role of ultrasound in the current

management scenario of the

infertile
patient
DR BHARTI GAHTORI
MBBS MD ( MAMC DELHI)
SPECIAL INTEREST IN HIGHRISK OBSTETRICS , ADVANCE 3D-4D
FETAL ULTRASOUND, FETAL ECHO AND 3D INFERTILITY
ULTRASOUND
 What is the preferred route
TRANSVAGINAL(RECTA
TRANSABDOMINAL L)

 • Low frequency
Vaginal ultrasound is dynamic and
High frequency
interactive
 • Poor resolution
examination  • Superb resolution
 • Good overview
• Check the mobility of organs • Poor overview
 • Scan the abdomen
– fixed organs = adhesions
 • Full bladder  • Abdomen not seen
• Check for site specific tenderness
 Explains organ
– which organs are involved in a• Empty
painfulbladder
process?
interrelationship better
 KEYPOINTS
 What is the correct scanning technique to image the
 cervix, uterus and ovaries effectively?

 What are the principal ultrasound features of:

 – the normal cervix
 – the normal uterus with endometrium -
orientation,deviation ,dimensions etc
 – the normal ovary/adnexae
The fIVE broad areas where ultrasound is used include:

 Ovulation Monitoring and assessment of reserve

 Assessment of endometrial growth with cycle
 Diagnosis of uterine, ovarian and other adnexal factors in the
infertile patient
 Prediction of outcomes in assisted reproduction technology
(ART) Cycles and
 Interventional Procedures
 PILOT SCAN

• During the first visit of the patient, a­Pilot scan is done.

This is done to exclude abnormalities of uterus, ovaries
and tubes.
• TVS combined with Doppler is the investigation of
choice for diagnosis of Mullerian anomalies and
acquired uterine abnormalities like fibroids,
adenomyosis, polyps, synechiae, etc.
• This scan is also done for abnormalities like ovarian
cyst, hemor­rhagic cyst, chocolate cyst,dermoid and also
hydrosalpinx.
 BASELINE SCAN
WHEN – DAY 2-3 of menstrual
cycle
WHY AT THIS TIME : At this time
of the cycle, estrogen and
progesterone are both at low levels.
Hence the ovaries have no active
follicle, endometrium is thin like a
single line as it has shed off during
menstruation. BEST TIME TO
OBTAIN LH/FSH VALUES
 To determine ovarian reserve—by counting the
antral follicles. (Antral follicle count).
 To determine adequate shedding of
endometrial lining on Day 2
 Assess pelvic pathology if any affecting the OI
or ART results
 To assess uterine cavity configuration if not
done earlier – IUI/ET
 To exclude residual follicle >10mm or cystic
areas prior to ART cycle
 To predict response to stimulation—normal
responder/hyper- responder/poor responder.
 Assessment of adequacy of downregulation
after GnRH agonist treatment.
NORMAL UTERUS WITH ENDOMETRIUM
UTERINE DIMENSIONS
CERVIX
NORMAL OVARIES
 NORMAL CUL DE SAC FLUID

ANTERIOR CUL DE SAC POSTERIOR CUL DE SAC

 DAY 3 OVARIAN RESERVE
ASSESSMENT ( AFC)
 12 / more immature follicles
( 2 -8mm)
 AFC Less than 5 –Poor responder
 AFC >20 - PCOD
 Total number of antral follicles
achieved the best predictive value for
favourable IVF outcome, followed by
Ovarian stromal FI, total ovarian
stromal area & total ovarian volume .
Kupesic S et al, Hum Reprod 2002;
17(4):950-55
POLYCYSTIC OVARIAN DISEASE
FOLLOW UP SCANS
 To monitor the response of
stimulation by assessing the
follicle growth and endometrium
thickness. (day 9-14). Follicles
grows at the rate of 1-2mm per
day
 Color Doppler identifies the
functional status of ovaries and
endometrium and thereby helps
in decision making for timing of
(hCG).
 Day 7 scan is done sometimes to
confirm selection of dominant
follicle
APPLEBAUM SCORING-
TO ASSESS ENDOMETRIAL
BLOOD FLOW & RECEPTIVITY

