This document discusses transvaginal ultrasound assessment of the female reproductive system for infertility diagnosis and treatment. It covers evaluation of the uterus, including endometrial thickness, uterine anomalies, fibroids, adenomyosis, and other abnormalities. It also discusses ovarian assessment including volume, antral follicle count, polycystic ovary syndrome, cysts, and diminished ovarian reserve. Key diagnostic features of structures like the corpus luteum are also summarized. The document provides guidance on using ultrasound to evaluate infertility and monitor treatment.

1. Aboubakr Elnashar

2. A. Diagnosis of the cause
B. Treatment of infertility
C. Diagnosis and treatment of
complications of infertility management
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3. Aboubakr Elnashar

4. Basic investigations
1.Semen analysis
2.Midluteal progesterone
3.HSG
Further investigations
TVS:
method of choice for assessing the female
reproductive organs
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5. Information
Uterus Assessment: Dimension, Endometrial: thickness, appearance
Abnormalities: Anomalies, Tumors
Ovaries Assessment: Position, Mobility, Volume, AFC
Abnormalities: PCOS, Anovulation, Cysts, Tumors
Tube Patency, Hydrosalpinx
Pelvis Free fluid, Mass
The Pivotal US (performed D8-12)
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6. I. Uterine factor
A. Assessment of the uterus:
• Dimension
• Endometrial thickness
B. Abnormalities
• Anomalies
• Tumors: fibroid, adenomyosis
• Endometritis
• Cavity: polyps, adhesions
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7. Endpmetrial thickness
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8. Zone 1 -- a 2 mm thick area surrounding the hyperechoic outer layer of
the endometrium
Zone 2 -- the hyperechoic outer layer of the endometrium
Zone 3 -- the hypoechoic inner layer of the endometrium
Zone 4 -- the endometrial cavity
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9. Normal endometrium.“Triple line” endometrium in midcycle.
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10. Secertory endometrium
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11. Secertory endometrium
RVF
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12. Uterine anomalies
TVS can detect 90%.
Uterine septae:
Best diagnosed
Transverse plane.
Periovulatory phase {in the early follicular
phase endometrium is thin}
DD.
IU adhesions
{isoechoic nature of the septum with the
myometrium}
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13. Bicornuate uterus
At cervical level At fundal level
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14. Transverse plane of the uterine fundus
two distinct endometrial cavities (arrows).
A subsequent 3-D confirmed that this was a partially septated
uterus
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15. Bicornuate uterus. Transverse 2-D image illustrating two
distinct endometrial cavities (arrows).
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16. Uterus didelphys, 2D scan
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17. Uterine septum, 3D
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18.  Fibroid
 Rounded distinct masses
 Echogenecity: increased, decreased or similar of
the myometrium.
± uterine enlargement.
 DD:
1. Ovarian cyst
2. RVF.
3. Adenomyosis.
 Submucous fibroids:
distort the midline echo
best diagnosed in the periovulatory phase
Decrease the chance of conception with IVFAboubakr Elnashar

19. Subclassification of fibroid
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21. Intramural fibroid
Examples of fibroids which
compromise the contours of the
endometrial cavity.
Refraction artifacts {tissue
density interfaces and the
texture of the fibroids} often aid
in their identification.
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22. Aboubakr Elnashar

23. Aboubakr Elnashar

24. Sagittal TVS:
a well-circumscribed hypoechoic mass (arrow) centered within the
endometrium(E), with a posterior acoustic shadow extending from
the edges of the mass.
An endocavitary leiomyoma
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25. Submucous fibroid
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26. Endocavitary fibroid.
Sagittal TVS: solid mass (arrowheads) with internal echogenicity
similar to that of the myometrium. The mass has a pedunculated
attachment (arrow) to the uterus and extends into the cervical
canal. Aboubakr Elnashar

