Transvaginal three-dimensional ultrasound: reproducibility of ovarian and endometrial volume measurements

Reliability and Agreement of Ultrasonographic Measures of the Ovarian Stroma: Impact of Methodology

OBJECTIVES

Increased ovarian stromal area (SA), stromal-to-ovarian area ratio (S/A), and echogenicity (SEcho) on ultrasonography have been proposed as diagnostic markers for polycystic ovary syndrome. Although several methods to evaluate the stroma exist, their reproducibility has not been defined which limits clinical utility. This study aimed to determine the interrater reliability and agreement of methods to evaluate SA, S/A, and SEcho.

METHODS

Five raters tested 3 methods to obtain SA and S/A, and one to obtain SEcho on 30 ovarian cineloops under two imaging conditions, simulating real-time (free-choice) or offline (fixed-frame) imaging. For SA, Method 1 subtracted follicular area from the ovarian area, Method 2 involved outlining the periphery of the stroma, and Method 3 represented a hybrid approach in which central follicles were subtracted from the outlined stroma. SEcho was scored on a subjective 3-tiered scale. Intraclass correlation coefficients (ICCs) and the coefficient of variation were determined for SA and S/A, and Fleiss' kappa agreement statistics (κ) were determined for SEcho.

RESULTS

Interrater reliability of SA was superior using Method 1 (ICC = 0.558 and ICC = 0.705) versus Method 2 (ICC = 0.522 and ICC = 0.230) or Method 3 (ICC = 0.429 and ICC = 0.305) under free-choice and fixed-frame imaging conditions, respectively. Interrater reliability of S/A was also moderate to poor across methods. SEcho was also not reliably assessed across raters (κ = <0.500).

CONCLUSIONS

Ultrasonographic assessments of the ovarian stroma were associated with moderate to poor reproducibility. Indirect estimates of the ovarian stroma (Method 1) could be optimized to yield a reproducible approach, clarifying the clinical relevance of the stroma.

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.

Recommendation Patterns among Gynaecologists and Radiologists for Adnexal Masses on Ultrasound

OBJECTIVE

Ultrasound is the primary modality used to evaluate adnexal lesions. Follow-up recommendations for ovarian cysts remain controversial between gynaecologists and radiologists. The objective of this study was to compare practice patterns for adnexal masses described on ultrasound on the basis of the interpreter's field of specialty.

METHODS

This study was conducted within the McGill University Hospital Network at two hospitals that differ in the department of interpretation of pelvic ultrasounds. In one hospital, all studies are reported by gynaecologists, and in the other, by radiologists. The study investigators collected data from pelvic ultrasounds of newly diagnosed ovarian lesions performed from May to June 2014. Multivariate logistic regression analyses were used to compare recommendation patterns between the two groups.

RESULTS

A total of 201 of 1110 pelvic ultrasound studies performed met our inclusion criteria. Gynaecologists interpreted 69 (34%) pelvic ultrasounds, and radiologists reported on 132 (66%). Reported adnexal mass types were not significantly different between the two groups. As compared with gynaecologists, radiologists were more likely to recommend MRI or CT scans (OR 11.76; 95% CI 1.17-117.78), as well as follow-up ultrasound studies (OR 4.67; 95% CI 1.66-13.1), and they were less likely to recommend no further imaging (OR 0.18; 95% CI 0.07-0.45). Groups did not differ in recommendation patterns for referral to a specialist.

CONCLUSION

There are significant differences in recommendation patterns between gynaecologists and radiologists in evaluating new adnexal masses on ultrasound. This difference can have important effects on resource use and patients' concerns.

3D and 4D studies from human reproduction to perinatal medicine

Three-dimensional ultrasound (3D US) is a modality of choice for prenatal diagnosis of congenital malformations. But 3D-four-dimensional US(4D US) is of utmost importance also to achieve pregnancy. 3D US plays an important role for diagnosis of PCO, to assess ovarian reserve and response and thus to decide optimum stimulation protocols. It adds to the information on follicular maturity and endometrial receptivity, thus improving the chances to achieve pregnancy for patients under treatment for fertility. 3D hystero-contrast-salpingography (HyCoSy) has also proved itself to be one of the best modalities for assessment of tubal patency. In this article, the role of 3D and 4D US is discussed for the following. I. Pretreatment assessment of the females desiring fertility which includes assessment of uterus and fallopian tubes. II. Monitoring of infertile females undergoing treatment. III. Assessment of very early pregnancy - especially in abnormal locations.

Endometrial Volume Measured by VOCAL Compared to Office Hysteroscopy for Diagnosis of Endometrial Polyps in Premenopausal Women with Abnormal Uterine Bleeding

The aim is to compare hysteroscopy, two-dimensional transvaginal ultrasound (2D TVUS), and three-dimensional (3D) Virtual Organ Computer-aided AnaLysis™ (VOCAL) to detect endometrial polyps (EPs) in premenopausal women with abnormal uterine bleeding (AUB). This prospective study was done at Ain Shams Maternity Hospital, Egypt, from March 5, 2015, to December 30, 2015, enrolling 118 premenopausal women with AUB. 2D TVUS, 3D VOCAL, and hysteroscopy were done. 109 patients reached final analysis. 36 women (33%) were diagnosed with EP by 2D TVUS. 50 (45.9%) had EP by hysteroscopy. Endometrial thickness was 10.1 mm by 2D TVUS and endometrial volume was 4.92 mL by VOCAL in women with EP by hysteroscopy compared to 9.9 mm and 3.50 mL in women with no EP, respectively (P = 0.223; P = 0.06). 2D TVUS has sensitivity, specificity, and positive and negative predictive values of 54%, 84.7%, 75%, and 68.5%, respectively. Endometrial thickness of >7.5 mm has sensitivity, specificity, positive and negative predictive values, and overall accuracy of 82%, 37.3%, 52.6%, 71%, and 57.8%, respectively. Endometrial volume of >1.2 mL has sensitivity, specificity, positive and negative predictive values, and overall accuracy of 90%, 42.4%, 57%, 83.3%, and 64.2%, respectively. 3D VOCAL may be used as a noninvasive method for the diagnosis of EP in premenopausal women with AUB.

