Ultrasound and Hysteroscopy in Infertility James M. Shwayder, M.D., J.D. Professor and Chair Department of Obstetrics and Gynecology University of Mississippi Medical Center Jackson, Mississippi
Ultrasound and Hysteroscopy in Infertility James M. Shwayder, M.D., J.D. Disclosures: Cook Ob-Gyn Philips Ultrasound Royalties Consultant
Learning Objectives Present a brief overview of female infertility Discuss the clinical conditions where ultrasound plays a primary role in evaluation Hysteroscopic correlation Describe and display various sonographic findings that lead to a specific diagnosis
Causes of Infertility Female factor 35% Male factor 30% Combined 20% Unexplained 15% Forti and Krausz. J Clin Endo Metab 1998; 83: 4177-88.
Causes of Female Infertility Tubal/peritoneal factor 25-30% Ovulatory dysfunction 15% Uterine/endometrial factor 5% Cervical factor 5% Others 45-50% Silva et al. The Female Patient 1987; 12: 14 Ruiz-Velasco et al. Fertil Steril 1987; 67: 687
Causes of Female Infertility Tubal/peritoneal factor 25-30% Ovulatory dysfunction 15% Uterine/endometrial factor 5% Cervical factor 5% Others 45-50%
Causes of Female Infertility Ultrasound Evaluation Uterus Congenital Malformations Polyps Fibroids Adhesions/Synechiae Endometrial receptivity
Uterine Congenital Abnormalities Infertility Upper tract abnormalities 1 st trimester SAB Ectopic pregnancy Premature delivery
Mullerian development Originate as an invagination of coelomic epithelium on the antero-lateral portion of the urogenital ridge 9 th week: Elongate into 3 regions
9 weeks 3 Regions Cranial vertical Fimbria Horizontal Isthmic portion of tube Caudal-Vertical Join in midline to form Y-shaped tubular structure - uterovaginal primordium (UVP)
Mullerian development Combinations of failed fusion (vertical fusion) and resorption (lateral fusion) leads to Mullerian abnormalities Prior to 1994 Caudal-cranial fusion Duplicated cervix, uterine didelphys After 1994 Bidirectional fusion Duplicated cervix, uterine septum, normal fundus
Mullerian development Uterine portion of UVP gives rise to uterus and upper 1/3 of the vagina Uterine septum undergoes apoptosis mediated by bel-2 gene regulating protein 22 weeks Mullerian derived fallopian tubes, uterus, and cervix are mature
Classification system of müllerian duct anomalies American Society of Reproductive Medicine Troiano R N, McCarthy S M Radiology 2004;233:19-34
Classification of Uterine Anomalies Ghi et al. Fertil Steril 2009;92:808-13.
Ghi et al. Fertil Steril 2009;92:808-13.
Uterine Malformations Prevalence Unicornate 9.6% Didelphys 8.2% Bicornuate 26.0% Septate 34.9% Arcuate 18.3% Grimbizis et al. Human Reprod Update 2001; 7:161-174.
Classification of Uterine Anomalies Grimbizis et al. Human Reproduction 2013; 28:2032 2044.
Grimbizis et al. Human Reproduction 2013; 28:2032 2044.
Grimbizis et al. Human Reproduction 2013; 28:2032 2044.
Uterine Malformations Fertile 4.3% Infertile 3.4% Recurrent pregnancy loss 12.6% Grimbizis et al. Human Reprod Update 2001; 7:161-174.
Uterine Malformations Fertile 6.7% Infertile 7.3% Recurrent pregnancy loss 16.7% Saravelos et al. Human Reprod Update 2008; 14:415-429.
Uterine Malformations Prevalence Population Hypo Unicorn Didelphys Bicorn Septate Arcuate General Fertile -- 0.4 0.4 4.0 27.2 68.0 Infertile 9.4 6.1 2.9 10.8 46.1 24.7 Rec SAB -- 2.3 0.8 5.3 26.5 65.2 Saravelos et al. Human Reprod Update 2008; 14:415-429.
Hysteroscopy Findings in Infertile Patients Author Valle Hamou Snowden Taylor Shwayder Number 142 279 77 400 75 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 45 8% 45 9% 8%
Diagnosis of Uterine Abnormalities Infertility Patients Modality Randolph Want Keitz Shwayder Pellerity Sens Spec Sens Spec Sens Spec Sens Spec Sens Spec HSG 80 70 90 20 88 96 TVS 98 76 83 10 80 SIS 92 92 100 100 98 96 MRI 100 100 Sen = Sensitivity Spe = Specificity All numbers in %
Uterine Congenital Abnormalities Imaging Accuracy Modality Accuracy HSG 20% 3D TVS 92% MRI 100% Braun P. Eur J Radiol 2005;53:274-9
Uterine Malformations Diagnosis Method Sensitivity Specificity PPV NPV Accuracy HSG compared to HS 2D US compared to HS SHG compared to HS 3D compared to HS and LS MRI compared to HSG and LS 78 90 83 91 86 56 99 96 87 84 93 99 97 98 97 100 100 100 100 100 100 79 NR NR 100 Saravelos et al. Human Reprod Update 2008; 14:415-429.
Uterine Malformations-Pregnancy Outcomes - Untreated Unicornate 54.2% Didelphys 55.9% Bicornuate 55.2% Septate 50.1% Arcuate 66.0% Grimbizis et al. Human Reprod Update 2001; 7:161-174.
