++
Definitions
Sonohysterography: sonographic imaging of the uterus aided by real-time transcervical infusion of contrast media.
Sonohysterosalpingography: sonographic imaging of the fallopian tubes and determination of fallopian tubal patency by use of real-time transcervical infusion of contrast media.
++
Gynecologic problems for which patients seek care include excessive or ill-timed bleeding, amenorrhea, pelvic pain, pelvic masses, and infertility. Transvaginal sonography enhances the diagnosis of problems beyond the external genitalia and cervix that are not visible on physical examination. One further refinement of this approach to gynecologic diagnosis is the use of sonographic contrast media. Clear fluids improve the detection and localization of soft tissue abnormalities in the uterine and pelvic cavities. Echogenic contrast media, with or without Doppler enhancement, allow acceptable demonstration of tubal patency, according to the limited data available. Sonohysterography (SHG) of the uterine cavity and sonohysterosalpingography (sonoHSG) of the tubes are informative variations of hysterosalpingography (HSG), a standard radiographic technique for studying the reproductive lumina outlined by transcervical infusion of iodinated contrast under fluoroscopic observation. When sonographic evaluation of the uterine lumen with contrast is combined with evaluation of the tubes, this procedure can be termed sonohysterosalpingography, or sonoHSG. This use of "double contrast" involves transcervical injection of saline to outline the uterine cavity, which then pools in the posterior cul-de-sac before instillation of positive (echogenic) contrast. The tubal lumen is thus outlined and the fimbriated end is evaluated for spill and its relationship to the ovary.
++
Contrast-enhanced transvaginal sonography eliminates exposure to unmetered fluoroscopic ionizing radiation and iodinated contrast, while obtaining detailed structural information. It can be performed in a small examining room. A standard gynecologic examining table with stirrups and a retractable basin are required. A single assistant is required, and the procedural equipment is readily available and inexpensive. A foot pedal for the ultrasound equipment is desirable.
++
Sonohysterography has also been called hysterosonography and saline infusion sonohysterography (SIS). Most importantly, the term hysterosonography has been designated a Current Procedural Terminology (CPT) code for billing. Sonohysterography can be confused with HSG, resulting in improper ordering and scheduling.
++
Historic Development Using Transabdominal Technique
++
The ease of discerning small details of the intrauterine contents in the presence of amniotic or spontaneous uterine fluid is well known. Early efforts to supply artificial fluid in the nonpregnant woman using transabdominal scanning were effective but cumbersome. In 1984, Richman et al reported the instillation of 70% dextran through a rigid uterine cannula during transabdominal sonographic observation before standard HSG in 34 patients.1 Their interest in the uterine cavity was limited to the observation that tubal obstruction produced sustained expansion of the uterine cavity. The observation of the accumulation of peritoneal fluid in 25 of 34 patients correctly identified at least unilateral tubal patency with an accuracy of 97%.
++
Randolph et al described the results of a similar approach ...