Approximately 5 percent of IVF pregnancies will result in an ectopic pregnancy, ie where the pregnancy implants outside the uterine cavity. These pregnancies are non-viable and may cause internal bleeding. Because of this risk an early diagnosis and early treatment is important and for this reason all patients are referred for an ultrasound examination following transfer to assess the site of pregnancy implantation.

A pregnancy test is routinely performed on day 16 following transfer. If this is positive a transvaginal ultrasound is arranged, usually for 4 to 5 weeks following transfer. The site , number and viability of the gestation(s) is / are documented.

At 6 weeks gestation (about 4 weeks following transfer) a pregnancy sac, a yolk sac, an embryo and embryonic heart motion should be visible. Delay in the appearance of these individual structures may be an indicator of subsequent miscarriage.

Miscarriage occurs in 15-20% of IVF pregnancies and the diagnosis is usually made upon inappropriately low hormone levels in association with poor prognostic markers noted on ultrasound. In many patients where signs of pregnancy failure are present a repeat ultrasound examination is necessary before a firm diagnosis of miscarriage can be made.

Why have a scan at 11-14 weeks?

Nuchal Translucency:
Currently the most accurate non invasive test for detecting Down syndrome during pregnancy is the measurement of the nuchal translucency with ultrasound between 11-14 weeks of pregnancy. This is normally less than 2.5mm and when increased (ie>2.5mm) may indicate the baby has Down syndrome or another chromosomal abnormality.

What is the Nuchal Translucency?
The nuchal translucency is a collection of fluid beneath the fetal skin in the region of the fetal neck and is present in all fetuses in early pregnancy. The fluid collection is however increased in many fetuses with Down syndrome and many other chromosomal abnormalities. It is called a "translucency" because on ultrasound it appears as a black space beneath the fetal skin. It is this black space that you will see measured during the ultrasound scan.

If the Nuchal Translucency is increased what happens next? If the nuchal translucency is increased then you will be offered a needle test which is called chorionic villus sampling or C.V.S. (ref CVS information leaflet). This test involves taking a biopsy from the placenta and examining the baby's chromosomes. In these circumstances an urgent report is requested (short term culture) and if sufficient cells are present in the sample the results may be processed as early as 2-3 days. The complete analysis (long term culture) takes 2-3 weeks.The normal short term culture excludes major chromosomal problems such as Down Syndrome and the long term looks at the chromosomes in greater detail thus excluding more subtle chromosomal abnormalities.

How is the scan performed?
We generally recommend that the scan be performed through the vagina (ref. transvaginal information leaflet). In these circumstances a very narrow ultrasound probe is gently placed a short distance into the vagina and the ultrasound beam directed towards the baby. With this approach greater detail is obtained of the fetal anatomy. However if you wish to have an ultrasound examination through the lower abdomen this can be arranged.

What happens if the chromosome test (CVS) is normal?
For patients where there was an increased nuchal translucency and later a normal CVS result, there is still a slight increased risk of a structural abnormality in the baby (6%, compared to the background risk of 2-3%); eg a congenital heart defect. For this reason a detailed examination of the fetal anatomy is required around 18-20 weeks.For most patients the anatomy is normal and the pregnancy progresses uneventfully.

What happens to the increased nuchal translucency with advancing pregnancy?
In the majority of patients this disappears and is not visible at the routine 18-20 week ultrasound. This explains why it is important that the scan be performed around 11-14 weeks. ie there is only a narrow window of opportunity when this ultrasound marker of chromosomal abnormality is evident.

What is the risk of the scan?
A transvaginal and transabdominal ultrasound examination is a safe investigation at all stages of pregnancy.

What else can the 11-14 week ultrasound scan show?
A scan at 11-14 weeks provides an opportunity to assess the anatomy of the baby. At this early stage of pregnancy it is now possible to determine many structural abnormalities previously only visible at 18-20 weeks. During the examination many parts the fetal anatomy will be pointed out to you. It is also an opportunity to determine the number of babies present and the baby's heart rate.

Normal Nuchal Translucency

This image shows a longitudinal section through a fetus with the head to the left and the legs to the right. The arrows point to the tiny collection of fluid beneath the fetal skin, ie. The Nuchal Translucency which in this baby is normal.

Increased Nuchal Translucency

This image shows a longitudinal section through a fetus at 11 weeks. The head is the left and the legs to the right. The arrows point to the increased Nuchal Translucency. Placental biopsy (CVS) in this fetus revealed Down Syndrome.

