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Delgado-Morell, A.; Nieto-Tous, M.; Andrada-Ripollés, C.; Pascual, M.�.; Ajossa, S.; Guerriero, S.; Alcázar, J.L. Transvaginal Ultrasound Accuracy in the Hydrosalpinx Diagnosis. Encyclopedia. Available online: https://encyclopedia.pub/entry/44204 (accessed on 13 May 2024).
Delgado-Morell A, Nieto-Tous M, Andrada-Ripollés C, Pascual M�, Ajossa S, Guerriero S, et al. Transvaginal Ultrasound Accuracy in the Hydrosalpinx Diagnosis. Encyclopedia. Available at: https://encyclopedia.pub/entry/44204. Accessed May 13, 2024.
Delgado-Morell, Aina, Mar Nieto-Tous, Cristina Andrada-Ripollés, Maria Ángela Pascual, Silvia Ajossa, Stefano Guerriero, Juan Luis Alcázar. "Transvaginal Ultrasound Accuracy in the Hydrosalpinx Diagnosis" Encyclopedia, https://encyclopedia.pub/entry/44204 (accessed May 13, 2024).
Delgado-Morell, A., Nieto-Tous, M., Andrada-Ripollés, C., Pascual, M.�., Ajossa, S., Guerriero, S., & Alcázar, J.L. (2023, May 12). Transvaginal Ultrasound Accuracy in the Hydrosalpinx Diagnosis. In Encyclopedia. https://encyclopedia.pub/entry/44204
Delgado-Morell, Aina, et al. "Transvaginal Ultrasound Accuracy in the Hydrosalpinx Diagnosis." Encyclopedia. Web. 12 May, 2023.
Transvaginal Ultrasound Accuracy in the Hydrosalpinx Diagnosis
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This entry is adapted from the peer-reviewed paper 10.3390/diagnostics13050948

Hydrosalpinx is a condition with a crucial prognostic role in reproduction, and its diagnosis by a non-invasive technique such as ultrasound is key in achieving an adequate reproductive assessment while avoiding unnecessary laparoscopies. 

hydrosalpinx transvaginal ultrasound diagnosis

1. Introduction

Infertility is related to tubal disease in 35% of cases [1]. Distal and proximal occlusion of the tubes—at the fimbrial and at the cornual end—cause fluid filling of the tubes, distending them and leading to the formation of hydrosalpinx. In vitro fertilization (IVF) therapies have changed the reproductive chances in sterility cases related to tubal obstruction, but hydrosalpinx has a negative impact on IVF outcomes according to the most recently published systematic review and meta-analysis on the topic [2].
Hydrosalpinx can develop after the onset of post-surgical adhesions or after a hysterectomy, but more frequently, its occurrence is related to an antecedent of acute pelvic inflammatory disease (PID) [3]. Taipale et al. followed a cohort of patients diagnosed of acute PID for three months, and after this period, 26.7% (23/86) of them had a sonographic suspicion of hydrosalpinx [4].
The gold standard for the hydrosalpinx diagnosis is histological confirmation, albeit laparoscopic direct observation is also an accepted method [3]. Non-invasive techniques such as ultrasound have been proposed as having a role in its diagnosis in order to achieve adequate reproductive assessment while avoiding unnecessary laparoscopies.
Classically, since a fluid-filled tube is theoretically visible by transvaginal ultrasound (TVS) as a cystic mass, hydrosalpinxes could be identified sonographically. Nevertheless, in some series it has been proved that they could be missed, especially when the bowel is occupied by gas and/or fecal material or when adhesions alter the normal pelvic anatomy [5].
Different authors have described the main sonographic characteristics to accurately diagnose hydrosalpinx. Timor-Tritsch et al. described this lesion as being typically an elongated-shaped cystic mass with anechoic or hypoechoic content, convoluted and with the presence of incomplete septa due to the ballooning and doubling-up of the tube. These incomplete septa originate as triangular hyperechoic wall-protrusions into the lumen, not reaching the opposite wall [6], and they are found in up to 85–93% of chronic hydrosalpinxes [6][7].
The presence of the called “beads-on-a-string” sonographic pattern is also a specific and reliable sign of chronic hydrosalpinx—hyperechoic mural nodules measuring 2–3 mm seen on the transverse section of the fluid-filled tube, which correspond to the flattened and fibrotic remnants of the endo-salpingeal folds [5][6].
Hydrosalpinx can also be the result of a present acute salpingitis, and not just the chronic consequence of a previous PID [6]. Some sonographic signs, nonetheless, contribute to establishing a differential diagnosis among acute and chronic salpingitis: the tubal wall is thickened in acute PID but not in the chronic hydrosalpinx [3][8]; the typical “beads-on-a-string” sign is not visible in acute salpingitis, but the “cogwheel sign” is found instead [3][6].

