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INFERTILITY

MOST COMMON CAUSES OF INFERTILITY INCLUDE:

1. Tubal blockage or Endometriosis(30-50%)


2.Ovulation disorders (40%)
3.Cervical factors(10%)
4.Luteal phase abnormalities(5%)
Unexplained infertility is found in 5-10% of cases.

COMMON INDICATIONS OF ULTRASOUND IN INFERTILITY:

1.Follicular study
2. Assessment of endometrial development
3. Assessment of tubal patency
4. Guided follicular aspiration.

FOLLICULAR STUDY
FOLLICULAR STUDY should ideally be started on 2nd or 3rd day of cycle. If any
non-functioning cyst is present then the treatment should be postponed till the time
of its disappearance since the the chances of conception are usally absent till the cyst
remains. Additionally if the Endometrium is quite thick on these days (normally
endometrium is thinnest in the menstrual phase ) then also the stimulation is not
done.

FOLLICLES
In the spontaneous non-stimulated menstrual cycle developing follicles between 3-5 mm
seen between 5 and 7 days of the cycle.One of these follicles is selected as the dominant
follicle and under the influence of FSH the granulosa cells within it synthesize
estrogen.By 8th to 12th day of the cycle the dominant follicle is distinguished from the
other follicles by its size.

Follicle of 10 mm and above in diameter is labelled as dominant follicle.

Trans vaginal scan showing multiple follicles Cumulus oophorus seen in a stimulated
in stimulated cycle ovary
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More than one dominant follicle may be seen in the same or different ovary.The follicle
appears as an echo free area surrounded by an echogenic border. The follicular diameter
is always measured from inside to inside. For most size determinations it is sufficient to
measure the greatest follicular diameter .
Usually follicle grows at the rate of 2-3 mm per day.
Oocyte maturation(follicle about to rupture) inferred by :
1.Size of follicle :Follicle rupture-b/w 18-28 mm
2. Cumulus oophorus-approx. 1mm consists of oocyte (0.1mm) surrounded by granulosa
.Crenated appearance-seperation of
theca from granulosa cells
4.Low level intra-follicular echoes due to
shedding of granulosa cells.
5.Estradiol levels-400pg /ml.

Cumulus oophorus(arrowhead)

Crenated appearance

A follicle showing cumulus oophorus is the one destined to ovulate. However cumulus
oophorus is seen in 20% cases of transabdominal and 70% cases of transvaginal
ultrasound. Cumulus oophorus is approximately 1-3 mm in diameter and consists of
oocyte (0.1mm) surrounded by granulosa cells.Cumulus usually appears as a central
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hypo-echoic area surrounded by hyperechoic rim.At times the hypoechoic central


component may be very small and difficult to visualize ,in such cases it appears as a
hyperechoic polypoid area. Ovulation occurs within 24 –36 hrs of demonstration of
cumulus oophorus. Additionally 24-36 hrs before ovulation the inner granulosa cell layer
may be seen to separate from outer thecal layer.This seperation initially appears as a line
of decreased echogenicity between the two layers & later folding & inward protrusion of
the granulosa layer & cumulus producing a crenated appearance. Also low level
intrafollicular echoes may be seen in a follicle mature for ovulation .Ovulation is
succeeded by fall in serum estradiol level and the theca cells of the corpus luteum begin
to synthesize progesterone.
Post-ovulatory phase of the cycle called luteal phase has a mean length of 14 days.

After ovulation the Graffian follicle changes to corpus luteum. Corpus luteum remains
for approx. 12-14 days after it first appears. It always disappears by the onset of
menstruation if pregnancy does not occur.If pregnancy occurs it continues for longer
period. Following changes occur in the follicle:
The follicle reduces in size with hypo-echoic nature having faint internal echoes.This
represents early corpus luteum. Later the wall of the corpus luteum thickens and the
echogenicity increases till the hypoechoic area gets reduced in size and ultimately
disappears.A mid-luteal phase Corpus luteum is thus mainly hyperechoic with small
central hypo-echogenicity.

