This document provides biographical and professional details about Prof. Narendra Malhotra. It lists his current and past positions including Professor at University of Sarajevo School of Science & Technology and various roles in medical associations. It also outlines his areas of specialization in obstetrics and gynecology as well as lists his publications, awards, and presentations. He is currently based in Agra, India and is director of several fertility clinics.

1. NAME : PROF.NARENDRA MALHOTRA
DESIGNATION: PROF. UNIVERSITY SARAJEVO SCHOOL OF SCIENCE & TECHNOLOGY (SSST)
V.P. WAPM(WORLD ASSOCIATION OF PRENATAL MEDICINE)
PRESIDENT ISPAT (2017-2019)
PAST PRESIDENT ISAR ( 2016 – 2017)
SEC GEN SAFOG (2015-2019)
PAST PRESIDENT FOGSI(2008)
MANAGING DIRECTOR GLOBAL RAINBOW HEALTH CARE, AGRA
DIRECTOR ART-RAINBOW –IVF (AGRA & DELHI)
CITY: AGRA, INDIA
AFFILIATIONS: M.D., F.I.C.O.G., F.I.C.M.C.H, F.R.C.O.G.,F.I.C.S., F.M.A.S., A.F.I.A.P.
AWARDS: BEST CITIZENS OF INDIA AWARD, MAN OF THE YEAR AWARD, CORION AWARD, AWARDED BEST PAPER AND BEST POSTER
AT FOGSI : 5 TIMES, ETHICON FELLOWSHIP, AOFOG YOUNG GYN. AWARD,
PUBLICATIONS: JEFFCOATE’S PRINCIPLES OF GYNECOLOGY, 9TH EDITION, OPERATIVE OBSTETRICS AND GYNECOLOGY 2ND EDITION, AN
INTRODUCTION TO GENETICS & FETAL MEDICINE, 2ND EDITION, FOGSI’S PRINCIPLES & PRACTICE OF OBSTETRICS &
GYNECOLOGY FOR PG’S 3RD EDITION, DONALD BOOK ON OBSTETRIC PRACTICAL PROBLEMS MANUAL 2ND EDITION,
ULTRASOUND IN OBSTETRICS & GYNAECOLOGY 5TH EDITION, EDITOR 25 BOOKS, MANY CHAPTERS, ON EDITORIAL
BOARD
OF MANY JOURNALS, EDITOR OF SERIES OF STEP BY STEP BOOKS.
OVER 35 PUBLISHED PAPERS, 165 CHAPTERS, 509 PRESENTATIONS, 28 ORATIONS.
SPECIAL INTRESTS: SPECIAL INTEREST IN HIGH RISK OBS., ULTRASOUND, ART & GENETICS.

2. narendra malhotra
Sonal panchal
Jaideep malhotra
cb nagori
sakshi tomar
neharika malhotra
special thanks to asim kurjak,ashok khurana and kuldeep singh
drnarendra@malhotrahospitals.com.

3. WELCOME AND TRIBUTES TO OUR
MENTOR PROF STUART CAMPBELL

4. This is because..
 Introduction of volume ultrasound has
significantly increased the information
available through imaging, especially in
reproductive medicine.
3D gives idea about the global structure and morphology.
3D power doppler assesses global vascularity
Thus both are believed to be more accurate in assessment of ovary-
follicle, uterus-endometrium.

5. Advantages of 3D ultrasound
1. Surface rendering
2. Multi-planar imaging
3. Exact volume measurement
4. Power Doppler quantification
5. Inversion mode
6. Automation
7. Virtual scan
Automatic Volume Scan
Multiplanar Volume Analysis

6. Automatic volume scan
Frontal fan scan with the vaginal 3D/4D probe
Time of data acquisition
1. Fast: low line density and
lesser resolution for moving
targets
2. Normal: higher line
density and better resolution
for normal situation
3. Slow: high density and
best resolution

7. Multiplanar volume analysis
 Orientation in real time
2D Mode
 Definition of the Region of
Interest (ROI)
 Automatic Volume
 Scan (3D Scan)
Free
Rotation
of Slices

8. Volume Rendering:Two methods
1.Surface rendering (eg. Fetus)
 Visualizes surface surrounded by hypoechoic
structure(fluid).
 The hypoechoic structure is characterized by selecting the
threshold parameter.
 Threshold parameter determines the quality of the
surface rendering image.
2.Transparent rendering (eg. Bony structure) Application
for bone, vessels & cystic structures
– The object of interest is characterized by hyper- or
hypoechoic structures such as bony structures or vessels
and cystic structures.

