Middle East Fertility Society Journal Middle East Fertility Society ISSN: 1110-5690 Vol. 11, Num. 2, 2006, pp. 93-96

Middle East Fertility Society Journal Vol. 11, No. 2, 2006, pp. 93-96

DEBATE

The value of 3D ultrasonography in infertility management

Comment by: Mona Aboulghar, M.D.

Assistant Professor of Obstetrics and Gynecology Faculty of Medicine Cairo University, Cairo, Egypt

Code number: mf06017

Ultrasound examination of any patient performing an infertility workup is an integral part of the management. This is always done by 2D transvaginal ultrasound. It allows proper examination of pelvic organs; uterus, ovaries and possibly tubes. In the last decade 3 D ultrasound has been extensively developed and applied and the field of it’s use has broadened. There is a strong prediction among workers in the field of ultrasound that in the near future every gynecology clinic will have a 3D ultrasound machine available.

Is there a real need to examine every infertility case using 3D ultrasound?

What are the definite advantages of 3D imaging over 2DUS?

 

* Probably the most important is the ability to obtain the 3 orthogonal planes of the structure examined, of which the coronal view is the most important to obtain, especially when examining the uterus. This view is essential for assessing the external uterine contour (of the fundus), to diagnose uterine anomalies. In addition determine exact site of lesions such as fibroids and polyps ( in relation to endometrium).

 

* 3D Volume calculations are possible to be made and have been shown to be reproducible (1). This has been proven to be of value in prediction of IVF outcome by measuring endometrial volume prior to ET as compared to endometrial thickness (2).However was found of no predictive value by other authors (3). Similarly 3D Endomerial volume measurement has been proven to be reproducible (4). Endometrial volume calculation as compared to endometrial thickness has been found superior in detection of endometrial carcinoma (5).

 

* The ability to store images obtained (3D volumes and cine loops) and manipulate them later going through lesions thoroughly and confirming the diagnosis (as polyps or submucous fibroids), without keeping the patient.

Clinical applications of 3D ultrasound imaging

Assessment of the uterus:

Uterine anomalies: several studies have shown the accuracy of 3D imaging in proper diagnosis of the type of uterine anomaly in comparison to x-ray HSG (6,7). This is mainly due to the ability to visualize the coronal section of the uterus and the fundal contour especially important in lateral fusion defects. This has been found to be enhanced with injection of saline (3D sonohysterography) (8). The procedure of sonohysterography is a very simple office based technique and provides immediate information which in many situations could obviate resorting to hysteroscopy (9).

The use of sonohysterography both in 2D & 3D examination has been proven to increase the sensitivity and specificity of detection of polyps, myomas and mullerian anomalies (10),(found to be higher with 3D US).

Comparing 3D sonohysterography with hysteroscopy in the diagnosis and classification of submuous fibroids showed a high agreement between both methods (92%) for fibroid polyps and submucous fibroids with <50% extension into the myometrium, this was less with submucous fibroids with >50% extension into the myometrium (11).

A large proportion of infertile patients are found to have associated fibroids, it was found that 1-2.4 % of infertile patients without any obvious cause of infertility had fibroids (12) and it is known that fibroids could have an impact on pregnancy rates and miscarriage rates whether in natural conception cycles or IVF cycles(13, 14,15).

Lev-Toaff (7) compared three techniques; 3D SHG with 2D SHG and x-ray HSG, 3D SHG was superior to the other two techniques, especially in visualizing polyps, fibroids, and adhesions as well as uterine malformations.

Kupesik and Kurjak (16) compared 2D US, TV colour Doppler, 2D sonohysterogrophy and 3DUS in evaluation of septate uterus prior to hysteroscopic removal. The sensitivity and specificity of 2D SHG and 3D US was highest ( 98% and 100 % ).

The ovaries:

Assessment of ovarian volume is known to be of value in predicting response to induction ovulation drugs and assessing ovarian reserve(17,18).This of course can be done using 2D, however volume calculation of irregular structures are best done using a reproducible method as 3D (19). Lass suggested that a mean ovarian volume of <3cm is a predictor of poor response to gonadotropins.

Kupesic and Kurjak (20) using 3D US analysed antral follicle count, ovarian volume and stromal area by studying data stored from 56 patients enrolled and IVF ET cycle. In addition using power Doppler, Flow index (FI) was calculated by a computer program built in the 3D machine (flow index gives an idea about blood flow in the outlined area). Total antral follicle count achieved the best predictive value for favourable IVF outcome, followed by ovarian stromal FI, peak E2 on day of HCG, total ovarian volume, total ovarian stromal area and age. Antral follicle count was correlated well with FI indicating higher stromal vasculartiy and thus higher perfusion. The advantage of such examination is that it is short, less time consuming as all calculations could be retrospectively analysed by studying stored data. Calculation of follicular volume (21)is an additional option when volumes of ovaries are stored, however it still remains to determine the optimal follicular volume correlated with the best IVF ET outcome.

Poehl (22) suggested that cumulus could be visualized by 3DUS and could be an indicatior for mature oocytes and successful fertilization, Follicles in which the cumulus could not be visualized in all three planes were unlikely to contain mature oocytes.

Fallopian tube assessment:

Assessment of tubal patency is classically always started by x HSG, this has been recommended by the NICE guidline to be used for screening of tubal occlusion, and is reliable in detecting proximal tubal occlusion (23).

With the broadening of application of transvaginal US, assessment of tubal patency hysterosalpingocontrast-sonography has been proven to be feasible with similar results to HSG (23). Two-dimensional hysterosalpingo-contrastsonography, as a screening test for tubal patency for subfertile patients, is limited by the difficulty in visualizing the entire Fallopian tube owing to its tortuosity. This major disadvantage can be overcome by means of the three-dimensional hysterosalpingocontrast- sonography (3D-HyCoSy).Chan et al (24) compared the efficacy of 3D-HyCoSy with diagnostic laparoscopy and its feasibility as a screening test for tubal patency. The sensitivity of 3D-HyCoSy for detecting tubal patency was 100% with a specificity of 67%. The positive and negative predictive values were 89 and 100%, respectively; the concordance rate was 91%. These results have been proven by other authors as well (25) and have been disagreed upon by other authors (26).

Color and power Doppler imaging

Power and Doppler volumes can give estimation of blood supply to a given area. This can be applied clinically in IVF patents in the late follicular phase Jarvela (27) studied ovarian blood flow and found the volume of flow to be higher in the dominant ovary.

Endometrial and subendometrial blood flow has been studied as well by many authors (28).

The advantages of 3D power Doppler is to demonstrate and quantify total endometrial and uterine blood flow. It was found to be significantly reduced in patients with unexplained infertility (29) and also to be negatively correlated to estradiol concentrations in IVF cycles (30).

Lastly it remains to point out that technical problems with 3D imaging are similar to those for 2D acquisition, patient habitus, shadowing artifacts, and experience in 2D scanning.

To obtain good 3D images and good 2D image has to be attained first.

CONCLUSION

3D US definitely carries many broad applications in it’s use, however still to be investigated and studied and compared to 2D to confirm it’s superiority and necessity in investigating infertile females.

REFERENCES

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