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Study Objective: To compare the positive predictive value (PPV) of diagnostic hysteroscopy (DH) and saline infusion sonography (SIS) for the detection of myomas and polyps in patients with abnormal uterine bleeding., Design: All consecutive women referred to our University Hospital diagnosed with an intrauterine polyp or myoma by office DH or SIS were included in the study. Patients referred to our clinic from 1993 through 2000 underwent DH. From 2001 through 2004 SIS was performed. After hysteroscopic removal in an inpatient setting, histopathologic results were used as a gold standard to calculate PPV of SIS and DH. (Canadian Task Force classification II-3), Setting: Tertiary referral center., Intervention: Diagnostic hysteroscopy and saline infusion sonography., Patients: Women in whom an intrauterine polyp or myoma was diagnosed either by DH or SIS MEASUREMENTS AND MAIN RESULTS: The PPVs of SIS and DH in the evaluation of intrauterine polyps and fibroids did not significantly differ. However, p = 0.3 is the significant difference for the PPV of SIS in premenopausal women comparing the PPV of SIS for fibroids (0.95) with the PPV of SIS for polyps (0.81)., Conclusions: Diagnostic hysteroscopy and saline infusion sonography are equivalent diagnostic tools for the detection of intrauterine myomas and polyps.

Objective: To evaluate the clinical relevance of 3-dimensional saline infusion sonography (3D-SIS) in addition to conventional SIS in women with abnormal uterine bleeding suspected of having intrauterine abnormalities., Methods: All women suspected of having intrauterine abnormalities were eligible. Before 3D-SIS, conventional SIS was performed. The results of these techniques were compared with the "combined method reference standard" (hysteroscopy, endometrial sampling, and clinical follow-up in cases with normal SIS findings). Diagnostic characteristics (with 95% confidence intervals [CIs]) of 3D-SIS and SIS were calculated as well as their respective accuracy in evaluating the histologic nature, the intrauterine extension, and the location of intrauterine abnormalities. Moreover, the reliability (kappa value) and clinical relevance of 3D-SIS were assessed., Results: A total of 49 women were included, and 4 women were excluded. The positive predictive values of 3D-SIS and SIS were, respectively, 1.00 and 0.86 (95% CI, 0.72-0.99; P = .15), and the diagnostic accuracy values were 0.98 (95% CI, 0.94-1.0) and 0.91 (95% CI, 0.83-0.99; P = .08). Saline infusion sonography and 3D-SIS were equally accurate in evaluating the histologic nature, intrauterine extent, and location of intrauterine abnormalities (respective kappa values: 0.85 versus 0.93; P = .88; 0.83 versus 0.83; and 0.77 versus 0.80; P = .81). The reliability of 3D-SIS was good: intraobserver and interobserver agreement (kappa) were 0.78 and 0.72. Three women (6.7%) had the benefit of additional 3D-SIS: in these women, SIS wrongly led to a diagnosis of intrauterine abnormalities (P = .08)., Conclusions: Three-dimensional saline infusion sonography is valid and reliable in women suspected of having intrauterine abnormalities and may indeed have relevant clinical value in addition to conventional SIS.

Background: Transvaginal ultrasound (TVU) is feasible and accurate in the differentiation between non-malignant and malignant ovarian abnormalities. However, despite the clinical relevance, the accuracy of TVU in the differentiation between the many different non-malignant cysts is unknown., Methods: Between 1992 and 2002, all women who had surgery at our centre because of a non-malignant ovarian cyst were included prospectively in this study. The sonographic characteristics as well as the expected histological diagnosis (the 'sonohistological diagnosis') were evaluated pre-operatively. This diagnosis was compared with the histopathological diagnosis, and diagnostic parameters [with 95% confidence interval (CI)] of the sonohistological diagnosis were calculated. Logistic models, with the sonographic characteristics as variables, were constructed for each histopathological diagnosis., Results: A total of 406 women were included consecutively. The overall diagnostic accuracy of the sonohistological diagnosis was 60% (95% CI 0.56-0.65). Only in cases of simple ovarian cysts did the diagnostic accuracy of the respective logistic model exceed that of the sonohistological diagnosis (0.88 versus 0.81, P < 0.01). The diagnostic accuracy of the sonohistological diagnosis for endometriotic and dermoid ovarian cysts was significantly better compared with the respective logistic model (0.84 versus 0.71, P < 0.01 and 0.87 versus 0.82, P = 0.03, respectively)., Conclusion: In approximately half of the non-malignant ovarian cysts, TVU is capable of distinguishing between the different histopathological diagnoses of non-malignant ovarian masses. Only in the diagnosis of simple ovarian cysts might use of the logistic models be helpful.

