Effects of virtual reality and nature sounds on pain and anxiety during hysterosalpingography: a randomized controlled trial

SUMMARY OBJECTIVE: The objective of this study was to determine the effects of listening to nature sounds alone and virtual reality plus listening to nature sounds on pain and anxiety in hysterosalpingography. METHODS: This three-arm parallel randomized controlled trial included 135 (45 in each group) women who underwent hysterosalpingography in Turkey. The virtual reality+nature sounds group viewed a nature video with virtual reality glasses and listened to nature sounds during hysterosalpingography, whereas the nature sounds group only listened to nature sounds. The control group received only routine care. RESULTS: During hysterosalpingography, women in virtual reality+nature sounds group experienced less pain than those in control group (p=0.009). After hysterosalpingography, pain levels were lower in both virtual reality+nature sounds group and nature sounds group than in control group (p=0.000 and p=0.000, respectively), anxiety levels were lower in virtual reality+nature sounds group than in nature sounds group and control group (p=0.018 and p=0.000, respectively), and anxiety levels were lower in nature sounds group than in control group (p=0.013). CONCLUSION: Virtual reality with nature content plus listening to nature sounds and only listening to nature sounds are effective in reducing pain and anxiety related to hysterosalpingography procedures in women. Compared with only listening to nature sounds, virtual reality plus listening to nature sounds further reduced hysterosalpingography-related pain and anxiety.

Comparación de hallazgos histeroscópicos vs. histerosalpingográficos en pacientes sometidas a tratamiento de fertilidad / Comparison of hysteroscopic vs. hysterosalpingographic findings in patients subjected fertilization treatment

Objetivo: Comparar los hallazgos histeroscópicos vs histerosalpingográficos en pacientes sometidas a tratamiento de fertilidad. Métodos: Estudio observacional, descriptivo, retrospectivo para determinar las causas de infertilidad, y analítico para evaluar la correspondencia de los hallazgos entre la histerosalpingografía y la histeroscopía de mujeres que asistieron a la consulta de fertilidad de la Clínica Leopoldo Aguerrevere, entre enero de 2018 y mayo de 2022. Resultados: Las causas de infertilidad más frecuentes fueron la edad (52,6 %), el factor tubárico (12,4 %) y la falla ovárica precoz (11,7 %); 47,4 % presentaban dos causas de infertilidad, 44,5 % solo una y 8,1 % tres causas. La fertilización in vitro (50,4 %) fue el tratamiento más utilizado para lograr el embarazo. En la histerosalpingografía se reportaron 67,9 % pacientes normales, del total de pólipos reportados, 5,1 % presentaron un pólipo y 4,4 % dos pólipos. En la histeroscopía se reportaron 46 % pacientes normales, del total de pólipos, 30,7 % presentó un pólipo, 4,4 % dos y 0,7 % tres pólipos. Entre los hallazgos más comunes hubo discordancia entre la histerosalpingografía e histeroscopía, siendo las coincidencias menores al 50 %. El índice Kappa, indicó que la correspondencia entre ambos estudios fue baja. Conclusiones: La histeroscopía es una técnica necesaria para el estudio de los trastornos endouterinos en mujeres infértiles, aportando información sobre lesiones endocavitarias uterinas, que pueden no ser apreciados con la histerosalpingografía, esta última puede emplearse para diagnóstico presuntivo de patología endometrial y evaluación de la permeabilidad de las trompas de Falopio(AU)

Objective: To compare hysteroscopic vs. hysterosalpingographic findings in female patients subject fertility treatment. Methods: Observational, descriptive, retrospective study to determine the causes of infertility, and analytical to evaluate the correspondence of the findings between hysterosalpingography and hysteroscopy of women who attended the fertility clinic of the Leopoldo Aguerrevere Clinic between January 2018 and May of 2022. Results: The most frequent causes of infertility were age (52.6%), tubal factor (12.4%) and early ovarian failure (11.7%); 47.4% had two causes of infertility, 44.5% only one and 8.1% three causes. In vitro fertilization (50.4%) was the most commonly used treatment to achieve pregnancy. In hysterosalpingography, 67.9 % normal patients were reported, of the total polyps reported, 5.1 % had one polyp and 4.4 % two polyps. In hysteroscopy, 46 % normal patients were reported, of the total polyps, 30.7 % presented one polyp, 4.4 % two and 0.7 % three polyps. Among the most common findings there was discordance between hysterosalpingography and hysteroscopy, with coincidences being less than 50%. The Kappa index indicated that the correspondence between the two studies was low. Conclusions: hysteroscopy is a necessary technique for the study of endouterine disorders in infertile women, providing information on uterine endocavitary lesions, which may not be appreciated with hysterosalpingography, the latter can be used for presumptive diagnosis of endometrial pathology and evaluation of permeability of the fallopian tubes(AU)

Effect of comfort theory-based nursing care on pain and comfort in women undergoing hysterosalpingography: a randomized controlled trial

SUMMARY OBJECTIVE: This study aims to examine the effect of comfort theory-based nursing care on pain and comfort in women undergoing hysterosalpingography. METHODS: This randomized control trial was conducted on 126 women (42 in each intervention and control group). Virtual reality glasses group (n=42), mobile-assisted education group (n=42), and control group (n=42). The control group received only routine care. Comfort levels were evaluated at the beginning and end of the study using the General Comfort Scale and pain levels evaluated at the beginning and end of the study using the Visual Analog Scale. RESULTS: The comfort theory-based nursing care (virtual reality glasses and mobile-assisted education group) was effective in increasing women's comfort with painful invasive procedures such as hysterosalpingography and reducing pain. CONCLUSION: It is recommended that a nurse be present in the hysterosalpingography process, providing nursing care services continuously and introducing this program to working nurses. Clinical Trial Registration Number: NCT04676932.

