3d vs hsg for tubal evaluation

1. Role of HYSTEROSALPINGOGRAM
in the era of 3D ULTRASOUND
Dr. REJI MOHAN
MD (JIPMER) DNB,FELLOW IN REPROD.MED(Belgium)
CONSULTANT IN OBGYN AND INFERTILITY
SAT HOSPITAL
GOVT.MEDICAL COLLEGE
THIRUVANANTHAPURAM

3. • Can ANY one imagine infertility
diagnosis and treatment without
imaging?
• Here I have the option of TWO
NO

4. CONTENTS
Hysterosalpingogram
3D ultrasound
Comparison
Scientific support
Conclusion

5. Ian Donald was
a Scottish
physician who
pioneered the
use of
diagnostic
ultrasound in
medicine
Wilhelm Conrad
Röntgen was a
German
mechanical
engineer and
physicist, who, on
8 November 1895,
produced and
detected
electromagnetic
radiation in a
wavelength range
known as X-rays or
Röntgen rays
Christian Andreas
Doppler was an
Austrian
mathematician
and physicist. He is
celebrated for his
principle — known
as the Doppler
effect — that the
observed
frequency of a
wave depends on
the relative speed
of the source and
the observer.

6. Hysterosalpingogram
• Hysterosalpingography is a radiologic for
evaluation of the uterine cavity, fallopian
tubes, and adjacent peritoneal cavity
following the injection of contrast material
through the cervical canal .
• It is performed as a real-time outpatient
examination under fluoroscopy with iodinated
water-soluble radio-opaque material.

7. Indications
Two contraindications for HSG:
PREGNANCY
ACTIVE PELVIC INFECTION
The examination should
be scheduled during days
7–12 of the menstrual
cycle (day1 being the first
day of menstrual
bleeding)

8. HSG Technique • We obtain four spot radiographs after
the scout radiograph.
• The first image is obtained during early
filling of the uterus and is used to
evaluate for any filling defect or
contour abnormality. Small filling
defects are best seen at this stage.
• The second image is obtained with the
uterus fully distended. The shape of the
uterus is best evaluated at this stage,
although small filling defects may be
obscured when the uterus is well
opacified.
• The third image (Fig 1c) is obtained to
demonstrate and evaluate the fallopian
tubes.
• The fourth image (Fig 1d) should exhibit
free intraperitoneal spillage of contrast
material.
• Additional spot radiographs are
obtained to document any abnormality
that is seen.

9. Complications of HSG
 Bleeding and infection are the most
common
The exclusive use of sterile instruments
minimizes the risk of infection.
Cramps
Systemic reaction to the contrast material
Perforation of the uterus or fallopian tubes
 Risk of irradiation

10. • During HSG, the average radiation dose to the
female gonads is 2.7 mGy and an effective
dose is 1.2 mSv.
• For comparison, the effective dose from
annual background radiation is 3.1 mSv and
from screening mammography is 0.4 mSv.

11. Uterus and anomalies
• HSG is helpful in the evaluation of the uterine
cavity only, providing indirect information
about the remainder of the uterus.
• At HSG, the uterus should look like an inverted
triangle with well-defined, smooth contours

12. Uterine anomalies can be due to
congenital abnormalities of uterine
shape,
 luminal filling defects, or
abnormalities of uterine contour

13. Congenital Abnormalities of Uterine
Shape

14. Luminal Filling Defects
Filling defects are common findings at HSG. Care should be
taken to flush the catheter thoroughly with contrast
material to avoid injecting air bubbles. Air bubbles manifest
as well-circumscribed lucencies that collect in the
nondependent portion of the uterus. They are often
mobile or transient when they are expelled into the
fallopian tubes. This fact can help differentiate air bubbles
from fixed filling defects
Uterine folds are normal
variants that are occasionally
seen at HSG. They are believed
to be caused by infolding of the
inner aspect of the myometrium
in an underdistended uterus.
Uterine folds parallel the long
axis of the uterus and can
extend into the uterine horns