In the state of Victoria a routine ultrasound examination is offered to most patients between 18-20 weeks , and is it is loosely referred to as the "18 week ultrasound". The purpose of this examination is to:

• To determine the viability of the pregnancy. In fact the heart rate may be measured as early as 6 weeks gestation.
• To determine the number of gestation sacs ie. singleton, twins , triplets and higher multiples.
• To determine the size and the gestation of the pregnancy. Several measurements are taken of the baby and include the head size, the abdominal circumference and the femur length.
• To assess the fetal anatomy. This involves a detailed examination of the fetal head ,brain, face, lips, heart, stomach, lungs, abdominal wall, kidneys, bladder, spine arms, legs, hands, and feet. Several landmarks within individual organ systems are noted and recorded on video film for archiving. Only upon request is fetal gender disclosed (assuming it can be seen).
• Assessment of the position of the placenta.
• Assessment of the liquor volume .
• Assessment of the pelvic anatomy and the cervix.

This examination is expected to detect the majority of major fetal malformations. It is important to appreciate however that such an examination does not detect all abnormalities. Many congenital heart abnormalities are complex and escape diagnosis at the 18 weeks ultrasound examination. Also in many instances the view of the fetus may he hampered by the fetal position at the time of examination. Also ,the tissue interposed between the ultrasound probe and the baby absorbs the ultrasound waves, so if a particular patient is overweight the fatty tissue of the abdominal wall may make visualisation of the fetus difficult. In these circumstances the patient may be rebooked for further assessment of the fetus.

Finally in certain circumstances fetal abnormalities may not be evident on ultrasound despite adequate views. This may be explained by the natural history of the condition where the abnormality only becomes evident in later pregnancy or where there are in fact no structural changes in the baby (eg. cerebral palsy, biochemical abnormalities and some chromosomal abnormalities).

1. What is Amniocentesis?
Amniocentesis is a procedure which involves passing a fine needle through the maternal abdomen and the uterine wall into the amniotic fluid around the fetus in order to obtain a sample of the amniotic fluid. From this fluid, fetal cells are harvested, cultured and treated to reveal their chromosomes. While an amniocentesis can be performed at any stage in pregnancy, it is usually performed between 14-16 weeks. The volume of fluid aspirated is about 1/6th of that present around the fetus and this is naturally replaced over the next 24 hours.

2. Who may be offered Amniocentesis?
Amniocentesis is generally offered to patients who a) are 37yrs and over at the estimated date of delivery, b) to women who have previously had a child with a chromosomal abnormality, c) patients who themselves have a chromosomal abnormality or other rare metabolic or genetic abnormalities and d) occasionally to mothers who are extremely anxious regarding the possibility of a chromosomal abnormality in their baby.

3. How is it performed?
An ultrasound examination is first performed to a) confirm the dates, b) to assess the position of the placenta (afterbirth), and c) assess the baby for ultrasound signs of chromosomal abnormality such as Down Syndrome. A point on the abdominal wall is selected by the operator using ultrasound. It is then cleaned with antiseptic and local anaesthetic is injected. The amniocentesis needle is then guided into the amniotic fluid (the fluid surrounding the baby) by tracking it's course on the ultrasound screen. It takes about 30 seconds to draw up the straw coloured fluid.

4. What are the risks of the test?
The principle hazard of the procedure is the risk of introducing infection into the pregnancy which may result in miscarriage. This complication occurs in only 1/200 tests performed. The warning signs of miscarriage include regular crampy period-like pains with fresh red bleeding which occur in the first 24-48 hours after the test. A small fluid leak is a rare problem with much less likelihood of progressing to pregnancy loss, this usually settles of its own accord. Because the procedure is performed with ultrasound guidance, fetal injury with the needle is extremely rare.

5. What happens to the specimen taken?
A 15-22ml sample of fluid is aspirated and dispatched to the laboratory. The baby's cells are extracted from the fluid and placed in a culture medium in a warm incubator. In 7-10 days when sufficient cells have grown, they are treated so the chromosomes are revealed. The chromosomes are examined under the microscope with ultraviolet light. Each individual chromosome pair (of which there are 23) are examined in detail. The laboratory scientist will examine the cells for an extra chromosome no. 21 (Down syndrome) and for any abnormality in the other 22 pairs of chromosomes.

6. What is to be expected after the test?
Most patients will experience a few crampy pains or some mild crampy abdominal discomfort after the test. This is due to irritation of the uterus by the amniocentesis needle or local anaesthetic. It is safe to take paracetamol or panadol but no stronger analgesic should be necessary. If the pains worsen then contact your doctor. Some spotting after the test is also not unusual, but should this progress to fresh red bleeding then contact your doctor. Many patients may be fortunate and experience no symptoms at all after the test. Take it easy for the rest of the day although there is no need for bedrest. It is probably a good idea for someone to take you home after the test. You may carry on as usual the day after the test.

