Use of Ultrasound for Infertility Diagnosis and Pregnancy

Abdominal and pelvic ultrasounds are the two most commonly used diagnostic ultrasounds. Abdominal ultrasound diagnoses the upper organs of your abdomen, while pelvic ultrasound diagnoses the cause of pain, swelling, infections of the pelvis, bladder, sex organs, and rectum. As ultrasounds are noninvasive, it causes little discomfort during the procedure. Let's understand the uses of abdominal and pelvic ultrasounds in detail,

Abdominal Ultrasounds and its uses

If you are suffering from pain and discomfort in the abdominal area, your doctor may recommend an abdominal ultrasound. Your doctor will diagnose the reason for your pain or distension by evaluating the organs located in the abdominal area like, liver, spleen, gallbladder, pancreas, urinary bladder, kidneys, and abdominal aorta [3].

Abdominal ultrasounds help your doctor to evaluate a variety of medical conditions like,

1. Cause of pain, enlargement, and distention in the abdomen
2. Presence of stones in kidneys or cholelithiasis [4]
3. To identify the presence of gallbladder stones
4. Presence of abdominal aortic aneurysm (AAA) (enlargement of the aorta, the main blood vessel at the level of the abdomen)
5. Hydronephrosis (excess fluid in the kidney due to build-up of urine)

Pelvic ultrasound and Its Uses

As discussed, pelvic ultrasound helps in the diagnosis of medical conditions related to organs situated in the pelvic region like, reproductive organs and organs of the urinary system. If you are suffering from painful periods, abnormal menstruation (irregular or heavy flow), and undiagnosed pelvic pain, your doctor may recommend a pelvic ultrasound.

The pelvic ultrasound helps in the diagnosis of,

• Cause of pelvic pain, problems with menstruation, and abnormal vaginal bleeding
• Uterine cysts and fibroids
• Cancers of ovaries and uterus,
• Stones of kidneys and gallbladder

There are three main types of pelvic ultrasounds - abdominal (commonly used in pregnancy), vaginal (for females), and rectal (for males). Before going into deep on the types of pelvic ultrasound, let's understand the procedure to take a pelvic ultrasound.

As it is a simple, non-invasive procedure, you don't have to prepare anything before the examination except for the cases where you are undergoing other medical procedures like surgery after the ultrasound. Wear loose-fitting, comfortable clothing for the appointment. You will be asked to drink at least 800ml to 1 liter of water one hour before the examination and would be requested to hold your urine until after the examination. Inside the ultrasound chamber, the doctor will apply a small amount of gel on the skin of the pelvic region. He will then place a handheld device and start moving it across the pelvic area. The moving device across your pelvis produces high-frequency sound waves that create real-time photos and videos of organs which will be visible on the monitor. This way, ultrasound helps to see images more clearly.

This pelvic ultrasound is considered the best method to note any growth or cyst or a lump. Let us discuss types of pelvic ultrasounds,

Transabdominal Ultrasound: This type of pelvic ultrasound is used to check the growth of babies in their mother's womb during pregnancy. During the procedure, the doctor will apply the gel on the stomach and move the probe around. The live image of the baby is displayed on the screen. During the ultrasound, the doctor will analyze the height of the baby's arms and feet, size of head and heart, and overall growth of the baby. The ultrasound also helps in identifying multiple pregnancies and the week of pregnancy. Additionally, it helps evaluate the position of the baby and the amount of amniotic fluid around the baby.

Transvaginal Ultrasound: This type of pelvic ultrasound is done only for females. It has a probe designed to fit into the vagina. The doctor will cover the probe head with a latex condom and insert it into the vagina. Transvaginal ultrasound is a preferred diagnostic method during the first trimester of pregnancy, as the fetus will be more clearly visible due to the proximity of the probe with the uterus. The process is painless and takes only 15 minutes to complete.

Other than pregnancy, Transvaginal ultrasound is used for,

1. Placement of the intrauterine device
2. To know the cause of infertility
3. To view the growth of ovaries
4. To diagnose the cause of abnormal vaginal bleeding or problems of menstruation
5. To identify the cause of unexplained pelvic pain
6. To identify any ectopic pregnancy

Transrectal Ultrasound: It is for males only and is designed such that the end of the probe can partially fit into the rectum. Your doctor will recommend a rectal ultrasound if you have problems with the prostate gland and seminal vesicles (male glands that secrete a part of semen) [5].

