role of us in evaluation of infertility dr. muhammad bin zulfiqar

Dr. Muhammad Bin ZulfiqarPGR IV FCPS Services Institute of Medical Sciences / [email protected]

Role of US in evaluation of infertility

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AIMSTo look for exact cause of infertilityUterine OvarianTubal

Infertility.Infertility is defined as failure to conceive a desired pregnancy after 24 months of unprotected sexual intercourse.Approximate 10% of couple are infertile.Male and female are equally affected. Primary infertility is infertility in a couple who have never had a child. Secondary infertility is failure to conceive following a previous pregnancy. Infertility may be caused by infection in the man or woman, but often there is no obvious underlying cause.

Causes of infertilityUterine causes:Congenital anomalies Infections Uterine synechiae Focal lesions Intra-uterine scar Cervical stenosis Reduced uterine perfusion Alteration of the endometrium thickness and vascularity.

Causes of infertilityOvarian causes: Follicular and ovulation abnormalitiesStromal vascularityEndometriosis.Tubal causes: InfectionObstruction.

Causes of infertilityHormonal Problems : These are the most common causes of anovulation. The process of ovulation depends upon a complex balance of hormones and their interactions to be successful, and any disruption in this process can hinder ovulation.

Imaging ModalitiesConventional approachHysterosalpingographySonohysterographyPelvic USAbdominalTVSMRI

Our focus is Ultrasound Imaging

Diagnostic armamentarium and its roleUSG ( TVS, TAS) : it is the first line investigation and can be coupled with color Doppler and 3D/4D scan USG helps in determining morphology perfusion ,thickness ,volume, vascularity . It detects pathological lesions , tubal lesions abnormalities of follicular maturation and ovulation . Tubal patency can be confirmed by sonosalphingography.

2-D & 3-D Ultrasound3D ultrasound is a useful complement to 2D ultrasound particularly in the diagnosis of uterine malformations. In suspicion of Mullerian duct anomalies, 3D ultrasound be carried out.MRI can be performed for the assessment of the cervix and vagina. Behr et al. Imaging of Mllerian Duct Anomalies. RadioGraphics 2012; 32:E233E250 Bermejo et al. Three-dimensional ultrasound in the diagnosis of Mullerian duct anomalies and concordance with magnetic resonance imaging. Ultrasound Obstet Gynecol 2010; 35: 593601.

Sonohysterographyused to evaluate uterine pathology because of its excellent diagnostic accuracy, minimal patient discomfort, low cost, and widespread availability. With the addition of transvaginal sonography, colour Doppler imaging, and sonohysterography, ultrasound has become a sensitive technique for detecting endometrial and myometrial pathology e.g. uterine synechiae, endometrial polyps, submucosal leiomyomas.It helps in checking tubal patency.

Uterine Assessment

DIAGNOSTIC USE OF ULTRASONOGRAPHY IN INFERTILITY INVESTIGATIONS: THE UTERUS

Congenital anomalies Infections Uterine synechiae Focal lesions Intra-uterine scar Cervical stenosis Reduced uterine perfusion Alteration of the endometrium thickness and vascularity.

Fig. 8.3 The three orthogonal planes sagittal, transverse, and coronal planes as well as the rendered image. The coronal image also portrays the hypoechoic junctional zone of the myometrium

Behr et al. Imaging of Mllerian Duct Anomalies. RadioGraphics 2012; 32:E233E250 Bermejo et al. Three-dimensional ultrasound in the diagnosis of Mullerian duct anomalies and concordance with magnetic resonance imaging. Ultrasound Obstet Gynecol 2010; 35: 593601.

