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Abnormalities of Corpus luteum Function
state is progressive, i.e., it continues to develop and is not selflimiting. This could explain why the vascular resistance in the
corpus luteum follows a similar pattern in these patients as in
women with a normally developing pregnancy.
Alcazar et al.
1
agreed only partly with the results of Salim.
They found a higher RI in missed abortions compared with a
control group. This may be explained by the fact that the impaired hCG production in a missed abortion could have a negative effect on the corpus luteum. On the other hand, Alcazar et
al. found no statistically significant changes of RI in threatened
abortions.
Outlook. The true capabilities of transvaginal pulsed and color
Doppler sonography in the assessment of corpus luteum and
ovarian blood flow have not yet been adequately explored.
With their help, however, it should be possible in the foreseeable future to better understand the physiology of reproductive processes and find ways to treat pathological conditions
that are not treatable at present.
References
1 Alcazar JL, Laparte C, Lopez-Garcia G: Corpus luteum blood flow in ab-
8
normal early pregnancy. J. Ultrasound Med. 15 (1996) 645–649
2 Beitinis IZ, McArthur JW, Turnbull BA, Skrinar GS, Bullen BA: Exercise
induces two types of human luteal dysfunction: Confirmation by urinary free progesterone. J. Clin. Endocrinol. Metab. 72 (1991) 1350–
1358
3 Dawood MY: Corpus luteal insufficiency. Curr. Opin. Obstet. Gynecol. 6
(1994) 121–127
4 Fay TN, Jacobs IJ, Teisner B, Westergaard JG, Grudzinskas JG: A bio-
chemical test for direct assessment of endometrial function: measurement of the major secretory endometrial protein PP14 in serum
during menstruation in relation to ovulation and luteal function. Hum.
Reprod. 5 (1990) 382–386
5 Gibson M, Badger GJ, Bym F, Lee KR, Korson R, Trainer TD: Error in his-
tologic dating of secretory endometrium: variance component analysis. Fertil. Steril. 56 (1991) 242–247
6 GlockJL, Blackman JA, Badger GJ, Brumsted JR: Prognostic Significance
of Morphologic Changes of the Corpus Luteum by Transvaginal Ultrasound in Early Pregnancy Monitoring. Obstet. Gynecol. 85 (1995)
37–41
7 Glock JL, Brumsted JR: Color flow pulsed Doppler ultrasound in diag-
nosing luteal phase defect. Fertil. Steril. 64 (1995) 500–504
8 Hecht BR, Bardawil WA, Khan-Dawood FS, Dawood MY: Luteal Insuffi-
ciency: Correlation Between Endometrial Dating and Integrated Progesterone Output in Clomiphene Citrate-Induced Cycles. Amer. J. Obstet. Gynecol. 163 (1990) 1986–1991
9 Insler V: Corpus luteum defects. Curr. Opin. Obstet. Gynecol. 4 (1992)
203–211
10 Jones GS: Luteal Phase Defect: A Review of Pathophysiology. Curr.
Opin. Obstet. Gynaecol. 3 (1991) 641–648
11 Kupesic S, Kurjak A: The assessment of normal and abnormal luteal
function by transvaginal color Doppler sonography. Eur. J. Obstet.
Gynecol. Reprod. Biol.72 (1997) 83–87
12 Kupesic S, Kurjak A, Vujisic S, PetrovicZ: Luteal phase defect: compari-
son between Doppler velocimetry, histological and hormonal
markers. Ultrasound Obstet. Gynaecol. 9 (1997) 1–8
13 McNeely MJ, Soules MR: The diagnosis of luteal phase deficiency: A
critical review. Fertil. Steril. 50 (1988) 1–15
14 Merce LT, Garces D, De la Fuente F: Conversion lutea de la onda de
velocidad de fluio ovarica: nuevo parametro ecografico de ovulacion y
funcion lutea. Acta Obstet. Gynecol. Scand. (ed. Esp.) 2 (1989) 113–114
15 Reshef E, Segars JH, Hill GA, Pridham DD, Jussman MA, Colston-Wentz
A: Endometrial inadequacy after treatment with human menopausal
gonadotropin/human chorionic gonadotropin. Fertil. Steril. 54 (1990)
1012–1016
16 Salim A, Z
luteum blood flow in normal and abnormal early pregnancy: Evaluation with transvaginal color and pulsed Doppler sonography. J. Ultrasound Med. 13 (1994) 971 –975
17 Strigini FAL, Scida PAM, Parri C, Visconti A, Susini S, Genazzani AR:
Modifications in uterine and intraovarian artery impedance in cycles
of treatment with exogenous gonadotropins: effects of luteal phase
support. Fertil. Steril. 64 (1995) 76–80
18 Tinkanen H: The role of vascularization of the corpus luteum in the
short luteal phase studied by Doppler ultrasound. Acta. Obstet. Gynecol. Scand. 73 (1994) 321–323
19 Yeko TR, Khan-Dawood FS, Dawood MY: Human corpus luteum:
Luteinizing hormone and chorionic gonadotropin receptorsduring the
menstrual cycle. J. Clin. Endocrinol. Metab. 68 (1989) 529–534
ˆ
alud I, Farmakides G, Schulmal H, Kurjak A, Latin V: Corpus
82
9 Interventional Ultrasound in Reproductive Medicine
S. Kupesic, A. Kurjak, and A. K. Er tan
Laparoscopy was the method of choice for oocyte retrieval in
the earliest case reports on successful in-vitro fertiliza-
21, 30, 31, 45, 70
tion
follicles maturing deep in the ovary or in an ovary concealed by
matted adhesions could not be directly visualized
laparoscopy usually required general anesthesia and was associated with increased perioperative morbidity and mortal-
. Its greatest disadvantage, however, was that
55
. Moreover,
Follicular Aspiration in Assisted Reproduction
Transabdominal Follicular Aspiration
Lenz et al.40were the first authors to describe ultrasoundguided follicular aspiration. Analgesic and sedative premedication allowed for a painless procedure with high patient acceptance
induce hyperprolactinemia, which could adversely affect the
microenvironment of the oocyte
Equipment. Early studies described the use of linear transducers
High-resolution transducers have a separate biopsy attachment with corresponding software. Most authors use a 16gauge needle with an inside diameter of 1.1 mm
coating on the needle counteracts the adhesive tendency of the
oocytes, while the sharp needle tip can easily pierce the ovarian tissue with minimal pressure or pain. To flush the follicle,
the proximal end of the needle is connected by Teflon tubing to
a syringe filled with warmed, heparinized culture medium.
