Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5807_Библиотеки_им_академика_М_И_Перельмана.pdf
Chapter 18: Uterine septum
3. McBean JH, Brumsted JR.
Septate uterus with cervical
duplication: a rare
malformation. Fertil Steril
1994; 62: 415–17.
4. March ChM. Mullerian
anomalies. Fertil News 24/1.
Endocrine Fertil Forum 1990;
13:1–5.
5. Ergun A, Pabuccu R. Atay V,
et al. Three sisters with
septate uteri: another
reference to bidirectional
theory. Hum Reprod 1997;
12: 140–2.
6. Muller PP, Musset R, Netter
A, et al. État du haut appareil
urinaire chez les porteuses de
malformations uterines:
etude de 133 observations. La
Presse Med 1967; 75:1331–6.
7. Acien P. Incidence of
Müllerian defects in fertile
and infertile women. Hum
Reprod 1997; 12: 1372–6.
8. Maneschi F, Zupi E, Marconi
D, et al. Hysteroscopically
detected asymptomatic
Müllerian anomalies.
J Reprod Med 1995; 40:
684–8.
9. Ashton D, Amin HK,
Richart RM, et al. The
incidence of asymptomatic
uterine anomalies in
women undergoing
transcervical tubal
sterilization. Obstet Gynecol
1988; 72:28– 30.
10. Raga F, Bauset C, Remohi J
et al. (1997). Reproductive
impact of congenital
Müllerian anomalies. Hum
Reprod 12: 2277–81.
11. Nasri MN, Setchell ME,
Chard T. Transvaginal
ultrasound for the diagnosis
of uterine malformations. Br
J Obstet Gynecol 1990; 97:
1043–5.
12. Heinonen PK. Reproductive
performance of women with
uterine anomalies after
abdominal or hysteroscopic
metroplasty or no surgical
treatment, J Am Assoc
Gynecol Laparosc
1997; 4: 311–17.
13. Grimbizis GF, Camus M,
Tarlatzis BC, et al. Clinical
implications of uterine
malformations
hysteroscopic treatment
results. Hum Reprod Update
2001; 7: 161–74.
14. Homer HA, Cooke TC
Li, ID. The septate uterus: a
review of management and
reproductive outcome. Fertil
Steril 2000; 73:1–14.
15. Buttram VC, Gibbons WE.
Muellerian anomalies: a
proposed classification (an
analysis of 144 cases). Fertil
Steril 1979; 32:40–6.
16. The American Fertility
Society. The American
Fertility Society classifications
of adnexal adhesions, distal
tubal occlusion, tubal
occlusion secondary to tubal
ligation, tubal pregnancies,
Müllerian anomalies and
intrauterine adhesions. Fertil
Steril 1988; 49: 944–55.
17. Fayez JA. Comparison
between abdominal and
hysteroscopic metroplasty.
Obstet Gynecol 1986; 68:
399–403.
18. Daly DC, Maier D, SotoAlbors C. Hysteroscopic
metroplasty: six years’
experience. Obstet Gynecol
1989; 73: 201–5.
19. March CM. Hysteroscopy as
an aid to diagnosis in female
infertility. Clin Obstet
Gynecol 1983; 26: 302–12.
20. Worthen N, Gonzalez F.
Septate uterus: sonographic
diagnosis and obstetric
complications. Obstet
Gynecol 1984; 64: 345–85.
21. Perino A, Mencaglia L,
Hamou J, et al.
Hysteroscopy for
metroplasty of uterine
septa: report of 24 cases.
Fertil Steril 1987;
48:321–3.
22. Dabirashrafi H, Bahadori M,
Mohammad K, et al. Septate
uterus: New idea on the
histologic features of
septum in this abnormal
and
the
uterus. Am J Obstet Gynecol
1995; 172: (1 pt 1): 105–7.
23. Kupesic S, Kurjak A. Septate
uterus: detection and
prediction of obstetrical
complications by different
forms of ultrasonography.
J Ultrasound Med 1998; 17:
631–6.
24. Baramki T. Congenital
uterine malformations. In:
Rizk B, Garcia Velasco JA,
Sallam H, Makrigiannakis A,
eds. Infertility and Assisted
Reproduction. Chapter 35.
Cambridge: Cambridge
University Press, 2008;
327–31.
25. Carrington BM, Hricak H,
Nuruddin RN, et al.
Müllerian duct anomalies:
magnetic resonance imaging
evaluation. Radiology 1990;
176: 715.
26. Kupesic S. Clinical
implications of sonographic
detection of uterine
anomalies for reproductive
outcome. Ultrasound Obstet
Gynecol 2001; 18: 387–400.
