Hysterosalpingo-contrast-sonography (HyCoSy) - a novel approach to

Abstract
Hysterosalpingo-contrast-sonography (HyCoSy)
– a novel approach to female upper genital tract imaging
and tubal patency assessment in outpatient clinic
RAFAŁ D. KOCYŁOWSKI, GRZEGORZ H. BRĘBOROWICZ
15% of couples in reproductive age are affected by the inability to conceive and bear a child. Anatomical disturbances are
Approximately
for 35-40% of female subfertility. Frequent organic causes of sterility and infertility are linked to the fallopian pathology. Standard
responsible
screening procedures of infertility include imaging techniques. Tubal patency is routinely assessed by hysterosalpingography (HSG)
female
diagnostic hysteroscopy and/or laparoscopy. Other technologies are nowadays intensively investigated to obtain the satisfactory balance
and
diagnostic/therapeutic accuracy and cost-effectiveness. Such a promising novel method seems to be hysterosalpingo-contrast-sonography
of
which is based on the ultrasonographic (US) evaluation of a female pelvis with contrast media substances infused intrauterine.
(HyCoSy),
could be performed on outpatient basis in many cases, reducing the need for a diagnostic hysteroscopy and/or laparoscopy. However, disten-
It
of uterine cavity with contrast medium used during HyCoSy procedure may be associated with a kind of unpleasant sensation, discomfort
tion
even unacceptable pain. The superiority of ultrasonographically based HyCoSy occurs in terms of the lack of ovarian irradiation and
or
allergy due to iodinated contrast used during HSG. Additionally HyCoSy enables scanning of the uterus and ovaries at the same time
avoiding
is not available in HSG. HyCoSy showed concordance with laparoscopy in 85.2% while HSG in 84.1%. New contrast media for ‘harmonic
which
in contrast-specific scanning and organ-specific contrast agents will significantly improve diagnostic possibilities in the nearest future.
imaging’
Key words: sterility and infertility, female pelvis imaging, tubal patency assessment, hysterosalpingography (HSG), hysteroscopy/laparoscopy,
hysterosalpingo-contrast-sonography (HyCoSy)
Introduction
Along with civilization development the phenomenon of
sterility and infertility increases. It is estimated that appro-
ximately 15% of couples in reproductive age are affected by
the inability to conceive and bear a child. About 60% causes
are caused by a female factor, 30% originate on male side and
the rest 10% derive either from immunological or unexplained
sources. Endocrinologic dysfunction and endometriosis affect
women in 30-50%, whereas anatomical disturbances are res-
ponsible for 35-40% of female subfertility [23]. The success at
achieving conception in the infertile couple with anatomical
abnormalities is currently very likely and available due to en-
doscopic correction [24].
Modern standard female screening procedures of inferti-
lity include imaging techniques, hormonal status evaluation
and microbiological testing. Frequent organic causes of steri-
lity and infertility are linked to the fallopian pathology. Tubal
patency is routinely assessed by hysterosalpingography (HSG)
and diagnostic hysteroscopy and/or laparoscopy (Hys/Lap).
However, relatively high costs of these methods as a first line
management are stressed. Therefore other technologies are
nowadays intensively investigated to obtain the satisfactory
balance of diagnostic/therapeutic accuracy and cost-effective-
ness. One of such a promising novel method appears to be
hysterosalpingo-contrast-sonography (HyCoSy), especially in
terms of a screening test for subfertile patients [8]. Moreover,
it could be performed on outpatient basis in many cases, re-
ducing the need for a diagnostic hysteroscopy and/or laparos-
copy [3].
Department of Perinatology and Gynecology, Medical University in Poznań, Poland
HyCoSy – basic information
Hysterosalpingo-contrast-sonography (HyCoSy) is based
on the ultrasonographic (US) evaluation of a female pelvis
with contrast media substances infused intrauterine, which are
regarded to significantly improve the diagnostic possibilities.
HyCoSy in fact combines the transvaginal ultrasonography
(TVS), saline infusion sonohysterography (SIS) and contrasted
sonosalpingography [5, 32].
