Measurement of perifollicular blood flow of the dominant preovulatory follicle using three-dimensional power Doppler

The effect of melatonin on ultrasound markers of follicular development: A double-blind placebo-controlled randomised trial

BACKGROUND

Melatonin is a potent oxygen scavenger and is capable of altering blood flow in various vascular beds.

AIMS

We aimed to determine the effect of melatonin on ovarian vascular indices during ovarian stimulation for in vitro fertilisation (IVF).

MATERIALS AND METHODS

This is a pilot double-blind placebo-controlled randomised trial. Sixty-nine women (mean age 35.8 ± 4.3 years) undergoing their first cycle of IVF were randomised to receive either placebo, 2, 4 or 8 mg of melatonin, twice a day. Each participant underwent a transvaginal ultrasound at days 6-10 assessing follicular number and size. The vascularisation index (VI), flow index (FI) and vascularisation-flow index (VFI) were measured. These indices were then correlated with embryological outcomes. Informed consent was obtained from participants. This trial was registered with the Australia New Zealand Clinical Trials Registry (ACTRN12613001317785).

RESULTS

The number of follicles did not differ between groups (P = 0.4). There were no differences in the VI (P = 0.4), FI (P = 0.1) or VFI (P = 0.3) in the right ovary or the FI (P = 0.3) or VFI (P = 0.3) in the left ovary between groups. When comparing placebo to any dose of melatonin, there were no differences in any measured parameter. While there was correlation between the number of follicles on ultrasound and all measured embryological outcomes, there was no correlation between ovarian vascular indices and these important clinical outcomes.

CONCLUSIONS

Melatonin does not appear to change ovarian vascular indices during ovarian stimulation. In addition, such vascular indices cannot predict the number or quality of oocytes or embryos obtained in an IVF cycle. These findings require confirmation in future larger studies.

From a circle to a sphere: the ultrasound imaging of ovarian follicle with 2D and 3D technology

Ultrasound follicular count (antral follicle count, AFC) is a necessary tool for measuring ovarian reserve, whereby the estimated number of follicles responsive to FSH can predict the number of oocytes retrieved in IVF cycles and may be the basis for individualized ovarian stimulation therapy. Advances in the ultrasound technology have recently lead to the improvement in resolution and quality of the image. Moreover the automatic measurements of follicular diameter by using some specific 3D software seems associated to several advantages when compared to the 2D technique. Examination time is reduced because the ultrasound scan data are stored and can be analyzed in detail at a later time. These data can be reconstructed in any plane, regardless of the original scan plane facilitating the detailed analysis. Another advantage is that this new technique reduces the operator's influence on scan interpretation and objectivity; therefore, interobserver variability is reduced. Using follicular volume obtained with sono AVC as the measure of follicular growth combined with volume-based criteria for the hCG triggering may in the future improve the treatment outcome compared to that achieved with conventional monitoring with follicular diameter. Better knowledge in this area could be helpful to optimize IVF outcome, by refining ovarian stimulation protocols and obtain high quality oocytes.

Computerized detection and recognition of follicles in ovarian ultrasound images: a review

Observing changes in females' ovaries is essential in obstetrics and gynaecological imaging, e.g., genetic engineering and human reproduction. It is particularly important to monitor the dynamics of ovarian follicles' growth, as only fully mature and grown follicles, i.e., the dominant follicles have a potential to ovulate at the end of a follicular phase. Gynaecologists follow this process in two dimensions, but recently three-dimensional (3-D) ultrasound examinations are coming to the fore. This paper surveys the existing computer methods for detection, recognition, and analyses of follicles in two-dimensional (2-D) and 3-D ovarian ultrasound recordings. Our study focuses on the efficiency, validation, and assessment of proposed follicle processing algorithms. The most important processing steps were identified in order to compare their performances. Higher ranking solutions are suggested for the so-called best algorithm for 2-D and 3-D ultrasound recordings of ovarian follicles. Finally, some guidelines for future research in this field are discussed, in particular for 3-D ultrasound volumes.

