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5 Application ofDiagnostic Ultrasound inGynecology
275
a
b
c
Fig. 5.93 Recurrence of myoma after operation. (a, b) Myomectomy
was carried out before. Ultrasonic reexamination shows in homogeneous myometrium, with multiple small myomas. (c) Subtotal hyster-
ectomy was carried out because of myoma 5 years before. Routine
ultrasonic following up shows a myoma on the top of the residual
cervix
Fig. 5.94 Recurrence of ovarian cancer. (a) A patient is followed up by
ultrasonography for 1 year after the operation of ovarian cancer.
Heterogeneous and irregular hypoechoic solid mass is visible in the
pelvis, with a diameter of about 5.0cm, accompanied by ascites in the
intestines. (b) A patient undergoes ultrasonography 2years after the
operation for ovarian cancer. Hypoechoic solid mass is found in the
pelvis with a diameter of 2.6cm, and the serum CA125 is signicantly
increased
276
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Fig. 5.95 Recurrence of uterine leiomyosarcoma. (a, b) The patient underwent a hysterectomy for leiomyosarcoma half a year before. Multiple
hypoechoic masses are detected in the pelvic and abdominal cavity by ultrasonography
T. Yang et al.
Fig. 5.96 Lymphocyst after tumor surgery. (a) Four months after the
operation of cervical cancer, the patient represented lower abdominal
pain. Ultrasonic scanning shows cystic echoes in bilateral ilium fossa,
Fig. 5.97 Pelvic encapsulated effusion. (a–d) Sonogram shows an irregular uid lesion in the pelvis of a patient after hysterectomy. Septum is
visible inside, and some patients may have lower abdominal pain
with a diameter of 2.5cm and 1.8 cm, respectively. (b) TAS shows a
cystic mass with a diameter of 4.7cm in the right ilium fossa, with a
thin wall and clear uid inside
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5 Application ofDiagnostic Ultrasound inGynecology
Fig. 5.97 (continued)
6. Rizzo S, Femia M, Buscarino V, etal. Endometrial cancer: an overview of novelties in treatment and related imaging key points for
local staging. Cancer Imaging. 2018 Dec 04;18(1):45.
7. Lin MY, Dobrotwir A, McNally O, et al. Role of imaging in the
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register study. Arch Gynecol Obstet. 2018;298(4):813–20.
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benign intrauterine focal lesions. J Med Ultrason (2001). 2015
Oct;42(4):533–40.
11. Wong M, Crnobrnja B, Liberale V, et al. The natural history of
Fig. 5.98 Mesosalpinx cyst. The cyst locates next to the ovary, with a
diameter of less than 5.0cm. The size and shape of the ovary are normal, and the patient has no symptoms.
Suggested Reading
1. Van T, Van D.Ultrasound diagnosis of endometriosis and adenomyosis: state of the art. Best Pract Res Clin Obstet Gynaecol.
2018;8(16–24):16–24.
2. Andres MP, Borrelli GM, Ribeiro J, etal. Transvaginal ultrasound
for the diagnosis of Adenomyosis: systematic review and metaanalysis. J Minim Invasive Gynecol. 2017;25(2):635–40.
3. Chen J, Chen W, Zhang L, etal. Safety of ultrasound-guided ultrasound ablation for uterine broids and Adenomyosis: a review of
9988 cases[J]. Ultrason Sonochem. 2015;27:671–6.
4. Brindha D, Kandaswamy A, Lakshmideepika C. Digital image
analysis of uterine ultrasound for classication of uterine Myoma
and Adenomyoma. J Med Imaging & Health Informatics.
2015;5(8):1603–6.
5. Perrot D, Fernandez H, Levaillant JM, et al. Quality assessment of pelvic ultrasound for uterine myoma according to the
CNGOF guidelines[J]. J Gynecol Obstetrics Human Reproduction.
2017;S2468784717300326
endometrial polyps. Hum Reprod. 2017;32(2):340–5.
12. Bittencourt CA, Dos Santos SR, Bernardo WM, et al. Accuracy
of saline contrast sonohysterography in detection of endometrial
polyps and submucosal leiomyomas in women of reproductive
age with abnormal uterine bleeding: systematic review and metaanalysis. Ultrasound Obstet Gynecol. 2017 Jul;50(1):32–9.
13. Sahdev A. Cervical tumors. Semin Ultrasound CT MR. 2010
Oct;31(5):399–413.
14. Comparetto C, Borruto F.Cervical cancer screening: a never-ending
developing program. World J Clin Cases. 2015 Jul 16;3(7):614–24.
