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Chapter 10: Ultrasonography and treatment in PCOS
(a) (b)
Figure 10.4(a, b). Images of a thickened endometrial stripe in PCOS patient with 8 months of amenorrhea.
(a) (b)
Figure 10.5(a, b). 3D ultrasound imaging of polycystic ovaries.
voxels, representing the average intensity of flow. The vascularization flow index (VFI), the mean color value in all the voxels
in the ROI, is a feature of both vascularization and flow.
A previous study reported thatafter ovarian FSH stimulation,
polycystic ovaries were larger and had higher VI, FI, and VFI
values than the normal ovaries [17]. After the hCG trigger
injection, there were no other differences than the larger volume
in PCOs, which was observed prior to stimulation. These differences may have implications for angiogenesis and altered blood
supply in polycystic ovaries. Recent advances in 3D ultrasound
have the potential of improving our understanding of follicular
development, ovulation, and uterine receptivity.
Follicular monitoring during COH using transvaginal ultrasound
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 1961, urinary
human menopausal gonadotropins (hMG), in which the ratio
of LH to FSH bioactivity is 1:1, became available for ovulation
induction. Recombinant human FSH became available in 1996
with a subcutaneous administration. Synchronous growth of
small (4–5 mm) antral follicles, followed by the selection and
growth of one dominant follicle that achieves the largest diameter and suppresses the growth of the subordinate follicles, can
be followed via ultrasound.
There are many choices for infertile patients with PCOS,
such as clomiphene citrate, possibly aromatase inhibitors,
or gonadotropins for ovulation induction, in-vitro fertilization
and embryo transfer, ultrasound-guided immature follicle puncture, and in-vitro maturation and fertilization of oocytes from
unstimulated cycles. Individualized treatment according to the
medical treatment conditions is the ideal. In patients with PCOS,
a low-dose, step-up protocol with FSH allows a gradual stimulation, ideally with fewer than 5 follicles. Figures 10.6, 10.7, 10.8
83
Section 2: Ultrasonography in infertility
Figure 10.6. Controlled ovarian hyperstimulation on day 3 in a patient
with PCOS.
Figure 10.7. Controlled ovarian hyperstimulation on day 7 in a patient
with PCOS.
reveal aseriesof2DUSimagesofa32-year-oldG0with
PCOS und ergoing COH with a subcutaneous d ose of FSH
37.5 i ncreased to 75 I U/day on day 7; she was tr i ggered
with hCG on day 11 and subsequently conceived with
artifi cial insemination (total motile sperm 12 1 million). In
gen eral, the dose is i ncrease d only if no response is documented on ultrasonography and serum estradiol m onitorin g. Ideally, inc rements of 37.5 I U a re then given at wee kly
interv als up to a maximum of 225 IU/day for insemination
cycles. Th e endometrial stripe typ ically is trilaminar, as
shown i n Figure 10.9 . The temptation to stimulate a patient
with PCOS with a higher d ose o f F SH must be weighed
against the risk of stimulating >5 follicles and cancellation
as a c onsequence in order to p revent the com plication o f
multiple pregnancy. The images i n Fig ures 10. 10 and 10. 11
reveal patients wi th PCOS aft e r stimulation with starting
doses o f FSH 150 I U and F SH 225 IU ; both recruited > 5
follicle s a nd we re cancelled.
For in-vitro fertiliza tion cycles, if a patient has undergone a
previou s cycle, the dose is tit rated on the basis of her respons e
to pre vious stimulat ion. If a patient w ith P COS also has
another indication to proceed to IVF, the startin g dose is
depen dent on the patient ’ s age, antral follicle count , and day 3
FSH. Minimal evidence is available on the optimal inter val for
increasi ng the dose in PCO S patient s. Whe n the ovarian follicles are matu re (17 – 18 mm), human chorion ic gonadotrop in
(hCG) , both urina ry and recom binant, may be used to trigger
ovulatio n. A dose of 250 μ g of recom binant hCG appear s to be
equivale nt to the stand ard doses of urinary hCG (5000 – 10 000
units).
