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- •Color Doppler Sonography in Gynecology and Obstetrics
- •Preface
- •Contributors
- •Contents
- •Physical and Technical Principles
- •Principles of Ultrasound Instrumentation
- •Analysis of B-Mode Information and Artifacts
- •Duplex and Color Doppler Sonography
- •Physical Principles of Motion Detection
- •Technical Principles and Equipment Settings
- •1 Physical and Technical Principles of Color Doppler Sonography
- •Historical Development
- •B-Mode Sonography
- •Physical Principles of Echo Production
- •Analysis of Doppler Information and Artifacts
- •New Technical Processes and Approaches
- •New Developments in Transducer Technology
- •New Techniques of Signal Acquisition and Processing
- •2 Safety Aspects of Doppler and Color Doppler Sonography
- •Mechanisms of Tissue Effects
- •Heating
- •Cavitation
- •Risk Assessment of Various Ultrasound Techniques
- •Duplex Sonography
- •Color Doppler
- •Power Doppler
- •Color Velocity Imaging (CVI)
- •Transvaginal Scanning
- •Ultrasound Contrast Agents
- •Exposure of Gas-Containing Tissues
- •Measures to Limit Risk
- •Recommendations
- •General Recommendations
- •Pulsed Doppler
- •Appendix: Statements on the Biological Safety of Diagnostic Ultrasound Fields
- •EFSUMB Statement on the Clinical Safety of Diagnostic Ultrasound
- •WFUMB Statement on Thermal Effects in Clinical Applications
- •3 Uterine Blood Flow in Fertile and Infertile Women
- •Uterine Blood Supply
- •Changes in Uterine Blood Flow during the Menstrual Cycle
- •Blood Flow Parameters in the Uterine Arteries
- •Uterine Blood Flow in InfertileWomen
- •Uterine Blood Flow and Fertilization Rate
- •Uterine Blood Flow in the Normal Cycle and during Ovarian Stimulation with Confirmed Ovulation
- •Endometrial Imaging
- •Conclusions
- •4 Uterine Causes of Infertility
- •Ultrasound Detection of Uterine Abnormalities
- •Congenital Anomalies
- •Endometrial Polyps
- •Submucous Leiomyomas
- •Adenomyosis
- •Endometritis
- •Asherman Syndrome
- •Ultrasound Detection of Endometrial Causes of Infertility
- •Effect of Endometrial Thickness and Morphology on Fertility
- •Effect of Age on Endometrial Function
- •Endometrial Peristalsis
- •Cervical Factor
- •Decline of Fertility in the Perimenopausal Period
- •Uterine Receptivity
- •Oocyte Quality
- •Ovarian Function
- •Effects of Estradiol and Progesterone on Vascular Resistance
- •Sympathetic Innervation of the Uterus
- •Estrogen Effect
- •Progesterone Effect
- •Effect of Age on Ovarian and Uterine Perfusion
- •Authors’ Study
- •Interpretation of the Results
- •Functional Evaluation of the Endometrium
- •Authors’ Studies
- •Patients and Methods
- •Examination Procedures
- •Results
- •Discussion of the Role of Doppler Examinations
- •Summary
- •Applications of Doppler Sonography in Reproductive Medicine
- •Assessment of Tubal Patency
- •Patients and Method
- •Examination Technique
- •Results
- •Discussion of the Value of the Test Procedures
- •Summary
- •8 Abnormalities of Corpus luteum Function
- •Morphology and Biochemistry of the Corpus luteum
- •Conventional Methods in the Diagnosis and Treatment of Luteal Phase Defect
- •Possible Causes of Luteal Phase Defect
- •Diagnosis of Luteal Phase Defect
- •Treatment of Luteal Phase Defect
- •Ultrasound and Doppler Sonography in the Detection of Luteal Phase Defect
- •LUF Syndrome
- •Blood Flow in the Corpus luteum during Early Pregnancy
- •Fallopian Tube Catheterization
- •Aspiration of Ovarian Cysts
- •Drainage of Cul-de-Sac Abscesses
- •Selective Reduction of Multiple Pregnancies
- •Techniques of Ultrasound Tubal Imaging
- •Hysterosonosalpingography
- •9 Interventional Ultrasound in Reproductive Medicine
- •Follicular Aspiration in Assisted Reproduction
- •Transabdominal Follicular Aspiration
- •Transurethral Follicular Aspiration
- •Transvaginal Follicular Aspiration
- •Embryo Transfer
