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4D Ultrasound & Infertility

Hesham Al-Inany, PhD

What is 4D Ultrasound?

4D fetal ultrasounds are similar to 3D scans, with the difference associated with time: 4D allows a 3-dimensional picture in real time, rather than delayed, due to the lag associated with the computer constructed image, as in classic 3-dimensional ultrasound

Uterine cavity assessment

The main advantage of pre cycle assessment using 3D is the coronal view of the uterine cavity to exclude;

Mullerian anomalies Uterine cavity lesions such as submucous fibroids ,

endometrial polyps & IU Synechiae

Do We have to manage Mullerian anomalies before the IVF cycle

All studies available on excision of septum prior to IVF are retrospective no RCS are available ( Bendifallah 2013)

Cochrane review 2013 on;Hysteroscopy for treating subfertility associated with suspected major uterine cavity abnormalities; insufficient evidence.

Mainly for the Obstetric Outcome

High incidence of Preterm Birth in Unicornuate, Septate and Bicornuate uterus

General consensus that fibroids do affect IVF outcome, submucous, intramural & subserous in decreasing order of importance ( decreases live birth rate, and myomectomy increases pregnancy rate by 50%.( somilgliana 2007)

Comparing 3D sonohysterography to Office hysteroscopy found substantial concordance between both techniques with less time of exam and less pain(Negm 2012)

Basal Ovarian Volume and AFC

Ovarian volume calculation

Three D ultrasound is more accurate in determining ovarian volume using the Virtual Organ computer-aided Analysis (VOCAL, GE Kretz) technique .

This technique employs a rotational method which involves the manual delineation of the ovarian volume throughout several planes as the data set is rotated through 180 degrees in a consecutive series of rotations ( angle dependant on number of planes chosen could range from 6 ◦ to 30◦ ) , until a calculated volume is generated

Basal antral follicle count shows 5-11 small follicles < 10mm in diameter .

Number of follicles at the early follicular phase has been reported to be a good test for prediction of ovarian response (Kwee 2007, Jayaprakasan 2008) . All follicles < 10mm are measured using 2D ultrasound in the longitudinal and transverse planes, however 3D techniques are now available for automatic calculation (SonoAVC) (Raine-Fenning 2008).

SonoAVC

A new automated ultrasound software technique has recently been developed which relies on volume calculation using 3-dimensional VOCAL technique and on colour coding of each follicle (SonoAVC, GE ) (Raine Fenning 2008).

A 3D volume is obtained of the stimulated ovary, and using the software will give mean diameter and volume of the hypo echoic areas within the ovary representing the follicles, it will then colour code each follicle differently allowing studying each one separately .

Greater accuracy Quick Reproducible Correlates well with aspirated fluid

volume

The main possible implantation markers that stuided by real time ultrasonography

• Endometrial thickness,• Endometrial volume • Endometrial morphological

patterns.• Endometrial Vascularity :1. Uterine Artery PI2. Endometrial and

Subendometrial Vasculature

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Ultrasound Parameters in Favour of Implantation

> 7 mm

TRILAMINAR > 2ml

PI < 3

FI > 20%VFI > 20 %

Endometrial &subendometrial flow

Using ultrasound imaging in implantation

Optimal conditions of implantation could be:-

Endometrium > 7 mm, Endometrial volume > 2 ml Hypoechogenic endometrium with 3 well

delinated layers, Uterine PI < 3, Presence of sub-endometrial vascular

flow. High VI,FI&VFI in endometrial & sub-

endometrial zone.

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