HyCoSy – description of the procedure
1) Device requirements
In order to perform HyCoSy examination one has to be
equipped with TVS scanning machine (optionally abdominal
transducer is necessary in certain cases), intrauterine cathe-
ter, contrast medium with applicator (a pump or a syringe)
and data storage system (e.g. printer). Relevant complemen-
tary guidelines have been established recently in details [2, 7].
2) Steps of HyCoSy procedure
a) Transvaginal (Ultra)Sonography (TVS)
With a patient lying in a feasible position standard TVS of
pelvis is performed, visualizing and detailing internal genital
organs from the cervix through uterus to adnexa, with adequa-
te measurements and descriptions (printed documentation is
recommended).
b) Saline Infusion System (SIS)
In this step a sterile intrauterine catheter is introduced
through the vagina and cervix. After proper fixation of the
catheter is confirmed, the first contrast is infused (usually
sterile saline solution) for more reliable visualization of ute-

18
rine cavity and endometrial layers. This part of the examina-
tion is called Saline Infusion Sonography and may be accom-
panied by some kind of patient discomfort due to uterine and
fallopian distention with fluid. The contrasted uterine space
images are suggested to being stored for further reevaluation.
c) Hysterosalpingo-Contrasted Sonography (HyCoSy)
Finally, when satisfactory scans of SIS application are ob-
tained, the last step takes place. Another contrast (usually air
bubbles) is transferred into uterus using the same catheter
still being at the same position within uterine space. This
allows assessing and visualizing tubal structure and patency.
The air bubbles or alternative contrast agents (e.g. Echo-
vist®), which are allocated to enhance the differentiation,
provide more recognizable pictures of the fallopian lumen.
Hence, the tubal structure assessment constitutes the parti-
cularly dedicated indication for that part of female genital tract
investigation. In fact this is the real hysterosalpingo-con-
trasted sonography. In some situations only one positive con-
trast is used i.e. Echovist® without saline or air. This modi-
fication although reasonable, increases costs of the exami-
nation and at least theoretically, constitutes danger of allergy.
If available, the movie proving contrast passage or any
blockade of the flow through examined tubes should be
recorded. At the end the catheter is removed after the rest of
the contrast substance is spilled out of the uterine cavity.
Advantages of application of the new method
TVS allows visualizing internal female genital organs with
adjacent structures in female pelvis and help differentiate
especially solid or cystic masses. Application of SIS enables to
distinguish abnormalities of endometrium and intracavitary
pathology more precisely than TVS alone. Finally, introduction
of another positive contrast medium apart from sterile saline
solution permits to assess tubal patency with high accuracy
[36].
HyCoSy joins the advantages of ultrasonographic evalua-
tion of female pelvis and hysterosalpingographic assessment
of fallopian tubes [22]. Because HyCoSy includes TVS and SIS
it also possesses diagnostic value of the both techniques in the
infertile couple investigation [16]. In comparison to HSG there
are no significant differences between the two methods con-
cerning the patient discomfort, duration of the procedures and
the volume of contrast media required to visualize the fallo-
pian tubes [4]. The superiority of ultrasonographically based
HyCoSy occurs in terms of the lack of ovarian irradiation and
avoiding allergy due to iodinated contrast used during HSG.
Additionally HyCoSy enables scanning of the uterus and ova-
ries at the same time which is not available in HSG. These
findings make HyCoSy more suitable for outpatient examina-
tion of subfertile women.
Comparing HyCoSy and HSG concordance with laparos-
copic dye pertubation, the same high rate (86.7%) was found
with 89.6% agreement between HyCoSy and HSG [14]. Accord-
ing to these evidence HyCoSy appears to be inexpensive,
quick and patient well tolerable diagnostic method of de-
R. D. Kocyłowski, G. H. Bręborowicz
termining the tubal status and uterine cavity at the time of
conventional US scan is performed in place of HSG and
pelviscopy.
HyCoSy – theoretical considerations
Adequate approach to HyCoSy methodology should also
consider several restrictions, difficulties and complications.
Selected technical and clinical situations are listed in table 1.
