Intravasation complicating hysterosalpingo-foam sonography (HyFoSy) using ExEm® Foam.

BACKGROUND: Transvaginal hysterosalpingo-foam sonography (HyFoSy) assesses tubal patency in an outpatient setting and without ionising radiation, unlike traditional hysterosalpingography (HSG) under fluoroscopy. Like HSG, HyFoSy may be complicated by uterine intramural contrast leak, leading to venous intravasation. Intravasation of particulate contrast agents risks pulmonary or cerebral emboli. AIMS: We aimed to assess the intravasation rate of HyFoSy using ExEm® Foam and association with endometrial thickness, ExEm® Foam volume, uterine length, adenomyosis severity, uterine morphology or pain score. METHODS: An ethics-approved retrospective study on all HyFoSy examinations between 23 January 2018 and 27 October 2021 on sub-fertile patients, trying to conceive. Initial transvaginal sonography confirmed anatomy, uterine morphology, adenomyosis severity and endometrial thickness. Subspecialist radiologists performed HyFoSy with sonographer assistance. Intravasation was identified in real time but also checked for afterwards. Patients were asked to rate instillation pain/discomfort from one to ten immediately afterward. RESULTS: Four hundred and thirty-six (n = 436) patients met inclusion criteria. Thirty (6.9%) experienced intravasation. Endometrial thickness and pain score were associated with intravasation. For every millimetre increase in endometrial thickness, the odds of intravasation decreased by 26% (P = 0.010). For every point increase on the pain scale, the odds of intravasation increased by 22% (P = 0.032). There was no evidence of an association between instilled ExEm® Foam volume or the other previously published parameters with intravasation. CONCLUSION: A 6.9% rate of intravasation was observed. Both endometrial thickness and pain score were significantly associated with intravasation. There was no evidence of an association between ExEm® Foam volume and intravasation.

Evaluation of the safety and effectiveness of tubal inflammatory drugs in patients with incomplete tubal obstruction after four-dimensional hysterosalpingo-contrast-sonography examination.

BACKGROUND: To investigate the safety and effectiveness of tubal inflammatory drugs in patients with incomplete tubal obstruction of at least one side after four-dimensional hysterosalpingo-contrast-sonography (4D-HyCoSy) examination. METHODS: Two hundred fifteen cases of tubal incomplete obstruction were diagnosed by ultrasonography from February 2019 to November 2020.According to retrospective analysis,the patients in this study were divided into experimental and control groups; the experimental group combined with salpingitis drugs, and the control group received blank control. Basic information, degree of pain, postoperative complications, and pregnancy rate were then compared between the two groups. RESULTS: Compared with the control group, there was no significant difference in the basic information; in preoperative, intraoperative, or postoperative pain; or in postoperative complications (P > 0.05). The cumulative pregnancy rate of the experimental group (26.8%) was statistically different from that of the control group (14.4%) (P < 0.05). CONCLUSIONS: We observed that for infertile patients with incomplete obstruction of at least one fallopian tube as diagnosed by contrast-enhanced ultrasonography, salpingitis-treatment drugs effectively improved the pregnancy rate postoperatively, with high effectiveness and safety. This regimen is thus worthy of further investigation and promotion in the future.

Cutaneous small-vessel vasculitis following hysterosalpingo-foam sonography (HyFoSy).

We present a case of diffuse skin immune reaction, diagnosed as cutaneous small-vessel vasculitis, following assessment of tubal patency by contrast ultrasound, which appears to be the first reported case of hypersensitivity reaction to sonographic tubal patency testing, based on a literature search. A 32-year-old woman presented with non-thrombocytopenic palpable purpura the day after assessment of tubal patency by two-/three-dimensional hysterosalpingo-foam sonography (HyFoSy) using ExEm® Foam. During real-time ultrasound, the observer identified flow in only the right tube when using saline with air as contrast medium; however, the same observer identified flow in both tubes after injecting ExEm Foam and the woman left the clinic without any complications. The next day, the patient was admitted with a complaint of a red-purple skin rash noticed the same morning, associated with moderate leg pain. Slow-motion analysis of the recorded videos and three-dimensional ultrasound datasets showed previously unnoticed venous intravasation of ExEm Foam into the myometrial vessels. Palpable purpura is typically found in vasculitis as a result of extravasation of red cells outside the inflamed blood vessel. This previously unreported side effect of tubal patency testing by HyFoSy, its potential rare organ consequences, as well as unknown consequences of venous intravasation by foam, should be included in the informed consent prior to the examination. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Hysterosalpingo-foam sonography (HyFoSy): Tolerability, safety and the occurrence of pregnancy post-procedure.