15. Park GE, Rha SE.Ultrasonographic ndings of low-grade endometrial stromal sarcoma of the uterus with a focus on cystic degeneration. Ultrasonography. 2016 Apr;35(2):124–30.
16. Alcázar JL. Extragenital endometrial stromal sarcoma arising in
endometriosis. Gynecol Obstet lnvest. 2012;73(4):265–71.
17. Lin LH.Is Doppler ultrasound useful for evaluating gestational trophoblastic disease? Clinics (Sao Paulo). 2015 Dec;70(12):810–5.
18. Asmar FTC. Uterine artery Doppler ow velocimetry parameters
for predicting gestational trophoblastic neoplasia after complete
hydatidiform mole, a prospective cohort study. Clinics (Sao Paulo).
2017 May;72(5):284–8.
19. Antonini F, Laterza L, Fuccio L, Macarri G. Gastric metastasis
from ovarian adenocarcinoma presenting as a subepithelial tumor
and diagnosed by endoscopic ultrasound-guided tissue acquisition.
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20. Hong LUO, Tai-zhu YANG, Fan YANG, etal. The value of transvaginal color Doppler ultrasonography in the diagnosis of endometrial polyps. West China Med J. 2011;26(3):410–2.
21. Jiao CHEN, Tai-zhu YANG, Fan YANG, et al. Ultrasonic manifestations of uterine endometrial stromal sarcoma. Chin J Imaging
Technol. 2014;30(4):600–2.
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Ultrasonography inFemale Infertility
andContraceptive Operation
HongLuo andHouqingPang
6
6.1 Ultrasonography intheDiagnosis
andTreatment ofFemale Infertility
I. The application of ultrasonography in the diagnosis of
female infertility
• Basic conceptions
• Infertility, a disease of the reproductive system, is
dened as the failure to achieve a clinical pregnancy
after 12months or more of regular unprotected sexual
intercourse. The causes include ovulation disorders
and congenital genital malformation. In this section,
we will talk about infertility caused by ovulation disorders, which is common in polycystic ovary syndrome
(PCOS), ovarian hyperstimulation syndrome, luteinized unruptured follicle syndrome, premature ovarian
failure, congenital ovarian insufciency, and bilateral
ovarian tumors.
• Common clinical methods for monitoring ovulation
include: basal body temperature, alteration of cervical
mucus, the blood level of estrogen and progesterone
invivo.
• Ultrasonography can continually monitor the periodic
variation of ovary and measure the size of follicle to
judge whether follicles are growing to mature follicle
and then ovulate. Continual ultrasonography monitor
can discover some peculiar condition, in which the
ovarian morphology is inconsistent with the level of
hormone.
• Ultrasonic diagnosis
– Ultrasound monitor of normal ovarian period
This chapter was translated by Feiran Liu, Department of Obstetrics
and Gynecology, Beijing Shijitan Hospital, Bejing, China
H. Luo (*) · H. Pang
Department of Ultrasonography, West China Second University
Hospital, Sichuan University, Chengdu, China
To monitor follicle, the ultrasound examination
should start on the fth day of menstruation
period to measure the size of ovary and count the
number of the follicle.
From the eighth to 12th day of menstruation
period, it is the key point to monitor the growth
of follicles every day or every other day and nd
the primary follicle with a diameter of 1–1.5cm.
The preovulatory phase is dened as the 11th to
13th day of menstruation period, and during this
phase the diameter of follicle is up to 1.5–1.7cm,
which is called dominant follicle.
The 13th and 14th day of menstruation period is
called ovulatory phase, during which the diameter of follicle is up to 1.8cm which is called a
mature follicle; the range of volume is 2.5–2.8ml
and the range of diameter is 1.7–2.4cm. Mature
follicle is located on the surface of ovary and
protrudes from it, round or oval, with high tension, clear cyst uid, and thin and clear inner
wall. Sometimes germ hillock is located by the
side of follicle, meaning that the ovulation will
happen in 36hours. The average growth speed of
follicle is 2–4mm per day, and 5hours before
ovulation the follicle grows 7mm.
When the level of hormone is up to some extent,
the mature follicle rupture to ovulate and then
follicle uid ow to Douglas pouch. After ovulation, the wall of follicle sac collapses and its
outline gets fuzzy. The formed blood body
shows slighter weak echo. Five to seven days
after ovulation, the blood body is transferred to
corpus luteum with spotty echo or latticed echo
in it, and CDFI shows surrounding blood ow.
