2D/3D/4D ULTRASOUND IN INFERTILITY MANAGEMENT
Abstract
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.
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