate of 21.8%. Overall agreement between the two procedures was 73%.
CONCLUSION. HSG is still a useful screening test for the evaluation of the uterine cavity in the study of primary or secondary infertility. In addition, HSG provides information concerning the assessment of tubal morphology and patency. We believe that these two procedures are complementary in the evaluation of the uterine cavity.
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Hysterosalpingography (HSG) is the most commonly used technique in the evaluation of infertility. It has traditionally been considered the gold standard for assessment of the fallopian tubes, giving reliable information about their patency and morphology. It is also recommended for the study of the uterine cavity in the diagnosis of and treatment planning for other gynecologic problems such as intrauterine adhesions and congenital anomalies. HSG is an indirect means of showing the interior of the uterus and fallopian tubes. Endometrial lesions are shown as filling defects or uterine wall irregularities. HSG also enables visualization of the general configuration of the cavity. Disadvantages of HSG include pelvic exposure to radiation, use of iodinated contrast medium, and patient discomfort.
During the last two decades, hysteroscopy has increasingly been gaining acceptance and is today a necessary tool in the investigation of female infertility. Hysteroscopy permits direct visualization of the cervical canal and the uterine cavity, enabling observation of the shape, relief, and vascular pattern of any abnormality. It also permits direct biopsy of lesions. Hysteroscopy is an office procedure performed without local or general anesthetic and causes minimal discomfort to the patient.
Hysteroscopy has traditionally been performed as an adjunct tool to evaluate abnormalities suspected as a result of HSG evaluation. Recent studies have shown increased benefit from combining diagnostic hysteroscopy and HSG in the evaluation of female infertility [1]. Hysteroscopy has two main applications in infertile patients: to evaluate the cervix and uterine cavity to rule out any lesions misdiagnosed on HSG and to manage intrauterine defects. Moreover, hysteroscopy is useful in identifying endometrial abnormalities not detectable on HSG.
The accuracy of hysteroscopy and HSG in the diagnosis of uterine cavity abnormalities has been compared in various studies [2-8]. HSG is associated with false-positive and false-negative rates, and hysteroscopy is more accurate than HSG, although the magnitude of the discrepancy is controversial [4]. The aim of our study was to evaluate the diagnostic accuracy of HSG and hysteroscopy in uterine cavity diseases in infertile patients, with hysteroscopy considered the gold standard.
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A radiologist performed HSG in patients in the preovulatory phase (eighth to tenth day of the cycle). Approximately 5-10 mL of a water-soluble contrast medium (Pielograf 70% [amidotrizoato meglumine], Juste SAQF) was introduced into the uterine cavity after placing a balloon catheter set for HSG. The soft rubber Foley catheter was inflated in the cervical canal under fluoroscopic control using a digital system (Multi Diagnost 3, Philips Medical Systems). Premedication with anti-inflammatory drugs was not routinely administered. Six spot radiographs were systematically obtained, including an underfilled view of the uterus to detect small endometrial lesions, an early filled view of the fallopian tubes, both anteroposterior and oblique projections of the entire genital tract showing the spill of contrast material at the peritoneum, and a postdrainage radiograph. Filling defects and uterine wall irregularities were the two main outcome measures on HSG. Single filling defects were diagnosed as polyps or submucosal myomas according to their morphology and uterine cavity configuration. Multiple diffuse nodular filling defects of the entire endometrial cavity were interpreted as endometrial hyperplasia. Uterine adhesions were seen as uterine wall irregularities, sometimes with sharply delineated filling defects of angulated contours.
Diagnostic hysteroscopy was performed by a gynecologist as an office procedure and scheduled during the secretory phase of the cycle, using a 3.8-mm-diameter lens-based rigid continuous-flow endoscope with an optical angle of 30° equipped with a 4-mm hysteroscopic diagnostic sheath and a xenon light source (Storz, GmbH). Hysteroscopy was performed without premedication or local or general anesthetic. The hysteroscope was introduced through the vagina and cervix into the uterine cavity without a speculum and without placing a tenaculum on the cervix. Approximately 200 mL of saline solution was used as a distention medium and was instilled by way of a conventional blood pressure cuff. Images were recorded with a video camera and seen on a monitor. Photographs were systematically obtained for both the patient's report and medical history.
Findings on HSG and hysteroscopy were reviewed retrospectively. The hysteroscopic findings were used as a reference standard to calculate sensitivity, specificity, positive and negative predictive values, and false-positive and false-negative rates.