Objective: The purpose of this study was to determine the amount of complications and the incidence of open- versus closed-entry (either by Veress needle or first trocar) technique in gynecologic laparoscopy in The Netherlands., Study Design: Questionnaire analysis of members of the Dutch Society for Gynaecological Endoscopy and Minimal Invasive Surgery was combined with a Medline literature search. Data related to complications on entry from January 1,1997, through December 31, 2001, were collected by questionnaire and were separated into group I (Veress needle or first trocar) and group II (open-entry technique). The number of laparoscopy procedures, years of experience, and indications to perform the chosen entry technique were collected., Results: Response rate was 98%. The procedures were performed by 187 gynecologists in 74 hospitals (72%) in The Netherlands. Groups I and II were comparable to each other, with respect to type of clinic (teaching vs nonteaching hospital), the number of procedures, and the experience of gynecologists. One hundred six gynecologists (57%) used only the closed-entry technique. This group reported 31 complications (0.1%) in 31,532 procedures. Even in the case of patients who were at risk for entry-related complications (previous laparotomy, obesity), pneumoperitoneum was established by the closed-entry technique. However, most gynecologists used an alternative insufflation point (eg, Palmer's point). The remaining 81 gynecologists used both entry techniques. However, the open-entry technique was used on special indications and in only 2.0% of cases (range: 1-20%). These special indications were suspected adhesions or previous laparotomy (90%) and obese (7%) or very thin patients (3%). These 81 gynecologists reported 20,027 closed-entry procedures and 579 open-entry procedures and complication rates of 0.12% and 1.38%, respectively (P<.001). Significantly more visceral lesions were found (P<.001) at open-entry technique in group II. Our literature search showed a calculated average entry complication rate for the closed-entry technique for visceral and vascular lesions of 0.44 of 1000 procedures and 0.31 of 1000 procedures, respectively., Conclusion: Although 43% of the gynecologists in this study performed the open-entry technique in laparoscopy, Dutch gynecologists seldom use this technique. When it is performed in selected patients, the number of complications is not reduced necessarily. In contrast to published data of general surgeons' findings, the number of entry-related complications in the open technique was significantly higher than the closed-entry technique. There is no evidence to abandon the closed-entry technique in laparoscopy. However, the selection of patients for an open- or alternative-entry procedure is still recommended.

Background: The intrauterine device (IUD) is an effective contraceptive method. The contraceptive power as well as the side-effects of IUD are thought to relate to the position of the IUD in the uterine cavity. We assessed the accuracy of clinical evaluation of IUD position., Methods: A prospective comparative study was performed. The clinical evaluation was compared with the TVU measurement of IUD position both immediately after insertion and 6 weeks after insertion. The primary outcome measures were the positive and negative predictive values (PPV and NPV) of the clinical evaluation of IUD position., Results: 195 women were included consecutively, 181 women (92.8%) were available for follow-up. The PPV and NPV of clinical evaluation of IUD position immediately after insertion were respectively 0.60 (95% CI: 0.39-0.81) and 0.98 (95% CI: 0.96-1.0). The prevalence of an abnormally positioned IUD was 7.7% (95% CI: 3.9-11.4). The PPV and NPV of the clinical evaluation at follow-up were respectively 0.54 (95% CI: 0.26-0.81) and 1.0 (95% CI: 0.98-1.0). The prevalence of abnormal position was 4.0% (95% CI: 1.7-7.1)., Conclusion: Clinical evaluation is an excellent test for the evaluation of the position of an IUD and routine TVU is not indicated for this purpose.

Objective: To assess the diagnostic accuracy of saline contrast hysterosonography in the evaluation of the uterine cavity in women complaining of abnormal uterine bleeding., Design: A systematic review and meta-analysis of diagnostic studies that compared saline contrast hysterosonography to a gold standard diagnosis based on either hysteroscopy with or without histological sampling or to hysterectomy., Setting: University Hospital., Sample: Twenty-four studies (including 2278 procedures)., Methods: Electronic databases were searched for relevant studies and references were cross checked. Validity was assessed and data were extracted independently by two authors. Heterogeneity was calculated, studies were plotted in an ROC area and data were pooled. Subgroup analysis was performed according to the validity area., Main Outcome Measures: The success rate of saline contrast hysterosonography. The pooled sensitivity, specificity, likelihood ratio's and post-test probabilities of saline contrast hysterosonography on the prediction of uterine cavity abnormality., Results: The largest population of homogeneous data were the studies with complete verification. In these studies, the pooled sensitivity and pooled specificity of saline contrast hysterosonography in uterine cavity evaluation were respectively 0.95 (95% CI 0.93 to 0.97) and 0.88 (95% CI 0.85 to 0.92), the likelihood ratios were respectively 8.23 (95% CI 6.2 to 11) and 0.06 (95% CI 0.04 to 0.09) and the post-test probabilities were respectively 0.91 (95% CI 0.89 to 0.94) and 0.07 (95% CI 0.04 to 0.10). The overall success rate of saline contrast hysterosonography was 93% (95% CI 92% to 94%). The feasibility of saline contrast hysterosonography in postmenopausal women (success rate 86.5%, 95% CI 83.2 to 89.8) is significantly lower (P < 0.01) compared with premenopausal women (success rate 95%, 95% CI 94% to 96%)., Conclusion: Saline contrast hysterosonography is accurate in the evaluation of the uterine cavity in pre- and postmenopausal women suffering from abnormal uterine bleeding. The feasibility of saline contrast hysterosonography is high, although significantly better in premenopausal women compared with postmenopausal women. We conclude that saline contrast hysterosonography, in combination with an endometrium aspiration if necessary, can become the standard diagnostic procedure in women with abnormal uterine bleeding.

