Ultrasonography and infertility: Aboubakr Elnashar

102

Transcript of Ultrasonography and infertility: Aboubakr Elnashar

Page 1: Ultrasonography and  infertility: Aboubakr Elnashar

E-mail: [email protected]

Page 2: Ultrasonography and  infertility: Aboubakr Elnashar

A. Diagnosis of the cause

B. Treatment of infertility

C. Diagnosis and treatment of

complications of infertility management

Page 3: Ultrasonography and  infertility: Aboubakr Elnashar
Page 4: Ultrasonography and  infertility: Aboubakr Elnashar

Basic investigations

1.Semen analysis

2.Midluteal progesterone

3.HSG

Further investigations

TVS:

method of choice for assessing the female reproductive organs

Page 5: Ultrasonography and  infertility: Aboubakr Elnashar

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)

Page 6: Ultrasonography and  infertility: Aboubakr Elnashar

I. Uterine factor

A. Assessment of the uterus:

• Dimension

• Endometrial thickness

B. Abnormalities

• Anomalies

• Tumors: fibroid, adenomyosis

• Endometritis

• Cavity: polyps, adhesions

Page 7: Ultrasonography and  infertility: Aboubakr Elnashar

Endpmetrial thickness

Page 8: Ultrasonography and  infertility: Aboubakr Elnashar

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

Page 9: Ultrasonography and  infertility: Aboubakr Elnashar

Normal endometrium.“Triple line” endometrium in midcycle.

Page 10: Ultrasonography and  infertility: Aboubakr Elnashar

Secertory endometrium

Page 11: Ultrasonography and  infertility: Aboubakr Elnashar

Secertory endometrium

RVF

Page 12: Ultrasonography and  infertility: Aboubakr Elnashar

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}

Page 13: Ultrasonography and  infertility: Aboubakr Elnashar

Bicornuate uterus

At cervical level At fundal level

Page 14: Ultrasonography and  infertility: Aboubakr Elnashar

Transverse plane of the uterine fundus

two distinct endometrial cavities (arrows).

A subsequent 3-D confirmed that this was a partially septated

uterus

Page 15: Ultrasonography and  infertility: Aboubakr Elnashar

Bicornuate uterus. Transverse 2-D image illustrating two

distinct endometrial cavities (arrows).

Page 16: Ultrasonography and  infertility: Aboubakr Elnashar

Uterus didelphys, 2D scan

Page 17: Ultrasonography and  infertility: Aboubakr Elnashar

Uterine septum, 3D

Page 18: Ultrasonography and  infertility: Aboubakr Elnashar

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

Page 19: Ultrasonography and  infertility: Aboubakr Elnashar

Subclassification of fibroid

Page 20: Ultrasonography and  infertility: Aboubakr Elnashar
Page 21: Ultrasonography and  infertility: Aboubakr Elnashar

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.

Page 22: Ultrasonography and  infertility: Aboubakr Elnashar
Page 23: Ultrasonography and  infertility: Aboubakr Elnashar
Page 24: Ultrasonography and  infertility: Aboubakr Elnashar

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

Page 25: Ultrasonography and  infertility: Aboubakr Elnashar

Submucous fibroid

Page 26: Ultrasonography and  infertility: Aboubakr Elnashar

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.

Page 27: Ultrasonography and  infertility: Aboubakr Elnashar

Adenomyosis

Page 28: Ultrasonography and  infertility: Aboubakr Elnashar

Myometrium (M):

1. Homogeneous

echotexture

2. Subendometrial haloas

(arrows):

thin hypoechoic band

Endometrium (E):

uniformly echogenic

NORMAL

Page 29: Ultrasonography and  infertility: Aboubakr Elnashar

1. Heterotopic endometrial glands and stroma:

Small echogenic islands

2. Smooth muscle hyperplasia.

Areas of decreased echogenicity

Histopathologic US correlation

Page 30: Ultrasonography and  infertility: Aboubakr Elnashar

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

Page 31: Ultrasonography and  infertility: Aboubakr Elnashar

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)

Page 32: Ultrasonography and  infertility: Aboubakr Elnashar

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

Page 33: Ultrasonography and  infertility: Aboubakr Elnashar

Adenomyosis. Sagittal TVS

Globular uterine enlargement with asymmetric thickening

Heterogeneity of the myometrium (arrows)

Poor definition of the endomyometrial junction (arrowheads).

E = endometrium.

