‫بسم اهلل الرحمن الرحیم‬

‫‪THE GYNECOLOGY U/S‬‬

‫‪2021‬‬
Female reproductive system
• Uterus
• Adnexa
• Fallopian tubes
• Ovaries
• Uterine ligaments
• Vagina
U/S examination of pelvis

• Distended urinary bladder aids

in visualization of pelvic
structures at TA ultrasound
• Visible structures:
• Uterus
• Ovaries
• Upper 2/3 of vagina
Uterus
• Two main parts (the
cervix and the body)
• The fundus is the portion
of the uterine body
located along the upper
surface of the uterus
Uterine positions

Various uterine positions.

A. Anteverted.
B. Retroverted.
C. Anteflexed.
D. Retroflexed.
The relationship of the
bladder (Bl ), uterus (Ut), and
vagina (v) can be seen
 Anteverted versus Retroverted uterus

Transabdominal longitudinal ultrasound images of an anteverted (image A) and a retroverted (image B)

uterus, demonstrate the fundus (arrow) of the anteverted uterus directed anteriorly, and the fundus (arrow)
of the retroverted uterus directed posteriorly. A, Anterior; P, posterior.
 Retroflexed versus retroverted uterus

A, Retroflexed uterus: transabdominal (TA) ultrasound. Longitudinal image of the uterus shows the uterine
fundus (F) directed posteriorly due to curvature (long arrow) between the cervix (arrowhead) and body (short
arrow) of the uterus. B, Retroverted uterus: TA ultrasound. Longitudinal image of the uterus shows the
fundus (F) directed posteriorly in the absence of a flexion between the cervix (arrowhead) and body (arrows)
of the uterus
Trans vaginal U/S image of uterus
 Uterine Size and Shape
• The normal nulliparous adult uterus measures up to 8 cm × 4 cm × 5 cm in length, AP dimension, and
width, respectively.
• Uterine size is often larger in patients with a history of pregnancy, increasing approximately 1 cm
following the first pregnancy and measuring up to 2 cm larger than a nulliparous uterus in a multiparous
woman.
Ovaries
• The ovaries are ovoid or teardrop in
configuration and elongated in
contour
• Follicles are depicted as rounded,
thin walled anechoic cystic
structures in the ovary
• Ovarian volume can be estimated
by multiplying length × width ×
depth and dividing by 2

Transverse trans abdominal image demonstrates the

ovaries lateral to the uterus
 Ovarian locations
• The ovaries are typically positioned lateral to the uterus and anteromedial to the internal iliac blood vessels
• Less frequently they are found posterior to the uterus in the cul-de-sac, or superior to the uterus
• Occasionally an ovary is situated anterior to the uterus, interposed between the uterus and the anterior abdominal wall

Midline longitudinal
trans vaginal scan shows
the left ovary in the cul-
de-sac, posterior to the
uterus .

Midline longitudinal trans abdominal scan depicts the right ovary superior to the
uterus. The left ovary is posterior to the uterus and contains a dominant follicle.
Fallopian tubes
• The normal fallopian tube is not routinely identified
by sonography, although when it is surrounded by
pelvic fluid it may be seen between the ovary and
the uterus.
• Hydrosalpinx
• Pyosalpinx
• Hematosalpinx
• Tubo-ovarian abscess

Gray-scale transabdominal ultrasound image (A) shows

a dilated tortuous tubular structure in the right adnexa,
consistent with a hydrosalpinx. Corresponding color
Doppler image (B) shows no blood flow in the structure
Vagina
• The vagina is identified on a
midline sagittal TA scan as an
echogenic line surrounded by
hypoechoic tissue
• Upper 2/3 of vagina

