Characterization of normal and polycystic ovaries using three-dimensional power Doppler ultrasonography

PURPOSE

To evaluate the characteristics of polycystic compared to normal ovaries using three-dimensional (3-D) power Doppler ultrasonography.

METHODS

We recruited 42 volunteers, all of whom were commencing IVF treatment. Each patient was examined in the cycle preceeding the start of drug therapy during the late follicular phase. If eight or more subcapsular follicles of 2-8 mm in diameter in one two-dimensional (2-D) plane were detected in either of the ovaries, the patient was categorized as having polycystic ovaries (PCO); otherwise the ovaries were considered normal. The parameters examined were volume of the ovary, vascularization index (VI), flow index (FI), vascularization flow index (VFI), and mean greyness (MG). In addition, the ovary was arbitrarily divided into cortex and stroma, and thereafter volume, VI, FI, VFI, and MG were calculated for these two regions.

RESULTS

Twenty-eight women had normal ovaries and 14 had PCO. The comparison between normal and PCO showed that as a group the PCO were larger, without any differences in VI, Fl, VFI, or MG. In patients with PCO, the right ovary was larger than the left one. In patients with normal ovaries, Fl was higher on the left side. Division into cortex and stroma revealed that there were no differences in cortical or stromal VI, FI, VFI, or MG between normal and PCO on either side.

CONCLUSIONS

The ovaries defined as polycystic were larger than normal ovaries, but there was no difference in the echogenicity of the stroma between polycystic and normal ovaries. We were also unable to demonstrate that the polycystic ovarian stroma was more vascularized than the stroma in the normal ovaries.

Three-dimensional sonographic and power Doppler characterization of ovaries in late follicular phase

OBJECTIVE

To determine ovarian blood flow characteristics using three-dimensional power Doppler ultrasound.

METHODS

We examined 30 patients (30 cycles) prior to the start of their in vitro fertilization treatment in the late follicular phase using three-dimensional power Doppler ultrasound. The volume, vascularization index, flow index, vascularization flow index, mean grayness and the presence of the dominant follicle were determined for each ovary separately.

RESULTS

The dominant follicle could be detected in 24 out of 30 cycles (80.0%). The volume of the dominant ovary was 9.9 (standard deviation, 4.0) cm3 and the volume of the non-dominant ovary 6.8 (standard deviation, 2.8) cm3 (P < 0.001). Mean grayness in the dominant ovary was 43.3 (standard deviation, 5.0) and in the non-dominant 47.2 (standard deviation, 4.0) (P < 0.001), but no other differences could be observed between dominant and non-dominant ovaries. The shell with a diameter of 2 mm surrounding the dominant follicle had a higher vascularization index (mean, 9.0; standard deviation, 5.9) and vascularization flow index (mean, 4.2; standard deviation, 2.8) than the whole dominant ovary (mean, 5.5; standard deviation, 2.5 and mean, 2.5; standard deviation, 1.3, respectively) (P = 0.003 and 0.002, respectively). In the cycles without a dominant follicle (n = 6), flow index (mean, 50.0; standard deviation, 5.9) and vascularization flow index (mean, 7.3; standard deviation, 6.2) on the left side were higher than on the right side (mean, 40.2; standard deviation, 3.1; mean, 1.5; standard deviation, 1.4; P-values 0.013 and 0.046, respectively).

CONCLUSION

In the dominant ovary, the volume was higher and mean grayness lower than in the non-dominant ovary. The vascularization index in the shell surrounding the dominant follicle was higher than the average vascularization index in the whole dominant ovary. In addition, there were differences in the vascularization and flow indices between right and left ovaries, which may be related to the anatomical difference in the venous drainage between right and left ovaries.

