Basics of tvs color doppler
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Dr. Poonam Loomba, a renowned expert in infertility and assisted reproductive technology (ART), highlights the importance of transvaginal ultrasound (TVS) in managing infertility, particularly in reproductive medicine and IVF procedures. The document outlines the technical aspects of TVS, including its advantages, limitations, and applications in assessing endometrial receptivity and follicle maturation. Additionally, it covers various doppler techniques and their relevance in evaluating blood flow, which is crucial for predicting the success of ART cycles.
Basics of tvs color doppler
- 1. Chairperson: Haryana Chapter Of ISAR ,2011-2015 Executive member ISAR 2016-2017 Associate RCOG Director: LOOMBA HOSPITAL AND IVF CENTRE , Ambala Cantt. HARYANA since 1988 Ex consultant at central hospital ,Arar, Saudi Arabia Ex senior resident Ganga Ram Hospital New Delhi. Graduate from GOMCO ,Patiala.1985. Awards: President’s gold medal at university level. Affiliations: ASRM,RCOG,FOGSI,ISAR,ACOG,,IAGE, ASPIRE,Foetal Medicine Foundation regular attendee at many national and international conferences. Achievements: First IVF/ART centre in haryana in 2003 Trained at CLEVELAND CLINIC U.S.A in IVF/ICSI Trained at HARVARD in advanced ultrasound in fetal medicine Advanced laparoscopy training at Kiel, Germany. Specialised : Infertility/ART, Fertility related Fields Laparoscopic surgeries, Fetal medicine Recurrent pregnancy loss www.loombahospital. com Dr.Poonam Loomba M.D. loombapoonam @gmail.com www.loombaivf.com
- 2. Basics of TVS and Colour Doppler Poonam Loomba ,M.D. Director and Consultant Loomba hospital and IVF Centre
- 3. TVS • Most important tool in management of infertility at each step. • The image resolution and magnification is as if we are looking at organs through a microscope. • Easy to perform • Cost effective for patient • Reliable • Non invasive • Patient friendly
- 5. Revolution in ultrasound • A Mode • B Mode ......1963 by Campbell • Static scan • Real time imaging • Computed Sonography • Transvaginal sector probe.....1983 • Colour Doppler .....1985 • 3D /4D .....1990 • The advent of TVS transformed reproductive medicine especially the monitoring and procedures associated with IVF.
- 6. Stated that any directional motion between a light source and observer would produce a shift in frequency or change In colour. This principle is now used as the basis for blood flow studies . Christian Doppler
- 10. Types of doppler and waves • Colour doppler • Power doppler • Spectral doppler • Continuous wave doppler • Pulse wave doppler
- 12. Power doppler
- 13. Spectral doppler
- 15. Learning objectives Display and discuss the basics of TVS in infertility and ART Use of colour and doppler in predicting success of ART. Special reference shall be made towards the significance of markers to evaluate endometrial receptivity and follicle maturation .
- 17. What should the mind know? • Anatomy, physiology and haemodynamics of reproductive organs. • Pathophysiology of diseases/anomalies as a cause of infertility. • Physical principles of color and doppler . • Your Ultrasound machine. • The limitations of ultrasound in the infertility evaluation.
- 18. Baseline scan in infertility Best done in the early follicular time to avoid distortion of ovarian volume caused by growing follicle High frequency probe with trans vaginal approach is used. Use a systematic approach Empty bladder Watch as you are placing the transducer Look at the bladder,and cervix(length and location Cervico uterine angle Uterus:Orientation,size,endometrial thickness Ovaries:location,size,and number of follicles . Document and save your findings electronically. .
- 19. Base Line Scan
- 22. Length of cavity and C/U angle
- 24. Adenomyosis
- 25. Normal Parameters • With 2D Uterus can be studied n Sagittal and Transverse planes. • Body of uterus to cervix ratio is 2:1 • Uterus is deviated to Rt Or Lt. Its Orientation depends upon fullness of bladder and rectum. • Uterus can be divided into endometrium,myometrium and serosa. • Normal texture of myometrium is homogenously echodense.
- 26. Assessment of uterine cavity Shape of uterine cavity Intracavitary lesions Endometrio myometrial junction Endometrial receptivity
- 27. Assessment of uterine cavity Greatest advantage of 3D is coronal section.
- 28. Differential diagnosis of congenital duplication abnormalities of uterus like bicornuate, septate and arcuate is based on external fundal contour and contour of the endometrial cavity.
- 29. Structural Uterine anomalies Seen in 4 % women with infertility and 15% with RPL
- 30. Normal shape of the uterine cavity... SEROSAL FUNDUS ENDOMETRIAL FUNDUS
- 31. Unicornuate uterus: normal shape in long section deviated Hypoplastic 2nd horn : sometimes Unicornuate Uterus
- 33. Endometrial polyp More echogenic than myometrium Isoechoic with endometrium Sessile or pedunculated Single feeding vessel
- 34. Intra uterine adhesions • Asymmetry of endometrial echo • Areas of endometrium <2mm • Echogenic area in the uterus • TVS sensitivity is 52% • TV SIS is 93.5 to 99.% accurate.