Serial fo llicular monitori ng utilizing ultrasound i s a reli able technique when undergoingCOH,especiallyin
patients with PCOS, who have a higher likelihood of developing OHSS (Figure 10.12). On counting of the number of
follicles and measurement of their sizes, PCOS patients may
need to be cancelled in order to prevent severe OHSS [18].
In Chapter 36 Rizk et al. discuss OHSS in detail. Rizk and
Aboulghan [19] suggest that certa in individuals m ay bene fi t
84
(a)
Figure 10.8(a, b). Controlled ovarian hyperstimulation on day 9 in a patient with PCOS.
(b)
Figure 10.9. Ultrasound imaging of a trilaminar endometrial stripe on day 7
of controlled ovarian hyperstimulation.
Chapter 10: Ultrasonography and treatment in PCOS
Figure 10.11. Image of a patient undergoing controlled ovarian
hyperstimulation with FSH 225 IU on day 7 of stimulation.
Figure 10.10. Image of a patient undergoing controlled ovarian
hyperstimulation with FSH 150 IU on day 5 of stimulation.
from measurement of serial serum estradiol levels, which in
conjunction with ultrasound may assist in close follicular monitoring and timing of the hCG trigger [19,20,21]. Furthermore,
real-time ultrasound examinations provide an excellent means
of following follicular development, and in the case of gonadotropin with insemination may detect >4 dominant follicles with
subsequent cancellation to prevent multiple pregnancies.
Universal follicle tracking proved to be time consuming and
required significant resources.
Conclusions
To summarize, the advent of ultrasound has provided a
diagnostic tool with clinical efficacy that is essential in evaluating and managing fertility treatmen t in women with
PCOS. In clinical practice, TV ultrasound monitoring
during 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 OHSS is essential.
Three-dimensional ultrasound is a relatively new imaging
modality that may improve the sensitivity and speci ficity of
ultrasound.
Figure 10.12. Image of a 39-year-old with PCOS after ovarian hyperstimulation
with FSH 225 IU and human menopausal gonadotropin 150 IU for 6 days
Key points in clinical practice
*
Ultrasound monitoring for follicular development in
women with PCOS undergoing controlled ovarian
hyperstimulation is a useful to ol, with the goal of prevention
of ovarian hyperstimulation syndrome and multiple
pregnancy.
*
Low-dose gonadotropin stimulation in women with PCOS
for ovulation induction is the ideal.
*
Development of >4 follicles in women undergoing
insemination may warrant cycle cancellation.
*
Recent advances in 3D ultrasound have the potential to
better our understanding of follicular development,
ovulation, and uterine receptivity.
85
Section 2: Ultrasonography in infertility
References
1. Stein I, Leventhal M.
Amenorrhea associated with
bilateral polycystic ovaries.
Am J Obstet Gynecol 1935;
29: 181–91.
2. Azziz R, Woods K, Reyna R.
The prevalence and features of
PCOS in an unselected
population. J Clin Endocrinol
Metab 2004; 89: 2745–9.
3. Hamilton-Fairley D, Taylor A.
ABC of subfertility:
anovulation. BMJ 2003; 327:
5469.
4. Polson DW, Adams J,
Wadsworth J, Franks S.
Polycystic ovaries – a
common finding in normal
women. Lancet 1988; 1(8590):
870–2.
5. Adams J, Polson DW, Franks
S. Prevalence of polycystic
ovaries in women with
anovulation and idiopathic
hirsutism. Br Med J (Clin
Res Ed) 1986; 293(6543):
355–9.
6. von Micsky LI. Cited by:
Kratochwil A, Urban G,
Friedrich F. Ultrasonic
tomography of the ovaries.
Ann Chir Gynaecol Fenn 1972;
61: 211–14.
7. Kratochwil A, Jentzsch K,
Brezina K.
Ultraschallanatomie des
weiblichen Beckens und
ihre klinische Bedeuntung.
