Transvaginal Ultrasonographic Findings of Infertile Females in Population of Lahore

: Failure of conception in women after frequent unprotected intercourse for one year is known as infertility. Ultrasound examination can detect certain pathologies that may result in primary or secondary infertility. Objective: To describe the various transvaginal ultrasonographic findings of infertile females in population of Lahore. Methods: The study was started after the consent of ethical committee of the University of Lahore. All the patients were registered in this study after signing the informed consent form. Toshiba Xario with transvaginal transducer frequency ranging from 9-12 MHz was used. Pathologies were evaluated through transvaginal scanning and sonographic data was kept in the ultrasound machine. A consecutive sampling technique was used and data was further evaluated with the help of Statistical Package for the Social Sciences version 24. Results: Among 138 females, PCOS was seen in 40.6% of the subjects. The second most common pathology was ovarian cyst which was seen in 10.9% of subjects. And the incidence of multiple fibroids was 5.1% as third most common pathology in both primary and secondary infertility cases. Most ovarian pathologies were found to be bilateral. 12.3% subjects had no findings on ultrasound. Conclusion: PCOS was the utmost common pathology connected with primary and secondary infertility. The second and third most common pathologies were ovarian cyst and multiple fibroids respectively. hysteroscopy, hysterosalpingiography and transvaginal ultrasound are the most satisfying procedures for assessment of pelvic abnormalities 12 . Transvaginal sonography is better than transabdominal sonography in diagnosing subtle irregularities with better imaging quality and it is usually used simultaneously with transabdominal ultrasound but not as a replacement 13 . Transabdominal ultrasonography cannot detect all pathologies causing hindrance in conception but transvaginal ultrasonography is more efficient in detecting causes of female infertility so problem can be solved. The purpose of this study is to evaluate all pathologies that can be diagnosed by transvaginal ultrasonography in the work up of female infertility to describe the spectrum of ultrasonography first-line modality of identification and administration of preoperative the intensity of the High standard of precision in the diagnosis of endometriosis quality of TVUS was by the diagnostic reliability of TVUS in deep endometriosis, sensitivity of 77.5% the standard pelvic ultrasonography conclusive of endometriosis. categorization of severity and intensity study