Longitudinal midline transabdominal (TA) image of the

pelvis depicts the vagina as a hyperechoic line surrounded
by hypoechoictissue posterior to the urinary bladder.
Pelvic Inflammatory Disease (PID)
• Most cases of PID are caused by
sexually transmitted infections
• such as gonorrhea and chlamydia
• clinical presentation of PID
includes fever, leukocytosis, and
cervical motion tenderness.
• PID is usually bilateral
• Endometritis
• Salpingitis
Ultrasound findings of PID
• Endometrial thickening or fluid due to
endometritis
• complicated purulent fluid in the pelvis
with internal echoes or fluid levels
• Pyosalpinx resulting in dilated fluid-filled
fallopian tubes, often with internal echoes
and fluid levels due to purulent material
• Periovarian and peritubal inflammatory
tissue causes poor definition of the
margins of pelvic structures

Longitudinal transvaginal image of a retroverted uterus

shows a distended uterine cavity with a fluid-fluid level
due to layering purulent material
Acute PID
• Enlarged uterus
• Increased echogenicity of uterus
• Blurred borders of uterus and
pelvic organs
• Fluid in the cul de sac
Chronic PID
• Normal size of uterus
• Normal or increased echogenicity of uterus
• Fluid in uterus and cul de sac
• Blurred borders of uterus
• Hydrosalpinx
• Tubo-ovarian abscess
Pelvic inflammatory disease
Tubo-ovarian abscess
Cervical erosion/ulceration
• Enlarged cervix
• Irregular borders
• Buck shot spots
Congenital uterine
malformations
• The müllerian ducts develop
into the uterus, cervix, upper
vagina, and fallopian tubes.
• Uterine malformations occur
due to failure of fusion of the
müllerian ducts, arrested
development of the müllerian
ducts, and failure of
resorption of the median
septum
Uterus didelphys
• Uterus didelphys is characterized
by two uterine horns and two
cervices separate from each other

A and B, Longitudinal
transvaginal (TV) images
demonstrate two uteri,
one on the right side (A)
and the other on the left
side (B). C, Transverse TV
image confirms the
presence of both a right
and left uterus. Two
cervices were also
identified. A B
Bicornuate uterus
• Bicornuate uterus
describes the presence of
two uterine horns that
communicate with each
other, and is associated
with an indented contour
of the upper margin of
the uterine fundus
• The bicornuate uterus
can be associated with a
single cervix (bicornuate
unicollis) or two cervices
(bicornuate bicollis).
Transverse transabdominal (A) and three-dimensional reconstructed coronal images (B)
of the uterus demonstrate two widely separated uterine horns (long arrows)
communicating with each other. Also note the prominent concave indentation in the
configuration of the uterine fundus (short arrows), which helps distinguish a bicornuate
uterus from a septate uterus. A septate uterus has a convex or flattened fundal contour.
Septate uterus
• Failure of resorption of all or part of
the median septum results in a
septate uterus, depicted as a
midline septum that extends from
the fundus caudally
• The length and width of the septum
exhibit substantial variation.
• The septum can end in the uterine
cavity, extend into the cervix, or
even involve the vagina.
• The upper surface of the fundus of
a septate uterus has a convex or flat
contour

Axial image of upper uterus (A) demonstrates no connection between

the right and left endometrium (short arrows) in the upper uterus.
 Arcuate uterus
• An arcuate uterus is characterized by mild
indentation of the superior portion of the
endometrium, with a nonindented
contour of the uterine fundus, and is
secondary to nearcomplete resorption of
the septum
• There is lack of consensus as to whether
arcuate uterus should be considered an
anatomic variant or in the spectrum of
uterine malformations.

