ROLE OF 3D ULTRASOUND IN UTERINE DISEASES

1. ROLE OF 3D U/S IN
UTERINE DISEASES
DR.RIYADH AL ESAWI
DMRD, MSc, PhD
Assisst.Prof.Diagnostic Radiology.
College of medicine .Kufa University

2. Embryology
• The female reproductive tract develops from a pair of Müllerian ducts
that form the following structures:
fallopian tube, uterus, cervix and the upper two-thirds of the vagina.
The ovaries and lower third of the vagina have different embryological
origins derived from germ cells that migrate from the primitive yolk
sac and the sinovaginal bulb, respectively.
• Normal development of the Müllerian ducts depends on the
completion of three phases:
1- organogenesis. Organogenesis is characterised by the formation of
both Müllerian ducts. Failure of this results in uterine
agenesis/hypoplasia or a unicornuate uterus
2- fusion; Fusion is characterised by fusion of the ducts to form the
uterus. Failure of this results in a bicornuate or didelphys uterus
3- septal resorption... Septal resorption involves subsequent resorption
of the central septum once the ducts have fused. Defects in this stage
result in a septate or arcuate uterus.

3. 1- CONGENITAL ANOMALIES
• The Müllerian duct anomaly classification is a seven-
class system that can be used to describe a number of
embryonic Müllerian duct anomalies
• class I: uterine agenesis/uterine hypoplasia
– a: vaginal (uterus: normal/variety of abnormal forms)
– b: cervical
– c: fundal
– d: tubal
– e: combined

4. • class II: unicornuate uterus/unicornis unicollis, ~15%
(range 6-25%)
– a: communicating contralateral rudimentary horn
contains endometrium
– b: non-communicating contralateral rudimentary
horn contains endometrium
– c: contralateral horn has no endometrial cavity
– d: no horn

5. • class III: uterus didelphys, ~7.5% (range 5-
11%)
• class IV: bicornuate uterus: 2nd most common
type ~25% (range 10-39%)
– a: complete division, all the way down to the
external os (bicornuate bicollis)
– b: partial division, not extending to the internal os
(bicornuate unicollis)

6. • class V: septate uterus: commonest anomaly,
~45% (range 34-55%)
– a: complete division, all the way down to the
internal or external os
– b: incomplete division, involving the endometrial
cavity but not the cervix
• class VI: arcuate uterus, ~7%
• class VII: in utero diethylstilbestrol
(DES) exposure (T-shaped uterus)

7. Arcuate uterus. (a) HSG image shows a
broad-based uterine fundal filling
defect (black arrowhead). White
arrowheads = patent fallopian tubes.
(b) Coronal 3D US image shows the
broad-based fundal myometrial
prominence (*) and a convex external
uterine contour (arrowheads). (c) Axial
gadolium-enhanced T1-weighted fat-
saturated MR image shows the convex
external uterine contour (arrow) and
the broad-based prominent fundal
myometrium (*).

8. CLASS VI
Long-uterine-axis T2-weighted fast
spin-echo image (TR/TE, 4,800/86)
image shows flat outer fundal
contour and saddle like indentation
of endometrial cavity consistent
with arcuate uterus. However,
there is wide intercornual distance
of more than 4 cm.

9. T2-weighted fast spin-
echo images (TR/TE,
4,800/86) of uterus show
flat outer fundal contour
(black arrow, and
complete septum
extending to external
cervical os ,white arrow
consistent with septate
uterus with complete
septum.
CLASS Va

10. Three-dimensional surface rendered ultrasound images of the uterine
cervix in three women with uterine malformations: (a) incomplete
cervical septum in a case of septate uterus; (b) complete cervical
septum in a case of septate uterus; (c) two diverging cervical canals in a
case of septate uterus with two cervices.
Class v

11. Incomplete septum
Class V b

12. Is it septated or arcuate

13. Septate uterus.
(a) Illustration shows a complete
septate uterus.
(b) HSG image of a partial septate
uterus.
(c) Coronal 3D US image of a partial
septate uterus.
The apex of the fundal contour
(arrow) is more than 5 mm above a
line drawn between the tubal ostia
(white line), a finding compatible
with a septate uterus.
(d) Axial T2-weighted MR image of a
complete septate uterus.

