Advanced Ultrasound Gynae Techniques

Advanced Ultrasound Gynae Techniques

Contrast Studies and Recurrent Miscarriage / Fertility Issues

Bill Smith

Clinical Diagnostic Services (Educational)

London

BMUS : Gynaecological Ultrasound Imaging and Management

• Comprehensive approach to gynaecological scanning

techniques

• Colour Doppler imaging techniques in gynaecology and

reproductive medicine

• Ultrasound contrast imaging of the uterine cavity and

Fallopian tubes

• Increasing impact of ultrasound imaging techniques in the

investigation of recurrent pregnancy loss

Advances in Gynaecological Ultrasound


techniques




Fallopian tubes




ULTRASOUND IN GYNAECOLOGY

Imaging Modalities and Formats

2D

Transvaginal

Grey Scale

2D

Transabdominal

Grey Scale

2D

Transrectal

Grey Scale

Colour Doppler

Imaging

3D

Transvaginal

Imaging

Contrast Imaging

SIS / HSS

3D Virtual

Imaging

(FlyThru)

Real Time

Elastography

2D

Transvaginal

Grey Scale

Colour Doppler

Imaging

Real Time

Elastography

TRS TVS TAS

3D TVS

SMI RTE

3D F/T 3D SIS


Scanning Applications

Pelvis

Transabdominal

Pelvis

Transvaginal

Pelvis

Transrectal

General

Abdominal

Thyroid Breast


Scanning Applications

Pelvis

Transabdominal

Pelvis

Transvaginal

Pelvis

Transrectal

General

Abdominal

Thyroid

TRS

TVS

TAS



2D

Transvaginal

Grey Scale

2D

Transabdominal

Grey Scale

2D

Transrectal

Grey Scale

Colour Doppler

Imaging

3D

Transvaginal

Imaging

Contrast Imaging

SIS / HSS

3D Virtual

Imaging

(FlyThru)

Real Time

Elastography

2D Transabdominal Grey Scale

TAS remains of significant benefit as part of pelvic ultrasound due to the following factors :

• Increased expansive field of

view

• Reduced transmission

frequencies associated with TAS

• Total patient acceptability

• Convenience of use

2D Transabdominal Grey Scale

TAS complements or provides an

appropriate alternative to TVS re :

• Anatomical studies – congenital malformations

• Delineation of large pelvic lesions

• Fibroids

• Pelvic pain

• Pelvic malignancy

• Renal tract examination

• Interventional / Theatre procedures

• TVS contraindicated



2D

Transvaginal

Grey Scale

2D

Transabdominal

Grey Scale

2D

Transrectal

Grey Scale

Colour Doppler

Imaging

3D

Transvaginal

Imaging

Contrast Imaging

SIS / HSS

3D Virtual

Imaging

(FlyThru)

Real Time

Elastography

2D Transrectal Grey Scale

TRS is of value in gynaecological terms re:

• Imaging of the deep pelvic structures and pelvic floor

• Imaging of the cervix

• Staging of pelvic ( cervical ) malignancy

• Assessment of endometriosis

• Imaging of the rectum

• Urinary / Faecal incontinence

• Interventional / Theatre procedures

• TVS contraindicated



2D

Transvaginal

Grey Scale

2D

Transabdominal

Grey Scale

2D

Transrectal

Grey Scale

Colour Doppler

Imaging

3D

Transvaginal

Imaging

Contrast Imaging

SIS / HSS

3D Virtual

Imaging

(FlyThru)

Real Time

Elastography

Colour Doppler Imaging

Spectral Doppler remains very

limited in the assessment of

gynaecological disorders and pelvic

lesions. High definition Colour Flow

Mapping and Power Doppler imaging

technologies have had a major impact

in diagnostic terms as well as their

effects on clinical management.

Colour Doppler Imaging

Visualisation of tissue vascularity

allows detailed evaluation of diffuse

disease processes as well as the

nature of gynaecological masses.

Neovascularity associated with high

risk changes can be identified at a

relatively early stage.

Modern colour Doppler imaging

provides the basis for ultrasound

(“subjective”) investigation of

functional as well as anatomical

features.



