Role of Hysterosalpingosonography in Evaluating Fallopian Tube Patency and Uterine Cavity
Hysterosalpingo-contrast sonography (HyCoSy) is recommended as a first-line test for evaluating tubal patency and uterine cavity abnormalities in cases of infertility or recurrent miscarriage, offering similar diagnostic accuracy to hysterosalpingography (HSG) with the advantages of avoiding radiation exposure. 1, 2
Diagnostic Options for Tubal Patency Assessment
Primary Testing Methods
- HyCoSy involves instilling echogenic contrast (typically agitated air and saline mixture) into the uterus with real-time ultrasound to observe the material distending the uterine cavity, filling the fallopian tubes, and spilling over the adjacent ovary 1
- HyCoSy demonstrates 91% accuracy compared to laparoscopy in diagnosing tubal patency in women with endometriosis 1, 2
- HSG remains an alternative first-line test with 65% sensitivity and 85% specificity for diagnosing tubal patency compared to laparoscopy 1, 2
- A comprehensive infertility examination can be performed in one session by combining transvaginal ultrasound (TVUS) with 3D imaging of the uterus and ovaries, followed by saline infusion sonography (SIS) and HyCoSy 1
Diagnostic Accuracy Considerations
- Regular sonohysterography without contrast is not supported for tubal occlusion assessment, though increased fluid in the posterior cul-de-sac following the procedure may indicate tubal patency 1
- TVUS alone is not effective for documenting tubal patency but has 86% sensitivity in detecting hydrosalpinx, which has implications for patients who may undergo in vitro fertilization 1, 3
- When comparing HyCoSy and HSG with laparoscopy as the reference standard, both methods demonstrate high negative predictive values (HSG: 94%, HyCoSy: 88%) 4
- HyCoSy has been found to have a higher positive predictive value (75%) compared to HSG (47%) in some studies 4
Uterine Cavity Assessment
- Saline infusion sonohysterography (SIS) provides excellent assessment of the uterine cavity and is particularly useful for evaluating potential causes of infertility, including intrauterine adhesions, endometrial polyps, and leiomyomas 1
- Sonohysterography has demonstrated superior sensitivity (81.8% vs 58.2%) and specificity (93.8% vs 25.6%) compared to HSG for detecting intrauterine abnormalities 5
- For Müllerian duct anomalies, MRI remains the gold standard with 100% accuracy, while 3D TVUS offers 92% accuracy in classification 6
- HSG has poor accuracy (only 16.7%) in characterizing Müllerian duct anomalies and cannot reliably differentiate between septate and bicornuate uterus 6
Clinical Considerations and Precautions
- Antibiotic prophylaxis should be considered at the physician's discretion, particularly with a prior history of pelvic inflammatory disease (PID) or if hydrosalpinx is noted during the study 1, 3
- HyCoSy is generally well-tolerated, causing less pain than HSG while avoiding exposure to ionizing radiation 7, 8
- The procedure is feasible for early assessment of reproductive status as a simple, safe, and cost-effective outpatient method prior to more invasive procedures 8
- HyCoSy may be limited by sonographic conditions, with optimal visualization requiring ideal imaging circumstances 8
Comparative Advantages of HyCoSy
- Avoids radiation exposure to the ovaries, which is particularly important in women trying to conceive 7
- Can be performed as part of a comprehensive ultrasound evaluation in a single session 1, 2
- Similar diagnostic accuracy to HSG when compared with laparoscopy 1, 9
- More comfortable for patients with fewer reported side effects 7, 8
- Provides real-time assessment of tubal patency and uterine cavity 1
HyCoSy represents an excellent first-line diagnostic approach for evaluating both tubal patency and uterine cavity abnormalities in the infertility workup, combining good diagnostic accuracy with patient comfort and safety advantages.