Monday, January 27, 2014

The NaPro Ultrasound Series

This post will hopefully serve as a resource for those of you who will be undergoing a NaPro Technology Ultrasound Series.  It is meant to clarify some common misconceptions regarding the series, as well as to educate the patient who may need to undergo the series at a facility that is not trained specifically to perform the study and read/interpret the results.  However, this is not to be taken in the place of your Dr's medical advice, nor is this post endorsed by any medical entity.  Rather, it will draw upon my education, experience, and current career working in the field of FertilityCare and NaPro Technology as both a FertilityCare Practitioner and RDMS (Ultrasonographer).

The Ultrasound Series, as developed by Dr Hilgers at the Pope Paul VI Institute, is a very detailed, and if done properly, very accurate means of evaluating ovarian function and the ovulatory process.  The results of the complete Ultrasound Series are invaluable in helping a NaPro Dr determine underlying causes of infertility and miscarriage (prior or future risk), and also serves to drive therapy decisions.

In the ideal situation, the Series is conducted as follows:

1) The patient begins by charting with the Creighton Model FertilityCare System.  They will have at least two cycles charted before the series.  (Why this is a crucial piece will be made clear later.)

2) A Baseline Ultrasound is performed, generally around Cycle Day 5-7.  This is a "complete pelvic ultrasound" which consists of both transabdominal and transvaginal imaging.
For the transabdominal portion, you will need to have a full bladder (ultrasound travels through fluid very well, making the full bladder an acoustic window to the uterus and ovaries).  A full bladder is also important because ultrasound hates air, and gas - which are generally present in the surrounding bowels.  The bladder pushes these shadows out of the way for optimal transabdominal imaging.  Finally, a full bladder makes it easy to quickly evaluate the bladder, making it quite obvious if there are any nodules or abnormalities with the bladder, itself.  (I have found bladder nodules in two female patients who were having routine pelvic ultrasounds this way - which later turned out to be bladder cancer.  They were treated and have good prognoses.  But, as a default, no matter HOW MANY pelvic ultrasounds a patient says they have had in the past, I never skip the transabdominal at the baseline!)
Once the transabdominal is done, the patient will empty their bladder completely for the transvaginal (just as important as having a FULL bladder is for the transabdominal, it is having an EMPTY bladder for the transvaginal).
The Baseline Ultrasound gives the sonographer and the Dr the "map" of your pelvis as it looks when things are quiet.  The timing is important because what is being evaluated are the pelvic organs in their inactive hormonal state (at the end of, or just after, the period):
We expect to see the endometrium (lining of the uterus) at its thinnest state, before it has proliferated - to evaluate for small masses like polyps or myomas that can be easily hidden later in the cycle when the lining is thicker.
We expect to see the ovaries at rest, before there are any dominant follicles - this helps us evaluate any structures we do see on the ovaries (like endometriomas, corpus luteum cysts/hemorrhagic cysts, simple cysts, dermoids, etc) and watch them over the course of the series to further evaluate their status (stable, growing, diminishing in size).  It also helps us to evaluate the size and contour of the ovaries themselves (polycystic ovaries, for example, can be difficult to diagnose if you only see the ovary at times when there are dominant follicles present).

3)  The Follow-Up Ultrasounds are then scheduled, ideally, by the sonographer and/or Dr who is performing and evaluating each ultrasound in real-time.  These follow-ups will be transvaginal only.  The first of these ultrasounds is projected to be about 4 days before the Peak Day.  (With 2 cycles of charting, this is easy to predict.  With irregular cycles, dry cycles, short, or long cycles, the chart is really key for timing the series to start properly.  And, as you'll see, also becomes of utmost importance during the evaluation of the ovulation process during the course of the series.)

During these follow-up ultrasound appointments, the main things being focused on will be:

  • the dilation of the cervix in the presence of cervical mucus (this is measured each day),
  • the presence or absence of cul-de-sac fluid (fluid can collect in this area of the pelvis),
  • the endometrial thickness and phase (menstrual, early proliferative, late proliferative, or secretory),
  • any masses or myomas that were evaluated during the baseline are re-evaluated to check stability and aid in diagnosis 
  • the ovarian follicular development, with any follicles over 1.0cm being measured in 3 planes to obtain a mean follicular diameter
  • the presence or absence of a cumulus oophorus (more on this later)

