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. 2) Ultrasound of the uterus
Ultra Sonography In Assisted Reproduction
2) Ultrasound of the uterus
Evalotion women and art monitoring

5. 2-Ultrasound of the uterus
Ultrasound assessment of the endometrium and the myometrium of the uterus is important in maximizing implantation both in natural pregnancies and in IVF.
Endometrial thickness and pattern varies throughout the menstrual cycle and is the parameter reviewed in most studies.
The endometrium is thin immediately after menstruation, thickens during the proliferative phase, is tri laminar before ovulation, and is thick and echogenic in the secretory phase of the cycle.

6. 2-Ultrasound of the uterus
A small amount of endometrial f1uid ( film in the middle of the cavity), thought to be mucus, can be seen before ovulation and it rapidly disappears.
However, significant endometrial fluid at the time of ET, usually visible with Hydro salpinges, is associated with poor prognosis and freezing all the embryos should be considered.

7. 2-Ultrasound of the uterus
Other assessment of the uterus besides the endometrium includes obtaining the size and position of the uterus and the presence of uterine fibroids or adenomyosis.
Assessment of the uterine cavity for fibroids, polyps, adhesions, and Mullerian anomalies is mandatory before ART.

8. 2-Ultrasound of the uterus
Ultrasound examination of the endometrium in a natural or mock cycle supplemented with estrogen and progesterone provides a noninvasive way to evaluate the endometrial development and receptivity before ET ،Synchronization between the endometrial and embryo development is essential for successful implantation.

9. Sonohysterography (SHG)
2-Ultrasound of the uterus
Sonohysterography
(SHG)

10. Sonohysterography (SHG)
SHG, Hysterosonogram, or saline infusion sonography are different names for a minimally invasive office technique used for the evaluation of intrauterine abnormalities.
By injecting saline into the uterus, the f1uid contrast enhances the visualization of the uterine cavity and filling defects such as, polyps, submucosal fibroids, adhesions, and uterine anomalies.

11. Sonohysterography (SHG)
The main uses for SHG are for abnormal uterine bleeding, screening of the uterine cavity prior to ART, and habitual abortion.
Contrast media may be also used for injection, such as saline mixed with air or Echovist.
The method for SHG according to AlUM and ACOG (73) are the following: Prior to SHG a preliminary routine TVS is performed with measurements of the endometrium, uterus, and the ovaries and evaluation for fluid in cul-de-sac.

12. Sonohysterography (SHG)
After cleansing the external os, the cervical canal and/or uterine cavity should be catheterized using aseptic technique, and appropriate sterile fluid (saline or water for injection) should be instilled slowly (emphasize by the authors) by manual injection under real-time sonographic imaging.

13. SHG should be done between days 5-10 of the menstrual cycle.
Sonohysterography (SHG)
Documentation should include images of the endometrial and cervicalcanals in at least two planes.
SHG should be done between days 5-10 of the menstrual cycle.
Intracervical catheter placement resulted in significantly less pain during SHG and also requires half the saline volume to perform.
Therefore, intracervical balloon placement should be preferred for SHG. SHG had been described also with gel instillation.

14. Sonohysterography (SHG)
Suspected abnormalities seen on TVS, including focal or diffuse endometrial thickening, and suboptimal images by 2D are enough to recommend further evaluation with SHG.
Studies comparing findings on SHG with 2D and 3D ultrasound, HSG, and hysteroscopy show excellent predictive value of SHG.

15. Sonohysterography (SHG)
One study comparing SHG with hysteroscopy showed 88% sensitivity, 100% specificity, and 100% positive predictive value (PPY) and 92% negative predictive value (NPY) for the detection of abnormality.
The advantages of SHG over HSG are that it can detect adnexal pathology such as PCOS or ovarian cysts at the same time.
Infertility patients have a lower rate of intracavitary lesions than patients with abnormal uterine bleeding and higher rate of uterine anomalies.

16. Sonohysterography (SHG)
This prospective study compared the incidence of uterine cavity anomalies in patients referred for infertility or abnormal bleeding group, showed that more patients in the bleeding group had intracavitary abnormalities such as polyps, fibroids, and adhesions as well as intramural abnormalities, and the infertility group had more congenital uterine anomalies.

17. Acquired Uterine Abnormalities
2-Ultrasound of the uterus
Acquired Uterine Abnormalities
(Uterine Fibroids, Adenomyosis, Polyps and Adhesions)

18. Acquired Uterine Abnormalities
For intramural fibroids, TVS is excellent for diagnosis, while for submucosal fibroids, SHG is better at showing the cavity involvement.
Using 3D ultrasound with the multiplanar display, especially the coronal views, allows precise localization of a myoma with respect to the endometrial cavity and has been shown to have the accuracy of hysteroscopy and better than 2D ultrasound (79).

19. Acquired Uterine Abnormalities
The 3D multiplanar display is also useful in some cases for differentiating adnexal lesions close to the uterus from lesions within or originating from the uterus; this obviates MRI in selected cases.
Studies looking at uterine fibroids show that the number of fibroids is underestimated by ultrasound compared to those found at surgery even when 3D is used.
Use of 3D ultrasound and 3D SHG for determining the position of the fibroids can be visualized in.

