RECENT ADVANCES IN GYNECOLOGY ULTRASOUND

1. RECENT ADVANCES IN
GYNAECOLOGIC ULTRASOUND
- FACT OR FICTION
DR. BHARTI PANTGAHTORI
MBBSMD (OB/GY) (M.A.M.C) DELHI
HIGHRISK FETAL ANDGYNAECOLOGYUSG SPECIALIST
SPECIALINTERESTIN FETALCARDIACEVALUATION, PLACENTAL STUDY, INFERTILITY
3D ANDDOPPLERUSG

2. JOURNEY SO FAR

3. Professor Ian Donald and his colleagues in Glasgow published a paper in
LANCET IN 1958 (Diasonograph )
• There work on ultrasound facilitated its practical application.
• Since then wider use of USG as a diagnostic modality in medical profession
3 IMPORTANT ADVANCEMENTS
• Introduction of vaginal transducer by Aloka and Kreztechnic
• In Germany, Richard Soldner an engineer who worked for Siemens developed
the first (almost) real time scanner
• Australia George Kossoff one of the most brilliant engineers in the history of
medical ultrasound built the Octason static scanner in 1962
PHASE OF ADVANCEMENT IN ULTRASOUND SCANNER
• Mechanical sector real time scanners were introduced by several companies
such as Aloka and Kretztechnic in the early to mid 70’s
• Multi-element linear array and phased array scanners in the mid to late 1970’s
• In 1979 Joachim Hackeloer a German doctor working on sabbatical in Glasgow
published his classic paper on the tracking of ovarian follicular growth

4. REVOLUTIONARY DECADE
• In 1985 Kretztechnic produced the first practical endovaginal mechanical
sector
• By 1985, Aloka had incorporated colour Doppler imaging (originally called
colour flow mapping) into their real time equipment.
• In 1984 Early studies on 3D imaging began in Japan by Kazunon Baba
• TVS allowed greater discrimination between benign and malignant masses.
Sassone and Timor Tritch first described a scoring system.
• Third generation 530D Voluson convinced the world that 3D/4D ultrasound
had a major role to play in both obstetrical and gynaecological imaging.
• Transvaginal ultrasound has proved to be reliable in assessing ovarian reserve
through measurement of the antral follicle count which was first described by
Reuss and colleagues in 1996
PHASE OF 3D ADVANCEMENT
• The modern real time scanning machine with high resolution abdominal and
endovaginal transducers, harmonic imaging, colour and power Doppler facilities
with a 3D/4D option was on the market by the year 2000
• 3D software that generates automated follicle volume measurement
(SonoAVC) permits faster measurement of AFC and tracking of follicular growth
during and an IVF cycle

5. WHAT MAKES ULTRASOUND A PREFERRED IMAGING
MODALITY !!!
NONINVASIVENESS
HIGHER PATIENT
COMPLIANCE
COST EFFECTIVENESS STATIC + REAL TIME IMAGING
LACK OF RADIATION/ SAFE
COMPARATIVELY LESS
TRAINING AND EXPERTISE
LOW MAINTAINENCE
VARIED TRANSDUCERS MEET
MOST BODY SCANNING
NEEDS

6. 4. Evaluation of delayed menses , oligomenorrhea,
and amenorrhea( 1° & 2° );
5. Evaluation of abnormal pelvic bleeding;
6. Evaluation, monitoring, and/or treatment of infertility
patients;
ACCORDING TO AIUM- INDICATIONS FOR PELVIC
SONOGRAPHY INCLUDE BUT ARE NOT LIMITED TO:
1.Evaluation in the presence of a limited clinical
examination of the pelvis;
2. Evaluation of pelvic pain; dysmenorrhea, dyspareunia
3. Evaluation of pelvic masses;

7. 7. Evaluation for signs or symptoms of pelvic infection;
8. Evaluation of congenital uterine and lower genital tract
anomalies;
9. Localization of an intrauterine contraceptive device;
10. Screening & FU for malignancy in high-risk patients;
11. Evaluation of incontinence or pelvic organ prolapse;
12. Guidance for interventional or surgical procedures;
13. Preoperative and postoperative evaluation of pelvic
structures. &
14. Evaluation of excessive bleeding, pain, or signs of
infection after pelvic surgery, delivery,or abortion;

