Transcript

Hi, everybody.

This is Dr. Jason Cox. I'm here tonight with Dr.

Gavin Puthoff. Uh,

tonight we're gonna be talking about a topic that, um,

centers around fertility.

I,

So, as usual, we have some housekeeping things to get

to before we start.

Um, this production's being put on by the Institute

for Advanced Medical Education.

The Institute for Advanced Medical Education is accredited,

uh, by the, in, by the, excuse me,

accreditation counsel for continuing medical education,

the A-C-C-M-E.

Um, the IAME designates this activity to be, uh,

one A-M-A-P-R-A category one credit.

Um, and physicians and attendees should only

claim the amount of credit that is commensurate

with their extent of the participation, uh, in compliance

with the essentials and standards of the A CC me.

The authors and the planners of this activity,

including myself and Dr.

Poff, disclose no financial relationships

with commercial interests or ineligible companies.

Um, any identified relevant conflicts

of interests which may have occurred have been mitigated

through the planning and content review process.

So, um,

everybody attending this webinar tonight should expect

to learn how to, um, apply an algorithmic approach

to the utilization of sonography in the diagnosis

and treatment of infertility.

Uh, learners will be able to

identify common structural abnormalities, um,

as demonstrated on ultrasound that contribute

to infertility, and then sonographers

and other members of the fertility team will be able

to employ ultrasound in their practice according

to the most recent guidelines and best practices.

Um, we do want to invite everybody here tonight to, um,

go ahead and check us out@ime.com.

There you can sign up for membership,

and that's also where you're gonna get your credit

for this webinar.

Um, and then stay completely to the end so

that you can get the link on how you can actually log in

and claim your credit.

Uh, we are taking attendance.

So typically, you know, when we do our educational events,

um, you know, we've had sonographers, we have

O-B-G-Y-N doctors, we have radiologists, um, on board

that are all part of the, uh, women's health team.

Right? And tonight specifically, we've got Dr.

Gavin Poff, uh, who's a, uh, fertility expert.

And I'd like to just take a brief moment to introduce him.

Um, Doctoroff is the founder

and medical Director of Veritas Fertility and Surgery.

He's a board certified gynecologist specializing in the

treatment of infertility, recurrent miscarriages,

endometriosis, and other gynecological conditions.

He's trained in surgical, how do we say this?

N PRO technology, N pro technology, um,

which is an advanced form of reproductive surgery

we're already learning here.

Uh, Dr. Poff earned his medical degree at the, uh,

university of Texas at Houston,

and he's completed his residency in obstetrics

and gynecology at Mercy Hospital St.

Louis for everybody at St. Louis.

We know that's colloquially called the baby factory.

That's right. That's right. It's a place to train.

Um, after he, uh, finished residency,

he completed his fellowship in medical

and Surgical N Pro Technology at the St.

Paul Institute

and Creighton University Medical Center in Omaha, Nebraska.

In 2015, Dr.

Puthoff started Mercy Clinic Fertility Services,

where he had the privilege of caring for many women

and couples seeking answers

and effective solutions for infertility

and other gynecologic conditions.

In 2020, Dr. Puthoff felt called to open Veritas fertility

and surgery to better meet the needs of his patients

with a concierge approach to fertility treatment

and advanced reproductive surgery.

Uh, Dr. Puthoff and his wife have seven children. Yep.

That's not a typo. It's not a typo. That's legit. Yes.

And he and his family enjoy bike rides,

spending time together, outdoors and family.

Movie nights must be amazing with seven kids.

Yes, it's a good time. We can fill up a couch for sure.

Yeah. So, just to introduce myself,

if you haven't met me before, I'm a, uh,

fellowship Trade Board certified radiologist

with over a decade of experience in clinical, uh,

and teaching radiology.

I personally specialize in ultrasound,

and I'm ultra specialized in musculoskeletal imaging.

I actually read, um, diagnostic obstetric

and gynecology ultrasounds every single day,

all day long when I'm not doing this.

Um, I have a clinic in St.

Louis that specializes in ultrasound.

Sometimes we get to, uh, the honor of working with Dr. Poff.

Um, and, uh, you know, one thing

that we're talking here today is kind of

how the collaboration between the radiology department, uh,

general ob, GYN, specialty OB GYN

and fertility, um, there's a lot

of different perspectives on how we do this, um, and,

and how he runs his algorithm

for the fertility treatment specifically.

You know, uh, radiologists

and sonographers, um, when they get out of training,

they kind of pick up a lot more stuff along the way

and through these collaborative talks, that's where

that information comes from.

That's not available to you from an institutional basis.

Um, I can tell you for sure, you know,

I learned a ton in my fellowship.

I learned a ton in my residency.

But then having worked in numerous different institutions,

I've, I've picked up a lot of information

that has been very helpful to me and my patients, um,

and my, my collaborating physicians.

So, without further ado, let's talk

Fertility. Sounds good.

Well, first of all,

I just wanna say real quick, uh,

thanks so much for having me on.

Uh, I think this is an awesome opportunity to be able

to share the knowledge that we both have in radiology and,

and also the care of our patients, you know, specifically

with this type of imaging modality.

Mm-hmm. And, uh, so it's a privilege.

I really appreciate the opportunity.

Yeah, absolutely. Great to have you on.

So, you know, when we're considering all of the, um,

the sort of the aspects of the workup

of our fertility patients, I,

I would be totally lost without pelvic ultrasound.

I mean, I think any clinician, any radiologist,

any sonographer, knows that it is a very cost effective,

very efficient, fairly non-invasive diagnostic imaging test

that we can glean so much information from.

And so it's a fantastic way for us to be able to begin

that workup for our patients

who maybe have never had a pelvic ultrasound in their entire

life, but are looking for answers.

So that's kind of our approach with our practice,

is we're looking for, trying to identify

and treat those underlying conditions

that are causing infertility, causing miscarriages,

causing other gynecologic issues,

like super heavy menstrual cycles, for example.

Mm-hmm. Or pelvic pain. So ultrasound is paramount to

what we do for the evaluation of our patients.

So, yeah, I think it's a great topic.

Yeah. So in, in coming from a radiology side, you know,

most of my patients are either coming in for pelvic pain,

um, either emergency department for, you know,

heavy bleeding or painful bleeding, uh,

post-coital pain, those kind of things.

