Echografie in het vruchtbaarheidsonderzoek bij de vrouw

Men and women who desire children aim for a healthy offspring. For a woman, this means an ovulation, successful conception and transport of the zygote along the fallopian tube, implantation in the endometrial cavity, progress of the pregnancy to viability and a safe delivery resulting in a live born child in good health and happy parents. A fertility investigation aims primarily at identifying factors that may affect the couple’s chances for a successful conception and embryo implantation. This work focuses on information concerning female fertility that is obtainable with ultrasonography. With current ultrasound technology available in most gynecological offices and fertility centers, it is possible to obtain reliable and accurate information on many aspects of a woman’s reproductive organs: evaluation of ovulation (ovarian morphology), tubal transport (tubal patency testing), implantation (morphology of the uterus and in particular the uterine cavity, endometrium, endomyometrial junction and myometrium) and pelvic endometriosis. Moreover, an ultrasound examination is relatively cheap, easy to perform from a logistic point of view and not very time consuming, expensive nor invasive compared to other diagnostic modalities. The study populations consist of prospective cohorts of consecutive women attending the Gynecological Ultrasound Unit (head Prof Dr D. Timmerman) of the Department of Obstetrics and Gynecology of the University Hospital Gasthuisberg in Leuven. The women were referred for targeted ultrasound evaluation of ovarian reserve/function, tubal patency, uterine cavity or endometriosis. Women included in this work were referred mostly by fertility specialists of the Leuven University Fertility Center (LUFC) (head: Prof Dr T. D’Hooghe; since 2016 Prof Dr C. Meuleman) or by gynecologists. The studies on contrast sonography of the uterine cavity (GIS) are part of the ‘bleeding clinic’ and the International Endometrial Tumor Analysis (IETA) project, both led by Dr T. Van den Bosch. The Clinical Data Miner (CDM) used for the inter- and intra-observer assessment studies is a KU Leuven project by Ir. A. Installé for web-based standardized data collection. The first chapter recalls some basic principles of medical imaging by ultrasound. It is important to take into account the technical limitations of ultrasound imaging. In women of reproductive age, the point of time in the menstrual cycle and/or the use of hormonal preparations are relevant when interpreting ultrasound images. Inappropriate timing may lead to reduced accuracy, erroneous diagnosis or to inconclusive results necessitating a repeat ultrasound scan. The second chapter is on reporting of ultrasound images. In reporting ultrasound findings, errors in communication can be avoided by using best practice initiatives on what to scan and how to report using standardized terms and definitions as proposed in the IOTA, IETA, and MUSA and IDEA consensus papers. It is equally important to specify the criteria used to define (ab)normality e.g. in CUA or PCOM. An ultrasound examination in the fertility workup is a real-time 2D evaluation of uterine and ovarian morphology and of adnexal and pelvic pathology (e.g. hydrosalpinx, endometriosis). Additional information can be obtained with 3D volume ultrasound and the use of contrast agents. 3D volume ultrasound is particularly useful to assess ovarian and uterine morphology (chapter 3). Coronal images of the uterus are needed for accurate diagnosis of CUA and are useful to assess the uterine cavity (e.g. position of IUCD), endometrium (e.g. polyp) and myometrium (e.g. junctional zone). A 3D volume to assess the number, size and follicle distribution may be particularly useful in multifollicular ovaries. Specific software (e.g. automated volume count, inversed rendering) may reduce examination time, improve inter- and intra-observer agreement and thus reliability of the assessment and improve communication with the patient and with those involved in patient management. Off-line analysis can be used in quality assessment, teaching and training. Contrast enhanced sonography is discussed in chapter 4. Anechoic contrast fluid instilled in the uterine cavity (FIS) improves the detection of congenital or acquired intracavitary lesions. Gel offers some practical advantages compared to saline. Hysterosalpingo-contrast-sonography (HyCoSy) is evaluation of tubal patency with ultrasound. An echogenic contrast agent such as gelfoam (HyFoSy) allows for accurate and reliable non-invasive screening and can replace HSG. An ultrasound-based approach in female fertility investigation is suggested in chapter 5. TV ultrasound allows for accurate assessment of uterine morphology, intracavitary and myometrial lesions, ovarian function and tubal patency. Deep infiltrating pelvic endometriosis and adenomyosis can be detected and mapped and the depth of invasion can be estimated. Finally, women should not be alarmed unnecessarily and/or be subjected to treatment because of ultrasound images only. The clinical relevance of ultrasound findings is to be ascertained and a risk benefit analysis is to be discussed with the patient before setting up treatment.status: publishe