8. 2D GRAYSCALE ULTRASOUND ADVANCEMENTS
TECHNOLOGY
1. INTIALLY TRANSABDOMINAL
THEN TRANSVAGINAL PROBE
2. TRANSRECTAL(8-10 MHz probe)
& TRANSPERINEAL (3.5-6 MHz. )
3. ADDITION OF COLOR DOPPLERS
TO ASSESS BLOOD FLOW
4. IMPROVED RESOLUTION
TECHNIQUES
1. INITIALLY TRANSABDOMINAL THEN
TRANSVAGINAL
2. LATER TRANSRECTAL AND
TRANSPERINEAL APPROACH
3. TVS WITH SALINE SONO
HYSTEROGRAPHY FOR EFFECTIVE
DELINEATION OF CAVITY
4. DOPPLER USED AS AN ADJUNCT
WHERE VASCULARITY ASSESSMENT
HELP IMPROVE DIAGNOSIS

9. NORMAL
UTERUS
NORMAL
ENDOMETRIUM

10. NORMAL
OVARY
NORMAL
CERVIX
NORMAL
OVARY
NORMAL
VAGINA

11. 2D CONVENTIONAL ULTRASOUND REMAINS THE
MAINSTAY AND TESTED IMAGING MODALITY FOR
PELVIC ANATOMIC AND FUNCTIONAL IMAGING
DRAWBACKS

12. SONOHYSTEROGRAPH
Y
• It improves the delineation
of the uterine cavity
• Saline is used as contrast
• Compared to hysteroscopy,
SHG has 87.5% sensitivity,
100% specificity, for the
detection of uterine cavity
abnormality like endometrial
polyp/ fibroid & Intrauterine
adhesions

13. 2D DOPPLER
ULTRASONOGRAPH
Y
• Highlights the vascularity and its
distribution
• Helps detect some of the
intrauterine lesions as the
feeding vessels of polyps and the
depth of myoma .
• Helps in differentiating between
benign and malignant component
of pelvic pathology by assessing
vascular resistance.

14. “Life isn’t about being
perfect; it’s about improving.
It’s not about achieving more,
acquiring more, or even
about actually being more.
It’s about becoming
better…better than you
were.”
― Toni Sorenson
RECENT ADVANCES

15. • One of the main advantages of 3D imaging of the uterus, on
the other hand, is the capacity to reconstruct the coronal plane.
• 3D ultrasound involves the acquisition of a series of 2D images
that can then be displayed collectively in a variety of imaging
modalities.
• 3D ultrasound scanning consists of four basic steps:data
acquisition, volume analysis and processing, image animation
and archiving of volumes.
3-DIMENSIONAL ULTRASOUND

16. • Three-dimensional ultrasound provides an accurate picture of
the uterine cavity, serosal surface, and the myometrium in
between.
• accurate measurement of organ dimensions and volumes,
• improved anatomic and blood flow information,
• improved assessment of complex anatomic anomalies,
• better specificity in regard to the confirmation of normality,
• standardization of the sonographic examination procedure,
• scanning times with cost effective use of equipment and
sonographer time,
• possibility of post processing the volumes,
• telemedicine and tertiary consultation
ADVANTAGES OF 3D USG OVER 2D

17. This format has been found to be useful for:
- Evaluation of uterine shape abnormalities (e.g.
Mullerian duct abnormalities) in conjunction with SIS
- Evaluation of intra-uterine device (IUD) location
- Problem-solving for uterine fibroids (particularly
% submucosal component) and fibroid mapping
- Endometrial polyps
- Intrauterine adhesions( synechie)
- Adenomyosis ( Junctional zone)
CORONAL PLANE IMAGING IN 3D ULTRASOUND

18. MULTIPLANAR RENDER MODE

19. CONGENITAL
UTERINE
ANOMALIES
• 3D ultrasound has contributed
the most and has become the
investigation of choice
• Ability to show both internal
uterine cavity and external
uterine contour in CORONAL
SECTION
• Accurate, noninvasive,
outpatient diagnosis of
congenital uterine anomalies.

20. IUCD
– Location of intrauterine
contraceptive devices:
displacement of intrauterine
contraceptive devices can
reduce their effectiveness.
The coronal plane images
provided by 3D ultrasound
provide views of both the
arms and shaft of the device
and the relation of these to
the endometrial cavity.

21. FIBROID
• 3D ultrasound has recently been
used to map the exact location of
fibroids in relation to the
endometrial cavity and
surrounding structures.
• This is extremely important in
triaging patients for surgery and
• Potentially useful in monitoring the
reduction in the size of fibroids in
patients receiving gonadotrophin-
releasing hormone analogs or
following uterine artery
embolization.