27. Nicolini U, Bellotti M,
Bonazzi B, et al. Can
ultrasound be used to
screen uterine
malformations? Fertil Steril
1987; 47:89–93.
28. Keltz MD, Olive DL, Kim
AH, et al.
Sonohysterography for
screening in recurrent
pregnancy loss. Fertil Steril
1997; 67: 670–4.
29. Soares SR, Barbosa dos Reis
MMB, Camargos AF.
Diagnostic accuracy of
sonohysterography,
transvaginal sonography,
and hysterosalpingography
in patients with uterine
cavity diseases. Fertil Steril
2000; 73: 406–11.
30. Exalto N, Stappers C, van
Raamsdonk LA, Emanuel
MH. Gel instillation
sonohysterography: first
experience with a new
technique. Fertil Steril 2007;
87: 152–5.
31. Jurkovic D, Geipel A,
Gruboeck K, et al. Threedimensional ultrasound for
the assessment of uterine
anatomy and detection
congenital anomalies: a
comparison with
hysterosalpingography and
two-dimensional
sonography. Ultrasound
Obstet Gynecol 5: 1995;
233–7.
32. Jurkovic D, Gruboeck K,
Tailor A, et al. Ultrasound
screening for congenital
uterine anomalies. Br J
Obstet Gynaecol 1997; 104:
1320–1.
33. Abuzeid OM, Sakhel K,
Abuzeid MI. Diagnosis of
various types of uterine
septum in infertile patients.
J Minim Invasive Gynecol
2005; 12(5): 117.
34. Hartman A. Uterine
imaging – malformations,
fibroids and adenomyosis.
Thirty-Ninth Annual
Postgraduate Program, Course
17 Reproductive Imaging –
How to Improve the Outcome
of Assisted Reproductive
Technology.NewOrleans,
Louisana; sponsored
by ASRM, October 22, 2006.
35. Weinraub Z, Maymon R,
Shulman A, et al. Threedimensional saline contrast
hysterosonography and
surface rendering
of uterine cavity
pathology. Ultrasound
Obstet Gynecol 1996; 8:
277–82.
36. Lev-Toaff AS, Pinheiro LW,
Bega G, et al. Threedimensional multiplanar
sonohysterography.
J Ultrasound Med 2001;
20: 295–306.
37. Ayida G, Kennedy S, Barlow
D, et al. Contrast sonography
for uterine cavity assessment:
a comparison of
conventional twodimensional with threedimensional transvaginal
ultrasound: a pilot study.
Fertil Steril 1996; 66: 848–50.
of
153
Section 2: Ultrasonography in infertility
38. Kupesic S, Kurjak A.
Diagnosis and treatment
outcome of the septate
uterus. Croat Med J 1998; 39:
185–90.
39. Toaff ME, Lev-Toaff AS.
Communicating uteri:
review and classification of
two previously unreported
types. Fertil Steril 1984; 41:
661–79.
40. Abuzeid M, Mitwally MF,
Ahmed A, et al. The
prevalence of fimbrial
pathology in patients with
early stages of endometriosis.
J Minim Invasive Gynecol
2007; 14:49–53.
41. Abuzeid MI, Sakhel K, Khedr
M, et al. The association of
endometriosis and uterine
septum. Hum Reprod Suppl
2003; 1: P-610.
42. Hirst BC. The operative
treatment of uterus
subseptus or semipartus with
a case report. Trans Obstet
Soc Phila 1919: 891–2.
43. Luikart R. Technique of
successful removal of the
septum uterine septus and
subsequent deliveries at
term. Am J Obstet Gynecol
1936; 31: 797–9.
44. Rock JA. Surgery for
anomalies of the Müllerian
ducts. In: Thompson JD,
Rock JA, eds. Te Linde’s
Operative Gynecology,
7th edn. Philadelphia,
PA: Lippincott, 1992;
603–46.
45 Choe KJ, Baggish SM.
Hysteroscopic treatment
of septate uterus with
neodymium-YAG laser.
Fertil Steril 1992;
57:81–4.
46. Abuzeid M, Sakhel K, Imam
M, Mitwally MF, Ashraf M,
Diamond MP. Reproductive
outcome after hysteroscopic
metroplasty in women with
primary infertility. J Minim
Invasive Gynecol 2008;
15: 80S.
47. Lin BL, Iwata Y, Miyamoto
N, et al. Three contrast
methods: an ultrasound
technique for monitoring
transcervical operations. Am
J
Obstet Gynecol 1987; 56:
469–72.
Mencaglia L, Tantini C.
48.
Hysteroscopic treatment of
septate and arcuate uterus.
Gynaecol Endosc 1996; 5:
151–4.