Arch Gynaecol 1973;
214: 273–5.
8. Hill L, Breckle R, Coulam C.
Asssessment of human
follicular development by
ultrasound. Mayo Clin Proc
1982; 57: 176–80.
9. Adams, J, Polson, DW,
Franks, S. Prevalence of
polycystic ovaries in women
with anovulation and
idiopathic hirsutism. Br
Med J 1986; 293: 355.
10. Rotterdam ESHRE/ASRMSponsored PCOS Consensus
Workshop Group. Revised
2003 consensus on
diagnostic criteria and longterm health risks related to
polycystic ovary syndrome.
Fertil Steril 2004; 81:19
11.
Welt, CK,
Gudmundsson, JA, et al.
Defining constant versus
variable phenotypic features
of women with polycystic
ovary syndrome using
different ethnic groups and
populations. J Clin
Endocrinol Metab 2006;
91: 4361.
12. Mason HD, Willis DS, Beard
RW, Winston RM, Margara
R, Franks S. Estradiol
production by granulosa
cells of normal
and polycystic ovaries:
relationship to menstrual
cycle history and
concentrations of
Arason, G,
–25.
gonadotropins and sex
steroids in follicular fluid.
J Clin Endocrinol Metab
1994; 79(5): 1355–60.
13. Brown JB, Beischer NA.
Current status of estrogen
assay in gynecology and
obstetrics. Obstet Gynecol
1972; 27: 205–35.
14. Black WP, Coutt JR,
Dodson KS, Rao LG S.
An assessment of urinary
and plasma steroid
estimations for monitoring
treatment of anovulation
with gonadotropins. Br
J Obstet Gynecol 1974; 81:
667–75.
15. Karlsson B, Granberg S,
Wikland M, et al.
Transvaginal
ultrasonography of the
endometrium in women with
postmenopausal bleeding – a
Nordic multicenter study.
Am J Obstet Gynecol 1995;
172:1488.
16. Allemand MC, Tummon IS,
Phy JL, Foong SC, Dumesic
DA, Session DR. Diagnosis of
polycystic ovaries by threedimensional transvaginal
ultrasound. Fertil Steril 2006;
85(1): 214–19.
17. Järvelä IY, Sladkevicius P,
Kelly S, Ojha K, Campbell S,
Nargund G. Comparison of
follicular vascularization in
normal versus polycystic
ovaries during in vitro
fertilization as measured
using 3-dimensional power
Doppler ultrasonography.
Fertil Steril 2004; 82(5)
1358–63.
18. Blankstein J, Shalev J, et al.
Ovarian hyperstimulation
syndrome: prediction by
number and size of
preovulatory ovarian
follicles. Fertil Steril 1987;
47:597–602.
19. Rizk B, Aboulghar M.
M
n management of
oder
ovarian hyperstimulation
syndrome. Hum Reprod
1991; 6:1082–7.
20. Rizk B, Aboulghar M.
Classification,
pathophysiology and
management of ovarian
hyperstimulation syndrome.
In: Brinsden PR, ed.
A Textbook of In Vitro
Fertilization and Assisted
Reproduction: The Bourn
Hall Guide to Clinical and
Laboratory Practice. 2nd edn.
New York, Parthenon
Publishing Group, 1991;
pp. 131–55.
21. Rizk B, Aboulghar M.
Ovarian hyperstimulation
syndrome. In: Rizk B ed.
Ovarian Hyperstimulation
Syndrome. Epidemiology,
Pathophysiology, Prevention
and Management.
Cambridge University Press,
2010; pp. 118–24.
86
Chapter
Ultrasonography of uterine fibroids
11
Angela Clough and Yakoub Khalaf
Introduction
A fibroid or leiomyoma is a benign smooth-muscle growth of
the uterus that can occur as a single lesion, though it more often
presents as multiple lesions. Fibroids are found in 20–40% of
women, generally from age 30 onwards, with a steady increase
in incidence with age [1]. Ultrasound is a noninvasive, well
tolerated, and relatively inexpensive way to accurately measure
and locate fibroids within the uterus/pelvis. Assessment of
fibroid size and location can be helpful for surgical planning
or for monitoring fibroid changes over time, whether they are
managed conservatively, medically or surgically.
