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

Ovarian Changes After Abdominal Hysterectomy for Benign Conditions

OBJECTIVES

To investigate any change in the ovaries, including early follicular serum follicle-stimulating hormone (FSH) level, total ovarian volume, total antral follicle count, and ovarian stromal blood flow, in patients who had undergone abdominal hysterectomy for benign conditions.

METHODS

Fifteen women with abdominal hysterectomy and conservation of ovaries for benign conditions and who were between 29 and 44 years old were recruited to undergo three-dimensional ultrasound examination with power Doppler to assess total ovarian volume, total antral follicle count, and vascularization index (VI), flow index (FI), and vascularization flow index (VFI) of ovarian stromal blood flow. Serum FSH, estradiol, and progesterone levels were checked on the same day. The results of the assessments were considered taken during the early follicular phase if the estradiol and progesterone levels were basal. Fifteen age-matched healthy women underwent the same assessments on the second day of menstruation.

RESULTS

Women with hysterectomy had significantly elevated serum FSH level and lower ovarian stromal blood flow indices, including VI, FI, and VFI, as compared with healthy women. The total antral follicle count and the total ovarian volume were similar between the two groups.

CONCLUSION

These changes may suggest altered ovarian function after hysterectomy.

Assisted reproductive techniques

Assisted reproductive technologies (ART) encompass fertility treatments, which involve manipulations of both oocyte and sperm in vitro. This chapter provides a brief overview of ART, including indications for treatment, ovarian reserve testing, selection of controlled ovarian hyperstimulation (COH) protocols, laboratory techniques of ART including in vitro fertilization (IVF), and intracytoplasmic sperm injection (ICSI), embryo transfer techniques, and luteal phase support. This chapter also discusses potential complications of ART, namely ovarian hyperstimulation syndrome (OHSS) and multiple gestations, and the perinatal outcomes of ART.

The root of reduced fertility in aged women and possible therapentic options: current status and future perspects

It is well known that maternal ageing not only causes increased spontaneous abortion and reduced fertility, but it is also a high genetic disease risk. Although assisted reproductive technologies (ARTs) have been widely used to treat infertility, the overall success is still low. The main reasons for age-related changes include reduced follicle number, compromised oocyte quality especially aneuploidy, altered reproductive endocrinology, and increased reproductive tract defect. Various approaches for improving or treating infertility in aged women including controlled ovarian hyperstimulation with intrauterine insemination (IUI), IVF/ICSI-ET, ovarian reserve testing, preimplantation genetic diagnosis and screening (PGD/PGS), oocyte selection and donation, oocyte and ovary tissue cryopreservation before ageing, miscarriage prevention, and caloric restriction are summarized in this review. Future potential reproductive techniques for infertile older women including oocyte and zygote micromanipulations, derivation of oocytes from germ stem cells, ES cells, and iPS cells, as well as through bone marrow transplantation are discussed.

Evaluation of ovarian reserve in infertile patients

Diminished ovarian reserve is a more common occurrence as more women postpone childbearing in modern societies due to social and demographic trends. Diminished ovarian reserve is one of the primary reasons for poor ART outcome. Due to high costs, side effects and heavy burden on patients on ART treatments, patient selection and counseling for prognosis is an important aspect before starting ART. Proper prediction of ovarian reserve before initiation of the treatment can decrease cycle cancellations, help clinicians to establish alternative treatment options (i.e.oocyte donation) for poor prognosis patients. However, indicators of ovarian reserve are not fully successful in predicting the outcome of the treatment. In this review, our aim was to discuss the efficacy of ovarian reserve tests on predicting poor ovarian response and treatment outcome in ART patients.

Prospective evaluation of early follicular ovarian stromal blood flow in infertile women undergoing IVF-ET treatment

BACKGROUND

To evaluate the role of early follicular stromal flow studies in predicting ovarian response during IVF-ET treatment and to assess their correlation with ovarian reserve parameters and clinical pregnancy achievement.

MATERIALS & METHODS

One hundred and sixty-eight consecutive and unselected infertile women undergoing their first IVF-ET treatment were included in the study. Basal ovarian reserve and stromal Doppler flow studies were performed in a natural cycle before starting treatment. Four Doppler indices were measured; peak systolic velocity (PSV), pulsatility index (PI), resistance index (RI) and systole/diastole ratio (S/D). Following completion of IVF-ET treatment Pearson's correlation analysis was performed to examine the correlation between Doppler indices, ovarian response, basal ovarian reserve parameters and clinical pregnancy achievement.

RESULTS

A positive correlation was found between the number of ≥14 mm follicles on hCG day and PSV. The number of ≥14 mm follicles and retrieved oocytes had a significant negative correlation with RI and S/D ratio. As well, the number of fertilized oocytes had a significant negative correlation with S/D ratio. Absence of a Doppler signal in one or both ovaries was significantly higher in the women with poor response (31%) as compared to women with normal response (16%). In addition, RI correlated positively with basal FSH as well as FSH/LH ratio and negatively with AFC. The S/D ratio had a negative correlation with AFC (p = 0.027). A significant positive correlation between PSV, total ovarian volume (p = 0.011) and mean ovarian volume (p = 0.019) was detected. However, no correlation between all four Doppler indices and age was detected. Moreover, Doppler indices did not differ significantly between conception and non-conception cycles following IVF-ET treatment.

CONCLUSIONS

Early follicular stromal Doppler signals is correlated with ovarian response as well as basal ovarian reserve parameters, but have no correlation with age neither with clinical pregnancy achievement in infertile women undergoing IVF-ET treatment.

