1. 1. The young, enthusiastic and energetic chief consultant at Rupal Hospital For Women, Surat, India for last 18 years Medical director and IVF consultant at Blossom IVF Centre,Surat,India Diploma in Reproductive Medicine from Kiel, Germany Intense training in Advanced infertility treatment at numerous workshops and conferences in USA and Europe. Invited as a faculty in various state,national and international conferences. Specialized in all kind of gynec endoscopic surgeries. Promotes health awareness by conducting Seminars and writing articles and specialty related books In addition of being techno-savvy person, she loves making friends, and keenly interested in music and Guajarati literature. She is actively associated with the leading cultural club of Surat-Tarbatar. Dr Rupal N Shah M.D.(OBGYN) Diploma in Reproductive Medicine (Germany) 6/21/2015 1Rupal Hospital For Women
2. 2. Ultrasound in Infertility Dr Rupal N Shah M.D.:D.G.O Diploma in Reproductive Medicine(Germany) Blossom IVF Centre, Rupal Hospital For Women Surat
3. 3. Sonography in Infertility Transvaginal Sonography is one of the indispensable investigations as far as infertility patient is concerned. It is the primary examination parallel to clinical assessment as it gives more information than any other single test and is noninvasive. 6/21/2015 3Rupal Hospital For Women
4. 4. Ultrasonography in infertility 1. Workup for infertility 2. Assisted reproduction technique 3. Early pregnancy scanning 4. Male Infertility 6/21/2015 4Rupal Hospital For Women
5. 5. Infertility workup Ovary 6/21/2015 5Rupal Hospital For Women
6. 6. Ultrasound evaluation of Ovarian Reserve Antral Follicle count The number of visible ovarian follicles(2-8 mm) on cycle day 2-3 Ovarian Volume limited value compared with antral follicle count for detection of diminished ovarian reserve. 6/21/2015 6Rupal Hospital For Women
7. 7. Antral Follicle Count 12 / more immature follicles ( 2 - 8mm) AFC Less than 5 -Poor responder Total number of antral follicles achieved the best predictive value for favourable IVF outcome, followed by Ovarian stromal FI, total ovarian stromal area & total ovarian volume Kupesic S et al, Hum Reprod 2002; 17(4):950-55 6/21/2015 7Rupal Hospital For Women
8. 8. Preovulatory scan 6/21/2015 Rupal Hospital For Women 8
9. 9. Prediction of ovulation Dominant Follicle > 14mm Grows 2-3 mm/day. Ovulation 18-24 mm. Sonolucent halo 24 hours prior to ovulation. Cumulus like shadow. In the hands of experienced operators, ultrasound alone suffices for cycle monitoring, with no necessity for additional hormonal estimations. Golan et al, Shoham et al and Tan SL et al
10. 10. 16mm Cumulus oophorus 3/4th vascularity Ovulation 16-24 mm. Vascularity - 3/4th of the follicle 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. 6/21/2015 10Rupal Hospital For Women
11. 11. Luteinized Unruptured Follicle-LUF Persistent follicle with thick walls. Progressive loss of cystic appearance. Thick echogenic endometrium. No fluid in POD.
