Correlation of ultrasonic and endocrinologic measurements in human menopausal gonadotropin therapy

A follicular scoring system for monitoring ovulation induction in polycystic ovary syndrome patients based solely on ultrasonographic estimation of follicular development

OBJECTIVE

To assess the predictive value of a follicular scoring system for monitoring ovulation induction in polycystic ovary syndrome (PCOS) patients, solely with ultrasound (US).

DESIGN

Ultrasound measurements were performed on alternate days to define a serial follicular score for monitoring ovulation induction with hMG alone, as well as GnRH analogue and hMG, in comparison with E2 concentration obtained on the same day.

SETTING

Outpatient Infertility Clinic, Department of Obstetrics and Gynecology.

PATIENTS

Thirty-four consecutive PCOS patients treated for 63 cycles.

MAIN OUTCOME MEASURE

The follicular score was established considering the summation of points obtained after measuring the mean diameter of each follicle > 5 mm, as follows: 5 to 8 mm = 1 point, 9 to 12 mm = 1.5 points, 13 to 16 mm = 2 points, > or = 17 mm = 3 points.

RESULTS

Follicular score correlated positively with E2 concentrations. A score of > or = 30 points was associated with E2 levels of concentration that reached > 1,500 pg/mL (conversion factor to SI unit, 3.671) and could predict ovarian hyperstimulation. A lower follicular score allowed hCG administration.

CONCLUSIONS

A follicular scoring system may be a safe, simple, and highly efficient method to replace serial E2 measurements in monitoring ovulation induction. Moreover, ovarian hyperstimulation may be predicted.

Differential c-jun gene expression with tonically administered steroids in rat ovary and uterus

OBJECTIVE

The purpose of this study was to evaluate the induction of the early regulatory gene c-jun in response to tonic exposure to estradiol and progesterone in rat ovary, uterus, and adrenal tissues.

STUDY DESIGN

Pellets containing estradiol-17 beta, progesterone, and estradiol-17 beta plus progesterone were placed subcutaneously in immature female Sprague-Dawley rats (N = 24). The ovary, uterus, and the adrenal were evaluated for c-jun expression by Northern analysis at 24 and 48 hours.

RESULTS

The c-jun messenger ribonucleic acid expression in the ovary and adrenal gland was inhibited with high, nonphysiologic doses of estradiol in progesterone and was induced with physiologic levels of estradiol. Physiologic levels of progesterone do not appear to influence the expression of c-jun in the ovary or adrenal gland. Uterine c-jun expression to estradiol and progesterone is generally the opposite of that observed in the ovary.

CONCLUSION

These findings suggest that there is both tissue and dose specificity of c-jun gene expression in steroidogenic and steroid-responsive tissues when steroid hormones are tonically administered.

Calculation of plasma estradiol levels by analysis of number and size of follicles measured by ultrasound

OBJECTIVE

To determine the possibility of immediate estimation of plasma estradiol (E2) levels in stimulated ovarian cycles using a multiple regression equation (MRE) based on the analysis of the number and size of ovarian follicles measured by pelvic ultrasound.

METHOD

E2 levels were measured by enzyme immunoassay (EIA) in 47 patients on the day of induction of ovulation with human chorionic gonadotropin (hCG). MRE was employed to calculate E2 levels after analysis of the number of follicles present, divided into three groups according to their greatest ultrasonic diameters A (10-14 mm), B (15-16 mm) and C (> or = 17 mm). The follicular lots were analyzed retrospectively and a MRE was determined. In a later prospective study, plasma E2 levels were measured by EIA and MRE in 36 patients on the day of induction of ovulation with hCG.

RESULTS

The following MRE was obtained for plasma E2 levels as a function of follicular diameter: MRE of E2 (pg/ml) = 556 + 95 A + 98 B + 108 C. In the prospective study, the correlation coefficient for the measurements of E2 levels by the two methods (EIA versus MRE) was 0.70.

CONCLUSION

The use of MRE based on the analysis of number and size of ovarian follicles measured by ultrasound permits a relatively precise indirect estimate of plasma E2 levels in stimulated ovarian cycles.

The value of transabdominal pelvic ultrasonography in monitoring of ovulation induction with gonadotropins

Seventy-five patients with a total of 306 human menopausal gonadotropin treatment cycles over the period 1984-1989 were analysed retrospectively to evaluate the value of transabdominal pelvic ultrasonography in prevention of complications arising from ovulation induction with human menopausal gonadotropins. There were 60 pregnancies giving a pregnancy rate of 19.6% per cycle. There was positive correlation between the number of follicles > or = 14 mm in mean diameter and the incidence and degree of hyperstimulation (p < 0.005) as well as the incidence of multiple pregnancies (p < 0.01). Ultrasonography is a useful adjunct for monitoring in such a program.