Flushing the follicle after it has been aspirated helps to maximize the oocyte recovery rate per punctured follicle
rigation lumen may be parallel or concentric to the aspiration
lumen. The first attempts employed manual aspiration with a
5 ml syringe. But since the uncontrolled pressure of manual
aspiration could cause rupture of the zone pellucida, operators
developed a foot-controlled mechanical aspiration pump with
a maximum pressure of 80–100 mmHg
cludes a comfortable operating table, sterile drapes and protective sleeves, sterile ultrasound gel, and a water bath or heating unit.
Patient preparation. Every patient requires thorough counseling and meticulous preparation. A large number of different
stimulation protocols are used to induce the growth of multiple follicles. A combination of endocrinological and sonographic data are used to determine the timing of hCG (human
chorionic gonadotrophin) administration. An ultrasound ex-
39
. General anesthesia was not used because it might
60
.
75
, whereas most operators today prefer sector scanners.
43, 75
. The Teflon
60
. The ir-
14
. Other equipment in-
ity. Another problem was that the pneumoperitoneum created
with carbon dioxide led to very slight, transient pH changes
that could have a harmful effect on the oocytes. In the early
1980 s, the first generation of real-time scanners offered sufficiently high resolution for the percutaneous ultrasound-
guided aspiration of oocytes.
amination is advised before the start of the procedure. The goal
of this examination is to determine the number and size of the
follicles and compare them with the data on the day of hCG administration. The patient should drink 2 liters of liquid one
hour before the procedure to distend the bladder. In some
cases it may still be necessary to insert a transurethral catheter
and instill Hartmann solution into the bladder, and the operator should understand the associated risks of iatrogenic infection and bladder irritation. A distended bladder permits clear
visualization of the ovarian follicles and moves the bowel out
of the area between the abdominal wall and ovaries.Combined
analgesic and sedative premedication is given to most patients,
and the needle insertion site is infiltrated with local anesthetic.
Other options are peridural or spinal anesthesia. The lower abdomen is prepared with an antiseptic solution, and the operative field is packed off with sterile drapes. The endovaginal
transducer is smeared with sterile ultrasound gel and covered
with a sterile protective sleeve. The control panel of the ultrasound unit is covered with sterile, transparent plastic film.
Technique. The puncture needle is inserted directly into the
bladder using freehand technique or a needle guide. After the
needle has pierced the posterior bladder wall and ovarian capsule, the needle tip is directed into the center of the closest follicle. The follicular fluid is aspirated, and the collapsed follicle
is flushed with an equal volume of culture medium. The needle
tip is kept within the ovary, and all the follicles are systematically aspirated using the same technique. The operator should
understand that inadequate bladder filling or pelvic adhesions
can alter the position of the ovaries and that overweight and
heavy scar tissue result in poor visualization of the pelvic or-
gans. After the procedure is completed, the patient may empty
her bladder and can usually be discharged home two hours
later.
Infertility Evaluation and Assisted Reproduction
83
84
Interventional Ultrasound in Reproductive Medicine
Transurethral Follicular Aspiration
Parsons50and Dellenbach17developed the transurethral technique of oocyte retrieval. The procedure was done on an outpatient basis to reduce costs. The patient was placed in the
lithotomy position with the operator on her right, the ultrasound cart on her left, and an assistant seated in the middle between the patient’s
9
legs
. The vulva was aseptically prepared
with chlorhexidine solution. The needle tip was introduced
through the side opening of the Foley catheter and passed
through the urethra into the bladder. After the bladder was
filled with Hartmann solution, the catheter cuff was inflated
and the needle tip wasadvanced out of the catheter.The operator then passed the needle tip through the posterior bladder
wall under sonographic guidance and directed it into the
nearest follicle. All the follicles weresuccessively aspirated and
flushed. Finally the needle was withdrawn, the bladder was
emptied, and the catheter was removed. The patient drank
several glasses of liquid and emptied her bladder before leaving the hospital. The overall complication rate was very low.
There were no complaints of cystitis or adnexitis following the
procedure.
9
Booker et al.8compared the transurethral route for ultrasoundguided follicular aspiration with the transvaginal route in a randomized prospective study. Considerably more follicles could be
visualized by the transvaginal route, but there were no differences
in the number of oocytes harvested, in the duration of the procedure, or in the fertility, embryo-transfer or pregnancy rates. This
led the authors to conclude that the transurethral and transvaginal
routes were of equal value for ultrasound-guided follicular aspira-
tion.
