Sonographic monitoring of ovarian follicular development

Bovine models for human ovarian diseases

During early embryonic development, late fetal growth, puberty, adult reproductive years, and advanced aging, bovine and human ovaries closely share molecular pathways and hormonal signaling mechanisms. Other similarities between these species include the size of ovaries, length of gestation, ovarian follicular and luteal dynamics, and pathophysiology of ovarian diseases. As an economically important agriculture species, cattle are a foundational species in fertility research with decades of groundwork using physiologic, genetic, and therapeutic experimental techniques. Many technologies used in modern reproductive medicine, such as ovulation induction using hormonal therapy, were first used in cows before human trials. Human ovarian diseases with naturally occurring bovine correlates include premature ovary insufficiency (POI), polycystic ovarian syndrome (PCOS), and sex-cord stromal tumors (SCSTs). This article presents an overview of bovine ovary research related to causes of infertility, ovarian diseases, diagnostics, and therapeutics, emphasizing where the bovine model can offer advantages over other lab animals for translational applications.

Optimization of oestradiol assays to improve utility in an in vitro fertilization setting

Background The measurement of oestradiol is an integral component for the management of ovarian stimulation for in vitro fertilization. Automated immunoassays offer fast assay times and high throughput, with less sensitivity and specificity. The aim of this study is to optimize the oestradiol assay in patients undergoing ovarian stimulation for in vitro fertilization via comparison of oestradiol values obtained using two immunoassays compared with mass spectrometry. Methods Patients undergoing ovarian stimulation were prospectively recruited. Serum samples were analysed with ADVIA Centaur® CP Immunoassay, Abbott Architect i1000® immunoassay and AB Sciex 5500 liquid chromatography-tandem mass spectrometry (LC-MS/MS) systems. Per cent bias was determined for each system to report the average tendency of the values to be larger or smaller than the LC-MS/MS value. Linear regression of total follicular volume and oestradiol was computed. Results The ADVIA Centaur® CP assay had a positive bias of 20% compared with LC-MS/MS, while the Architect i1000® had a non-significant, negative bias of 0.3%. With regression fit, a clear, positive relationship was seen between follicular volume and oestradiol. The Architect i1000® assay had a greater correlation (R²= 0.46) compared with Centaur® CP (R²= 0.36), when oestradiol values were >1000 pg/mL (3670 pmol/L). Conclusions The Abbott Architect i1000® oestradiol assay exhibits greater agreement with LC-MS/MS and exhibited better correlation to follicular volume when oestradiol values are >1000 pg/mL (3670 pmol/L), prompting a change in the clinic's oestradiol platform. Attention to assay quality assurance via LC-MS/MS can improve the oestradiol accuracy and permit more informed clinical decisions for improved patient outcomes.

Conservative treatment for complex neonatal ovarian cysts: a long-term follow-up analysis

OBJECTIVE

We aimed to investigate safety and effectiveness of a conservative approach for complex neonatal ovarian cysts and its long term impact on fertility.

STUDY DESIGN

Neonates with congenital complex ovarian cysts were conservatively managed and followed from the perinatal period to adolescence. Statistical analysis included Student's t-test, Mann-Whitney U-test, the Kaplan-Meier method, and the receiver operating characteristic curve.

RESULTS

The post-natal progressive dimensional reduction of diagnosed ovarian cyst was statistically significant. The Kaplan-Meier survival curves revealed the probability of persistence of the cyst was up to 5% at the age of 25 months. Long term follow-up revealed both ovaries visible at US in 60% of adolescent patients.

CONCLUSION

Conservative management of asymptomatic complex neonatal ovarian cysts can be safely undertaken. As far as the chances of the ovarian tissue to survive conservative treatment are concerned, the results are not encouraging.

Controlled ovarian hyperstimulation: are we monitoring the appropriate sex-steroid hormones?

We prospectively evaluated the behavior of serum 17-hydroxyprogesterone (17-OHP), sex-steroid hormones, and C-reactive protein (CRP) levels in 27 patients during controlled ovarian hyperstimulation (COH) for in vitro fertilization (IVF). While routine measurement of COH via serum 17-OHP may replace estradiol (E(2)) and progesterone levels, additional studies are needed to elucidate the ceiling level of serum 17-OHP beyond which intervention is required to prevent severe ovarian hyperstimulation syndrome.

