Ultrasound and infertility

Dr. Mohamed Hesham Anwar Prof. Obstetrics & Gynecology AL AZHAR UNIVERSITY

THE ROLE OF ULTRASOUND IN THE INVESTIGATION OF SUBFERTILITY

Transvaginal ultrasound (TVS) is the method of choice for assessing the female reproductive organs.

The pivotal ultrasound

(performed between days 8 to 12 of the menstrual cycle)
* Uterus and uterine cavity dimensions : anomalies/tumors Endometrium thickness appearance hydrosonography (if indicated) Uterine artery blood flow parameters PSV (peak systolic velocity) : PI (pulsatility index) * Ovarian morphology normal/polycystic/multicystic position/mobility volume/antral follicle count Follicular size Ovarian stromal and perifollicular blood PSV : flow parameters PI * Tubal patency hysterosalpingo contrast sonography : (HyCoSy) * Pelvis presence or absence of free fluid/masses within pelvis

Uterine assessment
An understanding of the normal morphology and general dimensions of the uterus is important. The dimensions and appearance of the uterus should be recorded in both the longitudinal or sagittal plane and at 90 rotation in the coronal plane.

FIBROIDS
Transvaginal sonography is an excellent method of demonstrating uterine pathology. Leiomyomata (fibroids) are a common finding in women during the reproductive years. They can be subserosal, intramural, submucosal or pedunculated . The presence of submucosal fibroids in particular is thought to interfere with embryo implantation. In addition, there is also an association with fibroids elsewhere in the myometrium and reduced fertility. The exact mechanism is unknown but might be related to an overall poor intrauterine environment impairing implantation.

Adenomyosis
Adenomyosis is a condition characterized by the presence of ectopic endometrium within the myometrium itself. Ultrasound features of adenomyosis can be subtle and are often best appreciated with real-time high resolution scanning rather than hard-copy images . Recognized features include:
Uterine enlargement without the presence of fibroids, often with an asymmetrical thickening of the anterior and posterior myometrium. The myometrium itself might have a heterogeneous appearance because of the presence of multiple small areas of ectopic endometrial tissue. More specific features might include myometrial nodules or cysts, possibly with discrete hemorrhagic foci.

Although somewhat controversial, it does appear to be more prevalent in women with subfertility.

Endometrial assessment
There are definitive changes of the endometrium throughout the menstrual cycle. Early in the menstrual cycle the endometrium is thin and is hypoechoic compared with the surrounding myometrium. As the follicular phase progresses, the endometrium thickens and takes on a characteristic trilaminar appearance . Following ovulation the endometrium becomes more heterogeneous with a hyperechoic appearance compared to the surrounding myometrium

Longitudinal (sagittal) and coronal views of a normal uterus. 1, Longitudinal diameter; 2, transverse diameter; 3, endometrial thickness; + + transverse diameter.

Longitudinal view of uterus demonstrating typical trilaminar appearance of proliferative phase endometrium.

Longitudinal view of the uterus demonstrating typical hyperechoic appearance of secretory phase endometrium. 1, Longitudinal diameter; 2, transverse diameter; 3, endometrial thickness.

INTRA-CAVITARY LESIONS
Lesions within the endometrium itself can also interfere with implantation. As well as the abovementioned submucous fibroids, endometrial polyps can also be responsible for failure of implantation. These polyps can be identified with careful transvaginal scanning as effectively as more invasive procedures such as hysteroscopy. Saline contrast hysterosonography (SCHS) can aid the diagnosis by further delineating the polyp.

Submucous fibroid projecting into the uterine cavity.

Saline contrast hysterosonography demonstrating the presence of an endometrial polyp.

Endometrial receptivity
Endometrial receptivity is a qualitative term used to describe a favorable situation with respect to implantation potential. The following factors are regarded as markers of endometrial receptivity:
minimum thickness of 7 mm trilaminar appearance uterine artery pulsatility index values (PI) < 3.0.

Uterine artery Doppler assessment.

The upper panel shows a waveform typical of normal vessel resistance. The lower panel demonstrates a waveform from a vessel with elevated resistance.

SUBENDOMETRIAL BLOOD FLOW

More recently, interest has focused on subendometrial blood flow. Using more conventional color Doppler it is possible to assess the degree of penetration of blood vessels into the endometrium. Absence of subendometrial vascularity correlates with a likelihood of failure of implantation.

Color Doppler interrogation of the uterus demonstrating subendometrial blood flow.

Ovarian assessment
Transvaginal ultrasound is an excellent method of assessing the ovaries. In general, one should assess the following parameters with respect to the ovaries: appearance dimensions [length (l), width (w), depth (d)] volume (l w d 0.5233) location/mobility/accessibility dominant follicle stromal/follicular Doppler blood-flow parameters.

Transvaginal scan demonstrating a normal ovary and its anatomical relationships with the uterus and internal iliac vessels.

Three-dimensional image of an ovary obtained with surface rendering software.