Table 1. Limitations and complications
during HyCoSy examination
1) Genital tract infections
2) Cervical stenosis
3) Endometrial cells spread
(endometriosis, endometrial carcinoma)
4) Contrast allergy
5) Patient discomfort (pain induction)
6) Vasovagal reactions
7) Congenital abnormalities
8) Menstrual/abnormal uterine bleeding
It seems to be obvious but worthy to mention that vaginal
and/or cervical infections should constitute a contraindication
to HyCoSy procedure except of step 1 (TVS alone). The re-
cent guidelines even recommend disinfection of sonographic
probe because the absolute certainty of latex membrane pro-
tection cannot be guaranteed. Also prophylactic antibiotic treat-
ment is suggested prior intrauterine contrast infusion [2, 7].
HyCoSy may not be applicable due to primary or post-trau-
matic cervical stenosis [14]. In such occasions careful mana-
gement is advised regarding desired pregnancy and cervical
incompetence.
Endometrial cancer cells transfer to peritoneal cavity is
quite unlikely in the infertile group of usually young patients
but malignant elements were found in fallopian spilled fluid
during evaluation of abnormal uterine bleeding [1]. Spread of
cervical cancer by HyCoSy seems to remain rather in theore-
tical speculations.
Allergic reactions to the contrast media like air bubbles,
Echovist® and albumins are also questionable although far
less reliable than during HSG when iodinated agents are used
[6]. Latex irritation should concomitantly be reviewed in
anamnesis.
Much more frequently reported adverse-events are pa-
tient’s discomfort or even pain ranging from period-like to
unbearable. 26% women experienced severe protracted pain
and/or vasovagal reactions with bradycardia and hypotension.
One third of the subjects required resuscitation with atropine
owing to prolonged symptoms [31]. In some cases disturbing
vaginal bleeding may occur following upper genital tract
contrasting [34].
Congenital abnormalities of the cervix and uterus (e.g.
uterus duplex) are also confusing situations leading to false
conclusions or even preventing the HyCoSy examination to be

adequately performed and fully completed. In such occasions
caution is urged as benefit may be obtained in endoscopic
management rather than forceful HyCoSy introduction.
Physiological (menstruation) or abnormal (pathological)
uterine bleeding may potentially be responsible for endome-
trial cells implantation and development of endometriosis
peritoneal cavity. Thus, timing the HyCoSy is estab-
within
during the follicular phase (till 10 lished th
and special
day)
precautions are warranted in pathological bleeding [37].
Evidence Based Medicine (EBM) about HyCoSy
Tubal patency is nowadays most frequently examined via
hysterosalpingography and by chromopertubation during
laparoscopy. The experimental data suggest an important and
significant role of HyCoSy in the process of upper genital tract
imaging in comparison with above mentioned standard
methods in the infertile women’s evaluation.
HyCoSy provided clinically valuable information about
tubal patency, ovarian pathology and uterine abnormalities as
first-line outpatient investigation in fertile units. The tech-
nique allowed detecting the presence of uterine abnormalities
in 18% (fibroids, structural deviations and polyps findings),
blocked tubes in 21% (8% could not be assessed due to
technical reasons) and ovarian pathology in 6% (PCOS and
cysts) among 132 infertile patients. Authors found this exa-
mination as simple and well tolerated procedure [5]. When
HyCoSy was compared with HSG, no significant differences
were found concerning technical background (duration of pro-
cedures and contrast consumption) or side-effects profile
(patient pain and discomfort) with superiority of HyCoSy
regarding the lack of X-ray exposure [4].
Contrasted sonography revealed agreement with HSG in
proximal and distal patency of tubes in 82.9% and 82.1%,
respectively while concordance in tubal occlusion in cor-
responding (proximal and distal) fallopian sections was 91.7%
and 60%, respectively [22]. That explains why HyCoSy could
be treated as highly efficient evaluation of tubal pathology and
successfully applied as a non-invasive screening method.
Strandell et al. [33] established significant reduction in both
time and cost in HyCoSy based simplified infertility protocol
versus routine management. Total diagnosis agreement in 74%
and partial correspondence in 13% were sufficient to suggest
adequate therapy in 36% of 99 subjects. However, Dijkman et
al. [13] found no strong arguments to replace HSG by HyCoSy
or to reject HyCoSy in fallopian pathology assessment as both
methods were comparable in tubal patency evaluation, pain
experience and preferences in a group of 100 women.
Contrary to the positive data about HyCoSy, Stacey et al.
