A prospective study to evaluate theefficacy of two- and three-dimensionalsonohysterography in women withintrauterine lesions

Camille Sylvestre, M.D., Tim J. Child, M.D., Togas Tulandi, M.D., andSeang Lin Tan, M.D.

McGill Reproductive Center, Department of Obstetrics and Gynecology, McGill University, Royal VictoriaHospital, Montreal, Quebec, Canada

Objective: To measure the accuracy of three-dimensional (3D) sonohysterography in detecting intrauterinelesions.

Design: Prospective study.

Setting: Teaching hospital.

Patient(s): Two hundred nine infertile patients suspected to have an intrauterine lesion on 2D ultrasound orhysterosalpingography.

Intervention(s): Three-dimensional ultrasound, 2D and 3D sonohysterography (SHG). Ninety-two of thepatients had a lesion distorting the endometrium on the 3D SHG, and those were referred for hysteroscopy.

Main Outcome Measure(s): Sensitivity and specificity of 2D, 3D ultrasound, and 2D SHG compared to 3DSHG.

Result(s): Of the 92 patients with a lesion, 48 had polyps, 35 submucous/intramural myomas, 3 both polypsand myomas, 4 mullerian anomalies, 1 thick endometrium, and 1 synechiae. Compared with the 3D SHGresults, the sensitivity and specificity were 97% and 11% for the 2D transvaginal ultrasound, 87% and 45%for the 3D ultrasound, and 98% and 100% for the 2D SHG. In the group of 59 patients who had hysteroscopy,the sensitivity of the 2D SHG and 3D SHG were 98% and 100%, with a positive predictive value of 95% and92%, respectively.

Conclusion(s): Three-dimensional sonohysterography allows precise recognition and localization of lesions.If 2D and 3D SHG are normal, invasive diagnostic procedures such as hysteroscopy could be avoided. (FertilSteril� 2003;79:1222–5. ©2003 by American Society for Reproductive Medicine.)

Key Words: 3D ultrasound, sonohysterography, intrauterine lesions, myomas, polyps

Hysterosalpingography and transvaginal ul-trasound are routinely used in the investigationof infertile patients. When hysterosalpingogra-phy or transvaginal ultrasound reveals an ab-normality in the uterine cavity, two-dimen-sional (2D) sonohysterography is usuallyperformed. This is a relatively easy test that canhelp delineate the nature (polyps, submucousmyomas, synechiae, or congenital anomalies)and extent of the lesions. If necessary, an op-erative hysteroscopy is then performed to con-firm and to treat the abnormality (1–5).

Compared with 2D ultrasound, 3D ultra-sound provides clearer visualization and moreaccurate evaluation of the uterine cavity (6–9).

It also allows more accurate assessment of theuterine anatomy, which is useful in cases ofsuspected congenital anomalies (10). A fewstudies have shown that 3D sonohysterographyis more precise than 2D sonohysterography,and can reduce the incidence of false-positiveresults (6–8). However, those studies werelimited to the assessment of the endometrialthickness and polyps in postmenopausalwomen.

As the incidence of intrauterine abnormali-ties is higher in infertile women than in thegeneral population, their accurate detection andtreatment are important to the final therapeuticsuccess, and it would be useful to determine the

Received August 2, 2002;revised and acceptedSeptember 5, 2002.Presented at the AnnualMeeting of the AmericanSociety for ReproductiveMedicine, Seattle,Washington, October 14–17, 2002.Reprint requests: CamilleSylvestre, M.D., McGillReproductive Center, RoyalVictoria Hospital F6.58, 687Pine Avenue West,Montreal, Quebec, H3A1A1 Canada (FAX: 514-843-1496; E-mail:camsylvestre@hotmail.com).

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efficacy of 3D sonohysterography in a wider population ofpatients. The aim of this study was to investigate the diag-nostic accuracy of 3D sonohysterography in infertile womenwith intrauterine lesions.

MATERIALS AND METHODS

From January 2001 to January 2002, 209 patients with asuspicious intrauterine lesion on 2D ultrasound or hystero-salpingogram were recruited for the study. The inclusioncriteria were healthy women aged 20–45 years and absenceof sexually transmitted disease, pelvic inflammatory disease,or pregnancy. Patients with active vaginal bleeding were alsoexcluded.

