Role of TVS in Infertility/ART

Poonam loomba,M.D. Loomba IVF Centre Ambala Cantt

Disclosure

Nothing to disclose

Learning objectives • Baseline scan in infertility

• Know the limitations of ultrasound in fertility evaluation

• Significance of new markers for endometrial receptivity and follicle maturation towards paving the path to SET.

• Ultrasound as a tool in Oocyte PU and ET.

Baseline scan in infertility Best done in the early follicular time(cycle day 3)to avoid distortion of ovarian

volume caused by growing follicle

High frequency probe with trans vaginal approach is used.

Use a systematic approach Empty bladder Watch as you are placing the transducer Look at the bladder,and cervix(length and location Cervico uterine angle Uterus:Orientation,size,endometrial thickness Ovaries:location,size,and number of follicles. Document and save your findings electronically. .

Baseline scan

Limitations of ultrasound

• Minimal and mild endometriosis• Flimsy pelvic adhesions• Some tubal abnormalities.

• But we can use the probe actively during exam to assess the mobility of pelvic structures in relation to each other.This gives us an idea of whether or not there are adhesions.

SLIDING ORGAN SIGN

Assessment of uterus

Shape of uterus and uterine

cavity

Intracavitary lesions

Endometrio myometrial

junction

Endometrial receptivity

Differential diagnosis of congenital duplication

abnormalities of uterus like bicornuate, septate and

arcuate is based on external fundal contour and

contour of the endometrial cavity.

Normal shape of the uterine cavity...

SEROSAL FUNDUS

ENDOMETRIAL FUNDUS

Volume USG, 3D and 4D USG has a major role to play in the diagnosis of uterine anomalies :

Virtual hysteroscopySensitivity of the Volume in USG for the detection of congenital uterine abnormalities is > 98%.

Unicornuate uterus: normal shape in long section deviated Hypoplastic 2nd horn : sometimes

Unicornuate Uterus

D/D bicornuate from septate

D/D bicornuate from septate

< 5mm

> 5mm

D/D bicornuate from septate> 90°

< 90°

3D US can show us the length, thickness and depth of the septum

D/D subseptate and arcuate

< 90° >

90°

D/D subseptate and arcuate

> 10 mm

< 10 mm

T shaped uterus

Intact regular endometrio-myometrial junction

is an important sign of a healthy

endometrium.

Junctional zone is damaged in

• Endometritis: acute or chronic

• adenomyosis

Damaged endometriomyometrial junction

Endometrial receptivity 30% of embryos transferred result in clinical

pregnancies .Fault may be in the embryo or the implantation bed.

Thickness Pattern

Blood flow to the endometrial and subendometrial zone

Volume

Normal endometriumMeasuring endometrial thickness

Endometrial thickness

• Increases from 4.6mm to 12.4mm on the day of LH surge.

• Average increase is 1 to 2mm per day in proliferative phase.

• Decreases by 0,5mm on the day of LH surge increasing again by 2mm in luteal phase.

CC vs HMG/FSH• Following the days CC is taken the ET is often decreased the

effect lasts no more than 3-4 days after last dose.

• In late follicular phase it escapes antioestrogenic effect and increases faster.

• With HMG and FSH it is greater than in spontaneous cycles.

• No pregnancies were seen when ET was <6mm on the day of hcg.• Biochemical pregnancies were pbserved more in ET <9mm or

>13mm.• It is advisable not to start OI if postmenstrual ET is 6mm or more.

Periovulatory endometrium:once the EM echo is well visualized use as much magnification as

possible

Endometrium in PCOD No Triple line

Thin endometrium indicating low estrogenic state

Endometrial waves• In 73% a wave direction switch occurs from

fundus to cervix and cervix to fundus before OPU (fertil steril 1999)

• The persisting waves until HCG predict a favourable outcome

• In a validation prospective study it was not confirmed if waves improved pregnancy outcomes(fertil steril 2005)

• Two more wave types are recoiling CF wave and a standing wave.(fertil steril2007)

Endometrial Waves

Blood flow• With the more sensitive colour doppler and power

doppler it is postulated that local vascularization at the site of implantation is more important than global vascularization of the uterus measured by RI in the uterine arteris.

• EPDA is defined as a part of endometrium where vascular signals with velocities >5cm/sec are detected.

• Subendometrial zone is 1mm outside endometrium where most of the cyclical changes take place.