Hysterosalpingography using Magnetic Resonance Imaging for infertility patients.

OBJECTIVE: Some studies have shown that it is possible to evaluate tubal permeability through MRI. Our aim is to perform a prospective study and to perform a comprehensive review in the literature regarding HSG-MRI. METHODS: We carried out a PUBMED search using the following keywords: hysterosalpingogram, hysterosalpingography, magnetic resonance imaging and MRI. As inclusion criteria, we included only papers published in English, and exams ran on humans. We also conducted a prospective inclusion of patients who had visited a human reproduction clinic between May/2017 and April/2019 for laboratory image diagnoses using HSG-MRI. RESULTS: Following the inclusion and exclusion criteria, we included seven original papers. Review papers and those written in a language other than English, were excluded. Between the period of May/2017 and April/2019, we selected ten patients for our study. The average exam duration was 30 minutes. Cervical catheterization was possible in all cases. There were no major complications. We highlight that in 8/9 of patients, we could directly visualize uterine tubes with contrast (excluding one patient with bilateral tubal ligation). CONCLUSIONS: Our initial experience with HSG-MRI shows promise. We demonstrated an optimized protocol for conducting an HSG-MRI (with excellent image quality). HSG-MRI had some advantages, such as not using ionized radiation, less pain and being able to analyze pelvic anatomy. Patients referred for a pelvic MRI as part of a more detailed investigation into infertility can also benefit from undergoing a simultaneous HSG using MRI.

Increased prevalence of endocervical Mycoplasma and Ureaplasma colonization in infertile women with tubal factor.

OBJECTIVE: Most women suffering from tubal factor infertility do not have a history of pelvic inflammatory disease, but rather have asymptomatic upper genital tract infection. Investigating the impacts of such infections, even in the absence of clinically confirmed pelvic inflammatory disease, is critical to understanding the tubal factor of infertility. The aim of this study was to investigate whether the presence of endocervical bacteria is associated with tubal factors in women screened for infertility. METHODS: This retrospective cross-sectional study involved 245 women undergoing hysterosalpingography (HSG), screened for endocervical colonization by Chlamydia trachomatis, Neisseria gonorrhea, Ureaplasma urealyticum and Mycoplasma hominis, as part of a routine female infertility investigation between 2016 and 2017. RESULTS: endocervical bacterial colonization by Chlamydia trachomatis, Ureaplasma urealiticum, Mycoplasma hominis and other bacteria corresponded to 3.7%, 9.0%; 5.7% and 9.8%, respectively. There was no colonization by Neisseria gonorrhea. The prevalence of tubal factor was significantly higher in patients with positive endocervical bacteria colonization, regardless of bacterial species. When evaluating bacteria species individually, the women who were positive for endocervical Mycoplasma hominis had significantly higher rates of tubal factor. Associations between endocervical bacterial colonization and tubal factor infertility were confirmed by multiple regression analysis adjusted for age and duration of infertility. CONCLUSION: Besides the higher prevalence of Mycoplasma and Ureaplasma infectious agents, the findings of this study suggest the possible association of endocervical bacterial colonization - not only Chlamydia trachomatis and Neisseria gonorrhea, but also Mycoplasma species with tubal performance.

Causes of misdiagnosis in assessing tubal patency by transvaginal real-time three-dimensional hysterosalpingo-contrast sonography

SUMMARY OBJECTIVE This study aims to investigate the causes of misdiagnosis in assessing tubal patency by transvaginal real-time three-dimensional hysterosalpingo-contrast sonography (TVS RT-3D-HyCoSy), in order to improve the diagnostic efficiency of TVS RT-3D-HyCoSy. METHODS A total of 162 oviducts of 83 infertility patients were examined by TVS RT-3D-HyCoSy. These results were compared with the gold standard for laparoscopic dye studies, and the misdiagnosed cases were analyzed. RESULTS TVS RT-3D-HyCoSy revealed that 68 oviducts were unobstructed and 94 obstructed. The results for the 144 oviducts were in line with the gold standard, while those for 18 oviducts were not. The accuracy rate of the TVS RT-3D-HyCoSy was 88.9%, and the misdiagnosis rate was 11.1%. The main causes of misdiagnosis included contrast medium countercurrent and diffusion, oviduct spasm, abnormal shape or position of the oviduct, pelvic adhesion, and poor imaging operation. CONCLUSION TVS RT-3D-HyCoSy can well-evaluate tubal patency, and understand and improve the cause of misdiagnosis. Furthermore, the diagnostic efficiency of TVS RT-3D-HyCoSy can still be further improved.

RESUMO OBJETIVO Este estudo tem como objetivo investigar as causas do diagnóstico equivocado na avaliação da patência tubária por meio da ultrassonografia de contraste histerosalpingo em tempo real transvaginal (TVS RT-3D-HyCoSy), a fim de melhorar a eficiência diagnóstica das TVS RT-3D-HyCoSy. MÉTODOS Um total de 162 ovidutos em 83 pacientes da infertilidade foi examinado por TVS RT-3D-HyCoSy. Esses resultados foram comparados com o padrão ouro para estudos de tintura laparoscópica, e os casos diagnosticados erroneamente foram analisados. RESULTADOS TVS RT-3D-HyCoSy revelaram que 68 ovidutos foram desobstruídos e 94 ovidutos foram obstruídos. Os resultados para os 144 ovidutos estavam em consonância com o padrão ouro, enquanto que aqueles para os 18 ovidutos, não. A taxa de acurácia do TVS RT-3D-HyCoSy foi de 88,9%, e a taxa de erro de diagnóstico foi de 11,1%. As principais causas de erro de diagnóstico incluíram contraponto e difusão do meio de contraste, espasmo do oviduto, forma ou posição anormal do oviduto, adesão pélvica e má operação de imagem. CONCLUSÃO TVS RT-3D-HyCoSy pode bem avaliar a patência tubária, e compreender e melhorar a causa do erro de diagnóstico. Além disso, a eficiência diagnóstica do TVS RT-3D-HyCoSy ainda pode ser melhorada.

