Alfred Kratochwil

Endometrial volume change during spontaneous menstrual cycles : volumetry by transvaginal three-dimensional ultrasound

OBJECTIVE At present, only limited data are available on endometrial volume during the menstrual cycle. Most of these studies deal with animal models and use magnetic resonance imaging for volume measuring. The application of three-dimensional ultrasound in endometrial volume estimation is the subject of this study. SETTING Patients visiting the outpatient unit of the division of endocrinology and reproductive medicine of a university hospital. PATIENT(S) Twenty patients with a history of a normal menstrual cycle were selected. INTERVENTION(S) Ultrasound examinations were performed during a single menstrual cycle in addition to routine laboratory tests. MAIN OUTCOME MEASURE(S) Uterus-endometrial volume ratio. RESULT(S) Data from 18 patients could be evaluated. In 81 examinations the endometrium volume could be determined. Mean endometrial volume measured by three-dimensional ultrasound was 1.23 cm3. Mean uterus volume was 48.93 cm3. The change of the uterus-endometrial volume ratio showed a good correlation with the day of menstrual cycle. Quadratic regression analysis of volume and cycle length was R2 = 0.432. CONCLUSION(S) Three-dimensional ultrasound allows assessment of volume data of the female internal genitalia. In this study changes of the endometrial volume in menstrual cycles were measured. Additional studies are required to give information on the clinical impact of this new technique of endometrial volume estimation.

Three-dimensional ultrasonographic imaging of fetal tooth buds for characterization of facial clefts

The purpose of this prospective study was to investigate whether the antenatal characterization of fetal facial clefts can be improved by three-dimensional ultrasonographic visualization of fetal tooth buds. Between January 1996 and June 1998, seventeen consecutive fetuses with facial clefts were examined for fetal maxillary tooth buds in the cleft area using three-dimensional multiplanar reconstruction. It was possible in all cases to classify the clefts either as cleft lip alone or unilateral cleft lip and palate or bilateral cleft lip and palate. Three-dimensional computed tomography and histological jaw sections of three stillborn infants were produced in order to examine the correlation between the sonographic, radiographical and histological findings. The prenatal characterization of the facial clefts by means of a visualization of the tooth buds showed to be accurate postnatally in all cases. The sonographic proof of tooth buds might gain increasing importance as this technique seems to facilitate and improve the prenatal classification of suspected facial clefts.

