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14
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. Epub 2011 May 25.
10.1098/
Principles of 3D Ultrasound
Maximilian Murtinger , Dietmar Spitzer ,
and Nicolas Herbert Zech
2
Introduction
Ultrasound (US) performance is a noninvasive,
painless procedure. Its applications are essential
for IVF (in vitro fertilization) therapy; employed
US frequencies range between 1 and 18 MHz,
which have no known harmful effects to the
patients, their gametes, or embryos [ 1 , 2 ].
Two-dimensional ultrasound (2D US) has
been used in medical applications for decades,
notably in artifi cial reproduction technology
(ART). Interestingly, the fi rst commercial threedimensional visualization was achieved not by
US but by magnetic resonance imaging (MRI)
and computed tomography (CT). However, the
fi rst reports on 3D US appeared in the early
1980s, almost simultaneously with the appearance of CT and MRI [
suffered from several initial problems. As a
result, more than one decade passed before the
fi rst commercial 3D US became available and
M. Murtinger , MD
IVF Centers Prof. Zech,
Römerstrasse 2, Bregenz 6900, Austria
e-mail: m.murtinger@ivf.at
N. H. Zech , MD (*)
Department of Obstetrics and Gynecology,
Medical University Graz,
Römerstrasse 2, 6900 Bregenz , Austria
e-mail: n.zech@ivf.at
D. Spitzer , MD
IVF Centers Prof. Zech, Innsbrucker
Bundesstrasse 35, Salzburg 5000, Austria
e-mail: d.spitzer@salzburg.ivf.at
3 – 5 ]. Nevertheless, 3D US
was introduced for clinical applications. This
was due to several factors. First, the development
of 3D US imaging had been limited by computing power, which, until the last decade, restricted
3D reconstruction to offl ine work stations.
Second, the clinical approach was handicapped
by problems intrinsic to US imaging: speckle,
clutter, grating lobe, and other artifacts [
Additionally, in the past the storage of 3D images
was unfeasible due to the limited storage capacity of the computers as well as the post-processing procedures, which are now considerably
facilitated by highly effi cient hardware and software. With the new data processors, the reconstruction procedure of 2D scans into 3D
structures can be carried out within a few seconds after the images have been acquired. Threedimensional images can also be generated with
2D ultrasound computed tomography, either by
shifting the measurement arrangement or by
moving the analyzed object. By this approach, at
each step only one layer is recorded, which is
then composed to a full-dimensional structure.
Therefore, even with conventional US scanners,
a composited 3D imaging (spatial compounding)
can be generated. Important for this technique is
the matching of the set of 2D images. The 3D
images are calculated by combining the information on the position and angulation of the images.
The required positional information is obtained
either by the conventional probe, the position of
the transducer measured, or by using a special
scanner. However, a system for positioning and
orientation of the scanner is still needed. To
6 ].
L.A. Stadtmauer, I. Tur-Kaspa (eds.), Ultrasound Imaging in Reproductive Medicine,
DOI 10.1007/978-1-4614-9182-8_2, © Springer Science+Business Media New York 2014
17
18
M. Murtinger et al.
reduce the number of orientations, special types
of ultrasound transducer systems were developed, allowing the acquisition of information
through only one viewing direction by electronic
focusing.
In 1984, Kazunori Baba fi rst described a 3D
ultrasound system. In 1986, he was the fi rst person on the globe to obtain 3D images of a
19-week fetus by processing the raw 2D images
on a minicomputer in 1986 [ 7 , 8 ]. In 1987 Olaf
T. von Ramm and Steven W. Smith patented “An
acoustic pulse echo imaging system capable of
producing an image of a three-dimensional
object utilizing a two-dimensional display. In the
system angular relationships of targets at all
ranges are maintained for display. The system
uses a two- dimensional transducer array of
piezoelectric elements; the array is steered to
assume transmit and receive orientations in both
azimuth and elevation by producing (1) a
directed transmit pulse and many similarly
directed receive orientations or (2) a non-directed
transmit pulse and many directed receive orientations. For each transmit pulse a parallel processing system produces several unique image
points whose locations in the image correspond
to the tangents of the angles of the receive orientations in the azimuth and elevation planes. The
brightness of each image point is the weighted
integral of the echo data received along each
receive path. As an option, range discrimination
capability is provided by means of a range
dependent gain control, brightness shading as a
function of range or a color display in which data
originating from different ranges is displayed in
different hues [ 9 ].”