- 35. Submucous fibroids –grading : to decide the route of surgery • T0- whole in endometrial cavity • T1 - >50% in endometrial cavity • T2- < 50% in endometrial cavity
- 37. Saline infusion sonohysterography More image than imagination May be as effective as hysteroscopy in detecting intra cavitary abnormalities More cost effective and simple to perform
- 38. SIS:- 20ML Normal saline is instilled using pediatric foley catheter no.8
- 40. Sono hystero salpingography • Saline • Saline +Air :Shake before injecting • Gray scale • Colour • Contrast media :Echovist,Sono Vue • 3d Power doppler
- 41. Colour doppler for tubalpatency
- 42. Alternative to sonohysterogram • Consider doing ultrasound in luteal phase. • Endometrium is hyperechoic and acts like contrast medium. • Add 3D image.
- 44. The high incidence of cavitary abnormalities and the potential improvements in pregnancy outcomes after hysteroscopic surgery highlights the importance of cavitary assessment
- 45. Intact regular endometrio-myometrial junction is an important sign of a healthy endometrium.
- 46. Junctional zone is damaged in • Endometritis: acute or chronic • adenomyosis
- 48. Endometrial receptivity 30% of embryos transferred result in clinical pregnancies .Fault may be in the embryo or the implantation bed. Thickness Pattern Blood flow to the endometrial and subendometrial zone Volume
- 49. Normal endometriumMeasuring endometrial thickness
- 50. Endometrial thickness • Increases from 4.6mm to 12.4mm on the day of LH surge. • Average increase is 1 to 2mm per day in proliferative phase. • Decreases by 0,5mm on the day of LH surge increasing again by 2mm in luteal phase.
- 51. CC vs HMG/FSH • Following the days CC is taken the ET is often decreased the effect lasts no more than 3-4 days after last dose. • In late follicular phase it escapes antioestrogenic effect and increases faster. • With HMG and FSH it is greater than in spontaneous cycles. • No pregnancies were seen when ET was <6mm on the day of hcg. • Biochemical pregnancies were pbserved more in ET <9mm or >13mm. • It is advisable not to start OI if postmenstrual ET is 6mm or more.
- 52. Thin endometrium indicating low estrogenic state
- 53. Periovulatory endometrium: once the EM echo is well visualized use as much magnification as possible
- 55. Endometrium in PCOD No Triple line
- 56. Endometrial waves • In 73% a wave direction switch occurs from fundus to cervix and cervix to fundus before OPU (fertil steril 1999) • The persisting waves until HCG predict a favourable outcome • In a validation prospective study it was not confirmed if waves improved pregnancy outcomes(fertil steril 2005) • Two more wave types are recoiling CF wave and a standing wave.(fertil steril2007)
- 59. Uterine artery doppler • High peak systolic flow • Very little end diastolic flow • Varies with age and phases of menstrual cycle. • RI is 0.88 until day 13 of ovulation. • During ovulation there is increase in RI • In late luteal phase around implantation window lowest impedance is seen. RI is 0.77 • 2D doppler detects blood vessels but 3D doppler studies morphology of vascularization and neovascularization.
- 61. Blood flow • With the more sensitive colour doppler and power doppler it is postulated that local vascularization at the site of implantation is more important than global vascularization of the uterus measured by RI in the uterine arteris. • RI of spiral arteries is 0.55. • EPDA is defined as a part of endometrium where vascular signals with velocities >5cm/sec are detected. • Lower IR and PR are seen when EPDA is <5cm/sec. • VI,FI and VFI in the subendometrial zone.VFI has 93.8% positive predictive value of predicting positive pregnancy outcomes
- 63. PROLIFERATION OF SPIRAL ARTERIES AND SUBSEQUENT ENDOMETRIAL “INVASION” ZONE I -- Only Myometrial Vessels Surrounding the Endometrium are Visualized. ZONE II – Vessels Penetrate Through the Hyperechogenic Endometrial Edge. ZONE III – Vessels reach the internal endometrial Hypoechogenic Zone. ZONE IV – Vessels reach the Endometrial Cavity. Deeper the vascularization noted better the outcome.