Axial two-dimensional (2D) image of the uterus shows no

connection between the endometrium in the right and left
upper uterus.
Unicornuate uterus
• Unicornuate uterus is an uncommon
uterine malformation that occurs
secondary to arrested development
of one of the müllerian ducts.
• It is difficult to identify on
ultrasound. Unicornuate uterus is
frequently associated with a
rudimentary uterine horn
• In some cases the rudimentary horn
contains a cavity and endometrium
and in others there is no cavity.
Pelvic masses
• Cystic masses
• Solid masses
• Complex masses
Pelvic cystic masses
• Single cystic masses
1. Uterine single cystic masses
2. Adnexal single cystic masses
• Inside ovaries
• Outside ovaries
• Multiple cystic masses
Uterine single cystic masses
• Hydrometrocolpos
• Hematometrocolpos
• Pyometra

Cervical stenosis. Longitudinal transvaginal image of a retroverted uterus

in a 70-year-old woman demonstrates fluid distending the endometrial
cavity due to cervical stenosis secondary to prior loop electrosurgical
excision procedure (LEEP).
 Hydrometerocolpos
• hydrometrocolpos refers to fluid-filled distention of
both the vagina and the uterus
• Elongated ovoid or cystic midline mass in the pelvis
• Seen in infants due to imperforated hymen
Hematometrocolpos
• refers to blood-filled
distention of both the
vagina and the uterus
• Seen at the time of puberty
due to imperforated hymen

marked distention of the vagina with material containing internal echoes

due to blood products secondary to vaginal obstruction. The complicated
fluid extends superiorly into the endometrial cavity consistent with
hematometrocolpos
 Hematocolpos

the endometrium appears

normal in the girl with
imperforate hymen,
consistent with
hematocolpos
 Pyometra
• Pus collection in uterus
• Cervical obstruction
• Secondary infection
• Cystic/complex mass
• Gas producing organisms
• Echogenic areas/PA shadow

Pyometra. Longitudinal TV image of the uterus in a woman with fever

and a long history of uterine obstruction reveals a dilated endometrial
cavity with internal echoes due to pyometra. There is also a small
amount of fluid in the endocervical canal
Single cystic masses of ovaries
• Follicular cyst
• Corpus luteum cyst
• Serous cystadenoma
 Follicular cyst
• follicular cyst forms when the
dominant follicle does not ovulate
and instead continues to enlarge
during the next menstrual cycle,
often growing considerably larger
than 3 cm.
• The term follicular cyst should not
be used to describe a normal
follicle.
Corpus luteum cyst
• the corpus luteum frequently
has a thick, peripheral rim of
tissue surrounding a
hypoechoic fluid-containing
center
• Pregnant women
• Vanishes before 20th week of
pregnancy

Corpus luteal cyst. Longitudinal transvaginal (TV) image of the left ovary reveals a
hypoechoic cystic structure with a thick, peripheral rim of tissue in an
intraovarian location, consistent with a corpus luteal cyst
Serous cystadenoma
• Simple benign cyst
• Biggest tumor seen in human
• Ultrasound of a benign serous
cystadenoma typically shows a
thin-walled cystic mass,
sometimes with septations
• Septations tend to be thin and
small papillary projections of
solid tissue are sometimes
seen
Serous cystadenoma. Longitudinal transvaginal image of a
serous cystadenoma shows a cystic mass with septations
Hydrosalpinx
• Comma or funnel shaped, kinked
cystic structure

Gray-scale transabdominal ultrasound image (A) shows

a dilated tortuous tubular structure in the right adnexa,
consistent with a hydrosalpinx. Corresponding color
Doppler image (B) shows no blood flow in the structure
Paraovarian cyst
Paraovarian cyst. Axial image of the
right adnexa depicts a small,
simple-appearing cyst adjacent to
the right ovary in a patient with a
positive pregnancy test. A
paraovarian cyst usually has a
simple appearance with a thin wall,
and does not exhibit the thick rim
of peripheral tissue typical of an
ectopic gestation
Pelvic multiple cystic masses
• Endometriosis
• Theca lutein cyst
• Polycystic ovaries
• Tubo-ovarian abscess (TOA)
 Endometriosis
• Endometriosis is defined as endometrial tissue
outside of the uterus.
• The ectopic endometrial tissue is usually implanted
on adnexal structures, most commonly the ovaries,
but may also be found on the fallopian tubes,
bladder, bowel, and other pelvic structures as well
as in a multitude of remote locations such as the
abdominal wall, lungs, thigh, and nose
• Larger lesions cause focal endometriomas,
sometimes referred to as chocolate cysts.
• The most typical sonographic appearance of an
endometrioma is a homogeneous, hypoechoic
ovarian mass exhibiting increased through
transmission and containing homogeneous low- or
medium-level echoes in a ground-glass pattern Transverse transvaginal images of the right ovary show
enlargement of the ovary by an endometrioma
containing homogeneous low-level echoes in a
ground-glass pattern
 Endometriosis

