Comparison between multidetector computed

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Apr 9, 2013 - and hysterosalpingography in assessment of infertile couples. Mohamed M. .... material (Telebrix Hystero) was injected into the metal cannula.
Middle East Fertility Society Journal (2013) 18, 191–195

Middle East Fertility Society

Middle East Fertility Society Journal www.mefsjournal.org www.sciencedirect.com

ORIGINAL ARTICLE

Comparison between multidetector computed tomography and hysterosalpingography in assessment of infertile couples Mohamed M. Shaaban Tarek H. Khalil b a b

a,*

, Ismail M. Awwad b, Mohamed M. Al Beblawy b,

Department of Obstetrics and Gynecology, Suez Canal University, Ismailia, Egypt Department of Radiology Suez Canal University, Egypt

Received 20 December 2012; accepted 1 January 2013 Available online 9 April 2013

KEYWORDS Multidetector CT; Hysterosalpingography; Infertility

Abstract Objective: To compare the efficacy of multidetector CT (MDCT) with conventional Xray hysterosalpingography (HSG) in the evaluation of infertile couples. Methods: Thirty-four patients with diagnosis of infertility, were evaluated with 4-row MDCT prior to HSG. All patients underwent diagnostic laparoscopy in the following period. Sensitivity, specificity, negative predictive value and positive predictive value of MDCT and HSG for the detection of tubal obstruction and pelvic adhesions were calculated. Results: Mean duration of the procedure for HSG and MDCT respectively was 26 ± 3.3 and 7 ± 1.1 min. MDCT has shown significantly less patient discomfort and mean effective dose of radiation. MDCT was able to diagnose a case of adenomyosis and a case of ovarian tumor further to HSG. HSG diagnosed two cases of unilateral tubal block, four cases of bilateral tubal block and six cases were suggested as pelvic adhesions due to abnormal smearing at the second film. MDCT diagnosed one case of unilateral tubal block, four cases of bilateral tubal block being unable to detect pelvic adhesions because of lack of delayed imaging. Using laparoscopy as a reference standard; sensitivity, specificity, positive predictive value and negative predictive value of MDCT and HSG in detecting tubal block were as follows: (100%, 96.7%, 83.3% and 100% for MDCT in comparison to 100%, 93.7%, 66.7% and 100% for HSG. Sensitivity, specificity, positive predictive value and negative predictive value of HSG in detecting pelvic adhesions were 42.8%, 88.8%, 50%, and 85.7. Conclusion: This study demonstrated the feasibility of evaluating the female reproductive system by MDCT.  2013 Production and hosting by Elsevier B.V. on behalf of Middle East Fertility Society.

* Corresponding author. Tel.: +20 01005153911. E-mail address: [email protected] (M.M. Shaaban). Peer review under responsibility of Middle East Fertility Society.

Production and hosting by Elsevier

1. Introduction Hysterosalpingography (HSG) is the diagnostic tool most frequently used to evaluate the uterine tubes and the endometrial cavity. The procedure, commonly performed under fluoros-

1110-5690  2013 Production and hosting by Elsevier B.V. on behalf of Middle East Fertility Society. http://dx.doi.org/10.1016/j.mefs.2013.01.013

192 copy, provides information about the cervical internal os, endometrial cavity, uterine-tubal junction (cornual ostuim), patency of the fallopian tubes, and spill into the peritoneal cavity. Also, the HSG provides indirect evidence of status of the fimbriae, pelvic adhesions and uterine, ovarian or adnexal masses (1), with, however, low specificity and sensitivity in differentiating these conditions (1,2). In the last 10 years, technical developments in computed tomogrphy (CT) and the emergence of the multi detector CT scanners (MDCT) enabled the evaluation of anatomic regions with isotropic spatial and temporal resolution. These advances allowed a whole new spectrum of diagnostic imaging techniques and procedures (3). Multi detector CT hysterosalpingography (MDCT HSG) is a novel, non invasive diagnostic modality that affords the unique opportunity to assess the uterus and fallopian tubes based on volumetric high resolution CT data, improving the visualization of the uterine cavity, external morphology of the uterus and morphology and patency of the tubes, besides the assessment of other pelvic structures (4). Multi detector CT scanners are considered today the state of the art technology to perform HSG studies (4,5). 2. Materials and method The study was approved by the ethics committee at the Suez Canal University. After signing relevant consents, thirty-four infertile patients were included in the study. The study was conducted at the Radiology and Obstetrics/Gynecology departments at the Suez Canal University during the period from June 2011 till February 2012. Eligible women were in the follicular phase of their cycles with no contraindications for HSG. The HSG procedures were performed with a Dinan 1000 Xray Unit and digitalization of the images was performed by a computed radiography unit. Standard HSG technique was performed with application of a vaginal speculum, a cervical single toothed tenaculum and a metal catheter applied to the external os of the cervix. Thereafter, 10 mL of iodine-contrast material (Telebrix Hystero) was injected into the metal cannula while obtaining a combination of radioscopy and spot radiographs until the diagnosis was obtained or intraperitoneal spill was documented. Four to six spot radiographs were obtained with 80–90 kV and 12–16mAs. The mean patient effective dose was 5.08 ± 0.21 mSv. The MDCT-VH was carried out immediately prior to the HSG. The studies were performed on a 4-row CT scanner (Toshiba Astrion multislice four Detectors): with the following technical parameters: collimation: 4 · 0.75 mm; slice thickness: 1 mm; slice increment: 0.5 mm; average scan time: 15 s; 120 kV; 200 mAs; rotation time: 0.75 s; mean patient effective dose: 3.02 ± 0.15 mSv. The MDCT-VH technique was based on the HSG technique. The patient was placed on the CT table in a supine position and the examination was performed by applying a metal catheter to the external os with (no = 10) or without (no = 24) the need to use a single toothed tenaculum. A total volume of 10 mL of iodine contrast dilution [1 mL of iodine contrast (Telebrix Hystero,) and 9 mL of saline solution] was injected into the uterine cavity. CT images were acquired once the contrast injection was completed.