15. Luminal Filling Defects
Synechiae are intrauterine adhesions that result from
scarring, most commonly secondary to the endometrial
trauma of curettage. Endometrial infections may also
result in synechia formation. Synechiae manifest as
irregular filling defects, most commonly as linear filling
defects arising from one of the uterine walls.
Multiple synechiae associated with infertility is known
as Asherman syndrome
Endometrial polyps are focal
overgrowths of the
endometrium. They usually
manifest as well defined filling
defects and are best seen
during the early filling stage
Sonohysterography has
become the preferred method
of imaging endometrial polyps

16. Abnormalities of Uterine Contour
• Only submucuos myomas
are depicted at hsg small
myomas like polyps can
best be seen during early
contrast material filling of
the uterus but may be
obscured when the
uterus is completely
opacified.
• Large myomas can distort
the size and shape of the
uterine cavity

17. Adenomyosis and scarring

18. Fallopian Tubes
• The fimbriated part is the funnel-shaped end of the
tube and is not usually seen at HSG.
• HSG is the best method for visualizing and evaluating
the fallopian tubes.
• Contrast material– enhanced sonohysterography has
been suggested as a means of assessing tubal patency .
• At HSG, the fallopian tubes should appear as thin,
smooth lines that widen in the ampullary portion .
• The fallopian tubes vary in location within the pelvis
and in degree of tortuosity.
• There should be free spillage of contrast material into
the peritoneal cavity

21. • HSG is a valuable tool in the evaluation of the
uterus and fallopian tubes.
• We all should become familiar with HSG
technique, the interpretation of HSG images,
and possible complications of this procedure.

23. What is 3D USG
• The acquired two-dimensional US images and
their predefined relative locations and
orientations are used to reconstruct the three-
dimensional US images in real time using novel
computational algorithms.
• Transvaginal approach is preferred in gynecologic
examination with 3D USG
• The transducer is held still close to the area of
interest, and a quick sweep at the desired angle is
performed
• Acquired data are used to obtain a volume

24. • The electronically stored data are processed to
display three orthogonal planes.
• These planes can be rotated or moved as
desired, and can be united to form a single 3D
image
• Another option is to view the volume in slices, as
in computerized tomography.
• This is called multi-slice imaging.
• The number of slices and the space between
them are user-defined.

26. • Normal uterus is easily assessed using 3D
ultrasound, where the coronal plane gives a good
image of the endometrial cavity, the surrounding
myometrium and of the uterine external contour,
a fact of most importance.
• Three dimensionalultrasound does not
substitute, but completes the examination by
offering a complete image of the uterine cavity in
one single acquisition, static rendering mode or
VCI-C , calculating the endometrial volume with
VOCAL II, as well as vascularity indices

28. Multiplanar and rendering modes of the uterus. Multiplanar
reconstructions from 3D ultrasound show a normal uterus in sagittal
(A), transverse (B) and true coronal (C) planes. Surface rendering
reconstructed image in a coronal plane of the uterus demonstrating
a normal uterine fundal contour (D). 3D: Three-dimensional.

29. Three-dimensional image of a normal uterus. The coronal
view shows both the uterine cavity and external contour of the
uterus clearly

30. Three-dimensional image of an arcuate uterus.
Please note that while the external contour of the uterus is
normal, there is mild fundal indentation in the cavity

31. Three-dimensional image of a septate uterus. The coronal
view clearly depicts the normal external contour of the uterus
and the deeply indented fundal part of the cavity

33. Congenital Anomalies

34. Arcuate uterus

35. Comparative images of the arcuate uterus:
(A) radiological HSG; (B) VCI-C acquisition in the coronal plane;
(C) inversion mode during SIS
3D acquisition with inversion mode creates a hysterogram sometimes of better quality
than the radiological image

36. Bicornuate uterus

38. Septate uterus in a 47-year-old woman. A coronal image of
the uterus shows the presence of a septum (asterisk) separating the
endometrial cavity into two sides. The uterine fundus is convex

41. Endometrial polyp
A multiplanar display of the images obtained from sonohysterography in a 42-year-
old woman shows the plane of acquisition (upper left), two reconstructed
orthogonal planes (upper right and lower left) and the three-dimensional rendered
image (lower right) of the endometrial polyp arising from the left uterine cornu.

