6/7/2017 1 Helen Kim Ultrasound in Infertility Helen H. Kim, MD Section Chief Reproductive Endocrinology and Infertility Obstetrics and Gynecology The University of Chicago Medicine June 2017 Helen Kim Ultrasound in Infertility • Disclosures: None • Learning Objectives – Understand the basic process of in vitro fertilization (IVF) – Understand process of ovarian follicle development – Understand advances in ultrasound technology led to development of modern IVF Overall Causes of Infertility Uterine and Cervical Factors 5% Unexplained 25% Ovulatory Dysfunction 20% Tubal and Peritoneal Disease 20% Male Factor 30% Boston IVF Handbook of Infertility, 2002
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6/7/2017
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Helen Kim
Ultrasound in InfertilityHelen H. Kim, MDSection ChiefReproductive Endocrinology and InfertilityObstetrics and GynecologyThe University of Chicago Medicine
June 2017
Helen Kim
Ultrasound in Infertility
• Disclosures: None
• Learning Objectives– Understand the basic process of in vitro fertilization (IVF)
– Understand process of ovarian follicle development
– Understand advances in ultrasound technology led to development of modern IVF
Helen Kim
Overall Causes of Infertility
Uterine and Cervical Factors
5%
Unexplained25%
Ovulatory Dysfunction
20%
Tubal and Peritoneal Disease
20%
Male Factor30%
Boston IVF Handbook of Infertility, 2002
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Helen Kim
Causes of Infertility: Female
Uterine and Cervical Factors
5%
Unexplained25%
Ovulatory Dysfunction
20%
Tubal and Peritoneal Disease
20%
Male Factor30%
Boston IVF Handbook of Infertility, 2002
• Female factors: 45% of infertility
• Ultrasound can provide insights– Tubal and Peritoneal Disease
Speroff L et al, Clinical Gynecologic Endocrinology and Infertility, 1999
Helen Kim
IVF Procedure: 1980
• Ovulation Induction (monitored by ULTRASOUND and estradiol)• Laparoscopic oocyte retrieval • Insemination in vitro• Incubation of the embryo 2.5 days • Transfer of 1 embryo into uterus
Transvaginal Ultrasound and Hormone Levels Guide Clinical Management
10 days stimulation
10 days stimulation
Helen Kim
Besser, GM and Thorner MO, Comprehensive Clinical Endocrinology, 2002
Endometrial Changes in Response To Estrogen and Progesterone
Estrogen Progesterone
Menses 5 14 21 28
Helen KimHelen Kim
IVF: Monitoring Endometrium
• Endometrial Thickness– No consensus regarding minimal
thickness for pregnancy• > 6 mm, 7 mm, 8 mm?• Pregnancy reported with 4 mm
– Thicker with gonadotropin tx– ? Optimal thickness
• < 14 mm? < 18 mm?
• Endometrial Pattern– Optimal is “triple‐line”– Positive and negative predictive
values for endometrial echo patterns are low
Baseline: Endometrium 4.3 mm
8 days of Stimulation: Endometrium 10.7 mm
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Helen Kim
IVF Procedure: 1980
• Ovulation Induction (monitored by ULTRASOUND and estradiol)• Laparoscopic oocyte retrieval • Insemination in vitro• Incubation of the embryo 2.5 days • Transfer of 1 embryo into uterus
• Lenz S et al, Collection of human oocytes for in vitro fertilization by ultrasonically guided follicular puncture. Lancet 1:1163
– 1983: Larger Linear Array• Wikland M et al, Collection of human oocytes by the use of sonography. Fertil Steril Vol 39 (5): 656
• Oocytes collected from 77% follicles
f: folliclent: needle tip
Helen Kim
• 1983: case report– Gleicher N et al, Egg Retrieval for in vitro
fertilization by sonographically controlled vaginal culdocentesis. Lancet 2: 508
• 1985: 124 retrievals– Full bladder; void after procedure– 2.2 oocytes/patient– Less pain than transabdominal– Simpler than laparoscopy– BUT ‐ precise location and puncture NOT
possible
– Dellenbach P et al, Transvaginal sonographicallycontrolled follicle puncture for oocyte retrieval. Fertil Steril Vol 44 (5): 656
1983: Transvaginal Oocyte Retrieval Guided by Transabdominal Ultrasound
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Helen Kim
1986: Transvaginal Oocyte Retrieval Guided by Transvaginal Ultrasound
Feichtinger W and Kemeter P, Transvaginal sector scan sonography for needle guided transvaginal follicle aspiration and other applications in gynecologic routine and research. Fertil Steril Vol 45 (5): 722
Helen KimHelen Kim
Transvaginal Ultrasound Guided Retrieval
Davis OK, Rsenwaks Z in Adashi EY et al. Reproductive Endocinology, Surgery, and Technology. Lippincott-Raven, 1996
• Surgical Procedure– Follicle punctured
– Fluid aspirated
– Oocytes collected in tube
Organon Teaching Slide
Van Voorhis B. N Engl J Med 2007;356:379-386
Helen KimHelen Kim
Ovaries on Day of hCG Trigger
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IVF Procedure: 1986
• Ovulation Induction (monitored by ULTRASOUND and estradiol)• Transvaginal ULTRASOUND guided oocyte retrieval • Insemination in vitro• Incubation of the embryo 2.5 days • Transfer of 1 embryo into uterus
– Fertilization: in Fallopian tube– Uterine implantation: Day 5‐6 blastocyst embryo
Helen KimHelen Kim
Ultrasound to Guide Embryo Transfer
• Results– Improve pregnancy and live
birth rate (10 RCT)– May decrease ectopic
pregnancy
• Catheter placement– More than 1 cm from fundus
in upper/middle area of uterine cavity
• Disadvantages– Full bladder– 2nd operator
Mains L, and Van Voorhis, BJ, Optimizing the technique of embryo transfer, Fertility and Sterility, 2010, Vol 94: 785
ASRM Guideline: Performing the embryo transfer, 2017
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Modern IVF Procedure
• Ovulation Induction (monitored by ULTRASOUND and estradiol)• Transvaginal ULTRASOUND guided oocyte retrieval • Insemination in vitro• Incubation of embryos 5‐6 days • Transfer of embryo(s) into uterus (with ULTRASOUND guidance)
• The Nobel Prize was awarded to Robert G. Edwards “for development of in vitro fertilization”
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"Robert G. Edwards - Facts". Nobelprize.org. Nobel Media AB 2013. Web. 18 Nov 2013. <http://www.nobelprize.org/nobel_prizes/medicine/laureates/2010/edwards-facts.html>
Helen Kim
2010: Assisted Reproductive Technology in United States