ROLE OF USG IN INFERTILITY DR NABANEETA FEMELIFE

ROLE OF USG IN INFERTILITY DR NABANEETA FEMELIFE FERTILITY FOUNDATION www. femelife. com

UTERINE/ENDOMETRIAL FACTOR Endometrial thickness obtained by twodimensional sonography is considered the most important parameter of endometrial growth a very thin endometrium (below 7 mm) seems to be accepted as a reliable sign of suboptimal implantation potential Endometrial pattern is defined as the relative echogenicity of the endometrium and the adjacent myometrium as demonstrated on a longitudinal ultrasound scan.

• The endometrial pattern does not appear to be influenced by the type of ovarian stimulation and it is of prognostic value in both fresh IVF, as well as frozen embryo transfer cycles

Normal endometrial patternproliferative vs secretory

• volume of the endometrium using 3 D ultrasound may help to correlate cycle outcome with a quantitative parameter rather than endometrial thickness

UTERINE PERFUSION • In anovulatory cycles, a continuous increase of the uterine artery RI has been detected • in some infertile patients, an end-diastolic flow is absent • absent diastolic flow might be associated with infertility and poor reproductive performance.

MULLERIAN ANOMALIES Congenital uterine malformations are variable in frequency and are usually estimated to represent 3– 4% septate uterus- During the first trimester of pregnancy, the risk of spontaneous abortion in this group is between 28% and 45%, while during the second trimester the frequency of late spontaneous abortions is approximately 5%. Hysteroscopic treatment is currently proposed as the procedure of choice for the management of these disorders

3 D ultrasound for the diagnosis of the septate uterus

Complete septum

• contrast 3 D hysterosonography offers a more comprehensive overview of the uterine cavity and surrounding myometrium, and gives access to planes unobtainable by conventional 2 D ultrasound examination.

Bicornuate uterus

ENDOMETRIAL POLYP • Endometrial polyp is the anatomic defect that is implicated in the etiology of arecurrent pregnancy loss and infertility. • Polyps appear as diffuse or focal thickening ofthe endometrium

SUBMUCOUS LEIOMYOMAS • their significance depends on their size and location • Large intracavitary myomas, which distort the shape of the uterine cavity and interfere with the endometrium are usually removed hysteroscopically • Sonographic texture ranges from hypoechoic to echogenic, depending on the amount of smooth muscle and connective tissue

Submucos fibroid

• Color doppler demonstrates myometrial blood vessels at its periphery • A significant difference was shown in blood flow characteristics for leiomyoma supplying vessels between entirely subserosal versus intramural or submucosal myoma

ADENOMYOSIS • A diffusely enlarged uterus without discrete fibroids, an intact endometrium and multiple small cysts in the myometrium have been reported as a suggestive appearance of adenomyosis • Disordered echogenicity of the middle layer of the myometrium is present

indistinct junctional zone between the endometrium and the myometrium, inhomogeneity of the myometrium, a thick posterior myometrium, and myometrial cysts.

Swiss cheese appearance

ENDOMETRITIS • Chronic endometritis is characterized with increased echogenicity, thickness and vascularity of the endometrium • calcified pelvic lymph nodes or smaller irregular calcifications in the adnexa, and deformity of the endometrial cavity suggestive of adhesions in the absence of a history of prior curettage or abortion

ASHERMAN’S SYNDROME • Destruction of the endometrium may result in scarring and the development of bands of scar tissue, or synechiae within the uterine cavity • occur as a result of a vigorous curettage of the uterus following an abortion or, more often, after curettage of an advanced pregnancy.

• Intrauterine synechiae do not present increased vascularity on color Doppler examination. Threedimensional ultrasound demonstrates a significant reduction of the endometrial cavity volume

OVULATORY FACTORS OF INFERTILITY Transvaginal sonography is considered the most reliable method for monitoring the follicular growth. It enables accurate prediction of ovulation and detection of the ovulation abnormalities Documentation of ovarian stromal vascularity at the initial baseline scan may be important and may provide useful information for assisted reproduction techniques

POLYCYSTIC OVARIAN SYNDROME • Polycystic ovarian syndrome (PCOS) is one of the causes of anovulation and amenorrhea. In its classic form it is characterized by infertility, oligo and amenorrhea, hirsutism, acne or seborrhea, and obesity. • ultrasonographic diagnosis of polycystic ovaries: multiple (n>10), small (2– 8 mm) peripheral cysts around a dense core of stroma in enlarged (≥ 8 ml) ovaries

LUTEINIZED UNRUPTURED FOLLICLE SYNDROME • Luteinized unruptured follicle (LUF) syndrome is characterized with regular menses and presumptive ovulation as suggested by a cyclic hormonal profile, similar to that seen in normal ovulatory women but without release of the ovum. • lower concentrations of estradiol and progesterone in peritoneal fluid compared with normal ovulatory cycles

• diagnosis is most commonly made on ultrasound examination, in which there is persistence of the ovarian follicle with progressive loss of its typical echo-free cystic appearance and accumulation of internal echogenicity

LUTEAL PHASE DEFECT • The formation of corpus luteum is an important event in reproductive cycle and one of the crucial factors in early pregnancy support • lack of progesterone, luteal phase of the cycle shorter than 11 days, and when related to endometrium, an outof- phase endometrium by 2 or more days

• corpus luteum abnormalitycan be detected by color Doppler ultrasonography • increased RI in both ovaries was associated with a nonviable pregnancy outcome.

TUBAL FACTOR OF INFERTILITY • The normal Fallopian tubes are narrow and usually not seen by transabdominal or transvaginal ultrasound unless they contain fluid within their lumina or area surrounded by fluid • Chronic hydrosalpinx is the ultimate remnant of the PID: the tube is occluded, thin-walled and filled with fluid

PERITONEAL FACTOR • Endometriosis is caused by foci of secretory endometrium outside of the uterus

Ultrasound Markers of Implantation

Ovarian sonography Follicular cyst Dermoid cyst Hemorrhagic cyst Paraovarian cyst

Endometriosis is defined as the presence of endometrial tissue outside of the endometrium and myometrium Endometriotic foci may appear as punctate spots or patches of variable color, with a slightly raised or puckered surface, forming nodules, cysts, or both. In one-third to onehalf of cases, ovarian endometriotic cysts are bilateral The cysts rarely exceed 15 cm in diameter

conclusion Sonography can play a critical role in the diagnosis and treatment of fertility disorders. transvaginal color Doppler and 3 D ultrasound with power Doppler facilities have made a significant improvement in the assessment of infertility Absent subendometrial an intraendometrialvascularization on the day of h. CG administration appears to be a useful predictor of failure of implantation in IVF cycles Quantification of endometrial volume by 3 D ultrasound in combination with blood flow studies contributes to the assessment of endometrial receptivity and has a potential to predict pregnancy rates in assisted reproductive techniques

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