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ORIGINAL ARTICLE
Ahead of print publication  

Comparison of transvaginal sonography with hysteroscopy in evaluation of uterine cavity anomalies for female Nigerian patients


1 Oak Endoscopy Centre; Department of Radiology, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria
2 Oak Endoscopy Centre; Department of Surgery, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria

Date of Submission31-Oct-2020
Date of Acceptance22-Jan-2021
Date of Web Publication03-May-2021

Correspondence Address:
Emeka Ray-Offor,
Department of Surgery, University of Port Harcourt Teaching Hospital, PMB6173, Port Harcourt, Rivers State
Nigeria
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ajiac.ajiac_16_20

  Abstract 


Introduction: Transvaginal sonography (TVS) and hysteroscopy are useful in investigating causes of intrauterine pathologies. Aim: To compare the diagnostic yield of TVS with hysteroscopy for the evaluation of uterine cavity anomalies in female Nigerian patients. Materials and Methods: This is a cohort study of patients referred with infertility and abnormal uterine bleeding that were consecutively evaluated with TVS by a radiologist and confirmed by hysteroscopy at a multi-disciplinary endoscopy centre in Port Harcourt metropolis, Nigeria. Study period was from June 2014 to November 2019. Variables collated were sociodemographic, radiological, and endoscopic findings, sensitivity, specificity, and predictive values. Statistical analysis was with SPSS version 20. Results: A total of 99 patients had hysteroscopy but 52 patients included in study. The age of patients ranged from 25 – 56 years; mean age of 39.4 ± 6.0 years. The sensitivity and specificity of TVS for detection of intracavitary uterine anomalies were 78.7% and 100% respectively. The positive and negative predictive values were 100% and 33.3% respectively. There was additional detection of intramural ± subserosa myoma by TVS alone in 28(53.8%) patients and ovarian cysts in 5(9.6%) patients. Conclusion: TVS is an effective screening tool for preoperative triage of women with infertility and abnormal uterine bleeding requiring therapeutic intervention for intracavitary uterine anomalies. Hysteroscopy remains the gold standard for diagnosis of endometrial pathologies.

Keywords: Hysteoscopy, sensitivity, specificity, transvaginal sonography



How to cite this URL:
Ray-Offor OD, Ray-Offor E. Comparison of transvaginal sonography with hysteroscopy in evaluation of uterine cavity anomalies for female Nigerian patients. Afr J Infertil Assist Concept [Epub ahead of print] [cited 2021 Nov 28]. Available from: https://www.afrijiac.org/preprintarticle.asp?id=315391




  Introduction Top


The normal adult uterus, which is in the pelvis, is the seat of multiple physiologic and pathologic processes. The anatomy and the contour of this structure can be assessed by an abdominal or transvaginal ultrasound probe. A switch to color Doppler mode enables the assessment of vascularity within lesions. In the past four decades, transvaginal sonography (TVS) has become the first-choice modality for the evaluation of the endometrium.[1] It is relatively cheap, noninvasive and does not involve ionizing radiation. Saline hysterosonography consists of TVS with concomitant instillation of normal saline as a sterile echogenic contrast medium into the uterine cavity using a transcervical catheter.[2] TVS and saline hysterosonography are superior to hysterosalpingography in the assessment of intrauterine pathologies.[3] However, hysteroscopy is the only technique that provides direct visualization of the uterine cavity, and it is therefore effective in the diagnosis and treatment of intrauterine pathologies.[4]

Hysteroscopy is indicated for the evaluation and/or treatment of the uterine cavity, tubal ostia, and endocervical canal in women with uterine bleeding disorders, Müllerian tract anomalies, retained intrauterine contraceptives or other foreign bodies, retained products of conception, desire for sterilization, recurrent miscarriage, and subfertility.[5] In day-to-day practice, a diagnostic hysteroscopy confirming the presence of pathology is followed by an operative hysteroscopy in a symptomatic woman. Hysteroscopy is the gold standard in assessing endometrial factor infertility; however, its awareness in our environment is still at base level.[6],[7] There is a paucity of African literature comparing diagnostic yield of TVS with hysteroscopy findings.

This study aims to objectively compare the diagnostic yield of TVS with hysteroscopy for the evaluation of uterine cavity anomalies in female Nigerian patients.


  Materials and Methods Top


Study setting

This study was conducted in a referral multidisciplinary endoscopy center in Port Harcourt metropolis of Rivers State Nigeria. The center also serves patients from neighboring states of the Niger Delta region of Nigeria.

