1 Department of Obstetrics and Gynecology and 2 Department of Perinatology, Kagawa Medical University, 17501 Ikenobe, Miki, Kagawa 761-0793, Japan
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Abstract |
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Key words: endometrium/high-frequency, real-time miniature transducer/normal menstrual cycle/saline infusion contrast intrauterine sonography/transvaginal sonography
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Introduction |
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With recent advances in miniaturization of the ultrasound transducer, Goldberg et al. (1991) showed the feasibility of passing flexible catheter-based high-resolution real-time ultrasound transducers into the endometrial canal and Fallopian tube to examine uterine abnormalities. Potential obstetric and gynaecological applications of intrauterine sonography for systematic examination of the developmental stages of the early embryo or detection of gross embryonic malformations have also been reported (Fujiwaki et al., 1995; Kikuchi et al., 1995
, 1996
; Tsuda et al., 1996
; Hata, 1996
; Hata et al., 1996
, 1997a
, Hata et al., b
, 1998
; Senoh et al., 1999).
The objective of the current study was to determine whether saline infusion contrast intrauterine sonography with high-frequency, real-time miniature transducer is useful for the evaluation of cyclic changes of the endometrial interface and texture during a normal menstrual cycle.
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Materials and methods |
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First, each patient was prepared and draped in the usual sterile fashion in the dorsolithotomy position. Before each intrauterine sonography procedure, an evaluation of the endometrium was performed by transvaginal sonography (7.5 MHz Mochida MEU-1581®; Mochida, Tokyo, Japan) with a sterile probe cover. A sterile speculum was inserted into the vagina. The ultrasonic catheter was introduced gently through the cervix and into the endometrial cavity until it could not be advanced any further. Once within the endometrial cavity, the catheter tip was advanced or withdrawn slightly until the endometrial texture was visualized. Next, after removal of the intrauterine ultrasound catheter, 12 ml of sterile saline solution was injected into the endometrial cavity with a catheter for artificial insemination, to compare sonographic images with and without saline in either the transvaginal or intrauterine sonographic technique. Then transvaginal sonography and intrauterine sonography were again sequentially performed. Endometrial biopsy was performed after ultrasound examinations, using a metal curette placed high in the uterine cavity (biopsy curette, CM-5283®; Atom, Tokyo, Japan). The endometrial sample was dated by an independent senior pathologist who was blinded to any clinical information concerning the study group. The criteria of Noyes et al. (1950) were used for endometrial dating. Each procedure was done in proliferative, and early or mid-secretory phase of the menstrual cycle in each patient. Ovulation was confirmed using ultrasound and basal body temperature in all patients. After all procedures, prophylactic antibiotics were administered in all patients. The subjective assessment of overall image clarity was compared between transvaginal and intrauterine sonography. Hormonal measurements such as oestradiol and progesterone were also performed at each examination in each patient.
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Results |
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Most endometrial textures in both proliferative and secretory phases were easier to view with intrauterine rather than transvaginal sonography, and this was especially true with an intrauterine saline infusion technique. Moreover, it was possible to obtain finer image quality of very small endometrial interfacial and internal textures with intrauterine sonography than with transvaginal sonography. In proliferative phase (10.7 ± 1.4 days) (oestradiol, 130.9 ± 41.8 pg/ml; progesterone, 0.61 ± 0.19 ng/ml), endometrium appeared as a leaflet pattern with hypo-echoic functionalis surrounded by minimal hyperechoic basalis and echogenic endometrial interface by transvaginal sonography (Figure 1a); intrauterine sonography showed anterior and posterior endometrial layers with different echogenecity that demonstrated the smooth interface of the endometrium (Figure 1b
). After intrauterine saline infusion, the smooth interface of the lumen was visualized with both transvaginal and intrauterine images, but intrauterine sonography depicted it more clearly and finely than transvaginal sonography (Figure 1c,d
). In secretory phase (18.9 ± 1.2 days) (oestradiol, 142.1 ± 34.7 pg/ml; progesterone, 14.33 ± 8.27 ng/ml), the endometrial layer appeared as a totally hyperechoic pattern using transvaginal sonography, and the interface of the endometrium could not be distinguished by transvaginal sonography because echogenicity of both anterior and posterior wall endometrium was the same (Figure 2a
). Intrauterine sonography characterized anterior and posterior endometrial layers as different echogenic patterns with slightly irregular interface of the endometrium (Figure 2b
). Under 12 ml of intrauterine saline infusion, the irregular endometrial interface was more evident than before infusion by intrauterine sonography (Figure 2d
), but not by transvaginal sonography (Figure 2c
). A few small vesicles in the endometrial layer were clearly visualized in secretory phase only by means of intrauterine sonography in six patients (40%) (Figure 3a
), but not visualized using transvaginal sonography (Figure 3b
). In this study, endometrial dating was closely related to menstrual dating in all examinations.
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Discussion |
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In this study, the contrast enhancement effect of intrauterine saline infusion was more marked under intrauterine than transvaginal sonographic examination. In transvaginal hysterosonography, a hysterosalpingography catheter with balloon is sometimes needed for preventing regurgitation of saline solution through the cervical canal because a clear image of the endometrial interface cannot be obtained without the proper amount of intrauterine saline pooling (Cullinan et al., 1995). In intrauterine sonography, however, only a scanty amount of saline pooling (1~2 ml) in the uterine cavity in secretory phase is required to enable a clear depiction of the endometrial interface and to reveal different endometrial textures between proliferative and secretory phases.
