Comparison of hysterosalpingography and laparoscopy in predicting fertility outcome.
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In this study, we compare the prognostic significance of hysterosalpingography (HSG) and laparoscopy for fertility outcome. In a prospective cohort study in 11 clinics participating in the Canadian Infertility Treatment Evaluation Study (CITES), consecutive couples who registered between 1 April 1984 and 31 March 1987 for the evaluation of subfertility and who underwent HSG and laparoscopy were included. Unilateral and bilateral tubal occlusion at HSG and laparoscopy were related to treatment-independent pregnancy. Cox regression was used to calculate fecundity rate ratios (FRR). Of the 794 patients who were included, 114 (14%) showed one-sided tubal occlusion and 194 (24%) showed two-sided tubal occlusion on HSG. At laparoscopy, 94 (12%) showed one-sided tubal occlusion and 96 (12%) showed two-sided tubal occlusion. Occlusion detected on HSG and laparoscopy showed a moderate agreement beyond chance (weighted kappa-statistic 0.42). The adjusted FRR of one-sided tubal occlusion at HSG was 0.80, whereas two-sided tubal occlusion showed an FRR of 0.49. For laparoscopy, the FRR were 0.51 and 0.15 respectively. After a normal or one-sided occluded HSG, laparoscopy showed two-sided occlusion in 5% of the patients, and fertility prospects in these patients were virtually zero. If two-sided tubal occlusion was detected on HSG but not during laparoscopy, fertility prospects were slightly impaired. Fertility prospects after a two-sided occluded HSG were strongly impaired in cases where laparoscopy showed one-sided and two-sided occlusion, with FRR of 0.38 and 0.19 respectively. Although laparoscopy performed better than HSG as a predictor of future fertility, it should not be considered as the perfect test in the diagnosis of tubal pathology. For clinical practice, laparoscopy can be delayed after normal HSG for at least 10 months, since the probability that laparoscopy will show tubal occlusion after a normal HSG is very low. (+info)
The assessment of endometrial pathology and tubal patency: a comparison between the use of ultrasonography and X-ray hysterosalpingography for the investigation of infertility patients.
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OBJECTIVES: The aim of the present study was to examine the role of hysterosalpingocontrast sonography (HyCoSy) as a screening test for endometrial and tubal pathology at the start of the infertility investigation protocol. METHODS: HyCoSy was compared with X-ray hysterosalpingography (HSG) for the assessment of the endometrial cavity and Fallopian tube patency. A total of 103 women with a history of at least 1 year's infertility were included. Each woman underwent both HyCoSy and HSG on the same day. Laparoscopy was performed in 43 cases. For HyCoSy examinations, saline was used for evaluation of the endometrial cavity and Echovist contrast medium to assess Fallopian tube patency. RESULTS: The concordance between HyCoSy and HSG for the presence of endometrial cavity pathology was 90%, but for tubal patency the concordance was lower (72%). HyCoSy classed more examinations of tubal patency as uncertain. HSG more frequently classified tubes as occluded. In the subset of patients in whom all three techniques were used, HSG and HyCoSy demonstrated a high concordance with laparoscopy (83% and 80%, respectively). The prevalence of occluded tubes according to laparoscopy as the reference standard was 13%. The two methods had a high negative predictive value for tubal disease (HSG, 94%; HyCoSy, 88%), and the positive predictive values were 47% and 75%, respectively. The detection rate for occluded tubes was 73% and 27%, and specificity 87% and 90%, respectively. CONCLUSIONS: Our data demonstrate that HyCoSy obtains similar information about the status of the endometrial cavity and Fallopian tube patency to that of HSG. It is possible that in some cases HyCoSy may replace HSG in order to select women with patent tubes who may be suitable for further infertility treatment without more invasive investigation. (+info)
Transvaginal salpingosonography for assessing tubal patency in women previously treated for pelvic inflammatory disease and benign ovarian tumors.
