Ultrasonography of the ovary

Aboubakr Elnashar

Benha university, Egypt ABOUBAKR ELNASHAR

Normal ovary

Technique

1. F.B., LS of the uterus, TS, slide the probe towards the fundus. Confirm the ovarian vessels entering laterally.

LS of the ovary: confirm: ovary is anterior to the ureter & internal iliac artery.

2. Turn the patient obliquely & scan the opposite ovary through the F.B., Reduce the gain

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Problems:

1. Ovary is not obvious:

use the blood vessels to lead you to the ovary.

2. After hysterectomy:

follow the internal iliac vessels into the pelvis.

3. Postmenopause

4. Gas filled loops:

tipping the head down, erect & oblique erect position

Get ut in transverse plane, put it in middle of screen

Follow the br lig

Push ovary downwards

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Position

Extremely variable.

TS:

lateral to the AV uterus

lateral & superior to the RV uterus.

In NP:

bounded by

oblitrated umbilical a. anteriorly

ureter & the internal iliac a. posteriorly

external iliac v superiorly.

Ovarian vessels may or may not be visualized at the superior aspect of the ovary. ABOUBAKR ELNASHAR

Echogenecity

Hypoechoic as compared to the uterus

{ multiple follicle in the cortex}.

Follicles:

Do not exceed 25 mm

round or ovoid, sharply marginated & anechoic.

Medulla & capsule:

higher echogenecity.

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ovary

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Volume

= L X WX T X 0.52

0.5 cm3 Prepubertal

5 cm3 Reproductive years 2.5X2.2X2 cm.

Diameter >3.5 cm is abnormal

2.5 cm3 Postmenopausal

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Ovarian size and appearance at different ages

Appearance Size Age

Follicles <10 mm 1 ml Neonate

Follicles < 5 mm <1.0 ml <2 y

Follicles <10 mm <2.5 ml Prepubertal

Follicles present 9.8 ± 5.8 ml Postpuberty

No follicles › 4 ml Postmenopause

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Mean ovarian volume

<3 cm3: poor response to HMG

very high cancellation rate during IVF (Lass et al, 1997)

Mean maximum ovarian diameter

measured in the largest sagittal plane

good estimation of ovarian volume

>3.5 cm: increase risk of OHSS

<2 cm: decreased ovarian reserve ABOUBAKR ELNASHAR

AFC: Resting follicles. Total number of follicles 2–8mm

counted in both ovaries

A threshold of 5 AF (2-5 mm) have the lowest error rate

for the prediction of poor response (Bancsi et al.,2004)

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Batista et al. 2012 ovarian response prediction index (ORPI) multiplying the AMH(ng/ml) level by the number of antral follicles (2–9 mm),and the result was divided by the age (years) of the patient.

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Early in the menstrual cycle. No medications being given.

9 antral follicles.

The ovary has normal volume (30X18mm).

Expect a normal response to injectable FSH.

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only 1 antral, other ovary had only 2 antrals

Ovarian volume: low

D3 FSH: normal

Attempts to stimulate ovaries for IVF were not successful

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At the beginning of a menstrual cycle, irregular periods, No

medications being given.

Antral follicles:16 are seen in this image. Ovary had a total of 35

antrals (only 1 plane is shown). This is PCO with a high antral

Ovarian volume= 37 X19.5mm

"high responder" to injectable FSH drugs.

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POF.

Only the stroma of the ovary is identified.

A very few follicles of less than 1 mm on the inferior aspect of

the ovary.

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Diagnosis of Spontaneous Ovulation 1. Mature F. (contain mature oocyte) = 17 – 25 mm

(Inner dimensions)

2. Deflation of the mature follicle

3. Intra peritoneal fluid

-Normal: 1-3 ml

-With ovulation: 4- 5 ml

4. CL: 4-8 days after ovulation

• Irregular thick wall .

• Hypoechoic

• May contain internal echos (hge.)

• 15 mm

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Mature follicle

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Atretic follicle of preovulatory diameter. thin follicle walls and sharp

transition at the fluid-follicle wall interface. The shape of the large

atretic follicle is compromised by small peripheral follicles. ABOUBAKR ELNASHAR

Corpus albicans

resulting from regression of a luteal structure from a

previous cycle.

hyperechoic structures within the ovary and they may

occasionally appear to be more pronounced owing to the

presence of surrounding follicles. ABOUBAKR ELNASHAR

Early Corpus Luteum. The site of

rupture of the dominant follicle

soon after ovulation appears as a

collapsed cystic structure (arrow)

on the ovary (o). u, uterus.

Corpus Luteum–Hypoechoic Solid

Appearance. The corpus luteum

appears as a hypoechoic solid mass

(arrow) on the right ovary (o) on

this transvaginal image.

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Corpus Luteum–Thick-Walled Cyst

Appearance. Transvaginal scan

shows an anechoic ovarian cyst

(between calipers, +, x) with

moderately thick walls.

