Transvaginal sonography of the uterine cavity with hysteroscopic correlation in the investigation of infertility.

This report describes the correlation of hysteroscopic findings with preoperative transvaginal sonography in 200 patients being investigated for infertility. Real-time ultrasound examination was performed on days 7, 14 and 21 in spontaneous ovulatory cycles. Diagnostic hysteroscopy was performed in the subsequent cycle. The abnormalities detected using transvaginal sonography were intrauterine adhesions, submucous fibroids, endometrial polyps, endometritis and a non-specific irregular endometrium. A total of 182 patients were diagnosed correctly to have an abnormality by transvaginal sonography giving a false-positive rate of 5.5%. The sensitivity of transvaginal sonography in detecting endometrial pathology was 98.9% with a positive predictive value of 94.3%. The positive predictive values for specific abnormalities were 98.5% for intrauterine adhesions, 91.7% for submucous fibroids, 91.4% for endometrial polyps, 85.7% for endometritis and 85.7% for irregular endometrium. These data show a strong correlation between findings from transvaginal sonography and hysteroscopy. Transvaginal sonography may be used to detect intrauterine pathology and identify patients in whom hysteroscopy and hysteroscopic surgery are indicated.

Decreased uterine perfusion--a cause of infertility.

There have been several causes of infertility attributed to gamete quality, congenital anatomical abnormalities and surgical complications. Published research into the reasons for failure of implantation of embryos has been confined to histochemical and histological studies of the endometrium. This paper presents preliminary data from an ongoing study to test the hypothesis that poor uterine perfusion is a cause of failure of implantation of embryos. It would follow that poor uterine perfusion is a cause of infertility. One-hundred-and-fifty-three patients who had been unsuccessful in conceiving despite three previous in-vitro fertilization attempts have been studied. Doppler ultrasound studies of the ascending branch of the uterine artery, during spontaneous ovarian cycles, revealed a poor mid-secretory uterine response in 48% of patients studied. Patients with poor mid-secretory uterine response were treated with orally administered hormone therapy to improve the mid-secretory uterine response prior to subsequent embryo replacement. The results of subsequent in-vitro fertilization therapy in patients with good uterine response and in women with improved uterine response after hormone therapy are presented. The numbers of patients in each group are insufficient for statistical analyses, but the trends observed support the hypothesis that poor uterine blood flow is a cause of infertility. Further evaluation is warranted.

Doppler ultrasound studies of the uterine artery in spontaneous ovarian cycles.

Doppler studies of the uterine artery using an off-set Doppler transducer with a mechanical sector imaging transducer indicate clear changes in uterine perfusion during the ovarian cycle. In this study, 16 volunteers had Doppler studies performed at least twice weekly during spontaneous ovarian cycles. Endocrine assays were performed on each occasion to measure plasma oestradiol, progesterone and luteinizing hormone levels. Conventional criteria to assess uterine impedance using systolic/end diastolic ratio and Resistance Index were modified to obtain meaningful results and a new flow velocity wave form classification is presented. The results indicate increasing uterine perfusion with rising levels of plasma oestradiol and progesterone and a direct correlation with falling oestrogen levels in the follicular phase. We conclude that off-set mechanical sector duplex systems can be used effectively to monitor uterine responses to the hormone environment.

Ovarian size in postmenopausal women.

Ovarian volumes have been determined by pelvic ultrasonography in 2246 apparently healthy postmenopausal women of whom 2221 were included in the statistical analysis. Factors associated with gonadal size have been identified, and reference ranges for derived indices have been determined for use (in association with criteria for abnormal morphology) in a screening programme for ovarian carcinoma. The right ovary was present in 98.9% of subjects and the left in 99.1%. The mean (SD; range) of right and left ovarian volumes were 3.58 (1.40; 1.00-14.01) and 3.57 (1.37; 0.88-10.9) ml respectively. Significant predictors of ovarian volume were years since the menopause, weight, parity, age at menopause, a history of hormone replacement therapy, and previously diagnosed breast cancer. Abnormal ovarian volumes were assessed from a score equal to the (observed mean log volume (MLV) minus the predicted MLV)/0.327. A simplified nomogram has been prepared for routine clinical use. The relative abnormality of one ovary was assessed from a ratio score equal to loge (larger ovarian volume/smaller ovarian volume)/0.211 compared with the 99th centile for the Gaussian distribution.

Screening for ovarian cancer.

This chapter has stressed the urgent need for a screening test for the early detection of ovarian cancer. Real-time, mechanical sector ultrasonography is non-invasive, rapid, painless and has no harmful effects. It can be used to determine ovarian morphology and measure ovarian volume quickly in 99.4 per cent of post-menopausal women. Used correctly, with a precise knowledge of the pelvic anatomy and with proper training in methodology, the risk of false positive diagnoses of ovarian enlargement is small. The incidence of ovarian abnormality diagnosed by ultrasound in this series was 3 per cent. The ovarian neoplasms included clear-cell carcinoma, and serous and mucinous cystadenomas. However, ultrasound appearances of ovarian neoplasms bore little, if any, correlation with the histological diagnosis. Thus, we believe that real-time mechanical sector ultrasonography is reliable in the detection of ovarian neoplasms but the diagnosis can be made only by histological examination. The potential of this technique as a screening test for the early detection of ovarian cancer warrants further evaluation.