Uterine Leiomyoma Variants: Case Reports and Literature Review

According to the World Health Organization (WHO) criteria for uterine smooth muscle, tumors have historically been distinct in benign leiomyomas, leiomyomas variants, and malignant leiomyosarcomas based on cytological atypia, mitotic rate, and presence or absence of tumor cell necrosis. Ultrasound, especially new techniques such as three-dimensional (3D)/four-dimensional (4D) ultrasound and 3D/4D color Doppler, is an excellent tool in the hands of ultrasonographers in the detection of atypical myomas and potential malignancy in uterine fibroids. Preoperative detection of malignancy in leiomyoma is a challenge for the ultrasonographer. It is very important to define an atypical leiomyoma by ultrasound examination because of its specificity, this type of leiomyoma can mimic leiomyosarcomas and can be precursors for the development of leiomyosarcoma. Keywords: Ultrasound morphology, Uterine leiomyoma variants, Three-dimensional/Four-dimensional ultrasound, Threedimensional power Doppler. Donald School Journal of Ultrasound in Obstetrics and Gynecology (2023): 10.5005/jp-journals-10009-197

Adnexal Masses

Fallopian tube inflammatory disease and tubal pregnancy are closely related. Inflammatory disease of the fallopian tubes leads to the inability for fertilization of the oocyte when the fallopian tube is completely closed; it also makes the path difficult for the gamete to transfer into the uterine cavity. The possibility of ectopic pregnancy is rising as a result of deformity and reduced mobility of the fallopian tubes. Most ectopic pregnancies occur in the fallopian tubes and rarely in other structures. It used to be difficult to diagnose an ectopic pregnancy, but now with two-dimensional (2D)/three-dimensional (3D) ultrasound and serum β human chorionic gonadotropin (hCG), the diagnosis is easy, and women with an ectopic pregnancy should no longer be in a situation where this pathological situation is a life-threatening diagnosis. Noninvasive transvaginal ultrasound (TVU) 2D/3D examination provides an opportunity for rapid selection of patients and candidates for direct laparoscopic (LPSC) access at the first examination in “everyday” practice. Due to the increased use of high-resolution TVU, around 80% of ectopic pregnancies are diagnosed on time, without severe abdominal hemorrhage. TVU identification of an adnexal mass, empty uterine cavity, and positive pregnancy test are the gold standard for diagnosis. Keywords: Ectopic pregnancy, Fallopian tube inflammatory disease, Positive pregnancy test, Transvaginal two-dimensional/three-dimensional ultrasound examination. Donald School Journal of Ultrasound in Obstetrics and Gynecology (2022): 10.5005/jp-journals-10009-194

Imaging of Acquired Uterine Lesions

In general, the group of acquired uterine lesions consists of enhanced myometrial vascularity (EMV)/arteriovenous malformation (AVM), the isthmocele, intrauterine adhesions (IUAs) (Asherman’s syndrome), and nabothian cysts. Uterine AVMs can be congenital or acquired. These vascular lesions can cause severe hemorrhage that can be life-threatening for a woman, so it has been recently suggested that curettage should not be performed in a patient who presents with abnormal uterine bleeding after an abortion or a delivery when there is an ultrasound-detected hypervascular area with turbulent flow within the myometrium. Color Doppler sonography is the preferred method of diagnosing uterine EMV/AVMs. The isthmocele is a myometrial defect resembling a pouch on the anterior wall of the uterine isthmus over a previous cesarean scar. Transvaginal ultrasound (TVUS) is the initial and most usual method described to assess the integrity of the uterus wall in nonpregnant patients. IUAs are also known as intrauterine synechiae or endometrial sclerosis. The most common presentation of Asherman’s syndrome is secondary infertility. Two-dimensional (2D)/three-dimensional (3D) TVUS is useful in measuring the thickness of the endometrial lining. Also, together with or without sonohysterography (injection of sterile saline into the uterine cavity) can show the adhesions that characteristically appear as “bridging bands” of tissue that distort the cavity. Nabothian cysts are a common occurrence on the cervix. These are retention cysts of the endocervical glands caused by chronic inflammation. 3D ultrasonography gives an excellent image and the possibility of detecting nabothian cysts. Keywords: Color Doppler sonography, Enhanced myometrial vascularity/arteriovenous malformation, Intrauterine adhesions (Asherman’s syndrome), Nabothian cysts, The isthmocele, Transvaginal ultrasound, Three-dimensional ultrasonography. Donald School Journal of Ultrasound in Obstetrics and Gynecology (2022): 10.5005/jp-journals-10009-194

