Assisted Reproductive Techniques_ Gyn US

what is infertility?

common disease that impacts 1 in 8 couples.

when is an infertility diagnosis made?

• for couples where the woman is less than 35 and there is a failure to conceive after 1 year of unprotected intercourse

• for couples where the woman is OVER 35 and there is failure to conceive after 6 months of attempts

what are things that contribute to rising infertility?

• increasing sexually transmitted disease

• delay of childbearing

• increasing damage from endometriosis

what is included in reasons for increasing sexually transmitted disease?

• Earlier onset sexual activity

• Multiple partners

• More women having cervical procedures due to cervical dysplasia or cancer

what does increasing sexually transmitted disease result in?

Results in higher incidence of PID

what is included in reasons for delay of childbearing?

• women putting career first

• couples choosing to delay for many years

know this image

how does sonography help?

in treatment and diagnosis of infertility

how can sonography be used to aid in diagnosis?

• transvaginal US

• structural anomalies and pathologies of uterus, tubes and ovaries

• Saline Infused Sonohysterography

• evaluate infertility in males

evaluate this image

what does uterine assessment evaluate?

• congenital anomalies

• expected appearance of endometrium during stage of uterine cycle

• uterine fibroids

3D uterine evaluation is rapidly growing as a technique to detect…

endometrial and myometrial abnormalities

what uterine congenital anomaly is most commonly associated with infertility?

septate uterus

what uterine congenital anomaly is associated with premature labor?

bicornuate uterus

what uterine congenital anomaly is associated with 2nd trimester pregnancy loss?

unicornuate uterus

where is the focus when assessing ovaries?

ovarian reserve and antral follicles

define ovarian reserve:

estimation of a woman’s remaining follicles

define antral follicle count:

the number of follicles measuring 2-10 mm early in the ovarian cycle (chocolate chip cookie count!)

what does antral follicle count do?

helps assess a woman’s potential for success for fertility treatments

varies according to woman’s age

antral follicle count is obtained via…

US using sweeping technique by sonographer

what is antral follicle count compared to?

AMH levels?

• helps in diagnosis of decreased ovarian reserve (DOR)

how does sonography assist in evaluating ovarian dysfunction?

• evaluating amenorrhea and oligomenorrhea

• detecting PCOS appearance which indicates anovulation

what endometrial measurement indicates poor implantation rate?

less than 6 mm

what is shown?

Asherman Syndrome/ Intrauterine Synechiae

what is shown?

endometrial polyp

what is shown?

submucosal leiomyoma

what plays a vital role in evaluating the myometrium?

3D Endovaginal sonography (EVS)

• can avoid radiation exposure of HSG if using 3D ultrasound

what structural anomalies are found in the myometrium?

• Fibroids

  • Distort Uterine Cavity

  • Impair blood supply to placenta

• Congenital Anomalies

• Adenomyosis

• Cause infertility by interfering with implantation

treatment of adenomyosis will…

render woman infertile

what is the source of infertility in approx. 14% of couples

occlusion of fallopian tubes

what is the source of about 25-35% of infertility?

damage to fallopian tubes

what can cause damage to fallopian tubes?

• endometriosis

• tubal infections (PID)

• previous ectopic pregnancy

• previous tubal surgery

• congenital strictures

one case of PID…

greatly increases risk of infertility

gold standard for assessing Fallopian Tubes?

laparoscopy

what is the imaging method of choice for fallopian tubes?

hysterosalpingogram (fluoroscopy)

what does SIS do?

• saline infused sonohysterography (SIS)

• avoids radiation exposure and helps visualize the tubes

what does visualization of fluid in cul de sac following an SIS mean?

demonstrates patency of at least one tube

what helps improve visualization of fluid flowing out of tube?

Color Doppler

what is a baseline sonogram?

• done as part of initial workup

• evaluates structures and do antral follicle count

when must a baseline sonogram be done?

• preferred to do in first few days of cycle/ EARLY FOLLICULAR phase (around day 3)

  • we do baseline US on period/ late period because there is nothing going on hormone wise

• MUST be done prior to any sort of medication treatment

what is in vitro fertilization?

fertilization of harvested oocyte by selected sperm in a petri dish

“test tube baby”

what are ART methods?

• controlled stimulation of ovaries

• intrauterine insemination

• oocyte harvest from stimulated follicles

• intracystoplasmic sperm injection (ICSI)

what is oocyte harvest from stimulated follicles?

IVF with embryo transfer

what is intracystoplasmic sperm injection (ICSI)?

sperm is injected into oocyte

what does a baseline sonogram evaluate for?