Does 75 IU difference improve the cycle performance in poor responders? Comparison of daily 375 versus 450 IU gonadotrophin doses

OBJECTIVE

To compare the efficacy on the cycle performance of 375 versus 450 IU/day gonadotrophin on the microdose flare-up protocol in poor responders.

STUDY DESIGN

A total of 91 poor responder patients who were treated with the microdose flare-up protocol were enrolled in this study. Group 1 (n = 40) was stimulated with 375 IU/day gonadotrophin. Group 2 (n = 51) was stimulated with 450 IU/day gonadotrophin. Main outcome measurements were accepted as the results of controlled ovarian hyperstimulation, implantation, clinical pregnancy, and live birth rates.

RESULTS

Baseline characteristics are similar between the two groups. Higher number of oocyte cumulus complexes and lower total gonadotrophin requirement were noted in Group 1 compared with Group 2. Number of metaphase II oocytes and implantation rates were similar between the groups. A trend toward higher clinical pregnancy and live birth rate was observed in Group 1 but these results did not reach statistical significance.

CONCLUSIONS

Total gonadotrophin costs are lower using the 375 IU/day gonadotrophin compared to the 450 IU/day in poor responders. Additional 75 IU/day does not give any improvement neither embryology nor pregnancy outcomes.

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.

Rational Use of TVS/Color and 3D in Evaluating Subfertile Women

Infertility is defined as the failure to conceive a desired pregnancy after 12 months of unprotected intercourse and affects approximately 10% of married couples. With recent technological development and proper use of medically assisted reproduction techniques, one half of these couples will become pregnant.

More than any other new method, ultrasound has made significant improvements in the modern management of female infertility. Transvaginal sonography provides the reproductive endocrinologists with a tool that cannot only evaluate normal and stimulated cycles but also assist in follicle aspiration and subsequent transfer of the embryo. The addition of color Doppler capabilities to transvaginal probes permits visualization of small intraovarian and endometrial vessels, allowing depiction of normal and abnormal physiologic changes in the ovary and uterus. This article reviews on the assessment of ovarian, uterine and tubal causes of infertility and on the current and future role of color Doppler and three-dimensional ultrasound in the field of reproductive endocrinology.

Change in the ovarian environment after hysterectomy as assessed by ovarian arterial blood flow indices and serum anti-Müllerian hormone levels

OBJECTIVE

The aim of this prospective study was to evaluate the changes in the ovarian environment after hysterectomy based on ovarian arterial blood flow indices and serum anti-Müllerian hormone (AMH) levels.

STUDY DESIGN

Ovarian arterial blood flow indices (pulsatile and resistance indices) by Doppler ultrasonography and serum AMH levels were measured at baseline and 1 week, 1 month, and 3 months after hysterectomy in 32 women ranging in age from 38 to 49 years, or at the time of screening in 21 age-matched controls. The study subjects underwent hysterectomy with conservation of both ovaries for benign diseases of the uterus (laparoscopy-assisted vaginal hysterectomy [LAVH], n=26; and total abdominal hysterectomy [TAH], n=6). The study subjects and controls were analyzed using a t-test or one-way analysis of variance.

RESULTS

No differences existed in demographic profiles, ovarian arterial blood flow indices, and serum AMH levels at baseline between the hysterectomy and control groups. Ovarian arterial blood flow indices did not change before and after surgery, and there were no serial changes in the mean levels of serum AMH at each time point (1.80+/-1.81 ng/mL [pre-operatively], 1.69+/-1.62 ng/mL [1 week post-hysterectomy], 1.42+/-1.34 ng/mL [1 month post-hysterectomy], and 1.52+/-1.72 ng/mL [3 months post-hysterectomy]; p=0.805). In addition, no significant differences in ovarian arterial blood flow indices and serum AMH levels existed between the LAVH and TAH groups.

CONCLUSION

This preliminary study suggests that hysterectomy does not affect the ovarian environment for up to 3 months post-operatively, as assessed by ovarian arterial blood flow indices and serum AMH levels.

Ultrasound tests of ovarian reserve; a systematic review of accuracy in predicting fertility outcomes

We conducted a systematic review of studies evaluating the diagnostic accuracy of all the ultrasound based tests of ovarian reserve, including antral follicle count (AFC), ovarian volume and stromal blood flow in predicting fertility outcomes and, where appropriate, performed a meta-analysis to determine the predictive_value at each cut-off value described in the literature. Included in the analysis were 17 studies for AFC, six studies for ovarian volume and six studies for stromal blood flow. Meta-analyses showed that women with AFC less than four were 8.7 times more likely not to get pregnant after IVF (two studies; 95% CI, 2.4-31.7) than women with AFC four or more. The sensitivity and specificity of AFC to predict cycle cancellation was 66.7% and 94.7%, respectively. Women with an AFC of less than four were 37 times (two studies; 95% CI, 13.68-100.45) more likely to have their cycle cancelled than women with AFC of four o r more. Ovarian volume measurement, at a cut off value of 3 cm3, showed specificity for prediction of cycle cancellation and non-pregnancy of 92% (three studies, 95% CI, 89-94) and 93% (three studies, 95% CI, 87-97), respectively. The clinical value of Doppler studies for ovarian stromal blood flow was unclear.

