Management

Transvaginal Sonography in Infertility

The advent of transvaginal color doppler sonography has added a new aspect to the diagnosis and management of infertile female

"Ultrasound today has revolutionised the practice of infertility. The 3-D ultrasound has given a new dimension of volume estimation. Color doppler helps in predicting success and complications" - Dr Nandita Palshetkar Infertility Specialist Lilavati Hospital's Bloom IVF Centre, Mumbai

Infertility is defined as inability to conceive after one year of unprotected intercourse. The incidence is rising day by day. Indeed there has been a marked increase in patient population in all infertility clinics the world over, during last two decades. The application of transvaginal sonography (TVS) in assessment and evaluation of an infertile couple has expanded widely. In fact, it is the first step investigation of choice for evaluation of infertile couple because it is safe, quick, and non invasive and gives a precise picture of pelvic anatomy.

Assessment of Female Reproductive Tract

Female partner is responsible for 40 per cent cases of infertility and contributes in another 20 per cent of mixed cases. Out of this major factors are ovulatory dysfunction (30 per cent) and tubal factors (25 per cent).

Ovarian study

The ovaries are generally easily recognised lying in ovarian fossa, on either side of the uterus. A course along the internal iliac artery would most often find the ovary anterior to its anterior and posterior bifurcation. The ovary is scanned for its morphology (normal/ polycystic) and for any abnormality (presence of cysts, tumors). It assesses the ease of 'access' to ovaries, as pick up is done using an ultrasound-guided method.

Assessment of Ovarian Reserve

It is the antral follicle that responds to the stimulation. Antral follicle count is a good predictor of ovarian reserve. It assists in deciding dose for ovarian stimulation. The count decreases with age in normal women. A count of 5-10 follicles on each side is considered normal. With more than 10 follicles per side (polycystic ovaries), a lower level of stimulation should be chosen. A low follicle count (less than 5/6 in total) predicts a poor response with more chances of cancellation.

Ovarian volume can also be used to asses' ovarian reserve but it is less predictive than the follicular count.

Detection of Cysts

USG helps is detecting any cyst present in the ovary and also helps in differentiating it into functional or pathological.

Diagnosis of Endometriosis

The endometrioma have typical features on ultrasound. The cyst wall is generally shaggy and irregular. These cysts are homogenous with a low level echo pattern and a good through transmission.

Uterus

A detailed view of myometrium and endometrium is taken. The direction (anteverted/ retroverted) and uterocervical length (UCL) is recorded. TVS is able to diagnose polyps, septum, fibroids and congenital anomalies with quite significant accuracy. It permits to proceed directly to operative hysteroscopy avoiding the need for a separate diagnostic procedure.

Fibroid

It is one of the most common benign neoplasm in women of reproductive age group. TVS is the most useful tool for screening of fibroids. It can accurately diagnose number, size and location of each fibroid. Distortion of cavity can also be assessed. Depending on this one can decide whether to operate or not and which modality (hysteroscopy/ laparoscopy) to use.

Adenomyosis

An enlarged uterus as in adenomyosis is associated with reduced uterine and endometrial receptivity. Increased echogenicity heterogeneous texture and thick posterior wall are important features on ultrasound.

Congenital Anomalies

They occur in about 0.5 per cent of general population. It is a significant cause for infertility and recurrent abortion. A septate uterus can be identified and can be differentiated from an arcuate uterus.

Polyps

Polyps and sub mucous fibroid can be easily identified with the help of sonography.

Hypoplastic uterus

A UCL of less than five cm is considered as abnormal. These women should be given at least a three months course of estrogen and progesterone prior to embryo transfer.

Endometrium

Normal endometrial cavity appears as a smooth triangular cavity in a 3-D ultrasound. The cyclical changes of the endometrium can be seen during the different phases of the menstrual cycle. The thickness and the pattern of endometrium changes under the influence of hormonal stimulation. It helps to ascertain receptivity of the endometrium which is important prior to embryo transfer.

Adenexal Pathology

USG helps in diagnosing hydrosalpinx and other adenexal abnormalities. Hydrosalpinx reduces the chances of pregnancy because the fluid which is embryo toxic may leak into the uterine cavity and hinders in implantation of embryos. It can differentiate between communicating and non- communicating hydrosalpinx as well. It is believed that patients with ultrasnographically visible hydrosalpinx have a poorer outcome if it is not removed.

Evaluation of Vagina and Cervix

USG can detect pathology in the vagina and cervix also though they are better detected by a P/S and a P/V examination. It aids to confirm direction of cervical canal so that the embryo transfer cannula can be moved in the same direction.

Evaluation of Male Partners

Male factor infertility comprises of almost 40 per cent of the cases. In suspected male factor infertility ultrasound is necessary to rule out structural anomalies. Ultrasound imaging is very sensitive in testicular evaluation.

Transrectal ultrasonography (TRUS) is an excellent screening test for ejaculatory duct pathologies and is indicated in all men with severe oligospermia and a low volume ejaculate.

Role of Color Doppler

The advent of transvaginal color doppler sonography has added a new aspect to the diagnosis and management of infertile female. It is a unique, non invasive technology used to examine blood flow in various organs. The circulation in reproductive organs (uterus, endometrium, and ovary) changes with menstrual cycle. These events are very well picked up by color doppler and further aids in making a definite diagnosis and management.

Ultrasound today has revolutionised the practice of infertility. The 3-D ultrasound has given a new dimension of volume estimation. Color doppler helps in predicting success and complications. In fact we cannot even imagine practicing infertility and ART without ultrasound in the modern era of technology.

Nanditapalshetkar@hotmail.com