Prediction of fetal sex by early pregnancy ultrasound localizing the implantation site lateralization

Abstract

The Prediction of fetal sex by early pregnancy ultrasound localizing the implantation site lateralization consider a very important step in investigation, in this work will be questionable results, the genetic factor, fetal sex determination might be influenced by other factors. Why male sex has a predilection for right-sided implantation while female sex implanted on the left side of the uterus so this study aimed to assess the accuracy of fetal sex prediction by localization of the implantation site at 5-7weeks of gestation using the two dimensional trans-abdominal U/S.

Full text

Al-Shaikh & Al-Jeborry (2019): Early pregnancy ultrasound December 2019 Vol. 22(9)
©Annals of Tropical Medicine & Public Health S259
Prediction of fetal sex by early pregnancy ultrasound localizing the implantation
site lateralization
**Milal M. Al-Jeborry,*Suhaila F. Al-Shaikh
*University of Babylon/College of medicine- Department of obstetrics and gynecology, Iraq.
Corresponding author:
**Corresponding author: Milal M. Al-Jeborry (aljeborrymilal@yahoo.com)
Abstract
The Prediction of fetal sex by early pregnancy ultrasound localizing the implantation site lateralization
consider a very important step in investigation, in this work will be questionable results, the genetic factor,
fetal sex determination might be influenced by other factors. Why male sex has a predilection for right-sided
implantation while female sex implanted on the left side of the uterus so this study aimed to assess the
accuracy of fetal sex prediction by localization of the implantation site at 5 -7weeks of gestation using the two
dimensional trans-abdominal U/S.
Keywords: site lateralization, fetal sex, pregnancy ultrasound
How to cite this article: Al-Shaikh SF, Al-Jeborry MM (2019): Prediction of fetal sex by early
pregnancy ultrasound localizing the implantation site lateralization, Ann Trop & Public Health; 22(9):
S259. DOI: http://doi.org/10.36295/ASRO.2019.22094
Introduction
Assessment of fetal sex in the antenatal period can be performed according to the request of the parents
using a non-invasive mid-trimester ultrasound examination regarded as a highly accurate method.(1)
Early, in the first trimester, ultrasonic assessment of fetal sex using two-dimensional (2D) ultrasound
(2-4).In 2001, V. Mazza et al. had mentioned that “Fetal sex expectation can be with a promising
accuracy at 69 days from the date of fertilization (5). Moreover when using three-dimensional (3D)
ultrasound for the diagnosis of fetal sex looking in the mid-sagittal plane at the genital tubercle and the
phallus direction and orientation either upward to predict the male fetal sex or downward direction to
predict the female fetal genitalia (6).To avoid technical errors during the examination of the position of
the genital tubercle and phallus direction, repetition of the assessment at the end of the examination
with both views (in the sagittal and transverse planes) is better to be done and to raise the degree of the
accuracy (7). Ramzi in 2011 published his work that explains the possible association between placental
site lateralization and fetal sex (8), while L. van Leijden et al in 2012 said a male fetus is associated with
higher nuchal translucency measures (9). Assessment of fetal DNA in the maternal serum is another way
to predict fetal sex as early as the 5th week of gestation (10). In our study, we aimed to assess the
accuracy of fetal sex prediction by localization of the implantation site at 5-7weeks of gestation using
the two dimensional trans-abdominal U/S.
Materials and methods
A prospective study was done In a private clinic for 18 months period which extended fr om April /
2018to October / 2019, the prediction of sex of fetuses by utilizing early two-dimensional
transabdominal ultrasound was performed in 620 pregnant women at (5-7) weeks of gestation by
determining the site of implantation of the gestational sac in right or left-sided of uterus which predicts
the site of attachment of placenta in future. A single sonographer performed all ultrasound
examinations, for all patients, at both 5-7 weeks gestation and (18 - 20) weeks of gestation. The
gestational age of the fetus was assessed by measuring gestational sac diameter or crown-rump length
in the first trimester of pregnancy and by measuring biparietal diameter, and femur length in the second
trimester of pregnancy. Verbal consent was obtained from all women for participation in the study.