Comparative analysis of 2-D versus 3-D ultrasound estimation of the fetal adrenal gland volume and prediction of preterm birth

OBJECTIVE

We aim to test the hypothesis that two-dimensional (2-D) fetal adrenal gland volume (AGV) measurements offer similar volume estimates as volume calculations based on 3-D technique.

METHODS

Fetal AGV was estimated by three-dimensional (3-D) ultrasound (VOCAL) in 93 women with signs/symptoms of preterm labor and 73 controls. Fetal AGV was calculated using an ellipsoid formula derived from 2-D measurements of the same blocks (0.523 × length × width × depth). Comparisons were performed by intraclass correlation coefficient (ICC), coefficient of repeatability, and Bland-Altman method. The corrected AGV (cAGV; AGV/fetal weight) was calculated for both methods and compared for prediction of preterm birth (PTB) within 7 days.

RESULTS

Among 168 volumes, there was a significant correlation between 3-D and 2-D methods (ICC = 0.979; 95% confidence interval [CI]: 0.971 to 0.984). The coefficient of repeatability for the 3-D was superior to the 2-D method (intraobserver 3-D: 30.8, 2-D:57.6; interobserver 3-D:12.2, 2-D: 15.6). Based on 2-D calculations, cAGV ≥ 433 mm3/kg was best for prediction of PTB (sensitivity: 75%, 95% CI = 59 to 87; specificity: 89%, 95% CI = 82 to 94). Sensitivity and specificity for the 3-D cAGV (cutoff ≥ 420 mm3/kg) was 85% (95% CI = 70 to 94) and 95% (95% CI = 90 to 98), respectively. In receiver-operating-curve curve analysis, 3-D cAGV was superior to 2-D cAGV for prediction of PTB (z = 1.99, p = 0.047).

CONCLUSION

2-D volume estimation of fetal adrenal gland using ellipsoid formula cannot replace 3-D AGV calculations for prediction of PTB.

Endometrial/uterine corporeal volume ratio (EV/UCV) as predictor of malignancy in women with postmenopausal bleeding

OBJECTIVE

To evaluate the role of endometrial/uterine corporeal volume ratio for the prediction of endometrial malignancy in cases of postmenopausal bleeding.

METHODS

Endometrial volumes and uterine body volumes excluding cervices measured by VOCAL (virtual organ computer-aided analysis) were estimated in 160 women with postmenopausal bleeding. Endometrial/uterine corporeal volume ratios were calculated for all. Endometrial biopsies and histopathological results were obtained for all. One hundred normal postmenopausal women were included as controls.

RESULTS

Histopathological results of the 160 women with postmenopausal bleeding revealed 53 atypia, 27 endometrial cancer and 80 benign conditions. An endometrial/uterine volume (EV/UCV) ratio of a cutoff value >0.017 was predictive of malignancy. Endometrial/uterine volume ratio was more sensitive than endometrial volume and endometrial thickness for prediction of endometrial cancer.

CONCLUSION

An endometrial/uterine volume ratio (EV/UCV) >0.017 is predictive of malignancy. (EV/UCV) was more accurate in the prediction of malignancy than endometrial thickness and endometrial volume.

Three Dimensional Power Doppler evaluation of human endometrium after administration of oxytocine receptor antagonist (OTRa) in an IVF program

PURPOSE

To compare endometrial and subendometrial morphological changes and vascularity as measured by 3D Power Doppler sonography, based on a specific scoring system between women subjected or not to oxytocine receptor antagonist (OTRa) during IVF cycles.

METHODS

Twenty-six women were divided into groups according to OTRa (Atosiban tractocide) administration. The first group (control n = 13 women) was examined with 3D Power Doppler 3 days after embryo transfer. The second group (n = 13 women) was administered 7.5 mg intravenous tractocide 2 days after embryo transfer and a 3D Power Doppler was performed after a day.

RESULTS

The control group presented the following ultrasonographic characteristics: (a) echogenic endometrium in all cases, (b) endometrial thickness >7 mm in all cases (84.6%), (c) endometrial volume >2.31 cm(3) in 5 cases (38.5%), (d) abnormal sub-endometrial halo in 3 cases (23.1%), (e) endometrial blood flow in 6 cases (46.2%) and (f) complex vessel's architecture in 2 cases (15.4%). In women who underwent OTRa administration were observed: (a) echogenic endometrium in 1 case (7.7%), triple line endometrium in 12 cases (92.3%), (b) endometrial thickness >7 mm in all cases, (c) endometrial volume >2.31 cm(3) in 11 cases (84.6%), (d) abnormal sub-endometrial halo in 3 cases (23.1%), (e) endometrial blood flow in 11 cases (84.6%) and (f) complex vessel's architecture in 6 cases (46.2%).

CONCLUSIONS

Women who have taken OTRa presented an endometrium with characteristics more predictive of implantation.

A standardized measurement technique may improve the reliability of measurements of endometrial thickness and volume

OBJECTIVE

To investigate whether standardization of the multiplanar view (SMV) when evaluating the uterus using three-dimensional ultrasonography (3D-US) improves intra- and interobserver reliability and agreement with regard to endometrial measurement.

METHODS

Two-dimensional (2D) and 3D-US was used to measure endometrial thickness by two observers in 30 women undergoing assisted reproduction treatment. Endometrial volume was measured with Virtual Organ Computer-aided AnaLysis (VOCAL(™)) in the longitudinal (A) and coronal (C) planes using an unmodified multiplanar view (UMV) and a standardized multiplanar view (SMV). Measurement reliability was evaluated by intraclass correlation coefficient (ICC) and agreement was examined using Bland-Altman plots with limits of agreement (LoA). The ease of outlining the endometrial-myometrial interface was compared between the A- and C-planes using subjective assessment.

RESULTS

Endometrial volume measurements using the SMV and A-plane were more reliable (intra- and interobserver ICCs, 0.979 and 0.975, respectively) than were measurements of endometrial thickness using 2D-US (intra- and interobserver ICCs, 0.742 and 0.702, respectively) or 3D-US (intra- and interobserver ICCs, 0.890 and 0.784, respectively). The LoAs were narrower for SMV than for UMV. Reliability and agreement were not much different between the A- and C-planes. However the observers agreed that delineating the endometrial-myometrial interface using the A-plane was easier (first and second observer, 50.0 and 46.7%, respectively) or 'comparable' (50 and 53.3%, respectively), but never more difficult than using the C-plane.

