ultrasonography and infertility: aboubakr elnashar
TRANSCRIPT
E-mail: [email protected]
A. Diagnosis of the cause
B. Treatment of infertility
C. Diagnosis and treatment of
complications of infertility management
Basic investigations
1.Semen analysis
2.Midluteal progesterone
3.HSG
Further investigations
TVS:
method of choice for assessing the female reproductive organs
Information
Uterus Assessment: Dimension, Endometrial: thickness, appearance
Abnormalities: Anomalies, Tumors
Ovaries Assessment: Position, Mobility, Volume, AFC
Abnormalities: PCOS, Anovulation, Cysts, Tumors
Tube Patency, Hydrosalpinx
Pelvis Free fluid, Mass
The Pivotal US (performed D8-12)
I. Uterine factor
A. Assessment of the uterus:
• Dimension
• Endometrial thickness
B. Abnormalities
• Anomalies
• Tumors: fibroid, adenomyosis
• Endometritis
• Cavity: polyps, adhesions
Endpmetrial thickness
Zone 1 -- a 2 mm thick area surrounding the hyperechoic outer layer of
the endometrium
Zone 2 -- the hyperechoic outer layer of the endometrium
Zone 3 -- the hypoechoic inner layer of the endometrium
Zone 4 -- the endometrial cavity
Normal endometrium.“Triple line” endometrium in midcycle.
Secertory endometrium
Secertory endometrium
RVF
Uterine anomalies TVS can detect 90%.
Uterine septae:
Best diagnosed
Transverse plane.
Periovulatory phase {in the early follicular
phase endometrium is thin}
DD.
IU adhesions
{isoechoic nature of the septum with the
myometrium}
Bicornuate uterus
At cervical level At fundal level
Transverse plane of the uterine fundus
two distinct endometrial cavities (arrows).
A subsequent 3-D confirmed that this was a partially septated
uterus
Bicornuate uterus. Transverse 2-D image illustrating two
distinct endometrial cavities (arrows).
Uterus didelphys, 2D scan
Uterine septum, 3D
Fibroid
Rounded distinct masses
Echogenecity: increased, decreased or similar of the myometrium.
± uterine enlargement.
DD:
1. Ovarian cyst
2. RVF.
3. Adenomyosis.
Submucous fibroids:
distort the midline echo
best diagnosed in the periovulatory phase
Decrease the chance of conception with IVF
Subclassification of fibroid
Intramural fibroid Examples of fibroids which
compromise the contours of the
endometrial cavity.
Refraction artifacts {tissue
density interfaces and the
texture of the fibroids} often aid
in their identification.
Sagittal TVS:
a well-circumscribed hypoechoic mass (arrow) centered within the
endometrium(E), with a posterior acoustic shadow extending from
the edges of the mass.
An endocavitary leiomyoma
Submucous fibroid
Endocavitary fibroid.
Sagittal TVS: solid mass (arrowheads) with internal echogenicity
similar to that of the myometrium. The mass has a pedunculated
attachment (arrow) to the uterus and extends into the cervical
canal.
Adenomyosis
Myometrium (M):
1. Homogeneous
echotexture
2. Subendometrial haloas
(arrows):
thin hypoechoic band
Endometrium (E):
uniformly echogenic
NORMAL
1. Heterotopic endometrial glands and stroma:
Small echogenic islands
2. Smooth muscle hyperplasia.
Areas of decreased echogenicity
Histopathologic US correlation
Myometrium:
Heterogeneous echotexture
Echogenicity: decreased
relative to that of the dorsal
myometrium
Myometrial cyst (curved
arrow)
Asymetrical uterine
enlargement
Endometrium:
excentric endometrial cavity
indistinct endometrial-
myometrial border
Adenomyosis
Bromley et al (2000)
2 or more of the followings:
1. Mottled heterogeneous myometrial texture: All
cases.
