Hysterosalpingogram (HSG) is a simple radiographic procedure that not only provides information about the patency and any intratubal lesions but also evaluates the uterine cavity for abnormalities associated with Müllerian dysgenesis, intrauterine adhesions, submucous myomas and endometrial polyps. Though HSG has a good sensitivity index there is a high false positive rate with a low specificity that then requires further diagnostic evaluation with hysteroscopy.
Hysteroscopy is recognised as gold standard test for identifying uterine anomalies as it allows direct visualisation of uterine cavity (NICE 2013). Office hysteroscopy performed on 1000 consecutive patients scheduled to undergo IVF revealed pathology in 38% of the patients (Hinkley et al 2004). The majority of abnormalities were endometrial polyps (32%), submucous myomas (3%) and intrauterine adhesions (3%). The other advantage of hysteroscopy is the potential to immediately treat any intracavitary lesion. Women with amenorrhoea who are found to have intrauterine adhesions should be offered hysteroscopic adhesiolysis because this is likely to restore menstruation and improve the chance of pregnancy. A case series (n=40) suggested that hysteroscopic adhesiolysis restored normal menstrual function in 81 % of women. Of the 16 infertile women in the series 63%(n=10) conceived and 37% (n=6) delivered a viable infant. (NICE 2013)(Evidence level 3).
Saline infusion sonograms
This involves injecting normal saline into the uterine cavity using an intrauterine balloon catheter, whilst scanning transvaginally at the same time. The sensitivity and specificity for detecting various anomalies (polyps, synechia, malformations and myomas) were 98% and 94%, respectively, compared with office hysteroscopy.