Transvaginal Probe Research Articles

OC10.01: Rectal deep endometriosis: transrectal approach with transvaginal probe to assess the infiltration of rectal mucosa

OC10.01: Rectal deep endometriosis: transrectal approach with transvaginal probe to assess the infiltration of rectal mucosa

Role of 3D and 3D Power Doppler to Assess Endometrial Receptivity in IUI Cycles

ABSTRACTBackgroundThe assessment of the endometrial receptivity at the time of human chorionic gonadotrophin (hCG) is one of the key factors for success of all ART procedures.AimTo assess, if 3D and 3D power Doppler assessment of endometrial receptivity before giving hCG, helps improving pregnancy rates in superovulation with IUI cycles.Settings and DesignA prospective randomized study of 2500 cycles of IUI was done over a period of twelve months for pre-hCG endometrial assessment.MethodEndometrial assessment was done on Voluson 730 Expert, (Wipro GE) using transvaginal multifrequency volume probe 5 to 9 MHz. When follicles and endometrium were considered mature by 2D US and color Doppler, 3D and 3D power Doppler assessment of the endometrium was done before giving hCG. These values were evaluated for conception and nonconception groups.ResultsConception rates were higher, when endometrial volume was between 3 and 7 cc. In our study, we have found endometrial FI > 20 and endometrial VFI > 40 as most optimum.Conclusions3D ultrasound is accurate for volume assessment of endometrium. 3D and 3D PD, when used with 2D US and color Doppler for pre-hCG endometrial assessment, it would definitely improve implantation rates in IUI cycles.

405 LEVELS OF HORMONES AND NITRIC OXIDE PRESENT IN FOLLICULAR FLUID UNDER OR NOT UNDER SUPEROVULATION IN MARES

The aim of the present study was to compare the levels of 17β-estradiol, testosterone, progesterone, inibin, and nitric oxide in follicular fluid between superovulated mares (G1) using equine pituitary extract (EPE) and nonsuperovulated mares (G2) used as control. Two estrus cycles from 24 mares (G1 = 12; G2 = 12) were monitored. In G1, the first cycle was used to determine the ovulation day (Day 0), followed by the administration of PGF2 (250 μg daily of cloprostenol; Sincrocio™, Ouro Fino, São Paulo, Brazil) on the first and second day of treatment with EPE. During the second cycle, EPE (25 mg i.m.) was administered twice daily from Day 7 to the ultrasound detection of a majority of follicles at least 35 mm in diameter. At this time, 2500 IU of hCG IV (Vetecor™, Hertape Calier, Minas Gerais, Brazil) was given. The same protocol was used for G2 as was used for G1 except that EPE administration was replaced by saline injections. For follicular aspiration, the mares were sedated with xilazine (0.5 mg kg-1; Sedazine™, Fort Dodge, São Paulo, Brazil) and acepromazine (0.05 mg kg-1; Acepram 1%™, Univet, Milton, Ontario Canada); hioscin bromide (Buscofin™, Agener União, São Paulo, Brazil) was also administered to reduce intestinal motility and to make ovary manipulation by way of the rectum easier. All follicles larger than 35 mm were aspirated using a Cook® double lumen needle (12 GA) in a transvaginal aspiration probe guided by ultrasonography. The number of aspirated preovulatory follicles was 4.75 ± 2.7 and 1.0 ± 0.0 for G1 and G2, respectively. The follicular fluid collected was centrifuged at 600 × g for 10 min in order to separate the fluid from the cells. The fluid was stored at -20°C and sent to the University of California (Davis, USA) for hormonal assay. The nitric oxide dosage was determined at São Paulo State University (Botucatu, Brazil) using the luminescent reaction of Griess. The comparison between groups of hormonal levels and nitric oxide was performed using the t-test at 5% significance. The results of the present study showed that the EPE treatment (G1), under the experimental conditions, did not lead to a significant change in the mean concentrations of the evaluated hormones or of nitric oxide in the follicular fluid when compared with the levels in G2. However, differences were found among the individuals only in G1 in all hormones (P < 0.05), with exception of progesterone (P > 0.05). Table 1.Mean and standard error of the follicular fluid hormones and nitric oxide levels of groups G1 and G2 Supported by FAPESP, Brazil.