BACKGROUND: Fallopian tube patency testing is an essential part of infertility evaluation. Hysterosalpingo-contrast sonography (HyCoSy) has been described as reliable, well tolerated and safe compared to other modalities such as laparoscopy and a dye test or hysterosalpingography. Limited availability of the previously used contrast has led to the introduction of a foam contrast agent as an alternative. AIMS: To assess the tolerability, safety and occurrence of pregnancy post-procedure of hysterosalpingo-foam sonography (HyFoSy). MATERIALS AND METHODS: A retrospective cohort study of women who had a HyFoSy at Queensland Ultrasound for Women from March 2013 to February 2015. A questionnaire was sent to their referring doctor to identify any complications or subsequent pregnancies with or without artificial reproductive technology (ART) within six months of the HyFoSy. RESULTS: Of 200 women, four cases were abandoned due to difficulty introducing the intracervical catheter, severe discomfort or a vasovagal episode. Response from referring doctors for 155 women reported no post-procedural complication. One hundred and eleven women were followed up for at least six months. Twenty-four out of 59 women (40.7%) who had ART and 24 out of 52 women (46.2%) who did not have ART conceived. Fifty percent of women who were nulligravida at the time of investigation, found to have at least one patent fallopian tube, whose partner had a normal semen analysis, spontaneously conceived within the time of follow up. CONCLUSIONS: HyFoSy is well tolerated and safe. A preponderance of pregnancies in the first month after HyFoSy suggests that a therapeutic effect may exist.

Pain and side effects associated with 4-dimensional hysterosalpingo-contrast sonography for evaluating of the fallopian tubes patency.

4-Dimensional hysterosalpingo-contrast sonography (4 D HyCoSy) using SonoVue is regarded as a really good option available for evaluating fallopian tubal patency. This study was designed to assess the pain and adverse effects incurred by women undergoing 4 D HyCoSy. Through evaluating the pelvic pain immediately after 4 D HyCoSy and 30 min after 4 D HyCoSy, the circumstances of the pain relief was also observed. The predictive factors of pain were assessed simultaneously. 827 consecutive women as part of infertility evaluation were included. The pain experienced was then assessed on a 10-cm visual analogue scale (VAS). Each patient was questioned to rate the pain at two different points of time (T1, immediately after 4 D HyCoSy; T2, 30 min after 4 D HyCoSy). 818/827 (98.9%) patients completed the procedure. Pain was experienced by 757/818 (92.5%) of subjects. 30 min after HyCoSy procedure, only 0.5% (4/818) patients feel severe pelvic pain and after 15-30 minutes of rest, these patients were relieved of pain. Age, cycle length, duration of menses, and duration of infertility were not significantly correlated with pain associated with 4 D HyCoSy as assessed by VAS. Women with tubal obstruction experienced a significant increase in 4 D HyCoSy-associated pain. There were significant differences in the degree of pain between different tubal patency (p <0.01). Overall, 4 D HyCoSy, a user-friendly, multidimensional technology, has the advantage of real-time, dynamic, well tolerated, and low serious complications, which make it a good way for evaluating fallopian tubal patency. The technique aids in making choices concerning further procedures for the diagnosis and treatment of infertility. Most of women experience pain associated with the procedure and 30 minute period of observation is useful.

Uterine rupture after balloon inflation of the intrauterine Foley catheter during laparoscopic chromopertubation.

