Posted on May 30th, 2017 by
transvaginal ultrasound, endovaginal, TV probe

TV Probe

Transvaginal Ultrasound ~
You’re Gonna Put What WHERE?!

I always know that face…the one with the saucer-like eyes and mouth gaping open in utter shock as soon as I speak the words “transvaginal ultrasound.” I point to the probe sitting so innocently on my machine. Poor thing…it gets such scathing rejection and so little credit!

I can’t really blame the patient. After all, a gynecological scan isn’t exactly something people volunteer for (unlike the OB ones – at least they have something cute to ogle!). I can’t tell you HOW MANY times patients have said, “Boy, these are more fun when there’s a baby in there.” A dollar for every one of those comments and I’d have a penthouse in Manhattan by now.

Most patients still in the baby-making stages of life are typically pretty familiar with a transvaginal ultrasound. It’s how we see Baby early in the first trimester or monitor the cervix. But many young or older women are not familiar with my long skinny friend. Some are mortified at the thought of this exam. To note, these patients are always there because of a problem which could be a whole myriad of issues from crazy periods to ovarian cysts.

The Transvaginal Ultrasound Protocol

One thing is for sure. Give me a woman with pelvic pain and, I can promise you, the last thing she wants to see is any ferociously-long object headed down south. I first apologize then promise that it’s quick and painless. I also add that at least they didn’t have to drink a gallon of water and hold it. Okay, I’m over-exaggerating. Some facilities still require patients to drink approximately 32 ozs of fluid for a transabdominal pelvic ultrasound (a scan on top the belly). You can read more about bladder preps here: How Much Water to Drink for Your Ultrasound

This little fact is usually enough to get a deliberately labored, “Okaaaaaay, what do I have to do now?” But it’s still a consent! Goal.

Transvaginal Ultrasound Provides You a Better Exam!

Vaginal ultrasound is probably, to me anyway, THE best ultrasound invention since ultrasound’s inception. I tell patients it really is the difference between night and day. It’s much like looking out of a clear glass window versus one with a sheer curtain drawn. I would say that about 95% of the time, I can see better when using the vaginal approach. A very large uterus or pelvic mass, however, would require an abdominal approach.

Did you just say you want a little Ultrasound Physics 101?? Well, I thought so! I’ll make it short. The transvaginal probe is built to deliver a higher-frequency sound wave which doesn’t penetrate very deep into the body. It offers by far the BEST resolution because the uterus and ovaries lie close to the probe. When we scan over the pelvis with a full bladder, the fluid provides a window for the uterus and ovaries behind it. However, by the time the sound waves get all the way down to those organs and back, we have a somewhat compromised image. The vaginal probe requires an empty bladder which allows us to see the uterus better.

We cover the probe with a condom or glove and insert it into the vaginal canal like a tampon. Be sure to let your sonographer know if you have a latex allergy! We place the probe against the cervix only; it does NOT enter into the uterus. The cervix remains closed (unless you’re in labor), so it cannot be inserted past this point. The sonographer obtains a magnified image of the uterus and ovaries and the areas immediately around them. We measure the uterus, endometrium (lining of the uterus), ovaries, and any pathology that we see related to those organs. Air and gas are not our friends, so sometimes those factors interfere with a good image.

How Long Does a Transvaginal Ultrasound Take?

About fifteen minutes, longer if the exam is complicated by pathology or if views we need are difficult to obtain. (By the way, “pathology” doesn’t always mean a worrisome or dangerous process!) When it’s over, the patient usually says the exam wasn’t that bad at all! Frequently, they will share the reason for their trepidation. It’s mostly because a friend had one done by a technologist with a heavy hand, making it quite a painful experience. I’ll usually respond by saying, “Firstly, you should ALWAYS tell someone when your exam is that painful. And, secondly, we don’t need to see your tonsils!” I’m not a comedienne, but that comment usually gets a much-needed laugh, and the end of the scan is very much appreciated:)


More coming about transvaginal ultrasound and your early OB scans with the release of my new book about first-trimester ultrasound. Hopefully, very soon! You can receive automatic updates on the book (along with a little something special when it publishes!) and the most current posts by subscribing to my blog. You’ll see where in the right margin! >>


And please feel free to email me any questions you have at

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Posted on October 26th, 2015 by

Embryonic Heartbeat on 9 Week Ultrasound

Ever see a real-time video clip of a 9 Week embryonic heartbeat? Just click on my link below:

9-Week Ultrasound – Embryonic Heartbeat

This clip demonstrates a quick video of Baby with transvaginal imaging. First, we see the head, then we see a long view of baby’s body and the incredible flicker of cardiac activity in the chest. The fetal head lies to the left of your screen and the small circle near baby’s bottom represents the yolk sac. Also, notice the thin white line around Baby. This is the amnion or amniotic membrane. Looking carefully, one can make out the beginning of arm and leg buds.

