The assessment of the diagnostic values of hysterosalpingography and transvaginal ultrasonography in primary and secondary infertile patients undergoing hysteroscopy

Abstract

Objective: To calculate sensitivity, specificity, positive and negative predictive values of transvaginal sonography (TVS) and hysterosalpingography (HSG) in the detection of intrauterine lesions, assuming hysteroscopy (H/S) and pathology results as gold standart, and to investigate the prevalance of intrauterine pathologies in primary and secondary infertile IVF patients who underwent H/S.

Material and Method: The present is a prospective cross-sectional study conducted with a total of 227 primary (Group 1) and secondary (Group 2) infertile patients who admitted to the Infertility and IVF clinic of Zeynep Kamil Training and Research Hospital between January and August 2013 and who underwent H/S. The procedure was performed in those with suspected intrauterine abnormalities or with two or more IVF failure. Primary outcome was to determine the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of TVS and HSG, assuming H/S as the gold standart test, in the detection of intrauterine abnormalities in primary and secondary infertile patient groups. Secondary outcome was to assess the prevalance of intrauterine pathologies based on the H/S results.

Results: Sensitivity, specificity, PPV and NPV of TVS in the detection of intrauterine abnormalities in Group 1 were 71%, 47%, 34% and 81%, respectively (p=0.042) and in Group 2 specificity and PPV were 69% and 16%, respectively (p=0.35) while in total patient group 72%, 49%, 33% and 84% (p=0.014). Measurement parameters of HSG in Group 1 were 57%, 46%, 74% and 29%, respectively (p=0.75) while in Group 2 60%, 36%, 71% and 25% (p=1) and in total patient group 55%, 48%, 74% and 28% (p=0.8). In H/S, 56,25% of patients with primary infertility and 36,8% of patients with secondary infertility were detected to have intrauterine abnormalities.

Conclusions: In detecting intrauterine abnormalities, TVS and HSG have similar sensitivity and spesificity values. However, NPV of TVS and PPV of HSG are higher. Use of TVS in the detection of intrauterine lesions as a diagnostic tool in total patient and primary infertile groups is statistically significant.

Keywords

• Transvaginal ultrasonography
• hysterosalpingography
• hysteroscopy
• infertility

Histeroskopi yapılan primer ve sekonder infertil hastalarda histerosalpingografi ve transvaginal ultrasonografinin tanısal değerinin incelenmesi

Öz

Amaç: Histeroskopi (H/S) yapılan primer ve sekonder infertil IVF hastalarında, intrauterin patolojilerin saptanmasında H/S ve patoloji sonuçlarını altın standart kabul ederek; transvajinal ultrasonografi (TVS) ve histerosalpingografinin (HSG) sensitivite, spesifite, pozitif ve negatif prediktif değerlerini hesaplamak ve intrauterin patolojilerin bu gruplardaki sıklığını belirlemektir.  

Gereç ve Yöntem: Bu çalışma Zeynep Kamil Eğitim ve Araştırma Hastanesi infertilite ve tüp bebek polikliniğine Ocak - Ağustos 2013 tarihleri arasında başvuran ve H/S yapılan, primer (Grup 1) ve sekonder (Grup 2) infertil 227 hasta ile yapılmış prospektif kesitsel tarzda bir çalışmadır. H/S, TVS ve/veya HSG’de patolojiden şüphelenilen ya da iki IVF başarısızlığı olan hastalara yapıldı. Çalışmanın birincil sonucu, H/S gold standart kabul edilerek TVS ve HSG’nin primer ve sekonder infertil hasta gruplarında uterin patolojileri saptamadaki spesifite, sensitivite, pozitif prediktif değer (PPD) ve negatif prediktif değerlerinin (NPD) hesaplanması ve ikincil sonucu, gruplarda H/S sonuçlarına göre intrauterin patoloji sıklığının belirlenmesidir.

Sonuç: Grup 1’de intrauterin patolojilerin tespit edilmesinde TVS’nin sensitivite, spesifite, PPD ve NPD değerleri sırasıyla %71, %47, %34 ve %81 (p=0.042) ve Grup 2’de spesifite %69 ve PPD’si %16 (p=0.35) iken total hasta grubunda sırasıyla %72, %49, %33 ve %84 idi (p=0.014). Grup 1’de uterin patolojilerin saptamasında HSG’nin ölçüm parametreleri sırasıyla %57, %46, %74 ve %29 (p=0.75) iken, Grup 2’de %60, %36, %71, %25 (p=1) ve total grupta %55, %48, %74, %28 (p=0.8) idi. H/S’de primer infertil hastaların %56.25’inde ve sekonder infertil hastaların %36.8’inde intrauterin patolojilere rastlandı.