Laparoscopic chromopertubation is considered "gold standard" for checking the tubal patency. Foley catheter is frequently used for blue dye during chromopertubation. Complications associated with the intra-uterine use of Foley catheter are infrequent. The mean normal capacity of the uterine cavity is about 9 ml, and an inflation of up to 30 ml (e. g. during thermal balloon ablation procedures) is considered safe. We report a uterine rupture in a 36-year-old woman undergoing laparoscopic chromopertubation due to primary infertility. Thirteen years ago, the patient had three consecutive laparotomies because of appendicitis, peritonitis and retroperitoneal abscess. For the present laparoscopy, the Foley catheter (Nelaton, charier 10, balloon 5 ml) was used. The first blocking of the balloon with 3.5 ml saline was insufficient; however after inflating with 5 ml, a rupture of the uterine fundus occurred. The balloon remained intact and both tubes appeared patent. The myometrium was sutured and the postoperative course was uneventful. We presume that-in the present case-the expansive capacity of the uterine wall may have been reduced after the series of severe pelvic inflammations. Nevertheless, if using a Foley catheter for the chromopertubation, the optimal pressure for its intrauterine fixation needs still to be determined.

Pain during Fallopian-tube patency testing by hysterosalpingo-foam sonography.

OBJECTIVES: To evaluate perception of pain during Fallopian-tube patency testing by hysterosalpingo-foam sonography (HyFoSy). METHODS: In this cross-sectional study, 216 consecutive women presenting at a university fertility clinic for HyFoSy examination were included. Patients were instructed to take ibuprofen 1 hour before the procedure. Immediately after the procedure, patients filled in a questionnaire concerning discomfort or pain experienced during the process, including a visual analog scale (VAS) score for perception of pain. RESULTS: The median VAS score for perception of pain during transvaginal ultrasound examination and during HyFoSy examination was 1.5 (95% CI, 1.2-1.7) and 3.6 (95% CI, 3.0-4.0), respectively. One-third of women reported that the level of discomfort or pain during HyFoSy examination was similar to that during the preceding transvaginal ultrasound examination and 48% of women considered HyFoSy examination to be neutral/unpleasant, but not painful. There was an inverse association between both patients' age and parity and the pain experienced. CONCLUSIONS: HyFoSy examination is tolerated well and allows for reliable tubal patency testing without exposing the patient to ionizing radiation in an outpatient setting with a low technical failure rate.

Hysterosalpingo-foam sonography, a less painful procedure for tubal patency testing during fertility workup compared with (serial) hysterosalpingography: a randomized controlled trial.

OBJECTIVE: To determine whether hysterosalpingo-foam sonography (HyFoSy) is a less painful first line tubal patency test than serial hysterosalpingography (HSG). DESIGN: A two-center, prospective, open-label, randomized, controlled trial. SETTING: University hospital and teaching hospital. PATIENT(S): 40 subfertile women, ages 18 to 41 years, with an indication for tubal patency testing as part of the fertility workup according to the Dutch Nederlandse Vereniging voor Obsteterie & Gynaecologie-guidelines. INTERVENTION(S): Tubal patency testing by HyFoSy versus serial HSG. MAIN OUTCOME MEASURE(S): Visual Analogue Scale (VAS) pain scores during tubal patency testing. RESULT(S): The median VAS score for pain perception during the HyFoSy procedure was 1.7 cm (interquartile range: 2.1) compared with 3.7 cm (interquartile range: 4.2) during HSG. The HyFoSy procedure also had a statistically significantly shorter procedure time compared with HSG, with a median of 5.0 minutes (interquartile range: 3.0) for HyFoSy versus 12.5 minutes (interquartile range: 16.0) for HSG. CONCLUSION(S): The HyFoSy procedure is a less painful and less time-consuming tubal patency test compared with HSG. CLINICAL TRIAL REGISTRATION NUMBER: Netherlands National Trial Register NTR3457.

Automated three-dimensional coded contrast imaging hysterosalpingo-contrast sonography: feasibility in office tubal patency testing.