Endosonography in obstetrics and gynecology

History of Endosonography.- References.- Safety Aspects of Endosonography.- 1 Biologic Effects of Ultrasound.- 1.1 Thermal Effects.- 1.2 Cavitation.- 1.3 Chromosome Damage.- 1.4 Sister Chromatid Exchange Rate.- 1.5 Epidemiologic Studies.- 1.6 Carcinogenesis.- 1.7 Statistical Considerations.- 1.8 Summary.- 2 Sterilization of Vaginal Probes.- References.- Advantages and Disadvantages of Endosonography.- 1 Advantages.- 2 Disadvantages.- Scanner Types.- 1 Linear-Array Scanners.- 2 Curved-Array Scanners.- 3 Sector Scanners.- Scan Planes.- 1 Definition of Scan Directions.- 2 Definition of Scan Planes.- Orientation of Scan Planes.- Reference.- Endosonographic Procedures.- 1 Vaginosonography.- 2 Hysterosonography.- 3 Rectosonography.- 4 Cystosonography.- References.- Normal Early Pregnancy.- 1 Chorionic Cavity.- 1.1 General.- 1.2 Vaginosonography.- 1.3 Recognition of Pseudogestational Sac.- 1.4 Correlation Between Chorionic Cavity and ss-hCG.- 1.4.1 Earliest Detection with Vaginosonography.- 1.4.2 Discriminatory Limit.- 2 Yolk Sac.- 2.1 General.- 2.2 Vaginosonography.- 3 Embryo.- 3.1 General.- 3.2 Vaginosonography.- 4 Cardiac Activity.- 4.1 General.- 4.2 Vaginosonography.- 5 Amniotic Cavity.- 5.1 General.- 5.2 Vaginosonography.- 6 Other Biometrie Data in the First Trimester.- 6.1 Biparietal Diameter.- 6.2 Trunk Diameter.- 6.3 Umbilical Cord and Placenta.- 7 Multiple Pregnancy.- 8 Summary.- References.- Disorders of Early Pregnancy.- 1 General.- 2 Threatened Abortion.- 3 Blighted Ovum.- 4 Missed Abortion.- 5 Incomplete Abortion.- 6 Hydatidiform Mole.- 7 Ectopic Pregnancy.- 7.1 General.- 7.2 Exclusion of Intrauterine Pregnancy.- 7.2.1 Recognition of a Pseudogestational Sac.- 7.2.2 Discriminatory Limit.- 7.3 Demonstration of an Intact Ectopic Pregnancy in the Adnexal Region.- 7.4 Nonspecific Masses in the Adnexal Region.- 7.5 Free Fluid in the Abdomen.- 7.6 Uncommon Sites of Ectopic Pregnancy.- 7.7 Summary.- References.- Vaginosonographic Examination of the Fetus.- 1 General.- 2 Indications.- 2.1 Examination of the Fetus in the First Half of Pregnancy.- 2.1.1 Biometry.- 2.1.2 Visualization of Fetal Organs.- 2.1.3 Screening for Anomalies.- 2.1.4 Anhydramnios.- 2.1.5 Sex Determination.- 2.1.6 2.2 Examination of the Fetus in the Second Half of Pregnancy.- 2.2.1 Examination of the Presenting Part.- 2.2.2 Vaginal Pulsed Doppler Examination of Fetal Arteries.- References.- Evaluation of the Cervix.- 1 General.- 2 Vaginosonography.- References.- Placenta Previa.- 1 General.- 2 Vaginosonography.- 3 Summary.- References.- Vaginosonographic Pelvimetry.- 1 General.- 2 Technique and Preliminary Results.- 3 Summary.- References.- Endosonography of the Uterus.- 1 Normal Anatomy.- 1.1 Size.- 1.2 Version and Flexion.- 2 Congenital Anomalies.- 3 Diagnosis of Myomas.- References.- Endosonography of the Ovaries.- 1 The Normal Ovary.- 2 Ovarian Cysts.- 2.1 Corpus Luteum Cysts.- 2.2 Dermoid Cysts.- 2.3 Endometriotic Cysts.- 2.4 Multiloculated Cysts.- 2.5 Ovarian Carcinoma.- 3 Inflammatory Adnexal Changes.- References.- Postoperative Endosonography.- References.- Intrauterine Contraceptive Devices.- 1 General.- 2 Vaginosonography.- References.