[31] stressed its diagnostic accuracy, costs and patient’s
discomfort as unfavorable compared with HSG. In this study
group of 118 patients more severe adverse-events (pain and
vasovagal reaction with the necessity of resuscitation) were
reported in HyCoSy as well as more technical failures were
noted. Similarly, Boudghene et al [6] recognized air-saline
HyCoSy as less correct to HSG in the screening of infertile
Hysterosalpingo-contrast-sonography (HyCoSy) 19
subjects. Only the use of special contrast medium enabled to
reach the same accuracy as standard approach.
In several studies all the three methods (HyCoSy, HSG
and laparoscopy) were concomitantly compared. HyCoSy
demonstrated normal anatomy and tubal patency with
sensitivity of 88% and specificity 100% for the right tube and
90% and 100% for the left one, respectively. The high reliabi-
lity permits advance selection of women requiring more inva-
sive diagnostic steps [28] and promotes usefulness in early
sterility diagnosis as easy, quick and low-risk outpatient
examination [9].
Similar positive opinions of HyCoSy as a valuable test for
scheduling the most suitable treatment of infertile couples
arouse when correlation of kappa values were found 0.48 for
patency and 0.67 for detection of at least one patent tube.
Meanwhile HyCoSy presented significantly lower sensitivity
(50%) but not a significantly higher specificity (75%) than
transvaginal sonography in tubal infertility-related adhesions
[16].
A large meta-analysis of 1007 patients established
concordance of 68.7% between HyCoSy and laparoscopy when
patients were taken into account or 83.1% if tubes were in-
vestigated. False patency rate was 6.7% and false occlusion
occurred in 10.3%. The same comparison for HyCoSy versus
HSG was 68.3%, 83.3%, 3.9% and 12.8%, respectively. HSG
occurred worse agreement than HyCoSy when compared with
laparoscopy as the corresponding findings were 63.6%, 76.3%,
11.2% and 12.5% respectively [18].
As reliable and safe modality for evaluating tubal patency,
especially suitable as an outpatient diagnostic procedure
before more invasive methods, HyCoSy showed concordance
with laparoscopy in 85.2% while HSG in 84.1%. Sensitivity was
85.2% for the two methods, specificity minimally higher for
HyCoSy (85.2% vs 83.6%) as well as PPV (71.7% vs 69.7%) and
NPV (92.9% vs 92.7%). Co-positivity and co-negativity was
66.7% and 81.8% between HyCoSy and HSG respectively, so
in some cases HyCoSy may replace HSG to select women with
patent tubes for infertility treatment without more invasive
investigation. HyCoSy and HSG provided similar information
about the status of endometrial cavity pathology (90%
concordance) and tube patency (72%), although HyCoSy more
often found evaluation of fallopian patency as uncertain while
HSG more frequently classified tubes as occluded. Sensitivity
and NPV were lower in HyCoSy than HSG (27% vs 75% and
88% vs 94%, respectively), specificity equal (90%vs 87%)
whereas PPV higher (75%vs 47%) [32].
The recent study comparing HyCoSy, HSG and laparos-
copy supported former observations that contrasted sono-
graphy is inexpensive, quick and well-tolerated method giving
the advantage of obtaining information on tubal status and
uterine cavity at the same time as conventional ultrasound
scanning is performed. HyCoSy had the same concordance
with laparoscopy as HSG (86.7%) and 89.6% when HyCoSy
faced HSG [14].
In studies evaluating HyCoSy versus laparoscopy as
golden standard, sensitivity ranged between 88-100%, spe-

20
cificity 55.6-82%, PPV 58-80% and NPV 96-100% [29,35].
However, the endoscopic reference is quite expensive so
women with normal HyCoSy and magnetic resonance imaging
(MRI) findings are regarded to have normal pelvis and may
not need routine surgical treatment [3] as agreement in
uterine abnormalities and tubal patency is 80.4% and 80%,
respectively [34].
HyCoSy and patient’s discomfort
Distention of uterine cavity with contrast medium used
during HyCoSy procedure may be associated with a kind of
unpleasant sensation, discomfort or even unacceptable pain.
In comparison with HSG, contrasted sonography affected 75%
(89/118) patients with discomfort ranging from 0 (no pain) to
2 (moderate) but one fifth (19.5%) experienced protracted
pain, while no severe adverse reactions occurred in 116 pa-
tients having hysterosalpingography performed by the same
operators [31].
