The cervix is the cylindrical portion of the uterus which enters the vagina and lies at right angles to it. It is well documented in the literature that pregnancy following assisted reproductive technologies (ART) has a higher risk of adverse outcomes. A meta-analysis comparing in-vitro fertilization (IVF) with spontaneous conceptions showed that IVF singleton pregnancies had significantly higher odds of perinatal mortality. Cervical funneling is described as dilatation of the internal os so that the cervical canal changes in shape, with bulging of the bag of membranes through the dilated cervix into the cervical canal. Vasa previa is diagnosed by transvaginal or transabdominal ultrasound, and with Doppler flow studies. Cervical pregnancy is a rare ectopic pregnancy defined as implantation of the gestational sac in the endocervix. Due to its difficult diagnosis, cervical pregnancy should be differentiated from the cervical stage of spontaneous abortion, nabothian cyst, and cervical choriocarcinoma.

This chapter presents a study which recognized that the resistance index (RI) of the uterine arteries was around 0.88 until day 13 of a 28-day cycle. The researchers measured the pulsatility index (PI) in 8 women with spontaneous cycles, 20 women undergoing induction of ovulation with clomiphene citrate, and 11 women undergoing controlled ovarian stimulation for in-vitro fertilization with gonadotropin-releasing hormone agonists (GnRH-a), human menopausal gonadotropin (hMG), and human chorionic gonadotropin (hCG). The intraovarian PI showed a gradual decrease from the early follicular (1.05) through the periovulatory (0.99) to the mid-luteal phase (0.85). The detection and quantification of follicular vascularity with pulsed color Doppler is used to predict oocyte recovery rate and hence may be useful in determining the most appropriate time to administer hCG. Oocyte/embryo selection for transfer may benefit from a brief color Doppler examination of each follicle at aspiration and pooling of oocytes with respect to follicles.

Ovarian cystic endometriosis, endometrioma, may present on ultrasonography as an easily identifiable hyper-refringent adnexal mass and the most frequent variation. Different studies have tried to evaluate the diagnostic capacity of transvaginal sonography (TVS) in deep endometriosis. When ultrasonographic findings were compared with surgical findings and pathology reports, a low sensitivity (around 30%) was reported for vaginal or rectovaginal septum endometriosis, with a high rate of false negatives. Infertile women with endometriosis have a higher prevalence of associated functional images, such as unruptured luteinized follicles, hydrosalpinges, adenomyosis, and/or intraovarian endometriosis that may interfere with oocyte retrieval. The role of TVS in the diagnosis of extraovarian endometriosis, an area where magnetic resonance imaging (MRI) has proved to be much more beneficial, is yet to be established. MRI offers a better suggestive diagnosis of adenomyosis than TVS due to its lower interobserver variability.

Clinically, adenomyosis is usually seen in women in their thirties but has been seen from the early twenties into the postmenopausal period. Pathologically, adenomyosis is confirmed if there are ectopic endometrial glands and stroma in the myometrium. This induces hyperplasia and hypertrophy of the adjacent smooth muscle, causing uterine enlargement. The sonographic diagnosis of fibroids has long been confused with that of adenomyosis. Leiomyomata or fibroids are common in women, with an increased incidence of 7 times in blacks and nulliparous women. In adenomyosis, the myometrium has areas of increased echogenicity that may be subtle and best appreciated with higher-resolution ultrasound scanners. The diagnosis of adenomyosis should not depend only on the sonographic appearance but must rather consider the whole picture or triad of history, sonographic features, and signs of tenderness. Adenomyosis has been suspected as cause of infertility. The treatment of adenomyosis is mainly symptomatic.

Hysterosalpingography (HSG) is the first diagnostic test used for patients with suspected mllerian anomalies. HSG can detect a two-chambered uterus and allow assessment of the size and extent of a septum. Two-dimensional (2D) ultrasonography was previously done by the transabdominal route, but transvaginal ultrasonography (TVS) is superior to the transabdominal route and is now the standard imaging technique for the uterus. The main advantage of three-dimensional (3D) ultrasonography over 2D is the ability to image the three orthogonal planes of the uterus, of which the coronal view is the most important. Sonohysterography is an ultrasound-aided technique that entails injection of normal saline into the uterine cavity. Many magnetic resonance imaging (MRI) studies have shown a very high sensitivity of 100%, and more recently values of 95% have been reported in cases of mllerian anomalies. Uterine mllerian anomalies have a high frequency of adverse obstetric implications.