PCO vs MCO
Polycystic ovaries are defined according to the following criteria (Adams criteria): 10 or more cysts of between 2 and 8 mm arranged peripherally ovarian volume of > 8 cm3 (implying increased ovarian stroma). Multicystic ovaries are distinguished from polycystic ovaries in that the cysts are spread throughout the ovary rather than peripherally.

Typical appearance of a polycystic ovary demonstrating peripherally situated cysts and centrally increased ovarian stromal density.

Poor Ovarian Reserve

When the ovarian volume is less than 3 cm3 and there are fewer than five antral follicles, the ovarian reserve is said to be reduced. This would imply that there is a significantly reduced chance of responding to ovarian stimulation during fertility treatment. It appears that this might be a more specific test than conventional early menstrual FSH estimation.

 Doppler to assess follicular blood flow can help identify those that contain better quality oocytes with greater fertilization potential and resultantly higher embryo implantation potential. Apart from assessing intrinsic ovarian morphology and function, transvaginal ultrasound is also ideal for identifying ovarian pathology. Lesions such as functional or hemorrhagic cysts, endometriomata and dermoid cysts can generally be seen easily and, in most situations, a reasoned judgment can be made about the need for further treatment prior to embarking on fertility treatment. Simple or thin-walled cysts of less than 5 cm diameter are generally benign and usually resolve without any further treatment. Hemorrhagic cysts are commonly associated with bleeding into the corpus luteum and also generally resolve

A large endometrioma demonstrating the typical ground glass appearance.

Dermoid cysts
are benign tumours that result from totipotential cells found in the ovary. They can contain many different tissue types and have a variable appearance on ultrasound. They are often poorly defined and can easily be mistaken for bowel. Discrete echodense areas within the cyst resulting from a solid nodule of tissue, e.g. bone, characterize some dermoids.

A dermoid cyst with characteristic poorly defined ultrasonographic features.

Follicular assessment
Doppler to assess follicular blood flow can help identify those that contain better quality oocytes with greater fertilization potential and resultantly higher embryo implantation potential. Using color Doppler imaging, it is apparent that the PSV of blood flow surrounding the follicle is the best indicator of angiogenesis. A significant increase in PSV during the periovulatory period is also reported. It appears as though there is a relationship between follicular flow velocity and oocyte quality within a particular follicle. Presumably, follicles with good blood flow have a higher oxygen tension within the follicle, implying that the oocyte is less susceptible to hypoxia and damage.

Normal ovary showing the presence of a preovulatory dominant follicle. Note the position of the two calipers, placed at 90 to each other, to obtain the mean follicular diameter of 20 mm in this plane.

A hemorrhagic corpus luteum.

Color Doppler interrogation of an ovary demonstrating normal ovarian stromal blood flow.

Color Doppler interrogation of an ovary demonstrating follicular blood flow.

Fallopian Tube assessment

Under normal circumstances, the fallopian tubes are not visible with ultrasound imaging unless there is fluid within the pouch of Douglas (rectovaginal space). However, when the tubes are damaged by infection they can become enlarged and form fluid-filled hydrosalpinges ( the fluid within the tubal lumen provides a negative echo contrast).

A hydrosalpinx. Note the presence of low level echoes within the distended fallopian tube, together with incomplete septations.

Hysterosalpingo-contrast sonography (HyCoSy)

Sonographic visualization of the fallopian tubesis also possible. (HyCoSy) involves the instillation of a positive contrast agent, such as Echovist (Schering AG,Germany), into the uterine cavity during scanning. Flow of the contrast medium through the tubes and into the peritoneal cavity can be readily seen. This procedure can be performed as an adjunct to the pivotal scan. Using either pulsed or color Doppler, improved sensitivity for contrast flow can be obtained.

Three-dimensional color power Doppler HyCoSy demonstrating free peritoneal spill of contrast dye.

The same image as Fig. 6.19 following surface rendering of the three-dimensional image.

OHSS
In moderate to severe OHSS, ultrasonography will demonstrate enlarged ovaries, possibly with the presence of ascites. Transvaginal ultrasound can also play a useful role in draining ascitic fluid to provide symptom relief.

OVARIAN HYPERSTIMULATION

3D Multiplanar Reconstruction Ovarian Hyperstimulation, Ascites

3D Reconstruction, Uterus, Adnexa Ovarian Hyperstimulation, Ascites

The appearance of an ovary demonstrating multiple follicular development characteristic of ovarian hyperstimulation syndrome.

OVARIAN HYPERSTIMULATION

Ovary (Transvaginal) Ovarian Hyperstimulation

A stimulated ovary demonstrating multiple follicles with follicular blood flow during IVF treatment.

Oocyte collection. The needle, with its echogenic tip, can be visualized within one of the follicles, prior to aspiration of its follicular fluid and oocyte. The path of the needle guide is demonstrated .)+ + +(

A transabdominal scan demonstrating the position of the catheter within the uterine cavity prior to embryo transfer. Note the appearance of the hyperechoic, luteinized endometrium.

YOU WILL REMEMBER

A LITTLE OF WHAT YOU HEAR, SOME OF WHAT YOU READ, CONSIDERABLY MORE OF WHAT YOU SEE, BUT ALMOST ALL OF WHAT YOU UNDERSTAND.