Ultrasound Obstet Gynecol 1999;13:301304

The sonographic identification of fetal gender

from 11 to 14 weeks of gestation
B. J. Whitlow, M. S. Lazanakis and D. L. Economides
Fetal Medicine Unit, Royal Free Hospital, London, UK

Key words:

FETAL GENDER, ULTRASOUND, 1114 WEEKS

ABSTRACT
conditions are currently diagnosed using chorionic villus
sampling (CVS), which is usually carried out after 11
weeks gestation. Non-invasive techniques to determine
fetal gender in the first trimester need to be more
thoroughly investigated in order to avoid fetal losses.
Although gender has been correctly diagnosed by sonography in the first trimester8,9, it is important to establish
the accuracy of detecting fetal gender prior to implementation in clinical practice. Should male gender be suggested
accurately by sonography in the first trimester, then prenatal diagnosis can be offered at an earlier stage to confirm
these findings, allowing the option of an early versus late
termination of pregnancy with resulting decrease in surgical complications10 and psychiatric morbidity11,12. On the
other hand, if female gender is suggested, then it may be
possible to avoid invasive testing. However, accuracy
would need to approach 99% to compare with invasive
testing. The aim of this study was to assess the success rates
of the sonographic determination of fetal gender in the first
trimester.

Objective To determine the feasibility of correctly identifying fetal gender from 11 to 14 weeks gestation.
Methods A prospective cross-sectional study in a university Department of Obstetrics and Gynaecology, London.
A total of 524 women from an unselected population
underwent a detailed assessment of fetal anatomy at 1114
weeks of gestation (confirmed by crownrump length) by
means of transabdominal sonography, and transvaginal
sonography (26%) when necessary. Fetal gender was identified in the transverse and sagittal planes, and was confirmed at birth.
Results The overall success of correctly assigning fetal
gender increased with gestational age from 46% to 75%,
79% and 90% at 11, 12, 13 and 14 weeks, respectively. The ability of the operator to assign fetal gender
significantly improved with increasing gestational age
(p < 0.0001), being 59%, 87%, 92% and 98% at 11, 12,
13 and 14 weeks, respectively. The accuracy of correctly
identifying fetal gender when attempted did not change
with gestational age. Fetal gender or the performance of the
scan by different operators did not affect the results.

METHODS

Conclusion Whilst the accuracy of sonographic determination of fetal gender at 1114 weeks is good, it still falls
significantly short of invasive karyotyping tests.

A total of 524 women attending a routine first-trimester

scanning clinic were recruited for this study. Scans were
arranged by midwives as part of ongoing research into
first-trimester detection of fetal anomalies. The midwives
were instructed to arrange the scan for 1213 weeks. There
were two elective abortions (for aneuploidy), one intrauterine death and another 74 cases in which the neonatal
outcomes could not be obtained. These cases were excluded from the study. Thus, a total of 447 fetuses were
included, for which gender assignment was obtained from
the neonatal records.
A detailed assessment of the fetal genitalia was
attempted initially with transabdominal sonography
(5.0-MHz Toshiba PVF-575 MT, Tokyo, Japan) using a
combination of transverse and sagittal views. The fetal

INTRODUCTION
There have been a number of studies using ultrasound to
detect and correctly identify fetal gender in the early second
and third trimesters16. As a consequence of improvements
in ultrasound technology, and with the advent of transvaginal sonography, identification of fetal gender starting
in the first trimester has been suggested7. The most important clinical application of determining fetal gender is in
cases with family histories of X-linked disorders such as
hemophilia and Duchenne muscular dystrophy. Such

Correspondence: Mr D. L. Economides, University Department of Obstetrics and Gynaecology, Royal Free Hospital, Pond Street, London
NW3 2QG, UK

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Revised 41198
Accepted 71298

Fetal gender at 1114 weeks

male genitalia were identified in the transverse plane when
a uniform, dome-shaped structure was seen at the base of
the fetal penis (representing the fetal scrotum), a longitudinal, mid-line echogenic line was seen at the base of the fetal
penis (representing the median penile raphe) and, in the
sagittal plane, the cranial/vertical direction of the fetal
phallus was also considered to be a feature of the male
fetus/phallus (Figure 1). The female genitalia were identified in the transverse plane by visualizing two or four
parallel lines, representing the labia majora and minora,
and in the sagittal plane by the caudally directed phallus7
(considered to represent the clitoris, see Figure 2). Transvaginal sonography (6.0-MHz Toshiba PVF-621 VT) was
employed if visualization of fetal genitalia was not adequate with transabdominal sonography (26%). The scans
were performed by one of six clinicians or one of six
ultrasonographers who were trained in assessing fetal anatomy and nuchal translucency in the first trimester. The
total scanning time was limited to 30 min, with the majority of scans completed within 10 min, and included measurement of nuchal translucency and assessment of fetal
anatomy.
Gestational age was calculated from crownrump length
in conjunction with menstrual or ovulation dating.

