The role of transvaginal sonography in diagnosis of female infertility: a study protocol

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It hurts both the psychological and physical aspects of a person. In order to tackle this issue, it is necessary to know the cause of infertility. Transvaginal ultrasound is an accurate, cost-effective, and rapid method for diagnosing the causes of infertility, which can reduce the need for invasive procedures like hysteroscopy. The main aim of this study is to describe the role of transvaginal ultrasonography in diagnosing various causes of female infertility." } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/12-1335/v2", "name": "The role of transvaginal sonography in diagnosis of female infertility:..." } } ] } Home Browse The role of transvaginal sonography in diagnosis of female infertility:... ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Thaker N and Dhande R. The role of transvaginal sonography in diagnosis of female infertility: a study protocol [version 2; peer review: 2 not approved] . F1000Research 2025, 12 :1335 ( https://doi.org/10.12688/f1000research.140962.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Study Protocol Revised The role of transvaginal sonography in diagnosis of female infertility: a study protocol [version 2; peer review: 2 not approved] Nirja Thaker https://orcid.org/0009-0003-0395-8273 1 , Rajasbala Dhande 1 Nirja Thaker https://orcid.org/0009-0003-0395-8273 1 , Rajasbala Dhande 1 PUBLISHED 30 Jul 2025 Author details Author details 1 Department of Radio-diagnosis, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, 442001, India Nirja Thaker Roles: Writing – Original Draft Preparation Rajasbala Dhande Roles: Supervision, Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Datta Meghe Institute of Higher Education and Research collection. Abstract Infertility has an increased incidence in today’s world. It hurts both the psychological and physical aspects of a person. In order to tackle this issue, it is necessary to know the cause of infertility. Transvaginal ultrasound is an accurate, cost-effective, and rapid method for diagnosing the causes of infertility, which can reduce the need for invasive procedures like hysteroscopy. The main aim of this study is to describe the role of transvaginal ultrasonography in diagnosing various causes of female infertility. READ ALL READ LESS Keywords INFERTILITY, TRANSVAGINAL ULTRASONOGRAPHY, DIAGNOSIS Corresponding Author(s) Nirja Thaker ( [email protected] ) Close Corresponding author: Nirja Thaker Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Thaker N and Dhande R. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Thaker N and Dhande R. The role of transvaginal sonography in diagnosis of female infertility: a study protocol [version 2; peer review: 2 not approved] . F1000Research 2025, 12 :1335 ( https://doi.org/10.12688/f1000research.140962.2 ) First published: 16 Oct 2023, 12 :1335 ( https://doi.org/10.12688/f1000research.140962.1 ) Latest published: 30 Jul 2025, 12 :1335 ( https://doi.org/10.12688/f1000research.140962.2 ) Revised Amendments from Version 1 We sincerely thank the reviewer for their detailed and constructive feedback, which has significantly improved the clarity and rigor of our study protocol titled “The role of transvaginal sonography in the diagnosis of female infertility.” In response, we have thoroughly revised the manuscript. We have corrected the inaccurate description of transvaginal ultrasound (TVUS), acknowledging it as a well-established diagnostic tool in gynecology. The rationale has been strengthened to emphasize the need for validating TVUS accuracy in diverse regional populations, with specific comparisons to gold-standard investigations such as HSG and laparoscopy. Our research question has been reframed using the PICO format, and objectives have been clearly defined with measurable outcomes such as sensitivity, specificity, and correlation with fertility outcomes. We now explicitly describe the comparator methods and reference standards for evaluating diagnostic accuracy. Sample size calculations have been updated using accurate prevalence data and specify the statistical software to be used (SPSS). Additionally, male factor infertility has been added to the exclusion criteria to ensure population homogeneity. We have ensured that all references are now accessible via DOIs or hyperlinks and will be formatted according to F1000 requirements. We hope these comprehensive revisions address the reviewer’s concerns and meet the standards of scientific rigor and transparency expected for publication. We sincerely thank the reviewer for their detailed and constructive feedback, which has significantly improved the clarity and rigor of our study protocol titled “The role of transvaginal sonography in the diagnosis of female infertility.” In response, we have thoroughly revised the manuscript. We have corrected the inaccurate description of transvaginal ultrasound (TVUS), acknowledging it as a well-established diagnostic tool in gynecology. The rationale has been strengthened to emphasize the need for validating TVUS accuracy in diverse regional populations, with specific comparisons to gold-standard investigations such as HSG and laparoscopy. Our research question has been reframed using the PICO format, and objectives have been clearly defined with measurable outcomes such as sensitivity, specificity, and correlation with fertility outcomes. We now explicitly describe the comparator methods and reference standards for evaluating diagnostic accuracy. Sample size calculations have been updated using accurate prevalence data and specify the statistical software to be used (SPSS). Additionally, male factor infertility has been added to the exclusion criteria to ensure population homogeneity. We have ensured that all references are now accessible via DOIs or hyperlinks and will be formatted according to F1000 requirements. We hope these comprehensive revisions address the reviewer’s concerns and meet the standards of scientific rigor and transparency expected for publication. To read any peer review reports and author responses for this article, follow the "read" links in the Open Peer Review table. READ REVIEWER RESPONSES Introduction Infertility is the inability to conceive after one year of unprotected intercourse. Approximately 15.5% of women globally are afflicted with infertility. 