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OBJECTIVE: The aim of this study was to evaluate the role of transvaginal salpingosonography in the assessment of tubal patency among women previously treated conservatively for pelvic inflammatory disease and surgically for a benign ovarian tumor. DESIGN: Twenty-two women were recruited for this study at the University Hospital of Oulu. Transvaginal salpingosonography was scheduled to be performed twice within a 3-month interval. X-ray hysterosalpingography was chosen as a reference method and was performed within 2 days of the second salpingosonography examination during the same menstrual cycle. Altogether, 31 Fallopian tubes were assessed with the second salpingosonography examination and X-ray hysterosalpingography. RESULTS: Twenty-nine Fallopian tubes were observed by both methods to be patent (i.e. 29 tubes by each method, but not necessarily the same tubes). An occlusion was diagnosed by each method in two tubes only, of which one appeared occluded by both methods, while one tube from each method appearing to be occluded was demonstrated to be patent using the other method. The agreement of transvaginal salpingosonography compared with X-ray hysterosalpingography was 94%, the sensitivity 50%, the specificity 97%, the positive predictive value 50% and the negative predictive value 97%. Two successive transvaginal salpingosonography examinations were performed in 18 patients with 27 Fallopian tubes. Disagreement was observed for only one tube. The agreement between these two examinations was 96%, the sensitivity 100%, the specificity 96%, the positive predictive value 67% and the negative predictive value 100%. The kappa coefficient was 0.78 (95% confidence interval 0.75-0.81). CONCLUSIONS: In conclusion, transvaginal salpingosonography can be used in patients with previous pelvic inflammatory disease and adnexal surgery due to its ease of use, reliability and low costs on an out-patient basis. Among these patients, tubal patency was a common finding. (+info)
Intrauterine donor insemination in single women and lesbian couples: a comparative study of pregnancy rates.
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The outcome of intrauterine donor insemination (IUI-DI) with frozen spermatozoa was analysed retrospectively in 675 cycles in single women (n = 122; 536 cycles) and lesbian (n = 35; 139 cycles) couples. The lesbian patients were younger at the initiation of treatment (mean 34.5 years; range 26-44) than the single women (mean 38.5; range 29-47) (P = 0.005). Clinical pregnancy rate was 36% in single women and 57% in lesbians (P < 0.05), the cumulative pregnancy rate after six cycles being 47% and 70% respectively, although the outcome was similar when related to age. The miscarriage rate was higher (35%) in single women than in lesbians (15%; P < 0.05), the rate being independent of maternal age. There were no apparent differences seen between the two groups with respect to the possible effect of parity, duration of infertility, causes of infertility and type of treatment at initiation of treatment; the sole exception was that the age of lesbian women was statistically significantly younger than that of single women (P < 0.005). When corrected for age, the pregnancy rates and complications were lower and higher respectively in single women but these differences did not reach statistical significance. However, the disparity between the treatment outcomes of single women and lesbian patients of similar ages may also reflect the fact that single women are likely to have failed to conceive for a period of time prior to referral to a specialist centre for treatment. (+info)
Optimal use of infertility diagnostic tests and treatments. The ESHRE Capri Workshop Group.
