Trans vaginal sonography in Assisted reproduction

1. Role of TVS in Infertility/ART
Poonam loomba,M.D.
Loomba IVF Centre
Ambala Cantt

2. Nothing to disclose

3. Learning objectives
• Baseline scan in infertility
• Know the limitations of ultrasound in fertility
evaluation
• Significance of new markers for endometrial
receptivity and follicle maturation towards paving
the path to SET.
• Ultrasound as a tool in Oocyte PU and ET.

5. Baseline scan in infertility
 Best done in the early follicular time(cycle day 3)to avoid distortion of
ovarian volume caused by growing follicle
 High frequency probe with trans vaginal approach is used.
 Use a systematic approach
Empty bladder
Watch as you are placing the transducer
Look at the bladder,and cervix(length and
location
Cervico uterine angle
Uterus:Orientation,size,endometrial thickness
Ovaries:location,size,and number of follicles
.
 Document and save your findings electronically.
.

6. Baseline scan

8. Limitations of ultrasound
• Minimal and mild endometriosis
• Flimsy pelvic adhesions
• Some tubal abnormalities.
• But we can use the probe actively during exam
to assess the mobility of pelvic structures in
relation to each other.This gives us an idea of
whether or not there are adhesions.

9. SLIDING ORGAN SIGN

10. Assessment of uterus
 Shape of uterus and uterine
 cavity
 Intracavitary lesions
 Endometrio myometrial
junction
Endometrial receptivity

12.  Differential diagnosis of congenital duplication
abnormalities of uterus like bicornuate, septate and
arcuate is based on external fundal contour and
contour of the endometrial cavity.

13. Normal shape of the uterine cavity...
SEROSAL FUNDUS
ENDOMETRIAL FUNDUS

14. Volume USG, 3D and 4D USG has a major role
to play in the diagnosis of uterine anomalies :
Virtual hysteroscopy
Sensitivity of the Volume in USG for
the detection of congenital uterine
abnormalities is > 98%.

15. Unicornuate uterus:
 normal shape in long section
 deviated
 Hypoplastic 2nd horn : sometimes
Unicornuate Uterus

16. D/D bicornuate from septate

17. D/D bicornuate from septate
< 5mm > 5mm

18. D/D bicornuate from septate
> 90° < 90°

19. 3D US can show us the length,
thickness and depth of the septum

20. D/D subseptate and arcuate
< 90° >
90°

21. D/D subseptate and arcuate
> 10 mm < 10 mm

22. T shaped uterus

23. Intact regular endometrio-myometrial junction
is an important sign of a healthy
endometrium.

24. Junctional zone is damaged in
• Endometritis: acute or chronic
• adenomyosis

26. Damaged endometriomyometrial
junction

27. Endometrial receptivity
30% of embryos transferred result in clinical
pregnancies .Fault may be in the embryo or the
implantation bed.
Thickness
Pattern
 Blood flow to the endometrial and subendometrial
zone
Volume

28. Normal endometriumMeasuring endometrial thickness

29. Endometrial thickness
• Increases from 4.6mm to 12.4mm on the day
of LH surge.
• Average increase is 1 to 2mm per day in
proliferative phase.
• Decreases by 0,5mm on the day of LH surge
increasing again by 2mm in luteal phase.

30. CC vs HMG/FSH
• Following the days CC is taken the ET is often decreased the
effect lasts no more than 3-4 days after last dose.
• In late follicular phase it escapes antioestrogenic effect and
increases faster.
• With HMG and FSH it is greater than in spontaneous cycles.
• No pregnancies were seen when ET was <6mm on the day
of hcg.
• Biochemical pregnancies were pbserved more in ET <9mm
or >13mm.
• It is advisable not to start OI if postmenstrual ET is 6mm or
more.

31. Periovulatory endometrium:
once the EM echo is well visualized use as much magnification as
possible

32. Endometrium in PCOD No Triple line

33. Thin endometrium indicating low
estrogenic state

34. Endometrial waves
• In 73% a wave direction switch occurs from
fundus to cervix and cervix to fundus
before OPU (fertil steril 1999)
• The persisting waves until HCG predict a
favourable outcome
• In a validation prospective study it was not
confirmed if waves improved pregnancy
outcomes(fertil steril 2005)
• Two more wave types are recoiling CF wave
and a standing wave.(fertil steril2007)

36. Blood flow
• With the more sensitive colour doppler and power
doppler it is postulated that local vascularization at
the site of implantation is more important than global
vascularization of the uterus measured by RI in the
uterine arteris.
• EPDA is defined as a part of endometrium where
vascular signals with velocities >5cm/sec are
detected.
• Subendometrial zone is 1mm outside endometrium
where most of the cyclical changes take place.
• The correlation is more significant in women with
poor embryo quality since IR are more if
Vascularization is better,

38. Power doppler imaging

39. PROLIFERATION OF SPIRAL ARTERIES AND
SUBSEQUENT ENDOMETRIAL “INVASION”
ZONE I -- Only Myometrial Vessels Surrounding the Endometrium are
Visualized.
ZONE II – Vessels Penetrate Through the Hyperechogenic Endometrial Edge.
ZONE III – Vessels reach the internal endometrial Hypoechogenic Zone.
ZONE IV – Vessels reach the Endometrial Cavity.
Deeper the vascularization noted better the
outcome.