1 In India, the prevalence ranges from 3.9 to 16.8% (according to the Government website). The standard workup for female infertility includes assessing ovarian reserve, tubal and uterine examination, hormonal issues such as thyroid disorders and prolactin abnormalities, and confirmation of polycystic ovarian syndrome/disorder (PCOS). 2 Female infertility causes are difficult to pinpoint. Although there are numerous therapies available, the treatment will be determined based on the cause of infertility. The most significant gains in assisted reproductive technology (ART) have resulted from advancements in pelvic structure evaluation tools. 3 Infertility evaluation necessitates histopathological testing as well as visualization using several imaging modalities. There are many causes of infertility, including ovarian (such as ovarian dysgenesis or agenesis, premature ovarian failure, oophoritis, chocolate cyst, and polycystic ovarian syndrome), uterine (such as fibroid, adenomyosis, mullerian duct anomalies, endometrial polyp, endometriosis, endometritis, and intra-uterine adhesions caused by infectious causes such as tuberculosis), cervical aetiology (such as cervical stenosis), tubal aetiology (such as tubal occlusion, hydrosalpinx, pelvic inflammatory illness, and endometriosis). 4 Because it is inexpensive, convenient, and gives basic information about the morphology of the uterus, cervix, endometrium, adnexa, and ovaries, ultrasound is the chosen initial modality of study for evaluating possible causes of female infertility. 5 Transvaginal sonography (TVUS) is a well-established and widely adopted diagnostic tool in gynecological imaging. It offers high-resolution visualization of pelvic organs and is considered the first-line modality for assessing uterine morphology, endometrial pattern, ovarian structure, and adnexal pathology. The clinical value of TVUS has been demonstrated across numerous studies dating back over three decades (e.g., Gratton et al., 1990; Ubaldi et al., 1998). A high-frequency transducer is implanted endovaginally to evaluate pelvic organs in detail. But other investigations are needed to confirm TVS’s role and to know how accurate it is in diagnosing various causes of primary and secondary infertility. 5 However, the heterogeneity of infertility causes in diverse populations and the evolving application of sonographic parameters (such as ovarian stromal assessment, AFC, and Doppler indices) suggest that re-evaluation of TVUS’s diagnostic performance in specific regional contexts remains relevant, particularly when compared against gold-standard methods like hysterosalpingography (HSG) or diagnostic laparoscopy. Rationale This study aims to quantify the diagnostic performance of TVUS in detecting common causes of female infertility, using established reference standards. By comparing TVUS findings with results from secondary confirmatory methods (e.g., HSG, laparoscopy, and hormonal assays), we aim to evaluate its diagnostic accuracy, reproducibility, and correlation with clinical fertility outcomes. Research question • Population: Women aged 20–40 years presenting with primary or secondary infertility. • Intervention: Transvaginal sonography. • Comparator: HSG, diagnostic laparoscopy, hormonal profile, semen analysis for male exclusion. • Outcome: Diagnostic accuracy of TVUS (sensitivity, specificity, PPV, NPV) in identifying ovarian, uterine, and tubal abnormalities. Aim This study aims to describe the role of transvaginal ultrasonography in diagnosing various causes of female infertility. Objectives • To evaluate the diagnostic accuracy (sensitivity, specificity, PPV, NPV) of TVUS in detecting structural and functional causes of female infertility, using appropriate reference standards. • To assess specific sonographic parameters (e.g., AFC, endometrial thickness, ovarian morphology, Doppler flow) and their correlation with fertility outcomes (e.g., conception within 6 months). • To compare the diagnostic performance of TVUS with other diagnostic modalities (e.g., HSG for tubal patency; laparoscopy for endometriosis) in a sub-cohort. • To describe the prevalence and distribution of infertility causes in the study population. Protocol The institute will begin data collection after the project has been ethically cleared. Once a patient passes the eligibility requirements for the study, the process will be described to them, and a written agreement will be obtained. A female attendant/nurse will be present throughout the process. Proper sanitary conditions will be maintained – Gloves will be worn by the health professionals, and a condom will be used to cover the transvaginal probe. Before the scan, the patient will be instructed to empty her bladder, and she will be scanned in the lithotomy position. TVS is performed with a 5-12 MHz endovaginal probe on ALOKA HITACHI ARIETTA S-70 and WIPRO GE LOGIQ P5 PRO ultrasound equipment during the follicular phase of the menstrual cycle (the 5th-13th day following menstruation). The TVS probe will first be covered with ultrasound gel, then with a condom, and finally with ultrasound gel again over the covered transducer. A female nurse will inject it into the patient. The uterus will be examined in both sagittal and transverse views to examine the entire uterine anatomy, including the cervix, ovaries, adnexa, myometrium, and endometrium (thickness and consistency). The measurement of uterine dimensions (length and height) is taken in the sagittal plane, whereas the width is assessed in the transverse plane (at the level of the tubal ostia). The mid-sagittal plane is used to evaluate endometrial thickness. Ovarian length, height, and width will be measured, as well as the baseline AFC (antral follicle count of follicles measuring 2-10mm and >10mm). 