INTRODUCTIONThe outcome of assisted reproductive technique largelydepends on the receptivity of the endometrial liningof the uterus. Measures aimed at evaluating the uterinecavity prior to treatment are very vital for decisionmaking and hence contribute to the overall successrate. The true prevalence of intrauterine lesions ininfertile women is not known but some studies havereported an incidence of about 16–24%1.

Saline infusion sonohysterography (SIS) is variouslyreferred to as sonohysterography, hysterosonographyand transvaginal sonography (TVS) with fluid contrastaugmentation2. It is a technique which involves theintroduction of a catheter into the endometrial cavityand sterile saline subsequently instilled to separate thewalls of the endometrium in order to visualize theendometrial cavity. The anechoic fluid is thenjuxtaposed against the echogenic endometrium, givingexquisite detail of the uterine lining.

Routine office hysteroscopy is a vital tool in theevaluation of the infertile patient. However screeningwith saline infusion sonohysterography yields similardiagnostic results but less invasive, better tolerated andless expensive3. Additionally with saline infusionsonohysterography, the adnexa can also be simulta-neously evaluated. These advantages may warrant itsroutine use as a useful screening tool before in vitrofertilization2,3.

The objectives of this study are to evaluate the practiceof routine saline infusion sonohysterography prior toassisted conception and to describe the findings andcomplications arising from the procedure.

MATERIALS AND METHODSA descriptive, retrospective study of all patients whohad routine saline infusion sonohysterography, at aprivate fertility clinic, prior to in vitro fertilization,between January 2008 and December, 2010. A totalof 760 patients had saline infusion sonohysterographyand the relevant data were extracted from their recordsand analyzed using SPSS version 17. Descriptive datawere presented in (%) for qualitative data and in themean ± SD and median (range) for quantitative data.The results of saline infusion sonohysterography werecompared with hysteroscopy and the following werecalculated for each examination: sensitivity, specificity,positive predictive value and negative predictive value.

TECHNIQUEThe procedure was carried out between days 5-10 ofthe menstrual cycle in patients who were menstruatingregularly. For postmenopausal women, it was carriedout after a withdrawal bleeding was achieved followingadministration of provera (medroxyprogesteroneacetate). This was to ensure that the test was done whenthe endometrium was thinnest and also to exclude earlypregnancy. Bleeding was not a contraindication toperforming saline infusion sonohysterography;

1. Department of Obstetrics & Gynaecology, University College Hospital, Ibadan2. Department of Obstetrics & Gynaecology, The Bridge Clinic, Victoria Island, Lagos

ROUTINE SALINE INFUSION SONOHYSTEROGRAPHY PRIOR TO ASSISTEDCONCEPTION: A REVIEW OF OUR INITIAL EXPERIENCE

G. Obajimi1 and B. Ogunkinle2

Correspondence:Dr. G. ObajimiDepartment of Obs. & Gynae.,University College Hospital,Ibadan.E-mail: gbolee@yahoo.com

ABSTRACTSaline infusion sonohysterography has been employed to evaluate the uterinecavity prior to commencement of assisted conception.Intra-uterine lesions playan important role in the outcome of assisted conception procedures. A descriptiveretrospective study of 760 patients who had saline infusion sonohysterographyprior to assisted conception, between January 2008 and December, 2010. Forty-sixpercent of the patients had intra-uterine pathologies. Submucous fibroidsaccounted for almost half (48.57%) of the pathologies, followed by adhesions(28.57%) and endometrial polyps (22.86%). Complications arising from theprocedure were minor and occurred in 26 patients (3.42%). Abdominal cramps,vaginal bleeding and vaginal discharge occurred in 14 (53.85%), 8 (30.77%) and 4(15.38%) respectively. The average duration of the procedure was 6 minutes witha range of 4-9 minutes. Saline infusion sonohysterography is a reliable, cost effectiveand safe diagnostic tool in the evaluation of the uterine cavity prior to assistedconception.

Keywords: Routine, Saline infusion sonohysterography, Assisted conception, Experience.

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however, it was avoided whenever possible, as theblood clot could give false positive results.

Preparation for the examination involved counselingabout the procedure and obtaining an informedconsent. Ten milligram (10mg) hyosine bromide tabletwas given 30 minutes before the procedure tominimize abdominal cramps. The instruments used forthe procedure were: a sterile speculum with an openside, cervical sounds in the event that the catheter didnot pass easily through the cervix, a 20-mL syringe, atenaculum, and a Wallace classic embryo replacementcatheter (Smith Medical) used to introduce the salineinto the endometrial cavity.The patient was placed in the lithotomy position,cleaned and draped. A sterile speculum was placed inthe vagina, and the cervix was brought into view. Thecervix was then cleansed with antiseptic solution. TheWallace classic embryo replacement catheter wasplaced at the external cervical os, and then advancedinto the endometrial cavity. The speculum was carefullyremoved, and the transvaginal probe reinserted besidethe catheter. Under transvaginal sonographic guidance(GE logiq 5 expert), approximately 10 to 30 ml ofwarm sterile saline was injected. Sonographic evaluationof the endometrial cavity was performed in bothcoronal and sagittal planes by the Gynaecologist trainedin basic sonography. The catheter was then removedand the procedure completed. Prophylactic antibioticwith augmentin (amoxicillin/clavulanic acid) 625mgtwice daily for 5 days was administered.

