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
(a) (b)
Chapter 29: US-guided embryo transfer
(c)
Figure 29.22 (a–d). The uterus is adherent to the anterior abdominal wall as a result of previous cesarean section. The ET catheter tip is being advanced into the
endometrial cavity.
(d)
the drop of culture medium containing the embryos (as indicated
by the drop of air seen on ultrasound) comes out of the catheter
tip (bullet appearance). This is compared with the situation in
which the drop of culture medium stays near the tip of the
catheter (no bullet appearance), which may suggest that the catheter tip is touching the fundus or part of the anterior/posterior or
lateral walls or that the tip is surrounded by mucus or blood.
This technique requires a full bladder, which, by itself, may
simplify embryo transfer by straightening the cervical uterine
access [33,34,35]. However, the degree of bladder filling should
be optimal. If it is minimally filled, the view of the endometrium
is not clear and its straightening effect is not present. On the
other hand, a markedly distended bladder has several disadvantages, including patient discomfort, a suboptimal view of the
endometrial lining, and a change in cervical position as a result
Figure 29.23. Transabdominal ultrasound scan illustrating a uterus adherent to
the anterior abdominal wall as a result of previous cesarean section. This picture
shows that the more the bladder is filled, the greater the likelihood of creating a
curve at the uterocervical angle.
of pushing on the vaginal speculum. In addition, a very
full bladder may push a retroverted uterus still further backward, which compromises the view of the endometrial lining.
Furthermore, if the uterus is adherent to the abdominal wall,
243
Section 3: Ultrasonography in assisted reproduction
(a)
(c)
(b)
(d)
244
(e)
overfilling of the bladder will not only have no effect on the view
of the endometrial lining, but also may further distort the
relationship between the cervical canal and the uterine cavity.
Therefore, care should be taken to ensure optimal filling, but
not underfilling or overfilling, of the bladder.
Figure 29.24 (a–e). Transabdominal ultrasound scans illustrating the
angle at the uterocervical junction as a result of previous cesarean section.
The pictures illustrate the ET catheter tip being advanced clearly, then
withdrawn after completion of the procedure.
Ultrasonographicguidance of ET may also have other poten-
tial advantages. Cervical lavage before ET should be done under
ultrasound guidance, which ensures complete removal of cervical mucus and avoidance of pushing of washing medium into
the endometrial cavity. The latter is accomplished by avoiding
Chapter 29: US-guided embryo transfer
(a)
(c)
(b)
(d)
Figure 29.25 (a–d). Transvaginal ultrasound scans illustrating subendometrial placement of the tip of the transfer catheter.
advancing the tip of the catheter more than 50% of the length
of the cervical canal. In the presence of a pinpoint nulliparous
os, suction of the cervical mucus should be performed, but one
should not perform cervical lavage as fluid may enter the endometrial cavity. Failure to monitor cervical cleansing and lavage
by ultrasound may potentially have harmful effects, e.g., trauma
to the region of internal os or even the endometrial cavity and
the possibility of pushing fluid into the endometrial cavity. New
technology from General Electric (GE, New York) allows
ultrasonography-guided ET using a 4D mode, with significant
advantage in the transfer process.
*
Transabdominal ultrasound guidance is essential for
meticulous and atraumatic ET.
*
Cervical suture should be considered in patients with a
history of:
Difficult mock trial
Problematic cervix
Pelvic adhesions (previous cesarean section)
Obesity
*
If severe difficulty is expected, consider:
Transvaginal ultrasound
Key points in clinical practice
*
Transvaginal ultrasound is mandatory for evaluation of the
uterus and endocervical canal prior to and on the day of
oocyte retrieval.
Tubal embryo transfer
4D ultrasound is a very useful tool and may
eventually replace 2D ultrasound for embryo
transfer.
245
Section 3: Ultrasonography in assisted reproduction
(a)
(c)
(b)
(d)
246
Figure 29.26(a–d). Transvaginal ultrasound scan illustrating subendometrial placement of the tip of the transfer catheter.