A B CEndometrium: spectrum of appearances. Transvaginal scans. A, Normal, thin, early-proliferative endometrium. B, Normal, late-proliferative endometrium with triple-layer appearance. Central echogenic line is caused by opposed endometrial surfaces surrounded by a thicker hypoechoic functional layer, bounded by an outer echogenic basal layer. C, Normal, early-secretory phase endometrium. The functional layer surrounding the echogenic line has become hyperechoic

Carol M. Rumack, MD, FACR. DIAGNOSTIC ULTRASOUND (FOURTH EDITION 2011 by Mosby, Inc., an affiliate of Elsevier Inc.)Continued

F D E Endometrium: spectrum of appearances. D, Normal, thick, hyperechoic late-secretory endometrium. E, Normal, thin, postmenopausal endometrium. F, Oval, well-defined polyp that is more hyperechoic than surrounding periovulatory endometrium

Carol M. Rumack, MD, FACR. DIAGNOSTIC ULTRASOUND (FOURTH EDITION 2011 by Mosby, Inc., an affiliate of Elsevier Inc.)Continued

G H IEndometrium: spectrum of appearances. G, Thickened endometrium caused by multiple small polyps confirmed on sonohysterogram. H, Thick, cystic endometrium caused by hyperplasia in patient taking tamoxifen. I, Thick, cystic endometrium caused by large polyp in patient receiving tamoxifen.

Carol M. Rumack, MD, FACR. DIAGNOSTIC ULTRASOUND (FOURTH EDITION 2011 by Mosby, Inc., an affiliate of Elsevier Inc.)

Uterine Anomalies

Bermejo et al. Three-dimensional ultrasound in the diagnosis of Mullerian duct anomalies and concordance with magnetic resonance imaging. Ultrasound Obstet Gynecol 2010; 35: 593601.

Congenital uterine abnormalitiesUnicornuate uterus


Congenital uterine abnormalitiesArcuate uterus


Congenital uterine abnormalitiesSubseptate uterus


Congenital uterine abnormalitiesseptate uterus with two cervices


Figure 6 To distinguish bicornuate uteri from septate uteri with three-dimensional ultrasound we used the formula proposed by Troiano and McCarthy15: a line was traced joining both horns of the uterine cavity. If this line crossed the fundus or was 5 mm from it, the uterus was considered bicornuate (a and b); if it was >5 mm from the fundus it was considered septate, regardless of whether the fundus was dome-shaped (c), smooth or discretely notched.


Congenital uterine abnormalitiesDidelphic uterus


Congenital uterine abnormalitiesseptate complete bicornuate uterus


Congenital uterine abnormalitiesPartial bicornuate uterus


septate uterus with pregnancy on right side


FIGURE 15-21. Endometritis: varying appearance in two patients. Transabdominal sagittal scans. A, Fluid-fluid level (arrow) within endometrial canal in patient with pelvic inflammatory disease; B, bladder. This resolved after antibiotic therapy. B, Multiple linear hyper echogenic foci with shadowing caused by gas are seen within a distended endometrial canal in a febrile postpartum patient.


Fibroids (leiomyomata)

May interfere with implantationS.M.Kelly et al. investigation of infertile coupleA one stop ultrasound based approach. Human reproduction vol.16, No 12 pp2481-2484, 2001

Fig. 21. Intramural leiomyomata are frequently visualized. Examples of fibroids which compromise the contours of the endometrial cavity are shown (AD). Refraction artifacts resulting from tissue density interfaces and the texture of the fibroids often aid in their identification.

Chizen, D, Pierson, R,Glob. libr. women's med., (ISSN: 1756-2228)2010; DOI 10.3843/GLOWM.10326S.M.Kelly et al. investigation of infertile coupleA one stop ultrasound based approach. Human reproduction vol.16, No 12 pp2481-2484, 2001 C.K. Chen, H.M. Wu, Y.K. Soong. Clinical Application of Ultrasound in Infertility: From Two-dimensional to Three-dimensional J Med Ultrasound 2007;15(2):126133

Adenomyosis

Heterotopic endometrial glands and stroma: Small echogenic islands Smooth muscle hyperplasia. Areas of decreased echogenicity

AdenomyosisFeaturesMyometrium: Heterogeneous echotexture Echogenicity: decreased relative to that of the dorsal myometrium Myometrial cyst (curved arrow) Asymmetrical uterine enlargement Endometrium: eccentric endometrial cavity indistinct endometrial-myometrial border

AdenomyosisDiagnostic criteriaBromley et al (2000) 2 or more of the followings: Mottled heterogeneous myometrial texture: All cases. Globular uterus: 95% of cases. Small myometrial lucent areas: 82%. Shaggy indistinct endometrial strips: 82%. The most predictive: ill-defined heterogeneous echotexture within the myometrium (Brosen et al, 2004)