And then, um, kind of incidentally, we find a lot

of fertility things that you end up treating.

Sure. Right. So how is it

that you typically get a patient into your clinic?

Well, I would say there's a, a few different avenues.

Sometimes other, uh, OBGYNs when they found

that a patient's having trouble achieving pregnancy,

they've done a few, um, management things already,

or a little bit of a diagnostic workup,

but it's sort of outside their scope.

They'll refer the patients to us for evaluation. Mm-hmm.

Um, certainly in today's world, Google, uh, social media,

word of mouth referrals, you know, my,

my experience is if you take great care of couples

and they're coming in, um, they're going

to be your best advertisers or your best advocates.

Mm-hmm. And I think our approach

to fertility valuation treatment is different enough.

We don't do IVF, we don't do artificial insemination.

We are really sort of pounding the pavement to try to find

what is that underlying issue.

And there's a lot of couples, a lot of women

who are really seeking that out.

So when they find us, they say, this is a bit different from

what I've been offered in the past.

This is different from the type

of care I've experienced in the past.

Mm-hmm. Um, so I really think that, that, you know,

that the care, uh, model

or the, the approach to treatments is just slightly

different from what a lot of other clinics would offer.

Just so, just enough that I think it draws a lot

of our patients just from,

from that approach. Yeah. Mm-hmm.

Do you find that that approach comes from a, uh,

experience base from your experiences where you, you decided

that, that this is how you get the patients

and make them, you know, get the best outcomes?

Is this outcomes based?

You know, it's interesting.

It's, I think it's a couple things.

Certainly that was part of my fellowship training.

The training was in medical

and surgical natural technology was stands

for natural procreative technology.

The goal really being to,

to give our patients a complete thorough

in-depth evaluation.

But I would say, even if I hadn't had the training, you,

we have patients who come into the office

and they are asking why, why is it

that we can't find anything abnormal in testing?

Nothing else is coming up in our diagnostic evaluation,

but we still have been infertile for three years

or five years, whatever it might be.

It's that why. And we've had patients tell us, you know,

our clinic is different because we actually seek to uncover

that why of infertility, which is, which is critical.

So, um, yeah, from an outcomes based perspective, I think,

um, you know, our results speak for themselves.

We see somewhere between a 65

to 75% overall cumulative pregnancy rate for our patients.

Wow. And our patients, you know, a lot

of 'em have been trying to get pregnant for quite some time.

Our average, uh,

patient has had over three years of infertility.

Um, potentially they've done IVF in the past. Mm-hmm.

Or they've, they've tried a lot of other treatment options.

So, uh, this is not your, uh, kind of, we just need

to throw some CLO in at them mm-hmm.

And they're gonna get better and, and get pregnant quickly.

So, yeah. I think, um, the outcomes are important.

Obviously. That's what speaks for itself.

Yeah. Yeah. 'cause that's what we're doing here,

even in this, in this educational event is Right, we want

to improve patient outcomes.

Sure. That's, that's what this is about.

Um, so obviously these patients have seen other doctors.

They've, you know, in our world of more

and more subspecialization, um, in,

in my clinic is the same way.

You know, my clinic, we only do ultrasound. We don't. Right.

You know, we've pulled that completely out of the, uh,

the radiology workflow.

Um, so what are some of the things that when,

when a patient comes in, you are finding, you know, just

as a broad overview before we get into the depth of

It. Sure, yeah.

Um, as far as causes or issues?

Yeah. Yeah. Um, certainly there can be structural

issues, fibroids, public adhesions.

Uh, endometriosis is a very common condition

that we find and that we treat.

You know, patients have polycystic ovary syndrome.

About 15% of patients, uh, you know, that we'd see are,

are coming in with ovulatory disorders.

Sometimes it's tubal factor.

Obviously, ultrasound doesn't help a whole lot

with the tubal factor evaluation.

But, um, and then another big one that we see,

and I've kind of become a referral, uh, center for this is,

uh, the treatment of uterine is missiles, which is a mm-hmm.

Cesarean scar defect, which is sort

of becoming more well known as a significant cause

of secondary infertility after C-section.

So it's really across the gamut.

It can be anything, you know, any, any of those,

uh, number of conditions.

And the beauty of the ultrasound obviously, is

that we can pick up so many of these just

with one simple imaging test. Mm-hmm. So,

Yeah. And coming from a

radiology standpoint, I don't know

how many times I see, um,

c-section scars on ultrasound every day.

Sure. And to me, it's just a blurb. Yep.

Hey, there's a scar, it's right here. Yep.

And, you know, the uterus is, you know,

the endometrial canal is collapsed.

It, I don't even think of it in that way.

So that's super interesting to me that this is,

this is something that, that, um, maybe I should mention,

you know, in my report, Hey, there's a,

there's a significant C-section scar.

Sure. You know, maybe this could

contribute to infertility. Yeah.

Certainly. Sometimes you can just see the scar,

but it's, it's not gonna be clinically relevant.

Other times, yeah.

Certainly we'll get to, to look

at some ultrasound images here.

Mm-hmm. But, um, it can be a major factor.

I actually think it's the leading cause

of secondary infertility after C-section

That's amazing. Beyond any

Others. Truthfully,

That blows my mind because, um,

without having this conversation,

I would've never put that much weight on it. Sure.

No, absolutely. Mm-hmm.

Okay. Um, so let's just start getting into some

of the things that you see and,

you know, we can talk about that.

Sure. So all of our patients would go

through a routine baseline pelvic ultrasound, um,

because, you know, their patients are ovulating, obviously.

Um, or we hope they're ovulating.

We like to do the ultrasound early on in the cycle. Mm-hmm.

Usually we say cycle day three through five,

we can stretch a little bit if we need to.

Mm-hmm. But that's the time that the ovaries are quiet.

We can get a good antral follicle count,

we can get good imaging of the uterine lining,

of the structure of the uterus.

So we're just kind of doing our global assessment.

This is our initial screening tool.

And of course, if we find issues that make us concerned

for fibroids and make us concerned for adhesions

or cysts, okay.

We can move on to that next level of an evaluation.

Sometimes with saline sonogram,

sometimes with other imaging. An HSG.

And is your, is your start when you start out,

are you doing transvaginal

and transabdominal, or one or the other? Yeah, we

Just skipped to just doing the

transvaginal for being efficient.

