• Dermoid cysts of the ovary account for 20% of ovarian neoplasms.
• These are benign germ cell tumours composed of tissues derived from two of the three germ cell layers (ectoderm, endoderm, and mesoderm) like tooth, hair, sebaceous secretions, thyroid tissue etc.
• Most of the dermoid cysts are silent and are incidentally detected; however some may be symptomatic due to large size resulting in compression of adjacent structures. Torsion or rupture
• Characteristic sonographic appearances include
  • Focal or diffuse hyper echoic component
  • Areas of acoustic shadowing also known as “the tip of the iceberg“ sign.
  • Intramural – fibroid located in the uterine wall.
  • Echogenic lines and dots also referred to as “dermoid mesh“ or “dot dash sign”. Rokitansky Nodule (hyper echoic component) corresponds to mixed hair and sebaceous material or calcication or bone or tooth.
  • Floating Echogenic Globules within a large mass is an uncommon appearance.
• Dermoid cysts of size >4 cm needs to be surgically removed for the risk of torsion.

• Leiomyomas (fibroids or myomas) are benign smooth muscle tumours with varying amounts of fibrous tissue and are the most common uterine neoplasm, reported in 20% to 30% of women over 30 years of age.
• These are usually multiple, causing enlargement of the uterus with a lobular serosal contour and may present with
  • Palpable pelvic mass,
  • Uterine enlargement,
  • Pelvic pain,
  • Anaemia, and
  • Dysfunctional uterine bleeding depending upon their location and size.
• Types of fibroids depending on the location are:
  • Intracavitary – fibroid located inside the uterine cavity
  • Submucosal – fibroid located just beneath the endometrium.
  • Intramural – fibroid located in the uterine wall.
  • Subserosal – fibroid located on the outer surface of the uterus.
  • Pedunculated – fibroid attached to the uterus with a pedicle.
• Approximately 5-10% of infertile women have fibroids . Their size and location determines whether fibroids affect fertility like sub mucosal or very large fibroids within the uterine wall.

• Typical features on ultrasound.
  • Heterogeneously enlarged uterus with lobular contour
  • Uterine enlargement,
  • Typically focal, well defined, round, sharply marginated, hypoechoic lesion within the myometrium or attached to it, often showing shadows at the edge of the lesion and/or internal fan shaped shadowing.
  • Hypoechoic, isoechoic, or echogenic relative to the myometrium. Majority are hypoechoic.
  • Small leiomyomas are typically homogeneous whereas those larger than 3 cm in diameter are often heterogeneous.
  • Surrounding myometrium can become compressed and form a pseudocapsule. Occasionally compressed lymphatics and vessels create a thin hypoechoic rim around intramural leiomyomas.
  • Edge refraction at the interface of the leiomyoma with the normal surrounding myometrium may help to identify an isoechoic leiomyoma.
  • Venetian blind artifact (shadows) – a sonographic finding typically associated with adenomyosis can also occur in uterine fibroids. The posterior shadowing may be dense or striated (comb-like). This is believed to be caused by the transitional zone between apposed tissues of different acoustic properties such as fibrous tissue and smooth muscle, as well as refraction from the edges of whorls and bundles of smooth muscle. Very helpful in differentiating an exophytic leiomyoma from an adnexal or ovarian mass
  • Peripheral blood flow on colour or power doppler images. Fibroids appear as “ring of fire” on power doppler Fibroids which are necrotic or have undergone torsion will show absence of flow
  • Increased blood velocity and decreased RI and PI in both uterine arteries occur in patients with uterine leiomyomas compared to healthy volunteers .This feature may have predictable value in growth rate evaluation of a benign uterine mass.
  • Degeneration may result in oedema with cystic spaces, echogenic haemorrhagic areas, dystrophic calcification