A B CAdenomyosis on transvaginal scans: spectrum of appearances. A, Subendometrial cyst (arrowhead, endometrium). B, Cysts and heterogeneity in anterior myometrium with poorly defined anterior endometrial border (arrowhead). C, Myometrial heterogeneity with poorly defined endometrial borders (arrowheads). Continued


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C D EAdenomyosis on transvaginal scans: spectrum of appearances. D, Multiple subendometrial cysts and echogenic nodules (arrow). E, Diffuse heterogeneous myometrium with multiple cysts and poorly defined endometrial borders (cursors). F, Large area of myometrial heterogeneity producing a focal mass effect and displacing endometrium (arrowhead). This may mimic a fibroid.

THE EVALUATION OF THE UTERINE CAVITY By using hysterosalpingosonography we can confidently detect endometrial and myometrial pathology e.g. uterine synechiae, endometrial polyps, submucosal leiomyomas.

Chizen, D, Pierson, R,Glob. libr. women's med., (ISSN: 1756-2228)2010; DOI 10.3843/GLOWM.10326S.M.Kelly et al. investigation of infertile coupleA one stop ultrasound based approach. Human reproduction vol.16, No 12 pp2481-2484, 2001 C.K. Chen, H.M. Wu, Y.K. Soong. Clinical Application of Ultrasound in Infertility: From Two-dimensional to Three-dimensional J Med Ultrasound 2007;15(2):126133

Fig. 22. Midsagittal image of the uterus with a hysterosalpingosonography catheter demonstrating correct placement of the balloon cuff. Instillation of saline has been initiated and the tip of the catheter is observed in the fluid to the left of the cuff.

Chizen, D, Pierson, R,Glob. libr. women's med., (ISSN: 1756-2228)2010; DOI 10.3843/GLOWM.10326

Fig. 23. Midsagittal (A) and transverse (B) images of a normal uterine cavity following instillation of saline. The fluid-endometrium interface is smooth and symmetrical.

Fig. 26. Transverse image of a bicornuate uterus taken during sonoHSG. The nature of the uterine cavity is revealed by the instillation of saline.

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.

Fig. 25. Images of endometrial polyps and adhesions recorded during hysterosalpingosonography (AD). sonoHSG is very helpful in identifying small and large lesions that are difficult to appreciate on unenhanced ultrasonography.

Fig. 11.1 Endometrial polyps. A single polyp located in a lateral wall at midcorpus, shown in two dimensional transvaginal ultrasonographic view ( a ) and in 3D imaging ( b ). Multiple polyps and submucosal fi broids (by Pathology) shown by 2D US ( c ) and by 3D US ( d )

Endometrial Polyp

Ovarian Assessment

Ovarian AssessmentPreovulatory follicleAtretic follicleSequences of follicular maturationCorpus hemorrhagicumCorpus albicans

Imaging plays a key role in the diagnostic evaluation of women forinfertility. The pelvic causes of female infertility are varied and rangefrom tubal and peritubal abnormalities to uterine, cervical, and ovariandisorders. In most cases, the imaging work-up begins with hysterosalpingography to evaluate fallopian tube patency. Uterine fillingdefects and contour abnormalities may be discovered at hysterosalpingography but typically require further characterization with hysterographic or pelvic ultrasonography (US) or pelvic magnetic resonance (MR) imaging. Hysterographic US helps differentiate among uterine synechiae, endometrial polyps, and submucosal leiomyomas.Pelvic US and MR imaging help further differentiate among uterineleiomyomas, adenomyosis, and the various mllerian duct anomalies,with MR imaging being the most sensitive modality for detecting endometriosis. The presence of cervical disease may be inferred initiallyon the basis of difficulty or failure of cervical cannulation at hysterosalpingography. Ovarian abnormalities are usually detected at US. The appropriate selection of imaging modalities and accurate characterization of the various pelvic causes of infertility are essential because the imaging findings help direct subsequent patient care.

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PREOVULATORY FOLLICLESFig. 1. Normal ovary during a natural menstrual cycle demonstrating normal follicle population and distribution on day 12 postmenstruation. A dominant follicle is visualized in the central portion of the image and several subordinate follicles from the wave (25 mm) are observed in the left lateral aspect of the ovary.