22. ENDOMETRIAL POLYPS
- Assessing whether or not a
patient has an endometrial
polyp and then determine the
size of the polyp and its pedicle.
-Studies have demonstrated that
the uterine cavity, endometrial
lining and myometrium are best
visualized using
sonohysterography, and that
these images are further
improved by the use of 3D
ultrasound.

23. UTERINE SYNECHIAE
-With SIS ,2D ultrasound may
present a diagnostic clue of
adhesions through the presence of
bands seen within the endometrial
echo.
-However, 3D imaging well
delineates the true narrowing or
“bands” adherent across the cavity
-3D ultrasound has better sensitivity
and predicted adhesions and cavity
damage with greater accuracy than
HSG in patients with suspected
Asherman’s syndrome. (Knop man et
al)

24. ADENOMYOSIS
-The most specific 2D feature for the
diagnosis of adenomyosis was
presence of myometrial cysts (98%
specificity; 78% accuracy), along with
heterogeneous myometrium
-On 3D TVS , the best markers
were JZ difference ≥4 mm and JZ
infiltration and distortion (both 88%
sensitivity; 85% and 82% accuracy,
respectively)
- The JZ may be regular, irregular,
interrupted, not visible,not assessable

25. 3D AND INFERTILITY
Sonography is employed for four main purposes in the
approach to female in fertility:
(1) to identify abnormal pelvic anatomy;
(2) to detect pathology causal or contributory to
infertility;
(3) to evaluate cyclic physiologic uterine and
ovarian changes; and
(4) to provide surveillance and visual guidance
during infertility treatment.

26. COMPONENTS OF INFERTILITY SCAN
1. Ovarian reserve assessment ( AFC, ovarian volume)
2. Polycystic Ovaries ( follicle count and volume)
3. Follicular development monitoring
4. Uterine cavity assessment ( 2D , SIS , 3D )
5. Endometrial receptivity assessment ( 3D and dopplers)
6. Ovarian-Endometrial Synchrony ( dopplers)
7. Corpus luteum Development
8. Cysts and Tumours ( 2D , 3D and other modalities)
9. Tubal Patency ( SIS , HyCoSy)
10.Assessment of ovarian hyperstimulation

27. SONO AVC
• SONO AVC is a 3D software with
automated calculation the no. of
follicles in individual ovaries and
gives good count assessment.
• Very useful for antral follicle
count assessment in IVF
protocols.
• For diagnosis of PCOS and early
prediction of ovarian
hyperstimulation when 3D
doppler is employed alongside

28. VOCAL
• VOCAL(virtual organ comp aided analysis) is an inbuilt
software in an advanced 3 D machine
which helps in measuring volume and
vascularity of any structure e.g ovary,
endometrium etc.
• Used by infertility specialist to assess
ovarian volume, stromal and
endometrial volume under infertility
protocol &PCOS
• In case of PMB, to evaluate
endometrial volume and chances of
malignancy (under research)

29. COLOR DOPPLER IN INFERTILITY
• Doppler ultrasonography can be
utilized to assess the endometrial
receptivity by determination of
endometrial and subendometrial blood
flow which affects embryo transfer and
implantation
• 3D US vascularization gives
schematical information about all
vessels and additionally quantifying
blood flow in the selected volume.
• 3D vascular indices can be measured:
vascular index (VI), flow index (FI), and
VFI (vascular flow index).

30. 3DPOWER DOPPLER AND VOLUME
POWER DOPPLER TO ASSESS
ENDOMETRIAL RECEPTIVITY
3D VASCULARIZATION INDICES

31. PREDICTING OHSS

32. ADNEXAL MASSES ON 3D

33. UROGYNECOLOGY ULTRASOUND
PERINEUM ANAL REGION

34. 3D SALINE INFUSION
HYSTEROGRAPHY
• 3D SIS provides coronal
plane and storage of data
• CORONAL view enhances
the detection rate of
endometrial pathologies
• Compared to hysteroscopy,
3D SHG showed sensitivity
94.2% and specificity of
98.5%,

35. HYSTERO CONTRAST
SONOGRAPHY(HyCoSy)
AIR IN SALINE CONTRAST SHOWING
BRIGHT ECHOGENIC BUBBLES S/O
TUBAL PATENCY

36. LIMITATIONS OF 3D
One of the main underlying prerequisites to a quality 3D image is a good
2D image.
For a good volume acquisition in 3D imaging an adequate elevation focus is
important with optimized imaging settings to enhance 3D imaging
Artifacts in 3D reconstructions can be less readily recognizable and have
the potential to distort an image enough to alter the diagnosis fact,
Considerable “learning curve” associated with the manipulation of 3D
ultrasound by the examiner. To optimize image as per Various settings,
which are machine-dependent require training and time
For near optimal coronal image and demarcation best time is the luteal
phase of cycle or when endometrial thickness ≥ 5mm