14. Bicornuated uterus.
Fundal defect.
Fundal defect more 10
mm.
fundal crest less than 5
mm.
CLASS IV

15. Uterus didelphys
-widely divergent
uterine horns.
- deep fundal cleft.
CLASS III

16. Vaginogram

17. CLASS IIa
Short-uterine-axis T2-
weighted fast spin-echo image
(TR/TE, 5,800/92) shows
typical appearance of
unicornuate uterus (arrow)
with rudimentary horn. There
appears to be endometrium
within rudimentary horn
(arrowhead).

18. Unicornuate uterus with an obstructed non communicating
rudimentary horn. Axial T2- weighted MR images show a
normal-appearing left unicornuate uterus (arrow in a) and an
obstructed non communicating right rudimentary horn with
layering debris (* in b). Class IIb

19. Unicornuate uterus with no rudimentary
horn. (a) Illustration shows a right
unicornuate uterus with no rudimentary
horn. (b) HSG image shows a small, oblong
uterine cavity (*) deviated to the right of
midline with a single fallopian tube
(arrowhead). (c) Axial T2-weighted MR
image shows a single uterine horn (*) and
cervix (arrowhead). (d) Coronal T2-
weighted MR image shows absence of soft
tissue adjacent to the right unicornuate
cervix (arrowhead), a finding indicating
absence of a rudimentary horn. (a courtesy
of Joanna Culley, BA.)
Class II d

20. To distinguish bicornuate uteri from septate uteri with three-
dimensional ultrasound we used the formula proposed by Troiano
and McCarthy: a line was traced joining both horns of the uterine
cavity. If this line crossed the fundus or was ≤ 5 mm from it, the
uterus was considered bicornuate (a and b); if it was > 5 mm from the
fundus it was considered septate, regardless of whether the fundus
was dome-shaped (c), smooth or discretely notched.

21. Mayer-Rokitansky-Küster-Hauser syndrome. (a) Sagittal T2-weighted MR image shows
complete absence of the cervix and uterus with an abnormally truncated vagina ending in
a blind pouch (arrowhead) between the rectum (r) and urinary bladder (b). (b) Axial T2-
weighted image shows the presence of normal ovaries (*). CLASS I

22. DES uterus. HSG image show
the classic T-shaped uterine
cavity due to diethylstilbestro
(DES) exposure (T-shaped
uterus).
CLASS VII

23. A- Arcuate cavity- normal outer uterine contour- obtuse angle- <1.5 cm
fundal indentation depth.
B- Partial septate uterus- normal outer uterine contour- acute angle at
central point- >1.5 cm fundal indentation depth.

24. Septate uterus with an incomplete cervical septum on
three-dimensional surface-rendered ultrasound (a)
and magnetic resonance imaging (b) CLASS V b

25. Septate uteri with a very wide septum have a large separation between the horns
and the three-dimensional sonographic structure of the septum is similar to that of
the myometrium. The morphology of the cavity and the type of signal obtained
from the septum on magnetic resonance imaging indicates the presence of
myometrium, leading to an incorrect diagnosis of bicornuate uterus, but applying
Troiano and McCarthy's,formula leads to the correct diagnosis of septate uterus
Bicornual distance > 4 cm
In HSG Bicornuated

26. Three-dimensional surface rendered ultrasound images showing different types of uterine
malformation using the American Fertility Society classification: (a) normal uterus; (b)
unicornuate uterus (Type IId); (c) didelphic uterus (Type III); (d) complete bicornuate uterus
(Type IVa); (e) partial bicornuate uterus (Type IVb); (f) septate uterus with two cervices (Type
Va); (g) partial septate/subseptate uterus (Type Vb); (h) arcuate uterus (Type VI); and (i)
uterus with diethylstilbestrol (DES) drug-related malformations (Type VII).

27. 3D U/S VS. MRI
The two imaging modalities are extremely similar. Images, according
to the American Fertility Society classification, show: (a) unicornuate
uterus (Type IId); (b) bicornuate bicollis uterus (Type IVb); (c) septate
uterus with two cervices (Type Va); (d) partial septate uterus (Type
Vb); (e) uterus with diethylstilbestrol (DES) drug-related
malformations (Type VII).

28. 2- ENDOMERIAL VOLUME
Endometrial volume
2D U/S..
3D US acquisition of an entire uterine volume
has allowed the estimation of the endometrial
volume through computer aided software, the
most well-known being VOCAL (Virtual Organ
Computer aided AnaLysis)
sagittal, transverse or coronal).

