In this presentation we will discuss role of Doppler US in Infertility, fertilization and assisted fertilization. we will discuss the favorable and unfavorable RI and PI. We will discuss role of doppler us in various gynecological malignancies.

1. Doppler Imaging in Gynecology
An Introduction
DR. Muhammad Bin Zulfiqar
PGR IV New Radiology Department
SHL/SIMS
radiombz@gmail.com

2. AIMS
• UTILITY IN DIFFERENT PELVIC PATHOLOGIES
• ROLE IN INFERTILITY
• ROLE IN FERTILIZATION

3. Introduction
• Physiological Changes
– Ovarian follicle
– Follicular Rupture
– Corpus Luteum
– Changes in endometrium with respect to
Menstrual cycle
• Pathological Changes
Alcazar, et al. Intratumoral blood flow in cervical cancer as assessed by transvaginal CDS: Correlation with tumor
characteristics. Intern J of Gynec Cancer. Jul 2003 Vol 13 (4).
8. Suren A, et al. 3D Color Power Angio imaging. Ultrasound Obs Gynecol. 1998 Feb; 11(2):133.

4. Techniques
• Abdominal Ultrasound
• Transvaginal Ultrasound (more important)
– Both these techniques are collaborated with
Doppler

5. Color Doppler in Cervical Cancer
• Controversial role in cervical cancer
– Neovascularity in the mass (not definitive).
– Response to chemotherapy via transvaginal color
Doppler.
– Combined clinical and radiological staging can identify
the patients needing
• post surgical radiotherapy and/or chemotherapy and
• help in the treatment planning versus clinical exam alone.
• Local recurrences following treatment are well
assessed radiologically by ultrasound. In cases of
doubt, MRI may be performed.
Alcazar, et al. Intratumoral blood flow in cervical cancer as assessed by transvaginal CDS: Correlation with tumor characteristics. Intern J of
Gynec Cancer. Jul 2003 Vol 13 (4).
8. Suren A, et al. 3D Color Power Angio imaging. Ultrasound Obs Gynecol. 1998 Feb; 11(2):133.

6. • Coronal color Doppler view of the cervix.
• Coronal scan demonstrating areas of
vascularity within the hypoechoic mass. No
obvious parametrial invasion was noted.

7. • Spectral color Doppler study.
• A mixed arterial and venous waveform is
demonstrated through the region of
neovascularity in the mass.

8. Neovascularization
• A study based on 'Folkman's theory of
neovascularisation' , was done according to
which malignant neoplasms elaborate a factor
named Tumor Angiogenesis factor (TAF),
which stimulates rapid formation of new
capillaries.
Dastur Adi E. Ultrasound and Doppler in Gynecological Cancers. J Obstet Gynecol India Vol. 60, No. 1 :
January/February 2010 pg 21-22

9. Neovascularization
• The study aimed at evaluating the efficacy of
Color and Spectral Doppler in diagnosing the
ovarian malignancy.
• In all, 121 patients with adnexal masses were
examined over a period of 2 years, out of which
60 patients with neoplastic ovarian tumors were
retained as the study subject.
• Color Doppler showed blood flow in 92.59
percent of malignant tumors in contrast to only
42.24 per cent of benign tumors.
Dastur Adi E. Ultrasound and Doppler in Gynecological Cancers. J Obstet Gynecol India Vol. 60, No. 1 :
January/February 2010 pg 21-22

10. Neovascularization
• Absent blood flow in a solid tumor almost
always ruled out the possibility of malignancy.
Spectral Doppler helped to assess the nature
of the blood vessels picked up on Color
Doppler.
Dastur Adi E. Ultrasound and Doppler in Gynecological Cancers. J Obstet Gynecol India Vol. 60, No. 1 :
January/February 2010 pg 21-22

11. Neovascularization
• In the present study. 96.29 per cent of malignant
tumors had PI less than 0.8 in contrast to only
6.06 per cent of benign tumors.
• Similarly, 92.59 percent of malignant tumors
showed RI less than 0.6 in contrast to only 9.09
per cent of benign tumors.
• Thus, Color Doppler and Spectral Doppler
tremendously increased the reliability in
diagnosing a malignant ovarian tumor.
Dastur Adi E. Ultrasound and Doppler in Gynecological Cancers. J Obstet Gynecol India Vol. 60, No. 1 :
January/February 2010 pg 21-22

