Introduction

One in six couples seeks help for infertility during their reproductive years. Subfertility investigations should be performed without delays (because female fertility decreases with age) and should be as noninvasive as possible. Many fertility clinics use diagnostic hysteroscopy to assess the uterine cavity and evaluate the tubal ostia. Laparoscopy is also often used to examine internal pelvic organs and to assess tubal patency. However, both hysteroscopy and laparoscopy are invasive and expensive tests which could be replaced by transvaginal ultrasound examination. Simplified ultrasound-based infertility investigation protocols have been described. The concept of a ‘pivotal’ pelvic ultrasound examination includes an examination of the uterus and uterine cavity, endometrium, ovarian morphology and follicular size, blood flow in the uterus and ovaries and hystero-contrast sonography (HyCoSy) to check tubal patency, all performed at the same examination. The late preovulatory phase of the menstrual cycle (days 8–12) is usually suggested as the optimal time to perform these examinations. Most studies involving the ultrasound techniques referred to in this chapter are classified as evidence grade B.

The pivotal scan

The aim of the pivotal scan is to assess the uterus, endometrium, fallopian tubes and ovaries.

Uterus

Ultrasound examination is as effective a diagnostic test as hysteroscopy or laparoscopy for the diagnosis of uterine abnormalities. Normal findings at ultrasound examination of the uterus and endometrium are described in Chapter 2. Uterine size and shape may be affected by ade-nomyosis or fibroids. The shape of the uterus can be also be distorted by congenital uterine anomalies.