Transvaginal Follicular Aspiration
Gleicher et al.25were the first authors to report on transvaginal
follicular aspiration guided by abdominal ultrasound. A
speculum is placed in the vagina, and the needle is passed
through the fornix to the ovary. Subsequent experience has
shown that the transvaginal approach guided with an endovaginal transducer is superior to all other ultrasound-guided
techniques
Advantages. The proximity of the transducer to the pelvic organs enables the use of high-frequency transducers that provide significantly better resolution and greater clinical efficiency.Owing to the natural compliance of the fornix, the tip of
the transducer can be moved closer to the ovaries by applying
gentle pressure. Since a full bladder is not required, the position of the pelvic organs is unchanged and the ovaries are located within the focal zone of the transducer. Overweight or
adhesions do not prevent visualization of the follicles and thus
are not a contraindication to this method.
Standard stimulation protocols are monitored with the aid
of transvaginal sonography
gained by hormone assays and by the color Doppler assessment of blood flow in the uterus and ovary
22
.
32
. Additional information can be
34, 37, 38
.
Preparations. The entire treatment is done as an outpatient
procedure. The patient is placed in the lithotomy position.
Sedatives (such as flunitrazepam, droperidol, or pentazocine)
can be given, but approximately 50% of IVF groups do not use
anesthesia or sedation
23
. Since follicular aspiration takes about
10 minutes on average, most patients tolerate the procedure
with no difficulties. Nevertheless, the operator should be
aware of possible hypotensive reactions or queasiness. Af ter
ultrasound gel has been applied to the transducer probe, the
protective sleeve (a sterile condom, surgical glove, or specially
designed sheath) is placed over the gel-smeared probe, avoiding any air bubbles that might cause artifacts. The gel should
not be used to lubricate the probe insertion because of its spermicidal and reputed embryotoxic properties
58
. Physiological
saline solution or culture medium should be used instead.
Technique. The vagina is irrigated with isotonic saline solution
or culture medium, and the transducer probe is inserted into
the vagina. A sterile needle guide is used for transvaginal follicular aspiration. An automatic puncture device has been
developed to avoid the potential risks of needle insertion. This
device consists of a movable metal tube and a guide mechanism into which the aspiration needle is inserted and se-
22
cured
. The device should be “locked and loade d” before it is
inserted into the vagina with the transducer. After the insertion, a detailed sonographic examination is done to locate the
uterus and ovaries. The probe is positioned so that the puncture line indicating the needle path is aimed precisely at the
center of the nearest follicle. The operator calculates the exact
distance along the puncture line to the targeted follicle and
“fires” the needle into the follicle. The follicular fluid is then
aspirated into a test tube connected to the aspiration pump.
The collapse of the follicle can be observed during aspiration of
the follicular fluid
22
. Flushing of the aspirated follicle may be
done to increase the number of retrieved oocytes. This is done
by infusing culture medium with heparin added through the
puncture needle or through a separate line. Without removing
the needle, the operator aspiratesall of the follicles that are situated along the puncture line.
Complications. Feichtinger et al.
24
described a low complication rate with ultrasound-guided follicular aspiration. In 2.4%
of cases the iliac vein was mistaken for a follicle and erroneously punctured. Ultrasound revealed intraperitoneal
bleeding into the cul-de-sac, but this resolved spontaneously
in all cases. It was shown that filling the bladder can stop the
bleeding by exerting pressure on the puncture site. The use of
color Doppler may provide a simple way to avoid this complication, as the iliac vessels are easily visualized with this technique.
Bleeding from the posterior vaginal wall is easy to diagnose
and can be stopped by compression. Pelvic inflammatory disease (PID) is considered a rare complication of transvaginal
follicular aspiration (0.14% of all patients)
24
. In most cases the
infection was caused by bacterially contaminated semen and
occurred in women with a prior history of PID.
GIFT (Gamete Intrafallopian Transfer) and ZIFT
(Zygote Intrafallopian Transfer)
GIFT. The GIFT procedure was developed to overcome various
obstacles to spermatozoon transport and the failure of the fallopian tube to capture the oocyte during ovulation
3
. Patients in
this program undergo ovarian stimulation under ultrasound
surveillance. The oocytes are harvested by laparoscopy, identified in the laboratory,and transferredto a catheter containing
100000 spermatozoa collected by the swim-up technique
The transfer catheter is introduced into the fimbriated end of
the fallopian tube, where its contents are gently emptied. By
bringing together the sperm and oocyte, this technique circumvents many of the factors that can disrupt sperm transport
and fusion
the success rate is 26.5% deliveries per oocyte retrieval
46
. Because fertilization occurs in the natural milieu,
61
.
Embryo Transfer
Fallopian Tube Catheterization
ZIFT. ZIFT is an advanced form of GIFT in which the oocytes are
harvested by transvaginal aspiration, fertilized in vitro, and
transferred the next day in the pronuclear stage into one of the
fallopian tubes using the GIFT technique
aspiration technique used in the ZIFT method is the same as
that described for IVF. The overall success rate appears to be
identical to that of GIFT and IVF.
Advantages and disadvantages. Disadvantages of the GIFT and
ZIFT procedures are that they cannot be used in patients with
3
.
tubal pathology and they require anesthesia and operating
room technique. Also, neither procedure can be used in
patients with male factor infertility since fertilization is uncertain. One refinement is to transfer the spermatozoa and oocytes into the fallopian tube by transcervical catheterization of
the tube, but this method is associated with the same pregnancy rates with no significant reduction in costs or risks.
