Overview of Sonography Gynecology Infertility Assessment, Protocols, and Interpretation
Infertility is when a woman is unable to get pregnant after one year of regular, unprotected sex if she’s under 35, or after six months if she’s older than 35. Approximately 15.5% of women experience this issue. The reasons for infertility can range from issues with the fallopian tubes (14%), to problems with ovulation (21%), to issues with the male’s sperm (26%). In many cases (28%), traditional tests can’t explain the cause of the infertility.
When doctors are figuring out why a woman is having trouble getting pregnant, they look at several different things. These include the woman’s ovarian reserve (how many eggs she has left), the health of her fallopian tubes and uterus, whether her thyroid is functioning properly, whether she has too much of the hormone prolactin, if she has polycystic ovarian syndrome (PCOS), the quality of the man’s sperm, and other important health factors that can affect a woman’s ability to get pregnant. Ultrasounds, which use sound waves to create pictures of the inside of the body, often play a big role when doctors are evaluating and managing infertility in women.
There are several different types of ultrasounds that can help doctors diagnose infertility:
- Baseline or screening ultrasounds look at the uterus, including the lining of the uterus and both ovaries. This type of ultrasound helps doctors measure and identify any abnormal findings, such as fibroids (noncancerous growths in the uterus), changes in the shape of the uterus, hydrosalpinges (a condition where the fallopian tubes are filled with fluid), and ovarian cysts (fluid-filled sacs in the ovary).
- Follicular monitoring ultrasounds help doctors track the growth of ovarian follicles (small sacs in the ovaries that contain an egg) and see how thick the lining of the uterus is. They also allow the doctors to note the consistency of the uterine lining.
- Saline Infusion Sonograms (SIS) involves injecting a small amount of saline (a saltwater solution) into the uterus, either with or without a 3D assessment. This helps doctors clearly see and assess the inside of the uterus for any abnormalities and can be used to check if the fallopian tubes are open.
In some cases, abdominal ultrasounds might be needed to get a better view of some of the woman’s reproductive structures that cannot be fully seen with an ultrasound probe inserted into the vagina. This is particularly useful for virgin or young girls who are trying to preserve their fertility or for individuals transitioning from female to male who are undergoing fertility treatments to reduce feelings of being in the wrong body. Abdominal scanning is also used to guide certain fertility procedures like sperm injection into the womb, embryo transfers, tissue samples taken from the inside lining of the uterus, and procedures done inside the uterus with a special tool called a hysteroscope.
Anatomy and Physiology of Sonography Gynecology Infertility Assessment, Protocols, and Interpretation
The menstrual cycle involves changes in both the endometrium, or lining of the uterus, and the ovarian follicles, or sacs in the ovaries. Doctors need to understand these changes to guide treatments like fertility monitoring or in vitro fertilization (IVF).
The endometrium thickens throughout the month due to hormones. It starts off thin after menstruation, and becomes significantly thicker during the follicular phase, the time leading up to ovulation. By then, it has a triple-layered appearance on ultrasound with a central line. It then becomes brighter and single-layered after ovulation during the luteal phase. Just before menstruation, it becomes a mix of light and dark areas due to menstrual blood. Doctors use ultrasound to measure its thickness and to observe changes in its pattern and blood vessels during the menstrual cycle.
The thickness of the endometrium is normally around 4.4 mm after menstruation but expands to around 10.3mm before ovulation. The triple-layered appearance during the follicular phase disappears after ovulation to form a single-layered structure. These changes could signal that ovulation has occurred. Irregular patterns may occur during menstruation or when there are issues like polyps, myomas (fibroids), or abnormal tissue growth.
The lining’s blood supply is classified into three levels. The first level shows no blood flow under the endometrium. In the second level, blood flows under this lining. In the third level, blood flows in both the lining and the layer beneath it.
A woman’s ovaries have follicles at different stages of growth: primordial, primary, secondary, tertiary, or antral follicles. The number of primordial follicles reflects a woman’s egg supply. These follicles are small and difficult to see on ultrasound, and the number decreases from around 6-7 million during fetal development to about 1000 at menopause.