• The correlation is more significant in women with poor embryo quality since IR are more if Vascularization is better,

Power doppler imaging

PROLIFERATION OF SPIRAL ARTERIES AND SUBSEQUENT ENDOMETRIAL “INVASION”

ZONE I -- Only Myometrial Vessels Surrounding the Endometrium are Visualized.

ZONE II – Vessels Penetrate Through the Hyperechogenic Endometrial Edge.

ZONE III – Vessels reach the internal endometrial Hypoechogenic Zone.

ZONE IV – Vessels reach the Endometrial Cavity.

Deeper the vascularization noted better the outcome.

Endometrial power doppler area

Endometrial volume by 3D by virtual organ computer aided analysis software

Significance of endometrial volume

• Endometrial and subendometrial vascularity are significantly lower in patients with endometrial volume <2.5 ml

• In IVF/ICSI cycles endometrial volume and Power doppler indexes are statistically significant in predicting the cycle outcome with SET. (Fertil.Steril 2008 jan 89)

• Lower PR are seen with EV <2.0ml and no pregnancies seen with <1.2ml

Imaging the uterine cavity

• 20% of infertile women have cavitary abnormalities including arcuate uterus,septate uterus,polyps, s/m myomas and adhesions.

• HSG Low sensitivity and specificity • TVUS Low sensitivity and specificity• SIS 81.3% and 100%• Hysteroscopy 87.5% and 100%• Gold standard is hysteroscopy.

Endometrial polyp

More echogenic than myometrium

Isoechoic with endometrium

Sessile or pedunculated

Single feeding vessel

Polyps on fertility • Limited data.• Lass et al 1999 : Polyps >2cm increase EPL• <2cm:No difference in pregnancy between resected vs

untreated patients• Mastrominas et al ,J am Assoc Gyn Lapro 1996

• PR in polypectomy vs.biopsy• N=101 Removal PR=63%• N=103 Biopsy PR=28%

Intra uterine adhesions

• Asymmetry of endometrial echo

• Areas of endometrium <2mm

• Echogenic area in the uterus

• TVS sensitivity is 52%

• TV SIS is 93.5 to 99.% accurate.

Saline infusion sonohysterography

More image than imagination

May be as effective as hysteroscopy in detecting intra cavitary abnormalities

More cost effective and simple to perform

SIS:- 20ML Normal saline is instilled using pediatric foley catheter no.8

Bulb of catheter

Dangling polyp synechiae

Alternative to sonohysterogram

• Consider doing ultrasound in luteal phase.

• Endometrium is hyperechoic and acts like contrast medium.

• Add 3D image.

Submucous fibroids –grading :to decide the route of surgery

• T0- whole in endometrial cavity

• T1 - >50% in endometrial cavity

• T2- < 50% in endometrial cavity

Tubes?

• Normally not seen

Hydrosalpinx appearances• Retort shaped cystic structure• Cogwheel sign• Waist sign• Incomplete septae

Tubes: Hydrosalpinx

Ovaries

• Ovarian volume and AFC ….measures of ovarian reserve

• PCOD

• Ovarian masses

• Ovulation studies with series of scans

AFC

• AFC in both ovaries performed during menstrual cycle or early follicular phase is currently the gold standard for OR.

• <5• 10-15• >15

AFC Normal

Poor afc

3 D Inversion Tecnology

Ovarian size and volume

Ovarian volume

• Volume is affected by cigarette smoking OCP age and cysts

• Superior to day3 FSH• Small volume predicts fewer follicles and low

PR independent of age(syrop 1999)• Large volume>10ml is associated with

increased OHSS.(10% TO 23.5%)

PCOS Criteria

• 12 or more follicles in each ovary2-9mm in size.• >10ml volume in one f the ovaries.• Distribution may be peripheral or scattered in

dense stroma.• Stromal hypertrophy• Stromal to ovarian area ratio cut off being 0.34

above which PCOS can be diagnosed.• Stromal echogenecity • Ovarian artery PI and RI are decreased,

• Polycystic ovarian morphology has been found

to be a better discriminator than ovarian

volume between polycystic ovarian syndrome

and control women.

Legro, et al, JCEM 90(5): 2571-79.

Stromal vascularity

• Even with same echogenecity, PCOS has more stromal flow.

OVARIAN STROMAL BLOOD FLOW

• PSV > 10cm/sec AFTER PITUITARY SUPRESSION• Stromal ri < 0.41 : 2/3rds WILL GET OHSS• Stromal pi < 0.75 : 1/2 will get pleural effusions

Follicular study

• Number of scans depend upon the response of the patient

• Hcg is delayed till majority reach maturation• Eggs can be retrieved from as small as 14mm and

as large as 24mm.• Decreased quality of oocytes from follicle

24mm.>• No difference in quality of oocytes from follicles

18-22mm in size.

