Chairperson: Haryana Chapter Of ISAR ,2011-2015Executive member ISAR 2016-2017Associate RCOG

Director: LOOMBA HOSPITAL AND IVF CENTRE ,Ambala Cantt. HARYANA since 1988Ex consultant at central hospital ,Arar,

Saudi ArabiaEx senior resident Ganga Ram HospitalNew Delhi.Graduate from GOMCO ,Patiala.1985.

Awards: President’s gold medal at university level.Affiliations: ASRM,RCOG,FOGSI,ISAR,ACOG,,IAGE,

ASPIRE,Foetal Medicine Foundationregular attendee at many nationaland international conferences.

Achievements: First IVF/ART centre in haryana in 2003 Trained at CLEVELAND CLINIC U.S.A in IVF/ICSI

Trained at HARVARD in advanced ultrasound in fetal medicineAdvanced laparoscopy training at Kiel,Germany.

Specialised : Infertility/ART, Fertility related Fields Laparoscopic surgeries, Fetal medicine

Recurrent pregnancy loss

www.loombahospital.com

Dr.Poonam LoombaM.D.

loombapoonam@gmail.com

www.loombaivf.com

Basics of TVS and Colour Doppler

Poonam Loomba ,M.D.

Director and Consultant

Loomba hospital and IVF Centre

TVS

• Most important tool in management of infertility at each step.

• The image resolution and magnification is as if we are looking at organs through a microscope.

• Easy to perform

• Cost effective for patient

• Reliable

• Non invasive

• Patient friendly

Revolution in ultrasound• A Mode• B Mode ......1963 by Campbell• Static scan• Real time imaging • Computed Sonography• Transvaginal sector probe.....1983• Colour Doppler .....1985• 3D /4D .....1990

• The advent of TVS transformed reproductive medicine especially the monitoring and procedures associated with IVF.

Stated that any directional motion between a light source and observer would produce a shift in frequency or change In colour.

This principle is now used as the basis for blood flow studies .

Christian Doppler

Doppler effect

Angle of insonation

Types of doppler and waves

• Colour doppler

• Power doppler

• Spectral doppler

• Continuous wave doppler

• Pulse wave doppler

Power doppler

Spectral doppler

Blood flow measurements

Learning objectives

Display and discuss the basics of TVS in infertility and ART

Use of colour and doppler in predicting success of ART.

Special reference shall be made towards the significance of markers to evaluate endometrial receptivity and follicle maturation .

What should the mind know?

• Anatomy, physiology and haemodynamicsof reproductive organs.

• Pathophysiology of diseases/anomalies as a cause of infertility.

• Physical principles of color and doppler .

• Your Ultrasound machine.

• The limitations of ultrasound in the infertility evaluation.

Baseline scan in infertility Best done in the early follicular time to avoid distortion of ovarian

volume caused by growing follicle

High frequency probe with trans vaginal approach is used.

Use a systematic approachEmpty bladderWatch as you are placing the transducerLook at the bladder,and cervix(length and locationCervico uterine angle Uterus:Orientation,size,endometrial thicknessOvaries:location,size,and number of follicles

. Document and save your findings electronically.

.

Base Line Scan

Length of cavity and C/U angle

Adenomyosis

Normal Parameters

• With 2D Uterus can be studied n Sagittal and Transverse planes.

• Body of uterus to cervix ratio is 2:1

• Uterus is deviated to Rt Or Lt. Its Orientation depends upon fullness of bladder and rectum.

• Uterus can be divided into endometrium,myometrium and serosa.

• Normal texture of myometrium is homogenously echodense.

Assessment of uterine cavity

Shape of uterine cavity

Intracavitary lesions

Endometrio myometrial

junction

Endometrial receptivity

Assessment of uterine cavity

Greatest advantage of 3D is coronal section.

Differential diagnosis of congenital duplication

abnormalities of uterus like bicornuate, septate and

arcuate is based on external fundal contour and

contour of the endometrial cavity.

Structural Uterine anomalies

Seen in 4 % women with infertility and 15% with RPL

Normal shape of the uterine cavity...

SEROSAL FUNDUS

ENDOMETRIAL FUNDUS

Unicornuate uterus:

normal shape in long section

deviated

Hypoplastic 2nd horn : sometimes

Unicornuate Uterus

Endometrial polyp

More echogenic thanmyometrium

Isoechoic with endometrium

Sessile or pedunculated

Single feeding vessel

Intra uterine adhesions

• Asymmetry of endometrial echo

• Areas of endometrium <2mm

• Echogenic area in the uterus

• TVS sensitivity is 52%

• TV SIS is 93.5 to 99.% accurate.