42. Endometrial power doppler area

43. Endometrial volume by 3D by virtual
organ computer aided analysis software

44. Significance of endometrial volume
• Endometrial and subendometrial vascularity
are significantly lower in patients with
endometrial volume <2.5 ml
• In IVF/ICSI cycles endometrial volume and
Power doppler indexes are statistically
significant in predicting the cycle outcome
with SET. (Fertil.Steril 2008 jan 89)
• Lower PR are seen with EV <2.0ml and no
pregnancies seen with <1.2ml

45. Imaging the uterine cavity
• 20% of infertile women have cavitary
abnormalities including arcuate uterus,septate
uterus,polyps, s/m myomas and adhesions.
• HSG Low sensitivity and specificity
• TVUS Low sensitivity and specificity
• SIS 81.3% and 100%
• Hysteroscopy 87.5% and 100%
• Gold standard is hysteroscopy.

46. Endometrial polyp
More echogenic than
myometrium
Isoechoic with
endometrium
Sessile or pedunculated
Single feeding vessel

47. Polyps on fertility
• Limited data.
• Lass et al 1999 : Polyps >2cm increase EPL
• <2cm:No difference in pregnancy between
resected vs untreated patients
• Mastrominas et al ,J am Assoc Gyn Lapro 1996
• PR in polypectomy vs.biopsy
• N=101 Removal PR=63%
• N=103 Biopsy PR=28%

48. Intra uterine adhesions
• Asymmetry of
endometrial
echo
• Areas of
endometrium
<2mm
• Echogenic area in
the uterus
• TVS sensitivity is
52%
• TV SIS is 93.5 to
99.% accurate.

49. Saline infusion sonohysterography
More image than imagination
May be as effective as hysteroscopy in
detecting intra cavitary abnormalities
More cost effective and simple to perform

50. SIS:- 20ML Normal saline is instilled
using pediatric foley catheter no.8

51. Bulb of catheter

52. Dangling polyp synechiae

53. Alternative to sonohysterogram
• Consider doing ultrasound in luteal phase.
• Endometrium is hyperechoic and acts like
contrast medium.
• Add 3D image.

54. Submucous fibroids –grading :
to decide the route of surgery
• T0- whole in endometrial cavity
• T1 - >50% in endometrial cavity
• T2- < 50% in endometrial cavity

58. Tubes?
• Normally not seen
Hydrosalpinx appearances
• Retort shaped cystic structure
• Cogwheel sign
• Waist sign
• Incomplete septae

59. Tubes: Hydrosalpinx

60. Ovaries
• Ovarian volume and AFC ….measures of
ovarian reserve
• PCOD
• Ovarian masses
• Ovulation studies with series of scans

61. AFC
• AFC in both ovaries performed during
menstrual cycle or early follicular phase is
currently the gold standard for OR.
• <5
• 10-15
• >15

62. AFC Normal

63. Poor afc

64. 3 D Inversion Tecnology

65. Ovarian size and volume

66. Ovarian volume
• Volume is affected by cigarette smoking OCP
age and cysts
• Superior to day3 FSH
• Small volume predicts fewer follicles and low
PR independent of age(syrop 1999)
• Large volume>10ml is associated with
increased OHSS.(10% TO 23.5%)

67. PCOS Criteria
• 12 or more follicles in each ovary2-9mm in size.
• >10ml volume in one f the ovaries.
• Distribution may be peripheral or scattered in
dense stroma.
• Stromal hypertrophy
• Stromal to ovarian area ratio cut off being 0.34
above which PCOS can be diagnosed.
• Stromal echogenecity
• Ovarian artery PI and RI are decreased,

68. • Polycystic ovarian morphology has been found
to be a better discriminator than ovarian
volume between polycystic ovarian syndrome
and control women.
Legro, et al, JCEM 90(5): 2571-79.

69. Stromal vascularity
• Even with same echogenecity, PCOS has more
stromal flow.

70. OVARIAN STROMAL BLOOD FLOW
• PSV > 10cm/sec AFTER PITUITARY SUPRESSION
• Stromal ri < 0.41 : 2/3rds WILL GET OHSS
• Stromal pi < 0.75 : 1/2 will get pleural effusions

71. Follicular study
• Number of scans depend upon the response
of the patient
• Hcg is delayed till majority reach maturation
• Eggs can be retrieved from as small as 14mm
and as large as 24mm.
• Decreased quality of oocytes from follicle
24mm.>
• No difference in quality of oocytes from
follicles 18-22mm in size.