Every day of the menstrual cycle, some of the tiny, sleeping primordial follicles start to grow bigger. This growth results in different types of follicles. From these, one follicle becomes destined to release an egg, while others disappear. It is this antral or tertiary follicle that releases an egg during ovulation.
Doctors use antral follicular count (AFC), or the total number of small follicles in both ovaries, as a standard way to measure a woman’s egg supply. The best time to measure the AFC is early in the menstrual cycle when there are no leftover structures from ovulation or ovarian cysts. But, AFC can be done at any time during the menstrual cycle if cysts are not blocking the view of the ovaries.
Each follicle grows under the control of the follicle-stimulating hormone (FSH) once it reaches a certain size. The follicle becomes dominant when it is larger than 10 mm. This dominant follicle grows an average of 1 to 1.4 mm each day from day eight to day twelve of the menstrual cycle. When it reaches around 20 to 24 mm, ovulation occurs. These sizes can vary, so doctors often watch for follicles to grow to at least 18 to 20 mm before retrieving eggs for IVF.
After ovulation, the follicle collapses and becomes the corpus luteum. This structure creates hormones to support implantation, where the fertilized egg attaches to the lining of the uterus. The corpus luteum appears as a “ring of fire” on a color flow doppler ultrasound because of the increased blood supply.
Why do People Need Sonography Gynecology Infertility Assessment, Protocols, and Interpretation
A transvaginal sonogram is a type of ultrasound that’s used for examining female reproductive organs. It can check for any irregularities in the uterus, ovaries, and nearby structures. Doctors might use this tool to look for problems like fibroids (non-cancerous growths in the uterus), polyps (small, usually non-cancerous growths), different unusual formations in the uterus, hydrosalpinx (a condition where a woman’s fallopian tube is blocked with fluid), or PCOS (Polycystic Ovary Syndrome: a hormonal disorder causing enlarged ovaries with small cysts).
This ultrasound can also help evaluate ovarian reserve- basically how many eggs are left in a woman’s ovaries. If fertility treatments are being used, it can keep an eye on how ovulation is progressing during the treatment cycle. This monitoring can happen during cycles with medicines like clomiphene citrate, letrozole, or gonadotropin with or without a procedure known as intrauterine insemination (IUI: a type of artificial insemination that involves placing sperm inside a woman’s uterus to help fertilization). Similarly, it is often used with In-vitro fertilization (IVF: the process of fertilization by extracting eggs, retrieving a sperm sample, and then manually combining an egg and sperm in a laboratory dish).
Transvaginal sonogram can gauge the right time to trigger ovulation during IUI and IVF. It also looks at the thickness of the endometrium (the lining of the uterus) during these procedures. Sometimes, for certain procedures like oocyte retrieval (extracting eggs from the ovaries for use in fertility treatments) or embryo transfer, and for other uterine procedures, the usual scanning through the abdomen doesn’t work as well.
On the contrary, doctors use a transabdominal sonogram (an ultrasound that takes pictures of abdominal organs) for women who have enlarged uteruses due to fibroids or adenomyosis (when endometrial tissue exists within and grows into the uterine wall), or both. It is also used when the uterus or ovaries are scarred and stick to the front of the abdominal wall due to past surgery, infection, or endometriosis (a disorder, where tissue that normally lines the uterus grows outside the uterus).
Another procedure is the saline infusion sonogram, which uses salt water injected into the uterus to make clearer images during an ultrasound. This can help examine if there are any problems inside the uterus, for example, polyps, fibroids under the uterine lining, intrauterine synechiae (bands of scar tissue inside the uterus), or uterine malformations (abnormally shaped uterus). This method can also be used to verify if a woman’s fallopian tubes (tubes that connect the ovaries to the uterus) are open or pat, instead of using a more traditional technique called a hysterosalpingogram (a special X-ray using dye to look at a woman’s uterus and fallopian tubes).