62
. The transvaginal
Intrauterine embryo transfer represents the last critical step in
in-vitro fertilization. Inadequate transfer of the embryo into
the uterine cavity can be an important factor in the failure of
implantation. For this reason, ultrasound-guided embryo
transfer might offer significant advantages over the traditional
“blind” transfer
Hurley et al.29performed intrauterine embryo transfer with a transcervical catheter in 94 patients using transvaginal ultrasound
guidance. The culture medium that contained the embryos was injected along with air bubbles so that the embryos could be optimally placed in the uterine cavity under visual guidance. This
method was particularly helpful in six cases where the catheter became “stuck” in the endocervical canal, contrary to the operator’s
impression that the catheter was accurately placed in the uterine
cavity.
27
.
Fallopian Tube Catheterization
Indications and technique. Fifteen percent of female infertility
cases are caused by proximal occlusion of the fallopian tubes.
The occlusions at that level may result from intraluminal cellular debris, mild adhesions, or muscular spasms
tubal catheterization can be used for both the diagnosis and
treatment of infertility patients
15, 16, 33, 56, 59, 68
in selecting patients for this procedure are the presence of bilateral tubal occlusions or the stenosis of the remaining tube in
patients who have had a unilateral salpingectomy
ter is advanced into the fallopian tube over a guidewire to
stretch open the tube. When aided by fluoroscopic guidance,
tubal catheterization has a success rate of 98 % for proximal occlusions in the area of the uterotubal junction but only 33% for
more distal stenoses
56
.
Ultrasound guidance. Transvaginal ultrasound can be used to
direct the tubal catheterization, although there has been little
64
. Transcervical
. The criteria used
27
. The cathe-
This method has also proved effective in patients with submucous leiomyomas or uterine anomalies. Moreover, the ultrasound-guided procedure allays anxiety by allowing patients
to watch the transfer on the monitor screen.
Lenz et al.
41
and Parsons et al.49used transvaginal ultrasound for guidance during transabdominal embryo transfer
through the wall of the uterus into the uterine cavity. This
method could provide an alternative to transcervical transfer
in patients with known cervical stenosis making it difficult to
pass a catheter through the cervical canal.
experience with this technique to date. Lisse and Sydow
44
de-
scribed tubal catheterization under transvaginal ultrasound
guidance. Concomitant laparoscopy confirmed the accurate
placement of the catheter in the proximal part of the tube
(3–6 cm from the intramural junction). Tubal patency was restored in 85% of the patients with a proximal occlusion. Breckenridge and
Schinfeld
11
and Thurmond et al.67recommend
transabdominal ultrasound as a simpler method of guiding the
catheter insertion than transvaginal ultrasound. They report
that the full bladder necessary for abdominal ultrasound
straightens the uterus and makes it more easily accessible.
Complications. Possible complications of transcervical tubal
catheterization are perforation of the fallopian tube, vasovagal
reactions during the procedure, and infection. Patients should
also be informed of the increased risk of ectopic pregnancy following the procedure.
Infertility Evaluation and Assisted Reproduction
85
Interventional Ultrasound in Reproductive Medicine
Aspiration of Ovarian Cysts
Indications and technique. Transvaginal ultrasound allows the
direct visualization and aspiration of persistent follicular
27
cysts
. These cysts can impair folliculogenesis either by hormone secretion or by compressing the tissue and restricting
blood flow. For the aspiration of an ovarian or paraovarian cyst,
the needle tip is introduced into the center of the cyst. The
merits of this procedure are debated in the literature. The fear
of seeding cells into the abdominal cavity from a potentially
malignant ovarian process has discouraged many operators
from using this method. While cytological analysis is always
performed on the aspirated cyst fluid, a negativecytological report is occasionally false-negative. The high sensitivity and
specificity of transvaginal color Doppler ultrasound in the
difference of benign and malignant adnexal masses can apparently aid the decision of which cysts should be aspirated
(Fig. 9.
1).
Fig. 9.1 Transvaginal scan of an anechoic ovarian cyst. Color Doppler
indicates a high RI (0.75) for blood flow in the pericystic tissue.
Recurrence rates. Bret et al.
perience with transvaginal ultrasound in the aspiration of ovarian
cysts. They described a recurrence rate after cyst aspiration of 48 %
9
in premenopausal patients and 80 % in postmenopausal women. Alcohol was injected into the aspirated cyst to prevent recurrence,
but this was successful in only four of seven patients
12, 13
published two reports on their ex-
12
.
Vaegemaekers et al.74performed the transvaginal aspiration of
32 unilocular, hypoechoic ovarian cysts (average diameter
45 mm) in infertile patients. The authors concluded from their
study that ovarian cyst aspiration in the early follicular phase
might reduce the dropout rate from IVF cycles.
Drainage of Cul-de-Sac Abscesses
In 30–40% of infertile patients, occlusion or dysfunction of the
fallopian tubes is the cause of the infertility. It is known that
tubal occlusion is a common sequel to PID. Because PID has a
high recurrence rate, it is reasonable to conclude that this
cause has a high incidence in the population of infertile
women.
The drainage of tubo-ovarian abscesses under sonographic
guidance can accelerate the healing process and enhance the
effectiveness of antibiotic therapy. The needle tip is advanced
Endometriosis. Endometriosis is considered a relative contraindication to cyst aspiration. Aboulghar et al.
