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Handbook of Infertility & Ultrasound for Practicing Gynecologists
Chaitanya Nagori, Sonal Panchal
SECTION 1: INFERTILITY
1:
Counseling of an Infertile Couple
WHEN TO START THE TREATMENT?
COUNSELING FOR SEMEN ANALYSIS
COUNSELING FOR CERVICAL FACTOR
WHAT INFORMATION DO WE GET FROM A NORMAL POSTCOITAL TEST?
COUNSELING FOR UTERINE FACTOR
COUNSELING FOR TUBAL FACTOR
COUNSELING FOR OVARIAN CAUSES
UNEXPLAINED INFERTILITY
COUNSELING FOR IN VITRO FERTILIZATION
Indications
Results
Cost
2:
Hormonal assessment of an Infertile Couple
INVESTIGATIONS FOR THE FEMALE PARTNER
Serum Follicle-stimulating Hormone
Serum Luteinizing Hormone
Serum Estradiol Level (E2)
Serum Progesterone
Serum Prolactin
Galactorrhea with Normal Prolactin Levels
17-OH-Progesterone
Serum Testosterone
Serum Dehydroepiandrosterone Sulfate
Inhibin A and B
Serum Antimüllerian Hormone
Introduction
Physiology
Antimüllerian Hormone and Polycystic Ovary
Antimüllerian Hormone
Antimüllerian Hormone and in vitro Fertility (Table 2)
Insulin Resistance
Thyroid Function Tests
Male Infertility
HYPERPROLACTINEMIA
THYROID DYSFUNCTION
ADRENAL DYSFUNCTION
Endocrine workup
3:
Clomiphene Citrate
INTRODUCTION
MECHANISM OF ACTION
INDICATIONS OF CLOMIPHENE CITRATE
WHO Group II Patients
Luteal Phase Defect
UNEXPLAINED INFERTILITY
CONTRAINDICATIONS
TREATMENT REGIMES
MONITORING
RESULTS
SIDE EFFECTS
Antiestrogenic Effects of Clomiphene Citrate
Risks of Clomiphene Citrate
TREATMENT ALTERNATIVES
Extended Clomiphene Treatment
Clomiphene Citrate + Glucocorticoids
Clomiphene Citrate + Estrogen
Clomiphene Citrate + Bromocriptine
Clomiphene Citrate + Human Chorionic Gonadotropin
Clomiphene Citrate + Gonadotropin
GnRH Agonist
Clomiphene Citrate + Antagonist
Clomiphene Citrate + Metformin
Clomiphene Citrate + Drilling
Clomiphene + Low Dose Aspirin
Prior Treatments
4:
Letrozole
INTRODUCTION
MECHANISM OF INDUCTION OF OVULATION
INDICATIONS
CHARACTERISTICS OF LETROZOLE
ADVANTAGES OF LETROZOLE
DOSES
SIDE EFFECTS (DRAW BACKS)
FUTURE USES
AUTHOR’S VIEW
LETROZOLE + GONADOTROPINS
5:
Gonadotropins
INTRODUCTION
PHYSIOLOGY
FSH Preparations Available (75 IU)
Principles of Gonadotropin Therapy
Physiology of Ovulation
Different Regimes of Gonadotropin Therapy
Indications of Gonadotropins Therapy
Step-up Protocol (Fig. 1)
Step-down Protocol (Fig. 2)
Chronic Low Dose Protocol (Fig. 3)
RECOMBINANT FOLLICLE STIMULATING HORMONE
Introduction
How is rFSH Produced?
Preparations
Properties
Comparison of rFSH with uFSH
Comparison of rFSH with uFSH-HP
rFSH versus Human Molecular Genetics
Facts about Highly Purified Human Molecular Genetics
Different Types of rFSH
FbM Concept (Fill by Mass)
Clinical Benefits of rFSH22
PROTOCOLS FOR ASSISTED REPRODUCTIVE TECHNOLOGY
Gonadotropins in Assisted Reproductive Technology
Individualized Dose Calculation for COS30
Newer Developments
Luteinizing Hormone Supplementation: For Whom, When and Why?