The classification of uterine anomalies divides the uterine septum into complete (septate) or partial (subseptate) groups according, respectively, to whether the septum approaches the internal os or does not. The complete septum that divides both the uterine cavity and the endocervical canal may be associated with a longitudinal vaginal septum. Although surgery (hysteroscopy, alone or with laparoscopy), constitutes the gold standard for the diagnosis of uterine septum, various imaging tools including hysterosalpingography (HSG), ultrasonography, and magnetic resonance imaging (MRI) have great value in the diagnosis, with high levels of accuracy. In infertility patients it is believed that incidentally discovered uterine septum and even arcuate uterus should be corrected hysteroscopically prior to any infertility treatment to enhance reproductive outcome. While the hysteroscopic approach for surgical resection of uterine septum is safe and effective, the choice of surgical technique (using sharp scissors or electrocautery) is an operator preference.

The size of the mass in three dimensions, its location, consistency, and borders (well-/ill-defined) should be determined for a diagnostic approach to masses. Generally, most diagnoses can be made by transvaginal ultrasonography; however, a combination of transabdominal and transvaginal scan should be considered as they have different advantages and disadvantages. Follicular ovarian cysts comprise the most common cystic adnexal mass seen in women of reproductive age. Luteal cysts are characterized by peripheral blood flow at Doppler examination and menstrual disturbances. Recently three-dimensional (3D) or volume ultrasonography has been added to the gynecologic assessment armamentarium. The availability of noninvasive ultrasonography has resulted in improved care for infertile women. The ability to diagnose and decide on appropriate treatment is invaluable in helping women to achieve better fertility outcomes where identified pathology is detrimental, but also in improving patient well-being where this may be more serious, such as malignancy, and is dealt quickly.

Patients with fertility problems may be referred for scrotal ultrasonography (US) to evaluate testicular size, to assess testicular parenchyma, to examine epididymal integrity, and to ascertain the presence of varicocele. The scrotal ultrasound scan is carried out with the patient in the supine position, exposing the scrotum with the thighs and the abdomen covered. The testis, epididymal head, epididymal body, and epididymal tail are examined sequentially. Pulsed Doppler is also utilized to detect a subclinical varicocele by demonstrating the presence as well as the duration of reverse venous flow in the testicular veins. The use of ultrasound-guided testicular sperm aspiration in azoospermic patients has been described. A 21-gauge butterfly needle is directed into the testicular regions to be sampled under real-time gray-scale and power Doppler sonographic guidance, avoiding the echogenic mediastinum testis and the vascular plexus of the tunica albuginea, as well as the prominent testicular parenchymal vessels.

The classic candidate for a transrectal ultrasonography (TRUS) evaluation has semen analysis findings consistent with complete distal ejaculatory obstruction, including low ejaculate volume (usually less than 1.5 ml), azoospermia, low pH (less than7), and absence of fructose. In most cases, TRUS can be performed as an outpatient procedure without the need for anesthesia. In order to understand the normal and pathological appearance of the ejaculatory structures on TRUS, it is important to appreciate their anatomic relationships and embryological origins. Traditionally, vasography after vasopuncture was used to evaluate the patency of the ejaculatory ducts. The types of pathologies found on a TRUS evaluation include agenesis or hypoplasia of urogenital structures, cysts, dilatations, calcifications, and stones. Distal ejaculatory duct obstruction (EDO) is strongly suspected in case of azoospermia in which TRUS reveals dilated seminal vesicles with an anteroposterior length greater than 15 mm, or ejaculatory ducts with diameter greater than 2.3 mm.

Acute pelvic pain is a common reason for women to seek urgent gynecologic evaluation. Although the classic clinical presentation is dysmenorrhea with premenstrual intensification, dyspareunia, and chronic pelvic pain, some patients, who may or may not know they have the condition, experience acute pelvic pain. Ovarian hyperstimulation syndrome (OHSS) is an iatrogenic complication of superovulation induction therapy with a varied spectrum of clinical and laboratory manifestations. Crampy pelvic pain due to hormonal changes, rapid growth of the uterus, and increased blood flow is a common sign of early pregnancy. If a patient fails a single course of methotrexate or has pelvic pain that is increasing, ultrasound can be helpful. If a patient continues to have pain after a presumed miscarriage, even if products of conception were confirmed cytologically, a heterotopic pregnancy should be a considered.