49. Nisolle M, Donnez J.
Endoscopic treatment of
uterine malformations.
Gynaecol Endosc 1996;
5: 155–60.
50. Fedele L, Bianchi S,
Marchini M, et al. Residual
uterine septum of less than
1cm after hysteroscopic
metroplasty does not impair
reproductive outcome.
Hum Reprod 1996;
11: 727–9.
51. Kormanyos Z, Molnar BG,
Pal A. Removal of a
residual portion of a uterine
septum in women of
advanced reproductive
age: obstetric outcome.
Hum Reprod 2006;
4: 1047–51.
52. Grimbizis G, Camus M,
Clasen K, et al.
Hysteroscopic septum
resection in patients with
recurrent abortions or
infertility. Hum Reprod 1998
13: 1188–93.
53. Daly DC, Maier D, SotoAlbers C. Hysteroscopic
metroplasty: six years’
experience. Obstet
Gynecol 1989; 73:
201–5.
54. Fedele L, Arcaini L, Parazzini
F, et al. Reproductive
prognosis after hysteroscopic
metroplasty in 102 women:
lifetable analysis. Fertil Steril
1993; 59: 768–72.
55. Jacobsen IJ, DeCherney A.
Results of conventional
and hysteroscopic surgery.
Hum Reprod 1997; 12:
1376–81.
56. Preutthipan S, Linasmita V.
Reproductive outcome
following hysteroscopic
treatment of the septate
uterus: a result of 28 cases
at Ramathibodi Hospital.
J Med Assoc Thai 2001; 84:
166–70.
57. Sentilhes L, Sergent F,
Roman H, et al. Late
complications of operative
hysteroscopy: predicting
patients
uterine rupture during
subsequent pregnancy.
Eur J Obstet Gynecol
Reprod Biol 2005; 120:
134–8.
58. Nisolle L, Donnez J.
Endoscopic treatment of
uterine malformations.
Gyaecol Endosc 1996; 5;
155–60.
at risk
of
154
Chapter
Ultrasonography and incidental ovarian pathology
19
Dimitrios Siassakos, Valentine Akande and Luciano G. Nardo
Introduction
Ultrasonography is an invaluable tool in the noninvasive assessment and monitoring of treatment in infertile women.
Incidental adnexal pathology is identified in 5–18% of such
women when using ultrasound (US). Transvaginal highresolution ultrasonography in particular has gained widespread
use in infertile women because of the detail that can be visualized when examining the pelvis and reproductive organs.
Incidental adnexal masses may be seen when pelvic ultrasound
or hysterosalpingo-contrast-ultrasonography (HyCoSy) is performed with the intention of evaluating uterine pathologies
potentially associated with subfertility, such as adhesions, polyps, submucous leiomyomas, and septae [1].
Adnexal pathology may also be seen when monitoring
ovarian response to stimulation with gonadotropins or ovulation induction with clomiphene citrate, during oocyte retrieval,
or at the time of US-guided embryo transfer. A functional
ovarian cyst is also a relatively common finding with the widespread use of gonadotropin-releasing hormone (GnRH) agonists, which initially provoke an initial follicle-stimulating
hormone (FSH) surge [2]. In addition, women undergoing
ovarian stimulation may present with acute pelvic pain because
of ovarian hyperstimulation syndrome (OHSS), pelvic infection, or ovarian accident.
In this chapter we will discuss a range of incidental adnexal
findings in nonacute presentations, their significance for reproduction and assisted reproductive technologies (ART), and how
to approach them once found.
Differential diagnosis
Imaging artifacts
Artifacts found during ultrasonography can be the result of
either operator technique or patient characteristics, for example, increased subcutaneous fat.
“Reverberation” occurs when reflections from a highly
reflective structure bounce back and forth within adjacent tissue before returning to the ultrasound probe, resulting in the
system recording each of these bounced reflections as a separate
structure. These can present as false septae within cysts.
“Refraction” occurs when sound is bent as a result of adjacent tissues with dissimilar sound propagation velocities. This
results in the position of a lesion being demonstrated as displaced’ e.g., a mass may be seen within the adnexae when it
actually belongs to another structure.
“Mirror image” occurs when strong reflectors send the
beam off the scan plane toward another lateral structure, and
the reflection of that structure returns via the same path all the
way back to the transducer. The system assumes that propagation occurred in an en tirely linear fashion, and places
the structure straight behind the strong reflector, as well as
in its original lateral position as scanned by another part of
the b eam.
To decrease the likelihood of such artifacts, one should aim
for achieving a perpendicular direction of the ultrasound beam
relative to the structure or organ under observation.
