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Middle East Fertility Society Journal Vol. 11, No. 2, 2006, pp. 96-98 DEBATE The value of 3D ultrasonography in infertility management Comment by: Maged Abdel Raouf Assistant Professor of Obstetrics and Gynecology Faculty of Medicine Cairo University, Cairo, Egypt Code number: mf06018 Infertility affects an estimated 15% of couples or about one in every seven marriages this figure is increasing constantly. Infertility evaluation should be efficient and thorough. There are 2 goals in this respect; a) To determine the etiology and b) to give a prognosis for future fertility. Despite the advances in assisted reproductive technologies (ART), it is important to determine the reason for infertility to provide an appropriate management plan. It must be recognized that not all infertile couples will have the financial, emotional and cultural resources to undergo studies essential for a thorough evaluation. The infertility workup is, after all, elective but the limitations of an incomplete investigation should be explained. Introduction of high frequency ultrasound in medicine had revolutionized the diagnostic accuracy of many gynecological disorders among which infertility is a very evident example. Recently, advances in 3D ultrasound made accurate non-invasive assessment of the pelvic organs feasible. The ability to visualize the oblique or coronal plane allow accurate volume measurement to be made especially of irregularly shaped objects. The basic structural information provided by conventional scans in the longitudinal and transverse planes can now be augmented by the new 3D ultrasound systems that provide an additional view of the coronal plane which is parallel to the transducer face. The computergenerated scan is displayed in three perpendicular planes. Translation or rotation can be carried out it one plane, while maintaining the perpendicular orientation of all three so that serial translation will result in an ultrasound tomogram from which volumetric data can be captured. Clinical applications of 3D ultrasound in infertility work-up:
Many studies have been published that emphasizes the superiority of 3D over 2D ultrasound in the accurate assessment of the previously mentioned aspects of investigation for infertility. Moreover the potential benefits of 3D ultrasound during IVF and ICSI programs are not questioned for example it can be of great value in the following occasions: -Assessment of uterine cavity before the procedure to exclude any pathology which may interfere with implantation after transfer or lead to early abortion. -Accurate assessment of the follicles during stimulation to select the mature ones. -Performing aspiration of the follicles under 3D ultrasound guidance which gives better results than 2D ultrasound. Also 3D ultrasound can be of help in diagnosis of some conditions which can affect fertility as ectopic pregnancy and pelvic inflammatory disease Uterine anomalies Uterine anomalies are associated with an increased risk of repeated first and second trimester abortion and preterm delivery. A meta analysis of published retrospective data indicated a marked improvement after hysteroscopic septoplasty. As many as 24% of women with recurrent pregnancy loss may have uterine anomalies. Three dimensional ultrasound offers 100% specificity for exclusion of uterine anomalies and is able to differentiate between different anomalies (1,2). Intrauterine pathology La Torre et al. (3) compared 3D ultrasound with conventional imaging with and without saline contrast in 23 patients in whom subsequent hysteroscopy had revealed the presence of 16 endometrial polyps. 2D ultrasound demonstrated a relatively poor specificity of 69.5%. This was improved to 94.1% when 2D was used with saline infusion. 3D revealed a specificity of 88.8% and then 100% when combined with saline infusion. Similar results were shown by Sylvestre et al. (4). Polycystic ovaries Several groups have used 3D ultrasound to demonstrate that ovarian volume and vascularity are increased in PCO. 3D also allows for the measurement of the stromal volume through the calculation subtraction of total follicular volume from total ovarian volume. Using this technique Kyei Mensah et al. (5) showed that stromal volume was positively correlated with serum androstenedione concentrations in 26 women with clinical evidence of PCO. However, using a similar approach Nardo et al. (6) were unable to demonstrate any relation between serum FSH, LH or testosterone and ovarian stromal volume in 23 infertile women with PCO. Tubal patency Kiyokawa et al. (7) found 3D saline sonohysterosalpingography was able to demonstrate the entire contour of the uterine cavity in 96% of cases compared to only 64% cases with conventional X-ray hysterosalpingography and was associated with a positive predictive value and specificity of predicting tubal patency of 100%. In 25 unselected infertile patients. Sladkevicius et al. (8) found 3D power Doppler imaging demonstrated free spill almost twice as often as conventional imaging when used during hysterosalpingography-contrast sonography. Assisted reproduction treatment Ultrasound is used to monitor the response to controlled ovarian stimulation and to guide the trans-vaginal collection of oocytes and subsequent transcervical transfer of embryos to the uterus. 3D U S may be used in all of these areas but has largely been applied as a predictor of ovarian response or ovarian reserve and as a determinant of endometrial receptivity. Three dimensional markers of ovarian reserve The mot important three markers predictive of ovarian response addressed by 3D U S are antral follicle counts, ovarian volume and ovarian blood flow. Three dimensional markers of endometrial receptivity These include endometrial thickness, volume and endometrial vascularity Procedures Three dimensional ultrasound gave a good results in transvaginal needle aspiration of follicles and in embryo transfer to the uterus transcervically. On the other hand, there is the problem of the high cost of the examination which represents another load over the infertile couple. So the logic question is it necessary to do this expensive test for infertile women? The answer looks difficult in view of the previously mentioned relatively higher diagnostic accuracy of the 3D US over other conventional methods. But it seems prudent to stress over some points in this respect; Firstly; 3D ultrasound examination should not be among the routine fertility workup; Secondly; to do the test there must be a preliminary 2D scan which showed an abnormality or proved to be inadequate for definite diagnosis so a 3D scan could be of help in reaching a diagnosis (i.e. for conditions diagnosed clearly by conventional methods no need to proceed for 3D examination with its extra cost). Thirdly; this policy can be changed in occasions of sophisticated reproduction assisted techniques as ICSI, for better results as the procedure itself is much costly than the 3D examination. Fourthly; every case should be studied individually to determine the most suitable tests for this particular situation and whether 3D ultrasound will be of value in such condition or just an extra financial load. REFERENCES
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