Study design

This was a prospective cohort study of all consecutive patients referred with infertility and abnormal uterine bleeding being evaluated with TVS by a radiologist and confirmed by hysteroscopy. Ethical clearance was obtained from the study center. Patients with no assessment by TVS performed within the study center prior to hysteroscopy were excluded from the study. The variables studied were sociodemographic, radiological, and endoscopic findings and sensitivity, specificity, and predictive values. An informed consent was obtained according to the Helsinki declaration during preprocedure clinic visit. A careful clinical evaluation for comorbidities was done with relevant laboratory tests ordered.

Transvaginal sonography

Transvaginal scan was performed by the same radiologist (ORO) in the follicular phase after menstrual flow using a transvaginal 6 MHZ transducer probe (DC 6 Mindray Ultrasound machine Mindray China). Patients were asked to lie on their backs with knees flexed. The transvaginal probe was covered with a probe cover before insertion into the vagina fornices. The endometrial cavity was visualized in two planes longitudinal and transverse. The endometrium was judged abnormal when it was equal to or thicker than 15 mm in the premenopausal period and equal to or thicker than 8 mm in the postmenopausal period. The presence of intracavitary uterine abnormalities was observed as diffuse or focal. Submucous myoma was defined as iso-/hypo-echoic solid masses with shadowing located at the myometrial–endometrial juncture. They were further assessed based on their size; location as anterior, posterior, or fundal; and their involvement of the muscular layers. Endometrial polyps were defined as predominantly echogenic endometrial lesions with or without a vascular pedicle and thin fluid rim, while adhesions were defined as irregular, thinned endometrial lining with areas of bands and calcification. Other abnormalities were noted.

Hysteroscopy

Hysteroscopy was scheduled after TVS in the follicular phase of the same cycle and performed by a gynecologist and a surgical endoscopist (ERO). There was no ripening of cervix done for diagnostic procedures, but there was routine insertion of 400 μg misoprostol into the posterior vaginal fornix the day preceding procedure for planned use of resectoscope. For diagnostic hysteroscopy, conscious sedation using intravenous benzodiazepine (diazepam 5–10 mg) and an opioid analgesic (pentazocine 30 mg) with intracervical infiltration of 1% lidocaine were administered. Spinal anesthesia was the preferred choice of pain management for operative hysteroscopy and administered by an anesthetist, but general anesthesia was offered to patients who objected to regional anesthesia after due counseling. The patient was put in lithotomy position and a “nontouch” technique was used to gain access into the uterine cavity using a Bettocchi hysteroscope with a 30° rod-lens telescope, (Karl Storz GbmH and Co., Tutlingen, Germany). A complete visualization of endometrial cavity was done with a video record of each procedure. For operative procedures, a Sims speculum was inserted into the vagina and anterior cervix grasped with tenaculum. The cervix was dilatated using Hegar's dilator size 6 to admit a 5 mm resectoscope. Normal saline was the distension medium for diagnostic procedures and instilled at a controlled pressure of 100–150 mmHg, but for operative hysteroscopy, 1.5% glycine was the distension medium used. The resection was performed using monopolar energy. Fluid deficit was estimated manually after the procedure.

Postprocedure

There was monitoring of vital signs for a minimum of 30 min postprocedure or till full recovery before same-day discharge. A prescription of doxycycline, metronidazole, and analgesics was given.

Statistical analysis

The results were summarized as numbers, mean + standard deviation, and percentages as appropriate using IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY, USA. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value were calculated.


  Results Top


A total of 99 female patients had hysteroscopy during the study period, but 52 patients underwent a preprocedure TVS evaluation in the center thus met the inclusion criteria. The age of patients ranged from 25 to 56 years and mean age of 39.4 ± 6.0 years. Nearly half of the study population was in the fifth decade of life – 27 (51.9%). The second most frequent age group was 30-39 years- 21(40.4%). Three patients and a sole patient were recorded in the third and sixth decades of life, respectively [Figure 1].
Figure 1: Transvaginal sonography hysteroscopy

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There was a high literacy rate in the study group with about four-fifth of patients having a tertiary level of education [Table 1]. One-half of patients were para 0 as the major indication for hysteroscopy was infertility in 42 (80.8%) patients. Abnormal uterine bleeding was the indication for procedure in 10 (19.2%) patients [Figure 2].
Figure 2: Indication for hysteroscopy in the study population

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Table 1: Sociodemographic of study population

