Retrospective Analysis Of Influencing Factors For Venous Intravasation During Transvaginal Four-dimensional Hysterosalpingo-contrast Sonography

Background Infertility is a common problem in gynecological clinics,affecting approximately 10 to 15%of couples worldwide.Although many factors can lead to infertility,tubal disorder is identified as a common cause in female infertility,accounting for approximately 20%of infertile women.Accurate assessment of tubal patency helps to analyze the cause of infertility and provides an important basis for clinical treatment optionsIn 1980s,ultrasound has been used to assess tubal patency.It has experienced progression from negative contrast agent to positive contrast agent,and evolved from 2D contrast modes to 4D contrast modes.Transvaginal 4D-dimensional hysterosalpingo-contrast sonography(TV 4D-HyCoSy),as a real-time,dynamic and multidimensional imaging approach,could evaluate fallopian tube patency and pelvic adhesion by observing the flow of contrast agent in the uterine cavity and fallopian tube,as well as the diffusion of contrast agent in the pelvic cavity.Compared with Laparoscopy Chromopertubation(LC)-the gold standard for evaluating tubal patency,the diagnostic accuracy of TV 4D-HyCoSy was 92.9%-94.4%.Therefore,TV 4D-HyCoSy could be an alternative method to hysterosalpingography(HSG)for evaluating tubal patency,with its advantages of higher accuracy,non-radiation,and safe profile.However,during TV 4D-HyCoSy,the contrast agent sometimes entered the myometrium and the pelvic venous plexus through abnormal pathways,and refluxed to the iliac vein.Contrast agent appeared in the myometrium of uterus after uterine cavity development,which presented as "dendronous","mesh-like","mist-cloudy"with irregular strong echo.This phenomenon was called "venous intravasation".Venous intravasation would affect the observation of fallopian tube development and pelvic cavity diffusion,resulting in disorder of the sonogram,unable to clearly distinguish the structure or shape of the fallopian tube.Venous intravasation was easily mistaken the developed blood vessel for fallopian tube,which may lead to false-negative results or false positive results.For the patients with severe venous intravasation,repeated examinations were needed due to failure to diagnosis the tubal patency,increasing patient mental and economic pressure.In addition,the potential risk of venous intravasation leading to infection,bleeding,etc.is unknown.The incidence of intravasation was 13.04%to 41.3%in TV 4D-HyCoSy,which was much higher than that in HSG(0.4%to 7.2%).However,there were few reports on the influencing factors of venous intravasation in TV 4D-HyCoSy.This study is intended to be a preliminary discussion in this regardObjective Retrospective analysis of the influencing factors for venous intravasation in TV 4D-HyCoSy,to reduce or eliminate venous intravasation and to improve the quality of fallopian tube images in TV 4D-HyCoSy.This is helpful to increase the accuracy of TV 4D-HyCoSy,a new method,to evaluate the extent of tubal patency.Method From December 2014 to August 2017,643 infertile patients accepted TV 4D-HyCoSy which included 253 cases of primary infertility and 390 cases of secondary infertility.The average age was(30.17±1.50)years old,infertility time is(1.81±1.60)years old.The inspection timing were 3-10 days after menstruation.Record the patient's basic clinical data(infertility type,age,infertility duration,history of intrauterine surgery,history of pelvic inflammatory disease,history of pelvic surgery,history of ectopic pregnancy,etc.)and:inspection timing(days after menstruation clean).Ultrasound was used to measure the endometrial thickness,and to observe the with or without of intrauterine lesionsBased on the analysis of TV 4D-HyCoSy ultrasound sonogram,the extent of tubal patency on 4D-HyCoSy were classified into 3 types as follows:Type A:The tube was patent,and the contrast agent flowed smoothly through it.The contrast agent filled the uterine cavity,flowed to the uterine cornu and through the fallopian tube,and finally sprayed at the fimbrial end of the tube.In addition,the passage of the tube was soft and naturally directed downward.Type B:The tube was patent,but the contrast agent did not flow smoothly inside it.We also saw the entire fallopian tube and the spillage at the fimbrial end of the tube could be observed,but the passage of the tube was stiff,discontinuous,filamental,angled,circuitous,or directed upward.Type C:The tube was blocked.The entire passage of the tube or the spillage at