Adenomyosis is a common disorder in the gynecologic population that consists of the presence of endometrial glands and stroma in the myometrium. Adenomyosis is associated with chronic pelvic pain, dysmenorrhea, dyspareunia, and feelings of pressure low in the pelvis due to uterine enlargement. Infection of the pelvis causes pain by several different mechanisms: pelvic inflammatory disease, puerperal infections, postoperative gynecologic surgery, and abortion-related infections. Pelvic congestion syndrome (PCS) is a pelvic pain syndrome caused by retrograde flow in an incompetent ovarian vein. Symptoms associated with PCS include a shifting location of pain, deep dyspareunia, and postcoital pain, with exacerbation of symptoms after prolonged standing. Ultrasound is a very useful tool for evaluating chronic pelvic pain sufferers. Patients have better satisfaction due to their understanding of their pain, with a goal of better productivity and return to normal function.

Over the last 25 years, progress in the field of assisted reproduction has paralleled that in ultrasonography. Normal fallopian tubes are not usually seen by ultrasound, though it is sometimes possible to visualize the fimbrial end within fluid in the pouch of Douglas. The ovaries are usually seen lateral to the uterus, in close relationship to the internal iliac vessels. They can be identified by their echogenic stroma and sonolucent follicles. A variety of ovarian reserve tests are used in routine clinical practice to assess a woman's ovarian performance prior to controlled ovarian hyperstimulation (COH) for in vitro fertilization (IVF). Transvaginal ultrasound-guided aspiration of ovarian follicles provides a safe and effective means of oocyte retrieval. Embryo transfer is a crucial step of IVF treatment. Ultrasound is a cornerstone of prevention and diagnosis of potential IVF complications such as ovarian hyperstimulation syndrome (OHSS) and multiple pregnancies.

This chapter discusses the usefulness of ultrasound in diagnosing normal and abnormal fallopian tubes using two-dimensional (2D) and three-dimensional (3D) transvaginal ultrasonography (TVS) and hysterosalpingo-contrast sonography (HyCoSy). HyCoSy involves the introduction of fluid into the uterine cavity and the fallopian tubes. The role of HyCoSy as a first-line procedure for the assessment of tubal patency has been examined in several studies. In most of the studies, the diagnostic capabilities of HyCoSy have been compared with the established reference methods of hysterosalpingography (HSG) or laparoscopy with dye insufflation, or both, and in the majority of the studies Echovist was used as the ultrasonographic contrast medium. A multicenter study in Scandinavia compared laparoscopic salpingectomy with no intervention prior to the first in vitro fertilization (IVF) cycle. The study demonstrated significant improvement in pregnancy and birth rates after salpingectomy in patients with hydrosalpinges that were large enough to be visible on ultrasound.

Ovarian volume decreases significantly in each 10-year period of a woman's fertile life. The ovarian size decreases in women greater than 40 years old. The volume of each ovary is calculated by measuring in three perpendicular directions and applying the formula for an ellipsoid. Using the largest cross-sectional sagittal view of the ovary, the mean ovarian diameter could be calculated from measurement of two perpendicular diameters. The combination of transvaginal ultrasound and pulsed color Doppler is increasingly used in gynecology to assess the hemodynamic changes in various physiological and pathological situations of the pelvic organs. Only one study has compared the predictive value of antral follicle count (AFC) measurement made using both two-dimension and three-dimension ultrasound in determining the outcome of response to ovarian stimulation as measured by the number of follicles that develop, the number of oocytes retrieved, and the pregnancy rate following assisted reproductive technologies (ART).

During the preclinical development of in-vitro fertilization (IVF) in the human, oocytes were frequently obtained at laparotomies for various indications and the time for the operative procedure was generally not scheduled close to ovulation. The ovaries could now easily be scanned without using the full-bladder technique, and transvaginal ultrasound-guided oocyte retrieval (TVOR) could generally be performed with only use of some sedative in combination with local anesthesia. In order to increase the oocyte recovery rate it was found that Teflon tubing between needle and sampling tube was optimal. Today there are various sampling sets commercially available, including needle, tubing, and sampling tubes. The different complications of TVOR are bleeding and infection. In conclusion, available data regarding possible adverse effects of ultrasonography on oocytes have been interpreted to indicate that the technique, in this respect, is as safe as laparoscopy.