2. Ultra Sonography In Assisted Reproduction
Dr. zohreh lavasani
Obstetrics & Gynecology Department
ARASH HOSPITAL
lIan Tur-Kaspa and laurel Stadtmauer 48
Ultra Sonography In Assisted Reproduction

3. Ultra Sonography In Assisted Reproduction1 2
INTRODUCTION
1) Ultrasound of the OVARY
2) Ultrasound of the uterus
3) Ultrasound of the FALLOPIAN TUBES
4) Ultrasound -guided IVF PROCEDURES (OR, ET)
5) Ultrasound For THE DIAGNOSIS AND TREATMENT OF ART COMPLICATIONS AND OUTCOME
CONCLUSIONS

4. 3) Ultrasound of the FALLOPIAN TUBES
Ultra Sonography In Assisted Reproduction
3) Ultrasound of the FALLOPIAN TUBES
Fallopian Tube Patency, Doppler and 3D Ultrasound, Hydrosalpinges and ART Outcomes

5. Fallopian Tube Patency
3- Ultrasound of the
FALLOPIAN TUBES
Fallopian Tube Patency
Tubal occlusion is seen in approximately 20% of women with infertility.
The traditional gold standard for tubal evaluation is laparoscopy with chromopertubation or HSG, and both have advantages and disadvantages.

6. Fallopian Tube Patency
After transcervical installation of saline, the cul-de- sac was evaluated for the appearance of free f1uid.
If free f1uid was visualized then it was concluded that at least one of the tubes were patent.
The ultrasonographic evaluation of tubal patency is referred to as hysterosalpingo contrast sonography (HyCoSy).

7. Fallopian Tube Patency
HyCoSy can be performed using air mixed with saline or Galactose-based microbubbles solution, Echovist.
HyCoSy is usually performed by injecting a small amount of contrast agent into the uterus via an intracervical balloon catheter.
During the instillation process a TVS is performed to assess for tubal f10w of contrast material and/or accumulation of contrast material in the pouch of Douglas.

8. Fallopian Tube Patency
HyCoSy allows for the evaluation of both the fallopian tubes and the uterus.
If intrauterine pathology is detected it is relatively easy to differentiate between uterine polyps and myomas.
HyCoSy is fairly well tolerated by patients and can usually be performed in less than 20 minutes.
Several studies have shown that for the diagnosis of tubal patency, HyCoSy is comparable to X-ray HSG and laparoscopic.

9. Fallopian Tube Patency
Agitated saline is produced by placing 19 cc of saline and l cc of air in a 20 mL syringe.
The syringe is then vigorously shaken and the mixture is injected into the uterus using a balloon catheter.
Care should be taken with this technique to insure the air alone is not accidentally injected into the uterus.

10. Fallopian Tube Patency
Sonographic criteria for tubal patency were bubbles entering the fallopian tube without production of a hydrosalpinx or exit of bubbles into the peritoneal cavity.
The results showed that tubal patency was confirmed in 89% of the tubes.
While HyCoSy can be a useful screening tool, there are several factors that decrease its utility.

11. Fallopian Tube Patency
The fallopian tubes often follow a tortuous course and it may be difficult to follow the passage of contrast through the entire length of the fallopian tube.
In addition, it is almost impossible to obtain an entire view of the fallopian tube on one 2D ultrasound image and it is difficult to image the distal ends of the tubes, if there are no hydrosalpinges.

12. Fallopian Tube Patency
Therefore, 2D HyCoSy requires significant skill on the part of the ultrasonographer.
There is also a significant learning curve associated with 2D HyCoSy.
Therefore, the visualization of true spill from the fimbriated end of the fallopian tube remains difficult.

13. Fallopian Tube Patency
Moreover, tubal pathology such as mucosal folds or salpingitis isthmica nodosa cannot be evaluated using HyCoSy.
Nevertheless, HyCoSy is an excellent tool for the assessment of tubal patency when performed by an experienced sonographer, and in many centers, especially in Europe, it serves as the first test for the evaluation of tubal patency.