Vaginal fetal fibronectin evaluation before and immediately after ultrasonographic vaginal cervical length measurements in symptomatic women at risk of preterm birth: A pilot study

Objective. To determine if vaginal ultrasound for cervical length measurement induces the release of vaginal fetal fibronectin (fFN), leading to a false-positive fFN test.Methods. Participants included women with singleton pregnancies at 24–34 weeks' gestation who presented with uterine contractions without bleeding or membrane rupture. Women who had had intercourse or underwent pelvic examination less than 24 h previously were excluded. The first fFN test was followed immediately by vaginal ultrasonography with a transvaginal probe (three images per patient) and, thereafter, a second fFN test.Results. The first fFN test was positive in three patients, and in all, the second, post-ultrasound, fFN test was also positive. In all women with a negative baseline fFN test (n = 25), the second, post-ultrasound, fFN test was also negative.Conclusion. Vaginal ultrasound examination does not artificially change the fFN status. This is in contrast to common understanding and may permit the performance of ultrasound examination before fFN, which can be restricted to cases of short cervix.

Ectopic pregnancy: Challenging accepted management strategies

Ectopic pregnancy is still the number one cause of maternal deaths in early pregnancy. The diagnostic capabilities of transvaginal ultrasound to confirm an EP are well founded. In fact, ultrasound technology, particularly the introduction of high-resolution transvaginal probes, has been the driving force behind the revolutionary change towards conservative management strategies in ectopic pregnancy care. Clinically stable women, however, with a scan diagnosis of a tubal ectopic pregnancy still routinely undergo surgery or are given methotrexate (MTX) at presentation. Conservative management for ectopic pregnancy may be considered in the context of clinical stability. Reassessment at 48 h allows evaluation of the trophoblast activity or 'trophoblastic load'. Falling serum hCG levels at 48 h suggest that the ectopic trophoblast is resolving spontaneously and it may be possible to avoid methotrexate administration in this sub-group. Women with increasing serum hCG levels at 48 h, indicating the trophoblast is still active, should be targeted for methotrexate. By calculating the pre-treatment hCG ratio (hCG 48 h/hCG 0 h), it is possible to triage women with an ectopic pregnancy for conservative management. There are, however, no randomised data to support the use of MTX over expectant management. In this review, some of the current management strategies in ectopic pregnancy management will be challenged.

Laparoscopically-assisted transabdominal oocyte retrieval in an infertility patient with ovarian malposition.

Infertility patients with malpositioned ovaries have considerable difficulty conceiving naturally because of extended fallopian tubes and ovarian malposition; such patients turn for help to assisted reproductive technology (ART) treatment. For most of these patients, ovarian malposition prevents transvaginal oocyte retrieval, so the transabdominal approach for oocyte retrieval is required. One of our infertility patients presented with ovarian malposition, and laparoscopy-assisted transabdominal oocyte retrieval was performed. We performed a Gonadotropin-releasing hormone agonist (GnRH-a) long protocol with human menopausal gonadotropin (hMG) ovarian stimulation, and used a standard transvaginal probe through the anterior abdominal wall for ovarian imaging and monitoring of the growing follicles. The patient underwent laparoscopically-assisted transabdominal oocyte retrieval-9 oocytes were recovered, and 5 were fertilized, and 2 embryos were transferred to the patient's uterus. The patient became pregnant and a gestational sac was detectable by transvaginal ultrasonography, but she spontaneously miscarried. The patient then received several laparoscopically-assisted transabdominal oocyte retrievals and finally became pregnant following a thawed embryo transfer during a hormone replacement cycle, and now her pregnancy is going well.

Three‐dimensional volume‐rendered imaging of embryonic brain vesicles using inversion mode

The purpose of this study was to present our first experience of normal embryonic brain vesicle shapes in the early first trimester of pregnancy, reconstructed by three-dimensional (3D) volume-rendered imaging using the inversion mode. Twenty-three women who were between 7.4 and 9.7 weeks of gestation were studied using 3D ultrasound with a mechanical 3.7-9.3 or 4.5-11.9 MHz 3D transvaginal probe. In order to clarify the anatomical correlation of the embryonic and fetal brain vesicles, the inversion mode was used. One patient who was at 7.4 weeks of gestation was excluded from the study because of the relative shallow scanning range of the 3D transvaginal transducer and very small embryonic brain structures. When viewed by means of transvaginal 3D volume-rendered imaging using the inversion mode, the brain vesicles were the most prominent structures at each week, and were clearly seen as multilobular consecutive structures. All embryos studied had five secondary brain vesicles. Moreover, the dramatic change of embryonic brain vesicle shapes with advancing gestation was noted during this period. Our results suggest that transvaginal 3D volume-rendered imaging using the inversion mode provides accurate visualization of embryonic brain vesicle structures in utero.