Submucous fibroids –grading :to decide the route of surgery

• T0- whole in endometrial cavity

• T1 - >50% in endometrial cavity

• T2- < 50% in endometrial cavity

Saline infusion sonohysterography

More image than imagination

May be as effective as hysteroscopy indetecting intra cavitary abnormalities

More cost effective and simple to perform

SIS:- 20ML Normal saline is instilled using pediatric foley catheter no.8

Sono hystero salpingography

• Saline

• Saline +Air :Shake before injecting

• Gray scale

• Colour

• Contrast media :Echovist,Sono Vue

• 3d Power doppler

Colour doppler for tubalpatency

Alternative to sonohysterogram

• Consider doing ultrasound in luteal phase.

• Endometrium is hyperechoic and acts like contrast medium.

• Add 3D image.

The high incidence of cavitary abnormalities

and the potential improvements in pregnancy

outcomes after hysteroscopic surgery

highlights the importance

of cavitary assessment

Intact regular endometrio-myometrial junction is

an important sign of a healthy endometrium.

Junctional zone is damaged in

• Endometritis: acute or chronic

• adenomyosis

Damaged endometriomyometrial junction

Endometrial receptivity 30% of embryos transferred result in clinical pregnancies .Fault may be in the embryo or the implantation bed.

Thickness

Pattern

Blood flow to the endometrial and subendometrial zone

Volume

Normal endometriumMeasuring endometrial thickness

Endometrial thickness

• Increases from 4.6mm to 12.4mm on the day of LH surge.

• Average increase is 1 to 2mm per day in proliferative phase.

• Decreases by 0,5mm on the day of LH surge increasing again by 2mm in luteal phase.

CC vs HMG/FSH• Following the days CC is taken the ET is often decreased the

effect lasts no more than 3-4 days after last dose.

• In late follicular phase it escapes antioestrogenic effect and increases faster.

• With HMG and FSH it is greater than in spontaneous cycles.

• No pregnancies were seen when ET was <6mm on the day of hcg.

• Biochemical pregnancies were pbserved more in ET <9mm or >13mm.

• It is advisable not to start OI if postmenstrual ET is 6mm or more.

Thin endometrium indicating low estrogenic state

Periovulatory endometrium:once the EM echo is well visualized use as much magnification as

possible

Secretory phase endometrium

Endometrium in PCOD No Triple line

Endometrial waves

• In 73% a wave direction switch occurs from fundus to cervix and cervix to fundus before OPU (fertil steril 1999)

• The persisting waves until HCG predict a favourable outcome

• In a validation prospective study it was not confirmed if waves improved pregnancy outcomes(fertil steril 2005)

• Two more wave types are recoiling CF wave and a standing wave.(fertil steril2007)

Uterine artery doppler

• High peak systolic flow• Very little end diastolic flow• Varies with age and phases of menstrual cycle.• RI is 0.88 until day 13 of ovulation.• During ovulation there is increase in RI • In late luteal phase around implantation window

lowest impedance is seen. RI is 0.77• 2D doppler detects blood vessels but 3D doppler

studies morphology of vascularization and neovascularization.

Blood flow

• With the more sensitive colour doppler and power doppler it is postulated that local vascularization at the site of implantation is more important than global vascularization of the uterus measured by RI in the uterine arteris.

• RI of spiral arteries is 0.55.• EPDA is defined as a part of endometrium where

vascular signals with velocities >5cm/sec are detected.

• Lower IR and PR are seen when EPDA is <5cm/sec.• VI,FI and VFI in the subendometrial zone.VFI has

93.8% positive predictive value of predicting positive pregnancy outcomes

PROLIFERATION OF SPIRAL ARTERIES AND

SUBSEQUENT ENDOMETRIAL “INVASION”

ZONE I -- Only Myometrial Vessels Surrounding the Endometrium are

Visualized.

ZONE II – Vessels Penetrate Through the Hyperechogenic Endometrial Edge.

ZONE III – Vessels reach the internal endometrial Hypoechogenic Zone.

ZONE IV – Vessels reach the Endometrial Cavity.

Deeper the vascularization noted better the

outcome.