As part of the routine investigation for infertility, patientsunderwent a baseline endovaginal 2D ultrasound betweenday 2 and day 5 of their menstrual cycle. Ultrasound exam-inations were performed using the Sequoia 512 ultrasoundmachine (ACUSON, Mountain View, CA) with a transvag-inal transducer of 5–8 MHz. Any suspicious lesion wasnoted and measurements taken. Those with a suspiciouslesion were arranged to undergo a 3D ultrasound, and a 2Dand 3D sonohysterogram.

The sonohysterogram was performed between day 5 andday 10 of the menstrual cycle, after menstrual bleeding hadended. The machine used was a VOLUSON 530D (Kretz-technik, Austria) with a transvaginal transducer of 5–7 MHzwith 2D and 3D capabilities. We used an intrauterine doublelumen insemination catheter (Laboratoire CCD, Paris,France). After insertion of the catheter, the transvaginaltransducer was reinserted to verify the position of the cath-eter, and 10–60 mL of 0.9% NaCl USP saline was injected.The sonohysterography was done on 2D first and the mea-surements of the lesion taken. Then the machine wasswitched to 3D and the measurements were repeated.

The test was considered normal if the outline of theendometrium was not distorted and no intrauterine lesionwas found. An endometrial polyp was defined as a smooth-margined, echogenic mass of variable size and shape, emerg-ing from the endometrium. A submucosal myoma was de-fined as a solid, round structure of mixed echogenicity,emanating from the myometrium and protruding into theuterine cavity. A single operator (C.S.) performed all thesonohysterograms. Women with abnormal findings on sono-hysterography were referred for hysteroscopy at a differenttime. The results were then compared.

Operative hysteroscopies were done under general anes-thesia, in an outpatient setting, with a 9-mm 30° angle rigidhysteroscope and resectoscope (Karl STORZ, Tuttlingen,Germany). The measurements and location of the lesionswere noted and all the procedures were done by a singlesurgeon (T.T.). To date, a group of 59 patients had under-gone hysteroscopy.

The Research Ethics Board of the Royal Victoria Hospitalapproved the study.

StatisticsThe sensitivity and specificity of 2D ultrasound, 3D ul-

trasound, and 2D sonohysterogram were calculated compar-ing each test with the 3D sonohysterographic findings. Thefindings in the group of patients who had hysteroscopy wascompared with the 2D and 3D sonohysterographic results.

RESULTSThe mean age of the patients was 35.7 � 12 years. The

reasons for consultation were infertility (188 patients,89.9%), recurrent pregnancy loss (12 patients, 5.7%), anddysfunctional uterine bleeding associated with infertility (9patients, 4.3%). No further surgical evaluation was plannedfor the 116 patients found to have absence of intrauterinelesion on the 2D sonohysterogram.

Of the remaining 93 patients, the following findings werefound on 2D sonohysterogram: 45 polyps (48.4%), 34 sub-mucous myomas (36.5%), 3 combinations of polyps andmyomas (3.2%), 4 mullerian anomalies (4.3%), 3 thick en-dometrium (3.2%), and 1 synechiae (1.08%). Three sono-hysterograms were inconclusive due to failure of adequatedilatation of the uterine cavity. When 3D sonohysterographywas performed, 3 more polyps and 1 myoma missed on the2D sonohysterography were seen. Moreover, only 1 of the 3patients diagnosed to have thick endometrium on the 2Dsonohysterogram was confirmed by the 3D sonohysterogram(Table 1).

When we compared the results of each test with the 3Dsonohysterogram, the sensitivity and specificity of the 2D

T A B L E 1

Correlation between 2D sonohysterography and 3Dsonohysterography.

2D sonohysterography 3D sonohysterography

Polyps 45 45Myomas 34 34Myomas � polyps 3 3Mullerian anomaly 4 4Thick endometrium 3 1 thick endometrium

2 polypsSynechiae 1 1Inconclusive 3 3Normal 116 114 normal

1 polyp1 myoma

Total 209 209

Sensitivity of 2D sonohysterography: 98%, specificity 100%, �PV: 100%,�PV: 98%.

Sylvestre. Three-dimensional sonohysterography. Fertil Steril 2003.

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transvaginal ultrasound were 97% and 11% (Table 2), and ofthe 3D ultrasound were 87% and 45% (Table 3).

There were five patients who refused to undergo hyster-oscopy, and one became pregnant while waiting for thesurgery. The correlation between the 2D sonohysterogramand hysteroscopy shows a sensitivity of 98% and a positivepredictive value of 95%.

When 3D sonohysterography and hysteroscopy werecompared, the sensitivity of 3D sonohysterography was100% and the positive predictive value was 92%. The spec-ificity could not be calculated as women who had normal 3Dsonohysterograms did not undergo hysteroscopic examina-tions.