CONCLUSIONS

Endometrial volume measurements are more reliable than endometrial thickness measurements and are best performed using SMV and the A-plane.

[Ovarian stimulation monitoring: past, present and perspectives]

Since the inception of Assisted Reproductive Technology (ART), knowing the moment of ovulation has always been a priority. Initially, the monitoring was accomplished by observing the luteinizing hormone (LH) surge just before ovulation. Currently, in all ART facilities, the monitoring of all stimulated ovulatory cycles is done by using the conventional two-dimensional (2D) ultrasound to measure follicle diameter and by drawing blood tests that measure estradiol, progesterone, and luteinizing hormone levels. These exams allow determination of the numbers and quality of growing ovarian follicles and evaluation of follicle maturity before choosing the appropriate time for ovulation triggering. The monitoring of ovulatory cycles has now become enhanced with the arrival of new software called SonoAVC. This software allows the utilization of 3D blocks to immediately calculate the total number and volume of the follicles inside the ovary. This automatic approach is faster, precise, and more efficient. It also has better reproducibility than the classical 2D diameters. Furthermore, certain ART professionals envision that by using the SonoVac technology, patients will no longer need to be monitored with regular ultrasounds and with systematic hormonal testing.

Three-dimensional ultrasound imaging

This review is about the development of three-dimensional (3D) ultrasonic medical imaging, how it works, and where its future lies. It assumes knowledge of two-dimensional (2D) ultrasound, which is covered elsewhere in this issue. The three main ways in which 3D ultrasound may be acquired are described: the mechanically swept 3D probe, the 2D transducer array that can acquire intrinsically 3D data, and the freehand 3D ultrasound. This provides an appreciation of the constraints implicit in each of these approaches together with their strengths and weaknesses. Then some of the techniques that are used for processing the 3D data and the way this can lead to information of clinical value are discussed. A table is provided to show the range of clinical applications reported in the literature. Finally, the discussion relating to the technology and its clinical applications to explain why 3D ultrasound has been relatively slow to be adopted in routine clinics is drawn together and the issues that will govern its development in the future explored.

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.

Assessment of ultrasonographic features of polycystic ovaries is associated with modest levels of inter-observer agreement

Background

There is growing acceptance that polycystic ovaries are an important marker of polycystic ovary syndrome (PCOS) despite significant variability when making the ultrasound diagnosis. To better understand the nature of this variability, we proposed to evaluate the level of inter-observer agreement when identifying and quantifying individual ultrasonographic features of polycystic ovaries.

Methods

Digital recordings of transvaginal ultrasound scans performed in thirty women with PCOS were assessed by four observers with training in Radiology or Reproductive Endocrinology. Observers evaluated the scans for: 1) number of follicles ≥ 2 mm per ovary, 2) largest follicle diameter, 3) ovarian volume, 4) follicle distribution pattern and 5) presence of a corpus luteum (CL). Lin's concordance correlation coefficients and kappa statistics for multiple raters were used to assess inter-observer agreement.

Results

Agreement between observers ranged from 0.08 to 0.63 for follicle counts, 0.27 to 0.88 for largest follicle diameter, 0.63 to 0.86 for ovarian volume, 0.51 to 0.76 for follicle distribution pattern and 0.76 to 0.90 for presence of a CL. Overall, reproductive endocrinologists demonstrated better agreement when evaluating ultrasonographic features of polycystic ovaries compared to radiologists (0.71 versus 0.53; p = 0.04).

Conclusion

Inter-observer agreement for assessing ultrasonographic features of polycystic ovaries was moderate to poor. These findings support the need for standardized training modules to characterize polycystic ovarian morphology on ultrasonography.

Individual ovarian volumes obtained from 2-dimensional and 3-dimensional ultrasound lack precision

Measuring ovarian volume has been suggested as a possible screening test to assess a woman's ovarian reserve. For such a screening tool to be clinically useful, knowledge of its precision and reproducibility is essential. Recent advances in ultrasound scanning techniques allow the measurement of volumes in three dimensions rather than the traditional estimation from two dimensions. Transvaginal 2-dimensional (2D) and 3-dimensional (3D) ultrasound examinations were performed on 49 women attending a tertiary centre for investigation or treatment for subfertility between January and May 2006. Two observers calculated ovarian volume using both 2D (prolate ellipsoid formula) and 3D techniques [virtual organ computer-aided analysis (VOCAL)] with rotation steps of 30 degrees (3D-30). For the four comparisons (inter- and intra-observer; 2D and 3D-30) intraclass coefficients of 0.97 to 0.98, and standard errors ranging from 17% to 14% (for inter-observer 2D and intra-observer 3D, respectively) were obtained. The corresponding coefficients of repeatability ranged from 33% to 28%. These results suggest that measurement of transvaginal ovarian volumes using both 2D and 3D ultrasound is imprecise for individuals. The imprecision is greater for lower ovarian volumes, which may be important in clinical practice. The average of two or more measurements is likely to be more accurate than a single measurement.

Prospective cohort study of three- versus two-dimensional ultrasound for prediction of oocyte maturity

OBJECTIVE

To determine whether three-dimensional follicular ultrasound (3-D) measurements are better predictors of optimal timing of hCG administration than two-dimensional (2-D) images, the current standard.

DESIGN

Prospective, cohort study.

SETTING

Tertiary referral center.

PATIENT(S)

Seventy-six patients undergoing IVF.

INTERVENTION(S)

Seventy-six consecutive patients undergoing serial follicular monitoring during IVF had an additional daily 3-D volume scan of their ovaries once lead follicles had reached 16 mm diameter.

MAIN OUTCOME MEASURE(S)

Number of mature oocytes retrieved.

RESULT(S)

The 2-D follicular diameter measurements predicted 25.4% of the observed variance in the number of mature oocytes retrieved. The 3-D follicular volume measurements were more predictive of outcome, accounting for 29.2% of the observed variance in number of mature oocytes retrieved. Follicles >22 mm diameter and 5 mL volume were associated with fewer mature oocytes reflecting an undesired postmature state. Follicles measuring 11 to 15 mm had a 50% chance of yielding a mature oocyte.