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The general definition of infertility is a lesser capacity to conceive than the mean capacity of the general population and infertile couples can be characterized in two groups: those unable to conceive without therapy and those who are hypofertile, but conceive without therapy. The initial diagnostic tests for infertility should include a midluteal phase progesterone assay, a semen analysis and a test for tubal patency such as a hysterosalpingogram. Measuring progesterone is the best test for confirming ovulation. To predict ovulation, evaluating the luteinizing hormone (LH) surge is the best single assay while measurement of LH plus preovulatory oestrogen is the best prediction. Today primary investigation of the morphology of the uterus and tubes should be by hysterosalpingography. However, ultrasound, particularly with simple contrast media, is likely to gain in importance. Laparoscopy should be reserved as a further diagnostic procedure or in combination with endoscopic surgery. There are situations in which semen analysis is of utmost importance and of absolute predictive value, namely, in cases of azoospermia. In general semen analysis remains a substantial part of the fertility workup, but any consideration of its predictive value has to be cautious. Performing genetic tests before, during and after assisted reproductive techniques (ART) is an intrinsic part of good clinical practice. These tests allow one to reach a correct diagnosis, to give adequate genetic counselling to the couple and their families in cases such as (i) women with Turner syndrome; (ii) men with 47, XXY; (iii) men or women with structural chromosomal aberration; (iv) men with Yq11 deletion or (v) men with congenital bilateral absence of vas deferens. Patients should, of course, be made aware of the occurrence of de-novo mutations taking place in the testis and in the embryo. Treatment of some causes of infertility are of proven value. For example induction of ovulation. Others are more controversial. Among the many empirical treatments suggested for the treatment of the various form of subfertility, surgical treatment of varicocele in the male, treatment of pelvic endometriosis in the female and the efficacy of the ART strategies offered to the subfertile couple are considered. Many varicocele studies are of poor quality. A few are good, but small in size. They do not show an improvement in pregnancy rates. Therefore, at the moment, there is insufficient scientific evidence for recommending routinely surgical treatment in subfertile and/or oligozoospermic men with a varicocele. Randomized, double-blind controlled trials demonstrated the modest efficacy of endometriosis ablation in increasing the pregnancy rate in infertile women while drugs suppressing ovulation are of no benefit to infertile women with endometriosis. Although the largest body of evidence available suggests that IVF success declines in repeated ART cycles, an accurate estimate of the true success rate in the 'nth' cycle of IVF treatment is not possible. Similarly little is still known of the reasons for the overall low continuation rates with IVF treatment. (+info)
Demonstration of a recto-vaginal fistula with the ultrasound contrast medium Echovist.
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The demonstration of a recto-vaginal fistula in a patient with Crohn's disease is described. The patient was examined by vaginal ultrasound using the contrast medium Echovist-200 (SHU 454, Schering AG, Berlin). This agent had not been used before under these circumstances and proved to be successful. (+info)
The use of chorionic villus biopsy catheters for saline infusion sonohysterography.
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BACKGROUND: Saline infusion sonohysterography is one of the recent refinements of ultrasonography that has the ability to enhance imaging of the uterine cavity in a safe, inexpensive and expedient manner. The technique can be difficult in women with a stenotic cervical os. This report describes a single-pass technique using chorionic villus sampling (CVS) catheters for saline infusion sonohysterography. METHOD: Saline infusion sonohysterography requires the transcervical passage of a catheter, through which saline is infused. The subsequent distension of the uterine cavity enhances the ability to detect intrauterine pathology with ultrasonography. In women with cervical stenosis, a catheter can be used in place of the more conventional two-pass technique, which requires the use of a uterine sound or probe followed by a conventional catheter. EXPERIENCE: We have used CVS catheters in women with cervical stenosis on 12 occasions. All have been successful and without significant discomfort to the patient. CONCLUSION: The use of CVS catheters for saline infusion sonohysterography in women with cervical stenosis can alleviate the need to remove the cervical probe prior to introduction of the catheter. (+info)
The value of Chlamydia trachomatis antibody testing as part of routine infertility investigations.
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Laparoscopy is considered the gold standard for the evaluation of tubal disease but it is an invasive and costly procedure. Chlamydia trachomatis antibody testing is simple and inexpensive and causes minimal inconvenience to the patient. Using the micro-immunofluorescence technique we assessed the significance of positive serology. There was a marked association between the titre and the likelihood of tubal damage. In the group with low titres (1 in 32) there was only a 5% incidence of tubal damage; however, there was a progressive increase in the incidence of tubal damage in those with higher titres. Twenty out of 57 patients with titres higher than 1 in 32 had tubal damage (35%). The difference between the two groups was statistically significant (P < 0.0001, chi(2) test). By using C. trachomatis antibody testing more widely it may be possible to reduce the number of laparoscopies performed. It should therefore become an integral part of the fertility work-up. (+info)