Introduction
Failure of conception in women after frequent unprotected intercourse for one year is known as infertility 1 . It is a historic problem impacting women's health and lifestyle causing social and psychological stress leading to agony and insecurity in their life 2 . The prevalence of female infertility among all infertile couples is 37% globally 3 . However, in Pakistan the prevalence of infertility is about 22% with 4% primary and 18% secondary infertility 4 . During the evaluation of infertile female the commencement of examination and background must include history of menstrual cycle, frequency and timing of intercourse, use of contraceptive medicines or devices, infection of pelvic cavity, previous pregnancies and their results, use of other medications, occupational exposures, abuse of substances, alcohol consumption, tobacco consumption, and any surgery of pelvic organs 5 . Fallopian tube, endometrial cavity and ovaries involvement in infertility are 92-100%, 50%, 10-30% respectively, whereas Genital Tuberculosis is rare 6 . GTB is a chronic infection which leads to infertility by producing deleterious effects on fallopian tube causing irremediable damage, it may be asymptomatic or present with undetermined symptoms 7 . Various risk factor associated with female infertility are advanced age (>35 years), elevated body mass index, age of onset of sexual activity, prior pelvic surgeries, stress, smoking, chemical and radiation exposure, insecticides, PID, contraceptive use, alcohol intake and drug abuse 8 . Infectious agents such as bacteria, viruses and other parasites affect normal human physiology and thus interfere with the normal process of reproduction 9 . Infertility is also caused by endocrine disorders such as different types of thyroid, ovarian, hypothalamic, pituitary and adrenal abnormalities 10 .Transvaginal sonography is a first line standard procedure for the determination of cause of infertility, whereas Pelvic ultrasonography is helpful in the diagnosis of PCOS, PID, fibroids, endometriosis, adenomyosis and abnormalities like ovarian cysts etc. Transvaginal sonography is cheap, free of radiation, completely safe, non-invasive, redoable, easy to perform and highly effective all around the world 11 . In female infertility, laparoscopy, hysteroscopy, hysterosalpingiography and transvaginal ultrasound are the most satisfying procedures for assessment of pelvic abnormalities 12 . Transvaginal sonography is better than transabdominal sonography in diagnosing subtle irregularities with better imaging quality and it is usually used simultaneously with transabdominal ultrasound but not as a replacement 13 . Transabdominal ultrasonography cannot detect all pathologies causing hindrance in conception but transvaginal ultrasonography is more efficient in detecting causes of female infertility so problem can be solved. The purpose of this study is to evaluate all pathologies that can be diagnosed by transvaginal ultrasonography in the work up of female infertility to describe the spectrum of Journal of Biology, Agriculture and Healthcare www.iiste.org ISSN 2224-3208 (Paper) ISSN 2225-093X (Online) Vol. 10, No.12, 2020 diagnostic findings. In this study we will describe the frequency of pelvic pathologies that can be detected on TVS. In a study conducted by Theresa Widrich, the significance of ultrasonography and predominantly of transvaginal sonography in the setting of diagnosis and treatment of infertility is explained. Transabdominal ultrasound gives a wide view of the pelvic cavity however transvaginal ultrasonography provides more convenience and assistance in the field of gynecology. TVUS is considered as the obligatory gadget in the work-up of gynecologic infertility such as the evaluation of the female pelvic cavity, supervision of ovulation and oocyte collection for in-vitro fertilization procedure. The further extension in the field of ultrasonography is its use with contrast media which circumvent the application of hysteroscopy and laparoscopy in specific cases. Advances in ultrasound such as Color Doppler, Color Power Angio (CPA) and three-dimensional USG can play an important role in the assessment of infertile patients 14 .In a study, Fraser MA. et al, illustrated the rolr of transvaginal ultrasonography in the detection of endometriosis. TVUS is considered as the first-line imaging modality for the diagnosis of endometriosis due to its enhanced identification rate and administration of preoperative evaluation regarding the intensity of the disease. High standard of precision was shown in the diagnosis of endometriosis when a better quality of TVUS was performed by a specialist. In evaluating the diagnostic reliability of TVUS in deep endometriosis, it has a sensitivity of 77.5% as compared to the standard pelvic ultrasonography which is not conclusive to exclude non ovarian form of endometriosis. It also contributes in the illustration of comprehensive categorization of severity and intensity of the disease that may aid in the surgical preparation and guiding the patient 15 . In a study conducted by M.Brassard. et al, the role of PCOS causing infertility in women is elaborated. PCOS is known to be one of the most common causes of infertility in women although it can be treated medically. It is typically found in young females. Almost 70% cases of PCOS cause a type of infertility in which ovulation is hindered. A well known efficacious method being used for the treatment of PCOS is the control of blood sugar level along with weight loss by exercise or diet. Weight loss is very effectual regarding the improvement in conception and also decreases the rate of unfavorable consequences of pregnancy corresponding to obesity 16 .

Methods
A Descriptive Cross-Sectional study was conducted at Gilani Ultrasound Centre and University Ultrasound Clinic Lahore. During 3 months of research period 138 females with the complain of primary and secondary infertility were willingly recruited. Examination was performed by using American Institute of Ultrasound in Medicine (AIUM) transvaginal ultrasound guidelines. Ultrasound machine Toshiba Xario with Transvaginal robe of frequency 9-12 MHz was used.