All of this information is recorded on a worksheet, and the SIZE OF THE LARGEST FOLLICLE then dictates when the next scan will be.
The protocol is:
If there are no follicles over 1.4cm, the patient returns in 3 days.
If the largest follicle is 1.4-1.6cm the patient returns in 2 days.
If the largest follicle is 1.6cm or larger, the patient returns the following day.
The protocol, here, is tried and true.  I cannot stress this enough.  Especially if this is the patient's FIRST ultrasound series, or in some cases even the first treatment cycle, DAYS CANNOT BE SKIPPED!  The entire series becomes a wash if a key day is missed.  Before I elaborate on this point, let me first explain-

The 6 Ovulatory Defects:

“Abnormal ovulation”:

1) Mature follicle: MFD ≥ 1.90cm, 

but CO either absent or retained

these follicles completely rupture 

over 24 hours

2) Luteinized unruptured follicle

developing follicle which never ruptures 

and becomes debris-filled; secretory 

changes evident in endometrium

3) Immature follicle: MFD less 

than 1.90cm; these follicles completely rupture

4) Partial rupture: rupture that is 

≤ to 0.75cm

5) Delayed rupture: rupture occurs

over 48 hour period; within the 

first 24 hours, follicle is reduced by less than 

or = 0.75cm

6) Afollicularism: follicle never 

reaches dominance (MFD of < 1.40cm)

(3, 4, and 5 are also stratified 

according to CO present, absent, 

or retained)

Hilgers, TW   The Medical and Surgical Practice of NaProTECHNOLOGY.  Pope Paul Institute Press, 2004.  259-268.

C.O. here refers to the cumulus oophorus, a structure which forms around the egg (inside the follicle) which is generally viewed easiest when the follicle is around 1.70cm.  A c.o. is not always visible on ultrasound; I have personally seen them less than 1/3 of the time, and from what I understand, this is similar to the stats at PPVI's ultrasound department.  Not seeing the c.o. is not indicative of an empty follicle, therefore.  But seeing the c.o. is always a good sign.

The cumulus oophorus is the semi-circle on the periphery of the follicle (black circle).  Quick tutorial- follicles are filled with fluid, fluid on ultrasound shows up black because the sound travels right through it, not creating any echoes on the image (anechoic).

So, in order to evaluate and rule in or rule out any of those 6 ovulatory defects, it is imperative that the protocol is kept for timing of ultrasounds.  A normal ovulation series may look like this:



Cervix is closed, at the end of the menstrual flow; no fluid in the cul-de-sac

The endometrial lining is thin and early proliferative phase (note the distinct 3 lines or trilaminar appearance)

The ovaries are "quiet" with no dominant or active follicles over 1.0cm

Follow-Up Ultrasounds:

DAY 12

Cervix is dilated all the way throughout (note the thick black line- remember black on ultrasound is fluid - this is cervical fluid, i.e. cervical mucus) By the by, that would be my beautiful cervix you're looking at, here.

The endometrium on day 12 is thicker and now in the late proliferative phase; this is evident by the bright "lines" with the dark gray in between the lines.  (Compare that to the lighter gray early proliferative lining.)

Now there is a dominant follicle on the ovary, measured in 3 planes to yield a mean follicular diameter of 2.10cm;  this is a mature follicle with a cumulus oophorus (can you see it?)

DAY 13
The next day, changes are already observed:  note how the cervix is still dilated, but not all the way throughout.  Also note the fluid (black) area underneath the cervix- that is cul-de-sac fluid.  Cul-de-sac fluid is clinically significant and helpful in diagnosing an ovulatory event.

More changes are noted in the endometrium - can you notice how the "lines" aren't as distinct as they were the day before?  This is consistent with an endometrial change from proliferative to secretory phase, in the midst!  Fascinating stuff, here, people!

The mature follicle now measures 2.33cm; also note the "blurry" appearance around the edges.  This is common to see right around the time of an ovulatory event.  IMPORTANT:  This patient has, up to this time, had pretty typical results, but her ovulation is not complete and anything can still happen.

DAY 14
The very next day, the cervix is once again completely closed (no mucus) and the area of cul-de-sac fluid is now larger.

The endometrium is now in an early secretory phase (bright gray shade throughout).

And this, my friends, is a corpus luteum.  On the day of rupture, it can be so small that it is nearly impossible to find at times, UNLESS the patient had been seen the day before by the same technician.  Corpus lutei can take on many different appearances, being completely black like this one, to more gray inside (often called "hemorrhagic" on ultrasound reporting), but the key is that it is smaller, with irregular borders (not crisp, round edges like the follicle).

This ovulation was diagnosed as a normal one (complete rupture of a mature follicle with cumulus oophorus).  In order for a rupture to be diagnosed as "complete" (not partial, or delayed), it must decrease in size by .75cm within 24 hours.

