ROLE OF US IN EVALUATING FEMALE INFERTILITY

Question 1

Evaluate cervix

Answer 1

• Role of cervix in fertility is to provide nonhostile environment to harbor sperm
• Cervix does this with glands that secrete mucus and crypts that hold sperm.
• Ultrasound used to evaluate cervical length during pregnancy to assess for cervical incompetence

Question 2

• In nongravid uterus cervix

Answer 2

• In nongravid uterus, it is difficult to assess the length or any opening in the cervix
• Hysterosalpingography (HSG) can be used to evaluate internal os diameter. Diameter <1 mm by HSG may indicate cervical stenosis.

Question 3

cervical stenosis

Answer 3

Diameter <1 mm by HSG may indicate cervical stenosis.

Question 4

Evaluating the Uterus

Answer 4

• Two main objectives:
1. Assess structural anatomy
2. Assess endometrium
• Assessing for structural anatomy refers to evaluating uterine shape (i.e., unicolis, bicornuate, «congenital malformations) and evaluating echogenicity.

Question 5

Congenital Uterine Anomalies

Answer 5

in:
• Müllerian duct development
• Fusion
• Resorption
• Anomalies are associated with renal anomalies except for arcuate or septate uteri.

Question 6

Congenital Uterine Anomalies

Answer 6

• Anomalies are associated with renal anomalies except for arcuate or septate uteri.

Question 7

Evaluating the Endometrium

Answer 7

• Can be measured throughout menstrual cycle to look for appropriate changes
• Thickness encompasses thickness of both anterior and posterior endometrial layers in sagittal plane.
• In first half of menstrual cycle, mucosa begins to proliferate because of increasing estrogen levels.

Question 8

Endometrium

Answer 8

• In first half of menstrual cycle, mucosa begins to proliferate because of increasing estrogen levels.

Question 9

3 line sign

Answer 9

Proliferative
endometrial phase seen as triple line sign
consisting of hypochoic mucosa and echogenic interface where they meet in central plane of uterus.

Question 10

secretory phase of endometrial cycle.

Answer 10

• After ovulation, progesterone secreted by corpus luteum
• Secretion of progesterone begins the secretory phase of endometrial cycle.
• During secretory phase, endometrium becomes thickened and very echogenic as result of stromal edema; there is loss of triple line sign.

Answer 11

Evaluating the Endometrium
• Thickness offat least 6 mm appears to represent central threshold for achieving pregnancy.
If enough progesterone is not produced in luteal phase, endometrial lining may be thinner than expected on ultrasound evaluation.
• Lack of progesterone production known as “luteal phase deficiency and may be associated with infertility and early pregnancy loss
Endometrial appearance important for planning for infertility treatment with embryo transfer

Question 12

luteal phase deficiency

Answer 12

• Lack of progesterone production known as “luteal phase deficiency and may be associated with infertility and early pregnancy loss “

Question 13

Evaluating the Endometrium
• Thickness offat least mm appears to represent central threshold for achieving pregnancy.

Answer 13

Evaluating the Endometrium
• Thickness offat least 6 mm appears to represent central threshold for achieving pregnancy.

Question 14

important for planning for infertility treatment with embryo transfer

Answer 14

Endometrial appearance important for planning for infertility treatment with embryo transfer

Question 15

• Other things that can make endometrium appear irregular or more echogenic than normal are submucosal fibroid polyps, adhesions.

Answer 15

• Other things that can make endometrium appear irregular or more echogenic than normal are submucosal fibroid polyps, adhesions.
• Saline infusion sonography (SIS) can be used in these situations to further delineate anatomic structure of endometrium.
SIS can demonstrate fibroids and polyps by outlining endometrial cavity.
Fibroids tend to have broad base and are more isoechoic to uterine myometrium.
Also tend to have circumferential flow around them

Question 16

Fibroids and polyps in US

Answer 16

Fibroids tend to have broad base and are more isoechoic to uterine myometrium.
Also tend to have circumferential flow around them
Polyps same ecohogenicity to Endometriom
Flow and Color in pedicule
Pedunculated in endometrial cavity

Question 17

Polyps

Answer 17

Polyps tend to have uniform hyperechoic appearance and narrow base attachment to endometrium (a stalk) and vascular pedicle feeding them.

Question 18

SIS FOR

Answer 18

• Fibroids and polyps can potentially impede implantation.
• If found, can be removed to enhance fertility
• SIS can be used to evaluate uterine cavity for synechiae, scars from uterine trauma.

