ultrasound of the female pelvis Chapter 31 Infertility Holdorf ultrasound of the female pelvis

Contents Causes of Infertility Ovulation Induction Ovulation Monitoring Assisted Reproductive Technologies Infertility Complications Multiple Gestations

There are many causes for infertility, which affects one in seven American couples. Approximately 40% are due to female factors, 40% to male factors, 5-10% is related to both partners, and 5-10% is unexplained.

Female factors include:   Anovulation and abnormal ovulation Tubal transport factors (Adhesions, hydrosalpinx) Endometriosis Uterine factors (myomas, congenital anomalies) Polycystic ovarian disease Others

Sonography is very valuable for baseline evaluation (both transabdominal and endovaginal imaging) to document any preexisting conditions. It is also used in in-vetro fertilization programs to:

Establish normal uterine anatomy and evaluate endocrine indicators, such as thickness and texture of the endometrium, and the presence of either intra-cavity lesions or intra-cavity fluid.   Monitor the development of the growing follicles, and thus determine the timely injection of hCG to trigger ovulation. Confirm ovarian response to various drugs (Clomid, Pergonal) or identify hyper stimulated ovaries. Guide oocyte collection from the ovaries.

Ovulation Induction Several pharmacologic agents can be used to induce satisfactory ovulation and increase the chances of fertilization. A few are as follows:

Clomid, Serophone – Medication comes in a tablet form and is used for women who have infrequent periods or long menstrual cycles Gonadotropin is an injectable medication that is used to induce the release of the egg once the follicles are developed and the eggs are mature. Glucophage- is given to patients as an insulin lowering medication. Most commonly used in polycystic ovarian syndrome patients, the medication has been shown to reverse the endocrine abnormalities seen with PCOS within two or three months. Parlodel-is a medication used to reduce pituitary tumor size, should one be present. Parlodel has few side effects and is relatively inexpensive.

Ovulation Monitoring Endovaginal Sonography (EVS) is the method of choice for monitoring follicular development. Follicles are typically aspired for IVF when they measure 18-24mm.

In Vitro vs. In vivo In vitro: performed or taking place in a test tube, culture dish, or elsewhere outside a living organism. In vivo: performed or taking place in a living organism.

IVF sonographic protocol Baseline transabdominal sonogram Preliminary EV evaluation of follicles Daily EV to monitor dominant follicle

Ovulation monitoring

ASSISTED REPRODUCTVIE TECHNOLOGIES Over the years, numerous assisted reproductive techniques have been developed, many of which use ultrasound for follicle monitoring or catheter guidance.

In Vitro Fertilization (IVF) Consists of ovarian stimulation, needle aspiration of the oocytes, incubation of the oocytes with sperm, and catheter delivery of two or four developing embryos into the uterus.

IVF

Zygote Intrafallopian Tube Transfer (ZIFT) Embryo or zygote is placed into the fallopian tube rather than the uterus as with IVF, via EV guided cannulization.

ZIFT

Gamete Intrafallopian Tube Transfer (GIFT) Sperm and ova are placed into the fallopian tube via EV guided cannulization

GIFT

What are the differences between GIFT and ZIFT? GIFT (gamete intrafallopian transfer) and ZIFT (zygote intrafallopian transfer) are modified versions of in vitro fertilization. Like IVF, these procedures involve retrieving an egg from the woman and re-implanting it after manipulation. Unlike IVF, the timing between mixing the sperm and eggs and the transfer is faster. In GIFT, the sperm and eggs are mixed together and immediately inserted. On the other hand, with ZIFT, the fertilized eggs -- ”zygotes”-- are inserted within 24 hours of the mixing.

Intrauterine Insemination In cases of male factor infertility, ultrasound may on occasion be used to guide catheter placement of a sperm preparation into the uterine fundus.

Intrauterine Insemination Intrauterine insemination (IUI) is a fertility treatment that involves placing sperm inside a woman's uterus to facilitate fertilization. The goal of IUI is to increase the number of sperm that reach the fallopian tubes and subsequently increase the chance of fertilization.

Infertility Complications Every medical procedure has some risks involved. Infertility treatments has certain complications associated with it.

Infertility treatment complications: OHSS: Ovarian Hyperstimulation Syndrome Multiple births

Ovarian Hyperstimulation syndrome (OHS) A condition resulting from excessive stimulation of the ovaries, OHS most commonly occurs in women taking infertility drugs. Mild cases usually resolve spontaneously following the next menstrual cycle. More severe cases are associated with a high mortality rate (up to 50%) and may require hospitalization for correction of fluid and electrolyte imbalances. OHS tends to be more severe in patients who conceive.

OHS Sonographic Findings Large simple cysts, with an ovarian diameter > 5 cm Bilateral Resemble theca lutein cysts

Hyperstimulated Ovary

OHS

Multiple gestations Incidence of multiples increases with more prevalent and successful infertility treatments. Multiple gestations can complicate pregnancy by impacting maternal health and well-being, Fetal outcome and there higher medical costs.  

Complications include: Although fertility drugs improve the egg production, it also increases a woman’s change of conceiving multiple births. Multiple pregnancies is one of the greatest health risks associated with infertility treatments like IVF. Complications include: Premature births Low birth weight High blood pressure Gestational diabetes

Infertility treatment Multiples