30-year-old woman turned to a gynecologist at the outpatient clinic. She has complaints about the absence of pregnancy for 2 years, with regular sexual activity without contraception. From the anamnesis: she had 3 pregnancies, 1 - full term labor, 2 - spontaneous abortion (last spontaneous abortion was 2 years ago). Menstruation is regular, moderate, painless. At gynecological examination doctor has not revealed any pathology. On ultrasound of the small pelvis: no pathology was detected. What examination is necessary and why: A ) Определение хр. инфекции – трубного-перитонеального фактора / Созылмалы инфекцияны анықтау- тубальды-перитонеальды фактор/ Definition of chronic infection - tubal-peritoneal factor B ) Определение количества пролактина- яичникового фактора /Аналық без факторы -пролактин мөлшерін анықтау/ Determination of the amount of prolactin-ovarian factor C ) Кольпоскопия- для определения шейчного фактора/ Кольпоскопия - жатыр мойны факторын анықтау/ Colposcopy - to determine the cervical factor D ) Гистеросальпингография -маточного фактора/ Гистеросалпингография-жатырлық факторы/ Hysterosalpingography - to determine the uterine factor E ) Проведение УЗИ малого таза- трубно-яичникового фактора/ Кіші жамбас-тубо-аналық без факторының ультрадыбыстық зерттеуін жүргізу/ Conducting an ultrasound of the small pelvis - to determine the tubo-ovarian factor One correct option
secondary infertility after spontaneous abortion hysterosalpingography tubal factor investigation
Answer: D - Hysterosalpingography (HSG) to determine the uterine factor / tubal-peritoneal factor
Clinical Reasoning
| Finding | Significance |
|---|---|
| Regular, painless, moderate menses | Ovulatory factor is unlikely |
| Normal gynecological exam | No obvious cervical/uterine pathology |
| Normal pelvic ultrasound | No ovarian masses, no obvious structural anomalies |
| 2 prior spontaneous abortions | Risk factor for intrauterine adhesions (Asherman's) and/or chronic endometritis |
| 2 years secondary infertility | Structural/tubal cause likely |
Why HSG is the Correct Next Step
"Tubal factor accounts for 25-35% of infertility. The incidence of tubal infertility has been reported to be 8%, 19.5%, and 40% after one, two, and three episodes of PID, respectively. Many patients with documented tubal damage have no history of PID and are presumed to have had subclinical chlamydial infections."
"Hysterosalpingography (HSG) is performed... to visualize the uterine cavity, fallopian tube architecture, and tubal patency."
- The uterine cavity - to detect intrauterine adhesions (Asherman's syndrome) from prior spontaneous abortions/evacuations
- Tubal patency - to rule out tubal occlusion from prior infection or post-abortion inflammation
Why the Other Options Are Less Appropriate Here
- A (Chronic infection / tubal-peritoneal factor): Serological testing for chronic infections (e.g., Chlamydia IgG) can support suspicion, but does not directly diagnose current structural tubal damage - HSG does. Also, the question asks what examination is necessary, and HSG is the definitive structural test.
- B (Prolactin / ovarian factor): Menses are regular, so anovulation from hyperprolactinemia is unlikely.
- C (Colposcopy / cervical factor): Cervical exam was already normal; no indication for colposcopy as a first-line infertility investigation here.
- E (Pelvic ultrasound): Already performed and was normal.
Conclusion
- Berek & Novak's Gynecology, p. 2058-2059 - Tubal Factor & Hysterosalpingography section
A 25-year-old woman came to see the gynecologist, complaining of a mass in the left ovary, revealed during an ultrasound scan. No complaints. Planning a pregnancy. Ultrasound: uterus 44 * 37 * 46 anteriorly. M-echo 7mm, right ovary 32 * 27 * 20mm of normal structure, left ovary 65 * 86 * 59 mm, contains hypoechoic formation 50 * 65 mm with hyperechoic suspension. With CDC, blood flow was not detected, there was no parietal component. There is no free fluid in the abdominal cavity. Your preliminary diagnosis: A ) зрелый фолликул/ жетілген фолликул/ mature follicle B ) фолликулярная киста левого яичника/ сол жақ аналық бездің фолликулярлық кистасы/ follicular cyst of the left ovary C ) эндометриоз левого яичника/ сол жақ аналық бездің эндометриозы/ left ovarian endometriosis D ) рак левого яичника/ сол жақ аналық без қатерлі ісігі/ left ovarian cancer E ) левосторонний аднекстумор/ сол жақ аднексумор/ left-sided adnexumor
ovarian endometrioma ultrasound hypoechoic hyperechoic suspension ground glass appearance diagnosis
Answer: C - Left Ovarian Endometriosis (Endometrioma)
Ultrasound Findings Analysis
| Ultrasound Feature | Finding in This Case | Significance |
|---|---|---|
| Cyst size | 50 x 65 mm | Large - functionally active |
| Echogenicity | Hypoechoic with hyperechoic suspension | = "ground glass" - classic for endometrioma |
| Blood flow (CDK/CDC) | None detected | No malignant neovascularization |
| Parietal/solid component | Absent | Against malignancy |
| Free fluid | Absent | Against rupture, malignancy |
| Locules | Appears unilocular | Typical for endometrioma |
Why This is an Endometrioma
"The typical ultrasound features of an endometriotic ovarian cyst in premenopausal women were described as 'ground-glass echogenicity of the cyst fluid, one to four locules and no solid parts.'" (sensitivity 93%, specificity 96% for endometrioma)
"Typical sonographic findings associated with an endometrioma include a unilocular cyst with low-level echogenicity representing old blood (commonly termed ground-glass feature)."
Why the Other Options Are Wrong
- A (Mature follicle): A mature follicle is typically 18-24 mm and purely anechoic (black). This cyst is 50x65 mm with internal echogenic content - far too large and complex to be a follicle.
- B (Follicular cyst): Follicular cysts are characteristically anechoic (no internal echoes), thin-walled, and typically <8 cm. The hyperechoic suspension rules this out.
- D (Ovarian cancer): Cancer would typically show vascularized solid components or papillary projections on Doppler. This cyst has no blood flow and no parietal component, making malignancy unlikely.
- E (Adnexal tumor/adnexumor): This is a non-specific umbrella term. Given the highly specific ultrasound features pointing to endometrioma, option C is the precise diagnosis.
Clinical Correlation
- Berek & Novak's Gynecology - Endometriosis: Ultrasound section, p. 632
- Sabiston Textbook of Surgery - Endometrioma section