RESULTSA total of 760 patients had saline infusionsonohysterography during the period of study. Themean age of the study group was 38.4 ± 6.70 years.

The mean body mass index was 24.0 ± 3.76 Kg/m2.Majority of the patients (78.6%) had secondaryinfertility with varying duration. About 45% haddurations between 5-9 years underscoring the unduedelay in seeking assisted conception services in ourenvironment. This however may be as a result of lackof sufficient funds for the procedure or poorknowledge about its availability. Over 90% of thepatients had tertiary education and were literate.

Variable n (%)Age (years) (mean+SD) 38.4 ± 6.70BMI (Kg/m2) (mean+SD) 24.0 ± 3.76

InfertilityPrimarySecondaryUnexplained

12859735

16.878.64.6

Education (Highest level)PrimarySecondaryTertiary

245713

0.35.9

93.8Duration of infertility (years)1-45-910-14>15

22834213753

30.045.018.07.0

Table 1: Patient’s demographics and duration ofinfertility

Findings n %Absent 411 54Pathology 349 46Submucous myoma 167 48Intra-uterine adhesions 140 40Endometrial polyps 41 12ComplicationsAbdominal cramps 14 53.8Vaginal bleeding 8 30.8Vaginal discharge 4 15.4Average duration (minutes) (mean+SD) 6.1 ± 2.6

Table 2: Sonohysterography findings/complications

Pathology Sonohysterography H ysteroscopySubmucous myoma 168 173Intra-uterineadhesions

140 144

Endometrial polyps 41 32

Table3: Comparison with hysteroscopy.

Sensitivity Specificity PPV NPV

Myoma 0.96 0.95 0.95 0.96Adhesions 0.93 0.97 0.97 0.95Polyps 0.94 0.97 0.78 0.99

Table 4: Diagnostic accuracy parameters of SIS for submucousmyoma, intra-uterine adhesions and endometrial polyps withrespect to hysteroscopic diagnosis

Clientele for assisted conception services in Nigeriamostly belong to the upper educated class of patientswho are often gainfully employed and financially stable.Forty-six percent of the patients had identifiableintrauterine lesions. Submucous fibroids constitutedalmost half of the intrauterine lesions (48%) whileendometrial polyps were the least detected lesions(12%).The diagnostic accuracy of saline infusionsonohysterography for fibroids and polypoid lesions

SIS, saline infusion sonohysterography, PPV, positive predictive value,NPV, negative predictive value

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was in agreement with subsequent hysteroscopyfindings (sensitivity of 96% and 94%, respectively).

Complications arising from the procedure were minorand not life threatening. Twenty six patients (3.42%)had complications as detailed in table 2. Abdominalcramp was the most encountered complaint andoccurred in over half of the patients (53.8%). Theaverage duration of the procedure was 6 minutes witha range of 4–9 minutes. Hence it can be adjudged aquick and safe screening tool.

DISCUSSIONSaline infusion sonohysterography takes advantage ofsaline as a negative contrast agent during transvaginalscanning and utilizes the uterine distension propertiesof saline, to reveal structural anomalies of theendometrial cavity4. Since uterine abnormalities underlieinfertility in close to 15% of patients seeking treatment,thorough diagnostic procedures, including modernimaging techniques in the evaluation of infertile womenare important4. In this study, uterine abnormalities werefound in 349 patients representing 46% of the studypopulation. This further emphasizes the importanceof uterine cavity evaluation before the commencementof assisted conception in the tropics.

The average age at presentation was 38.4 ±6.7 yearswith majority of the patients infertile for between 5-9years, invariably allowing considerable idle time foruterine lesions to develop due to prolonged intervalprior to conception. This may not be unrelated to theexpensive cost of assisted conception in the tropicsaveraging about 6,000 US dollars per cycle. Thepractice of fee for service in the absence of healthinsurance is also an important contributor to delayedfertility treatment. Secondary infertility accounted forgreater than three quarters of the study population inkeeping with a high rate of infectious morbidity in thetropics coupled with an increased propensity to seekingunorthodox care.