- •Obstetric Ultrasound
- •Overview
- •Monitoring Folliculogenesis
- •Development of the Corpus luteum
- •Changes in Endometrial Blood Flow
- •Luteal Blood Flow in Normal and Abnormal Pregnancies
- •Trophoblastic Invasion and Development of the Placenta
- •Implantation
- •Development of the Intervillous Circulation
- •Classic Theory
- •Objections and Alternative Theories
- •Color Doppler Studies
- •Vascularization of the Yolk Sac and Vitelline Duct
- •Changes in Uterine Perfusion after Placentation
- •Uterine Arteries and Spiral Arteries
- •Embryonic and Fetal Circulation
- •Fetal Vessels
- •Summary
- •12 Color Doppler Sonography in Ectopic Pregnancy
- •Importance of Transvaginal Sonography and Serum hCG
- •Transvaginal Color Doppler Sonography
- •Diagnostic Efficiency
- •Author’s Studies
- •Assessment of the Method
- •Summary
- •Conditions of Intrauterine Life
- •Physical Principles
- •Anatomical and Physiological Principles
- •Adaptive Processes during Pregnancy
- •Technique of Transvaginal Pulsed Doppler Flowmetry
- •Authors’ Studies
- •Uterine Perfusion in a Normal Pregnancy
- •Uterine Perfusion in an Abnormal Pregnancy
- •Discussion
- •Uterine Perfusion in a Normal Pregnancy
- •Uterine Perfusion in an Abnormal Pregnancy
- •Uterine Perfusion on Medication or after Uterine Manipulation
- •Summary
- •Doppler Flowmetry of Maternal Vessels as a Screening Test?
- •Applications of Color Doppler Sonography during Pregnancy
- •Technique of Transvaginal Doppler Sonography
- •Normal Development of Uterine Artery Doppler Spectra
- •Normal Values in Early Pregnancy
- •Early Doppler Examination of Uteroplacental Blood Flow in Abnormal Pregnancy
- •Patients
- •Results
- •Discussion
- •Summary
- •Establishing Normal Curves
- •Methodology
- •Defining the Normal Population
- •Plotting Quantile Curves
- •Results
- •Discussion
- •16 Venous Doppler Sonography
- •Historical Development
- •Physiology
- •Umbilical Vein
- •Ductus venosus
- •Inferior Vena Cava
- •Hepatic Veins
- •Clinical Applications
- •Intrauterine Growth Retardation Due to Chronic Placental Insufficiency
- •Growth Discordance in Multiple Pregnancy
- •Hydrops fetalis
- •Conclusion
- •Other Diseases
- •Specific Obstetric Problems
- •Importance of Nuchal Cord
- •Color Doppler Study on the Diagnosis of Nuchal Cord
- •Examination Technique
- •Results
- •Importance of Nuchal Cord Diagnosis in the Biophysical (ABCD) Profile
- •Role of Doppler Sonography in NC
- •Summary
- •18 Chronic Placental Insufficiency
- •Definitions
- •Definition and Incidence of Chronic Placental Insufficiency
- •Intrauterine Growth Retardation
- •Diagnosis of Chronic Placental Insufficiency
- •Diagnostic Systems
- •Indications for Doppler Sonography
- •Clinical Management of Chronic Placental Insufficiency Suspected from Doppler Findings
- •Antenatal Fetal Heart Rate Monitoring
- •Pathological Changes in Organ Systems
- •Biophysical Profile
- •Summary
- •Identifying Cases with IUGR
- •Obstetric Management
- •Surveillance of Compromised Fetuses
- •Absent End-Diastolic Flow (AEDF) and Reverse Flow
- •Absent End-Diastolic Flow in the Umbilical Artery and/or Fetal Aorta
- •Reverse Flow in the Umbilical Artery and/or Fetal Aorta
- •Clinical Results of AEDF or Reverse Flow in the Umbilical Artery and/or Fetal Aorta
- •Significance of Severely Abnormal Doppler Findings
- •Summary
- •20 Fetal Doppler Findings in Late Pregnancy
- •Physiological Findings in Late Pregnancy
- •Aorta: Quantitative Analysis
- •Aorta: Qualitative Analysis
- •Cerebral Arteries
- •Renal Arteries
- •Femoral Arteries
- •Changes in Findings at Term and in Postterm Pregnancies
- •Term Effect
- •Circulatory Balance
- •Summary
- •Pathophysiology and Technical Problems
- •Changes in Uterine ArteryWaveforms during Labor
- •Our Results
- •Discussion of Uterine Doppler Changes during Labor
- •IntrapartumWaveform Changes in Umbilical and Intrafetal Vessels