The influence of estradiol/follicle and estradiol/oocyte ratios on the outcome of controlled ovarian stimulation for in vitro fertilization

OBJECTIVE

The aim of the study was to evaluate the influence of the ratios of estradiol (E2) to either the number of follicles >14 mm on the day of human chorionic gonadotropin administration (E2/follicle) or the number of oocytes retrieved (E2/oocytes) during controlled ovarian hyperstimulation (COH) with gonadotropin-releasing hormone (GnRH)-agonist (agonist group) and GnRH-antagonist (antagonist group), on the outcome of in vitro fertilization (IVF) cycles.

PATIENTS AND METHODS

All consecutive women aged <35 years admitted to our IVF unit during a 6-year period with normal to high response to COH were retrospectively studied. Ovarian stimulation characteristics, number of oocytes retrieved, number of embryos transferred and pregnancy rate were assessed.

RESULTS

Six hundred and ninety consecutive IVF cycles were evaluated, 301 in the agonist group and 389 in the antagonist group. The ratios of E2/follicle and E2/oocyte were significantly higher in the agonist group (p < 0.001 for both). Moreover, while pregnancy rates within E2/oocyte ratio of 100-200 pg/ml were comparable between the agonist and antagonist groups, when E2/oocyte ratios were <100 pg/ml or >200 pg/ml, pregnancy rates were significantly higher in the agonist group. Furthermore, no difference in pregnancy rates was observed within the agonist group between different E2/oocytes ratios, while within the antagonist group, higher pregnancy rates were observed when comparing those with E2/oocyte ratio of 100-200 pg/ml with those with E2/oocyte ratio <100 pg/ml or >200 pg/ml.

CONCLUSION

While E2/oocyte ratio cannot predict the success of GnRH-agonist protocol, patients undergoing GnRH-antagonist protocol should reach E2/oocyte ratio within the 100-200 pg/ml range in order to achieve the best IVF outcome.

MR features of physiologic and benign conditions of the ovary

In reproductive women, various physiologic conditions can cause morphologic changes of the ovary, resembling pathologic conditions. Benign ovarian diseases can also simulate malignancies. Magnetic resonance imaging (MRI) can play an important role in establishing accurate diagnosis. Functional cysts should not be confused with cystic neoplasms. Corpus luteum cysts typically have a thick wall and are occasionally hemorrhagic. Multicystic lesions that may mimic cystic neoplasms include hyperreactio luteinalis, ovarian hyperstimulation syndrome, and polycystic ovary syndrome. Recognition of clinical settings can help establish diagnosis. In endometrial cysts, MRI usually provides specific diagnosis; however, decidual change during pregnancy should not be confused with secondary neoplasm. Peritoneal inclusion cysts can be distinguished from cystic neoplasms by recognition of their characteristic configurations. Ovarian torsion and massive ovarian edema may mimic solid malignant tumors. Recognition of normal follicles and anatomic structures is useful in diagnosing these conditions. In pelvic inflammatory diseases, transfascial spread of the lesion should not be confused with invasive malignant tumors. Radiologic identification of abscess formation can be a diagnostic clue. Many benign tumors, including teratoma, Brenner tumor, and sex-cord stromal tumor, frequently show characteristic MRI features. Knowledge of MRI features of these conditions is essential in establishing accurate diagnosis and determining appropriate treatment.

Ovarian and uterine sonography in healthy girls between 1 and 13 years old: correlation of findings with age and pubertal status

OBJECTIVE

Our objective was to correlate ovarian and uterine sonographic variables with age and pubertal status in a sample of healthy girls.

SUBJECTS AND METHODS

In this prospective study, 139 consecutive patients between 1 and 13 years old (mean +/- SD, 6.0 +/- 3.4 years) underwent sonography and hand radiography (for bone-age determination). Pubertal development was classified according to Tanner stages (prepubertal, 5.0 +/- 2.7 years [n = 117]; pubertal, 11.2 +/- 1.2 years [n = 22]). Uterine and ovarian longitudinal, transverse, and anteroposterior diameters were measured. Uterine fundal-cervical ratio was determined. Ovaries were morphologically classified as homogeneous, paucicystic, multicystic, macrocystic, and presenting isolated cysts. A p value less than or equal to 0.05 was considered significant.