Two years later, the fi rst commercially available 3D US instrument was marketed in 1989 by
the Austrian company Kretztechnik (Zipf/
Austria) which was founded by the engineer Paul
Kretz after the Second World War.
This instrument, the Combison 330 equipped
with 7.5 MHz and integrated 3D system was presented at the French radiology congress in Paris
in 1989 [ 10 ]. It utilized mechanical abdominal
volume scan transducers with the mechanical
swept-volume approach. Although the acquisition of the volume took only 1–2 s, rendering of
the image took up to almost 20 min on an exter-
nal computer. However, the rendering was also
limited in ability to provide a set of orthogonal
planes orientated images in strict relation to the
axis of the probe. Additionally, special scan
transducers were needed for this instrument.
They had to be held by their larger side, thus
making them rather diffi cult to handle. This
drawback was removed in the majority of the
later US instruments by a 90° rotation of the 3D
US device. In 1998, the Voluson 530D 3D system
implemented a technology that displayed not
only the 3D sectional images, but also processed
the data of the entire volume in real time. With
the commercial launch of this 3D instrument
platform, 3D ultrasound technology competed
with the higher priced CT and MRI instruments;
it allowed effective grayscale imaging, spectral
Doppler, color Doppler, and Angio Color Imaging
[ 11 ]. Two years later, the medical equipment
manufacturer GE Healthcare introduced a new
generation of clinical US systems, the Voluson
730 with real-time acquisition of volumes (16
volumes/s). Now, it is possible to detect and analyze even moving objects such as a fetus. With
the beginning of the new millennium, several
new software programs became available that
signifi cantly improved the image quality.
Currently, numerous 3D US instruments are
available (most of them semi- or fully automated), and it is extremely likely that dozens
of new machines will become available in the
next few years. The systems have become faster
and more advanced. Furthermore, the number
of compatible software programs exceeds the
amount of instruments sold. Virtual navigation, different modes of presentation (such as
tomographic ultrasound imaging (TUI) volume,
contrast imaging (VCI) and automated volume
calculation (SonoAVC), computer-aided analysis (VOCAL) calculation) , and other techniques
are now available; they are reliable, fast, and
user friendly [ 12 ]. With these features, the pos-
sibilities for clinical application become almost
unlimited; furthermore, use is increasing in the
clinical setting. Many post-processing tools
such as speckle reduction imaging, electronic
scalpel, and fi lters for brightness and contrast
facilitate handling. Data transfer and long-term
storage are now possible without any quality
2 Principles of 3D Ultrasound
19
loss. Although most procedures are still conducted with 2D scans, for a number of reasons, it is likely that the 3D technology will
be a supplementary tool—and in some cases,
a replacement—for 2D instruments in the fi eld
of ART in the future.
Basic Techniques of 3D US
The basic techniques of 3D US systems are
almost identical to those of 2D systems because
they use the same frequencies and wavelengths.
According to the US Food and Drug
Administration (FDA), the limit for obstetrical
ultrasound is 94 mW/cm 2 for the spatial peak
temporal average intensity and 190 W/cm 2 for
spatial peak pulse average for fetal imaging [ 13 ].
The principles of 3D Doppler US technology are
not a subject of this chapter but are summarized
in detail in a previous chapter.
Three-dimensional sonography in medicine
comprises data acquisition, analysis and processing of volume, image animation and fi nalizing of
the image, and data storage [ 14 ]. In principle,
there are three (respectively four) ways of achieving 3D data:
1. The tracked freehand method: Freehand 3D
ultrasound allows intraoperative imaging of
volumes of interest in a rapid and fl exible
manner [ 15 ]. This technique requires manual
movement of the probe through the ROI
(region of interest). However, as a prerequi-
site the exact angulation and position of the
US transducer are needed.