Yorum: TVS ve HSG intrauterin patolojileri yakalamada birbirlerine yakın sensitivite ve spesiviteye sahiptir. Fakat TVS’nin NPD, HSG’nin ise PPD daha yüksektir. Total grup ve primer infertil grupta intrauterin lezyonların tanınmasında TVS’nin tanısal bir araç olarak kullanımı istatistiksel olarak anlamlıdır.

Anahtar Kelimeler

• transvaginal ultrasonografi
• histerosalpingografi
• histeroskopi
• infertilite

Kaynakça

1. Rowe PC, Hargreave T, Mellows H. Diagnostic procedures of female partner, Other Procedures. WHO Manual for the Standardized Investigation and Diagnosisof the Infertile Couple. World Health Organization. Study Number: 78923. Cambridge: The Press Syndicate of the University of Cambridge; 1993.p.22.
2. Crosignani PG, Rubin BL. Optimal use of infertility diagnostic tests and treatments. The ESHRE Capri Workshop Group. Hum Reprod 2000;15:723-32.
3. Royal College of Obstetricians and Gynaecologists. Fertility: assessment and treatment for people with fertility problems.2004.
4. Bettocchi S, Nappi L, Ceci O, Selvaggi L. Office hysteroscopy. Obstet Gynecol Clin North Am 2004;31:641–54.
5. Demirol A, Gurgan T. Effect of treatment of intrauterine pathologies with office hysteroscopy in patients with recurrent IVF failure. Reprod Biomed Online 2004;8:590–4.
6. Doldi N, Persico P, Di SF, Marsiglio E, De SL, Rabellotti E, Fusi F, Brigante C, Ferrari A. Pathologic findings in hysteroscopy before in vitro fertilization-embryo transfer (IVF-ET). Gynecol Endocrinol 2005; 21:235–7.
7. Hinckley MD, Milki AA. 1000 office-based hysteroscopies prior to in vitro fertilization: feasibility and findings. JSLS 2004;8:103–7.
8. La Sala GB, Montanari R, Dessanti L, Cigarini C, Sartori F. The role of diagnostic hysteroscopy and endometrial biopsy in assisted reproductive technologies. Fertil Steril 1998;70:378-80.

9. Fatemi HM, Kasius JC, Timmermans A, van Disseldorp J, Fauser BC, Devroey P, Broekmans FJ. Prevalence of unsuspected uterine cavity abnormalities diagnosed by office hysteroscopy prior to in vitro fertilization. Hum Reprod 2010;25(8):1959-65.
10. Rogers PA, Milne BJ, Trounson AO: A model to show human uterine receptivity and embryo viability following ovarian stimulation for in vitro fertilization. J In Vitro Fert Embryo Transf 1986; 3(2):93–8.
11. Balmaceda JP, Ciuffardi I. Hysteroscopy and assisted reproductive technology. Obstet Gynecol Clin North Am 1995;22(3):507-18.
12. Brown SE, Coddington CC, Schnorr J, Toner JP, Gibbons W, Oehringer S. Evaluation of outpatient hysteroscopy, saline infusion hysterosonography and hysterosalpingography in infertile women: a prospective, randomized study. Fertil Steril 2000;74(5):1029-34.
13. Gaglione R, Valentini AL, Pistilli E, Nuzzi NP. A comparison of hysteroscopy and hysterosalpingography. Int J Gynaecol Obstet 1996;52:151–3.
14. Golan A, Eilat E, Ron-El R, Herman A, Soffer Y, Bukovsky I. Hysteroscopy is superior to hysterosalpingography in infertility investigation. Acta Obstet Gynecol Scand 1996;75:654–6.
15. Prevedourakis C, Loutradis D, Kalianidis C, Makris N, Aravantinos D. Hysterosalpingography and hysteroscopy in female infertility. Hum Reprod 1994;9(12):2353-51.
16. Taşkın EA, Berker B, Özmen B, Sönmezer M, Atabekoğlu C. Comparison of hysterosalpingography and hysteroscopy in the evaluation of uterine cavity in patients undergoing assisted reproductive techniques. Fertil Steril 2011;96:349-52.
17. Ayida G, Chamberlain P, Barlow D, Kennedy S. Uterine cavity assessment prior to in vitro fertilization: comparison of transvaginal scanning, saline contrast hysterosonography and hysteroscopy. Ultrasound Obstet Gynecol 1997;10:59–62.
18. Shalev J, Meizner I, Bar-Hava I, Dicker D, Mashiach R, Ben-Rafael Z. Predictive value of transvaginal sonography performed before routine diagnostic hysteroscopy for evaluation of infertility. Fertil Steril 2000;73:412–7.
19. Shokeir TA, Shalan HM, El-Shafei MM. Significance of endometrial polyps detected hysteroscopically in eumenorrheic infertile women. J Obstet Gynaecol Res 2004;30:84-9.