Value of ovarian stromal blood flow velocity measurement after pituitary suppression in the prediction of ovarian responsiveness and outcome of in vitro fertilization treatment

Effect of pituitary downregulation on antral follicle count, ovarian volume and stromal blood flow measured by three-dimensional ultrasound with power Doppler prior to ovarian stimulation

BACKGROUND

Despite the extensive use of gonadotrophin releasing hormone agonists (GnRH ag) for pituitary downregulation, the literature regarding their effect on ultrasound parameters for predicting ovarian responses are few and conflicting. The aim of this prospective study was to compare antral follicle count (AFC), ovarian volume and ovarian stromal blood flow measured by three-dimensional (3D) power Doppler ultrasound before and after pituitary downregulation.

METHODS

All patients received a long protocol of intranasal Buserelin from the mid-luteal phase of the cycle. In the early follicular phase of the preceding cycle before downregulation and on the second day of the treatment cycle after downregulation, patients underwent a blood test for serum FSH, LH and estradiol and a transvaginal scanning with 3D power Doppler to determine AFC, ovarian volume and ovarian 3D power Doppler flow indices.

RESULTS

Out of 104 women scanned, 85 women were analysed. Polycystic ovaries were encountered in 14 (16.5%) women. No significant differences in any of the ultrasound parameters were demonstrated before and after downregulation, in patients with normal ovaries or in those with polycystic ovaries.

CONCLUSION

AFC, ovarian volume and ovarian 3D power Doppler flow indices did not significantly change after a short-term treatment of GnRH agonist for pituitary downregulation.

Follicular blood flow is a better predictor of the outcome of in vitro fertilization-embryo transfer than follicular fluid vascular endothelial growth factor and nitric oxide concentrations

OBJECTIVE

To investigate the relationship between follicular blood flow and the follicular fluid vascular endothelial growth factor (VEGF) and nitric oxide (NO) concentrations and to determine which factor might be a better predictor of the outcome of IVF-ET.

DESIGN

Prospective study.

SETTING

Academic research laboratory.

PATIENT(S)

Forty-seven cycles of IVF (tubal factor, 25 cycles; male factor, 22 cycles) at the infertility clinic of Pusan National University Hospital from February 2002 to June 2002.

INTERVENTION(S)

Follicular blood flow was estimated on the day of hCG administration. Each follicular fluid sample was collected at oocyte retrieval, and follicular fluid VEGF and NO concentrations were assessed.

MAIN OUTCOME MEASURE(S)

Follicular blood flow and follicular fluid VEGF and NO concentrations according to the age of patients, the cause of infertility, and pregnancy rate.

RESULT(S)

Of 47 cycles, 18 (38.3%) cycles resulted in a pregnancy. Follicular blood flow was significantly higher in the pregnant group compared with the nonpregnant group, but there was no statistically significant difference in age and infertility cause. Follicular fluid concentrations of VEGF and NO did not show statistically significant differences in age, infertility cause, or pregnancy outcome. As the follicle size increases, the follicular blood flow and follicular fluid VEGF concentrations increased significantly but the follicular fluid NO concentrations decreased. There was no correlation between VEGF and NO concentrations in the follicular fluid by linear regression analysis.

CONCLUSION(S)

Our study showed that follicular blood flow was positively associated with the outcome of pregnancy. This is the first study to investigate the direct association of the follicular blood flow with pregnancy outcome after IVF-ET. These results suggest that follicular blood flow might be a more effective prognostic marker of the pregnancy outcome of IVF than follicular fluid VEGF or NO concentrations.

Early ovarian ageing: are women with polycystic ovaries protected?

Screening asymptomatic women in the general population for 'early ovarian ageing' will be more effective in high-risk groups. Recent findings support the hypothesis that women with polycystic ovaries (PCO) may have actually been born with a larger pool of resting follicles. The mechanism is almost certainly genetic and occurs in fetal life. If, as is widely accepted, the rate of depletion of the ovarian reserve depends primarily on the size of the remaining pool of small follicles, women with PCO will be unlikely to undergo an accelerated depletion of their follicle pool, normally seen in the late thirties, significantly earlier. In terms of asymptomatic screening for early ovarian ageing in the general population, women with PCO constitute a low-risk group and should therefore be excluded.