2. The untracked freehand systems: With these
systems, the operator moves the transducer in
a regular motion, while the 2D images are per-
formed. For a 3D image a linear or angular
spacing between the single images is assumed.
The major disadvantage of this technique is
that exact local positioning is not possible and
measurements, especially for volumes, are
highly inaccurate.
3. A three-dimensional visualization can be
intrinsically achieved by 2D transducer
arrays: These arrays generate pyramidal
pulses of the US and the echoes are converted
into 3D images. The advantage is that the
transducer can remain stationary and electronic scanning can be used to sweep a broad
ultrasound beam over the entire volume under
examination [ 16 ].
4. A fourth possibility is mechanical assemblies:
The transducer is moved either (1) linear,
(2) tilted, or (3) in a rotational movement about
its central axis by a mechanical assembly.
Reconstruction and Visualization of 3D Images and Post-processing
Software programs for reconstruction (rendering) and imaging play a dominant role in 3D US.
Several algorithms have been developed allowing for perfect visualization, manipulation, and
processing of the received 3D images. It is apparent that the progress in software development
was—and still is—the key to success for this
technique. Currently, numerous visualization
modalities are available:
1. Multi-planar view: This was the fi rst available
visualization mode in 3D US. The display presents the three orthogonal planes simultaneously: the longitudinal, transverse, and coronal
planes. The dataset can then be rotated or sliced
in order to view the region of interest (ROI).
The multi-planar view displays the exact spatial relationships between the three planes.
2. The tomographic ultrasound imaging (TUI) or
multi-slice technique: TUI allows for a comprehensive sequential analysis of the desired
organ (Fig. 2.1 ). The same imaging principle
is employed in CT and MRI. For example,
tomographic ultrasound imaging has been
reported to greatly simplify pelvic fl oor
assessment [ 17 ].
3. The static volume contrast imaging (VCI)
mode: This mode allows for the receipt of
information from adjacent slices in a volume.
This imaging mode was especially developed
to enhance the contrast between tissues or
organs that would appear similar on conventional 2D US [ 18 ]. VCI is currently applied
for detecting thoracic abnormalities [ 18 ] or
imaging fetal pelvic anatomy [ 19 ]; it was
found to be superior to 2D US in these
studies.
20
Fig. 2.1 Tomographic ultrasound image (TUI) of multiple follicles in a stimulated ovary
M. Murtinger et al.
4. Inversion mode: In inversion mode, volumes
are displayed in their entirety as an echogenic
area, while the grayscale portions of the image
are rendered as transparent. Some IVF and
obstetrical applications could benefi t from
this method [ 20 ].
5. Transparency mode: The transparency mode
(also known as maximum mode) images
regions with high echo density in a glass-like
mode. This mode is mostly used for imaging
of cartilaginous structures. With this mode,
high-echogenic voxels are higher valued.
6. The surface-rendering mode helps to detect
and display the surface of the structures. It is
most commonly used for the evaluation of
ovarian tumors [ 21 , 22 ]. This technique allows
surface reconstruction of conspicuous parietal
structures [ 21 ].
7. Glass-body rendering: Glass-body rendering
(GBR) imaging is a combination of the transparency and color or power Doppler mode. It
is very suitable for gynecologic applications;
however, it is most useful for vessel imaging.
In this mode the rendering algorithm is based
on the simultaneous representation of gray
and color Doppler scale [ 23 ].
8. Four-dimensional image techniques: The
four-dimensional image techniques (such as
the spatiotemporal image correlation (STIC))
allow for procedures such as echocardiography of the fetal heart [ 24 , 25 ]. The received
data is acquired by a single, automatic volume
sweep; subsequently, the software analyzes
the data according to their spatial and temporal domain and processes a 4D cine sequence.