12. Neovascularization
• Color Doppler served as an important tool to
rule out malignancy in solid tumors if they
failed to show any intratumoral vascularity.
• B-Mode USG in combination with Color
Doppler and Spectral Doppler is proposed as
the first and foremost diagnostic modality in
patients with ovarian tumor
• To establish the definite diagnosis of
malignancy early in the course of the disease.
Dastur Adi E. Ultrasound and Doppler in Gynecological Cancers. J Obstet Gynecol India Vol. 60, No. 1 :
January/February 2010 pg 21-22

13. Neovascularization
New blood vessel formation
• Benign conditions
–Ovulation (follicular development)
–Corpus luteum
–Placentation
–Ectopic pregnancy
–Wound healing
–Arthritis
–Chronic inflammation
–Benign tumors
• Endometriomas
• Occasional fibroids
• Malignancies
Dastur Adi E. Ultrasound and Doppler in Gynecological Cancers. J Obstet Gynecol India Vol. 60, No. 1 :
January/February 2010 pg 21-22

14. Resistance Patterns in Ovarian Masses
• High resistance (RI <1 >0.6)
–Cystadenomas, hemorrhagic cysts,
dermoid tumors, endometrioma
• Intermediate resistance (RI <0.6 >0.4)
–Dermoid tumors, endometriomas
• Low resistance (RI <0.4 >0)
–Ovarian cancer, inflammatory masses,
endometriomas, dermoids, corpus luteum
Dastur Adi E. Ultrasound and Doppler in Gynecological Cancers. J Obstet Gynecol India Vol.
60, No. 1 : January/February 2010 pg 21-22

15. Neoplastic Risk in Adnexal Masses
Risk is age and state dependent
Dastur Adi E. Ultrasound and Doppler in Gynecological Cancers. J Obstet Gynecol India Vol. 60, No. 1 :
January/February 2010 pg 21-22

16. Ovarian Masses
• The ultrasound features of a malignant growth have been
described as
– bilaterality,
– large size (> 5 cm),
– multiple locules,
– papillary excrescences or solid areas,
– presence of ascites or metastasis.
• The addition of Doppler and serum marker such as CA-125
has been used as a multimodality screening strategy.
• The sensitivity (89.5%) and specificity (99.8%) of the
multimodality approach were superior to the other groups
in detecting early ovarian cancer.
Dastur Adi E. Ultrasound and Doppler in Gynecological Cancers. J Obstet Gynecol India Vol. 60, No. 1 :
January/February 2010 pg 21-22

17. Color Doppler
• Doppler has been studied in its role in detecting
– vascular flow patterns and
– characterizing the resistance to blood flow in ovarian
tumors.
• Malignant growths are characterized by
neoangiogenesis and blood vessels with a poorly
developed muscularis. The blood flow in these vessels
is marked by low impedance and correspondingly, the
resistance index is low (RI < 0.3)
• In contrast, benign ovarian tumors and normal ovarian
blood flow is characterized by a high RI
Dastur Adi E. Ultrasound and Doppler in Gynecological Cancers. J Obstet Gynecol India Vol. 60, No. 1 :
January/February 2010 pg 21-22

18. Benign / Malignant Pelvic Masses
• In experienced hands, subjective evaluation of
the gray-scale ultrasound image is the best
ultrasound method for discriminating between
benign and malignant adnexal masses.
• The main advantage of adding Doppler
examination to subjective evaluation of the gray-
scale image is an increase in the confidence with
which a correct diagnosis is made.
Valentin L. Prospective cross-validation of Doppler ultrasound examination and gray-scale ultrasound imaging for
discrimination of benign and malignant pelvic masses. Ultrasound Obstet Gynecol. 1999 Oct;14(4):273-83.

