1. • The young, enthusiastic and energetic chief
consultant at Rupal Hospital For Women,
Surat, India for last 18 years
• Medical director and IVF consultant at
Blossom IVF Centre,Surat,India
• Diploma in Reproductive Medicine from Kiel,
Germany
• Intense training in Advanced infertility
treatment at numerous workshops and
conferences in USA and Europe.
• Invited as a faculty in various state,national and
international conferences.
• Specialized in all kind of gynec endoscopic
surgeries.
• Promotes health awareness by conducting
Seminars and writing articles and specialty
related books
• In addition of being techno-savvy person, she
loves making friends, and keenly interested in
music and Guajarati literature. She is actively
associated with the leading cultural club of
Surat-Tarbatar.
Dr Rupal N Shah
M.D.(OBGYN)
Diploma in Reproductive Medicine
(Germany)
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2. Ultrasound in Infertility
Dr Rupal N Shah
M.D.:D.G.O
Diploma in Reproductive Medicine(Germany)
Blossom IVF Centre,
Rupal Hospital For Women
Surat

3. Sonography in Infertility
• Transvaginal Sonography is one of the indispensable
investigations as far as infertility patient is
concerned.
• It is the primary examination parallel to clinical
assessment as it gives more information than any
other single test and is noninvasive.
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4. Ultrasonography in infertility
1. Workup for infertility
2. Assisted reproduction technique
3. Early pregnancy scanning
4. Male Infertility
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5. Infertility workup
Ovary
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6. Ultrasound evaluation of Ovarian Reserve
• Antral Follicle count
The number of visible ovarian follicles(2-8 mm)
on cycle day 2-3
• Ovarian Volume
limited value compared with antral follicle count
for detection of diminished ovarian reserve.
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7. Antral Follicle Count
• 12 / more immature follicles ( 2 -
8mm)
• AFC Less than 5 -Poor responder
• Total number of antral follicles achieved
the best predictive value for favourable
IVF outcome, followed by Ovarian
stromal FI, total ovarian stromal area &
total ovarian volume Kupesic S et al,
Hum Reprod 2002; 17(4):950-55
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8. Preovulatory scan
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9. Prediction of ovulation
• Dominant Follicle >
14mm
• Grows 2-3 mm/day.
• Ovulation 18-24 mm.
• Sonolucent halo 24 hours
prior to ovulation.
• Cumulus like shadow.
In the hands of experienced operators, ultrasound alone suffices
for cycle monitoring, with no necessity for additional hormonal
estimations.
Golan et al, Shoham et al and Tan SL et al

10.  16mm Cumulus oophorus 3/4th vascularity
• Ovulation 16-24 mm.
• Vascularity - 3/4th of the follicle
• On the day of HCG – If cumulus like echoes is not seen in all
three planes in the follicle , it is less likely to be mature
fertilizable oocyte.
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11. Luteinized Unruptured Follicle-LUF
• Persistent follicle
with thick walls.
• Progressive loss of
cystic appearance.
• Thick echogenic
endometrium.
• No fluid in POD.

12. Ultrasound diagnosis of PCO
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13. ESHRE/ASRM consensus revised
definition of PCOS ( 2003)
Two of the following three criteria and
exclusion of other etiologies:
1. Oligo and/or anovulation
2. Hyperandrogenism
3. Polycystic ovaries on TVS
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14. Ultrasound diagnosis of PCO is one of
the key features for diagnosis of
PCOD.
• This is done by a transvaginal scan done on day 2 – 3 of
the cycle
• 12 follicles of 2-9 mm in diameter in at least one ovary or
• Peripheral cystic pattern(Neckless pattern) or generalized
cystic pattern
• Increased ovarian volume (>10 cm3)
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15. Sono AVC
• Recently Sono AVC has also been
tried to measure the number of
antral follicles
• Adv: Can separate follicular number
of 2 -6 mm and 6 – 9 mm follicles
and prevents recounting of follicles
• Disadv: requires post processing.
VOCAL
Volume calculation by Computer
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16. Ovarian Cysts
• Corpus luteum – hemorrhagic cyst –
LUF
• Endometrioma
• Dermoid cysts
• Serous and mucinous cystadenomas
• Endometrioid tumours
• fibroma
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17. But it is more convenient to divide these
lesions according to morphology
• Nonseptated clear cysts
• Cysts with internal echoes
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18. Nonseptated clear cysts
• Thin walled
• Anechoic, clear
contents
• No vascualrity
Simple ovarian cyst
Paraovarian cyst