RESULTS

The uterus was identified in 96% of the patients (mean, 6.1 +/- 3.4 years). One ovary was visible in 93% (mean, 6.2 +/- 3.4 years), and both ovaries, in 81% (mean, 6.5 +/- 3.3 years). Neither ovary was visualized in 10 girls (mean, 2.5 +/- 2.2 years). Uterine parameters and ovarian volume were smaller in patients without thelarche (p < 0.0001). Mean ovarian and uterine size was smaller in girls until 8 years, intermediate between 9 and 11 years, and larger after 12 years (p < 0.0001). Chronologic age, bone age, and Tanner stage were correlated even before 7 years. Patients with and without thelarche presented different ovarian morphology (p = 0.01).

CONCLUSION

Uterine and ovarian growth was associated with age and puberty. Uterine length presented the best correlation with age. Multicystic ovaries seemed to be correlated with normal or premature pubertal stimuli.

Can we abandon routine evaluation of serum estradiol levels during controlled ovarian hyperstimulation for assisted reproduction?

OBJECTIVE

To assess whether abandoning measurement of serum estradiol (E2) and spacing ultrasound evaluations at greater intervals had an effect on the results of assisted reproduction technology (ART).

DESIGN

A retrospective comparison of two consecutive periods.

SETTING

Division of Assisted Reproduction Technology, Department of Obstetrics and Gynecology, Ha'Emek Medical Center, Afula, Israel.

PATIENT(S)

One thousand nine hundred and eighty-five controlled ovarian hyperstimulation (COH) cycles for ART were initiated during the years 1996 to 1999.

INTERVENTION(S)

During the first 2 years an intensive follow-up protocol was used that included E2 blood levels measurements. In the next 2 years a less intensive protocol was adopted that did not use E2 measurements.

MAIN OUTCOME MEASURE(S)

ART results and the rate of ovarian hyperstimulation syndrome (OHSS).

RESULT(S)

The patients' background characteristics did not differ between the two periods. The cancellation rate was not different (9.8% vs. 7.2%). There was no difference in the duration of stimulation or the amount of gonadotropins used. The number of oocytes retrieved (12.1 +/- 9.3 vs. 9.6 +/- 6.3), fertilization rates (74% vs. 75%), and clinical pregnancy rates (26.2% vs. 27.9%) did not differ. The incidence of severe ovarian hyperstimulation syndrome was not significantly different between the two periods.

CONCLUSION(S)

Controlled ovarian hyperstimulation for ART can be done reliably without routine, serial serum E2 measurements without compromising the treatment results.

Frequency of ovarian cysts in patients with autosomal dominant polycystic kidney disease

Extrarenal cysts occur in patients with autosomal dominant polycystic kidney disease (ADPKD) most frequently in the liver. Ovarian cysts have been reported in women with ADPKD, but their frequency has not been determined. Therefore, we analyzed the historical data in our database of 337 women with ADPKD and 199 of their unaffected female family members (NADPKD). In addition, we prospectively studied 25 nonpregnant, premenopausal women with ADPKD and 25 nonpregnant, premenopausal, age-matched control women recruited from the general population to assess the occurrence of ovarian cysts. No women in either the control or ADPKD groups were receiving exogenous estrogen or progesterone. All women underwent sonographic examination using a 5- or 7.5-MHz vaginal probe. A normal ovarian follicle was defined as a fluid-filled structure less than 2 cm in average diameter, and an ovarian cyst as one of 2 cm or greater. From the historical data, 28% of the women with ADPKD gave a history of ovarian cysts compared with 18% of the NADPKD women (P < 0.05). In the prospective study, the mean age of the women with ADPKD was not different from that of the control women (40.9 +/- 1.2 v 39.3 +/- 1.2 years; P = not significant [NS]). There was no difference in frequency of normal follicles found in women with ADPKD or controls (80% v 96%; P = NS), nor was there a difference in the frequency of ovarian cysts found in women with ADPKD or controls (12% v 12%; P = NS). There was no difference in the calculated ovarian volumes between the women with ADPKD and controls (9.9 +/- 2. 5 v 7.2 +/- 1.2 cm3). Among the women with ADPKD, there was no correlation between mean ovarian volume and mean renal volume, nor was there a significant relationship between the occurrence of hepatic cystic disease and ovarian cysts. Therefore, a prospective imaging study suggests that ovarian cysts have no increased frequency in women with ADPKD compared with women in the general population.