However, other studies found no differences in patients’
pain/discomfort feeling during the compared procedures [13,
22]. When HyCoSy was faced with chromolaparoscopy, the
most common complaint was pelvic pain in 36.7% (22/60 pa-
tients) followed by other events like nausea in 5% (3/60) and
incidentally vaginal bleeding in 3.33% (2/60), mainly related to
catheter insertion [34]. In clinical trial with infertile women in
approximately 50% of patients HyCoSy caused little or no pain,
in 40% moderate pain and only a small part complained about
serious discomfort (8%). In 3% the procedure was disconti-
nued due to the pain intensity [29].
Interestingly, the significant correlation between patient’s
discomfort and tubal patency was confirmed. Visual Analogue
Scale (VAS) standardized questionnaire assessment revealed
the lowest mean score in patients with patent tubes (4.6),
higher in subjects with distal occlusion (6.0) and maximal in
women with proximal pathology (8.7) [18, 22]. Although in
HyCoSy discomfort and pain similar to period sensation are
adverse events bothering 42.3% of patients with mild intensity
and 10.1% with severe, only 18% women require simple anal-
gesia [5]. The accompanying vasovagal reactions like nausea
occur quite rarely (7%) and only occasionally demand treat-
ment (1.9%) [18].
Ayida et al. [4] in specially designed study assessed tole-
rance of HyCoSy and HSG as outpatient tests in 66 infertile
women. No significant differences were detected between the
two methods concerning the frequency or severity of pain at
different stages during and after the procedure or analgesia
requirements. 84% patients reported pelvic pain as the most
frequent side effect, of which 100% during HyCoSy and 85%
during HSG described the feeling as less or equal to periods
pain. Only 18% women (24% HyCoSy, 13% HSG) required sim-
ple non-steroidal analgesia. The moment of HyCoSy procedure
was associated with pain in 56% of patients and 72% in HSG,
while in the following 24 hrs the feeling was confirmed in 41%
and 47%, respectively. In conclusion HyCoSy and HSG were
equally well tolerated for evaluation tubal patency and uterine
R. D. Kocyłowski, G. H. Bręborowicz
abnormalities without differences in mean time (12.1 ± 5.2
min versus 9.5 ± 4.8, respectively) and volume contrast-me-
dium consumption (9.4 ± 5.2 ml versus 11.4 ± 8.4 ml, respec-
tively).
Apart from contrast-related adverse events, the insertion
of catheter may also contribute to patient discomfort. There
were several types of contrast donors evaluated regarding
cost, patient tolerability, physicians’ ease of use, reliability,
time required for positioning and volume contrast necessary
for sonohysterography. No statistical differences were estab-
lished among the catheters although e.g. Foleycath was the
cheapest but most difficult to place and required more time
for correct positioning, while Goldstein catheter was the best
tolerated by the patients [11]. Replacing the need for repe-
titive cervical irritation by the single use of CVS probe in wo-
men with cervical stenotic was also described [25].
Improvements of HyCoSy diagnostic power and impact
The most cost-effective contrast agent for HyCoSy ap-
pears to be sterile saline solution with air bubbles. It can also
be regarded as the least allergic one. Additionally other po-
sitive contrasted media have been applied for HyCoSy proce-
dure. One of the most frequently used is Echovist® (SHU-
454). However, saline seems to be more appropriate for the
SIS step (assessment of uterine pathology) whereas Echovist
enhances the tubal patency evaluation [32]. The amplification
of diagnostic accuracy can be also achieved either by stimu-
lated acoustic emission (SAE) or advanced ultrasonographic
technologies. The insonation of Levovist® (echo-enhancing
contrast agent) with high acoustic power of ultrasonographic
machine leads to disintegration of microbubbless resulting in
SAE. That phenomenon applied for HyCoSy proved high
coefficiency (kappa = 0.76, 95% CI 0.56-0.96) with HSG,
allowing to visualize the free spilling from fallopian tubes into
the peritoneal cavity [26]. Also air-filled albumin microspheres
(Infoson®) engaged in other study, revealed higher corre-
lation with correct diagnoses (p = 0.006) than air-saline con-
trast alone and the same as HSG [6]. Another contrast sub-
stance, sonicated human serum albumin (Albunex®), occurred
agreement in 12 of 14 histopathologically examined tubes
[17].