2. Globular uterus: 95% of cases.
3. Small myometrial lucent areas: 82%.
4. “Shaggy” indistinct endometrial strips: 82%.
The most predictive:
ill-defined heterogeneous echotexture within the myometrium (Brosen et al, 2004)
DD: Fibroid: TVS
An effective, noninvasive, and relatively inexpensive
If the status of
-Lesion's margins plus
-Hypoechoic lacunae: Fibroid could be correctly diagnosed in 95% of cases.
Decreased uterine echogenicity without lobulations, contour abnormality, or mass effects,
Fedele L, Bianchi S, Dorta M, Zanotti F, Brioschi D, Carinelli S Am J Obstet Gynecol 1992 Sep; 167:603-6
Adenomyosis. Sagittal TVS
Globular uterine enlargement with asymmetric thickening
Heterogeneity of the myometrium (arrows)
Poor definition of the endomyometrial junction (arrowheads).
E = endometrium.
Asherman syndrome
Irregular reflective foci of the uterine cavity.
Best seen in the periovulatory phase
IU adhesions
Bright (hyperechoic) uterine lining - scar tissue in uterine
cavity
Endometrial polyps
Persistent hyperechogenic areas with variable cystic spaces.
Distort the cavity contour.
Best seen in midcycle
Not seen clearly in the midluteal phase or in stimulated cycles.
Endometrial polyp
Endometrial polyp
RVF uterus, thickened endometrium that measures 18
mm (calipers) with a focal area of increased
echogenicity (arrows), which was a polyp.
II. Ovarian factor
A. Assessment of the ovary
1. Ovarian volume
2. Antral follicle count:
B. Abnormalities
1.Anovulation
2.PCOS
3.Cysts:
Haemorhgic cyst
Endometriomata
Dermoid
Volume
= L X WX T X 0.52
0.5 cm3 Prepubertal
5 cm3 Reproductive years 2.5X2.2X2 cm.
Diameter >3.5 cm is abnormal
2.5 cm3 Postmenopausal
Mean ovarian volume
<3 cm3: poor response to HMG
very high cancellation rate during IVF (Lass et al, 1997)
Mean maximum ovarian diameter
measured in the largest sagittal plane
good estimation of ovarian volume
>3.5 cm: increase risk of OHSS
<2 cm: decreased ovarian reserve
AFC: Resting follicles. Total number of follicles 2–8mm
counted in both ovaries
A threshold of 5 AF (2-5 mm) have the lowest error rate
for the prediction of poor response (Bancsi et al.,2004)
Batista et al. 2012 ovarian response prediction index (ORPI) multiplying the AMH(ng/ml) level by the number of antral follicles (2–9 mm),and the result was divided by the age (years) of the patient.
Early in the menstrual cycle. No medications being given.
9 antral follicles.
The ovary has normal volume (30X18mm).
Expect a normal response to injectable FSH.
only 1 antral, other ovary had only 2 antrals
Ovarian volume: low
D3 FSH: normal
Attempts to stimulate ovaries for IVF were not successful
At the beginning of a menstrual cycle, irregular periods, No
medications being given.
Antral follicles:16 are seen in this image. Ovary had a total of 35
antrals (only 1 plane is shown). This is PCO with a high antral
Ovarian volume= 37 X19.5mm
"high responder" to injectable FSH drugs.
POF.
Only the stroma of the ovary is identified.
A very few follicles of less than 1 mm on the inferior aspect of
the ovary.
Diagnosis of Spontaneous Ovulation 1. Mature F. (contain mature oocyte) = 17 – 25 mm
(Inner dimensions)
2. Deflation of the mature follicle
3. Intra peritoneal fluid
-Normal: 1-3 ml
-With ovulation: 4- 5 ml
4. CL: 4-8 days after ovulation
• Irregular thick wall .
• Hypoechoic
• May contain internal echos (hge.)
• 15 mm
Mature follicle
Atretic follicle of preovulatory diameter. thin follicle walls and sharp
transition at the fluid-follicle wall interface. The shape of the large
atretic follicle is compromised by small peripheral follicles.