• Endometriosis is a condition in which endometrial glands and stroma are situated outside the uterus
• In this condition there is cyclical bleeding in the extra uterine endometriotic tissue which causes inflammation and pain during menses.
• Endometriosis occurs on the surface of the ovaries, uterine suspensory ligaments, walls of the uterus, fallopian tubes, and the peritoneal surfaces of the pouch of douglas. Other sites can be vagina, bladder, cervix, intestines, caesarean scars, abdominal scars etc.
• Endometriosis can be supercial with <5mm depth of penetration from surface or deep >5mm depth of penetration with fibrosis and muscular hyperplasia.
• Ovaries are the most common sites of endometriosis and are frequently involved with multiple and bilateral lesions.
• Classic sonographic appearance of an endometrioma (ovarian endometriosis) or chocolate cyst is homogenous and hypoechoic lesion with low to medium level echoes and no internal level echoes and no internal vascularity ie ground glass appearance.
• Occasionally it can appear completely anechoic resembling simple ovarian cyst or fluid-fluid levels with thickened wall and mural or central calcifications.
• Chronic endometrioma (long standing endometrioma) may mimic solid ovarian tumours.

• Ultrasound is one of the criteria for the diagnosis of polycystic ovarian syndrome (PCOS).
• Polycystic ovaries are detected by TVS (Trans vaginal sonography) in approximately 75% of women with clinical diagnosis of PCOS (1).
• TVS is a highly sensitive test for identification of Polycystic ovaries.
• Antral follicles are small follicles in the ovary ranging in size from 2-9 mm and grow over 10-12days in a menstrual cycle to select one dominant follicle which matures and releases the ovum.
• An AFC(Antral follicular count) of more than 12 in one or both ovaries of size 2-9mm arranged either peripherally or diffusely with a dense increased Volume of ovarian stroma.(2)
• Ovarian volume of greater than 10cm3 with no follicles measuring over 10mm in diameter is considered as PCOS.
• Recent guideline say AFC >25 in one or both ovaries is considered as USG criteria of PCOS.(3)

References.

• Gardener’s Text Book of ART 5th Edition Page 676
• Clinical Endocrinology 1991
• Human Reproduction update 2014; 20(3): 334-52

• Fallopian tubes are on either side of the uterus attached to it near cornua and the other end is free located adjacent to ovaries.
• It has interstitial, isthmic, ampullary and fimbrial parts. Interstitial end is attached to the uterus and fimbrial end is free.
• Fallopian tubes vary in length from 7-12cm.
• Normal tubes are usually not visualised by ultrasound.
• If there is a tubal pathology like hydrosalpinx in which tubes are blocked with accumulation of fluid in it, they can be visualised on USG.
• Presence of free uid in the pelvic cavity also can make the tubes visible.
• As tubes are not normally seen on ultrasound hysterosalpingography (HSG) or Hystrerosalpingo contrast sonography (HyCoSy) is used to know the tubal patency.
• Tubes are assessed during basic USG scan on 2nd day or 9th day of menstrual cycle.
• Few cysts like Paraovarian, paratubal cysts (cysts of morgagni) and those adjacent to uterus, vagina & superior to hymen like Gartner’s duct cyst can be seen on routine scan in some patients.

• Uterus is a pear shaped reproductive organ in a female of size 7cm in length and 4 cm in width in the reproductive age group.
• Its size varies with the age and parity of the women.
• Uterus has a body, cervix and two fallopian tubes one on each side.
• It is either Anteverted (tilting forwards) or Retroverted (tilting backwards).
• The sonographic examination of the uterus by the transvaginal approach is typically initiated at the midsagittal plane. This view is obtained by introducing the transvaginal transducer into the upper
• vaginal fornix while maintaining the reference notch on the transducer at the 12 o’clock position. In this view, the uterine fundus, uterine isthmus and cervix is seen and the uterine length is measured from the fundus to the external os.
• The depth (height) of the uterus (anteroposterior dimension) is measured in the same long- axis view from its anterior to posterior walls, perpendicular to the length
• This midsagittal view also allows for assessment and measurement of the endometrium. The endometrium should be analyzed for thickness, focal abnormalities, and the presence of fluid in the endometrial cavity.
• Measurement of the endometrium should include the anterior and posterior portions while excluding any endometrial fluids.
• Accurate evaluation and measurement of the endometrium is important especially in the presence of uterine bleeding. When measuring endometrial thickness on ultrasound, it is critical to ensure that the uterus is in a mid-sagittal plane, the whole endometrial lining is seen from the fundal region to the endocervix.
• The thickest portion is measured and the image is clear and magnified.
• Rotating the transducer 90 degrees counterclockwise (maintains correct orientation) allows for the display of the transaxial or transverse view of the uterus. The operator should fan the probe in the superior-inferior direction until the widest transverse view of the uterus is displayed. From this widest transverse view, the maximum width of the uterus is measured.
• On USG uterine relation to surrounding organs like ovaries, bladder and bowels can be assessed.
• Cervix as seen on USG with a clear layer of mucus in the cervical canal is a favourable sign re-ecting good level of oestrogen production.
• Important aspect of fertility scan is the examination of the endometrium in the assessment of endometrial receptivity based on the appearance like triple layer with the minimum thickness of 7mm and increased blood flow on colour doppler studies.
• On the 2nd day of menstrual cycle i.e. D2 endometrial lining is thin as most of it is shed.
• On the 9th day of menstrual cycle i.e. D9 the triple layer pattern is seen due to gradual increase in thickness of the endometrium due to the effect of the hormone called oestrogen. (This is the best time to asses endometrial polyp).
• On the 21st day of the menstrual cycle i.e. D21 the endometrial lining is homogenous and thick due to the effect of the hormone called progesterone.