42. Large endometrial polyp – conventional
transvaginal sagittal scan (A) and 3D image in
the coronal plane

44. C-plane image of the uterus with a submucosal fibroid.
A reconstructed image of the uterus in a 52-year-old woman shows
a submucosal fibroid (asterisk) arising from the right uterine wall,
located predominantly within the endometrial cavity.

45. Saline infusion hysterosalpingography under power Doppler
control shows easy passage of the fluid through both fallopian
tubes

47. Three-dimensional image of intrauterine synechia of the same
patient. The synechia is seen as an irregular hypoechoic line
starting from the right-fundal region, extending down to the
isthmic level

48. Asherman syndrome
3D TVUS by enabling multiplanar displays which simultaneously visualises three orthogonal
planes provides anatomic views that are often unattainable by 2D TVUS

49. The Fallopian Tubes
Bilaterally patent Fallopian tubes. (a–e) Three-dimensional hysterosalpingo-contrast
sonography using SonoVue (3D SonoVue-HyCoSy): coronal (a, c–e) and transverse (b) views
showing uterine cavity (U), with left (LS) and right (RS) tubes indicated. (a) Both tubes were
clearly visible laterally; left tube showed ends resembling a bird tail. (b) Uterine cavity in
transverse view with both tubes laterally; fimbrial ends of tubes (arrows) are indicated. (c)
Fimbrial ends of tubes tapered like a tree branch (arrows). (d) Fimbrial ends appeared like a
bird tail (arrows). (e) Arrows indicate SonoVue contrast medium spilling from fimbrial ends
of tubes (single arrows) and accumulating in the pouch of Douglas (arrow pair). (f) Image at
laparoscopy with chromotubation, with left side of patient indicated (L), showing blue dye
spilling from fimbrial ends of tubes (arrows).

50. • A normal Fallopian tube with contrast and
three dimensional reconstruction.

51. Three-dimensional image of hydrosalpinx showing the typical retort shape in
relation to the ipsilateral ovary and (B) Inversion mode displaying the
hydrosalpinx and ovarian follicles.

52. OVARIES
Sono AVC enables not only the visualisation of single follicles but also
calculates mean follicle diameter follicular volume and volume based diameter
of a follicle

53. SonoAVC imageshowing multiple follicles.
Eachfollicle is measured and assigned a different color
automatically for easier interpretation. Images in 3 orthogonal
planes are combinedto form a 3D image

54. VOCAL II – digitally reconstructed image of the
endometrium,including a periendometrial region (shell),
useful for vascularity indices calculations

55. Three D ultrasound is more accurate in
determining ovarian volume using the
VirtualOrgan computer-aided Analysis
(VOCAL, GE Kretz)technique .
This technique employs a rotational
method which involves the manual
delineation of the ovarian volume
throughout several planes as the data set
is rotated through 180 degrees in a
consecutive series of rotations ( angle
dependant on number of planes chosen
could range from 6 ◦ to 30◦ ) , until a
calculated volume is generated

56. Optimal conditions of implantation
• Endometrium > 7 mm,
• Endometrial volume > 2 ml
• Hypoechogenic
endometrium with 3 well
delinated layers,
• Uterine PI < 3,
• Presence of sub-
endometrial vascular flow.
• High VI,FI&VFI in
endometrial &
subendometrial zone.

57. 3D USG is a fast-evolving imaging technique that
holds a great potential for use in gynecology.
It i s Not hard to imagine that as more clinicians
gain access to 3D USG and improve their skills,
3D USG will prove to be an even more powerful
diagnostic device.

58. Hysterosalpingography
Advantage
To study the endometrial cavity and diagnose
mullerian abnormalities and endometrial
lesions
To assess the whole tube, condition of the
lumen.
• outpatient procedure
• is relatively inexpensive,
• does not require general anesthesia, and
• is associated with a therapeutic effect
Disadvantages
 Using iodinated contrast
 Exposure to radiation
 Is extremely painful
 Needs sedation
 Needs to be done in a radiology set up
 More over it is a static picture and
fimbrial condition can not be assessed.
 Spilling of the dye, however, does not
always indicate normal fallopian tubes.
 It takes an experienced expert to
correctly interpret "normal" tubal
anatomy on HSG.
 Needs an XRAY ROOM ,RADIATION
SAFETY