Two Cell Two Gonadotropins Theory
Luteinizing Hormone Threshold
LH Ceiling Effect
Current Opinion
SUMMARY
Stimulation protocol at Bourn Hall Clinic, London
Luteal Support
6:
Intrauterine Insemination
INDICATIONS OF INTRAUTERINE INSEMINATION
Most Common Indications
Other Uncommon Indications
STEPS OF IUI
SUPEROVULATION
Advantages of Superovulation
Conventional Protocol (Fig. 1)
Step-Down Protocol (Fig. 2)
Chronic Low Dose Protocol (Fig. 3)
Letrozole + Gonadotropins
Role of GnRH Agonist and Antagonist
Ultrasound Monitoring and Timing of hCG
Optimal pre-hCG Follicular Parameters (Fig. 4)
Optimal pre-hCG Endometrial Parameters (Fig. 5)
Ovulation Trigger
Timing of Insemination
Double Intrauterine Insemination
Physiology of rupture of follicle
Our Experience on Double IUI
Semen Preparation
Complications
Luteal Support
Our Experiences
7:
Sperm Preparation
INTRODUCTION
COMPOSITION OF SPERM PREPARATION MEDIA
COLLECTION OF SEMEN SAMPLE
Instruments and Equipment Required for Good Sperm Preparation
SPERM PREPARATION METHODS
Simple Washing
Reagents for Swim-up
Swim-up Methods
Density Gradient Methods
Method for Suprasperm
Variations with Other Media
Tips for a Better Yield of Sperms in Gradient Method
Preparation from the Frozen Sample
8:
Luteal Phase Defect
DEFINITION
WHY DOES LUTEAL PHASE DEFECT OCCUR?
Physiological Facts about Luteal Phase1
PATHOPHYSIOLOGY
DIAGNOSIS
Controversies in Diagnosis
THERAPY FOR LUTEAL PHASE DEFECT
Ovulation Induction
Human Chorionic Gonadotropin (hCG) Supplementation
Progesterone
Role of Progesterone
Different Progesterones
Progesterone Vaginal Effervescent Tablets
Advantage of Effervescent Tablet
PROGESTERONE GEL
PROGESTERONE COMBINATIONS
GnRhA as Luteal Support
Why Luteal Support in IVF?
Onset of Luteal Support
Duration of Luteal Support
9:
Ovulation Induction in Polycystic Ovary Syndrome
PRINCIPLES OF TREATMENT
TREATMENT MODALITY IN POLYCYSTIC OVARY SYNDROME
Weight Loss
Clomiphene Citrate
Letrozole
Insulin Lowering Drugs
ESHRE/ASRM 2007 Consensus
Metformin + Gonadotropins
Metformin in In Vitro Fertilization
Metformin after Conception
Metformin Alternatives
Clomiphene Citrate + Glucocorticoids
Gonadotropins
rFSH versus Human Molecular Genetics
rFSH/Highly purified Human Molecular Genetics
Chronic Low Dose Protocol
Can rFSH replace Clomiphene Citrate as a First-line of Treatment?
Antagonist (Fig. 1)
Gonadotropin-releasing Hormone Agonist
Antagonist + Agonist Protocol
Ovarian Drilling
Indications of Ovarian Drilling
PCOS and ART
In vitro Maturation
10:
Medical management of Male Infertility
INTRODUCTION
CRITERIA FOR MEDICAL MANAGEMENT IN MALE INFERTILITY
Case Study
TREATMENT OPTIONS
Specific Therapy
Empiric Therapy
Antioxidants
Vitamin E
Vitamin C
Vitamin B12
Folic Acid
Pentoxifylline
Selenium
Glutathione
Arginine
L-Carnitine and L-Acetyl/Carnitine
Co-enzyme Q 10
Vitamin D
11:
Recurrent Pregnancy Loss
INTRODUCTION
CAUSES OF RECURRENT PREGNANCY LOSS
Anatomical Causes
Congenital Causes
Classification by ASRM
Investigations
Unicornuate Uterus (Fig. 1)
Uterus Didelphys (Fig. 2)
Bicornuate Uterus (Fig. 3)
Septate Uterus (Fig. 4)
Management
Arcuate Uterus (Fig. 5)
Hypoplastic Uterus (Fig. 6)
Management
Acquired Causes (Fig. 2)
Antiphospholipid Syndrome
Etiology
Mechanism of Reproductive Failure in APS
Diagnosis of APL
Treatment
Aspirin
Heparin
Glucocorticoids
Intravenous Immunoglobulin
Thrombophilia
Acquired Thrombophilia
Treatment
Genetic Causes
Place of Fetal Karyotyping in RPL
Role of PGD
Alloimmunity
Immune Response in Normal Pregnancy
Infections and Recurrent Pregnancy Loss
Environmental Factors
Endometriosis
Endometriosis can Act Through
Psychological Causes
Role of Stress
Role of Tender Loving Care
Endocrine Causes
Thyroid
Diabetes Mellitus
LUTEAL PHASE DEFECT
Why Progesterone should be Used?
