Ultrasonography of the ovary

1. Ultrasonography of the ovary
Aboubakr Elnashar
Benha university, EgyptABOUBAKR ELNASHAR

2. Normal ovary
Technique
1. F.B., LS of the uterus, TS, slide the probe
towards the fundus. Confirm the ovarian vessels
entering laterally.
LS of the ovary: confirm: ovary is anterior to the
ureter & internal iliac artery.
2. Turn the patient obliquely & scan the opposite
ovary through the F.B., Reduce the gain
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3. Problems:
1. Ovary is not obvious:
use the blood vessels to lead you to the ovary.
2. After hysterectomy:
follow the internal iliac vessels into the pelvis.
3. Postmenopause
4. Gas filled loops:
tipping the head down, erect & oblique erect position
Get ut in transverse plane, put it in middle of screen
Follow the br lig
Push ovary downwards
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4. Position
Extremely variable.
TS:
lateral to the AV uterus
lateral & superior to the RV uterus.
In NP:
bounded by
oblitrated umbilical a. anteriorly
ureter & the internal iliac a. posteriorly
external iliac v superiorly.
Ovarian vessels may or may not be visualized at the
superior aspect of the ovary.ABOUBAKR ELNASHAR

5. Echogenecity
Hypoechoic as compared to the uterus
{ multiple follicle in the cortex}.
Follicles:
Do not exceed 25 mm
round or ovoid, sharply marginated & anechoic.
Medulla & capsule:
higher echogenecity.
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6. ovary
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7. ABOUBAKR ELNASHAR

8. 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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9. Ovarian size and appearance at
different ages
AppearanceSizeAge
Follicles <10 mm1 mlNeonate
Follicles < 5 mm<1.0 ml<2 y
Follicles <10 mm<2.5 mlPrepubertal
Follicles present9.8 ± 5.8 mlPostpuberty
No follicles› 4 mlPostmenopause ABOUBAKR ELNASHAR

10. 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

11. 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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12. 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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13. ABOUBAKR ELNASHAR

14. 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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15. 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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16. 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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17. 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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18.  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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19. Mature follicle
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20. 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

21. 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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22. Early Corpus Luteum. The site of
rupture of the dominant follicle
soon after ovulation appears as a
collapsed cystic structure (arrow)
Corpus Luteum–Hypoechoic Solid
Appearance. The corpus luteum
appears as a hypoechoic solid mass
(arrow) on the right ovary (o) onABOUBAKR ELNASHAR

23. 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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24. Corpus hemorrhagicum
thick walls of peripheral luteal tissue and a central
hemorrhagic clot with an interspersed fibrin network.
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25. 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

26. 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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27. 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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28. Endometrioma. Sagittal TVS
an ovarian mass with multiple fine internal echoes (arrows) and
several hyperechoic mural foci (arrowheads).
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29. Ovarian endometrioma (A, B).
The structure is hypoechoic and exhibits low amplitude
uniformly distributed echotexture in the cavities of the
cysts. ABOUBAKR ELNASHAR

30. 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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31. ABOUBAKR ELNASHAR

32. 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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33. PCO
Multiple peripheral
subcentimetric follicles (arrow).
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34. 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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35. PCOS
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36. Transabdominal and transvaginal USABOUBAKR ELNASHAR

37. Tuboovarian abcess
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38. Hyperstimulated ovary
Multiple follicles & cysts of different sizes & shapes
(Cogwheel)
Ascites
Follicular cysts
few mm to 10 cm.
Thin walled, unilocular & hypoechoic
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39. Hyperechoic (calcifications) Anechoic (simple cyst)
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41. OHSS
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43. Corpus luteum cyst
Similar to follicular cyst but hemorrhage is frequent & internal
echoes appear.
Difficult to be DD from ectopic pregnancy.
If ruptured: fluid in DP
Para ovarian cyst
Similar to functional cysts but may reach 15-20 cm
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45. C L cyst & uterus
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46. Dermoid cyst
Cystic mass containing a cone of solid tissue with highly
echogenic focus & posterior shadowing
Endometrioma
Cystic, mixed or solid. If cystic, difficult to dd from any
other cyst. Commonly low level echoes evently
distributed. 1-20 cm
ABOUBAKR ELNASHAR

47. Endometrioma
Hyperechoic wall foci
(in 35%)
Cysts With Low-level Echoes
Hemorrhagic
cyst
Lacelike
internal
echoes (in
40%)
Teratoma
Regional bright
echoes
(in 97%)
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50. Malignancy
1.Bilaterality
2. Ascites
3. Excrescencies
4. Thick walled cysts
5. Thick septa
6. Solid area within the mass
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51. Scoring system
(Sasson et al,1991)
Internal wall structure:
smooth, irregularities <3mm, > 3mm, mostly
solid
Wall thickness (mm):
<3, >3, mostly solid
Septa(mm):
No septa, <3 mm, >3 mm
Echogenecity:
Sonolucent, low, low with echogenic core,
mixed, high
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56. Transabdominal US of the ovary
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57. Transabdominal Vs Transvaginal US
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58. Absent uterus and ovaries
Congenital anomalies of the ovary
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59. Uterus without ovaries
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60. Pelvic inflammatory disease (PID)
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61. Tubo-ovarian cyst
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62. Ovarian abscess
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63. Tubo-ovarian abscess
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64. Bilateral tubo-ovarian abscess
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65. Ovarian abscess
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66. Pelvic abscess
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67. Ectopic pregnancy
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69. Ectopic pregnancy
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70. Acute abdomen (Torsion of a cyst)
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71. Folliculometry
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72. Chronic anovulation
Vs
Ovulatory cycles
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73. Corpus Luteum
•The great sonographic
mimic in the female pelvis.
•DD:
– endometrioma,
– abscess
– Neoplasm
– ectopic pregnancy .
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74. Corpus luteum
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75. Interventional US (ovum pickup)
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76. Transvaginal ovum pickup
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77. PCOD
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78. ABOUBAKR ELNASHAR