Physiological artifacts
The ability to identify abnormality relies on the operator ’ s
knowledgeofnormality,butalsoonrecognitionofthephysiological changes that occur in the menstrual cycle or in
response to treatment or pregnancy. For example, fluid in
the pouch of Douglas is a common feature and may relate to
the phase of the menstrual cycle. As such, there is almost
always a small amount present after ovulation. A rule of
thumb is that it should never be more than 2 cm in depth, or
more than two-thirds of the length of the uterus in the sagittal
plane. Increasing density or volume of hyperechoic particles
or strands is suggestive of pathology, for example, bleeding,
inflammation, or infection.
The ovary is a dynamic structure of utmost endocrine
importance for fertility, where follicles are noted to grow,
regress, or ovulate. When ovulation is impending, the mature
follicle can present as a simple cyst with a small internal protrusion, which represents the cumulus oophorus.
Multiple, unilateral, or bilateral ovarian peripheral echogenic foci are common and can be found in up to 49% of
women; these usually have a punctuate pattern and may represent psammomatous calcifications associated with superficial
epithelial inclusion cysts [3]. It must be noted, however, that
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
calcifications are also a feature of serous cystadenomas and
dermoids, and when uncertain further diagnostics should be
considered.
Bowel masses
Bowel masses are identified by the presence of m ultiple wall
layers (2– 5visible,“target” sign) and usually peristalsis. Fecal
matter can make diagnosis more difficult and necessitate
the use of enemas. If bowel shadowing makes the visualization of the pelvic organs difficult, placing the patient in
the Trendelenburg position may improve the ultrasound
picture.
Adnexal masses
Table 19.1 describes some of the incidental pathologies that
can be found while scanning the adnexal area. Sometimes
these can be difficult to visualize and mayrequirepositioning
the patient in a favorable position for adequate pelvic images
to be obtained; for example, placing the patient in a semilithotomy position, with the pelvis raised by placing a pillow
and/or fists under the buttocks, for a transvaginal ultrasound
scan.
Diagnostic approach to masses
The size of the mass in three dimensions, its location, consistency, and borders (well-/ill-defined) should be determined.
With regard to cysts, it is important to note wall thickness,
whether they are unilocular or multilocular, the presence, regularity and thickness of septae, the presence of nodules or
projections, or any other solid components. One should always
check the contralateral adnexum and the pouch of Douglas, as
well as around both adnexae for free fluid. The more abnormalities, the higher the index of suspicion of abnormal pathology such as malignancy.
Generally, most diagnoses can be made by transvaginal
ultrasonography; however, a combination of transabdominal
and transvaginal scan should be considered as they have different advantages and disadvantages (Table 19.2). Color and
power Doppler ultrasound examination may be a useful
Table 19.1. Differential diagnosis of incidental adnexal masses
Origin Usually cystic Solid or complex
Adnexal Functional cysts
(follicular, luteal, etc.)
Luteinized unruptured
follicle syndrome
Ovarian cystadenoma
Borderline ovarian tumor
Endometrioma
Dermoid
Embryological remnants
Hydrosalpinx
Ectopic pregnancy
Nonadnexal Round ligament cyst
Peritoneal inclusion cyst
Bowel loops
Uterine leiomyoma
(subserosal, broad
ligament)
Sex-cord tumors (fibroma,
granulosa cell)
Metastatic tumors
Pelvic kidney
Retroperitoneal masses
adjunct for assessing blood flow around cysts as well as within
masses and septae. Further examination with computed tomography (CT) or magnetic resonance imaging (MRI) may be
indicated in selected cases.
The patient’s age is important: young women (with infertility due to congenital anomalies) are more likely to have germ
cell tumors than women who are older than 40 years. For the
latter, the possibility of malignancy is increased.
History may elicit diagnostic clues: long-standing dyspareunia and dysmenorrhea in a patient with a thick-walled cyst
with internal echoes on ultrasound suggests an endometrioma
rather than a hemorrhagic corpus luteum, whereas a family
history of ovarian cancer should lower the threshold for further
investigation of any ovarian mass.
Selected laboratory tests such as CA-125 may be useful,
but also consider additional investigations if malignancy is
highly suspected or if there is concern about ureteric compression, particularly with large or retroperitoneal masses. It
should be noted that the clinical interpretation of tumor
marker levels may be difficult in patients who have had
fertility treatment or have endometriosis, as these are often
elevated in such cases.
Specific conditions
Functional cysts
Follicular ovarian cysts (Figure 19.1) comprise the most common cystic adnexal mass seen in women of reproductive age.
They are lined by granulosa cells, are usually an incidental
finding, and rarely reach a size larger than 8 cm. The cysts
tend to regress after one or two menstrual cycles.
