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Ultrasonography in Reproductive Medicine and Infertility
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Book description

Nowhere has the impact of ultrasonography been more dramatic than in reproductive medicine, particularly in the diagnosis of female and male infertility, the management of assisted reproductive procedures and the monitoring of early pregnancy. This authoritative textbook encompasses the complete role of ultrasonography in the evaluation of infertility and assisted reproduction. Covering every indication for ultrasonography in assisted reproductive technology, this will prove an invaluable resource in the evaluation of the infertile patient and optimization of the outcome of treatment. The interpretation of images to improve fertility and reproductive success is emphasized throughout. Ultrasonography in Reproductive Medicine and Infertility is essential reading for clinicians working both in IVF clinics and in office practice. It will be particularly useful to gynecologists, infertility specialists, ultrasonographers and radiologists working in reproductive endocrinology and infertility, assisted reproductive technology, ultrasonography and radiology.

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Contents


Page 1 of 2


  • Chapter 7 - Ethics of ultrasonography
    pp 64-66
  • View abstract

    Summary

    This chapter reviews the basic principles of radiologic tests, and describes the basic female anatomy. It provides information for appropriate imaging modalities for each part of the female genital tract. Currently ultrasound plays a role in monitoring the uterus during ovarian stimulation and early pregnancy. Assessment of uterine leiomyoma is historically achieved with ultrasonography, although computed tomography (CT) and magnetic resonance imaging (MRI) also offer detection of uterine fibroids. In reproductive medicine, imaging of the tubes is typically limited to evaluation of patency and distortion of normal anatomy, as in hydrosalpinges and salpingitis isthmica nodosum. Pituitary imaging is mostly performed in reproductive medicine for the infertile patient with persistently elevated prolactin levels or with levels over 100 ng/ml. Imaging is rarely performed in reproductive medicine specifically to evaluate for peritoneal disease. Laparoscopy is considered the gold standard for diagnosis of peritoneal processes such as endometriosis.
  • Chapter 9 - Ultrasonography and diagnosis of polycystic ovary syndrome
    pp 75-80
  • View abstract

    Summary

    Ultrasound examination is now considered as part of almost every clinic setting. The creation of an image from sound is achieved in three steps: producing a sound wave, receiving echoes, and interpreting those echoes. The four different modes of ultrasound used in medical imaging are: A-mode, B-mode, M-mode and Doppler mode. The Doppler frequency shift information can be displayed graphically in various ways that include color Doppler (directional Doppler), power Doppler, and spectral (pulsed) Doppler. The different modes of Doppler waves include: Continuous-wave Doppler (CW) and Pulsed-wave Doppler (PW). The blood flow measurements are performed by calculation of velocity, calculation of absolute flow and flow waveform analysis. Despite its impressive safety record of ultrasound to date, the intensity (or acoustic output) level of ultrasound used to scan the fetus in utero has increased almost eightfold over the level that was allowed in the early 1990s.
  • Chapter 10 - Ultrasonography and the treatment of infertility in polycystic ovary syndrome
    pp 81-86
  • View abstract

    Summary

    Hysterosalpingography allowed gynecologists and infertility specialists to study the uterine cavity, shape, and any abnormalities that could result from either congenital problems or acquired disease processes. Irregular uterine bleeding is not an uncommon phenomenon during reproductive period. Many of these cases are dysfunctional uterine bleeding that require endocrine evaluation as well as hematologic studies. Salpingography identifies a normal fallopian tube lumen or abnormalities related to iatrogenic factors such as tubal sterilization or pathology as a result of infection and various kinds of obstructive disease. Various pathological conditions have been identified in the isthmic portion of the fallopian tube with the use of hysterosalpingography. One of these conditions is salpingitis isthmica nodosa. Fallopian tube disease is the single most common cause of infertility and women routinely undergo hysterosalpingography in the course of the infertility work-up to evaluate this factor.
  • Chapter 11 - Ultrasonography of uterine fibroids
    pp 87-96
  • View abstract