Rendimiento diagnóstico de la histerosalpingografía por resonancia magnética: resultados iniciales / Diagnostic performance of magnetic resonance hysterosalpingography: initial results Abstract

Objetivo: Determinar el rendimiento diagnóstico de la histerosalpingografía por resonancia magnética (HSG-RM), utilizando la laparoscopia como método de referencia. Materiales y métodos: Se incluyeron 22 pacientes. A todas se les realizó una HSG-RM con un resonador 1.5 Tesla y luego una laparoscopia con cromotubación. Dos radiólogos examinaron las RM, determinando la permeabilidad tubaria por consenso. Se realizaron análisis descriptivos y de rendimiento diagnóstico. Resultados: La HSG-RM tuvo una tasa de éxito del 91%. La duración del estudio fue 49ą15 minutos, el volumen inyectado 26 ą 16 cm³ y la escala de dolor 30ą 19 de 100. La sensibilidad y especificidad de la HSG-RM fueron del 100% para la prueba de Cotte global y a la izquierda, y del 25% y 93,3% para la prueba de Cotte a la derecha, respectivamente. Hubo 2 complicaciones menores y ninguna importante. Discusión: Nuestros resultados iniciales demostraron una alta sensibilidad y especificidad. Si bien otros estudios analizaron la capacidad de la HSG-RM para evaluar la permeabilidad tubaria con buenos resultados, el uso de un patrón de referencia defectuoso dejaba margen para una duda razonable, impidiendo una recomendación basada en pruebas sólidas. Sin embargo, al cotejar nuestros resultados con los publicados, observamos un alto grado de concordancia en tanto el derrame positivo se diagnostica correctamente con una especificidad de 100% o con un porcentaje cercano a esta cifra. Conclusión: La HSG-MR es una alternativa factible y segura de la HSG convencional o virtual, la histerosonografía y la cromotubación.

Objective: To determine the diagnostic performance of magnetic resonance hysterosalpingography (MRHSG) using laparoscopic chromotubation as a method of reference. Materials and methods: Twenty-two patients were included. The MRHSG was performed in a 1.5 Tesla MR scanner. Afterwards, patients underwent laparoscopic chromotubation. MR images were examined by two trained radiologists, and tubal patency was determined by consensus. A descriptive analysis was carried out, as well as an analysis of the diagnostic performance. Results: MRHSG had a 91% success rate. Exam duration of the examination was 49ą15min, with an injected volume 26ą 16cc, and pain scale 30ą 19 out of 100. Sensitivity and specificity of MRHSG was 100% for global and left Cotte, and 25% and 93.3% for right Cotte, respectively. Only 2 minor and no major complications were observed. Discussion: The initial results of MRHSG have shown high sensitivity and specificity. Even though other studies have analysed the potential of MRHSG with good results, the use of a flawed reference standard left a margin for a reasonable doubt as regards its true potential, thus preventing a solid evidence based recommendation. Nevertheless, if our results are compared to those published, a high level of agreement is observed in that positive spillage is correctly diagnosed with specificities near or at 100%. Conclusion: MRHSG is a feasible and safe alternative to conventional or virtual HSG, ultrasound-hysterography and chromotubation.

Evaluación del canal cervical mediante histerosalpingografía virtual y su comparación con la prueba de transferencia embrionaria / Cervical Evaluation by Virtual Hysterosalpingography and its Comparison with the Embryo Transfer Test

Objetivo: Comparar la prueba del catéter cervical con la histerosalpingografía virtual (HSGV) en la evaluación del cuello uterino antes de la transferencia embrionaria. Material y métodos: Fueron evaluadas 100 pacientes con antecedentes de infertilidad. El día del examen, un ginecólogo realizó la prueba del canal cervical con un catéter de Wallace. Luego se realizó una HSGV con un tomógrafo de 256 cortes. Las imágenes fueron evaluadas por un radiólogo, y se determinaron la permeabilidad del cuello uterino, el ángulo cérvico-uterino y la presencia de patología cervical. Resultados: Se observó una buena correlación (r=0,92) en la evaluación de la permeabilidad del cuello uterino entre ambos métodos. En el 35 % de las pacientes la prueba del catéter cervical no fue exitosa, y la HSGV detectó pólipos, sinequias y trayectos sinuosos del canal cervical; mientras que en 23 pacientes el cuello uterino fue normal, pero el ángulo cérvico-uterino fue < 90°. Conclusiones: Hubo una buena correlación entre la HSGV y la prueba de catéter cervical en la evaluación de la permeabilidad del cuello uterino. La HSGV proporciona, además, información anatómica útil para identificar la causa probable del fracaso de la transferencia de embriones.

Objective: To compare cervical catheter test and virtual HSG in the evaluation of cervix before embryo transfer. Methods: We evaluated 100 patients with history of infertility. On the day of examination, a gynaecologist performed a cervical test with a Wallace catheter. Then, patients underwent Virtual HSG performed with a 256-slice CT scanner. CT images were evaluated by a radiologist, and the cervical patency, utero-cervical angle and the presence of cervical pathology were determined. Results: There was a good correlation (r=0,92) in cervical patency evaluation between both methods. Unsuccessful cervical catheter test was observed in 35% of patients. In these patients, Virtual HSG detected polyps, adhesions and sinuous cervical canal, while cervix was normal in 23 patients, but the utero-cervical angle was < 90°. Conclusions: There was a good correlation between HSG findings and the cervical catheter test in the evaluation of cervical patency. Moreover virtual HSG provides anatomic information useful to identify the probable causes of failure of embryo transfers.

