Complete evaluation of anatomy and

morphology of the infertile patient in

a single visit; the modern infertility
pelvic ultrasound examination

Departemen Obstetrik dan Ginekologi

FKUI - RSCM
• Objective : The comprehensive ‘‘one-stop shop’’
ultrasound evaluation of an infertile woman, will reveal
abundant information about the anatomy and
morphology of the pelvic organs and thereby avoid
costly radiation and iodinated contrast exposure.
• Keyword: Infertility, mullerian duct anomalies, HyCoSy,
Sonohysterogram

Fertility and Sterility® Vol. 105, No. 6, June 2016 0015-0282/$36.00

Copyright ©2016 American Society for Reproductive Medicine, Published by Elsevier Inc.
 Introduction
• The evaluation of infertility requires reliable, diagnostically,
accurate, minimally invasive, efficient, and cost-effective
approaches.
• Ultrasound has matured into a modality that can provide most
and often all of the same information necessary to diagnose
or exclude anatomic abnormalities of the female
reproductive tract
• Two-dimensional (2D)  initial investigation of the pelvis to
look at the uterus, adnexa, and ovaries
• Three-dimensional (3D)  enables capture of a volume of
ultrasound information that can then be reconstructed and
displayed in any plane

Fertility and Sterility® Vol. 105, No. 6, June 2016 0015-0282/$36.00

Copyright ©2016 American Society for Reproductive Medicine, Published by Elsevier Inc.
 Introduction
• Ultrasound offers unique advantages for
investigation of the female pelvis over other
modalities  will no longer have to undergo
multiple tests, often at different sites and over
multiple visits.
• The concept of ‘‘one-stop shopping’’ -- by
Campbell et al. (2001)
• This review will discuss the use of ultrasound in the
complete evaluation of the morphologic aspects of
the female pelvis as they relate to infertility.

Fertility and Sterility® Vol. 105, No. 6, June 2016 0015-0282/$36.00

Copyright ©2016 American Society for Reproductive Medicine, Published by Elsevier Inc.
 EVALUATION
OF THE UTERUS
• The best time for the initial ultrasound evaluation of the patient is between cycle
days 5 and 9, before ovulation has occurred
• The uterus is first imaged longitudinally, along the sagittal plane with the cervix at
one end of the image and the fundus at the other  imaging of the
endometrium, the junctional zone between the endometrium and the
myometrium, and the echotexture and symmetry of the myometrium.

Fertility and Sterility® Vol. 105, No. 6, June 2016 0015-0282/$36.00

Copyright ©2016 American Society for Reproductive Medicine, Published by Elsevier Inc.
 EVALUATION
OF THE UTERUS
• These standard 2D views of the uterus allow us to detect fibroids,
adenomyosis, polyps, and other uterine abnormalities

Fertility and Sterility® Vol. 105, No. 6, June 2016 0015-0282/$36.00

Copyright ©2016 American Society for Reproductive Medicine, Published by Elsevier Inc.
 EVALUATION
OF THE UTERUS

Fertility and Sterility® Vol. 105, No. 6, June 2016 0015-0282/$36.00

Copyright ©2016 American Society for Reproductive Medicine, Published by Elsevier Inc.
 EVALUATION
OF THE UTERUS

