Male factor 30% Combined 20% Unexplained 15% Consultant Philips Healthcare. Forti and Krausz. J Clin Endo Metab 1998; 83:

Transcription

1 Conflict of Interest Disclosure Ultrasound and Infertility Consultant Philips Healthcare William W. Brown, III, MD Director, Ambulatory Ob/Gyn & Ultrasound Denver Health Medical Center Associate Professor, Department of Ob/Gyn University of Colorado School of Medicine Learning Objectives Present a brief overview of female infertility Discuss the clinical conditions where ultrasound plays a primary role in infertility evaluation and treatment Display and describe various pelvic sonographic findings that improve diagnostic accuracy Causes of Infertility Female factor 35% Male factor 30% Combined 20% Unexplained 15% Forti and Krausz. J Clin Endo Metab 1998; 83: Tubal/peritoneal factor 25-30% Ovulatory dysfunction 15% Uterine/endometrial t i factor 5% Cervical factor 5% Others 45-50% 50% Female Infertility Baseline Ultrasound (TVS) Uterus Myomas, polyps, congenital malformations, endometrial receptivity, adenomyosis Ovaries Polycystic ovaries, endometriomas, cysts or masses, antral follicle count, ovarian volume Silva et al. The Female Patient 1987; 12: 14 Ruiz-Velasco et al. Fertil Steril 1987; 67: 687

2 Female Infertility Baseline Ultrasound (TVS) Fallopian tubes Chronic inflammatory disease Endometriosis (hematosalpinx) Cul-de-sac Adhesions, endometriosis General Adhesions, tenderness, organ mobility Pelvic What is the efficacy of TVUS 1? TVUS for 133 premenopausal infertile women one day prior to laparoscopy detecting pelvic pathology 86.2% sensitivity, specificity 97.8% 98.6% PPV, NPV 78.8% 61.1% sensitivity for pelvic adhesions 6 false negative cases of minimal endometriosis 1 Ubaldi F. Hum Reprod 1998;13:330-3 Tubal/peritoneal factor 25-30% Ovulatory dysfunction 15% Uterine/endometrial t i factor 5% Cervical factor 5% Others 45-50% 50% TUBAL/PERITONEAL Inflammatory tubal disease Pelvic adhesions Endometriosis Tubal patency Pelvic Inflammation Chronic Thin-walled cystic mass; beads on a string ; simple fluid; incomplete septa; non-tender Pelvic inclusion cyst Irregular shape, contain mostly sonolucent fluid, no clear cyst wall Normal ovary Adhesions Cystic mass extrinsic to ovary Ultrasound markers Shapes Beads-on-a-string Partial septa

3 Cystic mass extrinsic to ovary Cystic mass extrinsic to ovary Shapes Cystic mass extrinsic to ovary Tubular Sausage Shapes Shapes Oval Cyst(s) Pear Retort Serpiginous

4 Beads-on-a-string Thin-walled, partial septa Use of 3-D Rendering Use of 3-D Rendering Use of 3-D Rendering Inversion rendering Use of 3-D MPR Timor-Tritsch I. JUM 2005;24:681-88

5 Pelvic Adhesions Fine or thick Require the presence of fluid to visualize Pelvic Adhesions Fine or thick Require the presence of fluid to visualize Pelvic Adhesions Fine or thick Require the presence of fluid to visualize Pelvic Adhesions Sliding bowel sign Courtesy Dr. J. Shwayder Endometriosis Point tenderness with movement of the transducer Many lesions are fibrotic, without vascular activity 1 > 40% of lesions penetrate > 4mm 2 Presentation: infertility, dysmenorrhea, pelvic pain, dyspareunia, uterine fibroids 1 Koninckx et al. Fertil Steril 1992; 52: Martin et al. J Gynecol Surg 1989; 5: 55. Endometriosis Non-ovarian ovarian sites: Bladder Recto-vaginal septum Bowel Nodular, complex mass or cyst, point tenderness Organ immobility

6 Tubal Patency Saline Infusion Salpingosonography Tubal Patency Saline Infusion Salpingosonography Air + saline as contrast medium 86% concordance with laparoscopic chromopertubation, 67% with previously treated Fallopian tube 3-D power Doppler hysterosalpingo- contrast-sonography sonography with aqueous galactose solution for contrast 2 91% concordance with laparoscopy Sensitivity for tubal patency 100% 1 Spalding H. Hum Reprod 1997;12:306-9 Chan C. Acta Obstet Gynecol Scand 2005;84: Tubal/peritoneal factor 25-30% Ovulatory dysfunction 15% Uterine/endometrial t i factor 5% Cervical factor 5% Others 45-50% 50% OVARY Ovarian cysts/masses Endometrioma PCOS Ovarian reserve Endometrioma Ovarian Cysts/Masses Homogenous, low- level echoes 1 Sensitivity 90% Specificity 97% Septations 29% Fluid levels 5% 1 Ubaldi F. Hum Reprod 1998;13:330-3 Endometriod CA