Chapter 29: US-guided embryo transfer
(a)
(c)
(b)
(d)
Figure 29.27 (a–d). Transabdominal ultrasound scan illustrating controlled advancement of the ET catheter tip along the endometrial cavity to ensure proper
placement of embryos.
247
Section 3: Ultrasonography in assisted reproduction
(a)
(c)
(b)
(d)
(e)
References
1. Meldrum DR, Chetkowski R,
Steingold KA, de Ziegler D,
Cedars MI, Hamilton M.
Evolution of a highly
successful in vitro
fertilization-embryo
transfer program. Fertil
Steril 1987; 48:86–93.
2. Schoolcraft WB, Surrey ES,
Gardner DK. Embryo
transfer: techniques and
variable affecting success.
Fertil Steril 2001; 76 (5):
863–870.
3. Mansour RT, Aboulghar
MA. Optimizing the embryo
transfer technique.
Figure 29.28. (a–c) A curve in the endometrial cavity, giving it a banana shape.
(d) Mock trial catheter in a patient with a banana-shaped cavity. (e) Saline
sonogram in a patient with a banana-shaped cavity. Note the tip of the catheter
touching the anterior wall of the uterus.
Hum Reprod 2002; 17(5):
1149–53.
4. Rizk B. The Infuence of a
difficult embryo transfer on
the result. In: Allahbadia GN,
ed. Embryo Transfer, chapter
39. New Delhi: Jaypee
Brothers Medical Publishers,
2008: 391–6.
5. Englert Y, Puissant F, Camus
M, Van Hoeck J, Leroy F.
Clinical study on embryo
transfer after human in vitro
fertilization. J In Vitro Fert
Embryo Transf 1986; 3: 243–6.
6. Mansour R, Aboulghar M,
Serour G. Dummy embryo
transfer: a technique that
248
Chapter 29: US-guided embryo transfer
minimizes the problems of
embryo transfer and
improves the pregnancy rate
in human in vitro
fertilization. Fertil Steril
1990; 54: 678–81.
7. Wood EG, Batzer FR, Go KJ,
Gutmann JN, Corson SL.
Ultrasound-guided soft
catheter embryo transfers
will improve pregnancy rates
in in-vitro fertilization. Hum
Reprod 2000; 15: 107–12.
8. Visser DS, Fourie FL, Kruger
HF. Multiple attempts at
embryo transfer: effects on
pregnancy outcomes in an
in vitro fertilization and
embryo transfer program.
J Assist Reprod Genet 1993;
10:37–43.
9. Tomas C, Tapanainen J,
Martikainen H. The difficulty
of embryo transfer is an
independent variable for
predicting pregnancy in invitro fertilization treatments
[Abstract]. Fertil Steril 1998;
70(Suppl 1): S433.
10. Mansour RT, Aboulghar
MA, Serour GI, Amin YM.
Dummy embryo transfer
using methylene blue dye.
Hum Reprod 1994; 9: 1257–9.
11. Fanchin R, Harmas A,
Benaoudia F, Lundkvist U,
Olivennes F, Frydman R.
Microbial flora of the cervix
assessed at the time of
embryo transfer adversely
affects in vitro fertilization
outcome. Fertil Steril 1998;
70: 866–70.
12. Egbase PE, al-Sharhan M, alOthman S, al-Mutawa M,
Udo EE, Grudzinskas JG.
Incidence of microbial
growth from the tip of the
embryo transfer catheter
after embryo transfer in
relation to clinical pregnancy
rate following in vitro
fertilization and embryo
transfer. Hum Reprod 1996;
11: 1687–9.
13. McNamee P, Huang T,
Carwile A. Significant
increase in pregnancy rates
achieved by vigorous
irrigation of endocervical
mucus prior to embryo
transfer with a Wallace
catheter in an IVF-ET
program [Abstract].
Fertil Steril 1998; 70
(Suppl 1): S228.
