Ultrasonography and infertility: Aboubakr Elnashar

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2. A. Diagnosis of the cause B. Treatment of infertility C. Diagnosis and treatment of complications of infertility management 3. Basic investigations 1.Semen analysis 2.Midluteal progesterone 3.HSG Further investigations TVS: method of choice for assessing the female reproductive organs 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. I. Uterine factor A. Assessment of the uterus: Dimension Endometrial thickness B. Abnormalities Anomalies Tumors: fibroid, adenomyosis Endometritis Cavity: polyps, adhesions 6. Endpmetrial thickness 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. Normal endometrium.Triple line endometrium in midcycle. 9. Secertory endometrium 10. Secertory endometrium RVF 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. Bicornuate uterus At cervical level At fundal level 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. Bicornuate uterus. Transverse 2-D image illustrating two distinct endometrial cavities (arrows). 15. Uterus didelphys, 2D scan 16. Uterine septum, 3D 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. Subclassification of fibroid 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. 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. Submucous fibroid 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. Adenomyosis 24. Myometrium (M): 1. Homogeneous echotexture 2. Subendometrial haloas (arrows): thin hypoechoic band Endometrium (E): uniformly echogenic NORMAL 25. 1. Heterotopic endometrial glands and stroma: Small echogenic islands 2. Smooth muscle hyperplasia. Areas of decreased echogenicity Histopathologic US correlation 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. 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. 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. Adenomyosis. Sagittal TVS Globular uterine enlargement with asymmetric thickening Heterogeneity of the myometrium (arrows) Poor definition of the endomyometrial junction (arrowheads). E = endometrium. 30. Asherman syndrome Irregular reflective foci of the uterine cavity. Best seen in the periovulatory phase 31. IU adhesions Bright (hyperechoic) uterine lining - scar tissue in uterine cavity 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. Endometrial polyp 34. Endometrial polyp 35. RVF uterus, thickened endometrium that measures 18 mm (calipers) with a focal area of increased echogenicity (arrows), which was a polyp. 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. 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. Mean ovarian volume 3.5 cm: increase risk of OHSS 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. 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. PCO Multiple peripheral subcentimetric follicles (arrow). 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. III. Tubal factor 1.Tubal patency: SIS 2. Hydrosalpinx: decrease the chance of implantation with IVF 62. Hydrosalpinx 63. Hydrosalpinx well-constrained fluid accumulation in the adnexae. In some cases, adhesions between the oviduct and ovary may be visualized. 64. Pcos, hydrosalpinx 65. IV. Pelvis 1. Free fluid 2. Mass Hydrosalpinx Endometriomas Para ovarian Cyst Peritoneal cysts 66. Tubo ovarian abscess 67. I. Ovarian induction/IUI II. IVF: III.Aspiration of 1. Ovarian Cyst. 2. Hydrosalpinx 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. II. IVF 1. U.S between D10 & 15 of preceding IVF cycle: Uterus: fibroid Ovaries: size, PCO, ovarian cyst Tubes: hydrosalpinx 70. 2. COH: a. Confirm down regulation: Thin endometrium: 3 cm may affect ovarian response in the subsequent cycles . 2. Hydrosalpinx 76. I. OHSS II. Complications of oocyte retrieval III. Complications of early pregnancy 77. I. OHSS a. Diagnosis b. Treatment: paracentesis under TVS 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. CriticalSevereModerateMild Tense ascites Oligo/anuria Thromboembolism ARDS Ascites Oliguria Mod ab pain N V Ab bloating Mild ab pain Cl large hydrothoraxhydrothorax Ov12 cm* Ascites Ov812 cm* Ov8 cm*US Hct55% WCC25 000/ml Hct 45% Hypoprotein aemia Lab ICUIn ptOut pt, In pt: unable to control pain, N with oral tt, Difficulties in monitoring Out ptTT Mathur, 2oo5 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. II. Complications of oocyte retrieval Intra-abdominal bleeding Pelvic infection or abscess formation 82. III.Complications of early pregnancy more common a. Ectopic b.Miscarriage c. Multiple pregnancy: Diagnosis & treatment (selective fetal reduction) 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. 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. 2. Cystic mass: 3. Ring: (Bagel sign) hyperechoic ring around the gestational sac 4.Sac & embryo. Ipsilateral side: Corpus luteum: 85% of cases 86. C. D. pouch: Fluid with or without blood clots 87. loop Non cystic mass D pouch 88. Cystic mass 89. Ring 90. Sac & embryo 91. Multiple pregnancy 92. Thank you Aboubakr Elnashar