19. Cysts with internal echoes
• thick, echogenic wall
• internal echogenecity
Corpus luteum Heamorrhagic Endometrioma
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20. Heamorrhagic cyst
• The commonest
appearance is a fishnet
appearance
• Changes echogenicity over
time due to fibrinolysis of
a clot
• Scanty and high resistance
blood flow

21. Endometrioma
• Bilateral in 1/3 cases
• Thick shaggy walls
• With or without septae,
• internal echogenicity with
ground glass appearance
• Pain on pressure with the
probe
• Sometimes ‘kissing
ovaries”
• Vascularity may vary
between lesions.
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22. Dermoids
• Thick wall, echogenic material
in lumen
• Fluid fluid level
• Hyperechoic lines and
dots due to hair.
• Hyperechic/calcified echoes
due to teeth and bones
• Avascular

23. Uterus
Abnormalities of uterus
• Congenital
• Acquired
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24. Volume USG, 3D and 4D USG has a
major role to play in the diagnosis of
uterine anomalies :
Virtual hysteroscopy
Sensitivity of the Volume USG
for the detection of congenital uterine
abnormalites is > 98%.
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25. Congenital uterine anomalies
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26. Failure of one /more mullerian duct to develop
or to canalize-rudimentary horn
Unicornuate uterus:
• Uterus is not in midline
• normal shape in long section
• one cornual projection
• only one uterine artery
• 3D:Banana shaped uterine cavity
Rudimentary horn :
on other side as hypoechoic shadow
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27. Failure to fuse/abnormal fusion
• Uterus didelphys-double uterus
• Bicornuate uterus
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28. Failure to fuse/abnormal fusion
Uterus Didelphys
• Two separate uteri and cervix
• Uteri are Seen in midline or on
lateral pelvic wall as two well
developed uterine structure
• On transverse section ,both
uterine horns make a figure of
eight.
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29. Failure to fuse/abnormal fusion
Bicornuate Uterus
• Two separate uterine bodies and a
single cervix
• On transverse section widened
fundus and division of endometrial
cavity towards fundus
Volume US:
• Fundus shows dimple
• Distance between the line joining
the endometrial tips and the fundal
dimple is less than 5 mm
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30. Failure of resorption of midline
septum-Septate or arcuate uterus
Septate uterus
• Flat or convex external
contour
• Acute angle between
endometrial cavities
• Distance between line
joining the tips of endo
cavity to the deepest point
between the two cavities-
>10 mm
Arcuate uterus
• Convex external contour
• Obtuse angle between
cavities
• Distance between line
joining the tips of endo
cavity to the deepest point
between the two cavities
<10 mm
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31. Which is arcuate and which is
subseptate?
<90°>90°
Obtuse: arcuate Acute: subseptate

32. Septate uterus has highest implications on
pregnancy…
 Infertility
 Frequency of ectopic 27.34% as compared to 13.3%
otherwise.
 First trimester abortions : 28 – 45%
 Second trimester abortions : 5%
 Premature deliveries
 dystocia
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33. Bicornuate V/S Septate uterus
Bicornuate
• Fundus-dimple
• <5 mm uterine wall above
the line joining tips of 2
uterine cavity
• Angle between 2 cavities
>90 *
• Medial margins of endo
cavity -Convex
Septate
• Fundus-No dimple
• >5 mm uterine wall above
the line joining tips of 2
uterine cavity
• Angle between 2 cavities
<90*
• Medial margins of endo
cavity -streight
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34. Septum V/S bicornuate
>5mm : septate
<5mm: Bicorn

