In most practices, sonohysterography is immediately preceded by high-frequency transvaginal sonography (TVS). Exact menstrual dating and latex allergy are documented first, and a negative pregnancy test is obtained, along with a signed informed consent, when appropriate. The purpose of the baseline ultrasound is to confirm all pelvic findings prior to the fluid enhancement study. Although sonohysterography provides an indirect look inside the uterus, its ability to accurately diagnose intracavitary filling defects, such as myomas and polyps and adhesions and even malformations, matches that of the gold standard hysteroscopy. This chapter lists out specific imaging examples for submucous myoma, endometrial polyp, blood clot, endometrial malignancy, intrauterine synechia and congenital uterine anomaly. It outlines three-dimensional saline infusion sonohysterography (SIS), sonosalpingography or hysterosalpingo-contrast sonography, operative SIS, and sonovaginography. Combining TVS with vaginal saline infusion may improve the ability to image structures surrounding the vagina, such as the rectovaginal septum for endometriosis.

Ultrasound (US) measurement of the endometrium is now an indispensable part of ovulation induction monitoring and assisted reproductive technologies (ART). This chapter describes the use of US in the evaluation of infertility and monitoring ovulation induction for ART and for relations or artificial insemination. It discusses the critical US values for ovulation induction (OI) and in vitro fertilization (IVF). Endometrial Pattern, endometrial thickness, and endometrial waves are evaluated. On statistical analysis, biochemical pregnancies were significantly related to endometrial thickness and pattern and were unrelated to maternal age or number of previous spontaneous abortions. For optimal pregnancy and birth results, endometrial thickness should be 9 mm or thicker on, at the time of spontaneous luteinizing hormone (LH) surge, or when human chorionic gonadotropin (hCG) is administered, OI cycles for relations or intrauterine insemination (IUI) and when hCG is administered in IVF cycles.

Clomiphene revolutionized the management of infertility in 1967 when it was approved for treatment of anovulation due to polycystic ovaries (PCO). The pharmacokinetics and pharmacodynamics of clomiphene explain its characteristic actions. After ovulation induction with clomiphene, serum progesterone and estradiol serum levels are increased during the luteal phase of the cycle in a direct dose-response relationship. Ultrasound of the ovaries should always be performed before initiating clomiphene treatment for the first time to rule out preexisting ovarian neoplasm, endometriomas, and persistent corpus luteum cysts to evaluate the number and size of antral follicles. Progesterone is used to confirm ovulation to determine if the dose of clomiphene is sufficient. Pregnancy rates may be increased in clomiphene cycles by increasing the number of follicles that develop, by improving endometrial conditions and cervical mucus, and by intrauterine insemination (IUI) when numbers of sperm on a postcoital test are low or absent.

Ovulation induction (OI) that is not part of an in vitro fertilization (IVF) cycle is the cause of 40-70 percent of high-order multiple pregnancies (HOMP), pregnancies with three or more conceptus, and 11-21 percent of twins, in countries where modern infertility treatment is practiced. Clomiphene Citrate (CC) increases follicular stimulation hormone (FSH) secretion from the pituitary by temporarily blocking the negative feedback of estrogen that is necessary to regulate production and secretion of FSH. Pulsatile gonadotropin-releasing hormone (GnRH) administered subcutaneously or intravenously results in pregnancy and multiple pregnancies similar to low-dose gonadotropins. A widely used technique for reducing HOMP during controlled ovarian hyperstimulation-intauterine insemination (COH-IUI) treatment is to withhold human chorionic gonadotropin (hCG) administration when excessive numbers of follicles or estradiol (E) concentrations are present. OI should not be attempted, and IVF should be used instead for women who cannot safely carry a twin pregnancy.