I just, you know, in my experience, you know,

I think initially I was doing abdominal and transvaginal,

and I just felt like, uh, we weren't getting

a lot of additional information.

Mm-hmm. Unless somebody's got a large fibroid uterus.

So there's some sort of pelvic mass is not fully visualized

on a vaginal scan, then we'll also

add in the abdominal part.

Yeah. And that's, that's basically how my, uh,

clinic protocol works.

You know, it's default to transvaginal

unless it's a certain indication.

Sure. Or if there's another reason to, to, you know,

to jump out to there if we have this, you know,

17 centimeter uterus, you know, or,

or ovary that's hiding or, you know, something.

Yeah. Let's just get to the taste.

Just cut right to it. Get it going. Right. Yeah.

Get it going. Um, so tell us about,

you know, we've got this picture up here.

Just kind of run us through.

Um, you know, I, I thought, you know, one, one thing

that I would like to ask you about is the

importance of 3D imaging.

Yeah. So, you know, obviously we always get the, you know,

2D views, uh, which are really important I think

for, for our practice.

The 3D is great for identifying location

of fibroids relative to the endometrial cavity.

It's sort of like a cheater version of a saline sonogram.

Mm-hmm. We actually have some patients who say, well, I, I,

I don't wanna do the saline sonogram, or I can't do it,

or it just doesn't work out.

So oftentimes we get such a good image from our 3D scan

that we can rule out a mullar

anomaly, we can rule out mm-hmm.

You know, some sort of, uh, submucosal fibroid, um,

there are some other unusual masses

and other findings that we'd pick up better on a 3D scan

than we would just simply a 2D scan.

So it's a routine part of our

baseline pelvic to get the 3D images.

Yeah. And that's interesting. From a radiology

perspective, we don't do 3D unless we find something.

Sure. And then from your side, you're like,

we're doing 3D to find

Something. Why not? Yeah. It takes a couple extra

seconds.

We get a really good image,

especially like this middle photo.

Yeah. This middle picture. We're getting a,

a complete rule out of a uterine septum. Yeah. So this is

Perfect. And I, I can

say with the, uh, the newer technologies

that are coming out with follicle counting on three Ds,

I'm really liking those because I spend a lot

of time counting follicles clips.

Yep. Yeah. And this is just so nice.

Yeah. So we have something called sono A B, C,

uh, follicles.

So it allows us to just basically to do, do that 3D sweep

of the ovary, it automatically calculates

and we have it set to, to find all the follicles

between two and 10 millimeters.

Yeah. And that's our, that generates our,

That's amazing. And

it is quite accurate.

You can go through and manually adjust

It too. Yeah. And the two to 10

millimeters is the,

the current guidelines Right.

On, you know, what you're gonna count

and what you're not, you know,

things smaller than two millimeters may not be follicles.

Sure. Yeah. Um, so, so that's the current guidelines.

And then, just to bring up a, a good point.

The most recent A IUM uh,

practice parameter now recommends doing a, um,

3D coronal in certain patients

or in patients that have findings

that suggest a mulian abnormality.

So that just came out. It's very new.

And I, I, I think a lot

of more radiology practices are gonna start doing that.

I think that's a good idea. You know, I've,

I've had patients in the past who've had, um, sort

of accidental, undiagnosed, you know, they, they were told

that they had a, uh, a bi coordinate uterus.

Mm-hmm. But actually they had a complete uterine septum.

Mm-hmm. And it just wasn't picked up correctly.

And even at c-section, sometimes the

uterus can be so distorted mm-hmm.

That you can, that the obstetrician can be kind of misled

by prior imaging, say, yeah, okay.

It looks like it by cornea, uterus.

'cause one side's really stretched out mm-hmm.

Compared to the other. Um, I'm thinking

of several patients in my mind in particular.

And when you get the good 3D imaging,

you can definitely see, you know, the uterine fundus mm-hmm.

And kind of rule out one versus the other.

And, and I'm glad you brought that up,

because for my sonographers that I work with, you know,

the most common thing that I say, Hey, can you go back

and get another image for is I

can't see the fundus well enough.

Right. And if I would've had that 3D image,

it would, it would've been like that.

The other one, I don't know if you have it on your system

as well, but, um, I think it's something called omni view,

or at least in our GE system, it's called Omni View,

where if somebody's got a really, uh, retroflex

or plexed uterus, you can actually, um, sort of put this,

uh, drag this right into the cavity and basically spread

It out down the whole uterus, which is great.

Yeah. Those are really nice. I, yeah, it's very,

I read on one of those machines,

I read on multiple different manufacturers.

Um, I know a lot of manufacturers are coming out with, with

that, those same kind of technologies.

Yeah. Um, and what's interesting is, I,

I'm not sure if it came from

that the musculoskeletal world has a,

a view called a panoramic.

Mm-hmm. And so you wanna see this mass from, you know,

it goes from the forearm up to the elbow.

You do this panoramic imaging.

Interesting. Yeah. And That it elongates the whole

thing out and gives you a nice look at it. It's,

It's really good for those uterus

that don't play by the rule books.

Yeah. For sure. Yep.

So, some of the other things

that you will be finding in your patients, obviously a lot

of women have fibroids.

Sure. And, you know, a lot

of times when I'm reading out a case from the radiology

perspective, you know, somebody comes into the er,

they're having bleeding, you know, they've got a, um,

you know, a submucosal fibroid, um,

or, you know, they've got a, a massive fibroid

that is causing problems

or a whole bunch of fibroids that are causing problems.

And, you know, we're not thinking about it

from the fertility perspective.

Right. We're thinking about, Hey,

this patient has these fibroids.

We wanna monitor those and see what they,

what they do during pregnancy.

Sure. And then, so what is,

what is your take on the fibroids?

You know, it really comes down to size and location.

Mm-hmm. Obviously, the submucosal fibroids of any size,

well, I would say any size over one centimeter, let's say.

Mm-hmm. Um, certainly we want to discuss with our patients

that, that does know is known to increase the risk for, um,

having an early miscarriage mm-hmm.

Or even a later miscarriage in some cases.

So the type zero, the type one, the type two even,

or two hyphen five.

Um, all of those fibroids, you know, are starting to, uh,

sort of deviate or, or deflect the endometrial cavity.