When a Person Should Avoid Sonography Gynecology Infertility Assessment, Protocols, and Interpretation
There are several reasons why a woman may not be able to undergo a saline-infusion sonography, or SIS, which is a kind of ultrasound to check the womb:
- Pregnancy is one such case, because this ultrasound could affect the growing baby.
- Heavy menstrual bleeding or active bleeding can also prevent this kind of ultrasound because it makes it harder for doctors to see the womb clearly.
- A suspected infection, indicated by the woman’s symptoms, or unusual vaginal discharge seen during a check-up can also make this ultrasound unsafe or not useful.
Equipment used for Sonography Gynecology Infertility Assessment, Protocols, and Interpretation
You’ll need an ultrasound machine with two types of probes: one that can scan across your abdomen (transabdominal) and another one that the doctor can insert into your vagina (transvaginal). The probes that scan across your belly need to operate at 3.5 Megahertz (Mhz) or higher, while the ones used for vaginal scans need to operate at 5Mhz or higher.
Recently, 3D ultrasound has been found to be useful in performing a procedure called SIS (which is a type of ultrasound where saline is injected into the uterus to help the doctor see the uterus more clearly) and also in measuring AFC (antral follicle count, which is a test used to estimate the number of eggs a woman has left) and ovarian sizes.
Who is needed to perform Sonography Gynecology Infertility Assessment, Protocols, and Interpretation?
To carry out your procedure, a team of medical professionals is needed. This group consists of a sonographer, a special type of technician who knows how to use a machine that takes pictures of the structures inside your body. A radiologist (a doctor who specializes in using imaging methods to diagnose and treat diseases), an OBGYN who is trained to perform ultrasounds (this is a doctor specialized in women’s health and they know how to use sound waves to create images of the inside of your body), and reproductive endocrinology and infertility specialists (doctors who have special training in understanding why it is difficult for some people to get pregnant and offer treatments to help them). This team of experts will be working together to ensure that you receive the best care possible.
Preparing for Sonography Gynecology Infertility Assessment, Protocols, and Interpretation
A transabdominal scan is a type of ultrasound that looks at the organs and other structures in your abdomen. Your doctor may have you drink water before this test to make your bladder full. That’s because a full bladder can help push your intestines to the side and make it easier to see other organs in your pelvis during the scan. If you’re having a transvaginal scan, an ultrasound that’s done through your vagina, or a special ultrasound called a sonohysterosalpingogram (SIS) that checks your uterus and fallopian tubes, it’s better to have an empty bladder.
Doctors often choose to do an SIS test when you’re in the middle part of your menstrual cycle and you’re no longer bleeding. This helps them get a clearer picture and makes it easier to spot any issues like benign growths (polyps) or scar tissue (adhesions). Before you have an SIS test, your doctor will ask you to do a pregnancy test to make sure you’re not pregnant, as this procedure should not be performed if you are pregnant.
How is Sonography Gynecology Infertility Assessment, Protocols, and Interpretation performed
A transvaginal ultrasound is a technique used by doctors to examine pelvic structures like the uterus, ovaries, and the space between the rectum and the uterus (cul de sac). This test is mainly conducted when a woman is dealing with fertility issues.
The procedure begins with the patient lying down with knees bent and feet in holders called stirrups. A thin probe, called a transvaginal probe, is covered with a special gel and a condom-like cover to make sure it’s safe and comfortable to use. This probe is gently inserted into the patient’s vagina, either by the patient or the doctor, and it uses sound waves to create pictures of the reproductive organs.
During the test, the doctor examines different parts of a patient’s reproductive system. This includes the uterus (where a baby develops during pregnancy), endometrium (the lining of the uterus), ovaries (where eggs are produced), and cul de sac (the space between the uterus and the rectum). If there’s any fluid or adhesions (unusual scar-like tissue that causes organs to stick together) in the cul de sac, it’s important to address this.
