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The Role of Ultrasound in Evaluating Female Infertility Chapter 44
Terms in this set (140)
Inablity to conceive after 12 months of unprotected, regular intercourse
Infertility __ months for those 35 years or older
Who and what can cause infertility?
40%female 40% male %20 combined or unexplained
Infertility affects how many couples in the US?
1 in 7 couples
Male factor (decreased number/motility of sperm cells, obstruction)
Female factors for infertility causes:
Cervical factors - stenosis
Uterine factors (myoma, congenital anomalies)
Tubal and transport factors (adhesions, hydrosalpinx)
Anovulation & abnormal ovulation (PCOS)
Male factors for infertility causes:
obstruction of the spermatic ducts or vas deferens and scrotal varicoceles.
Very valuable baseline tool
Ovarian response to various drugs
Development of growing follicles
Timing of hCG injection
Establish normal uterine anatomy and evaluate endocrine indicators, such as thickness and texture of the ________________________, and presence of _____________________or _______________
Monitor the development of the growing follicles, and deteremine the timing of injection of _____ to trigger ovulation
Confirm ovarian response to various drugs (Clomid, Pergonal), or identify _______________________________
hyper stimulated ovaries
Guide______________ retrieval from ovaries
Role of cervix in fertility to provide ___________________________to harbor ______________
Glands that secrete______________ and _______________ that hold sperm
Ultrasound used to evaluate cervical length during pregnancy to assess for _________________________________
The length and opening in the cervix are difficult to asses in ________________________
Can be used to evaluate internal os diameter
Diameter <1 mm by HSG may indicate?
Diameter _____________ by HSG may indicate cervical stenosis
less than 1 mm
Hysterosalpingography, also called
is an x-ray examination of a woman's uterus and fallopian tubes that uses a special form of x-ray called fluoroscopy and a contrast material.
Hysterosalpingography is an x-ray examination of a woman's uterus and fallopian tubes that uses a special form of x-ray called __________________and a ________________material.
Evaluating the uterus two main objectives
Assess structural anatomy
Assess structural anatomy
(1) Assessing for structural anatomy refers to evaluating:
uterine shape (i.e. bicornuate, didelphys, septate, congenital malformations*1% of women)
focus on the congenital anomalies most easily assessed with ultrasound
(septate, bicornuate, and didelphys)
______ and ______ are best suited for evaluating uterine anomalies
US is good at depicting the two endometrial interfaces in the ____________________plane
This finding should alert sonographer to evaluate the pelvic anatomy for two versus one __________and __________
Didelphys or bicornuate uterus is associated with a higher rate of fertility complications such as?
fetal malposition, preterm labor/delivery, and miscarriage.
If pregnancy implants along the septum, the pregnancy may be at an increased risk of failure because of inadequate blood supply from the ________________
For these patients, the septum can be removed _____________________________to improve implantation and fertility success.
When assessing endometrium, evaluate _____________ and _________________characteristics and include evaluation for any ________________________
Thickness of at least ____millimeters appears to represent central threshold for achieving pregnancy
Endometrial appearance important for planning for infertility treatment with?
Endometrium can be evaluated during?
If not enough ___________________ produced in ___________________, endometrial lining may be ___________________ than expected on ultrasound evaluation
Lack of progesterone production known as "__________________________" and may be associated with infertility and early pregnancy loss
luteal phase deficiency
Lack of progesterone production known as "luteal phase deficiency" and may be associated with _________________ and ______________________________
early pregnancy loss
However there is no reproducible, clinically accepted standard to diagnose_______ in order to differentiate fertile from infertile women.
Other things that can make endometrium appear irregular or more echogenic than normal are:
What can be used in these situations to further delineate anatomic structure of endometrium
Saline infusion sonography (SIS)
SIS can demonstrate _______________ and _______________
Fibroids and polyps can potentially impede ________________________
Fibroids tend to have:
A broad base
More isoechoic to the uterine myometrium
Fibroids are more _______________________to the uterine myometrium
Polyps tend to have a uniform ___________________appearance
Polyps tend to have a narrow base attachment to the ___________________________
Polyps tend to have _______________ pedicle feeding them
SIS can also be used to evaluate uterine cavity for ____________________, scars from uterine trauma
What is associated with 50% reduction in pregnancy rate and doubling of spontaneous miscarriage rate?
__________________ assessed by injecting saline/air/contrast agent into tube and looking for spillage of fluid into cul-de-sac or by using contrast to evaluate for spillage
Because of expense of contrast imaging, most centers prefer to start with ________________________to evaluate tube patency
Look for spillage of saline, contrast, or air around _____________ or into posterior ________________
If spillage is seen, _____________is inferred.
If no spillage noted and patient complains of pain during injection, tube may be_______________
What can obstruct a fallopian tube.
A dilated obstructed tube on the left and obstruction of the right?
nondilated obstruction on both sides at the?
Huge bilateral dilation without spill into the peritoneum
During ovarian follicular phase, there are several antral follicles on ovary _______in diameter
Follicle selected to develop into dominant follicle in response to _____
Dominant follicle will grow at rate of approximately __to __mm/day until it reaches average diameter of ___ mm
Once reaching mean diameter of_____mm, dominant follicle will rupture
Sonographic findings associated with ovulation are echoes within fluid left behind (_____________________) or __________________in peritoneal cavity
corpus luteum cyst
Condition that can inhibit release of FSH and LH
PCOS is the condition that can inhibit release of?
FSH and LH
With______, follicles begin to grow but do not develop normally.
PCOS In this syndrome, immature follicles continue to produce ____________________ and __________________
This production of estrogen and androgen inhibits __________________________ function and prevents normal ovulation.