Longitudinal transvaginal image of the right ovary

Longitudinal transvaginal ultrasound image of the left
shows punctate echogenic foci in the wall of an
ovary depicts an endometrioma with a fluid-fluid
endometrioma. A ground-glass pattern of low-level
level due to layering of blood products.
internal echoes is also seen
 Theca lutein cyst

Theca lutein cysts. Axial transabdominal (TA) image of the right (A) and longitudinal TA image of the left (B) ovary in
the setting of a partial mole show marked ovarian enlargement with a multicystic, multiseptated appearance
(arrows), consistent with theca lutein cysts. B, Bladder; U, uterus.
Polycystic ovary syndrome (PCOS)
• endocrine disorder characterized by
hyperandrogenism and anovulation or oligo-
ovulation
• Stein leventhal syndrome
• There are frequently numerous small follicles that
line up along the Periphery of the ovary, just inside
the capsule, termed a string-of-pearls sign

String-of-pearls appearance of follicles. Transverse

transvaginal ultrasound image of the ovary shows small
follicles lined up around the periphery of the ovary, just
inside the capsule, resembling the appearance of a string of
pearls
 PCOS

Transverse transvaginal ultrasound image of the uterus and Transverse transvaginal image of the ovary shows
ovaries demonstrates ovarian size larger than expected relative increased prominence of centrally located stromal
to the uterus. tissue
 Tubo-ovarian abscess
• Thick borders
• Irregular
• Internal echo &
fluid filled
Pelvic solid masses
• Uterine solid masses
1. Benign endometrial hyperplasia
2. Endometrial cancer
3. Endometrial polyp
4. Cervical cancer
5. Fibroids
• Ovarian solid masses
1. Ovarian cancer
2. endometriosis
Benign endometrial hyperplasia

• Endometrial hyperplasia occurs

secondary to unopposed estrogen
stimulation and frequently causes
abnormal uterine bleeding.
• Endometrium AP Diameter ≥ 18
mm.
• Definitive diagnosis depends on
biopsy as sonography reveals
nonspecific endometrial thickening.
• The thickening is usually diffuse,
but less commonly is focal and
sometimes exhibits cystic changes. Longitudinal transvaginal images of a retroverted
uterus shows endometrial thickening (calipers) due to
endometrial hyperplasia.
 Endometrial cancer
• Ultrasound of endometrial
carcinoma reveals endometrial
thickening and heterogeneity, and
overlaps with the appearance of
endometrial polyps and endometrial
hyperplasia.
• Although the thickening tends to be
more irregular and heterogeneous in
carcinoma, this finding is not
specific.
• Irregularity of the border between
the endometrium and myometrium
suggests myometrial invasion Longitudinal transvaginal (TV) image of the uterus in a 47-year-old
woman demonstrate thickened, heterogeneous endometrium
(calipers) due to endometrial carcinoma.
 Endometrial carcinoma

Longitudinal TV image of the uterus demonstrates Image in a scan plane similar to that image with color and
thickened, heterogeneous endometrium measuring 2.47 spectral Doppler shows low-resistance blood flow in the
cm in thickness (calipers) due to endometrial carcinoma. endometrium
Endometrial polyp
• The typical ultrasound appearance of an
endometrial polyp is a focal, echogenic, round
or elongated lesion disrupting the normal
echotexture of the endometrium
• The echogenicity of polyps is helpful in
distinguishing them from submucosal fibroids,
which are more commonly hypoechoic and
frequently exhibit posterior shadowing.

