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Ultrasonography and infertility: Aboubakr Elnashar

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Ultrasonography and infertility: Aboubakr Elnashar

  1. 1. E-mail: elnashar53@hotmail.com
  2. 2. A. Diagnosis of the cause B. Treatment of infertility C. Diagnosis and treatment of complications of infertility management
  3. 3. Basic investigations 1.Semen analysis 2.Midluteal progesterone 3.HSG Further investigations TVS: method of choice for assessing the female reproductive organs
  4. 4. 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)
  5. 5. I. Uterine factor A. Assessment of the uterus: • Dimension • Endometrial thickness B. Abnormalities • Anomalies • Tumors: fibroid, adenomyosis • Endometritis • Cavity: polyps, adhesions
  6. 6. Endpmetrial thickness
  7. 7. 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
  8. 8. Normal endometrium.“Triple line” endometrium in midcycle.
  9. 9. Secertory endometrium
  10. 10. Secertory endometrium RVF
  11. 11. 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}
  12. 12. Bicornuate uterus At cervical level At fundal level
  13. 13. Transverse plane of the uterine fundus two distinct endometrial cavities (arrows). A subsequent 3-D confirmed that this was a partially septated uterus
  14. 14. Bicornuate uterus. Transverse 2-D image illustrating two distinct endometrial cavities (arrows).
  15. 15. Uterus didelphys, 2D scan
  16. 16. Uterine septum, 3D
  17. 17.  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 IVF
  18. 18. Subclassification of fibroid
  19. 19. 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.
  20. 20. 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
  21. 21. Submucous fibroid
  22. 22. 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.
  23. 23. Adenomyosis
  24. 24. Myometrium (M): 1. Homogeneous echotexture 2. Subendometrial haloas (arrows): thin hypoechoic band Endometrium (E): uniformly echogenic NORMAL
  25. 25. 1. Heterotopic endometrial glands and stroma: Small echogenic islands 2. Smooth muscle hyperplasia. Areas of decreased echogenicity Histopathologic US correlation
  26. 26. 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
  27. 27.  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)
  28. 28. 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; 167:603-6
  29. 29. Adenomyosis. Sagittal TVS Globular uterine enlargement with asymmetric thickening Heterogeneity of the myometrium (arrows) Poor definition of the endomyometrial junction (arrowheads). E = endometrium.
  30. 30. Asherman syndrome Irregular reflective foci of the uterine cavity. Best seen in the periovulatory phase
  31. 31. IU adhesions Bright (hyperechoic) uterine lining - scar tissue in uterine cavity
  32. 32. 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.
  33. 33. Endometrial polyp
  34. 34. Endometrial polyp
  35. 35. RVF uterus, thickened endometrium that measures 18 mm (calipers) with a focal area of increased echogenicity (arrows), which was a polyp.
  36. 36. 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
  37. 37. 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
  38. 38. 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 reserve
  39. 39. 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)
  40. 40. 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.
  41. 41. 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.
  42. 42. only 1 antral, other ovary had only 2 antrals Ovarian volume: low D3 FSH: normal Attempts to stimulate ovaries for IVF were not successful
  43. 43. 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.
  44. 44. 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.
  45. 45.  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
  46. 46. Mature follicle
  47. 47. 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.
  48. 48. 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.
  49. 49. 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.
  50. 50. 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.
  51. 51. Corpus hemorrhagicum thick walls of peripheral luteal tissue and a central hemorrhagic clot with an interspersed fibrin network.
  52. 52. 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.
  53. 53. 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.
  54. 54. Endometrioma Hyperechoic wall foci (in35%) Cysts With Low-level Echoes Hemorrhagic cyst Lacelike internal echoes (in 40%) Teratoma Regional bright echoes (in 97%)
  55. 55. Endometrioma. Sagittal TVS an ovarian mass with multiple fine internal echoes (arrows) and several hyperechoic mural foci (arrowheads).
  56. 56. Ovarian endometrioma (A, B). The structure is hypoechoic and exhibits low amplitude uniformly distributed echotexture in the cavities of the cysts.
  57. 57. 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
  58. 58. 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
  59. 59. PCO Multiple peripheral subcentimetric follicles (arrow).
  60. 60. 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).
  61. 61. III. Tubal factor 1.Tubal patency: SIS 2. Hydrosalpinx: decrease the chance of implantation with IVF
  62. 62. Hydrosalpinx
  63. 63. Hydrosalpinx well-constrained fluid accumulation in the adnexae. In some cases, adhesions between the oviduct and ovary may be visualized.
  64. 64. Pcos, hydrosalpinx
  65. 65. IV. Pelvis 1. Free fluid 2. Mass Hydrosalpinx Endometriomas Para ovarian Cyst Peritoneal cysts
  66. 66. Tubo ovarian abscess
  67. 67. I. Ovarian induction/IUI II. IVF: III.Aspiration of 1. Ovarian Cyst. 2. Hydrosalpinx
  68. 68. 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
  69. 69. II. IVF 1. U.S between D10 & 15 of preceding IVF cycle: Uterus: fibroid Ovaries: size, PCO, ovarian cyst Tubes: hydrosalpinx
  70. 70. 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
  71. 71. 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:
  72. 72. 4. Embryo transfer:
  73. 73. 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.
  74. 74. 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.
  75. 75. III. Aspiration of 1. Ovarian Cyst. Residual cyst > 3 cm may affect ovarian response in the subsequent cycles . 2. Hydrosalpinx
  76. 76. I. OHSS II. Complications of oocyte retrieval III. Complications of early pregnancy
  77. 77. I. OHSS a. Diagnosis b. Treatment: paracentesis under TVS
  78. 78. 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)
  79. 79. 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
  80. 80. 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.
  81. 81. II. Complications of oocyte retrieval Intra-abdominal bleeding Pelvic infection or abscess formation
  82. 82. III.Complications of early pregnancy more common a. Ectopic b.Miscarriage c. Multiple pregnancy: Diagnosis & treatment (selective fetal reduction)
  83. 83. 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
  84. 84. 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%
  85. 85. 2. Cystic mass: 3. Ring: (Bagel sign) hyperechoic ring around the gestational sac 4.Sac & embryo. Ipsilateral side: Corpus luteum: 85% of cases
  86. 86. C. D. pouch: Fluid with or without blood clots
  87. 87. loop Non cystic mass D pouch
  88. 88. Cystic mass
  89. 89. Ring
  90. 90. Sac & embryo
  91. 91. Multiple pregnancy
  92. 92. Thank you Aboubakr Elnashar
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