Mm-hmm. And so for those,

we do recommend hysteroscopic myomectomy in almost all cases

when we see the subcostal fibroids, you know,

the intramural fibroids.

It really kind of comes down to the size, uh,

patients preference as far as, um mm-hmm.

Sort of, you know, do they want to kind

of continue monitoring it?

Are they worried about what it might do in a pregnancy?

Usually five centimeters for me is the tipping point

to start to have that discussion about, you know,

this fibroid in pregnancy might be able to grow.

So one third of fibroids grow, one third shrink,

one third stay about the same size in the pregnancy.

So if it grows, they can degenerate, you know,

you want this, the, the placenta

and the fibroid are gonna be fighting for blood flow.

Mm-hmm. So obviously you want the placenta to win out.

Well, if the fibroid degenerates a pregnancy,

you can have a release of, you know, uh, uh,

prostaglandins mm-hmm.

Can actually cause preterm delivery, preterm contraction.

So we start to have those conversations about some

of those larger fibroids, uh,

subserosa we don't worry about quite as much.

Mm-hmm. Um, you know, if we're in there

for another surgery like endometriosis, great.

It's easy enough to just treat them sort of, uh,

prophylactically, if anything else.

Mm-hmm. But it's really comes down to those,

those really large intramural versus the, the submucosal

that we kind of, uh, want to have

that detailed discussion with our patients regarding.

Yeah. And again, it's, it's one centimeter or above.

Um, so there's no, there's no strict guideline.

So we started talking about the, the fact that it,

it is kind of a, a numbers game.

Mm-hmm. What, what percentage

of the endometrial cavity now is being affected

by this particular fibroid.

If I have a patient who's had multiple miscarriages

and we've done the full evaluation

and we don't see anything else,

but they have a one centimeter submucosal, I'll say,

look, I'll sleep better.

You'll sleep better if we know

that this is not gonna be an impact

for any future fertility, uh, future pregnancy.

So yeah, that's, in those cases,

I'll be a little bit more proactive about it.

And then just briefly, um, you do the, the myomectomy.

Um, how long are they gonna wait

before they come back for healing

and to start their fertility journey? Yeah.

So it depends on the type.

So if it's a submucosal fiber,

let's say it's a two three centimeter submucosal,

kinda like in this, in this photo mm-hmm.

If I'm resecting this size of fibroid,

we're affecting a lot of the endometrial cavity.

We're cutting down into the myometrial wall.

These carry the highest risk of intrauterine adhesion.

So these patients, we always want

to have a second look hysteroscopy

usually one to two months out.

Mm-hmm. As long as that second look looks good.

And we know we didn't thin the myometrial

wall during that procedure.

They're good to go for starting to try for pregnancy.

Mm-hmm. Almost immediately after that,

after the second look, if they have a large intramural

fibroid, and we're doing a laparoscopic myomectomy

and cutting, you know, two thirds, three quarters of the way

through the uterine wall, it's gonna be more of like a four

to six month wait time before they can

pursue a pregnancy. Hmm.

Okay. All right.

So here's some more uterine fibroids here.

Um, along with, let's see. Hey, do you want, can we blow

That up a little bit? Yeah. That just the, uh,

that's an ovary.

It's a 3D ovary. I don't know how that, uh,

Must have snuck in there. Somehow

s snuck in there. That's fine. Yeah.

Yeah. No. So this, this particular, oh, I, I think, oh,

These are the color images for that. Yeah.

So this is a different patient

from the prior one, actually.

Okay. Gotcha. So this is an interesting one.

'cause this is more of a, um, you know, a type two-ish.

It's, it's kind of more intramural at the same time.

It is, um, impinging on the uterine cavity.

These become a little bit more challenging to treat,

but we still do try to take these out hysteroscopically.

So for me, I'm always measuring

how much myometrial wall do we have mm-hmm.

Um, outside the fibroid, um, to make sure.

And generally in these, sometimes I'll even do a, uh, a, uh,

concurrent laparoscopy just to make sure we're not at risk

of thinning or perforating ears.

Mm-hmm. Gotcha. Yeah.

And I do hear a lot of, um, you know, a lot

of doctors will call me and say, Hey, um, you know, I need

to know specifically where these fibroids are.

Sure. And, you know, from a radiology perspective,

if I'm reading something in the ER

and it's like, Hey, this is for bleeding, you know,

I might just say, Hey, there's, there's multiple Right.

Fibroids, you don't need to know anything else.

And I don't need to know all that stuff. But I do, I do get

that there is some importance to, to naming,

you know, the locations of these.

So I typically will say, Hey, there's a,

I always give a type, you know,

and I always say it's either fundal mid,

or, you know, c cervical Yeah.

I think it covers the anterior poster.

Yeah. An posterior. Yeah. Um,

because one of the worst things to do is

whenever somebody gets a follow up for that

and they come in, I don't get the images per se.

It's always best if I have the comparisons

and then I have to read the report.

And it's just like one of my, one of my pet peeves is the,

uh, oh, fibroid uterus.

Right. Diagnosis, you know, see above, see

Above. And then up

there it says fibroid uterus. Right.

Right. We go, of course. Yeah. Yeah. Yeah.

So let's, let's take a look at this.

Um, so obviously endometriosis, right?

Um, I, I would say a lot

of people out there have family

members that are affected by it.

Sure. I do. Right.

So, um, and it's a common condition.

I mean, approximately, we think about 12 to 15% of women,

um, have endometriosis.

It's a minority of those

who have stage four endometriosis, like you would actually see.

So, you know, we always tell our patients,

a normal ultrasound doesn't rule out endometriosis.

Mm-hmm. Having no pelvic pain, um,

does not rule out endometriosis.

20% of women with endo can be completely symptom free.

Mm-hmm. And their only so-called symptom is the fact

that they're struggling to achieve a pregnancy.

I've had patients who've had stage three,

stage four endo normal ultrasounds, basically no pain.

I almost have to twist their arm into

saying, yeah, three outta 10 pain.

Um, and they've got extensive endometriosis.

So it's an interesting condition in that sense that, um,

we need imaging, but at the same time,

imaging doesn't tell the whole story.

Right. Now, when it comes to stage three

and stage four, obviously what, you know,

we're looking at these is for the purposes

of surgical planning and good patient counseling.