Salpingite istmica nodosa: revisão e diagnóstico histerossalpingográfico de 4casos de uma clinica radiológica privada / Salpingitis isthmica nodosa: review and hysterosalpingography diagnosis of 4 cases in a private radiology clinic

Objetivo: identificar os achados radiológicos da salpingite ístmica nodosa (SIN) a partir da histerossalpingografia e avaliar o local de comprometimento e sua repercussão na infertilidade. Métodos: em estudo retrospectivo foram revistos 2.800 protocolos, realizadas entre janeiro de 1987 e janeiro de 1997, em pacientes com história clínica de infertilidade feminina, tendo quatro com diagnóstico radiológico de SIN, sendo analisados etnia, idade, estado civil, queixa clínica atual, antecedentes clínicos, local e o lado do comprometimento. Resultados: entre as quatro pacientes com SIN, três eram melanodérmicas e uma caucasiana, com idade média de 35 anos na época do diagnóstico, duas solteiras, uma casada e uma divorciada. As queixas de infertilidade secundária estavampresentes em três pacientes com antecedentes de gravidez tubária prévia e outro de infertilidade primária, sem antecedentes de gravidez. Nas quatro pacientes com SIN, a porção tubária acometida foi a ístmica cornual, tubário bilateral em três e unilateral em uma. Em relação à peritonização, uma apresentava prova de Cotté positiva bilateral, duas com obstrução completa bilateral e uma com Cotté positiva em uma das tubas.Conclusão: SIN é mais frequente em pacientes melanodérmicas, na faixa etária média de 35 anos, com história clínica de infertilidade, de gravidez tubária inicial e recorrente e consequente obstrução tubária caracterizada por lesão na porção ístmica cornual da tuba uterina, geralmente de comprometimento bilateral.

Objective: to identify the radiological findings of salpingitis isthmica nodosa (SIN) through hysterosalpingography and evaluate the site of involvement and its impact on infertility. Methods: 2,800 protocols were reviewed in a retrospective study between January of 1987 and January of 1997, in patients with a clinical history of female infertility; four of them with a radiological diagnosis of SIN. Ethnicity, age, marital status, current clinical complaints, medical history, location, and side of involvement were analyzed. Results: among the four patients with SIN, three were dark-skin, and one was Caucasian, with an average age of 35 years at diagnosis, two single, one married, and one divorcee. Three patients presented complaints of secondary infertility with previous tubal pregnancy history, and another with primary infertility without pregnancy history. In the four patients with SIN, the tubal portion affected was the cornual isthmian, bilateral tubal in three, and unilateral in one. Regarding peritonization, one showed positive bilateral Cotte proof, two with complete bilateral obstruction, and one with positive Cotte in one of the tubes. Conclusion: SIN is more common in dark-skin patients, in the mean age of 35 years, with a clinical history of infertility, with initial and recurrent tubal pregnancy, and subsequent tubal obstruction characterized by lesion in the Isthmian cornual portion of the fallopian tube, usually with bilateral involvement.

Cromotubación histeroscópica: técnica alternativa para la evaluación de la permeabilidad tubárica y la cavidad uterina en un solo paso / Hysteroscopic chromotubation: an alternative technique for the evaluation of tubal patency and uterine cavity in a single step

La evaluación de la permeabilidad tubárica es un paso esencial en el estudio de la infertilidad femenina. Existen varios métodos que permiten realizar esta evaluación. La histerosalpingografía (HSG) se ha considerado el método estándar, sin embargo es conocida su limitación en la evaluación de la obstrucción proximal con alta tasa de falsos positivos. Presentamos una técnica alternativa para la evaluación por medio de cromotubación histeroscópica, que tiene entre otras, la ventaja de permitir la evaluacion del factor uterino y tubárico en un solo paso y además, supera la dificultad de los falsos positivos de la HSG, en cuanto a la obstrucción proximal.

The evaluation of tubal patency is an essential step in the study of female infertility. There are several methods to perform this evaluation. Hysterosalpingography (HSG) has been considered the standard method, however it is known to limitations in the assessment of proximal obstruction with high false positive rate. We present an alternative technique for evaluation by hysteroscopic chromo tubation, which has among others, the advantage of allowing the evaluation of uterine and tubal factor in one step and also overcomes the difficulty of false-positive HSG, as to the proximal obstruction.

Salpingite ístmica nodosa: diagnóstico histerossalpingográfico de uma causa de infertilidade / Isthmian nodosa salpingitis: histero-salpingography diagnosis of an infertility cause

Objetivo: demonstrar os achados da salpingite ístmica nodosa (SIN) por meio da histerossalpingografia e avaliar o local de comprometimento e sua repercussão na infertilidade feminina. Paciente e Métodos: em estudo retrospectivo foram revistas 2.800 histerossalpingografias realizadas entre janeiro de 1987 e janeiro de 2007 em pacientes com história clínica de infertilidade feminina. Destas, quatro pacientes apresentavam diagnóstico radiológico de SIN, sendo analisados seus principais aspectos radiográficos, como também os locais de comprometimento e suas repercussões na infertilidade. Resultados: das quatro pacientes em que foi encontrada a doença estudada a partir da investigação histerossalpingográfica da infertilidade, três tinham antecedentes de gravidez tubária, todas com comprometimento ístmico cornual, sendo três delas de comprometimento bilateral e uma unilateral. Uma delas apresentava prova de Cotté positiva bilateral, duas com prova de Cotté negativa bilateral e uma com tuba direita positiva e esquerda negativa. Conclusão: o diagnóstico da SIN é feito com base na histerossalpingografia, caracterizada pelo acúmulo do meio de contraste na parede tubária, distribuída na porção ístmica cornual ou ampolar, uni ou bilateralmente, acompanhado de história clínica de infertilidade, gravidez tubária, abortamento espontâneo e obstrução tubária.