Three-dimensional ultrasound as a predictor of pregnancy in patients undergoing ART

Different ultrasound parameters have been used to assess endometrial receptivity during ART treatment, including endometrial thickness, endometrial pattern, endometrial volume, Doppler of uterine arteries and endometrial blood flow. However, conflicting results have been reported with regard to their role in the prediction of pregnancy in ART treatment. The 3D ultrasound with power Doppler provides a unique tool with which to examine the blood supply of the whole endometrium and subendometrial region. Volume assessment can also be precisely performed by 3D ultrasound. Based on a med-line research and on our experience, the clinical use of 3D ultrasound is discussed in this review article.

SEGMENTATION OF OVARIAN ULTRASOUND IMAGES USING CELLULAR NEURAL NETWORKS

Segmentation of ovarian ultrasound images using cellular neural networks (CNNs) is studied in this paper. The segmentation method consists of five successive steps where the first four uses CNNs. In the first step, only rough position of follicles is determined. In the second step, the results are improved by expansion of detected follicles. In the third step, previously undetected inexpressive follicles are determined, while the fourth step detects the position of ovary. All results are joined in the fifth step. The templates for CNNs were obtained by applying genetic algorithm. The segmentation method has been tested on 50 ovarian ultrasound images. The recognition rate of follicles was around 60% and misidentification rate was around 30%.

Periovulatory follicular volume and vascularization determined by 3D and power Doppler sonography as pregnancy predictors in intrauterine insemination cycles

PURPOSE

To evaluate the relationship between volume and vascularization of the periovulatory follicle and subfollicular area measured by three-dimensional power Doppler ultrasound (US), and ovulation and pregnancy in patients undergoing intrauterine insemination (IUI).

METHODS

We studied 79 consecutive cycles of IUI on hCG administration day. We measured the periovulatory follicle and subfollicular area by means of three-dimensional power Doppler US. The stored volumes were processed with the VOCAL image processing software to calculate the volume of the follicle and the following vascular indices: vascularization index (VI), flow index (FI), and vascularization flow index (VFI).

RESULTS

The follicular volume was higher in anovulatory cycles (7.7 ± 3.7 cubic centimeters (CC) versus 4.1 ± 2.0 CC; p < 0.001). There was no difference between the follicular volumes in cycles with or without subsequent pregnancy. The vascular indices of the follicle did not differ significantly between ovulatory and anovulatory cycles, and between cycles that did and did not achieve pregnancy. Periovulatory subfollicular VI and VFI were lower in women who became pregnant (VI: 2.9 ± 2.3% versus 5.6 ± 4.6%; p < 0.05, and VFI: 1.1 ± 0.8 versus 2.2 ± 2.2; p < 0.01).

CONCLUSIONS

High values of follicular volume were associated with anovulatory cycles. Subfollicular VI and VFI might be used as markers of follicular quality and pregnancy predictors.

Pre-hCG 3D and 3D power Doppler assessment of the follicle for improving pregnancy rates in intrauterine insemination cycles

BACKGROUND

The assessment of follicular maturity at the time of human chorionic gonadotropin (hCG) is one of the key factors for the success of all assisted reproductive techniques.

AIM

To assess follicles by three dimensional (3D) and 3D power Doppler (PD) before giving hCG to improve pregnancy rates in intrauterine insemination (IUI) cycles.

DESIGN

Prospective randomized study.

MATERIALS AND METHODS

Ultrasound for pre-hCG follicular assessment was performed over a period of 10 months for all 1000 cycles of IUI. Follicular assessment was performed using a transvaginal multifrequency volume probe. Follicles considered mature by 2D US and color Doppler were assessed by 3D and 3D PD. These values were independently evaluated for the conception and the non-conception groups.

RESULTS

Conception rates were 32.3 and 27% respectively and individually when the perifollicular resistance index was < 0.50 and the peak systolic velocity was > 11 cm/s 10-12 h before hCG. Conception rates of 32% were achieved with a follicular volume between 3 and 7 cc. The conception rate was 32.3% in the cumulus group. A perifollicular vascularity index of between six and 20 gave conception rates of 35% and perifollicular flow index of 27-43 gave conception rates of 33%.