the fimbrial end was unable to be observed.TV 4D-HyCoSy ultrasound sonogram was analyzed retrospectively to record the with or without venous imtravasation.Analysis of the relationship between venous imtravasation and basic clinical data,inspection timing(days after menstruation clean),endometrial thickness,intrauterine lesions.Results1?The overall incidence of venous intravasation TV 4D-HyCoSy examination was performed successfully in 643 infertile patients,of which 169 cases were found with venous intravasation.The incidence of venous intravasation was 26.28%.2.?Relationship between basic clinical data and venous intravasation Intravasation was associated with infertility type,age,history of intrauterine surgery and history of ectopic pregnancy.The incidence of intravasation in the secondary infertility was higher than that in the primary infertility(35.0%VS.13%,P<0.001).The age of patients who occurred imtravasation was older than those without lintravasation The intravasation rate of patients with history of intrauterine surgery(30.96±5.56 years old VS.29.88±5.06 years old,P=0.020).The intravasation rate of patients with history of intrauterine surgery was significantly higher than those without history of intrauterine surgery(35.4%VS.13.0%,P<0.001).The rate of intravasation ofpatients with history of ectopic pregnancy was significantly higher than those without history of ectopic pregnancy(46.1%VS.24.0%,P<0.001).There were no significant differences between groups regarding infertility duration(P= 0.709),history of pelvic inflammatory disease(P= 0.607)and history of pelvic surgery(P= 0.051).3?Relationship between inspection timing,endometrial thickness and intravasationThe TV 4D-HyCoSy inspection timing of patients with intravasation was earlier than that in without intravasation(4.98±1.48 days VS.5.34±1.66 days,P<0.001).Endometrial thickness in patients with intravasation was significantly thinner than that in patients without intravasation(5.26 ±1.84mm VS.6.67 ± 2.56mm,P<0.001).4?Relationship between intrauterine lesions and venous intravasation 139 cases of infertility patients had uterine lesions,and there was no statistically significant difference between venous intravasation and intrauterine lesions(P=0.085).5.?The relationship between tubal patency and venous intravasation Based on the analysis of TV 4D-HyCoSy ultrasound sonogram,the patients were classified into six groups according to bilateral fallopian tube patency:the bilateral fallopian tube Type A group(A+A),one side fallopian tube Type A + one side fallopian tube Type B group(A+B),one side fallopian tube Type A group P one side fallopian tube Type C group(A + C),bilateral fallopian tube Type B group(B +B),one side fallopian tube Type B + one side fallopian tube Type C group(B + C),bilateral fallopian tube Type C group(C + C).The difference between the six groups was statistically significant(P<0.001).The intravasation rate of the bilateral Type C group(C + C)was highest(49.0%)and the intravasation rate of the bilateral Type A group(A+A)was lowest(15.4%).6.?Risk factors for venous intravasationLogistic regression result showed that secondary infertility,the bilateral fallopian tube patency types(C+C,B+C,B+B),endometrial thickness?5.45mm and taking TV 4D-HyCoSy examination after menstruation?6days were risk factors for intravasation.The patient's age,infertility duration,history of intrauterine surgery,intrauterine lesions,history of pelvic inflammatory disease,history of pelvic surgery,history of ectopic pregnancy were uncorrelated with intravasationConclusion The incidence of venous intravasation in TV 4D-HyCoSy is high.Intravasation was assoeiated with infertility type,age,history of intrauterine surgery and history of ectopic pregnancy,inspection timing,endometrial thickness,tubal patency.There were no significant differences between infertility duration,history of pelvic inflammatory disease,history of pelvic surgery,intrauterine lesions.Logistic regression analysis showed that secondary infertility,TypeC+C,TypeB+C,TypeB+B in bilateral fallopian tubal patency,endometrial thickness ?5.45mm and taking TV 4D-HyCoSy examination after menstruation:?6days were risk factors for intravasation.This study showed that TV 4D-HyCoSy examination on the 7th-10th day after menstruation clean or endometrial thickness>5.45mm can effectively help reduce the incidence of venous intravasation and improve the quality of fallopian tube images in TV 4D-HyCoSy.This is helpful to increase the accuracy of TV 4D-HyCoSy,a new method,to evaluate the extent of tubal patency.