CONCLUSION(S)

Three-dimensional follicular volume measurements have a stronger correlation with the number of mature oocytes retrieved than 2-D measurements. As 3-D technology improves, this parameter may replace 2-D measurements in the optimal timing of hCG before oocyte retrieval.

Volume segmentation and reconstruction from freehand three-dimensional ultrasound data with application to ovarian follicle measurement

This article presents a semi-automatic method for segmentation and reconstruction of freehand three-dimensional (3D) ultrasound data. The method incorporates a number of interesting features within the level-set framework: First, segmentation is carried out using region competition, requiring multiple distinct and competing regions to be encoded within the framework. This region competition uses a simple dot-product based similarity measure to compare intensities within each region. In addition, segmentation and surface reconstruction is performed within the 3D domain to take advantage of the additional spatial information available. This means that the method must interpolate the surface where there are gaps in the data, a feature common to freehand 3D ultrasound reconstruction. Finally, although the level-set method is restricted to a voxel grid, no assumption is made that the data being segmented will conform to this grid and may be segmented in its world-reference position. The volume reconstruction method is demonstrated in vivo for the volume measurement of ovarian follicles. The 3D reconstructions produce a lower error variance than the current clinical measurement based on a mean diameter estimated from two-dimensional (2D) images. However, both the clinical measurement and the semi-automatic method appear to underestimate the true follicular volume.

The pathogenetic enigma of polycystic ovary syndrome

Polycystic ovary syndrome (PCOS) is a complex disease with heterogeneous clinical and anatomical features that were first described in 1721 by Antonio Vallisneri. There is still a lack of consensus regarding the criteria to be used for diagnosis of PCOS. Transvaginal ultrasonography with Doppler studies of the ovarian and pelvic vasculature plays an important role in its diagnosis, but findings must be interpreted in light of the patient's symptoms and laboratory findings.

Endometrial volume as predictor of malignancy in women with postmenopausal bleeding

OBJECTIVE

To assess endometrial volume as a predictor of endometrial malignancy in women with postmenopausal bleeding.

METHODS

Endometrial volume was measured by virtual organ computer-aided analysis in 170 women with postmenopausal bleeding, and histopathologic results of endometrial biopsies were obtained for all. A group of 100 women without postmenopausal bleeding was used for control.

RESULTS

There were 90 cases of benign disease, 53 cases of atypia, and 27 cases of endometrial cancers in the study group. Whereas endometrial thickness was 9.61+/-5.12 mm (range, 5-20 mm) and endometrial volume was 3+/-1.1 mL (range, 1.8-5.4 mL) in women with atypia or cancer, they were 4.87+/-3.43 mm (range, 2-8 mm) and 1.52+/-0.82 (range, 0.6-2.2 mL), respectively, in women with benign disease. In the control group, endometrial volume was 1.15+/-0.14 mL (range, 0.6-1.3 mL). Volume was more sensitive than thickness for predicting malignancy, and a cutoff value of 1.35 mL was found to provide the best sensitivity.

CONCLUSION

An endometrial volume of 1.35 mL or greater may predict malignancy in women with postmenopausal bleeding.

Ovarian volume measurements in mice with high-resolution ultrasonography

OBJECTIVE

The aim of our study was to evaluate the intraobserver and interobserver variability of ovarian volume measurements in mice with high-resolution 2-dimensional ultrasonography (2DUS) and 3-dimensional ultrasonography (3DUS).

METHODS

Ovaries of 10 nude mice were visualized with a small-animal ultrasound scanner and a 40-MHz probe. For each ovary, volume was measured 3 times by 2 independent readers using both 2DUS and 3DUS methods. The 2DUS method used a biplane ellipsoid model. The 3DUS method estimated the volume by integrating 10 to 12 parallel image planes of the ovary after semiautomated outlining of the boundaries. For each type of measurement, intraobserver and interobserver standard error of measurement (SEM) values and minimal detectable volume changes were calculated by analysis of variance.

RESULTS

Two-dimensional ultrasonography showed much poorer reproducibility, with higher absolute intraobserver and interobserver SEM values (0.50 and 0.61 mm3, respectively) than 3DUS (0.20 and 0.35 mm3; P < .01). Relative intraobserver and interobserver SEM values were also much higher for 2DUS (12.20% and 14.88%) than for 3DUS (5.12% and 8.97%; P < .01). The minimal volume changes that could be detected with a 95% confidence level in successive measurements by the same (or different) observers were 33.90% (41.22%) for 2DUS and 14.10% (24.87%) for 3DUS.

CONCLUSIONS

High-resolution 3DUS can provide a reliable tool for noninvasive, longitudinal ovarian volume measurements in mice.

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.

Low endometrial volume may predict early pregnancy loss in women undergoing in vitro fertilization

PURPOSE

To evaluate the role of 3-D US measurement of the endometrium during early IVF-pregnancy and before the appearance of gestational sac in the prediction of pregnancies outcome.

METHODS

60 pregnant women following IVF treatment were included in the study. The women underwent transvaginal 3D US measurements of endometrial volume and thickness on day 15-17 post ET. Patients were followed and classified according to pregnancy outcome into 2 further groups. The group with early pregnancy loss and the group with ongoing pregnancy.

RESULTS

While no differences were observed between those who miscarried and those who did not in gestational age, endometrial thickness or volume, spontaneous early pregnancy loss was significantly higher in patients with endometrial volume <2 mL as compared to those with endometrial volume >2 mL.

CONCLUSIONS

3-D US measurement of endometrial volume of less than 2 mL during early IVF pregnancy and prior to the appearance of gestational sac is a powerful predictor of pregnancy loss.

Ultrasonography as a tool for the prediction of outcome in IVF patients: a comparative meta-analysis of ovarian volume and antral follicle count

OBJECTIVE

To investigate by meta-analysis the predictive capacity of ovarian volume as an ovarian reserve test in comparison to the antral follicle count (AFC).

DESIGN

Meta-analysis.

SETTING

Tertiary fertility center.

PATIENT(S)

Patients undergoing IVF.

INTERVENTION(S)

None.