Endometrial power doppler area

Endometrial volume by 3D by virtual organ computer aided analysis software

Significance of endometrial volume

• Endometrial and subendometrial vascularity are significantly lower in patients with endometrial volume <2.5 ml

• In IVF/ICSI cycles endometrial volume and Power doppler indexes are statistically significant in predicting the cycle outcome with SET. (Fertil.Steril 2008 jan 89)

• Lower PR are seen with EV <2.0 cm3 and no pregnancies seen with <1.2cm3

Tubes: Hydrosalpinx

Ovaries

• Ovarian volume and AFC ….measures of ovarian reserve

• PCOD

• Ovarian masses

• Ovulation studies with series of scans

AFC

• AFC in both ovaries .

• <5

• 10-15

• >15

D/d of ovarian masses:most are benign in women of reproductive age

Physiologic

• Follicular

• Simple

• Corpus luteum

Pathologic

Endometrioma

Mature cystic teratoma

Borderline

Malignancy

We recommend further evaluation of the mass prior to stimulation(repeat US ,LAPROSCOPY

Haemorrhagic cyst Endometriomtic cyst

Ovarian volume

• Volume is affected by cigarette smoking OCP age and cysts

• Superior to day3 FSH

• Small volume predicts fewer follicles and low PR independent of age(syrop 1999)

• Large volume>10ml is associated with increased OHSS.(10% TO 23.5%)

• Polycystic ovarian morphology has been found

to be a better discriminator than ovarian

volume between polycystic ovarian syndrome

and control women.

Legro, et al, JCEM 90(5): 2571-79.

What is specific in PCO morphology…

• Multiple antral follicles

• Distribution of antral follicles

• Stromal predominance

• Stromal vascularity

OVARIAN STROMAL BLOOD FLOW

• PSV > 10cm/sec AFTER PITUITARY SUPRESSION• Stromal ri < 0.41 : 2/3rds WILL GET OHSS• Stromal pi < 0.75 : 1/2 will get pleural effusions

Kupesic has shown correlation in the

ovarian stromal flow index and number of

mature oocytes retrieved in an IVF cycles

and pregnancy rates. Stromal FI ( < 11 low

responder, 11 -14 good, > 15 risk of OHSS)

Hum Reprod 2002; 17(4) : 950 - 55

Sono AVC

• Using inversion mode to render the volume

shows all the follicles as solid structures.

• This makes their definition very clear and are

easy to count.

3 D Inversion Tecnology

Follicular study

• Number of scans depend upon the response of the patient

• Hcg is delayed till majority reach maturation

• Eggs can be retrieved from as small as 14mm and as large as 24mm.

• Decreased quality of oocytes from follicle 24mm.>

• No difference in quality of oocytes from follicles 18-22mm in size.

Perifollicular blood flow

PERIFOLLICULAR VASCULARISATION

• GRADE 1 < 25%

• GRADE 2 < 50%

• GRADE 3 < 75%

• GRADE 4 > 75%

FOLLICULAR PARAMATERS

A.PERIFOLLICULAR VASCULARIZATION.

B.PERIFOLLICULAR RI 0.4 – 0.48

C.FOLLICULAR PSV > 10 CMS/SEC

Diameter predicts maturity and perifollicular vascularization predicts the quality of oocyte at retreival

DECIDING THE TIME OF HCG ?

This consisted of

Follicular volume

Visualization of cumulus

Perifollicluar VI

Perifollicular FI

Perifollicular VFI

Follicular volumes of between 3 – 7 cc are optimum

for oocyte retrieval .

The limits of agreement between the volume of the

follicular aspirate and 3D volume of the follicle were

+ 0.96 to – 0.43 with 3D and + 3.47 to – 2.42 by 2D

volume estimation.

Follicular Volume

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.

cumulus

Oocyte Retrieval

• Standard IVF retrieval

• Transvaginal probe 5-9 MHz

• 16-17 gauge needle

• Empty bladder before starting procedure

Ultrasound guided ET

• Full bladder for TAUS

• Assistant to

• Usually soft catheter is used

• Confirm position of loaded catheter

• Place embryos in middle part of uterine cavity .

• Confirm for the fluid bubble in the cavity.

Limitations of ultrasound

• Minimal and mild endometriosis

• Flimsy pelvic adhesions

• Some tubal abnormalities.

• But we can use the probe actively during exam to assess the mobility of pelvic structures in relation to each other.This gives us an idea of whether or not there are adhesions.

...........................Sign