- •Umbilical Cord Doppler during Labor
- •Effect of Intrapartum FHR Decelerations on Quantitative Parameters of Umbilical Blood Flow
- •Direct Effect of Intrapartum Fetal Hypoxia or Hypoxemia on Blood Flow Patterns in the Umbilical Arteries and Vein
- •Summary
- •22 Color Doppler Ultrasound in Fetal Echocardiography
- •Congenital Heart Disease—Incidence and Risk Factors
- •General Introductory Remarks on Color Doppler Sonography of the Fetal Heart
- •Special Features of Fetal Echocardiography
- •Ultrasound Examination of the Fetal Heart
- •Normal Findings
- •Management of Suspected Congenital Heart Disease
- •23 Use of Color Doppler in Echocardiography
- •Importance of Color Doppler Echocardiography in Prenatal Diagnosis
- •Examination of the Normal Heart
- •Equipment Settings
- •Examination Technique
- •Cardiac Valve Regurgitation
- •Functional Physiological Tricuspid Regurgitation
- •Pathological Tricuspid Regurgitation
- •Tricuspid and Mitral Valve Regurgitation
- •Semiquantification of AV Valve Regurgitation
- •Anomalies of Visceroatrial Blood Flow
- •Anomalies of Atrioventricular Blood Flow
- •Anomalies of Ventriculoarterial Blood Flow
- •Anomalies of Blood Flow through the Cardiac Septa
- •Color Doppler Sonography in Fetal Arrhythmias
- •Summary
- •Structure of the Human Placenta
- •Weight and Dimensions
- •Early Development of the Human Placenta
- •Structure of the Villous Tree
- •Microstructure of the Terminal Villus
- •Maturation of the Placenta
- •Vascular Architecture of the Villous Tree
- •Regulation of Villous Blood Flow
- •Concept of the Placentone
- •Morphology and Physiological Transformation of the Maternal Basal-Plate Vessels
- •Placental Insufficiency
- •Definition and Etiology of Placental Insufficiency
- •Placental Compensatory Mechanisms
- •Classification of Placental Insufficiency by its Progression
- •Morphological Counterparts of Latent or Overt Placental Insufficiency
- •Clinical Aspects of Placental Insufficiency
- •Pathophysiological Aspects of Placental Insufficiency
- •Pathomorphological Aspects of Placental Insufficiency
- •Validation of Doppler Findings by Placental Histology
- •Resistance Index of the Umbilical Arteries
- •End-Diastolic Blood Flow Velocities in the Umbilical Arteries
- •Clinical and Diagnostic Value of Doppler Sonography of the Umbilical Arteries
- •Gynecological Ultrasound
- •Classification of Uterine Anomalies
- •Diagnosis and Complications of Septate Uterus
- •Ultrasound in the Diagnosis and Treatment of Septate Uterus—Authors’ Results
- •Patients and Methods
- •Results
- •New Thoughts on Old Problems
- •Changes in the Normal Endometrium during the Menstrual Cycle
- •Changes in Endometrial Blood Flow during the Menstrual Cycle
- •Submucous Leiomyomas
- •Endometrial Polyps
- •Endometrial Hyperplasia
- •Adenomyosis
- •Endometritis
- •Incomplete Abortion
- •Decidua
- •Examination Technique, Anatomy, and Physiology
- •Leiomyomas (Fibroids)
- •Vascularization of Leiomyomas
- •Management of Uterine Leiomyomas and the Importance of Color Doppler Sonography
- •Medical Treatment with GnRH Agonists
- •Surgical Treatment
- •Vascular Diseases in the Lesser Pelvis (Varicose Veins or Arteriovenous Malformations)
- •Incidence of Endometrial Carcinoma
- •Diagnostic Investigation of Suspicious Endometrial Findings
- •Color Doppler Sonography
- •Examination of the Uterine Artery
- •Experience at the Department of Obstetrics and Gynecology, Homburg University Hospital, Saar
- •Patients and Methods
- •Visualization and Morphology of the Vessels
- •Resistance Indices of Endometrial Vessels
- •Effect of Menopausal Status and Hormone Use
- •Effect of Histopathological Parameters, with Reference to Prognostic Factors
- •Subendometrial and Myometrial Vessels
- •Summary
- •30 Malignant Uterine Tumors
- •Endometrial Carcinoma
- •Incidence
- •Risk Factors
- •Target Group for Screening
- •Screening: Dream or Reality?