FOLLICULAR PARAMATERS

A.PERIFOLLICULAR VASCULARIZATION.B.PERIFOLLICULAR RI 0.4 – 0.48C.FOLLICULAR PSV > 10 CMS/SEC Diameter predicts maturity and

perifollicular vascularization predicts the quality of oocyte at retreival

PERIFOLLICULAR VASCULARISATION

• GRADE 1 < 25%• GRADE 2 < 50%• GRADE 3 < 75%• GRADE 4 > 75%

Perifollicular blood flow

DECIDING THE TIME OF HCG ?

This consisted of

Follicular volume

Visualization of cumulus

Perifollicluar VI

Perifollicular FI

Perifollicular VFI

Follicular volumes of between 3 – 7 cc are optimum

for oocyte retrieval .

The limits of agreement between the volume of the

follicular aspirate and 3D volume of the follicle were

+ 0.96 to – 0.43 with 3D and + 3.47 to – 2.42 by 2D

volume estimation.

Follicular Volume

On the day of HCG – If

cumulus like echoes is not seen in all

three planes in the follicle , it is less

likely to be mature fertilizable oocyte.

cumulus

D/d of ovarian masses:most are benign in women of reproductive age

Physiologic • Follicular• Simple• Corpus luteum

Pathologic

EndometriomaMature cystic teratomaBorderlineMalignancy

We recommend further evaluation of the mass prior to stimulation(repeat US ,LAPROSCOPY

Haemorrhagic cyst Endometriomtic cyst

Oocyte Retrieval• Standard IVF retrieval

• Transvaginal probe 5-9 MHz

• 16-17 gauge needle• Empty bladder before starting

procedure

• Familiar with the machine

• Fix the ovaries against the transducer .

• Ultrasound screen should be at level with your eyes.

• Do not lose track of needle

Collection techniques Maintenance of suction: follicular fluid (and oocytes) may be

lost if entry into and exit from the follicle are made in the absence of suction. This gain, however, may be offset by possible damage due to the dramatic forward flow of fluid toward the collection tube.

Secondly, movement of the needle tip within the follicle: damage to the oocyte, particularly the cumulus, may occur because of collection technique. It is a common practice during oocyte collection to ‘spin’ the needle within the follicle.

Flushing may yield more number of eggs.

Flushing of follicles.

Again it is an individual approach .

40% retreival rate without flushing ,80% with two and 90% with four flushings.

In our clinic we do not routinely flush follicles and have >70% retreival rate.

Embryos day2

Embryo transfer is the most crucial step in IVF And the last one while climbing on the ladderOf success for IVF.

It is not as easy as it appears to be

Effect of “provider at ET”

• Learning curve:– ET trainees can reach an acceptable PR after the first

25-30 ETs.– Clinical pregnancy rates of fellows-in-training were

indistinguishable statistically from those of experienced staff by 50 transfers. (45.5% v 47.3%)

Papageorgiou TC et al. Hum Reprod 2001; 16:1415-1419

Variables affecting ET success

• Trial transfer/Mock ET• Catheter type• Touching the fundus• Difficult transfer• Usg guided

Cervico uterine angle

Ultrasound guided ET

• Full bladder for TAUS• Assistant to • Usually soft catheter is

used• Confirm position of

loaded catheter• Place embryos in middle

part of uterine cavity .• Confirm for the fluid

bubble in the cavity.

Advantages Disadvantages• Less trauma at ET• Confirm appropriate

location• Known length of

endometrial cavity• Decrease anxiety for

patient and clinician• Cochrane review

2007:Improved PR but no statistical difference in compliactions

• Need ultrasound equipment• Need assistant• Need full bladder• Increases duration of ET

• Flisser etal 2006 fertil steril:353-7

No significant difference in US et/Clinical touch ET

Operator experience dependant

3D/4D for Embryo Transfer

• Patient and physician satisfaction

• No comparison group• Still controversy in the

literature over best spot.

• Gergley et al Fertil steril 2005

Conclusion:

• 3D Volume technology has emerged as an effective noninvasive tool to detect structural uterine anomalies

• Accuracy of SIS matches that of hysteroscopy in detecting intra cavitary anomalies.

• Design more studies to incorporate new markers of endometrial receptivity and follicle study for success with SET.

Journey might be turbulent but ends up well with a safe landing