Aw, it’s so cute already!

Annotated Week 9 Embryonic Images

Here, I have added annotated still images from the video above:

9 week embryo, 9-week embryonic heartbeat

9 week embryo, amnion, 9-week embryonic heartbeat

Can anyone guess what the black represents? Yep! Amniotic fluid. You guys are so smart:)

Hope this was entertaining and informative! Please feel free to email me with your questions or comments at!

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Posted on July 22nd, 2015 by


I read something a little disturbing whilst surfing this universal web of ours called the internet.  I don’t often search anything ultrasound related unless it is a medical reference for the purpose of supporting the diagnosis of a case.  I have been told, however, that if I want to increase my visibility of this blog, I must submit my two cents on other sites and provide a link.  It’s very disturbing.  Where do I start??!  There’s so much misinformation out there and it’s very distressing to know people are believing everything they read or are misguided in some way themselves.

Someone wrote essentially a one-liner about her miscarriage.  She stated that she will absolutely never have another transvaginal ultrasound in pregnancy because the one time she allowed it, her baby died the next day.  I was so saddened by this statement.  I attempted to reach out to her with a direct email but it wasn’t possible.  I hope someday, in some small, remote and very unlikely way, she may stumble across this post.

ALL OB PATIENTS!!  Please know that scanning with an internal ultrasound probe in no way, shape or form causes miscarriage or fetal demise.  If this were the case, we would not be allowed to perform the examination! Our docs are in the business of helping you carry a healthy pregnancy and, hopefully, to term.  Transvaginal sonography is the best addition to sonography for early obstetric care and gynecologic studies.  It provides so much useful information for your physician that just cannot be seen with transabdominal scanning.

It helps us find your Baby’s heartbeat and determine gestational age early in the first trimester. It helps affirm for your doctor that your pregnancy is progressing normally or whether it is threatened because of bleeding or a shortened cervix.

Most of you know that your OB/GYN doc has your best interest at heart.  It’s unfortunate and sad that the coincidence of this tragic event happened after her examination..but it was not the cause.  I want you all to understand that having this exam done is what can help your doctor SAVE your pregnancy.  The goal is happy, healthy, full-term babies!  Sometimes we can help you achieve this; sometimes we can’t.  Either way, transvaginal ultrasound likely played an instrumental role in  providing your physician with much-needed and highly valuable information.

If the medical community feels it is safe enough for ourselves and our own families, we certainly want to provide you with the same quality care!

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Posted on July 17th, 2015 by

Every once in a while we have a patient who desperately wants to pin down the EXACT day she conceived so she can determine the father of her baby.  Ultrasound can give you a general time-frame within a few days of reliability early in the first trimester (about 8-10wks gestational age) but it cannot be specific to the day.  Moreover, ultrasound measurements become less accurate the farther along in the pregnancy you are.  Someone who shows up for dating at 23wks, for example, will get an estimate or “best educational guess” for a due date.  Determining paternity by ultrasound is not “cut and dried”.

Some would like us to pin it to the hour.  Sorry, ladies, but we just aren’t this good in ultrasound! Only DNA testing after Baby is born will help you in this case.  Literally, a young girl in college bounces into the practice one day hoping we could differentiate within one week between three possible candidates. She was very cavalier about her dire straights, and her mother who was with her thought it was just as funny. No judgement zone here, but I find it more of a serious matter when you’re talking about the father of a child you plan to raise for the next couple of decades…and beyond!

The first thing your doctor will ask is when your LMP or last menstrual period started.  Most people ovulate between days 10 and 14 but some people have very short cycles and others have longer ones so the actual day the egg is released is quite variable.  Some people experience very irregular periods, oftentimes skipping several months at a time, which is totally unreliable for dating, unless you know exactly the dates you had sex.  Moreover, semen can live for a few days within the vagina (don’t quote me and I’m sure this is an exact science in some literature but I am not an expert in the life cycle of sperm) so it would be hard to pinpoint the exact day of conception.

