ultrasound in infertility

1. 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

2. What is the preferred route
TRANSABDOMINAL
• Low frequency
• Poor resolution
• Good overview
• Scan the abdomen
• Full bladder
 Explains organ
interrelationship better
TRANSVAGINAL(RECTA
L)
 High frequency
• Superb resolution
• Poor overview
• Abdomen not seen
• Empty bladder
Vaginal ultrasound is dynamic and interactive
examination
• Check the mobility of organs
– fixed organs = adhesions
• Check for site specific tenderness
– which organs are involved in a painful process?

3. 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 appearance of the normal endometrium and ovary
varies significantly throughout the menstrual cycle in women
of reproductive age.
-It is important to be aware of the expected changes
in order to avoid misinterpreting physiologic changes as
pathologic.

4. 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

5. PILOT SCAN
• During the first visit of the patient, a Pilot 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.

6. BASELINE SCAN
 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.
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

7. NORMAL UTERUS WITH
ENDOMETRIUM

8. UTERINE DIMENSIONS

9. CERVIX

10. NORMAL OVARIES

11. NORMAL CUL DE SAC FLUID
ANTERIOR CUL DE SAC POSTERIOR CUL DE SAC

12. 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

13. 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

14. 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

15. 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)

16. 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.
In the hands of experienced
operators, ultrasound alone
suffices for cycle monitoring,
with no necessity for additional
hormonal estimations.
Ovulation 16-24 mm.
• Vascularity - 3/4th of the follicle
• 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.

17. 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

18. 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.

19. 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)

20. 3 DIMENTIONAL ULTRASOUND IN INFERTILITY
MULTIPLANAR RENDER MODE

21. 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.

22. 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.

23. 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

24. 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)

25. ENDOMETRIAL POLYP

26. 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

27. 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).

28. 3d Power doppler and volume
POWER DOPPLER FOR
ENDOMETRIAL RECEPTIVITY 3D VASCULARIZATION INDICES

29. PREDICTING OHSS

30. ADNEXAL MASSES ON 3D