7. How long before I know the results?
Depending on the rate of cell growth in the incubator results are available from as early as 10 up to 21 days. You will be contacted by phone with the result and a written report will also be mailed directly from the laboratory to your doctor. It is your doctor who will tell you the sex of your baby, if you want to know (this part of the result will not be given over the phone).

8. Are the results accurate?
A chromosome result is one of the most reliable medical tests which has an accuracy in the order of 99.9%.

What do I do following the procedure?
It is recommended that you have someone with you to drive you home. You should rest for approximately 48 hours after the procedure as you may experience some mild period type abdominal pains. For any other problems you should communicate with your own doctor.

Diagrammatic representation of an amniocentesis.

The patient's head is to the left and the legs to the right.

The needle is advanced into the largest pocket of fluid and 15-22 ml aspirated. It takes 5-10 minutes to set up the procedure and 1-2 minutes to aspirate the fluid. Sometimes the fetus may move in the way of the needle but this does not it cause any harm.

Rhesus disease is a condition which may affect the unborn baby. It gives rise to anaemia (low blood count) in the baby, usually late in pregnancy. It is a condition which occurs in partners with incompatable blood groups.

Approximately 85% of the Australian population have a Rhesus (Rh-D) positive blood group and 15% a (Rh-D) negative group.

When a Rh-D negative patient becomes pregnant by a Rh-D positive partner there is a 1 in 4 chance that the baby will be Rh-D positive. If the baby's Rh-D positive blood cells pass into the mother's bloodstream (as may occur at amniocentesis or chronic villus sampling (CVS) then the mother may produce antibodies against these cells. These antibodies may destroy the baby's own blood cells and thus cause anaemia.

If the mother is given an injection of Anti-D within 72 hours of the procedure (amniocentesis or CVS) then the baby's cells which have entered her bloodstream may be neutralised and thus harmful antibodies are not produced.

It is therefore routine practise to offer all Rh-D negative mothers Anti-D after amniocentesis or CVS.

It is important that we know your blood group at the time of your amniocenesis or CVS. If you do not know your blood group please ask your doctor for this information prior to your appointment.

Because Anti-D is a blood product (extracted from blood donated by someone else), it carries a small risk of transmitting viral or other infections. In Australia however, the screening of such blood products is stringent and such transmissions are extremely rare.

Anti-D is given by injection usually into the buttock or arm after the amniocentesis or CVS. You will be asked to sign a consent form to receive this injection.

Approximately 5 percent of IVF pregnancies will result in an ectopic pregnancy, ie where the pregnancy implants outside the uterine cavity. These pregnancies are non-viable and may cause internal bleeding. Because of this risk an early diagnosis and early treatment is important and for this reason all patients are referred for an ultrasound examination following transfer to assess the site of pregnancy implantation.

A pregnancy test is routinely performed on day 16 following transfer. If this is positive a transvaginal ultrasound is arranged, usually for 4 weeks following transfer. The site , number and viability of the gestation(s) is / are documented.

At 6 weeks gestation (about 4 weeks following transfer) a pregnancy sac, a yolk sac, an embryo and embryonic heart motion should be visible. Delay in the appearance of these individual structures may be an indicator of subsequent miscarriage.

Miscarriage occurs in 15-20% of IVF pregnancies and the diagnosis is usually made upon inappropriately low hormone levels in association with poor prognostic markers noted on ultrasound. In many patients where signs of pregnancy failure are present a repeat ultrasound examination is necessary before a firm diagnosis of miscarriage can be made.

What is the combined test?
This test has recently become available in Victoria. It is a screening test which combines the results of two proteins in the mothers blood with ultrasound to determine your risk of having a baby with Down syndrome and other chromosomal abnormalities. The accuracy of detecting Down Syndrome is approximately 85-90%. The advantage of this test over others is that a result is obtained early in pregnancy, around 11-14 weeks.

How is the test performed?
Blood is taken from your arm at approximately 10 weeks gestation. This should be arranged through your nearest approved pathology collection service as advised by your doctor. The blood is then dispatched to the Murdoch institute at the Royal Children's Hospital, in Parkville. Two blood proteins (PAPP-A and beta-HCG) are measured. Approximately 2 weeks later when the pregnancy is around 12 weeks an ultrasound scan is performed. At this examination the fetal development, size, and nuchal translucency are documented (refer Nuchal Translucency leaflet). The nuchal translucency result is faxed to the Murdoch Institute and the results of the blood test and ultrasound are combined to give one result.