9. Volume
calculation From 3 Orthogonal Planes
Calculation
Shell Thickness &
Shell Cubic Volume
VOCAL for measuring the volume size with its 3D image

10. Accuracy of volume measurement
 Intra- and inter-observer reliability
of volume measurment
confirmed
 Intra-class correlation: 0.9962-
0.9997
 Valid to within 4% of the true
volumes
(Raine-fenning et al., 2003)

11. Power Doppler: Angio-Histogram
VFI (Vascularizations-Flow Index)
By combining both FI & VI, first
impression about vessel density
FI (Flow Index)
Ave. # for the blood flow intensity
VI (Vascularization Index)
% for the vessel-density
Quantitative Analysis of Vascularization

12. approach to reproductive organs
Uterus
Ovary
Fallopian
tubes
Others

14. Uterus:Three-dimensional transvaginal ultrasound can depict a
coronal section of the uterus
1. Endometrial receptivity
2. Cavity problems : Fibroid and polyps
3. Congenital uterine abnormalities
4. Endometrial assessment in endometrial carcinoma

15. Endometrial receptivity
 > 2.5ml has a significantly higher pregnancy rates
 Median values for a favourable endometrium is 4.28 + /
- 1.9ml
 Subendometrial flow at the time of HCG > 5cms /sec
PSV,is good for implantation

16. No pregnancy when endometrial volume
< 3 ml and VI < 10
Exceptionally better pregnancy rates are
achieved with endometrial volume > 7ml
and subendometrial VI between 10 -35%.
Luis T Merce et al. 2D and 3D power doppler Ultrasound study of
endometrium as implantation marker, Text book of transvaginal
Sonography 241- 242.

17. VFI on the day of hCG is more sensitive than
volume, VI and FI for prediction of pregnancy.
VFI > 0.24 has
 sensitivity of 83.3%
 specificity of 88.9% ,
 PPv 93.8%
 NPV 72.3%
 for prediction of pregnancy with 33%
pregnancy rate.
Wu HM, et al, Detection of subendometrial vascularization blood flow by
three dimensional ultrasound may be useful for predicting pregnancy rate
for patients undergoing invitro fertilization-embryo transfer.Fertil Steril
2003; 79: 507-11

18. UTERINE VASCULARITY

20. Uterine causes of infertility
• uterine receptivity
•uterine anomalies
• submucous myomas
• endometrial polyps
• endometrial adhesions

21. CUT-OFF VALUE OF UTERINE PI & RI
PI = 3 - 4
RI = 0.93 - 0.95
• LOW UTERINE RECEPTIVITY
• VERY UNLIKELY IMPLANTATION
Steer et al., Fertil Steril 1992

22. HIGH NEGATIVE PREDICTIVE VALUE
IN CASES WITH MINIMAL ENDOMETRIAL
THICKNESS !!!
Gonan et al., Ultrasound Obstet Gynecol 1991
Khalifa et al., Hum Reprod 1992
CUT OFF VALUE
6 mm
7 mm
6mm

23. Relative echogenicity of the
endometrium and adjacent
myometrium as demonstrated on
a longitudinal US scan

24. SPIRALARTERY
BLOOD FLOW
ENDOMETRIAL
PERFUSION
UTERINE
RECEPTIVITY
IMPLANTATION
RATE

25. Spiral artery perfusion
4 TYPES OF COLOR MAPS
ZONE 1
ZONE 2
ZONE 3
ZONE 4

26. SUBENDOMETRIAL
ZONE
OUTER
HYPERECHOGENIC
ZONE
INNER
HYPOECHOGENIC
ZONE
PR = 26.7 %
PR = 36.4 %
PR = 37.9 %
P < 0.05
P > 0.05
Zaidi et al., Ultrasound Obstet Gynecol 1995

27. VASCULARISATION

28. 3D POWER DOPPLER
RENDERING AND QUANTIFICATION

29. VI
FI
VFI
NEW PARAMETERS
FOR PREDICTION OF
IVF OUTCOME
Kupesic et al, J Ultrasound Med 2001

30. A single coronal section
of the uterus cannot
demonstrate the whole
uterine cavity
(endometrium) when
the uterine cavity
curved too much.
sagittal section
coronal section

31. Three-dimensional images of the endometrial cavity or the
endometrium - extraction of the endometrial cavity and
volume measurement.