Having seen one example of a normal ovulation, with pretty "typical" cycle days for ovulation, you may now better understand the importance of the protocol.  Skipping days 12 and 13, here, would have been obvious mistakes - but what if days 12 and 13 were a Sunday and Memorial Day?  Or a weekend that a particular facility wasn't open?  

It's pretty obvious to most people that if doing an ultrasound series, days 12 and 13 probably aren't good days to skip ;)  However, this is where the Creighton chart comes in very much use, particularly when your Dr and/or Sonographer use it to guide the timing of ultrasounds.  Remember we said it is best to time the first follow-up ultrasound about 4 days before the anticipated Peak Day.  If the patient has not charted 2 cycles of the Creighton Model, yet, here is a real-life example (one of my long-distance charting clients) whose first ultrasound series was a wash as a result:

Patient had just started charting at the time of her first ultrasound, projected for Cycle Day 10 in the absence of prior Peak Days.  Cycle day 10 she was told she had no dominant follicles, and to return, per the protocol, in 3 days.
(Quick tutorial for those who don't know Creighton charts - the solid sticker days refer to days the woman is not seeing any cervical mucus observations, and therefore indicative that her ovaries are not yet producing dominant follicles.  The white stickers with babies are days that she is seeing mucus, and is therefore fertile.  The last "P"  on Cycle Day 23 indicates the last mucus day correlated closely to where this patient likely ovulated in her cycle.)

On Cycle Day 13, the patient returned, and was once again told there were no dominant follicles, and to return in 2-3 days (I think there was a weekend in here that meant the patient returned sooner since this particular facility wasn't open on weekends.)  On Cycle Day 15, the patient was hopeful because she started to see mucus - but once again her ultrasound showed no active follicles.  The Dr made the decision to stop the series, have the patient continue charting, and to let the office know if she experienced a Peak Day, or got her period.

In the absence of prior charting, there was no way for the Dr to know how poorly-timed these ultrasounds were.  Now looking at 2 consecutive cycles, we know that any ultrasound before Cycle Day 20 is pretty much a waste of money for this patient whose Peak Days are Day 23 and later.  The series was completed at a later time, and this patient was found to ovulate NORMALLY, just later than some women.  Thank goodness for the charting, which helped the Dr to repeat the series at a proper time; but imagine how much more productive it would have been to have the charting FIRST before wasting all those ultrasounds.

Timing with the charting is clearly important.  Missing days due to weekends or holidays or just simply because the facility doesn't know and understand the proper protocol is, quite frankly, my biggest pet peeve.  Understandably, not all NaPro Centers have their own ultrasound, and furthermore, not all are able to offer ultrasounds on weekends and holidays.  As a patient, you do what you need to do for yourself, your family, your budget, etc - not everyone can see a NaPro Fellow for surgery, for example.  And at the moment, there are only 2 NaPro ultrasound facilities that perform and read the Ultrasound Series as designed by Dr Hilgers:  Pope Paul VI Institute, and MorningStar Family Health Center.  We are hoping, with new training materials coming from PPVI, that this will change in the near future.  And, in the meantime, there are certainly other options for completing a series which can be helpful for your Dr.  

I urge those of you who have it within your means to go at the very least to a NaPro Center with ultrasound, to do so.  Even with the very best intentions, and all the information and instructions in the world, the reports we get back from imaging centers and hospitals are very often useless.  (If you have access to any of your reports from these places, you'll notice what I mean - see if the detail included matches the details we want to know listed above.)  RE offices, same thing.  We will get reports back with sizes of follicles, and that's about it.  RE's typically do not see the ovulation process on ultrasound, in fact - the last ultrasound is generally when the follicle is still immature measuring 1.80cm, and the patient is sent away with instructions (for intercourse, trigger injection, IUI, etc.)

Aside from the protocol (timing) and the charting, which are two crucial elements to having a successful Ultrasound Series, some other factors also come into play which can help in accuracy of diagnosis.  Having the same technician, the same eye looking at your sonograms from day to day (in live imaging, not just the radiologist or NaPro Dr looking at still images) is extremely helpful.  If you absolutely must have the Series done at an outside facility like a hospital or imaging center, you should request having the same technician - and perhaps speak to the Chief Sonographer ahead of time regarding what you will be doing, and how important it is for accuracy.  Oftentimes the Chief Sonographer may wish to do the scans themselves, or at least oversee the series.

Another important note, if having the series done at an outside facility (non-NaPro) is to ask them not to put any ultrasound gel on the outside of the probe cover.  I usually do not use anything on the outside of the probe cover, but if this is painful for you, you can request sterile water or bring your own Pre-Seed for use as a lubricant.