Placental morphogenesis in pregnancies with Down's syndrome might provide a clue to pre-eclampsia

Insufficient perfusion of placenta in pre-eclampsia is commonly associated with oxidative stress leading to increased superoxide formation and reduced invasion of uterine spiral arteries by differentiated migratory cytotrophoblasts. The superoxide dismutase (SOD) level, responsible for eliminating toxic superoxides, drops significantly in pre-eclampsia. On the contrary, the SOD synthesis increases dramatically, compared to that of normal placenta, in pregnancies with trisomy 21 (T21) fetus. However, despite a low level of placental hypoplasia, the overall perfusion of T21 placentae is comparable to that of normal pregnancy. In the light of recent reports on alternative modes of SOD function and factors regulating pathways of cytotrophoblast differentiation, here we have attempted to reconcile the two seemingly disparate pregnancy conditions and suggest that trisomy 21 pregnancies might provide new insight into our understanding of placental morphogenesis in pre-eclampsia.

Investigation of the infertile couple: a one-stop ultrasound-based approach

The appropriateness of many investigations for subfertility will continue to be of debate for some time yet. Of most benefit to the concerned couple would be a process that is diagnostically accurate, expeditious and reliable. It should be performed with a minimum of invasion and provide both patient and clinician with useful prognostic information regarding possible future treatment. This article is intended to illustrate the advantages of an ultrasound-based process of subfertility investigation. Discussed is the role of ultrasound compared with more invasive investigative methods such as laparoscopy and hysteroscopy. In addition, the potential capacity of newer advanced ultrasound technologies is reviewed.

Igf2/H19 imprinting control region (ICR): an insulator or a position-dependent silencer?

The imprinting control region (ICR) located far upstream of the H19 gene, in conjunction with enhancers, modulates the transcription of Igf2 and H19 genes in an allele-specific manner. On paternal inheritance, the methylated ICR silences the H19 gene and indirectly facilitates transcription from the distant Igf2 promoter, whereas on the maternal chromosome the unmethylated ICR, together with enhancers, activates transcription of the H19 gene and thereby contributes to the repression of Igf2. This repression of maternal Igf2 has recently been postulated to be due to a chromatin boundary or insulator function of the unmethylated ICR. Central to the insulator model is the site-specific binding of a ubiquitous nuclear factor CTCF which exhibits remarkable flexibility in functioning as transcriptional activator or silencer. We suggest that the ICR positioned close to the enhancers in an episomal context might function as a transcriptional silencer by virtue of interaction of CTCF with its modifiers such as SIN3A and histone deacetylases. Furthermore, a localised folded chromatin structure resulting from juxtaposition of two disparate regulatory sequences (enhancer ICR) could be the mechanistic basis of ICR-mediated position-dependent (ICR-promoter) transcriptional repression in transgenic Drosophila.

Human chorionic gonadotropin-to-oocyte collection interval in a superovulation IVF program. A prospective study

PURPOSE

The aim of this study was to investigate whether the hCG-oocyte collection interval has any influence on the oocyte recovery rate, fertilization rate, and outcome of IVF-ET cycles.

METHODS

Five hundred thirty-three consecutive patients undergoing their first IVF-ET treatment cycle at King's Assisted Conception Unit between 1993 and 1995 were included in this study.

RESULTS

There was no significant difference in the oocyte recovery rates, fertilization rates, or outcome of IVF-ET treatment among the hCG-oocyte collection intervals examined (33-41 hr). None of the 533 women studied had ovulated before oocyte collection.

CONCLUSIONS

The results do not suggest a trend toward increased ovulation more than 36 hr after hCG administration.