Endometrial polyp. Small, focal, round, echogenic lesion

disrupting the normal echotexture of the remainder of the
endometrium.
 Endometrial polyp

Large, focal, round, echogenic lesion in the superior portion of the endometrium
disrupting the normal multilayer echotexture of the endometrium seen inferior to
the polyp
 Endometrial polyp

Diffuse thickening and cystic changes in the endometrium Round polyp similar in echogenicity to adjacent secretory
due to a large polyp filling the endometrial cavity. endometrium is recognizable because it is surrounded by a
curvilinear, hypoechoic halo
Cervical cancer
• Ultrasound is of limited value in diagnosing and
staging cervical carcinoma because carcinoma is
usually initially suspected based on Pap smear
results.
• Nevertheless, ultrasound occasionally depicts a
mass corresponding to a cervical carcinoma, pelvic
lymphadenopathy due to metastasis, or tumor
invading adjacent organs.
• Dilatation of the endocervical canal secondary to
obstruction by cervical cancer or cervical stenosis
secondary to radiation therapy can also be
identified by sonography

Longitudinal transvaginal (TV) image of the cervix reveals an

irregularly shaped hypoechoic cervical mass corresponding to
cervical carcinoma.
 Fibroids
• Fibroids (leiomyomas) are the most common
uterine tumor and are frequently visualized at
ultrasound
• Fibroids are benign neoplasms and are often
multiple.
• Fibroid growth is estrogen dependent;
therefore they often enlarge until
menopause, after which they typically
become stable in size or involute unless the
patient is receiving hormone replacement
therapy.
• Some fibroids increase in size during
anovulatory cycles or pregnancy due to the
effects of estrogen, but these changes are not
consistently seen Enlarged lobulated uterus. Longitudinal transabdominal
images of the uterus in two patients demonstrate
enlargement and lobulation of the uterus due to fibroid
 Fibroids
• Fibroids exhibit a wide range of ultrasound
appearances
• The most common sonographic pattern is a
hypoechoic, solid uterine mass, although some
fibroids are hyperechoic or heterogeneous.
• Large exophytic fibroids can result in a lobulated
uterine contour

Large posterior intracavitary fibroid (F) is outlined by saline on this

saline infusion study (SIS). Note the echopenic contents with an
echogenic rim typical of a myoma. The fibroid extends into the
myometrium
Fibroids
• The uterus can be globular in configuration
secondary to a large intramural fibroid.
• Peripheral rim calcification is commonly
seen
• Fibroids sometimes contain coarse
calcifications in a distribution resembling a
popcorn pattern

Transvaginal image of the uterus demonstrates a

hyperechoic rim surrounding the majority of the fibroid due
popcorn pattern to calcifications along the margin.
 Submucosal fibroid
when the fibroid abuts or distorts the endometrium

A. Longitudinal transvaginal (TV) image of the uterus shows a small submucosal fibroid (arrow) deforming the posterior
contour of the endometrium (arrowheads). Note that a second fibroid (F2) is seen anteriorly. B, Submucosal,
intracavitary. Transverse TV image of the uterus reveals a small submucosal fibroid (F) surrounded by the endometrium
(arrows) due to intracavitary location
Intramural fibroid
• when the mass is
completely surrounded by
the myometrium

Axial TV image of the uterus depicts a

fibroid (long arrow) separate from the
endometrium (short arrow), completely
surrounded by the myometrium.
 Subserosal fibroid