Question 19

Synechiae

Answer 19

• Synechiae typically seen on ultrasound as linear strands of tissue entending from one wall of uterine cavity to other

Question 20

Hydrosalpinx associated

Answer 20

• Hydrosalpinx associated with 50% reduction in pregnancy rate and doubling of spontaneous miscarriage rate
• Removal of such damaged tubes can dramatically improve in vitro fertilization (IVF) success
• Tubal patency assessed by injecting saline into tube and looking for spillage of fluid into cul-de-sac or by using contrast to evaluate for spillage

Question 21

HSG HYSTRO SALPINGRAPHY SIS SALIN

Answer 21

Which contrast

Question 22

Fallopian tube

Answer 22

• Sonographers look for spillage of saline or air around ovary or into posterior cul-de-sac.
• If spillage is seen, patency is inferred.
• If no spillage noted and patient complains of pain during injection, tube may be blocked.
• Adhesions can obstruct a fallopian tube.

Question 23

Antral follicles

Answer 23

Antral follicles are small follicles (about 2-9 mm in diameter) that we can see - and measure and count - with ultrasound.
Antral follicles are also referred to as resting follicles.

Question 24

Sonographic findings associated with ovulation

Answer 24

• Once reaching mean diameter of 22 mm?, dominant follicle will rupture.
• Rupture may be associated with increase or decrease in size.
• Sonographic findings associated with ovulation are echoes within fluid left behind (corpus luteum cyst) or free fluid in peritoneal cavity.

Question 25

PCO

Answer 25

• Condition that can inhibit release of FSH and LH is polycystic ovary syndrome (PCOS).
• PCOS often occurs with diagnostic triad of
(1) oligoovulation,
(2) hyperandrogenism, and
(3) polycystic ovaries.
• With PCOS, follicles begin to grow but do not develop normally.
• In this syndrome, immature follicles continue to produce estrogen and androgen.

Question 26

the pituitary gland producing more in PCO

Answer 26

• This production of estrogen and androgen inhibits pituitary gland’s function and prevents normal ovulation.
• This is due to
the pituitary gland producing more LH than FSH, and follicles remaining in an arrested state of development with no mature ova being released.

Question 27

Peritoneal Factors

Answer 27

• May be cause for as many as 25% of infertility
cases
• Peritoneal factors are adhesions and endometriosis.
• Adhesions are bands of scar tissue that can obstruct fimbriated end of fallopian tube.
• Sometimes fluid will collect in between adhesions, resulting in peritoneal ipslusion cyst.

Question 28

Adhesions

Answer 28

• Adhesions are bands of scar tissue that can obstruct fimbriated end of fallopian tube.
• Sometimes fluid will collect in between adhesions, resulting in peritoneal inclusion cyst.

Question 29

Ovarian Induction Therapy

Answer 29

Ovarian Induction Therapy
• Refers to treatment in which ovarian stimulation achieved in controlled setting
• Obtain baseline TVS of ovaries to rule out ovarian cyst and assess for presence of dominant follicle.
• If cyst measuring >15 mm detected, could represent persistent follicular activity that could interfere with response to ovarian stimulation medication

Question 30

Ovarian Induction Therapy

Answer 30

• If serum estradiol elevated and large ovarian cyst present, oral contraceptives may be indicated to suppress follicular activity before starting ovarian stimulation therapy.
• Optimal time to assess for intracavitary masses (polyp, fibroid), singe lining of uterus is usually at its thinnest during this early proliferative phase

Question 31

• Once therapy started, ultrasound used to monitor

Answer 31

• Usually accomplished by administering clomiphene citrate (Clomid), oral aromatase inhibitors (i.e., letrozole), or human menopausal gonadotropins
• Once therapy started, ultrasound used to monitor number and size of follicles in days 8 to 14 (follicular phase) of menstrual cycle

Question 32

Sonographer needs to count and measure all follicles larger than

Answer 32

• Sonographer needs to count and measure all follicles >1 cm in longitudinal and transverse planes.
• Optimal mean measurement of mature follicle between 16 and 20 mm
• During this time ultrasound can be correlated with serum estradiol levels if follicular growth corresponds with adequate E2 production.

Question 33

Ovarian Induction Therapy

Answer 33

• Correct measurement of follicles important because human chorionic gonadotropin (hCG), substitute for LH, may be needed to be given intramuscularly to trigger ovulation

Question 34

Normal endometrial response associated with ovarian stimulation is increasing

Answer 34

• Assess thickness and echogenicity pattern of endometrial cavity.
  • Normal endometrial response associated with ovarian stimulation is increasing thickness from 2 to 3 mm to 12 to 14 mm.
  • Measure endometrial thickness-
  TVS uterus transvaginally in sagittal plane.
  • Measure from anterior to posterior endometrial interface.