Prior to the launch of these 4D techniques, the
examination of the fetal heart with conventional US was often diffi cult.
9. OmniView: OmniView (GE Medical
Systems, Kretztechnik, Zipf, Austria) is a
recently developed display technology for 3D
and 4D US that allows integration of volume
datasets and the simultaneous display of up
to three independent (non-orthogonal) planes
by manually drawing straight or curved lines
from any direction or angle [ 26 ].
Although many 3D US display techniques
have been employed (more than the ones
described in this chapter), the two most commonly used are multi-planar reformatting and
volume contrast rendering. Image quality
has improved since the 1990s; nevertheless,
2 Principles of 3D Ultrasound
21
the fi nal quality still depends on the accuracy of the scanned volumes (also see next
paragraph). Nevertheless, as previously mentioned, various software-based tools are currently available. Post-processing is done via
the electronic scalpel (Kretztechnik, Zipf,
Austria), contrast and brightness regulation,
or speckle reduction imaging (SRI). SRI was
established on the Voluson platform in 2004
by GE Healthcare. The electronic scalpel
allows for the removal of pre-located obscuring structures in three steps: (1) rotation of
the rendered image into a position where the
obscuring structures can be cut; (2) the selection of the cutting mode; and (3) creation of
the outline for the cut and activation of the
cutting mode [ 27 ]. Speckles are recurrent
problems in sonography due to interference
of ultrasound echoes; they produce diffi culties in differentiating anatomical structure.
Many approaches have been attempted with
the goal of reducing or even of eliminating
speckles. Most signifi cantly, the increased
computer processing power and speed of
calculation within recent years have allowed
more complex image-processing techniques
to reduce these artifacts without impairing image quality [ 28 ]. In addition, fi lter-
ing is widely used for undesired echoes that
are a recurrent phenomenon in sonography.
Filtering allows the suppression of unwanted
background noise or the enhancement of the
desired information (suppressing and enhancing fi lters) [ 29 ] .
Initially, data storage was a problem with 3D
technology. This problem has been resolved by
the improved storage capacity of the hard disk.
The acquired data can be readily stored without
quality loss either at the US systems itself or on
external media (CD, DVD, USB, or external hard
drive). The data can still be post-processed with
medical software and can be transferred, for
example, via (virtual private network) VPN
tunneling to another physician. Most importantly,
the data can be reloaded and subjected to an
additional expert opinion or used for education
[ 30 ]. This is an invaluable feature. Currently,
this capability facilitates optimal patient care.
Moreover, it might reduce medical malpractice
and might prove to be an essential step towards
standardization in this fi eld.
Advantages and Shortcomings of 3D US Techniques
Three-dimensional US allows visualization of all
three image planes (sagittal, transverse, and coronal) of the analyzed object, including planes
not accessible by 2D US. The viewed planes can
be chosen or changed by the user to view the
desired region under investigation. Using the
conventional 2D technique, the referring physician often had to integrate all the received 2D
images in a three-dimensional form to obtain an
impression about the anatomy and possible
pathologies.
The use of 2D ultrasound for measurement of
organs, such as the uterus or follicle volume, is
variable and at times inaccurate. Some diagnostic
and treatment IVF procedures require accurate
volume measurements (such as follicle monitoring). The accurate acquisition of volumes is only
possible with 3D US, especially when the analyzed structures are not spherical but complex
(i.e., follicles within a multi-follicular growth
complex; this problem will be discussed in a
subsequent chapter). 3D US is a relatively new
technique for gynecology and IVF. However,
studies have already been published reporting
high accuracy.
Use of the 3D technique together with the
appropriate software allows for the accessed 3D
volumes to be digitally stored. This is a tremendous advantage for later post-processing and
evaluation. Thus, the stored data can be reformatted and analyzed in various ways. Beyond all the
technical improvements, 3D US is still based on
conventionally received 2D US data. Thus, poor
US scanning techniques cannot be improved by
this innovative technique. Inadequate resolution
of 2D scans results in poor image quality of the
three- dimensional structures. Therefore the 2D
scans must be optimized in regard to (1) brightness, (2) the depth of fi eld, and (3) the correct
positioning of focus. The correct setting to
22
M. Murtinger et al.
achieve the optimal 2D scan is therefore a prerequisite for the best possible 3D calculation.