This chapter sets out to examine the role of ultrasound in
evaluating fibroids, by looking first at the etiology and classification of fibroids, then at fibroid diagnosis, prognosis, and
treatment.
Etiology and classification
The fibroid mass originates from neoplastic smooth-muscle
cells that undergo multiple division. It can vary in size from
just several millimeters to that of a huge pelvi c mass that can
extend into the abdominal cavity. Fibroids are responsive to
estrogen and progesterone and, therefore, are not present
before puberty and tend to shrink after menopause. The prevalence of fibroids in women of African descent is significantly
higher, and lesions are often larger and more numerous [2].
The predisposition to having fibroids can be hereditary.
The fibroid mass is usually round in shape, well circumscribed, and separated from the adjacent myometrium by a
pseudocapsule of connective tissue. The fibroid tissue has a
whirl-like or trabecular formation owing to the way smooth
muscle interlaces concentric bands of connective tissue. The
fibroid has a characteristic peripheral blood supply located in
the pseudocapsule, which feeds smalle r centripetal vessels supplying the center. If the fibroid grows rapidly, or to a significant
size, then the blood supply to the center can become insufficient, and ischemic necrosis may occur. Fibroids can increase
rapidly in size during pregnancy, resulting in an acute painful
condition called “red degeneration” in which there is extensive
necrosis involving the whole fibroid mass. Fibroids in the nonpregnant uterus can undergo a more chronic reduction of blood
supply, which can result in hyaline, cystic, fatty, and myxomatous degeneration.
Fatty changes within a fibroid can later result in fibrous
replacement or calcification, with the latter commonly seen in
lesions of postmenopausal women.
Location of fibroids
Fibroids can develop in any part of the uterine or cervical
muscle and can be confined to the muscle wall (intramural
fibroids), can form under the endometrial lining (submucosal
fibroids) or under the serosal covering of the uterus (subser-
osal fibroids) (Figures 11.1 and 11.2). However, not all fibroids
fall clearly into these three groups and they often have a shared
location; for example, an intramural fibroid may partially
intrude into the endometrial cavity, or a subserosal fibroid
may have a significant intramural component (see Table 11.2).
Occasionally, a fibroid m ay grow separately from the muscle
wall from which it arises, connected only by a pedicle that
conveys blood vessels to the mass. These fibroids can either
pedunculate into the uterine or cervical cavity ( fibroid polyp)
or outward into the pelvic cavity (pedunculated or exophytic
fibroid ). Rarely, these fibroids can develop within the broad or
round ligaments. Cervical fibroids are relatively uncommon
(1–3%) though they can be problematic, with a higher incidence of infection and bladder symptoms, and may give rise to
dystocia in labor.
Classification of fibroids impinging
on the uterine cavity
When fibroids originate from the uterine wall, but impinge on
the cavity, it is useful to describe the degree of cavity distortion
using the Wamsteker and de Blok classification [3].
Fibroids are classified as type 0 if they pedunculate 100%
into the cavity; as type I if they arise from the myometrium but
more than 50% of their mass is within the cavity; and as type II
if they again arise from the myometrium but have the greater
part of their mass within the myometrium, i.e., less than 50% in
the cavity. (See Table 11.1. and Figure 11.6.)
Ultrasonography in Reproductive Medicine and Infertility, ed. Botros R. M. B. Rizk. Published by Cambridge University Press. © Cambridge
University Press 2010.
Section 2: Ultrasonography in infertility
Table 11.1. Classification of fibroids impinging on the uterine cavity
Classification of fibroids impinging on the uterine cavity
0: pedunculated into the uterine cavity
I: extend >50% into the uterine cavity
II: extend <50% into the uterine cavity
Type 0 submucosal fibroid
Intramural fibroid
Type I submucosal
fibroid
Pedunculated fibroid
(in broad ligament)
Subserosal fibroid
Figure 11.1. Schematic diagram of varying fibroid locations in the uterus.