- •Authors’ Experience
- •Review of the Literature
- •Uterine Sarcoma
- •Authors’ Experience
- •Cervical Carcinoma
- •Conclusion
- •Treatment of Cervical Carcinoma
- •Assessing Treatment Response with Pulsed Color Doppler Sonography
- •Authors’ Studies
- •Discussion
- •Summary
- •Appearance of Normal Ovaries by B-Mode and Color Doppler Ultrasound
- •Specific Adnexal Masses
- •Cystic and Cystic-Solid Ovarian Masses
- •Solid Ovarian Masses
- •Conclusions
- •33 Malignant Adnexal Tumors
- •Color Doppler Sonography of Adnexal Malignancies
- •Review of the Literature
- •Neoangiogenesis
- •Detecting Blood Vessels and Defining their Location
- •Vascular Patterns
- •Pulsed Doppler Waveforms
- •Vascular Impedance
- •Blood Flow Velocities
- •Stages of Malignant Tumors
- •False-Positive Results
- •Conclusions
- •Contribution of Transvaginal Color Doppler Sonography
- •Three-Dimensional Imaging
- •Three-Dimensional Imaging of Vascular Patterns
- •Display Modes for Three-Dimensional Vascular Images
- •Ultrasound Technology in Tumor Diagnosis
- •Problems in the Interpretation of 3D Power Doppler Data
- •Current Methods for Evaluating Vascular Geometry and Function
- •Technique for Evaluating Vascular Geometry
- •Example of 3D Power-Mode Imaging of Benign and Malignant Gynecological Tumors
- •Advances in Tumor Therapy
- •Summary
- •Future Outlook
- •35 Ovarian Cancer Screening
- •Incidence and Five-Year Survival Rates of Ovarian Cancer
- •Requirements of a Screening Program
- •Definition
- •Screening Methods
- •Screening Parameters
- •Possible Screening Tests
- •Bimanual Pelvic Examination
- •Cul-de-sacWashings and Radiological Studies
- •Tumor Marker
- •Ultrasound
- •Who Should be Screened?
- •Age Distribution
- •Family History
- •Conclusion
- •Other Risk Factors
- •Historical Development
- •Blood Flow Detection
- •Number of Tumor Vessels
- •Resistance Index
- •Absolute Velocities
- •Doppler Waveform
- •Comparison of “Mirror Image Areas”
- •Conceptual Misunderstandings in the Interpretation of Doppler Measurements
- •Evolution of Breast Cancer Diagnosis
- •Continuous-Wave Doppler
- •Pulsed Doppler Techniques
- •Color Doppler
- •Equipment Settings
- •Examination Technique
- •Blood Flow Analysis
- •Study Results
- •Discussion
- •Conclusions
- •Flow Resistance in Malignant Breast Tumors
- •Authors’ Studies
- •Patients and Methods
- •Results and Discussion
- •Summary
- •Menopausal Status and Benign–Malignant Tumor Discrimination
- •Authors’ Studies
- •Patients and Methods
- •Results
- •Discussion
- •Summary
- •Applications of Color Doppler Sonography in Breast Cancer
- •Authors’ Studies
- •Methods
- •Results
- •Discussion
- •Conclusion
- •Index


i


Color Doppler Sonography in Gynecology and Obstetrics
iii
Werner O. Schmidt, M.D.