- 66. Endometrial power doppler area
- 67. Endometrial volume by 3D by virtual organ computer aided analysis software
- 68. Significance of endometrial volume • Endometrial and subendometrial vascularity are significantly lower in patients with endometrial volume <2.5 ml • In IVF/ICSI cycles endometrial volume and Power doppler indexes are statistically significant in predicting the cycle outcome with SET. (Fertil.Steril 2008 jan 89) • Lower PR are seen with EV <2.0 cm3 and no pregnancies seen with <1.2cm3
- 70. Ovaries • Ovarian volume and AFC ….measures of ovarian reserve • PCOD • Ovarian masses • Ovulation studies with series of scans
- 71. AFC • AFC in both ovaries . • <5 • 10-15 • >15
- 72. D/d of ovarian masses:most are benign in women of reproductive age Physiologic • Follicular • Simple • Corpus luteum Pathologic Endometrioma Mature cystic teratoma Borderline Malignancy We recommend further evaluation of the mass prior to stimulation(repeat US ,LAPROSCOPY
- 73. Haemorrhagic cyst Endometriomtic cyst
- 74. Ovarian volume • Volume is affected by cigarette smoking OCP age and cysts • Superior to day3 FSH • Small volume predicts fewer follicles and low PR independent of age(syrop 1999) • Large volume>10ml is associated with increased OHSS.(10% TO 23.5%)
- 75. • Polycystic ovarian morphology has been found to be a better discriminator than ovarian volume between polycystic ovarian syndrome and control women. Legro, et al, JCEM 90(5): 2571-79.
- 76. What is specific in PCO morphology… • Multiple antral follicles • Distribution of antral follicles • Stromal predominance • Stromal vascularity
- 78. OVARIAN STROMAL BLOOD FLOW • PSV > 10cm/sec AFTER PITUITARY SUPRESSION • Stromal ri < 0.41 : 2/3rds WILL GET OHSS • Stromal pi < 0.75 : 1/2 will get pleural effusions
- 81. Kupesic has shown correlation in the ovarian stromal flow index and number of mature oocytes retrieved in an IVF cycles and pregnancy rates. Stromal FI ( < 11 low responder, 11 -14 good, > 15 risk of OHSS) Hum Reprod 2002; 17(4) : 950 - 55
- 82. Sono AVC
- 83. • Using inversion mode to render the volume shows all the follicles as solid structures. • This makes their definition very clear and are easy to count.
- 84. 3 D Inversion Tecnology
- 85. Follicular study • Number of scans depend upon the response of the patient • Hcg is delayed till majority reach maturation • Eggs can be retrieved from as small as 14mm and as large as 24mm. • Decreased quality of oocytes from follicle 24mm.> • No difference in quality of oocytes from follicles 18-22mm in size.
- 88. PERIFOLLICULAR VASCULARISATION • GRADE 1 < 25% • GRADE 2 < 50% • GRADE 3 < 75% • GRADE 4 > 75%
- 89. FOLLICULAR PARAMATERS A.PERIFOLLICULAR VASCULARIZATION. B.PERIFOLLICULAR RI 0.4 – 0.48 C.FOLLICULAR PSV > 10 CMS/SEC Diameter predicts maturity and perifollicular vascularization predicts the quality of oocyte at retreival
- 90. DECIDING THE TIME OF HCG ?
- 91. This consisted of Follicular volume Visualization of cumulus Perifollicluar VI Perifollicular FI Perifollicular VFI
- 92. Follicular volumes of between 3 – 7 cc are optimum for oocyte retrieval . The limits of agreement between the volume of the follicular aspirate and 3D volume of the follicle were + 0.96 to – 0.43 with 3D and + 3.47 to – 2.42 by 2D volume estimation. Follicular Volume
- 93. On the day of HCG – If cumulus like echoes is not seen in all three planes in the follicle , it is less likely to be mature fertilizable oocyte. cumulus
- 94. Oocyte Retrieval • Standard IVF retrieval • Transvaginal probe 5- 9 MHz • 16-17 gauge needle • Empty bladder before starting procedure
- 95. Ultrasound guided ET • Full bladder for TAUS • Assistant to • Usually soft catheter is used • Confirm position of loaded catheter • Place embryos in middle part of uterine cavity . • Confirm for the fluid bubble in the cavity.
- 96. Limitations of ultrasound • Minimal and mild endometriosis • Flimsy pelvic adhesions • Some tubal abnormalities. • But we can use the probe actively during exam to assess the mobility of pelvic structures in relation to each other.This gives us an idea of whether or not there are adhesions.
Editor's Notes
- #8: There are significant differences between Grayscale, or B-Mode imaging, and Doppler imaging. IN the B-Mode image above, strong echo reflections cause pixels to be displayed on the image. The differences in strength result in varying shades of gray being displayed. In Doppler imaging, on the other hand, frequency changes cause the pixels within the image to be colored. The differences in frequency result in different colors being displayed. What do the colors mean, I will explain as we go.
- #12: The actual Doppler concept is the the same as the plane, when the transmitted sound wave from the transducer strikes a blood cell, echoes are emitted. When moving away, the echoes are stretched, and when moving towards, the echoes are compressed. Doppler instruments measure this change in frequency in order to determine velocity.