evaluation of uterine cavity

1. Your Name
SALINE INFUSION
SONOGRAPHY
SIS
DR. SOBHY HIKAL
Consultant
IVF & GYN.
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2. SIS
CONCEPT
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3. The concept
Acoustic enhancement
When the Ultrasound waves passes
through an echo free area (fluid), it
undergo very little energy loss and this
leads to increased echoes from
underlying structures.
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4. SIS
• SIS is a simple real ultrasound procedure.
• Few millimitres of sterile saline are instilled slowly into the uterine
cavity to separate anterior and posterior uterine walls.
• It is hypoechoic and would act as negative contrast medium which
would help in revealing any endometrial and subendometrial
pathology as well as delineating the shape of the cavity.
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5. EVOLUTION
In 1991, Mitri et al. In South Africa, using 8 Foley
catheter in the cervix, demonstrated that SIS is
more informative than conventional HSG……….
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6. SALINE INFUSION SONOGRAPHY
• The primary goal of SIS is to visualize the endometrial
cavity in more detail than is possible with routine
endovaginal sonograghy.
•
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7. SALINE INFUSION SONOGRAPHY
INDICATION
• Abnormal uterine bleeding.
• Uterine cavity abnormalities, especially
with regard to uterine myomas
polyps, and synechiae.
• Abnormalities detected on
endovaginal sonography, including
focal and diffuse endometrial or intra-
cavitary anormalities.
• Congenital abnormalities of uterus.
• Infertility, ( fertility work up ).
• Recurrent pregnancy loss.
• Inadequate imaging of endometrium by
TVS.25 June 2020 7S.H.