Question 35

TDI

Answer 35

• Technique used to treat male factor infertility
• With intrauterine insemination, catheter containing sperm placed into uterine fundus
• Sperm preparation may be from donor.
• Referred to as artificial insemination using donor sperm or therapeutic donor insemination (TDI)

Question 36

Complications Associated with Assisted Reproductive Technology

Answer 36

• Ovarian hyperstimulation syndrome (OHSS)
• Multiple gestations
• Ectopic pregnancy

Question 37

Complications Associated with Assisted Reproductive Technology

OHSS

Answer 37

• OHSS is syndrome that presents sonographically as enlarged ovaries with multiple cysts, abdominal ascites, pleural effusions.

Question 38

OHHS OFTEN SENN IN

Answer 38

• Often seen in patients who have undergone ovulation induction after administration of follicle-stimulating hormone or GnRH analogue followed by hCG

Question 39

• More severe cases of OHSS will

Answer 39

present with leg edema, ascites, pleural effusions, hypotension, polycythemia.

Question 40

Complications Associated with Assisted Reproductive Technology multiple gestation

Answer 40

• Patients who undergo in vitro fertilization at increased risk for having multiple gestations
• Estimated about 30% of in vitro fertilization pregnancies result in multiple gestation
• Concern with multiple gestations that if there are three or more fetuses, increased risk of fetal and/or neonatal morbidity and mortality

Question 41

Complications Associated with Assisted Reproductive Technology
ectopic pregnancy.

Answer 41

• Patients who undergo assisted reproductive technologies are at increased risk for ectopic pregnancy.
• Ectopic pregnancy is pregnancy implanted outside of uterus.
• Patients also at risk for having heterotopic pregnancy: ectopic pregnancy coexisting with intrauterine pregnancy

Question 42

heterotopic pregnancy

Answer 42

ectopic pregnancy coexisting with intrauterine pregnancy

Question 43

POSTOPERATIVE USES OF ULTRASOUND
indicate complications, such as

Answer 43

POSTOPERATIVE USES OF ULTRASOUND POSTOPERATIVE USES OF ULTRASOUND
Pain and the development of a pelvic mass after pelvic surgery can indicate complications, such as
• postonerative bloodina

Question 44

POSTOPERATIVE USES OF ULTRASOUND

Answer 44

POSTOPERATIVE USES OF ULTRASOUND
• to distinguish a distended bladder from an abnormal fluid collection at the operative site

• TVS provides the ability to palpate specific structures with the transvaginal probe and avoid the abdominal wound
valuable in determining the site of pain in a postoperative pelvis.
• Resolving hematomas often appear to be of a solid consistency and can be followed as they recede.

Question 45

Findings After Caesarean Section
Initial postpartum period after a cesarean section,
Most patients undergoing a cesarean delivery will have a transverse incision in the lower uterine segment.

Answer 45

Initial postpartum period after a cesarean section,
• Typical appearance - small echogenic foci, due to sutures and/or gas, in the anterior myometrium of the lower uterine segment normally seen for several weeks or months.
• One may also see heterogeneity in this region of the myometrium, probably due to small areas of hemorrhage

Question 46

Hematoma after CS

Answer 46

• Bladder flap hematomas, due to bleeding at the incision site, may occur in the lower uterine segment of the uterus or between it and the urinary bladder.
Sonographically, they appear as a mass of variable echogenicity

• Subfascial hematomas are thought to be due to disruption of inferior epigastric vessels and are located extraperitoneally.
They can appear as a mass of varlable echogenicity, located posterior to the rectus abdominal muscles of the lower abdgminal wall

Question 47

After several months, when healing is complete,
In CS

Answer 47

• a thin linear echo representing the hysterotomy scar can often be seen in the lower uterine segment
• is a normal, expected finding

Question 48

Scars in CS MAY MISTAKEN WITH

Answer 48

• More than one scar may be seen in patients with multiple prior cesarean deliveries.

• The myometrium superior to the scar, or between two adjacent scars, may have a convex outer contour can potentially be mistaken for a leiomyoma

Question 49

variable terminology has been used to describe this collection of fluid in the scar:

Answer 49

cesarean scar diverticuli,
cesarean scar pouch,
cesarean scar defect,
uterine niche, نیش
and
isthmocele

Question 50

Cesarean scar defects might also be a cause of

Answer 50

dysmenorrhea,
chronic pelvic pain, or
• infertility.
Larger defects, with thinner myometrium, seem to be associated with a higher likelihood of uterine rupture or dehiscence in a subsequent pregnancy

Question 51

Cesarean Section Scars Remote From
Time of Surgery on Transvaginal
Sonography (TVS).