Luteal cysts are characterized by peripheral blood flow at
Doppler examination (“ring” sign) and menstrual disturbances,
and are found in women with delayed menses. They are usually
irregular with thick echogenic walls, and can bleed internally and
assume an appearance similar to endometriomas. Sometimes
a fluid level can be seen within the cyst, representing blood
or clot.
Table 19.2. Comparison of transabdominal (TAS) versus transvaginal (TVS)
ultrasound scanning for incidental adnexal masses
Modality TAS TVS
Advantages Better penetration, offers
global view, and can
evaluate masses that lie
higher in the abdomen,
particularly in the
presence of adhesions
or fibroids
Good for assessing
moderate or significant
ascites
Can identify hydronephrosis
Disadvantages Low resolution;
differentiating masses
from bowel gases may
be a problem
Can assess adnexal/
mass tenderness
with the probe
Higher resolution, good
for assessing pelvic
anatomy
Not good for masses
that lie high, as a
result of its poor
penetration
156
Figure 19.1. Transvaginal image of simple (follicular) ovarian cyst.
Theca-lutein cysts are large, multiple, bilateral and can be
seen in association with ovulation induction, multiple pregnancy, or molar pregnancy.
Diagnostic approach and reproductive significance
Conservative management is the usual option. Ultrasound
follow-up after two to thre e menstrual cycles is indicated for
all simple cysts less than 5 cm in diameter. Surgery is reserved
for persistent cysts, particularly if they are more than 5 cm in
size and/or if symptomatic [4].
Ovulation induction may havetobepostponedfor
women with multiple theca-lutein cysts, but not for presumed follicular or corpus luteum cysts. The effect of the
latter on treatment cycles remains controversial. It is
important to record any cysts before ovarian stimulation
in order to monitor accurately the development of follicles,
or of any de novo cysts.
In the presence of anovulation these cysts are likely to
be hormonally active. It is good practice to commence
stimulated cycles only after spontaneous menstruation
indicates that hormonal levels are back to baseline.
Should menstruation not occur, further diagnostics should
be arranged.
Endometriomas
US appearance
Endometriosis is a very common finding in subfertile
women, and endometriotic cyst formations within the
ovary are known as endometriomas. They can be bilateral
and cause significant pelvic pain symptoms; they are often
found to be adherent to surrounding structures such as
bowel. They are cystic with hazy, uniform hyperechoic content similar to blood seen within hemorrhagic cysts
(Figure 19.2a, b) and the two can be difficult to distinguish
on ultrasonography.
Chapter 19: US and incidental ovarian pathology
Diagnostic approach
The sonographic appearance of endometriomas is usually
nonspecific, but includes having a homogeneous hyperechoic
carpet of low-level echoes [5](Figure 19.3). MRI is a good
diagnostic test, with sensitivity and specificity comparable to
those of laparoscopy.
Reproductive significance
Severe cases of endometriosis should be referred to units with
the necessary expertise to offer all available treatments in a
multidisciplinary context, including advanced laparoscopic
surgery before ART [6].
There is no evidence to support the use of ovarian suppression agents in the treatment of endometriosis-associated infertility, and such use should be avoided because of adverse effects
and the lost opportunity to conceive.
Subsequent spont aneous pregnancy rates may be improved
with laparoscopic cystectomy. Some physicians offer laparoscopic ovarian cystectomy if an ovarian endometrioma of
more than 4cm diameter is found. Theoretically, the surgery
aims to confirm the diagnosis histologically, reduce the risk of
infection, improve access to follicles during oocyte retrieval for
IVF, possibly improve ovarian response, and prevent progression of endometriosis. Nevertheless, a recent meta-analysis of
five studies showed that surgical management of endometriomas has no significant effect on IVF pregnancy rates and ovarian response to stimulation compared with no treatment [7].
If an endometrioma is seen during oocyte retrieval, it is
important to avoid aspirating it as there is a high risk of ovarian
infection.
Germ-cell tumors, including dermoids
The increased resolution capabilities provided by transvaginal
ultrasonography allow incidental detection of previously unsuspected cysts and permit identification of their nature. The
positive predictive value of TVS for the diagnosis of endometriomas and dermoid cysts is higher than 95% [8].
Dysgerminomas can be found in young patients presenting
with subfertility as a result of abnormal gonads (insensitivity/
dysgenesis) and have a 10–15% chance of being bilateral, but
usually the contralateral side has only microscopic involvement
not identifiable by ultrasound.
US appearance
Dermoids have variable appearance, and can present as (1)
solid, hyperechoic, either homogeneous or heterogeneous
masses; (2) fluid-filled areas with hyperechoic foci in their
wall; and (3) a mixed pattern, with solid and liquid areas [9].