Cumulative conception and live birth rates in natural (unstimulated) IVF cycles

IVF treatment, which involves ovarian stimulation, poses significant health problems such as ovarian hyperstimulation and is associated with a high incidence of multiple pregnancy and premature birth. In this paper, we demonstrate how natural cycle IVF is an effective and potentially cost-effective alternative treatment option for certain groups of infertile couples. The study was conducted in the Assisted Conception Unit at King's College School of Medicine, London. Fifty-two women with regular menstrual cycles whose partners had normal semen parameters were offered a total of 181 cycles of treatment (average 3.49 per couple). Life table analysis was used to calculate cumulative success rates after successive cycles of treatment. After four cycles, the cumulative probability of pregnancy was 46% with an associated live birth rate of 32%. To achieve maximal effectiveness, natural cycle IVF should be offered as a series of treatment cycles, for it is safer, less stressful and can be offered over consecutive cycles. Moreover, the avoidance of expensive drugs and reduced intensity of monitoring make natural cycle IVF less expensive than conventional treatment involving stimulation. We calculate that this treatment can be offered at approximately 23% of the cost of a stimulated cycle, suggesting that it may be a cost-effective alternative to conventional assisted conception techniques.

Emergency sperm extraction for transient erectile dysfunction prior to assisted conception

PURPOSE

During assisted conception treatment the male partner is under stress and consequently can fail to produce semen sample prior to egg collection. Failure to produce spermatozoa at a given time could lead to cancellation of the procedure.

METHODS

We report the use of emergency percutaneous epididymal sperm aspiration (PESA) for temporary erectile dysfunction in a couple undergoing in vitro fertilization treatment. In the last 2 years, we saw three men who failed to produce a semen sample on the day of their partners' egg collection procedure.

RESULTS

In the first case the male partner failed to produce semen after egg collection and the cycle was canceled. This clinical scenario was likely to recur and one of the options was to consider PESA. In the second case the male partner was counseled about the availability of PESA but he managed to produce spermatozoa at home. The third patient was unable to produce a semen sample despite being provided audiovisual support and being allowed to go home. Five hours after the egg collection, emergency PESA was performed after appropriate counseling. The procedure yielded motile spermatozoa which were used for intracytoplasmic sperm injection which resulted in successful fertilization, embryo transfer, and pregnancy.

CONCLUSIONS

This case emphasizes that surgical procedures, such as PESA,TESA, and TESE, are useful alternatives but should be the last option to obtain sperm for ART. Other nonsurgical procedures, such as audiovisual aids, producing sperm at home, and the use of sildenafil citrate (Viagra) must be offered first to men with temporary erectile dysfunction during ART treatment.

Does blastocyst culture eliminate paternal chromosomal defects and select good embryos?: inheritance of an abnormal paternal genome following ICSI

Following intracytoplasmic sperm injection (ICSI), approximately 60-70% of oocytes are fertilized and of these embryos, approximately 45% withstand in-vitro culture conditions to produce healthy blastocysts. The efficiency of implantation of 2-4-cell embryos selected at the pronuclear stage and that of blastocysts are comparable. However, prolonged selection of embryos in vitro (4-5 days), has been proposed to eliminate chromosomal abnormalities, more specifically those inherited by defective spermatozoa. This hypothesis is based upon the assumption that the paternal genetic contribution is indispensable for blastocyst development. Here we examine this hypothesis and suggest that phenotypic manifestation of paternal genomic abnormalities might not occur prior to implantation. In addition to the parent-of-origin effect during embryogenesis, blastocyst transfer may not prevent the inheritance of genetic defects involving 'male factor' loci.

Three-dimensional power Doppler imaging in the assessment of Fallopian tube patency

OBJECTIVE

The aim of the study was to evaluate the feasibility of three-dimensional power Doppler imaging (3D-PDI) in the assessment of the patency of the Fallopian tubes during hysterosalpingo-contrast sonography (HyCoSy).

METHODS

Women attending the fertility clinic were offered a Fallopian tubal patency test as part of the initial investigation. Hysterosalpingo-contrast sonography using contrast medium Echovist was performed on 67 women. Findings on the two-dimensional (2D) gray-scale scanning and three-dimensional power Doppler imaging were compared. The first technique visualizes positive contrast in the Fallopian tube; the second demonstrates flow of medium through the tube.