Answer 51

Pseudomass due to bulbous area of myometrium, in this instance located between two cesarean @ctions scars (arrows). This could be mistaken for a leiomyoma

Question 52

Postoperative Pelvic Masses

Answer 52

Postoperative masses may be
• abscesses, hematomas, lymphoceles, urinomas, or
• seromas.

Question 53

Sonographically, Abscesses are

Answer 53

• ovoid shaped, hypochoic masses with thick, irregular walls and posterior acoustic enhancement.
Variable internal echogenicity may be seen, and high-intensity echoes with shadowing caused by gas may be demonstrated.
• With optimized settings, color Doppler usually demonstrates vascularity within the wall of the abscess. The periphery vascular not in the Center because it is necroses and FiiO with debris

Question 54

Postoperative Pelvic Masses
Hematomas show a spectrum of sonographic findings, varying with time.

Answer 54

Initial hyperacute phase, hematomas are anechoic.
After organization and clot formation, they become highly echogenic.
With lysis of the clot, hematomas develop a reticular pattern and/or concave margins due to retracting clot, until
finally,
With complete lysis, they are again anechoic

Question 55

Pelvic lymphoceles occur

Answer 55

Postoperative Pelvic Masses
Pelvic lymphoceles occur after surgical disruption of lymphatic channels, usually after pelvflymph node dissection or renal transplantation.
Sonographically, lymphoceles are anechoic, having an appearance similar to that of urinomas, which are localized collections of urine, or seromas, which are collections of serum.
Sonography-guided aspiration may be necessary to differentiate these conditions.

Question 56

Postoperative Pelvic Masses
Late onset complications

Answer 56

Urinary tract complication
Bowl injury
Fistula

Question 57

Urinary tract complication

Answer 57

Postoperative Pelvic Masses
Late onset complications
Urinary tract complications:
may either appear on early or chronic phase. include ureteral stenosis ending in hydr©hephrosis, size discrepancy between the kidneys with a reduction of th affected one;
both these aspects may be studied on common transabdominal US.

Question 58

Postoperative Pelvic Masses
Late onset complications

Answer 58

Bowel injury.
bowel obstruction mostly due to adhesions. Adhesions are the most common cause of bowel obstruction after surgery
Imaging choice is CT

Question 59

Fistula

Answer 59

Fistula:
delayed complication,
often due to a bowel or urinary injury;
it occurs mostly in case of malignant indication to surgery and previous radiotherapy. The imaging of choice is MRI

Question 60

Features of Malignant Ovarian Neoplasms

Answer 60

US features that indicate malignancy include
• a solid component (particularly if there is visible flow in it at Doppler evaluation),
• thick septa, and
• ascites

Question 61

Serous cystadenocarcinoma of the ovary in a 38-year-old woman.
Describe it

Answer 61

Serous cystadenocarcinoma of the ovary in a 38-year-old woman.
Transvaginal color Doppler US scan demonstrates a complex ovarian cyst with septum and a solid nodule (arrow). There is flow within the solid nodule, typical of malignancy.

Question 62

Mature cystic teratoma in a 31-year-old woman.
.

Answer 62

Mature cystic teratoma in a 31-year-old woman.
Transvaginal US scan shows a complex ovarian cyst (long arrows) with low-level internal echoes and a markedly hyperechoic solid-appearing area (short arrow) with faint distal acoustic shadowing (S).
Dermoid plug or Rakitensky

Question 63

Hemorrhagic cyst with a clot in a 40-year-old woman

Answer 63

Hemorrhagic cyst with a clot in a 40-year-old woman.
Sagittal transvaginal color Doppler US scan shows a complex cystic mass within the periphery of the ovary.
The seemingly solid area within the cystic mass has concave margins (arrows) and no demonstrable flow, both typical features of a clot.

Answer 64

Collapsing ovarian cyst in a 34-year-old womar Sagittal transvaginal USScan shows the walls o the ovarian cyst, which are slightly irregular (arrows) due to collapse of the cyst as it involutes.
Or
Ruptured follicle
Crenulated دندانه دار.
Lated Crenu

Answer 65

Endometrioma in a 46-year-old woman.
Transverse transvaginal US scan reveals a complex ovarian cyst with homogeneous internal echoes.
It contains a small solid-appearing area (arrow).
Color Doppler US (not shown) did not demonstrate flow in the solid area. Ground glass or chocolate cysyt

Answer 66

Serous cystadenocarcinoma of the ovary in a 60-year-old woman.
Transvaginal US scan shows a complex ovarian cyst (calipers) with several thick septa (arrows) and solid areas. Color Doppler US scan (not shown) revealed flow in the septa and solid areas.