2. Summary of Evidence

The pooled estimated sensitivity is 84%, with very low observed heterogeneity (I2 = 0.00). The pooled estimated specificity is 99%, with a remarkable heterogeneity (I2 = 82.68) which cannot be explained by the differences in sample size, publication year, or on prevalence among the selected studies. Notwithstanding, it could be caused by the low PPV found in two of the studies [9][10] since it decreases to I2 = 5.23 when excluding these articles.
The article published by Bhatty et al. is the one with the lowest specificity (94.68%) and a presents a low PPV (50.00%) as well [9]. It is also the one with the lowest quality assessment at QUADAS-2, since the authors do not provide clear information on the patient selection and methodology used. Notwithstanding, due to its small sample size (n = 100, number of hydrosalpinxes = 10), the inclusion or exclusion of this specific study in the statistical analysis does not have a major impact on the pooled results.
The differences in TVS performance among the included studies could be related to differences in the sonographer’s experience, but this is not clearly stated in three out of the six studies [9][11][12].

3. Interpretation of the Results and Relevance of the Topic

There is increasing evidence showing that hydrosalpinx has a deleterious impact in IVF results because of its association to decreased implantation, clinical pregnancy, and ongoing pregnancy rates; and to higher risk of ectopic pregnancy and miscarriage [2]. This has been related to the negative impact of hydrosalpinx fluid on endometrial receptivity [13][14], to a toxic effect on early embryos [15], or to a mechanic or vascular alteration interfering with implantation [16][17].
Various approaches have been proposed for managing hydrosalpinx in the context of IVF. According to the last meta-analysis on this topic [2], the best IVF results are related to hydrosalpinx removal (salpingectomy) compared to other conservative managements, like proximal tubal occlusion—either surgical or hysteroscopic occlusion—or hydrosalpinx ultrasound-guided aspiration with or without sclerotherapy.
Although there are sufficient studies in the literature showing an improvement of the IVF performance after salpingectomy in the context of hydrosalpinx [18], no-one has yet assessed the overall evidence on the diagnostic accuracy of TVS for hydrosalpinx, even when it is the most used diagnostic tool for this entity in reproduction clinics.
Ultrasonography has a 99% pooled specificity. Therefore, after diagnosing hydrosalpinx through pattern recognition there is low probability in finding a different adnexal mass or no masses at all during its laparoscopic removal. By contrast, the overall pooled sensitivity and LR+ are lower, suggesting that some hydrosalpinxes could be missed or confused with other adnexal masses. This fact is also relevant, especially when considering the impact of the presence of hydrosalpinx in IVF outcomes. Additionally, another important point is the inter-observer reproducibility of TVS diagnosis of hydrosalpinx. There is no study addressing this issue. The assessment of this issue could help to define which are the more precise ultrasound features for establishing the diagnosis of hydrosalpinx, and probably to define the need for refining or re-defining the diagnostic criteria.
Overall, it is important to acknowledge that the population of all the studies included in the current meta-analysis are women with adnexal masses of all ages, not general population nor infertile women. It is well known that in infertile women, tubal disease could represent up to 35% of the causes of infertility [1] with a mean prevalence of hydrosalpinx between 10% and 13% when diagnosed by ultrasound [19]. Therefore, it could be presumed that with an increased prevalence of hydrosalpinx in this specific population, TVS could have a better performance.

