Complete evaluation of anatomy and morphology of the infertile patient in a single visit; the modern infertility pelvic ultrasound examination  Yvette S. Groszmann, M.D., M.P.H., Beryl R. Benacerraf, M.D.  Fertility and Sterility  Volume 105, Issue 6, Pages 1381-1393 (June 2016) DOI: 10.1016/j.fertnstert.2016.03.026 Copyright © 2016 American Society for Reproductive Medicine Terms and Conditions

Figure 1 Normal uterus. (A) A longitudinal view of the uterus showing the characteristic trilaminar pattern of the endometrium in the late proliferative phase, surrounded by normal myometrium. (B) Three-dimensional volume of a normal uterus showing the reconstructed coronal view. Note that this view permits the visualization of the entire endometrial cavity and serosal surface of the uterus. Fertility and Sterility 2016 105, 1381-1393DOI: (10.1016/j.fertnstert.2016.03.026) Copyright © 2016 American Society for Reproductive Medicine Terms and Conditions

Figure 2 Fibroid. (A) Two-dimensional image of an intracavitary fibroid, contained within the endometrial echo. (B) Coronal view using three-dimensional reconstruction demonstrating that the submucosal fibroid is located in the right side of the uterus projecting into the cavity just below the cornu. A second fibroid that is intramural is faintly seen on the other side. Fertility and Sterility 2016 105, 1381-1393DOI: (10.1016/j.fertnstert.2016.03.026) Copyright © 2016 American Society for Reproductive Medicine Terms and Conditions

Figure 3 Polyp. (A) Longitudinal two-dimensional view of an irregularly thickened endometrium within a retroverted uterus. (B) After saline instillation into the uterine cavity, outlining a small polyp. Color Doppler demonstrates a feeding vessel in the polyp. (C) The same polyp using three-dimensional reconstruction during the sonohysterography. The endometrium appears thin and normal except for the presence of the polyp in the lower uterine segment. Fertility and Sterility 2016 105, 1381-1393DOI: (10.1016/j.fertnstert.2016.03.026) Copyright © 2016 American Society for Reproductive Medicine Terms and Conditions

Figure 4 Adenomyosis. (A) Two-dimensional transverse view of an enlarged, globular uterus with heterogeneous appearing myometrium, a myometrial cyst, and ill-defined endometrium, all characteristic of adenomyosis. Not all cases display all features. (B) Three-dimensional reconstructed view of a uterus with extensive adenomyosis. Note the jagged interrupted junctional zone containing multiple subendometrial cysts consistent with invading dilated glands. Fertility and Sterility 2016 105, 1381-1393DOI: (10.1016/j.fertnstert.2016.03.026) Copyright © 2016 American Society for Reproductive Medicine Terms and Conditions

Figure 5 Bicornuate and septate uteri. These two images show the coronal uterine view of two women with different müllerian duct anomalies. Note that both uteri have similarly shaped endometrial cavities, hence the hysterosalpingographies (HSGs) would look alike although these women have different uterine anomalies. (A) Three-dimensional ultrasound in which an indentation can be seen on the serosal uterine surface indicated by calipers, consistent with a bicornuate uterus. (B) No such indentation, consistent with a complete uterine septum. Three-dimensional ultrasound is superior to HSG because it can demonstrate both the cavity and the serosal surface of the uterus, without dye or radiation, so as to make the correct diagnosis. An HSG, on the other hand, cannot be used to differentiate a septate from a bicornuate uterus. Fertility and Sterility 2016 105, 1381-1393DOI: (10.1016/j.fertnstert.2016.03.026) Copyright © 2016 American Society for Reproductive Medicine Terms and Conditions

Figure 6 Septate uterus. (A) Three-dimensional coronal view of a uterus with a complete septum. The depth of the septum is measured using a vertical measurement from the midcornual line to the bottom of the uterine portion of the septum, as demonstrated by the calipers. A measurement of ≥10 mm defines a septum. (B, C) Example before and after septum resection. (B) Incomplete septum using a three-dimensional reconstructed view. Note the measurement of the septum occurs from the midcornual line vertically. (C) Postsurgical image after this septum has been resected. Note that there is only a slight residual dip in the midline of the cavity. Fertility and Sterility 2016 105, 1381-1393DOI: (10.1016/j.fertnstert.2016.03.026) Copyright © 2016 American Society for Reproductive Medicine Terms and Conditions

Figure 7 Arcuate uterus. Three-dimensional coronal view of the uterus showing the arcuate shape of the endometrial cavity with a normal fundal serosal surface. Note that the measurement of the midline indentation of the cavity is made perpendicular from the cornual line. If the measurement is less than 10 mm, the shape is considered arcuate. Fertility and Sterility 2016 105, 1381-1393DOI: (10.1016/j.fertnstert.2016.03.026) Copyright © 2016 American Society for Reproductive Medicine Terms and Conditions

Figure 8 Unicornuate uterus. Three-dimensional coronal view showing a right unicornuate uterus. There is only a single uterine horn on the right with an endometrial cavity. The small bump on the left lower side of the uterus is a small rudimentary horn with no cavity. Fertility and Sterility 2016 105, 1381-1393DOI: (10.1016/j.fertnstert.2016.03.026) Copyright © 2016 American Society for Reproductive Medicine Terms and Conditions

Figure 9 Didelphic uterus. Three-dimensional coronal view of a uterus didelphys. Note that the field-of-view is set at 180° to capture an image of both horns simultaneously. The two uterine horns are completely separate and located very far apart in the pelvis, coming together just above the cervix. This type of uterus is typically difficult to image unless each horn is viewed separately. Fertility and Sterility 2016 105, 1381-1393DOI: (10.1016/j.fertnstert.2016.03.026) Copyright © 2016 American Society for Reproductive Medicine Terms and Conditions