Type II submucosal
fibroid
This assessment is often difficult to make on a 2D scan alone
and saline infusion sonohysterography is usually required
(described in the next section). An accurate diagnosis is essential to help decide on presurgical treatment and the mode of
surgery, and will help in giving an accurate prognosis to the
patient [3]. A similar classification system has been proposed
for intramural and subserosal fibroids to denote the degree of
involvement in the myometrial wall (see Table 11.2)[4]. This
classification may have a place in studies looking specifically at
the precise effect of intramural fibroids on fertility and
pregnancy.
Diagnosis
Ultrasound instrumentation and technique
The conventional way to image fibroids is by two-dimensional
(2D) scanning. Other imaging options are available for more
problematic fibroids, and these will be covered at the end of this
section.
For good visualization of fibroids, particularly of the outline,
the best imagingtechniqueis the transvaginal scan (TVS). With a
transvaginal approach, the probe is in closer proximity to the
uterus and a higher frequency can be employed, thus providing
better tissue definition. A TVS is performed with an empty
bladder using a curvilinear, multifrequency, endocavity transducer with a typical central frequency of 6.5 MHz. Fibroids can
be highly attenuating of the ultrasound beam due to their dense
and mixed tissue make-up, and this may result in poor throughtransmission and shadowing (see Figure 11.3). Because of this, it
is sometimes necessary to select a lower frequency to allow for
better penetration of the fibroid in order to view its posterior
aspect. If a uterus is significantly enlarged by fibroids, TVS may
fail to demonstrate the whole uterus and a transabdominal scan
Table 11.2. Classification of intramural and subserosal fibroids
Classification of intramural and subserosal fibroids
0: pedunculated subserosal fibroid
I: involvement of <50% of the outer uterine wall
II: involvement of >50% of the myometrial wall
III: fibroids that extend from the mucosa to the serosa
(TAS) is required. TAS is performed using a multihertz curvilinear abdominal transducer with a central frequency of
3.5 MHz. This approach provides a greater field of view to give
adequate demonstration of an enlarged uterus. The transabdominal transducer can also provide lower frequencies for better
penetration. TAS generally requires a full bladder for good
visualization of the pelvic organs, but this is seldom required in
cases where the uterus is grossly enlarged by fibroids. This is
because the loops of bowel that usually obscure the pelvic organs
are displaced by the enlarged uterus.
In addition to changing the ultrasound frequency, harmonic selection and higher power settings may also serve to
improve an ultrasound view of the fibroid uterus.
Ultrasound appearance of fibroids
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. It is important to recognize
that the fibroid has a definite outline because a heterogeneous
myometrium with ill-defined margins may represent adenomyosis (see differential diagnoses). Fibroids are commonly hypoe-
choic compared with the adjacent myometrium, but they can
also be isoechoic or even hyperechoic, in comparison, particularly if they undergo fatty or fibrous changes. Cystic degeneration
is seen on ultrasound as a central anechoic area that may sometimes contain internal echoes and fluid/fluid levels [5]. Fibrous
replacement within the fibroid tissue can be recognized on ultrasound as an overall increase in reflectivity. Calcification can also
occur, and is denoted by the presence of echogenic foci or a
bright outer rim, which often produce posterior acoustic shadowing on an ultrasound image (see Figure 11.3).