1
examined 21
patients after the transvaginal ultrasound-guided aspiration of
endometriotic cysts. They found six recurrences over a 12month follow-up period.
While the needle aspiration of endometriotic cysts is technically simple, the overall benefit and safety of this method
have not yet been adequately evaluated owing to the relatively
small number of patients in whom the procedure has been performed to date
42
.
into the abscess cavity, and the fluid inside the abscess is
aspirated as completely as possible. Then the needle is withdrawn or a drainage catheter is inserted
27
. Teisala et al.66reported on the drainage of 10 tubo-ovarian abscesses performed with antibiotic therapy and transvaginal ultrasound
guidance. Only mild sedation was needed for pain control, and
the procedure was well tolerated by the patients. The technique is a widely recognized alternative to laparoscopy in the
treatment of tubo-ovarian abscesses.
86
Selective Reduction of Multiple Pregnancies
During the past 15 years, the incidence of multiple gestation
has increased owing to the frequent use of ovulation-stimulating products and the more widespread use of assisted reproductive techniques. Multiple pregnancies are associated with a
high risk of morbidity and mortality. The likelihood of carrying
the pregnancy to term and bearing a healthy child is inversely
proportional to the number of fetuses. This has prompted efforts to selectively reduce the number of embryos to improve
the outcome for the remaining fetuses
6
. Selective reduction
can be offered in a pregnancy with more than four embryos,
27
usually reducing it to a twin pregnancy
. Normally the procedure is done after eight weeks’ gestation, when the spontaneous abortion rate is very low. A group of French authors
were the first to perform the procedure with a needle introduced under abdominal ultrasound guidance, and other
groups have adopted the same method
7, 10
. With advances in
transvaginal sonography, this technique has also been used
successfully in multifetal pregnancy reduction. The advantages
20
Techniques of Ultrasound Tubal Imaging
of the transvaginal technique are the shorter needle path and
the ability to direct the needle more precisely, thereby reducing the risk of injury to adjacent gestational sacs or pelvic organs.
Technique. The technique of transvaginal multifetal pregnancy
reduction consists of visualizing the gestational sacs with ultrasound, carefully analyzing the fetal heart tones, introducing
Techniques of Ultrasound Tubal Imaging
One aspect in the diagnostic investigation of infertility has remained largely unchanged over the past 20 years: the examination of the fallopian tubes. Rubin
tempt to evaluate tubal patency in 1954. Since then, the most
widely used methods of tubal examination have been radiographic hysterosalpingography and laparoscopic chromopertubation
48
.
Radiographic hysterosalpingography. For decades, hysterosalpingography (HSG) using radiographic contrast medium has
been the standard procedure for demonstrating the structure
of the uterus and fallopian tubes. One disadvantage of HSG is
the risk posed by ionizing radiation to the oocyte, which could
result in a congenital anomaly if fertilization were to occur.
57
described the first at-
the needle into the heart of the selected fetus, and injecting
0.5–1 ml of a 2 mEq /ml potassium chloride solution. The fetus
is then observed for 5–10 minutes to confirm cardiac asystole.
The patient should be reexamined with ultrasound three hours
after the procedure and again at one week. The disadvantageof
transvaginal fetal reduction is that it is still uncertain at this
early stageof pregnancy howmany fetuses would actually continue to grow without the procedure
42
.
Also, allergy to iodinated contrast medium is considered a contraindication to radiographic HSG (Table 9.
1). There is still dis-
agreement as to whether an oil-based or a water-based contrast medium is better for HSG.
Hysteroscopy. Hysteroscopy should be viewed as a complementary technique to hysterosalpingography. It can be used
for both the accurate investigation and treatment of endometrial polyps and submucous leiomyomas. It is also very
helpful in the diagnosis and treatment of intrauterine synechiae and some congenital uterine anomalies (Table 9.
1).
Laparoscopy. Laparoscopy has been the gold standard for the
diagnostic evaluation of tubal function during the past two
Infertility Evaluation and Assisted Reproduction
Table 9.1 Comparison of the advantages of laparoscopy,hysteroscopy, radiographic hysterosalpingography(HSG), and color Doppler hysterosal-
pingography in the assessment of tubal function
Criteria Radiographic HSG Hysteroscopy Laparoscopy Color Doppler HSG
Anesthesia
Risks
Necessary
facilities and
➤
Not required
➤
Pelvic infection
➤
Contrast allergy
➤
X-ray machine
➤
Fluoroscope
➤
⫾ General anesthesia
➤
Anesthesia risk
➤
Uterine perforation
➤
Bleeding
➤
Infection
➤
⫾ Operating room
➤
General anesthesia
➤
Anesthesia risk
➤
Intra-abdominal
injuries
➤
Bleeding
➤
Infection
➤
Operating room
➤
Not required
➤
Pelvic infection
➤
Color Doppler unit
equipment
Advantages
➤
Contrast visualization (evaluation
of the ampulla, demonstration of
intramural and intraluminal tubal
abnormalities)
➤
Visualization of uterine
cavity (polyps, synechiae,
leiomyomas, septa, etc.)
and of tubal ostia
➤
Treatment possible in the
same sitting
➤
Visualization of
abdominal cavity
and peritoneum
(adhesions, endometriosis, etc.)