Professor and Chairman
Department of Gynecology and Obstetrics
The Saarland University Hospital
Homburg, Germany
With contributions by:
F. Bahlmann
G. Bernaschek
W. Braendle
B. Breyer
J. Deutinger
A. K. Ert an
M. Friedrich
A. Funk
U. Gembruch
T. Golaszewski
D. Grab
H.-J. Hendrik
G. Hetzel
T. Hitschold
M. Holländer
B. Hüneke
A. Kleinkauf-Houcken
J. König
Asim Kurjak, M.D., Ph.D.
Professor
Department of Gynecology and Obstetrics
Sveti Duh Hospital
University of Zagreb
Zagreb, Croatia
R. Kubale
S. Kupesic
A. Kurjak
A. Lindinger
C. Lindner
H. Madjar
D. Mink
K. R. Reitnauer
H.-D. Rott
W. Schmidt
K. Sterzik
I. Tossounidis
K. Vetter
C. Villena-Heinsen
H.-J. Voigt
E. Weiss
T. Zodan
579 illustrations
90 tables
Thieme
Stuttgart · New York

iv
Library of Congress Cataloging-in-Publication Data
Farbdopplersonographie in Gynäkologie und Geburtshilfe. English.
Color Doppler Sonography in gynecology and obstetrics / [edited
by] Werner O. Schmidt, Asim Kurjak ; with contributions by F. Bahlmann ... [et al.] ; [translator, Terry Telger].
p. ; cm.
Includes index.
ISBN 3-13-130131-7 (GTV : alk. paper) -- ISBN 1-58890-179-3
(TNY : alk. paper)
1. Color Doppler ultrasonography. 2. Duplex ultrasonography.
3. Generative organs, Female--Ultrasonic imaging. 4. Breast--Cancer--Ultrasonic imaging. 5. Fetus--Ultrasonic imaging. 6. Ultrasonics
in obstetrics.
[DNLM: 1. Genital Diseases, Female--ultrasonography--Atlases.
2. Pregnancy Complications--ultrasonography--Atlases. 3. Ultrasonography, Doppler, Color--methods--Atlases. 4. Ultrasonography,
Prenatal--methods--Atlases. WP 17 F219 2005a] I. Schmidt, Werner,
Prof. Dr. II. Kurjak, Asim. III. Bahlmann, F. IV. Title.
RG107.5.U4F3713 2005
618’.047543--dc22
2004022003
This book is an authorized and updated translation of the German
edition published and copyrighted 2000 by Georg Thieme Verlag,
Stuttgart, Germany. Title of the German edition: Farbdopplersonographie in Gynäkologie und Geburtshilfe.
Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular
our knowledge of proper treatment and drug therapy. Insofar
as this book mentions any dosage or application, readers may
rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance
with the state of knowledge at the time of production of the
book. Nevertheless, this does not involve, imply,or express any
guarantee or responsibility on the part of the publishers in respect to any dosage instructions and forms of applications
stated in the book. Every user is requested to examine care-
fully the manufacturers’ leaflets accompanying each drug and
to check, if necessary in consultation with a physician or specialist, whether the dosage schedules mentioned therein or the
contraindications stated by the manufacturers differ from the
statements made in the present book. Such examination is particularly important with drugs that are either rarely used or
have been newly released on the market. Every dosage schedule or every form of application used is entirely at the user’s
own risk and responsibility. The authors and publishers request every user to report to the publishers any discrepancies
or inaccuracies noticed. If errors in this work are found after
publication, errata will be posted at
www.thieme.com
on the
product description page.