Um, when the endometrium is especially over two

to three centimeters, we start to worry

that this certainly is impacting the quality of the eggs

that are in that ovary, um, affects the ability

for that ovary to ovulate.

Mm-hmm. Endometriosis, especially when you get

to stage three, stage four, will never go

away or get better at its own.

So we, we start to talk to 'em about the, the pros

and cons of surgery at that point.

Mm-hmm. Um, you know, of course with endometriomas,

I feel like they're pretty easy

to pick up when you get used to seeing 'em.

We're looking at this sort of iso coic ground

glass appearance mm-hmm.

With somewhat more of a thickened, uh, uh, peripheral wall.

Um, you know,

sometimes the hemorrhagic cyst though can kind of throw a little

Yeah. I was gonna ask you. Um,

you know,

so I read MRI of the pelvis too.

Yeah. And, you know, there's, there's specific, you know,

ant mini is what we call 'em.

Like, Hey, these, this is omic for a, a,

um, you know, endometrioma.

And, and one of the common things I get is, Hey,

is this actually an endometrioma on the M mri?

Right. So that's what we're evaluating.

How often do you end up sending these patients to MR mri?

Actually, for our kind of, uh, rule out, uh,

between an endometrioma and a hemorrhagic cyst, we,

but generally just haven't come back in one to two months,

especially at two months.

Yeah. You should be able to see resolution

of the hemorrhoid cys,

whereas endometriomas are gonna hang out.

Um, actually alternatively, sometimes, we'll actually,

if I go back and, you know, review a bunch

of scans from patients who's coming to see me, who now has

what looks like a cyst mm-hmm.

Like, like an endometrioma, you can actually sometimes watch

these hemorrhagic cysts become endometriomas within

the matter of just a few months.

Mm-hmm. I mean, so the most common type

of endometrioma is a, a type two endometrioma where,

you know, the endometriosis essentially evaded

or invaded an already existing cyst.

Um, and so yeah, we, we definitely see this a lot,

but that's, we usually use the, the follow up ultrasound

to kind of be the best, uh, kind

of rule in for an endometrioma

Versus Yeah. Typically if

I see one that I think is, um, you know,

something like this one, I'm

like, Hey, that's an endometrioma.

Yeah. But if it's, you know, Lacey pattern, um, hey,

we're gonna do to six to 12 week follow up and,

and make sure that it, it, it resolves.

Yeah. So, yeah. That's, that's interesting.

I, I honestly don't know how they end up to me,

you know, on the MRIs.

Right. I do, I do 'em, you know,

I probably do a rule out endometrioma may maybe, um,

you know, two times a month

or so out of all of them. I mean,

We definitely utilize MRIs, um,

but we're usually using it more

to see if there's invasive bowel endometriosis, for example.

Yeah. Okay. So, um, it, it's more for surgical planning at

that point, you know, so a little, um,

pearl here on this particular patient,

which is why I chose this one, is look

what you can see right behind the cervix in the lower

posterior cul-de-sac, you see free pelvic fluid.

Yeah. Mm-hmm. So you may not care or think much about that,

but as a surgeon, I care greatly

because this basically proves to me

that her rectum is not stuck to the back of uterus.

Mm-hmm. She does not have an obliterated cul-de-sac, which,

you know, certainly women who have stage three,

stage four endometriosis are a risk

of having totally changes

what my surgical counseling would be for this patient.

Okay. Um, whether or not I can see free pelvic fluid

behind the uterus, so little tidbits here

and there, it's kind of nice if a ethnographer happens

to see it, to take a picture to, to label it.

Um, because I think that helps to kind

of delineate those patients

who may have more aggressive disease. Yeah.

That's interesting. Because, you know, I see that, I say,

Hey, there's physiologic fluid in there,

and I drive on Yeah. And

It's, oh man, I love to see this.

Yeah. This is great. It means

that their surgery's gonna be about three hours

shorter. Yeah. That's

Cool. Yep.

Actually, incidentally, this, this patient's

ultrasound was just a few months ago.

She had had, uh, the ultrasound was in July.

She had surgery in August. Mm-hmm.

And five and a half, almost six years of in fertility.

She's, uh, about seven weeks pregnant now. Amazing.

So we, we went in, we excised all the endometriosis.

We always endeavor to keep ovaries reconstruct mm-hmm.

The ovaries after he excised the endometriomas.

Um, and they do really well.

They start ovulating well after that.

So just by relieving the body of that sort

of inflammatory condition, we've immediately helped

to improve their fertility drastically.

Yeah, that's a really good point.

That it's, it's a physiologic thing too,

not just anatomic. Sure.

Yeah. These patients have a lot of symptoms, a lot

of pain all the time, so mm-hmm.

So the Isma seal this is, this was when, you know,

when we, when we first started talking about this project,

I was like, you know, I've seen this

more than I, more than I have.

Like, you know, I'm like, Hey, there's this,

there's this scar here,

and, you know, there's a defect in it and there's a cleft.

And I've just said, Hey, this, this is a C-section scar.

And I typically say, Hey, this patient has an increased risk

for, you know, rupture.

Sure. That's, that's what I'm thinking.

But you're, I wanna hear your take on it.

Yeah. So this is, it's a, it's a bit of a nuance issue,

but I, I think I can break it down by just saying,

the problem with the isus seal is twofold.

One is you have a pouch or a niche mm-hmm.

Where menstrual blood will get trapped

and will literally stay there for months.

That becomes a very inflammatory to toxic environment

that causes inflammation throughout the

entire uterine cavity.

It also, you know, uh, impairs the ability

for the sperm to get by there as well.

So, um, it, it definitely increases risk for miscarriage

and infertility just because of

the inflammatory environment.

So that's sort of problem number one.

Problem number two is, as you mentioned, is

that the residual myometrial thickness at the side of

that C-section scar,

if especially studies have shown if

it's under three millimeters mm-hmm.

There's a substantial increased risk

for uterine scar rupture.

So we sort of talk

with patients about this in two kind of, uh, aspects.

Even if somebody comes to us

and they say, well, you know, I'm not, I'm not, uh,

struggling with infertility,

but I'm just kind of, you know, whatever, I'm wanting

to get a tubal ligation reversal,

but I've had c-sections, we always

do this evaluation mm-hmm.

