P–727 Prevalence of ultrasound-detected gynaecological pathology in a One-Stop fertility clinic

Study question What is the prevalence of abnormal findings on transvaginal ultrasound scan (TVS) in a population of women presenting with subfertility to a One-Stop fertility clinic? Summary answer Two thirds of women in our population had ultrasound-detected pathology. The five commonest pathologies were uterine fibroids, polycystic ovaries, endometriosis, adenomyosis and benign ovarian cysts. What is known already Gynaecological pathology is common in women presenting with subfertility. However, their prevalence varies depending on the age, geography, background health of the population and study design. Few prevalence studies performed in the general female population show definitive associations with subfertility. As imaging techniques become increasingly sophisticated and patient demographics evolve over time, the prevalence of gynaecological pathology is anticipated to change. Understanding their prevalence in a subfertile population would shed light on the burden of disease, providing information about prevention strategies and service priorities. There are no published studies on the prevalence of ultrasound-detected gynaecological pathology in the subfertile population. Study design, size, duration This was a retrospective cross-sectional study of 1558 women presenting to a One-Stop fertility clinic of a university teaching hospital between January 2012 and December 2020. Participants/materials, setting, methods Women who attend the clinic routinely have their demographic data and a detailed clinical history taken prior to a transvaginal ultrasound scan. A clinical examiner trained in transvaginal ultrasonography performs the ultrasound examination in a standardized fashion. Ultrasound features and diagnoses are systematically recorded in an electronic database. We obtained demographic data and details of gynaecological diagnoses from the electronic database. We analysed the data using descriptive statistics and reported our results as proportions. Main results and the role of chance The median age of women at the time of scan was 35 years (range 21–46 years). The mean Body Mass Index was 24.8 kg/m2 (range 16.9–50.4 kg/ m2). The median duration of subfertility was 24 months (range 3–168 months). 472/1558 (30.3%, 95% CI 28.0–32.6) women had normal pelvic scans. The most frequent pathology seen in our population was uterine fibroids (410/1558, 26.3%; CI 24.1–28.6); 10.5% of these fibroids distorted the uterine cavity. Polycystic ovaries were the next most common pathology (363/1558, 23.3%; CI 21.2–25.4), followed by endometriosis (177/1558, 11.4%; CI 9.8–13.0), adenomyosis (160/1558, 10.3%; CI 8.8–11.9) and benign ovarian cysts (122/1558, 7.8%; CI 6.6–9.3). The other abnormalities seen on scan included congenital uterine anomalies (81/1558, 5.2%; CI 4.2–6.4), endometrial polyps (69/1558, 4.4%; CI 3.5–5.6), pelvic adhesions (44/1558, 2.8%; CI 2.1–3.8) and intrauterine adhesions (13/1558, 0.8%; CI 0.5–1.4). Of the 1086 women with abnormal scans, 832 (76.6%, CI 74.0–79.1) had one pathology detected on TVS and 254 (23.4%, CI 20.9–26.0) had more than one pathology detected. Limitations, reasons for caution A limitation of our study was the lack of histological confirmation of the ultrasound findings. Due to our smaller sample size, our prevalence could potentially be overestimated. Wider implications of the findings: The relevance of each pathology to chances of conception requires further examination to avoid under- or overtreating women in their fertility journey. Our findings may provide a background for future correlation studies. Furthermore, a scan quality assessment may be considered if the detection rate is substantially different in similar populations. Trial registration number Not applicable

Clinical relevance of routine transvaginal ultrasound in women referred with pelvic organ prolapse

Background The aim of this study was to investigate the prevalence of incidental findings on transvaginal ultrasound scan in women referred with pelvic organ prolapse by a general practitioner and to investigate which further examinations and treatments were performed as a result of these findings. Methods This was a retrospective cohort study that investigated women with pelvic organ prolapse referred to the outpatient urogynaecological clinics at Randers Regional Hospital and Aarhus University Hospital, Denmark. Results A total of 521 women were included and all of them were examined with a routine transvaginal ultrasound scan and a gynaecological examination. Prolapse symptoms only and no specific indication for transvaginal ultrasound scan were seen in 507 women (97.3%), while 14 women (2.7%) received scans on indication. Among the latter women, five (35.7%) had cancer. In the women with solely prolapse symptoms, 59 (11.6%) had incidental findings on transvaginal ultrasound scan, but all were benign. However, two patients were later diagnosed with cancer unrelated to the initial ultrasound findings. The treatment was extended with further examinations not related to POP in 19 of the women (32.2%) with incidental ultrasound findings. Conclusion The prevalence of incidental ultrasound findings was not high in the women referred with pelvic organ prolapse and no additional symptoms, and all these findings were benign. However, it should be considered that these findings resulted in further investigations and changes to the patients’ initial treatment plans. A meticulous anamnesis and digital vaginal examination are crucial to rule out the need for vaginal ultrasound.