38. • Elastography is an ultrasound imaging technique that measures tissue
stiffness in both physiological and pathological states.
• To obtain an elastographic image, a source of “stress” or “strain”
promotes tissue deformation to assess this stiffness (Stoelinga, 2014).
• There are three main types of ultrasound elasticity imaging:
-Potential areas of investigation include distinguishing
a) endometrial polyps from submucous pedunculated myomas,
b) endometrial cancer from benign endometrial thickening,
c)cervical cancer from normal cervix, and
c) leiomyomas from adenomyosis (Stoelinga, 2014).
ELASTOGRAPHY

39. It features the latest elastography that makes it easier for users to
distinguish benign from malignant masses through acquiring the strain
ratio between the target and reference area faster than the previous
models. This means that it could identify the isoechoic lesions that were
missed by 3D ultrasound.
5D ULTRASONOGRAPHY
The state of the art machine differs from the 3D/4D machines in
making highly precise calculations automatically.
A special feature of the machine is that the 3D information is
digitalized in the form of ‘tissue-blocks’ which then can be
stored and transferred.

40. • Intraoperative ultrasound has gained an established role in many
surgical procedures.
• It has been introduced mainly to overcome the two major drawbacks of
endoscopy:
a)the ability to show only the surface of the organs and
b)the lack of manual palpation of the structures.
• Hysteroscopic 5D ultrasound can be used during the resection of
Intrauterine adhesions and uterine septa, hysteroscopic myomectomy,
and for differentiation between septate and bicornuate uteri.
• Robotic 5D ultrasound is the latest version of intraoperative
sonography. It can accurately identify and track the target tissue during
the surgical procedures.
ENDOSCOPIC ULTRASOUND

43. • Microbubbles, are acoustically active nanoparticles containing gases
which are compressible ,act as ultrasound contrast agents ,specific to
molecular targets in intravascular compartment only due to their size
• With this technology , another dimension of ultrasound has become a
reality: diagnosing and monitoring pathological processes at the
molecular level.(CEUS) is continuous, dynamic and in real time.
• These agents can be targeted to specified sites by
1) manipulating the chemical properties of the microbubble shell
2)through conjugation of disease/molecule-specific ligands
3)antibodies to the microbubble surface.
• For ovarian cancer, CEUS may highlight tumor neovascularization in
developing microscopic tumors . In addition, as malignant vascular
channels are often incompetent, the resultant extravasation of RBCs
and contrast agent may be detected sonographically.
MOLECULAR IMAGING(Contrast enhanced)

44. • “Ultrasound biomicroscopy” allows real time in-vivo visualization of
histologic structures OTHERWISE seen with microscopy of resected
sectioned tissue.
• Malignant invasion of the underlying stroma is well visualized
• Thus, non-invasive imaging is possible allowing for real time,
dynamic and repeated histologic evaluation ,previously requiring
biopsy, staining and microscopy.
• For example, cervical lesions including hyperplasia, dysplasia and
malignancy are well differentiated with assessment of the mucosa,
connective tissue, epithelium and microvasculature.
ULTRASOUND BIOMICROSCOPY

45. 1. ADVANCEMENT IN THE RESOLUTION OF BASIC GRAYSCALE AND
DOPPLER
2 . INTRODUCTION OF 3D ULTRASOUND WITH RENDER, MULTIPLANAR , VCI,
TUI, SONO AVC, RENDER WITH DOPPLER ETC HAS TAKEN IMAGING TO NEXT
LEVEL
3.INTRODUCTION OF NEW TECHNIQUES LIKE SONOHYSTEROGRAPHY , HY-
CO-SY ETC THAT HELPS IN BETTER DELINEATION AND REPRODUCABILITY OF
BOTH 2D AND 3D IMAGES
5 . INTRODUCTION OF NEWER METHODOLOGIES & PROTOCOLS IN USG BY
STALWARTS LEADING TO IMPROVEMENT IN DIAGNOSIS E.G DOPPLERS IN
IVF, IOTA GROUP , 3D UROGYNECOLOGY , DEEP ENDOMETRIOSIS ETC
4. INTRODUCTION OF DIFFERENT PRINICIPLE BASED MODALITIES LIKE
ELASTOGRAPHY , 5D USG, VIRTUAL HYSTEROSCOPY ,ENDOSCOPIC
ULTRASOUND , MOLECULAR IMAGING, BIOMICROSCOPY ETC
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