3. 輸卵管 可抓到卵暢通 4. 子宮腔 內膜夠厚

Transcription

1 受孕四大必要條件 Hysterosalpingography; HSG Basic Body Temperature; BBT 彰基婦產部生殖醫學中心 中山醫學大學 吳信宏 協同主任 兼任助理教授 1. 精子 數目活動力外型 2. 卵子 成熟排卵 3. 輸卵管 可抓到卵暢通 4. 子宮腔 內膜夠厚 2009/10/ /10/8 2 胚胎成長 20 精卵結合 胚胎植入 Hysterosalpingography; HSG 卵子排出 精子進入 2009/10/8 3 1

2 HSG For evaluation of infertility HSG is, an average performed in 10 minutes, involves approximately 90 seconds of fluoroscopic time, and has an average radiation exposure to the ovaries of 1 to 2 rads. HSG 作的時機 Hysterosalpingography is performed between cycle days 5 and 10, following cessation of menstrual flow to to minimize infection and the the risk of flushing an ovum from the fallopian tube. 2009/10/ /10/8 6 The test causes cramping 檢查前 a nonsteroidal anti-inflammatory inflammatory drug taken 30 minutes prior to the procedure may minimize discomfort. 裝 Injection set An acorn cannula, pediatric Foley catheter,, or designated injection catheter is introduced just inside the external cervical os and contrast media is injected. A paracervical block may be indicated in selected patients, such as those with cervical stenosis. 2009/10/ /10/8 8 2

3 打顯影劑及攝影 Because rapid injection may cause tubal spasm, a slow injection of usually no more than 3 to 4 ml of media allows a clear outline of the uterine cavity. Generally, only three radiographic views are needed 1. a preliminary view before injecting contrast, 2. a view showing fill of the uterine cavity,, and 3. a third demonstrating spill of contrast from the tubes into the peritoneal cavity. Comparison of Oil-Based versus Water-Based Dye Used in the Hysterosalpingogram Fertility enhancement Patient discomfort Image quality Embolization Granuloma Oil: higher pregnancy rates Water: less cramping Water: rugae seen Oil: better image Minimal risk with either dye Greater risk for retained oil 2009/10/ /10/8 10 Hysterosalpingography Hysterosalpingography is generally performed on cycle day numbers 5 through 10. At this time, there should be minimal intrauterine clotting that could block tubal outflow or give the false impression of an intrauterine abnormality. Furthermore, a woman should not have ovulated and possibly conceived. For this test, iodinated contrast medium is 1. infused through a catheter 2. placed into the uterus. 3. filled the uterine cavity, then the tubal lumen 4. finally spilled out of the tubal fimbriae into the pelvic cavity 2009/10/8 11 輸卵管攝影 ( 影片由 MERCK SERONO 提供使用 ) 2009/10/8 12 3

4 The endometrial cavity is Normal HSG usually triangular or sometimes T-shapedT in the anteroposterior projection. In the lateral view it is oblong. The contour of the endometrium is usually smooth. It occasionally appears to have polypoid-filling defects that can be isolated or diffuse, and can be difficult to distinguish from endometrial polyps or hyperplasia (Lindheim( Lindheim, 2003a). Inadvertent injection of air bubbles introduces artifact. 2009/10/8 13 Contraindications to HSG 1. acute pelvic infection 2. active uterine bleeding 3. pregnancy 4. iodine allergy 2009/10/8 14 Complications of HSG Rare but can be serious. Acute pelvic infection The overall risk of acute pelvic infection serious enough to require hospitalization is less than 1 percent,, but may be up to 3 percent in women with prior pelvic infection (Stumpf( Stumpf,, 1980). Because of serious morbidity, routine prophylaxis is given with doxycycline orally, 100 mg twice daily, beginning the day before HSG and continued for 2 more days thereafter. 2009/10/8 15 In addition Complications of HSG Pelvic pain, uterine perforation, and vasovagal reactions may occur. Complications from the contrast include allergic reactions and entry into the vascular system with high injection pressures. Embolic phenomena, pelvic peritonitis, and granuloma formation with oil-based contrast agents are rare. 2009/10/8 16 4

