ultrasonography and infertility: aboubakr elnashar

E-mail: elnashar53@hotmail.com

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