M.M. Shaaban et al. Images were transferred to a workstation and reprocessed in three different ways: (i) Maximum intensity projections. (ii) Three-dimensional volume rendering reconstructions. (iii) Virtual endoscopy: endoscopic view of the lumen of the cervix canal, uterine cavity and fallopian tubes. Findings were obtained and classified by both methods into: Normal findings, (2) abnormal findings, including intrauterine filling defects, uterine malformations, cervical pathology, fallopian tubes’ pathology or extrauterine pathology or adhesions. Duration and grade of patient discomfort of each procedure were documented. The patients completed a questionnaire regarding the grade of discomfort during the procedures in a scale of four grades (G1: no discomfort; G2: slight discomfort; G3: moderate discomfort; G4: severe discomfort). All patients were scheduled for a diagnostic laparoscopy within the following 3 months. Laparoscopy was performed under general anesthesia using the standard technique (6). Data were collected and analyzed by SPSS 19.0 (SPSS, Chicago IL USA). Chi-square and paired t tests were used. Statistical significance was defined at p < 0.05. 3. Results No adverse events were encountered during the course of the study. Thirty-four patients were included. Mean age was 27.7 ± 5.8 years, mean duration of infertility was 2.6 ± 0.8 years. Mean duration of the procedure for HSG and MDCT was 26 ± 3.3 and 7 ± 1.1 min, respectively. Of the 34 patients studied, 19 patients (55.8%) showed normal findings. Abnormal findings diagnosed by either technique were as follows: tubal block: 6 (17.6%) detected by HSG and 5 (14.4%) detected by MDCT, Unilateral hydrosalpinx: 2 (5.8%) detected by both techniques, suggested pelvic adhesions: 6 (17.6%) detected by HSG, uterine anomalies: 2 (5.8%) detected by both techniques, adenomyosis: 2 (5.8%)

Table 1

Abnormal findings detected by the two techniques.

Tubal block Unilateral Bilateral Unilateral hydrosalpinx* Suggested pelvic adhesions** Uterine anomalies* Adenomyosis Ovarian tumor

HSG (%)

MDCT (%)

2 4 2 6 2 1 0

1 4 2 0 2 2 1

(5.8) (11.6) (5.8) (17.6) (5.8) (2.8)

(2.8) (11.6) (5.8) (5.8) (5.8) (2.8)

HSG: Hysterosalpingography; MDCT: Multi detector computed tomography. * The sum of abnormal exceeds the total number of pathological cases because two patients showed multiple diagnoses. ** No cases of pelvic adhesions were detected by MDCT because of lack of delayed image.

Comparison between multidetector computed tomography and hysterosalpingography in assessment of infertile couples Table 2

Laparoscopic confirmation of image findings.

Table 4

Grades of discomfort in the two techniques.

HSG/MDCT (%) Laparoscopy (%) ve cases Tubal patency Pelvic adhesions

26 (76.4) 0

26 (76.4) 4 (11.6)

+ve cases Unilateral tubal block* Bilateral tubal block*** Suggested pelvic adhesions* Unilateral hydrosalpinx Uterine anomalies Adenomyosis* Ovarian tumor**

2 4 6 2 2 1 1

1 3 3 2 2 2 1

* ** ***

(5.8) (11.8) (17.6) (5.8) (5.8) (2.8) (2.8)

Grade 1 discomfort Grade 2 discomfort Grade 3 discomfort

HSG

MDCT

P value

2 (5.8%) 20 (58%) 12 (35.2%)

16 (47%) 14 (41.1%) 4 (11.6%)