2D

Transvaginal

Grey Scale

2D

Transabdominal

Grey Scale

2D

Transrectal

Grey Scale

Colour Doppler

Imaging

3D

Transvaginal

Imaging

Contrast Imaging

SIS / HSS

3D Virtual

Imaging

(FlyThru)

Real Time

Elastography

Real Time Elastography

The technique compares the

compressibility or “hardness” /

“softness” of structures with that of

surrounding tissue. Colour mapping

of the relative compressibility of

tissues is superimposed onto the TVS

2D image.

RTE differentiates between normal

myometrial and endometrial tissue

and recognises tissue changes

associated with pathology or

functional (ovarian) activity.

Recent developments involve

utilisation of “shear wave

technology”.



2D

Transvaginal

Grey Scale

2D

Transabdominal

Grey Scale

2D

Transrectal

Grey Scale

Colour Doppler

Imaging

3D

Transvaginal

Imaging

Contrast Imaging

SIS / HSS

3D Virtual

Imaging

(FlyThru)

Real Time

Elastography

3D Transvaginal Imaging

In leading units, 3D (volumetric) ultrasound

is now established as an integral part of

transvaginal (TVS) ultrasound scanning.

The technology offers significant clinical and

practical benefits and enhances clinical

communication.

Modern systems are very easy to use and

utilisation of advanced 3D TVS technology

significantly shortens examination times for

gynaecological ultrasound scans. It provides

the basis for post-scan evaluation and

reporting.

Despite the practical and clinical value,

benefit to the patient and positive financial

implications, the role of 3D (volumetric)

ultrasound technology in gynaecology has yet

to be fully realised.


A single, automated (5-8 second) sweep, i.e.

“Survey Sweep”, of the ultrasound beam

through a selected volume of body tissues or

specific organ creates a wealth of anatomical

or clinical information.

This can be rapidly stored and easily retrieved

for manipulation of ultrasound data to create

omnidirectional anatomical planes. 3D

ultrasound information can be displayed in a

variety of imaging formats

The combination of 3D technology and TVS

ultrasound provides high resolution imaging

in all anatomical planes.

3D ultrasound imaging of the female pelvis is

easy, very straightforward from a technical

point of view.


Reduces scanning times

Post-scan reporting

More effective management of busy

scan lists

Image recording and archiving

Clinical communication

PRACTICAL ADVANTAGES

Reduced scanning times

Reduced exposure to ultrasound

energies

Reduced transducer movements

Increased diagnostic effectiveness and

improved clinical communication

PATIENT BENEFITS


• Uterine studies

• Ovarian studies

• Complex pelvic disease

• SIS + 3D virtual imaging

(“Ultrasound Hysteroscopy” )

CLINICAL APPLICATION


• General anatomy

• Anatomical malformations

• Myometrial / Endometrial

pathology

• IUD

• Uterine / Cervical malignancy

spread

• Fertility + ART management

• SIS

UTERUS


• General anatomy



pathology

• IUD


spread


• SIS

UTERUS


• General anatomy



pathology

• IUD


spread


• SIS

UTERUS


• General anatomy



pathology

• IUD


spread


• SIS

UTERUS


• Ovarian morphology

• Ovarian lesions

• Ovarian malignancy spread

• Adnexal (para-ovarian) lesions


OVARY

<18 yrs >18 yrs Gravida

Peri-menopausal Post-menopausal

Ovarian Follicle Stromal Patterns



• Ovarian lesions




OVARY



• Ovarian lesions




OVARY



• Ovarian lesions




OVARY

• Grade 3 - 4 Endometriosis

• Pelvic Malignancy

• Chronic / Acute PID

• Tubulo-Ovarian Masses

“ Complex ” Gynaecological Disease


3D volumetric TVS promotes the concept of post-scan

evaluation and reporting

C

CL

C

B

A

C

CL

C

B

A

a

C

CL

C

B

A

a

C

CL

C

B

A

C

CL

C

B

A

CL

C

CL

C

B

A CL

C

CL

C

B

A Rectum

Vag

C

CL

C

B

A

R

R

R

R

R R

R

V V V

V V V

Adhesions Adhesions Adhesions

Adhesions



2D

Transvaginal

Grey Scale

2D

Transabdominal

Grey Scale

2D

Transrectal

Grey Scale

Colour Doppler

Imaging

3D

Transvaginal

Imaging

Contrast Imaging

SIS / HSS

3D Virtual

Imaging

(FlyThru)