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The three most common pathologies detected by TVS in decreasing order of frequency were submucous myoma 17 (32.7%), intrauterine adhesion 9 (17.3%), and endometrial polyps 2 (3.8%). A diagnosis of submucous myoma(s) was confirmed at hysteroscopy in addition to detection of two false-negative cases from TVS. There were ten false-negative cases of endometrial polyp at TVS [Table 2]. A total of 15 cases of intrauterine adhesion were confirmed at hysteroscopy despite only 11 cases detected by the preceding TVS (four false negatives). Fifteen patients had no detectable intracavitary uterine lesion at TVS, but only five of these were confirmed as having no pathology during hysteroscopy (ten false positives). The PPVs for submucous myomas, intrauterine adhesions, and endometrial polyps by TVS were 89.5%, 73.3%, and 16.7%, respectively.
Table 2: Intracavitary uterine anomalies at transvaginal sonography and hysteroscopy

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Dual pathologies were detected in six hysteroscopies [Table 3]. TVS was used to detect intramural ± subserous myoma in 28 patients and adnexal pathologies of four cases (ovarian cysts). Generally, the sensitivity and specificity of TVS for detecting the presence of an intracavity uterine anomaly were 78.7% and 100%, respectively [Table 4].
Table 3: Multiple pathologies detected at transvaginal sonography and hysteroscopy in study population

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Table 4: Comparison of transvaginal sonography with hysteroscopy in the detection of intracavitary uterine anomalies

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  Discussion Top


Transvaginal ultrasonography is an affordable evaluation tool for gynecological pathologies. In this study of Nigerian female patients, transvaginal ultrasonography recorded a sensitivity and specificity of 78.7%, 100%, 100%, and 33.3%, respectively, for intracavitary uterine anomalies. This validates TVS as a noninvasive and effective screening tool for preoperative triage of female infertility and abnormal uterine bleeding requiring therapeutic intervention for intracavitary uterine anomalies. To the best of our knowledge, this is the first study in Nigerian patients objectively correlating findings of TVS with hysteroscopy in the assessment of intrauterine pathologies. Reports of similar studies from Europe and Asia have similar sensitivity and specificity for TVS.[8],[9] Hysteroscopy has the advantage of direct visualization, biopsy, and treatment but not widely practiced in our environment.

The primary indications for hysteroscopy in the study population were infertility and abnormal uterine bleeding [Figure 2]. These are common problems affecting women worldwide. Infertility can be defined as failure to conceive following 12 months of regular unprotected sex.[10] It can further be classified as primary or secondary infertility with primary infertility referring to a situation where the couple has never achieved conception, while secondary infertility is when there has been a previous pregnancy involving at least one individual in the couple. Basic investigations for female infertility include the assessment of cervical, uterine, tubal, and ovulatory factors. Endometrial factors in infertility refer to causes within the endometrium. These range from endometrial polyps, submucous myoma, endometrial hyperplasia, adhesions, foreign bodies, and endometrial cancers. An accurate diagnosis of these endometrial abnormalities has become a core part of fertility workup.

The three most common intracavitary anomalies diagnosed both by TVS and hysteroscopy in decreasing order of frequency were submucous myoma, intrauterine adhesions, and endometrial polyps. This is unlike reports from other Nigerian hysteroscopy studies with intrauterine adhesion and endometrial polyps more frequently seen than myomas in women with infertility.[11],[12] There was a high PPV of TVS for submucous myoma at 89.5%. In contrast, the PPV of TVS for endometrial polyps was low at 16.7%. The use of saline hysterosonography which comprises TVS with the instillation of contrast (saline) into the uterine cavity during the scan is reported to improve the sensitivity of test results.[13],[14] The contrasting agent gives clearer detail of the endometrium and myometrium. It remains unclear the precise mechanism by which endometrial polyps result in infertility; their removal has been reported to increase fertility.[15]

Hysteroscopy has the advantage of directly visualizing the uterine cavity and endometrium but cannot comment on myometrial or ovarian pathology. More than half of patients were noted to have intramural or subserosa myoma by TVS alone. Furthermore, there was detection of ovarian cysts in five patients. In day-to-day practice, a diagnostic hysteroscopy confirming the presence of pathology will be followed by an operative hysteroscopy in a symptomatic woman. The therapeutic procedures performed in study population included myomectomies, polypectomies, foreign-body retrieval, and adhesiolysis. There is the need to encourage the training and practice of hysteroscopy in our environment for its minimal access benefits of shorter hospital stay, better cosmesis, and reduced postoperative pain.

A limitation to this study is the probability of sampling/selection bias as the majority of patients were referred from a fertility center. Although the radiologist was blinded to any prior radiology study result, the knowledge of referral center may have induced a closer search for a uterine pathology.