Translator: Terry Telger, Fort Worth, Texas, USA
Illustrator: Angelika Kramer, Stuttgart, Germany
䉷 2005 Georg Thieme Verlag
Rüdigerstraße 14
70469 Stuttgart, Germany
http://www.thieme.de
Thieme New York, 333 Seventh Avenue,
New York, NY 10001 USA
http://www.thieme.com
Cover design: Angelika Kramer, Stuttgart, Germany
Typesetting by Druckhaus Götz GmbH, D-71636 Ludwigsburg,
gesetzt auf CCS Textline (Linotronic 630)
Printed in Germany by Grammlich, Pliezhausen
ISBN 3-13-130131-7 (GTV)
ISBN 1-58890-179-3 (TNY) 12345
Some of the product names, patents, and registered designs referred to in this book are in fact registered trademarks or proprietary names even though specific reference to this fact is not
always made in the text. Therefore, the appearance of a name
without designation as proprietary is not to b e construed as a
representation by the publisher that it is in the public domain.
This book, including all parts thereof, is legally protected by
copyright. Any use, exploitation, or commercialization outside
the narrow limits set by copyright legislation, without the publisher’s consent, is illegal and liable to prosecution. This applies
in particular to photostat reproduction, copying, mimeographing, preparation of microfilms, and electronic data processing and storage.

Preface
v
Color Doppler sonography has opened new scopes for our
specialty not just in perinatology but also in gynecology and
oncology. This new technology has enabled the precise visualization and detailed examination of highly complex vascular
structures.
The present book, which contains over 40 contributions
from leading experts, is intended to present relevant information in an easy-to-read format that will be an authoritative
guide in both routine and specialized diagnostic situations.
Practical tips and guidelines will help the reader to use color
Doppler ultrasound appropriately and effectively. Reference
curves and documentation guidelines are integrated into the
various chapters.
This book is being published at a time when the clinical
relevance of color Doppler sonography has become an extremely topical issue. By providing a comprehensive review of
the literature and a detailed subject index, the editors and contributing authors have tried to bring newcomers up to date on
the research aspects and clinical applications of color Doppler
imaging.
This book can also provide a valuable reference for interested colleagues who are preparing for national registry examinations.
The editors wish to thank their coauthors for their eager
willingness to collaborate on this project. We also acknowledge the consistently prudent and constructive help of Dr. A. K.
Ertan from our center, who coordinated the contributions, and
of the staff of Thieme Medical Publishers. Their efforts helped
to speed the book to its completion.
It was the explicit goal of the editors and contributors to
provide the interested reader and ultrasound user with a reference that would be of substantial value for everyday clinical
work.
Homburg, Saar and
Zagreb, Kroatien
Werner Schmidt
Asim Kurjak

vi
Contributors
Franz Bahlmann, M.D.
Supervising Physician
Gynecological Clinic
University of Mainz
Mainz, Germany
Gerhard Bernaschek, M.D.
Professor
University Hospital of Vienna
Department of Prenatal Diagnosis
and Therapy
Vienna, Austria
Wilhelm Braendle, M.D.
Professor
University Hospital Eppendorf
Department of Gynecological
Endocrinology and Reproductive Sciences
Hamburg, Germany
Branko Breyer, M.D.
Professor
Zagreb, Croatia
Josef Deutinger, M.D.
Professor
Department of Prenatal
Diagnosis and Therapy
Vienna, Austria
A. Kubilay Ertan, M.D.
Supervising Physician
The Saarland University Hospital
Homburg, Germany
Michael Friedrich, M.D.
Supervising Physician
The Saarland University Hospital
Homburg, Germany
Andreas Funk, M.D.
Associate Professor
Director Department of Obstetrics
and Gynecology
District Hospital Nürtingen
Nürtingen, Germany
Ulrich Gembruch, M.D.
Professor
Department of Obstetrics
Medical Center of Obstetrics
Bonn, Germany
Thomas Golaszewski, M.D.
Specialist for Gynecology and Obstetrics
Amstetten, Austria
Dieter Grab, M.D.
Associate Professor and
Supervising Physician
Department of Gynecology
University of Ulm
Ulm, Germany
Hans-Joachim Hendrik, M.D.
Supervising Physician
The Saarland University Hospital
Department of Prenatal Diagnosis
Homburg, Germany
Gert Hetzel
Siemens AG
Sales Dept. Sonography
Erlangen, Germany
Thomas Hitschold, M.D.