19. Endometrial Cancers
• Detectable flow is unusual in
–Normal endometrium
–Atrophic endometrium
–Most endometrial hyperplasias
• Flow is usually detectable (91%) of endometrial
Ca
• Flow pattern shows low resistance (average RI ~
0.42)

20. Endometrial Cancers
• Postmenopausal bleeding is the prime indicator
for the risk of endometrial cancer and
transvaginal ultrasound is the first step in the
triage for these women.
• Metanalysis have shown that when the
endometrial thickness is less than 5 mm, the risk
of
• endometrial malignancy is about 1 in 1000. In
such cases, endometrial sampling and
histopathology can be avoided.
Dastur Adi E. Ultrasound and Doppler in Gynecological Cancers. J Obstet Gynecol
India Vol. 60, No. 1 : January/February 2010 pg 21-22

21. Endometrial Cancers
• Ultrasound markers of malignancy are
• the disturbance of the interface between the
endometrium and myometrium
• presence of irregular, vascular mass lesions
inside endometrial cavity.

22. Endometrial Cancers
• Color Doppler is useful as an adjunct in
diagnosing endometrial cancer. The
subendometrial blood flow and the blood flow in
thickened and polypoidal endometrium shows
low resistance patterns in endometrial
malignancy and the RI is usually less than 0.3.
• Saline infusion sonography is useful in detecting
polyps and intracavitary masses. Preoperative
assessement with ultrasound results matches the
result of a CT or MRI assessment.
Dastur Adi E. Ultrasound and Doppler in Gynecological Cancers. J Obstet Gynecol
India Vol. 60, No. 1 : January/February 2010 pg 21-22

23. Luteal Cyst
• Detected during the secretory phase (D
15-28) of the menstrual cycle
• Size : 2-7 cm
• Polymorphism :
– Heterogeneous content with fibrin septa:
« fish net »
– Clot simulating vegetation
– Pseudo-solid cyst
Prof Soha Talaat

24. Luteal Cyst
• Color Doppler :
– Non vascular septa
– Vascularized thick wall
– May be misdiagnosed as a cystadenocarcinoma
 US Follow-up 2 months later (1 month is too early !!!)

25. Large
Functional
Cyst
• Trick : harmonic
imaging is useful to
ascertain that the
lesion is fluid-filled
Prof Soha Talaat

26. Color Doppler?
• Color Döppler is not
accurate :
– In 30 % of functional
ovarian cyst walls,
arteries are detected
– Presenting with a low
resistive index
• Do not take it for
malignancy !!!
Prof Soha Talaat

27. •
•Neovascularization detected
in the cyst wall
•Absence of color flow in
some echogenic portions like
blood clots in hemorrhagic
cysts and endomertiomas
suggest their benign cystic
nature .
Role of Color Doppler in Endometrioma
Prof Soha Talaat

28. Benign diffuse enlargement Torsion( edema)
• Ovarian torsion (adnexal
torsion) is an infrequent but
significant cause of acute
lower abdominal pain in
women.
• This condition is usually
associated with reduced
venous return from the
ovary as a result of stromal
edema, internal
hemorrhage,
hyperstimulation, or a mass.
Prof Soha Talaat

29. Doppler findings of
benign and malignant adnexal masses
Benign ovarian tumors
• Regular distribution of blood vessels
• Blood vessels are equally calibrated
• Blood vessels have muscle fibers with moderate-to-
high resistance index values (RI=0.42)
Prof Soha Talaat

30. Doppler findings of benign and
malignant adnexal masses
Malignant ovarian tumors
• Irregular distribution of blood vessels
• Blood vessels have irregular diameter
• Low resistance index values (RI<0.42)
• Display of tumoral lakes and arterio-venous
shunts

31. Ultrasound
• An enlarged ovary (>5 cm)
• Prominent peripheral nonovulatory follicles .
• Small amount of free fluid
• May depict the cyst (or, less commonly, the mass) that predisposed
the ovary to torsion.
Prof Soha Talaat

32. Doppler
• Imaging modality of choice
• An absence of arterial waveforms or high resistance to arterial flow
with absent venous flow are highly suggestive.
• Particularly when those findings are accompanied by ovarian
enlargement.
• However normal arterial waveforms do not rule out torsion.
Prof Soha Talaat