Cervical mucus status can be accurately estimated by transvaginal ultrasound during fertility evaluation

Examinations of the cervical mucus for determining its quantity and physical characteristics are used to provide a clinical marker for the timing of ovulation. We propose that transvaginal ultrasound, which is routinely used as a tool for monitoring follicular growth in patients undergoing ovulation induction, might also be used simultaneously for estimating cervical mucus measurements. With no additional effort or expense, these data may help to optimize individual patient management.

Transcervical microwave myolysis for uterine myomas assisted by transvaginal ultrasonic guidance

The effects of transcervical microwave myolysis at 2.45 GHz after microwave endometrial ablation for menorrhagia were examined in patients with myomas. A transcervical microwave irradiation system assisted by transvaginal ultrasonic guidance was developed. Ten patients waiting for microwave endometrial ablation for menorrhagia caused by myomas entered the study after complete informed consent was obtained. Their outcomes were examined at least 6 months after transcervical microwave myolysis using the system. After completion of microwave endometrial ablation, interstitial microwave irradiation was performed using a guiding needle set in a puncture adaptor attached to a transvaginal ultrasonic probe and a microwave applicator of 1.6 mm in diameter. Shrinkage of the myoma was measured at 3 months and > or =6 months after the operation. In nine patients with typical myomas, the major part consisting of a submucous or an intramural node 4.0-7.5 cm in size was necrotized. The typical myomas had shrunk by 41-68% at 3 months and 37-69% at > or =6 months after the operation. In one patient with a 6.8-cm cellular leiomyoma, necrosis was limited to the neighborhood of the applicator tip. Shrinkage was 17% at both 3 and 6 months. This patient required a second microwave endometrial ablation at 6 months to treat recurrent menorrhagia. None of the patients underwent hysterectomy after the treatment. No remarkable complications were encountered. Typical myomas shrink after microwave myolysis following microwave endometrial ablation. Transcervical microwave myolysis seems to be applicable as a low-invasive treatment for a typical myoma.

Maintaining quality assurance for sonographic nuchal translucency measurement: lessons from the FASTER Trial

To evaluate nuchal translucency measurement quality assurance techniques in a large-scale study. From 1999 to 2001, unselected patients with singleton gestations between 10 + 3 weeks and 13 + 6 weeks were recruited from 15 centers. Sonographic nuchal translucency measurement was performed by trained technicians. Four levels of quality assurance were employed: (1) a standardized protocol utilized by each sonographer; (2) local-image review by a second sonographer; (3) central-image scoring by a single physician; and (4) epidemiological monitoring of all accepted nuchal translucency measurements cross-sectionally and over time. Detailed quality assessment was available for 37 018 patients. Nuchal translucency measurement was successful in 96.3% of women. Local reviewers rejected 0.8% of images, and the single central physician reviewer rejected a further 2.9%. Multivariate analysis indicated that higher body mass index, earlier gestational age and transvaginal probe use were predictors of failure of nuchal translucency measurement and central image rejection (P = 0.001). Epidemiological monitoring identified a drift in measurements over time. Despite initial training and continuous image review, changes in nuchal translucency measurements occur over time. To maintain screening accuracy, ongoing quality assessment is needed.

Usefulness of endoscopic ultrasonography for preoperative staging of tumors of the ampulla of Vater

Background: It is difficult to evaluate local progression of tumors of the ampulla of Vater, because of the anatomical complexity and smallness of the ampulla. Although diagnosis of tumors of the ampulla by endoscopic ultrasonography (EUS) has been reported, local progression is difficult to diagnose, especially in patients with small tumors and without using an antispastic agent. We tried using the soft balloon cover of the transvaginal ultrasonography probe to perform EUS in such patients, because it deforms the ampulla less than the EUS balloon, and distend the duodenum adequately without an antispastic agent and with little water.