Differential diagnoses
Adenomyosis
Adenomyosis is a common differential diagnosis and is sometimes misdiagnosed as fibroids or “fibroid change.” As with
fibroids, adenomyosis is a common condition (20–40% in hys-
terectomy specimens) and presents with similar symptoms of
menorrhagia and dysmenorrhea. Careful examination by ultrasound will identify a more diffuse heterogeneous echo pattern,
with an absence of discrete encapsulated masses, even when the
adenomyosis is present in a localized collection or “adenomyoma.” An ultrasonic diagnosis of aden omyosis is further
strengthened by the de tection of small cystic areas within the
88
(a) (b)
Chapter 11: Ultrasonography of uterine fibroids
(c)
Figure 11.2a–d. Ultrasound images of (a) pedunculated fibroid arising from the cervix; (b) submucosal fibroid (with adjacent intramural fibroid in the cervix);
(c) intramural fibroid (with indeterminate intrusion on the cavity); and (d) subserosal fibroid.
myometrium, a bulky myometrium, and irregularity of the
endometrial/myometrial outline (see Figure 11.4a). Of note,
studies show that in 35–55% of women, fibroids and adenomyosis coexist [6].
(d)
of a fibroid polyp and has a classic “tongue” shape, rather than
the rounder form of a fibroid (see Figure 11.4c,d) Because the
polyp is echogenic it is more easily identified within the proliferative phase of the cycle, whereas a small submucosal fibroid
would be more easily seen in the secretory phase. Color Doppler
Diffuse leiomyomatosis
Diffuse leiomyomatosis is a rare condition in which there is
(as mentioned later) is a useful tool for distinguishing between a
polyp and a submucosal fibroid.
diffuse and uniform involvement of the entire myometrium by
multiple fibroids (see Figure 11.4b).
Ovarian mass
A pedunculated fibroid can be easily mistaken for an ovarian
Endometrial polyps
Adifferential diagnosis for a submucosal fibroid is an endome-
trial polyp. Polyps are common cavity lesions that originate from
endometrial rather than myometrial tissue. The ultrasound
appearance of the polyp is typically more hyperechoic than that
mass, particularly an ovarian fibroma (see Figure 11.2a).
Ultrasound confirmation of a pedunculated fibroid can be
made if both ovaries are identified separately from the fibroid.
If the fibroid is of a significant size, or located in the broad or
round ligament, it may not be possible to separate it from the
89
Section 2: Ultrasonography in infertility
(a)
Figure 11.3. (a) A longitudinal section and transverse section view of a submucosal fibroid that has a small central cystic lesion. (b) Posterior wall intramural fibroids
with calcified outlines; note how the strong posterior acoustic shadowing obscures the posterior uterine outline.
ovary. In this case, it is important to use color Doppler to
positively identify a pedicle connecting the fibroid mass to the
uterus (see Figure 11.7).
Leiomyosarcoma
A leiomyosarcoma is a rare smooth-muscle neoplasm that can
give the ultrasonic appearance of a large fibroid. Typically
presenting in a woman in her mid-fifties, the warning signs
are rapid growth, abnormal bleeding, pain, and occasionally
pyrexia. A definitive diagnosis is only determined from a
microscopic specimen.
Disseminated peritoneal leiomyomatosis
Disseminated peritoneal leiomyomatosis is a rare condition in
which multiple small benign smooth-muscle lesions diffusely
stud the peritoneal and omental surfaces. Although their distribution suggests a metastatic process, the lesions are generally benign.
Other pelvic masses
Other pelvic masses that may be confused with pedunculated
fibroids include bowel masses, pelvic kidneys, lymph nodes.
Braxton Hicks contractions can also mimic a fibroid in the
pregnant uterus.
Ultrasound reporting
A usefulway to record fibroids identified by ultrasound is to state
their size, type, and location. The fibroid may be measured in
three dimensions, though two may suffice as the lesions are
invariably round in shape. The location is noted in two planes,
first in the transverse plane, i.e., anterior, posterior, or right/left
lateral wall; then in the longitudinal plane, i.e., cervical, uterine
body, or fundus. Multiple fibroids may be listed, for example, “A
30 × 31 × 36 mm intramural fibroid was identified in the right
lateral fundal wall”.Ifthefibroid is pedunculated, then mention
(b)
of the uterine origin and location in the pelvic cavity is required.