DISCUSSIONIt is well recognized that distortion of the uterine cavity

can negatively affect the successful outcome of IVF-embryotransfer (11). It is apparent from the results of the presentstudy that with conventional 2D transvaginal ultrasound andhysterosalpingography as the initial screening tests, there area large number of false-positive results. This may be due tothe fact that any lesion visualized was suspected to distort the

endometrial lining. The sensitivity was high (97%), but thespecificity was very low (11%).

The 3D transvaginal ultrasound scan was more accurateand allowed the elimination of a number of myomas, polyps,and mullerian anomalies that had been thought to distort theendometrial cavity. The addition of a coronal plane alloweda better delineation of the uterus as the three planes could bevisualized simultaneously, and as a result the number ofexaminations deemed normal increased from 7.2% to 30.1%.

When we proceeded to the 2D sonohysterogram, 116previously abnormal 2D transvaginal examinations or hys-terosalpingograms revealed a normal uterine cavity. Many ofthe cases diagnosed as thick endometrium were in fact bloodclots at the time of the first ultrasound (6 of 24), and most ofthe myomas were intramural rather than submucosal (54 of101). One examination showed uterine synechiae, whichcould not be seen on the 2D transvaginal ultrasound. Thissupports the finding that sonohysterography is a more accu-rate test for the evaluation of the intrauterine cavity com-pared with the transvaginal ultrasound, due to the salinedistension of the uterine cavity.

We found that 3D sonohysterography provided us with amore precise evaluation of the intrauterine cavity. Using 3D

T A B L E 2

Correlation between 3D ultrasound and 3Dsonohysterography.

3D ultrasound 3D sonohysterography

Polyps 11 10 polyps1 normal

Myomas 101 31 myomas53 normal11 polyps3 polyps � myomas2 inconclusive1 mullerian anomaly

Myomas � polyps 2 2 polypsMullerian anomaly 5 3 mullerian anomaly

2 normalThick endometrium 24 0 thick endometrium

16 polyps6 normal2 myomas

Synechiae 0 0Inconclusive 3 1 inconclusive

1 normal1 myoma

Normal 63 51 normal9 polyps1 thick endometrium1 synechiae1 myoma

Total 209 209

Sensitivity of 3D ultrasound: 87%, specificity: 45%, �PV: 57%, �PV:81%.

Sylvestre. Three-dimensional sonohysterography. Fertil Steril 2003.

T A B L E 3

Correlation between 2D ultrasound and 3Dsonohysterography.

2D ultrasound 3D sonohysterography

Polyps 25 14 polyps10 normal1 thick

endometriumMyomas 133 34 myomas

71 normal21 polyps3 polyps � myomas2 inconclusive1 mullerian anomaly1 synechiae

Polyps � myomas 4 2 polyps2 normal

Mullerian anomaly 8 3 mullerian anomaly5 normal

Thick endometrium 18 7 polyps11 normal

Synechiae 2 1 polyp1 normal

Inconclusive 4 2 normal1 myoma1 inconclusive

Normal 15 12 normal3 polyps

Total 209 209

Sensitivity of 2D ultrasound: 97%, specificity: 11%, �PV: 47%, �PV:80%.

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sonohysterography we found three more polyps and onemyoma that had been missed on the 2D sonohysterogram.They had previously been interpreted as thick endometrium,which subsequently was eliminated by the addition of thethird dimension. Three of those four cases were confirmedby hysteroscopy; two polyps were confirmed and the myomaturned out to be nondistorting, thus a normal examination.

When the group of women who had undergone sonohys-terography and hysteroscopy were compared, we found thesensitivity and the positive predictive value of both the 2Dand 3D sonohysterograms to be high and not significantlydifferent. To date, not all patients have undergone a hyster-oscopic examination. However, 3D sonohysterography is arelatively easy examination and readily available in an in-fertility clinic equipped with a 3D ultrasound machine. Thediscomfort is tolerable for the patient with a very low risk ofbleeding and infection. A hysteroscopy would still be nec-essary if the sonohysterogram suggests an intrauterine le-sion. However, if a normal uterine cavity is diagnosed on 2Dand 3D sonohysterograms, then the patient would be sparedan unnecessary diagnostic hysteroscopy.

Acknowledgments: The authors thank the radiology technicians TheresaSzablak, Danielle Scott, Salpy Demirdjian, Ghislaine Cote, and DemetraCotsovos for their help in data collection.

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