Saline Infusion Sonohysterography

Robert D. Auerbach, M.D. FACOG

Senior Vice President & Chief Medical Officer
CooperSurgical, Inc.
Associate Clinical Professor
Yale University School of Medicine
Introduction

• Saline Infusion Sonohysterography (SIS)

• Transcervical introduction of fluid
• Provides enhanced endometrial visualization during TV U/S examination
• Benefits
 Easy to perform
 Minimal cost
 Well tolerated by patients
 Few complications
Indications & Contraindications

• Indications
• Abnormal Uterine Bleeding
• Infertility and habitual abortion
• Congenital abnormalities of the uterus
• Pre or postoperative evaluation of uterine myomas, polyps, cysts
• Suspected uterine cavity synechiae
• Inadequate TV U/S
Indications & Contraindications

• Contraindications
• Pregnancy
• Pelvic infection

AIUM standard for the performance of Saline Infusion Sonohysterography

www.aium.org/consumer/standards/saline.pdf
Indications - AUB

• Abnormal Uterine Bleeding (AUB)

• Accounts for many patients visits
• Diagnostic procedures
 TV U/S
 Endometrial Biopsy
 Hysteroscopy
 D&C – no longer considered an initial diagnostic test
Indications - AUB

•SIS is useful for finding focal lesions in AUB

• 106 patients with menometrorrhagia

Sensitivity Specificity

TV U/S 75% 76%

SIS 93%* 94%*

* Significant difference and comparable to hysteroscopy Dx rates

Kamel, HS, Darwish, AM, Mohamed, SA. Comparison of transvaginal
ultrasonography and vaginal sonohysterography in the detection of
endometrial polyps. Acta Obstet Gynecol Scand 2000; 79:60.
Indications - AUB

De Kroon, CD, Jansen, FW, Louwe, LA, et al. Technology assessment of saline
contrast hysterosonography. Am J Obstet Gynecol 2003; 188:945.

• Prospective series of 214 consecutive pre- and postmenopausal women

with AUB
• Suspected uterine abnormality on TV U/S
• SIS followed by hysteroscopy preferable to hysteroscopy initially
• Hysteroscopy could be avoided 84% of patients
Indications - AUB

• SIS can help distinguish:

• Anatomic AUB from anovulatory bleeding
• Postmenopausal bleeding from atrophy
 May help select appropriate candidates for endometrial sampling
• Differentiate focal lesions that need biopsy under direct vision versus a global
process that can be sampled blindly
Indication - Infertility

• Assessing the endometrium is part of the routine infertility & recurrent

pregnancy loss work-up
• SIS can Dx anatomic causes of infertility
• Submucous myomas
• Endometrial polyps
• Uterine anomalies
• Intrauterine adhesions
Indication - Infertility

• SIS is comparable or better than HSG

• Salle, B, Gaucherand, P, de Saint, Hilaire P, Rudigoz, RC. Transvaginal sonohysterographic
evaluation of intrauterine adhesions. J Clin Ultrasound 1999; 27:131.
• Darwish, AM, Youssef, AA. Screening sonohysterography in infertility. Gynecol Obstet
Invest 1999; 48:43.
• Alborzi, S, Dehbashi, S, Parsanezhad, ME. Differential diagnosis of septate and bicornuate
uterus by sonohysterography eliminates the need for laparoscopy. Fertil Steril 2002; 78:176.
• Alatas, C, Aksoy, E, Akarsu, C, et al. Evaluation of intrauterine abnormalities in infertile
patients by sonohysterography. Hum Reprod 1997; 12:487.

• HSG better at outlining fallopian tubes

Indication - Tamoxifen

• Tamoxifen is used extensively as adjunctive chemotherapy in

women with estrogen receptor-positive breast cancer
• May thicken the uterine wall in some women when viewed by TV
U/S
• May be polyps or abnormal endometrial tissue
Indication - Tamoxifen

• SIS has shown these changes are often microcysts of the basalis (focal
adenomyosis reactivation)
• Hann, LE, Gretz, EM, Bach, AM, Francis, SM. Sonohysterography for evaluation of the
endometrium in women treated with tamoxifen. AJR Am J Roentgenol 2001; 177:337.
• Elhelw, B, Ghorab, MN, Farrag, SH. Saline sonohysterography for monitoring
asymptomatic postmenopausal breast cancer patients taking tamoxifen. Int J Gynaecol
Obstet 1999; 67:81.