How should I interpret the results?
Your results will be given to you as a risk estimate; i.e. the chance of your baby having Down syndrome. For example if you are 28 years old your chance of having a baby with Down syndrome is about 1 in 600. But if you ultrasound result is favourable ie. a thin nuchal translucency, and biochemistry results favourable i.e. low levels of both proteins, this risk will be reduced to say 1 in 3500 and therefore would be reassuring. The combined will result will not however provide you with a definite 'yes' or 'no' answer as to whether your baby has Down Syndrome.

Do all pregnant women have this combined test?
No. The decision to have the blood test, the ultrasound, or both is entirely up to you. It is, however, worth considering a number of issues for example:

1. If testing showed that I was carrying a Down Syndrome baby what would I do?
2. The test does not identify ALL pregnancies with Down Syndrome.
3. At what risk figure should I proceed with CVS or amniocentesis.

Most patients choose to proceed with CVS or amniocentesis when the combined ultrasound and biochemistry risk reaches 1 in 300. But it is your choice as to what level you wish to rest with. These difficult issues may be discussed further with your doctor or ultrasound specialist.

Should I have CVS or amniocentesis instead of the combined test?
You may ask yourself should I not just proceed to the definitive test with CVS or amniocentesis and avoid having 2 tests. There are 2 principle reasons why you may choose not to proceed directly to needle testing. Firstly CVS and amniocentesis both carry a significant risk of miscarriage (CVS 1% and amniocentesis 0.5%) and secondly 95% of patients who have the combined test will be given a favourable result, lowering their age related risk.

How accurate is the Combined Test?
By combining the results of the early ultrasound and the early blood tests (ideally at 10 weeks) the test can identify approximately 9 out of 10 pregnancies in which the baby has Down syndrome. This is more accurate than each test alone. It is however important to realize that this test is only for chromosomal abnormalities such as Down syndrome and does not ensure that the baby is free of other possible birth defects.

If the ultrasound shows a thick nuchal translucency and the blood levels are high, your age related risk at 28yrs may be increased from say 1:600 to say 1 in 60. If this situation arises then you have the choice of a definitive test such as chorionic villus sampling or amniocentesis.

What is CVS?
Chorionic Villus sampling is a test which involves obtaining a small sample of tissue, the chorionic villi from the developing placenta. The placenta which has the same chromosome makeup as the baby may be then examined to check for genetic, DNA or biochemical abnormalities eg Down Syndrome, Cystic Fibrosis etc.

Who is offered CVS?
Most testing by CVS is offered to patients who are at particular risk of chromosomal abnormality such as Down syndrome. This would include mothers who are 37 years or older, and those who have had a previous Down syndrome baby. The test is also offered to those who have had a previous baby with other chromosomal or genetic abnormalities (such as metabolic disorders). On occasion the test is performed for those who are particularly anxious regarding the risk of chromosomal abnormality.

How is the test Performed?
The skin of the lower abdominal wall is cleansed with an antiseptic alcohol based solution. The skin and underlying tissues are injected with local anaesthetic. The discomfort felt during the injection of the local anaesthetic is similar to that felt when blood is drawn from the forearm. With ultrasound control a fine needle is then guided into the placenta and a biopsy of placenta tissue is taken (chorionic villi). Sometimes a dragging sensation is felt in the pelvis or in the legs during the procedure. This is a normal feature of the test. Also sometimes more than one biopsy is required.

When is the test Performed?
Ideally the test is performed between 11-12 weeks gestation , however it may be performed as early as 91/2 weeks and as late as 19 weeks.

What preparation do I need before the Test?
A moderately full bladder is preferable. This brings the pregnancy up into the abdominal cavity and thus accessible for the needle test. If you begin to feel very uncomfortable with a distended bladder then try to let some urine out as this may also hinder the test.

A scan is performed before the test in all patients to:

1. Make sure the baby is alive and well,
2. To determine whether there are twins or higher multiples
3. To check for abnormalities in the baby including the nuchal translucency (ref.10-14 week sac information leaflet). A variety of abnormalities may be detected at this early stage of pregnancy.

Finally it is also very important to know what your blood group is before the test, (ie Rh positive or negative). If possible ask your doctor to provide this information or bring along you blood group card at the time of the test. If you are negative blood group you will need an injection of anti-D after the test. This may be explained further by the Doctor at the time of the test.