Whitlow, Lazanakis and Economides

Approval from the Ethics Committee of the hospital was
obtained for this study.
Statistical analysis was performed using the Minitab
statistical package; 2 and logistic regression analyses were
performed to determine statistical difference in the results.
Fishers exact test was used when any of the single tabular
values were < 5.

RESULTS
The overall success of correctly identifying fetal gender
increased with gestational age from 46% to 75%, 79%
and 90% at 11, 12, 13 and 14 weeks, respectively. The
ability to assign fetal gender confidently using ultrasonography significantly improved with increasing gestational age from 11 to 14 weeks (p < 0.0001, Table 1 and
Figure 3).
There was no gender-specific significant difference in
assigning fetal gender with respect to gestational age (11
weeks, p = 0.2; 12 weeks, p = 0.3; 13 weeks, p = 0.2; 14
weeks, p = 0.4), or in the whole group of fetuses (p = 0.3).
This was confirmed by logistic regression (p = 0.8). The
number of male and female fetuses in which gender was not

Figure 1 Male fetus in sagittal section at 11 weeks (a). Note the

vertical/cranially directed phallus (arrow). Male fetus in transverse
section at 12 weeks (b). Note the dome-shaped scrotum in the
transverse plane (arrow)

Figure 2 Female fetus in sagittal section at 11 weeks (a). Note

the caudally directed phallus in sagittal section (arrow). Female
fetus in transverse section at 12 weeks (b). Note the triple parallel
lines representing the labia in transverse plane (arrow)

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Fetal gender at 1114 weeks

Table 1

Whitlow, Lazanakis and Economides

Fetal gender determination in relation to gestational age

11 weeks

Gender not assigned

Correct male
Incorrect male
Correct female
Incorrect female
Total correct when attempted
Total incorrect when attempted
Overall correct (% of total fetuses)
Total cases studied

12 weeks

13 weeks

14 weeks

31/76
10/15
5/15
25/30
5/30
35/45
10/45
35/76
76

41
67
33
83
17
78
22
46

22/165
66/74
8/74
57/69
12/69
123/143
20/143
123/165
165

13
89
11
83
17
86
14
75

13/155
73/81
8/81
50/61
11/61
123/142
19/142
123/155
155

8
90
10
82
18
87
13
79

1/51
25/28
3/28
21/22
1/22
46/50
4/50
46/51
51

2
89
11
95
5
92
8
90

Figure 3 Effect of gestational age on ability of operator to assign

fetal gender, correct identification of gender when attempted and
overall success of correct identification

assigned was analyzed at each gestational age and

there was no statistical difference between the two groups.
There was no statistical difference in the accuracy of
identification of fetal gender amongst the different operators (p = 0.43). The accuracy of correctly identifying fetal
gender when attempted did not significantly change with
gestational age (p = 0.07, by regression analysis).

DISCUSSION
The overall success of correctly identifying fetal gender at
1214 weeks was found to be 80%. The successful identification of fetal gender increased with gestational age and
was highest (90%) at 14 weeks. The ability of the operator
to assign male/female genitalia was also found to increase
with advancing gestational age. The male or female phenotype did not have a significant effect in assigning fetal
gender or in the accuracy of identification. These results are
similar to those of other investigators, who found an overall success rate of 85% and 77% between 12 and 14 weeks,