When the next menstruation is coming, the corpus luteum disappears and a new period will
start (Fig.6.1).
© Chemical Industry Press 2022
T. Yang, H. Luo (eds.), Practical Ultrasonography in Obstetrics and Gynecology,
https://doi.org/10.1007/978-981-16-4477-1_6
279
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H. Luo and H. Pang
Fig. 6.1 Period of the ovary. (a) The fth day of menstruation period, it shows multiple early follicles in various sizes. (b) Dominant follicle. (c)
Mature follicle. (d) Corpus luteum
– Polycystic ovaries
The ovary is enlarged, mostly bilaterally. The
echo of membrane of ovary enhanced and thickened, showing a clear boundary with the surrounding tissue.
More than 10 follicles can be seen in one sonographic section, with the range of diameter of
2–10mm, and the majority is no more than 6mm.
Follicles arrange in a wheels-like shape under
the ovarian membrane, surrounding the ovary, or
all the follicles in ovary are little follicles. The
ovarian medulla is enlarged and echo enhanced.
Because of anovulation, no typical mature follicle and sign of ovulation can be monitored in
continual ultrasound examination (Fig.6.2).
– Follicles agenesis
In both of the ovaries, the diameter of cyst is no
more than 9 mm. Under continual monitoring,
the follicle shows no sign of growing up during
the ovarian period (Fig.6.3).
– Small follicular cycle
During the continual monitoring through the
ovarian period, the average growth speed and the
average size of the follicle are signicantly lower
than normal.
The diameter of preovulatory follicle is no more
than 15mm with irregular shape and low tension
(Fig.6.4).
– Large follicular cycle
During ovarian cycle, ovulation happens when
the diameter of follicle is more than 30mm. The
egg cell is overripe and cannot be easily fertilized (Fig.6.5).
– luteinized unruptured follicle
During the continual monitor, the mature follicle
continues to grow up with a thickening follicle
wall, and the diameter of follicle can be more
than 40mm.
The reticular cystic occupation in the ovary will
disappear until the next menstruation. (Fig.6.6).
6 Ultrasonography inFemale Infertility andContraceptive Operation
281
a b
Fig. 6.2 Polycystic ovaries. (a) 22-years old, amenorrhea for 2years with polytrichia. The transvaginal ultrasound shows bilateral enlarged ova-
ries, and there are more than 10 follicles with diameter no more than 10mm. (b) 27-years-old, infertility. Sonogram shows polycystic ovaries
a b
Fig. 6.3 Follicles agenesis. (a) During the monitoring through the ovarian period, no follicle is developed. (b) 32-years-old, premature ovarian
failure. Sonogram shows no follicle in the atrophied ovary
Fig. 6.4 Small follicular cycle. The diameter of follicle is only 15mm
in ovulatory period and disappeared after one day
Fig. 6.5 Large follicular cycle. The diameter of follicle in ovulatory
period is more than 30mm
282
H. Luo and H. Pang
– Ovarian hyperstimulation syndrome (OHSS)
The bilateral ovaries are signicantly enlarged with
a thin-wall multilocular cyst, which is 20–60mm in
diameter, with weak spotty echo in it.
It may combine with hydrothorax and ascites
(Fig.6.7).
• Special tips
– Ultrasonography can clearly show the number, size,
tension, shape, the mature of follicle, estimate ovulation and corpus luteum formation.
– The growth speed of follicle is much more impor-
tant than the absolute value of the follicle size in the
process of the prediction of ovulation.
– In general, the follicle with a diameter of more than
17mm is able to be fertilized.
II. The application of ultrasonography in assisted
reproduction
• Ultrasound monitor of endometrium
– Endometrium is the place where fertilized egg
implants. Ultrasound examination can continually
monitor the thickness and morphological alteration
of the endometrium during menstruation period.
– In the early stage of hyperplasia, the endometrium
shows a thin hyperechoic line with a thickness of
less than 5mm (Fig.6.8).
– The thickness of endometrium increases to 10mm
during the upcoming ovulation.
– During the late stage of hyperplasia and the early
stage of secretory phase, the endometrium with
characterized lip-shape or ring-shape triple line layer
is suitable for the implantation of fertilized egg.
– As literature reported, during ovulation, endome-
trium characterized with triple-line sign, the thickness of which is more than 8mm, is more suitable
Fig. 6.6 Luteinized follicle. The cyst has thick wall and septum inside.