What happens the biopsy after it as been taken?
The specimen is sent to the laboratory and processed. The tissue is placed in a culture medium and then into an incubator for several days. When there are sufficient number of dividing cells the specimen is removed from the incubator and the placental cells are split open with an enzyme. The individual chromosomes are counted and analysed.

Every cell should contain 23 pairs of chromosomes. The test looks for an extra chromosome number 21 (Down syndrome). Each of the other 22 pairs of chromosomes are also examined. This includes chromosome pairs number 1,2,3,4, and so on up to the sex chromosomes (pair no 23). Therefore this test not only excludes an extra chromosome number 21(Down syndrome) but it excludes extra chromosomes in the other 22 chromosome pairs.

Also each individual chromosome pair is then stained with a special dye and examined under ultraviolet light. The individual bands of each chromosome are examined in great detail for subtle genetic abnormalities such as 1)insertion of genetic material into a chromosome , 2)deletion of genetic material from a chromosome and 3) exchanging of genetic material between chromosomes (called translocations). So this test excludes not only Down syndrome but a wide variety of additional subtle and major chromosome abnormalities.

What should I do after the test?
It is recommended that you take rest for the remainder of the day. This does not mean you should confine yourself to bed but rather you should just rest at home and avoid any strenuous activity including lifting any heavy weights. Most patients experience a short duration of mild crampy period-like pains, lower abdominal pains or even leg pains after the test. This is most likely to occur after the local anaesthetic wears off, ie within the first half hour after the test. Some patients experience slight vaginal blood spotting after the test which is also not unusual.

What are the risks of the test?
There is a 1% risk of miscarriage with the test. This usually related to infection introduced at the time of the procedure. Several antiseptic precautions are taken to minimise this risk.

The needle itself is at all times well distanced from the baby. In fact when the biopsy is taken the needle is positioned outside the pregnancy sac (ref. diagram overleaf).

Warning signs of miscarriage include strong regular period like pains with fresh red bleeding. Call your doctor should this occur. The time when miscarriage is most likely to occur is the first 24-48 hrs-7days after the test. Additional Complications of the test include failure of the specimen to grow sufficiently in the laboratory and uncertain laboratory results. These complications are very uncommon and if they do occur you still have the choice of an amniocentesis test at 15-16 week of pregnancy. This test will give the same information about the baby's chromosomes (refer amniocentesis information leaflet).

Diagramatic representation of a CVS

The mother's head is to the left and the legs to the right. The needle is directed under ultrasound control into the developing placenta. One or sometimes two biopsies are taken.

The ureter is a narrow tube which drains urine from the kidneys to the bladder (refer diagram to the right). Where the ureter meets the kidney is called the renal pelvis. This normally measures less than 4mm at the 18-20 week scan.

In 1-2% of pregnancies the renal pelvis of the baby is dilated to around 4-10mm. In most cases this is a normal variation which resolves in later pregnancy or shortly after delivery.

In some babies however, the dilatation may be due to reflux of urine or rarely obstruction of the ureter. Both of these conditions are treatable.

Where there is reflux, the urine flushes back up the ureters towards the kidneys each time the baby passes urine. In the majority of cases this resolves with time as the baby gets older and the valve mechanism between the bladder and ureters mature. With some babies however a short course of antibiotics is needed and only rarely is surgery performed to correct this problem.

With obstruction, the ureter may be partially blocked anywhere along its length from the kidney to the bladder. In the vast majority of babies the obstruction is mild and surgery is not required.

Therefore, it is important to follow up all babies with renal pelvis dilatation, in order to identify those who will require treatment for related problems in the future. In the majority of babies with renal pelvis dilatation however such treatment will not be required, and no long term kidney damage results.

Kidneys and Ureters

Kidneys with Renal Pelvis Dilatation

Follicle tracking involves tracking the development of eggs within the ovary from an immature state (primordial follicles) to a mature state (leading or dominant follicles). This process may be monitored with transvaginal ultrasound in combination with blood levels of the female hormones oestrogen and progesterone.

Follicles may be tracked in a natural cycle. When a leading follicle is seen (average size=22mm , with a range of 17-27mm) then intercourse may be appropriately timed. Alternatively drugs which promote release of the mature egg (leutinising hormone)may be administered.

For most patients on IVF treatment however, the ovaries are artificially stimulated with hormones (follicle stimulating hormone) which produces multiple mature eggs which are then harvested following administration of luteinising hormone. In this setting the follicular development is followed more closely. Usually between 2-4 scans and blood sampling are performed per treatment cycle. The timing of ultrasound guided needle aspiration of mature follicles is based on the scan and blood results.