7 PCO Rotterdam 2003 Criteria Two of the following three features (after excluding related disorders) : Oligo- or anovulation Clinical or biochemical signs of hyper- androgenism Polycystic ovaries Differentiate from multi-follicular or multi-cystic ovaries: 6 or more follicles, 4-10mm, not associated with other PCO features, most commonly seen in puberty, menopause PCOS 12 or more follicles measuring 2-9mm in diameter in at least one ovary &/or ovarian volume >10cm 3 (30% of PCOS patients have normal ovarian volumes) 1 26 follicles for PCOS vs. healthy 2 1 Balen et al. Hum Reprod Update 2003;9:505 2 Lujan M. Hum Reprod 2013;28:1361 Ovarian Reserve Ovarian Volume (0.52 x L x W x H) Volumes are correlated with antral follicle counts (AFC) 1 May help predict ART outcomes better than CD3 FSH 2 >9cc volume yielded no IVF cancellations and higher clinical pregnancy rate 3 Used in combination with serum tests AMH, Inhibin B, E2. 1 Syrop C. Infert Reprod Med Clin N Am 2003;14: Syrop C. Hum Reprod 1999;14: Syrop C. Fertil Steril 1995;64: Ovarian Reserve Antral Follicle Count (AFC) Tubal/peritoneal factor 25-30% Ovulatory dysfunction 15% Uterine/endometrial t i factor 5% Cervical factor 5% Others 45-50% 50% UTERUS Congenital uterine abnormalities Polyps Fibroids Adhesions Endometrial receptivity

8 Hysteroscopy Findings in Infertile Patients Congenital Uterine Abnormalities Author Valle Hamou Snowden Taylor Shwayder Number Normal 38% 42% 84% 55% 40% Malformations 6% 8% 1% 11% 17% Synechiae 20% 25% 8% 21% 3% Polyp/Myoma 32% 17% 3% 4% 32% Other 4% 8% 4% 9% 8% Congenital Uterine Abnormalities Infertility (?) Recurrent SAB Poor pregnancy outcome Pelvic pain/dysmenorrhea Pelvic mass Endometriosis Primary amenorrhea Incidental ultrasound finding Congenital Uterine Abnormalities Imaging Accuracy 1 HSG 20% 3-D TVUS 92% MRI 100% 1 Braun P. Eur J Radiol 2005;53:274-9 Raga, F. Fertil Steril 1996;65:523 Meng-Hsing, W. J Clin Ultrasound 1997;25:487 Kupesic, S. J Ultrasound Med 1998;17:631 Ghi T. Fert Steril 2009;92:808 Congenital Uterine Abnormalities Congenital Uterine Abnormalities Uterine Septum Pre-treatment Author Colacurci Carach Goldenberg Zioua Hamou Number Infertility 35% 76% SAB 57% 24% 77% 81%

9 Congenital Uterine Abnormalities Uterine Septum Author Colacurci Post-treatment treatment Results Cararach Goldenberg Zioua Hamou Pregnancies Preg Rate 56% 51% 53% 82% 5% Term Del Rate 68% 57% 71% 87% 42% SAB 18% 24% 44% 57% 32% Polyps/Fibroids Fibroids distorting the endometrial cavity diminish IVF pregnancy rates Most IVF studies relating to fibroids and outcome exclude patients with intracavitary lesions or large myomas Good data lacking about polyps. Do polyps of any size matter? ET of 5mm may not be reassurring 1 1 Breitkopf D. Obstet Gynecol 2004;104:120-5 Sub-Mucous Myomas Intrauterine Adhesions Resection No Resection # Pregnancy Rate 63.4% 28.2% RR 2.1 ( ) PRT of hysteroscopic myomectomy Spontaneous pregnancies Improved pregnancy rates with Type 0 and I myomas Shokeir et al. Fertil Steril 2010;94:794 Intrauterine Adhesions Intrauterine Adhesions

10 Intrauterine Adhesions Treatment Results Author Valle Hamou Lamcet March Pabuccu Number Pregnancies Pregnancy Rate 76% 87% 73% 94% 85% Viable Del Rate 79% 75% 71% 87% 57% Miscarriage Rate 18% 25% 26% 14% 32% Endometrial Receptivity Positive relationship between ET and embryo implantation success 1 1,294 IVF cycles, transfer of two blastocyst-stage stage embryos ET<9mm, clinical pregnancy rate 53% ET>16mm, clinical pregnancy rate 77% ET>16mm, marginal decrease in SAB 1 Richter K. Fertil Steril 2007;87:53-9 Infertility Treatment Ultrasound Uses--ART First understand the normal ovarian and endometrial changes in normal cycle Baseline scan of ovaries for structures that inhibit oocyte development (old corpora lutea, endometriomas, neoplasms) Ovarian volume, antral follicle counts to assess ovarian reserve Infertility Treatment Ultrasound Uses--ART Assess ovarian response during controlled ovarian stimulation, IVF Triggering ovulation Retrieval of oocytes Endometrial thickness/pregnancy Controversial (ovulation induction studies) Embryo transfer 3-D Summary Causes of infertility Ultrasound diagnosis Tubal disease Pelvic adhesions Endometriosis, ovarian dysfunction Uterine abnormalities Pre-operative counseling/planning Ultrasound use with infertility treatment