During continual observation, the cyst is disappeared after
menstruation
to be implanted by articial embryo. However, if
the endometrium is hyperechoic and more than
16mm or less than 8mm in thickness, the possibility of pregnancy decreases signicantly. If the endometrium is no more than 6mm in thickness, it is not
suitable to be implanted (Figs.6.9 and 6.10).
– During the treatment of articial cycle and assisted-
reproduction treatment of IVF-ET, ultrasound
examination is vital to monitor the morphology,
thickness, and echo of endometrium to ensure the
prediction of pregnancy and the treatment of articial cycle.
– Monitor the blood ow of the endometrium during
the mid-luteal phase after ovulation to evaluate the
endometrial receptivity (Fig.6.11).
• Ultrasound monitor of induced ovulation cycle
– Ultrasound examination can help to monitor the
development of follicle, evaluate the therapeutic
effect, prevent OHSS, and guide clinical medication
in the process of induced ovulation.
– Patients diagnosed with anovulatory infertility
should undertake ultrasound examination to exclude
ovarian cyst or polycystic ovaries before treatment.
– During medication treatment of induced ovulation,
the number of ovaries increases and the diameter of
ovaries can reach 8–10mm. More than one dominant primary follicle can be discovered. The diameter of the primary follicle can reach 18–25 mm,
indicating that the follicles get mature (Fig.6.12).
– Continually monitor the size of follicle with short
interval to direct the medication of induced fertilization both in duration and dosage during the process
of ovulation induced by medicine.
– Ultrasound monitor can direct the usage of medi-
cine in the process of induced ovulation to promote
rupture and ovulation of follicle at a suitable time.
• Application of color Doppler ultrasound in the monitor
of follicle
– Observe the distribution of uterine arteries and ovar-
ian vessels, the blood ow velocity, and blood ow
resistance to evaluate the function of the corpus
luteum and the development of follicles.
– Oyesanya found that the existence of blood ow of
follicle is signicantly related to the collection of
egg cells. Mature follicle with ow blood signals
under ultrasound could be collected with egg cells
of high quality. On the opposite, immature follicle,
without blood ow signals under ultrasound, cannot
be easily collected with egg cells (Fig.6.13).
– As mentioned in paper, the value of PI reaches the
lowest on the 9days after blood peak of LH, indicating good function of corpus luteum and good
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6 Ultrasonography inFemale Infertility andContraceptive Operation
283
Fig. 6.7 Ovarian hyperstimulation syndrome (a, b) the bilateral ova-
ries are signicantly enlarged with multilocular cyst after administration of ovulation drug, with the largest cyst diameter of 35mm. (c, d)
the bilateral ovaries are signicantly enlarged with multilocular cyst
after injection of ovulation drug, combined with hydrothorax and
ascites
Fig. 6.8 Early stage of hyperplasia. Sonogram shows the endometrium
as a thin hyperechoic line
Fig. 6.9 Triple-line sign of endometrium before ovulation
284
H. Luo and H. Pang
Fig. 6.10 Hyperechoic and fusiform endometrium during late
ovulation
Fig. 6.11 Blood ow is visible in the endometrium on the 21st day of
menstruation period
uterine blood perfusion. In this condition, the success rate of embryo implantation is high.
– Under Doppler examination, the diastole velocity of
the follicle artery is relatively slow in the early stage
of follicle development. There are abundant new
blood vessels surrounding the corpus luteum and
mature follicles. The decrease of blood resistance
means luteal function formation.
– In the natural ovulation cycle, the resistance of
artery in the ovary without follicle formation is
much higher than that with follicle formation. In the
induced ovulation cycle, when the diameter of follicle is more than 15mm, the blood resistance drops
down.
– The velocity of the follicle artery is slow, with
increased blood resistance, in the cases of follicular
Fig. 6.12 The image shows more than three dominant follicles after
medical ovulation treatment
Fig. 6.13 Blood ow spectrum around the follicle
dysplasia, luteal dysfunction, and unruptured follicle luteinization.
6.2 Ultrasound Diagnosis ofIntrauterine
Device
1. Basic conception
Intrauterine device (IUD) is the common method of
birth control, with the characteristic of efcient, simple,
reversible and economic. There are various IUDs in clinical application, which are displayed in Fig.6.14.
• Partial ectopic refers to that part of IUD inserts into the
myometrium, while the rest part is still in the cavity. It
usually occurs when the IUD is placed improperly or
placed for too long, the uterus shrinks after meno-
pause, or the IUD is relatively too large.
• Complete ectopic