Germ cell tumors tend to be solid.
Diagnostic features
Cystic lesions with hazy hyperechoic content can be difficult to
differentiate from endometriomas, but dermoids sometimes
157
Section 2: Ultrasonography in infertility
(a)
Figure 19.2. a) Fluid level with clot seen in transvaginal image of hemorrhagic ovarian cyst. (b) Transvaginal image of hemorrhagic ovarian cyst.
(b)
158
Figure 19.3. Three-dimensional multiplanar image of endometrioma.
Figure 19.4. Transvaginal ultrasound image of dermoid cyst.
contain bright hyperechoic areas, fluid levels and/or calcifications (Figure 19.4). Moreover, posterior or edge acoustic shadowing is common and can be pronounced.
Fat is sometimes seen within dermoid cysts by CT, but for
complex masses MRI may be indicated to exclude benign
lesions (endometriomas, fibroids, dermoids) before any surgery
is undertaken.
Reproductive significance
For malignant tumors, fertility-sparing surgery (unilateral
salpingo-oophorectomy) is possible but should not compromise staging. Whether to undertake biopsy of the contralateral
ovary is disputed as it may compromise ovarian function.
Chapter 19: US and incidental ovarian pathology
Cystadenomas and borderline ovarian tumors
These are the most common neoplastic tumors, but are more
likely to be benign or borderline in the context of subfertility in
women of reproductive age. In particular, prolonged use of
clomiphene citrate for more than 12 cycles has been associated
with increased risk of borderline ovarian tumor. A direct causal
relationship has been disputed, though, and conflicting results
and opinions seem to be a result of the interaction between
nulliparity and infertility, the former being a very strong confounder and clearly associated with ovarian cancer [1].
US appearance
Mucinous tumors may be very large at presentation and are
often multilocular with low-level echoes. Serous cystadenomas
may contain calcifications also known as “psammoma” bodies.
Diagnostic approach
As with any complex mass, particularly when additional features suggestive of malignancy are present (septae, excrescences, ascites, bilaterality), it is important to scan the upper
abdomen and liver as well as to check for hydronephrosis.
Doppler ultrasonography can provide additional information with regard to malignancy but is unreliable. Generally,
absence of blood flow reduces the risk of malignancy, whereas
the presence of low-resistance flow suggestive of neovascularization increases it.
MRI may be indicated to help distinguish a benign from a
malignantlesion. CT is theimagingmodalityofchoiceforstaging
and determining operability but is not as good as ultrasound in
demonstrating the degree of complexity of the primary tumor.
Sex cord tumors
Sex cord tumors include fibromas and granulosa cell tumors .
The latter are hormonally active and may affect fertility, but are
uncommon in this age group.
US appearance and diagnostic features
These tumors are usually solid but large ones may have cystic
centers. Fibromas can be hypoechoic with sound attenuation,
and may be associated with ascites, particularly when they are
large. Less common is Meigs syndrome, which includes presence of fibroma, ascites, and right hydrothorax. In women with
estrogen-secreting granulosa cell tumors, the endometrium is
noted to be thickened and sometime heterogeneous.
Reproductive significance
Hormone-producing tumors are associated with anovulation
and PCOS (polycystic ovary syndrome)-like phenotype if
androgenic. Estrogen-secreting tumors on the other hand are
often associated with menstrual disorders and possible breast
enlargement [10]. Removal is often necessary, but fertilitysparing surgery is occasionally possible.
Reproductive significance
All complex ovarian cysts should be treated with caution, and
liaison with a gynecologic oncologist is advisable. Ovarian or
tubal malignancy may be uncommon in women of reproductive age, but it may occur, and stimulation of the ovaries should
be avoided until complex lesions are managed, usually surgically, with conservative treatment reserved for certain cases
where malignancy is considered very unlikely.
With regard to borderline tumors, studies have found pregnancy rates of 40–49% after conservative treatment [11,12]. A
randomized controlled trial of 32 women affected by bilateral
early-stage borderline tumors compared with bilateral cystectomy oophorectomy plus contralateral cystectomy, and found a
significantly higher cumulative pregnancy rate in the bilateral
cystectomy group after a follow-up period of 7 years, without
detecting any difference in recurrence rate [13].
Hydrosalpinx or pyosalpinx
US appearance
These are usually complex cystic or tubular masses with echogenic walls (Figure 19.5a, b). Occasionally they can be difficult
159
Section 2: Ultrasonography in infertility
(a)
Figure 19.5. (a) Transvaginal 3D ultrasound image slices of hydrosalpinx; (b) 3D rendered image of hydrosalpinx.
to distinguish from fluid within pelvic adhesions or irregular
ovarian cysts.