Lower uterine segment thickness measurement in pregnant women with previous Cesarean section: reliability analysis using two‐ and three‐dimensional transabdominal and transvaginal ultrasound

To evaluate the reliability of two- and three-dimensional ultrasonographic measurement of the thickness of the lower uterine segment (LUS) in pregnant women by transvaginal and transabdominal approaches. This was a study of 30 pregnant women who had had at least one previous Cesarean section and were between 36 and 39 weeks' gestation, with singleton pregnancies in cephalic presentation. Sonographic examinations were performed by two observers using both 4-7-MHz transabdominal and 5-8-MHz transvaginal volumetric probes. LUS measurements were performed using two- and three-dimensional ultrasound, evaluating the entire LUS thickness transabdominally and the LUS muscular thickness transvaginally. Each observer measured the LUS four times by each method. Reliability was analyzed by comparing the mean of the absolute differences, the intraclass correlation coefficients, the 95% limits of agreement and the proportion of differences < 1 mm. Transvaginal ultrasound provided greater reliability in LUS measurements than did transabdominal ultrasound. The use of three-dimensional ultrasound improved significantly the reliability of the LUS muscular thickness measurement obtained transvaginally. Ultrasonographic measurement of the LUS muscular thickness transvaginally appears more reliable than does that of the entire LUS thickness transabdominally. The use of three-dimensional ultrasound should be considered to improve measurement reliability.

Pre-hCG 3D and 3D power Doppler assessment of the follicle for improving pregnancy rates in intrauterine insemination cycles

BACKGROUND:The assessment of follicular maturity at the time of human chorionic gonadotropin (hCG) is one of the key factors for the success of all assisted reproductive techniques.AIM:To assess follicles by three dimensional (3D) and 3D power Doppler (PD) before giving hCG to improve pregnancy rates in intrauterine insemination (IUI) cycles.DESIGN:Prospective randomized study.MATERIALS AND METHODS:Ultrasound for pre-hCG follicular assessment was performed over a period of 10 months for all 1000 cycles of IUI. Follicular assessment was performed using a transvaginal multifrequency volume probe. Follicles considered mature by 2D US and color Doppler were assessed by 3D and 3D PD. These values were independently evaluated for the conception and the non-conception groups.RESULTS:Conception rates were 32.3 and 27% respectively and individually when the perifollicular resistance index was < 0.50 and the peak systolic velocity was > 11 cm/s 10-12 h before hCG. Conception rates of 32% were achieved with a follicular volume between 3 and 7 cc. The conception rate was 32.3% in the cumulus group. A perifollicular vascularity index of between six and 20 gave conception rates of 35% and perifollicular flow index of 27-43 gave conception rates of 33%.CONCLUSIONS:3D ultrasound is much more accurate for volume assessment of the follicle. Presence of cumulus increases the surety of the presence of a mature ovum in the follicle. 3D and 3D PD when used with 2D US and color Doppler for pre-hCG follicular assessment would definitely improve pregnancy rates in IUI cycles.