Other appearances of corpus luteum are:


1.It may collapse and simulate the presence of two follicles.
2.Internal echoes forming a spoke wheel pattern demonstrated within the follicle.
At times the follicle completely collapses after ovulation and is no longer identified

TVS showing Early Corpus Luteum TVS showing late Corpus luteum(C)
(Corpus hemmorhagicum)—Between callipers.
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FIG—SHOWS CORPUS LUTEUM

Persistence of corpus luteum may be an early sign that nidation has occurred.

CYCLIC ENDOMETRIAL CHANGES


Endometrium has two zones –
(1) Inner functional zone, which is shed off during menstruation. It consists of central
compactum layer (is hyper echoic) & outer spongy layer. (2) Outer basal layer that remains
intact through out the cycle & is hyper echoic.
The echogenicity of spongiosum layer varies. It is hypo echoic in proliferative, gradually
transforming to isoechoic & finally to hyper echoic in secretory phase. The spongiosum layer is
poorly developed in early proliferative stage (days 5-9 of menstrual cycle) where the
endometrium usually appears as thin echogenic line .The early spongiosum layer whenever
visualized in early proliferative stage appears hypoechoic. In later proliferative stage ( day 10-
14) the spongiosum layer becomes isoechoic (under the influence of estrogen) with other two
layers .In secretory phase the spongiosum layer becomes hyperechoic(under the influence of
progesterone) often blurring the midline echo & thus loosing triple layered or multilayered
appearance.However early secretory endometrium (i.e. just after ovulation) may have triple or
multilayered appearance.Distal enhancement ,a feature of secretory endometrium is also
commonly seen behind late proliferative endometrium. Thus late proliferative and early
secretory endometrium are quite similar in appearance.

The periovulatory endometrium has large amount of mucin .The multiple interfaces created by
the mucin and other secretions may produce a multilayered endometrium.Also sometimes these
secretions may produce a nearly anechoic area in central part of endometrium called
pseudogestational ring.This may be a result of secretions within the compactum layer of
endometrium or in the inner portion of spongiosum layer.The presence of a multilayered
endometrium & pseudogestational ring are healthy signs.
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Endometrium increases in thickness and echogenicity throughout the menstrual cycle.


Maximum thickness and echogenicity is seen in the secretory phase.The increase of thickness is
maximum in the proliferative phase.The further increase in the secretory phase is little.Corpus
luteum secretes progesterone which maintains the endometrium.Corpus luteum usually
disappears within 12- 14 days of its formation if pregnancy does not occur.(If pregnancy occurs
corpus luteum remains and thickness and echogenicity continue to increase beyond the luteal
phase.) Endometrium in proliferative stage usually does not go beyond 12mm thickness & max.
total endometrial thickness in secretory phase is usually not more than 18 mm.
.
In the menstrual phase the functional layer is shed off & only basal layer remains hence a thin
endometrium(thickness—2-3 mm) consisting of two thin broken echogenic layers
( representing basal layer of each side) separated by a thin hypoechoic area of menstrual blood is
seen.

(A) (B)
Transabdominal scan showing.A.Thin echogenic endometrium of menstrual phase .
B.Hypoechic proliferative phase endometrium.

(C).-- L.S Peri-ovulatory endometrium(straight arrows). .(D).-- T.S.


Curved arrow shows cervical mucus seen sometimes in the peri ovulatory stage.Central hypo-
echoic halo seen in transverse section.
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Transabdominal Secretory endometrium (arrow) Proliferative Endometrium(TVS)-Multi


layered endometrium.Echogenicity is
slightly less than myometrial echogenicity

Peri-ovulatory endometrium(TVS) Secretory Endometrium(TVS).Thickness


The echogenicity of multiple layers is and echogenicity of endometrium is maximum.
Increased.

ENDOMETRIAL THICKNESS

If the endometrial thickness does not reach at least 7mm during stimulation the likelihood
of subsequent implantation is reduced.The endometrium thickness increase continuosly
from the proliferative phase to mid luteal phase.From mid luteal phase onwards the
endometrial thickness decreases.The increase in endometrial thickness is least
pronounced following stimulation with Clomiphene citrate.