The doctor evaluates the size and shape of the organs, checks for any abnormal growths like fibroids or cysts, and measures the thickness of the endometrium. They also count and measure the small fluid-filled sacs (follicles) in the ovaries. This information can be helpful in understanding your fertility conditions.
In some cases, a type of test called a saline infusion sonogram may be used. Just like the previous procedure, you’ll lay down and start with a regular transvaginal ultrasound. Then, a small tube is inserted into the cervix (the lower part of the uterus), and sterile salt water (saline) is gently pumped into the uterus. This helps the doctor get better images of the inside of your uterus. If necessary, this method can also determine if the fallopian tubes (tubes that carry eggs from the ovaries to the uterus) are open or closed.
In certain situations, an abdominal ultrasound may be done instead, where the doctor uses a probe on the outside of the lower abdomen to create images of your reproductive organs.
Overall, these tests provide important information about a woman’s reproductive health and can help identify any potential issues that might be affecting fertility.
Possible Complications of Sonography Gynecology Infertility Assessment, Protocols, and Interpretation
The procedures called SIS (saline infusion sonography) and sonohysterosalpingogram can sometimes lead to complications like pain, bleeding, and infection. To manage the pain, patients are usually advised to take a painkiller like ibuprofen about an hour before the procedure. Most doctors would suggest a dose of 400 to 600 mg.
After the procedure, it’s important for patients to keep an eye out for any signs of infection. These might include a fever, unusual vaginal discharge, pain in the pelvic area, or tenderness. It’s possible for these symptoms to appear up to a month after the procedure.
Bleeding a little after the procedure is common. However, it should stop within 24 hours. If there’s more bleeding after that, it might be necessary to get it checked out.
What Else Should I Know About Sonography Gynecology Infertility Assessment, Protocols, and Interpretation?
An ovarian assessment through ultrasound can give insight to doctors about a woman’s ability to conceive a child. The Antral Follicle Count (AFC) – a measure of the number of small follicles within the ovaries – offers accurate prediction of the ovarian response to fertility treatment, and the chances of successful IVF treatment. If this count is very low (less than 5), the woman’s ability to conceive becomes significantly reduced. Conversely, a higher count (20 or more) suggests an elevated ovarian response, and increased risk for ovarian hyperstimulation syndrome – a potentially risky overreaction to fertility drugs.
Fertility enhancing drugs, called gonadotropins, stimulate follicle growth. Follicles are the part of the ovary where eggs grow. Under these fertility treatments, multiple follicles tend to grow instead of the typical single one in a natural, drug-free cycle. The growth of these follicles under the influence of these fertility drugs is typically 1.7 to 2 mm daily. If follicles are the ideal size (between 18 and 20 mm), there is an 83.5% chance of egg retrieval. To avoid adverse effects like ovarian hyperstimulation and multiple births, ultrasounds are performed to monitor ovaries and determine the appropriate time for egg retrieval.
Polycystic Ovarian Syndrome (PCOS) is a hormonal condition in women that can cause difficulties in getting pregnant. Ultrasounds can assess ovarian volume and follicle number per ovary, which can assist in diagnosing PCOS. Other cysts, like teratomas (tumours that are usually benign) and endometriomas (fluid-filled cysts), can also be diagnosed through ultrasound.
Ultrasounds can be vital in examining the endometrium – the inner lining of the uterus – which plays a pivotal role in embryo implantation. Certain drugs like Clomiphene Citrate can affect endometrial development adversely. On ultrasounds, a thin endometrial lining can sometimes occur due to its anti-estrogenic effect. The chance of a successful pregnancy increases with a preovulatory endometrial thickness of 6.5 to 7 mm or above. High pregnancy rates are also seen when the endometrial blood flow is well-developed, signifying a healthy supply of nutrients to an embryo. Ultrasounds can, therefore, provide critical insight into the health and receptivity of the endometrium.
Abnormalities like polyps, endometrial fluid, adenomyosis, and leiomyomas might affect the chances of a successful pregnancy by altering endometrial receptivity. Ultrasound scans can assist in diagnosing such issues, further helping the treatment process.