Electronic ultrasound-reporting packages usually allow for categorization of the fibroids into size, type, and uterine location and
some will even produce a computer-generated schematic diagram of the fibroid positions in the uterus.
Other diagnostic options
3D scanning
2D scanning is limited to demonstrating a fibroid in the transverse and longitudinal planes. 3D scanning can show the fibroid
in the coronal plane, and this is particularly useful when assessing a fibroid that is within, or impinging on, the cavity. If there
is good image contrast between the fibroid and endometrial
lining, then clear visualization of the fibroid may be obtained.
Optimum contrast is most likely to be obtained during the
secretory phase of the cycle, when the endometrium becomes
hyperechoic (see Figure 11.5).
Saline infusion sonohysterography
Saline infusion sonohysterography (SIS) has become a vital tool
in the assessment of cavity distortion caused by fibroids [7].
This test involves introducing a small amount of saline into the
uterine cavity via a uterine cannula. By distending the cavity
with saline, it is usually possible to view clearly both the separated cavity surfaces for significant cavity wall distortion or
irregularity, and the “potential cavity” for space-occupying
lesions. If a fibroid impinges on the cavity then assessment is
made of what percentage of the lesion projects into the cavity,
and its degree of extension into the myometrium. It can then be
categorized as a Type 0, I, or II (as previously described) to help
plan the mode of surgical treatment.
3D scanning can be performed in conjunction with SIS to
provide the additional coronal plane for further diagnostic
accuracy.
90
Chapter 11: Ultrasonography of uterine fibroids
(a)
(c) (d)
(b)
Figure 11.4. (a) Typical appearance of adenomyosis; note the diffusely irregular myometrium, tiny cystic myometrial lesions, and irregular endometrial/myometrial
interface. (b) Transabdominal view of an enlarged uterus with multiple small fibroids throughout the myometrium suggestive of diffuse leiomyomatosis. (c) Small
submucosal fibroid; note the round outline and hypoechogenic appearance. (d) Endometrial polyp – in contrast with the fibroid the polyp is “tongue-shaped” and
hyperechogenic.
Hystero-contrast sonography (HyCoSy)
If a fibroid is situated close to the ostia, a HyCoSy test may help
to clarify whether the fibroid is causing an ostial obstruction, as
indicated by an absence of cornual exit of contrast. Echovist
(the contrast used for HyCoSy) also provides a “positive” contrast for clearly outlining submucosal fibroids, as demonstrated
in Figure 11.6.
Use of color/power Doppler
Color or power Doppler can be a useful in the assessment of the
fibroid blood supply. It is particularly useful in identifying the
pedicle connecting a pedunculated fibroid to the uterus when
there is uncertainty about the etiology of a fibroid lying within
thepelvis(Figure 11.7)[8]. It can also be used to help distinguish
Figure 11.5. 3D coronal view of the uterus demonstrating a large submucosal
fibroid centrally located in the body of the uterine cavity.
between an endometrial polyp and submucosal fibroid. The
polyp vessels typically have a central feeder vessel branching
91
Section 2: Ultrasonography in infertility
(a)
(c)
Figure 11.6a–d. SIS examinations of submucosal fibroids showing (a) type II, (b) type I, (c) type 0, and (d) type 0 clearly outlined by Echovist.
(b)
(d)
into smaller vessels, whereas the blood vessels to the fibroid are
identified at its periphery [8]. Color Doppler has also been used
for treatment planning and post-treatment follow-up for radiologic treatment of fibroids, such as uterine artery embolization.
92
Figure 11.7. Color Doppler identifies the pedicle between a pedunculated
fibroid (right) and the uterus.
Magnetic resonance imaging
Magnetic resonance imaging (MRI) is a valuable alternative imaging technique providing good soft-tissue contrast and tissue specificity. The cost and availability of MRI can be restrictive,
however, and it is therefore usually reserved for complicated cases.
Prognosis
Gynecological, obstetric, and postpartum complications
The most common gynecological symptoms of fibroids are
menorrhagia and dysmenorrhea and, when significantly