Diagnostic approach
Mucosal folds are characteristic and help differentiation from
other cystic tumors. There is no peristalsis, they may appear
convoluted, and the ovaries are seen separately. The presence of
internal echoes and particulate matter suggests pyosalpinx.
US appearance
These are small, round, unilocular, and thin walled
(Figure 19.6). They represent müllerian and mesonephric duct
remnants and carry no proven significance for fertility.
Diagnostic features
These should be separate from the ovaries. Gentle pressure w ith
the transducer will displace the cyst(s) away from the homolateral ovary, unless there are adhesions.
(b)
160
Reproductive significance
It is now well recognized that hydrosalpinges have a detrimental
effect on the outcome of IVF [14]. Transvaginal aspiration of
hydrosalpinges [15] at the time of oocyte collection for IVF
treatment has no benefit, whereas ultrasound-guided aspiration
before commencement of ART leads to a greater ovarian
response to stimulation, a greater number of embryos available
for transfer, and a trend toward higher pregnancy rates.
Salpingostomy can be considered if the hydrosalpinx is thin
walled, but the evidence to support this is lacking. On the other
hand, guidance from NICE [1] states that women with hydrosalpinges should be off ered salpingectomy, preferably laparoscopically, before IVF because this improves the chance of a live
birth (grade A recommendation). Proximal tubal occlusion is
another surgical option that may have less impact on ovarian
performance and response to ovarian stimulation while maintaining satisfactory pregnancy rates [16].
Fimbrial and paraovarian cysts
Fimbrial and paraovarian cysts are a common finding in
women of reproductive age and represent embryological
remnants.
Pedunculated subserosal and broad ligament leiomyomas
US appearance
Leiomyomas (fibroids) have a varied appearance but are usually
hypoechoic, with poor through-transmission and concentric
patterns (Figure 19.7). Calcification and cystic degeneration
are possible. They may grow under the influence of estrogen
in stimulated cycles.
Diagnostic approach
These should be seen separately from the ovaries and in continuation with the myometrium. Ultrasound alone is usually
adequate, and the use of the transabdominal approach may be
indicated. Occasionally, adhesions complicate diagnosis and
MRI becomes helpful, but a bimanual examination may be
informative before resorting to such diagnostic measures.
Reproductive significance
The main way these can affect reproductive potential varies and
depends on their location. They can result in adhesions,
Chapter 19: US and incidental ovarian pathology
Figure 19.6. Transvaginal ultrasound image of paraovarian cyst.
Figure 19.7. Ultrasound image of pedunculated fibroid.
compression, or stretching of fallopian tubes. Surgical intervention of subserous fibroids is not recommended for fertility reasons and may even be counterproductive by increasing scarring
and adhesions; however, surgery may be considered for fibroids
of considerable size and if they are causing symptoms.
The discussion of submucous and intramural fibroids and their
potential impact on fertility is outside the scope of this chapter.
Peritoneal cysts
Peritoneal cysts can be the result of surgery, trauma, pelvic
inflammatory disease, or endometriosis. The diagnostic
approach may include a laparoscopy. The impact on fertility
is dependent on the nature and extent of any coexisti ng adhesions involving the fallopian tubes.
New imaging techniques: three-dimensional
ultrasonography
Recently three-dimensional (3D) or volume ultrasonography
has been added to the gynecologic assessment armamentarium. There appear to be few differences in the diagnostic
accuracy of standard 2D versus 3D images in detecting pelvic
pathology [17], bu t 3D scanning can improve efficiency by
reducing scanning time and therefore improving patient
throughput [18]. Furthermore, 3D ultrasound is able to
rapidly acquire and store ultrasonographic data that can
later b e retrospectively analyzed with little loss of information. It is therefore likely that the application of 3D ultrasound scanning will increase in the future for diagnostic
purposes, particularly when the purchase cost of ultrasound
equipment falls.
Concluding remarks
The availability of noninvasive ultrasonography has resulted in
improved care for infertile women. The ability to diagnose and
then decide on appropriate treatment is invaluable in helping
women achieve better fertility outcomes where identified pathology is detrimental, but also in improving patient well-being where
this may be more serious, such as malignancy, and is dealt with
161
Section 2: Ultrasonography in infertility
speedily. It is nevertheless imperative that appropriate measures
are taken to reach the correct diagnosis to avoid unnecessary
intervention or the failure to deal with a potentially serious condition. As such, there is no avoidance of the need for appropriate
training, up-to-date, well-maintained equipment, and pathways
to allow appropriate referral shouldfurther interventionor investigations be required when suspected pathology is identified.