29. • There is significantly reduced pregnancy rates
with endometrial volumes of less than 2 ml
(Raga et al., 1999; Kupesic et al., 2001; Zollner et
al., 2003; Kovachev et al., 2005).
• no pregnancies in women with an endometrial
volume of less than 1 ml (Raga et al., 1999), or
with a volume of more than 8 ml (Kupesic et al.,
2001)

30. • Examples of estimating
endometrial volume (a)
and endometrial
vascularization (b) using
Virtual Organ Computer
aided AnaLysis (VOCAL) in
the multiplanar display.

31. 3-ENDOMETRIAL VASCULARITY
• almost 20 years ago used a laser Doppler technique to
directly assess red blood cell flux in the endometrium
during the menstrual cycle. They found that flux values
were highest at times associated with endometrial
growth and preparation for implantation, implying
that endometrial blood flow may be a useful
parameter for assessment of endometrial physiology
and receptivity. This was in line with the traditional
notion that decreased uterine blood flow may be a
cause of infertility presumably due to its associated
effect on the endometrial blood flow and receptivity.

32. VASCULARITY
• At the time, this was assessed by 2D US in the form of
pulsatility index and resistance index.
• Interestingly, although these markers were found to have
an association with ART outcomes in a number of early
studies (Sterzik et al., 1989; Steer et al., 1992; Coulam et
al., 1994; Serafini et al., 1994), they were not widely
adopted in clinical practice or further evaluated in clinical
trials.
• The primary reason was most likely because investigators
were not convinced that uterine artery blood flow actually
reflected the true blood flow to the endometrium; this is
with reason, since endometrial blood flow is known to arise
predominantly from the myometrium and also collateral
circulation between uterine and ovarian vessels

33. • Recenty endometrial blood flow is assessed more
directly. These involved either 2D Doppler indices of
spiral arteries adjacent to the endometrium, or the
identification of blood flow in the endometrium or sub-
endometrium on 2D Doppler.
• Most studies found a positive association between the
presence of endometrial and/or subendometrial blood
flow and the achievement of pregnancy.
• Assessing the endometrial blood flow more accurately
using the 3D US

34. • When 3D US is performed in combination with power Doppler, the
application of the VOCAL software can provide the so-called
vascularization index (VI), flow index (FI) and vascularization flow index
(VFI) for any desired volume of interest (i.e. the endometrium in this
case). It does this by assessing the number and intensity of the voxels
within a given volume. Voxels are essentially minuscule cubes within a
3D volume (similar to pixels being minuscule squares within a 2D
picture), that become coloured when Doppler flow is detected, and in
fact with increasing colour intensity as the speed of Doppler flow
increases. In terms of the indices used, VI denotes the ratio of coloured
voxels to all voxels within the volume and is expressed as a percentage
(i.e. ‘how much blood flow there is’); FI represents the mean power
Doppler signal intensity from all coloured voxels (i.e. ‘how strong the
blood flow is’) and VFI is the simple mathematical relationship derived
from multiplying VI by FI and dividing the result by 100 (i.e. a marker of
overall vascularization). The latter two (FI and VFI) are unitless and are
expressed as a numerical value ranging from 0 to 100 (Alcazar, 2008).

35. Power Doppler quantification
Vascular index Description
1-Vascularization index VI Colour values/(colour
values + grey‐scale values)
2- Flow index FI Weighted colour values/colour values
3- Vascularization flow index VFI Weighted colour
values/(colour values + grey‐scale values)

36. g = grey‐scale value in ultrasound image normalized to 0... 100;
c = colour value in ultrasound image normalized to 0... 100; low
intensity = 0; high intensity = 100; hg (x) = frequency of grey value x in
ultrasound image; hc (x) = frequency of color value x in ultrasound
image.

37. • The normal changes of 3D US vascularization
throughout the cycle have found to be more variable
than the changes in the endometrial thickness and
volume.
• In particular, there appears to be a pre-ovulatory
peak and post-ovulatory nadir during the peri-
implantation window in both the VI and FI (Raine-
Fenning et al., 2004a,b,c).
which does not follow the pattern of the endometrial
volume and thickness.

38. Hum Reprod, Volume 19, Issue 2, February 2004, Pages 330–338,
ttps://doi.org/10.1093/humrep/deh056
Virtual organ computer‐aided analysis (VOCAL™). This figure shows
a typical multiplanar display of the uterus...

