Role of hysteroscopy in diagnosis of subtle uterine anomalies in patients with normal hysterosalpingography

Abstract

Hysterosalpingogram (HSG) is an initial screening tool for evaluation of the uterus and the fallopian tubes. Although saline infusion hysterogram with 3-D US and diagnostic hysteroscopy (DH) are now the gold standard for evaluation of uterine factors, including subtle uterine septum and arcuate uterus, HSG is still being used for evaluation of such patients. The purpose of this study is to determine the role of HSG in the diagnosis of subtle incomplete uterine septum or an arcuate uterus in patients presenting with infertility and/or recurrent pregnancy loss. Retrospective Study. All patients (840) who presented to our unit with infertility and/or recurrent pregnancy loss (1992 - 2008) and subsequently underwent HSG and DH, were studied. The findings on HSG with respect to the appearance of the endometrial cavity were compared to the findings on DH. Two hundred ninety two patients (34.8%) were found to have either a subtle incomplete uterine septum (71.6%) or an arcuate uterus (28.4%) on hysteroscopy. In 141 (16.8%) patients, a septum was found on both HSG and DH. In 14 patients (1.7%), the HSG was negative when DH was positive. In 151 patients (18%), HSG was negative and the DH was positive. In 534 (63.6%) patients, both studies were negative. The ability of HSG to detect such subtle uterine anomalies had a sensitivity of 47%, a specificity of 97%, a positive predictive value of 91%, and a negative predictive value of 78%. When we compared the overall population studied to those with arcuate uterus alone, or incomplete uterine septum alone, with respect to sensitivity, specificity, and both positive and negative predictive values, the results were similar. This study suggests that when the clinical presentation of the patient suggests uterine factors, HSG alone should not be used to rule out arcuate uterus or subtle incomplete uterine septum. Hysteroscopy appears to be the gold standard before ruling out such anomalies.