Real Time

Elastography

Contrast Imaging : Uterine Cavity

SIS + 3D Virtual Imaging

Contrast Imaging : Fallopian Tubes

HSS

HSS.avi video

A flexible approach to pelvic scanning and developments in

ultrasound imaging technology provide a more effective

assessment of major organs and associated gynaecological

disorders. Comprehensive examination of the pelvis involves

any combination of the following:

• Scanning techniques - Transvaginal

• Imaging modalities - 2D - 3D - 4D

- Grey Scale

- Colour Doppler

- Elastography

• Ultrasound procedures - HSS (hysterosonosalpingiography)

- SIS (saline infusion sonohysterography)

- Ultrasound Hysteroscopy (FlyThru)



techniques




Fallopian tubes




Colour Doppler Imaging in Gynaecology and Reproductive Medicine

Clinical Applications of CFM

• Ovulation Monitoring and ART

• Uterus : Myometrium

Endometrium

Endocervix

• Ovaries : Functional

Neoplasms

• Complications of Pregnancy

Pre-ovulatory

Luteal Phase

Conception Cycle

Luteal Phase

Non- Conception Cycle

Ovarian

Dysfunction

CFM : Ovulation Monitoring and ART

Luteal Phase Assessment N = 100

• Natural cycle

Ovulation confirmed by U/S +/-

Urinary LH

• Single scan – ovulation + 7 days

(+/- 1 day)

Assessment of Corpus Luteum

Endometrium

• Serum Progesterone (P4)

Assay – Scan +/- 24 hrs

Follicular / Periovulatory Phase

Appearances

1 2 3 4

110

0

100

90

60

70

50

40

30

80

20

10

1 2 3 4

20

0

18

12

14

10

8

6

16

4

2

Corpus Luteum (Grade)

N=100


N=100

Non-conception Endom Grade A-

Non-conception Endom Grade A+

Conception Cycle Endom Grade A+

Non-conception Conception Cycle

End

om

etri

al T

hic

knes

s (m

m)

P4

(n

mo

l/l)

CFM : Early Pregnancy

CFM : Uterus

CFM : Endometrium

Endom.

Ca.

CFM : Endometrium

CFM : Endocervix

CFM : Ovaries

• Very often co-existing clinical issues. Significant overlap in

terms of clinical causes and ultrasound features associated

with both conditions.

• The major cause of both conditions is “ ovarian dysfunction ”

– very often associated with persistent, active follicular /

luteal cysts.

• “ Breakthrough ” ovarian follicular activity remains the chief

cause of PMB. “ Unopposed oestrogens ” associated with

active follicular cysts remains the major underlying cause of

perimenopausal disorders.

• “ Ovarian dysfunction ” is associated with atypical

endometrial proliferation as well as the formation and growth

of endometrial polyps and uterine fibroids.

Pelvic Pain / Abnormal Uterine Bleeding

Clinical symptoms and features associated with persistent

functional ( luteal and follicular ) cysts :

• Pelvic / abdominal pain

• Abnormal uterine ( menstrual ) bleeding

• Bloatedness and IBS type symptoms

• Breast symptoms

• Urinary tract symptoms

• Tiredness, headaches, PMS etc

• Endometriosis

• Pelvic hyperaemia

Pelvic Pain / Abnormal Uterine Bleeding

CFM : Ovaries

CFM : Ovaries

CFM : Ovaries

CFM : Ovaries

CFM : Ovaries

TVS – CFM

Serial Scanning

August

October

November

CFM : Complications of Pregnancy

CFM : Complications of Pregnancy


techniques




Fallopian tubes




SIS is now established as a routine ultrasound investigation in many

leading units. The procedure involves gradual distension of the

uterine cavity by transcervical instillation of normal saline solution.

3D TVS imaging provides detailed anatomical studies of the uterine

cavity and clearly delineates structural abnormalities or the presence of intracavital pathologies.