Objective: to demonstrate the findings of isthmian nodosa salpingitis (SIN) through histero-salpingography and evaluate the site of involvement and its impact on female infertility. Patients and Methods: a total of 2,800 histero-salpingographies were reviewed in a retrospective study between January of 1987 and January of 2007 in patients with a clinical history of female infertility. Of these, four patients presented radiological diagnosisof SIN; their main radiographic aspects, sites of involvement, and impact on infertility were analyzed. Results: out of the four patients in which the studied disease was found through the histero-salpingography infertility research, three had a history of tubal pregnancy, all with cornual isthmian involvement; bilateral in three of them and unilateral in one. One of them showed evidence of positive bilateral Cotté, two showed evidence ofnegative bilateral Cotté, and one bilateral with right positive tubal and left negative tubal. Conclusion: the diagnosis of SIN is achieved based on histero-salpingography, characterized by the accumulation of contrast medium on the tubal wall, distributed in the cornual or ampolar isthmian portion, uni- or bilaterally, and accompanied by clinical history ofinfertility, tubal pregnancy, spontaneous abortion, and tubal obstruction.

Infertilidad: histeroscopia versus ultrasonografía transvaginal e histerosalpingografía / Infertility: hysteroscopy versus ultrasonography transvaginal and hysterosalpingography

Objetivo: Comparar la histeroscopia con el ultrasonido transvaginal y la histerosalpingografía para el estudio de la cavidad uterina en la paciente infértil. Métodos: Estudio prospectivo descriptivo, comparativo de las pacientes de la Unidad de Fertilidad del Servicio de Ginecología del Hospital Universitario de Caracas entre marzo y noviembre de 2011. Resultados: Se evaluaron 33 pacientes con diagnóstico de infertilidad primaria y secundaria. La histeroscopia mostró alteraciones en 66,6 % predominando la sinequia uterina y el pólipo endometrial. La histerosalpingografía reportó una sensibilidad de 40,9 % y una especificidad de 81,8 % en comparación con la histeroscopia, con un valor predictivo positivo de 81,8 % y un valor predictivo negativo de 40,9.%. La tasa de concordancia entre los dos procedimientos fue de 50,4 %. El ultrasonido transvaginal reportó una sensibilidad de 45,5 % y una especificidad de 90,9 % en comparación con la histeroscopia, la concordancia entre estos dos procedimientos fue de 60,65 %. No hubo complicaciones durante la histeroscopia. Conclusiones: Consideramos que el ultrasonido transvaginal, la histerosalpingografía y la histeroscopia son complementarios en la evaluación de la paciente infértil, pero en vista de la baja tasa de sensibilidad y concordancia de los dos primeros, consideramos que la histeroscopia debe incluirse de rutina en el estudio de la pareja infértil.

Objective: The aim of this study was to compare the hysteroscopy, transvaginal ultrasound and hysterosalpingography in the study of uterine cavity in infertile patients. Methods: Descriptive, comparative study of patients from the Fertility Unit of Gynecology Service of the Hospital Universitario de Caracas between March and November 2011. Results: We evaluated 33 patients with primary and secundary infertility. Abnormal hysteroscopic findings were observed in 66, 6 %, in wich intrauterine adhesions and endometrial polyp were the most common findings. Hysterosalpingography reported a sensitivity of 40.9 % and specificity of 81.8 % compared with hysteroscopy, with a positive predictive value of 81.8 % and a negative predictive value of 40.9 %. Overall agreement between these two procedures was 50.4 %. Transvaginal ultrasound reported a sensitivity of 45.5 % and specificity of 90.9 % compared with hysteroscopy, with a positive predictive value of 90.9 % and negative predictive value of 45.5 %. Overall agreement between between these two procedures was 60.65 %. There were no complications during hysteroscopy. Conclusions: We believe that transvaginal ultrasound, hysterosalpingography and hysteroscopy are complementary in the evaluation of the infertile patient but given the low rate of sensitivity and consistency of the first two, we believe that routine hysteroscopy should be included in the study of the infertile couple.

Rol de la laparoscopia en la infertilidad inexplicada: experiencia del Hospital Clínico de la Pontificia Universidad Católica de Chile / Role of laparoscopy in unexplained infertility

Antecedentes: Existe una tendencia global creciente de no realizar laparoscopia diagnóstica en el estudio de pacientes con infertilidad inexplicada e histerosalpingografía normal. Este tipo de manejo podría tener ciertos inconvenientes dado que existen lesiones, especialmente tuboperitoneales, que no son diagnosticadas y pudiesen influir en los resultados. Nuestro grupo maneja estas pacientes con laparoscopia diagnóstica/terapéutica y posteriormente tres ciclos de inseminación intrauterina. Objetivos: Validar nuestro manejo de la infertilidad inexplicada, estimar la frecuencia de patología pélvica en pacientes con infertilidad inexplicada con histerosalpingografía normal, evaluar la tasa de embarazo posterior a la resolución laparoscópica de su patología y revisar la literatura existente. Resultados: Se revisaron todas las cirugías laparoscópicas realizadas en pacientes con infertilidad inexplicada del Hospital Clínico de la Universidad Católica, entre los años 2007-2011. De estas, 57 pacientes cumplían los criterios de inclusión y 39 recibieron al menos 1 ciclo de inseminación intrauterina posterior al procedimiento. El 82,4 por ciento de las pacientes presentaron hallazgos a la laparoscopia, siendo los más prevalentes la endometriosis grado I y II (57,8 por ciento), y las adherencias pelvianas (43,8 por ciento). De las 57 pacientes que fueron sometidas a laparoscopia diagnóstica/terapéutica, sólo 25 completaron 3 ciclos de inseminación intrauterina posterior, 8 lograron concepción (32 por ciento). Conclusión: Nuestros resultados son similares a los expuestos en otros trabajos en términos de hallazgos patológicos y tasa de fertilidad post laparoscopia. Dado el escaso acceso a técnicas de fertilización in vitro en nuestro medio, nuestro manejo plantea una excelente alternativa para este grupo de pacientes.