The procedure lasted averagely 6 minutes and was doneon an outpatient basis. As detailed earlier, instrumentsrequired for the procedure are relatively simple andgenerally disposable. However care must be taken toensure good transvaginal probe hygiene by ensuringthat the probe is covered with either a sterile probecover or a latex male condom. It is our practice to usea latex male condom as protective covering in orderto minimize cost.

Saline infusion sonohysterography has been performedwith various catheters including a flexible sterilecatheter, 2mm neonatal suction catheter5, 10 French

Nelaton catheter, 8–12-Fr Foley catheter and Cooksoft 500 IVF transfer catheter6. However in this study,we used the Wallace classic embryo replacementcatheter due to its availability, flexibility and ease ofpassage through the cervical os. Saline infusionsonohysterography also doubles as a mock embryotransfer procedure since the Wallace classic embryoreplacement catheter is our preferred choice on theday of actual embryo transfer.

Complications arising from the procedure expectedlywere minor and occurred in 26 patients (3.42%).Abdominal cramps being the most encountereddespite routine administration of 10mg hyosinebromide, an antispasmodic drug that blocks theparasympathetic pathway with the onset of actiontaking 30 minutes from oral administration. Variousstudies have been done on the analgesic requirementfor saline infusion sonohysterography and the majormechanism of pain was as a result of fluid distentionof the uterine cavity, resulting in the local release ofprostaglandins causing delayed rather than immediatepain7. However no statistically significant difference inpain relief was noted with the use of mefenamic acidor hyoscine bromide tablets7.

The diagnostic accuracy of saline infusionsonohysterography for submucous myoma,endometrial polyps and intrauterine adhesions was inmarked agreement with hysteroscopy, the goldstandard in the present study (sensitivity of 96%, 94%and 93%, respectively). A meta-analysis by Kroon et alin 2003 showed that the diagnostic accuracy of salineinfusion sonohysterography equals the accuracy ofdiagnostic hysteroscopy8. From our study, salineinfusion sonohysterography is a useful screening toolin evaluating the endometrial cavity with its highnegative predictive value (NPV) for submucousmyoma (96%), endometrial polyp (99%) andintrauterine adhesions (95%).

This study relied on data obtained from case recordsand may have been subjected to observer bias.However, a large number of patients were studiedand observer errors may not contribute significantlyto the outcome of study.

Various studies have evaluated saline infusionsonography and hysteroscopy and have been able toprove that it is quite accurate and cost effective ascompared to hysteroscopy9,10. Its comparable findingswith hysteroscopy, minimal risk, shorter duration ofprocedure and lower cost merits recommendation asan initial out-patient screening tool in infertility workup especially in the tropics.

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CONCLUSIONSaline infusion sonohysterography is a reliable, costeffective and safe out-patient screening tool for theevaluation of the endometrial cavity prior to assistedconception. It is less invasive, better tolerated andoffers simultaneous evaluation of the adnexa at thesame sitting. Routine use prior to assisted conceptionwould serve as a filter mechanism to reliably andefficiently exclude intrauterine lesions, therebyinfluencing decision making and overall outcome offertility treatment.

ACKNOWLEDGEMENTOur sincere appreciation goes to the management andstaff of Nordica Fertility Centre, Lagos.

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3. Kim AH, McKay H, Keltz MD, et al .Sonohysterograhic screening before in vitrofertilization. Fertil Steril 1998;68:841-844.

4. Brown SE, Coddington CC, Schnorr J, et al.Evaluation of outpatient hysteroscopy, salineinfusion sonohysterography, and hysterosalpingo-graphy, in infertile women: a prospective,randomized study. Fertil Steril. 2000;74:1029–1034.

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6. Bingol B, Gunenc Z, Gedikbasi A, et al .Comparison of diagnostic accuracy of salineinfusion sonohysterography, transvaginalsonography and hysteroscopy. Journal ofObstetrics and Gynaecology 2011;31(1): 54–58.

7. Rossathum J, Singpetch S, Somsin P, et al. Efficacyof mefenamic acid and hyoscine for pain reliefduring saline infusion sonohysterography in infertilewomen: a double blind randomized controlledtrial. European Journal of Obstetrics &Gynaecology and Reproductive Biology 2011;155(2):193-198.

8. Kroon CD, Bock GH, Dieben SW, Jansen FW.Saline contrast hysterosonography in abnormaluterine bleeding: a systematic review and meta-analysis. BJOG. 2003;110:938–947

9. Hamilton JA, Larson AJ, Lower AM, et al.Routine use of saline hysterosonography in 500consecutive, unselected, infertile women. HumReprod. 1998;13: 2463–2473

10. Salim R, Lee C, Davies B, et al. A comparativestudy of three-dimensional saline infusionsonohysterography and diagnostic hysteroscopyfor the classification of submucous fibroids. HumReprod. 2005;20:253–257

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