Diagnostic hysteroscopy is the standard investigation performed in the case of abnormal vaginal blood loss. More recently there has been increasing interest for minimal invasive saline contrast hysterosonography (SCHS) as this technique is less painful and less expensive. SCHS is indicated in case of abnormal uterine bleeding (premenopausal and postmenopausal), bleeding while using tamoxifen, suspicion of a congenital uterine abnormality and Asherman's syndrome. As well as intracavity abnormalities (polyps and myomas) SCHS can also be used to evaluate the intramural extension of myomas, which is necessary to assess whether hysteroscopic resection is possible. The sensitivity and specificity of SCHS for demonstrating intracavity abnormalities (with a prevalence of 54%) are 94% (95%-CI; 91-97) and 89% (95%-CI: 85-94) respectively. The positive and negative predictive values are 91% (95%-CI: 87-95) and 92% (95%-CI: 89-97) respectively. SCHS has a short learning curve and can be performed in an outpatient setting. SCHS fails more frequently in postmenopausal women than premenopausal women (12.5% vs. 4.7%; p = 0.03). The chance of a non-conclusive SCHS is 7.6% and is higher if the uterine volume is greater than 600 cm3 (relative risk: 2.63; 95%-CI: 1.05-6.60) and if two or more myomas are present: (RR 2.65; 95%-CI: 1.16-6.10). SCHS is 2 to 9 times cheaper than diagnostic hysteroscopy. It can replace 84% of the diagnostic hysteroscopies. SCHS, in combination with endometrial sampling, whenever indicated, might be able to replace diagnostic hysteroscopy as gold standard in the evaluation of the uterine cavity.

The objective of this study is to evaluate whether regular follow-up after insertion of an IUD protects against the risk and side effects of this contraceptive device. To study the effectiveness of the follow-up visits done after IUD insertion, we compared a group of women with regular follow-up visits (group A: after 6 weeks, 3, 6 and 12 months) with women who had non-regular follow-up visits (group B: after 6 weeks and annually) for pregnancy, expulsion rates and discontinuation. A total of 280 women were included (group A: 199, group B: 81). Three pregnancies and 2 unnoticed expulsions were observed. The detection rate of an unnoticed expulsion is 0.35 and 0.11 per 100 visits for, respectively, the visit 6 weeks after insertion and all successive visits. Women in group A came significantly more frequently for unscheduled visits [relative risk (RR): 1.6; 95% confidence interval (CI): 1.03-2.4]. The number of discontinuations, pregnancies and expulsions did not differ between groups, but women in group B had their IUD removed earlier (p < 0.01). We conclude that regular follow-up after the insertion of an IUD is not effective.

Objective: The purpose of our study was to evaluate to which extent saline contrast hysterosonography (SCHS) is able to replace diagnostic hysteroscopy in uterine cavity evaluation in women suspected of intrauterine abnormalities., Study Design: In this prospective observational study we performed SCHS instead of diagnostic hysteroscopy. Diagnostic hysteroscopy was performed in case of failed or inconclusive SCHS. Univariate and multivariate analyses were used to assess subgroups for their risk of failure and inconclusiveness., Results: Two hundred fourteen women were included consecutively. SCHS was conclusive in 180 cases (84.1%), failed in 12 (5.6%), and inconclusive in 22 (10.3%). Uterine size above 600 cm(3) was the best predictor of failure and/or inconclusiveness (positive predictive value 0.42)., Conclusion: SCHS was able to replace 84% of the outpatient diagnostic hysteroscopies in uterine cavity evaluation in women suspected of intrauterine abnormalities. Our study showed that diagnostic hysteroscopy can be restricted to inconclusive or failed SCHS.