Testing ovarian reserve to predict age at menopause

In modern society with women delaying pregnancy, predicting the age of the natural menopause with its preceding infertility will allow making informed choices about when to try starting to have children. Also if premature menopause could be predicted in young women, strategies could be instigated to reduce the long term health risks of early estrogen deficiency. This review examines the physiology of ovarian ageing, with the menopause being the final outcome. Long and short term predictive markers of the age of the menopause and the preceding natural infertility are evaluated. Many subtle changes in the endocrine regulation of ovarian function with advancing age may seem interesting but currently are not clinically useful as a predictive test. Examples are changes in concentrations of estradiol, progesterone, luteinizing hormone (LH) and activin, as well as follicle dynamics. Other features hold more promise. Among these are chronological age, family history, anti-Müllerian hormone (AMH), poor response to in vitro fertilization (IVF), basal follicle-stimulating hormone (FSH) and the antral follicle count for long term prediction. For short term prediction, cycle shortening and occurrence of vasomotor symptoms may prove useful. To date, none of these markers has been found to have sufficient predictive accuracy in individual women. Results of new and ongoing longitudinal studies may provide better predictive models. In particular, use of genetic profiles may add to the accuracy of currently known markers.

[The role of ultrasound examination to evaluate ovarian reserve of infertile patients]

The accurate assessment of ovarian reserve is an essential step before the treatment of infertile couples. Ovarian reserve could either be evaluated through clinical or biological parameters, but ultrasound plays a remarkable role, since it permits the direct visualization and count of ovarian antral follicles. Nevertheless, the available literature data are conflicting about the real sensibility and specificity of this method to predict the exact number of retrieved oocytes or the occurrence of pregnancy after a procedure for medical assisted reproduction. New technologies have been developed, as the 3D-ultrasound, who does not ameliorate ultrasound accuracy, but permits the reduction of the time necessary for patient's examination and virtually eliminates inter- and intra-observer bias. The place of the ovarian artery flow evaluation by Doppler remains unclear and need more studies.

Applications of estradiol and testosterone assays in the management of the infertile female patient

A collaborative effort to improve steroid hormone measurements in patient care was convened by the Centers for Disease Control in March 2008 to discuss the need for enhanced performance and standardization of clinical estradiol and testosterone assays. This article discusses the current status of estradiol and testosterone assays in the treatment of infertile women to include the assessment of ovarian reserve, ovulation induction and follicle tracking, ovarian hyperstimulation syndrome, and the role of testosterone in fertility management.

[Color Doppler imaging and measurements of intraovarian and intrauterine vascularization on basal ultrasound examination in spontaneous ovulatory and anovulatory cycles]

BACKGROUND/AIM

Any organs functioning directly depends on vascularization. It applies also to the uterus and ovary which go through changes of vascularization during a menstruation cycle. The aim of this investigation was to determine differences in intrauterine and ovarian stromal arterioral blood flow on basal ultrasound examination (day 2-4) between spontaneous ovulatory and anovulatory cycles.

METHODS

This prospective clinical investigation included 205 patients divided into two groups: with ovulatory and with anovulatory cycles.

RESULTS

Resistance to ovarian arterioral stromal blood flow was significantly lower in the patients with ovulatory cycles (pulsatile index--PI 0.97 +/- 0.4 vs 1.93 +/- 1.37; p = 0.001737; and (resistance index - RI 0.55 +/- 0.12 vs 0.68 +/- 0.14; p = 0.040033). There. were no statistically significant differences in arcuate arterioral blood flow in the pateints with ovulatory and anovulatory cycles (PI 1.21 +/- 0.34 vs 61 +/- 0,61 p = 0.136161 and RI 0.64 +/- 0.11 vs 0.74 +/- 0.07; p = 0.136649). The patients with ovulatory cycles had lower uterine radial arterioral blood flow than the patients with anovulatory cycles (PI 1.001 +/- 0.22 vs 1.61 +/- 0.23 p = 0.007501 and RI 0.55 +/- 0.08 vs 0.71 +/- 0.12; p = 0,0460113). The patients with ovulatory cycles had lower subendometrial arterioral blood flow resistance (PI 0.69 0.19 vs 1.385 +/- 0.09; p = 0.00622 and RI 0.44 +/- 0.09 vs 0.65 +/- 0.02; p = 0.027458).

CONCLUSION

Color Doppler ultrasuond imaging and measurements of intrauterine and ovarian stromal arterioral blood flow on basal ultrasound examination (day 2-4), showed lower resistance to blood flow in ovulatory than in anovulatory cycles.

Ovarian stromal blood flow following clomiphene citrate challenge test in infertile women

PURPOSE

To compare ovarian stromal blood flow indices in the follicular phase and after clomiphene citrate (CC) in infertile women.

METHODS

Pulsatility index (PI), resistance index (RI), and peak systolic blood flow velocity (PSV) of ovarian stromal vessels were determined by spectral Doppler analysis in the early follicular phase and on day 10 after CC. Serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), and estradiol concentrations were determined.

RESULTS

A total of 69 infertile women were included in the analysis. No significant differences in the average PI, RI, and PSV of ovarian stromal blood flow were demonstrated in the follicular phase and after CC despite a significant increase in serum estradiol concentration after CC. Serum FSH concentration was similar in the follicular phase and after CC, while serum LH concentration was significantly higher after CC. In the right ovary, ovarian stromal blood flow was absent in 13 (18.8%) patients in the follicular phase and in 6 (8.7%) patients after CC, but the difference did not reach statistical significance. In the left ovary, ovarian stromal blood flow was absent in 13 (18.8%) and 12 (17.4%) patients in the follicular phase and after CC, respectively.