Corpus Luteum–Thin-Walled Cyst

Appearance. This corpus luteum

(arrow, between cursors, +, x) has a

thin wall and contains anechoic fluid.

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Corpus hemorrhagicum

thick walls of peripheral luteal tissue and a central

hemorrhagic clot with an interspersed fibrin network.

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Failure of ovulation and development of “cystic” follicle.

The follicle typically grows larger than the mean preovulatory

follicle diameter of 23 mm, thin atretic follicle walls and small

flecks of particulate matter are frequently seen in the lumen or

aggregated at the side of the structure. ABOUBAKR ELNASHAR

Hemorrhagic anovulatory follicle.

Extravasated blood and an interspersed fibrin network are

observed within the lumen. The walls of this structure are thin,

echoic, and do not have the appearance of luteal tissue.

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Endometrioma

Hyperechoic wall

foci

(in35%)

Cysts With Low-level Echoes Hemorrhagic

cyst

Lacelike

internal

echoes

(in 40%)

Teratoma

Regional bright

echoes

(in 97%)

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Endometrioma. Sagittal TVS

an ovarian mass with multiple fine internal echoes (arrows) and

several hyperechoic mural foci (arrowheads).

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Ovarian endometrioma (A, B).

The structure is hypoechoic and exhibits low amplitude

uniformly distributed echotexture in the cavities of the

cysts. ABOUBAKR ELNASHAR

PCO: Rotterdam, 2004

At least one of the following

12 or more follicles in each ovary measuring 2 to

9 mm in diameter or

Ovarian volume >10 cm3.

Only one ovary meeting these criteria is

sufficient for diagnosis.

The follicle distribution & increase in stromal

echogenecity & volume are not required for

diagnosis.

Absence of mature follicle

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Technical recommendation

1. Regularly menstruating females should be scanned

between days 3-5

Oligo-/ amenorrhoeic should be scanned either at

random or between days 3-5 after progesterone –

induced bleeding

2. If there is evidence of a dominant follicle >10 mm or a

corpus luteum, the scan should be repeated the next

cycle.

3. Ovarian volume= 0.5X length X width X thickness

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PCO

Multiple peripheral

subcentimetric follicles (arrow).

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Subtypes of PCO: The images exhibit quite different appearances

in the size and distribution of follicles. A recent corpus luteum is

clearly visible in the ovary in panel (D).

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PCOS

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Transabdominal and transvaginal US ABOUBAKR ELNASHAR

Tuboovarian abcess

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Hyperstimulated ovary

Multiple follicles & cysts of different sizes & shapes (Cogwheel)

Ascites

Follicular cysts

few mm to 10 cm.

Thin walled, unilocular & hypoechoic

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Hyperechoic (calcifications) Anechoic (simple cyst)

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OHSS

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Corpus luteum cyst

Similar to follicular cyst but hemorrhage is frequent & internal echoes appear.

Difficult to be DD from ectopic pregnancy.

If ruptured: fluid in DP

Para ovarian cyst

Similar to functional cysts but may reach 15-20 cm

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C L cyst & uterus

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Dermoid cyst

Cystic mass containing a cone of solid tissue with highly echogenic focus & posterior shadowing

Endometrioma

Cystic, mixed or solid. If cystic, difficult to dd from any other cyst. Commonly low level echoes evently distributed. 1-20 cm

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Endometrioma

Hyperechoic wall foci

(in 35%)

Cysts With Low-level Echoes

Hemorrhagic

cyst

Lacelike

internal

echoes (in

40%)

Teratoma

Regional bright

echoes

(in 97%)

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Malignancy 1.Bilaterality

2. Ascites

3. Excrescencies

4. Thick walled cysts

5. Thick septa

6. Solid area within the mass

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Scoring system (Sasson et al,1991)

Internal wall structure:

smooth, irregularities <3mm, > 3mm, mostly solid

Wall thickness (mm):

<3, >3, mostly solid

Septa(mm):

No septa, <3 mm, >3 mm

Echogenecity:

Sonolucent, low, low with echogenic core, mixed, high

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Transabdominal US of the ovary

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Transabdominal Vs Transvaginal US

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Absent uterus and ovaries

Congenital anomalies of the ovary

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Uterus without ovaries

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Pelvic inflammatory disease (PID)

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Tubo-ovarian cyst

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Ovarian abscess

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Tubo-ovarian abscess ABOUBAKR ELNASHAR

Bilateral tubo-ovarian abscess

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Ovarian abscess ABOUBAKR ELNASHAR

Pelvic abscess

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Ectopic pregnancy

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Ectopic pregnancy

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Acute abdomen (Torsion of a cyst)

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Folliculometry

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Chronic anovulation

Vs

Ovulatory cycles

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Corpus Luteum

•The great sonographic

mimic in the female pelvis.

•DD:

– endometrioma,

– abscess

– Neoplasm

– ectopic pregnancy .

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Corpus luteum

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Interventional US (ovum pickup)

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Transvaginal ovum pickup

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PCOD

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