Professor and Director
Gynecological Clinic
Municipal Hospital Worms
Worms, Germany
Martin Holländer, M.D.
Department of Gynecology
The Saarland University Hospital
Homburg, Germany
Bernd Hüneke, M.D.
Professor and Head
Department of Prenatal Medicine
Gynecological Clinic and Polyclinic
University Hospital Eppendorf
Hamburg, Germany
A. Kleinkauf-Houcken, M.D.
Specialist for Gynecology and Obstetrics
Hamburg, Germany
Jochem König, M.D.
The Saarland University Hospital
Institute for Medical Informatics
Homburg, Germany
Reinhard Kubale, M.D.
Associate Professor
Institute for Radiology, Sonography,
and Nuclear Medicine
Pirmasens, Germany
Professor Sanja Kupesic, M.D., Ph.D.
Sveti Duh Hospital
Department of Obstetrics
Zagreb, Croatia
Professor Asim Kurjak, M.D., Ph.D.
Sveti Duh Hospital
Department of Obstetrics
Zagreb, Croatia
Angelika Lindinger, M.D.
Professor
The Saarland University Hospital
Department of Pediatric Cardiology
Homburg, Germany
Christoph Lindner, M.D.
Professor
Gynecological Hospital
Elim-Hamburg
Hamburg, Germany
Helmut Madjar
Associate Professor
Specialist Gynecology
German Clinic for Diagnostics
Wiesbaden, Germany
Dieter Mink, M.D.
Associate Professor
The Saarland University Hospital
Department of Gynecology
Homburg, Germany

Contributors
vii
Karin Reitnauer, M.D.
The Saarland University Hospital
Institute of Pathology
Homburg, Germany
Hans-Dieter Rott, M.D.
Professor
University of Erlangen-Nuremberg
Institute of Human Genetics
Erlangen, Germany
Werner O. Schmidt, M.D.
Professor and Chairman
Department of Gynecology and Obstetrics
The Saarland University Hospital
Homburg, Germany
Karl Sterzik, M.D.
Professor
Praxisklinik Frauenstrasse
Ulm, Germany
Isaak Tossounidis, M.D.
Department of Gynecology
The Saarland University Hospital
Homburg, Germany
Klaus Vetter, M.D.
Professor
Department of Obstetrics
Neukölln Hospital
Berlin, Germany
Carlos Villena-Heinsen, M.D.
Associate Professor
Municipal Hospital Baden-Baden
Gynecological Clinic
Baden-Baden, Germany
Hans-Joachim Voigt, M.D.
Professor and Director
Gynecological Clinic
Westpfalz Klinikum GmbH
Kaiserslautern, Germany
Erich Weiss, M.D.
Associate Professor
District Hospital Böblingen
Gynecological Clinic
Böblingen, Germany
Tina Zodan, M.D.
Gynecological Clinic
Universitätsspital Zürich
Zurich, Switzerland

viii
Contents
Physical and Technical Principles
1 Physical and Technical Principles of Color Doppler Sonography
R. Kubale and G. Hetzel
Historical Development ........................... 2
B-Mode Sonography .............................. 2
Physical Principles of Echo Production ................ 2
Principles of Ultrasound Instrumentation ............. 3
Analysis of B-Mode Information and Artifacts ......... 7
Duplex and Color Doppler Sonography .............. 9
Physical Principles of Motion Detection ............... 9
Technical Principles and Equipment Settings .......... 9
Technical Aspects of the Examination and Equipment
Settings ......................................... 16
Analysis of Doppler Information and Artifacts ......... 18
New Technical Processes and Approaches ........... 23
New Developments in Transducer Technology ......... 23
New Techniques of Signal Acquisition and Processing . . . 24
2 Safety Aspects of Doppler and Color Doppler Sonography
H.-D. Rott
Mechanisms of Tissue Effects ...................... 29
Heating ......................................... 29
Cavitation ....................................... 29
Risk Assessment of Various Ultrasound Techniques ... 30
Duplex Sonography ............................... 30
Color Doppler .................................... 31
Power Doppler ................................... 31
Color Velocity Imaging (CVI) ........................ 31
Transvaginal Scanning ............................. 31
Ultrasound Contrast Agents ........................ 31
Exposure of Gas-Containing Tissues .................. 32
Measures to Limit Risk ............................ 32
Recommendations ............................... 32
General Recommendations ......................... 32
Pulsed Doppler ................................... 32
Appendix: Statements on the Biological Safety of
Diagnostic Ultrasound Fields ...................... 33
EFSUMB Statement on the Clinical Safety of Diagnostic
