The Application Of Transvaginal Sonography In Assisted Reproductive Technology

With the postponement of child-bearing age and increased incidence of infertility, assisted reproductive technology (ART) has now been widely used in clinic. How to evaluate the embryonic developmental status accurately in the first trimester has always been a hot subject. The high-resolution transvaginal sonography (TVS) is currently the best way to check early pregnancy and of great importance in evaluating the developmental condition of embryo as well as predicting pregnancy failure.In natural pregnancy, gestational age (GA) is estimated based on the last menstrual period (LMP) or crown-rump length (CRL), which may deviate from the actual GA. However, in the IVF-ET procedure, the date of conception is quite accurate.In this study, we diagnosed heterotopic pregnancy (HP) after in vitro fertilization-embryo transfer (IVF-ET) using TVS, investigated the ultrasonographic markers (gestational sac diameter GSD, crown-rump length CRL, heart rate HR, yolk sac diameter YSD) of embryos, and analyzed aborted embryos by comparative genomic hybridization analysis (CGH) together with fluorescence in situ hybridization technology (FISH), which presenting small gestational sac, early symmetrical arrested growth and other ultrasonic morphological types in early pregnancy. And then we evaluated the diagnostic value of TVS in diagnosing HP as well as the predictive value of ultrasonographic markers for pregnancy outcomes in the first trimester and investigated the correlation between different ultrasonic morphological types and abnormal karyotypes in embryos from patients with early pregnancy loss (EPL) after IVF-ET. This study was divided into three parts as follows: CHAPTER ONEValue of transvaginal sonography in diagnosing heterotopicpregnancy after in vitro fertilization-embryo transferOBJECTIVE:To evaluate the diagnostic value of transvaginal sonography (TVS) in the diagnosis of heterotopic pregnancy (HP) after in vitro fertilization-embryo transfer (IVF-ET).METHODS:From January2005to December2011,16,483women received IVF-ET treatment and were diagnosed as clinical pregnancies by TVS in the reproductive center of our hospital,184out of whom were diagnosed as with a HP. We carried a retrospective review study for the clinical data of132cases, whose HPs were confirmed by surgeries and pathological examinations. The HP diagnosis was made if a visible intrauterine gestational sac was detected by TVS with any of the following indicators:(1)a yolk sac and/or fetal pole±cardiac activity in an extrauterine sac or (2) an empty extrauterine gestational sac observed as a hyperechoic ring; or (3) an inhomogeneous adnexal mass or blob sign adjacent to the ovary that moved separately from the ovary.RESULTS:1. Of the16,483women who had clinical pregnancies,174cases were diagnosed as having a HP by TVS, and10cases were missed, with an incidence of1.12%(184/16,483).52cases who were treated expectantly were excluded from the analysis due to lacking of pathological diagnosis. In the122HPs which were diagnosed by TVS and confirmed by surgeries and pathological examinations, three types of ultrasonographic images of ectopic pregnancy (EP) were seen:with a gestational sac found in70cases, a ring sign in21and an adnexal mass in31. The sensitivity and specificity of TVS in detecting HP were92.42%(122/132) and100%(16351/16351), with positive and negative predictive value of100%(122/122) and99.94%(16351/16361) respectively.2. According to the occurrence site, the132HPs confirmed by surgeries and pathological examinations were comprised of103tubal EPs and29non-tubal EPs. And the intrauterine pregnancy (IUP) outcomes were:93patients (70.45%) resulted in a live birth,37patients (28.03%) suffered an early miscarriage and2patients (1.52%) had a late miscarriage. There was no death in this study.CONCLUSION:The incidence of HP significantly increased in IVF-ET procedure. TVS promotes the early diagnosis and appropriate treatment for the unruptured EPs. And it is of great significance in the maintenance of the IUP till a term delivery and the prevention of the occurrence of adverse pregnancy outcomes. CHAPTER TWOValue of transvaginal sonography in predicting pregnancy outcomes after in vitro fertilization-embryo transferOBJECTIVE:To investigate the gestational sac diameter (GSD), crown-rump length (CRL), heart rate (HR) and yolk sac diameter (YSD) of embryos in6-10gestational weeks using TVS after IVF-ET and to assess the correlation between these ultrasonographic markers and gestational age (GA). And then, to evaluate the predictive value of these markers for pregnancy outcomes combined with maternal age (MA) and vaginal bleeding.METHODS:This was a retrospective review study.2601women were diagnosed with a single live embryo by TVS in the6-10gestational weeks from January2010to May2011in the reproductive center of our hospital. They were divided into two groups:the continue pregnancy group (n=2400) and the early miscarriage group (n=201). Patients in the continue pregnancy group were followed untill born. When the TVS examination was given, we measured the GSD, CRL, HR, YSD and recorded MA, vaginal bleeding and related other markers at the same time. Finally, we evaluated the predictive value of