If the eggs are less mature than expected the timing of egg collection is postponed and where the follicular development is in advance of the expected time then the date of egg collection is brought forward.

In most patients egg collection is performed as a transvaginal ultrasound guided procedure under anaesthetic. However in some patients in view of difficulty with vaginal access it may be performed transabdominally.

In some patients pain may be experienced following the procedure and if this pain worsens then an ultrasound examination may be performed to determine the presence or absence of internal haemorrhage after collection.

Normally the placenta is situated in the upper part of the uterus (womb) or along the front or back wall, well clear of the birth canal (cervix) see figure 1.

In 5% of pregnancies at 18-20 weeks, the placenta is situated low in the uterus either close to, or covering the cervix (see figure 2). As pregnancy progresses however, the lower part of the uterus grows such that the placenta eventually becomes clear of the cervix. In fact, in 95% of cases the placenta will be clear of the birth canal by 37 weeks of pregnancy.

Therefore if you are informed at your 18-20 week scan that the placenta is low, do not be alarmed, you can continue normal activities as usual. A repeat ultrasound should however be arranged at around 26-34 weeks of pregnancy to determine if the placenta has moved away from the cervix.

In a small number (5%) of pregnancies, the placenta remains low after 28 weeks. This is called placenta praevia (refer figure 3). A placenta which is praevia may cause vaginal bleeding in later pregnancy. Also in some patients with Placenta Praevia the baby may need to be delivered by Caesarean section. So in this situation extra care and monitoring of your baby and the placenta may be required. Your specialist will discuss with you the best way to manage this situation and advise you of any precautions.

A normally situated placenta

Figure1. The placenta is situated at the top of the uterus well clear of the neck of the womb (cervix).

A low placenta at 18 weeks

Figure 2. The placenta is situated low in the uterus. In 95% of patients however the placenta "moves up" in later pregnancy.

Placenta Praevia

Figure 3. The placenta covers the birth canal (cervix). of the womb (cervix)

About 1 in 10 women will develop vaginal bleeding after the menopause (the change of life). The blood loss is usually slight and often amounts to no more than a little spotting of underwear. It should always however be investigated.

In the vast majority of patients who develop such bleeding however, no serious cause is found. Most bleeding episodes are explained by the hormonal imbalance that occurs around the time of the change (menopause), by problems related to hormone replacement therapy (HRT) or by excessive dryness of the vagina.

In a very small number of patients the bleeding may be due to cancer of the lining of the uterus (the endometrium). It is therefore important to assess the endometrium to exclude cancer.

A transvaginal ultrasound examination of the uterus provides detailed views of the uterus and endometrium. A thin endometirium (ie less than 5mm) virtually excludes cancer of the endometrium (refer figure 1), however should another episode of bleeding recur after the scan it is still important that you let your doctor know.

In some patients the endometrium is thickened (>5mm) and this is usually explained by either problems with HRT or by overgrowth of the cells lining the cavity (hyperplasia). Hyperplasia may lead to the formation of a polyp (a grape-like structure that is attached by a narrow stalk to the endometrium). In a small number of patients however the appearances of a cancer may be seen. In these circumstances an endometrial biopsy (taking a sample of the endometrium) is required.

Menopausal Uterus with a Thin Endometrium

Figure 1 . The lining of the uterus (endometrium) is thin. This finding is very reassuring and almost excludes all cancers of the lining of the uterus.

Menopausal Uterus with a Thick Endometrium

Figure 2. The lining of the uterus (endometrium) is thickened. In most patients such thickening is related to HRT or a benign process in the endometrium.However in some cases it may indicate cancer and further investigations such as a curette may be required.

What is Miscarriage?
Miscarriage refers to the unexpected loss of a pregnancy from the time of conception up to 5 months of pregnancy. After this time the term stillbirth is used.

How do I know if a Miscarriage is happening?
Miscarriage usually starts with bleeding from the vagina, crampy abdominal pain or both. The pain and bleeding increase, the cervix (neck of the womb) opens and the placenta, fluid and embryo are passed through the vagina. In most cases this happens in early pregnancy and you will not recognize the embryo or placenta as both are very small. The most you will note is blood loss possibly with 'stringy material' which is the placenta. The blood loss is usually equivalent to a heavy period.

Not all patients however with pain and bleeding in early pregnancy progress to miscarriage and pregnancy loss. In fact, bleeding or spotting along with, crampy lower abdominal pains are quite common symptoms in early pregnancy and most settle with time. In only a few cases do the symptoms worsen and lead to miscarriage.

