Fertility Scan and Gynecology Ultrasound

What is ULTRASOUND??

Ultrasound imaging is a noninvasive medical test that helps physicians diagnose and treat medical conditions.

Ultrasonography has become an indispensable tool for clinicians to interpret images quickly and respond with timely, accurate decisions to deliver the most efficacious therapy.

FERTILITY SCAN

Ultrasonographic imaging is an effective, easy to use, safe, and readily available noninvasive means to evaluate fertility potential.
It has become one of the most useful tools available to assess the causes of infertility and to implement many of the treatments used to ameliorate infertility.
“One-stop shop” fertility testing has been recently introduced to provide infertility couples an easy and reliable way to fast results & provide valuable information about fertility potential within one hour during one visit.
The aim is to enable complex investigations within one hour providing time for discussions with a reproductive medicine specialist who will discuss management options with the couple.
Investigation of the woman is based upon the availability of high-quality ultrasound equipment with Doppler and (preferably) 3D facilities and usually involves assessment of tubal patency.
Investigations on the male partner are run in parallel and semen analysis results should be available for the post test discussions.

Procedure-

In a fertility scan a transvaginal scan is done with a high-resolution ultrasound machine with sensitive colour and spectral Doppler modalities to give the best results.
Three-dimensional (3D) ultrasound, although not essential, can provide additional valuable information and in future 3D colour power angiography (3D – CPA) may become an essential prerequisite.

TIMING OF FERTILITY SCAN-

Timing of the scan is also important and should be performed in following days-
Between days 10-12 of a regular (28 day) menstrual cycle to determining whether a ‘good’ dominant follicle is present & to assess the endometrial response.
Ovarian reserve assessment in a female is best performed on day 2-3 of the menstrual cycle,

USE OF ULTRASOUND IN INFERTILITY-

UTERUS: The aim of the scan is to demonstrate

Whether the uterus is anteverted or retroverted
Whether the uterus is mobile, semi mobile or immobile in the pelvis.
Dimensions of the uterus in all three planes should be measured (longitudinal, anteroposterior, transverse). A length of at least 75 mm (from fundus to cervix) is considered normal.

Endometrium-

An important aspect of the fertility scan is the examination of the endometrium in the assessment of endometrial receptivity.
Pre-ovulatory, triple layer endometrium with good spiral artery flow.
A trilaminar appearance with a minimum thickness of 7 mm and a uterine artery pulsatility index of less than 3 with the help of DOPPLER ULTRASOUND are regarded as reliable markers of good endometrial receptivity.
TVS is also done to excluding gross abnormalities of the uterus & cervix such as-
Congenital Anomalies (septate uterus, bicornuate and didelphys uterus)
Large Fibroids
Polyps
Aschermann syndrome
Adenomyosis
Echogenic or thin endometrium

3D/4D scan of uterus-

It is routinely performed to obtain a coronal plane of the uterus to identify anatomical congenital defects and also to demonstrate the precise position of submucous fibroids & polyps.

Large fibroids that grossly distort the endometrial cavity, or endometrial polyps greater than 5mm, require removal before fertility treatment begins.

Cervix:

Cervical-corporal ratio (1:2) should be assessed excluding “infantile-type” of uterus.
To see for cervical length.
To diagnose cervical incompetence.
A clear layer of mucus in the cervical canal is a favorable sign reflecting good level of estrogen production.

FALOPIAN TUBES:

Normal tube is usually invisible on ultrasound unless there is free fluid present in pelvis.
We are looking for tubal abnormalities like hydrosalpinx or swollen tubes suggestive of tubal disease.

OVARY:

Position, size and morphology of Ovaries.
Movement of the ovaries in relation to the uterus in response to abdominal palpation.
To assess accessibility of the ovaries for transvaginal egg collection in IVF.
ANTRAL FOLLICLE COUNTS can be assessed at any age to look for a reduction in follicle population, reflecting a reduction in fertility potential.
The DETECTION OF OVULATION is very important in the treatment of infertility.
Ultrasound is an important aid in predicting the time of ovulation more accurately than the basal body temperature and faster and cheaper than hormone profiles.
OVUM PICK-UP: Ultrasound is also used in transvaginal oocyte retrieval to obtain human eggs (oocytes) through sonographic directed transvaginal puncture of ovarian follicles in IVF.
Through transvaginal sonography ovarian cysts can be aspirated.
EMBRYO TRANSFER-At the end of IVF, the embryo is placed back into the uterus under transabdominal ultrasound guidance.

SSG (Tubal Patency Test)-

Sonosalpingography also known as Sion test, is a diagnostic procedure primarily used for evaluating patency of fallopian tubes.
It was introduced as a screening procedure for infertility investigations.
It is becoming more popular among practitioners due to absence of side effect.

PROCEDURE-

Under ultrasound scanning, a slow and deliberate injection of about 200 ml physiologic saline into the uterine cavity is accomplished via Foley catheter. An inflated bulb of the catheter prevents leakage of fluid outside uterine cavity. By visualizing the flow of saline along the tube and observing it as a shower at fimbrial end, tubal patency can be tested.

Presence of free fluid in pouch of Douglas also confirms tubal patency.

GYNECOLOGIC ULTRASONOGRAPHY –

Gynecologic sonography refers to the application of medical ultrasonography to the female pelvic organs (specifically the uterus, the ovaries, and the fallopian tubes) as well as the bladder, the adnexa, and the recto-uterine pouch.
The procedure may lead to other medically relevant findings in the pelvis.

Use of Ultrasound in Gynecology-

Gynecologic sonography is used extensively

To assess pelvic organs
To diagnose acute appendicitis.
To diagnose and manage gynecologic problems including endometriosis, leiomyoma, adenomyosis
To diagnose different ovarian cysts and lesions like dermoid cyst, complex ovarian cyst, hemorrhagic cyst, simple follicular cyst etc.
To diagnose PCOD (Polycystic ovarian disease)
To identify adnexal masses, including ectopic pregnancy.
To diagnose gynecologic cancer.

Sonohysterography / Saline Infusion Sonography (SIS)-

Sonohysterographyis a specialized procedure by which fluid, usually sterile saline (then called saline infusion sonography or SIS), is instilled into the uterine cavity, and gynecologic sonography performed at the same time.
SIS is highly sensitive in the detection of intrauterine abnormalities in subfertile women, comparable to hysteroscopy.
SIS is highly sensitive and specific test in the diagnosis of-

1-uterine polyps

2-submucous uterine fibroids

3- uterine anomalies

4- intrauterine adhesions (as part of Asherman’s syndrome),