sonographic markers together with MA, vaginal bleeding and other markers.RESULTS:1.There was a statistically significant difference in the MA between the continue pregnancy group and the early miscarriage group (30.60±4.31years VS32.67±4.35years, p<0.05); And the early miscarriage rate differed significantly among different MA groups (p<0.005).2.GSD, CRL, HR and YSD respectively had a linear correlation with GA (p<0.05) in the continue pregnancy group.3.The difference in GSD, CRL, HR and YSD of embryo between continue pregnancy group and the early miscarriage group were significant (p<0.05) in different GA except67-69gestational weeks due to small sample size (n=3); YSD differed significantly between these two groups only in some GAs (p<0.05)4.The ongoing pregnancy rate was92.27%when embryo was alive in6-10gestational weeks. When GSD, CRL, HR respectively below and YSD beyond (too small or too large) the normal reference range of the continue pregnancy group, the ongoing pregnancy rate were57.22%,51.00%,58.90%,71.60%, respectively. Four normal markers contributed to an ongoing pregnancy rate of97.32%; only6.90%when all four markers were abnormal. The value of each marker to predict the risk of miscarriage:GSD (OR=14.51), CRL (OR=22.08), HR (OR=22.38), YSD (OR=6.19), MA (OR=2.24), BLOOD (vaginal bleeding)(OR=5.21).5.The sensitivity of single ultrasonographic marker (GSD, CRL, mHR, YSD) to predict early pregnancy outcomes was41.29%,50.25%,65.67%,27.86%; And the specificity was95.38%,95.63%,92.13%,94.13%in6-10gestational weeks, respectively.6.Multivariate logistic regression analysis to predict pregnancy outcomes:GSD, CRL, YSD, HR, MA, BLOOD were risk factors for pregnancy outcomes.LogitP=-5.161+1.401GSD+1.876CRL+2.341HR+1.150YSD+0.530MA+2.006BLOOD.The efficiency of this equation to predict an early miscarriage was with a sensitivity of51.74%, specificity of99.29%, positive predictive value of85.95%, negative predictive value of96.09%, false-positive rate of0.71%, and the diagnostic accurate rate of95.62%.CONCLUSION:1. In the6-10gestational weeks after IVF-ET, older MA, vaginal bleeding, small gestational sac, short CRL, slow fetal heart rate and abnormal yolk sac (too large or too small) related to adverse pregnancy outcomes.2. Sonographic markers (GSD, CRL,HR, YSD) in early pregnancy together with MA, vaginal bleeding had important value in predicting pregnancy outcomes. CHAPTER THREE Correlation between ultrasonic morphological types and karyotypes in early pregnancy loss after in vitro fertilization-embryo transfer OBJECTIVE:To investigate the correlation between ultrasonic morphological types and karyotypes in embryos from patients with early pregnancy loss (EPL) after in vitro fertilization-embryo transfer(IVF-ET).METHODS:This retrospective analysis included patients who had been diagnosed by TVS as early single pregnancy loss after IVF-ET between January2005and December2011. All793aborted embryos had undergone cytogenetic analysis by comparative genomic hybridization analysis (CGH) together with fluorescence in situ hybridization technology (FISH). Correlation between ultrasonic morphological types and karyotypes was evaluated. Based on different ultrasonic morphological features, we classified the embryos into6types:empty sac, gestational sac with only yolk sac, normal ultrasound type, early symmetrical arrested growth, small embryo-fetus, and small gestational sac.RESULTS:1. In the793EPLs, the abnormal karyotype rate was44.77%(355/793); And the abnormal karyotype rate of different ultrasonic morphological types were as follows:small gestational sac of58.33%(14/24), early symmetrical arrested growth of56.17%(91/162), small embryo-fetus of50.49%(52/103), normal ultrasound of44.67%(67/150), anembryonic pregnancy of44.51%(77/173) and empty gestational sac of29.83%(54/181); The prevalence of chromosomal abnormalities was significantly higher in early symmetrical arrested growth group and markedly lower in empty sac group than that in total (p<0.05)2. Trisomy16(19.44%), monosomy X (13.80%), trisomy22(11.83%),trisomy21(7.04%), trisomy13(5.07%), and trisomy20(4.79%) were in turn the most frequent chromosomal abnormalities in the EPLs after IVF-ET, accounting for61.97%(220/355).3. The correlation between different ultrasonic findings and abnormal karyotypes were: (1) Trisomy16and trisomy22were found to be the most common karyotypes in EPLs presenting early symmetrical arrested growth, anembryonic pregnancy and small embryo-fetus.(2) Majority cases of the empty gestational sac were found to be correlated with monosomy X and trisomy22;(3) The most frequent chromosomal anomalies in EPLs with normal ultrasound were monosomy X and trisomy21;(4) Small gestational sac group had no obvious correlation with specific chromosomal abnormalities.CONCLUSION:1. There was a correlation between ultrasonic morphological types and karyotypes in EPLs after IVF-ET. And the early symmetrical arrested growth group had a higher rate of chromosomal abnormalities than that of the empty gestational sac group.2. Six types of chromosomal abnormalities (trisomy16, trisomy22, monosomy X, trisomy21, trisomy13and trisomy20) had the most frequency in the EPLs after IVF-ET.3. There was a correlation between different ultrasonic findings and specific abnormal karyotypes.