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Us in infertility


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ultra sonography in infertility

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Us in infertility

  1. 1. Aboubakr Elnashar
  2. 2. A. Diagnosis of the cause B. Treatment of infertility C. Diagnosis and treatment of complications of infertility management Aboubakr Elnashar
  3. 3. Aboubakr Elnashar
  4. 4. Basic investigations 1.Semen analysis 2.Midluteal progesterone 3.HSG Further investigations TVS: method of choice for assessing the female reproductive organs Aboubakr Elnashar
  5. 5. 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) Aboubakr Elnashar
  6. 6. I. Uterine factor A. Assessment of the uterus: • Dimension • Endometrial thickness B. Abnormalities • Anomalies • Tumors: fibroid, adenomyosis • Endometritis • Cavity: polyps, adhesions Aboubakr Elnashar
  7. 7. Endpmetrial thickness Aboubakr Elnashar
  8. 8. 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 Aboubakr Elnashar
  9. 9. Normal endometrium.“Triple line” endometrium in midcycle. Aboubakr Elnashar
  10. 10. Secertory endometrium Aboubakr Elnashar
  11. 11. Secertory endometrium RVF Aboubakr Elnashar
  12. 12. 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} Aboubakr Elnashar
  13. 13. Bicornuate uterus At cervical level At fundal level Aboubakr Elnashar
  14. 14. Transverse plane of the uterine fundus two distinct endometrial cavities (arrows). A subsequent 3-D confirmed that this was a partially septated uterus Aboubakr Elnashar
  15. 15. Bicornuate uterus. Transverse 2-D image illustrating two distinct endometrial cavities (arrows). Aboubakr Elnashar
  16. 16. Uterus didelphys, 2D scan Aboubakr Elnashar
  17. 17. Uterine septum, 3D Aboubakr Elnashar
  18. 18.  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 IVFAboubakr Elnashar
  19. 19. Subclassification of fibroid Aboubakr Elnashar
  20. 20. Aboubakr Elnashar
  21. 21. 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. Aboubakr Elnashar
  22. 22. Aboubakr Elnashar
  23. 23. Aboubakr Elnashar
  24. 24. 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 Aboubakr Elnashar
  25. 25. Submucous fibroid Aboubakr Elnashar
  26. 26. 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. Aboubakr Elnashar
  27. 27. Adenomyosis Aboubakr Elnashar
  28. 28. Myometrium (M): 1. Homogeneous echotexture 2. Subendometrial haloas (arrows): thin hypoechoic band Endometrium (E): uniformly echogenic NORMAL Aboubakr Elnashar
  29. 29. 1. Heterotopic endometrial glands and stroma: Small echogenic islands 2. Smooth muscle hyperplasia. Areas of decreased echogenicity Histopathologic US correlation Aboubakr Elnashar
  30. 30. 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 Aboubakr Elnashar
  31. 31.  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) Aboubakr Elnashar
  32. 32. 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; 167:603-6Aboubakr Elnashar
  33. 33. Adenomyosis. Sagittal TVS Globular uterine enlargement with asymmetric thickening Heterogeneity of the myometrium (arrows) Poor definition of the endomyometrial junction (arrowheads). E = endometrium. Aboubakr Elnashar
  34. 34. Asherman syndrome Irregular reflective foci of the uterine cavity. Best seen in the periovulatory phase Aboubakr Elnashar
  35. 35. IU adhesions Bright (hyperechoic) uterine lining - scar tissue in uterine cavity Aboubakr Elnashar
  36. 36. 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. Aboubakr Elnashar
  37. 37. Endometrial polyp Aboubakr Elnashar
  38. 38. Endometrial polyp Aboubakr Elnashar
  39. 39. RVF uterus, thickened endometrium that measures 18 mm (calipers) with a focal area of increased echogenicity (arrows), which was a polyp.Aboubakr Elnashar
  40. 40. 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 Aboubakr Elnashar
  41. 41. Volume = L X WX T X 0.52 0.5 cm3Prepubertal 5 cm3Reproductive years 2.5X2.2X2 cm. Diameter >3.5 cm is abnormal 2.5 cm3Postmenopausal Aboubakr Elnashar
  42. 42. 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 reserveAboubakr Elnashar
  43. 43. 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) Aboubakr Elnashar
  44. 44. 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. Aboubakr Elnashar
  45. 45. Aboubakr Elnashar
  46. 46. 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. Aboubakr Elnashar
  47. 47. only 1 antral, other ovary had only 2 antrals Ovarian volume: low D3 FSH: normal Attempts to stimulate ovaries for IVF were not successful Aboubakr Elnashar
  48. 48. 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. Aboubakr Elnashar
  49. 49. 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. Aboubakr Elnashar