14. Glass KB, Green CA, Fluker
MR, Schoolcraft WB,
McNamee
Multicenter randomized trial
of cervical irrigation at the
time of embryo transfer
[Abstract]. Fertil Steril 2000;
74: (Suppl 1): S31.
15. Dorn C, Reinsberg J,
Schlebusch H, Prietl G, Van
der Ven H, Krebs D. Serum
oxytocin concentration
during embryo transfer
procedure. J Obstet Gynecol
Reprod Biol 1999; 87:77–80.
16. Lesney P, Killick SR, Tetlow
RL, Robinson J, Maguiness
SD. Embryo transfer–can we
learn anything new from the
observation of junctional
zone contractions? Hum
Reprod 1998; 13(6): 1540–6.
17. Sallam HN. Embryo transfer:
Factors involved in
optimizing the success. Curr
Opin Obstet Gynecol 2005;
17: 289–98.
18. Abusheikha N, Lass A,
Akagbosu F, Brinsden P.
How useful is cervical
dilation in patients with
cervical stenosis who are
participating in an in vitro
fertilization-embryo transfer
program? The Bourn Hall
experience. Fertil Steril 1999;
72: 610–12.
19. Yanushpolsky EH, Ginsburg
ES, Fox JH, Stewart EA.
Transcervical placement of a
Malecot catheter after
hysteroscopic evaluation
provides for easier entry into
the endometrial cavity for
women with histories of
difficult intrauterine
inseminations and/or embryo
transfers: a prospective case
series. Fertil Steril 2000;
73:402–5.
20. Johnson N, Bromham DR.
Effect of cervical traction
PI, Meldrum
D.
with a tenaculum on the
uterocervical angle. Br J
Obstet Gynaecol 1991; 98(3):
309–12.
21. Sasy M, Abd el Fattah A,
Abozaid T, et al.
Comparison between
ultrasound-guided
embryo transfer and tubal
embryo transfer after
intracytoplasmic sperm
injection. Middle East Fertil
Soc J 2003; 8(3): 223–8.
22. Lodi S, Abdel Fattah A,
Aboziad T, et al. Gamete
intra-fallopian transfer or
intrauterine insemination
after controlled ovarian
hyperstimulation
treatment of
endometriosis. Gynecol
Endocrinol 2004; 19: 152–9.
23. Kato, O, Takatsuka R, Asch
R. Transvaginaltransmyometrial embryo
transfer: The Towako
Method. Fert Steril 1993; 59
(1): 51–3.
24. Woolcott R, Stanger J.
Potentially important
variables identified by
transvaginal ultrasoundguided embryo transfer.
Hum Reprod 1997;
12: 963–6.
25. Strickler RC, Christianson C,
Crane JP, Curato A, Knight
AB, Yang V. Ultrasound
guidance for human embryo
transfer. Fertil Steril 1985;
43:54–61.
26. Hurley VA, Osborn JC,
Leoni MA, Leeton J.
Ultrasound-guided embryo
transfer: a controlled trial.
Fertil Steril 1991; 55: 559–62.
27. Lindheim SR, Cohen MA,
SauerMV. Ultrasound guided
embryo transfer significantly
improves pregnancy rates in
women undergoing oocyte
donation. Int J Gynecol Obstet
1999; 66:281–4.
28. Kojima K, Nomiyama M,
Kumamoto T, Matsumoto Y,
Iwasaka T. Transvaginal
ultrasound-guided embryo
transfer improves pregnancy
for
infertility due to
and implantation rates after
IVF. Hum Reprod 2002; 16:
2578–82.
29. Anderson RE, Nugent NL,
Gregg AT, Nunn SL, Behr
BR. Transvaginal ultrasoundguided embryo transfer
improvesoutcome in patients
with previous failed in vitro
fertilization cycles. Fertil Steril
2002; 77:769–75.
30. Kan AKS, Abdalla HI, Gafar
A, et al. Embryo transfer:
ultrasound-guided versus
clinical touch. Hum
Reprod 1999; 14(9):
1259–61.
