mllerian anomalies are a group of female reproductive system malformations develop during early embryologic life ( 1 ) . these congenital abnormalities might present with irregular menses , repeated abortions and infertility , and the diagnosis often delays until adulthood . it is estimated that 3.5% of women with infertility have a congenital mullerian uterine anomaly , a 21-fold incre ased prevalence compared to normal fertile women ( 1 ) . 
 
 for this high prevalence , one of the first steps in the workup of female infertility is a radiologic evaluation for mllerian anomalies . the optimal diagnostic test should be accurate , cost - effective , and minimally invasive . hysterosalpingography ( hsg ) demonstrates fallopian tubal patency , submucosal fibroid , endometrial polyp , hypertonia , hyperkinesia , and intrauterine adhesions and septa . abdominal ultrasound displays external anatomy of the uterus and fallopian tubes , even in patients with an imperforate hymen , artic vagina , and transverse vaginal septum , without the risk of radiation , contrast allergy , uterine perforation , and infection ( 3 ) . hysteroscopy is known as the gold standard method for the visualization of the mllerian structures and simultaneous treatment . although hysteroscopy is safe and efficient , this invasive procedure is associated with increased risk of uterine cavity perforation , fluid overloads , bleeding and infection ( 4 - 6 ) . hsg and ultrasound are routinely used in the evaluation of infertility , and the accuracy of each modality in comparison of hysteroscopy as the gold standard method have been evaluated . however , the accuracy of their combination is still indeterminate . so the aim of this study was to compare the diagnostic accuracy of combined transvaginal sonography ( tvs ) and hsg with that of hysteroscopy in the assessment of uterine anomalies . after approval by ethics committee of iran university of medical sciences , the study was performed on medical records of infertile women who had diagnostic or therapeutic hysteroscopy at the department of obstetrics and gynecology of rasoul e akram hospital , tehran , iran , between januarys and march 2013 . our study population was infertile women with the report of mllerian anomalies in their tvs or hsg evaluation that random elected . the analysis was performed on patient s records which had complete data of prior two - dimensional tvs , hsg and hysteroscopy all done in our center . data of a full medical history and complete gynecologic physical examination was extracted from clinical visits for all patients . infertility was defined as the absence of conception in the at least past 12 months , despite unprotected intercourse . the age , duration of infertility , duration of the marriage , history of fertility or abortion , and menstrual characteristics of patients were recorded . menstrual bleeding was categorized as irregular if each cycle lasted > 35 days or the cycle length varied>10 days . infertility was categorized as primary or secondary based on the presence of any previous conception . abortion was defined as spontaneous loss of the fetus before 20 weeks of gestation . hysteroscopy had performed by experienced gynecologists during the proliferative phase of menstrual cycle , with a 4.5-mm rigid hysteroscopy equipped with a 30 degree lens . normal saline was used as the distension medium , and a cuff - mounted manometer controlled the pressure between 80 and 100 mmhg . hsg initiates with an injection of 10-ml contrast medium with a sterile cannula into the uterine cavity after placement of a vaginal speculum . then three plain radiographs were taken to illustrate filled view of the uterine cavity , filled view of fallopian tubes , and contrast medium leak into the abdomen . the sensitivity , specificity , and positive and negative predictive values of ultrasound and hsg were compared to hysteroscopy as the gold standard . accuracy was calculated as : 
 
 ( true positive + true negative)/ ( true positive + false positive + true negative + false negative ) 
 
 also in the study used of lr to calculate the probability of disorder while adapting to varying prior probability of the chance of disease from different contexts . likelihood ratio calculated with : 
 
 positive likelihood ratio : sensitivity / 1- specificity and negative likelihood ratio : 1-sensitivity / specificity data collected from 99 patients who underwent all three diagnostic modalities . the meansd age , meansd duration of marriage , and meansd duration of infertility were 29.1 6.47 years , 8.910.28 years , and 5.64.16 years , respectively . the diagnostic accuracy parameters of tvs , hsg , and the combination of both modalities are shown in table 2 . tvs reported 10 ( 11.3% ) patients as abnormal while only 30 ( 30.3% ) of them were confirmed using hysteroscopy ( sensitivity=98.55% , specificity=30% , ppv=76.4% , npp=90% ) . hsg detected abnormality in 21 ( 22% ) patients while only 78 ( 78% ) were normal with this test ( sensitivity=95.6% , specificity=60% , ppv=84.62% , npp=85.71% ) . when both modalities were combined , the sensitivity , specificity , ppv , and npv were 94.2% , 66.67% , 86.67% , and 83.33% , respectively . positive likelihood ratios for tvs , hsg , and combined modalities were 1.41 , 2.39 , and 2.83 , respectively . the diagnostic accuracy of single tvs , hsg or combined techniques was statistically similar that was equal to 77.7 , 84.8 and 85.8 % respectively . note : prevalence=48.5% , the numbers in parentheses are the limits of the 95% confidence interval . tvs : transvaginalsonography , hsg : hysterosalpingography , ppv : positive predictive value , npv ; negative predictive value 
 
 lr+ : positive likelihood ration , lr- : negative likelihood ratio . we found that when both modalities ( tvs ad hsg ) were combined , the sensitivity , specificity , ppv , and npv were 94.2 , 66.67 , 86.67 , and 83.33% , respectively . and the combination of both diagnostic modalities are accurate enough and are not different for assessing uterine malformation in infertile women . mllerian anomalies are associated with infertility , so an accurate diagnosis of these defects would result in proper management of infertility ( 7 ) . although the gold standard for diagnosis is hysteroscopy , there is a need for a noninvasive , easy and accurate method for evaluating infertile patients with suspected malformations . the aim of this study was to compare the accuracy of the combination of two other methods with hysteroscopy in infertile population . ultrasound is the preferred diagnostic test of mllerian anomalies in some centers because of its several advantages . it is an easy , economical , quick , non - invasive method for visualizing the external contour of uterine and myometrium simultaneously . however , the quality of its image easily degraded by bowel gas or abdominal fat pad . tvs can reveal more detailed information ( 3 ) . 
 
