1. Copyright © 2014 Wolters Kluwer All Rights Reserved Chapter 14 Infertility

2. The Clinical Problem Female infertility affects 10% of couples. Sonograms of the ovaries and uterus are one of the first investigations performed. Ultrasound is also used following follicular development and egg retrieval. Sonographer also looks for structural problems: congenital malformations, blocked pathways of sperm and ovum, distortion of endometrial cavity. 2 Copyright © 2016 Wolters Kluwer All Rights Reserved

3. The Clinical Problem Menstrual cycle physiology – Average cycle lasts 28 days – Varies from 25 to 35 days – Day 1 is first day of bleeding 3 Copyright © 2016 Wolters Kluwer All Rights Reserved

4. Anatomy Vagina Urethra Uterus Size Position Shape Menstrual cycle changes Fallopian tubes 4 Copyright © 2016 Wolters Kluwer All Rights Reserved

5. Anatomy Ovaries Location Size Menstrual cycle changes Pelvic muscles Ligament Spaces surrounding the uterus 5 Copyright © 2016 Wolters Kluwer All Rights Reserved

6. Anatomy 6 Copyright © 2016 Wolters Kluwer All Rights Reserved

7. Anatomy 7 Copyright © 2016 Wolters Kluwer All Rights Reserved Diagram of uterus.Sonographic image of uterus.

8. Anatomy 8 Copyright © 2016 Wolters Kluwer All Rights Reserved 3D view of the uterus showing the secretory endometrium extending toward the fallopian tubes at the fundus (arrows), forming the cornu.

9. Anatomy 9 Copyright © 2016 Wolters Kluwer All Rights Reserved Proliferative endometrium. Midcycle endometrium. Secretory endometrium.

10. Anatomy 10 Copyright © 2016 Wolters Kluwer All Rights Reserved Right adnexa showing the ovary. t n v ut

11. Anatomy 11 Copyright © 2016 Wolters Kluwer All Rights Reserved Ovarian follicles in early cycle.Corpus luteum (developed after ovulation at day 16).

12. Anatomy 12 Copyright © 2016 Wolters Kluwer All Rights Reserved Posterior cul-de-sac fluid (*).

13. Technique 13 Copyright © 2016 Wolters Kluwer All Rights Reserved Transvaginal scanning (endovaginal scanning, vaginal scanning) Preparation Instrumentation Transvaginal probe technique Orientation Transabdominal scanning

14. Pathology Congenital uterine malformations Polycystic ovaries Endometriosis Pelvic inflammatory disease Fibroids Uterine synechiae Ovulation disorders 14 Copyright © 2016 Wolters Kluwer All Rights Reserved

15. Guiding Therapy for Infertility Serial scanning for follicles Hysterosonosalpingography (HyCoSy) Hyperstimulation syndrome In vitro fertilization Follicular aspiration under ultrasonic guidance Gamete intrafallopian transfer 15 Copyright © 2016 Wolters Kluwer All Rights Reserved

16. Pitfalls Tampons in vagina can produce mass-like effect or cause shadowing. Degree of bladder distention will affect shape of pelvic structures. Uterus is not always in the midline. Do not mistake rectum or sigmoid colon for a mass or fluid. Failure to use a gynecologic table to elevate the hips may result in ovaries not being seen and urethra mistaken for a mass. 16 Copyright © 2016 Wolters Kluwer All Rights Reserved

17. Pitfalls Nabothian cysts in the cervix can be mistaken for follicles if only transvaginal approach is used. Compression of a follicle can cause distortions in measurement. Muscles of pelvis can be mistaken for ovaries. Failure to empty bladder completely before endovaginal study will lead to reverberation artifacts. Difficulty in seeing the endometrial cavity; may be aligned in the same axis as the ultrasonic beam. 17 Copyright © 2016 Wolters Kluwer All Rights Reserved

18. Differential Diagnoses: Causes of Infertility Visible with Sonography Uterine malformation Bicornuate uterus Subseptate uterus Septate uterus Hypoplastic uterus Endometrial synechiae Peritoneal disease—adhesions Intracavity and submucosal myoma 18 Copyright © 2016 Wolters Kluwer All Rights Reserved

19. Differential Diagnoses: Causes of Infertility Visible with Sonography Endometrial polyps Endometrial foreign body Polycystic ovary syndrome Dysfunctional ovulation Luteinized unruptured follicles Obstructed fallopian tube—hydrosalpinx Tuberculosis of genital tract 19 Copyright © 2016 Wolters Kluwer All Rights Reserved