33. Acute PID
• Early on, there may be no US signs
• Free fluid in cul-de-sac +/-behind adnexae
• Fluid in endometrial cavity
• Fluid in lumen of fallopian tubes
• No typical changes in doppler patterns or
indices
• Follicles (infected), with fuzzy margins

34. Tubovarian Abscess
• Complex, hypoechogenic, septated mass
• Acoustic enhancement
• Absent color doppler blood flow in mass
• Ill-defined margins
• Fluid in cul-de-sac
• Loss of anatomical landmarks as disease
becomes chronic

35. Chronic PID
• Hydrosalpynx
–Tubular anechoic structure
–Absent color doppler blood flow
i.e. not a vessel
• Mucosal folds and nodular projections
• Pyosalpynx
–Internal echoes
–Absent color doppler blood flow
–Adjacent ovary may indent tube wall

36. Ectopic Pregnancy
➤ Exclusion of an intrauterine chorion-type
structure
➤ Presence of an extrauterine and extraovarian
chorion-type structure
➤ Demonstrable embryonic heart activity and
movements within the structure (5% of cases)
➤ Enlarged uterus with a thickened endometrium
of high echogenicity
➤ Free fluid in the cul-de-sac and paracolic gutters
with clot formation and fibrin strands
(hemoperitoneum)

37. Role in Ectopic Pregnancy
• On color Doppler "ring of fire” is visualized, owing to the
low-impedance high diastolic flow seen in pregnancy that
can surround the tubal ring of an ectopic pregnancy.
• However, a hypervascular ring (Figs 13, 15) around a mass
in the pelvis is more likely to be visualized around the
corpus luteum than an ectopic pregnancy. This is because
both corpus luteum cysts and ectopic pregnancies can be
very vascular with low-impedance flow; however, corpus
luteum cysts are much more common than ectopic
pregnancies. Color Doppler imaging is most helpful when
an ectopic pregnancy is not seen but is highly suspected. In
that case color Doppler imaging can be used to help find a
mass surrounded by bowel loops.
Deborah Levine,MD. Ectopic Pregnancy. Radiology: Volume 245: Number 2—
November 2007

38. Role in Infertility
• Uterine flow velocity has a resistance index of 0.88 +/- 0.04 (2 SE) in
the proliferative phase and starts to decrease the day before
ovulation.
• A nadir of 0.84 +/- 0.04 is reached on day 18 and remains at that
level for the rest of the cycle.
• In anovulatory cycles, these changes do not occur. A subgroup of 12
women who lacked end diastolic flow in the uterine arteries during
the secretory phase were identified. Eleven of these women were
infertile, 8 of whom with primary infertility.
• Ovarian artery flow velocity is usually detected when the dominant
follicle reaches 12 to 15 mm. The resistance index is 0.54 +/- 0.04
and also declines on the day before ovulation.
• A nadir of 0.44 +/- 0.04 is reached 4 to 5 days later and slowly rises
to 0.050 +/- 0.04 before menstruation.
Kurjak A, Kupesic-Urek S, Schulman H, Zalud. Transvaginal color flow Doppler in the assessment of ovarian and uterine blood
flow in infertile women. Fertil Steril. 1991 Nov;56(5):870-3.

39. Role in Infertility
• There are changes in the flow velocity patterns of
the uterine and ovarian arteries during the
normal ovulatory menstrual cycle. Because these
changes in flow velocity begin before ovulation, it
can be suspected that they may involve
angiogenesis as well as hormonal factors. The
changes noted in these studies are statistically
significant but may be too small to be used as a
diagnostic tool in the study of infertility
problems.
Kurjak A, Kupesic-Urek S, Schulman H, Zalud. Transvaginal color flow Doppler in the assessment of ovarian and uterine blood
flow in infertile women. Fertil Steril. 1991 Nov;56(5):870-3.