➤
Treatment possible
in the same sitting
➤
No adverse reactions to
contrast media or dyes
➤
Can be repeated at any
time
➤
Requires active patient
cooperation (patient is
better informed)
➤
Permits analysis of tubal
motility
➤
Findings can be recorded
on videotape and discussed with the couple
➤
Best views can be printed
out for documentation
purposes and filed
➤
Does not require help of
radiology department
(lower costs)
Costs + ++ +++ +
87
Interventional Ultrasound in Reproductive Medicine
decades. It does require general endotracheal anesthesia,
however, and there is a risk of surgical complications such as
vascular and bowel injuries
2
, preperitoneal emphysema, and
postoperative pain. Laparoscopy permits the direct examination of the entire lesser pelvis and upper abdomen. Ovarian
diseases, genital anomalies, and tubal and ovarian function can
be evaluated. Laparoscopy also permits the identification and
staging of endometrial lesions in the lesser pelvis. Irrigating
fluid can b e sampled and cultured in patients with a prior history of PID (Table 9.
Transabdominal ultrasound. Richman et al.
1).
54
were the first to
report on the assessment of tubal patency with transabdominal ultrasound. They used a special intrauterine catheter for
this purpose (Harris Uterine Injector, Unimar, Canoga Park, CA ,
USA). At least 20 ml of the ultrasound contrast agent Hyskon
(dextran dissolved in dextrose, Pharmacia, Piscataway, NJ,
USA) is injected through the catheter, and the collection of this
fluid in the cul-de-sac is assessed as an indicator of tubal
patency.
Randolph et al.
53
used a comparable method in which
200 ml of isotonic saline solution was instilled into the uterus
through a Rubin cannula. The retrouterine fluid volume deter-
9
mined with transabdominal ultrasound was used as an index
for confirming the patency of one or both fallopian tubes, although sidedness could not be determined.
Transvaginal ultrasound. The ultrasound visualization of the
pelvic organs has been significantly improved by the use of
high-frequency endovaginal transducers. A full bladder is not
necessary for this examination. Usually the normal fallopian
tube cannot be demonstrated by transvaginal scanning unless
it is surrounded by fluid for contrast. This fluid can have
various sources:
➤
Normal peritoneal secretion, which occurs in many healthy
women
➤
Follicular fluid during or after ovulation
➤
Blood
➤
Ascites
➤
Purulent discharge from an infectious focus
The lumen of a normal fallopian tube that is not filled with
fluid cannot be visualized
69
.
discomfort than other conventional techniques. It also eliminates the problem of contrast allergy.
Contrast media. All materials that have a different sonodensity
from human tissue can be used as ultrasound contrast media.
They are divided into two categories: hypoechoic and hyperechoic. Isotonic saline, Ringer solution, and dextran solution are
examples of hypoechoic media. Their instillation helps to delineate hyperechoic boundary structures. The main disadvantage of these media is that they cannot demonstrate motion- or
flow-related phenomena. Hyperechoic contrast media amplify
the sonographic signals, making it possible todetect flow using
both B-mode and Doppler techniques. Gramiak and Shah
Meltzer et al.
47
discovered that tiny gas bubbles are excellent
26
and
reflectors of ultrasound waves. For this reason, all commercial
ultrasound contrast agents contain microbubbles. The products Echovist and Levovist (Schering, Berlin, Germany) consist
of a suspension of microbubbles that are produced from
special galactose microparticles. These microparticles are dissolved either in a galactose solution (Echovist) or in sterile
water (Levovist)
65
.
Contraindications. Color Doppler hysterosalpingography is
contraindicated by bleeding, pregnancy, or adnexal tumors detected clinically or sonographically. An ultrasound examination should be done before the procedure to assess the position
of the uterus and adnexa and exclude anomalies. The procedure should be postponed if acute PID is present. Prophylactic antibiotics should be used in patients with a prior history of
36
PID
.
Timing and preparation. Color Doppler hysterosalpingography
should be performed in the early follicular phase of the cycle
after the end of the menstrual period. This will prevent the introduction of menstrual blood residues into the abdominal
cavity. An examination in the immediate premenstrual phase
is recommended, as uterine constriction is greatest in this
phase of the cycle. The timing of the examination is of key importance in obtaining optimum results. Premedication or
sedation is routinely employed; good results have b een
achieved with 5–10mg of diazepam. Significant pain indicates
an occlusion with possible intravascular contrast or tubal rupture, so it should not be masked by anesthesia.
88
Hysterosonosalpingography
In 1989 Deichert et al.19developed a new transvaginal sonographic technique for evaluating the fallopian tubes, which
they called transvaginal hysterosalpingo-contrast sonography
or Hy-Co-Sy. The tubes were visualized and their patency was
tested by the transcervical injection of the hyperechoic ultrasound contrast agent SHU 454 (Echovist; Schering, Berlin, Germany) through a Rubin cannula or No. 8 bladder catheter. Tüfeckietal.
on an ambulatory basis, calling it transvaginal sonosalpingography. They evaluated tubal patency directly by the intrauterine injection of isotonic saline solution. This transvaginal examination is easily performed without anesthesia. It is
safe, noninvasive, and cost-effective, and causes less patient
71
simplified this procedure so that it could be done
Technique. After voiding, the patient is placed in the lithotomy
position on a gynecological chair. The vagina and cervix are
prepared with beta-isadone solution, and the cervix is exposed
with a speculum so that the os is easily accessible. The anterior
os is grasped with a tenaculum, and light traction is applied as
the catheter is gently inserted into the endocervical canal. The
uterine cavity is visualized with ultrasound, and the catheter
placement is checked for accuracy
(Fig. 9.