Getting a good dating scan in the first trimester by someone who is experienced in determining the best measurement is the next order of business, providing Baby is easy to see. I personally feel a transvaginal ultrasound at 8-10wks is the best time to obtain a CRL (crown-rump length, measurement from head to butt) because Baby is not too small or big.  A 6wk pregnancy where the embryo measures a whopping 3mm can be very difficult to see well.  At 12wks the fetus is fully formed and very active which can make obtaining a good measurement challenging.

See the images below to see the difference in a CRL at 6wks, 8wks and 11wks!

6wk embryo

6wk embryo

Baby is so small here that it can be hard to see in some patients depending on how it is positioned!


8wk fetus

8wk fetus

This is the best dating here! Baby is usually pretty easy to see now at about 1/2 inch.  This measurement is accurate within 1-2 days.


11wk fetus

11wk fetus

Dating is still fairly accurate here within about 3-5days.  They move a lot and bend and one can imagine that a bigger measurement will yield a baby a little farther along if he/she is stretched out vs curled in a little ball.


I get it; things happen.  People who are in a serious relationship break up.  They see someone else during the pause..rebound, shoulder to cry on, etc., and then reconnect.  This can be a wonderful reunion! But it can still make for a bit of a hairy situation if these encounters happened within 2wks of one another.

On a final note, imagine yourself in this situation.. You’re pregnant with twins.  You’re in the throes of labor.  Out pops your first baby.  Joy! Success! Beautiful!  Baby B is right behind.  Big push!  He’s out!  Oh.  Wait a minute.  One is black; one is white.  Yes, this definitely happened! Lucy, you have some ‘splaining to do!!

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Posted on June 23rd, 2015 by

Transvaginal ultrasound provides THE best contribution to ultrasound, bar none. It gives us a high resolution image because the probe lies closer to the organs and utilizes a higher frequency than abdominal probes. Most women come alone; some need the support of a spouse; some need the whole family!

Case in point. A young patient comes into the office with an entourage. I needed to check my memory twice, reminding myself that she wasn’t there for an OB appointment. With her was her mom, her child, and her boyfriend. Mom insisted on coming in for the exam along with the child. Of course, I could care less as long as the patient wants them in there. I have to ask all the same questions regardless of who else is in the room. If you don’t want someone hearing all your personal GYN business, you’d better have them wait outside. This wasn’t the case here on this day; nonetheless, no truer statement has ever been spoken…well, typed, that is.

Transvaginal Ultrasound is Not Always a Welcomed Approach!

About 80% of the time, I get the same reaction. I say the word “transvaginal,” and I see my patients’ eyes get as big as dinner plates. I realize the hesitation on several points. If you’ve never heard of it, if you’ve never had one done, or if you’ve never been to the GYN doc, I condone “the look.”

transvaginal probe

Honestly, I’d do the same if someone came at me with one of these sans my ultrasound education. Wouldn’t you?

If someone has had no sexual experience or if a patient has had a bad personal experience in the past which has left them emotionally scarred, the hesitation is understandable. Usually, I know about these well in advance. We plan around them by having the patient fill her bladder or by simply explaining the exam and allowing her the choice.

The examination almost always causes a bit awkwardness for the patient (though never for me). We always recommend the support of a spouse or friend if the patient feels anxious about the exam or results. Otherwise, a targeted visit for Marble Slab should immediately follow. Isn’t that the sole purpose for ice cream anyway? I think it would make for an interesting new ad campaign. Ice cream…the perfect post-stirrup consolation prize!

Thanks for reading and have a great day!

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Posted on May 23rd, 2015 by

The 11 Week Fetus – What Will You See?

You’re almost out of the woods! Your baby is now just shy of two whole inches in length from head to bottom. The 11 week fetus is looking more and more like a baby, and watching baby flop around like a little fish out of water always creates a chuckle for us spectators. Baby will sometimes be quite still, too, resting up a bit after all the cartwheels. So, don’t be alarmed if your baby is quiet during your ultrasound.

Transvaginal ultrasound is still usually the preferred method of scanning as it gives us the best resolution, but we can adequately measure what we need with the abdominal approach in most patients. Depending on where you have your examination performed, you may need to fill your bladder. Ugh, the dreaded bladder prep! Hopefully, you won’t have to drink an ocean of water for your ultrasound exam at 11 Weeks.

What Will My 11 Week Fetus Look Like?

Baby’s arms and legs are almost fully developed! Baby’s head still looks bigger than his or her body. This is totally normal! There is a lot of brain still growing in there. This appearance will stick around for several more weeks. All the black you can see around your baby is amniotic fluid.