MAIN OUTCOME MEASURE(S)

Poor ovarian response, nonpregnancy.

RESULT(S)

A total of 10 studies were detected reporting on ovarian volume and 17 studies on AFC. Because of heterogeneity among studies, calculation of one summary point estimate for sensitivity and specificity was not meaningful. However, for both tests, summary receiver operating characteristic curves for the outcome measures poor response and nonpregnancy could be estimated and compared. The AFC performed statistically significantly better than ovarian volume in the prediction of poor response. The overall accuracy for predicting nonpregnancy was poor for both tests. The clinical value in poor response prediction was only evident for the AFC as a considerable number of cases can be identified who will have a high chance of producing a poor response to stimulation. The clinical value for nonpregnancy was virtually absent for both tests.

CONCLUSION(S)

In conclusion, the predictive performance of ovarian volume toward poor response is clearly inferior compared with that of AFC. Therefore, the AFC may be considered the test of first choice when estimating quantitative ovarian reserve before IVF. For the prediction of cases with a very low chance for pregnancy, ovarian reserve testing with the use of ultrasound appears inadequate.

Three-dimensional ultrasound assessment of endometrial receptivity: a review

Three-dimensional ultrasound (3D US) is a new imaging modality, which is being introduced into clinical practice. Although this technique will not probably replace two-dimensional ultrasound, it is being increasingly used. It has been reported that 3D US is a very high reproducible technique. The endometrium has been paid special attention when using this technique. The aim of this paper is to address some technical aspects of 3D US and to review critically its current status in evaluating endometrial function with special focus in its role in predicting pregnancy in assisted reproductive techniques. In spontaneous cycles endometrial volume grows during follicular phase remaining constant through the luteal phase. Endometrial vascularization increases during follicular phase peaking 2-3 days before ovulation, decreasing thereafter and increasing again during mid and late luteal phase. Data from studies analysing the role of 3D US for predicting IVF outcome are controversial. An explanation for these controversial findings might be different design of reported studies, specially the timing of ultrasound evaluation.

Pituitary-ovarian response to the gonadotrophin-releasing hormone-agonist test in anovulatory patients with polycystic ovary syndrome: predictive role of ovarian stroma

OBJECTIVE

To evaluate the influence of ovarian stroma on basal and poststimulus androgen secretion in patients affected by secondary amenorrhoea and polycystic ovaries (PCO) at ultrasound (US).

DESIGN

Prospective study.

PATIENTS

Fifty-one patients with PCO selected from a group of 72 normal weight women aged 20-25 years affected by secondary amenorrhoea and 10 normal ovulatory controls.

METHODS

All subjects underwent US to evaluate volume, area, stromal area and stromal/total area ratio of both ovaries. Plasma levels of gonadotrophins, oestradiol (E2) and androgens were measured before and 24 h after GnRH-a injection. 60 min after stimulus LH and FSH were also assayed.

RESULTS

Thirty patients had increased ovarian stroma (IS) and 21 patients normal ovarian stroma (NS). Significantly higher LH levels characterized the IS group, both basally and after GnRH-a stimulation compared with NS and controls (P < 0.01). Baseline levels of androstenedione, testosterone and 17-OHprogesterone (17-OHP) were significantly higher in IS group. Moreover, 17-OHP hyper-response to GnRH-a was demonstrated in IS group in comparison to NS and control groups (P < 0.005).

CONCLUSIONS

Stroma evaluation may be of use in discriminating between different pathogenic factors in secondary amenorrhoea. This criterion may be applied to support the correct diagnosis of polycystic ovary syndrome (PCOS). Indeed, in line with the most recently proposed guidelines, patients affected by multifollicular ovaries could be classified as PCOS. The possibility of taking into account more than one US criterion or of carefully reanalysing the significance of increased stroma volume should be considered.

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.

Three- and 4-dimensional ultrasound in obstetrics and gynecology: proceedings of the American Institute of Ultrasound in Medicine Consensus Conference

The American Institute of Ultrasound in Medicine convened a panel of physicians and scientists with interest and expertise in 3-dimensional (3D) ultrasound in obstetrics and gynecology to discuss the current diagnostic benefits and technical limitations in obstetrics and gynecology and consider the utility and role of this type of imaging in clinical practice now and in the future. This conference was held in Orlando, Florida, June 16 and 17, 2005. Discussions considered state-of-the-art applications of 3D ultrasound, specific clinical situations in which it has been found to be helpful, the role of 3D volume acquisition for improving diagnostic efficiency and patient throughput, and recommendations for future investigations related to the utility of volume sonography in obstetrics and gynecology.

Intraobserver and interobserver reproducibility of ovarian volume, antral follicle count, and vascularity indices obtained with transvaginal 3-dimensional ultrasonography, power Doppler angiography, and the virtual organ computer-aided analysis imaging program

OBJECTIVES

The purpose of this study was to assess intraobserver and interobserver reproducibility of the parameters of ovarian response and oocyte ability, studied by 3-dimensional ultrasonography and power Doppler angiography (PDA), and the possible influence of the ovarian functional stage.

METHODS

Twenty-nine women were included in an in vitro fertilization program. Fourteen women were evaluated after pituitary suppression (basal group), and 15 were scanned on the human chorionic gonadotropin administration day, after gonadotropin ovarian stimulation (stimulated group). A first observer acquired 2 volumes for each ovary. Another observer performed a second analysis of the volumes acquired by the first observer. We analyzed ovarian volume, follicle number in the basal group, vascularization index, flow index, and vascularization-flow index. The volumes were processed by the Virtual Organ Computer-Aided Analysis imaging program using plane A and 15 degrees rotational steps.

RESULTS

Ovarian volume showed excellent intraobserver and interobserver agreement, with an intraclass correlation coefficient (Intra-CC) and an interclass correlation coefficient (Inter-CC) close to the unit. The Intra-CC and Inter-CC about the number of follicles were 0.964 and 0.978, respectively. Vascularity indices showed an Intra-CC greater than 0.90. The vascularization index and the vascularization-flow index showed higher interobserver than intraobserver reproducibility (Inter-CC > 0.96 for both). The flow index Inter-CC was 0.898. The reproducibility differences between the basal and stimulated ovary measurements were not significant.