If you are undergoing any fertility treatment, you may have to undergo ultrasound multiple times throughout the treatment. Transvaginal ultrasounds are done for fertility evaluation and to check the treatment progression, whereas abdominal ultrasounds are performed after the successful treatment and during the pregnancy.

During the fertility assessment, the doctor will look into the health condition of your ovaries, fallopian tube, uterus, and endometrial lining with the help of ultrasound. Once you start your fertility treatment, your doctor may take ultrasounds to monitor follicle development, evaluate the thickness of fallopian tubes, and an assessment of endometrium [6]. During the In-Vitro Fertilization, the doctor will use ultrasound as a guiding tool to retrieve eggs from the ovaries.

Some ultrasounds used during the fertility assessments are,

Antral Follicle Ultrasound: It is a type of transvaginal ultrasound used to determine ovarian reserve in women. It also helps in the diagnosis of Polycystic Ovarian Syndrome (PCOS). [7]

Sonohysterogram: During the sonohysterogram uterus is dilated by inserting a saline solution with the help of the catheter. This makes it easier for your doctor to look at the uterus and associated abnormalities (if any).

Hysterosalpingo-contrast Sonography (HyCoSy): This works just like sonohysterography. It helps to know whether your fallopian tubes are open or blocked. Here, saline or dye is used to check the potency of the uterus and fallopian tube.

3D Ultrasound: This type helps in providing clear and better images of uterine abnormalities and issues of fallopian tubes by creating 3 D dimensional images.

The most common and highly successful fertility treatment is In-Vitro Fertilization, also known as IVF treatment. If you are undergoing IVF treatment, you might wonder if you have to undergo ultrasounds during the IVF treatment, and if so, when and why is the ultrasound done for IVF. Let's discuss the uses of ultrasound in IVF treatment,

Ultrasound Scan Done Before IVF treatment

Once you visit your fertility doctor, he may first advise you to go for imaging tests like ultrasound along with other fertility tests. It helps them in understanding the cause of delayed pregnancy. The ultrasound before IVF helps the doctor in identifying underlying issues with your reproductive organs (ovaries, fallopian tubes, and uterus) that might be causing infertility. The medical conditions that can be determined by ultrasound are as follows,

Uterus examination- While examining your uterus, the doctor can look for fibroids or polyps, know about endometrial thickening and estimate the size and shape of your uterus.

• Uterine fibroids and polyps- If you have fibroids or polyps in your uterus, the fertility doctor will diagnose and can even estimate their size with ultrasound. If your doctor finds that these are larger and can cause problems, he will plan to remove them using Laparoscopy before starting your IVF. Complications like miscarriages, implantation issues, stillbirth, or early labor during your IVF pregnancy can occur if these are left untreated.
• Thickened endometrium- Your doctor can also clearly see the endometrial lining and can estimate its thickness by ultrasound. If he finds that your endometrium is in good health, then IVF treatment is started. Thus, ultrasound helps your doctor to know whether the endometrial thickness is at an optimum level and whether it has an adequate blood supply, which is essential for successful implantation.
• Shape and size of the uterus- You may face problems in getting conceived if you have an abnormally shaped uterus or if the uterus is of small size. Ultrasound can help to determine any abnormalities in the shape and size of the uterus before the doctor sets you up for IVF.

Ovaries examination- Fertility expert uses transvaginal ultrasound to diagnose the health of your ovaries. Medical conditions related to ovaries like cysts, primary ovarian insufficiency, and ovarian cancer can be easily diagnosed with transvaginal ultrasound.

• To estimate developing follicles- Formation of a healthy embryo is possible when your ovaries are in good health and when they can produce eggs. Your fertility level is measured by the presence and production of quality eggs in your ovaries. Before your doctor starts you on IVF treatment, he first orders an ultrasound scan to know the number of developing follicles, along with some other pre-pregnancy tests. Sometimes, your doctor may also order for a baseline pelvic ultrasound done on day two or day three of the menstrual cycle to know the condition and functioning of your ovaries. It gives information about the health of ovaries and helps to identify if the ovaries can produce mature eggs.
• Tumors of ovaries- Cancers of ovaries can be easily detected by doing an ultrasound scan before IVF [8]. Routinely done abdominal scans cannot detect ovarian cancers.
• Ovarian cysts- Pelvic or transvaginal ultrasound identifies the presence of any cystic growths in your ovaries.
• To identify the absence of ovary- Your doctor can see and identify your ovaries by using a regular transvaginal ultrasound. So, the doctor can check whether you have one or both ovaries.