12. 12. Ultrasound diagnosis of PCO 6/21/2015 12Rupal Hospital For Women
13. 13. ESHRE/ASRM consensus revised definition of PCOS ( 2003) Two of the following three criteria and exclusion of other etiologies: 1. Oligo and/or anovulation 2. Hyperandrogenism 3. Polycystic ovaries on TVS 6/21/2015 13Rupal Hospital For Women
14. 14. Ultrasound diagnosis of PCO is one of the key features for diagnosis of PCOD. This is done by a transvaginal scan done on day 2 3 of the cycle 12 follicles of 2-9 mm in diameter in at least one ovary or Peripheral cystic pattern(Neckless pattern) or generalized cystic pattern Increased ovarian volume (>10 cm3) 6/21/2015 14Rupal Hospital For Women
15. 15. Sono AVC Recently Sono AVC has also been tried to measure the number of antral follicles Adv: Can separate follicular number of 2 -6 mm and 6 9 mm follicles and prevents recounting of follicles Disadv: requires post processing. VOCAL Volume calculation by Computer 6/21/2015 15Rupal Hospital For Women
16. 16. Ovarian Cysts Corpus luteum hemorrhagic cyst LUF Endometrioma Dermoid cysts Serous and mucinous cystadenomas Endometrioid tumours fibroma 6/21/2015 16Rupal Hospital For Women
17. 17. But it is more convenient to divide these lesions according to morphology Nonseptated clear cysts Cysts with internal echoes 6/21/2015 17Rupal Hospital For Women
18. 18. Nonseptated clear cysts Thin walled Anechoic, clear contents No vascualrity Simple ovarian cyst Paraovarian cyst
19. 19. Cysts with internal echoes thick, echogenic wall internal echogenecity Corpus luteum Heamorrhagic Endometrioma 6/21/2015 19Rupal Hospital For Women
20. 20. Heamorrhagic cyst The commonest appearance is a fishnet appearance Changes echogenicity over time due to fibrinolysis of a clot Scanty and high resistance blood flow
21. 21. Endometrioma Bilateral in 1/3 cases Thick shaggy walls With or without septae, internal echogenicity with ground glass appearance Pain on pressure with the probe Sometimes kissing ovaries Vascularity may vary between lesions. 6/21/2015 21Rupal Hospital For Women
22. 22. Dermoids Thick wall, echogenic material in lumen Fluid fluid level Hyperechoic lines and dots due to hair. Hyperechic/calcified echoes due to teeth and bones Avascular
23. 23. Uterus Abnormalities of uterus Congenital Acquired 6/21/2015 Rupal Hospital For Women 23
24. 24. Volume USG, 3D and 4D USG has a major role to play in the diagnosis of uterine anomalies : Virtual hysteroscopy Sensitivity of the Volume USG for the detection of congenital uterine abnormalites is > 98%. 6/21/2015 24Rupal Hospital For Women
25. 25. Congenital uterine anomalies 6/21/2015 Rupal Hospital For Women 25
26. 26. Failure of one /more mullerian duct to develop or to canalize-rudimentary horn Unicornuate uterus: Uterus is not in midline normal shape in long section one cornual projection only one uterine artery 3D:Banana shaped uterine cavity Rudimentary horn : on other side as hypoechoic shadow 6/21/2015 26Rupal Hospital For Women
27. 27. Failure to fuse/abnormal fusion Uterus didelphys-double uterus Bicornuate uterus 6/21/2015 27Rupal Hospital For Women
28. 28. Failure to fuse/abnormal fusion Uterus Didelphys Two separate uteri and cervix Uteri are Seen in midline or on lateral pelvic wall as two well developed uterine structure On transverse section ,both uterine horns make a figure of eight. 6/21/2015 Rupal Hospital For Women 28
29. 29. Failure to fuse/abnormal fusion Bicornuate Uterus Two separate uterine bodies and a single cervix On transverse section widened fundus and division of endometrial cavity towards fundus Volume US: Fundus shows dimple Distance between the line joining the endometrial tips and the fundal dimple is less than 5 mm 6/21/2015 Rupal Hospital For Women 29
30. 30. Failure of resorption of midline septum-Septate or arcuate uterus Septate uterus Flat or convex external contour Acute angle between endometrial cavities Distance between line joining the tips of endo cavity to the deepest point between the two cavities- >10 mm Arcuate uterus Convex external contour Obtuse angle between cavities Distance between line joining the tips of endo cavity to the deepest point between the two cavities 5 mm uterine wall above the line joining tips of 2 uterine cavity Angle between 2 cavities 5mm : septate 50% in endometrial cavity T2_ < 50% in endometrial cavity 6/21/2015 39Rupal Hospital For Women
31. 40. Myometrial lesions Fibroids Adenomyoma / adenomyosis 6/21/2015 40Rupal Hospital For Women
32. 41. Intramural/Subserous Fibroids Well-defined,hypoechoic, homogeneous ,rounded lesions with peripheral hypoechoic rim. Enlargement of the uterus and distortion of the contour Sometimes heterogenicity due to degeneration or calcification On power doppler :Peripheral vascularity 6/21/2015 41Rupal Hospital For Women
33. 42. Adenomyosis Altered hyper and hypoechoic zones-swiss cheese appearance. Generalized involving the whole uterus or localized to one portion(adenomyoma) Power doppler:penetrating vascularity
34. 43. Endometrial Grading 6/21/2015 43Rupal Hospital For Women
35. 44. TVS for endometrial grading Endometrial thickness and endometrial pattern are useful prognostic parameters for successful pregnancy. 8-13 mm -Favorable 15 mm Problematic 6/21/2015 44Rupal Hospital For Women
36. 45. C B A TVS for endometrial grading The coexistance of a thinner endometrium(