CONCLUSION

Ovarian stromal blood flow indices were similar in the follicular phase and after CC.

Biomarkers of Ovarian Reserve

The primary function of the female ovary is the production of a mature and viable oocyte capable of fertilization and subsequent embryo development and implantation. At birth, the ovary contains a finite number of oocytes available for folliculogenesis. This finite number of available oocytes is termed "the ovarian reserve". The determination of ovarian reserve is important in the assessment and treatment of infertility. As the ovary ages, the ovarian reserve will decline. Infertility affects approximately 15%-20% of reproductive aged couples. The most commonly used biomarker assay to assess ovarian reserve is the measurement of follicle stimulating hormone (FSH) on day 3 of the menstrual cycle. However, anti-müllerian hormone and inhibin-B are other biomarkers of ovarian reserve that are gaining in popularity since they provide direct determination of ovarian status, whereas day 3 FSH is an indirect measurement. This review examines the physical tools and the hormone biomarkers used to evaluate ovarian reserve.

Different ovarian stimulation protocols for women with diminished ovarian reserve

PURPOSE

To review the available treatments for women with significantly diminished ovarian reserve and assess the efficacy of different ovarian stimulation protocols.

METHODS

Literature research performed among studies that have been published in the Pubmed, in the Scopus Search Machine and in Cohrane database of systematic reviews.

RESULTS

A lack of clear, uniform definition of the poor responders and a lack of large-scale randomized studies make data interpretation very difficult for precise conclusions. Optimistic data have been presented by the use of high doses of gonadotropins, flare up Gn RH-a protocol (standard or microdose), stop protocols, luteal onset of Gn RH-a and the short protocol. Natural cycle or a modified natural cycle seems to be an appropriate strategy. Low dose hCG in the first days of ovarian stimulation has promising results. Molecular biology tools (mutations, single nucleotide polymorphisms (SNPs)) have been also considered to assist the management of this group of patients.

CONCLUSIONS

The ideal stimulation for these patients with diminished ovarian reserve remains a great challenge for the clinician, within the limits of our pharmaceutical quiver.

Prediction of ovarian response and IVF/ICSI outcome by three-dimensional ultrasonography and power Doppler angiography

OBJECTIVE

The objective was to evaluate whether three-dimensional ultrasonography (3D-US) and power Doppler angiography (PDA) measurements can predict ovarian response and/or are associated with IVF/ICSI outcome.

STUDY DESIGN

A prospective clinical study in 65 women undergoing IVF cycles. Ovarian volume (OV), number of antral follicles > or =2mm (NAF) and PDA indices: vascularisation index (VI), flow index (FI), and vascularisation flow index (VFI) were evaluated by 3D-US and PDA on the day of pituitary suppression control. These measurements, age and BMI were correlated with the number of follicles>10mm on the hCG day and the number of oocytes retrieved.

RESULTS

Ovarian volume, NAF, VI, FI and FVI correlate significantly (P<0.01) with the number of follicles and oocytes recovered. Ovarian volume and the number of antral follicles predicted significantly the number of follicles (R=0.67; adjusted R(2)=0.43) and oocytes retrieved (R=0.63; adjusted R(2)=0.37). The oestradiol peak and the number of follicles, oocytes and Grade 1 embryos transferred were higher in the pregnant group.

CONCLUSIONS

Three-dimensional ultrasound and PDA make it easier to evaluate all the sonographic parameters implied in ovarian response. Ovarian volume and the number of antral follicles are the only independent predictors of the number of follicles developed and oocytes retrieved.

Undetectable basal ovarian stromal blood flow in infertile women is related to low ovarian reserve

To gain insight into the physiological significance of basal ovarian stromal blood flow and to assess whether its detection ability is related to ovarian reserve in infertility patients undergoing in vitro fertilization (IVF) - embryo transfer (ET) treatment. Thirty two consecutive infertile women scheduled for IVF-ET treatment were prospectively evaluated. Basal ovarian hormonal, ovarian volume and stromal blood flow studies were performed on day 3 of a natural cycle before treatment. The performer of the ultrasound studies was blinded to the clinical data. Women in the study were divided into two groups in accordance with estradiol level on the day of administration of human chorionic gonadotropin. Day-3 follicle-stimulating hormone and ovarian volume were significantly poorer in the women with low (group A) as compared with good (group B) ovarian reserve. Likewise, the numbers of follicles > or =14 mm in diameter, oocytes retrieved and embryos achieved were significantly lower in group A than group B. Six clinical pregnancies were obtained in group B, whereas no pregnancy was obtained in group A. Nine out of the 15 (60%) women in group A had undetectable basal stromal blood flow in at least one of the ovaries, whereas only one of the 17 (6%) women in group B had undetectable flow (p < 0.002). Basal stromal peak systolic blood flow velocity, pulsatility index and resistance index mean values did not differ significantly between the two groups. We conclude that undetectable basal ovarian stromal blood flow in at least one ovary is related to low ovarian reserve in infertile women undergoing IVF-ET. It seems that undetectable basal stromal blood flow is not solely a technical issue, but rather linked to the pathophysiology of ovarian aging.