CONCLUSIONS

3D ultrasound is much more accurate for volume assessment of the follicle. Presence of cumulus increases the surety of the presence of a mature ovum in the follicle. 3D and 3D PD when used with 2D US and color Doppler for pre-hCG follicular assessment would definitely improve pregnancy rates in IUI cycles.

Three and four-dimensional ultrasound in obstetrics and gynecology

PURPOSE OF REVIEW

Developments in ultrasound in general, but even more so in three-dimensional ultrasound, parallel the growth in computing power and speed of computer technology. It is not surprising, therefore, that three-dimensional ultrasound technology is constantly evolving at a fast pace. The purpose of this article is to provide enhanced diagnostic capabilities for the obstetrical and gynecologic provider.

RECENT FINDINGS

The most recent advances in three-dimensional ultrasound have to do with two main features. First, an increasingly fast acquisition speed, enabling quick sequences of fast moving organs such as the heart to be captured. Second, the increasing number of different display modalities, making understanding and analysis of normal anatomy and pathology easier for clinicians.

SUMMARY

This article highlights a selected number of clinical situations in which three-dimensional ultrasound meaningfully enhances the contribution of this fast evolving diagnostic imaging tool.

Embryo transfer and luteal support in natural cycles

Embryo transfer policy and luteal supplementation was reviewed, comparing literature data and the results from the Maribor IVF Centre. A retrospective analysis of 1024 cycles in patients undergoing IVF, intracytoplasmic sperm injection (ICSI) or testicular sperm aspiration in unstimulated cycles was carried out using four different approaches for cycle monitoring. This showed that the most successful protocol for monitoring was administration of human chorionic gonadotrophin (HCG) when serum oestradiol was >0.49 nmol/l and follicle diameter was at least 15 mm. The implantation rate per transferred embryo was higher when a blastocyst was transferred (42.8%) rather than a day-2 embryo (23.5%) in the same monitoring protocol. Analysis of the influence of patient age on the success of oocyte retrieval, oocyte fertilization, embryo transfer rate and delivery rate demonstrates that patient age does not influence the rate of positive oocyte retrieval or fertilization rate as much as it influences pregnancy rate per embryo transfer. The delivery rate per cycle was dramatically influenced by age in patients over 38 years. There is no clear evidence in the literature as to whether luteal phase support is necessary in natural cycles for IVF/ICSI. Comparing the data, a higher pregnancy rate was observed if HCG was administered after embryo transfer.

Assessment of changes in volume and vascularity of the ovaries during the normal menstrual cycle using three-dimensional power Doppler ultrasound

BACKGROUND

Our aim was to describe changes in the volume and vascularization of both ovaries, the dominant follicle and the corpus luteum during the normal menstrual cycle using three-dimensional (3D) power Doppler ultrasound.

METHODS

Fourteen healthy volunteers underwent serial transvaginal 3D ultrasound examinations of both ovaries on cycle day 2, 3 or 4, then daily from cycle day 9 until follicular rupture and 1, 2, 5, 7 and 12 days after follicular rupture. The volume and vascular indices of the ovaries, the dominant follicle and the corpus luteum were calculated off-line using virtual organ computer-aided analysis (VOCAL) software.

RESULTS

The volume of the dominant ovary increased during the follicular phase, decreased after follicular rupture and then increased again during the luteal phase. Vascular indices in the dominant ovary and the dominant follicle/corpus luteum increased during the follicular phase, the vascular flow index (VFI) in the dominant follicle being on average (median) 1.7 times higher on the day before ovulation than 4 days before ovulation (P=0.003). The vascular indices continued to rise after follicular rupture so that VFI in the corpus luteum was on average (median) 3.1 times higher 7 days after ovulation than in the follicle on the day before ovulation (P=0.0002). The volume and vascular indices in the non-dominant ovary manifested no unequivocal changes during the menstrual cycle.