Subserosal. Longitudinal TV image of the uterus depicts a Subserosal, exophytic. Longitudinal TV image of a
fibroid separate from the endometrium, abutting the outer retropositioned uterus depicts a fibroid separate from the
serosal margin of the uterus. endometrium, resulting in a prominent bulge in the outer
serosal margin of the uterus
Pedunculated fibroid
• pedunculated when connected to
the uterus by a stalk
• A pedunculated fibroid can torse and
undergo necrosis, causing pain

Longitudinal transabdominal image with

color Doppler of the upper uterus (UT)
shows a large pedunculated fibroid (2)
connected to the fundal portion of the
uterus by a peduncle (also termed stalk,
arrows). Color Doppler depicts blood
vessels extending from the uterus through
the peduncle to supply the fibroid. B,
Bladder.
 Pedunculated fibroid

Pedunculated fibroid resembling an adnexal mass. A, Transverse transvaginal image of the pelvis shows a solid mass (short
arrow) lateral to the uterus (U) in the expected region of the adnexa. The mass is connected to the uterus by a short stalk
(long arrow). B, Image with color Doppler corresponding to image A demonstrates blood flow in the stalk (long arrow)
connecting the solid mass (short arrow) to the uterus (U), confirming the mass is a pedunculated fibroid
 Cystic degeneration of fibroid
• A fibroid with cystic degeneration may resemble a fluid collection in an obstructed uterus or a
gestational sac

Fibroid: cystic degeneration. Transverse transabdominal (A) and longitudinal transvaginal (TV) (B) images of the pelvis
demonstrate a large fibroid (long arrows) with multiple internal cystic areas (short arrows). The TV image (B) shows the
fibroid is exophytic, arising from the fundal surface of the uterus (U).
 Prolapsed fibroid

Prolapsed fibroid. Longitudinal (A) and transverse (B) transvaginal (TV) images of the cervix demonstrate a
hypoechoic mass (arrows) distending the endocervical canal, corresponding to a fibroid that prolapsed from an
intracavitary location in the uterine body into the cervix.
Ovarian cancer
• Ovarian cancer has a high mortality rate, in part
because symptoms are uncommon and
nonspecific in the early stages of the disease.
• Sonography of ovarian cancer reveals a complex
cystic, mixed or solid ovarian mass.
• Morphologic features favoring ovarian
malignancy include thick (>3 mm) irregular
septations, wall thickening (>3 mm), and solid
nodular areas termed papillary excrescences
along the septations or along the inner wall of
the mass
• Solid nodules and masses should be carefully
scrutinized for blood flow with Doppler,
because the presence of flow increases the Malignant ovarian masses. Nodules and septations. Transverse
likelihood they are due to malignancy transvaginal image reveals a predominantly cystic ovarian mass with
septations and solid nodular foci consistent with papillary
excrescences along both the septations and wall of the mass
Ovarian cancer

Blood flow in solid components.

Transvaginal images of a predominantly
solid ovarian mass shows blood flow in
the solid components. Identification of
blood flow in solid components of an
ovarian mass significantly increases the
likelihood of malignancy.
Pelvic complex masses
• Uterine complex masses
1. Mole hydatiform
2. Choriocarcinoma
3. Missed abortion
4. Pyometra
• Adnexal compplex masses
1. Mucinous cysadenoma &
mucinous cystadenocarcinoma
2. Serous cysadenocarcinoma
3. Cystic teratoma (dermoid cyst)
4. Ovarian cancer
5. Ectopic pregnancy
 Choriocarcinoma
• Trophoblastic neoplasia, choriocarcinoma is a
malignant tumor that erodes blood vessels
and is prone to metastasize, and placental-site
trophoblastic tumor, which arises from the
implantation site of the placenta and is the
most lethal and rarest form.
• The ultrasound appearance of the uterus in
persistent trophoblastic neoplasia includes
cystic spaces or focal nodules of increased
echogenicity in the myometrium.
• Extensive tumors may penetrate beyond the
confines of the uterus into adjacent structures.
• Hyperemia and high-velocity low-resistance
arterial flow may also be seen.
Choriocarcinoma
Mucinous cystadenoma
• Ultrasound of a mucinous cystadenoma
typically shows a multilocular cystic mass
with thin septations and low- to medium-
level internal echoes corresponding to the
mucoid component of the mass
• The level of internal echogenicity may vary
between loculations.
• Papillary projections are sometimes seen in
mucinous cystadenomas