2 ). The tenaculum is
withdrawn, and the transducer is advanced into the posterior
fornix of the vagina. Then a maximum of 5–10 ml of the negative contrast medium (sterile saline solution) is slowly injected
into the uterine cavity under sonographic guidance (Fig. 9.
3).
The morphology of the uterus and the echo pattern and surface
contour of the endometrium can be evaluated at this time
(Figs. 9.
4–9.6). With the uterine cavity filled with anechoic
contrast medium, it is not difficult to detect uterine anomalies,
Techniques of Ultrasound Tubal Imaging
Fig. 9.2 Transvaginal scan of the uterus after insertion of the in-
trauterine catheter. The catheter cuff is visible at the level of the inter-
nal os.
Fig. 9.4 Transvaginal scan of the uterus after the injection of isotonic
saline solution. The color Doppler signals clearly define the triangular
uterine cavity.
Fig. 9.3 Transvaginal color Doppler hysterosalpingography. The con-
trast medium and color Doppler signals are directed by the intrauterine cannula into the uterine cavity.
Infertility Evaluation and Assisted Reproduction
Fig. 9.5 Power Doppler imaging makes it easier to evaluate the
uterine cavity and assess tubal patency.
Fig. 9.6 The regular surface of the uterine cavity is clearly demonstrated by the instillation of a negative contrast medium.
endometrial polyps, or submucous leiomyomas that project
into the uterine cavity. Next the color Doppler beam is directed
toward the tubal ostia. The use of a positive (echogenic) contrast medium will significantly increase the accuracy of tubal
patency assessment: color Doppler signals within the tube indicate patency (Fig. 9.
preted as tubal occlusion
7), while an absence of signals is inter-
51, 5 2
. The collection of contrast me-
Fig. 9.7 Color Doppler hysterosalpingography. The color-flow signals
are produced by saline solution flowing through the r ight fallopian
tube, confirming its patency.A collection of the anechoic fluid is visible
in the cul-de-sac.
dium in the cul-de-sac on the side of the selective injection,
demonstrated by transvaginal pulsed color Doppler scanning,
is a reliable indicator of tubal patency on that side. There is no
questionthat selective tubal injection increases the accuracy of
the procedure and of the interpretation.
If the patient experiences cramping pains, the contrast in-
jection should be halted for several minutes. If neither tube is
89
Interventional Ultrasound in Reproductive Medicine
Fig. 9.8 Transvaginal color Doppler image of the uterus and left
adnexa. The intrauterine cannula and the catheter are visible on the
left side. The color signals are produced by contrast medium flowing
into the left fallopian tube. The tube itself appears as a septate,
“sausage-like” structure owing to the collection of fluid proximal to its
fimbriated end.
defined by the contrast medium, this signifies a proximal tubal
occlusion at the ostial level, and the differential diagnosis
should include a tubal spasm. This spasm can be prevented by
administering of atropine (0.5 mg) before the examination.
9
Serious side-effects have not been reported during or after
transvaginal Doppler hysterosalpingography. The duration of
the examination is from 5 to 14 minutes. At the end of the procedure, the speculum examination is repeated and the vaginal
instruments are removed. The cervix is checked for any bleeding caused by the tenaculum, and compression is applied as
needed.
Problems. Problems in the diagnosis of tubal occlusion can
occur in patients with hydrosalpinx, as the fluid in the distended tube can mimic tubal patency by Doppler ultrasound
(Fig. 9.
8). Also, Doppler hysterosalpingography with saline so-
lution does not permit the assessment of tubal morphology.
Validity of the method. Using our modified technique, we compared the results of color Doppler hysterosalpingography with the
results of laparoscopic chromopertubation in 47 patients
Aloka SSD 680 and 2000 color Doppler systems were used. The results of color Doppler HSG agreed with those of chromolaparoscopy in 43 of the 47 patients (91.48%). There was one patient in
whom Doppler could not demonstrate patent tubes, but the presence of free fluid in the cul-de-sac gave indirect evidence of tubal
patency.
Thus, our results prove the safety and efficiency of transvaginal
Doppler hysterosalpingography in the assessment of tubal
patency without radiation exposure and without the use of
contrast medium. The costs of this method are significantly
35
. The
lower than those of radiographic hysterosalpingography, and
the result is available immediately
document all findings with a VCR or Polaroid camera
9.
1).
To assess the accuracy of the diagnosis of tubal occlusion by color
Doppler hysterosalpingography, Peters et al.
54
. It is good practice to
51
studied 129 infertil-
18
(Table
ity patients (Tables 9.2 and 9.3). When the results of ultrasound
HSG were compared with those of radiographic HSG and/or chromopertubation, 69 of 85 (81%) s tudies showed agreement, and 50
of 58 (86%) ultrasound HSG findings agreed with the results of
chromopertubation. The frequency of comparable findings be-
tween radiographic HSG and chromopertubation was 75 %.
Richman et al.
54
also compared their ultrasound results with
those of conventional HSG. Ultrasound detected bilateral tubal oc-
clusion with a sensitivity of 100%, and tubal patency was assessed
with a specificity of 96% (Table 9. 2).
In the 38 infertility patients studied by Tüfekci et
al.
71
(Table
9.3), the results of transvaginal sonosalpingography and laparoscopy showed complete agreement in 29 cases (76.32%) and partial
agreement in 8 cases (21.5%). Only one case (2.63%) showed a discrepant result.
Stern et al.
63
injected saline solution transcervically during
transvaginal color Doppler sonography in 238 women (Table 9.2).
