ULTRASOUND TREATMENT OF STERILITY AND INFERTILITY Sterility (infertility) is diagnosed with couples who do not have pregnancy even after a year of unprotected sexual intercourses. Frequency is about 8-15% of all the couples. Normal fertility is around 20% per cycle, but in normal population 60% of women conceive within the period of 6 months, 80% within 12 months and 90% within 18 months. When to start with a couple treatment depends on more factors, and the most frequently about the female patient’s age and anamnesis (surgical procedures in pelvis, PID – pelvic inflammatory disease, menstrual cycle disorder, endometriosis…) and anamnesis of a male partner- recovered diseases… Ultrasound is non-invasive diagnostic method which extremely well fits in the treatment of infertility and can detect most of the causes of sterility.

Ultrasound folliculometry (far more precise method than basal temperature measurement and measuring of LH secretions in urine)- it is being monitored whether there is any folliclogenesis at all (maturation of oocytes and release) in the ovaries – in the first part of the cycle, a dominant preovulatory follicle with an oocyte is being searched for and the time of ovulation is being predicted and in the second part of the cycle, yellow body as evidence of last population, is monitored with ultrasound. In Polyclinic Arcadia, folliculometry consists of 3 ultrasound examination on the days of menstrual cycle which are determined individually for each patient depending on the duration of the cycle or whether it is a natural cycle or a cycle simulated with medicines. Folliculometry is important because sometimes even a proper menstrual cycle consists of long first follicular phase (more than 19 days) and short lutein phase (less than 10 days) or vice versa, so that even with ovulation cycles, without ultrasound, it is sometimes difficult to determine the exact time of ovulation. It is sensible to combine this examination with serum oestradiol hormone screening. Follicle grows 1.6 mm a day during the natural cycle, 1.8 mm/day in a simulated cycle, and on one day before the ovulation, follicle is approximately 21.7 mm.

Diagnosis of endometriosis- 40% of women with sterility. It is the most common benign gynaecological disease and is characterized by presence of functional uterine mucosa outside the uterus- the most frequently an ovary. It interrupts the process of folliculogenesis and such patients often do not have ovulations.

Dermoid cyst- benign tumorous formation- very common with women of younger reproductive age. It also interrupts forming of leading follicle and ovulations.

Identification of the ovarium reserve of oocytes- the number of antral follicles in the ovary and ovary volume on the 3rd day of menstrual bleeding, combined with FSH hormone and oestradiol on the 3rd It is related to sterility or with a weak reaction on ovary stimulation with medicines.

Signs of interrupted ovulation- common disorders which include LUF syndrome (normal progesterone on the 21st day) and haemorrhagic anovulatory follicle (HAF) (low progesterone on the 21st day)

Yellow body formation (CL)- a sign of normal ovulation.

PCOS- polycystic ovary syndrome- broad spectrum metabolic disorder which can result in prolonged cycles, or even the absence of menstrual bleeding, sometimes with signs of increased levels of male sex hormones (acne, greasy hair, hair loss, enhanced hairiness), or absence of anovulation and consequent sterility, diabetes, high blood pressure, fatness, cholesterol level disorder. Ultrasound criteria are volume higher than 10 ccm, more than 12 follicles from 2-9 mm, hypoechogenic stroma more than 5.5 cm. Such patients often do not react to clomiphene stimulation and they frequently react too strong as an ovarian hyperstimulation syndrome. With sterility treatment, hormone and metabolic treatment is necessary- sometimes a normal cycle and ovulations are achieved only with therapy of unrecognized diabetes type II.

Ultrasound examination of oviducts – a normal oviduct is usually difficult to show due to anatomical relations of ultrasound similar organs- bowels, but it is easy to show pathologically changed oviduct- hydrosalpinx. In patients with sterility, a normal ultrasound result of oviducts does not exclude functionally damaged oviduct. Diagnostic protocols also include methods for examining the passage of oviducts- RTG HSG or SHSG sonohisteropapinnaography (ultrasound version of HSG) see below.

SHSG- for now, in Polyclinic, it is possible to do SALINE- SHSG with a negative contrast- saline solution and contrast 3D- SHSG is planned. This method includes evaluation of size, shape and contours of uterine cavity in all directions with 3D ultrasound and diagnostics of polyps, myoma and adhesions in the uterine cavity and with help of color and power Doppler to verify flow through the oviduct. Examination of ovarian patency is a part of basic diagnostic of sterility and especially with secondary sterility (after at least one proper pregnancy) when uterine diseases as the cause of sterility rise to 32% of proportion.

3D ultrasound examination of uterus- thickness and appearance of the lining of the uterus- endometrium is in line with changes in serum oestrogen level, synchrony of mucosal membrane and follicular changes on the ovaries, appearance of myometrium- muscle part of uterus- position of myoma, endometriosis of uterus, malformations of uterus (uterus arcuatus, unicornus- hemiuterus with or without rudimentary horn, complete or partial bicornus, complete or partial septum uteri, uterus didlephys, hypoplasia- dimorphic T-shaped uterus, uterine agenesis). Malformations require further processing HSG and/or MR of pelvis.

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