72. FOLLICULAR PARAMATERS
A.PERIFOLLICULAR VASCULARIZATION.
B.PERIFOLLICULAR RI 0.4 – 0.48
C.FOLLICULAR PSV > 10 CMS/SEC
Diameter predicts maturity and
perifollicular vascularization predicts
the quality of oocyte at retreival

73. PERIFOLLICULAR VASCULARISATION
• GRADE 1 < 25%
• GRADE 2 < 50%
• GRADE 3 < 75%
• GRADE 4 > 75%

74. Perifollicular blood flow

75. DECIDING THE TIME OF HCG ?

76. This consisted of
Follicular volume
Visualization of cumulus
Perifollicluar VI
Perifollicular FI
Perifollicular VFI

77.  Follicular volumes of between 3 – 7 cc are optimum
for oocyte retrieval .
 The limits of agreement between the volume of the
follicular aspirate and 3D volume of the follicle were
+ 0.96 to – 0.43 with 3D and + 3.47 to – 2.42 by 2D
volume estimation.
Follicular Volume

78. On the day of HCG – If
cumulus like echoes is not seen in all
three planes in the follicle , it is less
likely to be mature fertilizable oocyte.
cumulus

79. D/d of ovarian masses:most are
benign in women of reproductive age
Physiologic
• Follicular
• Simple
• Corpus luteum
Pathologic
 Endometrioma
Mature cystic teratoma
Borderline
Malignancy
We recommend further evaluation of the mass prior to stimulation(repeat US
,LAPROSCOPY

80. Haemorrhagic cyst Endometriomtic cyst

81. Oocyte Retrieval
• Standard IVF retrieval
• Transvaginal probe 5-9 MHz
• 16-17 gauge needle
• Empty bladder before
starting procedure
• Familiar with the machine
• Fix the ovaries against the
transducer .
• Ultrasound screen should
be at level with your eyes.
• Do not lose track of needle

82. Collection techniques
 Maintenance of suction: follicular fluid (and oocytes) may be
lost if entry into and exit from the follicle are made in the
absence of suction. This gain, however, may be offset by
possible damage due to the dramatic forward flow of fluid
toward the collection tube.
 Secondly, movement of the needle tip within the follicle:
damage to the oocyte, particularly the cumulus, may occur
because of collection technique. It is a common practice
during oocyte collection to ‘spin’ the needle within the
follicle.
 Flushing may yield more number of eggs.

84. Flushing of follicles.
Again it is an individual approach .
40% retreival rate without flushing ,80% with
two and 90% with four flushings.
In our clinic we do not routinely flush follicles
and have >70% retreival rate.

85. Embryos day2

86. Embryo transfer is the most crucial step in IVF
And the last one while climbing on the ladder
Of success for IVF.
It is not as easy as it appears to be

87. Effect of “provider at ET”
• Learning curve:
– ET trainees can reach an acceptable PR after the first
25-30 ETs.
– Clinical pregnancy rates of fellows-in-training were
indistinguishable statistically from those of
experienced staff by 50 transfers.
(45.5% v 47.3%)
Papageorgiou TC et al. Hum Reprod 2001; 16:1415-1419

88. Variables affecting ET success
• Trial transfer/Mock ET
• Catheter type
• Touching the fundus
• Difficult transfer
• Usg guided

89. Cervico uterine angle

90. Ultrasound guided ET
• Full bladder for TAUS
• Assistant to
• Usually soft catheter is
used
• Confirm position of
loaded catheter
• Place embryos in middle
part of uterine cavity .
• Confirm for the fluid
bubble in the cavity.

92. Advantages Disadvantages
• Less trauma at ET
• Confirm appropriate
location
• Known length of
endometrial cavity
• Decrease anxiety for
patient and clinician
• Cochrane review
2007:Improved PR but no
statistical difference in
compliactions
• Need ultrasound
equipment
• Need assistant
• Need full bladder
• Increases duration of ET
• Flisser etal 2006 fertil
steril:353-7
No significant difference in
US et/Clinical touch ET
Operator experience
dependant

93. 3D/4D for Embryo Transfer
• Patient and physician
satisfaction
• No comparison group
• Still controversy in the
literature over best
spot.
• Gergley et al Fertil steril
2005

94. Conclusion:
• 3D Volume technology has emerged as an
effective noninvasive tool to detect structural
uterine anomalies
• Accuracy of SIS matches that of hysteroscopy in
detecting intra cavitary anomalies.
• Design more studies to incorporate new markers
of endometrial receptivity and follicle study for
success with SET.

95. Journey might be turbulent but ends up well with a safe landing