5 A. Normal hysterosalpingogram. Radiopaque dye fills the uterine cavity and spills from both fallopian tubes into the peritoneal cavity. The dye catheter is seen beneath the endometrial contour. 2009/10/8 17 B. Asherman syndrome. Contrast dye fills a small and irregularly shaped endometrial cavity, often described as having a "moth-eaten" appearance. 2009/10/8 18 Tubal Disease C. Bilateral hydrosalpinges.. Note the marked tubal dilation and lack of spill of contrast medium at the fimbrial ends. 2009/10/8 19 In a large meta-analysis, analysis, HSG was demonstrated to have 65-percent sensitivity and 83-percent specificity for tubal obstruction (Swart,( 1995). ). Tubal contractions, particularly cornual spasm,, can give the incorrect impression of proximal fallopian tube obstruction (a false-positive result). Less common false-negative result 2009/10/8 20 5

6 One occlusion, one patent Many causes of tubal disease affect both tubes, and therefore it is clinically unusual to have unilateral disease. Unilateral obstruction with a normal contralateral tube is most likely due to the dye following the path of least resistance during the HSG procedure, however, laparoscopy with chromotubation should be considered prior to treatment to confirm a final diagnosis. Not for pelvic adhesion Hysterosalpingography is not reliable in detecting peritubal or pelvic adhesions, although loculation of dye around the tubes may be suggestive (see Fig. 19-5). Thus, HSG is an excellent predictor of tubal patency,, but is less effective at predicting normal tubal function or the presence of pelvic adhesions. 2009/10/ /10/8 22 Increase pregnancy rate Pregnancy rates have been reported to be increased following HSG, and have been suggested to result from flushing of intratubal debris. However, these reports followed evaluation with oil-based dyes rather than water-based dyes, which are currently preferred. Uterine Pathology Hysterosalpingography also provides analysis of the contour of the intrauterine cavity. A polyp, leiomyoma,, or adhesion within the cavity will block dye diffusion, resulting in an intrauterine "defect" in dye opacity on radiograph (Fig.( 19-6). False-positives may be obtained due to the presence of blood clots, mucus plugs, or shearing of the endometrium during placement of the intrauterine catheter. 2009/10/ /10/8 24 6

7 A. A broad-based based filling defect is formed during HSG by a submucous leiomyoma.. Note distortion of the left cornu by this mass. 2009/10/8 25 B. A more irregular filling defect is created by an endometrial polyp. Note that polyps generally have a less substantial attachment to the myometrium 2009/10/8 26 Uterine anomalies In general, developmental uterine anomalies are not causative for infertility,, but may be associated with miscarriage or later fetal loss, creating a management dilemma. It may be reasonable to surgically treat a uterine anomaly in an effort to improve pregnancy outcome. However, a couple must be carefully counseled that fertility itself is unlikely to be affected. Classification of müllerian anomalies. DES = diethylstilbestrol. 2009/10/ /10/8 28 7

8 A. Bicornuate uterus, due to a failure of fusion of the müllerian ducts, produces a fundal defect with wide- spaced uterine horns. 2009/10/8 29 B. Septate uterus due to a failure of resorption.. This moderate septum displaces the radiopaque dye to the level of the radiolucent injector balloon. 2009/10/8 30 Y-shaped uterus C.. Uterine didelphys consisting of two completely separate müllerian systems including duplication of the cervix. 2009/10/8 31 A Y-shaped Y uterus on hysterosalpingography may represent either a uterine septum or bicornuate uterus. In these cases, the external contour of the uterine fundus must be evaluated using MR imaging, high resolution sonography, or laparoscopy (see Fig ). A smooth fundal contour is consistent with a diagnosis of uterine septum. This is an important distinction, as a septum is often resected,, but a bicornuate uterus is generally not treated. 2009/10/8 32 8

9 HSG for intrauterine lesion Transaxial T2-weighted MR image of a septate uterus. A low-signal signal- intensity fibrous septum separates the two high-signal signal-intensity intensity endometrial cavities (arrow( ) and the fundal contour is normal, without indentation. 2009/10/8 33 Hysterosalpingography has been shown to accurately identify intrauterine pathology. In one study of over 300 women in which hysteroscopy was used as the gold standard, HSG was determined to be 98- percent sensitive and 35-percent specific,, with a positive predictive value of 70 percent and a negative predictive value of 8 percent. Most misdiagnoses were due to an inability to distinguish polyps from submucous leiomyomas,, a minimal problem, as these patients will undergo further evaluation and treatment in either case (Preutthipan( Preutthipan,, 2003; Randolph, 1986). Although other studies have not provided such impressive results, it is clear that HSG is a powerful tool for evaluation of the uterine cavity. 2009/10/8 34 Methods of septate and bicornuate uterus repair. A. Wedge excision of a septate uterus. B. Strassman technique repair of a bicornuate uterus. C. Tompkin technique repair of a septate uterus. 2009/10/8 35 Hysteroscopic photograph of a uterine septum. The flesh-colored septum divides the endometrial cavity into halves. (Courtesy of Dr. Kevin Doody.) 2009/10/8 36 9