STIMULATED CYCLES

Stimulation done in cases of ovulation abnormality and in IVF –ET.Most commonly used
medication for induction are Clomiphene citrate and HMG. Clomiphene is an estrogen
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antagonist and acts by binding to the estrogen receptors in pituitary and hypothalamus
causing pituitary to synthesize more FSH and recruiting more follicles.Follicular
monitoring is done from day 8.Examination of patients undergoing IVF-ET is started
earlier and done daily.

Although the pre-ovulatory E2-LH feedback may be intact (i.e. increased E2 level
causing LH surge due to positive feed back) in Clomiphene treated patients, some
patients are given HCG to induce final oocyte formation.Follicle development with C.C.
is different from that observed in spontaneous cycle.Each follicle seems to develop at an
individual rate and at times may be accelerated or slowed down.Therefore the largest
follicle on the given day may not be the same one that is the largest two days later and it
may not be the same one that is most mature.Also correlation between E2 and follicle
size is poor and the maximum pre-ovulatory diameter can range from 19 – 24 mm.

For in-vitro fertilization follicles are aspirated when they reach 15-18 mm in average dimension
and when there is evidence of mature follicle by estradiol values.(approximately 400pg/ml per
mature follicle.)Another sonographic sign of mature follicle is presence of low-level
intrafollicular echoes.

NORMAL LIFESPAN OF OOCYTE & SPERM.


DIFFERENCE IN LIFE SPAN & MOTILITY OF X & Y CHROMOSOME
Lifespan of oocyte is 12 -24 Hrs while that of sperm is 24-48 hrs.This characterstic should be
kept in mind for regulation of timing of artificial insemination.

Y chromosomes are believed to be more active but have a shorter lifespan compared to that of X
chromosome .

PHYSIOLOGICAL OVARIAN CYST (>3cm)

They may occur in stimulated cycles when the stimulated follicles which do not
undergo ovulation persist and enlarge over the remainder of the cycle.Presence of such
cysts may prevent ovulation induction in next cycle.Risk of torsion rupture are increased
in such cases.

TUBAL PATENCY ASSESMENT(SONOSALPINGOGRAPHY)

ADVANTAGES OVER HSG:

1.Free from radiation hazards.


2.Relatively less painful.
3.Gives information about peritubal collections.

METHOD:
1.Give the patient Inj.Buscopan I/M at least 20 min before beginning the procedure.
2..Make the patient lie in lithotomy position after emptying the bladder.
3.Insert Foley’s no.8 (pediatric) catheter into the cervix. & inflate the balloon with 1- 1.5
c.c saline so that it is held in position just above the External os.(If the balloon is kept at
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higher level the endometrial cavity will get obscured & pathologies of the endometrium
like polyp etc. will be missed.)
4.Fix the outer end of the catheter to Rubin’s canula to make a watertight connection.
5.Prepare a solution by mixing 25 c.c of Metronidazole infusion & 25 c.c of
Ciprofloxacin solution along with 1 vial of Dexamethasone.Fill this solution in a 50c.c
syringe & suck in a little bit of air into the syringe.Shake the syringe vigorously to form
air bubbles.Attach the syringe to Rubin’s canula. (Instead of the cipro-metro solution one
can use normal saline too.)

6.Now push in small quantities of the solution through the catheter at intervals and
visualize with transvaginal ultrasound simultaneously.

INFERENCE
NOTE:It is advised to make Video recording of the whole procedure & infer it later on .

The cavity will get outlined by the fluid & any irregularity of the cavity wall can be
noted.
Normal tubes will be seen as hyperechoic areas with reverberation due to the passage of
air through them. These hyperechoic area with turbulent movements are a sign of good
Peristaltic motility. With patent tubes turbulence of fluid will be seen in & around the
tubes as it is pushed in and fluid collection will be seen in Pouch of Douglas.fluid
Spillage from the tubal end (WATER FALL SIGN) may be seen by focusing at the
Ovaries since the fimbrial end of the tube will be adjacent to it.
Cavity is poor or delayed, then the indication may be of poor ciliary action of the tubes
And infertility may be due to the tubal factor inspite of tubal patency.
If the tube is not patent there will be collection of fluid proximal to the site of obstruction
& reversal of flow may be seen . Presence of TUBO-OVARIAN mass may suggest
severe degree of tubal blockage.

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