A prospective study examining the value of three-dimensional transvaginal ultrasonography during the diagnosis and evaluation of Asherman syndrome

Research question: What is the value of three-dimensional (3D) transvaginal ultrasonography (TVS) in the diagnosis and assessment of Asherman syndrome?

Design: This was a prospective study conducted at a hysteroscopy centre.

Results: A total of 685 participants were recruited, 65 dropped out and 620 were finally enrolled and analysed. The overall sensitivity, specificity and accuracy of 3D-TVS in the diagnosis of Asherman syndrome were 95.7%, 80.7% and 93.5%, respectively, and the sensitivity and accuracy were significantly higher than those of two-dimensional (2D) TVS (P < 0.001). The likelihood of 2D-TVS missing a case of mild intrauterine adhesions (IUA) was 43.7%, compared with only 6.2% for 3D-TVS. The frequency of involvement of each anatomical area by adhesions in decreasing order was right and left uterine side walls (both 80%), central or mid-cavity (31%), right cornual region (26%), left cornual region (23%), fundal wall (15%) and isthmus (4.5%). The correlation between 3D-TVS and hysteroscopy in each of the seven anatomical areas was analysed separately. The results showed good agreement with regard to the three uterine walls (fundus, left lateral and right lateral), with kappa values of 0.678-0.811. The likelihood of the IUA being severe in nature when there were five or more areas, three or four areas, or one or two areas was 82%, 37.1% and 6.3%, respectively (P < 0.001).

Conclusions: The diagnostic value of 3D-TVS is higher than that of 2D-TVS. In clinical practice, 3D-TVS should whenever possible replace 2D-TVS as the initial method of assessment to decide if hysteroscopy is necessary and to help with planning surgery.