Intravasation complicating hysterosalpingo‐foam sonography (HyFoSy) using ExEm® Foam

Abstract

BackgroundTransvaginal hysterosalpingo‐foam sonography (HyFoSy) assesses tubal patency in an outpatient setting and without ionising radiation, unlike traditional hysterosalpingography (HSG) under fluoroscopy. Like HSG, HyFoSy may be complicated by uterine intramural contrast leak, leading to venous intravasation. Intravasation of particulate contrast agents risks pulmonary or cerebral emboli.AimsWe aimed to assess the intravasation rate of HyFoSy using ExEm® Foam and association with endometrial thickness, ExEm® Foam volume, uterine length, adenomyosis severity, uterine morphology or pain score.MethodsAn ethics‐approved retrospective study on all HyFoSy examinations between 23 January 2018 and 27 October 2021 on sub‐fertile patients, trying to conceive.Initial transvaginal sonography confirmed anatomy, uterine morphology, adenomyosis severity and endometrial thickness. Subspecialist radiologists performed HyFoSy with sonographer assistance. Intravasation was identified in real time but also checked for afterwards. Patients were asked to rate instillation pain/discomfort from one to ten immediately afterward.ResultsFour hundred and thirty‐six (n = 436) patients met inclusion criteria. Thirty (6.9%) experienced intravasation. Endometrial thickness and pain score were associated with intravasation. For every millimetre increase in endometrial thickness, the odds of intravasation decreased by 26% (P = 0.010). For every point increase on the pain scale, the odds of intravasation increased by 22% (P = 0.032). There was no evidence of an association between instilled ExEm® Foam volume or the other previously published parameters with intravasation.ConclusionA 6.9% rate of intravasation was observed. Both endometrial thickness and pain score were significantly associated with intravasation. There was no evidence of an association between ExEm® Foam volume and intravasation.

Ultrasound‐guided Lipiodol® hysterosalpingography: A prospective study on pregnancy and complication rates

“…We performed US-HSG with ExEm® Foam prior to Lipiodol® installation as we have observed an intravasation rate of 6.9% (30/436) at HyFoSy, a risk inversely associated with endometrial thickness. 10 Five out of 52 patients enrolled did not proceed to Lipiodol® injection as intravasation was diagnosed at initial HyFoSy using ExEm® Foam. An additional safety factor is the echogenicity of ExEm® Foam mixing with Lipiodol® increases conspicuity of intravasation at trans-vaginal US -white highly echogenic bubbles penetrating myometrium is unmistakable and immediately visible, if the uterus is on screen (Video S1 and Figure S1).…”

“…Intravasation of anechoic OSCM may be sonographically occult, as intravascular blood is also anechoic, and detection under US guidance may be slower than at fluoroscopy as the entire uterus is not always in the field of view. We performed US‐HSG with ExEm® Foam prior to Lipiodol® installation as we have observed an intravasation rate of 6.9% (30/436) at HyFoSy, a risk inversely associated with endometrial thickness 10 . Five out of 52 patients enrolled did not proceed to Lipiodol® injection as intravasation was diagnosed at initial HyFoSy using ExEm® Foam.…”

“…Contrast volume varies, typically 2-8 mL, and is supplied in 10 mL vials. 10 While either water-or oil-soluble contrast agents can be used, water-soluble contrasts are cheaper, with lower risk of allergic reactions and lower theoretical risk of pulmonary, retinal, and intracerebral embolism associated with intravascular injection of larger particlesized oil-based contrast. 11,12 Few reports assess Lipiodol® uterine bathing and tubal flushing at US-HSG regarding safety and fertility impact.…”

“…Fluoroscopic HSG, HyCoSy and HyFoSy usually employ hand‐injecting contrast media into the uterine cavity, and fallopian tubes to observe intraperitoneal cavity spill. Contrast volume varies, typically 2–8 mL, and is supplied in 10 mL vials 10 . While either water‐ or oil‐soluble contrast agents can be used, water‐soluble contrasts are cheaper, with lower risk of allergic reactions and lower theoretical risk of pulmonary, retinal, and intracerebral embolism associated with intravascular injection of larger particle‐sized oil‐based contrast 11,12 …”