Contrast Imaging in Gynaecology and Reproductive Medicine

Saline Infusion Sonohysterography (SIS)

3D TVS imaging of the distended cavity demonstrates

• Intracavital / submucosal fibroids

• Endometrial polyps

• Intracavital adhesions

• Detailed endometrial examination

• Cavity wall contour





SIS is routinely used in leading units as part of the investigation and

clinical management of abnormal uterine bleeding as well as

recurrent miscarriage and female infertility.

Advanced 3D (FlyThru) imaging technology has created the concept

of “Ultrasound Hysteroscopy”



“Ultrasound Hysteroscopy”

FlyThru 3D Imaging of the Uterine Cavity

High Resolution

TVS

Advanced 3D

Technology

Saline Infusion

Sonohysterography

FlyThru Virtual

Imaging

Advanced 3D Ultrasound in Gynaecology


HSS is now established as the routine procedure for examining the

patency and general healthiness of the Fallopian tubes. It has been

shown to be an effective alternative to X-ray HSG.

HSS combined with SIS as part of the same procedure demonstrates

internal features of the uterine cavity as well as the Fallopian tubes. Ultrasound imaging of the myometrium also demonstrates

associated myometrial disease or lesions involving the cavity.

TVS ultrasound is regarded as safe without risks associated with

ionising radiation.

Patients appear to tolerate HSS contrast media better and experience

less general discomfort compared to X-ray HSG. Instillation of

contrast media with HSS is much more gentle compared with that required as part of X-ray HSG.


Hysterosonosalpingiography (HSS)


Video HSS.avi









X-ray HSG


techniques




Fallopian tubes




A Review of Ultrasound Scan Findings in Patients

Presenting with a History of Recurrent Miscarriage

B. Smith and N. Stillwell, CDS, London

Mr M. Aziz, Ealing Hospital, London

Mr R. Rai, St Mary’s Hospital / Imperial College London

Mr Y. Gordon, London

WCRPL Cannes 2016

Causes of Recurrent Pregnancy Loss

Unexplained +

Chromosomal / Genetic

Immunological +

Thrombophilia

Infection + Cervical

Hormonal

Uterine Anomalies

Causes of Recurrent Pregnancy Loss

Unexplained +


Immunological +

Thrombophilia


Hormonal

Uterine Anomalies

Diagnostic Value of

Ultrasound Examination

Diagnostic Value of “Advanced” Ultrasound Technology

Unexplained +


Immunological +

Thrombophilia


Hormonal

Uterine Anomalies Definite - “crucial”

Partly - “underutilised”

Undetermined - consider: • multifactorial causes of RPL

• utilisation of u/s imaging modalities

No role


Unexplained +


Immunological +

Thrombophilia


Hormonal

Uterine Anomalies


Unexplained +


Immunological +

Thrombophilia


Hormonal

Uterine Anomalies


Immunological +

Thrombophilia


Hormonal

Uterine Anomalies Unexplained +


Immunological +

Thrombophilia


Hormonal

Uterine Anomalies


Unexplained +


Immunological +

Thrombophilia


Hormonal

Uterine Anomalies


BMUS 2001 / ESHRE 2002

Unexplained +


Immunological +

Thrombophilia


Hormonal

Uterine Anomalies

N=100

1 2 3 4

20

0

18

12

14

10

8

6

16

4

2


Non-conception Endom Grade A-

Non-conception Endom Grade A+

Conception Cycle Endom Grade A+

Endom

etri

al T

hic

knes

s (m

m)

N=100

1 2 3 4

110

0

100

90

60

70

50

40

30

80

20

10


Non-conception

Conception Cycle

P4 (

nm

ol/

l)


Unexplained +


Immunological +

Thrombophilia


Hormonal

Uterine Anomalies


Unexplained +


Immunological +

Thrombophilia


Hormonal

Uterine Anomalies

LH Testing commenced

LH Testing POSITIVE


Unexplained +


Immunological +

Thrombophilia


Hormonal

Uterine Anomalies

Cycle no.