Fig. 2. Atretic follicle of preovulatory diameter. Note the 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.

Fig. 3. Color flow Doppler image demonstrating perifollicular vascularity around a preovulatory follicle. Visualization of the complete paths of vascular flow around large follicles is challenging owing to the tortuous path of the vascular supply to the dominant follicle.

Sequence of images (AI) recorded during ovulationin situ. The images in the sequence were taken to represent the times at which 90%, 80%, 70%, and so on of the follicle fluid was extruded from the follicle. Time code markers are displayed in the lower left portion of the images.

Power flow Doppler image of a mature, mid-cycle luteal gland demonstrating marked periluteal vascular flow.

Power (A) and color (B) flow Doppler images of recently ovulated follicles/new luteal glands on the day of ovulation.

Corpus hemorrhagicum demonstrating thick walls of peripheral luteal tissue and a central hemorrhagic clot with an interspersed fibrin network.

Corpus albicans resulting from regression of a luteal structure from a previous cycle. Corpus albicans are typically visualized as hyperechoic structures within the ovary and they may occasionally appear to be more pronounced owing to the presence of surrounding follicles.

Ovulation failure

Images from a woman who developed hemorrhagic anovulatory follicles during a study of natural cycle folliculogenesis and ovulation (A, B). There is evidence of extravasated blood in the lumen of the structures and the walls are thin did not develop any visual evidence of luteinization. Progesterone levels were below those accepted as clinically normal.

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 are observed and small flecks of particulate matter are frequently seen in the lumen or aggregated at the side of the structure.

Image of a 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.

BENIGN OVARIAN NEOPLASIADermoid CystEndometrioma

Images of a small intraovarian dermoid cyst (A, B). The cyst is completely embedded in the ovary and is surrounded by focal areas of hyperechoicity. Small follicles are observed in the surrounding stroma. Folliculogenesis and ovulation were impaired in this ovary. The contralateral ovary demonstrated compensatory hypertrophy.

EndometriosisOvary m/c secondaily involves other pelvic structures . Usg shows a typical endometrioma locate in the ovary cystic lesion with low level internal echoes ( chocolate cyst of ovary) The tubes may be involved in form of hematosalphinx or with peritubal adhesions, a posteriorly displaced uterus , kissing ovaries ,angulated small bowel loops , elevated posterior vaginal fornices , multilocuilated fluid collections are indirect indicator of pelvic adhesions

EndometriosisEndometriosis is found in 25%50% of infertile women, and 30%50% of women with endometriosis are infertile Laparoscopy is the mainstay for diagnosis

Images of ovarian endometrioma (A, B). The structure is hypoechoic and exhibits low amplitude uniformly distributed echotexture in the cavities of the cysts.

A B CEndometriosis: spectrum of appearances. Transvaginal scans. A to D, Uniform low-level echoes within a cystic ovarian mass. A, Typical peripheral echogenic foci. B, Fluid-fluid level. C, Avascular marginal echogenic nodules. Continued

D E FEndometriosis: spectrum of appearances. Transvaginal scans. D, Bilateral disease. E, Endometriotic plaque on posterior surface of uterus (arrows). F, Filling the pouch of Douglas (arrows). U, Uterus.

Premature Ovarian FailureFig. 14. Image from a woman in premature ovarian failure. Only the stroma of the ovary is identified. A very few follicles of less than 1 mm diameter can be observed on the inferior aspect of the ovary.

Polycystic Ovarian SyndromeCharacterised by combination of multiple clinical manifestations ( hirsutism, anovultory cycle and infertility) hormonal imbalance

Polycystic Ovarian SyndromeThe diagnosis of polycystic ovarian syndrome is based on hormone imbalance and laboratory findingsUSG rounded ovaries , normal or increased volume . Multiple subcentrimetric follicles ( 15) with no dominant follicle ( string of pearl appearance ) . Thickened walll and echogenic and Vascular stroma)

Images from women with differing expressions of the four major subtypes of the metabolic syndrome associated with polycystic ovary syndrome (AD). The images exhibit quite differing ultra sonographic appearances in the size and distribution of follicles within PCOS ovaries. A recent corpus luteum is clearly visible in the ovary in panel (D).