40. Role in Fertilization
• Steer et al.23 calculated the likelihood of
pregnancy on the day of embryo transfer based
on pulsatility values in the uterine arteries.
• According to their findings, the likelihood of
pregnancy was greatest when medium PI values
were measured in the uterine artery. In 35% of
cases, pregnancy did not occur when the mean PI
value before the embryo transfer was greater
than 3.0.
Steer CV, Mills CV, Campbell S: Vaginal color Doppler assessment on the day of embryo transfer (ET) accurately predicts
patients in an invitro fertilization programme with suboptimal uterine perfusion who fail to become pregnant. Ultrasound
Obstet. Gynecol. 1 (1991) 79–82

41. Role in Assisted Fertilization
• Tsai et al. investigated the prognostic value of uterine
perfusion on the day of human chorionic gonadotropin
(hCG) administration in patients who were undergoing
intrauterine insemination.
• They calculated the PI of the ascending branch of the
uterine artery on the day of hCG administration and
compared the vascular resistance in the uterine artery with
the outcome of intrauterine insemination.
• No pregnancy occurred when the PI was greater than 3.
The fertilization rate was 18% when the PI was less than 2
and 19.8% when the PI was between 2 and 3.
• These data indicate that the measurement of uterine
perfusion on the day of hCG administration may be of value
in predicting the success of intrauterine insemination.
Tsai YC, Chang JC, Tai MJ, Kung FT, Yang LC, Chang SY: Relationship of uterine perfusion to outcome of
intrauterine insemination. J. Ultrasound Med. 15 (1996) 633–636

42. Role in Assisted Fertilization
• Zaidi et al. investigated whether the assessment of uterine artery blood
flow by transvaginal color Doppler scanning on the day
• of hCG administration in patients undergoing in-vitro fertilization
• (IVF) could predict pregnancy and implantation rates.
• One hundred thirty-five patients undergoing 139 IVF cycles were
analyzed. The results of the study suggest that the measurement of the
uterine artery PI on the day of hCG administration can predict the
likelihood of successful implantation, since the highest pregnancy rate
(34.7%) was associated with a uterine artery PI between 2 and 3.
• If possible, hCG should be administered when the uterine artery PI is
less than 3 in order to achieve a high implantation rate.
Zaidi J, Pitroff R, Shaker A, Kyei-Mensah A, Campbell S, Tan SL: Assessment of uterine artery blood flow on the day
of human chorionic gonadotropin administration by transvaginal color Doppler ultrasoun in an in vitro
fertilization program. Fertil. Steril. 5(2) (1996) 377–381

43. Uterine Blood Flow in the Normal Cycle and during
Ovarian Stimulation with Confirmed
Ovulation
• Kupesic and Kurjak measured blood flow
velocities in the uterine, radial, and spiral
arteries during the periovulatory period of
normal cycles and in stimulated cycles with
confirmed ovulation.
• In normal cycles, the uterine artery PI was
3.16 two days before ovulation and decreased
to 2.22 on the day before ovulation.
Kupesic S, Kurjak A: Uterine and ovarian perfusion during the periovulator period
assessed by transvaginal color Doppler. Fertil. Steril. 60 (1993) 439–443

44. Uterine Blood Flow in the Normal Cycle and during
Ovarian Stimulation with Confirmed Ovulation
• This difference was not observed in stimulated
cycles. The mean PI was 3.06 and remained
unchanged during the periovulatory period.
• Distinct waveforms could be recorded from
the endometrium and myometrium during
this period. The PI in the radial and spiral
arteries showed higher values in stimulated
cycles than in normal cycles.
Kupesic S, Kurjak A: Uterine and ovarian perfusion during the periovulator period
assessed by transvaginal color Doppler. Fertil. Steril. 60 (1993) 439–443

45. Conclusion
• Blood flow changes in the spiral arteries can be
considered an accurate predictor of implantation
success rates in patients undergoing IVF and
embryo transfer.
• In patients who are found to have unfavorable
uterine blood flow in the current treated
menstrual cycle, the embryos should be frozen
and the transfer postponed for a normal cycle or
a cycle with favorable endometrial blood flow in
response to therapy.

