Imaging in Infertility

India, the world’s second most populous nation at 1.3 billion people after China (1.4 billion) has always intrigued demographers.

However, few know about an entirely unexpected problem that is currently bedevilling Asia’s third largest economy — a dramatic decline in its fertility rate. While this may be welcome news for the overpopulated nation, it also points to the disconcerting trend of young couples unable to procreate.

The World Population Prospects: The 2017 Revision report estimates that the fertility rate of Indians (measured as the number of children born to a woman), has plummeted by more than 50 percent, from 4.97 during the 1975-80 period to 2.3 for the current period of 2015-20. By 2025-30, the report projects, the rate will nosedive further to 2.1, touching 1.86 from 2045-50 and 1.78 from 2095-2100.

A fertility rate of about 2.2 is generally considered the replacement level, the rate at which the population would hold steady. When the fertility rate dips below this number, the population is expected to decline.

Urban Indian fertility is now at levels seen in developed countries and in some places among the lowest in the world. According to the Indian Society of Assisted Reproduction, infertility currently affects about 10 to 14 percent of the Indian population, with higher rates in urban areas where one out of six couples is impacted. Nearly 27.5 million couples actively trying to conceive suffer from infertility in India.

 “Childbearing is considered an essential role in life and a yardstick by which women’s worth is measured. So infertility invites social stigma. It is time we recognize it as a perilous personal and public health issue.”

Both male and female partners can be equally responsible for the inability to conceive a child. For long, infertility was a cross that women had to bear. But it has been found that less than 30 percent of Indian men have normal semen characteristics leading to conception problems for women.

Lifestyle ailments are increasingly playing villain too, especially obesity and diabetes. Sexually transmitted infections, polycystic ovarian syndrome, fibroids, and genital TB are other new areas of concern among women.

Rapid urbanization, hormonal changes (especially in prolactin levels, which are found in many infertility cases), job pressures, vehicular pollution, and postponing parenthood are considered as other salient reasons for infertility in India.

Role Of Ultrasonography In Infertility

Congenital Developmental Anomalies-

Uterine malformations are a various group of congenital uterine anatomic abnormalities originated from the development defect of mullerian ducts during fetal development . They are associated with higher incidences of infertility, recurrent abortions, intrauterine fetal death, intrauterine growth retardation, pre-mature delivery, fetal malposition, caesarean section, retained placenta, and such gynecological complications as hematocolpos and hematometra . Uterine anomalies are detected in approximately 1-3% of all women ; however, 10-25% of the women seek infertility workup .

Sonography, in combination with 3D Imaging, has an important role in the investigation and classification of the uterine anomalies.

Uterine Fibroids/Myomas –

Fibromas are benign tumors of the uterus, which mostly originate from smooth muscle. However, they may contain various amount of fibrous connective tissue (3, 18-21). They are the most common pelvic masses among the reproductive aged women, which is found in 20-40% of these population

Fibromas, which are also known as myomas, leiomyomas, and fibroids, arise within the uterine myometrium, nevertheless, they may be some-times detected in the cervix, ovaries, or broad ligament. Fibromas are classified into three groups based on their location.

1. Intramural fibroids are the most prevalent types, located within the myometrium and totally surrounded by it.

2. Subserosal fibroids are externally extending to the serosa, which can pass to the pelvic cavity and make a “pedunculated uterine fibroma” within pelvic cavity.

3. Submucosal fibroids grow into the endometrial cavity; they are the least common, but the most significant type due to causing more symptoms and infertility.

TVS and transabdominal sonography (TAS) are the primary imaging methods used in the investigation of female pelvis, and the technique of choice in the evaluation of uterine myomas .

 In experienced hands, the sonographic examination facilitates the detection of the amounts, types, location, and size of the fibromas as well as the amount of endometrial distortion due to myomas, which is very important in the infertility workup.

Therefore, these points should be considered in sonography reports.

It’s worth noting that in case of small fibromas of less than 5 mm in diameter or in obese patients, the TVS would be more accurate and sensitive than the TAS.

