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

1. Interventional Ultrasound in
Infertility
Hesham Al-Inany, M.D, PhD

2. Focus of this lecture
• Not talking about emerging technology

6. But talking about current Procedures
• Before IVF
• For IVF
• After IVF

7. PCOS

8. • 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

9. Difficulties encountered
Non stimulated ovaries;
Difficult accessibility; abdominal pressure
Recurrence rate is high (after 6 month)

10. 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

11. 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

12. Not suitable
• If the cyst recurred
• If CA125 more than 35
• If not entirely cystic

13. 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)

14. 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?

15. Three Steps management
• TVUS aspiration
• Followed by medical treatment
• Followed by laparoscopic cystectomy or IVF
• Has not been evaluated till now

16. Transcervical metroplasty
• Asymptomatic woman: no treatment
• Prophylatic metroplasty before IVF has been
proposed
• US guidance can be an alternative to
hysteroscopic metroplasty

18. IVF procedure

19. Ovum Pick up
• General anesthesia or sedation or none
• TV U/S guided: corner stone for OPU
• Single or double aspiration needle

22. 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

23. 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

24. ET under US

25. Ultrasound guided ET
• Full bladder to straighten the utero-cervical
angle
• Trans-abdominal U/S
• Special catheters ecchogenic

26. 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).

27. After IVF
• What can interventional US offer??

28. 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

29. • However, systemic methotrexate is easier and
effective

30. SER or MFPR
• Done at 7 weeks
• Easy , simple rapid
• Only by aspiration , no injection of potassium
chloride

31. Complications
• Bleeding
• Vanishing twin(14.4%)
• Abortion (4%)

32. 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

33. Coelocentesis
• Between 6 -12 weeks
• Advantage of early Prenatal diagnosis(< 10w)
• 95% success rate bet 7 - 10weeks
• Low rate of contamination by maternal cells.

34. Coelocentesis
• Early amnio and CVS not performed before
10weeks
• Less traumatic to embryo & placenta
• Fetal loss = 0r < that in early amnio.

37. Conclusion
• Interventional ultrasound is becoming more
and more in use
• Advancement in technology will extend its use
in different applications

38. Thank You

39. Thank You