39. Endometrial volume and blood flow measured by 3D
Doppler ultrasound

41. 4-JUNCTIONAL ZONE
• The junctional zone can be seen as a hypoechoic halo surrounding the endometrium in the
three-dimensional (3D) ultrasound (US) coronal plane: In a normal uterus a smooth
endometrial outline with the enveloping junctional zone should be seen (a). In a uterus with
adenomyosis, the endometrial outline along with the junction zone may be distorted or
interrupted; additionally myometrial changes such as hypoechoic shadows or cysts may be seen
(b).

42. JUNCTIONAL ZONE
It represents a distinct layer of the inner
myometrium, and envelops the entire endometrial
cavity. It is mesenchymal in origin, the inner
myometrium along with the junctional zone is
derived from the embryonic paramesonephric
ducts, from which the endometrium also arises
(Noe et al., 1999).

43. • Why it is hypoechoic on U/S ?
It consist of normal myocytes, but with a greater
nuclear-cytoplasmic ratio and a higher density of
blood vessels compared with the smooth muscle
cells of the outer myometrial zone (Tetlow et al.,
1999).

44. • Role of JZ in pregnancy
• Excessive myometrial contractions, which have been
shown to originate exclusively from the junctional
zone (Brosens et al., 2010), are known to reduce
pregnancy rates in both natural (Ijland et al., 1997)
and ART cycles (Fanchin et al., 1998).
• In early implantation, there is disruption in the
junctional zone due to interplay between local
vascular and perfusion changes and the junctional
zone (Turnbull et al., 1995).
• In later pregnancy, defective deep placentation
resulting from absent or incomplete transformation
of the spiral arteries within the junctional zone has
been associated with pre-eclampsia and IUGR

45. An abnormal junctional zone is one that is characterized
by thickening or hyperplasia (Exacoustos et al., 2014).
MRI ; MRI is the traditional gold standard method of
choice for the assessment of the JZ.
2D U/S
3D U/S, the 3D US coronal view allows a delineation of
the entire lateral and fundal aspects of the junctional
zone, which is rarely visualized on 2D US.
The hypoechoic features of the junctional zone often
appear more pronounced on 3D versus 2D US.

46. • In MRI, a reduced contrast between the myometrium
and the junctional zone were more likely to conceive.
a thickened junctional zone was in fact strongly
associated with adverse outcomes following IVF, with
an implantation failure of 95.8% in women with an
average thickness of 7 mm or more (Maubon et al.,
2010).
• However, a study using 2D US found the opposite
result, reporting an overall thicker junctional zone in
women who conceived versus those that did not
(5.1 ± 1.1 versus 4.2 ± 1.5, respectively; <0.01).

47. JZ contrast

48. 5-Acquired uterine anomalies
A-Polyps
• US images of an
endometrial
polyp: This was
initially not seen
on 2D US (a), but
suspected on 3D
US (b) and later
confirmed on 3D
saline infusion
sonography (SIS)
(c).

49. B-FIBROID
From DR.Huda

50. C-ADENOMYOSIS
• Adenomyosis is defined as the benign invasion of
ectopic endometrial glands within the myometrium,
either diffusely (adenomyosis), or in a localized
manner (adenomyoma) (Campo et al., 2012; de
Ziegler et al., 2016).
• A Similar to junctional zone abnormalities, the
pathophysiology linking adenomyosis and infertility
appears to relate to abnormal uterine contractility,
altered endometrial function and receptivity, and
impaired implantation and decidualization (Campo et
al., 2012).

51. • The 2D US :
globular and enlarged uterus; asymmetrical anterior and posterior uterine walls;
diffusely irregular myometrial echotexture with hypo- or hyperechogenic
features (i.e. subendometrial/myometrial cysts and echogenic islands);
subendometrial fan-shaped shadowing radiating across the myometrium;
increased blood flow in the affected area; thickened, irregular, ill-defined or
interrupted junctional zone (Exacoustos et al., 2014; Van den Bosch et al.,
2015). Of these, the enlarged heterogenous myometrium appears to be the
commonest finding, while the most accurate feature for diagnosis has been
shown to be subendometrial fan-shaped shadowing (or striations) (Kepkep et
al., 2007). When assessing the diagnostic accuracy of 2D US against a
confirmed histological diagnosis of adenomyosis, a systematic review and
meta-analysis showed that 2D US had a sensitivity of 72% (95% CI 65–79%),
specificity of 81% (95% CI 77–85%), positive likelihood ratio of 3.7 (95% CI 2.1–
6.4) and negative likelihood ratio of 0.3 (95% CI 0.1–0.5).
• MRI proved to be slightly superior than 2D US, with a sensitivity of 77% (95%
CI 67–85%), specificity of 89% (95% CI 84–92%), positive likelihood ratio of 6.5
(95% CI 4.5–9.3) and negative likelihood ratio of 0.2 (95% CI 0.1–0.4)
(Champaneria et al., 2010).