10 Basic Body Temperature; BBT Hysterosalpingogram of a patient with Asherman syndrome. This image is digitally reversed, with the radiopaque contrast medium appearing black against a radiolucent background. Irregular filling defects (arrows( ) are seen within the endometrial cavity. (Courtesy of Dr. Kevin Doody.) 2009/10/8 37 Basal body temperature (BBT) Basal body temperature (BBT) charting has long been used to identify ovulation. This test requires that a woman's morning oral temperature be graphically charted. Oral temperatures are usually 97.0 to 98.0 F F during the follicular phase. A postovulatory rise in progesterone levels increases basal temperature by approximately 0.4 to 0.8 F. This biphasic temperature pattern is strongly predictive of ovulation (Bates,( 1990). Basal body temperature (BBT) Nevertheless, although this test has the advantage of being inexpensive,, it is insensitive in many women. Furthermore, for a couple wishing to conceive, the temperature increase follows ovulation, and therefore the window of maximal fertility has been missed (Grinsted( Grinsted,, 1989; Luciano,, 1990; Moghissi,, 1992). Although this test may be useful for a couple first attempting to conceive, it has generally fallen out of favor as an infertility diagnostic tool (Fig.( 19-4). 2009/10/ /10/

11 如何知道卵巢功能 Biphasic pattern seen on this basal body temperature chart suggests ovulation. 2009/10/ 年齡 2. 月經週期第三天的濾泡刺激激素 (FSH( FSH) ) 數值 3. 月經週期第三天的黃體化激素 (LH( LH) ) 數值 4. 月經週期第三天的女性賀爾蒙 (E2( E2) ) 數值 5. 口服排卵藥物 Clomiphene 刺激試驗 6. 超音波檢查 7. 多囊性卵巢症候群評估 一般而言,FSH, 關係排卵數目, 而年齡關係排卵品質 2009/10/8 42 Biophysical Ultrasound: 2D or 3D Ovarian volume Antral follicle count (AFC) Ovarian stromal blood flow Uterine dimensions Follicle density Biochemical Basal (early follicular) levels: FSH, LH, E2 Inhibins and activins Anti-Müllerian hormone (AMH) Ovarian stimulation tests: GnRH agonist stimulation test (G-test) hmg test Clomiphene citrate challenge test (CCCT) 1. 月經規律性 2. 排卵自覺徵兆 3. 基礎體溫表 (BBT) 如何知道排卵 4. 測量尿液 ( 或其他方法 ) 排卵激素 (LH) 反應 5. 超音波或抽血追查排卵反應 FSH (EFORT) 2009/10/ /10/

12 % of cycles Probability of Ovulation Relative to Midpoint of the Cycle 4.3 < Mid-pt > Days Peak day used as proxy of ovulation Source: IRH analysis of WHO 1981 data /10/ 自覺排卵 月經週期 基礎體溫 尿液排卵試劑 子宮頸黏液 2009/10/ /10/ /10/

13 量基礎體溫 Basal Body Temperature Method (BBT) 2009/10/ % 2009/10/8 50 Urine LH kits These kits are commercially available and require testing daily urine samples for the presence of the hormone LH,, which is the trigger to ovulation. If a surge in LH is detected, ovulation is about to occur and timing for intercourse or inseminations is optimal for that day and the next day. These tests have been shown to be quite accurate in detecting ovulation, although about 7% of the time an LH surge is detected but no ovulation occurs. 子宮頸黏液 A = Intermediate type mucous B = Infertile type mucous C = Fertile type mucous 2009/10/ /10/

14 排卵日前後的受孕機率 (0 為排卵日 ) % 11% 15% 20% 26% 15% 9% 5% 0% 2009/10/ /10/ /10/ /10/