Transvaginal ultrasonography has an important role in assessing the endometrium. With 2DUS, a single measurement of endometrial thickness in the sagittal plane is widely used in assisted reproductive technology and in pregnancy prediction. Endometrial volume, measured with 3DUS, has been studied as a potentially more accurate parameter. The endometrial pattern was related to the likelihood of implantation. This pattern correlated in a positive fashion with subsequent implantation. 3D ultrasound and 3D power Doppler parameters have been applied to assisted reproductive techniques as outcome predictors, although studies are still scarce, they show very promising results.

The differential diagnosis of adnexal masses still constitutes a major clinical challenge. B-mode ultrasonography is the most used imaging technique and it is the base for this differential diagnosis with acceptable results in terms of sensitivity but a relatively high false positive rate for predicting ovarian cancer. The role of pulsed Doppler remains controversial and seems to be not reproducible in clinical practice. In the last years, a new technology such as 3D ultrasound—both morphology and 3D Angio power Doppler—has become available for discriminating between benign and malignant ovarian tumors. In this article I aim to review critically recent literature of this topic.

Transvaginal sonography has been shown to be an accurate technique for discriminating between benign and malignant adnexal masses. Accurate preoperative differential diagnosis of adnexal masses is essential for optimizing patients’ treatment. The advancement and wider availability of therapies of assisted conception have occurred to a large extent as a result of developments in ultrasonography. Transvaginal color Doppler has opened up exciting new possibilities for the better understanding of the physiology and pathophysiology of ovarian blood flow, resulting in a number of completely new diagnostic parameters.

The advances in ultrasound technology has changed the management of infertility. With the advent of color Doppler, pulse Doppler, 3D US and then 3D power Doppler the previously unexplained causes of failure of fertilization and implantation can now be explained. 3D and 3D power Doppler can now be used for the assessment of the maturity of the follicle and receptivity of the endometrium and can give better idea about the functional maturity of the follicle and the endometrium, to decide the timing of hCG administration for all assisted reproductive techniques for better pregnancy rates. The accuracy of diagnosis and monitoring of infertility treatments such as ovulation induction has greatly increased because of the availability of sophisticated ultrasound technology and equipment.1

Prevention of prematurity by a prematurity-preventionprogram, including “Self-Care”-measures for the pregnant women.

Prevention of early prematurity (< 32 gest.w.) and of very low birthweight infants (< 1500 g) is one of the most urgent tasks of perinatal medicine. Particularly ascending genital infection is the most important avoidable cause of early prematurity. For the prevention of these infections the “protective lactobacillus system” plays a crucial role. Bacterial vaginosis and/or ascending genital infection start mostly with a disturbance of this vaginal milieu–which we consider as a “precursor”.

Our program is based on an anamnestic assessment of prematurity risk, the early detection of warning signs (including screening for preinfection respectively infection signs by regular measurement of the vaginal pH) and, if necessary, the appropriate therapeutic measures. The program includes “Self-Care”-measures by the women themselves (preferably for all pregnant women) and additional special measures for women at risk, for example, the ETCO for women with recurrent premature births.

The Self-Care—measures for pregnant women are an additional measure to regular prenatal care. In our own study, we had 1120 multiparae and we compared the outcome of the pregnancy with self-care activities with the outcome of the immediate previous pregnancy. Our program was then used in the entire state of Thuringia (Germany). In the second half of the year 2000, the Self- Care Program was employed and the statistically evaluated results for the entire state were compared with those from the first half of 2000 without the program (in each half-year there have been more than 8.000 births). After that, several German health insurance companies used our prenatal-care self-examination program in a pilot project to their pregnant members.

The early total cervix occlusion (ETCO) is a preventive measure particularly for cases with two or more late abortions (> 12 + 0 gw) or early premature births (< 32 + 0 gw) in the patient's history with either infection as cause for these events or when no other cause has been found, but when for instance premature rupture of membranes occurred. The Total Cervix Occlusion creates a complete barrier against ascending infections within the cervical canal (as opposed to the cerclage).

With regards to the Self-Care—measures: In all studies the rate of premature births could be considerably reduced. Most interesting are the results of the prematures at particularly high risk. In our collective, the rate of very low birthweight infants (< 1500 g) could be reduced from 7.8% in the immediate previous pregnancy to 1.3%. In Thuringia, the rate of infants born < 32 + 0 gw was reduced from 1.36 to 0.94% respectively in infants < 1000 g from 0.61 to 0.38%. After the campaign in Thuringia had been finished, the prematurity rates monitored in 2002 were again as high as before. The first evaluation of a health insurance company in the German state North-Rhine-Westfalia (NRW) shows that the insured patients had a prematurity rate of 7% compared with the overall prematurity rate in NRW of 9.6%.

The Self-Care Program for pregnant women proved to be a very efficient method for the prevention of prematurity and should be recommended to every pregnant woman. In cases where this is not possible, at least doctors and midwives should measure the vaginalpH at each prenatal care examination. The Early Total Cervix Occlusion is an effective preventive measure for women with recurrent late abortions or prematures births and it seems to be also a good measure to prevent premature births in multiple pregnancies. More research in this area is necessary.

First trimester risk assessment has become a reliable screening tool for trisomy 21, replacing age-based risk assessment. On the basis of the ethical concept of the physician as fiduciary, the professional virtues of integrity and self-sacrifice, and the ethical principles of respect for autonomy, beneficence, and justice, we argue that the obstetrician has an ethical obligation to routinely offer pregnant women first trimester risk assessment in high quality centers. We then argue that both obstetricians and specialists in risk assessment have a strict ethical obligation to identify, responsibly manage, and disclose both economic and non-economic conflicts of interests, especially when they are hidden Ethics is an essential dimension of implementation of first trimester risk assessment for trisomy 21.

Three-dimensional ultrasound is advantageous in studying normal embryonic and fetal development, as well as providing information for families at risk for specific congenital anomalies by confirming normality. The introduction of highfrequency transvaginal transducers has resulted in remarkable progress in ultrasonographic visualization of early embryos and fetuses. Three-dimensional ultrasound imaging in vivo compliments pathologic and histologic evaluation of the developing embryo, giving rise to a new term: 3D sonoembryology.

Ultrasound examination has become the “golden standard” in follow-up of the development and complications in early pregnancy. With introduction of transvaginal sonography a possibility for early morphological and biometrical ultrasound examinations has been significantly improved. The essential aim of an early pregnancy ultrasound is not only to diagnose a pregnancy, but also to differentiate between normal and abnormal pregnancy. Application of color Doppler ultrasound has enabled functional hemodynamic presentation and evaluation soon after implantation.