Fertility and Sterility® Vol. 105, No. 6, June 2016 0015-0282/$36.00

Copyright ©2016 American Society for Reproductive Medicine, Published by Elsevier Inc.
 EVALUATION
OF THE UTERUS
• Bingol et al. reported on a comparison between transvaginal
ultrasound, sonohysterography, and hysteroscopy for the
diagnosis of polyps and fibroids.
• Detection of polyps
o transvaginal ultrasound  sensitivity (0.87), specificity (0.80), PPV (0.73), and
likelihood ratio (4.46)
o Sonohysterography  sensitivity (1.0), specificity (0.93), PPV 0.90, and
1likehood ratio (5.33)
o the gold standard of 100% for hysteroscopy.
• Detection of submucosal fibroids,
o transvaginal scans  sensitivity (0.95), specificity (0.96), PPV (0.92) and
Likehood ratio (23.13)
o sonohysterography sensitivity (0.99), specificity (0.98), PPV (0.96) and
Likehood ratio (47.26)
o Hysteroscopy  sensitivity (1.0), specificity (0.98), PPV (0.96) and Likehood
ratio (48.75)
Fertility and Sterility® Vol. 105, No. 6, June 2016 0015-0282/$36.00
Copyright ©2016 American Society for Reproductive Medicine, Published by Elsevier Inc.
 EVALUATION
OF THE UTERUS
Evaluation of uterine abnormalies
• The diagnostic accuracy of both 3D ultrasound and MRI is 90% to 95% for
detecting the specific type of uterine anomaly
• 3D ultrasound  an accurate picture of the uterine cavity, serosal surface, and
the myometrium in between.
EVALUATION
OF THE UTERUS
EVALUATION
OF THE UTERUS
EVALUATION
OF THE UTERUS
 EVALUATION
OF THE UTERUS
• Although 3D ultrasound can often identify uterine lesions
correctly, introducing saline increases the detection rate of
intracavitary lesions.
 EVALUATION
OF THE UTERUS
• If the endometrium is not adequately seen sonographically,
attempting to distend the cavity is helpful to detect adhesions and
Asherman's syndrome
 EVALUATION
OF THE FALLOPIAN TUBES
• With standard 2D ultrasound, a hydrosalpinx will often appear as multiple,
noncommunicating fluid collections in the adnexa
• The 3D inverse mode can be helpful to visualize the entire tube, in which all the
fluid-filled portions within a volume become opaque, forming a cast of the cystic
tube
 EVALUATION
OF THE FALLOPIAN TUBES
• Luciano et al  the accuracy of HyCoSy for tubal patency determination is
comparable to HSG when compared with the gold standard of laparoscopic
chromopertubation
• Evaluating the fallopian tubes with HyCoSy is feasible, accurate, better tolerated,
and less costly compared with HSG.
 EVALUATION
OF THE OVARY
• Ultrasound criteria are used to distinguish a normal ovary from polycystic ovaries
o >11 follicles <10 mm in size
o or an ovary that is >10 cm3 in volume and does not contain a follicle >9 mm
 EVALUATION
OF THE OVARY
• Ovarian masses such as endometriomas, dermoids, or functional cysts can influence fertility.
Patients with endometriosis will often have an ovarian cyst with characteristic low-level
echoes that is typical of an endometrioma
• Ovarian masses such as endometriomas, dermoids, or functional cysts can influence fertility.
EVALUATION
OF THE OVARY
EVALUATION
OF THE OVARY
 EVALUATION
OF THE OVARY
• Abrao et al.  diagnostic for recto-sigmoid endometriosis
o transvaginal ultrasound  sensitivity (98%), specificity (100%) and
accuracy (99%)
o MRI's  sensitivity (83%), specificity (98%) and accuracy (90%)
sensitivity, specificity, and accuracy of 83%, 98%, and 90%,
respectively
• A meta-analysis of 10 prospective  the pooled sensitivity and
specificity of transvaginal ultrasound for detecting bowel implants of
endometriosis  sensitivity (91%), Specificity (98%), PPV 30.36 and NPV
0.09
• Saba et al.  Detecting deep infiltrating endometriosis
o Ultrasound sensitivity (86%), Specificity (73%)
o MRI sensitivity (90%), Specificity (73%)

Fertility and Sterility® Vol. 105, No. 6, June 2016 0015-0282/$36.00

Copyright ©2016 American Society for Reproductive Medicine, Published by Elsevier Inc.
 EVALUATION
OF THE OVARY
• Ultrasound provides another important advantage: the ability to
visualize blood flow with Doppler imaging without the need for contrast
 EVALUATION
OF THE OVARY
• patient may have an ovarian tumor discovered at the first evaluation
for infertility. If the blood flow pattern is central and abundant in a solid
or partially solid mass, the possibility of a malignancy or borderline
tumor must be considered
 Conclusion
• the comprehensive ‘‘one-stop shopping’’ ultrasound evaluation
(cycle days 5 to 9)  abundant information about the anatomy and
morphology of the pelvic organs.
• We propose the following sequence for this baseline transvaginal
ultrasound examination: the practitioner measures and evaluates the
uterus using both 2D and 3D ultrasound
• The sonohysterogram performed at this juncture allows detailed
evaluation of the endometrial cavity using 3D, followed by inflation of
the balloon on the catheter to test tubal patency by HyCoSy.
• A number of imaging approaches can help illuminate causes of
infertility
• Many of these evaluations entail considerable expense and involve
ionizing radiation and/or administration of various contrast agents.

Fertility and Sterility® Vol. 105, No. 6, June 2016 0015-0282/$36.00

Copyright ©2016 American Society for Reproductive Medicine, Published by Elsevier Inc.
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THANK YOU