Identification of follicles with fertilizable oocytes by sequential ultrasound measurements during follicular development

Patients undergoing ovulation induction for in vitro fertilization and embryo transfer (IVF-ET) were monitored daily with serum estradiol-17 beta (E2) and ultrasound. The location of each individual follicle was established by taking ultrasound images through serial sections of the ovary. The diameter of each follicle and the volume of its follicular wall (FW) were determined from ultrasound images using a computer-controlled image analyzer. A total of 44 follicles from nine patients was studied, with an overall fertilization rate of 46% In all patients, serum E2 levels increased prior to human chorionic gonadotropin (hCG). Whereas changes in either the average diameter or the volume of the entire follicle did not identify follicles with fertilizable oocytes, FW volume measurements were predictive. Prior to hCG, FW volume increased 24 +/- 8%/day in follicles with fertilizable oocytes but decreased 3 +/- 6%/day in follicles with nonfertilizable oocytes (P less than 0.05). Three major patterns of follicular development were observed for follicles with nonfertilizable oocytes: slow growing (less than 20% increase in FW volume), nongrowing (no change in the FW volume), and "degenerating" (a decrease in the FW volume), suggesting that these follicles are "postmature." These data demonstrate that FW volume measurements made from sequential ultrasound images provide an accurate method to identify those follicles that contain fertilizable oocytes.

Diagnostic imaging of fertility disorders

It is estimated that as many as 15% of married couples are affected by fertility disorders. The number of such couples seeking medical help has increased dramatically in the past 10 years due to both relative and absolute factors. The increase in population, the rising rate of sexually transmitted diseases, and the reduced availability of adoptable infants all contribute to the magnitude of this problem. The role of diagnostic imaging in the effective and compassionate care of couples desiring offspring is the subject of this review. Infertility is a disorder of a couple, not of two individuals. The diagnostic evaluation, therefore, must include both partners. Hysterosalpingography and ultrasound constitute the mainstay of the evaluation of the female member. The various techniques and complications of hysterosalpingography are reviewed. The normal appearance of the uterine cavity together with a review of the numerous anomalies and variations that might be encountered are presented. Along similar lines, the possible filling defects, synechiae, postoperative changes, and other alterations that may be encountered in imaging the uterine cavity are described. Evaluation of the fallopian tubes is of paramount importance, primarily to assess patency but also to assess the possibility of patent but diseased salpinges or disease of the surrounding peritubal tissue. Recently, interventional techniques using radiographic and sonographic control have been developed and are beginning to demonstrate promising results in the management of fallopian tube obstruction. These procedures, adapted from previously established radiographic interventive techniques, are discussed. The role of diagnostic imaging of the male partner is of lesser magnitude. Clinical assessment and semen evaluation generally permit adequate assessment of the male factor. Occasionally, however, vasography and seminal vesiculography are called into play. More frequently, sonographic evaluation to establish the presence of varicoceles is necessary. Such techniques are reviewed, as well as the interventional approaches for ablating varicoceles. The application of conventional and transvaginal sonography in the management of gynecologic fertility disorders is reviewed. Follicular monitoring, guided follicle aspiration, assessment of the status of the endometrium, guided embryo transfer and tubal cannulation, and evaluation of other pelvic disorders are significant factors in the appropriate management of the infertile couple.(ABSTRACT TRUNCATED AT 400 WORDS)

Ultrasound in the evaluation of normal and induced ovulation

In the past several years sonography has become an invaluable research tool for the investigation of spontaneous and induced ovulation and has added to the understanding of folliculogenesis and reproductive endocrinology. In practical terms, in ovulation induction sonography assists in the evaluation of the number and distribution of follicles, necessary for adequate interpretation of estrogen levels. Although there is no ideal size when it can be assumed that a follicle is mature, estimation of follicle size is of value and is a good guide to the timing of hCG administration. If the follicles are extremely small or there is evidence of hyperstimulation, these observations, together with the E2 levels, may be used to decide whether a further ultrasonic examination is warranted for the assessment of follicular growth or whether the treatment cycle should be abandoned. Provided follicular size is within normal limits, the diameter of the largest follicle may also be used in IVF programs to determine when the patient should be admitted to the hospital for more intensive monitoring of follicular development and the administration of hCG. Ultrasound is also valuable in patients with only one ovary accessible to laparoscopy. Even if the largest follicle is in the inaccessible ovary, the treatment cycle does not have to be abandoned, provided that several follicles are developing in the contralateral ovary. If neither ovary is accessible laparoscopically, percutaneous oocyte aspiration offers the patient the opportunity of IVF and embryo transfer.