- Endosonographic Diagnosis of Carcinoma.- 1 Cervical Carcinoma.- 1.1 General.- 1.2 Staging.- 1.2.1 Rectosonography Vs Vaginosonography.- 1.2.2 Intracervical Extent of Disease.- 1.2.3 Vaginal Infiltration.- 1.2.4 Parametrial Infiltration.- 1.2.5 Infiltration of the Bladder Wall and Rectum.- 1.2.6 Comparison of CT, MRI, and Endosonography.- 1.3 Follow-up of Inoperable Cervical Carcinoma.- 2 Corpus Carcinoma.- 2.1 General.- 2.2 Early Detection.- 2.3 Staging.- 2.3.1 Hysterosonography.- 2.3.1.1 Carcinoma Confined to the Endometrium.- 2.3.1.2 Myometrial Invasion.- 2.3.1.3 Extension to the Cervix.- 2.3.2 Vaginosonography.- 2.4 Summary.- 3 Ovarian Carcinoma.- 3.1 General.- 3.2 Early Detection.- 4 Vaginal Carcinoma.- 5 Diagnosis of Recurrent Carcinoma.- 5.1 General.- 5.2 Detection of Recurrence.- References.- Diagnostic Evaluation of Urinary Incontinence.- 1 General.- 2 Vaginosonography and Rectosonography.- 3 Perineal and Introital Sonography.- References.- Infertility.- 1 General.- 2 Evaluation of the Menstrual Cycle.- 2.1 General.- 2.2 Visualization and Measurement of the Follicles.- 2.3 Corpus Luteum.- 2.4 Cyclic Endometrial Changes.- 2.5 Correlation of Folliculometry with Hormonal Parameters.- 2.6 Doppler Measurements of Blood Vessels in the Lesser Pelvis.- 3 Endocrine Disorders.- 3.1 Corpus Luteum Insufficiency.- 3.2 LUF Syndrome.- 3.3 PCO Syndrome.- 4 In Vitro Fertilization.- 4.1 General.- 4.2 Stimulation Therapy.- 4.3 Determining the Time of Ovulation.- 4.4 Inadequate Stimulation Therapy.- 4.4.1 Hyperstimulation.- 4.4.2 Insufficient Stimulation.- 4.5 Follicular Aspiration.- 4.5.1 Laparotomy and Laparoscopy.- 4.5.2 Ultrasound-Guided Aspiration Methods.- 4.5.3 Vaginal Follicular Aspiration Guided by Vaginosonography.- 4.6 Embryo Transfer.- 5 Summary.- References.- Endosonographically Guided Punctures.- 1 General.- 2 Technical Aspects.- 2.1 Scanner Types.- 2.2 Freehand Needle Technique.- 2.3 Needle Guides.- 2.4 Preparation of the Patient.- 3 Indications.- 3.1 Follicular Aspiration.- 3.1.1 General.- 3.1.2 Vaginal Follicular Aspiration Guided by Vaginosonography.- 3.2 Aspiration of Cysts.- 3.2.1 Cyst Wall Biopsy.- 3.2.2 Sclerotherapy.- 3.2.3 Abscess Drainage.- 3.3 Puncture of Tubal Pregnancy.- 3.4 Selective Embryocide.- 3.4.1 General.- 3.4.2 Ultrasound-Guided Embryocide.- 3.5 Fine-Needle Aspiration Biopsy.- 3.6 Chorionic Biopsy.- 3.6.1 General.- 3.6.2 Chorionic Biopsy Using a Vaginal Scanner.- 3.7 Vaginal Decompression of Hydrocephalus.- References.- Vaginal Doppler Techniques.- 1 Basic Principles of Doppler Ultrasound.- 2 Vaginal Probes.- 2.1 Continuous Wave Doppler.- 2.2 Pulsed Doppler.- 2.3 Doppler Waveforms.- 3 Vaginal Pulsed Doppler Techniques.- 3.1 Examination Procedure.- 3.2 Advantages of Vaginal Doppler.- 4 Clinical Applications.- 4.1 The Uterine Artery.- 4.1.1 Normal Pregnancy.- 4.1.2 Complicated Pregnancy.- 4.2 Fetal Vessels.- 4.2.1 Early Pregnancy.- 4.2.2 The Fetal Internal Carotid Artery.- 4.3 Uterine Artery Flow in Cervical Carcinoma.- 4.4 Infertility.- 4.4.1 Failure of Implantation After Embryo Transfer.- 4.4.2 The Ovarian and Iliac Arteries in Stimulated Cycles.- 5 Clinical Significance of Vaginal Pulsed Doppler Blood Flow Studies.- References.- Subject Index 183.