OBJECTIVE: To evaluate the feasibility of transvaginal hysterosalpingo-contrast sonography (HyCoSy) with new automated three-dimensional coded contrast imaging (3D-CCI) software in the evaluation of tubal patency and visualization of tubal course. METHODS: Patients undergoing HyCoSy with automated 3D-CCI software were evaluated prospectively. First, to evaluate the feasibility of 3D visualization of tubal course, we performed consecutive volume acquisitions while injecting SonoVue contrast agent. We then performed conventional two-dimensional (2D) real-time HyCoSy to confirm tubal patency status by detection of saline and air bubbles moving through the Fallopian tubes and around the ovaries. We also evaluated visualization with CCI of the contrast agent around the ovaries, side effects and pain during and after the procedure, by visual analog scale (VAS) (ranging from 0 to 10, with 0 corresponding to no pain and 10 corresponding to maximum pain). RESULTS: A total of 126 patients (252 tubes) underwent 3D-CCI HyCoSy followed by 2D real-time HyCoSy. According to the final 2D real-time evaluation, bilateral tubal patency was observed in 111 patients, bilateral tubal occlusion in four patients and unilateral tubal patency in 11 patients. The concordance rate for tubal patency status between the first 3D volume acquisition and the final 2D real-time evaluation was 84% and that between the second 3D volume acquisition and the final 2D real-time evaluation was 97%. A pain score >5 on VAS was recorded in 58% of patients during the procedure, but a pain score ≤ 5 was recorded in 85.7% of patients immediately after the procedure. CONCLUSIONS: HyCoSy with automated 3D-CCI technology retains the advantages of conventional 2D HyCoSy while overcoming the disadvantages. 2D HyCoSy is highly observer-dependent and is only accurate in the hands of experienced investigators; by obtaining a volume of the uterus and tubes, automated 3D volume acquisition permits visualization of the tubes in the coronal view and of the tubal course in 3D space, and should allow less experienced operators to evaluate tubal patency status relatively easily.

Should a hysterosalpingogram be a first-line investigation to diagnose female tubal subfertility in the modern subfertility workup?

Tubal assessment is an integral part of female fertility evaluation. While diagnostic laparoscopy is gold standard, it is not suitable to be used as a screening test. Hysterosalpingogram (HSG) has been advocated as first-line investigation historically. With advances in diagnostics, more tests are available, such as hysterosalpingo contrast sonography (HyCoSy) and Chlamydia antibody titre (CAT) are available. The CAT test is much cheaper, less invasive and can be performed at any time during the cycle. The CAT test can also be used as a means of identifying which patients need further evaluation. HyCoSy has same diagnostic accuracy as HSG, without exposing women to radiation. We argue that HSG is out of date and has no place in a modern infertility evaluation. We also suggest a pathway (based on history, clinical and ultrasound evaluation) for investigations to screen for and diagnose tubal pathology.

Hysterosalpingo-contrast sonography versus radiographic hysterosalpingography in the evaluation of tubal patency.

OBJECTIVE: To compare the efficacy of hysterosalpingo-contrast sonography (HyCoSy) using a saline solution with that of radiographic hysterosalpingography (HSG) in the assessment of tubal patency. METHOD: We compared the findings obtained by the 2 methods with those obtained by standard diagnostic laparoscopy with the chromopertubation test in a study with 88 infertile women younger than 40 years. RESULTS: The sensitivity, specificity, and diagnostic accuracy of HyCoSy and HSG were similar, and 65 (74%) of the women reported the pain associated with HyCoSy as mild to moderate. CONCLUSION: The HyCoSy procedure is well tolerated and can be used as a primary tool for the evaluation of tubal patency in infertile women.

Chlamydia trachomatis in subfertile women undergoing uterine instrumentation. How we can help in the avoidance of iatrogenic pelvic inflammatory disease?

Guidelines drawn up for patients undergoing termination of pregnancy state that there should be a protocol for either screening or treating for Chlamydia trachomatis. So far guidelines for other techniques that require instrumentation of the uterus (e.g. hysterosalpingography) remain unclear and controversial. By looking for other less invasive techniques we will be able to avoid these problems in a proportion of cases. Screening or treatment should be performed in those cases requiring uterine instrumentation.

Methemoglobinemia following chromopertubation in treated pelvic tuberculosis.

Methylene blue administered through cervix is used to check tubal patency at laparoscopy. Although methylene blue is used to treat methemoglobinemia it can also produce methemoglobinemia in susceptible individuals. A case of methemoglobinemia induced by methylene blue in a patient with treated pelvic tuberculosis is presented.

