Role of Ultrasound in Evaluating Female Infertility

gyno

Infertility

the inability to conceive within 12 months with regular coitus; over 35 it’s 6 months

Infertility is estimated to affect _____ couples

1:7

Percentages of who is at fault in fertility

40% women

40% men

20% are combined male/female

Male infertility factors

inadequate number of sperm

decreased motility of sperm

scrotal varicoceles

obstruction of spermatic ducts or vas deferens

Scrotal varicoceles increase _____ ______ or heat in the ______ causing sperm to be ineffective

blood flow; testes

Cervical incompetence

cervix is too small and opens too early in pregnancy

Cervix role in infertility

provide a nonhostile environment to harbor sperm

Hysterosalpingography (HSG)

used to evaluate the internal os diameter

A cervical measurement of less than ______ may indicate cervical ______

1 mm; stenosis

Congenital uterine anomalies occur in approximately ______ of women

6.7 %

Bicornuate Uterus

two endometrial cavities, a wide body, and two fundal cavitites (“horns”)

A bicornuate uterus has a higher rate of fertility complications like

fetal malposition

preterm labor/ delivery 

miscarriage

Septate Uterus

two uterine cavities and a single fundus

A septate uterus is associated with a _____ incidence of infertility because it does not have a good ____ _____ to survive

high; blood network

A septate uterus appears as two ______ cavities without a ______ notch

endometrial; fundal

T-shaped uterus

caused by the exposure to diethlystilbestrol (DES) in utero

a T-shaped uterus _______ baby girls _______

sterilizes; in utero

There is a loss of the “three line sign” in the endometrium after

ovulation

Progesterone ramps up the endometrial ______

thickness

Luteal phase deficiency

lack of progesterone production

associated with infertility and early loss

Fibroids vs. polys blood flow

fibroids have circumferential flow

polyps have a pedicle (stalk)

Synechia

scars from uterine trauma

Tubal patency

assessed by injecting saline or contrast into the tube to look for spillage of fluid in the cul-de-sac

Dominant follicles grow at a rate of approximately ___ to ___ mm per day until it reaches an average diameter of ____ mm

1-3; 22

Once a dominant follicle hits _____ cm and isn’t going away it is considered a _____

2.5; cyst

The best predictor of ovulation is serum ______; at least _______

progesterone; 3 ng/ml

This hormone rises just before ovulation and can be found in patient’s urine

LH (luteinizing hormone)

In PCOS, follicles begin to ____ but do not develop _______

grow; normally

In PCOS, immature follicles continue to produce _______ and ________; this inhibits _______ function

estrogen and androgen; pituitary

In PCOS, the body produces more LH than _____ leading to the mature _____ being released with _________; this prevents normal ovulation

FSH; ova; ovulation

Why PCOS occurs

obesity

diabetes

thyroid, adrenal, or pituitary gland dysfunction

Endometrial carcinoma can be caused by _______ elevation of _______; can occur in PCOS because the uterus is not completely ______ out and always has a thickened ______

chronic; estrogen; cleaned; endometrium

Peritoneal factors may be the cause for as many as ________ of infertility cases

10-13%

Adhesions

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

sometimes fluid collects between these resulting in peritoneal inclusion cysts

Most common site of endometriosis

ovaries, often bilaterally

Ovarian Induction Therapy

treatment in which ovarian stimulation is achieved in a controlled setting

The first step in ovarian induction therapy is

to obtain a baseline endovaginal ultrasound of ovaries to rule out a cyst or dominant follicle

Clopiphene citrate (clomid) 

drug that results in multiple dominant follcles

Human menopausal gonadotropin

pergonal

In ovarian induction therapy, ultrasound is used to monitor the _______ and ____ of follicles days 10 to ___

number; size; 14

If a patient is taking clomid, after they become ______ their progress needs to be followed to prevent ________

pregnant; miscarriage

hCG can be a substitute for ____ that may be injected ___________ to trigger ovulation

LH; intramuscularly

Most accurate way to measure the endometrium

endovaginally and in the longitudinal plane

In Vitro Fertilization (IVF)

method of fertilizing ova outside of the body

IVF steps

1. collecting mature ova

2. mixing them in a dish with a sample of spermatoza

3. placing resulting embryo back to into uterus

IVF treatment plan consists of

ovarian monitoring

needle aspiration of oocytes

incubation of oocytes

fertilization

transferring embryo into uterus

Oocyte retrieval can be accomplished:

laparoscopically

transabdominally

endovaginally

In IVF, a _____cm 17- gauge needle is placed ___________ to guide the ovum

35; endovaginally

IVF steps

1. oocytes retrieved

2. fertilized in a dish

3. incubated for 48-74 hours

4. embryo is transferred into the uterus

Optimal placement of ________ is within ___ cm of the apex of the _______

embryos; 2; fundus

What is the function used to trace the endometrial interface from cervix to the apex of the fundus in IVF?

trace function, NEED A STEADY HAND

Ultrasound is used for guidance in

Gamete intrafallopian transfer (GIFT)

Zygote intrafallopian transfer (ZIFT)

GIFT and ZIFT are:

used for patients who have at least one functional fallopian tube

GIFT and ZIFT success rates per cycle

22-28%

GIFT vs. ZIFT

GIFT: fertilization occurs INSIDE the woman’s body

ZIFT: fertilization occurs OUTSIDE of the woman’s body

Intrauterine Insemination (IUI)

used to treat male factor infertility

In IUI, sperm _________ may be from a ______

preparation; donor

Artificial insemination using donor sperm

AID

IVF complications

Ovarian hyperstimulation syndrome (OHSS)

multiple gestations

ectopic pregnancies

Severe cases of OHSS

leg edema

ascites

pleural effusions

hypotension

polycythemia

enlarged ovaries with multiple cysts

Percentage of multiple gestations in patients who do IVF

30%

There is a concern if there are _____ or more fetuses, increased risk of fetal and neonatal _______ and ________

3; mortality; morbidity

Fetal reduction options

performed by injecting potassium chloride into the fetal chest or heart

Patients who undergo ART are at an increased risk for ________ or ________ pregnancy

ectopic; heterotopic

Heterotopic pregnancy ratios

1:4000 but with ART is 1:100