In case of submucosal fibroid and suspected endometrial distortion, it may be difficult to differentiate myoma from polyp. Consequently, further imaging modalities, such as sonohy-sterography or tree-dimensional (3D) sono-graphy, are required for detailed investigation.


Adenomyosis is a common benign condition in which ectopic endometrial glands grow into the uterine myometrium .

The TVS is the first step imaging modality for the evaluation of the women suspected to have adenomyosis. Accordingly, several studies have indicated that TVS has a high sensitivity and accuracy in the diagnosis of adenomyosis, compared to the magnetic resonance ima-ging (MRI).

Intrauterine Adhesions

Intrauterine adhesion (uterine synechiae, IUAs) is described as the presence of fibrotic tissue within the endometrial cavity, which causes intracavitary adhesions . It is an acquired condition resulted from trauma to the basal layer of the endometrium usually following curettage or infection. Adhesions range from minor synechiae to severe cohesive adhesions (Asherman’s Syndrome). The most common complications associated with IUA are amenorrhea, infertility, recurrent abortions, and preterm birth .

IUA is detected well by saline sono-Hysterography .

Tubal abnormalities

Finally, although normal fallopian tubes are usually not seen on an infertility ultrasound, a type of abnormal fallopian can be seen. Occasionally, if the distal end of a fallopian tube become blocked,  the tube will fill with fluid. This is called a hydrosalpinx. It is important to determine the presence of a hydrosalpinx  since the presence of hydrosalpinges will indicate not only blocked fallopian tubes but also reduce the success rate of treatments such as IVF.

  • To assess the (inner lining of the uterus) Endometrium for any abnormalities such as Endometrial Polyp
  • Ovarian  abnormalities eg Cysts,tumours
  • Adnexal (area around the ovaries) abnormalities

SONOHSG –    Saline


              Contrast medium

Ultrasound for monitoring infertility treatments

The most common treatments used for infertility employ the use of fertility medications . These medications stimulate the development of eggs in the ovaries. The eggs grow inside of the follicles. The follicles fill with fluid and enlarge while the egg is developing. The size and number of these developing follicles can be accurately determined with infertility ultrasound. In this way, the physician can determine the appropriate time to either trigger ovulation or perform an IVF egg retrieval.

Infertility ultrasound is also used to monitor the growth and development of the uterine lining and the colour Doppler is used to assess the follicular and the endometrial (uterine lining)vascularity .

Role of Color Doppler  in ovulation monitoring

  • To assess the Perifollicular flow which helps in predicting the ovulation (Important in IUI Cycles)
  • for timing of the Trigger
  • To asses the quality of the follicle- Fertilization of a Hypoxic follicle have high chances of developing an embryo with chromosomal abnormalities.
  • Probability of producing grade I & II embryos in IVF cycles
  • Doppler study of uterine receptivity done on the day of Hcg- can predict successof implantation of the embryo

Ultrasonogaphy in male infertility

To look for

  • Scrotal Ultasound and doppler
  • Vericocele
  • Epididymal abnormalities, undecended testes
  • Transrectal Ultrasound
  • Imaging of prostate, seminal vesicles and vas deference
  • Obstructive azoospermia (OA)
  • Penile Ultrasound
  • evaluates physical causes of erectile dysfunction.

Ultrasound in Endometriosis


Typically endometriosis presents in young women, with a mean age of diagnosis of 25-29 years, although it is not uncommon among adolescents. Up to 5% of cases are diagnosed in postmenopausal women. Potential risk factors include family history and short menstrual cycles. Racial predisposition remains controversial 

It is difficult to ascertain the overall prevalence of endometriosis, but in women who underwent laparoscopy for various reasons, the prevalence was as follows 5:

  • asymptomatic women (laparoscopy for tubal ligation): 1-7%
  • primary infertility: 17-50%
  • pelvic pain: 5-21%

What can the ultrasound diagnose?