6 AFC is calculated by adding the total follicles of both ovaries (AFC5 is regarded as low, AFC>=20 is called ovarian hyperstimulation syndrome, and AFC=4 indicates a chance of menopause within the next 7 years). 7 – 9 Free fluid and sliding sign (to see adhesion) are seen in examination of the culdesac- This involves applying gentle pressure through probe on the lower abdomen to assess the gliding of anterior rectum and sigmoid colon along the posterior aspect of the upper portion of uterus, cervix, and vaginal wall. When the sliding sign is “Negative”, it indicates the obliteration of the pouch of Douglas, which can be due to endometriosis. Thus, data will be collected regarding the various causes of infertility relating to adnexal, uterine, and cervical pathologies, and ovarian causes (by measuring the ovarian volume, follicular size, and ovarian reserve assessment in the form of antral follicular count). Also, data regarding causes of infertility will be collected from different modalities like Magnetic resonance imaging of the pelvis and hysterosalpingography, and results of other modalities will be compared with results from transvaginal ultrasound. As this is mainly a descriptive study, the data(causes) will be enumerated in a tabular form. And wherever possible accuracy of transvaginal sonography in diagnosing infertility will be mentioned in percentage (as compared to different modalities). Statistical analysis will be performed using SPSS software. Consent A written consent will be obtained in either Marathi or English from all the patients included in this study. Ethical approval Ethical approval was obtained from the Institutional Ethics Committee (Datta Meghe Institute of Higher Education and Research), Re-regd. No. ECR/440/Inst/MH/2013/RR-2019)-Dated- 21/03/2023. Methods All participants will undergo baseline clinical evaluation followed by TVUS on days 2–5 of the menstrual cycle. Parameters such as endometrial thickness, follicular count, ovarian volume, and uterine morphology will be documented. Subsequently, patients will undergo confirmatory testing as clinically indicated (HSG for tubal evaluation, laparoscopy for suspected endometriosis, and hormone profile for ovulatory status). TVUS findings will be compared to these reference standards to compute diagnostic accuracy. Study design This study will be a descriptive prospective cross-sectional study conducted on patients visiting the OPD department as well as the IPD patients of the Hospital from January 2023 to January 2025. The population will consist of married women in the age group of 18-40 years with the inability to conceive for one year despite being sexually active, who present to the gynecology department. We will use purposive sampling to recruit the participants. Sample size: Formula with prevalence with proportion Topic: female infertility. Prevalence = 3.9 to 16.6% (average -10.25%) ( website ) Formula α: type I error = 0.05 Estimated proportion (p) = 0.10 Estimation of error (d) = 0.05 n > = Z 2 1 − α / 2 x p 1 − p / d 2 Minimum sample size needed = 139 Duration of study: 2023 – 2025 Inclusion criteria • All married female patients between the ages of 18 and 40 who present to ABVRH with a provisional clinical diagnosis of infertility (including primary and secondary). Exclusion criteria • Female patients under the age of 18. • Female patients above the age of 40. • Married female patients who refuse to give consent. • Married female patients with suspected infertility caused by medication, radiation, or pituitary, adrenal, or thyroid gland issues. • Female patients who are married and have a uterine congenital abnormality. • Diagnosed male factor infertility (confirmed by semen analysis). • Recent pelvic surgery (<6 months). • Incomplete follow-up or refusal to undergo confirmatory tests. Study Status: Recruitment. Discussion A study, ‘Role of transvaginal ultrasonography and diagnostic hysteroscopy in assessing endometrial cavity of women presenting with infertility’ was conducted by K. Sarala et al . in 2018. This study concluded that hysteroscopy can be regarded as the gold standard in the diagnosis of infertility. The study compared the transvaginal findings with hysteroscopic findings. The transvaginal findings and hysteroscopic findings were similar. The various causes of infertility were endometrial hyperplasia, submucous fibroids, endometrial polyps, adhesions, and congenital malformations in decreasing order of frequency, respectively. Thus, it was concluded that although hysteroscopy is considered the gold standard, transvaginal sonography can be used as an initial investigation in infertility work. 10 In the study conducted by Maysa S. Elkerdawy et al. on the role of ultra-sonography (USG) in the management of primary infertility, it was found that 60% of patients had uterine abnormalities (mainly subseptate and bicornuate uterus) while approximately 23% of patients had ovarian pathology (mainly polycystic ovaries). Only a small percentage of patients had tubal and cervical pathologies (like hydrosalpinx, cervical mass, etc.). It was further found that USG can be used as a primary tool for investigation. 