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Overall agreement correlation between HSG and hysteroscopy was 73%. The sensitivity of HSG was 81.2% and specificity, 80.4%. The positive predictive value was 63.4% and the negative predictive value, 83.7%. Furthermore, results of HSG were false-negative in 9% of patients and false-positive in 21.8%. Hysteroscopic examination of the 37 patients with normal findings on HSG showed six to have uterine cavity abnormalities including three cases of endometrial polyps, two cases of endometrial hyperplasia, and one submucosal myoma. In 15 of the 41 patients depicted on HSG as having endocavitary abnormalities, hysteroscopy revealed no abnormality. HSG findings included a single filling defect in seven patients, multiple filling defects suggestive of endometrial hyperplasia in five patients, irregular contour interpreted as small adhesions in two, and a unicornuate uterus in one. Findings on HSG and hysteroscopy correlated in 57 patients, revealing no abnormalities in 31 and showing several abnormal conditions in 26. The most common intrauterine finding was endometrial polyps (n = 12), followed by intrauterine adhesions (n = 8), submucosal myomas (n = 3), and endometrial hyperplasia (n = 2). In one patient, HSG and hysteroscopy showed abnormal but discordant findings, with endometrial hyperplasia with multiple filling defects seen on HSG but only one polyp seen on hysteroscopy.
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HSG and hysteroscopy are two different approaches to the uterine cavity. The accuracy of HSG and hysteroscopy for detecting uterine abnormalities in infertile patients has been discussed by various authors [2-8]. Hysteroscopy has an increased accuracy over HSG, although the magnitude of this discrepancy is controversial. Although some authors have suggested that HSG should be completely replaced by hysteroscopy [3, 9, 10], others have found that hysteroscopy added little information when HSG results were negative [7]. HSG is considered to have a high sensitivity (60-98%) [1, 3] but a low specificity (15-80%) [1, 3], with elevated false-positive and false-negative rates. In our series, the sensitivity of HSG was 81.2% and its specificity, 80.4%, with a false-negative rate of 9% and a false-positive rate of 21.8%. There was a high correlation between the findings of the two procedures, with an overall agreement of 73%. The results of this study show a high sensitivity and specificity in the detection of intrauterine lesions, a low false-negative rate, and a moderate false-positive rate. Compared with previously reported results [3], our series showed a higher specificity and a lower false-negative rate.
Further studies are needed to determine the possible bias originating from the fact that the two procedures were performed during different phases of the menstrual cycle and different cycles; these differences could affect the trophic changes of the endometrium (e.g. endometrial hyperplasia ([Figs. 2A, 2B] or polyps).
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The advantages of HSG include the ease of the study, its safety, and cost-effectiveness in comparison with hysteroscopy. In addition, HSG provides information about tubal patency or blockage. Several disadvantages are inherent in the technique, including exposure to ionizing radiation, use of iodinated contrast material, and often discomfort for the patient. The differential diagnosis of intrauterine filling defects includes polyps (Figs. 3A, 3B), endometrial hyperplasia, submucosal myomas (Figs. 4A, 4B), intrauterine synechia (Figs. 5A, 5B), and septa. False-positive findings can be caused by air bubbles, mucus, and debris that mimic filling defects. False-negative findings can result from an excessive amount of contrast media in the uterus that obliterates the shadows caused by small endometrial lesions.
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Hysteroscopy is a safe and quick examination (< 5 min) for the direct and accurate diagnosis of intrauterine abnormalities. It permits direct visualization of the interior of the uterine cavity, revealing the nature and localization of endocavitary lesions; allows diagnosis of infectious, functional, and organic abnormalities; and allows guidance of endometrial biopsies and cultures for histologic evaluation. Moreover, if a therapeutic approach is indicated, hysteroscopic surgery is widely accepted as the most effective [11, 12].
The results of this study show that HSG is a reliable technique for diagnosing uterine abnormalities. The discrepancies between the diagnoses obtained on HSG and hysteroscopy are expected because HSG localizes the defects, whereas hysteroscopy visualizes them directly. Because of the valuable information that HSG provides about the cavity and tubes, it remains mandatory in the evaluation of infertility. When an intrauterine abnormality is detected, the nature, localization, and extent of the lesion should be determined by direct hysteroscopic visualization. When HSG shows no abnormality, the indication of hysteroscopy has been questioned. We believe that when HSG shows no abnormality, the indication of hysteroscopy must not be discarded because it adds additional and exclusive information about hormonal, trophic, inflammatory, and infectious disorders that may be responsible for poor reproductive outcome in nearly 25% of cases.
In conclusion, we believe that these two procedures are complementary in the evaluation of infertile women; each approaches the uterine cavity in a different way and each has advantages and limitations. HSG is a useful but indirect test and remains one of the first steps in the evaluation of infertility, so hysteroscopy should not totally replace HSG.
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