2.2.1\ Cycle Considerations

In premenstrual patients SSG ideally should be scheduled between days 4 and 7 of the menstrual cycle (Lindheim et al. 2006) (Fig. 7a). However, for congenital anomaly evaluation, the timing of the sonography examination is not critical (Fig. 7b). For SSG, cycle considerations of conventional hysterosalpingography should be considered.

In patients with irregular bleeding the examination can be performed without the benefit of optimal scheduling. In such cases, any potentially confusing residual blood within the endometrial cavity can be assessed during SSG using a combination of gentle catheter manipulation and saline flush during real-time sonographic visualization (Lindheim et al. 2006).

2.2.2\ Technical Considerations

Imaging should not only focus on conventional sagittal and transverse imaging of the pelvis but

a

c

also include orthogonal images along the long axis of the uterus to characterize the external uterine contour. Transabdominal ultrasound is usually best performedwitha2–6MHztransducer.Transvaginal ultrasound should be performed with an 8–5 MHz transducer. Transvaginal sonography has the advantage of improved spatial resolution, although at the expense of a decreased field of view.

SSG utilizes transvaginal sonography during instillation of either saline or contrast medium into the uterine lumen. It is best performed after sonohysterography, since sonohysterography is vital in delineating the endometrial surfaces for the presence of synechiae or intraluminal lesions such as polyps (Fig. 7c) or submucosal fibroids.

The examiner is encouraged to apply gentle pressure with the probe while sonographically assessing the mobility of the uterus, ovary, and tube.

Saline can be used initially for assessment of tubal patency. However, if there is any doubt

b

Fig. 7  Normal TVUS: clear demarcation of the relatively thick and hyperechoic endometrium (arrowheads) during the secretory phase (a), minimal fluid retention during the

proliferation phase of the cycle (b), small polyp detected during sonohysterography (c)