hCG Supplementation
Hyperprolactinemia and Pregnancy Loss
Polycystic Ovarian Syndrome
Investigations for Recurrent Pregnancy Loss
Carry Home Message for Management of RPL
12:
Practical Tips for Infertility Management
DRUGS
INVESTIGATIONS
PROCEDURES
IVF AND ICSI
USG
PRESCRIPTION
FOR BEGINNERS
SECTION 2: ULTRASOUND
13:
Basic Transvaginal Sonography
METHOD
BASIC PROBE MOVEMENTS
EQUIPMENT SETTINGS
OPTIMIZING THE IMAGE
DOPPLER SETTINGS
Making the Correct Doppler Settings
Artifacts
ORIENTATION, OBSERVATION AND INTERPRETATION OF TRANSVAGINAL SCAN
Orientation
Systematic Assessment of the Uterus
The Endometrium
The Myometrium
The Serosa
The Cervix
Measurements
Adnexa
14:
Ultrasound of Uterine Diseases
CONGENITAL UTERINE ABNORMALITIES
Four Major Disturbances are Causative of Any Müllerian Abnormality
Uterine Aplasia
Unicornuate Uterus
Uterus Didelphys
Bicornuate Uterus
Septate-Subseptate Uterus
Arcuate Uterus
Hypoplastic Uterus
T-shaped Uterus
ON COLOR DOPPLER
VOLUME ULTRASOUND
Fibroids Affect Fertility because of…
ADENOMYOSIS
On Ultrasound
ENDOMETRIUM
ENDOMETRITIS
ENDOMETRIAL HYPERPLASIA
POLYPS
SYNECHIAE
METHOD
ENDOMETRIAL MALIGNANCY
Effects of Tamoxifen on Endometrium
Stages of Endometrial Metaplasia
Endometrial Cystic Atrophy
UTERINE SCAR
CERVICAL LESIONS
15:
Ultrasound in gynecology: Adnexal diseases
OVARIAN LESIONS
Ultrasound Based Classification of Ovarian Lesions
Nonseptated Clear Cysts
Cysts with Internal Echogenecities and No Septae
Solid Lesions
Complex Lesions with Cystic and Solid Areas
TUBAL LESIONS
Pelvic Inflammatory Disease
Ectopic Pregnancies
On Ultrasound
MISCELLANEOUS LESIONS
16:
Cycle Assessment for Infertility Treatment by Ultrasound
INTRODUCTION
BASELINE SCAN
BASELINE SCAN OF OVARIES
US and Doppler features for Polycystic Ovaries
Enlarged Ovaries
Multiple Antral Follicles (2–9 mm)
EVOLUTION OF PCOS
Predominant Hyperechoic Stroma
Sensitivity for diagnosis of PCOS14
Uterus
Preovulatory Scan
Features of a Mature Follicle
Application of 3D US for Follicular Assessment
Features of a Mature Endometrium
Endometrial Grading33 (Figs 16A to C)
Secretory Scan
Luteinized Unruptured Follicle
Luteal Phase Defect
17:
Normal and Abnormal First Trimester Pregnancy
CONFIRMATION OF PREGNANCY
Location of Gestational Sac
Tubal Ectopic
Ovarian Ectopic (Fig. 12C)
Abdominal/Peritoneal Ectopic (Fig. 13)
Early Detection of Multiple Gestation
Growth and Progress of Pregnancy
Gestational Sac (Fig. 15)
18:
Fetal Screening for Chromosomal Anomalies
NEURAL TUBE ANOMALIES
Holoprosencephaly (Fig. 2)
Acrania/Exencephaly and Anencephaly (Figs 3A and B)
Iniencephaly (Fig. 6)
Spina Bifida and Hydrocephalus (Figs 7A and B)
FACIAL ANOMALIES
OCULAR ABNORMALITIES
CARDIAC ABNORMALITIES
ABDOMINAL ABNORMALITIES
Diaphragmatic Hernia (Fig. 13A)
Duodenal Atresia (Fig. 13B)
Omphalocele (Fig. 14)
Gastroschisis (Fig. 15)
GENITOURINARY ANOMALIES
SKELETAL ABNORMALITIES
MISCELLANEOUS ABNORMALITIES
CHROMOSOMAL MARKERS
Nuchal Translucency
Causes of Increased Nuchal Translucency
Significance
The Fetal Medicine Foundation Multicenter Project Report
Limitation
Nuchal Fold Thickness (Fig. 19)
Cystic Hygroma (Figs 20A and B)
Ductus Venosus Flow
Nasal Bone (Fig. 22)
Frontomaxillary Facial Angle (Fig. 23)
Tricuspid Regurgitation (Fig. 24)
Intracranial Translucency (Fig. 26)
Calculating the Risk
Background Risk Factors
Chart of Likelihood Ratios