59. Advantages of 3D
• The data volume, which is acquired in seconds while sweeping, can be
stored and reviewed later.
• Shortens the examination time and makes it possible to manipulate and
review the data even in the absence of the patient.
• It can also be used for consulting colleagues, auditing, and educational
purposes
• An outstanding property of 3D USG is its capability to obtain images in
previously unavailable planes using 2D USG.
• Coronal plane can provide detailed information about uterus and adnexa,
and it is especially helpful in diagnosing congenital uterine anomalies.The
user is not limited by these conventional planes
• It is possible to construct any plane from the acquired volume data

60. Disadvantages of 3D USG
• Not as widely available as 2D USG, resulting in limited access to the
device. Therefore, clinicians are more experienced in 2D USG.
• Manipulating a volume can be a cumbersome and time-consuming
process for the inexperienced user. This may result in an inclination
to stay on safe ground and not making full use of the 3D USG
technology.
• The volume data obtained using 3D USG are remarkably large.
• Archiving, sharing, or transferring can be an issue, especially in
busy clinics.
• Last of all, it should be remembered that although 3D USG
produces less artifacts than 2D USG, as all imaging techniques, 3D
USG is not artifact-free.

61. Advantages of 3D over HSG
Highly sensitive and specific tool for accurately diagnosing congenital
uterine anomalies
Non-invasive
Fast
Reproducible
Readily available
Relatively cost-effective.(XRAY ROOM ,RADIATION SAFETY)
Over time, it is strongly possible that 3D USG may become the gold
standard in diagnosing uterine anomalies, sidelining HSG, MRI.
Hysteroscopy and laparoscopy may then be used for therapeutic
purposes only.

62. • Concordance rates among the initial diagnosis by
HSG and 3-DUS were 30.4%, 75%, 83% and 80%
for bicorne, arcuate, septate and unicornuate
uterus, respectively. In different cases applied
hysteroscopy, the result were 100% in
concordance with the 3-DUS evaluations .
According to these studies, real time 3-DUS is the
accurate test for the diagnosis of CMA.
• Zohav E, Melcer Y, Tur-Kaspa I, Rabinson J, Anteby EY, Orvieto R. The
role of 3-dimensional ultrasound for the diagnosis of congenital
uterine anomalies. Open J Obstet Gynecol 2011; 1: 238-241.

63. Ludwin et al. 2- and 3-D US and SIS versus Hysteroscopy With Laparoscopy in the
Diagnosis of Septate, Bicornuate, and Arcuate Uteri,Journal of Minimally Invasive
Gynecology, Vol 20, No 1, January/February 2013

64. Piotr Szkodziak et al. Usefulness of three dimensional transvaginal ultrasonography
and hysterosalpingography in diagnosing uterine anomaliesGinekol Pol. 2014, 85, 354-
359
HSG ALLOWS THE ASSESSMENT OF UTERINE CAVITY AND NOT
THE EXTERNAL CONTOUR.
SENSITIVITY IS 78 % AND SPECIFICITY IS 90%.
3D HAS A 100% SENSITIVITY SPECIFICITY,PPV AND NPV

66. FUTURE
• CT VHSG
• MR VHSG
COMPLETE SEPTABICORNUATE
CORNUAL POLYP

67. TO CONCLUDE
• In the era of 3D USG HSG has still got a role to play in the initial
evaluation of the uterus and adnexa,HSG remains the inv of choice
when you need a evaluation of fallopian tube .
• As told by dr Cohen in ASRM 2005
• Endovaginal 3DUS is a non-invasive, outpatient diagnostic modality
which enables a detailed assessment of uterine morphology and is
superior to other techniques used for the same purpose.
• 3DUS has recently become a mandatory step in the initial
investigation of MDA and intrauterine lesions to assess whether
hysteroscopic evaluation of the endometrial cavity is indicated.
• Sonography, in the hands of a skilled practitioner, with a good
technological basis, is one of the best diagnostic tools in gynecology
and can successfully replace more invasive methods

68. • WITH THE LATEST GADGETS
• You can See better, do ART better.

69. Thank you
&
god bless you
drrejimohan@gmail.com
9447044485