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
TRANSABDOMINAL TRANSVAGINAL(RECTAL)

 • Low frequency  High frequency

Vaginal ultrasound is dynamic and interactive
 • Poor resolution
examination • Superb resolution
••Check
 Good overview
the mobility of organs
• Poor overview
 • Scan the abdomen
– fixed organs = adhesions
••Check
 Full bladder • Abdomen not seen
for site specific tenderness
 Explainsorgans
– which organ are involved •inEmpty bladder
a painful process?
interrelationship better
 KEYPOINTS
What is the correct scanning technique to
image the
-The appearance of the normal endometrium
 cervix, uterus and ovaries effectively?
and ovary varies significantly throughout the
menstrual cycle in women of reproductive age.
 What are the principal ultrasound features
of:
-It is important to be aware of the expected
the normal
–changes cervix
in order to avoid misinterpreting
–physiologic
the normal changes
uterusaswith
pathologic.
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, 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.

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 • On the day of HCG – If cumulus like
suffices for cycle monitoring, echoes is not seen in all three planes in
with no necessity for additional the follicle , it is less likely to be mature
hormonal estimations. fertilizable oocyte.
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