46. Doppler in Menopause—Ovarian Artery
• Premenopausal
– The RI is 0.54 shortly before ovulation, starts to
decline two days before ovulation, and reaches its
low point of 0.44 at the time of ovulation.
– The mature corpus luteum normally has a
diameter of 1–3cm and shows low impedance
values (mean RI 0.43).
– On just the 23rd day after menstruation, the
corpus luteum begins to undergo regressive
changes.
– Decreased blood flow velocities and an increased
RI (mean value 0.49) are the typical signals of
these changes Zalud I, Kurjak A: The assessment of luteal blood flow in pregnant and non-pregnant
women by transvaginal color Doppler. J. Perinat. Med. 18 (1990) 215–221

47. Doppler in Menopause—Ovarian
Artery
• Postmenopausal
– Absent diastolic flow in the ovarian artery was a
common finding in the early postmenopausal period
and was consistently present in women who had been
in menopause for more than 11 years
– any signals that are detected with color Doppler
ultrasound in the postmenopausal ovary should be
considered highly suspicious for abnormal
neovascularization and should prompt a detailed
investigation with pulsed Doppler.
Zalud I, Kurjak A: The assessment of luteal blood flow in pregnant and non-pregnant women
by transvaginal color Doppler. J. Perinat. Med. 18 (1990) 215–221

48. Uterine blood flow after menopause
• Continuous diastolic flow seen in the uterine
arteries of all healthy, fertile control subjects.
• The uterine arteries of postmenopausal women
showed increasing vascular impedance that was
manifested by a narrow systolic waveform and a
high RI.
• It should be noted, however, that the change in
vascular impedance and absence of diastolic flow
in the ovarian arteries are the most conspicuous
signs.
Bonilla Musoles F, Marti MC, Ballester MJ: Normal uterine arterial blood flow in postmenopausal women assessed by
transvaginal color Doppler sonography: the effect of hormone replacement therapy. J. Ultrasound Med. 14 (1995) 497 –
501

49. Color Doppler Sonography for the Optimization of
Assisted Reproduction
• The implantation rate declines with increasing pulsatility index
(Fig. 6.19).
• No pregnancies were achieved above a pulsatility index of
3.5 or above a resistance index of 0.95.
• A pulsatility index over 3.5 or a resistance index over 0.95
signified a nonreceptive endometrium with a specificity of
100% and a sensitivity of 14%. The positive predictive value
for these cutoff limits is 100%.
Zaidi J, Campbell S, Pittrof R, Tan SL: Endometrial thickness, morphology vascular penetration and velocimetry in
predicting implantation in an in vitro fertilization program. Ultrasound Obstet. Gynecol. 6 (1995) 191–198
B. Hüneke, A. Kleinkauf-Houcken, C. Lindner, and W. Braendle. Color Doppler Sonography in Gynecology and
Obstetrics

50. Color Doppler Sonography for the Optimization of
Assisted Reproduction
B. Hüneke, A. Kleinkauf-Houcken, C. Lindner, and W. Braendle. Color Doppler Sonography
in Gynecology and Obstetrics

51. Endometrial receptivity.
• Doppler measurements of uterine blood flow
can be used in the assessment of endometrial
receptivity. High uterine vascular resistance
implies a markedly reduced chance of
fertilization.
• Decreased uterine perfusion can be a significant
obstacle to implantation in infertile patients. Very
high vascular resistance in the uterine arteries
reflects poor endometrial receptivity and
suggests that assisted reproductive techniques
will be unsuccessful.
• .
B. Hüneke, A. Kleinkauf-Houcken, C. Lindner, and W. Braendle. Color Doppler
Sonography in Gynecology and Obstetrics

52. Endometrial receptivity.
• Although the sensitivity of uterine artery
impedance measurements is only 14% owing to
the numerous factors that affect receptivity,
resistance values above the 90th percentile
predict a nonreceptive endometrium with 100%
specificity and a positive predictive value of
100%.
• With a severe decrease in uterine perfusion, the
likelihood of implantation is so low that assisted
reproduction therapies should be discontinued
without appropriate preliminary treatment
B. Hüneke, A. Kleinkauf-Houcken, C. Lindner, and W. Braendle. Color Doppler
Sonography in Gynecology and Obstetrics

53. Diagnostic quality of transvaginal sonographic examinations
without color Doppler and with color Doppler

54. THANK YOU