Background: There is an increased global tendency for avoiding a diagnostic laparoscopic surgery, among patients with unexplained infertility and a normal histerosalpingography. This decision may have certain consequences, as there may be undiagnosed lesions, such as tuboperitoneal ones, which could have an impact in the management of these patients. Our group treats them with diagnostic therapeutic laparoscopy, followed by three cycles of intrauterine insemination. Objectives: Validate our management of unexplained infertility, estimate the frequency of pelvic pathology in patients with unexplained infertility with a normal histerosalpingography, evaluate the pregnancy rate after the laparoscopic resolution of their pathology, and review the existent literature. Results: We reviewed all laparoscopic surgeries performed in patients with unexplained infertility in Hospital Clínico de la Pontificia Universidad Católica, between 2007-2011. From these, 57 patients met the inclusion criteria, and 39 of them received at least one intrauterine insemination cycle after the procedure. Laparoscopic alterations were present in 82.4 percent of the patients, being the most prevalent ones endometriosis grade I and II (57.8 percent) and pelvic adhesions (43.8 percent). Of the 57 patients who underwent laparoscopy, only 25 completed three cycles of intrauterine insemination, 8 of which conceived (32 percent). Conclusion: Our results are similar to those exposed in other series, regarding pathologic findings and fertility rate after laparoscopy. As there is limited access to advanced reproductive techniques in our country, our management represents an excellent choice for this group of patients.

Obstrução tubária em mulheres com imunofluorescência indireta positiva para clamídia / Tubal occlusion in women with indirect positive immunofluorescence for chlamydia

Objetivos: Avaliar o desempenho da imunofluorescência indireta para Chlamydia trachomatis em rastrear obstrução tubária. Métodos: Este é um estudo retrospectivo com 204 pacientes atendidas em um centro universitário e particular de infertilidade na cidade de Goiânia no período de 2006 a 2009. Para avaliar o risco de obstrução tubária as pacientes foram divididas em dois grupos: pacientes “expostas” à clamídia (imunofluorescênciaindireta ≥1:16) e “não expostas” (imunofluorescência indireta <1:16). Verificou-se, então, as pacientes que tiveram a “doença” (obstrução tubária) e “controles” (sem obstrução tubária) na histerossalpingografia. Para os cálculos foram utilizados os testes Qui-quadrado (χ2) e Exato de Fisher. O nível de p escolhido foi 0,05. Resultados: Das 72 pacientes com titulação significativa, 34 (47,2%) apresentaram a ocorrência de obstrução tubária. Em relação às 132 pacientes com titulação não significativa, somente 18 (13,7%) apresentaram obstrução tubária (p<0,001). Foi observado também um aumento progressivo entre os níveis de anticorpos e a probabilidade de obstrução tubária (p<0,001). Conclusões: Os resultados deste estudorevelaram que a sorologia para Chlamydia trachomatis é válida para rastreamento de lesão tubária, portanto, pode facilitar decisões naquelas mulheres que devem prosseguir com novas investigações.

Purpose: To evaluate the ability of indirect immunofluorescence for Chlamydia trachomatis to screening tubal occlusion. Methods: This is a retrospective study with 204 electronic records of patients attended at a university and private infertility center in the city of Goiania, in the period of 2006 to 2009. To evaluate the risk of tubal occlusion the patients were divided into two groups: patients “exposed” to chlamydia (IFI≥1:16) e “unexposed” (IFI<1:16). It was verified patients who had the “disease” (tubal occlusion) and “control” (without tubal occlusion) in the hysterosalpingography. For the calculations the Chi-square (χ2) and Fisher Exact Test were used. The p chosen level was 0,05. Results: Of the 72 patients with significant titers, 34 (47,2%) showed the occurrence of tubal occlusion. Concerning the 132 patients with no significant titers, only 18 (13,7%) had tubal occlusion(p<0,001). We also observed a progressive increase in the levels of antibodies and the likelihood of tubal occlusion (p<0,001). Conclusions: The results indicate that serology for Chlamydia trachomatis is valid for screening of tubal damage and may facilitate decisions on which women should proceed with further investigations.

Two consecutive intrauterine pregnancies following transperitoneal ovum migration / Duas gestações intrauterinas consecutivas após migração transperitoneal do óvulo

CONTEXT: Transperitoneal migration is a mechanism for oocyte retrieval that is generally demonstrated in certain cases of ectopic pregnancy. However, the association between these two conditions is debatable. The rare occasions on which intrauterine pregnancy following transperitoneal migration can be documented are an opportunity for studying this topic. CASE REPORT: We report the case of a female with a history of salpingectomy due to an ectopic pregnancy at 31 years of age. Two subsequent pregnancies were intrauterine. In both of them, ultrasound revealed that the corpus luteum was located in the ovary ipsilateral to the salpingectomy. CONCLUSION: To our knowledge, this is the first reported case of two intrauterine pregnancies following transperitoneal migration, carried to term, and resulting in the delivery of two healthy children. The clinical and physiological implications are discussed.

