Infertility Us 15-7

7/31/2019 Infertility Us 15-7

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Ultrasound and infertility

Dr. Mohamed Hesham Anwar

Prof. Obstetrics & Gynecology

AL AZHAR UNIVERSITY


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THE ROLE OF ULTRASOUND IN THE

INVESTIGATION OF SUBFERTILITY Transvaginal ultrasound (TVS) is the method of

choice for assessing the female reproductive

organs.


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The pivotal ultrasound(performed between days 8 to 12 of the menstrual cycle)

* Uterus and uterine cavity dimensions : anomalies/tumors

Endometrium

thickness

appearance

hydrosonography (if indicated)

Uterine artery blood flow parameters PSV (peak systolic velocity) : PI

(pulsatility index)

* Ovarian morphology normal/polycystic/multicystic

position/mobility

volume/antral follicle count

Follicular sizeOvarian stromal and perifollicular blood PSV : flow parameters PI

* Tubal patency hysterosalpingo contrast sonography : (HyCoSy)

* Pelvis presence or absence of free fluid/masses within pelvis


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Uterine assessment An understanding of the normal morphology

and general dimensions of the uterus is

important.

The dimensions and appearance of the uterus

should be recorded in both the longitudinal or

sagittal plane and at 90 rotation in the

coronal plane.


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FIBROIDS Transvaginal sonography is an excellent method of

demonstrating uterine pathology.

Leiomyomata (fibroids) are a common finding inwomen during the reproductive years. They can be

subserosal, intramural, submucosal or pedunculated . The presence of submucosal fibroids in particular is

thought to interfere with embryo implantation.

In addition, there is also an association with fibroids

elsewhere in the myometrium and reduced fertility. The exact mechanism is unknown but might be relatedto an overall poor intrauterine environment impairingimplantation.


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Adenomyosis Adenomyosis is a condition characterized by the presence of

ectopic endometrium within the myometrium itself.

Ultrasound features of adenomyosis can be subtle and are oftenbest appreciated with real-time high resolution scanning ratherthan hard-copy images .

Recognized features include: Uterine enlargement without the presence of fibroids, often with an

asymmetrical thickening of the anterior and posterior myometrium.

The myometrium itself might have a heterogeneous appearancebecause of the presence of multiple small areas of ectopicendometrial tissue.

More specific features might include myometrial nodules or cysts,possibly with discrete hemorrhagic foci.

Although somewhat controversial, it does appear to be moreprevalent in women with subfertility.


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Endometrial assessment There are definitive changes of the endometrium

throughout the menstrual cycle.

Early in the menstrual cycle the endometrium is thin andis hypoechoic compared with the surroundingmyometrium.

As the follicular phase progresses, the endometriumthickens and takes on a characteristic trilaminarappearance .

Following ovulation the endometrium becomes moreheterogeneous with a hyperechoic appearancecompared to the surrounding myometrium


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Longitudinal (sagittal) and coronal views of a normal uterus. 1, Longitudinal diameter;

2, transverse diameter; 3, endometrial thickness; + + transverse diameter.


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Longitudinal view of uterus demonstrating typical trilaminar appearance of

proliferative phase endometrium.


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Longitudinal view of the uterus demonstrating typical hyperechoic appearance of

secretory phase endometrium.

1, Longitudinal diameter; 2, transverse diameter; 3, endometrial thickness.


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INTRA-CAVITARY LESIONS Lesions within the endometrium itself can also

interfere with implantation.

As well as the abovementioned submucous

fibroids, endometrial polyps can also beresponsible for failure of implantation.

These polyps can be identified with carefultransvaginal scanning as effectively as more

invasive procedures such as hysteroscopy. Saline contrast hysterosonography (SCHS) can aid

the diagnosis by further delineating the polyp.


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Submucous fibroid projecting into the uterine cavity.


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Saline contrast hysterosonography demonstrating the presence of an endometrial polyp.


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Endometrial receptivity Endometrial receptivity is a qualitative term

used to describe a favorable situation with

respect to implantation potential.

The following factors are regarded as markers

of endometrial receptivity:

minimum thickness of 7 mm

trilaminar appearance

uterine artery pulsatility index values (PI) < 3.0.


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Uterine artery Doppler

assessment.

The upper panel shows a waveform typical of

normal vessel resistance.

The lower panel demonstrates a waveform

from a vessel with elevated resistance.


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SUBENDOMETRIAL BLOOD FLOW More recently, interest has focused on

subendometrial blood flow.

Using more conventional color Doppler it is

possible to assess the degree of penetration of

blood vessels into the endometrium.

Absence of subendometrial vascularity

correlates with a likelihood of failure of

implantation.


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Color Doppler interrogation of the uterus

demonstrating subendometrial blood flow.


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Ovarian assessment Transvaginal ultrasound is an excellent method of

assessing the ovaries.

In general, one should assess the followingparameters with respect to the ovaries:

appearance

dimensions [length (l), width (w), depth (d)]

volume (l w d 0.5233)

location/mobility/accessibility dominant follicle

stromal/follicular Doppler blood-flow parameters.


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Transvaginal scan demonstrating a normal ovary and its anatomical

relationships with the uterus and internal iliac vessels.


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Three-dimensional image of an ovary obtained with surface rendering software.


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PCO vs MCOMulticystic ovaries

are distinguished from

polycystic ovaries in

that the cysts arespread throughout the

ovary rather than

peripherally.

Polycystic ovaries are defined according to

the following criteria

(Adams criteria):

10 or more cysts of

between 2 and 8 mm

arranged peripherally

ovarian volume of > 8cm3 (implying increased

ovarian stroma).