Al-Shaikh & Al-Jeborry (2019): Early pregnancy ultrasound December 2019 Vol. 22(9)
©Annals of Tropical Medicine & Public Health S259
Assessment of site of implantation of gestational sac was performed in all cases by utilizing VENO 20
transabdominal ultrasound (F2-5C Convex probe Vinno Company 2-6.5mhz) at 5-7 weeks of gestation
by performing scans in sagittal plane (fundo anterior and fundo posterior) for assessment of
implantation position, in addition to scan on transverse plane (left lateral, right lateral, anterior left,
posterior left, anterior right). Sixty-three women were excluded because they developed abortion or
they were lost from follow up and the remaining 557 women were followed up by 2ndtrimester U/S at
18 – 20 weeks gestation to assess the sex of fetuses and placental position which were determined. For
obtaining an accurate assessment of fetal sex in the second trimester and in third trimesters, multiple
views were obtained including axial, transverse and coronal views. Ultrasound scanning of the uterus
in both sagittal and transverse planes was performed initiating from midline to the right then to the left
of midline.
Women with ectopic pregnancy, multiple pregnancies, pregnancy with centrally located gestational
sac, fetal death or refusal of patients were excluded from the current study. Examination of the genital
area by utilizing both horizontal plane and midsagittal plane with fetal sex was diagnosed as male ( by
the presence of penis with a scrotum) or female (detecting 2-4 lines sign of labia), with confirmation of
sex of babies later on the following the delivery.
Results
The studied women's ages range between (14 - 46) years with mean of (25.42 ± 6.41) years, about 50%
of them was housewives and the remaining women having jobs (educated of the university,
institutional or secondary school levels). The parity of them ranged between (0 – 9), 231 (41.47%)
women were nulliparous, and 326 (58.52%) were multiparous women. One hundred twenty-nine
women (22.15%) presented with a history of abortion ranging between (1 - 6) abortions, 9 (1.61%) of
them presented with habitual abortions (more than 3 consecutive abortions) Table (1).
For the implantation site at (5-7) week’s gestation in 557 singleton pregnancies, 366 (65.71%) were RT
sided implantation site and 191 (34.29%) were implanted on the LT side of the uterus Table (2). By
follow up of them in the second trimester U/S at (18-20) weeks for determination of the fetal sex as
follow: Regarding the singletons: 334 (91.26%) of the RT sided implantation were males and 32
(8.74%) were females. On the other hand of the 191 LT sided implanted GS, 167 (87.43%) were
females and only 24 (12.57%) were males (Table 2). Gender confirmation was done after delivery and
all of the/S determined sex was correct except one woman (0.18%) who was determined to have a girl
by U/S but she delivered a boy.
Table 1: Women Characteristics
Singleton
Patients
group
(557)
RT/ SIDED, GS
implantation at 5-
7 weeks
N (%)
U/S FETAL
GENDER at 18-20 weeks
N (%)
LT/ SIDED
GS implantation
at 5-7 weeks
N (%)
U/S FETAL
GENDER at 18-20 weeks
Singleton
(557)
366 ( 65. 71 )
MALE
FEMALE
191 ( 34. 29 )
MALE
FEMALE
334
(91.26)
32
(8.74)
24 (12.66)
167 (87.34)