4 In the study carried out by Salaam AJ et al. on the topic of evaluation of infertile women using transvaginal USG, primary fertility constituted about 42% of total subjects while secondary infertility constituted about 58%, and about 54% had normal TVS findings and rest (46%) had abnormal findings like uterine fibroid, free fluid in Pouch of Douglas (POD), endometritis, and hydrosalpinx in the decreasing order of frequency. It was also found that there was a significant difference in volume between the right and left ovaries in infertile women with Polycystic Ovaries (PCO). This study found that a high yield of sonographic anomalies was observed on transvaginal sonography in infertile subjects, bolstering TVS's essential function as a useful diagnostic tool for evaluating infertility. 11 In the study conducted on transvaginal sonographical findings by Nafeesa Binti Hussain et al. on women presenting with inability to conceive, they inferred the following: 75%of cases were of primary infertility while 25% of cases were of secondary infertility, and the most common pathological findings were polycystic ovarian syndrome (69%), followed by chronic pelvic inflammatory disorder, fibroid, anatomical disorders, endometrial or cervical polyps, and endometritis in decreasing order of frequency. The study concluded that PCO was the most frequent finding in women with infertility, which was easily diagnosed by transvaginal sonography. 5 Scope Transvaginal ultrasonography is a highly accurate method for detecting various disorders in the female reproductive system. The goal of this study is to identify the many diseases of primary and secondary infertility and to demonstrate the diagnostic accuracy of TVS as a main inquiry in infertility. Dissemination This study will enumerate the various causes of infertility in today’s scenario in India, which will be educational and helpful in future planning of focus areas for further studies. This study will establish the importance of Transvaginal sonography as a first line in the diagnosis of infertility. Data availability No data are associated with this article. References 1. Expert Panel on Women’s ImagingWall DJ, Reinhold C, et al. : ACR Appropriateness Criteria® Female Infertility. J. Am. Coll. Radiol. 2020 May; 17 (5S): S113–S124. PubMed Abstract | Publisher Full Text 2. Kondagari L, Kahn J, Singh M: Sonography Gynecology Infertility Assessment, Protocols, and Interpretation. 2023 Jun 7. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan–. PubMed Abstract 3. Aflatoonian A, Mashayekhy M: Transvaginal Ultrasonography in Female Infertility Evaluation. Donald School J. Ultrasound Obstet. Gynecol. 2015; 9 (2): 174–180. Publisher Full Text 4. Elkerdawy MS, Ali MA, Keriakos NN: Ultrasound Role in Management of Female Infertility. Med. J. Cairo. Univ. 2020 Sep; 88 (4): 1523–1530. 5. Hussain NB, Das RR: Transvaginal Ultrasound Findings Among the Women Presenting with Infertility. Chattagram Maa-O-Shishu Hosp. Med. Coll. J. 2018 Jul; 16 (2): 31–35. Publisher Full Text 6. AIUM Practice Parameter for the Performance of a Focused Ultrasound Examination in Reproductive Endocrinology and Female Infertility. J. Ultrasound Med. 2019 Mar; 38 (3): E1–E3. PubMed Abstract | Publisher Full Text 7. Coelho Neto MA, Ludwin A, Borrell A, et al. : Counting ovarian antral follicles by ultrasound: a practical guide. Ultrasound Obstet. Gynecol. 2018 Jan; 51 (1): 10–20. PubMed Abstract | Publisher Full Text 8. Depmann M, Broer SL, van der Schouw YT , et al. : Can we predict age at natural menopause using ovarian reserve tests or mother's age at menopause? A systematic literature review. Menopause. 2016 Feb; 23 (2): 224–232. PubMed Abstract | Publisher Full Text 9. Wellons MF, Bates GW, Schreiner PJ, et al. : Antral follicle count predicts natural menopause in a population-based sample: the Coronary Artery Risk Development in Young Adults Women's Study. Menopause. 2013 Aug; 20 (8): 825–830. PubMed Abstract | Publisher Full Text | Free Full Text 10. Sarala K, Misra K: Role of Transvaginal Sonography and Diagnostic Hysteroscopy in Evaluation of Endometrial Cavity in Infertile Women. Int. J. Contemp. Med. Res. 2018; 5 (5): E12–E15. Reference Source 11. Kolade-Yunusa HO, Abdullahi HI, Salaam AJ: Evaluation of infertile women using transvaginal ultrasound in a tertiary health facility. Jos. J. Med. 2019; 13 (2). Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 16 Oct 2023 ADD YOUR COMMENT Comment Author details Author details 1 Department of Radio-diagnosis, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, 442001, India Nirja Thaker Roles: Writing – Original Draft Preparation Rajasbala Dhande Roles: Supervision, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (2) version 2 Revised Published: 30 Jul 2025, 12:1335 https://doi.org/10.12688/f1000research.140962.2 version 1 Published: 16 Oct 2023, 12:1335 https://doi.org/10.12688/f1000research.140962.1 Copyright © 2025 Thaker N and Dhande R. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Thaker N and Dhande R. The role of transvaginal sonography in diagnosis of female infertility: a study protocol [version 2; peer review: 2 not approved] . F1000Research 2025, 12 :1335 ( https://doi.org/10.12688/f1000research.140962.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 2 VERSION 2 PUBLISHED 30 Jul 2025 Revised Views 0 Cite How to cite this report: Al Balushi H. Reviewer Report For: The role of transvaginal sonography in diagnosis of female infertility: a study protocol [version 2; peer review: 2 not approved] . F1000Research 2025, 12 :1335 ( https://doi.org/10.5256/f1000research.183679.r407166 ) The direct URL for this report is: https://f1000research.com/articles/12-1335/v2#referee-response-407166 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 10 Sep 2025 Halima Al Balushi , Sultan Qaboos University, Seeb, Oman Not Approved VIEWS 0 https://doi.org/10.5256/f1000research.183679.r407166 This study addresses an important clinical question regarding the diagnostic role of transvaginal ultrasonography in female infertility. The topic is highly relevant, given the need for less invasive, cost-effective, and widely available diagnostic methods in infertility workups. However, the ... Continue reading READ ALL This study