CONCLUSIONS

There is an excellent intraobserver and interobserver reproducibility of the ovarian volume, follicle counts, and 3-dimensional PDA indices. The ovarian functional stage has no influence on the reliability. Three-dimensional ultrasonography and PDA improve the study of ovarian parameters, and their reliability impels a change in the current clinical routine of performing and interpreting ultrasonography.

Clarifying the role of three-dimensional transvaginal sonography in reproductive medicine: an evidenced-based appraisal

This overview describes and illustrates the clinical applications of three-dimensional transvaginal sonography in reproductive medicine. Its main applications include assessment of uterine anomalies, intrauterine pathology, tubal patency, polycystic ovaries, ovarian follicular monitoring and endometrial receptivity. It is also useful for detailed evaluation of failed and/or ectopic pregnancy. Three-dimensional color Doppler sonography provides enhanced depiction of uterine, endometrial, and ovarian vascularity.

Predictive values of ultrasound monitoring of the menstrual cycle

PURPOSE OF REVIEW

This review summarizes the current knowledge about ultrasound scanning values in monitoring the structural and functional changes of the uterus and ovaries during the menstrual cycle.

RECENT FINDINGS

The views that ovulation is more frequently right sided have been challenged, with recent data suggesting that ovulation occurs randomly. A 'follicular wave phenomenon', providing a new model for ovarian function during the menstrual cycle, has been described. Follicular development occurs in a wave-like fashion and women with two waves have earlier endometrial development due to earlier increase of the dominant follicle estrogen production. Myometrial contractions during menstrual cycle should be considered in the assessment of endometrial thickness. Uterine-ovarian arterial blood flow impedance is important in understanding the normal physiology of the menstrual cycle and may be of use in assisted conception protocols.

SUMMARY

At present, ultrasound scanning has an important role in noninvasive assessment of endometrial and ovarian cyclical changes and may be of particular importance in assisted conception procedures. Further work is likely to help in understanding its full diagnostic potential.

Measurement of the speed of sound in follicular fluid

BACKGROUND

Measurement of ovarian follicles by ultrasound is common practice in fertility treatment. However, the effect of the speed of sound is not taken into account. We present results from a study aimed at measuring this.

METHODS

The speed of sound was measured in samples of follicular fluid aspirated from patients undergoing fertility treatment. The transmitted and received pulses from a single element ultrasound transducer were recorded using a digital oscilloscope for a pulse passed through a sample of the fluid. The distance over which the pulse travelled was known from calibration with pure water. Variation with temperature was investigated in the range 25-45 degrees C. Dependence on ultrasound frequency, patient and time from aspiration were also investigated.

RESULTS

The speed of sound in follicular fluid was found to be 1550+/-3 m/s at 37.3 degrees C using 5.0 MHz ultrasound. The speed varied from 1528+/-3 m/s at 24.8 degrees C to 1561+/-3 m/s at 44.8 degrees C. Variation with patient, time and frequency were not detected.

CONCLUSION

The speed of sound in follicular fluid at body temperature is 1550 m/s. This small difference from the speed assumed by the ultrasound machine corresponds to the systematic bias in volume measurement evident in previously published results.

Defining endometrial growth during the menstrual cycle with three-dimensional ultrasound

OBJECTIVE

To define the changes in endometrial morphometry that occur during the normal menstrual cycle and to examine the discriminatory power of volumetric analysis over conventional two-dimensional measurements in quantifying the effect of compounding factors on endometrial growth.

DESIGN

The design was that of a longitudinal observational study. Subjects were seen on an alternate-day basis until ovulation and then every four days until the next menstrual period.

SETTING

A University teaching hospital.

POPULATION

Thirty women with regular cycles and acceptable "normal", menstrual patterns.

METHODS

Three-dimensional ultrasound data were acquired and subsequently analysed by a single observer.

MAIN OUTCOME MEASURES

Endometrial thickness and volume.

RESULTS

Both endometrial volume and thickness increased significantly during the follicular phase (P < 0.001), reaching a plateau around the time of ovulation and remaining relatively stable throughout the luteal phase. These changes in endometrial thickness and volume were highly correlated (R(2)= 0.767; P < 0.001). Parity was associated with a significantly greater endometrial volume than nulliparity (4.159 vs 2.234 cm(3); P < 0.05).

CONCLUSIONS

This study has defined the relative and absolute changes in endometrial growth, both in terms of thickness and volume, throughout the normal menstrual cycle. These data provide a reference for future three-dimensional studies investigating menstrual disorders, pathophysiological change and subfertility.

Role of three-dimensional ultrasound in assessment of women undergoing urethral bulking agent therapy

PURPOSE OF REVIEW

The technique of three-dimensional ultrasound imaging has been developed over the past 15 years, and has been particularly embraced by the field of obstetrics. More recently, advances have been made in gynecological applications, with promise demonstrated in pelvic floor and lower urinary tract imaging. A clinically useful extension of three-dimensional ultrasound imaging of the lower urinary tract is the assessment of urethral bulking agent therapy, as three-dimensional ultrasound imaging provides an objective means of assessing technical outcomes (i.e. periurethral position, configuration and volume of bulking agent). Our aim is to review recent developments in the use of three-dimensional ultrasound imaging in female incontinence, focusing on its role in the assessment of women undergoing urethral bulking agent therapy for stress urinary incontinence.

RECENT FINDINGS

Three-dimensional ultrasound imaging provides reproducible, affordable and clinically relevant information in the assessment of urethral bulking agent therapy with collagen. Serial, long-term three-dimensional ultrasound imaging assessment has enabled a definition of the technical outcome associated with a durable improvement in continence. The optimal volume varies widely between patients, but a circumferential or horseshoe-shaped periurethral configuration of collagen is strongly correlated with a durable improvement in continence. This finding is in agreement with limited data from a two-dimensional ultrasound assessment of Macroplastique.

SUMMARY

Three-dimensional ultrasound imaging provides an objective means of assessing technical outcomes from urethral bulking agent therapy not available previously. The volume and configuration information obtained allows for rational therapeutic decision-making, particularly with regard to determining the need for re-injection and recognizing the failure of an adequate therapeutic trial.