CONTEXTO: A migração transperitoneal é um mecanismo de captação do oócito demonstrado, em geral, em determinados casos de gravidez ectópica. No entanto, a associação entre ambas é discutível. As raras ocasiões em que uma gestação intrauterina após migração transperitoneal pode ser documentada são uma oportunidade para o estudo deste tópico. RELATO DE CASO: Relatamos o caso de uma mulher com salpingectomia aos 31 anos, por gravidez ectópica. Duas gestações subsequentes foram intrauterinas. Em ambas, ultrassonografia evidenciou presença do corpo lúteo em ovário do mesmo lado da salpingectomia. CONCLUSÃO: No nosso conhecimento, trata-se do primeiro caso relatado com duas gestações intrauterinas após migração transperitoneal, terminadas com o nascimento de duas crianças saudáveis. As implicações clínicas e fisiológicas são discutidas.

Histerosalpingografía virtual por TC multidetector de 64 filas: hallazgos en 2.500 pacientes / 64-Row multidetector CT virtual hysterosalpingography: findings in 2500 patients

Objective. To depict typical features of virtual hysterosalpingography (VHSG) in infertile patients. Material and methods: 2500 VHSG performed using a 64-row MDCT were evaluated. Results: Cervical abnormalities visualized corresponded to parietal irregularities (21 percent); thickened folds (9 percent); polyps (11 percent); diverticula (5 percent); cervical strictures (8 percent), and synechiae (1.5 percent). At the level of uterine cavity, polyps (44 percent); submucous myomas (8 percent); intramural and subserosal fibroids (11 percent); synechiae (10 percent); malformations (10 percent); adenomyosis (4 percent), and cesarean section scar (3 percent). Unilateral hydrosalpinx (7 percent) and bilateral hydrosalpinx (2 percent). Tubal obstruction was reported in 6 percent of cases. The average radiation dose was 0.94 mSv. Eighty-four percent of the patients reported mild pain or no postoperative discomfort. Conclusions: The virtual hysterosalpingography allowed a proper assessment of the internal genital organs, providing useful diagnostic information on infertility and other gynecological disorders. It constitutes a virtually painless, low-dose radiation technique, besides being well tolerated by patients.

Objetivo. Ilustrar los hallazgos característicos de la histerosalpingografía virtual (HSG-V) en pacientes en estudio de infertilidad. Material y métodos: Se evaluaron 2500 HSG-V efectuadas con un equipo de TCMD de 64 filas. Resultados A nivel del cuello se visualizaron irregularidades parietales (21 por ciento); pliegues engrosados (9 por ciento); pólipos (11 por ciento); divertículos (5 por ciento); estrechez (8 por ciento; y sinequias (1,5 por ciento). A nivel de la cavidad: pólipos (44 por ciento); miomas submucosos (8 por ciento); intramurales y subserosos (11 por ciento); y sinequias (10 por ciento); malformaciones (10 por ciento); adenomiosis (4 por ciento); cicatriz de cesárea (3 por ciento). Hidrosalpinx unilateral (7 por ciento) y bilateral (2 por ciento); obstrucción tubaria en el 6 por ciento de los casos. La dosis de radiación promedio fue 0.94 mSv. El 84 por ciento de los pacientes refirieron disconfort leve o ausente. Conclusiones: La HSG-Virtual permitió una adecuada evaluación de los órganos genitales internos, brindando información diagnóstica útil en infertilidad y otros desórdenes ginecológicos. Es una técnica poco dolorosa, bien tolerada por las pacientes y con baja dosis de radiación.

Laparoscopia na decisão da estratégia terapêutica para o casal infértil / Laparoscopy in the decision of treatment strategy for the infertile couple

OBJETIVO: avaliar a contribuição da laparoscopia diagnóstica na abordagem do casal infértil. MÉTODOS: estudo retrospectivo com análise dos 86 casos consecutivos de pacientes acompanhadas em consulta de esterilidade que foram submetidas à laparoscopia entre Janeiro de 2004 e Dezembro de 2006. Oitenta e duas pacientes tinham realizado histerossalpingografia (HSG) previamente à laparoscopia. Avaliaram-se os achados laparoscópicos bem como os procedimentos acessórios efetuados, e correlacionaram-se os achados histerossalpingográficos com os da laparoscopia. A análise estatística foi efetuada com o Statistical Package for the Social Sciences 15. A sensibilidade e a especificidade da HSG foram determinadas e os intervalos de confiança calculados assumindo-se um erro alfa de 0,05 (IC95 por cento). RESULTADOS: na laparoscopia foram identificadas alterações compatíveis com endometriose em 21 casos (24,4 por cento), salpinge uni/bilateral em 14 casos (16,3 por cento) e doença inflamatória pélvica em 16 casos (18,6 por cento). Procedeu-se à adesiólise e à fulguração dos focos de endometriose em oito pacientes. Foram feitas duas salpingostomias, duas quistectomias do paraovário, duas quistectomias do ovário e três drillings do ovário. A prova de permeabilidade tubar foi normal em 44 casos (53 por cento), revelou obstrução unilateral em 21 (25,3 por cento) e obstrução bilateral em 17 (20,5 por cento). Os resultados da histerossalpingografia foram concordantes com os da laparoscopia em 44 dos 82 casos (53,7 por cento). Quando definimos doença como qualquer forma de obstrução tubar presente na laparoscopia, a sensibilidade da HSG foi 0,79 (IC95 por cento=0,62-0,9) e a especificidade 0,58 (IC95 por cento=0,42-0,73). Quando limitamos a definição de doença à presença de obstrução tubar bilateral na laparoscopia, a sensibilidade e a especificidade da HSG foram 0,47 (IC95 por cento=0,24-0,71) e 0,77 (IC95 por cento=0,64-0,86), respectivamente. Em nove casos (15,3 por cento) em que a HSG havia sido normal ou revelado apenas obstrução unilateral, a laparoscopia revelou obstrução bilateral. Em 15 casos (65,2 por cento) em que a HSG havia demonstrado obstrução bilateral, a laparoscopia foi normal ou revelou apenas obstrução unilateral. CONCLUSÕES: a laparoscopia demonstrou sua relevância diagnóstica e terapêutica revelando-se fundamental na clarificação do status tubo-peritoneal. Permitiu a realização concomitante de atos terapêuticos, possibilitando a definição da melhor estratégia terapêutica no casal infértil.