31. Coreleu B, Carreras O, Veiga
A, et al. Embryo transfer
under ultrasound guidance
improves pregnancy rates
after
in vitro
fertilization.
Hum Reprod 2000; 15(3):
616–20.
32. Abou-Setta AM, Mansour
RT, Al-Inany H, Aboulghar
MM, Aboulghar MA, Serour
GI. Among women
undergoing embryo transfer,
is the probability of
pregnancy and live birth
improved with
ultrasound guidance
over clinical touch alone?
A systemic review and
meta-analysis of
prospective randomized
trials. Fertil Steril 2007; 88
(2): 333–40.
33. Sundstrom P, Wramsby H,
Persson PH, Liedholm P.
Filled bladder simplifies
human embryo transfer. Br J
Obstet Gynecol 1984;
91: 506–7.
34. Lewin A, Schenker JG,
Avrech O, Shapira S, Safran
A, Friedler S. The role of
uterine straightening by
passive bladder distention
before embryo transfer in
IVF cycles. J Assist Reprod
Genet 1997; 14:32– 4.
35. Abou-Setta AM. E ff ect of
passive uterine straightening
during embryo transfer: a
systematic review and metaanalysis. Acta Obstet Gynecol
2007; 86: 516–22.
249
Section 4
Chapter
Early pregnancy after infertility treatment
First-trimester pregnancy failure
30
William W. Brown, III
Introduction
Transvaginal sonography (TVS) has revolutionized the medical
care available to women in early pregnancy by essentially
replacing the historical approach of clinical assessment alone.
Today’s machine and software improvements and highresolution probe capabilities allow providers a remarkable
real-time window with which to observe many aspects of
embryological development. By their doing so, this standardof-care technology is now widely used to detect fetal structural
defects in the first trimester and to screen for chromosomal
anomalies.
Unfortunately, not all pregnancies are normal and many
fail. Approximately 25% of women will risk losing their
pregnancy by presenting with bleeding, and one-half of those
will miscarry, although actual rates of spontaneous abortion
(SAB) may vary and depend upon many factors, including
maternal age and previous obstetric history. The vast majority
of these losses occur during the embryonic period of development and are due to chromosomal abnormalities.
Ultrasound is often the primary modality used to diagnose,
and sometimes predict, miscarriage, and it is essential to recognize the altered images that deviate from normal and imply
or threaten adverse outcome. The application of ultrasound in
the management of early pregnancy failure is highlighted in this
chapter.
Many clinical presentations in early pregnancy warrant
TVS, including an unknown last menstrual period (LMP)
with a positive pregnancy test, threatened abortion with bleeding, confirmation of viability in the infertility patient, and acute
onset of pelvic pain. The focus of the examination is to determine the location of the pregnancy, to document viability when
possible, and to confirm or establish gestational age. A complete
pelvic study should evaluate the uterus, cervix, endometrial
cavity, cul-de-sac, bilateral adnexa, and, when appropriate, the
abdomen for signs of hemoperitoneum. While the pregnancy
status may be the primary reason for investigation, it is important not to overlook other incidental findings which can sometimes substantially complicate an otherwise normal pregnancy,
such as a coexistent intrauterine device, uterine or adnexal
masses, or congenital uterine anomalies.
First-trimester sonography in normal and failed early pregnancy
Gestational sac
In a normally developing pregnancy, the early embryonic blastocyst implants into the uterine endometrium by 23 days of
menstrual age. The gestational sac (GS) is an ultrasound term
that signifies the conceptus; it is seen as a spherical, fluid-filled
cavity within the endometrium that is surrounded by an echogenic rim (Figure 30.1). It may be visible with high-frequency
endovaginal transducers as early as the end of the second week
after fertilization, and it is the earliest ultrasound sign of an
intrauterine pregnancy. The specific ultrasound appearance of
the fluid collection within the endometrial cavity, as well as its
size and its correlation with serum human chorionic gonadotropin (hCG) levels, are all very important since the differential
diagnosis includes a normal pregnancy, simple fluid, embryonic demise, blood, decidual cyst, and the pseudosac of an
ectopic pregnancy. Unfortunately, the mere presence of even a
true GS does not guarantee viability, as the loss rate at this stage
of pregnancy is still as high as 11.5% [1].