In the image below, you’ll see the Crown-Rump Length (CRL) measuring Baby from head to butt on the left-hand side of the screen. Notice Baby measures about 4.3cm now – just shy of two inches (5cm = 2″)! A tiny foot is easily seen in the upper, right which is about 1/2 inch long. Last but not least, a tiny pair of legs and feet can be easily distinguished at the bottom. So cute!


11 week fetus


Hit me up if you have any questions about the 11 week fetus or anything else ultrasound-related at my email address, and subscribe!


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Posted on November 24th, 2014 by

Ultrasound’s job is to find pathology, aka disease. More pathology means more time dedicated to each patient’s examination and reporting.

I cannot remember a time when I’ve seen two cases of cancer in one week…one ovarian and the other was a suspected fallopian tube cancer which is very rare. Either way, it is always a bit dis-heartening to see a mass in the pelvis with concerning size or features.  Sometimes we take one look and just know it is something bad for this patient.  It’s hard for me knowing I have to put a smile on my face and show this patient out the door. I think about how her life will be changed and what she will have to face in the upcoming months. I think about her family and how they must feel upon hearing the news and then facing the repercussions with her.

The only thing that makes me feel a little better is knowing it was caught but feeling a little sad the patient didn’t come in sooner.  We all do it.  We put off symptoms thinking they’ll go away or it’s nothing.  We can’t ignore the things our bodies are trying to tell us.  The best we can do is to address it sooner than later and hope it turns out to be nothing. If nothing is really something, maybe something can be done to treat you now vs having few choices later.

I have thought of those two ladies many times.  I keep checking their charts and with their doctors to follow-up for news.  I have kept them in my prayers.  It makes me a little sad to think of how their holiday might be changed for the worse.  Alternatively, it’s also quite surprising how such news can also be a Pandora’s box of unexpected blessings and thankfulness.  I wish them much of both.


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Posted on August 9th, 2014 by

Are we ever too old for ultrasound?  Do we ever get to an age where we won’t ever have a need for a pelvic ultrasound exam?  ..Never.

Working for obstetricians means they also manage their patients before and after they have babies which means that not only do I scan many babies but I also perform diagnostic ultrasound on a number of baby-free uteri and accompanying ovaries.  Moreover, my 70-80 year old patients have never even fathomed vaginal imaging.  Unfortunately, we ladies have female issues long before and long after our babies come along..everything from pelvic pain to ovarian cysts to abnormal periods to postmenopausal bleeding. I have heard more than once that they “NEVER thought they’d be doing THIS again”.  I wish I had a dollar for every time I’ve heard this in my career.  I’d probably be in Costa Rica somewhere sipping on a little umbrella drink with my toes in the sand.

My response to them is always the long as you are a woman and your heart is beating, you will ALWAYS have to put your feet in stirrups. We will never ever be too old for ultrasound, a pelvic exam or those awkward metal foot holders. Believe me, it’s not my favorite way to spend 30 minutes, either.  Feet here and slide on down to the end, Ladies!

I’m coming back in my next life as a man.

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Posted on July 12th, 2014 by

Technology has its pros and cons. We THINK we want to know the second we conceive…but do we really? When all we can see is early first trimester sacs, your doc cannot confirm the pregnancy is off to a good start. At least not until we can see an embryo and strong heartbeat at 6 Weeks. Some patients find out that (often times) ignorance is bliss. The wait is long and miserable! This is why your doc will elect to scan you around Week 7 or 8.

Early First Trimester Sacs – Week 4

Very early in the pregnancy, less than 4 Weeks gestational age, we can’t see a thing. To clarify, we start to see a gestational sac at around 4 Weeks. This sac will measure only about 2mm and will literally appear as a tiny black blip within the uterus. All we can report at this time is that we think it’s an early sac.

Week 5

Monumental changes are happening every week!  At 5 Weeks pregnant, we see a much bigger sac. However, it’s only enough information to say, yes, the sac has grown, it measures around 5 Weeks, and that is good. Around 5 1/2 Weeks, we should see the presence of a yolk sac. It looks like a little circle inside of the sac and provides nutrients for Baby who is still too tiny to see by ultrasound. Below is about a 5 1/2 Week pregnancy of twins (obviously! Dichorionic/Diamniotic or fraternal).