In addition, most artifacts, which are common
in 3D or 4D US, are also similar to those of 2D
US because both techniques are based on the
same principle. Improper calibration and operation is one major source of the production of inferior data as well as for poor interobserver
reliability. This holds true for both, 2D and 3D
US. One exception might be the appearance of
artifacts due to the movement of the examined
objects with 4D US. However, the application of
4D US does not play a dominant role in ART
because most of the analyzed structures are
immotile. However, it is not unequivocally clear
whether the 4D technique might be of future
value for ART. For example, endometrial blood
fl ow analyzed by 4D US might become an additional parameter for the prediction of embryo
implantation in the future.
The 3D visualization technique offers no
additional advantages in regard of reducing the
aforementioned artifacts. The effective improvements of US imaging is due to accompanying
post- processing software. However, this technical processing cannot be regarded separately as
these are integrated components of high-quality
3D instruments.
The rapidly increasing processing power was
also one basic requirement for the introduction of
portable US systems. This innovation, together
with standardized higher image quality, standardized image storage, and compression techniques
such as the Digital Imaging and Communications
in Medicine (DICOM) standard, enables a medical network and improved patient care.
Applications of 3D Ultrasound in ART
Several clinical trials have demonstrated the
superiority of 3D systems compared to conventional 2D US. The images of the structure’s surfaces become fully apparent (as a result of their
three-dimensional nature). The detailed advantages of the 3D sonography, especially for IVF,
are discussed within the Chap. 20 . However,
studies concerning 3D US in the context of IVF
therapies are still limited. Conversely, 3D US in
monitoring is commonly used during pregnancy
and a crucial tool in prenatal diagnosis because
the volumes of fetal organs can be accessed more
accurately by the new 3D techniques rather than
by conventional 2D US. Thus, fetal anomalies
can be recognized more readily [ 31 , 32 ].
The applications of 3D US in IVF are also
summarized in the Chap. 20 . However, an over-
view of the applications of 3D sonography will
be presented here. The investigation of the uterus,
ovaries, and fallopian tubes are a prerequisite of
an IVF cycle. Uterine pathology such as myomas, malformations (see Figs. 2.2 and 2.3 ) and
carcinomas can signifi cantly impair the outcome
of IVF therapy [ 33 ], and sometimes patient
health. In addition to MRI and CT, 2D US was
and is currently used for the detection of congenital malformations of the female reproductive system. However, it lacks specifi city and image
quality [ 34 – 37 ]. Three-dimensional sonography
allows a more accurate calculation of the uterine
volume. It also allows a more precise estimation
of endometrial morphology and volume.
Endometrial volume and morphology are the
most crucial factors for IVF success. Nonoptimal
endometrial lining or a small endometrial volume
impacts embryo implantation. In these cases, it
might be prudent to consider embryo cryopreservation and opt for a cryocycle [ 38 ]. In addition,
3D techniques such as 3D Doppler enable the
visualization of endometrial blood fl ow and neovascularization of cervical carcinomas, which are
completely beyond the scope of conventional
2D US.
Imaging modes such as the glass-body mode
are the most optimal for the recognition of tumorfeeding vessels. The glass-body mode is a very
good method for hysterosalpingo-contrastsonography (HyCoSy) to detect abnormal varicosity in the adnexal region. The use of 3D US
dramatically facilitates HyCoSy and provides a
better assessment of tubal patency [ 39 ].
Furthermore, 3D US techniques enable an
estimation of the ovarian reserve and can be
applied during follicle monitoring [ 40 ]. Thus,
particular automated systems such as the
2 Principles of 3D Ultrasound
23
Fig. 2.2 3D image of a uterine myoma (Voluson E8)
Fig. 2.3 3D image of uterus arcuatus (Voluson E8)