Biochemical Correlation
19:
Systematic Examination of Fetal Central Nervous System
INTRODUCTION
TIME OF EXAMINATION
EQUIPMENT AND APPROACH
Transabdominal Approach
Transvaginal Approach
METHOD OF TRANSVAGINAL SCAN
IMAGING SPECIFICATIONS
QUALITATIVE EXAMINATION OF THE HEAD
Transventricular Plane
Lateral Ventricles
Cavum Septum Pellucidum
Pathologies Diagnosed on this Plane (Figs 7A to E)
Transcerebellar Plane (Fig. 8)
Cisterna Magna
Dandy-Walker Malformation
Transthalamic Plane (Fig. 10)
STUDY OF THE CEREBRAL VASCULATURE
QUALITATIVE EVALUATION OF FETAL SPINE
QUANTITATIVE ASSESSMENT OF HEAD
Biparietal Diameter
Head Circumference
Ventricular Atrium
Cerebellum
Cisterna Magna
CORONAL PLANES (FIG. 20)
Transfrontal Plane (Fig. 21)
Transcaudate Plane (Fig. 22)
Transthalamic Plane (Fig. 23)
Transcerebellar Plane (Fig. 24)
SAGITTAL PLANES (FIG. 25)
Midsagittal Plane (Figs 26A and B)
FETAL SPINE EXAMINATION IN HIGH-RISK PATIENTS DEMANDS STUDY OF ALL THE THREE PLANES (FIGS 30A TO C)
On Sagittal Plane
Coronal Plane
20:
Fetal Echocardiography for Obstetrician
INTRODUCTION
EQUIPMENT SETTINGS
M Mode Study
EVALUATION OF THE HEART
Deciding the Cardiac Situs
Abnormal Cardiac Situs
Cardiac Position (Fig. 10)
Cardiac Axis
Cardiac Size (Fig. 13)
Rate and Rhythm
STUDY OF INTERNAL CARDIAC ANATOMY
Four Chamber View
Features of Normal Four Chamber
Left Ventricular Outflow Tract
Right Ventricular Outflow Tract
Three Vessel View
Short Axis View
Arch/Longitudinal Views
Fetal Circulation (Fig. 31)
CLASSIFICATION OF CARDIAC DISEASES
Septal Defects
Right Heart Anomalies
Left Heart Anomalies
Conotruncal Defects
Single Ventricle Defects
Other Cardiac Defects
Arrhythmias
21:
Role of Ultrasound in Diagnosis and Management of IUGR
DEFINITION
Classifications
Integrated Classification: By Kurjak 1976
Risk Factors for IUGR
US DIAGNOSIS OF IUGR
Crown Rump Length
Head Measurements (Fig. 1)
Biparietal Diameter, Head Circumference and Cerebral Index
Femur Length and Humerus Length (Fig. 3)
Abdominal Diameter and Circumference (Fig. 4)
HC/AC Ratio
Fetal Organs Biometry
Prediction of PIH and IUGR
Physiology
Silent Period of Increased Resistance
Pathophysiology
Stage of Hypoxemia
Initial Phase
Advanced Phase
Terminal Phase
Aortic Isthmus Flow (Fig. 17)
Obstetric Management Depending on Doppler Findings
22:
USG in Male Infertility
INTRODUCTION
ANATOMY: MALE GENITAL TRACT
US Technique
Normal Appearances on US: Gray Scale (Figs 2A to C)
Varicocele (Figs 3A to D)
USG: Gray Scale
Color Doppler
TESTICULAR ANOMALIES
Testicular Atrophy
Causes
USG
Cryptorchidism (Undescended Testis)
US
Testicular Neoplasms
Malignant Testicular Tumors
US
Benign Tumors
Orchitis
Microlithiasis
Testicular Infarction
Trauma
TRANSRECTAL ULTRASOUND
Technique
Anatomy
Vas Deferens (Fig. 5A)
Seminal Vesicles (Fig. 5B)
Ejaculatory Ducts (Fig. 6)
Prostatic and Periurethral Cysts
Prostatic Inflammation
23:
3D and 4D US in Obstetrics and Gynecology
GENETIC SCAN
Facial Abnormalities
Cranial Abnormalities
Central Nervous System
Spinal Abnormalities
Chest
Abdomen
Limb Abnormalities
Placenta
Limitations of 3D–4D US
Conjoined Twins
Ectopic Pregnancy
GYNECOLOGY
Acquired Uterine Abnormalities
Fibroids
Polyp
Synechiae
Ovarian Lesions
Ovarian Cysts
Dermoids
Infertility
PREOVULATORY SCAN
Follicular Assessment
INDEX
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