using transabdominal sonography11,12. They are also in

agreement with earlier work by Bronshtein and colleagues7,
who found an overall success rate at 1314 weeks of just
under 80% using transvaginal sonography.
A number of factors can affect the correct identification
of fetal gender. First, the motivation and skill of the operator are paramount when making confident identification of
fetal gender in the first trimester. Second, the resolution of
the transvaginal transducer is likely to be superior to a
transabdominal transducer. Although transvaginal sonography has been shown to be acceptable to the majority of
low-risk women13, transabdominal sonography does not
involve extra staff (i.e. chaperones). Factors that could
inhibit adequate visualization of fetal genitalia include fetal
hyperactivity, crowding of the fetal genitalia (legs
crossed/cord between legs), unfavorable fetal position, maternal bowel gas shadowing and maternal obesity. Maternal obesity is not, however, a problem when transvaginal
sonography is used.
The significant improvement in the confidence of the
operators to identify fetal gender with advancing gestational age may be explained by the development and
embryology of the fetus. At 6 weeks, the external genitalia
of the sexes are similar, and it is impossible to differentiate
the two14. At this stage, they consist of genital swellings on
either side of the genital tubercle and the urethral folds. In
the male fetus, the genital tubercle elongates between 6 and
13 weeks, at which time the urethral folds close over the
urethral plate to form the penile urethra. During this stage,
the urethral tubercle is known as the phallus. It is interesting to note that the genital swellings, which in the male give
rise to the scrotum, may be confused with the labia minora
and majora (which in the female fetus also develop from
the genital swelling).
In a transverse plane at 1114 weeks, the genital swellings form a dome-shaped scrotum in the male fetus and
three or four parallel lines (i.e. the labia) in the female.
Some investigators reported that a transverse view of the
fetal genitalia was more helpful in gestations between 12
and 14 weeks11. This is contrary to other investigators1,
who have found that the direction of the phallus is more
helpful in the early ultrasonographic determination of fetal
gender. It has been suggested that the direction of the
phallus may be vertical/cranially directed in the male fetus
because the penile corpora cavernosa are permanently congested and therefore the penis is in a constant erect state7.

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Fetal gender at 1114 weeks

Early determination of fetal gender could be of clinical
relevance in cases of a positive family history of X-linked
disorders such as hemophilia, Duchenne muscular
dystrophy and chronic granulomatous disease, possibly
avoiding invasive diagnostic techniques with the inevitable
small risk of miscarriage. Determining gender in the fetus
at mid- and late gestations is probably of little use, apart
from management of labor in carriers of hemophilia, in
whom invasive procedures and instrumental deliveries
should be avoided for potentially affected males15. Some
early studies suggested that the determination of a male
fetus might help to enhance pulmonary maturity by the
use of steroids16; however, other investigators showed no
difference in such outcomes with regard to fetal gender17.
The subtle differences in the growth patterns of male and
female fetuses are also so small that determination of
gender in order to use separate biometrical reference
ranges are impractical in the clinical setting. The level of
-fetoprotein is significantly lower in female fetuses with
Downs syndrome than their male counterparts, although
again this is likely to be of little clinical value18. In one
study, it was suggested that toxemia may be frequently
associated with the male fetus, but again this would be
unlikely to alter obstetric management19.
Other methods of determining fetal gender include the
examination of fetal DNA from the maternal circulation,
and this may achieve better sensitivity (94% vs. 67%) in
the first trimester compared to the second trimester20.
Indeed, Sekizawa and co-workers21 have even developed a
method enabling the prenatal diagnosis of Duchenne
muscular dystrophy using a single fetal nucleated erythrocyte in maternal blood. Cervical washings and analysis
using fluorescent in situ hybridization have been shown to
have a sensitivity for detecting a male fetus of around 83%,
and this is no better than using ultrasonography. Therapeutic techniques in which X- and Y-chromosome-bearing
spermatozoa can be separated by flow cytometry are also
being studied, and early results are promising22. This
may enable intrauterine insemination of X-chromosomecarrying sperm from the husband/partner, so avoiding the
need for prenatal diagnosis of fetal gender.
The social implications of antenatal gender identification need to be remembered. In developed countries, it has
been shown that the majority (74.7%) of women are in
favor of knowing the ultrasonographic interpretation of
fetal gender, and the accuracy rate at the 20-week scan is
around 97%5. However, in developing countries, fetal
gender should not be examined as a matter of routine,
because of the lack of skilled/available manpower, making
routine fetal gender determination impractical4.

ACKNOWLEDGEMENTS
We would like to thank the departmental ultrasonographers and Drs R.A. Kadir, I.K. Chatzipapas and S.M.
Verdin for their help with performing ultrasound examinations and we would also like to thank Wellbeing for
supporting this study. Dr B. Whitlow is a William and
Florence Blair-Bell (Wellbeing) Research Fellow.

Whitlow, Lazanakis and Economides

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