Assessment of ovarian reserve

PURPOSE OF REVIEW

Various methods have been proposed and are currently used in the assessment of ovarian reserve in order to predict the outcome in assisted reproduction. This review focuses on the current information regarding the ovarian reserve markers and tests, an active area of research.

RECENT FINDINGS

Female age alone is a rough parameter for assessing ovarian reserve. The basal follicle stimulating hormone level is not adequately sensitive to predict poor outcome and the same is true for other basal parameters, including basal estradiol, the follicle stimulating hormone/luteinizing hormone ratio, and inhibin-B levels. The clomiphene citrate challenge test has a low sensitivity but this sensitivity is greater than that of basal follicle stimulating hormone. The value of other hormonal dynamic tests remains to be determined. Among the ultrasound markers the total antral follicle count seems to be promising. Ovarian biopsy in this assessment is controversial. History of poor response to ovarian stimulation is a strong indicator for declining ovarian function.

SUMMARY

There is currently no clinically useful predictive test sufficiently accurate and distinct in time from controlled ovarian stimulation to assess ovarian reserve accurately. Further research is warranted to validate the ovarian reserve tests in the general population and in populations with different causes of infertility.

Age-related decline in fertility

A progressive decline in fecundity with advancing age is a reality, attributed primarily to the detrimental impact of various aging processes on female gametes. Despite medical advances that have dramatically prolonged the female life span, declining numbers and deteriorating quality of oocytes, and an increasing incidence of meiotic errors and aneuploidy of gametes and embryos, reduce clinical pregnancy rates and escalate pregnancy wastage. Increased fetal aneuploidies in ongoing pregnancies and an increased predisposition to obstetric morbidities further contribute to the diminishing reproductive successes associated with advancing age. The age of male partners, despite the decline in semen parameters and sexual performance with aging, does not appear to have a major impact on the eventual fertility of the aging couple. The contributions of age-related impaired sexuality and ejaculatory problems, although slight albeit significant, to declining fertility in the aging should be appreciated in appropriate cases. With the realization of the age-related detriment on fertility potential and the limitations of available therapeutic interventions, management of subfecundity in women beyond their mid-30s should be approached aggressively. Success of ovulation induction with clomiphine citrate or gonadotropins is marginal in women aged older than 40 years; a case can be made to proceed directly with ART in women in this age group, especially when there is coexisting male factor or pelvic disease. Except for the use of donor oocytes, the outcome of various therapeutic interventions to optimize reproductive performance in women aged older than 44 years remains dismal. A broader application of PGD techniques may contribute to improved live birth rates in reproductively aging women. The greater likelihood of obstetric complications in pregnancies resulting from donor oocytes and an increased prevalence of age-related medical problems complicating pregnancy should prompt a thorough medical evaluation before proceeding with ART.

Three-dimensional power Doppler imaging of ovarian stromal blood flow in women with endometriosis undergoing in vitro fertilization

OBJECTIVE

The aims of this retrospective study were to investigate whether the quantification of ovarian stromal blood flow and/or leptin concentration are predictive of in vitro fertilization (IVF) outcomes in women after laparoscopic ovarian cystectomy for large endometriomas.

METHODS

Twenty-two women undergoing IVF after laparoscopic surgery for ovarian endometriomas (> 6 cm) comprised the study group. Twenty-six women with tubal factor infertility constituted the control group. Ovarian stromal blood flow was evaluated by three-dimensional (3D) power Doppler ultrasound imaging using virtual organ computer-aided analysis (VOCAL( trade mark )). Serum and follicular fluid (FF) leptin concentrations were quantified using an enzyme-linked immunosorbent assay kit.

RESULTS

There were significantly decreased ovarian stromal blood flow parameters (including vascularization index, flow index (FI), and vascularization flow index) in the endometriosis group without an evident difference in total ovarian volume on the day of human chorionic gonadotropin. The value of FF leptin demonstrated a negative correlation with ovarian stromal FI in the control group, but there was a loss of this effect in the endometriosis group.

CONCLUSIONS

Quantification of ovarian stromal blood flow by 3D power Doppler ultrasound in women with endometriosis may provide an important prognostic indicator in those undergoing IVF.

Optimal treatment for poor responders to ovarian stimulation: does in vitro insemination offer any advantages to intrauterine insemination?