An image of an oviduct visualized from the uterine cornu to the fimbria. The ampulla, infundibulum and very fine interfaces representing the fimbria may be appreciated on the superior aspects of the ovaries.

The fimbria of the oviduct are clearly visualized in free fluid surrounding the ovary following ovulation or hysterosalpinography.

Transvaginal ultrasound image of a woman with 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.

Ultrasound guidedoocyte retrieval. The oocyte collection needle is visualized entering into a large follicle. Etching around the tip of the needle enhances its visualization. The image is presented in the standard medical imaging orientation. (Image courtesy of Dr Roger Stronell.)

A B CHemorrhagic cysts on transvaginal scans: spectrum of appearances. A, Acute hyperechoic hemorrhagic cyst. B, Acute hemorrhagic cyst mimicking a solid lesion. C, Color Doppler ultrasound shows peripheral ring of vascularity (ring of fire), typical of a corpus luteum, but no vascularity within the cyst Continued

D E FHemorrhagic cysts on transvaginal scans: spectrum of appearances. . D, Large cyst containing multiple internal low-level echoes. E, Reticular pattern of internal echoes and septations within cyst. F, Reticular pattern. Continued

G H IHemorrhagic cysts on transvaginal scans: G, H, and I, Variations in clot retraction. The clot in I suggests a solid mass. Lack of color Doppler ultrasound signal supports its benign nature.

Tubal Assessment

Anatomy and Physiology of Fallopian TubesThe fallopian tubes connect the peritoneal cavity to the extra peritoneal world Conduction of sperm from the uterine end toward the ampulla, conduction of ova in the other direction from the fimbriated end to the ampulla, and support as well as conduction of the early embryo from the ampulla into the uterus for implantationChizen, D, Pierson, R,Glob. libr. women's med., (ISSN: 1756-2228)2010; DOI 10.3843/GLOWM.10326S.M.Kelly et al. investigation of infertile coupleA one stop ultrasound based approach. Human reproduction vol.16, No 12 pp2481-2484, 2001 C.K. Chen, H.M. Wu, Y.K. Soong. Clinical Application of Ultrasound in Infertility: From Two-dimensional to Three-dimensional J Med Ultrasound 2007;15(2):126133

Fallopian Tubes

length from 716 cm (average, 12 cm1-2cm

2-3cm

5-8cm

trumpet-shaped

The fallopian tubes have three segments that are visible at hysterosalpingography: the interstitial portion, which traverses the myometrium; the isthmic portion, which courses within the broad ligament; and the ampullary portion, which is adjacent to the ovary

Tubal diseaseDestruction or obstruction and peritubal adhesionsHsg is useful for assessing tubal patency. Mri is superior to usg in assessing tubal diseaseDilated tube appear as fluid filled tortuous sausage shaped masses adjacent to the uterus with incomplete septae appearing as hyperechoic mural nodules ( beads of string sign) and short linear projections ( cogwheel appearance) the presence of partially effaced longitudinal folds inside the masses is specific for fallopian tubes on MRI. The presence of a normally appearing ipsilateral ovary is a clue to the presence of tubal masses

Sonographic Tubal AssessmentNormal tubes not visibleHydro salpinges can be clearly delineatedHystero-contrastsonography (HyCoSy) provide similar information regarding tubal patency and uterine cavity when compared to HSG

Free fluid collection in the cul-de-sac following successful demonstration of oviductal patency. Oviductal fimbria are clearly observed in the collected fluid.

( a ) Waist sign of a hydrosalpinx, marked by the asterisks , as seen with 2-D ultrasound. ( b ) Beads on a string sign of a hydrosalpinx demonstrated by 2-D ultrasound

Images of hydrosalpinx (A, B). Hydrosalpinx is usually easily diagnosed as well-constrained fluid accumulation in the adnexae. In some cases, adhesions between the oviduct and ovary may be visualized.

TAKE HOME MESSAGEUS (Abdominal, TVS and Doppler US) is an excellent imaging modality to diagnose cause of infertility.It is equally effective in suggesting infertility management when compared with HSG and MRI.

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role of us in evaluation of infertility dr. muhammad bin zulfiqar

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