Because we don't want them to get pregnant now

with a high risk pregnancy scenario.

The other problem, uh, certainly is having the,

the niche there at the M SEAL site also increases the risk

for having a cesarean scar pregnancy. Mm-hmm.

I was gonna Ask about that. A whole nother problem.

Mm-hmm. Um, I incidentally, I've just seen probably four

to five patients in the last several months who've, uh,

who've had this in the past, or I've even took care

of a patient who had, um, you know, a 10

and a half weeks cesarean scar pregnancy, very complicated,

very high risk scenarios,

high risk surgeries and treatments.

So if we can help to address

and treat this sooner, we help abnormal bleeding,

we help improve fertility, we all produce the risk

for miscarriage, and certainly help

to improve the obstetric outcomes for these patients.

So, yeah, it's a, it's a big deal.

And I would say, um, I jokingly, uh, say to my patients,

this is kind of my niche, you know?

Mm-hmm. Uh, we have patients

who come in literally from all over

the world just for the surgery.

And I think that's, uh, unfortunately, it's a demonstration

of how little it's understood and how little

or how few surgeons really treat it or understand how to

Treat it. Yeah. Yeah. And I,

I honestly haven't encountered it in

my clinical practice Yeah.

Before. Um, as far as, you know,

obviously, you know, when you're a,

when you're such a specialty

doctor, you see 'em all the time.

Sure. 'cause they're all funneling too. Oh, yeah.

Yeah. No, all of our patients that we do,

we screen anybody who has a history of C-section, um,

especially when they present with miscarriages mm-hmm.

Or infertility. Um, 51% have had a Utes missile

that is clinically relevant.

Mm-hmm. Like large enough

that actually needs to be operated on.

Now, there's two different options.

You can either treat a hysteroscopically, we kind

of smooth down the inside of the muscle.

Mm-hmm. Thickness is adequate.

And usually I use about four uh, millimeters as that cutoff,

uh, or laparoscopically.

We essentially just excise that entire lower uterine segment

and reconstructed in multiple

Layers. And are you

using intraoperative ultrasound

to guide that at all, or you just

I'm seeing, uh, I actually don't.

Okay. Um, but what we do instead is we have, um,

two surgeons working concurrently.

Mm-hmm. Um, and the assistant surgeon will perform a, uh,

hysteroscopy during my laparoscopy

and actually trans illuminates this area.

You know, we always say, oh yeah, virus really shouldn't

be see-through.

It shouldn't glow. Yeah. But when it's only a couple

millimeters of tissue, you can better bet you're gonna see

that, uh, that defect when they do the scope inside. Yeah.

I remember in, uh, that brings up a memory from medical

school when I rotated through, uh, gen surge

and I was on the, uh, the GI rotation.

Um, 'cause in radiology when we put in a a, a GI tube, um,

or I mean a, a percutaneous gastrostomy tube, um, you know,

we actually, uh, kind of, you know, we do a, um, we do a,

a angiogram to look where the arteries are.

Mm-hmm. And then we use ultrasound to like,

help us guide our, our way in there,

and then we poke through there

and then pull, pull, you know, push it through there.

Interesting. Yeah. But then I remember on GI,

they actually trans illuminated the stomach.

That's great. Yeah. With the scope. Yep.

So that's, that's pretty cool. It's a similar approach.

Exactly. Yeah. Yeah. And it gives us, you know, it helps us

to know exactly where it is,

but also where is the thinnest part of the scar.

Mm-hmm. So we can really get a full com,

You know? Yeah. And the light obviously

is gonna come

through the, the thinnest part.

You got it. Oh, okay. Yeah.

So, um, one question, and this may not even be a thing.

Do you see placental problems with cyma seals? Yeah,

Certainly. You definitely are,

are at risk for, um,

placental accreta spectrum conditions.

Mm-hmm. So, um, whether it's, you know, placenta accreta,

or in accreta or even perreta mm-hmm.

If it implants anywhere on the anterior uterine wall, um,

and you've got an untreated esal, certainly higher risk.

I actually had a patient recently who, um,

was high risk for another reason.

She had undergone a laparoscopic ESAL repair

and her, her placenta was interior.

And her MFM said, had you not had the smsu repair

and reconstructed the uterine wall, almost certainly,

because the, she's already showing early signs of,

of placenta accreta.

Mm-hmm. He said, you almost certainly would've already

been at per, at this point.

Mm-hmm. So, um, yes, definitely a risk.

'cause it's just less muscle for it to have

to invade and go through. So,

Yeah. Yeah.

Okay. So, yeah.

Interesting. Um, you know, obviously I'm gonna,

I'm gonna tell you, this is what I

see all the time. Yep. So this,

See every day this is the same patient.

Yeah. So actually this one tricked me.

I looked at the initial ultrasound,

I said, okay, interesting.

'cause her history to me would say, look,

you probably have an esal postmenstrual brown bleeding being

the most common symptom.

Mm-hmm. She did have postmenstrual brown bleeding.

When you do the saline sauna though mm-hmm.

What will happen is that as you're flushing the uterine

cavity, you actually will knock loose blood

clots that are stuck inside.

So the blood clot, I think is what is obscuring Yeah.

The visibility of the ES missile and the initial baseline.

Yeah. They probably, you know, has a similar, um,

a similar echogenicity to the surrounding parenchyma.

But, you know, that's why these really nice pictures.

And that's why I do like transvaginal. Yeah.

Um, it's gonna give you that high resolution.

And, you know, obviously ultrasound gets better every year

where you can actually see more of a,

a fibrillar pattern with the, with the muscle. Um,

It's true. No, I

mean, this is, this is critical to to say,

and that's why we just do a screening SIS

on every patient Yeah.

Who comes through with symptoms

and a history of, of, uh, of a C-section.

Yeah. Yeah. And,

and from a radiological standpoint,

I'm glad you guys are doing those mm-hmm.

Because, um, it's a,

it's a huge ordeal in the radiology department.

Right. I know, I know. You know, we, we get in there

and, you know, I still, I still do some of the, uh,

the history of X picograms, um, for maybe for eser devices.

Sure. You know, stuff like that. You know, this stuff,

you know, it's time to move on.

Yeah. For that, you know, there's,

there's times and places, but,

Well, in my mind, also, obviously, once a patient is here,

they're, they're kind of, yeah.