Growth patterns of human ovarian volume during intrauterine and postnatal organogenesis

BACKGROUND

Ovarian volumes during pre-pubertal, reproductive or menopausal life in a healthy female have been studied by in vivo and anatomical methods. In contrast, conclusive studies on normal human ovarian volume during intrauterine and postnatal organogenesis, when the folliculogenesis occurs, do not exist.

AIM

To assess the growth patterns of ovarian volume during human ovarian definitive histogenesis using morphometric methods.

SUBJECTS

Twenty-five left ovaries removed from fetuses, newborns and children with karyotype 46,XX, ranging from 15 to 74 weeks of development.

OUTCOME MEASURES

The ovaries were completely cut obtaining serial sections. Ovarian volume was calculated both with the ellipsoid method, using its length, maximum and minimum diameters, and the Cavalieri quantitative morphometric method. The age-related pattern of ovarian volume was studied using linear regression analyses.

RESULTS

Ovarian volume calculated with the Cavalieri method increased from 16 mm3 at the 15th week of development to over 300 mm3 at the end of the process, with a 20-fold increase compared to the initial volume. Ovarian volume calculated with the ellipsoid method ranged between 25 to over 380 mm3, with a 15-fold increase. On average, ellipsoidal volume over-estimated the true Cavalieri volume (mean difference -14%, S.D. 29, p=0.014, Student's t-test for paired samples). Linear regression curves were developed to predict ovarian volume at any age. Overall, the approximation was better for Cavalieri volume (approximately, 72% of variance explained by the linear regression) than for ellipsoid volume (59% of explained variance).

CONCLUSIONS

During the intrauterine and postnatal organogenesis, the normal growth rate of human ovary was almost linear. The calculation of ovarian volume using Cavalieri method does not depend on assumptions about the organ shape and it appears to be more appropriate.

Reproducibility of the study of placental vascularization by three-dimensional power Doppler

AIMS

To assess the reproducibility of 3D power Doppler study of placental vascularization in order to establish its methodological bases for its further application in normal and pathological pregnancies.

METHODS

A prospective study was carried on 30 normal singleton pregnancies from 14 to 40 weeks. To evaluate placental vascularization 3D power Doppler was applied to obtain a "placental biopsy". The spherical volume acquired was analyzed using the VOCAL imaging program. Two consecutive measurements were taken from each patient by a single observer, obtaining a total of 60 datasets. Placental volume (PV), Mean Gray (MG), Vascularization Index (VI), Flow Index (FI) and Vascularization Flow Index (VFI) were calculated. Intra-class correlation coefficient (ICC) and intra-observer agreement was evaluated.

RESULTS

PV and MG presented an ICC of 0.98 and 0.94 respectively, with differences approaching zero. All 3D power Doppler vascular indices (VI, FI and VFI) showed a correlation greater than 0.85, with a better intra-observer agreement for the flow indices (FI and VFI).

CONCLUSIONS

Placental vascular biopsy through 3D power Doppler is a new and simple tool to routinely study placental vascularization in human pregnancy. Our results provide the validation of the technique demonstrating a good reproducibility of the 3D power Doppler parameters when applied to the study of the placental vascular tree in normal pregnancies.

Plasma homocysteine in polycystic ovary syndrome: does it correlate with insulin resistance and ethnicity?

BACKGROUND

Polycystic ovary syndrome (PCOS) is associated with insulin resistance and premature coronary artery disease (CAD). Hyperhomocysteinaemia is a recognized risk factor for atherosclerosis, particularly among migrant South Asians, and has recently been shown to be correlated positively with the degree of insulin resistance/hyperinsulinaemia.

OBJECTIVES

To compare total plasma homocysteine (Hcy) in PCOS with controls from ethnic groups at high and low risk of insulin resistance.

METHODS

Case control study of three ethnic groups, Sri Lankans (SL), British Asians (BA) and white Europeans (C), with and without PCOS at specialist centres in Sri Lanka and Yorkshire, UK. Fasting total plasma Hcy concentration was analysed by fluorescence polarization immunoassay and examined for any correlation with age, body mass index (BMI), central obesity, fasting insulin and insulin sensitivity [calculated by the Quantitative Insulin Sensitivity Check Index (QUICKI) method], lipids and testosterone in each ethnic group.

RESULTS

Eighty SL with PCOS and 45 controls, 47 BA with PCOS and 11 controls, and 40 C with PCOS and 22 controls were studied. Both Asian groups with PCOS were younger than affected Europeans (P = 0.008). Sri Lankans with PCOS had significantly lower BMI values than other affected groups: mean +/- SEM (SL) 26.3 +/- 0.95; (BA) 30.59 +/- 7.54; (C) 32.1 +/- 5.95 kg/m2 (P = 0.006). However, waist : hip ratios (WHR) of Sri Lankans with PCOS were similar to others: mean +/- SEM (SL) 0.97 +/- 0.01 (BA) 1.04 +/- 0.02 (C) 0.92 +/- 0.01, P = 0.33. Mean plasma Hcy was significantly higher in all PCOS groups than in their ethnically matched controls (Student's t-test): (SL) 10.2 +/- 1.9 vs 9.0 +/- 3.8, P = 0.01; (BA) 7.9 +/- 1.9 vs 6.8 +/- 2.5, P < 0.0001; (C) 8.3 +/- 2.3 vs 6.8 +/- 1.5, P = 0.0007 micromol/l. Sri Lankans with PCOS had significantly greater Hcy concentrations than British Asians and Europeans with PCOS [P = 0.001; single-factor analysis of variance (anova)] and also significantly greater fasting insulin concentrations [(SL) 242.9 +/- 38.9; (BA) 89.4 +/- 8.9; (C) 48.6 +/- 4.8 pmol/l (P = 0.0003)] and significantly lower QUICKI [(SL) 0.308 +/- 0.004; (BA) 0.335 +/- 0.005; (C) 0.375 +/- 0.002 (P = 0.0007)]. Fasting plasma Hcy correlated best with fasting insulin (r = 0.56, P = 0.0001) and QUICKI (r =-0.53, P < 0.0001) in Sri Lankans with PCOS. Hcy in PCOS subjects from all three ethnic groups correlated significantly with fasting insulin following adjustment for age, BMI and WHR (r = 0.45, P = 0.0001), but this was not evident in the controls (r =-0.32, P = 0.1).