Sonographic assessment of ovarian reserve. Its correlation with outcome of in vitro fertilization cycles

Ovarian reserve is a crucial factor for normal ovarian response and the achievement of pregnancy after in vitro fertilization (IVF). Recently, the study of morphological markers by means of ultrasonographic counting of antral follicles (AFC) has proved useful. The present prospective study included 327 consecutive IVF patients who had a basal ultrasound scan of their ovarian reserve during the early follicular phase and had a first IVF cycle between 1 and 3 months later. We performed 313 ovum pick-ups with a mean of 11.1 +/- 7.9 oocytes retrieved. The pregnancy rate per aspiration was 34.5%. Clear and significant differences were observed between normal and low response with respect to AFC, follicle-stimulating hormone (FSH) level and age. We also found that AFC correlated negatively and significantly with age, FSH and LH, and positively and also significantly with the total number of follicles, estradiol level and the number of oocytes retrieved. Using receiver operating characteristic curves, the cut-off value of AFC for poor response was 7 follicles. The value of AFC for predicting pregnancy was lower, although patients with AFC of 8 or more follicles obtained significantly higher pregnancy rates. We consider that AFC should be included in the study of the infertile patient.

Ageing and ART: a waste of time and money?

In many societies, more and more young women are delaying childbearing until the fourth decade of life. It is well known that fertility is remarkably reduced with increasing age of women in both natural conceptions and assisted reproductive technology (ART). In this chapter, the effect of ageing on the pregnancy rate in ART, and the options available to improve the reproductive outcomes in women of advanced age will be presented after understanding the mechanism of reproductive ageing and the effects of ageing on the reproductive outcomes in normal women. It is important to identify the predictive factors associated with a better treatment outcome.

The 3D vascular status of the follicle after HCG administration is qualitatively rather than quantitatively associated with its reproductive competence

BACKGROUND

The objective of this study was to determine whether the vascular status of a single pre-ovulatory follicle is associated quantitatively and/or qualitatively with its reproductive competence.

METHODS

We studied 61 monofollicular IVF-embryo transfer cycles. Just before single oocyte retrieval, follicle vascularization was detected by transvaginal power-Doppler, 3-dimensionally reconstructed, and analysed quantitatively by coloured/gray voxel ratio [vascularization index (VI)] and qualitatively by blood cell displacement [flow index (FI)] calculation. Cycles were sorted in two sets of two groups: low VI (<or=8%, n = 44) and high VI (>8%, n = 17); low FI (<or=30, n = 22) and high FI (>30, n = 39).

RESULTS

Patients' characteristics, fertilization rates, and embryo morphology were comparable in all groups. In contrast, clinical pregnancy rates/oocyte retrieval (4% versus 33%, P < 0.009) and implantation rates (11% versus 50%, P < 0.04) were markedly poorer in the low as compared to the high FI groups, respectively, but remained similar between the low and the high VI groups (22% versus 23% and 38% versus 44%, respectively).

CONCLUSIONS

A qualitative (FI) rather than quantitative (VI) relationship exists between vascular status and functional quality of the follicle after HCG administration.

A systematic review of tests predicting ovarian reserve and IVF outcome

The age-related decline of the success in IVF is largely attributable to a progressive decline of ovarian oocyte quality and quantity. Over the past two decades, a number of so-called ovarian reserve tests (ORTs) have been designed to determine oocyte reserve and quality and have been evaluated for their ability to predict the outcome of IVF in terms of oocyte yield and occurrence of pregnancy. Many of these tests have become part of the routine diagnostic procedure for infertility patients who undergo assisted reproductive techniques. The unifying goals are traditionally to find out how a patient will respond to stimulation and what are their chances of pregnancy. Evidence-based medicine has progressively developed as the standard approach for many diagnostic procedures and treatment options in the field of reproductive medicine. We here provide the first comprehensive systematic literature review, including an a priori protocolized information retrieval on all currently available and applied tests, namely early-follicular-phase blood values of FSH, estradiol, inhibin B and anti-Müllerian hormone (AMH), the antral follicle count (AFC), the ovarian volume (OVVOL) and the ovarian blood flow, and furthermore the Clomiphene Citrate Challenge Test (CCCT), the exogenous FSH ORT (EFORT) and the gonadotrophin agonist stimulation test (GAST), all as measures to predict ovarian response and chance of pregnancy. We provide, where possible, an integrated receiver operating characteristic (ROC) analysis and curve of all individual evaluated published papers of each test, as well as a formal judgement upon the clinical value. Our analysis shows that the ORTs known to date have only modest-to-poor predictive properties and are therefore far from suitable for relevant clinical use. Accuracy of testing for the occurrence of poor ovarian response to hyperstimulation appears to be modest. Whether the a priori identification of actual poor responders in the first IVF cycle has any prognostic value for their chances of conception in the course of a series of IVF cycles remains to be established. The accuracy of predicting the occurrence of pregnancy is very limited. If a high threshold is used, to prevent couples from wrongly being refused IVF, a very small minority of IVF-indicated cases (approximately 3%) are identified as having unfavourable prospects in an IVF treatment cycle. Although mostly inexpensive and not very demanding, the use of any ORT for outcome prediction cannot be supported. As poor ovarian response will provide some information on OR status, especially if the stimulation is maximal, entering the first cycle of IVF without any prior testing seems to be the preferable strategy.

Power Doppler ultrasound assessment of follicular vascularity in the early follicular phase and its relationship with outcome of in vitro fertilization

OBJECTIVE

To determine whether ovarian perifollicular blood flow (PFBF) in the early follicular phase (EFP) was associated with treatment outcome.

DESIGN

Retrospective longitudinal cohort study.

SETTING

Tertiary referral centre/university hospital.

