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Normal Hysterosonogram Report Template (Saline Infusion)
Normal saline infusion sonohysterogram report template: pre-infusion stripe, cavity distension and smooth endometrial surfaces, with single-layer notes.
EXAMINATION: Saline infusion sonohysterography. CLINICAL HISTORY: [indication] COMPARISON: [date of prior pelvic ultrasound, or None available]. TECHNIQUE: Transvaginal ultrasound of the pelvis before and during instillation of sterile saline into the endometrial cavity through a transcervical catheter. [x] mL of saline was instilled. The patient tolerated the procedure well. FINDINGS: Pre-infusion: The uterus is anteverted, measuring [x] x [x] x [x] cm. The endometrial stripe measures [x] mm. Cavity distension: Adequate and symmetric distension of the endometrial cavity. Endometrium: Smooth, uniform endometrial surfaces. The single-layer endometrial thickness measures [x] mm. No endometrial polyp, submucosal fibroid, focal endometrial thickening or synechia. Myometrium: Normal echotexture. No fibroid distorting the cavity. Right ovary: [x] x [x] x [x] cm. Unremarkable. Left ovary: [x] x [x] x [x] cm. Unremarkable. Cul-de-sac: Trace free fluid, as expected after saline instillation. IMPRESSION: 1. Normal saline infusion sonohysterogram. Smooth endometrial surfaces without polyp or submucosal fibroid.
Dictation notes
- Measure the endometrium as a single layer during distension — adding the two layers across the fluid overstates the thickness and manufactures pathology.
- A blood clot mimics a polyp — it is mobile and avascular, while a true polyp is fixed with a feeding vessel on color Doppler; say which discriminator you used.
- Schedule the study in the early proliferative phase (about cycle days 4-10) — secretory endometrium folds into pseudo-polyps and sets up a repeat examination.
Related references
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