• A Guide to Infertility Ultrasounds

      The tests, exams and procedures that make up assisted reproductive technology (ART) diagnosis and treatment can be confusing and even intimidating to new infertility patients. Ultrasounds are practically synonymous with pregnancy; but did you know that ultrasounds also go hand-in-hand with assisted reproductive technology (ART)? Ultrasound imaging is commonly used throughout most infertility treatments in order to give the doctor an accurate look at your pelvic organs. As treatment continues, re-checking things on an ultrasound is an easy way to chart progress and change.

      Ultrasounds are safe, painless, and a very important component of your treatment. This article is designed to demystify the ultrasound experience for you before you go. That way, you can focus on the bigger picture during your exam, and use the time you have with your doctor wisely.

      What Your Doctor Sees
      Your doctor can tell a lot about your fertility and treatment progress by looking at your pelvic organs via ultrasound. An ultrasound is a live, moving picture of your insides. Ultrasounds allows your doctor to visualize your:

      Uterus, including:

      • size
      • shape
      • contents
      • thickness of lining
      • presence or absence of fibroids
      • presence or absence of polyps

      Ovaries, including:

      • size
      • shape
      • position within abdominal cavity
      • antral follicles
      • follicles
      • follicle size/shape
      • ovarian cysts

      Pregnancy, including:

      • gestational sac
      • fetal pole
      • heartbeat
      • position of placenta
      • number of fetuses
      • bloodflow (via doppler ultrasound)
      • etc.

      The Ultrasound Machine

      Most portable ultrasound machines are very similar in look and style. They all have the same basic components, and are used for the same tasks. There are higher-end models available that have more bells and whistles, but a basic setup is all many doctors need for their practices.

      As you can see in the picture below, there are several different components of the portable ultrasound machine. The display is like a computer monitor; it shows the doctor (and you) a live picture of your insides. The pulse controls allow your doctor to make adjustments to the amplitude, rate and frequency of the sound waves. The keyboard is for inputting text (like a computer keyboard). And the computer's CPU and printer run the machine and then print out the results. Some models have a tape or DVD attachment, so that a recording of the exam can be saved for the records.

      The transducer is a wand or box that is attached to the ultrasound machine via a long cord. There are differently-shaped transducers for different uses.
      In the photo above, the transducer is not pictured. (There is a small hook that is visible above the keyboard on the right side of the picture. This is where the transducer can be hung when not in use.)

      Abdominal Ultrasound

      You've probably seen an abdominal ultrasound being performed. If not in person, you almost assuredly have seen one on television. They're quite common; abdominal ultrasounds are the type of imaging done when a woman is pregnant. For an abdominal ultrasound, the person performing the exam (typically a doctor, nurse, or ultrasound tech) holds the transducer. A small amount of ultrasound gel (a water-soluble gel) is placed on the abdomen, and then the transducer is placed gently on top of the gel. The gel not only provides a lubricated surface for the transducer to glide across, it also enhances the picture. Ultrasound waves must travel through fluid. And since the ultrasound waves need to travel through fluid, you need a full bladder before and during the abdominal ultrasound (and the relief of having an abdominal ultrasound be over never felt so good).

      Transvaginal Ultrasound
      One of the most common parts of an infertility exam is the transvaginal ultrasound. For a lot of women, just reading the word 'transvaginal' is enough to cause some anxiety. And yes, while it works exactly how you think it might (based on its name), it's really not as awful as you may be imagining.

      Rather than the short, wide transducer used for abdominal ultrasounds, a transvaginal ultrasound uses a long, thin wand. The wand is covered in ultrasound gel and then a condom is layered over the top. This arrangement helps keep the transducer in contact with the body at all times, in addition to keeping everything sanitary.

      Because the transducer wand has to be inserted into the vagina, it is necessary for you to lay on the exam table with your feet in the gynecological stirrups. Most doctors want you undressed 'from the waist down' (take off pants/skirt and underwear), although some will have you get completely undressed and put on a gown. In both cases, you will be given a sheet to hold on to which will help you cover yourself when the doctor is not performing the exam.

      For some unknown reason, nearly all exam tables are oriented so that the foot of the table faces the doorway. Perhaps it's a coincidence, or a quirk of how doctors' exam rooms are usually organized, or maybe it's a strange twist of comic, cosmic fate. In any case, there is absolutely NO NEED to be in the 'exam position' before your doctor walks in and says hello.

      No matter what your comfort level may be with a full pelvic exam, the transvaginal ultrasound exam is going to be easier, more comfortable, and much quicker. The doctor will touch you gently so that you know exactly where his hands are, and then he will guide the transducer wand into your vagina. The doctor will likely shift his focus to the ultrasound monitor, so that he can position the wand exactly where he needs it. When the doctor is finished with the exam he will simply remove the wand, hand it to an assistant for cleaning, and hand you a few tissues. Most doctors will step out and let you wipe off the gel and put your pants back on before coming back to talk. Others simply keep talking to you and you have to try your best to look cool and intelligent while sitting pant-less on a too-short table.

      What does the imaging look like?

      Here are a few examples of what you might see on a transvaginal ultrasound. The first few times you look at the images, you might not see much more than fuzzy gray streaks. Rest assured, your doctor is very used to seeing these images and knows exactly what to look for.

      Ovary. Follicles visible as
      dark spots.
      Uterus. Deflated balloon

      The image on the left is that of an ovary during FSH stimulation of an IVF cycle. Each of the dark spots is a growing follicle. The doctor uses this image in conjunction with your E2 (estradiol) level to gauge your progress, adjust your stimuation medications, and determine when it is time to induce ovulation before retrieval.

      The image on the right is that of a uterus. The deflated-balloon shape is typical. The brighter white line in the center of the balloon indicates the inner lining of the uterus; by measuring in this area, your doctor can determine the thickness of your endometrium - which in turn indicates whether or not the uterus is ready to receive an embryo transfer.

      Although there is a lot of information on these pages, there are really only a few things you need to know. if you're starting infertility treatments of any kind, ultrasounds are standard imaging procedures that your doctor will use regularly to monitor your progress. There is usually little or no discomfort; if you do experience discomfort, speak up and tell your doctor. Often, doctors don't know how you're feeling unless you speak up and tell them.
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