Middle East Fertility Society Journal
Middle East Fertility Society
Vol. 11, Num. 2, 2006, pp. 93-96
Middle East Fertility Society Journal Vol. 11, No. 2, 2006, pp. 93-96
The value of 3D ultrasonography in infertility management
Comment by: Mona Aboulghar, M.D.
Assistant Professor of Obstetrics and Gynecology
Faculty of Medicine
Cairo University, Cairo, Egypt
Code number: mf06017
Ultrasound examination of any patient performing an infertility workup is an integral part of the management. This is always done by 2D transvaginal ultrasound. It allows proper examination of pelvic organs; uterus, ovaries and possibly tubes. In the last decade 3 D ultrasound has been extensively developed and applied and the field of it’s use has broadened. There is a strong prediction among workers in the field of ultrasound that in the near future every gynecology clinic will have a 3D ultrasound machine available.
Is there a real need to examine every infertility case using 3D ultrasound?
What are the definite advantages of 3D imaging over 2DUS?
- * Probably the most important is the ability to obtain the 3 orthogonal planes of the structure examined, of which the coronal view is the most important to obtain, especially when examining the uterus. This view is essential for assessing the external uterine contour (of the fundus), to diagnose uterine anomalies. In addition determine exact site of lesions such as fibroids and polyps ( in relation to endometrium).
- * 3D Volume calculations are possible to be made and have been shown to be reproducible (1). This has been proven to be of value in prediction of IVF outcome by measuring endometrial volume prior to ET as compared to endometrial thickness (2).However was found of no predictive value by other authors (3). Similarly 3D Endomerial volume measurement has been proven to be reproducible (4). Endometrial volume calculation as compared to endometrial thickness has been found superior in detection of endometrial carcinoma (5).
- * The ability to store images obtained (3D volumes and cine loops) and manipulate them later going through lesions thoroughly and confirming the diagnosis (as polyps or submucous fibroids), without keeping the patient.
Clinical applications of 3D ultrasound imaging
Assessment of the uterus:
Uterine anomalies: several studies have shown
the accuracy of 3D imaging in proper diagnosis of
the type of uterine anomaly in comparison to x-ray
HSG (6,7). This is mainly due to the ability to
visualize the coronal section of the uterus and the
fundal contour especially important in lateral
fusion defects. This has been found to be enhanced
with injection of saline (3D sonohysterography)
(8). The procedure of sonohysterography is a very
simple office based technique and provides
immediate information which in many situations
could obviate resorting to hysteroscopy (9).
The use of sonohysterography both in 2D & 3D
examination has been proven to increase the
sensitivity and specificity of detection of polyps,
myomas and mullerian anomalies (10),(found to be
higher with 3D US).
Comparing 3D sonohysterography with
hysteroscopy in the diagnosis and classification of
submuous fibroids showed a high agreement between
both methods (92%) for fibroid polyps and
submucous fibroids with <50% extension into the
myometrium, this was less with submucous fibroids
with >50% extension into the myometrium (11).
A large proportion of infertile patients are found
to have associated fibroids, it was found that 1-2.4 %
of infertile patients without any obvious cause of
infertility had fibroids (12) and it is known that
fibroids could have an impact on pregnancy rates and
miscarriage rates whether in natural conception
cycles or IVF cycles(13, 14,15).
Lev-Toaff (7) compared three techniques; 3D
SHG with 2D SHG and x-ray HSG, 3D SHG was
superior to the other two techniques, especially in
visualizing polyps, fibroids, and adhesions as well as
Kupesik and Kurjak (16) compared 2D US, TV
colour Doppler, 2D sonohysterogrophy and 3DUS in
evaluation of septate uterus prior to hysteroscopic
removal. The sensitivity and specificity of 2D SHG
and 3D US was highest ( 98% and 100 % ).
Assessment of ovarian volume is known to be
of value in predicting response to induction
ovulation drugs and assessing ovarian reserve(17,18).This of course can be done using
2D, however volume calculation of irregular
structures are best done using a reproducible
method as 3D (19). Lass suggested that a mean
ovarian volume of <3cm is a predictor of poor
response to gonadotropins.
Kupesic and Kurjak (20) using 3D US analysed
antral follicle count, ovarian volume and stromal
area by studying data stored from 56 patients
enrolled and IVF ET cycle. In addition using
power Doppler, Flow index (FI) was calculated by
a computer program built in the 3D machine (flow
index gives an idea about blood flow in the
outlined area). Total antral follicle count achieved
the best predictive value for favourable IVF
outcome, followed by ovarian stromal FI, peak E2
on day of HCG, total ovarian volume, total ovarian
stromal area and age. Antral follicle count was
correlated well with FI indicating higher stromal
vasculartiy and thus higher perfusion. The
advantage of such examination is that it is short,
less time consuming as all calculations could be
retrospectively analysed by studying stored data.
Calculation of follicular volume (21)is an
additional option when volumes of ovaries are
stored, however it still remains to determine the
optimal follicular volume correlated with the best
IVF ET outcome.
Poehl (22) suggested that cumulus could be
visualized by 3DUS and could be an indicatior for
mature oocytes and successful fertilization,
Follicles in which the cumulus could not be
visualized in all three planes were unlikely to
contain mature oocytes.
Fallopian tube assessment:
Assessment of tubal patency is classically
always started by x HSG, this has been
recommended by the NICE guidline to be used for
screening of tubal occlusion, and is reliable in
detecting proximal tubal occlusion (23).
With the broadening of application of
transvaginal US, assessment of tubal patency
hysterosalpingocontrast-sonography has been
proven to be feasible with similar results to HSG
(23). Two-dimensional hysterosalpingo-contrastsonography,
as a screening test for tubal patency
for subfertile patients, is limited by the difficulty in
visualizing the entire Fallopian tube owing to its tortuosity. This major disadvantage can be overcome
by means of the three-dimensional hysterosalpingocontrast-
sonography (3D-HyCoSy).Chan et al (24)
compared the efficacy of 3D-HyCoSy with
diagnostic laparoscopy and its feasibility as a
screening test for tubal patency. The sensitivity of
3D-HyCoSy for detecting tubal patency was 100%
with a specificity of 67%. The positive and negative
predictive values were 89 and 100%, respectively;
the concordance rate was 91%. These results have
been proven by other authors as well (25) and have
been disagreed upon by other authors (26).
Color and power Doppler imaging
Power and Doppler volumes can give estimation
of blood supply to a given area. This can be applied
clinically in IVF patents in the late follicular phase
Jarvela (27) studied ovarian blood flow and found the
volume of flow to be higher in the dominant ovary.
Endometrial and subendometrial blood flow has
been studied as well by many authors (28).
The advantages of 3D power Doppler is to
demonstrate and quantify total endometrial and
uterine blood flow. It was found to be significantly
reduced in patients with unexplained infertility (29)
and also to be negatively correlated to estradiol
concentrations in IVF cycles (30).
Lastly it remains to point out that technical
problems with 3D imaging are similar to those for 2D
acquisition, patient habitus, shadowing artifacts, and
experience in 2D scanning.
To obtain good 3D images and good 2D image
has to be attained first.
3D US definitely carries many broad applications
in it’s use, however still to be investigated and
studied and compared to 2D to confirm it’s
superiority and necessity in investigating infertile
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- Zollner U, et al. Endometrial volume as assessed by threedimensional
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