They're, they're here because they're having issues.

And then at the time of the imaging,

I can immediately give them the,

this doesn't need to be treated surgically.

Mm-hmm. Or look, these are your risks

and this is why I'd recommend treating the surgically.

And we start having that conversation pretty quickly.

Yeah. Which is nice. Yeah.

That's, that's really nice. Yeah. Immediate

Feedback from the, you know, from the

clinician who's there doing it.

I think it's, I think it's, there's,

Yeah. It's really nice. Yeah.

All right.

So what are we showing here? Yeah, basically

It's a little bit of a dark photo, but this is

what we're showing is, is sort of

how we do our measurements.

So we're, we're measuring the size of the niche itself,

the anterior posterior measurement,

the cranial co measurement.

We, we measure the residual,

my mutual thickness just anterior to the defect itself.

Um, and usually you can pick up a pretty decent, uh,

serosal margin there at the mm-hmm.

You know, the bladder uterus interface.

And then we also wanna measure

how far it is from the cervix, more

for surgical planning for me.

Mm-hmm. Um, and then also

what the adjacent myometrial thickness is

just superior to the defect.

That kind of helps us know, look, this is

what it should be or should have been.

And this is kind of how thin the myometrial

wall is now at that site.

Mm-hmm. So, um,

and then the transverse, of course, again, you wouldn't have

to go this detailed unless I, in my mind,

unless you're kind of planning a surgery.

Right. So in these cases, it just, it helps me to be able

to reference this image either before

or during surgery, uh, when we're going to fix these. Yeah.

Okay. Okay.

Here's another picture here

with the isma seal on the, yeah. So I,

This is a good example of, you know,

the patient on the left, uh, obviously has had a C-section.

You can see a little bit of an indentation there, but, um,

and not an isma seal versus,

And again, I see that every single day.

Yeah. And, and, and this is on a salience sa mm-hmm.

So we would be able to pick it up

if there's a problem. Yeah.

Well, You'll notice about the SIS that,

that are coming from my office, is you mm-hmm.

You don't see a balloon in the uterus. Yeah.

So we do not use a balloon catheter.

The balloon catheter, unfortunately,

what it un ends up doing is sort

of inflating right over the, the niche.

Okay. And so you actually don't get the best sort

of clean out of the, of that scar, um, defect.

And so we use a Goldstein IS catheter,

which has essentially a little cone

that sits on the outside of the cervix.

It works great. Patients have less discomfort from it,

but also gives us the best imaging

of the, of the scar itself. Mm-hmm.

Technically speaking, is that, uh, more of a

push forward when you're doing it?

Because I haven't used one of those. Yeah.

You just apply just the very slightest amount, pressure,

pressure as you're injecting with the six

CCC syringe. Yeah.

I, I kind of like that too,

because, um, you know, if you inflate the balloon, you know,

too proximal, that doesn't

Feel good. No. They're

hating you right away. Yeah. Yeah.

So, honestly, most of our patients have

essentially no cramping with these.

That's, that's amazing. Yeah. That's really nice.

All right. So we're gonna move into some

erian abnormalities.

Um, and I, I love that, you know,

you brought this 3D image here.

Yeah. So one, you wanna take us through this?

Yeah. So basically any patient who presents, well,

obviously they're, they're getting their baseline

ultrasound, whether they're infertility

or recurrent miscarriage, but especially those

who have recurrent pregnancy loss, we're always looking

for those muer and anomalies.

You know, somebody like this who has a complete uterine

septin that goes all the way down to their cervix,

they carry an 80% risk

for miscarriage every time they're getting pregnant.

Mm-hmm. Um, at the same time,

the treatment is relatively straightforward

and it's long, long lasting.

And once you take out the septum

once it's done for life Yeah.

Which is fantastic. So I would say to our patients

who have these types of, uh, mu anomalies, you know,

of all conditions is kind

of the most straightforward one to have and to treat.

So, um, even though it looks funky

and they kind of, you know,

feel bad about my uterus isn't normal, know mm-hmm.

Well, there's, there's five to 7% of women who are walking

around with the mulet and, and

anomaly just like you, so mm-hmm.

Um, but again, the good news is

that you can fix these, uh, really straightforward.

So, yeah, So this is an interesting one.

So, um, we've had several patients in the last several years

who have come in with, um, significant, uh, pelvic pain, um,

and they just haven't gotten an

answer, you know, what's going on.

Um, so when you do these scan it, you kind of want to say,

well, wait a second, could that be a,

a rudimentary horn that's non communicating?

Mm-hmm. Because you're sort of seeing this hyper coke area

that kind of almost looks like the endometrial cavity.

Right. Um, but if you look closely, you know,

the uterine cavity is in normal triangular shape,

so we don't actually, 'cause with the rudimentary horn,

you'd have to have unicorn unit on one side mm-hmm.

And the rudimentary ho horn on the other.

So there's a very rare, um, issue called an accessory,

cavitated accessory and cavitated uterine mass.

Mm-hmm. And essentially what's happening is

that these poor ladies are, are having many periods inside

of a contained cavity.

Mm-hmm. And these areas start to grow

and, and change in size.

They become very, very painful and very inflammatory.

These really, in most cases, are just gonna be best treated

by surgical excision.

And once they're exci, it's a mulet anomaly, it's gone.

It's not gonna come back. Yeah. So, um,

outstanding outcomes, you know, going in

and treat this, um,

just from a patient's symptom perspective, uh, there's

so rare, it's kind of hard to delineate whether

or not this would actually cause

infertility or cause miscarriages.

Certainly it's inflammatory.

It could cause, you know, other issues and pain.

Um, but yeah, the,

the effect on fertility is a little bit, uh, more

Tricky. Yeah. And when you get

that out of there,

you're just gonna buy a valve and, and look at it.

'cause you know, to me that that could have been a fat,

you know, that could have been a fatty tumor. I've seen

Those. Yeah. So I do, you

know, in the process of exci 'em mm-hmm.

Uh, when we're, when we're grasping

with our laparoscopic graspers, oftentimes you can kind of,

um, see the type of tissue that it is.

Um, and, but yeah, we usually open them up

and you can see basically it's like almost like an old

endometrioma type of Yeah.

Uh, fluid that's inside of it. Mm-hmm.