8. SALINE INFUSION SONOGRAPHY
TIMING
• According to the ACOG guidelines, SIS
should be performed on day 5-10 of
menstrual cycle.
• The secretory phase is avoided because of
false- positive finding from folds and
wrinkles in the lining.
• Polyps…… best seen postmenstrual.
• Adhesions, fibroids, cavity anomalies….
Best seen midluteal.
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9. SALINE INFUSION SONOGRAPHY
CONTRAINDICATIONS
• In a woman who is pregnant or could be
pregnant.
• Pelvic infection or unexplained pelvic
inflammatory disease.
• Do not perform SIS on patients with an
intrauterine device in place.
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10. SALINE INFUSION SONOGRAPHY
PROCEDURE
• The procedure is explained to the patient,
including the small risk of increased
bleeding as well as the even smaller risk of
infection(1%).
• Consent is obtained.
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11. SALINE INFUSION SONOGRAPHY
PREMEDICATION
Doxycycline (100mg)
• Night before SIS – 1 capsule Doxycycline.
• Morning of SIS – 1 capsule Doxycycline.
• (2 hrs), before SIS – 2 pain pills ( NSAID).
• Evening of SIS – 1 capsule of Doxycycline.
• Morning after SIS – 1 capsule of doxycycline.
Azithromycin (500mg)
• Day before SIS – 2 capsules of Azithromycin.
• Day of SIS – 1 capsule of Azithromycin
2 hrs, before SIS before – 2 pain pills (
NSAID).
• Then once daily for 3 to 5 days.
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12. SALINE INFUSION SONOGRAPHY
PROCEDURE
• If adnexal tenderness or pain suspicious for an
active pelvic infection is found before fluid
infusion, the examination should be deferred
until after an appropiate course of treatment.
• In the presence of nontender hydrosalpinx,
consideration may be given to administering
antibiotic at the time of the examination.
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14. Instrumentation
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16. Instrumentation
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17. SIS, PROCEDURE
• Complete and strict
aseptic technique.
• The patient is placed
in the lithotomy
postion.
• Sterile speculum is
Placed into the
vagina, and the
cervix is
brought into view.
• The cervix is then
cleansed with
povidone-iodine
solution.
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18. SIS, PROCEDURE
• The catheter and the balloon must be
flushed with sterile saline before
insertion to remove as much air as
possible.
• Any air within the catheter will be
introduced into endometrial canal may
obscure abnormalities during scanning.
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19. SIS, PROCEDURE
The ballon is then
deflated, and
evaluation of the
lower uterine
segment and
endocervical
region is
performed.
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20. SIS
what could be seen
A normal cavity appears as anechoic space
surrounded by endometrium on all sides.
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21. SIS
what could be seen
Polyps appear as
echogenic
structures
surrounded by the
anechoic fluid. The
stalk might be
evident at one side.
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22. SIS
what could be seen
• Submucous fibroid
push into the cavity
with normal
overlying
endometrium.
• The myoma could be
echogenic or
relatively echo poor
lesions with broad
base continous with
myometrium.
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23. SIS
WHAT COULD BE SEEN
Intrauterine adhesions could appear as bright bands across
the cavity but as well they could prevent uterine cavity
dilatation with saline depending on the severity of the
condition and location of the adhesions.
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24. SIS
WHAT COULD BE SEEN
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25. 3D SIS
endometrial polyp
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26. 3D SIS
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27. THE THICKENED ENDOMETRIUM
MAY BE A POLYP
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28. THE THICKENED ENDOMETRIUM
MAY BE A POLYP
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29. THE THICKENED ENDOMETRIUM
MAY BE A POLYP
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30. THE THICKENED ENDOMETRIUM
MAY BE A SUBMUCOSAL LEIOMYOMAS
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31. SIS
3D US. SUBMUCOUS FIBROID
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32. SIS
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33. 3D SIS
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34. SIS
Congenital uterine anomalies
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35. THE THICKENED ENDOMETRIUM
MAY BE AN ENDOMETRIAL HYPERLASIA
Endometrium thickness = A-B
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36. ENDOMETRIAL CANCER
Endometrial cancer is typically a diffuse process,
but cases can appear as a polypoid mass
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37. SONOHYSTEROGRAPHY
ٍSonohysterography can accurately detect the
percentage of fibriod into the endometrial cavity
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38. ADVERSE EVENTS
COMPLICATIONS
Discomfort
Cramping ( minor ) 33.3%
Pain (menstrual like)
( sever pain ) 11.5% cecinilli et al
Infection 2.5% Dubinsky et al
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39. EFFECTIVENESS
In 10 studies where sonohysterographic findings
were compared with surgical findings and
histological assessment (hysteroscopy +biopsy
OR hysterectomy) it was found that SIS has high
senstivity and sepecificity for evaluation of
abnormal uterine bleeding .
Sensitivity 94.9%
Specificity 89.3%
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40. HYCOSY WITH ECHOVIST
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41. WHAT IS A HYCOSY
Hysterosalping-contrast-sonography (usually shortened to HyCoSy ) is
a simple and well-tolerated outpatient ultrasound procedure used to
assess the patency of the fallopain tubes . As well as detect
abnormalities of the uterus and endometrium.
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42. HYCOSY PROCEDURE
Hysterosalpingo contrast sonography
(HyCosy) is a transvaginal ultrasound
technique in which a mixture of air and
saline is infused into the uterine cavity
and observe the flow along the
fallopian tube to assess tubal patency.
The bright echoes generated by the
saline and air bubbles makes tubal
visualized possible.
The procedure is also called sonography
hysterosalpingogram or Sono HSG.
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43. HYCOSY
The HyCoSy method is an acceptable time-
efficient and well-tolerated altrenative to HSG .
it has been found to have comparable accuracy
in the assenssment of the uterine cavity and
tubal patency.
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44. SALINE AFTER AIR
Saline after air-continuous or dotted hyperechoic
line-air bubbles move rapidly with saline.
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45. SALINE AFTER AIR
Contrast is slowly and steadily injected into the
uterine cavity through the catheter.
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46. HYFOSY
MODEFICATION OF FLUID
there was a 100% agreement between tubal
Patency and data according to HyFoSy testing and
laparoscopic chromopertubation testing.
CONCLUSION:
• HyFoSy is both feasible and accurate in the
diagnosis of tubal patency.
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50. Diagnostic accuracy of saline infusion
sonography in the evaluation of uterine
cavity abnormalities prior to assisted
reproductive techniques: a systematic
review and meta-analyses
S. Seshadri T. El-Toukhy A. Douiri K. Jayaprakasan Y. Khalaf
Human Reproduction Update, Volume 21, Issue 2, 1 March 2015, Pages 262–
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CONCLUSIONS
SIS is a highly sensitive investigative modality and comparable to the
gold standard tool, hysteroscopy in the detection of intrauterine
abnormalities in subfertile women. SIS is a highly sensitive and specific
test in the diagnosis of uterine polyps, submucous myomas, uterine
anomalies and intrauterine adhesions and can be used as a screening
tool for subfertile patients prior to IVF treatment.

51. Transvaginal sonography, saline contrast
sonohysterography and hysteroscopy for the
investigation of women with postmenopausal
bleeding and endometrium > 5 mm
Dr E. Epstein
A. Ramirez
L. Skoog
L. Valentin
First published: 12 December 2002
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Conclusion
Saline contrast sonohysterography is as good as hysteroscopy at
detecting focally growing lesions in the uterine cavity in women with
postmenopausal bleeding. However, neither hysteroscopy nor saline
contrast sonohysterography can reliably discriminate between benign
and malignant focal lesions. Distension difficulties at saline contrast
sonohysterography should raise a suspicion of malignancy.

52. The Diagnostic Accuracy of Two- vs Three-
Dimensional Sonohysterography for
Evaluation of the Uterine Cavity in the
Reproductive Age
Author links open overlay panelWalidEl-SherbinyMDAkmalEl-MaznyMDNermeenAbou-
SalemMDWael SayedMostafa
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Conclusion
3D SHG can be used in the initial evaluation of the uterine
cavity in women of reproductive age, with accuracy
comparable to that of hysteroscopy.

