2D/3D/4D ULTRASOUND IN INFERTILITY MANAGEMENT
Background: Ultrasound examination is becoming a more and more important diagnostic tool in infertil- ity treatment. Development of ultrasound equipment offers a lot of information about the physiology and morphology of gynecological organs. Beside the 2D view on structures, the new 3D technology enables us to view the whole volume in all planes. 4D view enables us a 3D view in certain time, i.e. a 3D live scan.
Content: Ultrasound is used in fertility management for infertility diagnostics and in following of treatment.
Ultrasound in infertility diagnostics: Ultrasound is used for examination of uterus, tubes, ovaries and peritoneal cause of infertility. It can be used in different menstrual phases: proliferative, periovulatory and secretory phase.
Examination of uterus: A 2D scan can measure the size of the uterus (length, width and depth) and a 2D flow (colour and power doppler). With 3D technology we can measure the whole volume with VOCAL (virtual organ computer-aided analysis) and 3D circulation with the index (VI – vascular index, FI – flow index and VFI – vascular flow index) in the uterus. A 2D scan can help us define uterine malformations, fibroids and adenomyosis to a certain extent. However, a 3D scan offers more accurate diagnosis of these malformations. Endometrium is examined separately. With 2D the width is measured and morphology and focal lesions (polyp, fibroids, adhesions) are examined. With 3D the real sagital plane for the width measurement can be defined . We can measure the volume of endometrium and subendometrium and 3D circulation in endometrium and subendometrium. The FIS (f luid instlation sonography) is very useful when examining the endometrium; saline or gel can be used for uterine instalation. We can measure and define the position of the structures in the endometrium more accurately when they are surrouned by saline or gel. We can view these structures with a surface view, similar to the one used for hysteroscopy. With this information we can explain the pathology to the patient and easily plan the surgical procedures.
Examination of the tubes: With 2D US we can see the tubes in the pelvis only if there are dilatations, but sometimes it is difficult to distinguish them from the neighbouring forma- tions. With a 3D ultrasound we can define the shape and continuity of the tube and we can view the tube from different angles (inversion mode). Different contrast media are used for determining tubal patency. Tubal patency can be diagnosed with 2D HyCoSy (Hysterosal- pingo Contrast Sonografy) or 3D HyCoSy.
Examination of the ovary: With the 2D ultrasound the size of ovaries is measured and the morphology of ovaries is examined. With the 3D ultrasound the volume of the ovaries, follicles, cysts and tumors can be measured. Furthermore, position of the ovaries with re- gard to their surrounding can be defined. With the 3D surface mode we can see the surface view of the inner layer of the follicle or the cyst. The volume of the liquid structures can be measured with VOCAL or sonoAVC (sono automated volume count). The number of the antral follicles strongly correlates with fertility potential markers such as FSH and AMH. Examination of peritoneum: The position of gynaecological organs and ascites are defined.
Examination of vagina: Endometriotic nodules can be excluded with ultrasound. A 3D ultrasound can define the exact position of the nodule.
Ultrasound in the following of infertility treatment: Before the ovarian stimulation it is mandatory to exclude pelvic pathology that can influence the stimulation. Ovarian stimulation: We follow the natural or stimulated cycles with an ultrasound in view of follicular and endometrial growth. SonoAVC offers us automatic volume count of all follicles. This information enables us to change the stimulation protocol and avoid OHSS more accurately comparing to the standard 2D technology.
Oocyte puncture: US puncture is done with ultrasound-guided needle. Great vessels around the vagina and on the needle line can be avoided if colour doppler is used. With 3D surface mode good quality follicles can be identified. Embryotransfer (ET): The angle between cervical canal and corpus uteri can be mea- sured before the embryotransfer. The introduction of the ET catheter can be followed with the 2D transabdominal probe. More exact location of the catheter can be visualized with 4D US. With this method we can avoid touching the uterine fundus with the catether and avoid bleeding in the foetus surroundings.