20. Acquired Uterine Abnormalities
Recent systematic review confirmed that ART outcomes are decreased in women with submucosal fibroids, and hysteroscopic removal improves significantly the outcome.
A meta-analysis study showed a significantly lower PR if submucosal fibroids are present; RR 0.32, and that removal of submucosal fibroids improves clinical PRs with a RR 2.03.

21. Acquired Uterine Abnormalities
Intramural fibroids appear to decrease fertility, but the results of myomectomy are unclear, and recent two RCTs failed to demonstrate clear Benefits.
On ultrasound adenomyosis appears as asymmetry and thickening of the uterine walls with loss of endometrium-myometrium border and hypoechogenic nodules in the myometrium.

22. Acquired Uterine Abnormalities
Endometrial polyps may be found in about 15% of the infertile women.
The benefit of polypectomy leading to higher PRs.
Based on these studies, polyps diagnosed prior to IVF should be removed.
Polyps of <1.5 cm can be removed hysteroscopically even during stimulation , as shown in a retrospective study.

23. Acquired Uterine Abnormalities
The management of polyps seen during the course of IVF should be individualized given the number of embryos created, the previous reproductive
history of the patient, and the individual clinics' success rates for their ART program.

24. Congenital Uterine Anomalies
2-Ultrasound of the uterus
Congenital Uterine
Anomalies

25. Congenital Uterine Anomalies
It has been demonstrated that conventional 2D ultrasound imaging is a good screening tool for the detection of congenital uterine anomalies and has a high sensitivity for some anomalies.
However, the ability of 2D ultrasound to distinguish between different types of uterine abnormalities is limited and operator dependent.

26. Congenital Uterine Anomalies
In addition, both routine 2D ultrasound and HSG lack the specificity for differentiating arcuate, bicornuate, and septate uterus.
Precise classification of a uterine anomaly is of clinical importance because the need for intervention and the type of intervention depends on this distinction.

27. In 3D the stored data can be reformatted and analyzed in numerous.
Congenital Uterine Anomalies
MRI is especially accurate in the diagnosis of uterine anomalies but its main disadvantages include high cost and limited availability.
In 3D the stored data can be reformatted and analyzed in numerous.
Correlation between these three planes is used to confirm a given desired plane, such as the mid- sagittal or midcoronal plane.

28. Congenital Uterine Anomalies
The optimal time to examine patients for the presence of uterine anomalies is the luteal phase of the cycle when the endometrium is thick and echogenic and the cavity can be clearly differentiated from the surrounding myometrium.
The most important advantage of 3D ultrasound over HSG is the ability to visualize both the uterine cavity and myometrium. (uterine masses and congenital anomalies)

29. Monitoring Endometrial Thickness during ART Cycle
2-Ultrasound of the uterus
Monitoring Endometrial
Thickness during ART Cycle

30. Monitoring Endometrial Thickness during ART Cycle
Endometrial pattern can be classified as:
type A, a multilayered triple-line endometrium consisting of a hyperechogenic outer and central lines
type B, an intermediate isoechogenic pattern with a non-prominent central line, and
type C, which is an entirely homogeneous endometrium.

31. Monitoring Endometrial Thickness during ART Cycle
Endometrial thickness is measured from outside to outside in an anterior-posterior view at the widest point.
Patients with a thin endometrium following ovarian stimulation have a significantly lower PR.
A triple layer endometrial pattern and an endometrial thickness greater than 7mm have been proposed as markers of endometrial receptivity.

32. Monitoring Endometrial Thickness during ART Cycle
Low dose aspirin and vaginal Sildenafil (Viagra) have been used to treat patients with thin endometrium.
(suboptimal endometrial blood flow and may have scar tissue).
However, studies are not consistently showing increased uterine receptivity and IVF success and are based on small numbers.

33. Monitoring Endometrial Thickness during ART Cycle
However, other studies found that a minimum endometrial thickness of 6mm is acceptable for implantation.
(thickness as little as 4mm and max 8-10mm) and thickness (>14mm), a high miscarriage rate was reported.

34. Monitoring Endometrial Thickness during ART Cycle
An excessively thick endometrium may start in a previous cycle, so therefore ovarian stimulation should not be started following menstruation if the endometrial thickness is greater than 6mm.
Increased preclinical or biochemical miscarriages are also seen with endometrial thicknesses 6-8 mm verses 9mm or greater.

35. Monitoring Endometrial Thickness during ART Cycle
Assessment of endometrial blood flow adds a physiological dimension to the anatomical ultrasound parameters and has drawn a lot of attention in recent years.
Endometrial and sub-endometrial blood flows can be more objectively and reliably measured with three-dimensional power Doppler ultrasound.

36. Monitoring Endometrial Thickness during ART Cycle
The absence of color Doppler mapping at endometrial and sub-endometrial levels is relied to a significant decrease in implantation rate, whereas the PR increases when vessels can be depicted reaching the sub-endometrial halo and the endometrium.
Endometrial volume can now be reliably determined by 3D ultrasound. (2.5ml)

37. Monitoring Endometrial Thickness during ART Cycle
Merce et al. concluded that 3D ultrasound and power Doppler angiography is a useful examination to assess endometrial receptivity in IVF/ICSI and endometrial transfer cycles.
Doppler in 2D has not been shown to benefit for fertility at this time in studies with large numbers.
No triple line are poor prognosticating factors in the success of IVF and freezing all the embryos until an evaluation of the uterine cavity may be recommended.

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