addresses an important clinical question regarding the diagnostic role of transvaginal ultrasonography in female infertility. The topic is highly relevant, given the need for less invasive, cost-effective, and widely available diagnostic methods in infertility workups. However, the current proposal suffers from issues related to scope, outcome clarity, comparator heterogeneity, and methodological rigor. In particular, the lack of distinction between diagnostic and clinical outcomes, limited follow-up period, and potential underpowering of sub-analyses are significant concerns. These limitations should be addressed to ensure the study produces clinically meaningful and generalizable findings. Major Concerns Overly broad scope The study attempts to evaluate the role of TVUS in detecting ovarian, uterine, and tubal abnormalities, as well as its correlation with fertility outcomes. This breadth may limit feasibility, as sufficient sample size and statistical power will be required across multiple subgroups. Narrowing the focus to the most clinically relevant or prevalent conditions could strengthen the design. Ambiguity in outcomes The manuscript presents diagnostic accuracy as the primary outcome, but also includes conception within six months as an endpoint. These represent different outcome categories (diagnostic vs. clinical). Clear distinction between primary and secondary outcomes is necessary to avoid dilution of the study’s main objective. Heterogeneous comparators The comparators (HSG, laparoscopy, hormonal assays) evaluate different infertility factors. Without explicit clarification of which reference standard applies to which abnormality, results may be difficult to interpret. For instance, tubal factors should primarily be validated against HSG or laparoscopy, while ovarian function should be referenced against hormonal profiles. Confounding from male infertility Although male infertility is to be excluded via semen analysis, mild or borderline abnormalities may still affect fertility outcomes. This could confound the relationship between TVUS findings and conception rates. A stricter exclusion protocol or sensitivity analysis may be warranted. Clinical outcome follow-up Limiting conception outcomes to six months may underestimate correlations, as many couples achieve conception beyond this timeframe even without intervention. A longer follow-up period would improve the robustness of fertility outcome assessment. Minor Concerns Cost-effectiveness and patient acceptability While diagnostic accuracy is central, real-world clinical adoption also depends on cost-effectiveness and patient comfort. The study could be strengthened by at least discussing these aspects. Reproducibility of TVUS While the study mentions assessing reproducibility, it does not specify whether intra-observer and inter-observer variability will be measured. These are critical in imaging studies and should be incorporated. Age range limitations Restricting the study population to women aged 20–40 may limit generalizability, especially as infertility is common in women over 40. This should be acknowledged as a limitation. Power of sub-analyses The planned comparison of TVUS with laparoscopy and HSG in a sub-cohort raises concerns about sample size adequacy. Underpowered subgroups may yield imprecise estimates of diagnostic accuracy. Prevalence estimates Reporting both prevalence of infertility causes and diagnostic performance from the same dataset could risk circular interpretation, particularly if TVUS misclassifications are not carefully adjusted against reference standards. Is the rationale for, and objectives of, the study clearly described? Partly Is the study design appropriate for the research question? Partly Are sufficient details of the methods provided to allow replication by others? Partly Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests: No competing interests were disclosed. Reviewer Expertise: reproductive medicine, regenerative mdeicine, fertility preservation, molecular biology I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Al Balushi H. Reviewer Report For: The role of transvaginal sonography in diagnosis of female infertility: a study protocol [version 2; peer review: 2 not approved] . F1000Research 2025, 12 :1335 ( https://doi.org/10.5256/f1000research.183679.r407166 ) The direct URL for this report is: https://f1000research.com/articles/12-1335/v2#referee-response-407166 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 16 Oct 2023 Views 0 Cite How to cite this report: Tsakos E and Xydias EM. Reviewer Report For: The role of transvaginal sonography in diagnosis of female infertility: a study protocol [version 2; peer review: 2 not approved] . F1000Research 2025, 12 :1335 ( https://doi.org/10.5256/f1000research.154371.r223667 ) The direct URL for this report is: https://f1000research.com/articles/12-1335/v1#referee-response-223667 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 30 Nov 2023 Elias Tsakos , EmbryoClinic IVF, Thessaloniki, Greece Emmanouil M Xydias , EmbryoClinic IVF, Thessaloniki, Greece Not Approved VIEWS 0 https://doi.org/10.5256/f1000research.154371.r223667 This is a protocol for a prospective, cross-sectional study with the reported aim of assessing the role of transvaginal ultrasound in the diagnosis of female infertility. I unfortunately have located several issues with the proposed protocol, which I will divide ... Continue reading READ ALL This is a protocol for a prospective, cross-sectional study with the reported aim of assessing the role of transvaginal ultrasound in the diagnosis of female infertility. I unfortunately have located several issues with the proposed protocol, which I will divide into subcategories. Background/introduction: The breakdown of infertility and the causes is quite adequate. However, I find issue with the description of the role of transvaginal ultrasound (TVUS) as a