Ultrasound
WFUMB Statement on Thermal Effects in Clinical Applications
10
..................................... 33
25
........................................ 33
Infertility Evaluation and Assisted Reproduction
3 Uterine Blood Flow in Fertile and Infertile Women
S. Kupesic and A. Kurjak
Uterine Blood Supply ............................. 36
Changes in Uterine Blood Flow during the Menstrual
Cycle ........................................... 36
Blood Flow Parameters in the Uterine Arteries ......... 36
Blood Flow Parameters in the Radial and Spiral Arteries . 37
Uterine Blood Flow in Infertile Women ............. 38
Uterine Blood Flow and Fertilization Rate ............. 39
Uterine Blood Flow in the Normal Cycle and during
Ovarian Stimulation with Confirmed Ovulation ...... 39
Endometrial Imaging .............................. 39
Conclusions ...................................... 39

4 Uterine Causes of Infertility
S. Kupesic and A. Kurjak
Contents
ix
Ultrasound Detection of Uterine Abnormalities ...... 41
Congenital Anomalies ............................. 41
Endometrial Polyps ............................... 41
Submucous Leiomyomas ........................... 42
Adenomyosis .................................... 44
Endometritis ..................................... 44
Asherman Syndrome .............................. 44
Ultrasound Detection of Endometrial Causes of
Infertility ....................................... 45
Effect of Endometrial Thickness and Morphology on
Fertility
Effect of Age on Endometrial Function ................ 47
Endometrial Peristalsis ............................ 47
Cervical Factor ................................... 47
......................................... 45
5 Changes in Uterine and Ovarian Perfusion with the Onset of Menopause
A. Kurjak and S. Kupesic
Decline of Fertility in the Perimenopausal Period .... 50
Uterine Receptivity ................................ 50
Oocyte Quality ................................... 50
Ovarian Function ................................. 51
Effects of Estradiol and Progesterone on Vascular
Resistance ...................................... 51
Sympathetic Innervation of the Uterus ............... 51
EstrogenEffect ................................... 51
ProgesteroneEffect ............................... 52
Effect of Age on Ovarian and Uterine Perfusion ...... 52
Authors’ Study ................................... 52
Interpretation of the Results ........................ 54
6 Color Doppler Sonography for the Optimization of Assisted Reproduction
D. Grab and K. Sterzik
Functional Evaluation of the Endometrium ......... 57
Authors’ Studies ................................. 58
Patients and Methods ............................. 58
Examination Procedures ........................... 58
Results .......................................... 61
Discussion of the Role of Doppler Examinations ........ 64
Summary ....................................... 66
7 Pulsed Doppler and Color Duplex Sonography in the Assessment of Tubal Patency
B. Hüneke, A. Kleinkauf-Houcken, C. Lindner, and W. Braendle
Applications of Doppler Sonography in Reproductive
Medicine ........................................ 69
Assessment of Tubal Patency ...................... 69
Patients and Method .............................. 69
Examination Technique ............................ 70
Results .......................................... 73
Discussion of the Value of the Test Procedures ......... 74
Summary ....................................... 75
8 Abnormalities of Corpus luteum Function
S. Kupesic, A. Kurjak, and T. Zodan
Morphology and Biochemistry of the Corpus luteum .77
Conventional Methods in the Diagnosis and
Treatment of Luteal Phase Defect .................. 78
Possible Causes of Luteal Phase Defect ................ 78
Diagnosis of Luteal Phase Defect ..................... 78
Treatment of Luteal Phase Defect .................... 79
Ultrasound and Doppler Sonography in the Detection
of Luteal Phase Defect ............................ 79
LUF Syndrome .................................... 79
Blood Flow in the Corpus luteum during Early
Pregnancy ...................................... 81
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