Conclusions: There is an increasing number of ultrasound machines offering us beside 2D, 3D and 4D technology. It is important to learn the applications and use them in our daily practice. The recorded volumes can be examined at any time in any plan. In any unclear pathology the recorded volume can be send for second opinion and discussed further.
Merz E. Ultrasound in Obstetrics and Gynecology, Vol 2: Gyne- cology, 2ed ed., New York, NY: 2007, Thieme.
Ng EHY, Chan CCW, Tang OS, Yeung WSB, Ho PC. Endometrial and subendometrial blood flow measured during early luteal phase by three dimensional Power Doppler ultrasound in pa- tients with small intramural fibroids during in vitro fertilization treatment. Hum Reprod 2005; 20: 501–6.
Ng EHY, Chan CCW, Tang OS, Yeung WSB, Ho PC. Factors af- fecting endometrial and subendometial blood flow measured by three-dimensional power Doppler ultrasound during IVF treatment. Hum Reprod 2006; 21: 1062–9.
Ng EHY, Chan CCW, Tang OS, Yeung WSB, Ho PC. The role of endometrial and subendometrial blood flows measured by three-dimensional power Doppler ultrasound in prediction of pregnancy during IVF treatment. Hum Reprod 2006; 21: 164–70.
Ng EHY, Chan CCW, Tang OS, Ho PC. Comparison of endometrial and subendometrial blood flow among patients with and with- out hydrosalpinx show on scanning during in vitro fertilization treatment. Fertil Steril 2006; 85: 333–8.
Reine-Fenning NJ, Campbell BK, Clewes JS, Kendall NR, John- son IR. The reliability of virtual organ computer-aided analysis (VOCAL) for the semiqualification of ovarian, endometrial and subendometrial perfusion. Ultrasound Obstet Gynecol 2003; 22: 633–9.
Reine-Fenning NJ, Campbell BK, Kendall NR, Clewes JS, Johnson IR. Quantifying the changes in endometrial vascularity through- out the normal menstrual cycle with three-dimensional power Doppler angiography. Hum Reprod 2004; 19: 330–8.
Reine-Fenning NJ, Campbell BK, Kendall NR, Clewes JS, Johnson IR. Endometrial and subendometrial perfusion are impaired in woman with unexplained subfertility. Hum Reprod 2004; 19: 2605–14.
Tomaževič T. Pomen vaginalnega ultrazvoka v postopkih op- loditve z biomedicinsko pomočjo. In: Virant-Klun I, Meden- Vrtovec H, Tomaževič T. Od nastanka gamet do rojstva. Narodna in univerzitetna knjižnica, Didakta 2002. p.113–6.
Wu HM, Chiang CH, Huang HY, Chao AS, Wang HS, Soong YK. Detection of the subendometrial vascularization flow index by three-dimensional ultrasound may be useful for predicting the pregnancy rate for patients undergoing in vitro fertilization- embryo transfer. Fertil Steril 2003; 79: 507–11.
The Author transfers to the Publisher (Zdravniški vestnik/Slovenian Medical Journal) all economic copyrights following form Article 22 of the Slovene Copyright and Related Rights Act (ZASP), including the right of reproduction, the right of distribution, the rental right, the right of public performance, the right of public transmission, the right of public communication by means of phonograms and videograms, the right of public presentation, the right of broadcasting, the right of rebroadcasting, the right of secondary broadcasting, the right of communication to the public, the right of transformation, the right of audiovisual adaptation and all other rights of the author according to ZASP.
The aforementioned rights are transferred non-exclusively, for an unlimited number of editions, for the term of the statutory
The Author can make use of his work himself or transfer subjective rights to others only after 3 months from date of first publishing in the journal Zdravniški vestnik/Slovenian Medical Journal.
The Publisher (Zdravniški vestnik/Slovenian Medical Journal) has the right to transfer the rights, acquired parties without explicit consent of the Author.
The Author consents that the Article be published under the Creative Commons BY-NC 4.0 (attribution-non-commercial) or comparable licence.