relatively new method of assessment. TVUS is by no means a new method, but a well-established diagnostic tool, which has become an indispensable part of gynecological examination and its value has been already demonstrated repeatedly by many published studies. Rationale: Once more, the value of TVUS in the assessment of pelvic anatomy is well-known and has been described long ago, take for instance the articles by Gratton et al 1 , which describes the assessment of normal pelvic anatomy via the use of TVUS over 30 years ago. Likewise, its value in the infertile patient has also been demonstrated long ago and repeatedly, for example by Ubaldi et al. in 1998 2 . Overall, your rationale, in my opinion, does not demonstrate a gap in medical knowledge, or a lack of sufficient data in order to justify this research (at least in its present form, see also “research question”). Research question: This is the most problematic part of this protocol in my opinion. The research question is very broad and vague. The “role” is not a quantifiable outcome, to use, it is a subjective metric. Outcomes such as diagnostic accuracy, cost, safety, tolerability, diagnostic efficacy compared to alternative diagnostic methods, complications, reproducibility of results, values of ultrasonographic measurements etc are more appropriate for medical research, as they evaluate specific aspects of the performance of this diagnostic method (continued in the next point). In your “Objectives”, the most important section of the research protocol, you introduce the potential of comparing to other methods (point 3), but again, this is too vague, it is not clear which specific methods will be used and whether they will apply to all patients. In point 2 of the “Objectives”, you also introduce the interesting potential of specific measurements, however, you do not explain what is to be done with these measurements. Will they be compared to a health control? Will they be utilized as prognosis factors of fertility, based on whether the woman achieves pregnancy? Simple collection and presentation of data does not suffice, analysis and evidence-based interpretation is necessary. Related to the above, you need to define your research question and your outcomes/objectives more clearly and using quantifiable measures. I suggest using the PICO format, or one of its alternatives 3 . Sample size: the website you cite demonstrated that the average rate of infertility was 12.6 per cent (n = 113; 95% CI: 10.5-15.0%), so you should use this percentage, unless there were other sources as well. Additionally, please provide the statistical software that you used to conduct the sample size calculation. In your exclusion criteria, since you wish to assess female fertility only, you should exclude cases of male factor infertility as well. Therefore, some screening of the husbands’ reproductive health may also be necessary to achieve homogeneity. In your “Scope”, you introduce the additional, different objective of quantifying the various causes of infertility, thus introducing an epidemiological surveillance angle. Right after that, you mention that the goal is also to demonstrate the diagnostic accuracy of TVUS. However, diagnostic accuracy studies require a reference standard in order to determine sensitivity, specificity and other parameters, which is something not mentioned in your protocol. References: most references are not accessible, please provide links or DOI. Overall, if I had to summarize my recommendations, they would be to apply a narrower focus on your research question. Define specific, quantifiable outcomes and use comparators when and if necessary. If diagnostic accuracy is the outcome, then a reference standard, such as hysteroscopy will be required. Even if your ultimate aim is to simply collect and present epidemiological data, confirmation of the diagnoses made by ultrasound will be required by a reference standard. Additionally, infertility is frequently caused by multiple factors, so you will need to address that as well. In any case, major revision are required. Is the rationale for, and objectives of, the study clearly described? Partly Is the study design appropriate for the research question? No Are sufficient details of the methods provided to allow replication by others? Yes Are the datasets clearly presented in a useable and accessible format? Not applicable References 1. Gratton D, Harrington C, Holt S, Lyons E: Normal Pelvic Anatomy Using Transvaginal Scanning. Obstetrics and Gynecology Clinics of North America . 1991; 18 (4): 693-711 Publisher Full Text 2. Ubaldi F, Wisanto A, Camus M, Tournaye H, et al.: The role of transvaginal ultrasonography in the detection of pelvic pathologies in the infertility workup. Hum Reprod . 1998; 13 (2): 330-3 PubMed Abstract | Publisher Full Text 3. Aslam S, Emmanuel P: Formulating a researchable question: A critical step for facilitating good clinical research. Indian J Sex Transm Dis AIDS . 2010; 31 (1): 47-50 PubMed Abstract | Publisher Full Text Competing Interests: No competing interests were disclosed. Reviewer Expertise: Obstetrics & Gynaecology, Fertility, Gynaecological Surgery, Robotic Surgery, Minimally Invasive Surgery We confirm that we have read this submission and believe that we have an appropriate level of expertise to state that we do not consider it to be of an acceptable scientific standard, for reasons outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Tsakos E and Xydias EM. Reviewer Report For: The role of transvaginal sonography in diagnosis of female infertility: a study protocol [version 2; peer review: 2 not approved] . F1000Research 2025, 12 :1335 ( https://doi.org/10.5256/f1000research.154371.r223667 ) The direct URL for this report is: https://f1000research.com/articles/12-1335/v1#referee-response-223667 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 16 Oct 2023 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 Version 2 (revision) 30 Jul 25 read Version 1 16 Oct 23 read Elias Tsakos , EmbryoClinic IVF, Thessaloniki, Greece Emmanouil M Xydias , EmbryoClinic IVF, Thessaloniki, Greece Halima Al Balushi , Sultan Qaboos University, Seeb, Oman Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Al Balushi H. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 10 Sep 2025 | for Version 2 Halima Al Balushi , Sultan Qaboos University, Seeb, Oman 0 Views copyright © 2025 Al Balushi H. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Not Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This study addresses an important clinical question regarding the diagnostic role of transvaginal ultrasonography in female infertility. The topic is highly relevant, given the need for less invasive, cost-effective, and widely available diagnostic methods in infertility workups. However, the current proposal suffers from issues related to scope, outcome clarity, comparator heterogeneity, and methodological rigor. In particular, the lack of distinction between diagnostic and clinical outcomes, limited follow-up period, and potential underpowering of sub-analyses are significant concerns. These limitations should be addressed to ensure the study produces clinically meaningful and generalizable findings. Major Concerns Overly broad scope The study attempts to evaluate the role of TVUS in detecting ovarian, uterine, and tubal abnormalities, as well as its correlation with fertility outcomes. This breadth may limit feasibility, as sufficient sample size and statistical power will be required across multiple subgroups. Narrowing the focus to the most clinically relevant or prevalent conditions could strengthen the design. Ambiguity in outcomes The manuscript presents diagnostic accuracy as the primary outcome, but also includes conception within six months as an endpoint. These represent different outcome categories (diagnostic vs. clinical). Clear distinction between primary and secondary outcomes is necessary to avoid dilution of the study’s main objective. Heterogeneous comparators The comparators (HSG, laparoscopy, hormonal assays) evaluate different infertility factors. Without explicit clarification of which reference standard applies to which abnormality, results may be difficult to interpret. For instance, tubal factors should primarily be validated against HSG or laparoscopy, while ovarian function should be referenced against hormonal profiles. Confounding from male infertility Although male infertility is to be excluded via semen analysis, mild or borderline abnormalities may still affect fertility outcomes. This could confound the relationship between TVUS findings and conception rates. A stricter exclusion protocol or sensitivity analysis may be warranted. Clinical outcome follow-up Limiting conception outcomes to six months may underestimate correlations, as many couples achieve conception beyond this timeframe even without intervention. A longer follow-up period would improve the robustness of fertility outcome assessment. Minor Concerns Cost-effectiveness and patient acceptability While diagnostic accuracy is central, real-world clinical adoption also depends on cost-effectiveness and patient comfort. The study could be strengthened by at least discussing these aspects. Reproducibility of TVUS While the study mentions assessing reproducibility, it does not specify whether intra-observer and inter-observer variability will be measured. These are critical in imaging studies and should be incorporated. Age range limitations Restricting the study population to women aged 20–40 may limit generalizability, especially as infertility is common in women over 40. This should be acknowledged as a limitation. Power of sub-analyses The planned comparison of TVUS with laparoscopy and HSG in a sub-cohort raises concerns about sample size adequacy. Underpowered subgroups may yield imprecise estimates of diagnostic accuracy. Prevalence estimates Reporting both prevalence of infertility causes and diagnostic performance from the same dataset could risk circular interpretation, particularly if TVUS misclassifications are not carefully adjusted against reference standards. Is the rationale for, and objectives of, the study clearly described? Partly Is the study design appropriate for the research question? Partly Are sufficient details of the methods provided to allow replication by others? Partly Are the datasets clearly presented in a useable and accessible format? Not applicable Competing Interests No competing interests were disclosed. Reviewer Expertise reproductive medicine, regenerative mdeicine, fertility preservation, molecular biology I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. reply Respond to this report Responses (0) Al Balushi H. Peer Review Report For: The role of transvaginal sonography in diagnosis of female infertility: a study protocol [version 2; peer review: 2 not approved] . F1000Research 2025, 12 :1335 ( https://doi.org/10.5256/f1000research.183679.r407166) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/12-1335/v2#referee-response-407166 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2023 Tsakos E et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 30 Nov 2023 | for Version 1 Elias Tsakos , EmbryoClinic IVF, Thessaloniki, Greece Emmanouil M Xydias , EmbryoClinic IVF, Thessaloniki, Greece 0 Views copyright © 2023 Tsakos E et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Not Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This is a protocol for a prospective, cross-sectional study with the reported aim of assessing the role of transvaginal ultrasound in the diagnosis of female infertility. I unfortunately have located several issues with the proposed protocol, which I will divide into subcategories. Background/introduction: The breakdown of infertility and the causes is quite adequate. However, I