• There are two ovaries on each side of the uterus in the ovarian fossa. They are oval in shape and with a mean volume of approx 4.9ml. The ovary often lies on the internal iliac artery and vein but does not maintain a consistent relationship with these vessels.
• On baseline imaging ovaries are evaluated for normal expected findings and to screen any abnormality.
• In the first half of the menstrual cycle (follicular phase) a normal ovary will demonstrate multiple Antral follicles which measures between 2-9 mm in maximum diameter, they are best evaluated on D2 or D3 of menstrual cycle. Normal AFC is 5-10 in each ovary, if AFC is < 4 combined in both ovaries it is decreased ovarian reserve. If AFC ≥ 12 in any/ either ovaries it indicates polycystic ovaries. Normal stromal blood flow velocity is 6-12cm/sec.
• In a natural cycle a dominant follicle of size 17-24mm develops in one of the ovaries matures and releases the egg (ovum) during ovulation.
• On color Doppler, flow velocity tends to increase at . …. and immediately after ovulation.
• After ovulation a corpus luteum is frequently seen during the second half of the menstrual cycle secretory phase).
• On power Doppler it appears like a ring of fire due to increased blood flow.
• Corpus luteum appears as a round anechoic cystic mass with a homogenous, thick, moderately echogenic wall.

TAS:

Bladder should be almost full so patient needs to drink more water.

Steps:

• Patient is made to lie down on her back.
• Abdomen is exposed with a bed sheet covering her legs.
• USG is performed with a trans abdominal probe after application of jelly on lower abdomen.

TVS:

Bladder should be empty.

Steps:

• Patient lies down on her back with legs flexed at knee and hip joints and legs apart.
• A transvaginal probe covered with jelly and probe cover is gently inserted inside the vagina and scan done.

Benefits of Ultrasound:

To look for any disease of the uterus, ovaries, tubes and adnexa

• Uterus: To look for size, shape, mobility, position, endometrial thickness, echogenicity of the endometrium and any masses in the uterine well. E.g. fibroids, polyps in the uterine cavity, adenomyosis. Color doppler for blood flow in the endometrium is done which predicts uterine receptivity.
• Ovaries: To look for size, volume, AFC, any ovarian cysts like follicular cysts, encapsulated cysts, dermoid cysts, endometriotic cysts, ovarian tumors etc. Color doppler of ovarian dominant follicle gives an idea of quality of the oocyte.
• Tubes: Normal fallopian tubes are not visualized in USG. If they are enlarged with fluid-filled in them as in Hydrosalpinx, they can be seen on USG.
• Adnexa: Any masses like pedunculated fibroids, cysts. E.g. Paraovarian cysts.

Q- Why is ultrasound done?

• To look for any disease in uterus, ovaries, tubes and pelvis – Which may cause Infertility.
• Done to asses uterus for size position Anteverted (anterior tilting)/ Retroverted (posterior tilting) Endometrial thickness (thickness of the uterine lining), Myometrium, cervix.
• In Ovaries to look for size, volume and follicular number.
• To look for any fluid in the pelvis (lower abdomen) which indicates infection or pelvic tuberculosis.

Q- How is it done?