53. Ultrasound Obstet Gynecol. 2000 May;15(5):372-6.
Comparison of transvaginal ultrasonography
and saline infusion sonography for the
detection of intracavitary abnormalities in
premenopausal women.
Dijkhuizen FP1, De Vries LD, Mol BW, Brölmann HA, Peters HM, Moret E, Heintz AP.
25 June 2020 S.H. 53
CONCLUSION:
The diagnostic accuracy of SIS is higher than the
accuracy of TVS. A combined approach using
endometrial thickness measurement by TVS and,
reserving SIS for patients with increased (> 5 mm)
endometrial thickness, or endometrium inadequately
visualized on TVS, is the optimal method of reducing
the hysteroscopy rate.

54. Cochrane Database Syst Rev. 2017 May 5;5:CD011126. doi: 10.1002/14651858.CD011126.pub2.
Three-dimensional saline infusion sonography
compared to two-dimensional saline infusion
sonography for the diagnosis of focal intracavitary
lesions.
Nieuwenhuis LL1, Hermans FJ2, Bij de Vaate AJM1, Leeflang MM3, Brölmann HA1, Hehenkamp
WJ1, Mol BWJ4, Clark TJ5, Huirne JA1.
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AUTHORS' CONCLUSIONS:
Low-quality evidence suggests that 3D SIS may be very accurate in detecting
intracavitary abnormalities. Meta-analysis revealed no statistically significant
differences between 2D SIS and 3D SIS. Summary sensitivity and summary
specificity are higher for 3D SIS, but margins of improvement are limited
because 2D SIS is already very accurate. When the technology and
appropriate expertise are available, 3D SIS offers an alternative to 2D SIS.
Both 2D SIS and 3D SIS should be considered alternatives to diagnostic
hysteroscopy when intracavitary pathology is suspected in subfertile women
and in those with abnormal uterine bleeding.

55. JSLS. 2011 Oct-Dec; 15(4): 471–474.
Hysterosalpingography Versus
Sonohysterography for Intrauterine
Abnormalities
Uchenna C. Acholonu, Jr., MD, James Silberzweig, MD, Daniel E. Stein, MD, and Martin Keltz, MD
25 June 2020 S.H. 55
Conclusion:
Although hysterosalpingography is the standard screening test for
the diagnosis of tubal infertility and can provide useful
information about the uterine cavity, sonohysterography is more
sensitive, specific, and accurate in the evaluation of the uterine
cavity.

56. J Obstet Gynaecol. 2011;31(1):54-8. doi: 10.3109/01443615.2010.532246.
Comparison of diagnostic accuracy of
saline infusion sonohysterography,
transvaginal sonography and
hysteroscopy.
Bingol B1, Gunenc Z, Gedikbasi A, Guner H, Tasdemir S, Tiras B.
25 June 2020 S.H. 56
SIS seems to be superior to TVS,
for uterine pathologies, with respect
to hysteroscopy as the gold
standard.

57. Fertil Steril. 2000 Feb;73(2):406-11.
Diagnostic accuracy of sonohysterography,
transvaginal sonography, and
hysterosalpingography in patients with uterine
cavity diseases.
Soares SR1, Barbosa dos Reis MM, Camargos AF.
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CONCLUSION(S):
Sonohysterography was in general the most accurate
test. Its diagnostic accuracy was markedly superior for
polypoid lesions and EH, with total agreement with the
gold standard. In diagnosis of intrauterine adhesions,
SHG had limited accuracy, similar to that obtained by
HSG, with a high false-positive diagnosis rate.

58. Saline Infusion Sonography Can Improve
Outcome in Subsequent ICSI Cycles When No
Intrauterine Pathology Is Detected
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CONCLUSION: SIS can be used to assess the endometrial
cavity prior to ICSI cycle; moreover, SIS might be
associated with improved outcomes when no intrauterine
pathology is detected. Confirmation of this finding via future
robust randomized trials is needed and would be useful to
further guide clinical practice.
Available from:
https://www.researchgate.net/publication/309105104_Saline_Infusion_Sonography_Can_Improve_Ou
tcome_in_Subsequent_ICSI_Cycles_When_No_Intrauterine_Pathology_Is_Detected [accessed Oct
18 2018].

59. J Hum Reprod Sci. 2016 Oct-Dec; 9(4): 236–240.
Comparison between findings of saline
infusion sonohysterography and office
hysteroscopy in patients with recurrent
implantation failure
Ahmed Reda, Ahmed Sherif Abdel Hamid, Rowaa Mostafa, and Eman Refaei
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CONCLUSION:
Our findings suggest a good role of SIS
in the workup for RIF saving more
invasive procedure for selected cases.

60. SIS
Low-tech Low-cost
Well tolerable No radiation
Effective Exposure
Easy
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