PATIENTS

Thirty-four women underwent 37 IVF cycles, which resulted in 35 embryo transfers.

INTERVENTIONS

Serial transvaginal scans using power Doppler ultrasound during the follicular phase. Ovarian PFBF of follicles > or =5 mm was subjectively assessed using a modified grading system (grades 0-4).

MAIN OUTCOME MEASURES

Ovarian PFBF and pregnancy.

RESULTS

Treatment cycles were retrospectively divided into two groups: Group 1 (n=20) had cycles with at least one small (5-10 mm) or medium (11-14 mm) size follicle(s) of high grade (2-4) PFBF on cycle day 5 or 6 or 7; and Group 2 (n=17), had cycles that did not. Group 1 had a significantly higher proportion of high grade large follicles in the late follicular phase (35% vs. 21%) (OR 2.0; 95% CI 1.1-3.7) and higher clinical pregnancy rate (47% vs. 12%) (OR 6.3; CI 1.1-35.7) compared to Group 2.

CONCLUSION

High grade ovarian PFBF in the EFP during IVF is associated with both high grade PFBF in the late follicular phase and a higher clinical pregnancy rate.

Ovarian stromal vascularity is not predictive of ovarian response and pregnancy

The role of ovarian stromal vascularity in the prediction of the ovarian response and pregnancy in infertile women was evaluated by comparing age of women, body mass index (BMI), basal FSH concentration, antral follicle count (AFC) and ovarian stromal vascularity indices measured by three-dimensional power Doppler ultrasound. A total of 111 women in their first IVF cycle were analysed. They were aged <40 years with basal FSH concentration <10 IU/l on recruitment for IVF treatment. AFC, mean ovarian volume and mean ovarian 3D power Doppler flow indices were determined on day 2 of the treatment cycle prior to a standard regimen of ovarian stimulation. Ovarian response was represented by the number of oocytes, serum oestradiol, the duration and dosage of gonadotrophins. AFC achieved the best predictive value in relation to the number of oocytes obtained, followed by age of women and BMI. Basal FSH concentration was the only predictive factor for the duration and dosage of gonadotrophin used. Mean ovarian 3D power Doppler flow indices were not predictive of pregnancy in a multiple logistic regression analysis. Ovarian 3D power Doppler flow indices measured after pituitary down-regulation were not predictive of the ovarian response and pregnancy in the IVF treatment.

Mean ovarian diameter (MOD) as a predictor of poor ovarian response

PURPOSE

To determine the predictive value of mean ovarian diameter of ovarian response in controlled ovarian hyperstimulation (COH), in outcome with normal FSH level in early follicular phase of menstrual cycle.

METHODS

A prospective study established the prognostic value of the mean ovarian diameter of total 57 cases, including 17 patients undergoing IVF treatment with poor ovarian response and 40 patients (control group) with adequate ovarian response.

RESULTS

The mean ovarian diameter (MOD) of patients in the cancelled group was significantly lower (19.23 +/- 2.78) than in a comparable control group (24.67 +/- 3.38) [p < 0.001]. The mean ovarian diameter was a good predictor of poor ovarian response-area under receiver operating characteristic curve-ROCAUC = 0.88. The best criterion value discriminating between cancelled cycle and punctured was < or = 20.6 mm.

CONCLUSIONS

Our data demonstrate that the mean ovarian diameter provides good prognostic information in outcomes with poor ovarian response during controlled ovarian hyperstimulation in IVF. The test is easy to perform and it is a good informative resource.

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.

Mullerian inhibiting substance levels at the time of HCG administration in IVF cycles predict both ovarian reserve and embryo morphology

BACKGROUND

Pre-antral and early antral follicles secrete Müllerian inhibiting substance (MIS), suggesting that MIS may directly reflect ovarian reserve. Since little is known about how ovarian reserve affects oocyte quality, we attempt here to assess the predictive value of MIS on embryo morphology and IVF outcome. To do so, we measured MIS at the time of HCG administration 36 h prior to oocyte retrieval.

METHODS

A total of 257 patients undergoing IVF were prospectively recruited. We measured MIS levels by enzyme-linked immunosorbent assay at the time of HCG, and compared the MIS values to day 3 FSH levels in the prediction of embryo morphology and IVF outcome.

RESULTS

The distribution of MIS levels was skewed, with a median of 2.7 ng/ml (range 0 to 28.5 ng/ml). MIS values at the time of HCG administration inversely correlated with basal FSH levels (P = 0.002), and both correlated significantly with patient age, number of mature follicles, number of oocytes retrieved and serum estradiol levels. MIS levels correlated significantly with a greater number of 6-cell embryos and better embryo morphology score, while basal FSH levels did not correlate with these outcome variables. MIS levels > or =2.7 ng/ml portended improved oocyte quality as reflected in a higher implantation rate (P = 0.001) and a trend toward a better clinical pregnancy rate (P = 0.084).

CONCLUSIONS

MIS levels seem to predict not only ovarian reserve, but also embryo morphology. Measurement of MIS at the time of HCG administration may, therefore, in the future improve management of patients undergoing treatments with assisted reproductive technology.

Ovarian stromal blood flow in the prediction of ovarian response during in vitro fertilization treatment

BACKGROUND

This study evaluated the role of ovarian stromal blood flow in the prediction of the ovarian response of infertile women by comparing age of women, body mass index (BMI), basal FSH concentration, antral follicle count (AFC) and ovarian stromal blood flow indices measured by power Doppler in two-dimensional ultrasound. Patients were aged <40 years with basal FSH <10 IU/l on recruitment for IVF treatment.