32. Three-dimensional images of the endometrial cavity or the
endometrium - 3D images of the endometrial cavity

33. V = 20.5 ml
ENDOMETRIAL VOLUME
MEASUREMENTS

34. Assessment of uterine cavity
Greatest advantage of 3D is coronal section
 Shape of uterine cavity
 Health of the uterine cavity
Invasive lesions
Distorting lesions
 Receptivity of endometrium

35. Normal shape of the uterine cavity...

36. Volume USG, 3D and 4D USG has a major
role to play in the diagnosis of uterine
anomalies :
Virtual hysteroscopy
Sensitivity of the Volume USG for
the detection of congenital uterine
abnormalites is > 98%.

37. Abnormal uterine shape is due to congenital
uterine abnormalities.

38. Uicornuate uterus:
 normal shape in long section
 deviated
 Hypoplastic 2nd horn : sometimes
Unicornuate Uterus

39. 3D US has an
advantage of
assessing both
these contours at
a time.
 Differential diagnosis of congenital duplication
abnormalities of uterus like bicornuate, septate and
arcuate is based on external fundal contour and
contour of the endometrial cavity.

40. Duplication abnormalities …
Ultrasound senstitivity specificity
 TVS 95.21 % 92.21%
 TVCD PD 99.29% 97. 23%
 Volume USG 98.38% 100%
 Sonohysterography 98.18% 100%
 Richman TS et al, Radiology 1984
We all know that this D/D between septate and bicornuate uterus
is the most important as it is the septate uterus that has highest
negative impact on fertility outcome.

41. D/D of bicornuate from septate uterus…

42. D/D bicornuate from septate

43. D/D bicornuate from septate
< 5mm > 5mm

44. Septae may be of variable length and thickness.

45. And the second controversy is...
Subseptate from arcuate.

46. D/D subseptate and arcuate
< 90° >
90°

47. D/D subseptate and arcuate
> 10 mm < 10 mm

48. T shaped uterus

49. RIC5-9-D Volume
Endocavity Probe
 Helping you see more anatomical information displayed in a single
image

50. Sonohysterography
 This is the investigation of choice for
differential diagnosis of intracavitary lesions
and also diagnoses mullerian abnormalities of
uterus.

51. Uterine cavity problems

53. ENDOMETRIAL POLYP

55. Dangling polyp

56. Asherman’s syndrome
VIGOROUS CURETTAGE
TBC
HYPERECHOGENIC AVASCULAR
BRIDGES WITHIN THE
UTERINE CAVITY
Significant reduction of the
endometrial cavity volume

57. Uterine Synechia

58. Endometrial calcification

59. Submucous leiomyoma
ATROPHY OF THE
ENDOMETRIAL GLANDS
& STROMA
OVERLYING
LEIOMYOMA
INTERFERENCE WITH
GROWTH OF
THE FETUS
VASCULAR OBSTRUCTION
& VENOUS DILATATION
OF THE ENDOMETRIUM
CONGESTION
REDUCED DELIVERY
OF HORMONS
INADEQUATE
PLACENTATION

60. Submucous fibroids –grading :
to decide the route of surgery
 T0- whole in endometrial cavity
 T1 - >50% in endometrial cavity
 T2- < 50% in endometrial cavity

61. Multiple fibroids
Minimum mode to show
multiple polyps

62. Evaluation of
endometriomyometrial junction

63.  SAFE & NONINVASIVE
 OPD PROCEDURE
 EASY TO PERFORM
 WELL TOLERATED
 RESULTS ARE REPRODUCIBLE
 MILD PAIN
 SENSITIVITY AND SPECIFICITY OF APX 80% IN MOST
STUDIES
 TUBAL SPASM
SONOHYSTEROSALPINGOGRAPHY

64. fallopian tubes
 Color doppler sonosalpingography is a fairly good and
acurate method to evaluate the fallopian tube patency in
infertile women
 This can be used as a first line screning test ,as it provides
additional information of the pelvic
organs(uterus,endometrium)

65. 3 D SONOSALPINGOGRAPHY USING
COLOR AND PULSED DOPPLER

66. 3 D COLOR CODED IMAGING
USING SONOVUE

67. TUBAL PATENCY IN B-MODE
• visualization of tubal segment
over 2 cm length
PULSED DOPPLER SCANNING
• broad Doppler band in patent tubes
COLOR DOPPLER
• the perfused tubes are shown in
color

68. AGREEMENT BETWEEN
METHODS
HyCoSy/HSG HyCoSy/lps. & dye
Complete 57-100 % 53-98 %
agreement
Partial 0-30 % 2-47 %
agreement
(1989-2000)

69. hydrosalpinx

70. 3D:hydrosalpinx inversion mode

71. sonoAVC of hydrosalpinx

75. SonoAVC
Sonography-based Automated Volume Count
Automatically calculates the number and volume of
hypoechoic structures in a volume dataset.
Can significantly reduce time for assessment and reporting.
From the calculated volume an average diameter can be calculated.
It also lists the objects according to their size.