RESULTS

Contrast medium Echovist produced prominent signals on the 3D-PDI image. Free spill from the fimbrial end of the Fallopian tubes was demonstrated in 114 (91%) tubes using the 3D-PDI technique and in 58 (46%) of tubes using conventional HyCoSy. The mean duration of the imaging procedure was less with 3D-PDI, but the operator time which included postprocedure analysis of the stored information was similar. A significantly lower volume of contrast medium (5.9 +/- 0.6 mL) was used for 3D-PDI in comparison with that (11.2 +/- 1.9 mL) used for conventional 2D HyCoSy.

CONCLUSION

Color coded 3D-PDI with surface rendering allowed visualization of the flow of contrast through the entire tubal length and free spill of contrast was clearly identified in the majority of cases. The 3D-PDI method appeared to have advantages over the conventional HyCoSy technique, especially in terms of visualization of spill from the distal end of the tube, which was achieved twice as often with the 3D technique. Although the design of the investigation did not allow the side effects of the two techniques to be compared, the shorter duration of the imaging and lower volume of the contrast medium used suggested that the 3D-PDI technique might have a better side-effect profile. The 3D-PDI technique allowed better storage of the information for re-analysis and archiving than conventional HyCoSy.

New use of Argyle trocar catheter: treatment of pelvic abscess following transvaginal ultrasound-directed follicle aspiration (UDFA)

This report describes the use of an Argyle trocar catheter for the drainage of pelvic abscesses following transvaginal ultrasound-directed follicle aspiration (UDFA) for oocyte collection. Three patients treated with this technique recovered uneventfully. We conclude that the use of an Argyle trocar catheter for colpotomy in the management of pelvic abscesses appears to be simple and effective.

Ultrasound derived indices of follicular blood flow before HCG administration and the prediction of oocyte recovery and preimplantation embryo quality

The principal aim of the study was to relate ultrasound-derived indices of blood flow in individual follicles on the day of, but before, the administration of human chorionic gonadotrophin (HCG) to the subsequent recovery of oocytes and the production of preimplantation embryos. Data were obtained from 21 women (aged 29-43 years) with bilateral tubal occlusion, who were undergoing treatment by in-vitro fertilization (IVF) and embryo transfer. Transvaginal ultrasonography with colour Doppler imaging and pulsed Doppler spectral analysis were used to measure follicular volume and derive indices of blood flow. The end-points for each follicle were the volume, peak systolic velocity (PSV), pulsatility index (PI), and the recovery or non-recovery of an oocyte, the subsequent production or non-production of a preimplantation embryo and the morphological grade of each embryo. A total of 94 follicles were studied; 74 oocytes were recovered (79%) and 40 embryos (33 grade I or II) were produced. There were four clinical pregnancies (pregnancy rate 25.0% per transfer, 19.0% per patient). There was a significant correlation between whether or not follicular blood flow was detected and whether or not an oocyte was recovered (P < 0.05, chi 2 test). The values for volume and PI were not clinically useful. The PSV (cm/s, mean +/- SD) was higher in follicles that were associated with the production of an embryo (12.7 +/- 5.9) compared with those that were not (8.5 +/- 5.0; P < 0.05, Student's t-test). The probability of producing a grade I or grade II embryo was 75% if the PSV was > or = 10 cm/s. The corresponding value was 40% if the PSV was < 10 cm/s and 24% if blood flow was not detected (i.e. PSV < 3 cm/s). There was a significant increase (P < 0.05, Student's t-test) in the PSV before aspiration in those follicles associated with the subsequent production of an embryo. We conclude that the value for PSV, before the administration of HCG, can be used to identify follicles with a high probability of producing an oocyte and a high grade preimplantation embryo. The information may also be used to time the administration of HCG to achieve the optimum number and quality of embryos for patient management.

A prospective randomized study comparing needles of different diameters for transvaginal ultrasound-directed follicle aspiration

OBJECTIVE

To determine whether the use of smaller diameter needles at oocyte collection reduces pain without jeopardizing the treatment outcome.

DESIGN

Prospective randomized study.

SETTING

The Assisted Conception Unit, Kings College Hospital, United Kingdom.