Fallopian tubes examination- Once released the female egg travels through the fallopian tube where it meets the sperm and gets fertilized. If there are any issues with fallopian tubes, the egg will not be able to meet the sperm for fertilization. Hence, the fertility expert will check issues with the fallopian tubes, that might be delaying your pregnancy such as,

• Blocks in fallopian tubes
• Presence of absence of fallopian tube (like surgical removal of tube or the absence of fallopian tubes since birth)
• Cyst or any infection in tubes

Ultrasound Scan Done During IVF treatment

An ultrasound scan done while you are on IVF treatment helps your doctor to evaluate the growth of follicles and to check the thickness of the endometrial lining. Apart from using the ultrasound as a guiding tool during the egg retrieval process, it also helps the fertility expert to understand how your body is responding to the treatment. The ultrasound during the IVF is performed to,

• Estimate your response to ovarian stimulation drugs- When you are undergoing IVF treatment, you have to take stimulation drugs to increase your egg production. Your doctors need to know if the medications are working and your follicles are growing as expected or not. Your doctor will check the follicle growth with the help of ultrasound and will estimate the date of ovulation accordingly. During the day of ovulation (release of eggs from the ovaries), you have to visit the clinic for an ultrasound-guided egg retrieval procedure.
• Uterine lining- Healthy endometrial lining is essential for pregnancy as it helps in the implantation of the embryo. The proper development of the uterine lining is evaluated by using an ultrasound scan. Studies show that if the thickness of your uterine lining is 6mm or less, it might result in an unsuccessful pregnancy. So, most of the doctors would prefer the uterine thickness of at least 8 to 11mm to start the process of embryo transfer (ET).

Ultrasound Scan Done After IVF treatment

Once the IVF treatment is successful, further growth and development of the baby inside your womb is checked by performing ultrasound scans.

• To confirm your pregnancy - After two weeks of embryo transfer, the doctor will perform a pregnancy test to confirm pregnancy. Pregnancy tests are followed by repeated ultrasound scans that help your doctor to know about proper implantation of embryos into your uterus after the IVF.
• Detecting fetal heartbeat - Ultrasound can also detect the fetal heartbeat, and the doctor can track the growth of your baby inside the womb.

After your IVF treatment, you will have a series of ultrasound scans done for assessing the growth of the baby. You will have these scans done vaginally for obtaining accurate images. Vaginal scans are safe for you and your baby. Ultrasound scans done at these stages are very crucial parts of your fertility treatment process, as there is a greater chance to identify and to act upon any possible problems with your pregnancy.

Your doctor will schedule your first ultrasound scan at 4 to 5 weeks after embryo transfer, and this would approximately be around the 6th or 7th week of pregnancy (if the IVF is successful). If your doctor suspects of an ectopic pregnancy (a pregnancy that happens outside of your uterus), then he will schedule an ultrasound earlier, which would be around 3 ½ weeks after embryo transfer.

An ultrasound done at 6th week of your IVF pregnancy helps your doctor to assess your baby's health in the following ways,

• Detect fetal heartbeat
• Determine whether there are single or multiple pregnancies
• See the development of the baby

You have to undergo two more scans after your first scan at week 8th/9th and then at week 12th of your pregnancy.

There are no serious risks associated with ultrasound as it is non-invasive and does not use any radiations. Fetal ultrasound is a safe procedure, other than the mild discomfort and pressure caused by the transducer when placed on the abdomen or in the vagina.

A few of the benefits for an ultrasound during pregnancy are,

• It helps doctors in managing pregnancy and taking care of the fetus.
• Parents can see their baby even before birth, helping to develop bonding with their baby.

While using Transvaginal ultrasound, the ultrasound transducer is covered with a latex condom and then placed in your vagina. These latex condoms may sometimes irritate your skin and cause an allergic reaction. Tell your doctor about allergies before undergoing an ultrasound. Usage of ultrasound assures you to have a successful progression and completion of every step of your IVF pregnancy.