References

  1. Honoré, G.M.; Holden, A.E.; Schenken, R.S. Pathophysiology and management of proximal tubal blockage. Fertil. Steril. 1999, 71, 785–795.
  2. Capmas, P.; Suarthana, E.; Tulandi, T. Management of hydrosalpinx in the era of assisted reproductive technology: A systematic review and meta-analysis. J. Minim. Invasive Gynecol. 2021, 28, 418–441.
  3. Romosan, G.; Valentin, L. The sensitivity and specificity of transvaginal ultrasound with regard to acute pelvic inflammatory disease: A review of the literature. Arch. Gynecol. Obstet. 2014, 289, 705–714.
  4. Taipale, P.; Tarjanne, H.; Ylöstalo, P. Transvaginal sonography in suspected pelvic inflammatory disease. Ultrasound Obstet. Gynecol. 1995, 6, 430–434.
  5. Guerriero, S.; Ajossa, S.; Gerada, M.; Virgilio, B.; Pilloni, M.; Galvan, R.; Laparte, M.C.; Alcázar, J.L.; Melis, G.B. Transvaginal ultrasonography in the diagnosis of extrauterine pelvic diseases. Expert Rev. Obstet Gynecol 2008, 3, 731–752.
  6. Timor-Tritsch, I.E.; Lerner, J.P.; Monteagudo, A.; Murphy, K.E.; Heller, D.S. Transvaginal sonographic markers of tubal inflammatory disease. Ultrasound Obstet. Gynecol. 1998, 12, 56–66.
  7. Molander, P.; Sjöberg, J.; Paavonen, J.; Cacciatore, B. Transvaginal power Doppler findings in laparoscopically proven acute pelvic inflammatory disease. Ultrasound Obstet. Gynecol. 2001, 17, 233–238.
  8. Sayasneh, A.; Ekechi, C.; Ferrara, L.; Kaijser, J.; Stalder, C.; Sur, S.; Timmerman, D.; Bourne, T. The characteristic ultrasound features of specific types of ovarian pathology. Int. J. Oncol. 2015, 46, 445–458.
  9. Bhatty, S.; Bilal, A.; Abideen, Z.; Ahmad, A.; Laique, T. Role of Ultrasonography in Diagnosing Adnexal Masses: Cross-Sectional Study. Pak. J. Med. Sci. 2020, 14, 917–918.
  10. Sokalska, A.; Timmerman, D.; Testa, A.C.; Van Holsbeke, C.; Lissoni, A.A.; Leone, F.P.G.; Jurkovic, D.; Valentin, L. Diagnostic accuracy of transvaginal ultrasound examination for assigning a specific diagnosis to adnexal masses. Ultrasound Obstet. Gynecol. 2009, 34, 462–470.
  11. Guerriero, S.; Ajossa, S.; Lai, M.P.; Mais, V.; Paoletti, A.M.; Melis, G.B. Transvaginal ultrasonography associated with colour Doppler energy in the diagnosis of hydrosalpinx. Hum. Reprod. 2000, 15, 1568–1572.
  12. Yazbek, J.; Helmy, S.; Ben-Nagi, J.; Holland, T.; Sawyer, E.; Jurkovic, D. Value of preoperative ultrasound examination in the selection of women with adnexal masses for laparoscopic surgery. Ultrasound Obstet. Gynecol. 2007, 30, 883–888.
  13. Savaris, R.F.; Giudice, L.C. The influence of hydrosalpinx on markers of endometrial receptivity. Semin. Reprod. Med. 2007, 25, 476–482.
  14. Mukherjee, T.; Copperman, A.B.; McCaffrey, C.; Cook, C.A.; Bustillo, M.; Obasaju, M.F. Hydrosalpinx fluid has embryotoxic effects on murine embryogenesis: A case for prophylactic salpingectomy. Fertil. Steril. 1996, 66, 851–853.
  15. Nackley, A.C.; Muasher, S.J. The significance of hydrosalpinx in in vitro fertilization. Fertil. Steril. 1998, 69, 373–384.
  16. Granot, I.; Dekel, N.; Segal, I.; Fieldust, S.; Shoham, Z.; Barash, A. Is hydrosalpinx fluid cytotoxic? Hum. Reprod. 1998, 13, 1620–1624.
  17. Mansour, R.T.; Aboulghar, M.A.; Serour, G.I.; Riad, R. Fluid accumulation of the uterine cavity before embryo transfer: A possible hindrance for implantation. J. Vitr. Fertil. Embryo. Transf. 1991, 8, 157–159.
  18. Johnson, N.; Van Voorst, S.; Sowter, M.C.; Strandell, A.; Mol, B.W.J. Surgical treatment for tubal disease in women due to undergo in vitro fertilisation. Cochrane Database Syst. Rev. 2010, 1, CD002125.
  19. Harb, H.; Al-Rshoud, F.; Karunakaran, B.; Gallos, I.D.; Coomarasamy, A. Hydrosalpinx and pregnancy loss: A systematic review and meta-analysis. Reprod. Biomed. Online 2019, 38, 427–441.
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Subjects: Obstetrics & Gynaecology
Contributors MDPI registered users' name will be linked to their SciProfiles pages. To register with us, please refer to https://encyclopedia.pub/register :
Aina Delgado-Morell
,
Mar Nieto-Tous
,
Cristina Andrada-Ripollés
,
Maria Ángela Pascual
,
Silvia Ajossa
,
Stefano Guerriero
,
Juan Luis Alcázar
View Times: 412
Revisions: 2 times (View History)
Update Date: 15 May 2023
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