  Conclusion Top


Hysteroscopy remains the gold standard for diagnosis and treatment of intracavitary uterine anomalies. TVS has a screening role in the preoperative triage for women, especially with submucous myoma requiring therapeutic intervention for female infertility and abnormal uterine bleeding. TVS has an advantage over hysteroscopy in the additional detection of myometrial and/or adnexal pathologies.

Acknowledgment

We wish to acknowledge Dr. Tamunomie Kennedy Nyengidiki, Elijah Onwudiwe, Solomon Amadi, and Kalanne Opusunju for their technical assistance in the conduct of this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Babacan A, Gun I, Kizilaslan C, Ozden O, Muhcu M, Mungen E, et al. Comparison of transvaginal ultrasonography and hysteroscopy in the diagnosis of uterine pathologies. Int J Clin Exp Med 2014;7:764-9.  Back to cited text no. 1
    
2.
Berridge DL, Winter TC. Saline infusion sonohysterography: Technique, indications, and imaging findings. J Ultrasound Med 2004;23:97-112.  Back to cited text no. 2
    
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Philips CH, Benson CB, Ginsburg ES, Frates MC. Comparison of uterine and tubal pathology identified by transvaginal sonography, hysterosalpingography, and hysteroscopy in female patients with infertility. Fertil Res Pract 2015;1:20.  Back to cited text no. 3
    
4.
Bettocchi S, Ceci O, di Venere R, Pansini MV, Pellegrino A, Marello F, et al. Advanced operative office hysteroscopy without anaesthesia: Analysis of 501 cases treated with a 5 Fr. bipolar electrode. Hum Reprod 2002;17:2435-8.  Back to cited text no. 4
    
5.
Bosteels J, van Wessel S, Weyers S, Broekmans FJ, D'Hooghe TM, Bongers MY, et al. Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities. Cochrane Database Syst Rev 2018;12:CD009461.  Back to cited text no. 5
    
6.
Snowden EU, Jarrett JC 2nd, Dawood MY. Comparison of diagnostic accuracy of laparoscopy, hysteroscopy, and hysterosalpingography in evaluation of female infertility. Fertil Steril 1984;41:709-13.  Back to cited text no. 6
    
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Soares SR, dos Reis MM, Camargos AF. Diagnostic accuracy of sonohysterography, transvaginal sonography, and hysterosalpingography in patients with uterine cavity diseases. Fertil Steril 2000;73:406-11.  Back to cited text no. 7
    
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Ryu J, Kim B, Lee J, Kim S, Lee SH. Comparison of transvaginal ultrasonography with hysterosonography as a screening method in patients with abnormal uterine bleeding. Korean J Radiol 2004;5:39-46.  Back to cited text no. 8
    
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Narayan A, Goswamy RK. Transvaginal sonography of the uterine cavity with hysteroscopic correlation in the investigation of infertility. Ultrasound Obstet Gynecol 1993;3:128-33.  Back to cited text no. 9
    
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Zegers-Hochschild F, Adamson GD, Dyer S, Racowsky C, de Mouzon J, Sokol R, et al. The international glossary on infertility and fertility care, 2017. Fertil Steril 2017;108:393-406.  Back to cited text no. 10
    
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Okohue JE, Onuh SO, Akaba GO, Shaibu I, Wada I, Ikimalo JI. A 3-year review of hysteroscopy in a private hospital in Nigeria. World J Lap Surg 2009;2:26-9.  Back to cited text no. 11
    
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Ugboaja JO, Oguejiofor CB, Igwegbe AO, Oranu EO. Abnormal hysteroscopy findings among a cross section of infertile Nigerian women. Niger J Clin Pract 2019;22:9-15.  Back to cited text no. 12
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Badu-Peprah A, AOdoi AT, Dassah ET, Amo-Wiafe Y. Sonohysterography: Time to step up its use in gynaecologic imaging in West Africa. Afr J Reprod Health 2011;15:133-9.  Back to cited text no. 13
    
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Alborzi S, Parsanezhad ME, Mahmoodian N, Alborzi M. Sonohysterography versus transvaginal sonography for screening of patients with abnormal uterine bleeding. Int J Gynaecol Obstet 2007;96:20-3.  Back to cited text no. 14
    
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Varasteh NN, Neuwirth RS, Levin B, Keltz MD. Pregnancy rates after hysteroscopic polypectomy and myomectomy in infertile women. Obstet Gynecol 1999;94:168-71.  Back to cited text no. 15
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

 
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