14. 3- Ultrasound of the
FALLOPIAN TUBES
Doppler and 3D Ultrasound
The use of color Doppler with 2D HyCoSy has been shown to increase the ability to diagnose true tubal occlusion and help differentiate between the contrast material that has spilled out of the tube and the surrounding bowel.

15. Doppler and 3D Ultrasound
The accuracy color Doppler mapping for tubal patency compared to HSG and laparoscopy was with sensitivity of 76% with a specificity of 81% and a PPV and NPV of 66% and 89%, respectively.
The ability of 3D ultrasound to depict entire volumes of tissue makes it ideal for HyCoSy.
Using 3D ultrasound, a volume of the entire fallopian tube can be obtained.

16. Doppler and 3D Ultrasound
The volume can then be manipulated and the tube can be followed throughout its entire length.
In addition, 3D color power Doppler can be used to depict the flow of contrast material through the entire length of the fallopian tube.

17. Doppler and 3D Ultrasound
In addition 3D-HyCoSy with color power Doppler seems to be accurate as it was found to agree with laparoscopy with chromopertubation 99% of the time.
The region of interest is selected by placing the 3D ultrasound box over the parametrium.

18. Doppler and 3D Ultrasound
Then the probe is held in place as the contrast is instilled into the uterus and tubes.
The ultrasound machine automatically sweeps the predefined area of interest and acquires all the images.
As a result, 3D HyCoSy is less operator dependent, easier to perform, and has less of a learning curve than 2D HyCoSy.

19. Doppler and 3D Ultrasound
Moreover, 2D HyCoSy can only be evaluated in real time (unless the examination is taped).
On the other hand, 3D HyCoSy can be evaluated anytime by simply reviewing the saved volumes.
Consequently, the volumes can be reinterpreted, if necessary, to evaluate different angles or answer.

20. Hydrosalpinges decrease IVF PRs by 50% .
3- Ultrasound of the
FALLOPIAN TUBES
Hydrosalpinges and ART Outcomes
Hydrosalpinges decrease IVF PRs by 50% .
Even hysteroscopic tubal occlusion had been suggested for some patients.
If a hydrosalpinx appears during stimulation, ultrasound guided aspiration of hydrosalpinges at oocyte collection can be an option.

21. Hydrosalpinges and ART Outcomes
A randomized, blinded study showed that 30% of the fallopian tubes in the aspiration group re- accumulated by 14 day after the aspiration.
This study implies that the window of opportunity may be present at oocyte aspiration, but not significantly earlier and even then, there may be re-accumulation by the transfer.

22. Hydrosalpinges and ART Outcomes
Aboulghar et al. (143) reported that aspiration one month prior to retrieval did not improve pregnancy rates.
If a hydrosalpinx develops during stimulation, an alternative option is to freeze all embryos and perform a salpingectomy later.

23. 4) ULTRASOUND-GUIDED IVF PROCEDURES
Ultra Sonography In Assisted Reproduction
4) ULTRASOUND-GUIDED IVF PROCEDURES
OOCYTE RETRIEVAL (OR)
EMBRYO TRANSFER (ET)

24. Laparoscopy was the first technique used for oocyte retrieval.
4- ULTRASOUND-GUIDED
IVF PROCEDURES: OR & ET
Laparoscopy was the first technique used for oocyte retrieval.
The ultrasound-guided follicular aspiration was first described in the early 1980s .
It is usually performed under sedation with a 17-gauge needle.
This size needle is optimal as it is thick enough to avoid deviating from the puncturing line and not too narrow to avoid harming the oocyte-cumulus complex.

25. 4- ULTRASOUND-GUIDED
IVF PROCEDURES: OR & ET
Thinner needles and lower pressure should be used for the in-vitro maturation technique of aspiration of immature eggs and smaller follicles.
The tip of the needle is echogenic and can be visualized at all times and is aligned with the ultrasound beam.
Care should be made to avoid blood vessels, bowel, or bladder, especially the internal iliac vein and artery.