PATIENTS

One hundred twelve patients undergoing an IVF-ET treatment cycle.

INTERVENTIONS

Study patients were aged < or = 38 years and had at least six follicles > 14 mm on the day of oocyte collection. Patients were randomized to follicle aspiration with a 15- (n = 34), 17- (n = 41), or 18- (n = 37) gauge (g) single channel needle. Intravenous pethidine and diazepam were used for analgesia and sedation. Pain was quantified by means of questionnaires completed by the patient and by her partner postoperatively.

RESULTS

A greater proportion of patients reported severe to unbearable pain with the 15-gauge compared with the 17-gauge (44% versus 22%) or 18-gauge (44% versus 16%) needles. Partners' perception of severe pain experienced by patients showed the same trend when the 15-gauge was compared with the 17- (62% versus 29%) and 18-gauge (62% versus 22%) needles. There was no significant difference between the needles regarding the oocyte collection rate, fertilization rate, proportion of oocytes with fractured zonae, cleavage rate, implantation rate, and pregnancy rate per cycle.

CONCLUSIONS

Reducing the size of the needle used for oocyte collection from 15 to 17 or 18 gauge reduces pain without affecting the number of oocytes collected, their quality, or the clinical pregnancy rate.

The impact of ovarian cystectomy on ovarian response to stimulation during in-vitro fertilization cycles

This study was carried out to investigate whether ovarian cystectomy interferes with follicular recruitment and the number of oocytes retrieved in an in-vitro fertilization (IVF) cycle. Patients who had previously undergone unilateral ovarian cystectomy (n = 90) and control patients (n = 90) with no history of ovarian surgery were included in our study. The parameters compared were the number of follicles recruited and the number of oocytes obtained from each ovary. In patients who had undergone surgery, the normal ovaries recruited a significantly higher number of follicles (P < 0.001) and yielded a significantly higher number of oocytes (P < 0.001) compared with the contralateral ovaries which had undergone cystectomy. In the control patients, no significant differences were identified between the left and right ovaries. These results demonstrate that ovarian cystectomy reduces follicle and oocyte numbers in ovulation induction cycles.

Associations between ultrasound indices of follicular blood flow, oocyte recovery and preimplantation embryo quality

The aim of this study was to elucidate possible relationships between ultrasound indices of follicular blood flow, oocyte recovery and the subsequent production and morphological quality of preimplantation embryos. A total of 27 women with bilateral tubal occlusion, undergoing treatment for infertility by in-vitro fertilization and embryo transfer, contributed data from 29 cycles. Transvaginal ultrasonography with colour Doppler imaging and pulsed Doppler spectral analysis was used to obtain indices of blood flow for each follicle immediately before it was aspirated. The main outcome measures for each follicle were the pulsatility index, peak systolic velocity, recovery or non-recovery of an oocyte and the subsequent production or non-production of an embryo. A total of 126 follicles were studied, 102 oocytes were recovered and 58 embryos (49 at grades I or II) were produced. There were six clinical pregnancies (pregnancy rate 27.3% per embryo transfer, 22.2% per patient). There was a significant correlation (P < 0.0001, chi2 test) between whether or not follicular blood flow was detected and whether or not an oocyte was recovered. The sensitivity of a test based on the presence of detectable blood flow and the subsequent recovery of an oocyte was 74% and the positive predictive value was 93%. The peak systolic velocity (PSV, measured in cm/s, mean +/- SD) in follicles with detectable blood flow was significantly higher in follicles that were associated with the production of a preimplantation embryo (19.7 +/- 10.8) compared with those that were not (9.9 +/- 5.3, P < 0.0001, Student's t-test). There was a 70% chance of producing a grade I or II embryo if the follicular blood velocity was >/=10 cm/s, compared with 14% if the PSV was <10 cm/s, or 18% if no blood flow was detected. We conclude that there is a physiological relationship between follicular blood velocity, oocyte recovery and the production of a high-grade preimplantation embryo, which may form the basis of a useful clinical test.