Color Doppler technique improves the diagnostic accu-
racy of HyCoSy in suspected tubal occlusion and provides
more vivid documentation of free tubal passage. It is also po-
tentially advantageous in cases of dislocated tubes which may
therefore be detected more easily and quickly [10, 28]. High
correspondence of Color Doppler HyCoSy with laparoscopic
findings (82.5-92%) is quite convincing and promising for the
future application as first-line diagnostic work-up with infertile
women [12, 19, 21]. Color Power Doppler HyCoSy proved to
be superior to conventional HSG in evaluating adjacent myo-
metrial structures, adnexa and follicular maturation; equal to
HSG in visualizing the passage of the contrast medium into
abdominal cavity but inferior to HSG in imaging the fallopian
tubes owing to their tortuosity [15]. However, it seems to be

esolved when 3D technique is added for examination which
enables better assessment of uterine cavity than HSG (depic-
tion in 96% vs 64%, p < 0.005) and acceptable prediction of
tubal patency by 3D HyCoSy with positive predictive value of
100%, negative predictive value in 33.3%, sensitivity 84.4% and
specificity of 100% to HSG as a reference [20]. On the other
hand, 3D Power Color Doppler HyCoSy improves even more
the tubal visualization (91% vs 46%) and decreases contrast
volume consumption in comparison to 2D HyCoSy. That mo-
dality of HyCoSy might have better side-effect profile and pro-
vide convenient storage of data [30] but is no longer cost-effec-
tive in outpatient office.
Future perspectives and developments of HyCoSy
It can be expected that pressures from insurance com-
panies to reduce costs of medical management will result in
novel approaches. HyCoSy already nowadays meets several
desired criteria for cost-effective, reliable and acceptable
method as a component of first-line infertility screening avail-
able on outpatient basis. Moreover, wider horizons are opened
in front of the technique enlarging its diagnostic and even
therapeutic potential.
First, new contrast media for so called ‘harmonic ima-
ging’ in contrast-specific scanning and organ-specific contrast
agents will significantly impact diagnostic possibilities in the
nearest years to come [27]. Then, the combination of HyCoSy
with fine, flexible endoscopic device guided through the infu-
sion catheter would expand the recognition of upper genital
tract morphology, physiology and infertility factors especially
within intrafallopian lumen. This may also broaden the use
into therapeutic approach e.g. intrauterine or intratubal adhe-
siolysis. Such futuristic visions may not have to be very unlike-
ly as there are already similar procedures called fertiloscopy
and transcervical falloscopy, currently undergoing clinical
trials [36].
Thus, the enriched HyCoSy could therefore be recogni-
zable as Hysterosonography-Conducted Salpingoscopy in
which not only the infertility cause is identified but also ade-
quately treated either by the passage restoration or finally
even with GIFT or ZIFT in assisted reproductive techno-
logy/technique. But still would it be cost-effective and outpa-
tient available procedure in our offices?
References
Alcazar J.L., Errasti T., Zornoza A. (2000). Saline infusion sono-
[1]
in endometrial cancer: assessment of malignant
hysterography
dissemination risk. Acta Obstet. Gynecol. Scand. 79(4):
cells
321-2.
American College of Obstetrics and Gynecologist Technology
[2]
(2004). Saline infusion sonohysterography. Int. J.
Assessment
Obstet. 84(1): 95-8.
Gynaecol.
Ayida G., Chamberlain P., Barlow D. et al. (1997). Is routine
[3]
laparoscopy for infertility still justified? A pilot study
diagnostic
the use of hysterosalpingo-contrast sonography and
assessing
resonance imaging. Hum. Reprod. 12(7): 1436-9.
magnetic
Ayida G., Harris P., Kennedy S. et al. (1996). Hysterosalpingo-
[4]
contrast sonography (HyCoSy) using Echovist-200 in the out-
Hysterosalpingo-contrast-sonography (HyCoSy) 21
investigation of infertility patients. Br. J. Radiol. 69
patient
910-3.