Study of endometrial thickness and pregnancy outcome following induction of ovulation and intrauterine insemination in primary infertility

Objective: Infertility affects approximately 10–15% of couples. Assessment of the endometrium with ultrasound has become a standard procedure during the diagnostic workup and treatment of infertility. Our study was designed to investigate whether endometrial thickness on the day of human chorionic gonadotropin administration is a predictor of intrauterine insemination (IUI) success as the primary outcome. Materials and Methods: In the prospective observational study, a serial transvaginal ultrasound scan was performed to measure endometrial thickness following ovulation induction with clomiphene citrate and IUI. One hundred and nine IUI cycles were chosen and the outcome was measured in terms of whether pregnancy occurred or not. Results: There was a statistically significant difference (P = 0.001) between the two groups with respect to mean endometrial thickness (mm). It was also seen significantly higher numbers of pregnancy in Group A (endometrial thickness ≥ 7 mm). Conclusion: The present study identified a statistically significant difference in mean endometrial thickness between cycles that resulted in pregnancy and those did not. Consequently, clinicians providing IUI for infertile couples must pay close attention to endometrial development.

Cesarean Scar Hysterotomy: Assessment by Three-dimensional Transvaginal Ultrasound Scan

ABSTRACT Objective The combined study of two-dimensional (2D) and three-dimensional (3D) sonographic records may be useful to diagnose wound dehiscence from hysterotomy and forecast the well-being of future gestations. In that respect, irregular cicatrization patterns can be identified from the early puerperium over the whole postparturition recovery period, and may encourage the need for further cesarean in new pregnancies to come. Subjects and Methods A random sample of 42 female patients were subjected to transvaginal sonographic exploration at three sampling times, namely 4 days, 4 months, and 1 year following hysterotomy. All of these women recovered successfully from their cesarean and were discharged from hospital 5 days after parturition. The 2D and 3D surveys were subsequently undertaken at each of the three study times. Four days after surgery, the 2D ultrasound scan aimed at evaluating the early evolution of the uterine scar. On the contrary, 3D echographies were implemented frame-to-frame, in a transverse direction, from the right to left sides of the uterus. Results The 3D sonographic records from those dehiscent wounds displayed at this time a wide, irregular hypoechogenic area crossed over by linear structures representing the suture material (Vycril). Such a record was called a “shark bite” pattern. The latter puerperal dehiscence pattern persisted in the isthmic region for 4 months and 1 year after delivery. It consistently featured a notch between the scar borders that run perpendicular to the complete extent of the internal myometrium layer and bordered the anterior uterine wall. By considering the length of the hysterotomy-derived notch over the whole study period, two types of scars could be differentiated through 2D sonographic surveys, scar notches >2/3 (n=9) or ≤1/3 (n=4) of the total scar lengt. Six of the 13 wound-dehiscent women monitored in this study became pregnant within 2 years after their former cesarean. All were subjected to a second hysterotomy, before which an in situ examination of the previous uterine scar could be made. Early puerperal ultrasound scan focusing on hypoechogenic areas across the borders of hysterotomy-derived scars under suturing pressure must be undertaken by means of 2D transvaginal ultrasound scan, with the bonus that such exploration can be extended through several months to a 1 year period after surgery. The extent of dehiscent myometrium areas and the depth of the notch remaining between the serose and the cervical channel of the stigma can be used as reliable indicators for defective cicatrization processes and should be used as background information aiding in future gestations. The 3D transvaginal ultrasound scan provides the practitioner with thorough records of myometrial failure and enhances the morphological study of iatrogenic pathologies originating from cesarean surgery. The state and extent of healed vs failing cicatrization areas can be easily assessed by means of 3D transvaginal ultrasound scan. How to cite this article Troyano JM, Clavijo MT, Martinez-Wallin I, Molina-Betancor A, Alvarez-de-la-Rosa M, Padilla AI, Bajo-Arenas J. Cesarean Scar Hysterotomy: Assessment by Three-dimensional Transvaginal Ultrasound Scan. Donald School J Ultrasound Obstet Gynecol 2017;11(1):82-87.