244 ENDOTOXIN AFFECTS OOCYTE DEVELOPMENTAL COMPETENCE IN DAIRY COWS

Mastitis is the most common disease affecting dairy herds. The influence of mastitis on the oocyte and on early embryonic development is unclear. The aim of the present study was to examine the effects of endotoxin on oocyte developmental competence. Six lactating Holstein cows were synchronized using the Ovsynch protocol. PGF2α was administered on Day 6 after the second GnRH injection, and 36 h later, either Escherichia coli endotoxin (LPS, 10 μg, n = 3) or saline (n = 3) was administered to one udder quarter of each cow. Milk samples were collected and rectal temperatures were recorded after treatment. Cows treated with LPS showed a typical increase in body temperature (40.27°C ± 0.37), whereas cows treated with saline did not (38.9°C ± 0.04). A higher (P &lt; 0.05) somatic cell count was noted for cows treated with LPS. At the acute phase (6 h after LPS administration), which is characterized by increased secretion of cytokines and other substances, plasma samples were collected, and follicular fluid (FF) from the preovulatory follicle was aspirated by transvaginal probe (Pie Medical, Maastricht, The Netherlands) to serve as a maturation medium for IVF procedures. In 2 different experiments, bovine oocytes aspirated from ovaries collected from a local abattoir were matured (22 h, 5% CO2, 38.5°C) in the indicated media, fertilized (18 h), and cultured for 8 days (KSOM, 5% CO2, 5% O2, 38.5°C). The proportion of oocytes that cleaved and developed to blastocysts was recorded 44 h and 7 to 8 days postfertilization (p.f.). In the first experiment, oocytes were matured in standard maturation medium (TCM-199, control), in FF aspirated from cows treated with saline (FF-saline) or in FF from cows treated with LPS (FF-LPS). Cleavage rate to the 2- to 4-cell stages did not differ among groups. However, the proportion of developed blastocysts in the FF-LPS group was lower than that in the FF-saline and control groups (10.6 v. 22.4 and 24.4%, respectively; P &lt; 0.05). In the second experiment, oocytes were matured in standard maturation medium (control), plasma obtained from cows treated with saline (Plasma-saline), or plasma from cows treated with LPS (Plasma-LPS). Similar to the first experiment, cleavage rate did not differ among groups, and the proportion of blastocysts for the Plasma-LPS group on Day 7 p.f. was lower than that for the Plasma-saline and control groups (11.0 v. 25.5 and 34.7%, respectively; P &lt; 0.05). A slight increase in blastocyst formation was noted on Day 8 p.f. in both the FF-LPS and Plasma-LPS groups (16.9 and 14.8%, respectively). Nevertheless, it remained lower (P &lt; 0.05) than that in the control, FF-saline, and Plasma-saline groups (30.0, 27.3, and 28.7%, respectively). Although the mechanism is not clear, the findings suggest that endotoxin has deleterious effects on the ovarian pool of oocytes. Whether this is also the case for natural clinical mastitis remains to be examined. The authors thank D. Wolfenson from The Hebrew University of Jerusalem for his assistance with this work.

Different Sonographic Approaches Are Able to Assess Accurately the Extension of Deep Pelvic Endometriosis

Study Objective: Magnetic Resonance Imaging (MRI) has emerged to be the best diagnostic imaging to evaluate the extent pelvic deep infiltrating endometriosis (DIE). Transvaginal sonography (TVS) is very accurate in diagnosing ovarian endometriomas but shows some diagnostic limits in the evaluation of the detection and extension of DIE. The aim of this study was to evaluate the accuracy of different sonographic approaches in the assessment of posterior DIE compared to laparoscopical and histological findings. Design: Patients with pelvic DIE underwent sonographic evaluation prior to laparoscopic surgery, using a transvaginal sectorial probe, first transvaginally (TVS) then transrectally (TRS). Furthermore vaginosonography was associated to the transrectal examination. Setting: University hospital. Patients: Fifty patients with pelvic DIE scheduled for laparoscopic surgery. Intervention: An accurate mapping of the extension of the disease was performed at sonographic examinations (TVS, TRS, vaginosonography) and during laparoscopy. The mapping was based on a detailed list of locations which described the endometriotic/fibrotic infiltrating tissue in terms of presence or absence on different sides of the posterior and anterior pelvis: pouch of Douglas, rectovaginal septum (RVS), uterosacral ligaments (USL), vaginal walls, rectal-sigmoid wall and bladder. Measurements and Main Results: The sensitivity in the diagnosis of endometriotic nodules of the USL and of the distal rectal and sigmoid wall was similar for TVS alone (88%, 90%) and after TRS and vaginography (89%, 90%). Whereas the accuracy in the diagnosis of rectovaginal nodules, in particular for those infiltrating the RVS and posterior vaginal fornix, improves significantly with TRS and vaginosonography (TVS alone 67% vs. 91%). Conclusion: TVS/TRS and vaginosonography performed by skilled sonographers provide accurate informations about the presence and the extension of pelvic DIE, similar to those reported for MRI. In particular it improves the diagnosis of the infiltration of the rectal wall, RVS and vaginal fornix.

Sonorectovaginography: A New Sonographic Technique for Imaging of the Posterior Compartment of the Pelvis