Al-Shaikh & Al-Jeborry (2019): Early pregnancy ultrasound December 2019 Vol. 22(9)
©Annals of Tropical Medicine & Public Health S259
Table 2: fetal gender by U/S at 18-20 weeks in relation to GS implantation at 5-7
weeks in singletons:
Discussion
A male or a female fetus is an important parental question once a mom gets pregnant, a traditional
ultrasound examination at 16-18 weeks of gestation usually answers this question. Ramzi (2007)
adopted his new method for determination or prediction of fetal sex much earlier in gestation and
specifically at the 6th week of gestation by locating the laterality of the chorionic villi by performing a
Doppler study in addition to 2-dimensional ultrasound (8). The current study depends on Ramzi’s
method with slight modification utilizing two-dimensional sonography only for localization of the site
of implantation for fetal sex prediction in early pregnancy which is a very early noninvasive method
which might help the parents in determining their fetal gender, and any possible-linked health problems
(8).
Routine early dating ultrasound examination is a part of daily practice in the antenatal care unit,
therefore adding the gestation sac location determination is an easy and practical, non-invasive way,
the most relevant method is the sagittal sign method that performed after the twelfth-week gestation
that “orientation of the phallus related to the gender, from 12 weeks onward: caudal with the female
fetuses and anterior with the males” (6) In the current study gender prediction of 91.26% for male with
right-sided implantation of gestational sac and 87.43% for female with left-sided implantation of
gestational sac, referring to Ramzi’s method who’s results revealed higher prediction rate approaching
to 97.5% for both female and male sexes and this can be explained by the use of Doppler study that
was used in that study which revealed the placental vascularity with higher accuracy than the 2D U/S
alone in placental localization in early pregnancy (6 weeks)(8).
Searching the web for resembling method revealed another study by L. Shan and S. (2010) who found
that in 89 fetuses the placenta was located on the right side and of these 45 (51%) were males. The
placenta was located on the left side in 110 fetuses and 63 (57%) of these were female which was very
low detection rate when compared with the genital tubercle angle method at 11-14 weeks gestation, the
fetal gender was correctly predicted in103 of 108 fetuses (95%) (11). In addition to the genetic factor,
fetal sex determination might be influenced by other factors. Why male sex has a predilection for right-
sided implantation while female sex implanted on the left side of the uterus? This could be related to
possible uterine polarity? Ovum polarity? Sperm polarity? And even heterogeneous uterine
vascularity? (12). Sperm transport might be influenced by the possible movement of the endometrium (13,
20).
The majority of animal cells reveal clear polarity, referring to the occurrence of asymmetry at the
molecular level. The corner stone was the negative regulation of contractility of actomyosin that was
WOMEN
CHARACTERISTICS
RANGE
MEAN ± SD
N (%)
AGE (YEARS)
14 - 46
25.42 ± 6.41
557 (100)
PARITY
0 – 9
1.36 ± 1.57
557 (100)
NULLIPAROUS
0
0
231 (41.47)
MULTIPAROUS
1-9
2.3 ± 1.42
326 (58.52)
ABORTIONS
1-6
1.67 ± 1.03
129 (22.15)
EDUCATIONAL
LEVEL
(N = 557)
UNLEARNED
8 (1.44)
PRIMARY SCHOOL
271 (48.65)
SECONDARY SCHOOL
92 (16.52)
UNIVERSITY & INSTITUTE
183 (32.85)
HIGHER EDUCATION
3 (0.53)

