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Yaakov Melcer, Ron Maymon, ‘One-stop shop’ ultrasound evaluation of an infertile patient: doing less is no longer an option, Human Reproduction, Volume 37, Issue 8, August 2022, Pages 1952–1953, https://doi.org/10.1093/humrep/deac132
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Sir,
We read the article by van Welie et al. (2022) with great interest. The authors conducted a multicenter, prospective, comparative study with a randomized design on 1026 women who underwent hysterosalpingo-foam sonography (HyFoSy) and hysterosalpingography (HSG).
Their findings show that using either HyFoSy or HSG in infertile women leads to similar pregnancy outcomes, although HyFoSy is associated with significantly less pain. Van Welie et al. (2022) thus conclude that HyFoSy should be the first-choice tubal patency test during fertility work-ups.
However, their study, although highly important, misses a number of crucial steps. The assessment of the uterine cavity, tubal patency and the ovaries constitutes a key component of female infertility work-ups. The benefits of a comprehensive ‘one-stop shop’ concept for the evaluation of the genital tract in infertile patients was initially suggested by Kelly et al. (2001) and reiterated more recently by Groszmann and Benacerraf (2016). They also stressed the value of a single comprehensive ultrasound (US) examination in a sequence composed of a two-dimensional (2D), a three-dimensional (3D) US and a Doppler, followed by sonohysterography to evaluate the uterine cavity, and a hysterosalpingocontrast sonography to assess tubal patency.
In our hospital clinic, our ‘one-stop shop’ procedure consists of a comprehensive US evaluation of the female pelvis that incorporates 4 different steps in one exam. The first step is the initial 2D US scan of the pelvic organs. This yields information not only about the pelvic anatomy, uterus and ovaries but also identifies pelvic pathologies including endometriosis, adenomyosis, hydrosalpinx (Melcer et al., 2022a). The second step is the 3D US, given that there is a higher prevalence of congenital uterine anomalies in infertile women than in the general population (Chan et al., 2011). Because the structure of the uterus impacts successful implantation, any congenital anomalies that could be associated with impaired reproductive performance need to be identified. The third step involves saline or lidocaine (Melcer et al., 2021a) infusion sonography to achieve distension and allow visualization of the uterine cavity. During the exam, the hyper-echogenic foam (HyFoSy) can be visualized as it moves from the uterine cavity, then along the fallopian tubes into the peritoneal cavity. Unfortunately, the uterine cavity cannot be fully assessed with hyperechogenic contrasts, because they mask the identification of hyperechoic intracavitary lesions. This is why saline infusion sonography is now considered the gold standard equivalent of hysteroscopy for the detection of intrauterine abnormalities (Seshadri et al., 2015). This highly sensitive and specific test can diagnose uterine polyps, submucous myomas, uterine anomalies and intrauterine adhesions and be used to screen for infertile patients (Seshadri et al., 2015). The fourth step is the administration of HyFoSy to evaluate tubal patency (Melcer et al., 2022a,b). Research has indicated that hyper-echogenic foam is an accurate, safe tubal patency technique and a suitable alternative to HSG (Exalto and Emanuel, 2019). Our recent systematic review and meta-analysis confirmed that HyFoSy can accurately diagnose tubal occlusion and performs similarly to standard tests. The combined sensitivity and specificity estimates were 0.99 (95% CI: 0.89–0.99) and 0.91 (95% CI: 0.53–0.98), respectively, with a positive and negative likelihood ratio of 11.5 (95% CI 1.5–87.5) and 0.006 (95% CI 0.0003–0.12), respectively. The diagnostic odds ratio was 1931.008 (95% CI 69.7–53460.8) (Melcer et al., 2021b).
Thus overall, although van Welie et al. (2022) should be congratulated for their findings, their study needs to be seen as just one part of the comprehensive ‘one-stop shop’ concept for the evaluation of the genital tract of infertile patients. Given its proven advantages, we recommend incorporating this ‘4 step evaluation’ into routine female infertility work-ups. Doing less is no longer an option.
Conflict of interest
None.