Mucinous cystadenoma. Longitudinal transvaginal image shows a multilocular septated cystic mass with varying levels of
echogenicity in the loculations. The medium-level internal echoes seen in the largest loculation are due to mucinous
material in the mass
Mucinous cystadenocarcinoma
• Mucinous cystadenocarcinomas are more
likely to exhibit papillary projections and
thick septations with nodules and blood
flow than mucinous cystadenomas, and can
have an ultrasound appearance that is
indistinguishable from that of a serous
cystadenocarcinoma

Mucinous cystadenocarcinoma. Longitudinal

transvaginal image with power Doppler shows
septations and solid components with internal
blood flow
Pseudomyxoma peritonei
• Rupture of a benign or malignant mucinous
ovarian neoplasm can result
• in pseudomyxoma peritonei, in which mucin-
secreting cells in the peritoneal cavity produce
a gelatinous material that fills the abdomen
and can compress adjacent organs.
• Other etiologies of pseudomyxoma peritonei
include rupture of an appendiceal mucocele,
appendiceal cancer, and gastrointestinal tract
tumor, or pancreatic tumor.
• Ultrasound of pseudomyxoma peritonei
reveals fluid in the peritoneal cavity that
contains low- to medium-level internal echoes
globules. Longitudinal transabdominal image of the abdomen in a
and septations, and exhibits mass effect patient with pseudomyxoma peritonei due to metastatic mucinous
pancreatic cancer shows numerous rounded, mobile globules filled with
mucin and fibrous material in the peritoneal cavity.
Pseudomyxoma peritonei

Pseudomyxoma peritonei: loculations with internal

echoes. Coronal transvaginal image of the left pelvis
in a patient with metastasis to the left ovary from a
gastrointestinal tract malignancy shows multiple
loculations of fluid containing internal echoes (long
arrows).
Serous cystadenocarcinoma
• Serous tumors are the most common epithelial ovarian
neoplasms and include benign serous cystadenoma and
malignant serous cystadenocarcinoma.
• Serous tumors are frequently bilateral, especially when
malignant, with approximately 50% of serous
cystadenocarcinomas involving both ovaries.
• Serous cystadenocarcinomas are more likely to exhibit a
multilocular appearance, with thick walls and more
numerous thick septations.
• Papillary projections and irregular solid tissue are often
seen along the cyst wall and septations.

Serous cystadenocarcinoma. Transverse transvaginal

image with color Doppler and spectral Doppler shows
solid nodules (arrows) in the mass. Spectral Doppler
waveform from a solid component reveal low-resistance
arterial blood flow.
Cystic teratoma (dermoid cyst)
• A dermoid is a common benign ovarian germ-cell
neoplasm composed of mature epithelial elements
including various combinations of skin, hair,
desquamated epithelium, sebum, lipid material,
calcification, and teeth.
• The terms dermoid and benign cystic teratoma are used
interchangeably.
• Dermoids are present from birth but due to their slow
growth are typically not detected until the second and
third decades of life.
• Identification of one or more highly echogenic
components with posterior sound attenuation due to a
mixture of hair and sebaceous material is common and
has been termed the dermoid plug or Rokitansky nodule. Longitudinal transabdominal image of a dermoid in
the right ovary shows a rounded, highly echogenic
component corresponding to a dermoid plug
immediately adjacent to a cystic component. The
uterus is seen adjacent to the dermoid.
 Dermoid
• Only the superficial component of the lesion may
be visualized due to attenuation of the
ultrasound beam, resulting in a substantial
portion of the mass not being seen, termed the
tip-of-the-iceberg sign
• Interlacing hyperechoic linear and punctate
echoes are also frequently identified and
correspond to crossing hair strands within the
mass (also referred to as dermoid mesh, lines and
dots, or sparkling-line sign)