The correlation between ultrasound HSG and chromopertubation
in this study was 81% versus 60% between radiographic findings
and chromopertubation. In 49 women who underwent all three
procedures, the color Doppler results correlated with chromoper-
tubation more often than the findings of radiographic HSG (82 %
versus 57%). The authors recommended that ultrasound HSG be re-
peated before the definitive diagnosis of a unilateral tubal occlusion.
Deichert et al.
18
sought to determine whether the additional
use of pulsed Doppler sonography could improve the tubal diagnosis reached with gray-scale imaging in doubtful cases (Table 9.3).
They concluded from their study that pulsed Doppler can be recommended as a supplement to gray-scale imaging in cases of suspected tubal occlusion where intratubal flow is detectable only over
a short distance.
Allahbadia
2
reported a 92.59% rate of agreement between
color Doppler examination and HSG or laparoscopy (Table 9.3).
HSG and laparoscopy agreed in 100% of cases.
Possible therapeutic implications. The diagnostic value of this
method is beyond question, and we may speculate about its
possible therapeutic applications
36
. The increased pregnancy
rate during the first three months after the procedure (two
patients in our study) could be the result of mechanical irrigation of the uterine cavity, which can flush mucus plugs from
the uterus, disrupt peritoneal adhesions, or have a stimulatory
effect on the tubal cilia.
Ayida et al.
4
did a study to determine how patients would
tolerate Hy-Co-Sy and HSG as outpatient tests. The procedures
used to evaluate tubal patency and uterine anomalies were
90
Table 9.2 Correct results of ultrasound
hysterosalpingography compared with
radiographic hysterosalpingography
Authors Total
number
Richman et al. (1984)
Peters et al. (
1991)
Stern et al. (1992)
Volpi et al. (1991)
54
51
63
72
36 100 96
27 19 70.37
89 72 80.90
21 19 90.47
Correct results
(%)
Sensitivity
(%)
Specificity
(%)
References
Table 9.3 Correct results of ultrasound hysterosalpingography com-
pared with chromopertubation
Authors Total
number
Allahbadia et al.
(19934)
2
Tüfekci et al. (1992)
Peters et al. (1991)
Kupesic et al.
35
(1994)
Stern et al. (1992)
Deichert et al.
18
(1992)
Volpi et al. (1996)
Holte et al. (1995)
Volpi et al. (1991)
27 25 92.59
71
38 37 97.37
51
58 50 86.20
47 43 91.48
63
121 99 81.82
16 16 100.00
73
29 24 82.70
28
14 12 85.70
72
21 17 80.90
Correct results
(%)
Sensitivity
(%)
tolerated equally well. There were no significant differences in
the frequency or severity of pains at different stages during and
after the procedure. The analgesia requirements were also
comparable.
the only noninvasive method available for the analysis of tubal
motility.
The most accurate interpretation can be made during the
procedure itself, as the flow of contrast medium can be tracked
through the entire genital tract. To obtain as much information
as possible, the procedure should be performed by an experienced examiner who is familiar with the color Doppler
method, the relevant anatomyand pathology, the necessary instrumentation, and the technique of contrast injection. There is
no question that the development of Hy-Co-Sy is proving to be
a safe and well-tolerated option in the evaluation of tubal status.
Comments. Although ultrasound-guided procedures are most
commonly used in assisted reproductive medicine, similar
techniques can also be used in other clinical situations. The accuracy of the method and its high patient acceptance have contributed greatly to the more widespread use of transvaginal
needle procedures. The growing use of assisted reproductive
technologies has led to a marked increase in ectopic pregnancies. The use of pulsed and color Doppler sonography in the diagnosis and treatment of ectopic pregnancy is covered in Chapter 12.
References
Infertility Evaluation and Assisted Reproduction
Albunex. In a recent study, Holte et al.28investigated the safety and
efficacy of a new ultrasound contrast medium, Albunex, for evaluating tubal patency by transvaginal sonography (Table 9.3). All of
the women had sought medical attention because of uterine leiomyomas and excessive menstrual bleeding and were scheduled for
a hysterosalpingectomy three weeks after the ultrasound examina-
tion. Albunex and saline solution were alternately injected transcer-
vically during transvaginal ultrasound scanning. There were no serious side-effects. Agreement between hystero-contrast sonography
(Hy-Co-Sy) and the postoperative testing of tubal patency was observed in 12 of 14 cases. The discrepancy between Hy-Co-Sy and
postoperative findings in the other two cases was attributed to the
location of the uterine myomas. The results suggest that Albunex
can be safely used as a contrast medium in ultrasound investiga-
tions of tubal patency.
Recommendations and objections. Volpi et al.73recommended
transvaginal sonography (using air bubbles and saline as contrast media) as the first step in assessing tubal patency. Equivocal or definite tubal occlusions should be investigated further
by laparoscopy.
It should also be considered that normal findings in color
Doppler HSG examinations cannot replace diagnostic laparoscopy in all cases. Several authors have criticized the costs and
diagnostic efficacy of the method. The costs of the ultrasound
system, including the extra equipment for color Doppler scanning, combined with indirect costs relating to equipment wear,
depreciation, and person-hours, must be taken into account.
Unlike the authors cited above, Balen et al.
51
found that ultrasound contrast hysterosonography using a negative (sterile
saline) or positive (Echovist) contrast medium was not sufficiently accurate in the evaluation of tubal patency.
Color Doppler HSG versus radiographic HSG. While radiographic HSG is the most accurate method for the diagnosis of
intramural or intraluminal tubal disease, color Doppler HSG is
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