Ultrasound findings in endometriosis. What infertile couples need to know

Ultrasound findings in endometriosis: What infertile couples need to know

For millions of women around the globe, endometriosis is not just a diagnosis, but a journey characterized by chronic pelvic pain, heavy menstrual bleeding and, in many cases, infertility. For couples facing the challenges of infertility, understanding how endometriosis is assessed can be a crucial step on the road to effective treatment. Ultrasonography is at the forefront of this process, providing a non-invasive insight into the complexity of the condition.

Understanding endometriosis

Endometriosis occurs when tissue that resembles the lining of the uterus grows outside the uterus, often affecting the ovaries, bowel, bladder and other structures in the pelvic area. This misplaced tissue can lead to painful symptoms and may be a major factor in infertility. Although laparoscopy with histologic confirmation remains the gold standard for diagnosis, ultrasound has become an indispensable tool for initial evaluation and surgical planning.

The role of ultrasound in diagnosis

Ultrasound examinations use sound waves to produce images of the internal pelvic anatomy. Two main ultrasound techniques are used to assess endometriosis:

Transabdominal ultrasound

• Overview: A probe is placed on the abdomen.
• Strengths: Provides a general overview of the pelvic organs.
• Limitations: May lack the detail needed to detect subtle lesions.

Transvaginal ultrasound (TVS)

• Overview: A small probe is carefully inserted into the vagina.
• Strengths: Provides high-resolution images of the uterus, ovaries and surrounding structures and is therefore the preferred method for detecting endometriosis.
• Advanced techniques: -sonovaginography* involves inserting a small amount of ultrasound gel into the posterior fornix of the vagina to improve visibility, particularly in cases of deep infiltrating endometriosis (DIE). -Transrectal ultrasound may also be used in selected cases to assess bowel involvement.

In patients with suspected severe endometriosis— - especially those with significant bowel pain— - light bowel preparation prior to the ultrasound examination can optimize image quality.

A systematic approach in four steps

To standardize ultrasound examinations, the IDEA group (International Deep Endometriosis Analysis) recommends a four-step evaluation:

1. Routine assessment: Assessment of the uterus and adnexa for signs of adenomyosis and the presence of endometriomas.
2. Adhesion markers: Look for signs of adhesions in the pelvis, such as restricted organ mobility and retroflexion of the uterus.
3. Sliding Sign: Assess the anterior and posterior cul-de-sac in real time to detect adhesions.
4. Deep Infiltrating Endometriosis: Detect nodules in the anterior and posterior compartments that indicate deep infiltrating disease.

This methodical approach not only helps with diagnosis, but also assists the surgeon in planning interventions, which can reduce the need for repeat surgery.

Important ultrasound findings in endometriosis

An ultrasound examination can reveal various features that suggest a suspicion of endometriosis. Here are the typical findings doctors look for:

Endometriomas

• Location: Ovaries
• Appearance: -Well demarcated, round or oval masses with a homogeneous “ground glass” texture. -May be unicellular or multicellular, with some variations such as irregular walls or internal clots.
• Clinical significance: Strongly associated with moderate to severe endometriosis and infertility.

Deep infiltrating endometriosis (DIE)

• Localization: Bowel, bladder, uterosacral ligaments
• Appearance: -Hypoechoic (darker) nodules or irregular masses. -When the bowel is involved, these lesions appear as irregular thickening of the bowel wall.
• Clinical significance: These can complicate surgical treatment and often contribute to chronic pain.

Adhesions

• Localization: Anywhere in the pelvis
• Appearance: -Restricted mobility of the pelvic organs. -An abnormal “gliding sign” in the pouch of Douglas, indicating the presence of fibrous bands.
• Clinical significance: Adhesions may distort pelvic anatomy and complicate fertility treatments.

Anatomical distortion

• Location: Uterus, ovaries and fallopian tubes
• Appearance: -Displacement of the organs or obliteration of the rectouterine pouch. -“Kissing ovaries” occur when the ovaries are contracted, a sign of pronounced endometriosis.
• Clinical significance: Such distortions can hinder natural conception and make surgical interventions more difficult.

Abnormal fallopian tubes

• Location: Fallopian tubes
• Appearance: Elongated, serpentine, cystic structures with “incomplete septa”
• Clinical significance: An abnormal appearance of the fallopian tubes may contribute to infertility by interfering with the transportation of eggs.

Superficial endometriosis

• Localization: Surface of the abdominal organs
• Appearance: Typically small lesions that are often overlooked on standard ultrasound examinations.
• Clinical significance: Although common, it is difficult to detect superficial endometriosis; however, imaging in the second half of the menstrual cycle can sometimes reveal subtle abnormalities.

Limitations and complementary techniques

Although ultrasonography is a powerful diagnostic tool, it also has its limitations:

• Superficial lesions: Small, near-surface endometriotic implants are often not visible.
• Dependence on the examiner: The accuracy of the ultrasound depends heavily on the skills and experience of the examiner.
• Limited visibility: Some pelvic regions cannot be visualized adequately.

Other imaging modalities can be used for a comprehensive evaluation:

• Magnetic Resonance Imaging (MRI): Provides detailed soft tissue contrast and is particularly useful for evaluation of DIE.
• Laparoscopy: Remains the definitive method for diagnosis, providing direct visualization and histologic confirmation.

A common clinical pathway is to start with transabdominal and transvaginal ultrasound and continue with MRI or laparoscopy if further clarification is required.

The bottom line for infertile couples

For couples struggling with infertility, the journey to diagnosing and treating endometriosis can be overwhelming. However, ultrasonography offers a less invasive, highly informative insight into the condition, helping to determine the location and severity of endometriotic lesions. This early insight can be instrumental in developing effective treatment strategies — whether surgical, medical or a combination of both.

If you suspect that your fertility is being affected by endometriosis, you should schedule a comprehensive ultrasound with your healthcare provider. Early detection and a well-planned treatment strategy can make a significant difference in managing symptoms and improving your chances of conception.

Stay informed, stay hopeful, and remember: knowledge is the first step to a cure