Acknowledgments
The author are extremely grateful to Dr N. Raine-Fenni ng,
Nottingham University, UK for kindly providing the images,
some of w hich have been published (Rain e-Fenning N,
Jayaprakasan K , Deb S. Picture of the month. Threedimensional ultrasonographic characteristics of endometriomata. Ultrasound Obstet Gynecol 2008; 31:718–24).
References
1. National Institute for Clinical
Excellence. Assessment and
Treatment for People with
Fertility Problems. London:
RCOG Press, 2004.
2. Jenkins JM, Anthony FW,
Wood P, Rushen D, Masson
GM, Thomas E. The
development of functional
ovarian cysts during pituitary
down-regulation. Hum
Reprod 1993; 8(10): 1623–7.
3. Kupfer MC, Ralls PW, Fu YS.
Transvaginal sonographic
evaluation of multiple
peripherally distributed
echogenic foci of the ovary:
prevalence and histologic
correlation. Am J Roentgenol
1998; 171(2): 483–6.
4. Nardo LG, Kroon ND,
Reginald PW. Persistent
unilocular ovarian cysts in a
general population of
postmenopausal women: is
there a place for expectant
management? Obstet Gynecol
2003; 102(3): 589–93.
5. Kurjak A, Kupesic S.
Ultrasonic assessment of
ovarian endometriosis. In:
Kupesic S, Kurjak A, de
Ziegler D, eds. Ultrasound and
Infertility. London: Informa
Health Care, 1999.
6. Royal College of Obstetricians
and Gynaecologists. The
Investigation and
Management of
Endometriosis. Green-top
Guideline No. 24. RCOG,
London, 2006 [www.rcog.org.
uk/index.asp?PageID=517].
7. Tsoumpou I, Kyrgiou M,
Gelbaya TA, Nardo LG. The
effect of surgical treatment for
endometrioma on in vitro
fertilization outcomes:
a systematic review and
meta-analysis. Fertil Steril
2009; 92(1): 75–87.
8. Jermy K, Luise C, Bourne T.
The characterization of
common ovarian cysts in
premenopausal women.
Ultrasound Obstet Gynecol
2001; 17(2): 140–4
9. Serafini G, Quadri PG,
Gandolfo NG, Gandolfo N,
Martinoli C, Derchi LE.
Sonographic features of
incidentally detected, small,
nonpalpable ovarian
dermoids. J Clin Ultrasound
1999; 27(7): 369–73.
10. Van Holsbeke C, Domali E,
Holland TK, et al. Imaging of
gynecological disease (3):
clinical and ultrasound
characteristics of granulosa
cell tumors of the ovary.
Ultrasound Obstet Gynecol
2008; 31(4): 450
11.
Tinelli FG,
Grotta F, Tinelli A, Cicinelli
E, Schonauer MM.
Pregnancy outcome and
recurrence after conservative
laparoscopic surgery for
borderline ovarian
tumors. Acta Obstet
Gynecol Scand 2007
86(1): 81–7.
12. Boran N, Cil AP, Tulunay G,
et al. Fertility and recurrence
results of conservative
surgery for borderline
ovarian tumors. Gynecol
Oncol 2005; 97(3): 845–51.
13. Palomba S, Zupi E, Russo T,
et al. Comparison of two
–6.
Tinelli R, La
fertility-sparing approaches
for bilateral borderline
ovarian tumours: a
randomized controlled
study. Hum Reprod 2007;
22(2): 578–85.
14. Siassakos D, Syed A, Wardle
P. Tubal disease and assisted
reproduction. Obstet Gynecol
2008; 10:80–7.
15. Sowter MC, Akande VA,
Williams JA, Hull MG. Is the
outcome of in-vitro
fertilization and embryo
transfer treatment improved
by spontaneous or surgical
drainage of a hydrosalpinx?
Hum Reprod 1997; 12(10):
2147–50.
16. Gelbaya TA, Kyrgiou M,
Tsoumpou I, Nardo LG. The
use of estradiol for luteal
phase support in in vitro
fertilization/
intracytoplasmic sperm
injection cycles: A systematic
review and meta-analysis.
Fertil Steril 2008; 90(6):
2116–25.
17. Benacerraf BR, Shipp TD,
Bromley B. Improving the
efficiency of gynecologic
sonography with 3dimensional volumes:
a pilot study. J Ultrasound
Med 2006; 25(2):
165–71.
18. Hagel J, Bicknell SG. Impact
of 3D sonography on
workroom time efficiency.
Am J Roentgenol 2007;
188(4): 966–9.
162