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Typical appearance of a polycystic ovary demonstrating peripherally situated cysts

and centrally increased ovarian stromal density.


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Poor Ovarian Reserve When the ovarian volume is

less than 3 cm3 and there arefewer than five antral follicles,the ovarian reserve is said tobe reduced.

This would imply that there is asignificantly reduced chance ofresponding to ovarianstimulation during fertilitytreatment.

It appears that this might be a

more specific test thanconventional early menstrualFSH estimation.


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Doppler to assess follicular blood flow can help identify those thatcontain better quality oocytes with greater fertilization potential andresultantly higher embryo implantation potential.

Apart from assessing intrinsic ovarian morphology and function,transvaginal ultrasound is also ideal for identifying ovarian pathology.

Lesions such as functional or hemorrhagic cysts, endometriomata anddermoid cysts can generally be seen easily and, in most situations, areasoned judgment can be made about the need for furthertreatment prior to embarking on fertility treatment.

Simple or thin-walled cysts of less than 5 cm diameter are generallybenign and usually resolve without any further treatment.

Hemorrhagic cysts are commonly associated with bleeding into thecorpus luteum and also generally resolve


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A large endometrioma demonstrating the typical ground glass appearance.


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Dermoid cysts are benign tumours that result from totipotential

cells found in the ovary.

They can contain many different tissue types and

have a variable appearance on ultrasound.

They are often poorly defined and can easily be

mistaken for bowel.

Discrete echodense areas within the cystresulting from a solid nodule of tissue, e.g. bone,

characterize some dermoids.


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A dermoid cyst with characteristic poorly defined ultrasonographic features.


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Follicular assessment Doppler to assess follicular blood flow can help identify those that

contain better quality oocytes with greater fertilization potentialand resultantly higher embryo implantation potential.

Using color Doppler imaging, it is apparent that the PSV of bloodflow surrounding the follicle is the best indicator of angiogenesis.

A significant increase in PSV during the periovulatory period is alsoreported.

It appears as though there is a relationship between follicular flowvelocity and oocyte quality within a particular follicle.

Presumably, follicles with good blood flow have a higher oxygentension within the follicle, implying that the oocyte is lesssusceptible to hypoxia and damage.


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Normal ovary showing the presence of a preovulatory dominant follicle. Note the

position of the two calipers, placed at 90 to each other, to obtain the mean follicular

diameter of 20 mm in this plane.


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A hemorrhagic corpus luteum.


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Color Doppler interrogation of an ovary demonstrating normal ovarian stromal

blood flow.


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Color Doppler interrogation of an ovary demonstrating follicular blood flow.


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Fallopian Tube assessment Under normal circumstances, the fallopian

tubes are not visible with ultrasound imagingunless there is fluid within the pouch of

Douglas (rectovaginal space). However, when the tubes are damaged by

infection they can become enlarged and formfluid-filled hydrosalpinges ( the fluid within

the tubal lumen provides a negative echocontrast).


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A hydrosalpinx. Note the presence of low level echoes within the distended fallopian

tube, together with incomplete septations.


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Hysterosalpingo-contrast sonography

(HyCoSy) Sonographic visualization of the fallopian tubesis also

possible.

(HyCoSy) involves the instillation of a positive contrastagent, such as Echovist (Schering AG,Germany), into

the uterine cavity during scanning.

Flow of the contrast medium through the tubes andinto the peritoneal cavity can be readily seen.

This procedure can be performed as an adjunct to thepivotal scan.

Using either pulsed or color Doppler, improvedsensitivity for contrast flow can be obtained.


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Three-dimensional color power Doppler HyCoSy demonstrating free peritoneal spill of

contrast dye.


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The same image as Fig. 6.19 following

surface rendering of the three-dimensional image.


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OHSS In moderate to severe OHSS, ultrasonography

will demonstrate enlarged ovaries, possibly

with the presence of ascites.

Transvaginal ultrasound can also play a useful

role in draining ascitic fluid to provide

symptom relief.


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OVARIAN HYPERSTIMULATION

3D Multiplanar Reconstruction

Ovarian Hyperstimulation, Ascites 3D Reconstruction, Uterus, AdnexaOvarian Hyperstimulation, Ascites
http://www.obgyn.net/us/gallery/Gyn_Abnormal_Ovarian_Hyperstimulation_2.jpghttp://www.obgyn.net/us/gallery/Gyn_Abnormal_Ovarian_Hyperstimulation.jpg


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The appearance of an ovary demonstrating multiple follicular development

characteristic of ovarian hyperstimulation syndrome.


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OVARIAN HYPERSTIMULATION

Ovary (Transvaginal)

Ovarian Hyperstimulation
http://www.obgyn.net/us/gallery/Gyn_Abnormal_Ovarian_Hyperstimulation_Color.jpg


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A stimulated ovary demonstrating multiple follicles with follicular blood flow during

IVF treatment.


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Oocyte collection. The needle, with its echogenic tip, can be visualized within one of the

follicles, prior to aspiration of its follicular fluid and oocyte. The path of the needle

guide is demonstrated .)+ + +(


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A transabdominal scan demonstrating the position of the catheter within the uterine

cavity prior to embryo transfer. Note the appearance of the hyperechoic, luteinized

endometrium.


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YOU WILL REMEMBER

A LITTLE OF WHAT YOU HEAR,

SOME OF WHAT YOU READ,

CONSIDERABLY MORE OF WHAT YOU SEE,

BUT

ALMOST ALL OF WHAT YOU UNDERSTAND.


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