Interventional ultrasound in infertility

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Ultrasound is diagnostic tool but now it can be used as interventional one. How?? this talk may illustrate this issue

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  • volume calculation using 3-dimensional VOCAL technique and on colour coding of each follicle (SonoAVC, GE )
  • With no incidence of adhesions
  • Interventional ultrasound in infertility

    1. 1. Interventional Ultrasound in Infertility Hesham Al-Inany, M.D, PhD
    2. 2. Focus of this lecture • Not talking about emerging technology
    3. 3. But talking about current Procedures • Before IVF • For IVF • After IVF
    4. 4. PCOS
    5. 5. • Injection of warm sterile saline (75C) into the ovarian stroma under TVUS monitoring using ovum pickup needle. • Ovulation has been achieved in 73.1% of clomiphene citrate resistant PCOS cases and resulted in pregnancy in 26.9% of these cases. No adverse effects were recorded and the procedure was tolerable in most cases
    6. 6. Difficulties encountered Non stimulated ovaries; Difficult accessibility; abdominal pressure Recurrence rate is high (after 6 month)
    7. 7. Cyst aspiration • Some cysts appear after administration of GnRH analogues , due to the flare up effect, they may result in delay of down regulation and failure of the estradiol level to drop , in these cases TV cyst aspiration is our usual practice
    8. 8. Entirely cystic adenxal mass • Transvaginal ultrasound cyst aspiration can be proposed as an alternative for surgery for women with:- • Previously diagnosed as having extensive pelvic adhesions or peritoneal cyst • Pregnant women before 14 weeks gestation • Persistent cyst after OC use for 3 month
    9. 9. Not suitable • If the cyst recurred • If CA125 more than 35 • If not entirely cystic
    10. 10. Aspiration of Hydrosalpinx • In women who are identified to have visible hydrosalpinges by US during COH, aspiration of hydrosalpinges during oocyte collection may be effective in improving pregnancyrate (Hammadieh et al, 2008)
    11. 11. Aspiration of endometriotic cysts • Larger caliber of needle • Takes longer time • Difficult to empty • Sometimes u need to inject saline • Risk of infection • Recurrence rate is high • Injection of sclerosing material e.g alcohol?
    12. 12. Three Steps management • TVUS aspiration • Followed by medical treatment • Followed by laparoscopic cystectomy or IVF • Has not been evaluated till now
    13. 13. Transcervical metroplasty • Asymptomatic woman: no treatment • Prophylatic metroplasty before IVF has been proposed • US guidance can be an alternative to hysteroscopic metroplasty
    14. 14. IVF procedure
    15. 15. Ovum Pick up • General anesthesia or sedation or none • TV U/S guided: corner stone for OPU • Single or double aspiration needle
    16. 16. Difficulties encountered • High inaccessible ovaries; abdominal pressure, tenaculum manipulation of cervix pulling down ovary • Fibroids, adenomyosis ( proper precycle evaluation, myomectomy) • No follicles on aspiration; expect with poor response, older age , low E2 levels; flushing of the follicle
    17. 17. Complications • Pain: Severe 3% (Ludwig 2006) • Bleeding; vaginal site bleeding; pressure, pack, rarely sutures (2.8%, Ludwig 2006), ureteral injury • Injury; vaginal perforation, iliac vessels, retro- peritoneal haematoma (Azem 2000) • Infection; pelvic abscess, tuboovarian abscess ( Dicker 1993; 14 out of 3,656),usually with aspiration of endometriotic cysts or hydrosalpinx • Ovarian torsion • OHSS
    18. 18. ET under US
    19. 19. Ultrasound guided ET • Full bladder to straighten the utero-cervical angle • Trans-abdominal U/S • Special catheters ecchogenic
    20. 20. It is evidence Based • Two recent meta-analysis one by our group, found a higher live birth , ongoing pregnancy, clinical pregnancy & implantation rates and easier transfers with ultrasound guided technique (Abousetta , Brown 2007).
    21. 21. After IVF • What can interventional US offer??
    22. 22. Ectopic pregnancy • Ectopic pregnancy after IVF are usually diagnosed very early and before being undisturbed • Transvaginal intratubal injection of methotrexate under sonographic guidance is feasible • Can be alternative to Laparoscopy
    23. 23. • However, systemic methotrexate is easier and effective
    24. 24. SER or MFPR • Done at 7 weeks • Easy , simple rapid • Only by aspiration , no injection of potassium chloride
    25. 25. Complications • Bleeding • Vanishing twin(14.4%) • Abortion (4%)
    26. 26. Aspiration of ascitic fluid in OHSS • When there is distress app 3 litres • Aspiration + IV human albumen • TV U/S guided • Simple no anesthesia • Might need to repeat • Severe cases have decreased markedly due protocol of coasting and Antagonist
    27. 27. Coelocentesis • Between 6 -12 weeks • Advantage of early Prenatal diagnosis(< 10w) • 95% success rate bet 7 - 10weeks • Low rate of contamination by maternal cells.
    28. 28. Coelocentesis • Early amnio and CVS not performed before 10weeks • Less traumatic to embryo & placenta • Fetal loss = 0r < that in early amnio.
    29. 29. Conclusion • Interventional ultrasound is becoming more and more in use • Advancement in technology will extend its use in different applications
    30. 30. Thank You
    31. 31. Thank You

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