Al-Shaikh & Al-Jeborry (2019): Early pregnancy ultrasound December 2019 Vol. 22(9)
©Annals of Tropical Medicine & Public Health S259
provoked through sperm action locally (14, 18). Another study on nematodes showed that the sperm
produces a polarity signal in the posterior part of the embryo leading to down regulation of contraction
of the cortex (15). The membranes on the surface of sperm reveal differing values of electrostatic
potential which is proportionate to sialic acid levels in the sperm surface through its maturation
process. A new process for the isolation of sperms with a low level of fragmented DNA depends on
utilizing an electrical charge-based technology in IVF (16). A randomized trial conducted by Karimi et
al. reported that the Zeta method is a new method to enhance the outcome of assisted reproduction in
infertile men (17-19). Further studies need to investigate the real factors behind the association between
implantation site and fetal sex.
Our conclusions forthis study provides a simple non-invasive method for early detection of fetal sex by
incorporating implantation site localization to the routine dating ultrasound with a high prediction rate.
References:
1. Meagher S. and Davison G. “Early second-trimester determination of fetal gender by ultrasound.”
Ultrasound Obstet. Gynecol. 1996; 8: 322-324
2. Efrat Z, Aknifenwa OO, Nicolaides KH. "First-trimester determination of fetal gender by ultrasound."
Ultrasound ObstetGynecol (1999): 13:305-7.
3. Efrat Z., Perri T., Ramati E.,Tugendreich D. andMeiznerI.,“Fetal gender assignment by first-trimester
ultrasound”. Ultrasound ObstetGynecol2006; 27: 619–621
4. Whitloe BJ, Lazanakis MS, and Economides DL."Thesonographic identification of fetal gender from 11
to 14 weeks gestation." Ultrasound ObstetGynecol (1999): 13:301-304.
5. MAZZA V., FALCINELLI C., PAGANELLI S., CONTU G., MANTUANO S. M., BATTAFARANO
S. D., FORABOSCO A. * and VOLPEA. “Sonographic early fetal gender assignment: a longitudinal
study in pregnancies after in vitro fertilization.”UltrasoundObstetGynecol 2001; 17: 513–516.
6. Youssef A., De Musso F., Montaguti E., Cariello L., SalsiG.,Maroni E., Pilu G., Rizzo N., Ghi T.
Prospective validation of the use of three-dimensional ultrasound for fetal gender determination in the
first trimester. Ultrasound in Obstetrics & Gynecology, Poster abstracts (p03.06)2012; 40 (Suppl. 1):
171–310
7. Pedreira D. A. L., Yamasaki A. and CzeresniaC. E. “In search for the ‘third point”. Ultrasound
ObstetGynecol2000; 15: 262–3
8. SAAD RAMZI ISMAIL, The relationship between placental location and fetal gender (Ramzi’s
method). OBGYN.Net. vol. No. June, 14, 2011
9. VanLeijden L., KokN., SnijdersR., PajkrtE. Accuracy of first trimester fetal sex determination in a
routinesetting. Ultrasound in Obstetrics & Gynecology, Poster abstracts (p03.05) 2012; 40 (Suppl. 1):
171–310
10. Heidi Anne Duerr, New Blood Test Reveals Fetus Gender Five Weeks after Conception. OBGYN.Net.
Vol. No. February, 1, 2012.
11. The S., ChanL. The role of placental location assessment in the prediction of fetal gender.Ultrasound in
Obstetrics & Gynecology, (Poster abstracts P18.17). 2010; 36 (Suppl. 1): 242
12. Harris.V.G. "Relation between placental site and length of gestation." BJOG 82.7 (1975): 581-584.
13. Kunz, G., Beil, D., Deininger, and H. "The dynamics of rapid sperm transport through the female genital
tract: evidence from vaginal sonography of uterine perstalsis and hysterosalpingoscintigraphy." Hum
Reprod (1996): 11, 627-632.
14. Johnston D.S. and Ahringer J. Cell Polarity in Eggs and Epithelia: Parallels and Diversity. Cell May 28
2010; 141: 757-774
15. Munro E., Nance J., and Priess, J.R. Cortical flows powered by asymmetrical contraction transport PAR
proteins to establish and maintain anteriorposterior polarity in the early C. elegansembryo. Dev. Cell
(2004); 7: 413–424.
16. Simon L1, Ge SQ, CarrellDT.Sperm selection based on electrostatic charge.MethodsMol Biol. 2013;
927:269-78.
17. Karimi N, MohseniKouchesfahani H, Nasr-Esfahani MH, Tavalaee M, Shahverdi A, Choobineh H. -
DGC/Zeta as A New Strategy to Improve Clinical Outcome in Male Factor Infertility Patients following
Intracytoplasmic Sperm Injection: A Randomized, Single-Blind, Clinical Trial.Cell J. 2020 Apr;
22(1):55-59. Epub 2019 Sep 8.
18. Al-Shareefi, E., Sahib, A.H.A. and Hameed, I.H., 2019. Phytochemical Screening by FTIR
Spectroscopic Analysis and Anti-Fungal Activity of Fruit Extract of Selected Medicinal Plant of
Rutagraveolens. Indian Journal of Public Health Research & Development, 10(1), pp.994-999.
19. Al-Shareefi, E., Sahib, A.H.A. and Hameed, I.H., 2019. In vitro Antibacterial and Anti-Fungal Activities
of Methanolic Extract of Menthapulegium. Indian Journal of Public Health Research & Development,
10(1), pp.988-993.