 in the present study , ultrasound only identified uterine abnormalities in 19 of 48 defects , missing almost 60% . in a similar study , caliskan et al . ( 8) reported the sensitivity and specificity of two - dimensional sonography as 30.2 and 78.1% in the follicular phase ( 42.1 and 81.2% in the luteal phase , respectively ) . ( 9 ) have reported a sensitivity of 44.4% , specificity of 100% , ppv of 100% , and npv of 91.8% for tvs in the diagnosis of uterine malformations . on the contrary , tvs has demonstrated 100% sensitivity and 80% specificity in detecting mllerian anomalies in a study by pillerito et al . although the operator 's experience and the type of transducer might result in different test accuracy , owning to its poor sensitivity in this series , 2d tvs does not seem like a suitable tool for screening uterine anomalies . 
 
 in our study hsg had not similar diagnostic sensitivity to tvs . the overall accuracy of hsg for identifying uterine malformations was almost 84.8 % . in a study by acholonu et al . ( 11 ) the hsg had the sensitivity of 58.2% and specificity of 25.6% ( accuracy , 50.3% ) for detecting mllerian anomalies in infertile population . ( 12 ) compared the hsg with laparoscopy and reported the sensitivity of 63% , specificity of 89.3% , ppv of 92% , npv of 55% , and total accuracy of 72% in diagnosing peritoneal factors of infertility . another study of 216 infertile women presented the sensitivity of 80.3% , specificity of 70.1% , ppv of 84.5% , npv of 64.5% , and accuracy of 76.4% for hsg in detecting intrauterine abnormalities ( 13 ) . brown et al . ( 14 ) estimated 60% accuracy of hsg for detecting mllerian anomalies . reuter et al . ( 15 ) reported the accuracy of differential diagnosis of septate and bicornate uterine hsg interpreted by a radiologist , a gynecologic , and combined with ultrasound examination as 55 , 62.5 and 90% respectively . bocca et al . ( 16 ) analyzed the accuracy , costs , risks and benefits of 3d tvs and hsg among an infertile population with confirmed congenital mllerian anomalies and reported the 3d tvs a more accurate , cost - effective , and safer method . other investigators have also recommended 3d tvs for detecting mllerian anomalies ( 8,17 ) . in a study by faivre et al . ( 18 ) , 3d tvs was compared with hysteroscopy and mri in differential diagnosis of bicornate and septate uterus and the reported accuracy was 100 , 90 and 77% for each diagnostic method respectively ; they concluded that the 3d tvs is a mandatory step in the assessment of patients with suspected anomalies . hysteroscopy is not usually performed in patients with normal ultrasound or hsg findings , so the diagnostic accuracy of these methods could be easily affected . because both diagnostic tests are interpreted by physicians , the experience of the clinician influences the results . in conclusion , 2d tvs , hsg , and the combination of both diagnostic modalities are not accurate enough for detecting uterine malformations . further studies are needed to evaluate the accuracy of 3d tvs and its combinations in the diagnosis of different uterine anomalies
background : mllerian anomalies are associated with infertility . 
 hysteroscopy as the gold standard for evaluating mllerian anomalies is an invasive , expensive and risky procedure which requires enough experience . 
 transvaginal sonography ( tvs ) and hysterosalpingography ( hsg ) are less invasive procedures , but there is 
 little known about the accuracy of these tests . 
 the aim of this study was to evaluate the accuracy of the combination 
 of tvs and hsg with hysteroscopy as the gold standard . 
 methods : medical records of infertile women who were undertaken all three diagnostic modalities were reviewed 
 to analyze their sensitivity , specificity , positive predictive value ( ppv ) , and negative predictive value 
 ( npv ) . 

 results : ninety - nine infertile women were assessed with a meansd age of 29.16.47 years , meansd duration 
 of themarriage of 8.910.28 years , and meansd duration of infertility of 5.6 4.16 years . 
 the sensitivity , 
 specificity , ppv , and npv of tvs were 98.55% , 30% , 76.4% , and 90% , respectively . 
 hsg had a sensitivity of 
 95.6% , specificity of 60% , ppv of 84.62% , and npv of 85.71%.when both modalities were combined , the sensitivity , 
 specificity , ppv , and npv were 94.2 , 66.67 , 86.67 , and 83.33% , respectively . 
 the diagnostic accuracy 
 of single tvs , hsg or combined techniques was statistically similar that was equal to 77.7 , 84.8 and 85.8 % 
 respectively . 
 conclusion : the accuracy of combination of two diagnostic modalities , 2d tvs and hsg is not higher than 
 hsg alone for assessing uterine malformation in infertile women .