Corpus albicans
resulting from regression of a luteal structure from a
previous cycle.
hyperechoic structures within the ovary and they may
occasionally appear to be more pronounced owing to the
presence of surrounding follicles.
Early Corpus Luteum. The site of
rupture of the dominant follicle
soon after ovulation appears as a
collapsed cystic structure (arrow)
on the ovary (o). u, uterus.
Corpus Luteum–Hypoechoic Solid
Appearance. The corpus luteum
appears as a hypoechoic solid
mass (arrow) on the right ovary (o)
on this transvaginal image.
Corpus Luteum–Thick-Walled
Cyst Appearance. Transvaginal
scan shows an anechoic
ovarian cyst (between calipers,
+, x) with moderately thick
walls.
Corpus Luteum–Thin-Walled Cyst
Appearance. This corpus luteum
(arrow, between cursors, +, x) has
a thin wall and contains anechoic
fluid.
Corpus hemorrhagicum
thick walls of peripheral luteal tissue and a central
hemorrhagic clot with an interspersed fibrin network.
Failure of ovulation and development of “cystic” follicle.
The follicle typically grows larger than the mean preovulatory
follicle diameter of 23 mm, thin atretic follicle walls and small
flecks of particulate matter are frequently seen in the lumen or
aggregated at the side of the structure.
Hemorrhagic anovulatory follicle.
Extravasated blood and an interspersed fibrin network are
observed within the lumen. The walls of this structure are thin,
echoic, and do not have the appearance of luteal tissue.
Endometrioma
Hyperechoic wall
foci
(in35%)
Cysts With Low-level Echoes Hemorrhagic
cyst
Lacelike
internal
echoes
(in 40%)
Teratoma
Regional bright
echoes
(in 97%)
Endometrioma. Sagittal TVS
an ovarian mass with multiple fine internal echoes (arrows) and
several hyperechoic mural foci (arrowheads).
Ovarian endometrioma (A, B).
The structure is hypoechoic and exhibits low amplitude
uniformly distributed echotexture in the cavities of the
cysts.
PCO: Rotterdam, 2004
At least one of the following
12 or more follicles in each ovary measuring 2 to 9
mm in diameter or
Ovarian volume >10 cm3.
Only one ovary meeting these criteria is sufficient
for diagnosis.
The follicle distribution & increase in stromal
echogenecity & volume are not required for diagnosis.
Absence of mature follicle
Technical recommendation
1. Regularly menstruating females should be scanned
between days 3-5
Oligo-/ amenorrhoeic should be scanned either at
random or between days 3-5 after progesterone –
induced bleeding
2. If there is evidence of a dominant follicle >10 mm or a
corpus luteum, the scan should be repeated the next
cycle.
3. Ovarian volume= 0.5X length X width X thickness
PCO
Multiple peripheral
subcentimetric follicles (arrow).
Subtypes of PCO: The images exhibit quite different appearances
in the size and distribution of follicles. A recent corpus luteum is
clearly visible in the ovary in panel (D).
III. Tubal factor
1.Tubal patency:
SIS
2. Hydrosalpinx:
decrease the chance of implantation with IVF
Hydrosalpinx
Hydrosalpinx
well-constrained fluid
accumulation in the adnexae.
In some cases, adhesions
between the oviduct and ovary
may be visualized.
Pcos,
hydrosalpinx
IV. Pelvis
1. Free fluid
2. Mass
Hydrosalpinx
Endometriomas
Para ovarian Cyst
Peritoneal cysts
Tubo ovarian abscess
I. Ovarian induction/IUI
II. IVF:
III.Aspiration of
1. Ovarian Cyst.
2. Hydrosalpinx
I. Ovarian induction/IUI
Monitoring:
• Base line scan on D2 or 3 of the cycle
• US on D8 of stimulation:
Follicles: number & size
Endometrium: thickness & appearance
• Repeat /2-3 days depending on the size of
leading follicle, until it is 18 mm
II. IVF
1. U.S between D10 & 15 of preceding IVF cycle:
Uterus: fibroid
Ovaries: size, PCO, ovarian cyst
Tubes: hydrosalpinx
2. COH:
a. Confirm down regulation:
Thin endometrium: <4 mm,
quiescent ovaries containing only small follicles
b. Follicular development & endometrial thickness:
D6 stimulation
Repeat daily or alternate day depending on response
US guided oocyte retrieval.
