Saline Infusion

Sonography

Dr. H. Adnan Abadi, SpOG (K)

Saline Infusion Sonography
Minimally invasive office
technique designed to
maximize investigation of
the female genital tract

Transvaginal sonography
(TVS) is performed while
sterile saline is infused
into the uterus to distend
the endometrial cavity
Indication
Abnormal Recurrent
Infertility
uterine bleeding pregnancy loss

Postmenopausal Abnormal TVS Postoperative

bleeding finding assessment

Indistinct
Intrauterine Adhesions
endometrium

Retained
products of
conception
Preprocedure
Considerations
Absolute • Pregnancy
contraindication • Active pelvic infection

• After the end of the

Timing menstrual flow and
prior to ovulation

• Medroxyprogesterone
acetate 10 mg daily for
In AUB patients 10 days to the
withdrawal bleeding
Procedure
Put speculum in the vagina to visualize the
cervix

Do aseptic procedure to the cervix

Insert catheter that has been

pre-filled with sterile saline 10–
12 ml into the uterus

After the catheter has been

placed, the speculum is removed
from around the catheter

The vaginal probe is inserted

into the vagina
 Sagittal view, normal empty
uterine cavity

(a) SIS catheter advanced to

the mid-body of the uterus.
(b) Balloon catheter pulled
back to the level of the internal
cervical os. Air in the balloon
filled with saline is responsible
for the obvious linear shadow
(arrow).
 Lower uterine segment
(a) Catheter tip at the level of the internal cervical os,
instillation of fluid is begun as the catheter is completely
withdrawn.
(b) Distended lower uterine segment at the termination of the
SIS procedure.
 Blood in the endometrial
cavity
• May cause confusion.
• Direct visualization of the
cavity during gentle
catheter manipulation
and saline flushes
differentiating mobile
blood products
•Longitudinal TVS of the retroverted
uterus obtained during SIS

The balloon (arrowhead) dislodging

echogenic clot (arrow) in the
endometrial cavity
Optimizing performance
Uterine
distension
Sterile SIS tray Speculum (Balloon catheter filled
1-2 ml for adequate
distention)

Patient Cervical stenosis

discomfort (Use tenaculum Sub-optimal
bring the uterus and
(oral analgesic can be cervix into horizontal visualization
given) plane)

Lower uterine
segment
evaluation
Diagnostic Accuracy

• SIS accurately diagnose intracavitary filling defects  “gold

standard” hysteroscopy

Complication

• Cervical stenosis in postmenopausal woman

• Fibroid uterus
• Intraperitoneal spread of endometrial cancer
Specific Imaging
Examples
 Submucous myoma

• Most common tumor

found in females
• SIS is accurately diagnosing
submucosal myomas 
penetrate variably into
the endometrial cavity
Sagittal view of a large Type I posterior
submucous myoma
Minimal myometrial penetration. This
solid, and posterior acoustic shadowing
has ultrasound characteristics that are
typical for a fibroid.
 B
A (B) True coronal view of the uterus.
(A) Coronal view of the uterus Intracavitary fluid outlines two
filled with saline. Type 0 distinct masses:
submucous myoma. The
(1) a Type 0 submucous myoma
mass is incompletely lined
(calipers); (2) a central, brightly
by endometrium and blood
echogenic polyp.
clot (arrow).
 Endometrial polyp
• The most common filling
defects identified by
sonohysterography
• Have a sessile or pedunculated
base
Retroverted Uterus With Two
• Usually an oval or fusiform Polyps
shape That are isoechoic with
• Mostly homogeneous echoes endometrium. The larger mass
though they may appear to protruding from the anterior wall
have “microcysts” has a microcystic appearance.
A
(A) Color-flow image of an
anterior endometrial polyp
with a sessile base and a (B) True coronal view of the
central “feeder vessel.”
B
uterus. Intracavitary fluid
outlines two distinct masses:
(1) a Type 0 submucous
myoma (calipers); (2) a
central, brightly echogenic
polyp
 Endometrial Malignancy
Histological biopsy  to make a firm diagnosis

Histo-pathological
results inadequate
sampling

Biopsy diagnosis
Sonohysterography
doesn’t match th
useful when
TVS finding

Patient with AUB

whose endometrium
on TVS is not visible
(a) Abnormal endometrial (b) Application of color-flow reveals a
thickness measured (calipers) central “feeder vessel” (arrow)
in a postmenopausal patient
with bleeding. Office biopsy
reported tissue insufficient for
diagnosis.
(c) Saline surrounds a homogeneously echodense filling defect
(calipers), suggestive of polyp. The endometrium lining the
cavity is very thin and symmetric.
(d) Benign polyp confirmed on hysteroscopy.
 Two views of endometrial cancer
(a) Diffuse adenocarcinoma. Endometrium (calipers) is mostly
homogeneous and very thick.
(b) (b) Focal carcinosarcoma. This is not an SIS image; the fluid
in this endometrial cavity is blood. Office biopsy can miss
this diagnosis,especially given the thin, symmetric
endometrium seen anteriorally
 • Complication of uterine curettage
Intrauterine synechia • Patients asymptomatic and
present with unexplained
infertility

This patient very light, short menses beginning after uterine curettage for
spontaneous miscarriage.
(a) sagittal view and (b) coronal view show a thick adhesive band that
partially obliterates the uterine cavity.
 Congenital Uterine
Anomaly

• Uterine malformations 
The poorest reproductive
outcome
• Sonohysterography better
than HSG and TVS to
differentiate a septate from
a complete bicornuate
uterus
• Subseptate uterus in coronal SIS.
• A partial septum (arrow) in
combination with a normal
surface uterine contour (broken
curved line).
• Endometrial polyps (arrowheads).
3D Saline Infusion
Sonography
 Advantages

Coronal view of the uterus

maximizes the information
The volume data can be
about the endometrial
evaluated in any planed
cavity, the myometrium,
and the fundal contour
 3D SIS
(a) transverse, (b) sagittal; (c) coronal.
The ability to see all 3 orthogonal
planes helps to locate exactly
the size and position of both a
posterior submucous myoma (arrow)
and a left lateral endometrial polyp
(arrowhead).
Daftar Pustaka
• Callen, Peter W. Callen’s Ultrasonography in Obstetrics and
Gynecology 6th Edition. Elsivier:2017.

• Penny, Steven M. Examination Review for Ultrasound

Abdomen & Obstetrics and Gynecology 2nd Edition. Wolters
Kluwer: 2018.

• Botros. Ultrasonography in Reproductive Medicine and

Infertility. Cambridge University Press: 2010.