52. • For the 3D US assessment, the coronal plane of the uterus
was assessed with either the render or OmniView mode
(VCI 2–4 mm slices). They then used the markers of JZdif ≥4
mm (defined as a difference between the largest and
smallest junctional zone thickness observed on the coronal
plane of ≥4 mm) and junctional zone infiltration/distortion,
to diagnose an adenomyotic uterus.
• Interestingly, they found 3D US to be marginally more
accurate than 2D US with an overall accuracy for diagnosis
of 89% versus 83%, respectively. In particular, the
sensitivity, specificity, PPV and NPV for 3D versus 2D US was
91%, 75%, 88%, 90%, and 85%, 86%, 92%, 82%, respectively
(Exacoustos et al., 2011)

53. D-Intrauterine adhesion
• Intrauterine adhesions
Intrauterine adhesions are typically the result of
trauma to the endometrium, which may result in
the adherence of opposing raw surfaces, through
the formation of fibrotic tissue (Yu et al., 2008).
• Adhesion associated with infertility in up to 43%
of women.

54. • Hystroscope; gold standard.
• limitations, as first, its reproducibility is hampered by the fact that
it relies solely on the subjective impression of the operator, second
it has reduced ability to differentiate between congenital uterine
anomalies (such as unicornuate uteri when only one side of the
cavity can be visualized), and third the examination is limited or not
possible when there is obliteration in the lower part of the uterus
preventing the cavity from distending with fluid (Amin et al., 2015).
• 2D US is very variable, with some authors reporting sensitivity,
specificity, PPV and NPV of 91%, 100%, 100% and 98.5%,
respectively (Fedele et al., 1996), while others have reported rates
of 0%, 95.2%, 0% and 95.2%, respectively (Soares et al., 2000)

55. • 2D SIS is superior than conventional 2D.
• Several studies have suggested that 2D SIS is superior to 2D US in
diagnosing intrauterine adhesions (Salle et al., 1999; Soares et al.,
2000; Sylvestre et al., 2003). Some studies have found 2D SIS to be
similar (Soares et al., 2000) or superior (Acholonu et al., 2011) to
HSG when compared to the gold standard of hysteroscopy. In a
systematic review and meta-analysis comparing 2D SIS with
hysteroscopy, the sensitivity, specificity, positive and negative
likelihood ratios were 0.82 (95% CI 0.65–0.93), 0.99 (95% CI 0.98–
1.00), 34.58 (95% CI 16.68–71.70) and 0.36 (95% CI 0.22–0.58),
respectively (Seshadri et al., 2015).
• The authors in fact concluded that 2D SIS could be considered as
an alternative to hysteroscopy in daily practice.

56. • Pal et al. (2000) were one of the first to suggest
that 3D US may be superior to 2D US and HSG in
detecting and mapping intrauterine adhesions in
a carefully presented case report.
• Knopman and Copperman (2007) found 3D US
sensitivity of 100%) that were confirmed on
hysteroscopy.
• Aboulghar et al. (2011) also reported a high
accuracy rate of 92%.
• 3D SIS, should be superior than 3D.

57. • A case with concomitant intramural fundal fibroid and intrauterine adhesions: (a) 2D US
could not clearly delineate the relationship between the fibroid and the endometrial
cavity; (b) 2D SIS showed an apparently normal uterine cavity with no significant
indentation from the fibroid; (c) 3D SIS confirmed the position of the fibroid but
revealed an undiagnosed area of intrauterine adhesions in the left ostium.
• 3D SIS had a sensitivity of 90% and specificity of 95% for the diagnosis of intrauterine
adhesions.

58. 2D SIS image of a uterus with an adhesion band in the middle dividing
the cavity in two compartments. This patient had myomectomy before.

59. • An example of a woman with intrauterine adhesions treated
in the outpatient setting using intrauterine balloon therapy
(Saravelos and Li, 2016a,b): 3D SIS is shown before therapy (a)
and post therapy (b). (HDLive rendering, Inverse HDLive
rendering and SonoAVC is demonstrated, respectively.)