The role of ultrasound in female infertility management

Ultrasound became an important help for the diagnosis of infertility by demonstration of the pelvic organs, of growing ovarian follicles, of intrafollicular structures and of cyclic uterine endometrial changes. Ultrasonic particularities of ovaries and their landmarks such as the ovarian artery, are described. Average ovarian blood flow can be measured. In hormone stimulated cycles, the ultrasonic examination is repeated through ovulation, induction and even afterward. The average diameter of the growing follicle is measured. The results of more than 8000 scans allowed the deduction that ovulation induction would be successful if the preovulatory follicular diameter was between 18 and 24 mm. Where two or more follicles of that diameter are present, multiple pregnancy occurs. The risk of overstimulation can be assessed. The importance of ultrasound is even higher than estradiol because it is impossible to differentiate between one big, some medium or many small follicles with hormone assays. It is possible to see the cumulus oöphorus, but not earlier than 1-2 days before ovulation. Following successful ovulation the mature follicle appears to have a more solid than cystic make-up. Signs of a failure of ovulation are given. Cyclic changes in the histology of the endometrium are described and make it possible to predict ovulation within 12 hr. Ultrasound is an important aid in predicting the time of ovulation more accurately than the basal body temperature and faster and cheaper than hormone profiles. Ultrasound plays a role in egg collection and replacement of the embryo. The detection of ovulation is very important in the treatment of infertility. This was only possible for a longtime by hormone profile. Nowadays ultrasound is an accepted method in the diagnostic procedures of this field. It permits the visualization of the position and size of the uterus, Fallopian tubes and ovaries, the exclusion of genital anomalies and the demonstration of physiological changes of these organs during the menstrual cycle. The main points of ultrasound in the diagnosis of infertility are as follows: Demonstration of the pelvic organs (uterus, Fallopian tube, ovary) and vascular structures. Demonstration of growing ovarian follicles (Measurement of their numbers and sizes). Demonstration of intrafollicular structures (Cumulus oöphorus, Corpus luteum). Demonstration of cyclic uterine endometrial changes. Most of the results were first obtained with high-resolution compound scanners, but the new generation of real-time scanners are equally capable. Sector scanners are superior to linear-array-parallel scanners, especially for the demonstration of specific structural ch

Ultrasound measurement of ovarian follicles stimulated by human gonadotropins for oocyte recovery and in vitro fertilization

Ultrasonic monitoring of ovarian follicles and estimation of serum estradiol (E2) were performed in 51 patients in whom oocyte aspiration for in vitro fertilization was planned. All patients received human menopausal gonadotropin and human chorionic gonadotropin. The daily growth rates of ovarian follicles were recorded ultrasonically for 6 days prior to aspiration. Serum plasma E2 was determined daily during the same period. Follicular dimensions based on the volume of aspirated fluid correlated very well with the ultrasonic measurements. Follicular growth was correlated with increasing peripheral blood E2 levels. The mean follicular diameter increased from 10.8 mm 6 days before aspiration to a maximum of 16.0 mm on the day of presumptive ovulation in a group of patients characterized as low E2 responders. In normal and high E2 responders, the values were from 9.7 mm and 10.5 mm to 16.9 mm and 17.6 mm, respectively. The mean sizes of the follicles by ultrasound 20 hours before laparoscopy were 16.0 mm for the right ovary, 16.6 mm for the left ovary, and 18.5 mm in patients with only one ovary. At laparoscopy the mean diameters calculated from the volume of the aspirated fluids were 17.5 mm, 17.4 mm, and 19.3 mm, respectively. Multiple follicles developed in all but 2 of the 51 patients.

Combined screening laparoscopy and timed follicle aspiration for human in vitro fertilization

Twenty-seven patients underwent ultrasonographic and clinical monitoring of a spontaneous cycle so that human chorionic gonadotropin administration could be timed in an attempt to schedule the screening laparoscopy at the optimal time for oocyte aspiration. Inadequate ovarian access was encountered in only 2 of 26 laparoscopies. Seven patients had ovulated by the time of scheduled laparoscopy. Nine mature, seven immature, and three postovulatory oocytes were obtained, and seven embryo transfers were accomplished. The number of eggs obtained per laparoscopy was 0.73. The attempt to control the time of ovulation was unpredictable, few mature oocytes were obtained, and the procedure offered little ultimate benefit to the patient.