2D/3D Ultrasound Findings of Uterine Carcinosarcoma: A Case Report and Literature Review

Uterine carcinosarcoma is an infrequent, yet an invasive malignant tumor of the uterus. We presented the case of a 76-yearold menopausal woman with the first sparse bleeding and ultrasound findings of a large polypoid formation filling the uterine cavity. Ultrasound, specially more advanced techniques as 3D ultrasound and 3D Color Doppler ultrasound provide very useful data not only in the recognition of tumor mass, but also in terms of the structure, differentiation and stage of the malignancy. Keywords: 2D ultrasound, 3D color Doppler transvaginal ultrasound, Uterine carcinosarcoma. Donald School Journal of Ultrasound in Obstetrics and Gynecology (2022): 10.5005/jp-journals-10009-192

Uterine Fibroids (Leiomyoma, Myoma)

Uterine fibroids (leiomyomas, myomas) are the most common tumor formations of the uterus. These are tumors with benign potential and the occurrence of malignancy or finding of leiomyosarcoma is rare. Fibroids can occur in any part of the uterus. They can appear on the cervix and the corpus in the broad ligament. The general classification of fibroids is based on their localization and is divided into intramural, submucosal, and subserosal fibroids. The appearance of uterine fibroids on ultrasound is determined by the structure of the tumor itself. Therefore, there are several types of classifications that aim to localize the tumor itself preoperatively. The most commonly used one now is by the International Federation of Gynecology and Obstetrics (FIGO) PALM-COEIN (polyp, adenomyosis, leiomyoma, malignancy and hyperplasia, coagulopathy, ovulatory dysfunction, endometrial, iatrogenic, and not yet classified) classification. From what has been stated so far, it can be seen that ultrasound is essential in the detection of fibroids, their number, dimensions, and topography in terms of the body of the uterus, but also important information about the relationship between the tumor and the cavity of the uterus. Three-dimensional (3D) ultrasonography improves the image of leiomyoma, volume, and localization. With 3D saline infusion sonohysterography (SIS) ultrasonography, it is possible to make a solid presurgical score et sub mucous leiomyoma in terms of treatment choice and certainly a prognosis in terms of preserving the reproductive potential of the uterus. Keywords: International Federation of Gynecology and Obstetrics, Three-dimensional saline infusion sonohysterography ultrasonography, Three-dimensional ultrasonography, Uterine fibroids (Leiomyomas, Myomas). Donald School Journal of Ultrasound in Obstetrics and Gynecology (2022): 10.5005/jp-journals-10009-194

Everyday Practice of 2D/3D Vaginal Ultrasound in Reproductive Gynecology

The key point of this review is to evaluate the diagnostic capability of the initial 2D/3D vaginal ultrasound (US) for the most common conditions that have negative impact on the reproductive potential in women. From our experience with 2D/3D transvaginal US as the initial examination in more than 10,000 patients in the last couple of years, we choose specific cases of different pathologies such as fibroids, endometrial polyps, endometrial synechiae, uterine congenital anomalies, polycystic ovaries (PCOs), ovarian follicular monitoring, and endometrial receptivity assessment. Vaginal US is the method of choice for initial examination in evaluation of the reproductive potential in female patients. The 2D vaginal US examination gives only preliminary data, while the 3D vaginal US increases the efficiency and predictive value of the examination. Some pathologies detected on 2D vaginal US such as uterine anomalies, in general, indicate the presence of the anomaly, while 3D vaginal US fully detects the type of uterine anomalies. Doppler techniques bring detection of neovascularization in specific pathologies and give a view of the vascularization in general, which is essential in this field. Combination of 2D and 3D US is a powerful tool in the hands of a gynecologist in everyday practice. Improvement in 3D, 3D Doppler, and power Doppler vaginal US supplemented with new software tools rises the predictive value of US in the diagnosis of female reproductive system pathology and makes it equal with other diagnostic tools such as magnetic resonance imaging. On the contrary, 2D and 3D US examination are less traumatic for the patients and are less expensive. Keywords: 2D/3D ultrasonography, 3D Doppler, Reproductive gynecology. Donald School Journal of Ultrasound in Obstetrics and Gynecology (2020): 10.5005/jp-journals-10009-164

