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How USG has helped in early diagnosis & treatment in infertility

 Ultrasonography (USG) is a useful and first line investigation used to assess the cause of  infertility and to institute treatment accordingly. USG is an effective, safe, inexpensive, radiation free, non-invasive and  readily available tool. 

 Role of ultrasound in female infertility 

 Ultrasound is used to evaluate the pelvic organs (uterus and ovaries), growing ovarian follicles, and cyclic uterine endometrial changes.

 Evaluation of uterus :

 A) Structural anatomy - Using both 2D and 3D ultrasound congenital mullerian anomalies can be diagnosed and classified according to ESHRE/ESGE classification of uterine anomalies. 

 B) Pathologies:       

  1) Fibroid : seen in 5-10% of infertile women. Distortion of the endometrial cavity, abnormal endometrial receptivity, altered hormonal milieu, and endometrial development are the causative factors for infertility in fibroids. USG provides the number, exact location and size of  fibroids,  thus  helps in thorough planning of surgical intervention if necessary.      

   2) Adenomyosis : Adenomyosis results in structural and functional defects of the uterine junctional zone and thus resulting in disturbed uterine peristalsis and sperm transport, increased inflammatory response in the endometrium causing impaired implantation. All these factors contribute to sub fertility and increased risk of miscarriage in Adenomyosis. The ultrasonographic features of Adenomyosis are globular uterus,  asymmetrical myohyperplasia, rain shower appearance and myometrial cyst. 

 Endometrium :

 Is a dynamic structure undergoing cyclical changes. The endometrial pattern acts as an indirect measure of hormonal status during the cycle. Pathological features such as thin endometrium, poor endometrial blood flow, presence of polyp or intrauterine adhesions can result in sub fertility. And all these pathologies are accurately assessed using USG (both 2D + 3D). 

 Ovary :

 USG is used for diagnosis and monitoring of treatment cycle in sub fertile women. 

 1)        Follicular monitoring : Is an integral part of investigation in  subfertile women.  Serial scans during follicular phase evaluates the growth of the follicle, estimates the time of follicular rupture, the ideal time to trigger ovulation and occurrence of ovulation.

 2)        Antral follicular count: Estimated on day 2 of menstrual cycle, follicles of 2- 8 mm size measured and counted in each ovary. Diminished ovarian reserve diagnosed when AFC < 5. Early diagnosis of diminished ovarian reserve helps planning accurate treatment such as IVF, thus reducing time to pregnancy.

 3)        Endometriotic cysts :Endometriosis causes profound inflammatory response in the pelvis, affecting oocyte quality, sperm transport and function, luteinized unruptured follicle, defective corpus luteum, altered endometrial receptivity and also presence of adhesions results in sub fertility. Presence of unilocular cyst with ground glass appearance of the contents and peripheral blood flow are the USG features of endometriotic cyst. 

INTRODUCTION

 Ovarian cancer screening isn’t as simple as getting an ultrasound. The characterization of ovarian masses and distinguishing between benign and malignant pathology is important both to decrease unnecessary anxiety and enable decisions regarding optimal treatment. Benign pathology may be best treated conservatively or in a general gynaecology unit using a minimal access approach. Conversely, suspected malignant masses should be referred to specialized units for further management. Thus prior knowledge of the nature of ovarian masses is essential not only for the patient but in order to organize clinical services in terms of planning, costs and overall management.

 Transvaginal ultrasonography (TVS) is the most commonly employed imaging modality for the assessment of adnexal masses, and a number of prediction models have been created to maximize its predictive capability. In many countries the risk of malignancy index (RMI) which combines ultrasound features, serum CA125 levels and the menopausal status of the patient is still used to characterize ovarian pathology. Unfortunately, both of these are flawed when it comes to screening the general population. Asking for a transvaginal ultrasound or blood test when you’re at an average risk for ovarian cancer isn’t the best idea.

 These findings suggest that with adequate training and knowledge of the common features associated with particular pathologies, ultrasound examiners should be able to reliably diagnose and differentiate between certain specific types of adnexal pathology. It is important to remember that when evaluating women with an adnexal mass, ultrasound characteristics need to be correlated with the clinical history, as well as signs and symptoms before arriving at a diagnosis. Ovarian cancer is one of those diseases you probably assume you’re being screened for when you go to your well-woman exams, but that’s not really the case. Ovarian cancer screening, in fac t, isn’t recommended at all for women at average risk for the condition, but that’s not something that most people know.