What Causes Miscarriage?
Up to 15% of pregnancies are lost as a result of miscarriage. Some pregnancies are lost before you miss your period and therefore go unnoticed, but most are lost at 5-12 weeks of pregnancy. Most miscarriages occur as a result of a chromosomal or genetic problems in the developing embryo. In a sense they are nature's way of dealing with a pregnancy where the baby is likely to be born with serious physical or mental handicap. The earlier the miscarriage occurs the more likely there is a serious genetic or chromosomal problem. For example at 5-6 weeks of pregnancy approximately 60-70% of miscarriages are due to chromosomal or genetic abnormalities such as Down Syndrome.

The Grief of Miscarriage
Pregnancy loss is a sad and upsetting time for both you and your partner. Most patients before they present with signs of miscarriage have begun to think ahead in pregnancy and about the end result of a healthy baby. The news of miscarriage therefore comes as a great shock. Experiencing grief and sadness is however a normal and important response in these circumstances and helps in the long run with the emotional healing process which follows with time.

What Happens Next?
Most patients require a curettage following miscarriage. This is a procedure which involves a brief hospital admission, a light anaesthetic, dilatation of the cervix (opening of the neck of the womb) and removal of the remaining tissue from within the uterine cavity. Dilatation and curettage, or "D&C" brings an end to the pain and bleeding and reduces the risk of pelvic infection particularly with late miscarriages. Many patients find this procedure helpful in that it helps to recover more speedily with the grief of the situation and enables them to start thinking more positively and possibly about the next pregnancy.

In some patients, particularly those who miscarry in early pregnancy, when only a tiny amount of remaining tissue is present in the uterus, a D&C is not necessary. The small volume of remaining tissue is either reabsorbed back into the body or passed through the vagina.

When will I be able to get pregnant again?
It is generally advised that you should wait for at least the return of a normal period. This allows regeneration of the lining of the uterus and creates a more favorable environment for implantation of the next pregnancy.

Will this happen to me again?
For most patients there is no significant increased risk of miscarriage in the next pregnancy. Your miscarriage risk with the next pregnancy is therefore similar to the background risk i.e. as though you are on a fresh starting block. Investigations for miscarriage are generally arranged only if you have had the misfortune of having 3 or more consecutive miscarriages.

There are several other circumstances in which ultrasound guided procedures may be performed.

Obstetrics:

• Fetal blood sampling
• Paracentesis
• Amnioreduction
• Fetal thoracocentesis
• Fetal bladder tap
• Amnioinfusion
• Fetal intraperitoneal saline infusion

These procedures are performed infrequently. Fetal blood sampling is performed where there is a suspicion of fetal anaemia of other rare fetal blood count problems. The sample of blood is taken from the umbilical cord or from a small vein inside the baby's liver.

Gynaecology:

• Transvaginal pelvic cyst aspiration
• Transabdominal pelvic cyst aspiration
• Saline instillation into the uterine cavity
• Assessment of tubal patency

In certain circumstances simple ovarian or other pelvic cysts may be aspirated using a fine needle until complete cyst collapse is observed. This in many circumstances, provides almost immediate relief from the associated pain.

Instilling saline into the uterine cavity is a useful technique which facilitates visualisation of the uterine cavity and is particularly useful when small polyps within the cavity are suspected. Following instillation these polyps now bathed in fluid become obvious.

What are polycystic ovaries?
PCO are ovaries which contain an excessive number of primordial follicles. Primordial follicles are tiny fluid filled sacs which contain the eggs. An ultrasound of the ovaries during the reproductive years usually shows on average 4-12 follicles in each ovary. When more than 15 follicles are present, the ovary is called "polycystic". This should not be confused with polycystic ovarian syndrome (PCOS).This is a condition which describes a disturbance of many blood hormones, weight gain and excess hair growth which is more commonly associated with severe PCO, ie 30-50 follicles in each ovary.

What is the cause of polycystic ovaries?
In a normal menstrual cycle there are usually 5-10 follicles at the beginning of the cycle. Later in the cycle usually around day 14, one follicle gets bigger (leading follicle) and shortly thereafter ovulation takes place with release of the egg. The remaining eggs regress and disappear before the next cycle. These events are usually after every 4 weeks and result in the monthly menstrual bleed. With polycystic ovaries, this cyclical sequence of events does not take place. Instead, no leading egg develops and there is a build up of small immature follicles with successive cycles. Despite extensive research no single cause explains this variation from normal.

How common are Polycystic Ovaries?
This is a very common condition and it is estimated that about one in three women between the ages of 13-50 years have this condition.

Is this a serious condition?
This is not a serious condition; in fact the vast majority of patients do not require any form of treatment.