METHODS

All received a standard regimen of ovarian stimulation in their first IVF cycle. AFC, pulsatility index, resistance index and peak systolic blood flow velocity of ovarian stromal vessels were determined on the second day of the treatment cycle prior to ovarian stimulation. Ovarian response was represented by the number of oocytes, serum oestradiol, and the duration and dosage of gonadotrophins.

RESULTS

A total of 136 women were included in the analysis. Basal FSH concentration achieved the best predictive value in relation to the number of oocytes obtained, followed by AFC and BMI. AFC was the only predictive factor of serum oestradiol concentration on the day of HCG while BMI was predictive of the gonadotrophin dosage.

CONCLUSION

Ovarian stromal blood flow indices measured by power Doppler ultrasound had no predictive value for the ovarian response.

Comparison of ovarian stromal blood flow between fertile women with normal ovaries and infertile women with polycystic ovary syndrome

BACKGROUND

Conflicting information exists in the literature with respect to ovarian stromal blood flow in women with polycystic ovary syndrome (PCOS). We compared the ovarian stromal blood flow and serum vascular endothelial growth factor (VEGF) concentration between fertile women with normal ovaries and infertile women with PCOS.

METHODS

In the second to fourth day of the menstrual period, they underwent transvaginal scanning with three-dimensional (3D) power Doppler to determine total antral follicle count (AFC), total ovarian volume, total ovarian vascularization index (VI), flow index (VFI) and vascularization flow index (VFI). Serum FSH, LH and VEGF concentrations were also checked.

RESULTS

107 fertile controls and 32 PCOS women were recruited. Fertile controls and PCOS women had similar total ovarian VI/FI/VFI after controlling for age of the woman, although PCOS women had significantly higher total AFC, total ovarian volume and serum LH concentration than fertile controls. Total ovarian VI/FI/VFI were significantly higher in normal weight (BMI < 25 kg/m2) PCOS women than their overweight (> or = 25 kg/m2) counterparts.

CONCLUSIONS

Fertile controls and PCOS women had similar total ovarian 3D power Doppler flow indices. Normal weight PCOS women had significantly higher total ovarian 3D power Doppler flow indices than their overweight counterparts.

Power Doppler ultrasound assessment of ovarian perifollicular blood flow in women with polycystic ovaries and normal ovaries during in vitro fertilization treatment

OBJECTIVE

To evaluate whether ovarian perifollicular blood flow (PFBF) varies by ultrasound among women with polycystic and normal ovaries undergoing in vitro fertilization (IVF).

DESIGN

Prospective observational cohort study of women undergoing IVF treatment.

SETTING

Department of reproductive medicine at a university teaching hospital.

PATIENT(S)

Thirty four women with regular spontaneous ovulatory menstrual cycles undergoing IVF divided into two groups according to findings on a baseline transvaginal ultrasound scan: group 1 consisted of 20 women with ultrasound-evident normal ovaries (USNO group), and group 2 consisted of 14 women with ultrasound-evident polycystic ovaries (USPCO group).

INTERVENTION(S)

Serial transvaginal power Doppler ultrasound assessments throughout the follicular phase of ovarian stimulation.

MAIN OUTCOME MEASURE(S)

Ovarian PFBF and ovarian stromal artery pulsatility index.

RESULT(S)

Women with USPCO had a significantly lower ovarian stromal artery pulsatility index at the time of the first ultrasound assessment before starting the FSH injections compared with USNO women. However, there was no difference in ovarian PFBF between women with USPCO and USNO during the follicular phase of ovarian stimulation for IVF.

CONCLUSION(S)

There is no difference in ovarian follicular vascularity between women with polycystic and normal ovaries during ovarian stimulation at IVF treatment.

Antral follicle count and FSH concentration after clomiphene citrate challenge test in the prediction of ovarian response during IVF treatment

BACKGROUND

We compared: (i) antral follicle count (AFC) in the early follicular phase, after the clomiphene citrate challenge test (CCCT) and before ovarian stimulation following pituitary down-regulation; and (ii) age of women, body mass index, basal and stimulated serum FSH concentrations and AFC in predicting the ovarian response of infertile women aged <40 years with basal FSH <10 IU/l on recruitment in their first IVF cycle.

METHODS

Two months prior to the treatment cycle, AFC and basal FSH concentration were determined on day 2-3 of a spontaneous period and on day 10 after CCCT. All women received a standard stimulation regimen. Ovarian response was represented by the number of oocytes, serum estradiol, the duration and dosage of gonadotrophins.

RESULTS

There was no significant difference between basal, stimulated and down-regulated AFC. AFC achieved the best predictive value in relation to the number of oocytes, followed by combined FSH concentration (sum of the two FSH concentrations) and age of women. Both basal AFC and combined FSH concentration were predictive factors of serum estradiol concentration, whereas stimulated FSH concentration was predictive of the total dosage of gonadotrophins.

CONCLUSION

Combined FSH concentration after CCCT provides additional information in predicting ovarian response.

Prognostic value of some ovarian reserve tests in poor responders

BACKGROUND

The objective of this study was to determine the prognostic value of the basal estradiol (E2) and inhibin-B levels, the antral follicle count (AFC), and the clomiphene citrate challenge test (CCCT) of ovarian response in controlled ovarian hyperstimulation (COH), in an outcome with normal follicle-stimulating hormone (FSH) concentration in the early follicular phase of the menstrual cycle.