 There are actually no recommended screening tests for ovarian cancer in people who don’t have symptoms and don’t have an increased risk of developing the condition. 

 Ovarian cancer is a scary disease—it affects about 20,000 women in the U.S. each year, according to the Centers for Disease Control and Prevention (CDC). Unfortunately, only about 20 percent of cases are caught in the early stages. So it makes sense that we would all want to know how to get screened for this condition so that we could discover it and treat it as early as possible. Unfortunately, the science isn’t there yet.

 The manual pelvic exams may be helpful, although ovarian cancers would be very difficult to feel with this test. When you do a pelvic exam, you’re inserting a finger into the vagina, pushing down from above, and basically feeling for an obvious mass, thickening, or extreme tenderness. It’s very inaccurate as you are just kind of squeezing together the uterus and ovaries. It’s hard to detect a smaller mass. 

 While a transvaginal ultrasound can help find a mass on a woman’s ovary, it can’t tell whether that mass is cancerous or benign. When transvaginal ultrasounds are used for screening, most of the masses found are not cancerous. The CA-125 blood test also isn’t perfect. More common conditions like endometriosis and pelvic inflammatory disease can also cause high levels of CA-125, which could lead to other unnecessary tests. Not only that, not everyone who has ovarian cancer has a high CA-125 level. 

 As you can see, knowing the signs and symptoms of ovarian cancer is incredibly important. The symptoms of ovarian cancer can be subtle, but the most common ones include bloating, pelvic or stomach pain, trouble eating or feeling full quickly, and having urinary symptoms like feeling to urinate often. This is a little tricky because these symptoms can also be caused by other benign diseases. But when they’re caused by ovarian cancer, they’re usually persistent and a change from your normal.

 So, who should be tested for ovarian cancer? 

How USG has helped in early diagnosis & treatment in infertility Ultrasonongraphy (USG) is a useful and first line investigation used to assess the cause of  infertility and to institute treatment accordingly. USG is an effective, safe, inexpensive, radiation free, non-invasive and  readily available tool. Role of ultrasound in female infertility Ultrasound is used to evaluate the pelvic organs (uterus and ovaries), growing ovarian follicles, and cyclic uterine endometrial changes. Evaluation of uterus : 

 A) Structural anatomy - Using both 2D and 3D ultrasound congenital mullerian anomalies can be diagnosed and classified according to ESHRE/ESGE classification of uterine anomalies. 

 B) Pathologies:         

1) Fibroid : seen in 5-10% of infertile women. Distortion of the endometrial cavity, abnormal endometrial receptivity, altered hormonal milieu, and endometrial development are the causative factors for infertility in fibroids. USG provides the number, exact location and size of  fibroids,  thus  helps in thorough planning of surgical intervention if necessary.       

  2) Adenomyosis : Adenomyosis results in structural and functional defects of the uterine junctional zone and thus resulting in disturbed uterine peristalsis and sperm transport, increased inflammatory response in the endometrium causing impaired implantation. All these factors contribute to sub fertility and increased risk of miscarriage in Adenomyosis. The ultrasonographic features of Adenomyosis are globular uterus,  asymmetrical myohyperplasia, rain shower appearance and myometrial cyst. Endometrium : Is a dynamic structure undergoing cyclical changes. The endometrial pattern acts as an indirect measure of hormonal status during the cycle. Pathological features such as thin endometrium, poor endometrial blood flow, presence of polyp or intrauterine adhesions can result in sub fertility. And all these pathologies are accurately assessed using USG (both 2D + 3D). Ovary : USG is used for diagnosis and monitoring of treatment cycle in sub fertile women. 

 1)        Follicular monitoring : Is an integral part of investigation in  subfertile women.  Serial scans during follicular phase evaluates the growth of the follicle, estimates the time of follicular rupture, the ideal time to trigger ovulation and occurrence of ovulation. 

 2)        Antral follicular count: Estimated on day 2 of menstrual cycle, follicles of 2- 8 mm size measured and counted in each ovary. Diminished ovarian reserve diagnosed when AFC < 5. Early diagnosis of diminished ovarian reserve helps planning accurate treatment such as IVF, thus reducing time to pregnancy. 

 3)        Endometriotic cysts :Endometriosis causes profound inflammatory response in the pelvis, affecting oocyte quality, sperm transport and function, luteinized unruptured follicle, defective corpus luteum, altered endometrial receptivity and also presence of adhesions results in sub fertility. Presence of unilocular cyst with ground glass appearance of the contents and peripheral blood flow are the USG features of endometriotic cyst.