(826):
Ayida G., Kennedy S., Barlow D., Chamberlain P. (1996). A com-
[5]
of patient tolerance of hysterosalpingo-contrast sonoparison
(HyCoSy) with Echovist 200 and X-ray hysterosalpingography
for outpatient investigation of infertile women. Ultragraphy
Obstet. Gynecol. 7(3): 201-4.
sound
Boudghene F.P., Bazot M., Robert Y. et al. (2001). Assessment
[6]
Fallopian tube patency by HyCoSy: comparison of a positive
of
agent with saline solution. Ultrasound Obstet Gynecol.
contrast
525-30.
18(5):
Breitkopf D., Goldstein S.R., Seeds J.W. (2003). ACOG Commit-
[7]
on Gynecologic Practice. AIUM standard for the perfortee
of saline infusion sonohysterography. American Institute
mance
Ultrasound in Medicine; American College of Obstetricians
of
Gynecologists; American College of Radiology. J Ultrasound
and
22(1): 121-6.
Med.
Campbell S., Bourne T.H., Tan S.L., Collins W.P. (1994). Hyste-
[8]
contrast sonography (HyCoSy) and its future role
rosalpingo
the investigation of infertility in Europe. Ultrasound
within
Gynecol. 4(3): 245-53.
Obstet.
Deichert U. (1993). Contrast hysterosalpingography (or HyCoSy).
[9]
Fertil. Sex. 21(3): 213-6.
Contracept
Deichert U., Schlief R., van de Sandt M. et al. (1990). Transvagi-
[10]
contrast hysterosalpingo-sonography with the B-image pronal
and color-coded duplex sonography for the assessment of
cedure
tube patency. Geburtshilfe Frauenheilkd. 50(9): 17-21.
fallopian
Dessole S., Farina M., Capobianco G. et al. (2001). Determining
[11]
best catheter for sonohysterography. Fertil. Steril. 76(3):
the
605-9.
Dietrich M., Suren A., Hinney B. et al. (1996). Evaluation of tu-
[12]
patency by hysterocontrast sonography (HyCoSy, Echovist)
bal
its correlation with laparoscopic findings. J. Clin. Ultra-
and
24(9): 523-7.
sound.
Dijkman A.B., Mol B.W., van der Veen F. et al. (2000). Can hys-
[13]
replace hysterosalpingography
terosalpingocontrast-sonography
the assessment of tubal subfertility? Eur. J. Radiol. 35(1): 44-8.
in
Exacoustos C., Zupi E., Carusotti C. et al. (2003). Hysterosal-
[14]
sonography compared with hysterosalpingograpingo-contrast
and laparoscopic dye pertubation to evaluate tubal patency.
phy
Am. Assoc. Gynecol. Laparosc. 10(3): 367-72.
J.
Guazzaroni M., Mari A., Politi C. et al. (2001). Ultrasound hyste-
[15]
with Levovist in the diagnosis of tubaric patenrosalpingography
Radiol. Med. (Torino). 102(1-2): 62-6.
cy.
Guerriero S., Ajossa S., Mais V. (1996). The screening of tubal
[16]
in the infertile couple. J. Assist. Reprod. Genet.
abnormalities
407-12.
13(5):
Holte J., Rasmussen C., Morris H. (1995). First clinical expe-
[17]
with sonicated human serum albumin (Albunex) as an intrience
ultrasound contrast medium. Ultrasound Obstet. Gyrafallopian
6(1): 62-5.
necol.
Holz K., Becker R., Schurmann R. (1997). Ultrasound in the in-
[18]
of tubal patency. A meta-analysis of three compavestigation
studies of Echovist-200 including 1007 women. Zentralbl.
rative
119(8): 366-73.
Gynakol.
Kalogirou D., Antoniou G., Botsis D. et al. (1997). Is color Dop-
[19]
necessary in the evaluation of tubal patency by hysteropler
sonography. Clin. Exp Obstet. Gynecol. 24(2):
salpingo-contrast
101-3.
Kiyokawa K., Masuda H., Fuyuki T. et al. (2000). Three-dimen-
[20]
hysterosalpingo-contrast sonography (3D-HyCoSy) as an
sional
procedure to assess infertile women: a pilot study.
outpatient
Obstet. Gynecol. 16(7): 648-54.
Ultrasound
Kleinkauf-Houcken A., Huneke B., Lindner C., Braendle W.