27. Adenomyosis
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28. Myometrium (M):
1. Homogeneous
echotexture
2. Subendometrial haloas
(arrows):
thin hypoechoic band
Endometrium (E):
uniformly echogenic
NORMAL
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29. 1. Heterotopic endometrial glands and stroma:
Small echogenic islands
2. Smooth muscle hyperplasia.
Areas of decreased echogenicity
Histopathologic US correlation
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30. Myometrium:
Heterogeneous echotexture
Echogenicity: decreased
relative to that of the dorsal
myometrium
Myometrial cyst (curved
arrow)
Asymetrical uterine
enlargement
Endometrium:
excentric endometrial cavity
indistinct endometrial-
myometrial border
Adenomyosis
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31.  Bromley et al (2000)
2 or more of the followings:
1. Mottled heterogeneous myometrial texture: All
cases.
2. Globular uterus: 95% of cases.
3. Small myometrial lucent areas: 82%.
4. “Shaggy” indistinct endometrial strips: 82%.
The most predictive:
ill-defined heterogeneous echotexture within the
myometrium
(Brosen et al, 2004)
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32. DD: Fibroid: TVS
 An effective, noninvasive, and relatively
inexpensive
 If the status of
-Lesion's margins plus
-Hypoechoic lacunae: Fibroid could be correctly
diagnosed in 95% of cases.
Decreased uterine echogenicity without
lobulations, contour abnormality, or mass
effects,
Fedele L, Bianchi S, Dorta M, Zanotti F, Brioschi D, Carinelli S
Am J Obstet Gynecol 1992 Sep; 167:603-6Aboubakr Elnashar

33. Adenomyosis. Sagittal TVS
Globular uterine enlargement with asymmetric thickening
Heterogeneity of the myometrium (arrows)
Poor definition of the endomyometrial junction (arrowheads).
E = endometrium. Aboubakr Elnashar

34. Asherman syndrome
Irregular reflective foci of the uterine
cavity.
Best seen in the periovulatory phase
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35. IU adhesions
Bright (hyperechoic) uterine lining - scar tissue in uterine
cavity
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36. Endometrial polyps
Persistent hyperechogenic areas with
variable cystic spaces.
Distort the cavity contour.
Best seen in midcycle
Not seen clearly in the midluteal phase
or in stimulated cycles.
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37. Endometrial polyp
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38. Endometrial polyp
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39. RVF uterus, thickened endometrium that measures 18
mm (calipers) with a focal area of increased
echogenicity (arrows), which was a polyp.Aboubakr Elnashar

40. II. Ovarian factor
A. Assessment of the ovary
1. Ovarian volume
2. Antral follicle count:
B. Abnormalities
1.Anovulation
2.PCOS
3.Cysts:
Haemorhgic cyst
Endometriomata
Dermoid Aboubakr Elnashar

41. Volume
= L X WX T X 0.52
0.5 cm3Prepubertal
5 cm3Reproductive years
2.5X2.2X2 cm.
Diameter >3.5 cm is abnormal
2.5 cm3Postmenopausal
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42. Mean ovarian volume
<3 cm3: poor response to HMG
very high cancellation rate during IVF
(Lass et al, 1997)
Mean maximum ovarian diameter
measured in the largest sagittal plane
good estimation of ovarian volume
>3.5 cm: increase risk of OHSS
<2 cm: decreased ovarian reserveAboubakr Elnashar

43. AFC: Resting follicles.
Total number of follicles 2–8mm
counted in both ovaries
A threshold of 5 AF (2-5 mm) have the lowest error rate
for the prediction of poor response (Bancsi et al.,2004)
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44. Batista et al. 2012
ovarian response prediction index (ORPI)
multiplying the AMH(ng/ml) level by the number of
antral follicles (2–9 mm),and the result was divided
by the age (years) of the patient.
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45. Aboubakr Elnashar

46. Early in the menstrual cycle. No medications being given.
9 antral follicles.
The ovary has normal volume (30X18mm).
Expect a normal response to injectable FSH.
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47. only 1 antral, other ovary had only 2 antrals
Ovarian volume: low
D3 FSH: normal
Attempts to stimulate ovaries for IVF were not successful
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48. At the beginning of a menstrual cycle, irregular periods, No
medications being given.
Antral follicles:16 are seen in this image. Ovary had a total of 35
antrals (only 1 plane is shown). This is PCO with a high antral
Ovarian volume= 37 X19.5mm
"high responder" to injectable FSH drugs.
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49. POF.
Only the stroma of the ovary is identified.
A very few follicles of less than 1 mm on the inferior aspect of
the ovary.
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50.  Diagnosis of Spontaneous Ovulation
1. Mature F. (contain mature oocyte) = 17 – 25 mm
(Inner dimensions)
2. Deflation of the mature follicle
3. Intra peritoneal fluid
-Normal: 1-3 ml
-With ovulation: 4- 5 ml
4. CL: 4-8 days after ovulation
• Irregular thick wall .
• Hypoechoic
• May contain internal echos (hge.)
• 15 mm
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51. Mature follicle
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52. Atretic follicle of preovulatory diameter. thin follicle walls and sharp
transition at the fluid-follicle wall interface. The shape of the large
atretic follicle is compromised by small peripheral follicles.Aboubakr Elnashar

