Chapter 9b
Ultrasound - Seeing with Sound

from the book How to Have a Baby: Overcoming Infertility
by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.

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Recent Advances in Ultrasound

Ultrasound technology has made dramatic advances in recent years, and now tests have been described which allow the doctor to use ultrasound to assess tubal patency. Basically, these involve passing a fluid into your tubes through the uterus; and the gynecologist can see the passage of the bubbles into the tubes and out into the abdomen. Since this test ( sonosalpingography) can be done in the doctor's clinic itself, and does not involve X-ray radiation, it has advantages - especially for documenting that the tubes are normal. However, the gold standard for tubal testing remains HSG and laparoscopy today.

Doppler: The newer ultrasound machines have Doppler attachments which allow the doctor to judge the flow of blood in the blood vessels. The most exciting advance is that of Colour Doppler, where the blood flow can be mapped in color on the monitor. While still a research tool, it may provide important information for assessing the infertile patient in the coming years.

Three – dimensional ultrasound. Using sophisticated microprocessors, the newest ultrasound machines allow the doctor to reconstruct the image, so that he gets a three dimensional view. While this provides excellent pictures, the true value of this technique for infertility still has to be evaluated.

Ultrasound now also offers infertile patients newer treatment options not available before. Modern surgical techniques have progressively become less and less invasive - all to the patient's benefit ! From laparotomy to laparoscopy , and now to ultrasound guided procedures, we are witnessing a change in the gynecologist's armamentarium from the knife to the endoscope to the guided needle !

The benefits to the patient are many and include : reduced costs; reduced hospitalisation ; reduced risk of complications; and better preservation of fertility, with increased chance of conception for the future.

Ultrasound-guided procedures can be used to treat a variety of problems seen in the infertile woman:

1. Egg pickup for IVF - The use of vaginal ultrasound for egg pickup has made egg retrieval a short, simple and inexpensive procedure, which can be performed in a day-care unit, under sedation and local anesthesia . The ovaries are normally present in the pouch of Douglas, and are very accessible transvaginally. Moreover, the presence of adhesions does not interfere with egg collection.
    
2. Ovarian cyst aspiration. An ovarian cyst is a very common condition in which fluid collects in the ovary. However, cysts which are more than 5 cm in size need to be treated, as they can cause problems ( eg twisting and rupture). Normally, surgery had to be done to remove these cysts - and often this damaged the surrounding normal ovary as well. With ultrasound-guidance, we can stick a needle from the vagina into the cyst, and empty the contents ( usually clear fluid ) by sucking it out. This empties the cyst, which often does not recur.
    
3. Treatment of ectopic pregnancy . With technological advances ( ultrasound and beta-HCG blood tests) the diagnosis of tubal pregnancy can be made very early, usually before rupture. It can be treated by injecting a toxic chemical, methotrexate, into the sac, which causes the tissue to die and then get reabsorbed, without any surgery whatsoever. In more advanced tubal pregnancies, potassium chloride can be injected direct into the heart of the baby in the ectopic gestational sac, thus killing it and preventing it from growing.
    
4. Ultrasound-guided tubal embryo and gamete transfer for IVF and GIFT techniques. Techniques have been devised to pass a special tube - the Jansen-Anderson catheter set - into the fallopian tubes through the vagina under ultrasound guidance, so as to place the embryos and /or the gametes in the fallopian tube. Since the tube offers a better environment for the gametes and embryos than the uterine cavity, it is believed that this will improve pregnancy rates.
    
5. Tubal recanalisation for cornual blocks (proximal tubal obstruction). Often cornual blocks are due to the presence of mucus plugs and amorphous debris in the tubal lumen. Ultrasound guided tubal catheterization can effectively treat the blocked tubes in some of these patients.

The scope of ultrasound guided procedures has increased dramatically in the last few years; and with further improvements in technology, we can expect this list to become even longer, and doctors become more versatile with using this technology.

by Dr. Aniruddha Malpani, MD and Dr. Anjali Malpani, MD.

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