CONCLUSIONS

Substantial changes occur in volume and vascularization of the dominant ovary during the normal menstrual cycle. 3D power Doppler ultrasound may become a useful tool for assessing pathological changes in the ovaries, for example, in subfertile patients.

Assessment of the ovarian volume, number and volume of follicles and ovarian vascularity by three-dimensional ultrasonography and power Doppler angiography on the HCG day to predict the outcome in IVF/ICSI cycles

OBJECTIVE

The aim of this prospective study was to investigate whether ovarian blood flow is related to embryological parameters and whether it could be a predictor of outcomes of IVF/ICSI.

METHODS

Eighty infertile women underwent ovarian stimulation with gonadotrophins after a long protocol with GnRH agonists. The ovarian volume (OV), number of follicles (NF) and follicular volume (FV) of all follicles >10 mm and vascularization index (VI), flow index (FI) and vascularization-flow index (VFI) were obtained by three-dimensional (3D) ultrasonography and power Doppler angiography (PDA) on the day of HCG administration. These parameters were tested for their relation with IVF laboratory parameters.

RESULTS

The OV, FV, VI, FI and VFI were significantly greater in the pregnant group. The NF and FV were the only independent predictors of the number of oocytes retrieved, mature and fertilized, and the number of embryos developed and their cumulative embryo score. Nevertheless, the number of grade 1 embryos depends on the NF and the VI. The ovarian FI and the number of transferred grade 1 embryos can predict gestation in 76% of IVF patients. A low FI and non-grade 1 embryo transferred are also associated with an increased pregnancy loss.

CONCLUSION

3D ultrasonography and PDA allow for an easier ovarian assessment in IVF cycles. The predictive value of IVF outcome suggests a high clinical usefulness of this new technique.

The effect of HMG and recombinant human FSH on oocyte quality: a randomized single-blind clinical trial

OBJECTIVE

To compare the effect of HMG and rhFSH on oocyte quality in ICSI cycle.

SETTING

Vali-e-Asr university teaching hospital.

METHOD

Prospective single-blind randomized clinical trial.

SUBJECTS

Sixty women undergoing ovarian stimulation for ICSI were randomized to receive a standard protocol of either HMG or rhFSH in down-regulation cycles.

INTERVENTIONS

Prior to microinjection, each oocyte was assessed regarding the nuclear maturity, morphology of zona plucida, cytoplasmic appearance and polar body morphology. Fertilization rate was followed.

MAIN OUTCOME

The percentage of metaphase II oocytes in HMG and rhFSH groups.

STATISTICAL ANALYSIS

Statistical analyses were carried out by the Mann-Whitney, Fisher's exact, chi2 tests and Student's t-test.

RESULTS

No significant differences were found between two groups in regard to the demographic data, the ovarian response and pregnancy/implantation rates (P>0.05). The percentage of metaphase II oocytes in HMG and rhFSH groups were 81.3% versus 80.6%, respectively.

CONCLUSIONS

There were no significant differences between parameters such as, oocyte quality and percentage of metaphase II oocytes between these two groups.

Recent advances in the sonographic assessment of vascularity and blood flow in gynecologic conditions

OBJECTIVE

This overview presents recent advances in sonographic depiction of vascularity and blood flow in the uterus, ovaries, and breasts. Enhanced sonographic visualization and evaluation of intraorgan vascularity has resulted from improved image processing and display. Future advances, such as the use of contrast enhancement, are also mentioned in this overview as one of many topics for future investigation.

STUDY DESIGN

This is an overview of the topic based on review of the literature and the authors' experience.

RESULTS

Specifically, the sensitivity of color Doppler sonography has been enhanced with the use of amplitude or power Doppler techniques. Spatial depiction of vascularity has improved because of 3-dimensional and "live 3-dimensional" processing.

CONCLUSION

The combination of more sensitive color Doppler sonography and 3-dimensional imaging provides both anatomic and physiologic assessment of the vascularity and blood flow of the ovary, uterus, and breast.