find issue with the description of the role of transvaginal ultrasound (TVUS) as a relatively new method of assessment. TVUS is by no means a new method, but a well-established diagnostic tool, which has become an indispensable part of gynecological examination and its value has been already demonstrated repeatedly by many published studies. Rationale: Once more, the value of TVUS in the assessment of pelvic anatomy is well-known and has been described long ago, take for instance the articles by Gratton et al 1 , which describes the assessment of normal pelvic anatomy via the use of TVUS over 30 years ago. Likewise, its value in the infertile patient has also been demonstrated long ago and repeatedly, for example by Ubaldi et al. in 1998 2 . Overall, your rationale, in my opinion, does not demonstrate a gap in medical knowledge, or a lack of sufficient data in order to justify this research (at least in its present form, see also “research question”). Research question: This is the most problematic part of this protocol in my opinion. The research question is very broad and vague. The “role” is not a quantifiable outcome, to use, it is a subjective metric. Outcomes such as diagnostic accuracy, cost, safety, tolerability, diagnostic efficacy compared to alternative diagnostic methods, complications, reproducibility of results, values of ultrasonographic measurements etc are more appropriate for medical research, as they evaluate specific aspects of the performance of this diagnostic method (continued in the next point). In your “Objectives”, the most important section of the research protocol, you introduce the potential of comparing to other methods (point 3), but again, this is too vague, it is not clear which specific methods will be used and whether they will apply to all patients. In point 2 of the “Objectives”, you also introduce the interesting potential of specific measurements, however, you do not explain what is to be done with these measurements. Will they be compared to a health control? Will they be utilized as prognosis factors of fertility, based on whether the woman achieves pregnancy? Simple collection and presentation of data does not suffice, analysis and evidence-based interpretation is necessary. Related to the above, you need to define your research question and your outcomes/objectives more clearly and using quantifiable measures. I suggest using the PICO format, or one of its alternatives 3 . Sample size: the website you cite demonstrated that the average rate of infertility was 12.6 per cent (n = 113; 95% CI: 10.5-15.0%), so you should use this percentage, unless there were other sources as well. Additionally, please provide the statistical software that you used to conduct the sample size calculation. In your exclusion criteria, since you wish to assess female fertility only, you should exclude cases of male factor infertility as well. Therefore, some screening of the husbands’ reproductive health may also be necessary to achieve homogeneity. In your “Scope”, you introduce the additional, different objective of quantifying the various causes of infertility, thus introducing an epidemiological surveillance angle. Right after that, you mention that the goal is also to demonstrate the diagnostic accuracy of TVUS. However, diagnostic accuracy studies require a reference standard in order to determine sensitivity, specificity and other parameters, which is something not mentioned in your protocol. References: most references are not accessible, please provide links or DOI. Overall, if I had to summarize my recommendations, they would be to apply a narrower focus on your research question. Define specific, quantifiable outcomes and use comparators when and if necessary. If diagnostic accuracy is the outcome, then a reference standard, such as hysteroscopy will be required. Even if your ultimate aim is to simply collect and present epidemiological data, confirmation of the diagnoses made by ultrasound will be required by a reference standard. Additionally, infertility is frequently caused by multiple factors, so you will need to address that as well. In any case, major revision are required. Is the rationale for, and objectives of, the study clearly described? Partly Is the study design appropriate for the research question? No Are sufficient details of the methods provided to allow replication by others? Yes Are the datasets clearly presented in a useable and accessible format? Not applicable References 1. Gratton D, Harrington C, Holt S, Lyons E: Normal Pelvic Anatomy Using Transvaginal Scanning. Obstetrics and Gynecology Clinics of North America . 1991; 18 (4): 693-711 Publisher Full Text 2. Ubaldi F, Wisanto A, Camus M, Tournaye H, et al.: The role of transvaginal ultrasonography in the detection of pelvic pathologies in the infertility workup. Hum Reprod . 1998; 13 (2): 330-3 PubMed Abstract | Publisher Full Text 3. Aslam S, Emmanuel P: Formulating a researchable question: A critical step for facilitating good clinical research. Indian J Sex Transm Dis AIDS . 2010; 31 (1): 47-50 PubMed Abstract | Publisher Full Text Competing Interests No competing interests were disclosed. Reviewer Expertise Obstetrics & Gynaecology, Fertility, Gynaecological Surgery, Robotic Surgery, Minimally Invasive Surgery We confirm that we have read this submission and believe that we have an appropriate level of expertise to state that we do not consider it to be of an acceptable scientific standard, for reasons outlined above. reply Respond to this report Responses (0) Tsakos E and Xydias EM. Peer Review Report For: The role of transvaginal sonography in diagnosis of female infertility: a study protocol [version 2; peer review: 2 not approved] . F1000Research 2025, 12 :1335 ( https://doi.org/10.5256/f1000research.154371.r223667) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. 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