Results
A total of 138 participants including primary and secondary infertile individuals were recruited in this study. Out of them 72 (52.2%) presented with the history of primary infertility and the remaining 66 (47.8%) with secondary infertility, Table 1 The age group in years of study range from 10 minimum to 41 maximum with mean age at that time being 28.1449 years and the standard deviation being 5.42440. The gravidity among the females of study group ranges from 0 minimum and 5 maximum with mean gravidity being 0.8333 and standard deviation being 1.11776. The parity of the females ranges from 0 minimum and 3 maximum with mean parity being 0.4928 and standard deviation being 0.81273. The number of abortions/miscarriage ranges from 0 minimum and 4 maximum with mean abortions/miscarriage being 0.3478 and standard deviation being 0.73148, Table 3. PCOs was the most commonly seen pathology with highest frequency reported in 56 (40.6%) patients. The second most commonly seen pathology was ovarian cyst 15 (10.9%) followed by multiple fibroids 7 (5.1%) as the third most commonly seen pathology.
Right ovarian endometrioma measuring 62.7 mm x 60.4 mm and left polycystic ovary

Graph 1. Frequency distribution of all detected pathologies
As for the location of pathology 1 (0.7%) was reported in the anterior wall of uterus, 59 (42.8%) pathologies in bilateral ovaries, 14 (10.1%) in the left ovary, 3 (2.2%) in the posterior wall of uterus and 12 (8.7%) in the right ovary.

Discussion
The results of our study propose that there is higher occurrence of primary infertility in comparison to secondary infertility. These findings are similar to the findings of another study in which the prevalence of primary infertility was 69.5% and that of secondary infertility was 30.5% 17 .The most common endocrine disorder in women is PCOS resulting in 75% cases of infertility due to absence of ovulation 18 . The amalgamation of anovulation and higher Journal of Biology, Agriculture and Healthcare www.iiste.org ISSN 2224-3208 (Paper) ISSN 2225-093X (Online) Vol. 10, No.12, 2020 31 levels of androgens leads to polycystic ovaries. PCOS is correlated with other medical conditions in the female patients such as hypertension, obesity, insulin resistance, cardiovascular disease, diabetes mellitus type 2, metabolic disorders, dyslipidemia, endometrial hyperplasia and carcinoma. Skin related symptoms of high androgen levels include alopecia, hirsutism, seborrhea, acne and virilization in critical cases. Infertility caused due to PCOS is related with higher levels of LH secretion and higher LH/FSH ratio 19 . According to our study the leading cause of infertility is also PCOS effecting almost 40.6% of cases in both primary and secondary infertile females.Genitourinary tract infections results in infertility in almost 15% of cases. At the age of 35, salpingitis causes subfertility in almost 2.5% of women. Pelvic Inflammatory disease (PID) occurs due to several infection causing agents such as Chlamydia Trachomatis, gonorrhea and multiple anaerobic infections of upper genital tract. Lower genital tract infection results from different bacterial, fungal and protozoan causes such as Bacterial Vaginosis, Candida Albicans and Trichomonasvaginalis. PID advances through vagina to cervix, uterus, endometrium and fallopian tubes 20 . In our study PID is the second main pathology diagnosed in the patients of primary as well as secondary infertility and were seen in 8.7% of cases.Uterine myomas are one of the remarkable cause of infertility and other medical conditions such as spontaneous abortion and complications in pregnancy. Submucosal fibroids effects fertility and upsurges the rate of spontaneous abortion and can be treated through myomectomy. Intramural fibroids also reduce fertility and surge the risk of spontaneous abortion but myomectomy is not the sole treatment to reinstate the normal position. However, subserosal fibroids do not effect fertility but they do upturn the risk of abortion. Complications associated to pregnancy caused by fibroids are intrauterine growth retardation, placental abruption, cesarean delivery, placenta previa ,retained placenta, postpartum hemorrhage, malpresentation and preterm labor. Fibroids may be symptomatic or asymptomatic, common symptoms include acute and chronic pelvic pain, urinary frequency, abnormal uterine bleeding and constipation. Almost 2.4% of women experience infertility due to fibroids 21 . In our study multiple fibroids were seen in 5.1% of females presenting with infertility and this was the third most common pathology seen in our study.

Conclusion
PCOS was the utmost collective pathology related with main and secondary infertility. The second and third most common pathologies were ovarian cyst and multiple fibroids respectively.