  50. 50.  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 Aboubakr Elnashar
  51. 51. Mature follicle Aboubakr Elnashar
  52. 52. 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.Aboubakr Elnashar
  53. 53. 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. Aboubakr Elnashar
  54. 54. 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.Aboubakr Elnashar
  55. 55. 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. Aboubakr Elnashar
  56. 56. Corpus hemorrhagicum thick walls of peripheral luteal tissue and a central hemorrhagic clot with an interspersed fibrin network. Aboubakr Elnashar
  57. 57. 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.Aboubakr Elnashar
  58. 58. 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. Aboubakr Elnashar
  59. 59. Endometrioma Hyperechoic wall foci (in35%) Cysts With Low-level Echoes Hemorrhagic cyst Lacelike internal echoes (in 40%) Teratoma Regional bright echoes (in 97%) Aboubakr Elnashar
  60. 60. Endometrioma. Sagittal TVS an ovarian mass with multiple fine internal echoes (arrows) and several hyperechoic mural foci (arrowheads). Aboubakr Elnashar
  61. 61. Ovarian endometrioma (A, B). The structure is hypoechoic and exhibits low amplitude uniformly distributed echotexture in the cavities of the cysts. Aboubakr Elnashar
  62. 62. 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 Aboubakr Elnashar
  63. 63. 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 Aboubakr Elnashar
  64. 64. PCO Multiple peripheral subcentimetric follicles (arrow). Aboubakr Elnashar
  65. 65. 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). Aboubakr Elnashar
  66. 66. III. Tubal factor 1.Tubal patency: SIS 2. Hydrosalpinx: decrease the chance of implantation with IVF Aboubakr Elnashar
  67. 67. Hydrosalpinx Aboubakr Elnashar
  68. 68. Aboubakr Elnashar
  69. 69. Hydrosalpinx well-constrained fluid accumulation in the adnexae. In some cases, adhesions between the oviduct and ovary may be visualized. Aboubakr Elnashar
  70. 70. Pcos, hydrosalpinx Aboubakr Elnashar
  71. 71. IV. Pelvis 1. Free fluid 2. Mass Hydrosalpinx Endometriomas Para ovarian Cyst Peritoneal cysts Aboubakr Elnashar
  72. 72. Tubo ovarian abscess Aboubakr Elnashar
  73. 73. I. Ovarian induction/IUI II. IVF: III.Aspiration of 1. Ovarian Cyst. 2. Hydrosalpinx Aboubakr Elnashar
  74. 74. 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 Aboubakr Elnashar
  75. 75. II. IVF 1. U.S between D10 & 15 of preceding IVF cycle: Uterus: fibroid Ovaries: size, PCO, ovarian cyst Tubes: hydrosalpinx Aboubakr Elnashar
  76. 76. 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 Aboubakr Elnashar
  77. 77. 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: Aboubakr Elnashar
  78. 78. 4. Embryo transfer: Aboubakr Elnashar
  79. 79. Aboubakr Elnashar
  80. 80. 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.Aboubakr Elnashar
  81. 81. 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. Aboubakr Elnashar
  82. 82. III. Aspiration of 1. Ovarian Cyst. Residual cyst > 3 cm may affect ovarian response in the subsequent cycles . 2. Hydrosalpinx Aboubakr Elnashar
  83. 83. Aboubakr Elnashar
  84. 84. I. OHSS II. Complications of oocyte retrieval III. Complications of early pregnancy Aboubakr Elnashar
  85. 85. I. OHSS a. Diagnosis b. Treatment: paracentesis under TVS Aboubakr Elnashar
  86. 86. 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) Aboubakr Elnashar
  87. 87. CriticalSevereModerateMild •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 ptOut pt, In pt: unable to control pain, N with oral tt, Difficulties in monitoring Out ptTT Mathur, 2oo5 Aboubakr Elnashar
  88. 88. 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. Aboubakr Elnashar
  89. 89. Aboubakr Elnashar
  90. 90. II. Complications of oocyte retrieval Intra-abdominal bleeding Pelvic infection or abscess formation Aboubakr Elnashar
  91. 91. III.Complications of early pregnancy more common a. Ectopic b.Miscarriage c. Multiple pregnancy: Diagnosis & treatment (selective fetal reduction) Aboubakr Elnashar
  92. 92. 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 Aboubakr Elnashar
  93. 93. 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% Aboubakr Elnashar
  94. 94. 2. Cystic mass: 3. Ring: (Bagel sign) hyperechoic ring around the gestational sac 4.Sac & embryo. Ipsilateral side: Corpus luteum: 85% of cases Aboubakr Elnashar
  95. 95. C. D. pouch: Fluid with or without blood clots Aboubakr Elnashar
  96. 96. Aboubakr Elnashar
  97. 97. loop Non cystic mass D pouch Aboubakr Elnashar
  98. 98. Cystic mass Aboubakr Elnashar
  99. 99. Ring Aboubakr Elnashar
  100. 100. Sac & embryo Aboubakr Elnashar
  101. 101. Multiple pregnancy Aboubakr Elnashar
  102. 102. Thank you Aboubakr Elnashar Aboubakr Elnashar