Page 34: Ultrasonography and  infertility: Aboubakr Elnashar

Asherman syndrome

Irregular reflective foci of the uterine cavity.

Best seen in the periovulatory phase

Page 35: Ultrasonography and  infertility: Aboubakr Elnashar

IU adhesions

Bright (hyperechoic) uterine lining - scar tissue in uterine

cavity

Page 36: Ultrasonography and  infertility: Aboubakr Elnashar

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.

Page 37: Ultrasonography and  infertility: Aboubakr Elnashar

Endometrial polyp

Page 38: Ultrasonography and  infertility: Aboubakr Elnashar

Endometrial polyp

Page 39: Ultrasonography and  infertility: Aboubakr Elnashar

RVF uterus, thickened endometrium that measures 18

mm (calipers) with a focal area of increased

echogenicity (arrows), which was a polyp.

Page 40: Ultrasonography and  infertility: Aboubakr Elnashar

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

Page 41: Ultrasonography and  infertility: Aboubakr Elnashar

Volume

= L X WX T X 0.52

0.5 cm3 Prepubertal

5 cm3 Reproductive years 2.5X2.2X2 cm.

Diameter >3.5 cm is abnormal

2.5 cm3 Postmenopausal

Page 42: Ultrasonography and  infertility: Aboubakr Elnashar

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

Page 43: Ultrasonography and  infertility: Aboubakr Elnashar

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)

Page 44: Ultrasonography and  infertility: Aboubakr Elnashar

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.

Page 45: Ultrasonography and  infertility: Aboubakr Elnashar
Page 46: Ultrasonography and  infertility: Aboubakr Elnashar

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.

Page 47: Ultrasonography and  infertility: Aboubakr Elnashar

only 1 antral, other ovary had only 2 antrals

Ovarian volume: low

D3 FSH: normal

Attempts to stimulate ovaries for IVF were not successful

Page 48: Ultrasonography and  infertility: Aboubakr Elnashar

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.

Page 49: Ultrasonography and  infertility: Aboubakr Elnashar

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.

Page 50: Ultrasonography and  infertility: Aboubakr Elnashar

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

Page 51: Ultrasonography and  infertility: Aboubakr Elnashar

Mature follicle

Page 52: Ultrasonography and  infertility: Aboubakr Elnashar

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.

Page 53: Ultrasonography and  infertility: Aboubakr Elnashar

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.

Page 54: Ultrasonography and  infertility: Aboubakr Elnashar

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.

Page 55: Ultrasonography and  infertility: Aboubakr Elnashar

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.

Page 56: Ultrasonography and  infertility: Aboubakr Elnashar

Corpus hemorrhagicum

thick walls of peripheral luteal tissue and a central

hemorrhagic clot with an interspersed fibrin network.

Page 57: Ultrasonography and  infertility: Aboubakr Elnashar

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.

Page 58: Ultrasonography and  infertility: Aboubakr Elnashar

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.

Page 59: Ultrasonography and  infertility: Aboubakr Elnashar

Endometrioma

Hyperechoic wall

foci

(in35%)

Cysts With Low-level Echoes Hemorrhagic

cyst

Lacelike

internal

echoes

(in 40%)

Teratoma

Regional bright

echoes

(in 97%)

Page 60: Ultrasonography and  infertility: Aboubakr Elnashar

Endometrioma. Sagittal TVS

an ovarian mass with multiple fine internal echoes (arrows) and

several hyperechoic mural foci (arrowheads).

Page 61: Ultrasonography and  infertility: Aboubakr Elnashar

Ovarian endometrioma (A, B).

The structure is hypoechoic and exhibits low amplitude

uniformly distributed echotexture in the cavities of the

cysts.

Page 62: Ultrasonography and  infertility: Aboubakr Elnashar

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

Page 63: Ultrasonography and  infertility: Aboubakr Elnashar

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

Page 64: Ultrasonography and  infertility: Aboubakr Elnashar

PCO

Multiple peripheral

subcentimetric follicles (arrow).

Page 65: Ultrasonography and  infertility: Aboubakr Elnashar

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).

Page 66: Ultrasonography and  infertility: Aboubakr Elnashar

III. Tubal factor

1.Tubal patency:

SIS

2. Hydrosalpinx:

decrease the chance of implantation with IVF

Page 67: Ultrasonography and  infertility: Aboubakr Elnashar

Hydrosalpinx

Page 68: Ultrasonography and  infertility: Aboubakr Elnashar
Page 69: Ultrasonography and  infertility: Aboubakr Elnashar

Hydrosalpinx

well-constrained fluid

accumulation in the adnexae.