53. Corpus albicans
resulting from regression of a luteal structure from a
previous cycle.
hyperechoic structures within the ovary and they may
occasionally appear to be more pronounced owing to the
presence of surrounding follicles.
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54. Early Corpus Luteum. The site of
rupture of the dominant follicle
soon after ovulation appears as a
collapsed cystic structure (arrow)
on the ovary (o). u, uterus.
Corpus Luteum–Hypoechoic Solid
Appearance. The corpus luteum
appears as a hypoechoic solid
mass (arrow) on the right ovary (o)
on this transvaginal image.Aboubakr Elnashar

55. Corpus Luteum–Thick-Walled Cyst
Appearance. Transvaginal scan shows
an anechoic ovarian cyst (between
calipers, +, x) with moderately thick
walls.
Corpus Luteum–Thin-Walled Cyst
Appearance. This corpus luteum (arrow,
between cursors, +, x) has a thin wall and
contains anechoic fluid.
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56. Corpus hemorrhagicum
thick walls of peripheral luteal tissue and a central
hemorrhagic clot with an interspersed fibrin network.
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57. Failure of ovulation and development of “cystic” follicle.
The follicle typically grows larger than the mean preovulatory
follicle diameter of 23 mm, thin atretic follicle walls and small
flecks of particulate matter are frequently seen in the lumen or
aggregated at the side of the structure.Aboubakr Elnashar

58. Hemorrhagic anovulatory follicle.
Extravasated blood and an interspersed fibrin network are
observed within the lumen. The walls of this structure are thin,
echoic, and do not have the appearance of luteal tissue.
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59. Endometrioma
Hyperechoic wall
foci
(in35%)
Cysts With Low-level Echoes
Hemorrhagic
cyst
Lacelike
internal
echoes
(in 40%)
Teratoma
Regional bright
echoes
(in 97%)
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60. Endometrioma. Sagittal TVS
an ovarian mass with multiple fine internal echoes (arrows) and
several hyperechoic mural foci (arrowheads).
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61. Ovarian endometrioma (A, B).
The structure is hypoechoic and exhibits low amplitude
uniformly distributed echotexture in the cavities of the
cysts. Aboubakr Elnashar

62. PCO: Rotterdam, 2004
At least one of the following
12 or more follicles in each ovary measuring 2 to 9
mm in diameter or
Ovarian volume >10 cm3.
Only one ovary meeting these criteria is sufficient
for diagnosis.
The follicle distribution & increase in stromal
echogenecity & volume are not required for diagnosis.
Absence of mature follicle
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63. Technical recommendation
1. Regularly menstruating females should be scanned
between days 3-5
Oligo-/ amenorrhoeic should be scanned either at
random or between days 3-5 after progesterone –
induced bleeding
2. If there is evidence of a dominant follicle >10 mm or a
corpus luteum, the scan should be repeated the next
cycle.
3. Ovarian volume= 0.5X length X width X thickness
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64. PCO
Multiple peripheral
subcentimetric follicles (arrow).
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65. Subtypes of PCO: The images exhibit quite different appearances
in the size and distribution of follicles. A recent corpus luteum is
clearly visible in the ovary in panel (D).
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66. III. Tubal factor
1.Tubal patency:
SIS
2. Hydrosalpinx:
decrease the chance of implantation with IVF
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67. Hydrosalpinx
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68. Aboubakr Elnashar

69. Hydrosalpinx
well-constrained fluid
accumulation in the adnexae.
In some cases, adhesions
between the oviduct and ovary
may be visualized.
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70. Pcos,
hydrosalpinx
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71. IV. Pelvis
1. Free fluid
2. Mass
Hydrosalpinx
Endometriomas
Para ovarian Cyst
Peritoneal cysts
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72. Tubo ovarian abscess
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73. I. Ovarian induction/IUI
II. IVF:
III.Aspiration of
1. Ovarian Cyst.
2. Hydrosalpinx Aboubakr Elnashar