A retrospective study was performed of 1832 consecutive in vitro insemination (IVF)/intracytoplasmic sperm injection (ICSI) cycles over 18 months, to analyse the benefits or otherwise to the patient of continuing with in vitro treatment or converting the assisted conception cycle to intrauterine insemination (IUI). Two hundred and seventy cycles were identified in which three follicles or fewer were obtained after controlled ovarian hyperstimulation; in 143 of these cycles, the clinicians or patients elected to abandon all treatment, whereas treatment was continued in 127 patients. In 79 cycles, the patients proceeded with IVF/ICSI and in 48 patients, the cycles were converted to IUI. Data were analysed with regard to the clinical pregnancy rate. In addition, the data for IUI were compared with eight cycles of supraovulation IUI (S/IUI) performed over the same period. There were no significant differences in clinical pregnancy rates among any treatment modality 6/48 (12.5%), 6/79 (7.7%) and 1/8 (12.5%) for IUI, IVF and S/IUI, respectively (P = 0.64). The lowest total number of motile spermatozoa required to achieve pregnancy using IUI was 2.0 x 10(6). In conclusion, it appears that, if the treatment is suitable, patients who respond poorly to controlled hyperstimulation for IVF would not be disadvantaged in achieving a pregnancy by offering them conversion to the medically and financially less interventional IUI.

Three-dimensional ultrasonographic ovarian measurements and in vitro fertilization outcome are related to age

OBJECTIVE

To evaluate whether the number of ovarian antral follicles, ovarian volume, and ovarian stromal blood flow change with age and to prospectively analyze whether three-dimensional ultrasonographic measurements predict ovarian response and IVF outcome.

DESIGN

Prospective analysis.

SETTING

Assisted reproductive unit.

PATIENT(S)

Fifty-six consecutive women 22 to 43 years of age with normal basal serum FSH concentrations who were undergoing their first IVF cycle.

MAIN OUTCOME MEASURE(S)

Number of ovarian antral follicles, ovarian volume, and ovarian stromal flow index were determined by three-dimensional and power Doppler ultrasonography. Pretreatment measurements were compared with number of recovered oocytes, fertilization rates, and pregnancy rates.

RESULT(S)

As patient age increased, significant trends in ovarian volume, number of follicles, and stromal vascularity decreased. Three-dimensional ovarian measurements and fertilization rates differed significantly among age groups. For each age group, a higher number of antral follicles, greater ovarian volume, and favorable ovarian stromal vascularity was associated with higher number of retrieved oocytes and increased pregnancy rates.

CONCLUSION(S)

Increasing patient age is associated with poor ovarian response, as represented by smaller ovarian volume, lower antral follicle count, and poor stromal vascularity. Three-dimensional power Doppler ultrasonography can help to individualize IVF in patients regardless of age.

Age and resting follicle number predict response to gonadotropin stimulation in in vitro fertilization cycles

OBJECTIVE

The purpose of this study was to assess whether age, resting follicle number, intraovarian blood flow, and/or ovarian volume are predictive of follicular response and oocyte quality in patients with in vitro fertilization.

STUDY DESIGN

A retrospective chart review was done on 90 in vitro fertilization cycles that were completed in a university setting. Multiple linear regression analysis was used to assess the predictive value of age, resting follicle number, pretreatment ovarian volume, and peak systolic velocity for response to gonadotropin stimulation.

RESULTS

Age was predictive (P <.05) for the number of oocytes retrieved, the number that reached two pronuclei, and the number of embryos that reached > or = 4 cells by day 3 after insemination. Resting follicle number was also predictive of follicular response and subsequent embryonic development. Peak systolic velocity and ovarian volume were both found to be of no value.

CONCLUSION

Age and resting follicle number can be used as additional parameters to support patient counseling before in vitro fertilization stimulation.

Day 5 inhibin B levels in a treatment cycle are predictive of IVF outcome

BACKGROUND

Day 5 serum inhibin B during IVF treatment has been investigated as a predictor of outcome.

METHODS

A total of 54 women (< or = 39 years, normal menses and endocrine profiles) were treated with urinary gonadotrophins or recombinant FSH following pituitary down-regulation. Serum day 3 FSH in a preceding cycle was <8.5 IU/l. Plasma inhibin B, inhibin A and estradiol were determined after 4 days of gonadotrophin administration (day 5).