60. E-Caesarean scar defect
• A Caesarean scar (CS) defect or niche is predominantly an
ultrasonographic diagnosis and relates to the presence of a
hypoechoic area within the myometrium of the lower
segment, reflecting the discontinuation of the myometrium
at the site of a previous Caesarean section.
• The causes;- low incision through cervical tissue,
inadequate suturing of the lower segment myometrial wall,
adhesion formation over the CS impairing effective healing,
and patient-related factors that impair wound healing or
increase inflammation (van der Voet et al., 2014).
• CS defects may associated with postmenstrual spotting
and subfertility.

61. • By 2D US with 2D SIS we should measure
myometrial thickness adjacent to the scar defect
(MTS) and the residual myometrial thickness
over the scar defect (RMT).
• Niche parameters, including depth (both
perpendicular to niche base and maximal depth),
maximal width, width at niche base, RMT and
volume, can be measured.

62. • 3D SIS, is most accurate and reproducible
method. Indeed combined 2D/3D SIS may
prove to be the most informative examination
as it can clearly depict the extent of the defect
not only in terms of depth but also laterality.

63. A case with a
Caesarean scar
defect as seen
on 2D US/SIS
and 3D US/SIS.

64. F-IUCD LOCALIZATION

65. Intratubal and intrauterine devices
3D SIS is superior than 2D U/S in assessment of intratube Essure
coil used in ART and assessment presence and position of
intrauterine device especially for the less echogenic levonorgestrel-
releasing Mirena device

66. A) 3D ultrasound of T-shaped IUD in sufficiently large endomentrial
cavity; B) 3D ultrasound of conventional T-shape in average size
uterine cavity with maximum width of 22.40 mm.

67. A) 3D ultrasound of the frameless copper IUD in a less than average
uterine cavity; B) idem in a greater than average uterine cavity. The
correct position of the anchor can be verified by 2D or 3D ultrasound
(see arrows).

68. Types of malpositioned intrauterine
devices
1-Expulsion: Passage either partially or completely
through the external cervical os.
2-Displacement: Rotation or inferior positioning in the
lower uterine segment or cervix.
3-Embedment: Penetration of the myometrium without
extension through the serosa.
4-Perforation: Penetration through both the myometrium
and the serosa, partially or completely.

69. Uterine size may differ among women (e.g. parous vs. nulliparous); therefore, assessing the
transverse fundal diameter pre-insertion using the 3D coronal plane allows placement of the
correct size IUD (Figure 1).
Different types of malpositioned IUDs can be diagnosed by the 3D coronal view.
In embedment there is penetration of the IUD into the myometrium without extension
through the serosa (Figure 2 – embedment of an arm (arrow).
In displacement, there can be rotation (Figure 3 rotated IUD) or inferior positioning of the IUD
in the lower uterine segment or cervix (Figure 4- Inferior displacement with embedment of
one of the arms (arrow)).
Perforation can be partial or complete with penetration of the IUD through the serosa.
Lastly, fragmentation in which there is retention of a broken piece of the IUD after expulsion
or removal.

70. A) Hysteroscopic view of IUD with both arms embedded for 5 mm in the
uterine wall; B) Close view of left arm embedded in the uterine wall
causing abnormal bleeding and pain.
Clin Obstet Gynecol Reprod Med, 2016 doi: 10.15761/COGRM.1000145 Volume 2(3): 183-188

71. G-Embryo transfer
A cohort study using 3D U/S in assessment of catheter
tip in embryo transfer (n = 5073) where they
concluded that since introducing this technique,
their centre saw a 10.0% increase in the pregnancy
rate and a 1.3% reduction in ectopic pregnancy rate
(from 1.8% to 0.5%, per embryo transfer) (Gergely,
2010).

72. • identification of
the embryo
flash following
transfer with 2D
and 3D US using
both standard
and inverse
mode
rendering.

73. Implantation and early pregnancy
• Examples of angular, interstitial and cervical pregnancies diagnosed with 3D
US: The first is within the uterine cavity, albeit in the superior lateral aspect of
the cavity, medial to the uterotubal junction; The second is within the
interstitial portion of the fallopian tube adjacent to an empty uterine cavity;
The third is within the cervical canal, adjacent to an empty uterine cavity. The
first pregnancy is intrauterine and potentially viable, whereas the latter two
are ectopic and non-viable.
3D U/S is superior than 2D in localization of implanted gestation

74. GREAT THANKS