title: Diagnostic accuracy of saline infusion sonography in the evaluation of uterine cavity abnormalities prior to assisted reproductive techniques: a systematic review and meta-analyses.
abstract: BACKGROUND
  The diagnostic accuracy of a 2-D transvaginal scan, which is commonly employed to evaluate the regularity and shape of the uterine cavity in subfertile women, is relatively poor compared with other diagnostic modalities like saline infusion sonography (SIS) or hysteroscopy. SIS is a minimally invasive, cost-effective and acceptable diagnostic modality. Therefore the aim of this systematic review was to assess the diagnostic accuracy of SIS in the evaluation of the uterine cavity in subfertile women.
  
  
  METHODS
  A systematic review was conducted of diagnostic studies that compared SIS with hysteroscopy. Twenty relevant studies (including 1645 procedures) were identified and a subsequent meta-analysis was performed. Electronic databases were searched for relevant studies and references of relevant studies were cross checked. Validity was assessed and data were extracted independently by two authors. Heterogeneity was examined, studies were plotted in an ROC area and data were pooled. The main outcome measure was the diagnostic accuracy of saline infusion sonography. The pooled sensitivity, specificity, likelihood ratios and the post-test probabilities of saline infusion sonography on the prediction of uterine cavity abnormalities were calculated.
  
  
  RESULTS
  The pooled sensitivity of SIS in the detection of all intrauterine abnormalities was 0.88 (95% confidence interval (CI): 0.85-0.90). The pooled specificity was 0.94 (95% CI 0.93-0.96). The positive and negative likelihood ratios were 20.93 (95% CI: 9.06-48.34) and 0.15 (95% CI: 0.10-0.22), respectively. SIS had good accuracy in the detection of all intrauterine abnormalities (area under the summary receiver operating curve (sROC) = 0.97 ± 0.01). SIS also had a high pooled sensitivity and specificity in the detection of congenital uterine anomalies, 0.85 (95% CI: 0.79-0.90) and 1.00 (95% CI 0.99-1.00), respectively. However the limitations of the review include the heterogeneity amongst the included studies.
  
  
  CONCLUSIONS
  SIS is a highly sensitive investigative modality and comparable to the gold standard tool, hysteroscopy in the detection of intrauterine abnormalities in subfertile women. SIS is a highly sensitive and specific test in the diagnosis of uterine polyps, submucous myomas, uterine anomalies and intrauterine adhesions and can be used as a screening tool for subfertile patients prior to IVF treatment.
authors.affiliation: Assisted Conception Unit, Guys Hospital, 11th Floor, Tower Wing, Great Maze Pond, London SE1 9RT, UK v9dya@hotmail.com.
authors.forename: S
authors.initials: S
authors.lastname: Seshadri
authors.affiliation: Assisted Conception Unit, Guys Hospital, 11th Floor, Tower Wing, Great Maze Pond, London SE1 9RT, UK.
authors.forename: T
authors.initials: T
authors.lastname: El-Toukhy
authors.affiliation: Department Of Public Health Sciences, King's College London, Capital House, 5th Floor, Room 505, 42 Weston Street, London SE1 3QD, UK.
authors.forename: A
authors.initials: A
authors.lastname: Douiri
authors.affiliation: Royal Derby Hospital, Derby & NURTURE, University of Nottingham, Nottingham NG7 2UH, UK.
authors.forename: K
authors.initials: K
authors.lastname: Jayaprakasan
authors.affiliation: Assisted Conception Unit, Guys Hospital, 11th Floor, Tower Wing, Great Maze Pond, London SE1 9RT, UK.
authors.forename: Y
authors.initials: Y
authors.lastname: Khalaf
mesh_terms: D005260:Female; D006801:Humans; D007247:Infertility, Female / Q000000981:diagnostic imaging*; D027724:Reproductive Techniques, Assisted; D012680:Sensitivity and Specificity; D014463:Ultrasonography / Q000379:methods*; D014564:Urogenital Abnormalities / Q000000981:diagnostic imaging*; D014599:Uterus / Q000002:abnormalities* / Q000033:anatomy & histology / Q000000981:diagnostic imaging*
keywords: hysteroscopy; hysterosonography; saline infusion sonography; sonohysterography