Okay. Yeah.

All right. This is one of my favorites. Yeah.

It's everybody's favorite. Right? Yeah.

And, you know, so from a radiology standpoint,

I see this every day all day long.

Um, you know, I just basically look at this

and I, you know, for me the, you know,

the Rotterdam criteria is, is mainly,

but what I go with Sure.

And, you know, there are some new international standards

and everybody's trying to push up the number

of follicles every single time, which

Makes sense, of course, right? Yeah,

yeah, yeah. 'cause you're gonna,

you're gonna capture, you know,

you're gonna have less false positives, uh, obviously,

but, um, I really like the, uh, 10 milliliter,

um, cutoff. Yeah.

The volume size. Yeah. The volume size. Yeah.

Because, you know, I can see these, you know,

like this right here, you know, obviously I think

that's probably greater than 20 when I look at it.

Sure. And, um,

and then, you know, hyper echogenic, central stroma.

Yeah. And then now with microvascular imaging, I think

that's actually gonna come out

and show a lot more blood flow in the center.

Sure. No, that makes sense. Yeah.

Um, you know, obviously PCOS is a common cause mm-hmm.

Um, for oligo ovulation

or oligomenorrhea, um, infrequent periods,

difficulty achieving pregnancy.

Um, you know, there, it's, it's sort of treated

with medications that help

to improve ovulation, which is great.

At the same time, I think every patient deserves to have,

you know, a good clear diagnosis.

Some people are kind of, well, I had cyst,

so therefore I have PCOS.

They're a little bit confused on the nomenclature, I think.

So being able to look at the imaging with them

and say, you know, you have follicles, you know, you're 28,

you've got 12 follicles.

Well, at the same time, you don't really have

polycystic ovarian morphology.

Mm-hmm. Your cycles are pretty regular.

I don't really think that you have PCOS.

Um, A MH is not yet part of the, uh, diagnostic criteria

of course, but I think it does lend some assistance

to helping to delineate some of these patients who,

you know, maybe you're just a 24-year-old

and you've got 20

follicles, and for you that's totally normal.

Yeah. Um, uh, versus, you know, a 38-year-old who has,

you know, an follicle count of, you know,

15 to 20 in each ovary.

Mm-hmm. So the A MH does help to kind of, um, clear some

of the, uh, some of the cloudiness around the diagnosis

of PCOS in my mind.

Um, but also helps us to identify, you know, the, the dosing

of medications that would be

appropriate mm-hmm. Appropriate for different

Patients. So now, now say

a patient comes in

and their goal is to get pregnant.

Are you treating them for herm?

Um, you know, like, what are we doing here?

Are we just, yeah, so just going for the fertility side, we

Talk about everything. Yeah. Obviously, we

wanna talk to 'em about their underlying

risk factors, increased risk having breast cancer.

Mm-hmm. You know, type two diabetes,

endometrial hyperplasia.

We talk about the need for having regular cycles, whether

or not they're trying to get pregnant or not.

Mm-hmm. Now first we're focusing on symptoms, otherwise.

Okay, sure. Yeah. We'll give 'em some spironolactone.

Mm-hmm. Um, but much beyond that, you know,

we're gonna have you see another clinician to kind of deal

with those other secondary symptoms.

Um, from a fertility perspective,

obviously we're using ovulation induction medication.

So, uh, now first line actually is

Letrozole used to be C Clomid.

Mm-hmm. Clomid, of course, comes with a, a, you know,

higher side effect profile.

So the letrozole is the benefit also

of mono follicular development as opposed

to multi follicular development

that we oftentimes will see the Clomid.

So, um, yeah, we,

we generally would just say from a fertility perspective,

there's a medication that can help to address this.

Now not all patients actually respond well to medication.

So that becomes a bit of a challenge.

And we'll kind of talk about, um,

the focal maturation study here in a bit.

Yeah. Um, the watching of ovulation is important.

I know a lot of clinicians will just,

here's your CLO prescription,

here's your Letrozole prescription.

You know, let us know if you, uh,

get a positive pregnancy test.

Some patients don't respond, some patients over respond.

I've had patients, you know, get 15 follicles

with a normal dose of CH Clomid.

Mm-hmm. So it's, it kind of is frightening to think of Yeah.

Doing ovulation medications

without any ultrasound monitoring. So Yeah.

And I think I've, you know,

in my career I've probably seen five cases

of hyperstimulation Sure.

Syndrome in the er. Right.

You know, I think, um, um, you know,

it's definitely something to worry about and,

and to keep an eye out for.

Um, in, in your practice, are you just handing off

to the in hospital gyno at

that point whenever somebody comes in with that?

Or how are you treating that?

So thankfully none of our patients, I mean,

you're not dealing it.

So, you know, we'll give patients injectable tro.

Its actually just in the last few weeks, I've had a patient,

she had a higher A MH, she doesn't technically have PCOS,

but she has a higher A MH.

Okay. Um, so she did, she developed, uh, 12 follicles. Hmm.

And she was pretty darn uncomfortable.

So we give her, you know, the, the risk factor

or the, the, the symptoms mm-hmm.

To kinda watch out for. Um,

but yeah, I mean, thankfully I haven't had to admit anybody.

Yeah. Um, if, if I did, I would probably take, take care

of them in hospital then.

Yeah. Um, make sure, you know,

fluid down all that stuff. It looks good.

Yeah. Okay. So that brings us

to the antral follicle count and follicle maturation.

Yeah. And I think that's something definitely

that deviates away from general radiology.

Sure. Whenever people are coming through, um, you know,

'cause a lot of times, you know, somebody will, some

of people will be undergoing fertility treatment

and have abdominal pain or something.

Right, right. Lower quadrant abdominal pain

obviously comes in a lot.

Um, and then they're worried about appendicitis,

and then obviously these come up.

Right. So, you know,

We Yeah.

The incidentals and, and so we're,

we're not reporting on antra follicle count

unless somebody says, Hey, this is a

Follicle count. Right.

So take us through that. It's true.

So, so the intra follicle is kind of,

that's part of our baseline scan.

Mm-hmm. Once we've done that, once we kind of leave

that alone, um, you know, similar to how there's MRI

and there's functional M mri mm-hmm.

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Fertility: A Conversation on the Role of Ultrasound in Diagnosis and Treatment

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