Air embolus associated with tubal insufflation.

A patient underwent laparoscopy for a rectovaginal mass, dysmenorrhea, and infertility. After CO(2) pneumoperitoneum was established the laparoscope was placed without difficulty. Before the procedure was completed, the tubes were insufflated with air through a 20-ml syringe attached to a Cohen cannula. Tubes were patent. No other intraabdominal manipulation was performed at that time. During tubal insufflation the patient's end-tidal CO(2) decreased to 18%, partial pressure of oxygen decreased to 83%, and pulse increased to 130/minute. The CO(2) pneumoperitoneum was released, and the woman stabilized spontaneously. The CO(2) pneumoperitoneum was again established, with no further difficulty. The time relationship with tubal insufflation and lack of recurrence on reestablishing pneumoperitoneum suggest that air embolization during tubal insufflation occurred.

Methemoglobinemia induced by methylene blue pertubation during laparoscopy.

Methylene blue is used to check tubal patency during laparoscopy. A case of methemoglobinemia which was induced by methylene blue is presented. Methemoglobinemia is usually treated with methylene blue; however, in patients with glucose-6-phosphate dehydrogenase deficiency, methylene blue can induce methemoglobinemia.

Pulmonary edema following intrauterine methylene blue injection.

Methylene blue is a commonly used dye in diagnostic procedures such as fistula detection, delineation of body tissues during surgery and for checking the patency of fallopian tubes. Many such dyes interfere with accurate measurement of oxygen saturation by a pulse oximeter. We report here a case in which methylene blue hot only interfered with pulse oximetery but also caused pulmonary edema in an ASA grade 1 patient.

Inflammatory peritonitis with ascites after methylene blue dye chromopertubation during diagnostic laparoscopy.

An uneventful chromopertubation was performed with methylene blue dye during diagnostic laparoscopy for infertility. Approximately 24 hours later the woman experienced acute abdominal distention and pain. Emergency exploratory laparotomy revealed peritoneal ascites consistent with a sterile inflammatory exudate. No visceral injury was found. The patient was treated empirically with corticosteroids with resolution of her symptoms.

Transcervical tubal cannulation and salpingoscopy in the treatment of tubal infertility.

Transcervical tubal cannulation and salpingoscopy are two recent techniques used for the evaluation of tubal patency and pathology. Selective tubal cannulation cannot determine the nature of the obstructive process, although it does allow for the demonstration of potential tubal patency. This may be important in deciding whether therapies requiring tubal patency may be used in specific clinical situations. Because currently there are no controlled studies in the literature evaluating this technique, the therapeutic value of the procedure must be considered unproven at this time. Salpingoscopy gives more detailed information concerning the tubal mucosa. The identification of specific tubal lesions has been described with this modality. The predictive value of salpingoscopy in cases of severe anatomic distortion, ie, fibrous obliteration, seems obvious. However, its predictive value in the presence of more subtle lesions needs to be studied further because its role as a therapeutic modality is as yet undefined.

[Effect of hydrotubation on the anatomical state of oviducts in women with mechanical infertility]. / Wplyw hydrotubacji na stan anatomiczny jajowodów u kobiet z nieplodnoscia mechaniczna.

The aim of the paper was to evaluate the anatomical state of uterine adnexa in women operated on due to mechanical infertility. Hydrotubation were previously applied in 31 women stemming from various centres in the country, while in 31 such a treatment was not performed at all. The mentioned groups of women were encumbered, to a similar degree, with a risk factor of infertility, except for the duration of sterility, which in those treated by hydrotubation lasted on the average 2 years longer. From 5 to 50 hydrotubations were carried out, most frequently in series of 5 procedures. It was reported by the women that 8 of them after hydrotubation experienced hypogastric pain persisting for some days, and in 6 there was acute adnexitis. Destructive changes in uterine adnexa, being estimated during the reconstructive operation, were decidedly more advanced in women treated by hydrotubation. That was expressed mainly by frequent appearance of lytic adhesions as well as by more advanced fibrosis of oviducts, particularly that of endosalpinx. Unchanged oviducts, after their release from adhesions, also appeared less frequently.