• It is done by two methods TAS (Transabdominal scan) TVS (Transvaginal scan) – TAS is done with full bladder abdominally: It is preferred in patients who have vaginismis, enlarged uterus or other pelvic masses.
• TVS is done after emptying bladder by inserting probe gently inside vagina. It is mostly preferred over TAS as it provides a clear view of the uterus, ovaries and other pelvic structure.

Q- When it is done?

• It is done usually with respect to fertility assessment on D2, D9 and D21.
• D2 USG (2nd day of the menstrual cycle) is done to look for Antral Follicular Count (AFC) which predicts the fetility potential of the ovary and its response to treatment. Normal Antral Follicular Count (AFC) is 5-10 in each ovary of the size 2-9mm. -To look for any cysts (follicular, corpus luteal) from the previous menstrual cycle, endometrioma, dermoid cyst.
• D9 USG (9th day of the menstrual cycle) is done to look for Endometrial lining which is usually triple layered with good blood flow on using color Doppler, which indicates adequate Endometrial receptivity.
• D21 USG (21st day of the menstrual cycle) to look for secretory changes in Endometrium.

Diagnosis of Infertility – Young minds and hearts which are jubilant and ecstatic with the thought of starting their families and having children are shattered by the news that they can’t become parents on their own.

Whom to talk to and share the news and ask for help is the prime concern of young couples. Privacy of their lives is breached and so are their dreams and aspirations.

Individuals react to the diagnosis of infertility differently and it is normal to ask ‘Why me?’ and to feel sad, angry, worried or just totally shocked. However, for most people, it is the momentous emotional impact that takes them by surprise.

In our experience, they react to the situation in different ways depending upon their social support, spiritual evolution, and surrender to the situation.

Couples may be shocked or surprised and pray that this is a wrong diagnosis. They may not know how to react or may become quiet and isolated.

Some of them become angry, frustrated and blame each other and God for what is happening to them. They repeatedly ask themselves and us – why it is happening to them out of all people known to them.

Latter on the feeling of isolation sets in, initially from immediate friends, latter families, and then from themselves.

Finally, a great sense of loss occurs next some with constant grieving with the thought of delayed parenthood. Occasionally the negative emotions become excruciatingly intense and substantially demoralizing.

Learning to recognize the impending negative emotional conflict is necessary and it is essential to understand that facing these paralyzing issues at the onset is essential.

Facing the problem together with an ethical guide in the form of a compassionate IVF specialist, having trust in the family, and maintaining optimal spiritual and physical health are the cornerstone of infertility treatment.

Keeping these in mind we would be regularly writing on this platform various emotional outcomes of infertility management and methods to lessen if not completely eradicate the stress associated with the infertility treatment.

चमत्कार! महिला के हाथ में तैयार होंगे अंडाणु

नई दिल्ली ।। डिकल साइंस के क्षेत्र में देश में एक बड़ी कामयाबी मिलने की उम्मीद पैदा हुई है। भारत में एक अहम मेडिकल प्रक्रिया के तहत डॉक्टर पहली दफा एक महिला को उसकी बांह के अगले हिस्से (फोरआर्म) में अंडाणु विकसित करने में मदद करेंगे। अगर यह सफलतापूर्वक हो जाता है तो इससे कैंसर या अन्य उपचार की वजह से बांझपन का शिकार हुए मरीजों को एक बड़ी सौगात मिल सकती है।

यहां के आर्मी हॉस्पिटल रिसर्च एंड रेफरल के डॉक्टरों ने कैंसर मरीजों के ओवेरियन टिश्यू (गर्भाश्य उत्तक) को सुरक्षित रखा है। इन टिश्यू को वे बाद में उनके अग्रबाहु या पेट में उस समय इंप्लांट करेंगे, जब इन्हें संतान पैदा करने की इच्छा होगी। इन मरीजों को ओवेरियन टिश्यू से अंडाणु (एग्स) विकसित करने में मदद करने के लिए दवाएं दी जाएंगी।