74. I. Ovarian induction/IUI
Monitoring:
• Base line scan on D2 or 3 of the cycle
• US on D8 of stimulation:
Follicles: number & size
Endometrium: thickness & appearance
• Repeat /2-3 days depending on the size of
leading follicle, until it is 18 mm
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75. II. IVF
1. U.S between D10 & 15 of preceding IVF cycle:
Uterus: fibroid
Ovaries: size, PCO, ovarian cyst
Tubes: hydrosalpinx
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76. 2. COH:
a. Confirm down regulation:
Thin endometrium: <4 mm,
quiescent ovaries containing only small follicles
b. Follicular development & endometrial thickness:
D6 stimulation
Repeat daily or alternate day depending on response
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77. US guided oocyte retrieval.
The oocyte collection needle is visualized entering into a large
follicle. Etching around the tip of the needle enhances its
visualization.
3. Oocyte retrieval:
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78. 4. Embryo transfer:
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79. Aboubakr Elnashar

80. Embryo transfer is enhanced by the use of ultrasound
guidance to place the embryos at the optimal uterine
location. The small hyperechoic areas distal to the catheter
tip represent microbubbles of air expelled from the transfer
pipette and serve to visualize embryo placement.Aboubakr Elnashar

81. TVS-monitored embryo transfer.
(a) Before embryo transfer. The arrow indicates the tip of the
outer sheath. The arrowhead indicates the tip of the catheter.
(b) After embryo transfer. The arrow indicates two air bubbles.
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82. III. Aspiration of
1. Ovarian Cyst.
Residual cyst > 3 cm may affect ovarian response in
the subsequent cycles .
2. Hydrosalpinx
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83. Aboubakr Elnashar

84. I. OHSS
II. Complications of oocyte retrieval
III. Complications of early pregnancy
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85. I. OHSS
a. Diagnosis
b. Treatment:
paracentesis under TVS
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86. OHSS
• Suspicion:
large number of medium sized follicle (14-15 m)
E2 > 3000 pg/ml
More fluid in the pouch of Douglas
• TAS is better for monitoring than TVS
(press on tense large ovary) (ov.> 10 cm)
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87. CriticalSevereModerateMild
•Tense ascites
•Oligo/anuria
•Thromboembolism
•ARDS
• Ascites
•Oliguria
•Mod ab pain
•N± V
•Ab bloating
•Mild ab pain
Cl
•large hydrothorax•±hydrothorax
•Ov›12 cm*
•Ascites
•Ov8–12 cm*
Ov‹8 cm*US
•Hct›55%
•WCC›25 000/ml
•Hct ›45%
•Hypoprotein
aemia
Lab
•ICU•In ptOut pt,
In pt: unable to
control pain, N
with oral tt,
Difficulties in
monitoring
Out ptTT
Mathur, 2oo5
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88. Moderate OHSS.
Both ovaries are enlarged and are observed in the posterior cul-
de-sac.
The ovaries are in close contact and displace the uterus
anteriorly.
Both ovaries contain several large unruptured follicles.
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89. Aboubakr Elnashar

90. II. Complications of oocyte retrieval
Intra-abdominal bleeding
Pelvic infection or abscess formation
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91. III.Complications of early pregnancy
more common
a. Ectopic
b.Miscarriage
c. Multiple pregnancy:
Diagnosis & treatment (selective fetal reduction)
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92. Ectopic pregnancy
A. Uterine
1. No IU gestational sac
2. Pseudogestational sac
(a fluid collection or debris in the cavity)
10-20% of ectopic P.
No double decidual sac sign
No yolk sac or embryo
Not eccentric (within the cavity)
3. No yolk sac in a G. sac > 20 mm
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93. B. Adnexal
1. Non cystic mass:
(Blob sign) inhomogeneous small mass next to the
ovary with no sac or embryo.
By pressing the vaginal probe gently against the
ectopic it moves separately to the ovary.
The most appropriate sign.
Sensitivity 84% & specificity 99%
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94. 2. Cystic mass:
3. Ring:
(Bagel sign) hyperechoic ring around the gestational
sac
4.Sac & embryo.
Ipsilateral side: Corpus luteum: 85% of cases
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95. C. D. pouch:
Fluid with or without blood clots
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96. Aboubakr Elnashar

97. loop
Non cystic mass
D pouch
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98. Cystic mass
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99. Ring
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100. Sac & embryo
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101. Multiple pregnancy
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102. Thank you
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