    Summary

    A careful vaginal examination allows detection of pathology of the pouch of Douglas, such as nodules of the rectovaginal septum or fixed retroverted uterus. The five steps in the fertiloscopy procedure are: hydropelviscopy, dye test, salpingoscopy, microsalpingoscopy, and hysteroscopy. Hydropelviscopy is performed by first inserting a Verres needle into the pouch of Douglas. This needle is inserted 1 cm below the cervix, and then saline solution is instilled through a perfusion line using no other pressure than gravity. Introduction of a Verres needle and then of the fertiloscope in the pouch of Douglas sometimes raises fear of rectal injury. The fundamental question was to know at an early stage whether fertiloscopy was as accurate as laparoscopy, which was considered at that time the "gold standard" in infertility investigation. The only real complication is represented by rectal injury. However, such injury may be always treated conservatively with antibiotics without surgical intervention.
  • Chapter 12 - Ultrasonography of the endometrium
    pp 97-102
  • View abstract

    Summary

    In most practices, sonohysterography is immediately preceded by high-frequency transvaginal sonography (TVS). Exact menstrual dating and latex allergy are documented first, and a negative pregnancy test is obtained, along with a signed informed consent, when appropriate. The purpose of the baseline ultrasound is to confirm all pelvic findings prior to the fluid enhancement study. Although sonohysterography provides an indirect look inside the uterus, its ability to accurately diagnose intracavitary filling defects, such as myomas and polyps and adhesions and even malformations, matches that of the gold standard hysteroscopy. This chapter lists out specific imaging examples for submucous myoma, endometrial polyp, blood clot, endometrial malignancy, intrauterine synechia and congenital uterine anomaly. It outlines three-dimensional saline infusion sonohysterography (SIS), sonosalpingography or hysterosalpingo-contrast sonography, operative SIS, and sonovaginography. Combining TVS with vaginal saline infusion may improve the ability to image structures surrounding the vagina, such as the rectovaginal septum for endometriosis.
  • Chapter 13 - Ultrasonography of the cervix
    pp 103-112
  • View abstract

    Summary

    In 1869, a hemorrhagic uterine growth was diagnosed and cauterized with silver nitrate, thus qualifying the procedure to be the first operative hysteroscopy during direct visualization of endometrial cavity. The pressure required to separate the walls of a normal-sized uterine cavity (with saline) is less than 50mmHg. A solution containing 35% dextran 70 (molecular weight 70,000 kDa) was introduced as a distending medium for hysteroscopy. Compared with placebo, use of misoprostol among premenopausal women before hysteroscopy was found to result in fewer cervical lacerations, most probably secondary to a reduced need for cervical dilation. Despite the increasing adoption of hysteroscopy as an ambulatory procedure, protocols for local anesthesia and/or analgesia remain far from uniform. In a flexible hysteroscope, fiberoptic bundles (flexible) transmit the image to the eyepiece or the camera. Pregnancy and genital tract infections are obvious contraindications to hysteroscopy.
  • Chapter 14 - Color Doppler imaging of ovulation induction
    pp 113-118
  • View abstract

    Summary

    The principle of autonomy recognizes that it is the voluntary decision of the patient to authorize or refuse clinical management based on adequate and complete disclosure by the physician about the patient's condition and management with the understanding of this information by the patient. If the patient refuses the ultrasound examination due to the fears of its harmful effects, the physician must clarify the facts to the patient, support her, and illuminate her fears. During obstetric ultrasound scanning and in occasional circumstances where the unborn child may suffer from a condition that needs a treatment and this treatment threatens the mother's life, there must not be any obligation upon her to tolerate this treatment. All fetal treatment necessitates accessing the fetus through the pregnant woman's body, and nonsurgical treatments have long been a part of pregnancy care. Ethics as a subdiscipline of ultrasound examination and intervention has significant clinical implications.
  • Chapter 15 - Ultrasonography of pelvic endometriosis
    pp 119-125
  • View abstract