76. Infolding of follicular wall

77. Selection if >4
exams/cycle
Cut-off value set
New Graph & Exam Summary
SonoAVCTM
follicle
SonoAVC
Index
Graph with 2 lines

78. Other tools for volume calculation .....

79. 3D 4 D PCOD

80. Ovarian volume
Antral follicle count
Stromal volume

81. Stromal vascularity
 Even with same echogenecity, PCOS has more
stromal flow.

82. Volume histogram

83.  Women with PCOS had
 higher AFC(median 16.3 v/s 5.5 per ovary),
 ovarian volume ( 12.56 v/s 5.6ml)
 stromal volume ( 10.79 v/s 4.69ml)
 stromal vascularization (VI 3.85v/s 2.79%, VFI 1.27 v/s
0.85).
 Though 2Dpower Doppler indices were not higher in
PCOS than in controls. Lam PM, et al, Hum Reprod 2007
Dec ; 22(12):3116-23

84. Deciding the stimulation protocol

85. Predictors of ovarian response are
enumerated as:
Number of antral follicles
Stromal flow: stromal FI
Total ovarian stromal area
Total ovarian volume
Kupesic S et al, Hum Reprod 2002; 17(4):950-55

86.  AFC is reported the
benefit to predict ovarian
response and reduce
cancellation cycles.
Chang MY, et al. Fertil Steril 1998;
69:505-10

87. Antral follicle when counted by inversion mode:
likely to get 60% of follicles of the counted antral
follicles in IVF cycles.
Prof Nick Rainne-Fenning :
study of 600 cycles
 Antral follicle count and
ovarian volume showed
significant correlation with
AMH.
Mei-Jou Chen et al, Hum Reprod,
23(4):952-957; February, 2008.

88. It is interesting to know that
 Measurement of ovarian stromal flow in early
follicular phase is related to subsequent ovarian
response in IVF treatment.
Zaidi J, et al. Obstet Gynecol 1996;
88:779-84
Ovarian Volume < 3 cc was
significantly predictive of higher IVF
cancellation rates > 50%.
Lass A, Hum Reprod 1992,12(2) : 294 – 97.

90. In spite of deciding the time of hCG based
on 2D and CD assessment of the follicle,
there were lots of failures.
3D US was therefore tried for follicular
assessment with 3D PD.

91.  Follicular volumes of between 3 – 7 cc are optimum
for oocyte retrieval .
 The limits of agreement between the volume of the
follicular aspirate and 3D volume of the follicle were
+ 0.96 to – 0.43 with 3D and + 3.47 to – 2.42 by 2D
volume estimation.
Follicular Volume

92. On the day of HCG – If
cumulus like echoes is not seen in all
three planes in the follicle , it is less
likely to be mature fertilizable oocyte.
cumulus

93. Perifollicular 3D PD

94. Follicles with more uniform perifollicular
vascular network are more likely to
produce pregnancy.

95. Perifollicular 3DPD

96. Even when the age of the patient and
total number of follicles are similar, the
ovarian volume was significantly higher in
the patients who developed OHSS (
271+/- 87 v/s 157.30 +/- 54.20ml)
Pre hCG OHSS prediction
SonoAVC for IVF pre hCG

97. Conclusion
 Volume ultrasound is the modality of choice for
uterincavity assessment & endometrial pathology
 With 3D contrast even the fallopian tubes can mow
we visualised nicely
 Volume USG – VOCAL and colour histogram –in our
experience have proved to be of added value in
evaluation of ovarian response, endometrial
receptivity and Pre HCG follicular and endometrial
evaluation.

98. Newer machines and
technology has made it
possible to have usg as an
accurate tool for complete
reproductive
assesment…anatomical and
physiological
BT12 Enhancements
New clinical value for you
and your patients

99. THANK YOU
CONGRATULATIONS TO ALL ON 40YRS OF
ART

100. Special thank you to prof campbell

101. THANK YOU

102. THANKYOU