CONCLUSIONS

Elevation of fasting plasma homocysteine in PCOS varies with ethnicity and correlates significantly with fasting insulin. High homocysteine in young Sri Lankans with PCOS has major implications for their long-term risk for atherosclerosis.

Correlating structure and function: three-dimensional ultrasound of the urethral sphincter

OBJECTIVE

Three-dimensional (3D) ultrasound facilitates assessment of the anatomy of the urethral sphincter, a decrease in sphincter volume being associated with stress incontinence. Urethral pressure profilometry (UPP) is used to assess urethral sphincter function although it is not diagnostic of stress incontinence. The aim of this pilot study was to determine whether 3D sphincter volume can be correlated with the area under the UPP curve.

METHODS

Primigravid women were recruited antenatally between 32 and 42 weeks' gestation. 3D transvaginal ultrasound scans of the urethra were performed in modified lithotomy position with a comfortably full bladder. Length and cross-sectional area were measured allowing the sphincter volume to be calculated. UPP measurements were performed with a Gaeltec solid-state pressure transducer and the area under the curve mapped out and calculated. All scans and measurements were repeated between 3 and 6 months postpartum.

RESULTS

Nineteen women participated in the study. Antenatal and postnatal data were available in all cases. There was a statistically significant correlation between antenatal sphincter volumes and area under the UPP curve although this relationship was lost following delivery.

CONCLUSIONS

There appears to be a correlation between structural anatomy and functional anatomy in the antenatal period although following delivery this is lost.

Quantitative three-dimensional sonographic assessment of pelvic blood after transvaginal ultrasound-guided oocyte aspiration: factors predicting risk

OBJECTIVES

To evaluate the fluid volume in the pelvis immediately and 3-5 days after transvaginal ultrasound-guided oocyte aspiration (TOAS) and to identify predictive factors for intraperitoneal bleeding.

METHODS

This was a prospective study of 83 infertile women undergoing controlled ovarian hyperstimulation followed by TOAS and embryo transfer (ET). Pelvic blood volume was measured by three-dimensional (3D) ultrasound examination 3-5 h after TOAS (post-TOAS), and prior to ET (2-3 days after TOAS; pre-ET). Pelvic blood volume was then correlated with the following procedure-related variables: day of hCG administration: number and diameter of ovarian follicles, endometrial thickness, serum estradiol levels; day of TOAS: number of retrieved oocytes, patient's perceived pain (Likert scale), duration of TOAS, diameters (using two-dimensional (2D) ultrasound) and 3D volume of pelvic fluid; day of ET: 2D diameters and 3D volume of pelvic fluid, perceived pain; pregnancy rate.

RESULTS

The mean +/- SD volume of blood measured by 3D ultrasound after TOAS and before ET was 12.94 +/- 16.88 (range, 0-98.00) mL and 19.13 +/- 17.84 (range, 0-70.20) mL, respectively. Blood volume in the pelvis correlated most strongly with number of oocytes retrieved (post-TOAS: P < 0.01; pre-ET: P < 0.05), followed by pain level (post-TOAS: P < 0.01), number of follicles (post-TOAS: P < 0.05) and endometrial thickness (post-TOAS: P < 0.05). When all study variables were held constant, the number of oocytes and serum estradiol level proved to be significant predictors of the amount of fluid in the pelvis (post-TOAS/pre-ET: P < 0.01). If 2D ultrasound was used, the best predictor of fluid volume after TOAS was the width of the fluid scanned in the pelvis (P < 0.001).

CONCLUSIONS

The amount of blood in the pelvis following TOAS in the present series was within acceptable clinical limits. The number of retrieved oocytes and pain after TOAS were found to be indicators of patients at risk of excessive bleeding. These findings have important implications for the improvement of postprocedural care.

Three-dimensional ultrasonography in gynecology: technical aspects and clinical applications

OBJECTIVE

The aim of this work was to review the technical aspects and clinical applications of three-dimensional ultrasonography in gynecologic imaging.

METHODS

With the use of a computerized database (MEDLINE), articles on three-dimensional ultrasonography were reviewed. Other pertinent references were obtained from the references cited in these articles. In addition, we reviewed our own clinical experience over the past 7 years.

RESULTS

Numerous applications of three-dimensional ultrasonography have been reported, including imaging of the uterus, the endometrial cavity, adnexa, and the pelvic floor and color and power Doppler applications. The accuracy of volume calculations and the networking opportunities with three-dimensional ultrasonography have also been reported. Technical problems and limitations of this technique are summarized.

CONCLUSIONS

Three-dimensional ultrasonography has proved to be a useful imaging tool for clinical problem solving in gynecology, especially in imaging the uterus and uterine cavity.

Three-dimensional sonographic morphologic assessment in complex adnexal masses: preliminary experience

OBJECTIVE

To evaluate the role of three-dimensional transvaginal sonography in assessing complex adnexal masses.

METHODS

Forty-one women (mean age, 49.5 years; range, 23-75 years) with the diagnosis of complex adnexal masses on the basis of two-dimensional transvaginal sonography were reevaluated by three-dimensional transvaginal sonography. Two different sonologists evaluated the two- and three-dimensional transvaginal sonograms. Criteria indicative of malignancy included the presence of gross papillary projections, solid areas, and solid echogenicity for both techniques. Three women (7%) had bilateral masses, giving a total of 44 masses that were ultimately assessed. A definitive histologic diagnosis was obtained in every case after surgical tumor removal.

RESULTS

Twenty-one tumors (47.7%) were proved malignant, and 23 (52.3%) were benign. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy for two- and three-dimensional transvaginal sonography were 90%, 61%, 68%, 87%, and 75% and 100%, 78%, 81%, 100%, and 89%, respectively. There were no statistical differences between two- and three-dimensional transvaginal sonography (McNemar test, P = .687). The agreement between both examiners was high (kappa index = 0.71).

CONCLUSIONS

The use of three-dimensional transvaginal sonography does not significantly improve the two-dimensional transvaginal sonographic morphologic assessment of complex adnexal masses; however, we found it useful for reinforcing initial diagnostic impressions.