    Summary

    Power Doppler ultrasound (US), in combination with three-dimensional US and virtual organ computer-aided analysis (VOCAL), is a very good approach for investigating the global ovarian vascular network and its correlation with ovarian response in assisted reproductive technology (ART). An ovarian vascular map is easily obtained from a sagittal section of the ovary. Three-dimensional US has become a key tool for diagnosing uterine malformations. Leiomyomas and endometrial polyps are the most frequent benign uterine pathologies, and both can interfere with the reproductive process. The human endometrium undergoes intense angiogenesis during menstrual cycle, and angiogenesis is a key process for successful embryo implantation and development. In reproductive medicine, it is crucial to exclude ectopic pregnancy as early as possible. 3D US is a more accurate technique for evaluating the relationship between the gestational sac and uterine septum and for differentiating between a cornual pregnancy and a displaced intracavitary pregnancy.
  • Chapter 17 - Congenital uterine malformations
    pp 134-140
  • View abstract

    Summary

    Currently, ultrasound is the most widely used noninvasive means of evaluating ovarian morphology in women with suspected polycystic ovary syndrome (PCOS). Although the most commonly used diagnostic sonographic features of PCOS are follicle number and ovarian volume, there is no complete consensus regarding the best criteria for ultrasound diagnosis. Transabdominal ultrasound has been largely superseded by transvaginal scanning because of greater resolution and, in many cases, patient preference. The transabdominal route is, of course, required in adolescent girls and virginal women who decline a transvaginal scan. The different ultrasound criteria for diagnosis of PCOS are: anthral follicle count, total ovarian volume, stromal area and ovarian area, stromal echogenicity, and vascularity. The Rotterdam criteria for the diagnosis of PCOs include the presence of 12 or more follicles in each ovary measuring 2-9 mm in diameter and/or increased ovarian volume (greater than 10 ml).
  • Chapter 18 - Uterine septum
    pp 141-154
  • View abstract

    Summary

    Three-dimensional (3D) ultrasound technologies are beneficial in some applications of obstetrics and gynecology and may aid in the evaluation of abnormal ovaries. Although the diagnostic criteria of polycystic ovary syndrome (PCOS) do not include 3D imaging, Allemand performed a study establishing the diagnostic threshold for 3D Ultrasonography of PCOS. The administration of gonadotropins for both insemination cycles as well as in-vitro fertilization cycles relies upon the use of serial real-time ultrasound examinations. In clinical practice, TV ultrasound monitoring during controlled ovarian hyperstimulation (COH) is performed to improve safety and precise monitoring of ovarian response to gonadotropin stimulation. PCOS patients have an increased number of preantral follicles; hence, close monitoring for ovarian hyperstimulation syndrome (OHSS) is essential. 3D ultrasound is a new imaging modality that improves the sensitivity and specificity of ultrasound. Recent advances in 3D ultrasound have the potential to better our understanding of follicular development, ovulation, and uterine receptivity.
  • Chapter 19 - Ultrasonography and incidental ovarian pathology
    pp 155-162
  • View abstract

    Summary

    A transvaginal scan (TVS) is performed with an empty bladder using a curvilinear, multifrequency, endocavity transducer with a typical central frequency of 6.5MHz. A fibroid outline is usually well visualized by TVS, even in the very small lesion, because of the pseudocapsule. The mixed tissue make-up of the fibroid produces a heterogeneous echo pattern on an ultrasound scan and can be highly attenuating of the ultrasound beam in some lesions. The most common gynecological symptoms of fibroids are menorrhagia and dysmenorrhea and, when significantly enlarged, they can also cause compression of adjacent pelvic structures. Most studies that have examined the relationship between fibroids and miscarriage rates have looked predominantly at intramural fibroids, with few data available on impact of submucosal fibroids. Myolysis is ablation of a fibroid mass by use of radiofrequency (RF) electricity, cryoprobes or focused ultrasound.

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