Fertility Ultrasound helps determine if the uterus, tubes and ovaries are normal.
For patients trying to get pregnant, evaluation of the pelvic organs by imaging techniques remains an important part of the work-up. There are four basic methods, transvaginal ultrasound (TVS), hysterosalpingogram (HSG), fluid ultrasound (FUS) and hysteroscopy. Each of these four methods has advantages and disadvantages, and therefore the needs of the patient should determine which tool is utilized. In certain cases, additionally one might need an MRI which is a special interest of Dr Batzofin.
All methods are utilized the after the period and before ovulation in order to avoid interference from intrauterine blood clots, and an early intrauterine pregnancy Scheduling these tests is best from day 7-12 of the cycle for most women.
Transvaginal ultrasound is routinely used in the initial evaluation of the infertile patient and provides information about diseases such as ovarian cysts, dilated tubes uterine fibroids, large endometrial polyps, and birth defects of the uterus. Advantages of TVS are that it is a well tolerated, radiation-free method which provides information on the size and position of the uterus, and tubo-ovarian diseases. The disadvantages of TVS are its limited accuracy in diagnosing abnormalities of the endometrial cavity and tubal pathology. The average cost of a TVS ranges between $150-450.depending on the extent of the study. It is important to keep in mind that endometrial polyps can be hormone dependent lesions. Accordingly, they may be present but non-expanded and therefore, not show up during periods of low hormonal stimulation, only to ‘rear their ugly head’ during the time of maximal stimulation in a cycle.
TVS should be routinely used for women having difficulty trying to conceive but needs to be supplemented by one of the other methods to gather more information about status of the fallopian tubes and the endometrial cavity.
HSG or Hysterosalpingogram
HSG (Hysterosalpingogram) is the traditional method used in the evaluation of the infertile patient and provides extensive information about the endometrial cavity as well as the fallopian tubes. Advantages of an HSG include evaluation of the endometrial cavity with high sensitivity (i.e. presence of myomas, polyps, intrauterine adhesions, congenital anomalies), the fallopian tubes (i.e. proximal or distal block, presence of tubal rugae, adhesions), and the possibility of a spontaneous pregnancy following the procedure.
The disadvantages s include the risk of infection (1-3%), abdominal pain, radiation exposure (very low) and inability sometimes to distinguish a polyp from a fibroid tumor. Water or oil based contrast material can be used to perform an HSG, and is a topic of debate regarding the advantages and disadvantages of one over the other. Results of a meta-analysis that included 6 randomized and 6 non-randomized clinical trials concluded that oil based media can have a therapeutic value (1).
There is a measurable increase in the ability to conceive in the month or two after the test. in the meta-analysis, but this was not confirmed in a larger study.(2).). Today most centers use water based media which is thought to give improved images of the uterus compared to the oil-based media. The average cost of an HSG is between $600-800.
HSG should be preferred when information about tubal patency is needed, such as a high risk patient for tubal disease, infertility treatment that may involve intrauterine inseminations, any suspected pelvic pathology such as endometriosis, and IVF candidates that carry the risk for having hydrosalpinges. Its high sensitivity for detecting intrauterine pathology makes it a useful tool for evaluation of the endometrial cavity. FUS could be used prior to IVF in a patient at low risk for tubal disease, proven fertility or someone who has had a recent laparoscopy providing information about her tubal status. FUS performed with the use of new three-dimensional ultrasound machines may also be useful in differentiating between uterine congenital abnormalities (septate vs. bicornuate uterus).
Typical Findings on HSG
|Figure 1. Normal uterus and tubes||Figure 2. Hydrosalpinx or fluid filled tube blocked at the end near the ovary|
Fluid Ultrasound (FUS)
Fluid ultrasound (FUS) involves saline injection into the endometrial cavity and simultaneous transvaginal sonography to visualize the endometrial cavity. This test provides information about the pathological lesions in endometrial cavity (i.e. myomas, polyps, adhesions, and congenital anomalies) as well as limited information on tubal patency. Fluid in the cul-de-sac during the procedure suggests tubal patency, but whether one or both tubes are patent can not be determined. For intracavitary lesions it has the accuracy comparable to hysteroscopy, which is considered the gold standard.
Advantages of fluid ultrasound in infertility evaluation include low infection risk, easy tolerability and the lack of need for anesthesia. Disadvantages are the lack of comprehensive evaluation of fallopian tubes and the need for a second procedure such as hysteroscopy if an intracavitary lesion is suspected. Average cost of a fluid ultrasound can range from $750-1000 including the office visit.
Examples of fluid ultrasounds
|Figure 1 Normal cavity||Figure 2. Intrauterine fibroid which also resembles a polyp|