In some cases, adhesions

between the oviduct and ovary

may be visualized.

Page 70: Ultrasonography and  infertility: Aboubakr Elnashar

Pcos,

hydrosalpinx

Page 71: Ultrasonography and  infertility: Aboubakr Elnashar

IV. Pelvis

1. Free fluid

2. Mass

Hydrosalpinx

Endometriomas

Para ovarian Cyst

Peritoneal cysts

Page 72: Ultrasonography and  infertility: Aboubakr Elnashar

Tubo ovarian abscess

Page 73: Ultrasonography and  infertility: Aboubakr Elnashar

I. Ovarian induction/IUI

II. IVF:

III.Aspiration of

1. Ovarian Cyst.

2. Hydrosalpinx

Page 74: Ultrasonography and  infertility: Aboubakr Elnashar

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

Page 75: Ultrasonography and  infertility: Aboubakr Elnashar

II. IVF

1. U.S between D10 & 15 of preceding IVF cycle:

Uterus: fibroid

Ovaries: size, PCO, ovarian cyst

Tubes: hydrosalpinx

Page 76: Ultrasonography and  infertility: Aboubakr Elnashar

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

Page 77: Ultrasonography and  infertility: Aboubakr Elnashar

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:

Page 78: Ultrasonography and  infertility: Aboubakr Elnashar

4. Embryo transfer:

Page 79: Ultrasonography and  infertility: Aboubakr Elnashar
Page 80: Ultrasonography and  infertility: Aboubakr Elnashar

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.

Page 81: Ultrasonography and  infertility: Aboubakr Elnashar

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.

Page 82: Ultrasonography and  infertility: Aboubakr Elnashar

III. Aspiration of 1. Ovarian Cyst.

Residual cyst > 3 cm may affect ovarian response in

the subsequent cycles .

2. Hydrosalpinx

Page 83: Ultrasonography and  infertility: Aboubakr Elnashar
Page 84: Ultrasonography and  infertility: Aboubakr Elnashar

I. OHSS

II. Complications of oocyte retrieval

III. Complications of early pregnancy

Page 85: Ultrasonography and  infertility: Aboubakr Elnashar

I. OHSS

a. Diagnosis

b. Treatment:

paracentesis under TVS

Page 86: Ultrasonography and  infertility: Aboubakr Elnashar

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)

Page 87: Ultrasonography and  infertility: Aboubakr Elnashar

Critical Severe Moderate Mild

•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 pt Out pt,

In pt: unable to

control pain, N

with oral tt,

Difficulties in

monitoring

Out pt TT

Mathur, 2oo5

Page 88: Ultrasonography and  infertility: Aboubakr Elnashar

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.

Page 89: Ultrasonography and  infertility: Aboubakr Elnashar
Page 90: Ultrasonography and  infertility: Aboubakr Elnashar

II. Complications of oocyte retrieval

Intra-abdominal bleeding

Pelvic infection or abscess formation

Page 91: Ultrasonography and  infertility: Aboubakr Elnashar

III. Complications of early pregnancy

more common

a. Ectopic

b.Miscarriage

c. Multiple pregnancy:

Diagnosis & treatment (selective fetal reduction)

Page 92: Ultrasonography and  infertility: Aboubakr Elnashar

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

Page 93: Ultrasonography and  infertility: Aboubakr Elnashar

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%

Page 94: Ultrasonography and  infertility: Aboubakr Elnashar

2. Cystic mass:

3. Ring:

(Bagel sign) hyperechoic ring around the gestational

sac

4.Sac & embryo.

Ipsilateral side: Corpus luteum: 85% of cases

Page 95: Ultrasonography and  infertility: Aboubakr Elnashar

C. D. pouch:

Fluid with or without blood clots

Page 96: Ultrasonography and  infertility: Aboubakr Elnashar
Page 97: Ultrasonography and  infertility: Aboubakr Elnashar

loop

Non cystic mass

D pouch

Page 98: Ultrasonography and  infertility: Aboubakr Elnashar

Cystic mass

Page 99: Ultrasonography and  infertility: Aboubakr Elnashar

Ring

Page 100: Ultrasonography and  infertility: Aboubakr Elnashar

Sac & embryo

Page 101: Ultrasonography and  infertility: Aboubakr Elnashar

Multiple pregnancy

Page 102: Ultrasonography and  infertility: Aboubakr Elnashar

Thank you

Aboubakr Elnashar