26. 4- ULTRASOUND-GUIDED
IVF PROCEDURES: OR & ET
The current standard of care for oocyte retrieval is transvaginal aspiration under ultrasound guidance and there are no RCTs comparing the techniques of transabdominal versus transvaginal approaches.
Flushing of follicles has not been shown to make a difference in oocyte yield, is known to take more time, and should not be routinely performed.

27. 4- ULTRASOUND-GUIDED
IVF PROCEDURES: OR & ET
ET is a critical step in ART and can be performed with or without ultrasound guidance.
The ultrasound-guided ET significantly improved clinical PR (OR 1.49, CI , P< ) .
There were no statistical differences for ectopic pregnancy, miscarriage, or multiple gestation rates.

28. 4- ULTRASOUND-GUIDED
IVF PROCEDURES: OR & ET
Ultrasound guidance of the transfer catheter resulted in higher PRs in all but one of the studies identified; this difference was significant in five of the eight studies.
The one study, which did not show any difference, varied from the others in several ways.

29. 4- ULTRASOUND-GUIDED
IVF PROCEDURES: OR & ET
The Cochrane review (148) also compared the incidence of retained embryos for ultrasound versus clinical touch.
In one study the catheter touched the top of the uterus in 35% of the transfers and the reduction of retained embryos occurred by ultrasound guidance with mid-uterine ET.

30. Retained embryos lead to an increased risk of blood on the catheter.
4- ULTRASOUND-GUIDED
IVF PROCEDURES: OR & ET
Retained embryos lead to an increased risk of blood on the catheter.
Blood on the catheter decreased PR by %.
The majority of programs are using ultrasound guidance and our experience has shown improvement.

31. 4- ULTRASOUND-GUIDED
IVF PROCEDURES: OR & ET
The advantages of ultrasound guidance are that the physician can avoid touching the fundus with the catheter and can reduce the incidence of difficult transfers by allowing the direction of the catheter along the contour of the cavity and make sure the embryos are placed properly.

32. 4- ULTRASOUND-GUIDED
IVF PROCEDURES: OR & ET
Several transfer catheters with echogenic tips have been produced, which make it easier to visualize the placement, but without significant increase in pregnancy rates.
A few studies on comparing 2D versus 3D ultrasound guidance show a possible advantage of 3D in monitoring catheter placement but this is not commonly used.

33. 5) ULTRASOUND FOR THE DIAGNOSIS AND TREATMENT OF
Ultra Sonography In Assisted Reproduction
5) ULTRASOUND FOR THE DIAGNOSIS AND TREATMENT OF
ART COMPLICATIONS AND OUTCOME
OHSS, Early Pregnancy Complications and Multiple Pregnancies

34. 5- ULTRASOUND OF ART
COMPLICATIONS AND OUTCOME
Ultrasound for the Diagnosis and Treatment of
Ovarian HyperStimulation Syndrome (OHSS)
OHSS is a serious iatrogenic condition that arises in women undergoing ovulation induction with fertility medication, and occurs during the luteal phase of the ovulatory cycle after hCG trigger, peaking usually 3 to 7 days later or during early pregnancy.

35. Diagnosis and Treatment of OHSS
Ultrasound for the
Diagnosis and Treatment of OHSS
The incidence of severe OHSS ranges from 0.5% to 5% with increased risks in women with PCOS, thin, young women and women using long luteal agonist protocols with high E2 levels ( ).
It is characterized by vascular endothelial growth factor (VEGF) overexpression, ovarian enlargement, and pelvic discomfort.

36. Diagnosis and Treatment of OHSS
Ultrasound for the
Diagnosis and Treatment of OHSS
In more severe cases, abdominal distention, nausea and vomiting, and ascites and pleural effusions also may occur.
Patients may develop oliguria, tachypnea, and blood clots.
The ovaries can grow to more than 5-10 cm in diameter, predisposing them to torsion

37. Diagnosis and Treatment of OHSS
Ultrasound for the
Diagnosis and Treatment of OHSS
Sonographic findings in patients with OHSS include markedly enlarged multicystic ovaries.
Doppler evaluation may be performed in symptomatic patients to help assess for torsion, although the presence of blood flow does not exclude the diagnosis in either the abdominal or the vaginal approach under ultrasound guidance.