What sort of problems may polycystic ovaries cause?
For most patients it causes no problems and the condition goes unnoticed. For some patients, particularly those with >30 or so follicles, the following symptoms may develop:

1. Infertility
2. Infrequent or Irregular periods
3. Acne
4. Increased Facial Hair

Is there any treatment for this condition?
If however you are having difficulty getting pregnant or having menstrual problems there is a wide range of treatment options and most have high success rates. These may be discussed fully with your family doctor or specialist.

How is the examination performed?
A special transducer or probe which is slightly thicker than a tampon is used . It is covered with a disposable vinyl glove and lubricating gel, then gently placed into the vagina under ultrasound control. The probe sits in the vagina throughout the examination which usually takes between 10-15 minutes. You will be completely covered with a drape during the examination. Most patients find the examination far less uncomfortable when compared to a cervical PAP smear. The ultrasound images of your pelvis will be displayed on a television monitor situated above the examination couch. If you wish these will be pointed out and explained to you as the examination progresses. Should you not wish to see your examination please inform the staff at reception or the technician prior to the scan.

Transvaginal or Transabdominal Ultrasound: Do I have a choice?
It is always your choice as to which method of examination you have performed . With transvaginal ultrasound the probe is positioned close the uterus, fallopian tubes, ovaries and other pelvic structures and thus a far superior quality ultrasound image is obtained. In certain circumstances a transvaginal ultrasound examination is not possible or not advisable; for example, if you have not had sexual intercourse before and do not use tampons during your periods or there is scarring and tenderness in the vagina then a Transabdominal ultrasound is the preferred approach. If there are any concerns or enquires regarding the examination you may contact the department prior to the examination or speak to the technician on the day prior to the scan. If you prefer a female technician to perform the scan then this can also be arranged.

What information may be obtained from Transvaginal Ultrasound?
A pelvic ultrasound may detect a wide variety of diseases of the female genital tract, some of which require treatment. The examination assesses the structure of the vagina, cervix, uterus, fallopian tubes, ovaries and other pelvic structures. During the scan the technician may need to gently press on your abdomen to move bowel out of the way and bring the ovaries and other pelvic structures into view. This also enables assessment of abnormal tenderness in the pelvis which can be pinpointed so as to help in identifying the source of the pain.

What are the preparations I should take before the Ultrasound examination?
The transvaginal examination is best performed with the bladder empty. The receptionist will ask you to empty your bladder just prior to your scan. It is important that you remove any tampons before the examination. If you are at the beginning or in the middle of you period this is not a problem, in fact in many instances this is an advantage when assessing a variety of gynaecological problems. A disposable plastic backed tissue sheet ("bluey") is placed beneath you on top of the examination couch. After the examination the probe will be gently removed, the vinyl protective covering disposed of and the probe placed in a disinfectant solution. You will be given some tissues to remove the excess gel and you may then get changed in your own privacy. Similar to a smear test there may be some spotting after the scan. If you prefer to have an abdominal ultrasound then a moderately full bladder is necessary. To this effect you should drink 2-3 glasses of water before your appointment.

 

A fibroid is a benign growth of muscle which develops in the wall of the uterus. Fibroids range is size from 5-10mm (the size of a pea) to 150mm (the size of a football). They are very common and are present in up to 30% of women. They generally do not cause any problems and many patients go through life with their fibroids unnoticed.

Some patients do however run into problems which may include:

1. Infertility
2. Heavy or irregular periods
3. Pain

Infertility may occur as a result of blockage of the fallopian tubes (refer figure1.). Such a blockage may prevent the sperm from meeting the egg just before conception or prevent the embryo's passage toward the uterus. Fertility may also be reduced if the fibroids significantly disrupt the cavity of the uterus (refer fig.1).

Irregular bleeding with fibroids is usually the result of enlargement or distortion of the uterine cavity. Sometimes a small fibroid actually within the cavity may also cause heavy and irregular bleeding.

If fibroids enlarge to such a size that they outgrow their blood supply degeneration of the muscle may occur and pain may result. Degeneration may also occur in pregnancy. Both of these complications are rare.

Problematic fibroids may be treated with a variety of hormones to decrease their size. It may however, take several months before a reduction in size is noted. Other fibroids may be dealt with by surgery. If the fibroid is small and positioned within the cavity it may be possible to introduce a narrow telescope into the uterine cavity and remove the fibroid. Larger fibroids are usually approached either through keyhole or open surgery.

Uterine Fibroids

Figure 1: This diagram shows the various locations of uterine fibroids.