1

2

3

4

5

LH +ve cycle day

9

10

10

8

15

Scan Ovul. cycle day

14

16

15

14

16

Outcome

Miscarriage

Miscarriage

Non-pregnant

Miscarriage

Pregnancy


“Aberrations” of the Ovulatory Cycle

• Luteal phase issues

• Poor endometrial development

• Receding periovulatory

endometrium

• Retrograde menstruation

• Discrepancy LH vs U/S ovulation

Patient numbers 32/71

Unexplained +


Immunological +

Thrombophilia


Hormonal

Uterine Anomalies

• The impression persists that ultrasound assessment remains

relatively underused in the investigation of recurrent pregnancy

loss

• A comprehensive approach to ultrasound scanning involving a full

range of imaging modalities increases the diagnostic impact of

ultrasound in the investigation of recurrent pregnancy loss

• The role of ultrasound in the evaluation of ovulatory disorders

associated with recurrent pregnancy loss does not appear to be

fully recognised

• Monitoring of ovulatory cycles provides valuable information

regarding functional, anatomical and pathological causes of

recurrent pregnancy loss. It also supports the concept of “preconception planning”

Conclusions

The Impact of Advanced 3D Ultrasound Technology in the Investigation and Management of Recurrent Miscarriage

B. Smith and N. Stillwell, CDS, London

Mr M. Aziz, Ealing Hospital, London

Mr R. Rai and Dr S Das, St Mary’s Hospital / Imperial College London

WCRPL Cannes 2016



2D

Transvaginal

Grey Scale

2D

Transabdominal

Grey Scale

2D

Transrectal

Grey Scale

Colour Doppler

Imaging

3D

Transvaginal

Imaging

Contrast Imaging

SIS / HSS

3D Virtual

Imaging

(FlyThru)

Real Time

Elastography

Fly Thru

Virtual 3D Ultrasound Imaging

• established as an integral

element of SIS procedure

• automatic and manual

navigation through the volume

• hybrid endoscopy with

ultrasound information

• great tool for intervention

planning and follow up

Advanced “FlyThru” technology provides the basis for

ULTRASOUND HYSTEROSCOPY

Virtual 3D Ultrasound Imaging

High Resolution

TVS

Advanced 3D

Technology

Saline Infusion

Sonohysterography

FlyThru Virtual

Imaging



FlyThru virtual 3D imaging promotes the concept of

“Ultrasound Hysteroscopy”. Its major applications in terms of

clinical practice currently include:

• General Gynaecology - assessment of abnormal uterine

bleeding

• Reproductive Medicine - investigation of infertility and

recurrent miscarriage

• Pre-requisite in IVF management

• Increasing use of transcervical ultrasound guided

interventional procedures

• Clinical communication and pre-surgical planning


Ultrasound Findings at SIS

Normal

Myometrial disease fibroids, adenomyosis etc

Intracavital lesions fibroids, polyps, RPOC etc

Anatomical Malformations

Intracavital adhesions

Ultrasound Findings at SIS

Clinical trial flawed due to (1) lack of feedback from clinical units

and (2) diagnostic confidence levels resulting in 3D virtual imaging

offering an alternative to diagnostic hysteroscopy

Clinical findings:

Patient follow up data available only 57/723

Ultrasound diagnosis Normal 27 Abnormal 30

Hysteroscopic findings Normal 28 Abnormal 29*

* *

The value of 3D Virtual Imaging (“Ultrasound Hysteroscopy”) in the

investigation of RPL

• Enhanced ultrasound imaging of the uterine cavity

• Effective in the detection of intrauterine adhesions particularly

following intracavital surgical procedure

• Reliable indicator in selecting patients requiring conventional

hysteroscopy and subsequent endoscopic surgical procedure

• Considerable value in terms of pre-surgical planning and clinical

communication

Conclusions

Thank you for your attention

and enjoy the rest of the meeting

BMUS Study Day

York 2016

Ultrasound in Gynaecology and

Reproductive Medicine

The Impact of Advanced 3D Virtual Imaging in the

Investigation of Abnormal Uterine Bleeding

and Reproductive Medicine

Bill Smith

Clinical Diagnostic Services (Educational)

London

BMUS Study Day

Thank you for your attention

and enjoy the rest of the meeting

BMUS Study Day

London 2016

Advances in Gynaecological

Ultrasound

Documents

Advanced Ultrasound Gynae Techniques