But if I leave you with anything, I want to leave you with this- I am still learning, every day, and I am still seeing new things I've never seen before in the ovulation process, on ultrasound.  It is easy to make mistakes.  It is easier to catch those mistakes, however, when you are following the protocol, and have the experience to know what normal and what abnormal looks like.  The NaPro Ultrasound Series can be a wealth of information for your NaPro Dr - if performed and read correctly.  


Lucky as Sunshine said...

Thanks for your wealth of knowledge!

Stephanie Z said...

Thanks for sharing all that detail! If/when I have to do the series, I want you to be the one doing it. (Hope that didn't sound too weird...)

Unknown said...

Thank you!! Your post will help me better explain the process to my clients.

Kaitlin @ More Like Mary said...

You are a blessing to so many!

ecce fiat said...

Thanks so much for this! This is one of the next steps on my IF "to-do" list and it's been on there for ages, so this is both extra encouragement to just do it already and also really helpful information.

Kari Beadner said...

When a women is preparing for surgery with Dr. Hilgers is it mandatory for the series to be completed at PPVI or can other more local hospitals be used.

In your experience?

Amy @ This Cross I Embrace said...

Kari, PPVI will only approve their patients completing a series at the 2 locations I mentioned where the Drs have specifically trained in how to perform and read. So, they can either go to PPVI, or MorningStar in New Jersey (where I work).

Sew said...

The comolus huh? Are you talking dirty to me?

Very informative post!

the misfit said...

It's really great to see all that detail. It gives me a new respect for the value of the process. (On the other hand, I'm still comfortable with my decision not to miss half a day of work practically every other day for weeks. I appreciate your encouragement for people to have this done, but I concluded that it would be extremely disruptive to the small amount of normal life I had left after years of IF, and I wasn't willing to sacrifice that when I knew that, whatever else the series accomplished, it would cure nothing.) So I guess my take-away is - it's good to have as thorough as possible an understanding of what your diagnostic and treatment options are, as early as possible, and this post is of inestimable value in that vein. But I find that a lot of patients conclude that once they know about all their options, they're obliged to pursue them all (and I'm not even talking about ART). I think that's not true. As a medical professional, of course you need an arsenal at your disposal. As a patient, I think you need to feel comfortable with saying, "Enough." And I think a lot of people find it hard to work with both. (Or feel it their place to make nasty comments to other suffering patients who clearly don't DESERVE to be mothers because they haven't seen the exact same doctor, done 100% of the same treatments, etc. Those people can KMA, as I hope I've told them all by now...)

Amy @ This Cross I Embrace said...

Lol misfit, I always enjoy your honest reactions ;) I think this post is designed more for the patient who is about to undergo a series, or who has had several already with inconclusive results. It kills me to see so many wasted series due to poor timing (just heard of yet another tonight from a new charting client). In other words, I totally agree with all you've said here.

Amy @ This Cross I Embrace said...
This comment has been removed by the author.
JellyBelly said...

I am so proud that you have wanded my ladyparts. Only very special friend get to bond via the ultrasound wand.

Amy @ This Cross I Embrace said...

They even get to sport the fancy blog button!

JellyBelly said...

And some even get to sleep in your guest room and do yoga in your parlour!

Unknown said...

Thank you for posting about this topic! I've had two U/S series done about a year a part. Both were LUF cycles :(

It seems like LUF is virtually unknown/unstudied even in the Creighton Model world. Are you seeing patients with LUF ever successfully ovulate on an U/S series? I am beginning to wonder if my body doesn't create LUF's every single month. If you can comment on seeing any succes in treating that at your clinic, I would be much obliged.

polkadot said...

Thanks so much for this post. It is so helpful and informative.

St. Rita's Roses said...


Amy @ This Cross I Embrace said...

Hi Amanda,
It is rare to see someone who LUFs every single cycle, but it can happen, particularly in treatment cycles. I think many times the LUFs are a result of adhesions around or near the ovary. But, one of the patients who did have chronic LUFs every cycle (who is also a blogger) after taking a break from treatment, went on to ovulate normally when we repeated the series a year later.
In other words, I don't personally think once a chronic LUFer, always a chronic LUFer, and more often than not the treatments NaPro uses do work to treat LUFs.

The Will Of God In All Things said...

I was in Omaha at PPVI last week doing the ultrasound series, and it turned out that mine was only 1.7cm when it ruptured: Immature. They said it's a hormone issue and can be treated. I had a total of 8 ultrasounds and had to stay in a hotel in Omaha all week, but it's so worth it to know it was done right. Thanks for the informative post!

Unknown said...

Your post is very helpful for sonography students to learn more about the process. Thanks for sharing all the detail. Best regards from Lisa

Mary Ann said...

Thank you for posting this!