We describe the use of a new sonographic technique for imaging of the posterior compartment of the pelvis: sonorectovaginography. Sonorectovaginography uses instillation of fluids (saline solution and ultrasound gel) in the vagina, pouch of Douglas, and rectum for the purpose of creating acoustic interfaces between the vagina, cervix, rectum, and pouch of Douglas. We performed sonorectovaginography in a woman with chronic pelvic pain during laparoscopy. Urinary catheters were introduced into the rectum and vagina. Sterile saline solution was introduced into the abdominal cavity through a laparoscopic trocar and in the rectum via a rectal catheter. The transvaginal probe was then inserted, and sterile ultrasound gel was introduced into the vagina through the vaginal catheter under sonographic guidance. Sonorectovaginography has helped us create acoustic interfaces and enhanced simultaneous visualization of the vaginal walls, posterior vaginal fornix, retrocervical area, rectovaginal septum, rectal wall, and pouch of Douglas. Imaging of the posterior compartment of the pelvis is of paramount importance for identification of potentially difficult endometriosis cases, such as those complicated by obliteration of the pouch of Douglas or infiltration of the retrocervical area, rectovaginal septum, or vaginal or rectal wall. Sonorectovaginography may prove helpful in evaluating this compartment of the pelvis in women with suspected deep endometriosis. Its reproducibility, tolerability, and accuracy, however, need to be validated prospectively, and normative data for the rectovaginal septum also need to be established.

Ovarian follicular flushing among low-responding patients undergoing assisted reproductive technology

A randomized comparison trial was performed to evaluate whether follicular reaspiration with use of a double-lumen retrieval needle improves oocyte recovery when compared with direct follicular aspiration among low-responding patients undergoing ART. There were no differences observed in the number of oocytes retrieved (single lumen: 6.5 +/- 2.2 oocytes, double lumen: 7.2 +/- 2.3 oocytes) whereas follicular reaspiration with the double-lumen retrieval needle resulted in a twofold increase in procedure time.

OC067: Detection rate of early fetal echocardiography and spectrum of congenital heart disease

To evaluate the detection rate of early fetal echocardiography and to describe the spectrum of congenital heart diease (CDH). Retrospective analysis of 3521 singleton pregnancies between 11 + 0–13 + 6 weeks of gestation of a mixed risk population from 1997–2006 in a tertiary referral centre with complete follow-up. A sequential two-dimensional and color coded Dopler echocardiography was performed in all cases using transvaginal and transabdominal high frequency probes. 104 CHDs were diagnosed in the study population. Seventy-eight (75%) within the first trimester, another fourteen (13.5%) in the 2nd trimester and further five (4.8%) in the 3rd trimester. Seven CHDs (6.7%) were diagnosed postnatally. The in utero detection rate of CHD was 93.2% (97/104). The spectrum of CHD changed with advancing gestation and differed from the cases diagnosed postnatally. Early fetal echocardiography is feasible with high accuracy in low- and high risk pregnancies in experienced hands. However, the developmental nature of many cardiac defects must be considered, and therefore the necessity of a mid-gestation fetal echocardiography is underlined.

Transvaginaler Farbdoppler für die Beurteilung von gynäkologischen Pathologien im kleinen Becken

Transvaginal colour Doppler Sonography was used to assess circulation in pelvic vessels in a group of 611 non-pregnant and 88 pregnant patients. A 5 MHz transvaginal probe was used to visualize the pelvic anatomy and blood flow. Further analysis was made by pulsed Doppler where flow velocity waveforms were recorded and analysed by calculation of resistance index (RI). In the normal flow pattern, the diastolic flow component was absent or small and the value of RI was greater than 0.50. In the abnormal flow pattern, the large diastolic flow component was evident and the value of RI was less than 0.50. The transvaginal colour Doppler assessment of tumour vascularity can be used for better non-invasive characterisation of adnexal tumour and may be potentially useful as a screening test for ovarian malignancy. Because of its high sensitivity, specificity and accuracy, transvaginal colour Doppler Sonography is the imaging of choice, in diagnostic procedure of early pregnancy failure and ectopic pregnancy. The guidance of a pulsed Doppler beam by colour flow mapping helps to locate areas of the most abundant flow and makes examination more reproducible, faster and easier.

Current status of vaginal sonography. Part I: Basic principles and gynecologic diagnosis

During the last 8 years transvaginal sonography or vaginosonography has become an essential part of diagnosis in gynaecology and obstetrics. Due to the outstanding image quality of the pelvic viscera without requiring a full bladder technique, vaginosonography is performed more and more often in clinical and private medical practice. In several applications transvaginal scanning has replaced transabdominal scanning. Due to the development of small-diameter probes it is now possible to examine patients with an intact hymen or with a very narrow vagina. The combination of transvaginal probe and Doppler-/colour Doppler technique opens up new avenues in gynaecological ultrasound, especially for tumour diagnosis in the lower pelvis. However, transvaginal sonography cannot be used universally in gynaecology and obstetrics as the diagnosis is limited to findings in the lower pelvis because of the limited penetration depth.