Ch 46 Ultrasound in Evaluating Female Infertility

inability to concieve within 12 months

infertility

provide non hostile environment for sperm

role of cervix in fertility

ultrasound used to evaluate ______ during pregnancy to assess for ______-

cervical length, cervical incompetence

in _______ uterus, length of and any opening in the in the cervix is difficult to asses

non gravid

can be used to evaluate internal os diameter

hysterosalpingography

diameter less than ____ by HSG may indicate cervical stenosis

1mm

2 main objectives when evaluating the uterus

assess structural anatomy

assess endometrium

refers to evaluating uterine shape and echogenicity

asses structural anatomy

evaluate thickness, echogenicity, and any intracavity lesions

asses endometrium

finding of congenital mullerian anomalies should alert sonographer to evaluate for

any other duplication

renal anomalies

associated with high incidence of infertility

septate uterus

can be measured throughout menstrual cycle to look for app

endometrium

thickness representing current threshold of achieving pregnancy

at least 6mm

if not enough ____ is secreted during _____ phase, endometrial lining may be ______ than expected

progesterone

luteal

thinner

AKA luteal deficiency

lack of progesterone production

may be associated with infertility and early pregnancy loss

luteal deficiency

can make endometrium appear irregular or more echogenic than normal

submucosal fibroids

polyps

adhesions (synechiae)

can be used to further delineate anatomic structure of endometrium

saline infusion sonography

fallopian tubes are evaluated for ______ and to _______

hydrosalpinx, patency

hydrosalpinx associated with ____ reduction in pregnancy rate and ______ of spontaneous miscarriage rate

50%

doubling

can dramatically improve IVF success

surgical removal of damaged fallopian tube

tubal patency is assed by

injecting saline into a tube and looking for spillage of fluid into CDS

if spillage is seen, ______ is inferred

patency

if no spillage is noted and patient complains of pain during injection

tube may be blocked

during follicular phase, there are several antral follicles on ovary greater than

5mm

follicle selected to develop into dominant follicle in response to

FSH

dominant follicle grows at rate of

1-3mm per day

average diameter of dominant follicle

22mm

once reaching diameter of 22mm, dominant follicle will

rupture

sonographic findings associated with ovulation

corpus luteum cyst

free fluid in pelvis

diagnostic triad of PCOS

oligoovulation, hyperandrogenism, polycystic ovaries

May be cause for as many as 25% of infertility cases

peritoneal inclusion cysts

peritoneal factors

adhesions

endometriosis

bands of scar tissue that can obstruct fimbriated end of fallopian tube

adhesions

sometimes fluid will collect between adhesions, resulting in

peritoneal inclusion cysts

gold standard for imaging adhesions and endometriosis

laparoscopy

treatment in which ovarian stimulation is achieved in a controlled setting

ovarian induction therapy

ovarian induction therapy step 1

obtain baseline TV scan of ovaries to rule out cysts and assess for presence of dominant follicle

if cyst measuring greater than _____ detected, could represent persistent follicular activity that could interfere with response to ovarian stimulation medication

15mm

if _________ is elevated and large ovarian cyst is present, ________ may be given to suppress follicular activity

serum estradiol

oral contraceptives

oral contraceptives often administered

clomid

letrozole

human menopausal gonadotropins

once therapy is started, US is used to monitor number and size of follicles in days _______ of menstrual cycle

8-14 (follicular phase)

sonographers will count and measure all follicles measuring

greater than 1cm

optimal mean measurement of mature follicle

22mm or 2cm

correct measurement of follicles is important because _______, a substitute for ______ may need to be given to trigger ovulation

hcG

LH

normal endometrium response associated with ovarian stimulation is

increasing thickness from 2-3mm to 12-14mm

method of fertilizing the human oocyte outside the body

IVF

ZIFT

zygote intrafallopian transfer

zygote is transferred into fallopian tube

zygote =

sperm and egg combined

mature oocytes are collected and mixed in a dish with a sample of sperm resulting in embryos that are then placed back into the uterus

IVF

treatment plan for IVF

ovarian monitoring

needle aspiration of oocytes

incubation of oocytes

fertilization

transfer embryos into uterus

optimal placement. of embryos

within 2cm of the apex of the fundus

technique used to treat male factor infertility

intrauterine insemination

fertilization outside the body

in vitro fertilization

GIFT

gamete intrafallopian transfer

Gamete =

Ege and sperm separately

egg and sperm are placed into the Fallopian tube

GIFT

sperm donor AKA

therapeutic donor insemination

complications of A.R.T

ovarian hyperstimulation syndrome

multiple gestations

ectopic pregnancies

A.R.T =

assisted reproductive treatment

presents sonographically as:

enlarged ovaries with multiple cysts

ascites

in some cases pleural effusion, leg edema, hypotension and polycythemia

ovarian hyperstimulation syndrome

often seen in younger patients who have undergone aggressive ovulation induction

more common in patients with PCOS

ovarian hyperstimulation syndrome

_______% of in vitro fertilization pregnancies result in multiple gestations

30

concern with multiple gestations is

increased risk for fetal morbidity

in pregnancies with 3 or more fetuses, patients are often counseled on

fetal reduction options

ectopic pregnancy coexisting with intrauterine pregnancy

heterotopic pregnancy

if over 35, infertility is the inability to concieve within ______ months

6

cervix provides non hostile environment with

glands that secrete mucus and crypts that hold the sperm

2 uterine cavities and a single fundus

septate uterus

congenital anomalies most easily assessed with US

septate

bicornuate

didelphys

scars or adhesions from uterine trauma and/or infections

synechiae

associated with ashermans syndrome

synechiae

proliferative

what phase of endo cycle

best predictor of ovulation

progesterone level of at least 3ng/ml

clomiphene citrate AKA

clomid