[21]
Combining B-mode ultrasound with pulsed wave Dop-
(1997).
for the assessment of tubal patency. Hum. Reprod. 12(11):
pler
2457-60.

22
Korell M., Seehaus D., Strowitzki T., Hepp H. (1997). Radiolo-
[22]
versus ultrasound fallopian tube imaging. Painfulness of the
gic
and diagnostic reliability of hysterosalpingography
examination
hysterosalpingo-contrast-ultrasonography with Echovist 200.
and
Med. 18(1): 3-7.
Ultraschall
Mettler L., Czuppon A.B. (1987). Immunologie der Reproduk-
[23]
Urban & Schwarzenberg, 7-9, German.
tion.
Mettler L. (ed.) (2002). Endoskopische Abdominalchirurgie in
[24]
Gynäkologie. Schauttauer GmbH, Stuttgart, New York, 53-
der
56.
Platt L.D., Agarwal S.K., Greene N. (2000). The use of chorio-
[25]
villus biopsy catheters for saline infusion sonohysterogranic
Ultrasound Obstet. Gynecol. 15(1): 83-4.
phy.
Prefumo F., Serafini G., Martinoli C. et al. (2002). The sonogra-
[26]
evaluation of tubal patency with stimulated acoustic emisphic
imaging. Ultrasound Obstet. Gynecol. 20(4): 386-9.
sion
Schlief R., Bauer A. (1996). Ultrasound contrast media. New
[27]
in ultrasound diagnosis. Radiologie. 36(1): 51-7.
perspectives
Schlief R., Deichert U. (1991). Hysterosalpingo-contrast sono-
[28]
of the uterus and fallopian tubes: results of a clinical
graphy
of a new contrast medium in 120 patients. Radiology.
trial
213-5.
178(1):
Schwarzler P., Concin H., Wohlgenannt K. (1997). Cost effecti-
[29]
media in vaginal ultrasound uterus and fallopian tube diagnove
Ultraschal. Med. 18(1): 8-13.
sis.
Sladkevicius P., Ojha K., Campbell S., Nargund G. (2000).
[30]
power Doppler imaging in the assessment
Three-dimensional
Fallopian tube patency. Ultrasound Obstet. Gynecol. 16(7):
of
644-7.
Stacey C., Bown C., Manhire A. (2000). HyCoSy – as good as
[31]
claimed? Br. J. Radiol. 73(866): 133-6.
R. D. Kocyłowski, G. H. Bręborowicz
Strandell A., Bourne T., Bergh C. et al. (1999). The assessment
[32]
endometrial pathology and tubal patency: a comparison bet-
of
the use of ultrasonography and X-ray hysterosalpingograween
for the investigation of infertility patients. Ultrasound Obsphy
Gynecol. 14(3): 200-4.
tet.
Strandell A., Bourne T., Bergh C. et al. (2000). A simplified
[33]
based infertility investigation protocol and its impli-
ultrasound
for patient management. J. Assist. Reprod. Genet.
cations
87-92.
17(2):
Tanawattanacharoen S., Suwajanakorn S., Uerpairojkit B. et al.
[34]
Transvaginal hysterosalpingo-contrast sonography (HyCo
(2000).
compared with chromolaparoscopy. J. Obstet. Gynaecol.
Sy)
26(1): 71-5.
Res.
Tanawattanacharoen S., Suwajanakorn S., Uerpairojkit B. et al.
[35]
Transvaginal hysterosalpingo-contrast sonography (Hy
(1998).
compared with chromolaparoscopy: a preliminary report.
CoSy)
Med. Assoc. Thai. 81(7): 520-6.
J.
Watrelot A., Hamilton J., Grudzinskas J.G. (2003). Advances in
[36]
assessment of the uterus and fallopian tube function. Best
the
Res. Clin. Obstet. Gynaecol. 17(2): 187-209.
Pract.
Wolman I., Groutz A., Gordon D. et al. (1999). Timing of sonohys-
[37]
in menstruating women. Gynecol. Obstet. Invest.
terography
48(4): 254-8.
J Rafał D. Kocyłowski
of Perinatology and Gynecology
Department
University in Poznań
Medical
Polna 33, 60-566 Poznań, Poland
ul.
rkocylow@gmail.com
e-mail: