Time for an ultrasound revolution in reproductive medicine.

If you have strong views on any matter related to ultrasound, it is highly likely you will receive a summons to write an editorial on the subject for the White Journal. This editorial is my attempt to justify my frequently expressed opinion that ultrasound is not used effectively in most departments of reproductive medicine and proper use of modern technological developments would improve the quality and costeffectiveness of patient care. In order to make my case, I carried out a survey of British reproductive medicine units to determine how they use ultrasound in their practice. This is an international journal and so I apologise that the survey only involved UK units but I hope the results are nevertheless interesting to international readers of the journal. I asked five specific questions (Table 1) to key members of assisted conception and reproductive medicine centers and received replies from 72 out of the 75 in vitro fertilization (IVF) centers in the UK. In only four centers was color Doppler used in clinical practice to assess uterine blood flow. Three other centers had a color Doppler facility on their machine but no one was trained to use it. Fourteen centers carried out hysterosalpingocontrast sonography (HyCoSy) for assessment of tubal patency and 17 were using saline contrast sonohysterography for the assessment of the uterine cavity. Five centers (predominantly within the National Health Service) were carrying out research projects primarily involving ultrasound and six centers were using routine ultrasound guidance for embryo transfers. Thus it seems that unlike fetal medicine units, reproductive medicine departments have not embraced the latest technological advances despite the fact that there have been over 200 peer-reviewed publications in major scientific journals during the past 10 years demonstrating the use of Doppler to elucidate neoangiogenic events in the reproductive system and the physiological changes during endometrial and ovulatory cycles. Sadly therefore, in a country that pioneered gynecological ultrasound and regards itself as developed in terms of patient care, it seems that the use of ultrasound is confined to basic follicle tracking, measurement of endometrial thickness, identification of gross abnormalities within the pelvis and ultrasound-guided egg collection. Extensive use of laparoscopy and hysteroscopy in the investigation of infertile women remains a gold standard practice in most centers, despite recent evidence that with modern equipment the baseline ultrasound scan in most circumstances can provide equally good anatomical and better physiological information less expensively and less invasively. I will briefly outline some of the reasons why I believe reproductive medicine units should invest in high-quality ultrasound equipment and ensure that their personnel are trained to use this equipment effectively. The basic minimum would be a high-resolution machine with sensitive color and spectral Doppler. Threedimensional (3D) equipment, while not essential can provide additional valuable information and in the future 3D color power angiography (3D-CPA) may become an essential prerequisite. Table 1 Survey of UK in vitro fertilization centers: questions asked