G. Obajimi1 and B. Ogunkinle2
- Department of Obstetrics & Gynaecology, University College Hospital, Ibadan
- Department of Obstetrics & Gynaecology, The Bridge Clinic, Victoria Island, Lagos.
Saline infusion sonohysterography has been employed to evaluate the uterine cavity prior to commencement of assisted conception.Intra-uterine lesions play an important role in the outcome of assisted conception procedures. A descriptive retrospective study of 760 patients who had saline infusion sonohysterography prior to assisted conception, between January 2008 and December, 2010. Forty-six percent of the patients had intra-uterine pathologies. Submucous fibroids accounted for almost half (48.57%) of the pathologies, followed by adhesions (28.57%) and endometrial polyps (22.86%). Complications arising from the procedure were minor and occurred in 26 patients (3.42%). Abdominal cramps, vaginal bleeding and vaginal discharge occurred in 14 (53.85%), 8 (30.77%) and 4 (15.38%) respectively. The average duration of the procedure was 6 minutes with a range of 4-9 minutes. Saline infusion sonohysterography is a reliable, cost effective and safe diagnostic tool in the evaluation of the uterine cavity prior to assisted conception.
Keywords: Routine, Saline infusion sonohysterography, Assisted conception, Experience.
Dr. G. Obajimi
Department of Obs. & Gynae.,
University College Hospital,
The outcome of assisted reproductive technique largely depends on the receptivity of the endometrial lining of the uterus. Measures aimed at evaluating the uterine cavity prior to treatment are very vital for decision making and hence contribute to the overall success rate. The true prevalence of intrauterine lesions in infertile women is not known but some studies have reported an incidence of about 16–24%1.
Saline infusion sonohysterography (SIS) is variously referred to as sonohysterography, hysterosonography and transvaginal sonography (TVS) with fluid contrast augmentation2. It is a technique which involves the introduction of a catheter into the endometrial cavity and sterile saline subsequently instilled to separate the walls of the endometrium in order to visualize the endometrial cavity. The anechoic fluid is then juxtaposed against the echogenic endometrium, giving exquisite detail of the uterine lining.
Routine office hysteroscopy is a vital tool in the evaluation of the infertile patient. However screening with saline infusion sonohysterography yields similar diagnostic results but less invasive, better tolerated and less expensive3. Additionally with saline infusion sonohysterography, the adnexa can also be simultaneously evaluated. These advantages may warrant its routine use as a useful screening tool before in vitro fertilization2,3.
The objectives of this study are to evaluate the practice of routine saline infusion sonohysterography prior to assisted conception and to describe the findings and complications arising from the procedure.
MATERIALS AND METHODS
A descriptive, retrospective study of all patients who had routine saline infusion sonohysterography, at a private fertility clinic, prior to in vitro fertilization, between January 2008 and December, 2010. A total of 760 patients had saline infusion sonohysterography and the relevant data were extracted from their records and analyzed using SPSS version 17. Descriptive data were presented in (%) for qualitative data and in the mean ± SD and median (range) for quantitative data. The results of saline infusion sonohysterography were compared with hysteroscopy and the following were calculated for each examination: sensitivity, specificity, positive predictive value and negative predictive value.
The procedure was carried out between days 5-10 of the menstrual cycle in patients who were menstruating regularly. For postmenopausal women, it was carried out after a withdrawal bleeding was achieved following administration of provera (medroxyprogesterone acetate). This was to ensure that the test was done when the endometrium was thinnest and also to exclude early pregnancy. Bleeding was not a contraindication to performing saline infusion sonohysterography; however, it was avoided whenever possible, as the blood clot could give false positive results.
Preparation for the examination involved counseling about the procedure and obtaining an informed consent. Ten milligram (10mg) hyosine bromide tablet was given 30 minutes before the procedure to minimize abdominal cramps. The instruments used for the procedure were: a sterile speculum with an open side, cervical sounds in the event that the catheter did not pass easily through the cervix, a 20-mL syringe, a tenaculum, and a Wallace classic embryo replacement catheter (Smith Medical) used to introduce the saline into the endometrial cavity. The patient was placed in the lithotomy position, cleaned and draped. A sterile speculum was placed in the vagina, and the cervix was brought into view. The cervix was then cleansed with antiseptic solution. The Wallace classic embryo replacement catheter was placed at the external cervical os, and then advanced into the endometrial cavity. The speculum was carefully removed, and the transvaginal probe reinserted beside the catheter. Under transvaginal sonographic guidance (GE logiq 5 expert), approximately 10 to 30 ml of warm sterile saline was injected. Sonographic evaluation of the endometrial cavity was performed in both coronal and sagittal planes by the Gynaecologist trained in basic sonography. The catheter was then removed and the procedure completed. Prophylactic antibiotic with augmentin (amoxicillin/clavulanic acid) 625mg twice daily for 5 days was administered.