Sonographer here.
The gel is a transmission medium used to help transmit the sound waves through the skin and into the body and back to the transducer again. If no gel is used, a thin layer of air is trapped between the ultrasound transducer and the skin and no sound can be transmitted or received.
It’s usually a water-based gel, which is viscous enough that it stays on the skin. Technically saline can be used, but it has low viscosity and therefore won’t stay where you want it to.
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