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Ultrasound in infertility

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Ultrasound in infertility

  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 <10 mm •6/21/2015 Rupal Hospital For Women 30
  31. 31. Which is arcuate and which is subseptate? <90°>90° Obtuse: arcuate Acute: subseptate
  32. 32. Septate uterus has highest implications on pregnancy…  Infertility  Frequency of ectopic 27.34% as compared to 13.3% otherwise.  First trimester abortions : 28 – 45%  Second trimester abortions : 5%  Premature deliveries  dystocia 6/21/2015 32Rupal Hospital For Women
  33. 33. Bicornuate V/S Septate uterus Bicornuate • Fundus-dimple • <5 mm uterine wall above the line joining tips of 2 uterine cavity • Angle between 2 cavities >90 * • Medial margins of endo cavity -Convex Septate • Fundus-No dimple • >5 mm uterine wall above the line joining tips of 2 uterine cavity • Angle between 2 cavities <90* • Medial margins of endo cavity -streight 6/21/2015 Rupal Hospital For Women 33
  34. 34. Septum V/S bicornuate >5mm : septate <5mm: Bicorn
  35. 35. Acquired uterine anomalies Endometrial myometrial 6/21/2015 35Rupal Hospital For Women
  36. 36. Endometrial pathologies • Synechie • Polyps • Submucous fibroids 6/21/2015 Rupal Hospital For Women 36
  37. 37. Synechiae  Hyperechoic bands traversing through the endometrial cavity  In thick synechiea 3D US can be used for exact assessment of restriction of endometrial cavity. 6/21/2015 37Rupal Hospital For Women
  38. 38. Polyps • non-specific endometrial thickening or focal masses within the endometrium • May appear as just diffusely thickened endometrium,without visualisation of descrete mass(Mimicks endometrial hyperplasia) • A feeding vessel may be seen extending to polyp on colour doppler imaging 6/21/2015 38Rupal Hospital For Women
  39. 39. Submucous fibroids -Grading(ESGE Clssification) • T0- whole in endometrial cavity • T1 - >50% in endometrial cavity • T2_ < 50% in endometrial cavity 6/21/2015 39Rupal Hospital For Women
  40. 40. Myometrial lesions • Fibroids • Adenomyoma / adenomyosis 6/21/2015 40Rupal Hospital For Women
  41. 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
  42. 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
  43. 43. Endometrial Grading 6/21/2015 43Rupal Hospital For Women
  44. 44. TVS for endometrial grading Endometrial thickness and endometrial pattern are useful prognostic parameters for successful pregnancy. • 8-13 mm -Favorable • <6 and >15 mm – Problematic 6/21/2015 44Rupal Hospital For Women
  45. 45. C B A TVS for endometrial grading The coexistance of a thinner endometrium(<7mm) and no-triple line pattern reflects poor receptivity of the endometrium and low clinical pregnancy rate. Triple line endometrium 6/21/2015 45Rupal Hospital For Women
  46. 46. Abnormal endometrial patterns • Premature secretory endometrial pattern • Calcifications in endometrial cavity • Fluid in endometrial cavity 6/21/2015 46Rupal Hospital For Women
  47. 47. Zone 1 - Myometrium surrounding the endometrium. Zone 2 - Hyperechoic endometrial edge Zone 3- Internal endometrial hypoechoic zone. Zone 4 - Endometrial cavity 2 3 4 Endometrial vascularity zones Applebaum scoring
  48. 48. Absent subendometrial and intraendometrial vascularization on the day of hCG, appears to be a useful predictor of failure of implantation in IVF, irrespective of morphological appearance. 6/21/2015 48Rupal Hospital For Women
  49. 49. When pregnancy is achieved in absence of endometrial and subendometrial flow on the day of embryo transfer, more than half of these pregnancies will finish as spontaneous miscarriage. Chein LW, et al, Assessment of uterine receptivity by the endometrial-subendometrial blood flow distribution pattern in women undergoing IVF-ET. Fertil Steril 2002; 78:245-51 6/21/2015 49Rupal Hospital For Women
  50. 50. Hydrosalpinx Fusiform cystic lesion Cog wheel sign Incomplete septae Cyst wall thicker than 5mm in almost all acute inflammations and app.3 % of chronic lesions 6/21/2015 50Rupal Hospital For Women
  51. 51. Assisted reproduction technique • Monitoring of ovarian response • Oocyte retrieval / embryo transfer under ultrasound guidance • Prediction of ovarian response and pregnancy 6/21/2015 51Rupal Hospital For Women
  52. 52. Oocyte Retrieval 6/21/2015 52Rupal Hospital For Women
  53. 53. Ultrasound guided embryo transfer 6/21/2015 53Rupal Hospital For Women
  54. 54. Tubal patency-Sonosalpingography Advantages OPD procedure, less time consuming, cost effective,NoninvasiveNo anasthesia,No radiation, no iodinated contrast,Reproducible and reliable for assessment of tubal patency 6/21/2015 Rupal Hospital For Women 54
  55. 55. Tubal patency-Sonosalpingography Disadvantages • Tubal spasm • Hydrosalpinx gives tubal flow – false positive for patency • Technical competence required • Site of block can not be located exactly • Intratubal pathology cannot be detected • Peritubal adhesions and tubal motility can not be assessed • Findings are subjective. 6/21/2015 55Rupal Hospital For Women
  56. 56. USG in Male Infertility Male factors are primary cause of infertility in 20-30% of couples and a contributing factor in another 20-25% of patients. A systemic and logical evaluation of the infertile male by USG helps to distinguish between correctable and noncorrectable abnormalities
  57. 57. USG in male infertility • Scrotal Ultrasound and doppler -Vericocele -Epididymal abnormalities,undecended testes • Transrectal Ultrasound -Imaging of prostate,seminal vesicles and vas deference -Obstructive azoospermia(OA) • Penile Ultrasound -evaluates physical causes of erectile dysfunction. 6/21/2015 57Rupal Hospital For Women
  58. 58. www. blossomivfindia.com Thank You 21-06-2015 Rupal Hospital For Women

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