Endometriosis is defined as the presence of tissue similar to that of the lining of the uterus (endometrium) outside of the uterus, most commonly on and below the ovaries, and deep in the pelvis behind the uterus, called the Pouch of Douglas. Here, the endometriosis grows on the ligaments behind the uterus and on the vagina and rectum. It also may grow on the bladder, appendix, and even sometimes in the upper abdomen or in the abdominal wall in the scars of a laparoscopy or caesarean delivery.

There are many presentations of endometriosis which may be identified by the surgeon at laparoscopy. A distinction is made between superficial lesions and deep infiltrating endometriosis.

In the majority of women with endometriosis the endometriosis found in the pelvis has only implanted superficially.

Superficial lesions of endometriosis can never be diagnosed on ultrasound as they have no real mass, only colour, which cannot be detected with ultrasound. These lesions can cause as much pain as some deep infiltrating lesions but they can only be seen on laparoscopy. They may be removed during a laparoscopy and special preoperative measures are rarely required.

In about 20% of women with endometriosis the endometriosis will not just superficially implant in the pelvis, but it will infiltrate into pelvic structures, mainly into bowel, bladder, the vagina and ligaments behind the uterus (uterosacral ligaments). This form of the disease is called deep infiltrating endometriosis (DIE).

Because lesions of endometriosis infiltrate into ligaments, vagina, bowel and bladder, adhesions can occur between organs such as the bowel and the uterus or the uterus and the ovaries.

Ultrasound can detect deep infiltrating endometriosis with a high degree of accuracy.

The larger the lesion, the easier it is to see on ultrasound, but in the hands of experienced imaging specialists lesions of only a few millimetres may be diagnosed.

Why is the preoperative diagnosis of deep infiltrating endometriosis important?

The gold standard of endometriosis diagnosis is laparoscopy as laparoscopy can diagnose all forms of endometriosis, something no other test can.

It is however important to have a detailed ultrasound prior to considering a laparoscopy to look for deep infiltrating endometriosis. Often when deep infiltrating endometriosis is unexpectedly found at laparoscopy, the removal of endometriosis cannot be completed as special preparation is required to allow removal of such lesions. The woman may need specific bowel preparation, and often it is preferable to have a colorectal surgeon present at the surgery since a section of bowel may need to be removed.

The preoperative diagnosis of deep infiltrating endometriosis may give a first explanation for symptoms but more importantly, it gives an indication of the extent of the disease, it provides patients with the time to think about the extent of the surgery they are prepared to submit to; and gives the surgeons an idea of what they will find during the surgery so they can prepare better for the operation and advise patients better regarding other treatment options available.

Ultrasound will not detect superficial lesions so in case of a normal ultrasound a laparoscopy may still indicated when there are significant symptoms.

How is the ultrasound performed?

A normal ultrasound is performed using a transvaginal probe (a thin instrument about the thickness of your thumb that is gently placed into the vagina to allow better vision of the pelvic structures).

The scan may be done through the rectum also when the transvaginal approach is difficult. The ultrasound usually takes 30 minutes.

Because endometriosis can infiltrate the bowel, the doctor who does the ultrasound will carefully look at the bowel during the transvaginal ultrasound.

When the rectum is empty, the views of the bowel are generally better since faeces and gas in the bowel cause shadows on ultrasound. For this reason some doctors prefer you to take a mild bowel preparation prior to the ultrasound when you have had a past history of severe endometriosis or when you have significant bowel pain during your periods.

This consists of a mild laxative the night before the ultrasound and an enema an hour before the ultrasound. If you don’t have a proven history of significant endometriosis, or no significant bowel symptoms or signs on examination, it is probably not necessary to take bowel preparation and a regular scan could be performed.

Why the  ultrasound scan performed to look for Endometriosis is different than a routine ultrasound scan?

A ‘normal’ gynaecological ultrasound traditionally only involved looking at the uterus and ovaries.

Unless endometriosis forms cysts on the ovaries (endometriomas) it is therefore not picked up with a traditional gynaecological ultrasound.

Therefore an advanced imaging and technique along with the expertise are required to perform this scan.