Immature Ovarian Teratoma

We present our experience of diagnosing immature ovarian teratoma with 2D and 3D vaginal ultrasound. A 29-year-old female patient with no symptoms was examined for routine gynecology examination before the start of an in vitro fertilization program. The patient had two previous surgeries both for ovarian cystectomy and histopathology finding of mature cystic ovarian teratoma. Left oophorectomy was performed for complex ovarian mass that demonstrated immature ovarian teratoma on final pathology. The neoplasm was well-differentiating (low-grade), according to two-tiered (low- and high-grade) system, and in IA stage, according to the Union for International Cancer Control (UICC) and American Joint Committee on Cancer (AJCC). The oncologist's council proposed that no treatment is needed. Keywords: 2D/3D ultrasonography, Immature teratoma, Ovarian teratoma. Donald School Journal of Ultrasound in Obstetrics and Gynecology (2020): 10.5005/jp-journals-10009-167

The day of embryo transfer affects delivery rate, birth weights, female-to-male ratio, and monozygotic twin rate

Objective To compare the reproductive outcomes between the transfer of cleavage-stage embryos and blastocysts in two different age groups of patients. The reproductive capacity of women decreases by age. This decrease in capacity is directly related to a lower ovarian reserve and errors in the meiotic spindle of the oocyte, which increase chromosomal abnormalities and the formation of aneuploidy embryos with lower chances of implantation. Materials and Methods A total of 1400 intracytoplasmic sperm injection cycles were analyzed. The study patients were divided into two age groups [aged < 36 years (Group I) and aged ≧ 36 years (Group II)]. The groups were subdivided according to the day of embryo transfer (ET)—Day 3 (ET3) and Day 5 (ET5). Results In both age groups, transfer of blastocysts resulted in a higher clinical pregnancy rate and deliveries. An increased twin birth rate was observed in patients who were younger than 36 years on both transfer days compared with those who were older than 36 years of age. There was an elevated percentage of newborn males on ET5 in both age groups. Monozygotic twinning (MZT) rate was observed only among younger patients (<36 years of age), specifically on ET5 compared with ET3. There was no significant difference in the mean birth weight of singleton and twins between the ET3 and ET5 subgroups in the younger group of patients except for the triplets who were significantly heavier in the ET5 group compared with the older group (≧36 years of age) where significant difference was found only on the mean birth weight of singleton. Conclusion The study suggests that if a blastocyst can be obtained in patients of advanced age (≧36 years), it improves their baby take-home rates. Younger patients (aged < 36 years) should undergo elective single blastocyst transfers to reduce multiple pregnancy rates

Impact of active female smoking on controlled ovarian stimulation in intracitoplasmic sperm insemination cycles

Aim To examine the impact of smoking among females on controlled ovarian stimulation (COS), at intra-cytoplasmatic sperm injection (ICSI) outcome. Methods A prospective analysis of outcomes of 876 women (fresh, non donor cycles) of which 559 (63.8%) were non-smokers, 317 (36.2%) were smokers, underwent standard COS/ICSI treatment. Results Among smokers, the average time of COS, expressed in days, was significantly longer compared with non-smokers (10.5±2.10 vs. 10±1.90 p<0, 05). There were no registered significant differences in the number of retrieved oocytes, (10.4±6.8 vs10.3±6.9), mature oocytes (8.6±5.8 vs. 8.4±5.9), in the group of non-smokers versus smokers. However, smoking and age have a significant impact of the number of high-quality embryos, i.e. older smokers had a lower number of high-quality transferred embryos (non-smokers ≥ 35 years : smokers ≥ 35 years; 1.9±1.1 vs. 1.6±1). On multiple logistic regresion analysis, factor that had a significantly negative impact of clinical pregnancy was maternal age. Conclusion Smoking among patients entering the COS and ICSI fertilization process had insignificant negative impact on the final outcome of the process resulting in reduced pregnancy rate. The chance for the pregnancy declines with age, but smoking did not significantly influence the outcome. Key words: in vitro fertilisation, high - quality embryos, clinical pregnancy rat