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)

The accuracy of urinary luteinizing hormone testing in predicting ovulation

Transvaginal ultrasonography and daily urinary luteinizing hormone testing were used to evaluate the accuracy of urinary luteinizing hormone testing in predicting ovulation in 33 spontaneously ovulating women beginning on cycle day 10. Ovulation was confirmed in all patients with luteal phase progesterone levels and endometrial biopsy specimens. The results demonstrated that transvaginal ultrasonography and urinary luteinizing hormone testing detected ovulation in all cycles. However, the onset of urinary luteinizing hormone occurred after follicle rupture was documented by ultrasonography in 9% of the women studied. Thus the question of accuracy of urinary luteinizing hormone testing in prediction contrasted to detection of ovulation is raised. This observation is of importance in patients in whom prediction of ovulation is critical to treatment management. Therefore, an ultrasonographic examination to confirm the presence of an unruptured follicle on the day of onset of urinary luteinizing hormone surge is recommended, particularly in patients failing to conceive after three to six cycles of artificial insemination when the inseminations are timed with the onset of urinary luteinizing hormone surge.

Factors affecting fetal loss in induction of ovulation with gonadotropins: increased abortion rates related to hormonal profiles in conceptual cycles

Thirty-six first-trimester abortions (9.7%), 16 second-trimester abortions (4.3%), 11 ectopic pregnancies (2.9%), and 10 stillbirths (2.7%) occurred in 373 conceptual cycles after gonadotropin induction of ovulation. Fetal wastage was higher in spontaneous pregnancies that occurred before therapy (54.3%, p less than 0.0001) and lower with subsequent spontaneous pregnancies (10.1%, p less than 0.05). Significant risk factors for overall fetal loss during induced ovulation were a continuous rise of estrogen excretion until ovulation (p less than 0.01) and previous abortion (p less than 0.05). For first-trimester abortion, the risk factor was continuous estrogen rise (p less than 0.01); for second-trimester abortion, the risk factors were a low luteal pregnanediol-to-estrogen excretion ratio (p less than 0.002), increased age at conception (p less than 0.02), and high baseline estrogen excretion (p less than 0.05). Multiple pregnancy was not significant. The continuous rising estrogen pattern may serve as a marker of abnormal oocyte maturation. We propose that future studies on infertility treatment should report on pregnancy outcome.

Improved pregnancy rate with monitoring of gonadotropin therapy by three modalities

The frequency of complications during gonadotropin therapy was reduced after the introduction of rapid estrogen assays. However, pregnancy rates remained low especially in normoestrogenic women. One hundred forty-three infertile normoestrogenic women were treated with human menopausal gonadotropin-human chorionic gonadotropin for 661 cycles. Almost all cycles were ovulatory. Whereas 53.7% of the patients conceived when drug administration was monitored by cervical score and serum estradiol levels only, 72.1% became pregnant when treatment was monitored by these modalities and real-time ultrasonography of the ovaries (p less than 0.05). Mean serum estradiol levels were significantly higher when ultrasonography was used to monitor response, but complications such as multiple births and ovarian enlargement did not occur more often. The data suggest that "true" ovulation occurs more often when ovarian imaging is used to determine drug dosage. Because of the higher pregnancy rate achieved by combined clinical (cervical score), biochemical (serum estradiol), and sonographic methods of monitoring, this approach should replace less extensive techniques.

The effect of pregnant mare serum gonadotropin on mouse embryos fertilized in vivo or in vitro

The effect of increasing doses of exogenous gonadotropin stimulation for ovarian hyperstimulation was studied utilizing mouse embryos fertilized in vivo or in vitro. Increased rates of embryo degeneration, fragmentation, and triploidy, increased sister-chomatid exchange, and decreased fertilization rates were observed in high-dose stimulation groups. It appears, therefore, that oocyte and/or embryo quality may be affected by increased amounts of exogenous gonadotropin stimulation.

Urinary oestrogen levels and follicle ultrasound measurements in clomiphene induced cycles with an endogenous luteinizing hormone surge

Total oestrogen in urine and the ultrasonic size of the follicles were measured in relation to the onset of the endogenous luteinizing hormone (LH) surge (day 0) in 18 cycles induced with clomiphene citrate in an in-vitro fertilization programme. Oestrogen values in urine (microgram/24 h) increased progressively during the late follicular phase up to the day of the onset of the surge. The mean maximum follicle diameter (22.3, SD 4.7 mm) estimated by ultrasound was measured on day 0. At the onset of the LH surge, the values of urinary total oestrogen showed a better relation with the total volume of the first three follicles in order estimated by ultrasound (r = 0.71) than with the mean ultrasonic diameter of the leading follicle (r = 0.56). A wide range of individual values for both urinary oestrogen and follicle size was found. In another group of 32 women treated with clomiphene for recovery of oocytes used for research purposes, a good correlation was found between the mean ultrasonic follicle diameter 16 h before the laparoscopy and the follicle diameter calculated from the fluid volume at aspiration (r = 0.80). These results suggest that the decision when to give human chorionic gonadotrophin (hCG) in an in-vitro fertilization programme remains arbitrary in many individual cases. Apart from the oestrogen levels, the calculation of the size of all follicles, instead of only the leading one, may give further help in timing the hCG.