Figure 10 Unclassified uteri. Three-dimensional coronal views of two different patients who have not been able to conceive and who have unclassified uterine anatomy. (A) Severely T-shaped and very wide uterus, a very unusual configuration. (B) Uterus that is almost completely tubular without the usual triangular shape at the fundus, and not unicornuate. Fertility and Sterility 2016 105, 1381-1393DOI: (10.1016/j.fertnstert.2016.03.026) Copyright © 2016 American Society for Reproductive Medicine Terms and Conditions

Figure 11 Sonohysterography. Three-dimensional coronal reconstructed view of a normal uterus during a sonohysterogram. Note the tip of the catheter past the internal os. The saline in the cavity outlines a normal endometrial surface. Fertility and Sterility 2016 105, 1381-1393DOI: (10.1016/j.fertnstert.2016.03.026) Copyright © 2016 American Society for Reproductive Medicine Terms and Conditions

Figure 12 Asherman's syndrome. These are two- and three-dimensional views of a uterus with multiple adhesions, consistent with Asherman's syndrome. (A) Multiple bands or synechia outlined by saline during a sonohysterogram. (B) Three-dimensional reconstructed view, showing a more global picture of the deformed and scarred uterine cavity. Note the catheter in the endometrial cavity. Fertility and Sterility 2016 105, 1381-1393DOI: (10.1016/j.fertnstert.2016.03.026) Copyright © 2016 American Society for Reproductive Medicine Terms and Conditions

Figure 13 Hydrosalpinx. (A) Large hydrosalpinx as seen in two-dimensions showing what appears to be a septated cyst. (B) Three-dimensional volume demonstrating that the cyst in the upper two frames actually represents a hydrosalpinx oriented in a different plane from the two-dimensional scanning plane. It is best appreciated in the left lower image because the hydrosalpinx lies within the reconstructed plane. (C) The same hydrosalpinx using the volume inverse mode where the cystic parts are opaque, much like a cast. These images are all reconstructed from the same volume, thus showing the versatility of volume imaging by ultrasound. Fertility and Sterility 2016 105, 1381-1393DOI: (10.1016/j.fertnstert.2016.03.026) Copyright © 2016 American Society for Reproductive Medicine Terms and Conditions

Figure 14 Hysterosalpingo-contrast sonography (HyCoSy). Transverse two-dimensional view through the uterine fundus showing fine echogenic lines emanating from both cornua. These lines represent air in the proximal fallopian tubes. Fertility and Sterility 2016 105, 1381-1393DOI: (10.1016/j.fertnstert.2016.03.026) Copyright © 2016 American Society for Reproductive Medicine Terms and Conditions

Figure 15 Endometrioma. Two-dimensional transvaginal view of a typical endometrioma showing relatively smooth walls and low-level, homogeneous internal echoes. Blood flow is only seen in the periphery. Fertility and Sterility 2016 105, 1381-1393DOI: (10.1016/j.fertnstert.2016.03.026) Copyright © 2016 American Society for Reproductive Medicine Terms and Conditions

Figure 16 Kissing ovaries. Two-dimensional transverse view across the cul-de-sac and uterine body, showing the uterus and both ovaries; the left one contains an endometrioma. Note that both ovaries are adhered to the posterior uterine serosa in the cul-de-sac and adhered to each other, coined kissing ovaries, in this patient with extensive endometriosis. Fertility and Sterility 2016 105, 1381-1393DOI: (10.1016/j.fertnstert.2016.03.026) Copyright © 2016 American Society for Reproductive Medicine Terms and Conditions

Figure 17 Endometriosis implants on bowel. Two-dimensional views from two different patients, both of whom have stage IV endometriosis involving the bowel. (A) Hypoechoic lobular lesion (calipers) behind the cervix representing an implant of endometriosis on the anterior wall of the rectosigmoid. (B) More spiculated endometriotic implant in a different patient. The irregular spiculated look has been coined the “comet sign” (37). Fertility and Sterility 2016 105, 1381-1393DOI: (10.1016/j.fertnstert.2016.03.026) Copyright © 2016 American Society for Reproductive Medicine Terms and Conditions

Figure 18 Corpus luteum. Two-dimensional view of a right ovarian cyst shows some solid material within the cyst and intense circumferential blood flow. There is no evidence of blood flow within the cyst, and the abundant flow gives the appearance of a ring of fire, typical of a corpus luteum. This is a hemorrhagic corpus luteum with retracting clot within the cystic portion. Fertility and Sterility 2016 105, 1381-1393DOI: (10.1016/j.fertnstert.2016.03.026) Copyright © 2016 American Society for Reproductive Medicine Terms and Conditions

Figure 19 Borderline ovarian tumor. This patient had bilateral borderline cystadenomas discovered during an initial scan for infertility. (A, B) Two-dimensional images of the left ovarian tumor with color Doppler showing internal nodularity containing vascularity, worrisome for a malignancy. Fertility and Sterility 2016 105, 1381-1393DOI: (10.1016/j.fertnstert.2016.03.026) Copyright © 2016 American Society for Reproductive Medicine Terms and Conditions

Figure 20 Polycystic ovary (PCO). (A) Set of three-dimensional reconstructed images showing a typical ovary with sonographic criteria consistent with PCO. (B) Three-dimensional volume image using inverse mode showing the ovary of a different patient with PCO, demonstrating the numerous, <10 mm individual follicles. Fertility and Sterility 2016 105, 1381-1393DOI: (10.1016/j.fertnstert.2016.03.026) Copyright © 2016 American Society for Reproductive Medicine Terms and Conditions