• uterine anomalies (fibroids, endometrial abnormalities, and congenital anomalies)

• ovarian masses

• PCOS

• baseline antral follicle count

• measure ovarian follicle

what are Clomid and Letrozole?

common fertility medications that stimulate secretion of FSH and LH from pituitary gland

what do hCG injections do?

helps induce/ force ovulation

what are progesterone suppositories?

support implantation and early pregnancy by improving receptivity of endometrium

what is the first step of fertility treatment usually?

ovulation induction with fertility medication like letrozole (aka femara)

what does ovulation induction result in?

a single dominant follicle

the ovulation induction technique is used on what women?

women who are anovulatory

• draw serial blood samples to monitory hormone levels

• do serial EV sonograms to monitor development of follicle

what is Controlled Ovarian Hyperstimulation (COH)?

used for couples with unexplained infertility

• deliberately induce formation of multiple follicles for oocyte harvest or IUI

what is IUI?

want 3-4 follicles to develop and ovulate to improve chances of sperm finding one to fertilize

• increase likelihood of multiple pregnancy

what is used in IUI?

• use either clomid or gonadotropins

what is oocyte harvest?

use injectable gonadotropins

• once follicles reach 16-20 mm diameter, use US guidance to aspirate oocytes from follicles

what does oocyte harvest have increased risk of? what is there no increased risk of?

• Increased risk of Ovarian Hyperstimulation Syndrome (OHSS)

• No increased risk of high order multiples because not all eggs are fertilized/implanted.

for patients on clomid/ letrozole, may…..

• may only do a single EV exam 5 days after last dose of medication to document follicle response

• follicle should grow 1-2 mm/ day and should reach about 20 mm diameter at ovulation

for patients on injections…

closer monitoring is needed

• medication dosage adjusted based on follicular response seen sonographically

• ASRM recommends performing sonogram after 4-5 days of treatment and then every 1-3 days following depending on follicular response.

• Important to monitor for OHSS & to time hCG injection

how do you measure ovarian follicles?

• inner to inner

• get average diameter by measuring length, width, and height. add them together and divide by 3.

when monitoring ovarian follicles, what follicles should be measured and reported?

measure and report mean diameters of each follicle greater than 10 mm

when should hCG injections be timed/ done?

when largest follicle has mean diameter of about 17 mm and other follicles are at least 15 mm

what does 3D US aid in with the monitoring of ovarian follicles?

automated measurement and counting of follicles

what is visualized?

controlled ovarian stimulation

understand 3D follicle count image:

what occurs during the periovulatory period?

• At mid-cycle, document follicle size and endometrial thickness and appearance.

• When follicles reach desired size, hCG is injected to trigger ovulation for patients undergoing IUI or timed intercourse or to mature follicles for aspiration.

• Ultrasound guidance is utilized for oocyte harvest.

what is ovarian hyperstimulation syndrome?

• OHSS

• serious complication

symptoms of Ovarian Hyperstimulation?

• mild abdominal discomfort

• hemodynamic shift resulting in massive ascites and pleural effusions

• acute renal failure manifested as oliguria

in severe cases, what can occur in ovarian hyperstimulation syndrome?

ovaries will be very large (over 10 cm in diameter) and are at increased risk of torsion or rupture.

• rupture and hemorrhage can be fatal

what should be done if OHSS is mild?

if severe?

if no pregnancy?

• If mild, continue treatments and monitor

• If severe, discontinue treatments, withhold hCG injection, monitor closely.

• If no pregnancy, symptoms will resolve on their own.

  • Most often accompanies pregnancy, resulting in hospitalization & paracentesis with severe symptoms.

what is shown?

controlled ovarian stimulation

oocyte harvest is done under…

EV sonographic guidance using sterile technique

what occurs during embryo transfer?

• After IVF or ICSI, zygote is incubated for 3-5 days before implantation.

• Goal is successful singleton pregnancy

• Done with sonographic guidance.

• transabdominal approach with a full bladder.

some countries ban…

why?

anything more than one embryo transferred at a time

• increases cost for patients if they dont have have a successful first time

• reduces multiple pregnancy outcomes

in USA, typically how many embryos are implanted?

can be 1-5 embryos depending on patient’s age and history predicting likelihood of success.

• TYPICALLY implant 1-2, rarely more than 3

how do we monitor success of implantation?

• Regardless of technique, pregnancy test and/or sonogram are performed 1-3 weeks following ovulation, insemination, or oocyte harvest. (About 1-2 weeks after embryo transfer)

• Of course, will monitor pregnancy throughout gestation as with any “high risk” pregnancy

when should you look for heartbeat in monitoring success of implantation?

6.5 weeks after LMP or 4 weeks after fertilization

what is multi-fetal reduction?

• In cases of development of 3 or more embryos, couples may be counseled to abort all but 2 embryos.

• Saline injected into gestational sac of embryos who are smaller or who are easier to access.

• Done with sonographic guidance.