35. Acquired uterine anomalies
Endometrial
myometrial
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36. Endometrial pathologies
• Synechie
• Polyps
• Submucous fibroids
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37. Synechiae
 Hyperechoic bands
traversing through the
endometrial cavity
 In thick synechiea 3D US
can be used for exact
assessment
of restriction of
endometrial cavity.
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38. Polyps
• non-specific endometrial
thickening or focal masses within
the endometrium
• May appear as just diffusely
thickened endometrium,without
visualisation of descrete
mass(Mimicks endometrial
hyperplasia)
• A feeding vessel may be seen
extending to polyp on colour
doppler imaging
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39. Submucous fibroids
-Grading(ESGE Clssification)
• T0- whole in endometrial cavity
• T1 - >50% in endometrial cavity
• T2_ < 50% in endometrial cavity
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40. Myometrial lesions
• Fibroids
• Adenomyoma / adenomyosis
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41. Intramural/Subserous Fibroids
• Well-defined,hypoechoic,
homogeneous ,rounded lesions with
peripheral hypoechoic rim.
• Enlargement of the uterus and
distortion of the contour
• Sometimes heterogenicity due to
degeneration or calcification
• On power doppler :Peripheral
vascularity
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42. Adenomyosis
• Altered hyper and hypoechoic
zones-swiss cheese appearance.
• Generalized involving the whole
uterus or localized to one
portion(adenomyoma)
• Power doppler:penetrating
vascularity

43. Endometrial Grading
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44. TVS for endometrial grading
Endometrial thickness and endometrial pattern
are useful prognostic parameters for successful
pregnancy.
• 8-13 mm -Favorable
• <6 and >15 mm – Problematic
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45. C
B
A
TVS for endometrial grading
The coexistance of a
thinner
endometrium(<7mm)
and no-triple line
pattern reflects poor
receptivity of the
endometrium and low
clinical pregnancy rate.
Triple line endometrium
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46. Abnormal endometrial
patterns
• Premature
secretory
endometrial
pattern
• Calcifications in
endometrial cavity
• Fluid in
endometrial cavity
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47. Zone 1 - Myometrium
surrounding the
endometrium.
Zone 2 - Hyperechoic
endometrial edge
Zone 3- Internal endometrial
hypoechoic zone.
Zone 4 - Endometrial cavity
2
3 4
Endometrial vascularity zones
Applebaum scoring

48. Absent subendometrial and
intraendometrial vascularization on the
day of hCG, appears to be a useful
predictor of failure of implantation in IVF,
irrespective of morphological
appearance.
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49. When pregnancy is achieved in absence of
endometrial and subendometrial flow on the
day of embryo transfer, more than half of
these pregnancies will finish as
spontaneous miscarriage.
Chein LW, et al, Assessment of uterine receptivity by the
endometrial-subendometrial blood flow distribution pattern in
women undergoing IVF-ET. Fertil Steril 2002; 78:245-51
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50. Hydrosalpinx
Fusiform cystic lesion
Cog wheel sign
Incomplete septae
Cyst wall thicker than 5mm in
almost all acute inflammations and
app.3 % of chronic lesions
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51. Assisted reproduction technique
• Monitoring of ovarian response
• Oocyte retrieval / embryo transfer under
ultrasound guidance
• Prediction of ovarian response and
pregnancy
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52. Oocyte Retrieval
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53. Ultrasound guided embryo transfer
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54. Tubal patency-Sonosalpingography
Advantages
OPD procedure, less time
consuming, cost
effective,NoninvasiveNo
anasthesia,No radiation, no
iodinated contrast,Reproducible
and reliable for assessment of
tubal patency
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55. Tubal patency-Sonosalpingography
Disadvantages
• Tubal spasm
• Hydrosalpinx gives tubal flow – false
positive for patency
• Technical competence required
• Site of block can not be located exactly
• Intratubal pathology cannot be detected
• Peritubal adhesions and tubal motility
can not be assessed
• Findings are subjective.
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56. USG in Male Infertility
Male factors are primary cause of infertility
in 20-30% of couples and a contributing
factor in another 20-25% of patients.
A systemic and logical evaluation of the
infertile male by USG helps to distinguish
between correctable and noncorrectable
abnormalities

57. USG in male infertility
• Scrotal Ultrasound and doppler
-Vericocele
-Epididymal abnormalities,undecended testes
• Transrectal Ultrasound
-Imaging of prostate,seminal vesicles and vas
deference
-Obstructive azoospermia(OA)
• Penile Ultrasound
-evaluates physical causes of erectile dysfunction.
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58. www. blossomivfindia.com
Thank You
21-06-2015 Rupal Hospital For Women