Looking for endometriosis involves looking not just at the uterus and ovaries but also at the bladder, the ligaments behind the uterus, the vaginal wall and the bowel. It also involves assessing the mobility of the ovaries and checking whether there is sliding between the bowel and the uterus.

Ultrasound in PCO/ Polycystic ovaries

Transvaginal ultrasound is one of the main tools a physician has when it comes to diagnosing polycystic ovary syndrome(PCOS). The images found on the ultrasound, in conjunction with the results of blood tests and a thorough patient history and physical, are used to diagnose this syndrome.

Diagnosing Polycystic Ovaries (PCO)

Characterized by high levels of androgens, (male hormones like testosterone), polycystic ovary syndrome (PCOS) is an imbalance of sex hormones. Since these hormones are involved in the regulation of bodily processes ranging from reproduction to metabolism, the condition can lead to a wide variety of signs and symptoms of PCOS.

PCOS Exclusions

The first step when evaluating your symptoms, exam and laboratory findings is to exclude other disorders which might cause these findings. These conditions (which may appear similar to PCOS but are different) include:

  • Thyroid disease: Differentiating PCOS from thyroid disease is made more difficult in that some forms of thyroid disease are more common in people with PCOS, and some of the tests used to diagnose thyroid disorders are inaccurate in people with PCOS.
  • Hyperprolactinemia
  • Congenital adrenal hyperplasia
  • Cushing’s disease

Diagnostic Criteria for PCOS (The Rotterdam Criteria)

The current diagnostic criteria for women with PCOS state that a woman has PCOS if she has two of the following three criteria (with the exclusion of all other criteria):

1. Absent or irregular menstrual cycles (eight or fewer periods in one year). Since only two of these three criteria need to be met, there are some women who will meet the criteria for a diagnosis of PCOS despite having regular monthly menstrual cycles.

2. High androgens on blood work or signs of high androgens in the body such as acne, excessive hair growth (hirsutism), or male pattern hair loss (androgenic alopecia). Blood tests often reveal elevated testosterone and free testosterone levels as well as dehydroepiandrosterone sulfate (DHEAS) levels.

3. The presence of follicles—commonly referred to as cysts erroneously—on an ultrasound (see clarification below). Some criteria define PCOS as having 12 or more small follicles (that are between two and nine mm in diameter) in both ovaries. However, in the United States, physicians do not typically rely solely on that definition in order to make a diagnosis. There are many women who have cystic ovaries without symptoms of hyperandrogenism, and many women who have been diagnosed with PCOS who do not have classically “cystic” ovaries.

How Is a Transvaginal Ultrasound Performed?

For the procedure, a lubricated ultrasound probe is placed inside the vagina, which transmits an image of the internal organs onto a screen. The doctor then measures and takes pictures of your ovaries and shares them with your doctor. 

Does Transvaginal Ultrasound Hurt?

Some women may experience very mild discomfort while the technician pushes down during the ultrasound (remember, full bladder!), depending on the ease in which the sonographer can locate the internal reproductive organs.

What Is the Doctor Looking for on the Ultrasound?

The sonographer will examine your uterus, cervix, and uterus. The number of follicles on your ovary will be counted to yield what is known as an antral follicle count (AFC).

What Are Antral Follicles?

Antral follicles are resting follicles that are found in the ovary at the beginning of each menstrual cycle. They are approximately two to nine mm in size (less than half an inch). A high antral follicle count indicates that a woman has a large number of eggs remaining in her ovary and, in some cases, PCOS.​

Cysts vs. Follicles in PCOS

Both cysts and follicles are more common in women with PCOS than those without the condition. Many confuse cysts with follicles.

Despite its name, women with PCOS don’t typically produce cysts, but rather follicles are used as part of the diagnostic criteria (see below).

Women with PCOS tend to produce follicles, which are small collections of fluid in the ovary and are the result, not the cause of, the imbalance of sex hormones. Each month, a woman produces follicles that mature and get released from the ovaries in order to be fertilized. Because of the hormone imbalance, these follicles don’t mature and don’t get released by the ovaries, which often leads to infertility.