RESULTS

Day 5 inhibin B was the most highly correlated with the number of mature follicles (>14 mm), oocytes retrieved and fertilized. Receiver operating characteristic analysis gave high accuracy for day 5 inhibin B in predicting ovarian response and indicated that a threshold of 400 pg/ml may be helpful in the decision as to whether to continue treatment. Women with <400 pg/ml (n = 16) had lower numbers of follicles, mature follicles, oocytes retrieved, fertilized and cleaved compared with those >400 pg/ml (n = 36) and this threshold gave a positive likelihood ratio of 30, 92.9% sensitivity, 95.0% specificity and 86.7% positive predictive value to detect poor ovarian response. Day 5 inhibin B was the best predictor of pregnancy (no live births and four cycles cancelled, low inhibin group; nine live births and no cancelled cycles, high inhibin group).

CONCLUSIONS

Normogonadotrophic, normogonadal women with day 5 inhibin B <400 pg/ml in down-regulated cycles have a poor response to ovarian stimulation and are less likely to conceive compared with women with higher day 5 inhibin B.

In vitro maturation and fertilization of oocytes from unstimulated ovaries: predicting the number of immature oocytes retrieved by early follicular phase ultrasonography

OBJECTIVE

To select women who will benefit most from in vitro maturation (IVM) of oocytes treatment, this study was undertaken to examine the ability of a transvaginal ultrasonography to predict the number of immature oocytes collected from unstimulated ovaries.

STUDY DESIGN

The relationship between the number of immature oocytes retrieved and the pregnancy rate was assessed in 189 IVM treatment cycles. In 96 consecutive cycles, an early follicular phase transvaginal ultrasonographic measurement of the antral follicle count (AFC), ovarian volume, and peak ovarian stromal blood flow velocity (Vmax) was performed, and the results were correlated with the number of immature oocytes.

RESULTS

The clinical pregnancy rate increased significantly with the number of oocytes retrieved (P =.02) and was 26.8% (15/56) in those with >10 immature oocytes. The AFC, ovarian volume, and ovarian stromal Vmax were all predictive of the number of oocytes retrieved, but when the other factors were controlled by multiple regression analysis the AFC was the only significant predictor (P <.001).

CONCLUSIONS

Pregnancy rates after IVM correlate with the number of immature oocytes retrieved. This is best predicted by an ultrasonographic assessment of the AFC.

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.

Antral follicle counting in predicting the retrieved oocyte number after ovarian hyperstimulation

PURPOSE

To evaluate the antral follicle (AF) counting in predicting the outcome after controlled ovarian hyperstimulation (COH) and IVF-ET.

METHODS

Infertile women who accepted the COH and IVF-ET were included prospectively. Day

Angiogenesis in ovarian follicular and luteal development

Angiogenesis is the process of new capillary formation from previously existing mature vessels. The adult ovary exhibits dramatic growth and regression of capillary networks on a cyclic basis. Ovarian follicles and the corpus luteum contain and produce endothelial cell-specific factors, which may act alone or in concert to regulate the process of angiogenesis. These factors are ultimately controlled by endocrine, paracrine and autocrine regulation, as well as by metabolic cellular signals such as intracellular oxygen content and ageing. Aberrant production of these angiogenic factors may be the cause of vascular dysfunction and the development of ovarian disorders. Recent technological advances for monitoring blood flow and measuring angiogenic factors could assist in accurately diagnosing ovarian disorders. Further elucidation of specific physiological role(s) of factors involved in angiogenesis of the pre-ovulatory follicle and developing corpus luteum may be useful in addressing issues of infertility in women.

Advanced ultrasound examination in the management of subfertility

The development of new ultrasound techniques such as colour power angiography (CPA) and three-dimensional ultrasound may expand the role of ultrasound in the management of the infertile couple. Measurements of follicular blood flow velocities appears to predict the development of a healthy oocyte while high ovarian stromal vascularity is associated with polycystic ovary and the risk of ovarian hyperstimulation syndrome. Three-dimensional ultrasound with CPA provides spatial evaluation of volume flow in pelvic organs which has been used to measure vascular changes in the endometrium and improve the evaluation of tubal patency.