Variability of ovarian follicular growth in natural menstrual cycles

Variation of ovarian follicular growth has been found to be too great for conventional statistical methods to provide valuable information when this growth has been related to menstrual age or peak volume day. A method that relates follicular growth to its start (follicular growth age) is presented. With the use of this dating method, variability of follicular growth was found to be within limits that could be handled by simple methods. Follicular volume growth followed a sigmoid-shaped curve and was well described by our growth equation.

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 use of ovarian ultrasonography in monitoring ovulation induction

Ovarian ultrasonography is a new diagnostic technique which has become almost essential in monitoring ovulation. Recent improvements in ultrasound technology have allowed for accurate assessment of the number and size of the developing follicles and their rate of growth, as well as ovulation and postovulatory events. In the nonstimulated cycle follicular size correlates well with optimal maturation and there is a linear correlation between follicular diameter and plasma estradiol (E2 levels). In stimulated cycles, because of asynchrony of various recruited cohorts of follicles, these rules are not as steadfast. These observations indicate that when there is endogenous gonadotropic activity, follicular growth stimulated by human menopausal gonadotropins (hMG) does not develop synchronously. The aim should be, therefore, not only to improve the monitoring system but mainly to synchronize the cohorts of follicles recruited for development in any one cycle by a better regimen for ovulation induction. In view of the high success rate of hMG treatment in patients without endogenous gonadotropin secretion, it is tempting to speculate that inducing similar conditions in women with endogenous gonadotropin production may have a significant change in the pattern of follicular development in their conception rate.

Inherent sources of ultrasound variability in relation to follicular measurements

Determination of ovarian follicular size and number by real-time ultrasound lacks the precision that has been ascribed to it. Four major error sources inherent in the scanning and interpreting process were analyzed to determine the relative contributions to overall variation. The sources measured were machine, sonographer, sonologist, and patient bladder volume. A protocol using a normal clomiphene-stimulated woman allowed the determination of the coefficient of variance for both follicular number and follicular diameter as well as a mean diameter range in each of the categories. A large degree of variation was found in all groups. Surprisingly, it was noted that maximal bladder filling did not produce optimal images. We believe that while variability in ultrasound can be recognized and lessened, it cannot be eliminated. Thus, caution must be used when ultrasound follicular comparisons are made within each program from day to day and particularly between institutions. A liberal range should be allowed for optimal follicle sizes for any given stimulation protocol.

Hormonal and ultrasonic characteristics of 23 clomiphene citrate stimulated cycles resulting in pregnancies after in vitro fertilization and embryo transfer

In vitro fertilization (IVF) and embryo transfer (ET) were successful in 24 clomiphene citrate stimulated cycles in 22 patients. Ovarian follicular growth was monitored by ultrasound (US) and serum estradiol (E2) concentrations in order to determine the most favorable time for the induction of ovulation by administration of human chorionic gonadotropin (hCG). The day of the hCG injection was considered day 0. After an almost linear growth the mean diameter of the dominant follicle reached 19.3 +/- 2 mm on day 0. Serum E2 concentrations also increased in almost linear fashion up to a maximum of 1,037 +/- 322 pg/ml on day +1. On day 0 the mean serum E2 concentration was 862 +/- 279 pg/ml. A mean serum E2 concentration per dominant and codominant follicle of 328 +/- 100 pg/ml was found on day 0. There was no linear correlation between the follicular diameters and the serum E2-values on the same day. The time of ovum recovery was often different to the time at which ovulation would have been expected in a normal cycle.

Clinical applications of techniques used in human in vitro fertilization research

Human in vitro fertilization-embryo transfer not only provides an opportunity for pregnancy in women who were previously considered to be sterile, but also provides a unique method by means of which basic reproductive physiology can be investigated. From September, 1981, to September, 1982, 71 women with normal cycles who elected to attempt in vitro fertilization-embryo transfer underwent timed laparoscopy for recovery of oocytes. Oocytes were recovered in 60 patients, with embryo transfer resulting in 50 patients, and normal implantation occurred in nine patients. There was a significant correlation between ultrasound observation of follicle size and serum estradiol levels, thus making ultrasound monitoring of follicular growth during stimulation with clomiphene citrate or human menopausal gonadotropin in anovulatory women clinically useful. The technique of sperm washing employed for in vitro fertilization has now been used with good results for intrauterine insemination in patients with infertility due to a cervical factor or oligospermia. Therefore, the techniques used in human in vitro fertilization-embryo transfer are now clinically applicable for couples with infertility due to causes other than tubal disease.