• Routine sonographic screening of the endometrium of asymptomatic

women taking Tamoxefen has not been recommended by ACOG
SIS Technique

• Usually scheduled between day 5 – 10 of the menstrual cycle

• No routine anesthesia or analgesia needed
• Bimanual exam
• Place speculum
• Aseptic prep of the cervix
• SIS
• Flush catheter
• Insert catheter
 May be accomplished without the need for a tenaculum
SIS Technique

• Fill balloon and snug catheter against

the internal os
• Remove speculum
• Attach 10ml syringe of sterile saline
• Insert TV U/S probe
SIS Technique

• Fluid is instilled while the probe is shifted to each cornual region

• Long axis plane
• Turn probe 90 degrees and instill more fluid
• Coronal plane
• Fan from the endocerival canal to the fundus
Findings - Normal
Normal SIS with Balloon Inflated
Findings - Polyp

TV US for abnormal SIS demonstrates fundal

bleeding revealed an ill- polyp
defined mass
Polyp - Removal

Polyp removed under U/S guidance leaving a normal endometrial

cavity (left)
Multiple Polyps

Multiple polyps in a 52-year-old woman with abnormal bleeding. Saline

infusion sonohysterography shows multiple polypoid masses (arrows)
outlined by the anechoic saline.
Cancerous Polyps

Papillary serous carcinoma in a 71-year-old woman with postmenopausal

bleeding. Findings from blind endometrial biopsy performed before the SIS
were negative.
Findings – Submucosal Myoma

TV US shows myoma with SIS shows myoma protruding into

non-distinct borders endometrial cavity
Findings - Tamoxifen

TV US showing irregular SIS showing thin endometrium

endometrium and cysts and sub-basalis cysts
Endometrial Hyperplasia

Saline infusion sonohysterography shows diffuse endometrial thickening

and multiple cystic areas (arrowheads). Pathologic examination showed
simple endometrial hyperplasia.
Endometrial Hyperplasia

Endometrial hyperplasia in a 54-year-old woman with menorrhagia showing

areas of focal thickening of the endometrium. Pathologic examination
revealed complex endometrial hyperplasia without atypia.
Findings – Endometrial Cancer

TV US shows 7mm SIS demonstrates inapprop. thick

endometrium after menses – endometrium – biopsy reveals well
should be no > than 4mm differentiated adenocarcinoma
Metastatic Cancer

Mass in a 71-year-old woman with a history of breast cancer treated with

tamoxifen for approximately 2 years who had PMP bleeding. SIS shows an
inhomogeneous focal mass (arrows). Pathologic examination revealed
metastatic breast cancer to the uterus.
Findings - Adhesions

Intrauterine adhesions in a 33-year-old woman undergoing a fertility

workup with a history of 2 dilation and curettage procedures. Saline
infusion sonohysterography shows a poorly distensible endometrial
cavity with adhesions (arrows).
Technical Difficulties & Complications

• Passing the catheter

• Cervical stenosis
• Uterine position
• Uterine abnormality
• Poor visualization
• Unable to retain fluid (patulous cervix)
• Infection
• Same risk as HSG
• Obtain cultures and Rx with AB based on risk factors
Technical Difficulties & Complications

• Cancer dissemination – positive cytology equals at least Stage IIIA

• Theoretic concerns
• HSG study with spill survival rates unchanged
 Devore, GR, Schwartz, PE, Morris, JM. Hysterography: a 5-year follow-up in patients
with endometrial carcinoma. Obstet Gynecol 1982; 60:369.

• False positive
• Attributed to blood clots, intrauterine debris, mucus, shearing of the
endometrium and thickened endometrial folds
Getting Fooled

Inadvertent injection of a small amount of air. The air appears as a bright

echogenic focus in the fundal region of the endometrial cavity
Getting Fooled

Blood clot mimicking a mass.

The patient had
postmenopausal bleeding.
Initial images (A and B) show
an echogenic mass in the C
A endometrial cavity (arrow).
Color Doppler imaging (C)
shows no color flow within
the mass. During the
examination, the mass was
dislodged with the catheter,
and the final image (D) shows
a normal thin endometrium. D
B
Technical Difficulties & Complications

• Prospective study of 1153 women age 23-64 undergoing SIS

• Failure to complete procedure: 7%
• Pelvic pain: 3.8%
• Vagal response: 3.5%
• Nausea: 1%
• Post procedure fever: 0.8%

Dessole, S, Farina, M, Rubattu, G, et al. Side effects and complications of

sonohysterosalpingography. Fertil Steril 2003; 80:620.
Summary

• SIS provides enhanced endometrial visualization

• Improves sonographic detection of polyps, hyperplasia, cancer, myomas
and adhesions
• Can help avoid invasive procedures
• May optimize preoperative evaluation who require therapeutic
intervention