Congenital Uterine Abnormalities
Uterine Congenital Abnormalities
Subseptate Uterus
1. External contour (Fundal serosa) 2. Fundal endometrium 3. Lower uterine segment 4. Cervix
Uterine Septum
1. External contour (Fundal serosa) 2. Fundal endometrium 3. Lower uterine segment 4. Cervix
Uterine Anomalies External contour (Fundal serosa) < 1 cm = Normal, arcuate, septum > 1 cm = Bicornuate, didelphys Fundal endometrium < 1 cm = Arcuate or normal > 1 cm = Septate or subseptate Lower uterine segment 1 cavity = Subseptate or bicornuate 2 cavities = Septate or didelphys (see cervix) Cervix 2 cervices = Didelphys
Arcuate Uterus
Arcuate with SIS
Hysteroscopic Treatment of Uterine Septum Post-treatment Author Colacurci Cararach Goldenberg Zioua Hamou Pregnancies 446 51 53 19 34 Preg rate 56% 51% 53% 82% 5% Term Del Rate 68% 57% 71% 87% 42% SAB rate 18% 24% 44% 5% 32% <12 wks 15% 13% >12 wks 4% Still Pregnant 4%
14 y.o. G0P0 Vaginal septum on limited examination
Left Adnexa
Congenital Uterine Abnormalities 17 y.o. with severe pelvic pain
Congenital Uterine Abnormalities
Congenital Uterine Abnormalities
Uterine Congenital Abnormalities Imaging Accuracy Modality Accuracy HSG 20% 3D TVS 92% MRI 100% Braun P. Eur J Radiol 2005;53:274-9
Mullerian Abnormalities SIS in 1227 infertile women Mullerian Anomaly Renal Anomalies Type # % # % Total 324 26.4 8 2.5 Arcuate 232 71.6 1 0.4 Septate 68 20.9 3 4.4 Unicornate 11 3.4 1 9.9 Didelphys 8 2.5 1 12.5 Bicornuate 5 1.5 2 40.0 None (Normal) 903 73.6 0 0.0 Gunn et al. AIUM Annual Meeting. Prevalence of renal duct abnormalities in women with Mullerian duct abnormalities diagnosed with 3-Dimensional sonohysterography. 2011 (Toronto, Canada)
Uterine Factor Polyps/Fibroids Fibroids distorting the endometrial cavity impair pregnancy rates Most IVF studies relating to fibroids and outcome exclude patients with intracavitary lesions 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
23 y.o. G0 Presents with irregular, heavy bleeding for 9 months Desires pregnancy
2D Ultrasound Sagittal 19.3 mm G0 LMP=?IRREG BC: NONE GYN SURG: NONE
AUB - 2D SIS
AUB - 3D SIS
Multiple Endometrial Polyps
2D SIS Polyp
Endometrial Polyp
European Society of Hysteroscopy classification of submucous myomas Type 0 Pedunculated without intramural extension Type I Sessile < 50% intramural extension Type II > 50% intramural extension Associated with higher failure rate Associated with need for repeat surgical procedures
Submucous Myoma Type 0
Submucous Myoma Type I
Submucous Myoma Type I
Submucous Myoma Type II
Intramural Myoma
Arcuate Uterus
Intramural Endometrium Submucous-Type I Intramural
Sonohysterography Endometrial Polyps and Fibroids
Uterine Factor
Uterine Factor Combination
Results of Hysteroscopic Myomectomy Author Valle Hamou Donnez Corson Mergui Verasteh Number 16 48 77 13 15 36 Preg Rate (%) 62 56 67 77 40 53 Deliv Rate (%) 50 46 67 61 27 36 SAB rate (%) 20 19 0 20 33 32
Results of Hysteroscopic Myomectomy Author Valle Hamou Donnez Corson Mergui Verasteh Number 16 48 77 13 15 36 Preg Rate (%) 62 56 67 77 40 53 Deliv Rate (%) 50 46 67 61 27 36 SAB rate (%) 20 19 0 20 33 32 Grimbizis et al. Human Reprod Update 2001; 7:161-174.
Infertility Outcomes of Hysteroscopic Surgery Finding # Pg % RR BR% RR SAB Myoma 36 52.8 2.02 36.1 31.5 < 2 cm 33.3 25.0 > 2 cm 62.5 2.64* 41.7 1.74 > 3 cm 75.0 4.72* Polyp 23 78.3 3.89* 65.2 2.44 27.7 Normal 19 42.1 1.00 36.8 1.00 37.5 * p < 0.05
Polyps and Infertility Stamatellos et al. Arch Gynecol Obstet 2008; 277:395-399
Polyps and Infertility Stamatellos et al. Arch Gynecol Obstet 2008; 277:395-399
Uterine Synechiae
ASRM Classification of Intrauterine Adhesions Score 0 1 2 4 Stage Cavity Involved < 1/3 --- 1/3 2/3 > 2/3 1-4 I (mild) Type of Adhesions --- Filmy Filmy & Dense Dense 5-8 II (mod) Menstrual Pattern Normal Hypo --- Amen 9-12 III (severe)
Uterine Synechiae
Uterine Factor Intrauterine Adhesions
Uterine Factor Intrauterine Adhesions
28 y.o. G2P0020 Presents with recurrent pregnancy loss Cyclical pain Light flow on a monthly basis hcg = negative
Transverse synechiae
Results of Treatment of Uterine Synechiae Author Valle Hamou Lamcet March Pabuccu Number 187 69 185 38 40 Pregnancies 143 60 135 36 34 Pregnancy Rate 76% 87% 73% 94% 85% Viable Del Rate 79% 75% 71% 87% 57% Miscarriage Rate 18% 25% 26% 14% 32%
Summary Causes of infertility Uterine abnormalities Mullerian abnormalities Polyps and fibroids Uterine synechiae Ultrasound and Hysteroscopy
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