The oocyte collection needle is visualized entering into a large
follicle. Etching around the tip of the needle enhances its
visualization.
3. Oocyte retrieval:
4. Embryo transfer:
Embryo transfer is enhanced by the use of ultrasound
guidance to place the embryos at the optimal uterine
location. The small hyperechoic areas distal to the catheter
tip represent microbubbles of air expelled from the transfer
pipette and serve to visualize embryo placement.
TVS-monitored embryo transfer.
(a) Before embryo transfer. The arrow indicates the tip of the
outer sheath. The arrowhead indicates the tip of the catheter.
(b) After embryo transfer. The arrow indicates two air bubbles.
III. Aspiration of 1. Ovarian Cyst.
Residual cyst > 3 cm may affect ovarian response in
the subsequent cycles .
2. Hydrosalpinx
I. OHSS
II. Complications of oocyte retrieval
III. Complications of early pregnancy
I. OHSS
a. Diagnosis
b. Treatment:
paracentesis under TVS
OHSS • Suspicion:
large number of medium sized follicle (14-15 m)
E2 > 3000 pg/ml
More fluid in the pouch of Douglas
• TAS is better for monitoring than TVS
(press on tense large ovary) (ov.> 10 cm)
Critical Severe Moderate Mild
•Tense ascites
•Oligo/anuria •Thromboembolism
•ARDS
• Ascites
•Oliguria
•Mod ab pain
•N± V
•Ab bloating
•Mild ab pain
Cl
•large hydrothorax •±hydrothorax
•Ov›12 cm*
•Ascites
•Ov8–12 cm*
Ov‹8 cm*
US
•Hct›55%
•WCC›25 000/ml
•Hct ›45%
•Hypoprotein
aemia
Lab
•ICU •In pt Out pt,
In pt: unable to
control pain, N
with oral tt,
Difficulties in
monitoring
Out pt TT
Mathur, 2oo5
Moderate OHSS.
Both ovaries are enlarged and are observed in the posterior cul-
de-sac.
The ovaries are in close contact and displace the uterus
anteriorly.
Both ovaries contain several large unruptured follicles.
II. Complications of oocyte retrieval
Intra-abdominal bleeding
Pelvic infection or abscess formation
III. Complications of early pregnancy
more common
a. Ectopic
b.Miscarriage
c. Multiple pregnancy:
Diagnosis & treatment (selective fetal reduction)
Ectopic pregnancy
A. Uterine
1. No IU gestational sac
2. Pseudogestational sac
(a fluid collection or debris in the cavity)
10-20% of ectopic P.
No double decidual sac sign
No yolk sac or embryo
Not eccentric (within the cavity)
3. No yolk sac in a G. sac > 20 mm
B. Adnexal
1. Non cystic mass:
(Blob sign) inhomogeneous small mass next to the
ovary with no sac or embryo.
By pressing the vaginal probe gently against the
ectopic it moves separately to the ovary.
The most appropriate sign.
Sensitivity 84% & specificity 99%
2. Cystic mass:
3. Ring:
(Bagel sign) hyperechoic ring around the gestational
sac
4.Sac & embryo.
Ipsilateral side: Corpus luteum: 85% of cases
C. D. pouch:
Fluid with or without blood clots
loop
Non cystic mass
D pouch
Cystic mass
Ring
Sac & embryo
Multiple pregnancy
Thank you
Aboubakr Elnashar