This chapter discusses the usefulness of ultrasound in diagnosing normal and abnormal fallopian tubes using two-dimensional (2D) and three-dimensional (3D) transvaginal ultrasonography (TVS) and hysterosalpingo-contrast sonography (HyCoSy). HyCoSy involves the introduction of fluid into the uterine cavity and the fallopian tubes. The role of HyCoSy as a first-line procedure for the assessment of tubal patency has been examined in several studies. In most of the studies, the diagnostic capabilities of HyCoSy have been compared with the established reference methods of hysterosalpingography (HSG) or laparoscopy with dye insufflation, or both, and in the majority of the studies Echovist was used as the ultrasonographic contrast medium. A multicenter study in Scandinavia compared laparoscopic salpingectomy with no intervention prior to the first in vitro fertilization (IVF) cycle. The study demonstrated significant improvement in pregnancy and birth rates after salpingectomy in patients with hydrosalpinges that were large enough to be visible on ultrasound.

This chapter reviews the basic principles of radiologic tests, and describes the basic female anatomy. It provides information for appropriate imaging modalities for each part of the female genital tract. Currently ultrasound plays a role in monitoring the uterus during ovarian stimulation and early pregnancy. Assessment of uterine leiomyoma is historically achieved with ultrasonography, although computed tomography (CT) and magnetic resonance imaging (MRI) also offer detection of uterine fibroids. In reproductive medicine, imaging of the tubes is typically limited to evaluation of patency and distortion of normal anatomy, as in hydrosalpinges and salpingitis isthmica nodosum. Pituitary imaging is mostly performed in reproductive medicine for the infertile patient with persistently elevated prolactin levels or with levels over 100 ng/ml. Imaging is rarely performed in reproductive medicine specifically to evaluate for peritoneal disease. Laparoscopy is considered the gold standard for diagnosis of peritoneal processes such as endometriosis.

Over the last 25 years, progress in the field of assisted reproduction has paralleled that in ultrasonography. Normal fallopian tubes are not usually seen by ultrasound, though it is sometimes possible to visualize the fimbrial end within fluid in the pouch of Douglas. The ovaries are usually seen lateral to the uterus, in close relationship to the internal iliac vessels. They can be identified by their echogenic stroma and sonolucent follicles. A variety of ovarian reserve tests are used in routine clinical practice to assess a woman's ovarian performance prior to controlled ovarian hyperstimulation (COH) for in vitro fertilization (IVF). Transvaginal ultrasound-guided aspiration of ovarian follicles provides a safe and effective means of oocyte retrieval. Embryo transfer is a crucial step of IVF treatment. Ultrasound is a cornerstone of prevention and diagnosis of potential IVF complications such as ovarian hyperstimulation syndrome (OHSS) and multiple pregnancies.

Ultrasound examination is as effective a diagnostic test as hysteroscopy or laparoscopy for the diagnosis of uterine abnormalities. Three-dimensional ultrasound has been used to assess uterine anatomy and to detect congenital anomalies of the uterus. Ultrasound examination is used to monitor endometrial growth and ovarian response to the medical treatment. Appropriate endometrial growth indicates good endometrial receptivity. Appropriate ovarian response to gonadotrophin stimulation increases the chances that good quality eggs will be released in ovulation induction cycles and that good embryos will be available for embryo transfer in in vitro fertilisation (IVF) cycles. Ultrasound is also used to monitor embryo transfer. Both greyscale ultrasound examination of the endometrium and Doppler ultrasound examination of the uterine arteries have been used to assess 'endometrial receptivity' in IVF cycles. Ultrasound greyscale imaging is regarded as sufficiently accurate to be used alone for monitoring follicular growth during gonadotrophin therapy.

Gamete intrafallopian transfer (GIFT) involves a direct transfer of human gametes, sperm and oocytes into the fallopian tubes. Zygote intra-fallopian transfer (ZIFT) involves the transfer of embryos at the pronucleus stage into the fallopian tubes. In in vitro fertilization (IVF), the four- to eight-cell embryo is transferred 48-72 hours after oocyte collection and thus reaches the uterine cavity some two to three days earlier than would occur in a natural cycle. Centres offer comprehensive assisted conception, including IVF, GIFT and ZIFT. IVF-embryo transfer has become acceptable, with improvements in vaginal ultrasound, oocyte retrieval techniques and ambulant care with local sedation and analgesia. In women aged above 40 years, a flexible number of oocytes transferred during GIFT maximizes the chance of achieving singleton pregnancy. ZIFT is indicated for couples who have had repeatedly failed IVF cycles. GIFT/ZIFT is considered for patients who have cervical stenosis or in utero exposure to diethylstilbestrol.