Zone 1 - Myometrium surrounding

the endometrium.
Zone 2 – Hyperechoic endometrial
edge
Zone 3- Internal endometrial
hypoechoic zone.
Zone 4 - Endometrial cavity
 POSITIVE FINDINGS IN UTERINE ASSESSMENT
 These included 7 parameters:
 1. Endometrial thickness in greatest AP dimension of 7 mm or greater (full-
thickness measurement)
 2. A layered (“5 line") appearance of the endometrium
 3. Blood flow within Zone 3 using color Doppler technique
 4. Myometrial contractions causing a wave like motion of the endometrium
 5. Uterine artery blood flow, as measured by PI, less than 3.0
 6. Homogeneous myometrial echogenicity
 7. Myometrial blood flow seen on gray-scale examination (internal to the
arcuate vessels)
 Prediction of ovulation
Dominant Follicle > 14mm
• Grows 2-3 mm/day.
• Ovulation 18-24 mm.
• Sonolucent halo 24 hours prior to
ovulation.
• Cumulus like shadow.
Ovulation 16-24 mm.
In the hands of experienced
• Vascularity - 3/4th of the follicle
operators, ultrasound alone suffices • On the day of HCG – If cumulus like echoes is
for cycle monitoring, with no not seen in all three planes in the follicle , it is
necessity for additional hormonal less likely to be mature fertilizable oocyte.
estimations.
HYDROSALPINX
-Fusiform cystic lesion
 Cog wheel sign
 Incomplete septae
 Cyst wall thicker than 5mm
in almost all acute
inflammations and approx 3
% of chronic lesions
 3D ULTRASOUND
 One of the main advantages of 3D imaging of the uterus, on
the other hand, is the capacity to reconstruct the coronal plane.
 3D ultrasound involves the acquisition of a series of 2D images
that can then be displayed collectively in a variety of imaging
modalities.
 3D ultrasound scanning consists of four basic steps:data
acquisition, volume analysis and processing, image animation
and archiving of volumes.
 CORONAL PLANE IMAGING IN 3D ULTRASOUND

 This format has been found to be useful for:

- Evaluation of uterine shape abnormalities (e.g Mullerian
duct abnormalities) in conjunction with SIS
 - Problem-solving for uterine fibroids (particularily %
submucosal component) and fibroid mapping
 - Endometrial polyps
 - Intrauterine adhesions( synechie)
 - Adenomyosis ( Junctional zone)
3 DIMENTIONAL ULTRASOUND IN INFERTILITY

MULTIPLANAR RENDER MODE

 CONGENITAL
UTERINE
ANOMALIES
• 3D ultrasound has contributed
the most and has become the
investigation of choice
• Ability to show both internal
uterine cavity and external
uterine contour in CORONAL
SECTION
• Accurate, noninvasive,
outpatient diagnosis of
congenital uterine anomalies.
 FIBROID
• 3D ultrasound has recently been used
to map the exact location of fibroids in
relation to the endometrial cavity and
surrounding structures.
• This is extremely important in triaging
patients for surgery and
• Potentially useful in monitoring the
reduction in the size of fibroids in
patients receiving gonadotrophin-
releasing hormone analogs or
following uterine artery embolization.
 ADENOMYOSIS
• The most specific 2D feature for the
diagnosis of adenomyosis was presence
of myometrial cysts (98% specificity;
78% accuracy), along with heterogeneous
myometrium
• -On 3D TVS , the best markers were JZ
difference ≥4 mm and JZ infiltration and
distortion (both 88% sensitivity; 85%
and 82% accuracy, respectively)
• - The JZ may be regular, irregular,
interrupted, not visible,not assessable on
CORONAL VIEW
 UTERINE SYNECHIAE
-With SIS ,2D ultrasound may present a
diagnostic clue of adhesions through the
presence of bands seen within the
endometrial echo.
-However, 3D imaging well delineates the
true narrowing or “bands” adherent
across the cavity
-3D ultrasound has better sensitivity and
predicted adhesions and cavity damage
with greater accuracy than HSG in
patients with suspected Asherman’s
syndrome. (Knop man et al)
ENDOMETRIAL POLYP
 SONO AVC
• SONO AVC is a 3D software with
automated calculation the no. of
follicles in individual ovaries and
gives good count assessment.
• Very useful for antral follicle count
assessment in IVF protocols.
• For diagnosis of PCOS and early
prediction of ovarian hyperstimulation
when 3D doppler is employed
alongside
 COLOR DOPPLER IN INFERTILITY
• Doppler ultrasonography can be utilized
to assess the endometrial receptivity by
determination of endometrial and
subendometrial blood flow which affects
embryo transfer and implantation
• 3D US vascularization gives schematical
information about all vessels and
additionally quantifying blood flow in
the selected volume.
• 3D vascular indices can be measured:
vascular index (VI), flow index (FI), and
VFI (vascular flow index).
 3d Power doppler and volume
POWER DOPPLER FOR
ENDOMETRIAL RECEPTIVITY 3D VASCULARIZATION INDICES
PREDICTING OHSS
ADNEXAL MASSES ON 3D