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Pilot study: initial transvaginal ultrasound steers Tx course.

MONTREAL -- The first infertility consultation for a couple should include a detailed transvaginal ultrasound, results of a pilot study suggest.

"This has been standard practice in our clinic for 14 years, but I know of clinics that don't do any ultrasonography as part of their initial infertility work-up," said Dr. Donna Chizen, and ob.gyn. at the University of Saskatchewan, Saskatoon.

Her study suggests that the results of the first-visit ultrasound are key in directing a couple's therapy, obviating less useful therapy and saving time and money for both the couple and the clinic. She presented the study in a poster presentation at the 18th World Congress on Fertility and Sterility, sponsored by the International Federation of Fertility Societies.

"If I do an ultrasound the first time I see a patient, it will help me decide where to go from there-whether a test should be done or can be avoided, whether surgery should be done before offering therapy, or whether therapy should be started right away, and so on," she said in an interview.

Her retrospective study involved a review of 200 first-visit ultrasounds at her clinic between 1994 and 1995. Most of the women (79%) were aged 35 years and younger, 17% were aged 36-40 years, and the rest were aged 41-45 years.

Approximately 25% of the women had at least one abnormal ovary. Some women required further investigation to rule out neoplastic disease, treat endometriomata, or confirm hemorrhagic luteal structures. Others had nonneoplastic size cysis (>3 but <6 cm) or menopausal size ovaries that could alert the physician to a problem with ovulation, she explained.

With respect to the uterus, 18% of women had congenital abnormalities, including arcuate and septate cavities, as well as unicornuate and bicornuate morphologies, didelphys and signs of polyps or fibroids in the uterine lining.

"It's important to exclude structural causes of miscarriage or very preterm delivery, so knowing about the cavity contour can help a physician provide appropriate treatment before starting fertility therapy," she explained. "Although fibroids generally do not interfere with fertility, those that involve the uterine cavity or excessive numbers of fibroids may be significant for infertility."

Uterine fibroids caused endometrial compression in 2.5% of the women.

A comparison of ovarian follicle diameters and corpora lutea to endometrial patterns showed that 6% of the study participants had out-of-phase menstrual cycles. This may be related to inadequate ovarian hormone production or may reflect abnormal uterine responses to hormones, she said.

Simply counting the total number of follicles in an ovary can be very useful for directing treatment. "If I see very few follicles I am concerned about poor fertility potential, and I may offer them more aggressive therapy right from the start. However, if I see an increased follicle population I may be very careful to use a very low dose of ovulation induction medication in order to prevent multiple ovulations and multiple gestations," she said.

In the study participants, the total ovarian follicle population was decreased (less than 10 follicles) in 10.5% of the women, borderline increased (between 20 and 30 follicles) in 5%, and increased (more than 30 follicles) in 14.5%.

There was an unequal distribution of follicles between the right and left ovaries in 15.5% of women. "An uneven follicle distribution may indicate that damage has occurred in one of the ovaries or that ovulation does not occur in one ovary. It is important to assess whether each ovary is effective at releasing oocytes, especially if fallopian tube damage has occurred," she said.

Dr. Chizen stressed that without a first-visit ultrasound many of the abnormalities detected in her study might not have been found until quite far into the infertility investigation.

She cautioned that when infertility ultrasounds are done by a general radiology department, the detection of abnormalities specific to a fertility assessment may be overlooked.

"Often, if a patient is sent to a radiologist for an infertility ultrasound, the radiologist will be sure to comment about any possible signs of overt pathology but won't concentrate on some of the more subtle reasons for infertility," such as a decrease in the total number of ovarian follicles, clues that ovulation is not occurring, the follicle growth pattern expected at that time of the menstrual cycle, or an unusually shaped uterus, so that's why I do an ultrasound in the clinic when I am deciding what should be done about infertility," she said.


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Title Annotation:Gynecology
Author:Johnson, Kate
Publication:OB GYN News
Date:Jul 15, 2004
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