The anechoic space that represents the earliest GS is the
exocoelomic fluid of the blastocyst, and it is surrounded by an
echogenic ring of trophoblastic tissue comprised of chorionic
villi. A measured thickness of the sac rim of 2 mm or more can
help identify the fluid collection as an intrauterine pregnancy,
and this chorionic membrane should also have an echodensity
that exceeds that of the myo metrium [2]. The earliest visible GS
is more likely to be located eccentrically buried within the
endometrium, and it is small enough not to distort the endometrial lining interface (Figure 30.2).
One ultrasound finding that can reliably signal a pregnancy
within the uterus is the double decidual sac sign (DDS)
(Figure 30.3). Here there are two echogenic rings surrounding
the sonolucent sac [3]; the inner is the decidua capsularis, the
outer is the decidua parietalis or decidua vera, and the two rings
are separated by a thin layer of fluid. Unfortunately, this finding
is not always present until the gestational sac mean sac diameter
(MSD) is approximately 10 mm. By then, on endovaginal
Ultrasonography in Reproductive Medicine and Infertility, ed. Botros R. M. B. Rizk. Published by Cambridge University Press. © Cambridge
University Press 2010.
Section 4: Early pregnancy after infertility treatment
Figure 30. 1. Transverse view of the uterus revealing an early gestational sac.
The sonographic hallmarks are a fluid-filled, sonolucent chorionic cavity
surrounded by an echogenic rim of trophoblastic-decidual tissue.
Figure 30.3. Double decidual sac sign, consisting of the inner decidua
capsularis (arrow) and the outer decidua parietalis (or vera, arrowhead).
Figure 30.2. Despite very early menstrual dating, features that help distinguish
the sonolucent structure shown as a likely gestational sac (arrowhead) are its
echogenic rim and its eccentric location in relation to the endometrial interface
(arrow). Once a true yolk sac becomes visible within the gestational sac, the
intrauterine location of the pregnancy is confirmed.
ultrasound, it is easier and typically more predictable to locate
the yolk sac as a definitive means of confirming pregnancy
location within the uterus, thereby diminishing the clinical
usefulness of the DDS sign.
Because both hCG levels and GS growth are directly related
to trophoblastic function, there is a correlation between sac size,
hCG level, and gestational age. The discriminatory level for
hCG at which the GS should always be seen on transvaginal
ultrasound is commonly cited to be between 1000 and 2000
mIU/ml, and the value in a viable pregnancy of less than 10
weeks’ gestation should rise by at least 53% in two days [4]. This
information is of critical importance to the care provider who is
faced with the clinical possibility of ectopic pregnancy or, more
commonly, the nonviable intrauterine pregnancy or spontaneous miscarriage. In addition, once the GS is firmly visualized,
the MSD can be expected to grow at a rate of about 1.1 mm per
day [5], and no less than 0.6 mm per day. Such a MSD is
obtained by averaging the cephalocaudad, anteroposterior,
Figure 30.4. Abnormal intrauterine gestational sac as evidenced by ill-defined,
irregular debris (arrowhead) in close proximity to the yolk sac.
and transverse sac dimensions as measured from the chorionic
fluid interface.
The GS, unfortunately, cannot serve as an accurate or precise measurement of gestational age due to its wide confidence
limits, but it can and should be used to monitor the sequential
sonographic milestones of the early, normal intrauterine pregnancy. GS growth rate, location, appearance (Figure 30.4), and
size can all be used as helpful indicators when assessing pregnancy viability and the likelihood of continued normal growth.
A poor or weak choriodecidual reaction of the surrounding sac
rim, irregular sac contour (Figure 30.5), and low-set position of
the sac within the lower uterine segment are all strong indicators of a nonviable pregnancy, and serial ultrasound follow-up
examination is warranted. Bromley et al. [6] describe a small GS
252