आर्मी हॉस्पिटल रिसर्च एंड रेफरल के लेफ्टिनेंट जनरल नरेश कुमार ने बताया कि आगामी जनवरी महीने में पहली दफा हम बांझपन की शिकार एक महिला के फोरआर्म की त्वचा के अंदर उसके ही सुरक्षित रखे गए ओवेरियन टिश्यू को इंप्लांट करेंगे। ऐसा अंडाणुओं को विकसित करने के लिए किया जाएगा, जो निकट भविष्य में उसे मां बनने में मददगार साबित होगा। उन्होंने कहा कि इस तरह का इंप्लांट देश में पहली दफा हो रहा है।

गौरतलब है कि कैंसर का इलाज करवाने, जिसमें कीमोथेरपी, रेडियोथेरपी और रेडिकल सर्जरी शामिल हैं, की वजह से हर साल अनगिनत महिलाओं में समय से पहले ‘मीनोपॉज’ और बांझपन की समस्या आ जाती है और वे मां बनने की उम्र में रहने के बावजूद संतान सुख से महरूम रह जाती हैं।

इस अस्पताल की एआरटी क्लिनिक में आईवीएफ (इन विट्रो फर्टिलाइजेशन) के विशेषज्ञ कर्नल पंकज तलवार ने बताया, पुरुषों और महिलाओं के लिए कैंसर बेहद दुखद हो सकता है, क्योंकि इसका उपचार उन्हें बांझ बना सकता है। इस महिला के मामले में हमने उसके ओवेरियन टिश्यूज को उसका कैंसर का इलाज शुरू होने से पहले ही सुरक्षित रख लिया। अब यह महिला कैंसर से पूरी तरह मुक्त है। हमलोग अब लोकल एनिस्थिसिया का इस्तेमाल कर उसके फोरआर्म की स्किन के अंदर ओवेरियन टिश्यू इंप्लांट करेंगे। अगर इसके कुछ दिनों के बाद इंप्लांट की गई जगह पर मटर के दाने के बराबर उभार या सूजन आ जाता हैं, तो हमलोग इस प्रयोग को कामयाब मानेंगे। इसके बाद हमलोग इस उभार वाली जगह से अंडाणुओं को निकाल लेंगे और तब महिला इन-विट्रो फर्टिलाइजेशन (आईवीएफ) तकनीक से गर्भधारण कर सकती है। इस पूरी प्रक्रिया में तीन से चार महीने लगने की उम्मीद है।

अभी तक इस तकनीक का इस्तेमाल कर पूरी दुनिया में सात-आठ शिशुओं का जन्म हो चुका है। इस अस्पताल के डॉक्टरों ने अभी तक दो युवा कैंसर मरीजों के टेस्टिक्यूलर टिश्यू, 53 लोगों के स्पर्म सैंपल और 13 ऐसे मरीजों के ओवेरियन टिश्यू को सुरक्षित रखा है।

New Tech to Grow Eggs on Womens Arm – Doctors at Army Hospital Research and Referral have found a procedure to help women cancer survivors conceive. Every year, cancer treatment causes premature menopause and infertility in thousands of women of reproductive age in India.

The eggs will be grown in a woman’s forearm, which, the doctors at the hospital claim, is a first-of-its-kind procedure in the country.

“In January we will transplant her preserved ovarian tissue under the skin of her forearm to harvest eggs, which will help her conceive in the future. This is the first time that this type of transplant is taking place in the country,” said Lieutenant General Naresh Kumar, commandant, Army Hospital Research and Referral.

The ovarian tissue of cancer patients will be preserved in the lab before treatment, which can later be grafted on their forearm or abdomen when they would want to have children.

“The tissue will be pre-tested to avoid the possibility of any cancer cells in them, and to help the ovarian tissue to produce eggs, specifics drugs will be administered to these women,” said lieutenant-general Kumar.

The procedure brings a ray of hope for many couples, as premature menopause and infertility is a potential side-effect of cancer treatments such as chemotherapy, radiotherapy, surgery, etc.

“The woman, who is cancer-free, will undergo surgery under local anesthesia, wherein we’ll implant an ovarian piece beneath the skin of her forearm. The eggs should develop after some days. She will notice a pea-sized lump at the transplant site, from where we’ll extract eggs later for in-vitro fertilization,” said Kumar.

That’s about the new tech to grow eggs on womens Arm. The entire process is expected to take three to four months and costs between R1.5 lakh to R2 lakh.

First Published: Dec 29, 2010, 01:27 IST