This is due to pituitary gland producing more ____ than ____, which causes follicles to remain in arrested state of development; no mature ova is released
Adhesions and endometriosis
Adhesions are bands of scar tissue that can obstruct fimbriated end of?
Sometimes fluid will collect in between adhesions, resulting in______________________
peritoneal inclusion cyst
Refers to treatment in which ovarian stimulation achieved in controlled setting
Ovarian induction therapy
Obtain baseline TVS of ovaries to rule out ____________________and assess for presence of ___________________
If cyst measuring ____________ detected, could represent _______________________ activity that could interfere with response to _____________________________-
ovarian stimulation medication
The gold standard for evaluating adhesions and endometriosis is_________________________
Women with PCOS may often present with irregular bleeding and a thickened endometrium as a result of the chronic exposure to ______________________.
Because of the chronic elevations of androgens, some women may reveal ______________________
Sonographic findings for PCOS
Round ovary with multiple small immature follicles on periphery
Follicles 2 to 9 mm in diameter
Serum progesterone level of at least ___ ng/ml
What rises just before ovulation and can also be found in the patient's urine.
The degree of openness of a tube, such as a blood vessel or catheter; the relative absence of blockage.
The imaging work-up begins with ______________________________ to evaluate fallopian tube patency.
Hysterosalpingography, also called
is an x-ray examination of a woman's uterus and fallopian tubes that uses a special form of x-ray called fluoroscopy and a contrast material
______________OCCLUSION MOST COMMON CAUSE
Synechiae typically seen on ultrasound as ________________ of tissue extending from one wall of uterine cavity to other
The presence of follicular activity may be further evaluated by correlating the sonographic findings with serum estradiol levels
serum estradiol levels
If elevated, and a large ovarian cyst is present, _____________________________may be indicated to suppress follicular activity before beginning therapy
Comes in tablet form and is used for women who have infrequent periods or long menstrual cycles
Clomiphene Citrate (Clomid, Serphene)
An injectable medication that is used to induce the release of the egg once the follicles are developed and the eggs are mature
Given to patients as an insulin lowering medication. Most commonly used in PCOS, this medication has been shown to reverse the endocrine abnormalities seen with PCOS within 2 - 3 months
Used to lower prolactin levels, and will also help reduce pituitary tumor size, should one be present. Has few side effects and is relatively inexpensive
Ovarian induction therapy usually accomplished by administering _______________________ (Clomid) or human menopausal__________________________
Ovarian induction therapy expected to result in the enlargement of multiple ____________________
Once therapy started, ultrasound used to monitor number and size of follicles in days__ to ___ (______________________phase) of menstrual cycle
Sonographer needs to count and measure all follicles______ in longitudinal and transverse planes
Optimal mean measurement of mature follicle between?
During this time ultrasound can be correlated with serum estradiol levels if follicular growth corresponds with adequate ___ production
Correct measurement of follicles important because ______, substitute for ____, may need to be given intramuscularly to trigger ovulation
Normal response associated with ovarian stimulation is an increasing thickness of_____________to __________________
Thin endo (____________ and abnormal echogenicity = decreased _________________
What is a method of fertilizing human oocyte outside body
In vitro fertilization (IVF)
Mature oocytes collected and mixed in dish with sample of?
Resulting embryos then placed back into the?
Treatment plan for IVF consists of?
ovarian monitoring, needle aspiration of oocytes, incubation of oocytes, fertilization, and transferring embryos into uterus.
Oocyte retrieval accomplished with?
transvaginal ultrasound guidance
Once oocytes received, they are fertilized in a dish and incubated for a few days before transfer into the?
IVF Sonographer first maps out the?
Trace function - trace from ____________ to ____________ of the ______________ to determine length
Optimal placement is considered to be within ____ of the _________of the ____________
Using TA guidance, a catheter is inserted through the cervix and placed within ______of the fundus
Embryos slowly released, and a transfer ___________________ is visible on ultrasound
After embryo transfer, the catheter is checked under a __________________ to ensure that all embryos are transferred.
Technique used to treat male factor infertility
With intrauterine insemination, catheter containing sperm placed into _____________
Sperm preparation may be from donor - Referred to as artificial insemination using donor sperm or?
therapeutic donor insemination
GIFT stands for?
gamete intrafallopian transfer
ZIFT stands for?
zygote intrafallopian transfer
What are modified versions of in vitro fertilization (IVF)
ZIFT and GIFT
The difference between IVF and ZIFT and GIFT is that ZIFT and GIFT fertilized embryo is being transferred into the ________________________ instead of the uterus
Because the fertilized egg is being transferred into the tube it is also called?
tubal embryo transfer (TET)
The main difference between GIFT and ZIFT is that ZIFT transfers a fertilized______________directly into the _____________________while GIFT utilizes a mixture of __________and__________
Complications Associated With Assisted Reproductive Technology
Ovarian hyperstimulation syndrome (OHSS)
More severe cases of OHSS will present with?
leg edema, ascites, pleural effusions, hypotension, polycythemia
Sonographic findings in severe OHSS cases will demonstrate?
enlarged ovaries with multiple cysts, ascites, and pleural effusions
Polycythemia also known as?
Is a disease state in which the hematocrit (the volume percentage of red blood cells in the blood) is elevated
Polycythemia is divided into two main categories;
primary and secondary
Polycythemia can be linked to secondary causes, such as?
chronic hypoxia or tumors releasing erythropoietin.
Polycythemia vera is due to abnormally increased red cell production in the?
Patients who undergo in vitro fertilization at increased risk for having?
multiple gestations - 30%
Concern with multiple gestations that if there are three or more fetuses, increased risk of fetal and/or ________________________ and______________________
Patients who undergo assisted reproductive technologies are at increased risk for?
Patients also at risk for having heterotopic pregnancy:
ectopic pregnancy coexisting with intrauterine pregnancy
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