METHODS

Fifty-two patients undergoing IVF treatment were included in the study. Blood samples were collected for assessment of basal E2, FSH, and inhibin-B levels. Transvaginal ultrasound of an unstimulated cycle was performed to determine the mean antral follicle count (AFC). Serum FSH concentration was measured again on day 10 for CCCT performance.

RESULTS

The mean values of women's age, and basal and day 10 FSH levels were significantly higher in cancelled cycles than in the control group, whereas basal inhibin-B and AFC were significantly higher in the latter. The mean basal E2 concentration was similar in both groups. The results from the logistic regression analysis show that CCCT (cut-off point FSH > 12.5 mIU/ml; AUCROC = 0.90) was a better single predictor of poor ovarian response than AFC (AUCROC = 0.85) and inhibin-B (AUCROC = 0.79) with a correct prediction for CCCT (86.5%), antral follicle count (84.6%), and for inhibin-B (82.7%).

CONCLUSIONS

In women with normal basal FSH level, the determination of E2 has no prognostic value for the outcome of poor responders. However, CCCT, AFC, and inhibin-B tests, when applied separately, produce good prognostic values. CCCT is the best single predictor of poor ovarian response, followed by antral follicle count and basal inhibin-B values. In spite of that, CCCT does not add significantly to the simpler AFC ultrasound test in the prediction of poor ovarian response.

Tailoring FSH and LH administration to individual patients

Many clinical trials have been carried out to find the optimal gonadotrophin starting dose for IVF. The consensus for patients undergoing first treatment and <40 years old is a range stretching from 150 to 250 IU/day. The varying ovarian response to gonadotrophins may be due to factors such as age, basal FSH, number of antral follicles and body mass index, all of which should be taken into account before choosing the type of protocol and the amount of gonadotrophins to use. Increasing the dose of recombinant FSH does not compensate for the age-related decline in retrievable oocytes. Higher doses of gonadotrophins are required in overweight patients, but enhanced protocols are thought to only marginally improve live birth rates in obese women. The actual role of LH in controlled ovarian stimulation is still a matter of debate. A therapeutic 'window' of LH concentrations, below which oestradiol production is inadequate and above which LH may be detrimental to follicular development has been described.

Fertility in female cancer survivors: pathophysiology, preservation and the role of ovarian reserve testing

The improved long-term survival of adolescents and young women treated for cancer has resulted in an increased focus on the effects of chemotherapy on ovarian function and its preservation. These women may seek advice and treatment regarding their reproductive status, including ways of preserving their fertility and preventing a premature menopause--factors that can have a profound impact on their quality of life. This article comprehensively reviews ovarian reserve testing (ORT) in general. Special emphasis is placed on patients with cancer, including the pathophysiology of gonadal damage following chemotherapy, fertility preservation and the potential role of ORT. Baseline parameters of ovarian reserve [FSH LH, estradiol, inhibin B and anti-Mullerian hormone (AMH)] have not yet performed sufficiently well in predicting poor outcome in assisted reproduction, but biochemical markers of ovarian reserve appear to be better than chronological age. Inhibin B and AMH show potential for future use. Dynamic testing appears to show much promise, especially stimulated levels of inhibin B and estradiol. The most promising tests of ovarian reserve are the biophysical markers, where total antral follicle count was found to be most discriminatory followed by ovarian volume. Combination of biochemical, biophysical and clinical markers of ovarian reserve may also improve predictive capacity. However, there is a lack of data pertinent to ORT in cancer. As yet there is no single clinically useful test to predict ovarian reserve accurately. Patients with cancer represent a distinct cohort who have particular concerns about their future fertility and the possibility of a premature menopause, they can benefit greatly from knowledge of their functional ovarian reserve. Large, prospective, randomized, adequately controlled studies specific to different geographical areas are required in a control population of comparable reproductive age to determine the potential role of ORT in clinical practice.

Comparison of follicular vascularization in normal versus polycystic ovaries during in vitro fertilization as measured using 3-dimensional power Doppler ultrasonography

OBJECTIVE

The growth of the follicles induced by gonadotropins during IVF treatment is accompanied by physiologic angiogenesis, which is essential for the maturation of the oocytes. We describe the IVF-induced changes in the vascularization and compare normal with polycystic ovaries (PCOs).

DESIGN

Prospective study.

SETTING

Assisted reproductive unit at a university hospital.

PATIENT(S)

Sixty women who underwent IVF cycles.

INTERVENTION(S)

The ovarian vascularization was measured after pituitary down-regulation, FSH stimulation, and hCG-injection using three-dimensional power Doppler ultrasonography.

MAIN OUTCOME MEASURE(S)

The total ovarian vascularization was divided by the number of follicles.

RESULT(S)

After pituitary suppression, the ovarian vascularization/follicle was lower in polycystic ovary (PCO) patients. During ovarian stimulation, follicles in PCOs required a lesser amount of FSH to acquire the same level of vascularization than the follicles in normal ovaries. In addition, hCG induced an increase in the follicular vascularization in both normal and PCOs. The follicle count correlated with the total vascularized volume in the ovaries throughout the IVF cycle.

CONCLUSION(S)

Follicles in PCOs seem to be less vascularized than the follicles in normal ovaries after GnRH treatment but not after gonadotropin stimulation. It is possible that restricted blood supply to the follicles in PCO might be associated with the follicular arrest that is observed. We could confirm that follicles in PCO are more sensitive to gonadotropin stimulation than follicles in normal ovaries.