Yolk Sacs, 5 Weeks pregnant, twin pregnancy, early first trimester sacs


Week 6

6 Weeks pregnant, 6 Week ultrasound, 6 Week embryo

By the next week at 6 Weeks gestation, an embryo measuring about 3.5mm with cardiac activity should be seen! A nice, round yolk sac and a bigger gestational sac factor into what we expect for this exam. Baby is still very tiny, and it can be difficult to visualize well if the embryo is lying against the wall of the gestational sac.

At 7 Weeks we can see a little better, and Baby is a few mm larger. But 8 Weeks usually gives us a great image of what we want to see!

Week 8

Baby, on your 8 Week ultrasound, is much easier to measure at this point.

8 Weeks pregnant, 8 Week ultrasound, early first trimester

Isn’t the growth in two weeks incredible?!!!

It’s all a process of Mother Nature. It can’t be rushed, and only time will tell if your pregnancy is growing appropriately! If you think you are farther along by your LMP (last menstrual period) dates, we perform an ultrasound, and we don’t see what we expect, it can feel like such a long wait! There’s no way to know whether the pregnancy may not be progressing normally or whether you may just be too early!

It’s so hard to wait. And it may feel like the longest week or two of your life before your doctor orders another scan!

What most women do (and I caution you to not!) is to talk to friends and family and search Dr. Google furiously for what to expect. Only no article or blog post can predict the outcome, and only that next scan will (hopefully!) give you answers.

Here’s sending you best wishes and much-needed patience to all you expectant moms out there!

Email me at with your questions or comments:)


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Posted on July 7th, 2014 by

Can we see cervical dilation on ultrasound?

In short, not routinely. This is a question I’ve gotten often from patients in the third trimester almost weekly. Can ultrasound determine cervical dilation? Though ultrasound is a good method of determining cervical incompetence or shortening of the cervix early in your pregnancy, cervical dilation remains something your doctor has to check for manually later on.

Now, there have been some school of thought with regard to scanning vaginally and obtaining a 3D view of the cervix to measure dilation seen at the external os (your doctor’s view of your cervix with a speculum), but I’ve only seen this in an article pertaining to a conducted study. The good ol’ finger assessment is still the most routine method used for determining any degree of dilation of the cervix.

It’s just another one of those uncomfortable things we have to tolerate with our feet in stirrups, Ladies!  Here’s to OB docs with small hands!

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Posted on April 13th, 2014 by

There exists a whole plethora of reasons to do an ultrasound on the female pelvis before and after a little bun is baking in the oven. I know, I know, it’s not as much fun to talk about those “other” things but they are just as important as Baby. So today’s post is dedicated to the under-appreciated empty uterus.

Our bodies are amazing pieces of fleshy technology! We are a well-oiled machine, my friend, and the same holds true for GYN parts. The uterus bleeds like crazy in attempt to remove things that shouldn’t be there or will make us sick and the ovaries produce a cyst and ovulate (release the egg) every single month (for most women). The lining of our uterus gets thick every month JUST IN CASE a baby might want to implant there and if not, sheds with a period. Again, this is if your parts are functioning like clock-work.  When they aren’t, my docs come to the rescue. See, they are not just baby catchers!

Many symptoms warrant your gynecologist to order a pelvic ultrasound. Abnormal bleeding of any kind at any age is a good place to start..too much bleeding, not enough bleeding, no bleeding, bleeding between periods, painful periods (are any of them pleasant?) and bleeding after menopause are a few of the most common reasons.  Periods are no fun and having one for a month is certainly no celebration!  Pelvic pain or discomfort, bloating or something felt by your doctor during a pelvic exam are other very routine causes for ordering this exam.  Maybe something was diagnosed by a previous ultrasound or CT (CAT scan) and a follow-up was ordered to see if it is resolved.  If you have a family history of some GYN disease, this is yet another indication for ultrasound.  There are certainly many more which is why there are volumes dedicated to the subject in med school.

If one is ordered for you, check with your doctor regarding prep.  Sometimes you have to drink a ton of water for an abdominal scan, most often you don’t in which case this would be a transvaginal ultrasound.  It may sound terrible but it’s not, especially if you are sexually active.  If this is the case (let me think of a politically correct way to say this), the probe is much skinnier than, hopefully, anything that has been introduced to you before.  There.  How was that??  I didn’t say exactly what I wanted here but you get the point.   In other words, if you can manage one, the other will not be a problem!

Here is a link to one of my favorite early posts on the subject of transvaginal exams (you may have to copy and paste the link).  Enjoy!

And since not many people really want to see an image of a uterus or ovary, I’ll attach one of a very cute baby instead!


And what a precious little angel this one is!


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