The small vesicular echo-free spaces were visualized by intrauterine sonography in one of nine women examined in the early secretory phase, and in five of six patients in the mid-secretory phase. It is well known that secretion in the endometrial glands increases after ovulation and production reaches a maximum in the mid-secretory phase. The small vesicles recognized in the secretory phase might be considered as the pooling of secretion from the endometrial glands. These results suggest that intrauterine sonography might be more suitable than transvaginal sonography for visualization of the endometrial cyclic changes, especially using the saline infusion technique.
With respect to limitations associated with intrauterine sonography, it is an invasive diagnostic procedure requiring sterile conditions, although we and previous authors (Goldberg et al., 1991; Fujiwaki et al., 1995
; Kikuchi et al., 1995
; Hata, 1996
; Hata et al., 1996
, 1997a
, Hata et al., b
, 1998
; Kikuchi et al., 1996
; Tsuda et al., 1996
; Senoh et al., 1999a
, b
) encountered no immediate complication. Moreover, the images obtained with this method are cross-sectional (i.e. perpendicular to the long axis of the uterus), so the evaluation of the fundus is theoretically difficult (Kikuchi et al., 1995
). Another limitation of the high-frequency transducer is the lack of penetration depth, which produces a poor quality of images in the area next to the transducer. Moreover, there is the difficulty in the interpretation of images obtained using the high-frequency probe, and particular training may be necessary.
In conclusion, intrauterine sonography provides additional information in the visualization of anatomical structures of the endometrium. These results suggest that intrauterine sonography may be a valuable tool in imaging the endometrium, complementary but not replacing transvaginal sonography in infertility practice.
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Notes |
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References |
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Cullinan, J.A., Fleischer, A.C., Kepple, D.M. and Arnold, A.L. (1995) Sonohysterography, a technique for endometrial evaluation. Radiographics, 15, 501514.[Abstract]
Doherty, C.M., Silver, B., Binor, Z. et al. (1993) Transvaginal ultrasonography and the assessment of luteal phase endometrium. Am. J. Obstet. Gynecol., 168, 17021709.[ISI][Medline]
Fujiwaki, R., Hata, T., Hata, K. and Kitao, M. (1995) Intrauterine ultrasonographic assessments of embryonic development. Am. J. Obstet. Gynecol., 173, 17701774.[ISI][Medline]
Goldberg, B.B., Liu, J.B., Kuhlman, K. et al. (1991) Endoluminal gynecologic ultrasound, preliminary results. J. Ultrasound Med., 10, 583590.[Abstract]
Grunfeld, L., Walker, B., Bergh, P.A. et al. (1991) High-resolution endovaginal ultrasonography of the endometrium, A noninvasive test for endometrial adequacy. Obstet. Gynecol., 78, 200204.[Abstract]
Hata, T. (1996) Intrauterine sonography for the assessment of embryonic development. Med. Imag. Int., 6, 1115.
Hata, T., Fujiwaki, R., Senoh, D. and Hata, K. (1996) Intrauterine sonographic assessments of embryonal liver length. Hum. Reprod., 11, 12781281.
Hata, T., Manabe, A., Makihara, K. et al. (1997a) Assessment of embryonic anatomy at 68 weeks gestation by intrauterine and transvaginal sonography. Hum. Reprod., 12, 18731876.[Abstract]
Hata, T., Senoh, D., Hata, K. and Miyazaki, K. (1997b) Intrauterine sonographic assessments of embryonic heart diameter. Hum. Reprod., 12, 22862291.[Abstract]
Hata, T., Manabe, A., Aoki, S. et al. (1998) Three-dimensional intrauterine sonography in the early first-trimester of human pregnancy, preliminary study. Hum. Reprod., 13, 740743.[Abstract]
Khalifa, E., Brzyski, R.A.G., Unhinger, S. et al. (1992) Sonographic appearance of the endometrium: the predictive value for the outcome of in-vitro fertilization in stimulated cycles. Hum. Reprod., 7, 681684.[Abstract]
Kikuchi, A., Waco, T., Kobayashi, K. et al. (1995) Intrauterine ultrasonography with a high-frequency probe, preliminary report. Obstet. Gynecol., 85, 457461.
Kikuchi, A., Waco, T. and Kobayashi, K. et al. (1996) Intracervical US with a high-frequency miniature probe, a method for diagnosing early invasive cervical cancer. Radiology, 198, 411413.[Abstract]
Li, T.C., Nuttall, L., Klentzeris, L. and Cooke, I.D. (1992) How well does ultrasonographic measurement of endometrial thickness predict the results of histological dating? Hum. Reprod., 7, 15.[Abstract]
Noyes, R.W., Hertig, A.T. and Rock, J. (1950) Dating the endometrial biopsy. Fertil. Steril., 1, 325.[ISI][Medline]
Senoh, D., Yanagihara, T. and Hata, T. (1999a) Clinical application of intrauterine sonography with high-frequency, real-time miniature transducer in gynecologic disorders. Gynecol. Obstet. Invest., 47, 108113.[ISI][Medline]
Senoh, D., Hayashi, K. and Akiyama, M. et al. (1999b) Laparoscopy assisted intrauterine sonography with high-frequency, real-time miniature transducer for assessment of the Fallopian tube. Hum. Reprod., 14, 704706.
Tsuda, H., Kawabata, M., Yamamoto, K. and Umesaki, N. (1996) Diagnosis of myometrial invasion of endometrial cancer by intrauterine ultrasonography with a high-frequency probe and fluid contrast augmentation in the uterine cavity, a preliminary study. Br. J. Obstet. Gynaecol., 103, 840841.[ISI][Medline]
Widrich, T., Bradley, L.D., Mitchinson, A.R. and Collins, R.L. (1996) Comparison of saline infusion sonography with office hysteroscopy for the evaluation of the endometrium. Am. J. Obstet. Gynecol., 174, 13271334.[ISI][Medline]
Submitted on April 20, 1999; accepted on July 12, 1999.