Interventional ultrasound in infertility

Interventional Ultrasound in Infertility

Hesham Al-Inany, M.D, PhD

Focus of this lecture

• Not talking about emerging technology

HIFU

But talking about current Procedures

• Before IVF• For IVF• After IVF

PCOS

• Injection of warm sterile saline (75C) into the ovarian stroma under TVUS monitoring using ovum pickup needle.

• Ovulation has been achieved in 73.1% of clomiphene citrate resistant PCOS cases and resulted in pregnancy in 26.9% of these cases. No adverse effects were recorded and the procedure was tolerable in most cases

Difficulties encountered

Non stimulated ovaries; Difficult accessibility; abdominal pressureRecurrence rate is high (after 6 month)

Cyst aspiration

• Some cysts appear after administration of GnRH analogues , due to the flare up effect, they may result in delay of down regulation and failure of the estradiol level to drop , in these cases TV cyst aspiration is our usual practice

Entirely cystic adenxal mass

• Transvaginal ultrasound cyst aspiration can be proposed as an alternative for surgery for women with:-

• Previously diagnosed as having extensive pelvic adhesions or peritoneal cyst

• Pregnant women before 14 weeks gestation• Persistent cyst after OC use for 3 month

Not suitable

• If the cyst recurred• If CA125 more than 35• If not entirely cystic

Aspiration of Hydrosalpinx

• In women who are identified to have visible hydrosalpinges by US during COH, aspiration of hydrosalpinges during oocyte collection may be effective in improving pregnancy rate (Hammadieh et al, 2008)

Aspiration of endometriotic cysts

• Larger caliber of needle• Takes longer time• Difficult to empty• Sometimes u need to inject saline• Risk of infection• Recurrence rate is high• Injection of sclerosing material e.g alcohol?

Three Steps management

• TVUS aspiration• Followed by medical treatment • Followed by laparoscopic cystectomy or IVF• Has not been evaluated till now

Transcervical metroplasty

• Asymptomatic woman: no treatment• Prophylatic metroplasty before IVF has been

proposed• US guidance can be an alternative to

hysteroscopic metroplasty

IVF procedure

Ovum Pick up

• General anesthesia or sedation or none• TV U/S guided: corner stone for OPU• Single or double aspiration needle

Difficulties encountered

• High inaccessible ovaries; abdominal pressure, tenaculum manipulation of cervix pulling down ovary

• Fibroids, adenomyosis ( proper precycle evaluation, myomectomy)

• No follicles on aspiration; expect with poor response, older age , low E2 levels; flushing of the follicle

Complications• Pain: Severe 3% (Ludwig 2006)

• Bleeding; vaginal site bleeding; pressure, pack, rarely sutures (2.8%, Ludwig 2006), ureteral injury

• Injury; vaginal perforation, iliac vessels, retro-peritoneal haematoma (Azem 2000)

• Infection; pelvic abscess, tuboovarian abscess ( Dicker 1993; 14 out of 3,656),usually with aspiration of

endometriotic cysts or hydrosalpinx • Ovarian torsion• OHSS

ET under US

Ultrasound guided ET

• Full bladder to straighten the utero-cervical angle

• Trans-abdominal U/S• Special catheters ecchogenic

It is evidence Based

• Two recent meta-analysis one by our group, found a higher live birth , ongoing pregnancy, clinical pregnancy & implantation rates and easier transfers with ultrasound guided technique (Abousetta , Brown 2007).

After IVF

• What can interventional US offer??

Ectopic pregnancy

• Ectopic pregnancy after IVF are usually diagnosed very early and before being undisturbed

• Transvaginal intratubal injection of methotrexate under sonographic guidance is feasible

• Can be alternative to Laparoscopy

• However, systemic methotrexate is easier and effective

SER or MFPR

• Done at 7 weeks• Easy , simple rapid• Only by aspiration , no injection of potassium

chloride

Complications

• Bleeding• Vanishing twin(14.4%)• Abortion (4%)

Aspiration of ascitic fluid in OHSS

• When there is distress app 3 litres• Aspiration + IV human albumen• TV U/S guided• Simple no anesthesia• Might need to repeat• Severe cases have decreased markedly due

protocol of coasting and Antagonist

Coelocentesis

• Between 6 -12 weeks

• Advantage of early Prenatal diagnosis(< 10w)

• 95% success rate bet 7 - 10weeks

• Low rate of contamination by maternal cells.

Coelocentesis

• Early amnio and CVS not performed before 10weeks

• Less traumatic to embryo & placenta

• Fetal loss = 0r < that in early amnio.

Conclusion

• Interventional ultrasound is becoming more and more in use

• Advancement in technology will extend its use in different applications

Thank You

Thank You