Longitudinal transabdominal image shows multiple

dermoid plugs
Dermoid
C, Tip-of-the-iceberg sign. Longitudinal
transvaginal image of the left ovary shows the
superficial component of a dermoid (long arrows).
The deep component of the mass is not visualized
due to attenuation of the sound beam. D and E,
Transabdominal (D) and transvaginal (E) images of
dermoids in two different patients show interlacing
hyperechoic linear and punctate echoes (arrows)
corresponding to hair strands in the mass, a
finding frequently referred to as the dermoid mesh
or sparkling-line sign. F, Transverse transabdominal
image of a large dermoid shows a calcification
(long arrow) with posterior shadowing. There is
also a nonshadowing, highly echogenic posterior
fluid level (short arrow) and an anterior fluid
component (arrowheads) corresponding to sebum.
 Dermoid

Transverse transvaginal image of a Longitudinal transabdominal image of Transverse transvaginal image of a

dermoid shows a fat fluid level with dermoid shows floating fat globules. dermoid shows multiple components
a highly echogenic floating including a dermoid plug, dermoid
component mesh corresponding to a hairball, and
anechoic fluid due to sebum
Infertility
• Infertility is defined as the inability to conceive after 1 year of unprotected
intercourse of reasonable frequency
• It can be subdivided into primary infertility, that is, no prior pregnancies,
and secondary infertility, referring to in infertility following at least one
prior conception
• Infertility is common and affects 10 to 15 percent of reproductive-aged
couples
Infertility
• Male
• Impotent
• Infertile
• Female
• Mental disorders
• Hormonal disorder
• Uterine abnormality
• Female genital tract disorders
 Follicular study
• Baseline U/S examination (day
8)
1. Uterine size
2. Endometrial thickness
3. Size of ovaries (right and left)
4. The largest follicle (location and
size)
• Serial ultrasound examinations
(Days 12, 14, 16, 18 or days 11,
13, 15, 17)
Dominant follicle
• Maximum size (18-24 mm)
• Rupture and ovulation
Free fluid relate to ovulation
Ovarian Hyperstimulation Syndrome
• Ovarian hyperstimulation syndrome is
associated with the most severe cases of
hyperstimulated ovaries and is diagnosed
when fluid shifts occur in conjunction with
hyperstimulated ovaries.
• This typically occurs in the setting of a
first-trimester pregnancy following
ovulation induction for assisted fertility
• Ultrasound of ovarian hyperstimulation
syndrome reveals markedly enlarged
ovaries with multiple cysts, ascites, and
pleural effusions Longitudinal transabdominal images of the right ovary
reveal enlarged ovary with multiple cysts consistent with
ovarian hyperstimulation
 Ovarian Hyperstimulation Syndrome

Longitudinal transabdominal images of Transabdominal ultrasound images of the rightand left upper
the left ovary reveal enlarged ovary quadrants reveal a large amount of free intraperitoneal fluid and a
with multiple cysts consistent with left pleural effusion
ovarian hyperstimulation
In Vitro Fertilization
• If the fallopian tubes are absent or blocked, conception cannot occur
because the ova cannot reach the uterus.
• With in vitro fertilization, the mature follicles are aspirated to retrieve
the eggs.
• The retrieval of the eggs is performed either at laparoscopy or under
ultrasonic guidance.
• Of in vitro ertilization procedures, 10% to 25% will result in a
pregnancy.
• Egg retrieval is generally guided with ultrasound.
 END
OF ULTRASOUND BASIC CONCEPTS

Dr. Mohammad Dawood Haqshanas

(Sonologist, Echocardiologist, General surgery and laparoscpoy specialist)
2021