PURPOSE: to evaluate the contribution of diagnostic laparoscopy to approach the infertile couple. METHODS: retrospective analysis of 86 consecutive cases of patients who were accompanied in the infertility appointments and were submitted to diagnostic laparoscopy from January 2004 to December 2006. Eighty-two of these patients had been submitted to hysterosalpingography (HSG) prior to laparoscopy. The laparoscopic findings were analyzed, as well as the accessory procedures, and the results of the hysterosalpingography and of the laparoscopy were correlated. Statistical analysis was performed by the use of the Statistical Package for the Social Sciences 15. The sensitivity and the specificity of HSG were determined and the confidence intervals were calculated with an alpha error of 0.05 (95 percentCI). RESULTS: the laparoscopy revealed 21 cases of endometriosis (24.4 percent), 14 cases of uni/bilateral inflammatory disease of the salpinx (16.3 percent), and 16 cases of pelvic inflammatory disease (18.6 percent). Adhesiolysis and ablation of endometrial lesions were performed in eight patients. There were also other accessory procedures: two salpingostomies, two paraovarian cystectomies, two ovarian cystectomies and three ovarian drillings. The tubal patency test during laparoscopy was normal in 44 cases (53 percent), revealed unilateral obstruction in 21 cases (25.3 percent) and bilateral obstruction in 17 cases (20.5 percent). The results of the hysterosalpingography were similar to those of the laparoscopy in 44 out of the 82 cases (53.7 percent). HSG sensitivity was 0.79 (95 percentCI=0.62-0.9) and its specificity was 0.58 (95 percentCI=0.42-0.73) when the disease was defined as any form of tubal occlusion detected with the laparoscopy, wheter this occlusion was one-sided or two-sided. HSG sensitivity and specificity were 0.47 (95 percentCI=0.24-0.71) and 0.77 (95 percentCI=0.64-0.86), respectively, when the definition of the disease was limited to two-sided tubal occlusion. In nine cases (15.3 percent) in which HSG had shown normal findings or only a unilateral occlusion, laparoscopy revealed a two-sided occlusion. And in 15 cases (65.2 percent) in which HSG had shown a two-sided occlusion, laparoscopy revealed normal findings or one-sided occlusion. CONCLUSIONS: the laparoscopy demonstrated its diagnostic and therapeutic relevance, proving to have fundamental importance for the clarification of the tuboperitoneal status. It has permitted the development of concomitant accessory therapeutic procedures, thus defining the best treatment strategy for the infertile couples.

Utilidad de la histerosalpingografía como método diagnóstico en la infertilidad / Usefulness of hysterosalpingography in diagnosis in infertility

Objetivo: presentar una base a nuestra experiencia el estado actual de la histerosalpingografía (HSG) discutiendo las diferentes metodologías utilizadas y los hallazgos relacionados con anormalidades tanto a nivel uterino como de las trompas de Falopio. Material y Métodos: Estudiamos 256 pacientes consecutivas desde Julio de 2004 a Mayo de 2007 con edad media de 32.3 años en los días 7 a 10 del ciclo menstrual. Se colocó espéculo y luego de la higiene y antisepsia de la cavidad vaginal se utilizó pinza listerina para la fijación uterina y se administró material de contraste iodado a la cavidad uterina a través de cánula de Rubistein con oliva plástica bajo control radioscópico. Se obtuvieron incidencias radiográficas digitales en decúbito dorsal con relleno parcial, total y ambas oblicuas. Luego de las mismas se realizó la prueba de Cotte. Resultados: En 7 casos no se pudo realizar el estudio por incapacidad de canular el orificio cervical externo. En los demás estudios los resultados fueron clasificados en normales, defectos de relleno intrauterinos, adenomiosis, anomalías mûllerianas, hidrosálpinx, espasmos tubario, obstrucción tubaria, prueba de Cotte positiva o negativa uni o bilateral y sospecha de adherencias pelvianas o masas anexiales acorde a la distribución del material de contraste en la cavidad abdominal. Conclusión: La HSG sigue siendo e la actualidad el estudio de elección para la valoración de las trompas de Falopio y también de gran utilidad para la evaluación interna de la cavidad uterina. Hemos evidenciado un incremento paulatino de las pacientes que se someten a este tipo de estudio proporcional al desarrollo de nuevas metodologías terapéuticas médicas y quirúrgicas para el tratamiento de la infertilidad.

Purpose: To show our experience related to the actual state of the hysterosalpingography including techniques and findings that compromise the uterus and the Fallopian tubes. Material and Methods:We have studied 256 patients from July 2004 till May 2007 with a media of 32.3 years of age, between the days 7 and 10 of the menstrual cycle. We have used an speculum, cleaned the vaginal cavity and afteruterus fixation, the contrast material have been introduced through a Rubistein canula with a plastic olive. We have obtained radiographs in different positions such as partial and full filled endometrial cavity, both oblique incidences and post Cotte test. Results: In 7 cases we couldn´t perform the study because of tiny external cervical orifice. In the rest of the patients thefindings have been classified in normal, uterine filling defects, adenomyosis, müllerian anomalies, hydrosalpinx, tubalspasm, tubal obstruction, positive or uni o bilateral negative Cotte test, and peritoneal or anexial masses suspicion.Conclusion: The HSG is the elective study for the study of the Fallopian tube and have great utility to evaluate theendometrial cavity. We have observed an increase in the number of patients that go through this study related to thedevelopment of new therapeutical strategies (medical or surgical) for the treatment of infertility.