2. 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
ABOUBAKR ELNASHAR
3. 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
ABOUBAKR ELNASHAR
4. 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
5. 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.
ABOUBAKR ELNASHAR
8. Volume
= L X WX T X 0.52
0.5 cm3Prepubertal
5 cm3Reproductive years
2.5X2.2X2 cm.
Diameter >3.5 cm is abnormal
2.5 cm3Postmenopausal
ABOUBAKR ELNASHAR
9. Ovarian size and appearance at
different ages
AppearanceSizeAge
Follicles <10 mm1 mlNeonate
Follicles < 5 mm<1.0 ml<2 y
Follicles <10 mm<2.5 mlPrepubertal
Follicles present9.8 ± 5.8 mlPostpuberty
No follicles› 4 mlPostmenopause ABOUBAKR ELNASHAR
10. 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 reserveABOUBAKR ELNASHAR
11. 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)
ABOUBAKR ELNASHAR
12. 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.
ABOUBAKR ELNASHAR
14. 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.
ABOUBAKR ELNASHAR
15. only 1 antral, other ovary had only 2 antrals
Ovarian volume: low
D3 FSH: normal
Attempts to stimulate ovaries for IVF were not successful
ABOUBAKR ELNASHAR
16. 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.
ABOUBAKR ELNASHAR
17. 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.
ABOUBAKR ELNASHAR
18. 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
ABOUBAKR ELNASHAR
20. 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
21. 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
22. Early Corpus Luteum. The site of
rupture of the dominant follicle
soon after ovulation appears as a
collapsed cystic structure (arrow)
Corpus Luteum–Hypoechoic Solid
Appearance. The corpus luteum
appears as a hypoechoic solid mass
(arrow) on the right ovary (o) onABOUBAKR ELNASHAR
23. 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.
ABOUBAKR ELNASHAR
24. Corpus hemorrhagicum
thick walls of peripheral luteal tissue and a central
hemorrhagic clot with an interspersed fibrin network.
ABOUBAKR ELNASHAR
25. 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
26. 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.
ABOUBAKR ELNASHAR
28. Endometrioma. Sagittal TVS
an ovarian mass with multiple fine internal echoes (arrows) and
several hyperechoic mural foci (arrowheads).
ABOUBAKR ELNASHAR
29. Ovarian endometrioma (A, B).
The structure is hypoechoic and exhibits low amplitude
uniformly distributed echotexture in the cavities of the
cysts. ABOUBAKR ELNASHAR
30. 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
ABOUBAKR ELNASHAR
32. 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
ABOUBAKR ELNASHAR
34. 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).
ABOUBAKR ELNASHAR
38. Hyperstimulated ovary
Multiple follicles & cysts of different sizes & shapes
(Cogwheel)
Ascites
Follicular cysts
few mm to 10 cm.
Thin walled, unilocular & hypoechoic
ABOUBAKR ELNASHAR
43. 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
ABOUBAKR ELNASHAR
46. 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
ABOUBAKR ELNASHAR
47. Endometrioma
Hyperechoic wall foci
(in 35%)
Cysts With Low-level Echoes
Hemorrhagic
cyst
Lacelike
internal
echoes (in
40%)
Teratoma
Regional bright
echoes
(in 97%)
ABOUBAKR ELNASHAR