Endosonographically Guided Punctures

Culdocentesis was an important diagnostic procedure before the advent of laparoscopy, but its importance has diminished with routine use. Before the advent of vaginosonographically guided follicular aspiration, endosonography played only a minor role as a means of directing invasive procedures in gynecologic patients, although some attempts were made to obtain cytologic or histologic confirmation of pelvic wall recurrence of cervical cancer using an endosonographically guided needle. The use of vaginosonography to demonstrate structures in the lesser pelvis has shown that a needle inserted vaginally must travel only a short distance to reach the ovaries. Because the ovaries are usually located very close to the vaginal wall in the region of the cul-de-sac, the vaginal approach offers an obvious solution to the problem of the “long-distance” aspiration.

Vaginal Doppler Techniques

The Doppler effect, named for the Austrian physicist Christian Johann Doppler, is based on the fact that all wave phenomena, including sound and light, undergo a change of frequency and wavelength when the source of the wave and the observer are moving relative to each other. In acoustics, the number of sound vibrations that reach the listener per unit time change according to whether the sound source is moving toward or away from the listener. The original basis on which Doppler formulated his law — the color change observed in distant, receding stars (Doppler 1843) — applies with equal validity to acoustic waves (Buys Ballot 1845).

Disorders of Early Pregnancy

Bleeding and cramping are among the most fequent complications of pregnancy in the first trimester. Since clinical and laboratory studies are unable to establish the integrity of the pregnancy or the viability of the fetus with absolute confidence, sonography provides the only means of assigning a specific diagnosis to the initially nonspecific symptoms. Moreover, the prognostic value of ultrasound in this situation can be a great comfort to the patient who has learned little from hormone tests and pelvic examinations but is alarmed and distressed by her symptoms. Given the lack of acceptance of early ultrasound screening at many centers, it is rare for an abnormal pregnancy to be recognized in the first trimester before clinical symptoms have appeared.

Endosonographic Diagnosis of Carcinoma

Approximately 30% of all carcinomas in women are genital cancers, and approximately half of those are carcinomas of the cervix. However, successful early detection by screening examinations has led in some countries to a relative decline in the incidence of cervical carcinoma compared with corpus carcinoma in recent years, and it has become possible to detect about one-third of all cervical carcinomas in stage I and roughly another one-third in stage II (Michalica 1981; Bernoth et al. 1984).

History of Endosonography

Twenty-five years ago, when ultrasound was introduced as a diagnostic tool in medicine, its noninvasive character was considered to be a great advantage (Kratochwil et al. 1966) (Fig. 1). Even then it was apparent, however, that the examination of intrapelvic organs could be significantly improved by passing ultrasound transducers into natural body orifices so that the region of interest could be scanned at closer range (Kratochwil et al. 1969) (Fig. 2). The rationale for this modality, called endosonography, is based on the relation of the penetration and resolution of ultrasound waves to their frequency. While lower frequencies show good penetration but relatively poor resolution, higher frequencies penetrate less deeply but show very good resolution. It was reasonable, then, to attempt to improve the imaging of intrapelvic organs by placing higher-frequency transducers in closer proximity to the region of interest.

Vaginosonographic Examination of the Fetus

Transabdominal ultrasound, with its large field of view, can demonstrate the presenting fetal part very easily and usually can depict numerous anatomic details. However, this can be difficult if the presenting part is already low in the pelvis when the study is performed. Even in the second trimester it can be difficult to visualize certain fetal structures if the presenting part is shadowed by the fetal limbs. Cases of this kind require either a different examination technique or a different route of approach.

Endosonography of the Ovaries

Today the main indication for ultrasound evaluation of the ovaries is the monitoring of follicular maturation. Vaginosonography also has a role in the evaluation of equivocal adnexal findings and in the differential diagnosis of ovarian masses. It must be emphasized, however, that vaginosonography is a macroscopic examination technique, and that one should not be tempted to make a histologic diagnosis on the basis of sonographic findings. It should also be remembered that a sonographic diagnosis made by a gynecologist is influenced by the experience of the examiner and his knowledge of clinical findings and all other available studies. This is by no means unfortunate, because the gynecologic specialist should be able to make a better evaluation in these cases than the nonspecialist.