38. Early Pregnancy Complications and Multiple Pregnancies
5- ULTRASOUND OF ART
COMPLICATIONS AND OUTCOME
Early Pregnancy Complications and Multiple Pregnancies
Ultrasound is essential for the diagnosis of clinical pregnancy, for position of the pregnancy, and the number of sacs and fetuses.
The emphasis has been on reducing the number of embryos transferred to reduce the risk of multiple births.

39. Early Pregnancy Complications and Multiple Pregnancies
In a normally developing pregnancy a blastocyst implants by 23 days of menstrual age.
The first structure identified by TVS is the gestational sac (GS) as a spherical, fluid-filled cavity surrounded by an echogenic rim.
A double decidual sac sign is a reliable signal of an intrauterine pregnancy (IUP)

40. Early Pregnancy Complications and Multiple Pregnancies
There is a correlation between sac size and hCG level and gestational age, but there is variability and it is helpful to monitor sequential sonographic milestones.
The first structure inside the GS is the yolk sac (YS), followed by the embryo.
The YS is a spherical, echogenic ringlike formation with a sonolucent center and its presence confirms a true IUP with 100% PPV.

41. Early Pregnancy Complications and Multiple Pregnancies
The confirmation of YS is necessary by menstrual days or six weeks gestation.
Fetal heart rate is visible from six weeks and two days gestation based on embryo transfer dates.
It is seen as a linear echo density next to the yolk sac.
The embryo or fetal pole is measured along its long axis and is called a "crownrump length" (CRL).

42. Early Pregnancy Complications and Multiple Pregnancies
Sub-chorionic hematoma, a fluid collection between the chorionic membrane and deciduas, is very common with ART pregnancies and is associated with abnormal placentation and higher risks of miscarriages.
Twinning should be classified as either monozygotic (a single ovum divides into two embryos) or dizygotic (two separate ova) and dichorionic! diamniotic, mono-chorionic! diamniotic or mono- chorionic/ mono-amniotic.

43. Early Pregnancy Complications and Multiple Pregnancies
A pregnancy of unknown location may require serial ultrasounds.
Ultrasonography is the primary diagnostic modality for ectopic pregnancy.
The visualization of a fluid-filled sac outside the uterine cavity that contains an embryo or a yolk sac is definitive for ectopic pregnancy.
An adnexal mass with the "tubal ring" is also highly predictive.

44. Early Pregnancy Complications and Multiple Pregnancies
The presence of an IUP in an asymptomatic patient conceived by IVF should not exclude the diagnosis of a concurrent ectopic called heterotrophic pregnancy, so evaluation of the adnexa should be done in all circumstances.

45. Ultra Sonography In Assisted Reproduction
CONCLUSIONS

46. CONCLUSIONS
Modern ART and infertility treatments cannot be imagined today without ultrasound imaging, and advances in both fields have occurred simultaneously.
Using advanced ultrasound techniques for the assessment of uterine cavity and tubal patency should eliminate almost completely women fear of pain from such procedures (159).

47. As costs decrease, Accessibility will increase.
CONCLUSIONS
The use of 3D visualization of the pelvic structures is the most striking advancement in the use of ultrasound in ART.
As costs decrease, Accessibility will increase.

48. CONCLUSIONS
The future will bring smaller and portable ultrasounds for increased access in underserved communities as well as more standardization and
increased automation with savings in time and possible improved outcomes.

49. With modern ultrasound usage, we can see better, and do ART better.
CONCLUSIONS
The reduction in OHSS and in multiple gestations is one of the key concerns of ART treatments and with recent advances in IVF as well as ultrasound guidance, success of mild stimulation and an elective single embryo transfer can be maximized.
With modern ultrasound usage, we can see better, and do ART better.
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50. سپاسگزارم